Medicare for None: A Response to the State-Based Universal Health Care Act of 2021
Proponents of a state-based universal healthcare approach believe states can be incubators for change, and that ultimately, once one state shows the way, all states will follow—but we have yet to see any evidence of this.
by Anna Malinow and Kay Tillow - Common Dreams - May 17, 2021
The Covid-19 pandemic has laid bare the inequities, inefficiencies, and ineffectiveness of our healthcare system. If there was ever a time for healthcare reform, this is it. But some healthcare activists and their progressive allies, suffering from the frustration and disillusion brought on by the refusal of President Joe Biden and Congress to consider structural reform, have accepted this defeat and turned to state-based reform, jeopardizing Medicare across the country. Healthcare is a national responsibility. To palm it off to states is a step backwards: the dream of Newt Gingrich and Ronald Reagan to shrink the federal government.
The U.S. doesn't need to dismantle Medicare, it needs to improve it and expand it to every person.
Based on the historical precedents set by the Affordable Care Act (ACA), the story of Medicaid expansion serves as a cautionary tale to those who’d like to leave healthcare to the states.
On June 28, 2012, the U.S. Supreme Court issued a ruling on the constitutionality of the Affordable Care Act, Congress's attempt to provide near-universal health coverage by mandating individuals and employers to purchase health insurance, expanding Medicaid by lowering eligibility criteria, and widening health insurance protections. The court upheld the constitutionality of the individual mandate but gave states the "option" not to expand Medicaid, calling expansion "unconstitutionally coercive." With this ruling, the Supreme Court opened the door to the balkanization of the ACA: those that expanded Medicaid, those that considered it, and those that would oppose it permanently. It gave the southern states a political out and allowed the further racialization of Medicaid.
Of the original 26 states that brought the case before the Supreme Court, 12, mostly southern states with large populations of color, have not expanded Medicaid, two have passed but not yet implemented expansion, and three only did so last year. A decade after the passage of the bill, these are the states that suffer the worst health outcomes: when compared to expansion states, non-expansion states have seen worse overall mortality rates, more hospital closures, and even higher high school dropout rates. In 2018, states that did not expand Medicaid passed up $43 billion in federal funds.
With the reintroduction of Congressman Ro Khanna’s State-based Universal Health Care Act of 2021, we are about to see a similar balkanization of Medicare, the one national program that guarantees healthcare to everyone over the age of 65. The act, which would offer pass-through federal fund waivers, including Medicare, Medicaid, TriCare, Exchange, and federal employee health benefit dollars, to states with a plan to provide comprehensive health benefits to 95% of its residents (defined as citizens or lawfully residing immigrants) within five years, would end Medicare as we know it.
Obtaining a waiver under this act does not set single payer as the model to achieve universal healthcare. In fact, states might choose to go the way of the ACA, a mishmash of employer and individual mandates, greater expansion of Medicaid, and more generous subsidies for the Exchanges. The act would base benefits on the ACA, thus, significant gaps, such as no prescription drug coverage, limited reproductive rights, and no long-term care, would persist. There is nothing in the act that precludes giving Medicare money to private insurance companies, strengthening profit-driven companies to pursue obscene profits and deny care elsewhere. The U.S. would become a nation of 50 different healthcare tiers, at war with each other over federal dollars. States could band into a region to request a waiver application, pitting regions against one another. States unwilling to cover their residents could sit it out, much like the states sitting out Medicaid expansion, creating yet another form of racism and uneven health outcomes. If challenged in court, this new expansion could be ruled "coercive" again, giving some states a political out. But this time, seniors in non-universal states would see their Medicare dollars shunted over to states that provide their residents some form of healthcare. This is the dismantling of Medicare.
Proponents of a state-based universal healthcare approach believe states can be incubators for change, and that ultimately, once one state shows the way, all states will follow. We have yet to see any evidence of this in the U.S., and to bet Medicare on this flawed proposal seems unwise. The Supreme Court ruling set a precedent that states can use federal healthcare dollars as they see fit. Instead of seeing this as the problem, the sponsors of this bill see it as an opportunity to compromise: allow southern states to gut Medicare while allowing more progressive states to "have" universal healthcare.
The U.S. doesn't need to dismantle Medicare, it needs to improve it and expand it to every person. The country must replace its broken, fragmented, profit-driven and racist system with a universal, affordable, accountable, comprehensive, evidence-based, equitable, single-payer national Medicare for all, not Medicare for none. Every resident of every state deserves this. This is something on which we can all agree.
Let's Go All Out for Universal Health Care in the US
We have to persuade not only the public, but also legislators, that
enacting a huge tax increase to fund health care is a good idea.
We should continue to vigorously advocate for a universal publicly funded privately delivered health care system at every level throughout America—state as well as national.
The article by Ana Manilow and Kay Tillow, published in Common Dreams on May 29, 2021, sounds a cautionary note about attempts to create state-based universal health care systems, because they will certainly increase the amount of fragmentation in the Medicare program. They are almost certainly right, and more fragmentation is the last thing we need in our already too fragmented "system." I know both Malinow and Tillow, and have utmost respect for their experience and judgment.
There is no doubt that a uniform national program of Improved Medicare for All would be the best way to go, on the grounds of simplicity, efficiency, effectiveness and political sustainability. But so far I see no evidence that the Congress, as it is now constituted, has any appetite to enact anything close to Improved Medicare for All on a national scale anytime soon.
