For the First Time, 45 Counties Could Have
No Insurer in the Obamacare Marketplaces
by Haeyoun Park and Audrey Carlsen - NYT - June9. 2017
Next year, about 35,000 people buying insurance in Affordable Care Act marketplaces in 45 counties could have no carriers to choose from. This would be the first time that has happened since the marketplaces were opened in 2014.
The estimate is based on a New York Times analysis that also found that about 3 million people in 1,388 counties could have just one insurer available to them.
WASH.
WIS.
MICH.
WYO.
PA.
IOWA
NEB.
NEV.
DEL.
ILL.
UTAH
OHIO
W.VA.
COLO.
VA.
KAN.
MO.
KY.
N.C.
TENN.
OKLA.
ARIZ.
S.C.
GA.
ALA.
MISS.
TEX.
FLA.
ALASKA
Sources: Kaiser Family Foundation; New York Times compilation of company announcements. | Note: The map does not include plans offered outside the Obamacare marketplaces. Most Americans get coverage through work or the government.
About 45 percent of counties are expected to have one or no insurer in the marketplaces — where about 12 million people buy their own coverage — unless another carrier steps in.
The analysis started with data from the Kaiser Family Foundation showing which companies currently offer plans in each county and combined that with announcements from insurance companies saying which counties they plan to exit or enter next year.
Some insurance companies are still deciding what they will do in 2018, and others may reverse course, so these numbers could go up or down. But they provide an early look at the direction in which the markets are heading.
Most people who buy insurance in the Obamacare marketplaces receive federal subsidies to offset the cost of premiums. In places without any insurers, customers may not have affordable options.
Typically, markets with fewer insurers have also seen larger increases in prices, according to research by the Robert Wood Johnson Foundation and the Urban Institute.
People whose marketplace has only one insurer may also have fewer plans to choose from, according to Cynthia Cox, an executive at the Kaiser Family Foundation.
Many of these places are in rural areas with few customers, who are costly to cover. Urban or more populated areas tend to offer more choices.
In February, Humana became the first major insurer to pull out of the marketplaces entirely, prompting President Trump to again declare that “Obamacare continues to fail.”
Three months after the Humana announcement, Blue Cross Blue Shield announced that it would step in to fill a void in the Knoxville, Tenn., market. Otherwise, 16 counties in the state would have had no insurance options because Humana is currently the only insurer there.
Nashville
Knoxville
TENN.
Memphis
This week, Anthem, one of the nation’s largest insurers, announced that it would pull out of the Ohio marketplace in 2018, potentially leaving more than 10,000 people with no option in about 20 counties.
Ohio counties at risk of having
no Obamacare insurer in 2018
Cleveland
Columbus
OHIO
Cincinnati
Anthem, the only carrier in more than 275 counties outside Ohio, has not committed to offering plans in other states.
Counties covered by Anthem in 2017
ME.
WIS.
N.H.
NEV.
N.Y.
CONN.
IND.
OHIO
COLO.
MO.
VA.
CALIF.
KY.
GA.
If Anthem exited the marketplaces nationally, it would leave nearly 300,000 people at risk of having no marketplace insurer in 2018, Ms. Cox said.
How the Landscape Has Changed
Obamacare marketplaces are already thin in many parts of the country. About a third of counties nationwide have only one insurer, according to data released by the Kaiser Family Foundation.
Counties with one or no insurer
2016
2017
2018
2014
2015
16% of counties
6%
7%
33%
45%
The number of counties with just one insurer has more than doubled since 2014, while the number with three or more has declined substantially.
Counties with
one or no insurer
Three or more
insurers
2014
515
1,570
2015
175
2,121
2016
225
1,993
2017
1,036
949
2018
1,433
813
No insurer
Source: Kaiser Family Foundation (2014-17 data);
company announcements (2018 data)
company announcements (2018 data)
Most Americans get health insurance from a job or government program, but about 22 million people buy individual policies under Obamacare. More than half of them use Obamacare marketplaces, where most of them get a federal tax credit to help pay for coverage.
The rest buy directly from an insurer or broker, outside the Obamacare marketplaces. A recent Times analysis showed that many insurers are now choosing to sell exclusively outside the marketplaces, where their customers are not eligible for federal subsidies.
But because customers cannot use subsidies for these plans, many may not be able to afford coverage.
Republicans’ Secretive Plan for Health Care
by Miranda Yaver - NYT - June 9, 2017
While many Americans make sense of James Comey’s testimony on his meetings with President Trump, Republican senators are quietly moving toward something that has been their party’s goal for nearly eight years: dismantling the Affordable Care Act. The question, of course, is how they plan to replace it.
Republicans in the Senate will need 50 votes to pass their version of the American Health Care Act. Several senators have expressed reservations about the House version of the bill, which withdraws federal support for Planned Parenthood and rolls back the Medicaid expansion accomplished by the A.C.A.. Despite the lack of consensus within the party, Senator Mitch McConnell, the majority leader, on Wednesday began the process of fast-tracking the bill under Rule 14, which enables the Senate to bypass the committee process and instead move the bill on to the Senate calendar for a vote as soon as it is ready.
This will allow the legislation to move much as it did in the House – swiftly and secretively. The Senate aims to vote by the end of the month, and will probably do so with no hearings. This stands in stark contrast to the process leading up to the passage of the Affordable Care Act, which included over 100 congressional hearings..
The A.H.C.A.’s fast-tracking is not driven by necessity, but rather by the concern that a more transparent legislative process would lay bare the reality that the bill, if passed, would cause millions of Americans to lose their health insurance and drive up costs for millions of others.
With only 20 percent of Americans supporting the A.H.C.A. (and only 8 percent believing the Senate should pass the House version of the bill), and support for Obamacare at an all-time high, Senate Republicans are in a bind. While abandoning the A.H.C.A. in favor of fixing Obamacare would reflect the will of the majority of the American people, it would require abandoning a central campaign pledge to the Republican base and result in an untenable reconciliation process with the more conservative House. But pursuit of a deeply unpopular policy that is likely to have disastrous health and economic consequences for millions could be far costlier as the Republicans face the possibility of a stinging defeat in 2018.
With much public attention currently diverted to the investigation into the Trump campaign’s ties to Russia, Republicans may feel that now is the right time to move on health care. But just as town halls and phone calls conveyed to many House members deep concerns about the A.H.C.A., ordinary Americans can now demand to see the text of the legislation and tell their senators how a loss of insurance coverage would affect them. Though some relatively centrist senators including Dean Heller of Nevada recently warmed to the phase-out of Medicaid expansion over the next seven years, others like Susan Collins of Maine, Lisa Murkowski of Alaska and Bill Cassidy of Louisiana may be receptive to concerns about the future of Medicaid and protections for those with preexisting conditions.
It would be myopic and reckless for Republicans to advance legislation that harms millions for the short-term gain of a legislative victory.
After all, voters may not properly attribute policy gains like the Medicaid expansion to the legislation that President Obama championed, but they will remember who took their health care away.
A Key Republican Demands Subsidies to Calm Insurance Markets
by Robert Pear - NYT - June 8, 2017
WASHINGTON — A powerful House Republican said Thursday that Congress should immediately provide money for subsidy payments to health insurancecompanies, which have been demanding big rate increases or fleeing from Affordable Care Act markets because of President Trump’s threat to cut off the funds.
The Republican, Kevin Brady of Texas, who is the chairman of the House Ways and Means Committee, went out of his way to make clear that he now believes that Congress should continue the subsidies, which compensate insurers for reducing deductibles and other out-of-pocket costs for seven million low-income people.
The Trump administration has sent mixed signals on the issue, as the president seeks leverage to win legislation to repeal the Affordable Care Act. That has destabilized insurance markets and jeopardized a health law that Mr. Trump says is collapsing.
Mr. Trump has said he can stop the payments “anytime I want,” and his budget director, Mick Mulvaney, refers to the subsidies as “Obamacare bailout payments.”
But at a budget hearing on Thursday, Mr. Brady said the payments were needed “to help stabilize the insurance market and help lower premiums for Americans trapped in Obamacare.”
“We should act within our constitutional authority now to temporarily and legally fund cost-sharing reduction payments as we move away from Obamacare,” Mr. Brady said. “Insurers have made clear the lack of certainty is causing 2018 proposed premiums to rise significantly.”
His statement came one day after Senate Republicans said they were coalescing around a bill that would continue the cost-sharing subsidies, even as they tried to repeal much of the Affordable Care Act.
The Republican moves may be a response to political pressure: Democrats say Republicans will be responsible if the government cuts off the cost-sharing payments and premiums then skyrocket or markets collapse in some states.
The federal government spends $7 billion a year on the subsidies. The money goes directly to insurers, which are required to provide discounts to low-income people regardless of whether the companies are reimbursed by the government.
House Republican leaders had refused to provide money for the subsidies in their bill to repeal the Affordable Care Act, which was approved by the House last month. The White House balked at including the money in a sprawling spending bill to finance the government through September. And Mr. Trump has threatened to withhold the subsidies as a way to force Democrats to negotiate with him on a replacement for the 2010 health care law.
But Mr. Brady said the payments were needed to help consumers.
“Obamacare’s design flaws were not the fault of the American people,” Mr. Brady said. “The people now trapped in Obamacare did what the government mandated them to do — they complied with the law. They should not be left out to dry.”
House Republicans filed a lawsuit in 2014 asserting that the Obama administration was paying the subsidies illegally because Congress had never appropriated money for them, and a Federal District Court judge agreed last year. She ordered a halt to the payments, but suspended her order to allow the government to appeal. That appeal is still in progress, though it is unclear how far the Trump administration will take the fight.
At separate hearings of the House Ways and Means and Senate Finance Committees on Thursday, Tom Price, the secretary of health and human services, got a tongue-lashing from Democrats who said he and Mr. Trump were pursuing policies that could deprive millions of Americans of health care and coverage.
Representative Suzan DelBene, Democrat of Washington, said the administration was causing “chaos, confusion and instability in the market.”
In response to similar criticism from senators, Mr. Price said: “Nobody is interested in sabotaging the system. Nobody is cheering the challenges that we have in the system.”
The Trump administration cut back efforts to encourage enrollment in health plans under the Affordable Care Act, is loosening enforcement of the requirement for people to have coverage and has refused to say if it will continue paying the subsidies.
Democratic senators, including Debbie Stabenow of Michigan and Thomas R. Carper of Delaware, asked Mr. Price why the administration was destabilizing insurance markets.
In response, Mr. Price said the markets were deteriorating before Mr. Trump took office. In Michigan, Delaware and many other states, he said, average premiums doubled in the past four years.
Mr. Price, a former congressman from Georgia, defended proposals in the president’s budget that would sharply reduce the growth of Medicaid.
Even Senator Johnny Isakson of Georgia, a Republican who once held Mr. Price’s House seat, expressed doubts about the proposed cutbacks. In Georgia, he said, Medicaid helps pay for more than half of all births, and of the 1.9 million people in the state’s Medicaid program, 1.3 million are children.
“We are talking, first and foremost, about children” who could be hurt if the program is cut, he said.
Under questioning by Democrats, Mr. Price stood by his statement last month that “there are no cuts to the Medicaid program” in the House bill to repeal the Affordable Care Act. The nonpartisan Congressional Budget Office said the bill would reduce projected federal spending on Medicaid by more than $800 billion over 10 years and reduce expected enrollment by 14 million people.
Still, Mr. Price said, federal spending on Medicaid would increase from year to year, just not as fast as under current law.
Senator Bob Casey, Democrat of Pennsylvania, told Mr. Price, “You have been deliberately misleading.”
The secretary said he “absolutely” disagreed with the budget office report. (As chairman of the House Budget Committee in 2015, Mr. Price helped select the director of the Congressional Budget Office, Keith Hall, who Mr. Price said at the time had a “vast understanding” of economic policy.)
Outcry Over EpiPen Prices Hasn’t Made Them Lower
by Charles Duhigg - NYT - A few weeks ago, after some particularly incompetent parenting on my part (nuts in the dessert, a rushed trip to an emergency room after my child’s allergic reaction), I visited the local pharmacy to fill an EpiPen prescription.
You might recall EpiPen as last year’s poster child for out-of-control drug prices. Though this simple medical device contains only about $1 of the drug epinephrine, the company that sells it, Mylan, earned the public’s enmity and lawmakers’ scrutiny after ratcheting up prices to $609 a box.
Outraged parents, presidential candidates and even both parties in Congress managed to unite to attack Mylan for the price increases. By August, the company, which sells thousands of drugs and says it fills one in every 13 American prescriptions, was making mea culpas and renewing its promise to “do what’s right, not what’s easy,” as the company’s mission statement goes.
So I was surprised when my pharmacist informed me, months after those floggings and apologies had faded from the headlines, that I would still need to pay $609 for a box of two EpiPens.
Didn’t we solve this problem?
Not quite. What’s more, Mylan is back in the news. On Wednesday, regulators said the company had most likely overcharged Medicaid by $1.27 billion for EpiPens. The same day, a group of pension funds announced that they hoped to unseat much of Mylan’s board for “new lows in corporate stewardship,” including paying the chairman $97 million in 2016, more than the salaries of the chief executives at Disney, General Electric and Walmart combined.
Over the last several weeks, I’ve spoken with 10 former high-ranking executives at Mylan who told me that they weren’t surprised EpiPen prices were still high. Nor were many startled by last week’s developments.
Mylan, they said, is an example of a firm that has thrived by learning to absorb, and then ignore, opprobrium. The company has an effective monopoly on a lifesaving product, which has allowed its leaders to see public outrage as a tax they must pay, and then move on.
Mylan has been called out again and again over the years — by the company’s own employees, regulators, patients, politicians and the press — and hasn’t changed, even as revenue has skyrocketed, hitting $11 billion last year. The firm is a case study in the limits of what consumer and employee activism, as well as government oversight, can achieve.
Which means this time, if we’re hoping for a different outcome, something more needs to be done.
To understand Mylan’s culture, consider a series of conversations that began inside the company in 2014. A group of midlevel executives was concerned about the soaring price of EpiPens, which had more than doubled in the previous four years; there were rumors that even more aggressive hikes were planned. (Former executives who related this and other anecdotes requested anonymity because they had nondisclosure agreements or feared retaliation. Aspects of their accounts were disputed by Mylan.)
In meetings, the executives began warning Mylan’s top leaders that the price increases seemed like unethical profiteering at the expense of sick children and adults, according to people who participated in the conversations. Over the next 16 months, those internal warnings were repeatedly aired. At one gathering, executives shared their concerns with Mylan’s chairman, Robert Coury.
Mr. Coury replied that he was untroubled. He raised both his middle fingers and explained, using colorful language, that anyone criticizing Mylan, including its employees, ought to go copulate with themselves. Critics in Congress and on Wall Street, he said, should do the same. And regulators at the Food and Drug Administration? They, too, deserved a round of anatomically challenging self-fulfillment.
When the executives conveyed their anxieties to other leaders, including the chief executive, Heather Bresch, these, too, were brushed off, they told me.
Those top leaders’ responses are a far cry from the message on Mylan’s website, which says that “we challenge every member of every team to challenge the status quo,” and that “we put people and patients first, trusting that profits will follow.”
But Mylan is a prime example of how easy it is for leaders to say one thing publicly and act differently in private. When we talk about consumer or employee activism, we tend to focus on firms like United Airlines, which quickly apologized and changed its policies after a video emerged of a passenger being dragged off a plane.
However, in many other cases, outrage is ineffective. Mylan’s behavior persists because it is hard, and often tedious, for employees and the public to continue complaining — particularly when bosses disagree, or when some newer outrage appears on our Facebook feed.