We have to persuade not only the public, but also legislators, that enacting a huge tax increase to fund health care is a good idea.
There are ongoing efforts in over twenty states to enact universal health care. Only one state, Vermont, has made a serious attempt to implement a universal health care system.
That attempt failed. Its failure was not due to economic, technical or statutory barriers, but almost entirely due to politics. Peter Shumlin, the Governor of Vermont at the time of the attempts to enact universal healthcare system there, failed to adequately inoculate Vermont voters against the shock of transferring millions of dollars of private sector spending into taxes, as would have been required by full implementation of Green Mountain Care.
Shumlin, who barely won re-election for a second term, consequently throwing his re-election into the legislature, lost his nerve in the face of the prospects of the need to ask the legislature, that was poised to vote on his own election—for a substantial tax increase to fund Green Mountain Care despite the likely savings in overall health care spending that would have resulted if the program had been implemented.
The aversion to taxes and the resultant large government that is baked into American culture, (dating back to colonial times (Thomas Paine labeled government "a necessary evil") is a major impediment to enactment of a universal health care program in the United States. It is one that proponents of universal health care, whether in the form of a state-wide or a national program, must overcome.
We have to persuade not only the public, but also legislators, that enacting a huge tax increase to fund health care is a good idea. I believe that as our healthcare system becomes increasingly dysfunctional—and increasingly expensive, voters will become increasingly willing to accept that reality. We UHC advocates must become much more effective at making the case that taxes, not private premiums and out-of-pocket payments, are the only just, merciful, and fair way to fund health care. They are likely the only way to achieve universal coverage. The U.S.is the last of the wealthy Democracies to accept this reality.
We must also be more effective about explaining the virtues of everybody being in the same program (one size does fit all), and of a simpler, more transparent health care system with public accountability and the ability to control overall system-wide costs in a less intrusive way than the current system. As the current pandemic has demonstrated, we must also have a system that encourages policy-based investments in public health, whether in a national or state-based system—that only public funding can achieve. If there is any silver-lining in the Covid-19 pandemic, it is that has exposed the need for more investment in public health, which is undeniably a public good.
We must continue our intense focus on defending against the lies we know are coming from the opponents of major systemic changes, even as we continue our campaign to win over the public for the idea of a publicly funded, universal health care system.
But at the same time, we must go on offense by focusing more on the benefits of such a systemic change for the vast majority of Americans. We all agree that a Universal federally funded and managed health care system is the best way to making health care as a right a reality in the US.
This is a classic example of the perfect being the enemy of the good. The paramount question is not whether we can achieve that perfect result, but how to get there from here, given the clash of interests in our current dysfunctional health care system
Unfortunately, the current power of the medical-industrial complex in Congress is such that federal legislators must pay "tribute" to the the large health care corporations (just like the Mafia) that increasingly control the American healthcare system. The ACA is the prime example of one of the outcomes of this reality.
As an advocate for the past ten years of a state-wide program of publicly funded privately delivered universal health care in Maine, I can attest to the power of that idea to the public, if they believe it is achievable.
In reaction to the suggestion of a national solution to the problem's of our healthcare system, people often roll their eyes. They don't believe it's achievable, because they don't believe they have the power to overcome the political barriers that prevent that outcome. But when they hear about the possibility of a state-level solution, they pay attention and become activists in trying to make it happen—because they believe they may make a difference at a state-level.
Just last month, over 70 Maine voters turned out to testify at a legislative hearing in support of universal healthcare bills that have been submitted to the legislature this session. The committee of jurisdiction of one of the bills (Maine LD 1045), not quite ready to vote to pass the bill due to concern that the state would lose some of its federal healthcare funds, carried the bill forward (didn't kill it), and agreed to support it in the future on the condition that Ro Khanna's State Based Universal Health Care bill (H.R. 5010), or something like it, was passed by Congress. They plan to introduce a joint-resolution to the full legislature later this year, asking Maine's Congressional Delegation to support Representative Khanna's bill.
That would likely would not have happened if Maine AllCare, the state-level universal health care advocacy group I helped establish in 2010, had not been conducting educational programs for the public explaining the benefits of universal health care and organizing for support of a state-based plan. In addition, we developed the language of and are advocating for the passage of a Resolve that we hope to put on the 2022 ballot expressing public support for a publicly funded, privately delivered universal health care plan in Maine.
We believe such a program would not only be a step towards towards Medicare for All, but may be the only way to achieve such a program in the foreseeable future.
I share the concerns of Manilow and Tillow. I wish it was not so difficult to do the right thing in the U.S. I wish our country did not suffer from the systemic racism that has contributed so much to the difficulties they point out in their essay, and wish the American public had not been so susceptible to the anti-government propaganda from the right wing we have endured for the past 45 years. I wish we had not experienced the massive takeover of our health care system by profit-driven multi-national corporations. I wish the political class and some members of The Supreme Court didn't think corporations are equivalent to people and money is equivalent to speech. But that is the reality we are living in, and we have to find a way around it.
The idea of state-level universal health care, despite its shortcomings, is a powerful and compelling tool for education and for organizing the power of the people that will be absolutely necessary to overcome the power of the medical-industrial complex.
People, at least here in Maine, respond differently to initiatives that are seen as local as opposed to national and near as opposed to distant, because they feel there's a better chance they, as individual voters, can have a positive impact on the outcome.
Mobilizing the power of the people is the best shot we have to halt the destruction of our patient-focused healthcare system, and to preserve Medicine as a self-regulating profession governed by the Hippocratic Oath, rather than the pursuit of maximum profitability,
We should continue to vigorously advocate for a universal publicly funded privately delivered health care system at every level throughout America—state as well as national. That may be the only way to effectively reach and motivate enough of the American public to finally achieve our common goals as a nation—health care as a right for every resident of the U.S.—a goal that is already a reality in most wealthy, industrialized democratic societies, but remains only an aspirational vision in our own. Let's use every tool at our disposal to turn that aspiration into a reality.
https://www.commondreams.org/views/2021/06/03/lets-go-all-out-universal-health-care-us
Letter to the Editor - Ellsworth American - May 27, 2021
Dear Editor: The pandemic has laid bare the harsh realities of our current for-profit health care system. Besides my own personal and professional story battling this impersonal, complex and expensive system, I was further compelled to work on the issue of health care when the pandemic exposed the many failures of our current system of accessing and providing health care in our country. Although health care policy is set at the national and state level, local governments must often deal with the consequences of an unaffordable and inequitable health insurance system. The skyrocketing costs of insurance premiums for municipal employees are straining local government budgets.
Now many towns are adopting resolutions calling for the state Legislature to design and implement a health care plan that will cover every Maine resident with medical care. This effort has been pioneered by Maine AllCare, an organization that promotes the establishment of a publicly funded health care system (https://maineallcare.org). In my own town of Trenton, instead of being voted on by the town selectmen, a resolution was presented for a vote at the Town Meeting on May 17, and a large majority of Trenton residents voted to support the creation of an equitable health care plan for all Maine residents. It is time for a change that will benefit all the residents of Maine and without risking personal bankruptcy. We can do better and must! And thankfully the citizens of Trenton recognize this.
Starr C. Gilmartin Trenton
https://ellsworthamerican-me-app.newsmemory.com/?publink=20b2154f7
Can the Rich Pay for a Better America?
The budget proposal released by the Biden administration last week calls for almost $5 trillion in new spending over the next decade — that is, outlays in excess of its “baseline” estimate of the spending that would take place without new policies. Some of the extra money would be borrowed, but most of it — $3.6 trillion — is supposed to come from new revenues.
President Biden has, however, repeatedly promised not to increase taxes on households making less than $400,000 a year. And his budget does indeed propose raising all the additional money via higher receipts from corporations and high-income individuals.
It’s worth noting, by the way, that the two proposals that have attracted the most attention — raising the corporate tax rate, which Donald Trump cut from 35 to 21 percent, up to 28 percent, and raising the top individual rate back to 39.6 percent — account for only a fraction of the proposed revenue increase (just over a quarter). Most of the money is supposed to come from closing loopholes and eliminating perceived inequities — things like giving the I.R.S. the resources to crack down on wealthy tax cheats, eliminating rules that allow many capital gains to go completely untaxed and closing off some of the major avenues for corporate tax avoidance.
Still, is trying to “build back better” by taxing only the very affluent feasible? Is it wise? Could it be done more effectively?
My answer is yes to the first two questions, if you assume — as I think we should — that given the political realities Biden needs to keep his ambitions fairly modest. The answer to the third is, it’s complicated.
There are, as I see it, three main critiques of Biden’s tax approach, two of which deserve to be taken seriously.
The unserious critique is the claim that raising taxes on corporations and high incomes would cripple the economy. Assertions that prosperity depends on keeping taxes at the top low have been refuted by experience time and time again — most recently in the failure of the Trump tax cuts to deliver the promised immense investment boom.
The only reason the obsession with low taxes for the rich retains any influence is that keeping this zombie shambling around serves the interests of corporations and the wealthy. So let’s not waste time on it.
A far more serious critique of Biden’s approach comes from the left. There’s a good case that the kind of society progressives want us to become, with a very strong social safety net, can’t be paid for just by taxing the rich. A country like Denmark, for example, does have a high top tax rate (although it’s not that much higher than the effective tax rate facing high-income New Yorkers, who pay state and city as well as federal taxes). But Denmark also has very high middle-class taxation, in particular a 25 percent value-added tax, effectively a national sales tax.
And the fact that even the Nordic countries feel compelled to raise a lot of money from the middle class suggests that there are limits — much higher than conservatives claim, but limits nonetheless — to how much you can raise just by taxing the rich.
So if you want Medicare for all, Nordic levels of support for child care and families in general, and so on, just raising taxes on the 400K-plus elite won’t get you there. And many progressives — myself included — would like us to have these things.
It would, however, be incredibly risky politically to try selling members of the U.S. middle class on the idea that paying substantially higher taxes would be worth it because of all the benefits they would receive.
Would you advise Biden to take that risk — especially at a time when democracy itself is under attack? Surely it makes sense to pursue a more modest agenda, one that would still make a huge difference to American lives but that could be financed by raising taxes only on corporations and the wealthy.
But what form should those tax increases take? There are many interesting, smart ideas out there — for example, Elizabeth Warren’s proposed wealth tax — that didn’t make it into the Biden plan. There have also been technical critiques of the details of Biden proposals — and tax policy is an area where details really matter.
Oh, and it’s likely that one way or another revenues would fall short of what the Biden administration is projecting, and that as a result deficits would be larger. Given that the U.S. government can borrow at negative real interest rates, however, this isn’t a big concern.