But the costs of going silent are real. Regulators missed an opportunity to reform Mylan in 2012 when the company produced a television commercial showing a mother driving her son to a birthday party and implying that he could eat whatever he wanted, despite his nut allergy, as long as an EpiPen was nearby to counteract a reaction. The commercial also suggested that an EpiPen was a sufficient treatment on its own.
Mylan knew neither of those was true, according to executives from that period. In fact, Mylan had recently started a major lobbying effort to encourage schools to stock EpiPens by arguing that people with serious food allergies are always at risk, and that EpiPens were a necessary supplement to emergency medical treatment.
Before the birthday advertisement aired, the ad went through multiple internal review processes. Mylan executives told Ms. Bresch that the commercial was improper. One employee went so far as to send an internal email saying the advertisement would increase the frequency of allergic reactions, according to a person who saw the correspondence.
Ms. Bresch disagreed. She said it was better to act boldly, according to a former executive who participated in that conversation.
So the advertisement went on television. And a record number of consumer complaints arrived at the Food and Drug Administration. The agency ordered the commercial pulled after just a few days because it was “false and misleading,” “overstates the efficacy of the drug product” and “may result in serious consequences, including death.” The agency ordered Mylan to broadcast another ad, this one acknowledging that the “EpiPen cannot prevent an allergic reaction.”
But regulators never investigated why Mylan’s internal protocols had allowed the dangerous ad to air. And a year later, Mylan received something akin to a government endorsement. President Barack Obama signed a federal law encouraging schools to stock emergency epinephrine supplies. The White House celebrated it as the “EpiPen Law.”
When I approached Mylan about these and other anecdotes, the company disputed employees’ accounts. In a statement, it wrote that “any allegations of disregard for consumers who need these lifesaving drugs, government officials, regulators or any other of our valued stakeholders are patently false and wholly inconsistent with the company’s culture, mission and track record of delivering access to medicine.”
Mr. Coury declined to be interviewed, but Ms. Bresch sat down with me last month at Mylan’s Manhattan offices. She said that Mylan was “a pretty rare and unconventional company,” and that it was focused on delivering low-cost drugs. A broken health care system, she said, is responsible for the inefficiencies and high prices that plague consumers.
She added that Mylan had responded promptly when the Food and Drug Administration criticized the company’s advertisement in 2012, and that the EpiPen had become more expensive because Mylan had invested in public awareness and improving the device.
“Look at what we’ve built, and what we deliver day-in and day-out,” Ms. Bresch told me, “and at the center of all of that is the patient.”
But it seems hard to reconcile those comments with allegations from employees, regulators and other companies. In December, attorneys general in 20 states accused Mylan and five other firms of conspiring to illegally keep prices high on an antibioticand a diabetes drug. In October, Mylan returned nearly a half-billion dollars to the federal authorities in an attempt to stem the investigation into overcharging that regulators cited on Wednesday. And in April, one of Mylan’s competitors, Sanofi, filed a lawsuit accusing the firm of committing antitrust violations to keep an EpiPen competitor off the market.
Then there are situations that, at other firms, might have set off firings or corporate soul-searching, but that at Mylan caused neither. In 2007, reporters discovered that Ms. Bresch had not received the M.B.A. degree she claimed on her résumé. In 2012, Mr. Coury was criticized by investors and the media for repeatedly using the company plane to fly his son to music concerts. (And then there was the time, in 2013, when Mr. Coury, at a Goldman Sachs conference, indicated his dislike for hypothetical questions by saying that “if your aunt had balls, she’d be your uncle.”)
In our interview, Ms. Bresch said there was nothing in Mylan’s culture she would change. The company also said it had found no evidence of price-fixing or antitrust behavior, that the government overcharges had resulted from an innocent disagreement over regulatory interpretations and that Mylan’s compensation policies were appropriate.
“We are a for-profit business, and we have a commitment to shareholders,” Ms. Bresch told me. “But I think if there’s any company out there that has demonstrated you can do good and do well, we’re one of the few.” For instance, Ms. Bresch noted that Mylan had recently released a generic version of EpiPen.
When I asked my pharmacist for the generic EpiPen, he told me that I would have to wait 90 minutes, until he could get my doctor on the phone to authorize the substitution. Then, he charged me $370 for the generics.
Mylan points out there are online coupons for EpiPen customers. In fact, the company says that since it came under attack in August, nearly 90 percent of EpiPen buyers have paid less than $100 per box because of insurance, discounts or coupons.
But for parents in urgent need of an EpiPen, or for patients who are poor, are not internet savvy or have high insurance deductibles — which are increasingly common — those programs can mean little. The most vulnerable often end up paying the highest prices, which is troubling when you consider that 15 million Americans have food allergies.
But hope springs eternal. With the recent criticisms coming on the heels of last year’s controversies, Mylan will have to change, right?
Perhaps. But only if people stay angry and active. Doctors need to write different prescriptions. Pharmacists need to guide patients to alternatives. Investors should examine further efforts to elect new Mylan board members.
In the meantime, I still believe — perhaps foolishly — that sustained attention might create change. And so, as long as Mylan flouts the norms of good corporate behavior, it seems worth continuing to scrutinize what the company is doing, and questioning why EpiPens cost so much.
by JP Massar - The Daily Kos - June 7, 201
I’ve gathered together many of the questions people ask, and objections they raise, when single payer health care is discussed. Accompanying the questions are my answers: some definitive, some an admission of doubt and uncertainty. With a few jabs and a bit of snark thrown in.
So enjoy! And point your dubious friends here when they ask you any of these 50+ questions...
THE BASICS
Q. What is SB 562?
A. It's legislation introduced by Senator Richard Lara into the California legislature in 2017, designed to create a single-payer, universal health care system in the state. It would set up an organization called Healthy California to administer the program.
A. It's legislation introduced by Senator Richard Lara into the California legislature in 2017, designed to create a single-payer, universal health care system in the state. It would set up an organization called Healthy California to administer the program.
Q. Who would it cover?
A. Everyone who is a resident of California, using a residency requirement very similar to that of California's current Medicaid program (MediCal).
A. Everyone who is a resident of California, using a residency requirement very similar to that of California's current Medicaid program (MediCal).
Q. Including undocumented individuals?
A. Yes. Everyone.
A. Yes. Everyone.
Q. Homeless people?
A. Yes. Everyone.
A. Yes. Everyone.
Q. Health insurance company CEO's?
A. Hmmm. Maybe there'll be an exception...
A. Hmmm. Maybe there'll be an exception...
Q. What would it cover?
A. Pretty much everything. Anything you'd normally think of as associated with doctors and hospitals as well as mental health services, dental services, vision, medical equipment purchases, nursing home and long-term care, and on. You can find a non-limiting list in the legislation (Chapter 4, 100630).
A. Pretty much everything. Anything you'd normally think of as associated with doctors and hospitals as well as mental health services, dental services, vision, medical equipment purchases, nursing home and long-term care, and on. You can find a non-limiting list in the legislation (Chapter 4, 100630).
Q. What would people have to pay to get services?
A. Zero. Zip. Nada. $0.00. No copays, no fees, no deductibles, no premiums.
A. Zero. Zip. Nada. $0.00. No copays, no fees, no deductibles, no premiums.
Q. How would it work from an individual's perspective?
A. You'd get a Healthy California membership card. You make an appointment. You present your card. You get treated. You go to a pharmacy. You get your medicine. You never pay anything.
A. You'd get a Healthy California membership card. You make an appointment. You present your card. You get treated. You go to a pharmacy. You get your medicine. You never pay anything.
Q. How would it work from a company's perspective?
A. Companies would no longer have to deal in any way with health insurance, health insurance companies, self-insurance, or health benefits. It would all just go away.
A. Companies would no longer have to deal in any way with health insurance, health insurance companies, self-insurance, or health benefits. It would all just go away.