So what is Biden doing wrong? Honestly, I can’t tell. I like to think that I know a fair bit of economics and can recognize the difference between real experts and hacks. But tax policy is really hard — partly because you’re trying to make rules that can withstand assaults from very well paid accountants — and there are seriously credible experts on both sides of the detailed tax debates. Some of my go-to tax experts are now in the administration!
What this means, I suspect, is that while some of the critiques may well be correct, Biden’s proposals are appropriate in their general thrust and probably don’t have huge flaws in their details. My biggest concern isn’t that he’ll botch important issues, it is that Democrats in Congress — some of whom are still far too deferential to moneyed interests — will water down the things he’s trying to do right.
https://www.nytimes.com/2021/06/03/opinion/biden-taxation-rich.html?referringSource=articleShare
Using Email And Letters To Reduce Choice Errors Among ACA Marketplace Enrollees
by Andrew Feher and Isaac Menashe
Abstract
During the 2019 open enrollment period in California’s Affordable Care Act (ACA) Marketplace, we used a randomized intervention to examine the effects of email and postal messages on choice errors, where low-income households enroll in gold or platinum plans although they are eligible for cost-sharing reduction (CSR) silver plans with lower premiums and higher actuarial values. Relative to the control group, assignment to the email-only treatment increased plan switching to CSR silver plans by 2 percentage points (an 11 percent increase), and assignment to the mail-plus-email treatment increased plan switching to CSR silver plans by 3.9 percentage points (a 22 percent increase). The mail-plus-email treatment significantly increased plan switching across all subpopulations in which choice errors were made. Consumers who switched out of a plan chosen in error saved an average of $84 per month in premiums and $56 per month in reduced out-of-pocket expenses. Our results indicate that low-cost nudges can help low-income enrollees obtain more generous coverage at a lower price and that the combination of email and postal messages is more effective at increasing plan switching than email alone to rectify choice errors.
https://www.healthaffairs.org/doi/10.1377/hlthaff.2020.02099
Editor's Note -
Of course with a Medicare-for-All system, "choice errors" would be reduced to zero!
- SPC
The Potter Report
Death & Debt by Deductibles
by Wendell Potter - The Potter Report - May 28, 2021
Congrats, America! Earlier this month you passed an annual milestone: Two days after Tax Day, you made it to... Deductible Relief Day!
What's that? It’s the day where the average person with employer-based health insurance has spent enough on health expenses to finally meet their deductible.
Health insurance deductibles have been rising so rapidly (year after year after year) that the Kaiser Family Foundation decided to track the trend to show how severely Americans are getting ripped off (and sick). And it’s bad.
As you might guess, the Deductible Relief Day is being pushed further each year. In 2005, you had to wait until February 28. By 2009, you wouldn’t be popping champagne until March 18. In 2019, you waited two months more than that.
As the Kaiser Family Foundation noted, in 2009, the average deductible was $533 for a single person. In 2018, it was $1350. How? The insurance industry strategy of moving all of us into high-deductible plans (one of the many gross abuses I saw first-hand at Cigna) has paid off well for my former employers.
In 2018, about 85% of covered workers were enrolled in a high-deductible plan, up from just 50% ten years earlier. Another way of looking at this: Average enrollee spending on deductibles more than tripled between 2007 and 2017.
And Kaiser didn't look at people who buy their coverage on their own through the ACA exchanges. They're in even *worse* shape. The Commonwealth Fundfound that 40% of people in ACA plans are underinsured because of high out-of-pocket charges – and many likely never meet their deductibles.
As a result, millions of Americans are not going to the doctor or picking up prescriptions. Insurers LOVE that. It's far fewer claims to pay! It’s why, when many other businesses went belly up during COVID-19, insurers made record profits: medical treatment was less accessible!
President Biden, are you paying attention to this? You must.
Millions of people WITH insurance who voted for you, including folks on Obamacare, CAN’T USE IT because of deductibles! Insurers can charge families up to $7,200 before they’ll pay a dime. It keeps going up. Every. Single. Year.
No wonder more and more Americans with insurance are turning to GoFundMe or bankruptcy court. It’s not just the premiums you gotta worry about, Joe. Deductibles are eating us alive. You and Congress need to pay attention before NO Americans can meet their deductibles.
A $10,322 Tab For A Sleep Apnea Study Is Enough To Wreck One Patient's Rest
by Michelle Andrews - Kaiser Health News - May 27, 2021
José Mendoza's snoring was bad — but the silence when he stopped breathing was even worse for his wife, Nancy. The sudden quiet would wake her and she waited anxiously for him to take another breath. If too many seconds ticked by, she pushed him hard so that he moved and started breathing again. This happened several times a week.
Diagnosed with severe sleep apnea 15 years ago, Mendoza was prescribed a continuous positive airway pressure, or CPAP, device to help him breathe easier. But the machine was noisy and uncomfortable. After a month, he stopped using it.
Late in 2019, Mendoza, 61, went to an emergency department near the family's Miami home with an excruciating headache. He thought it was related to his high blood pressure, a condition sometimes linked to obstructive sleep apnea. But after a battery of tests, clinicians concluded his obstructive sleep apnea itself was likely causing his headache and cardiac problems. He needed a new CPAP machine, they said.