Q. How would it work from a medical services provider's perspective?
A. Logically, a service would scan your card, provide services to you, and then bill the Healthy California Trust Fund, which would process the request and send the service provider a check. Of course the details may be different (e.g., reimbursements may be aggregated and sent in one weekly check, covering everyone treated, or sent via an electronic transfer). Most importantly health service providers would not be dealing with twenty different insurance companies' rules and regulations, questions of coverage or denial of claims issues.
A. Logically, a service would scan your card, provide services to you, and then bill the Healthy California Trust Fund, which would process the request and send the service provider a check. Of course the details may be different (e.g., reimbursements may be aggregated and sent in one weekly check, covering everyone treated, or sent via an electronic transfer). Most importantly health service providers would not be dealing with twenty different insurance companies' rules and regulations, questions of coverage or denial of claims issues.
There's another way - the Kaiser way (integrated care). The legislation allows Healthy California to pay an organization like Kaiser a fixed fee per person per year (perhaps adjusted by age). It would be Kaiser's responsibility to make ends meet from that revenue stream. In such a case there wouldn't even be a need for billing or reimbursement.
COSTS
Q. What will it cost?
A. A guesstimate by the staff of the California Senate Appropriations Committee put the cost at $400 billion annually. A detailed analysis by economists using hard data and modelling arrived at a figure of $330 billion annually.
A. A guesstimate by the staff of the California Senate Appropriations Committee put the cost at $400 billion annually. A detailed analysis by economists using hard data and modelling arrived at a figure of $330 billion annually.
Q. That's a lot of money, even by Carl Sagan standards. How could we possibly come up with a sum like that?
A. In order for these numbers to have any meaning, they must be compared to what California spends now on health care per year. That's close to $370 billion! So the money already exists and is being used for the same purposes. No one has to "come up with it."
A. In order for these numbers to have any meaning, they must be compared to what California spends now on health care per year. That's close to $370 billion! So the money already exists and is being used for the same purposes. No one has to "come up with it."
That $370B figure includes all money spend by the federal government in California (e.g., Medicare, Medicaid, CHIP, ACA subsidies, emergency room subsidies, etc), all money spent by the state and local governments (insurance premiums for employees, costs to keep County hospitals open, mental health services spending, etc), all money spent by employers on health insurance premiums and other health benefits, and all money spent by individuals on premiums, co-pays, deductibles, fees, medical equipment, etc.
For more perspective, the GDP of California is $2.6 Trillion.
Q. So depending on who you believe, it will either cost California $30B more per year or $40B less per year?
A. Yes. Keep in mind the smaller figure is based on a rigorous analysis by a team of academics — led by Robert Pollin. Governor Brown’s former economic advisor - with extensive experience in these matters. The larger figure was a fairly quick guesstimate by competent legislative staff but was by no means a rigorous analysis.
A. Yes. Keep in mind the smaller figure is based on a rigorous analysis by a team of academics — led by Robert Pollin. Governor Brown’s former economic advisor - with extensive experience in these matters. The larger figure was a fairly quick guesstimate by competent legislative staff but was by no means a rigorous analysis.
Q. Why might it cost less?
A. Insurance companies would go away. So no more insurance company profits and far less paperwork and red tape. Fewer emergency room visits. Healthier individuals overall whose conditions are treated before they become million-dollar problems. The ability (and mandate) to negotiate drug prices with pharmaceutical companies. The mandate to negotiate fair and reasonable prices for medical services based on Medicare reimbursement rates, which are less than current private-market prices. Along with other efficiencies that can be realized once you have a non-profit, single-payer entity managing the system.
A. Insurance companies would go away. So no more insurance company profits and far less paperwork and red tape. Fewer emergency room visits. Healthier individuals overall whose conditions are treated before they become million-dollar problems. The ability (and mandate) to negotiate drug prices with pharmaceutical companies. The mandate to negotiate fair and reasonable prices for medical services based on Medicare reimbursement rates, which are less than current private-market prices. Along with other efficiencies that can be realized once you have a non-profit, single-payer entity managing the system.
Q. Why might it cost more?
A. Higher utilization and frivolous use. More people (everyone) covered. Possible increased fraud.
A. Higher utilization and frivolous use. More people (everyone) covered. Possible increased fraud.
Q. Is there any evidence one way or another?
A. We know that other countries, most notably Canada and Taiwan, have single-payer systems and costs a) are much less than they are in the United States per capita, and b) they don't have unacceptable problems with too much utilization, frivolous use or fraud.
A. We know that other countries, most notably Canada and Taiwan, have single-payer systems and costs a) are much less than they are in the United States per capita, and b) they don't have unacceptable problems with too much utilization, frivolous use or fraud.
We know that Canada negotiates drug prices and gets around a 30% reduction vis a vis the prices we pay in America.
We know that our existing single-payer system in the United States - Medicare - has far lower administrative overhead than private insurance companies.
We know, from our own personal experience and studies, that insurance companies impose huge bureaucratic burdens both on doctors and patients.
Of course we don't know for sure what will happen until we try.
Q. What if the analysis is wrong and it does cost more?
A. We still get universal coverage, dental and vision for everyone, the elimination of medical debt, peace of mind, no more bake sales and GOFUNDme's when someone gets sick, and more. We retain the ability to look at what's going wrong and make the appropriate corrections, unlike the situation now, where the ACA, even if it survives, can't be tweeked or repaired because of Republican intransigence.
A. We still get universal coverage, dental and vision for everyone, the elimination of medical debt, peace of mind, no more bake sales and GOFUNDme's when someone gets sick, and more. We retain the ability to look at what's going wrong and make the appropriate corrections, unlike the situation now, where the ACA, even if it survives, can't be tweeked or repaired because of Republican intransigence.
FINANCING
Q. Where will the money to pay service providers come from? How does it get into the Healthy California Trust Fund?
A. California would take all the money it's getting now from the Federal government, and all other state and local allocations for health care, and direct it into the Trust Fund. New sources of revenue (aka new taxes) will be created to fund the difference, which is approximately $100B using the study's numbers.
A. California would take all the money it's getting now from the Federal government, and all other state and local allocations for health care, and direct it into the Trust Fund. New sources of revenue (aka new taxes) will be created to fund the difference, which is approximately $100B using the study's numbers.
Q. Did you say 'new taxes' ?
A. Yes. Taxes. The same sort of mechanism that now pays for schools and roads would also be used henceforth to pay for health care. It's radical, but the alternative is continuing to pay health insurance company CEO's millions to pay people low wages to stamp DENIED on claims.
A. Yes. Taxes. The same sort of mechanism that now pays for schools and roads would also be used henceforth to pay for health care. It's radical, but the alternative is continuing to pay health insurance company CEO's millions to pay people low wages to stamp DENIED on claims.
Q. What taxes?
A. There is no specific additional tax written into the legislation at the moment. However, the financial analysis study proposed two revenue sources:
A. There is no specific additional tax written into the legislation at the moment. However, the financial analysis study proposed two revenue sources:
- A gross receipts tax for businesses of 2.3% in lieu of all the health insurance costs they now incur, imposed only on receipts over $2,000,0000. (Therefore, the smallest businesses would pay nothing, and a small business with, say, $2,500,000 in gross receipts, would pay only on $500,000, not $2,500,000, for a total annual bill of $11,500). The bigger the business, the higher the effective rate.
- An increase in the sales tax of 2.3%, with a rebate to low-income households to insure that the net effect on those with low income is minimal, or even net beneficial.
Q. Why aren't these funding sources written into the legislation?
A. Because the financing proposal came out too late to be inserted into the legislation before it was voted on by the California Senate (the legislature now has a 72-hour posting rule, which, while it may or may not have actually applied here, was honored by the Senate).
A. Because the financing proposal came out too late to be inserted into the legislation before it was voted on by the California Senate (the legislature now has a 72-hour posting rule, which, while it may or may not have actually applied here, was honored by the Senate).
Also, because there are other financing mechanisms possible (e.g. a progressive payroll tax, progressive capital gains and interest income taxes, or a carbon tax), and the authors want an open debate and flexibility.