But first, he had an at-home sleep test. Mendoza's pulmonologist said it was not detailed enough and ordered a visit to an overnight sleep lab to get extensive data.
Mendoza arrived at the sleep center at about 8 p.m. one night in early February and was shown into a spacious room with a sofa, a TV and a bed. After he got into his pajamas, a technician attached electrodes to his head and chest to track his brain, heart, lung and muscle activity while he slept. The technician fitted him with a CPAP with two small cannulas for his nose. Despite the unfamiliar setting and awkward equipment, Mendoza slept that night.
After the study, Mendoza started using the same, more comfortable CPAP model he'd used during the study.
"Now I'm not snoring. I feel more energetic. I'm not as tired as I was before," he says.
The new CPAP was helping both Mendozas get a better night's sleep — until the bill came.
The Patient: José Mendoza, 61, has a Humana HMO plan through the construction company where he works as a truck driver. It has a $5,000 deductible and an out-of-pocket maximum of $6,500 for covered care by in-network providers. Once his deductible is satisfied, he owes 50% in coinsurance for other billed charges. (Nancy Mendoza, who works as a social worker, and their two teenage children are covered under her employer plan.)
Medical Service: An overnight sleep study at a hospital sleep center to determine the type of mask and the proper levels of airflow and oxygen needed in Mendoza's CPAP to treat his severe obstructive sleep apnea.
Total Bill: $10,322, including a $9,853 outpatient charge for the sleep study and a $469 charge for the sleep specialist who interpreted the results. Humana's negotiated rate for the total was $5,419. Mendoza owed the bulk of that: $5,157, including $262 in coinsurance and $4,895 to satisfy his deductible. Humana also paid $262.
Service Provider: University of Miami Health System's sleep medicine facility at Bascom Palmer Eye Institute in Miami
What Gives: Sleep studies are somewhat controversial and have been flagged in the past as being overused. Not everyone who snores needs this evaluation. But with Mendoza's pauses in breathing and hypertension, he likely did.
According to Dr. Vikas Saini, president of the Lown Institute, a think tank that analyzes low-value health care, sleep studies fall into a gray zone.
"They are incredibly useful and necessary in certain clinical circumstances," he says. "But it's known to be one that can be overused."
But how much should it cost to be monitored at home or in a hospital sleep lab? That's the question. The Office of Inspector General at the federal Department of Health and Human Services has identified billing problems for the type of sleep study Mendoza had that led to Medicare overpayments.
The University of Miami Health System's total charge was high by nearly every measure, but so was the allowed amount that Humana agreed to pay the health system for the study. And because Mendoza's skimpy health plan has a deductible of $5,000, he's on the hook for paying almost all of that hefty bill.
Mendoza's Humana plan agreed to pay the hospital $5,419 for the sleep study he had. That's nearly six times what Medicare would pay for the same service nationally — $920 — according to data from the Centers for Medicare & Medicaid Services.
Private insurers typically pay higher rates than Medicare for care, but that multiple is "much higher than what other insurers would pay," says Jordan Weintraub, vice president of claims at WellRithms, a company that analyzes medical bills for self-funded companies and other clients.
Consider the total facility charge of $9,853. The average charge in the United States for a sleep study of the same type is just over half that amount at $5,384, according to Fair Health, a national independent nonprofit that tracks insurance charges.
Charges in the Miami area are on the high end of the national range. The average billed charges for similar hospital sleep studies in Miami range from $2,646 to $19,334, Weintraub says. So Mendoza's bill is not as high as the highest in the area, and is just under the average in Miami.
"Billed charges are just completely fictitious," says Weintraub. "There's really no grounds for charging it other than that they can."
More telling than what other Miami hospitals are charging for sleep studies is what the University of Miami Health System reports it actually costs the hospital to do the procedure. And that figure was just $1,154 on average in 2019, according to WellRithms' analysis of publicly available cost report data filed with CMS. That year, the hospital's average charge for the type of sleep study Mendoza had was $7,886, according to WellRithms.
Mendoza doesn't pay premiums for his health plan, but his "free" coverage has a cost. The $5,000 deductible and high coinsurance leaves him woefully exposed financially if he needs medical care, as the family discovered. Nancy Mendoza's plan has a lower deductible of $1,350, but her employer charges extra to cover spouses who have coverage available to them at their own jobs.
Obstructive sleep apnea is often undiagnosed, sleep medicine experts agree, and sleep studies can result in a diagnosis that leads to necessary treatment to help prevent serious problems like heart attacks and diabetes.
"From that perspective, sleep testing is actually underprescribed," says Dr. Douglas Kirsch, medical director of sleep medicine at Atrium Health in Charlotte, N.C., who is past president of the American Academy of Sleep Medicine, a professional group.
After strong growth by independent and hospital-affiliated lab-based sleep centers over several years, there's been a shift toward home-based sleep tests recently, says Charlie Whelan, vice president of consulting for health care at Frost & Sullivan, a research and consulting firm.
"The entire sleep medicine field is deeply worried about a future where more testing is done at home since it means less money to be made for in-center test providers," Whelan says.
Resolution: When the bill arrived, Nancy Mendoza thought it must be a mistake. José's home sleep test hadn't cost them a penny, and no one had mentioned their financial responsibility for the overnight test in the lab.
She called the billing office and asked for an itemized bill. There were no complications, no anesthesia, not even a doctor present. Why was it so expensive? But what they received wasn't any more enlightening than the summary bill.
She got a clear impression that if they didn't pay they'd be sent to collections. To avoid ruining their credit, they agreed to a two-year payment plan and got their first installment bill, for $214.87 in April. Nancy thinks the overall charge is too high: "It's not fair [for] people who are in the low end of the middle class."
Lisa Worley, associate vice president for media relations at the University of Miami Health System, said in a statement that Mendoza "does not qualify for financial assistance because he has health insurance."
But the health system's posted financial assistance policy clearly states that financial assistance is available to "underinsured individuals with a balance remaining after third party liability of $1000 or more, whose family income for the preceding 12 months is equal to or less than 300% [of the federal poverty guidelines]."
Under a less detailed version of the hospital policy included in one of their bills, the Mendozas meet the income threshold for "assistance provided on a sliding scale."
In her statement, Worley referred to Mendoza's sleep test as an "elective service." The health system website says it "provides financial assistance for emergency and other medically necessary (non-elective) care."
Mendoza's sleep study was medically necessary. The emergency department staff evaluated him and determined he needed a new CPAP to deal with serious medical problems caused by his obstructive sleep apnea. His pulmonologist concurred, as did his insurer, which preauthorized the sleep study.
In a statement, Humana wrote: "With sleep studies, there can be a wide range of costs, depending on the complexity of the case and the setting."
The insurer refused to comment on Mendoza's case specifically, even though the Mendozas had given permission to discuss it.
The Takeaway: The Mendozas followed the rules: They used an in-network provider and got prior authorization from their insurance company for the test.
Unfortunately, they are caught between two financial traps of the U.S. health care system: high-deductible health plans, which are increasingly common, and sky-high billing.
With a high-deductible plan, it's crucial to try to learn what you'll owe before receiving nonemergency medical care. Ask for an estimate in writing; if you can't get one, try to shop for a different provider who will give you an estimate.
Be aware that insurance plans that may have zero or low premium costs may not be your best option for coverage.
Once you are stuck with a high bill that hits a high deductible — as is the case with the Mendozas — remember you can still negotiate with the hospital. Find out what a more reasonable charge would be and ask for your bill to be adjusted. Also inquire about payment assistance from the hospital: Most hospitals must offer this option by law (though they often do not make it easy to apply for it).
If a doctor suggests a sleep study, ask if you can do one at home, and whether it's really needed. And, remember: Not every snore is sleep apnea.
Dan Weissmann, host of An Arm and a Leg podcast, contributed to the audio version of this story.
https://www.blogger.com/blog/post/edit/3936036848977011940/39091408658604165
America is bleeding and no amount of patching by the President will fix a healthcare system that doesn't care if we die
by Henry Broeska - Op-Ed News - June 6, 2021
Historically, the United States has greatly lagged behind other nations in providing affordable health care to its citizens. Moreover, the Covid pandemic has put American health-care disparities in a bright spotlight. A glaring example, recognized throughout 2020, has been that African Americans, Hispanics, and indigenous Americans are experiencing an incidence of Covid infection and rates of hospitalization many times greater than white Americans.
On the 2020 campaign trail, President Biden frequently repeated that if elected, he would "take care of your healthcare coverage the same way I take care of my family." His promise to 'fix' health care in America mainly consisted of promoting a subsidized plan through expansion of The Patient Protection and Affordable Care Act of 2010 (ACA, aka 'Obamacare').
Once in office, he opened up a national special-enrollment period for the federal health-insurance marketplaces and started offering subsidized rates to some 30 million Americans who didn't have health insurance. By April 2021, his administration triumphantly proclaimed that nearly 940,000 Americans had newly signed up for health insurance. Great! That leaves only 29 million Americans without a health plan of any kind. So what is the president's plan for the rest of his 'family?'
By way of comparison, the number of families in Canada, the UK, Germany, and Japan without comprehensive health insurance in any year was and is, always 'zero.' Recessions and pandemics don't affect health coverage because it's something everyone in over 40 other wealthy countries enjoys as a birthright. They don't need a benevolent leader to bestow upon them a privilege they already have. Comprehensive health care also costs less than half per capita of what Americans pay for their uneven care benefits.
Corporate Cannibalism
The health-care 'fix' that President Biden is attempting takes place in a country that is much changed since he and President Obama worked together on passage of the Affordable Care Act in 2010. For example, over 200 hospitals have closed since then, leaving huge swaths of rural America (colloquially known as 'health-care deserts') without any tertiary-care medical facilities. And rural hospital closures have only increased through the pandemic. In 2020 alone, 47 rural hospitals closed and another 673 suddenly became vulnerable to shutting down due to revenue challenges.
Secondly, mergers between big providers and big insurers are continuing to consolidate the majority of health-care services in the largest urban markets. Where these mergers occur, markets typically see price rises of between 40% and 65% for hospital services.
Thirdly, equity funds have been rapidly purchasing specialty-physician practices in local markets (such as all of the radiology services). These managed funds then 'roll-up' the package and sell to a 3rd-party investor for a quick profit. In the past decade, this monopolistic pricing scheme has been the source of 'surprise medical bills' frequently endured by patients for services that they didn't know weren't covered by their insurance.
None of these changes does anything to protect or improve the health of Americans. The same unimproved or reduced services are simply being sold in a different wrapper to the same client base for more money. The financial term for an industry that behaves this way is appropriately called 'corporate cannibalism.' And the grave consequences for this uncontrolled behavior can be seen in the accompanying chart.