[Nerdlyness warning — The next four questions are a bit on the policy wonk side. You can scroll down to “Prospects for Passage” if that’s not your thing.]
Q. What happens if the Federal government refuses to give California the money it's currently spending in California on medical services if California sets up a single-payer system? Doesn't the Trump administration already hate us?
A. Yes, they already hate us. No, they can't just say "Screw you." And if they try to, there is sound legal basis for suing to compel them to provide the money. The Feds can't let Indiana get special waivers to do what they want with Medicaid money while not letting California have the same rights.
A. Yes, they already hate us. No, they can't just say "Screw you." And if they try to, there is sound legal basis for suing to compel them to provide the money. The Feds can't let Indiana get special waivers to do what they want with Medicaid money while not letting California have the same rights.
Existing Medicare law already allows California to take over the administration of Medicare. Medicare and Medicaid are the two biggest chunks of money coming from the Feds.
Could it get messy? Indeed. Could Trump figure out a legal way to screw California over? It's certainly possible. But since there is no possibility of a better health care system any time soon at the Federal level, and a significant possibility of a worse one - that California will suffer immensely from - we need to push forward.
Q. What happens to this plan if Congress repeals the ACA?
A. Congress isn't considering repealing the ACA. At least not currently. They want to change the way the ACA exchange subsidies are doled out, and change Medicaid reimbursement, cutting the amount of each (and they want to give states greater authority to screw people). So the amount of money that California (and every other state) would receive from the Feds would be reduced, but it would not be eliminated.
A. Congress isn't considering repealing the ACA. At least not currently. They want to change the way the ACA exchange subsidies are doled out, and change Medicaid reimbursement, cutting the amount of each (and they want to give states greater authority to screw people). So the amount of money that California (and every other state) would receive from the Feds would be reduced, but it would not be eliminated.
If states gets less money from the Feds for healthcare, either that money has to be made up somehow by the state and/or its people or everyone gets less healthcare, takes on more medical debt, and starts dying. The latter may be acceptable in Alabama but is probably not going to play well in the Golden State.
So either our state taxes go up to cover the shortfall, or companies and people with enough money start paying out-of-pocket for more of their health care. The former seems like a fairer thing to do. And given that the Republican plan, the ACHCA, is basically a tax cut for the rich, it seems fairest of all for the state to then tax California's rich to claw back some or all of that bonanza and use it for health care.
Q. What about ERISA (Employee Retirement Income Security Act), Federal legislation which reserves for the Federal government the right to regulate self-funded employer health plans such as those offered by large corporate employers?
A. That could be a problem. Changing ERISA would require an Act of Congress. California seemingly cannot otherwise force self-funding companies operating in California to become part of its single-payer plan.
A. That could be a problem. Changing ERISA would require an Act of Congress. California seemingly cannot otherwise force self-funding companies operating in California to become part of its single-payer plan.
However, there is nothing that prevents California from taxing businesses using the gross receipts tax regardless of whether they self-insure their employees or not. What company in its right mind would continue to choose to self-insure its California employees, effectively paying for their health care, AND pay the gross receipts tax? Why not voluntarily drop the self-insurance plan and save a lot of money?
Q. So if you institute these new taxes and now the state is going to spend some $330B on health care, that will more than double the state budget. What about that?
A. Yes, the state budget would increase by a large factor, in a technical sense.
A. Yes, the state budget would increase by a large factor, in a technical sense.
The money will come into the state in various forms, and immediately go out again directly to the Healthy California Trust fund, where it will then be disbursed to health care providers.
Remember, California’s (as in everyone in California's) budget for health care is already $370B. Whether electronic money flows through a state owned computer and therefore technically increases the state "budget," or the Feds, insurance companies and people send the money to health care providers is a technical detail that the press and opponents have blown up into a scare headline: "State budget would more than double!"
Remember, California’s (as in everyone in California's) budget for health care is already $370B. Whether electronic money flows through a state owned computer and therefore technically increases the state "budget," or the Feds, insurance companies and people send the money to health care providers is a technical detail that the press and opponents have blown up into a scare headline: "State budget would more than double!"
Ultimately, the money still goes to the health care providers. The path it takes is of pretty much no concern to those receiving health care, taxpayers or anyone else except the insurance companies who will no longer be able to extract their pound of flesh.
In meaningful terms the State budget will increase by the costs to administer the Healthy California program - a bunch of people will have to be hired by the state, and paid like other State employees. Administration is estimated to be about five percent of total spending, so we're talking about a some $17 billion "non-vacuous" increase in spending for the State of California.
PROSPECTS FOR PASSAGE
Q. Won't any financing require a 2/3rd majority in both houses of the legislature?
A. Yes. Any increase in taxes requires a supermajority, per the California Constitution. Democrats currently have 2/3rds majorities in both houses but were only able to obtain 23 votes out of the 27 Democrats in the Senate (with no Republican ayes) for SB 562. Since the financing mechanism was not yet in the bill, it only required a majority, 21, and it passed. The Assembly is considered more conservative than the Senate.
A. Yes. Any increase in taxes requires a supermajority, per the California Constitution. Democrats currently have 2/3rds majorities in both houses but were only able to obtain 23 votes out of the 27 Democrats in the Senate (with no Republican ayes) for SB 562. Since the financing mechanism was not yet in the bill, it only required a majority, 21, and it passed. The Assembly is considered more conservative than the Senate.
Q. So the legislation is doomed?
A. Who can say? Even if it were miraculously to pass both houses with a supermajority it might still face a veto from Governor Brown.
A. Who can say? Even if it were miraculously to pass both houses with a supermajority it might still face a veto from Governor Brown.
HOWEVER various analyses have concluded that some provisions of the legislation would require a constitutional amendment to overcome certain constitutional restrictions. In California a constitutional amendment can only be passed by the voters, but needs a simple majority. So if parts of the legislation require a vote on a supporting constitutional amendment anyway, the bill itself could be turned into a ballot initiative and voted on by the people at the same time - again, with only a majority vote to become law. That could happen in June of 2018 but more likely in November, 2018.
Therefore the legislation could theoretically be enacted without the legislature's or the Governor's support.
Another path would be fort enough signatures to be gathered to put it on the ballot — then go to the negotiating table with the Legislature and the Governor to have them pass and sign some form of the bill, avoiding the enormous effort a ballot initiative would entail. This was how California's eventual $15 statewide minimum wage came to be, and the recently renewed millionaire's tax.
Yet another more distant possibility is that after 2018 there will be a different Governor and possibly an even more progressive legislature. Lt. Governor Newsom has endorsed the idea of single payer for California, and he is probably the front-runner at the moment of those who have announced a run for Governor.
OBJECTIONS.
Q. Isn't this a government takeover of the health care system?
A. No. It's the replacement of the health care REIMBURSEMENT SYSTEM as it exists now (a bizarre combination of for-profit insurance companies, cash payments by individuals and government payments) with a single, government administered, reimbursement system.
A. No. It's the replacement of the health care REIMBURSEMENT SYSTEM as it exists now (a bizarre combination of for-profit insurance companies, cash payments by individuals and government payments) with a single, government administered, reimbursement system.
The health care system itself is not changed by this legislation, nor is it "taken over." True, the legislation allows Healthy California to regulate health care in various ways - but there is already regulation under the ACA and before the ACA there was a patchwork of Federal and State regulation of the industry.
In fact, the legislation provides for the reverse of a takeover. It specifically calls for medical decisions to be made by medical experts - your doctors - rather than by either health insurance company death panels or by government bureaucrats.
Q. Won't people come from other states and get free health care?
A. They can't just drive or fly in, get free health care and leave. They would have to become residents.
A. They can't just drive or fly in, get free health care and leave. They would have to become residents.
Q. Won't people move here from states where they would otherwise have to pay for expensive treatments or die?
A. It's possible. Neither the Sierras nor the Mojave Desert proved enough of a barrier to keep people out hundreds of years ago; the fruit inspection stations along I80, I15 and I10 probably won't be able to either (snark).
A. It's possible. Neither the Sierras nor the Mojave Desert proved enough of a barrier to keep people out hundreds of years ago; the fruit inspection stations along I80, I15 and I10 probably won't be able to either (snark).
Again, you would have to become a resident, which takes time. And money. People who can afford it might choose instead to do "medical tourism" to another country for a month or two instead of picking up stakes and literally moving.
It is interesting to note that a similar situation existed vis a vis Massachusetts, with Romneycare, before the ACA was passed. All the sick people and people with pre-existing conditions in the country could have decided to move to Massachusetts, get residency, and be covered via Medicaid or subsided insurance on their exchange. But that didn't happen.
The passage and implementation of single payer in California may prompt other states to do so as well, which would limit the problem.
In truth, we simply don't know for sure what will happen.
Q. Won't people go to the doctor for every little ache and pain?
A. There may be a few people who do this. If so, it seems like it is a reasonable tradeoff to have a few people get more care than they need than to have a bunch of people not get enough care. I don't know about you, but the last thing I want to do is go to a doctor or a dentist if I don't have to, have my blood drawn and/or have to pee in a cup. This simply does not appear to be a serious problem in any of the countries that have universal health care.
A. There may be a few people who do this. If so, it seems like it is a reasonable tradeoff to have a few people get more care than they need than to have a bunch of people not get enough care. I don't know about you, but the last thing I want to do is go to a doctor or a dentist if I don't have to, have my blood drawn and/or have to pee in a cup. This simply does not appear to be a serious problem in any of the countries that have universal health care.
Q. Won't doctors order unnecessary tests, have people come in 'for yuks' so they can bill for appointments, and prescribe unnecessary drugs?
A. That could happen. Remember, we do have proof of concept in Canada and Taiwan, and it doesn't seem to be a budget-killing problem in those countries. And as it stands right now doctors could (and some of them probably do!) order unnecessary tests, create unnecessary appointments and prescribe unnecessary drugs.
A. That could happen. Remember, we do have proof of concept in Canada and Taiwan, and it doesn't seem to be a budget-killing problem in those countries. And as it stands right now doctors could (and some of them probably do!) order unnecessary tests, create unnecessary appointments and prescribe unnecessary drugs.
Q. Won't costs explode?
A. We'll never know for sure until we try. They haven't in other countries. The legislation provides the Healthy California Board with sufficient oversight and regulatory authority to insure that this doesn't happen. Whether they will use that mandate appropriately only time can tell.
A. We'll never know for sure until we try. They haven't in other countries. The legislation provides the Healthy California Board with sufficient oversight and regulatory authority to insure that this doesn't happen. Whether they will use that mandate appropriately only time can tell.
The flip side of this question is that costs have already exploded. We pay far more per capita for health care than any other advanced country and it keeps going higher faster than the inflation rate. Are we going to keep doing the same thing over and over and expecting anything to change?
Q. Won't businesses object?
A. Maybe, but they shouldn't. The study shows that all businesses will save money - especially small businesses which now pick up part or all of their employees health costs.
A. Maybe, but they shouldn't. The study shows that all businesses will save money - especially small businesses which now pick up part or all of their employees health costs.
Q. Won't the Chamber of Commerce object?
A. Yes, they will (and already have). Fuck them.
A. Yes, they will (and already have). Fuck them.
Q. Won't the insurance companies object?
A. Yes, they certainly will (and already have). Fuck them and the horses they ride in on (keeping in mind we are against cruelty to animals, just in favor of rhetorical devices). Health insurance companies are by definition unethical and immoral - once you get sick, the best outcome for them is that you die, quickly. It’s better for all of us if they, instead, die quickly.
A. Yes, they certainly will (and already have). Fuck them and the horses they ride in on (keeping in mind we are against cruelty to animals, just in favor of rhetorical devices). Health insurance companies are by definition unethical and immoral - once you get sick, the best outcome for them is that you die, quickly. It’s better for all of us if they, instead, die quickly.
Q. Won't the drug companies object?
A. Yes, they certainly will. Fuck them and their $1000 a dose pills.
A. Yes, they certainly will. Fuck them and their $1000 a dose pills.
Q. What if drug companies refuse to sell to California?
A. They don't refuse to sell to Canada. They don't refuse to sell to Taiwan. They don't refuse to sell to the Veteran's Administration, which pays significantly reduced prices. they don't refuse to sell to other countries that regulate drug prices. Why would they refuse to sell to the world's 6th largest economy? And if they do, we can tell Google, Apple, Twitter and Facebook to cut off their access to Internet search and social media (snark).
A. They don't refuse to sell to Canada. They don't refuse to sell to Taiwan. They don't refuse to sell to the Veteran's Administration, which pays significantly reduced prices. they don't refuse to sell to other countries that regulate drug prices. Why would they refuse to sell to the world's 6th largest economy? And if they do, we can tell Google, Apple, Twitter and Facebook to cut off their access to Internet search and social media (snark).
Q. Won't people freak out when they hear you'll be raising the sales tax?
A. Assuming that a sales tax hike is written into the legislation, yes, yes they will. (This freaking out concept would apply to just about any proposed tax). It remains to be seen whether facts and math can convince people that a sales tax hike of 2.3% is a sensible way to pay for health care instead of what people are paying now.
A. Assuming that a sales tax hike is written into the legislation, yes, yes they will. (This freaking out concept would apply to just about any proposed tax). It remains to be seen whether facts and math can convince people that a sales tax hike of 2.3% is a sensible way to pay for health care instead of what people are paying now.
All we can do is try:
Let's say a household buys $20,000 in taxable goods a year (remember, rent or mortgage, which consumes a large part of post-tax income, groceries, movies, live entertainment and certain other things are not sales-taxable in California, so $20K is A LOT of taxable goods for the average family). That household would pay $460 in increased sales tax. For that they get completely free health care for the entire household. What an incredible deal.
Do the math. Only those with enormous incomes who also spend a lot on material goods are going to come out behind. Even if your household spends $200,000 on taxable goods in a year you still only pay $4600 for everyone's healthcare!
The proposal also sees to it that poor households will basically get back all that they have spent in sales tax, possibly even more, through a tax rebate.
Will people have enough common sense to see this and reject the hysterical anti-tax rhetoric we know will be thrown at the proposal?
ALTERNATIVE APPROACHES
Q. Why don't we just tax the rich to pay for the single-payer plan?
A. Revenue sources such as capital gains taxes are notoriously variable, so one reason not to rely solely on taxing the rich is to have a steadier funding stream.
A. Revenue sources such as capital gains taxes are notoriously variable, so one reason not to rely solely on taxing the rich is to have a steadier funding stream.
Also, California recieved about $12B in capital gains tax revenue in 2016. Even doubling the capital gains tax rate would therefore bring in at most another $12B.
Using a gross receipts tax that is paid mostly by big businesses does seem to be a pretty reasonable way to "tax the rich," albeit indirectly.
This all said, there is no obvious reason why the financing plan could not also contain various direct "tax the rich" methods such as progressive increases in taxes on capital gains, interest and income.
Q. Why don't we tax X more? Why don't we implement a new Y tax? (For all conceivable values of X and Y).
A. You have to do something, it can't be too complicated, and you don't want to do everything. Everyone has their favorite tax scheme. Mine is a carbon tax with rebates. Yours may be an increase in the millionaire's tax. Ultimately, someone has to pick some subset of possible taxes that will bring in enough revenue and run with it. It is unlikely that any particular scheme will be able to please even most of the people most of the time. The goal is not to argue for years over the "perfect" revenue producing scheme, it's to make sure that everyone gets the healthcare they need.