American Health Care: Costing you more to live your shorter life
Fig 1 (below) indicates the shocking deterioration of the life expectancy of Americans against the rising cost of providing care. Why is this important? Various studies have demonstrated substantial mortality differences associated with insurance coverage. A quick analysis of the graph below reveals some painful truths about American health care when compared to other wealthy nations.
Fig. 1. Life Expectancy vs Health Expenditure- 1970-2020
ig. 1. Life Expectancy vs Health Expenditure- 1970-2020
(Image by Henry Broeska) Details DMCA
Author's rendering from various sources: 1. World Bank Health Expenditure and Financing OECD Stat. 2. CDC Vital Statistics Rapid Release; no 10. Health Statistics. Feb. 2021.
Tracing the US line forward from the 1970s, it can be observed that costs vs life-expectancy gains in the US were, for a while, comparable to all other wealthy countries with publicly-managed universal health-care systems (UHC). Then around 1980, things literally started going sideways for the US.
Starting in the 1980s, new technologies and expensive new breakthrough drugs drove the price of health care up. Nations with universal health care had to scramble to keep rising costs in line with the rate of inflation so taxes didn't balloon. Most countries found ways to devise strict cost controls on all medical goods and services while still providing timely, universal access to care.
For example, to control excessive drug pricing, most national governments require complete cost transparency from drug companies. Before any new drug can be included on the national formulary, it first must be reviewed for safety and efficacy, and the drug manufacturers must agree to sell it at a price that is pre-determined by a formula.
The US has no such national agencies that guard against excessive drug pricing. The drug companies are allowed to determine the price, and insurance plans simply adjust the cost of the plans they sell. If the consumer pays enough, insurance plans allow the demand to be satisfied without too much constraint.
Vulnerable American sub-populations who don't have traditional jobs, can't afford, or who don't qualify for insurance are shut out of coverage. Medicare and Medicaid along with the Affordable Care Act are supposed to fill the gaps, but those programs are far from adequate.
The differences between the two types of national health policies (that is, the US vs the rest of the world) show up on the graph. From 1980 on, gains in life expectancy in the US occurred at a slower rate for the money spent on health care. Around 2014, the turning point was reached. Health plans continued to be excessively priced and became more restrictive. 'Surprise bills' became more frequent, personal medical debt grew, and more Americans put off going to the doctor. Adding insult to injury, the Covid-19 pandemic has accelerated both the mortality rate and the rate of medical-debt growth. The end result of all of these deviations from the norm is that less care is delivered to Americans at critical times.
Whatever the underlying reasons, more Americans died at an increased rate and life expectancies started to fall. While the downward trend in life expectancy is just starting to show up in the wealthiest American populations, it was certainly felt first and most among minority populations of color, the poor, and rural-based populations, where access to health care is the lowest.
The line on the bottom of the graph has been broken out for African-American men. These data contribute to the overall US data. The plunging life expectancies for African- American males, at 68.3 years in 2020, means that this sub-group is now on par with life expectancies in the bottom quartile of all global nations.
Conclusions
The trend lines displayed in Fig. 1 are powerful momentum indicators taken from real-world data over approximately 50 years. The steady trends exhibited by each country are unlikely to change unless there is a sudden turnaround of the factors that drove the data to move in that direction.
For developed countries with UHC, it means that their life expectancies, and the ancillary benefits that go along with it (ie., better health, better QoL), will also continue to rise fairly significantly, while the cost of running their systems will continue to be affordable and cost-effective.
But for the United States, it means that health-care costs will continue to increase at rates greater than the general rate of inflation and move beyond affordability for many--without any requirement whatsoever to improve or maintain the health of Americans.
Those trend lines on the graph are speaking to us. At a glance they are making the best argument that can be made for health-care reform in the United States.
They are saying that if Americans are sincere about wanting to get back 'in-line' with the rest of the developed world, we should be asking ourselves what all of those other countries did to increase and maintain their national life expectancies at four to five years higher than the US, while spending half as much on health care.
Of course the answer rests partially with the fact that every one of those nations removed 'the profit motive' from the delivery of health care when they wrote their social-policy legislation.
Unchecked corporate greed means that future health-care costs are locked into a rate of price growth that will soon be beyond affordability for a huge segment of the American population. New subsidies for small groups here and there are not the answer. Subsidies always distort the real costs.
The only way that President Biden will be able to follow through on his promise to take care of all Americans 'like he would his family,' is if he follows the examples practiced by every other advanced nation. His health and social-welfare policies must reflect their purpose to heal the sick and save lives. Health care must not just be for those who can afford it--or the privileged few who own shares in private health-care companies. For the United States, the only policy change that will reverse the current trend is universal access to care based on clinical need, not an individual's ability to pay.
https://www.opednews.com/articles/1/America-is-bleeding-and-no-by-Henry-Broeska-
2014_Access_America_Covid-19-210602-701.html
The Covid Vaccine Is Free, but Not Everyone Believes That
Concern over unexpected bills was one of the reasons respondents in a U.S. survey gave for hesitation about getting the shot.
by Sarah Kliff - NYT - June 1, 2021
When Paul Moser considers getting a coronavirus vaccine, he also thinks about his outstanding medical debt: $1,200 from a few urology visits that he has been unable to pay off.