A. You have to do something, it can't be too complicated, and you don't want to do everything. Everyone has their favorite tax scheme. Mine is a carbon tax with rebates. Yours may be an increase in the millionaire's tax. Ultimately, someone has to pick some subset of possible taxes that will bring in enough revenue and run with it. It is unlikely that any particular scheme will be able to please even most of the people most of the time. The goal is not to argue for years over the "perfect" revenue producing scheme, it's to make sure that everyone gets the healthcare they need.
Q. Why aren't there any co-pays? Wouldn't that put a stop to the most frivolous abuses? Wouldn't it make the system cost less?
A. Co-pays are a severely regressive tax, especially on poor families with kids. And if you start exempting people, co-pays become an even larger administrative burden than they would be otherwise.
A. Co-pays are a severely regressive tax, especially on poor families with kids. And if you start exempting people, co-pays become an even larger administrative burden than they would be otherwise.
Again, better to put up with a bit of frivolous usage than have people unable to go to the doctor when they or their kids need to.
Copays would only gross the health care system a few billion dollars, not a significant percentage of what health care costs.
It's just not worth it, and they violate the principle that health care is a right.
Q. Why don't we just do a 'Medicare for All' model?
A. At some level it is already a lot like Medicare for All. Everyone is covered, and the government pays the bills. At another level, this is a lot better. No monthly payments, no confusion about Parts A, B C and/or D. No having to have supplementary coverage for the 20% Medicare doesn't pay for. No confusion about which drug plan to choose...
A. At some level it is already a lot like Medicare for All. Everyone is covered, and the government pays the bills. At another level, this is a lot better. No monthly payments, no confusion about Parts A, B C and/or D. No having to have supplementary coverage for the 20% Medicare doesn't pay for. No confusion about which drug plan to choose...
Q. Why don't we go with the Swiss [ German, Japanese, French, UK ... ] model?
A. If people proposed going with the Swiss model (private, highly regulated companies with everyone required by law to obtain policies for basic health insurance, no profits allowed on this basic insurance, low limits on deductibles and cost sharing, limits on premiums as a percent of income, and subsidies for the poor), or the Japanese model (similar to the Swiss, but with additional strict controls on medical fees), or the French model (single-payer-ish, with a single insuring entity covering 84% of the population, along with co-pays and complicated reimbursement rules) other people would ask why we weren't going with the Canadian model.
A. If people proposed going with the Swiss model (private, highly regulated companies with everyone required by law to obtain policies for basic health insurance, no profits allowed on this basic insurance, low limits on deductibles and cost sharing, limits on premiums as a percent of income, and subsidies for the poor), or the Japanese model (similar to the Swiss, but with additional strict controls on medical fees), or the French model (single-payer-ish, with a single insuring entity covering 84% of the population, along with co-pays and complicated reimbursement rules) other people would ask why we weren't going with the Canadian model.
Every other advanced country has some sort of universal health care system that doesn't let private, for-profit health insurance and pharmacutical companies run amok. These systems run the gamut from an actual takeover of the health industry (the NHS, in the UK) to the Swiss and German models, which still allow insurance companies to exist but keep them under control.
No one is saying that the proposed SB 562 single-payer system is a perfect system. But it's pretty clear that a) no one knows what THE perfect system is, and b) our current system seems to be worse than any we could choose from.
Again, you have to pick some way. At some point the parameters have to be chosen. We know single-payer works (as do other mechanisms for universal care), and there's no point spending decades debating the perfect system and parameters while people continue to get screwed and the country reverts to a system with even less care.
LOGISTICAL ISSUES
Q. Won't it take a long time to see a doctor?
A. This has not been the experience in other countries; in fact it is just the opposite in serious and emergency situations. For certain things, like elective surgery, it may indeed take longer as has been reported in other countries. But that's a small price to pay to have your cancer treatment start the day after you are diagnosed instead of waiting two months to have the treatment approved by an insurance company.
A. This has not been the experience in other countries; in fact it is just the opposite in serious and emergency situations. For certain things, like elective surgery, it may indeed take longer as has been reported in other countries. But that's a small price to pay to have your cancer treatment start the day after you are diagnosed instead of waiting two months to have the treatment approved by an insurance company.
The time it takes to see a doctor depends on how many doctors there are, as well as how many people want to see one. The supply of doctors is not easily changed in this country, and the legislation does not address this issue except in a very general way. It's certainly something that should be addressed, and should be addressed on a national level.
Q. What about all the people employed by insurance companies?
A. Some of them will quickly find work in similar jobs elsewhere, or with the Healthy California administration. The legislation provides for job training benefits and assurances that people will be given assistance over the years of transition. (A comforting twist is that we know they won't have a financial problem just because they get sick if they are still unemployed!)
A. Some of them will quickly find work in similar jobs elsewhere, or with the Healthy California administration. The legislation provides for job training benefits and assurances that people will be given assistance over the years of transition. (A comforting twist is that we know they won't have a financial problem just because they get sick if they are still unemployed!)
Q. What about extending the single payer system in California to other likeminded states like Oregon?
A. In principle it makes perfect sense. In practice, the logistics of getting it to work in just one state will be challenging enough - trying to negotiate an interstate compact before getting it up and running first in California is probably unrealistic.
A. In principle it makes perfect sense. In practice, the logistics of getting it to work in just one state will be challenging enough - trying to negotiate an interstate compact before getting it up and running first in California is probably unrealistic.
Also, my understanding is that any such interstate pact would have to be approved by Congress. This could be a stumbling block.
Q. What if you, as a Californian, travel to another state?
A. The legislation provides for the Healthy California administration to work the details out in those cases. But since health facilities in other jurisdictions will know that you have insurance and know they will get paid you should be treated almost like royalty...
A. The legislation provides for the Healthy California administration to work the details out in those cases. But since health facilities in other jurisdictions will know that you have insurance and know they will get paid you should be treated almost like royalty...
Q. If I'm already on Medicare, what happens to me?
A. You'll get a Healthy California card and you'll continue to get health care as you do now. You'll just stop paying monthly Medicare premiums, co-insurance, and any other fees.
A. You'll get a Healthy California card and you'll continue to get health care as you do now. You'll just stop paying monthly Medicare premiums, co-insurance, and any other fees.
Q. If I'm not a Californian but am visiting and need medical care, how will that work?
A. The legislation does not specify that. The Healthy California Board will have the authority to create regulations and procedures to deal with these matters.
A. The legislation does not specify that. The Healthy California Board will have the authority to create regulations and procedures to deal with these matters.
Q. What about workman's compensation?
A. The legislation gives the newly established Healthy California Board two years to come out with a plan to incorporate WC into single payer. For the nonce, it will apparently continue as is. The simple solution would be "do it like they do it in Canada" which still operates a Workman's Compensation system but where
A. The legislation gives the newly established Healthy California Board two years to come out with a plan to incorporate WC into single payer. For the nonce, it will apparently continue as is. The simple solution would be "do it like they do it in Canada" which still operates a Workman's Compensation system but where
...medical benefits are not the primary driver of workers' compensation costs. Canada's loss of earnings benefits/wage loss benefits are the primary driver of costs due to the publically funded nature of the healthcare system.
so it looks like they’ve make Workman’s Compensation work alongside and with their single-payer system while still continuing to exist as a separate entity.
Q. Kaiser says they would be destroyed if SB 562 were to become law. Is that true?
A. Kaiser is an "integrated health care delivery system" as well as being an insurance entity. The legislation provides for integrated health care systems such as Kaiser. Kaiser would have to stop being an insurance company, of course, but all their doctors, hospitals and impressive, computerized, integrated health systems would remain.
A. Kaiser is an "integrated health care delivery system" as well as being an insurance entity. The legislation provides for integrated health care systems such as Kaiser. Kaiser would have to stop being an insurance company, of course, but all their doctors, hospitals and impressive, computerized, integrated health systems would remain.
It's not clear why they think they could not operate in the new environment. One reason might be that they would lose customers because people would prefer the freedom to choose any provider instead of just Kaiser employees. A counterargument is that patients which Kaiser does not currently accept, such as some people who qualify for MediCal in some counties such as Alameda, could enroll in Kaiser.