Mr. Moser, a 52-year-old gas station cashier in New York State, has friends who were surprised by bills for coronavirus tests, and worries the same could happen with the vaccine. For now, he’s holding off on getting his shot.
“We were told by the legislators that all the testing was supposed to be free, and then surprise, it’s $150,” he said. “I agree it’s important to get vaccinated, but I don’t have a sense of urgency around it.”
Congress passed laws barring pharmacies and hospitals from billing patients for coronavirus vaccines. Signs at vaccination sites advertise that the shot is free. From the beginning, health officials and government leaders have told the public it won’t cost anything. And there have been few reports of people experiencing charges.
Even so, some unvaccinated adults cite concerns about a surprise bill as a reason for not getting the shot. Many of them are accustomed to a health system in which the bills are frequent, large and often unexpected.
A recent Kaiser Family Foundation poll found that about a third of unvaccinated adults were unsure whether insurance covered the new vaccine and were concerned they might need to pay for the shot. The concern was especially pronounced among Hispanic and Black survey respondents.
“The conversations we have are like: ‘Yes, I know it’s good. Yes, I want it, but I don’t have insurance,’” said Ilan Shapiro, medical director of AltaMed, a community health network in Southern California that serves a large Hispanic population. “We’re trying to make sure everyone knows it’s free.”
The confusion may represent a lack of information, or skepticism that a bill won’t follow a visit to the doctor. Liz Hamel, director of survey research at Kaiser, said it could reflect people’s experience with the health system: “People may have heard it’s available for free, but not believe it.”
Congress has tried to protect patients from bills for coronavirus vaccines and tests. Early in the pandemic, it mandated that insurers waive co-payments and deductibles for both services, and set up a fund to reimburse doctors seeing uninsured patients.
Even so, patients found themselves facing bills for testing — some for over $1,000. Some doctors billed uninsured patients for tests rather than the new, federal fund. Others tacked on unexpected fees and services to the testing visit.
The rules for vaccine billing were made even stricter. To become vaccinators, doctors and pharmacies had to sign a contract promising not to bill patients for shots.
The stronger protections appear to have worked. While many patients have encountered coronavirus bills for testing — The New York Times has documented dozens of cases in bills submitted by readers — there have been only a handful involving vaccines.
Still, some unexpected charges have slipped through: Patients in Illinois, North Carolina and Colorado have mistakenly received vaccine bills. In all cases, vaccine providers reversed the charge and apologized for the errors.
The federal government has received some complaints about unexpected charges, and recently warned doctors against billing patients.
Surprise bills for coronavirus vaccines, tests and other medical care can leave an impression on patients. Americans with medical debt are more likely to skip needed care than people who hold other types of debt, like outstanding credit card bills or student loans, according to a 2013 study by Lucie Kalousova, an assistant professor of sociology at the University of California, Riverside.
“For someone who has incurred medical debt, they may be told by the media and everyone else that the vaccine is cost-free, but they’ve also had this very negative, prior encounter with the medical system that has created feelings of mistrust,” she said.
Some patients who worried about the cost of a coronavirus vaccine said they always expect a bill to follow a doctor’s appointment. They cited stories from friends or family members who ended up with expensive coronavirus testing and treatment bills, and wondered why the vaccine would be any different.
“This is America — your health care is not free,” said Elizabeth Drummond, a 42-year-old mother in Oregon who is unvaccinated. “I just feel like that is how the vaccination process is going to go. They’re going to try to capitalize on it.”
It’s also possible that survey research overstates how many Americans fear getting a surprise vaccine bill. When The Times, through Kaiser’s help, conducted follow-up interviews, some poll respondents who voiced this concern said it didn’t actually matter much to them.
Instead, they said they responded that way to express frustration with the vaccine or the wider American health system.
“The cost is the smallest detail,” said Cody Sirman, a 32-year-old who works in manufacturing in Texas and who has decided to go unvaccinated. He said he wouldn’t mind paying for the vaccine if he trusted it — but he doesn’t: “I think the vaccine is a complete sham. It was just a way to see how much control the government can have over the population.”
For many, the potential cost of a vaccine is only part of a constellation of reasons for remaining unvaccinated. It can often be hard for pollsters to know — or even patients to identify — the decisive factor. Separate research from the Census Bureau last month found that Americans were more worried about vaccine side effects than about potential charges.
“Most people aren’t saying they’re just concerned about one thing; it’s usually a lot of things,” said Ms. Hamel of the Kaiser Family Foundation.
Tiffany Addotey, a 42-year-old school bus driver in North Carolina, does cite a concern about cost. That stems mostly from her experience trying to get a coronavirus test.
“It concerns me that some places were charging like $200 for coronavirus tests,” she said. “I didn’t pay. I went home. I have enough bills as it is.”
There are other things that concern her, like the safety of the vaccine given its fast development, as well as the recent Johnson & Johnson vaccine pause.
When Ms. Addotey was informed that federal law makes the vaccine free for all Americans, she responded, “So I’ll just have to pay my co-pay?”
Learning that it really would be free, with no co-payment, “helped a little bit,” she said. But it wasn’t enough to put her mind at ease about getting vaccinated, at least not yet.
“I’m going to try and wait for it to be on the market a little longer,” she said. “I feel like I will get it, after a little more research and a little more time.”
https://www.nytimes.com/2021/06/01/upshot/covid-vaccine-hesitancy-cost.html
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