If Kaiser can actually provide good healthcare cheaper than average, and they are being paid the average by Healthy California, then maybe Kaiser should give people a "signup bonus" to become or stay on as a member.
Since Kaiser serves a large portion of California's population, it's clear that whatever happens, Kaiser will not be allowed to just vanish.
MISCELLANEOUS
Q. They say single payer has already failed in Vermont and Colorado, so it makes no sense to try it in California. Is this true?
A. It's false. Single-payer has never actually been implemented in any state. Vermont passed legislation that would have implemented it, but then they got cold feet. Colorado had a ballot initiative which, if it had passed, would have implemented a rather odd variant of single-payer, quite different from this proposal. But it did not pass.
A. It's false. Single-payer has never actually been implemented in any state. Vermont passed legislation that would have implemented it, but then they got cold feet. Colorado had a ballot initiative which, if it had passed, would have implemented a rather odd variant of single-payer, quite different from this proposal. But it did not pass.
Vermont's size, economic situation and demographics are radically different than California. The funding proposal to pay for the Vermont legislation, a payroll tax, was very different than the proposed funding mechanism for California. Claiming a system that was never implemented and had a much less sensible funding mechanism as proof that a similar system won't work in California is a bogus argument.
Q. Some say price controls are the only way to save money and stop the rise in costs. Why doesn't SB 562 insist on price controls?
A. Some other countries have price controls; some don't. SB 562 provides for mandated negotiations that result in "fair and reasonable" prices for medical services and for drug supplies.
A. Some other countries have price controls; some don't. SB 562 provides for mandated negotiations that result in "fair and reasonable" prices for medical services and for drug supplies.
Q. If people no longer went bankrupt as a result of medical problems wouldn't that be a boon for California's economy? Has that been factored in to the calculations?
A. It would be a boon. To the best of my knowledge, it hasn't been factored in.
A. It would be a boon. To the best of my knowledge, it hasn't been factored in.
Q. If Californians saved $40B a year in health care costs, who's going to make out?
A. Mainly people who are now paying their own premiums - self-employed middle class types, for example, and small businesses who are now paying premiums for their employees.
A. Mainly people who are now paying their own premiums - self-employed middle class types, for example, and small businesses who are now paying premiums for their employees.
Q. Seems like that would be also boost California’s economy, encouraging people to start their own businesses and allow small companies to hire new employees?
A. Seems that way. I’m not aware of any analysis along those lines.
A. Seems that way. I’m not aware of any analysis along those lines.
Q. How will California’s homeless become eligible if they don’t have any residence?
A. California’s homeless population is generally eligible for MediCal, the state’s Medicaid program, and Healthy California will use similar means of determining residency. California also makes it easy for homeless people to register to vote, another way of establishing residency.
A. California’s homeless population is generally eligible for MediCal, the state’s Medicaid program, and Healthy California will use similar means of determining residency. California also makes it easy for homeless people to register to vote, another way of establishing residency.
Q. Won't this make California a Socialist paradise? And isn't that bad?
A. Hmmm.
A. Hmmm.
Q. What about medical marijuana?
A. The legislation doesn't address that. Even if medical marijuana were found to be appropriate to be prescribed by doctors in California under the Healthy California system there would still be the issue of federal funds being used to pay for it.
A. The legislation doesn't address that. Even if medical marijuana were found to be appropriate to be prescribed by doctors in California under the Healthy California system there would still be the issue of federal funds being used to pay for it.
That’s all folks! That covers a whole lot of the questions people have asked about SB 562 in diaries I’ve published previously, such as the ones below.
People with Medicare still forced to go without critical uncovered care
by Diane Archer - Just Care - June 7, 2017
We need to expand Medicare so that it covers all essential medical costs. Today, people with Medicare typically spend $4,000 a year out-of-pocket on health care costs. While the Medicare premiums and cost-sharing are their biggest expense, according to a May 2017 Commonwealth Fund issue brief, long-term care, prescription drugs and dental care, which Medicare do not cover, take a big toll on their pocketbooks. As a result, people with limited incomes and people with costly health care needs. often are forced to go without critical uncovered care, which tends to be unaffordable.
- For the general Medicare population, long-term care represents more than a quarter (28 percent) of out-of-pocket spending and prescription drugs represent another quarter (25 percent) of their spending. Dental care represents 11 percent. Seven out of 10 older people will eventually need long-term care services and supports.
- For people with Medicare living in the community, not in a nursing home, long-term care represents 8 percent of total out-of-pocket health care spending. Prescription drug costs represent a third (33 percent) of out-of-pocket costs. Dental care represents 14 percent.
- People with several chronic diseases or severe cognitive or physical conditions typically spend more than three times more out of pocket than people in good health, $5,519 vs. $1,549.
The Commonwealth Fund issue brief does not take into consideration the hundreds of billions of dollars in Medicaid cuts in President Trump’s and the GOP’s proposed budgets. More than 11 million people with Medicare depend on Medicaid to help pay for premiums and health care services that Medicare does not cover. If these cuts are enacted, out-of-pocket costs will rise dramatically for these “dual-eligibles” and many of them will likely have no choice but to go without necessary care.
The GOP’s Obamacare sabotage continues
Editorial Board - The Washington Post - June 10, 2017
ANOTHER WEEK, another insurance company deserting patients in a wide swath of the country. Last Tuesday, Anthem announced it would pull out of the Obamacare marketplace in Ohio, potentially leaving individual insurance-buyers in about a fifth of the state’s counties without Affordable Care Act coverage to purchase. The news came after insurers in various other states announced or threatened market exits or big rate hikes over the past several weeks.
Are these moves more evidence that Obamacare is fundamentally unworkable? Hardly. Of greedy insurance companies callously disregarding their customers’ health? Not that either. Anthem explained clearly what is responsible for its retreat: Republican sabotage of the health-care system.
The Trump administration has been serially unclear about whether it will keep funding a crucial subsidy program, known as cost-sharing reductions . Without them, insurers would have to jack up premiums to cover their costs or leave markets that would become deeply unprofitable to them. Just as experts and industry officials predicted, insurance companies have done both as the uncertainty about these subsidies has grown.
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Key Republicans understand the damage they are doing. “Insurers have made clear the lack of certainty is causing 2018 proposed premiums to rise significantly,” House Ways and Means Committee Chairman Kevin Brady (R-Tex.) said Thursday, arguing that Congress should step in. As the administration still appears determined to stoke uncertainty, lawmakers would have to move quickly to prevent more damage.
The question of cost-sharing reductions is only the biggest of many fears the Trump administration is inspiring. The president’s maladministration could include lax enforcement of the individual mandate to purchase health insurance, inadequate efforts to enroll more people in coverage and other gratuitous subversions of the finely tuned system Obamacare sought to create.
The GOP, however, still seems more motivated to solve a problem that does not exist — saving a health-care system supposedly on the path to inevitable collapse by repealing and replacing Obamacare. Senate Majority Leader Mitch McConnell (R-Ky.) is reportedly determined to vote soon on an Obamacare repeal-and-replace bill, getting the issue off the agenda ahead of the summer. The senators piecing together the language appear to be moderating the bill the House passed last month, and they could have a draft soon as they work toward a vote in coming weeks.
It is good news that senators may make their bill more centrist rather than, as the House did, more austere in order to pass it. But repeal-and-replace is unnecessary and, even in a more moderate form, risks doing great harm. Rolling back Medicaid, no matter when it is done, could result in many near-poor people losing coverage. Skimping on subsidies that help people buy insurance and loosening certain coverage regulations could hike deductibles and price poorer and older people out of the market.
Meanwhile, if the Senate fails to pass a bill but the GOP’s Obamacare sabotage continues, the health-care system would develop large coverage holes and face the risk of enrollment declines after years of progress expanding coverage.
Polls show Americans would prefer that the existing system be fixed.
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