Hometown: Washington state
Home country: USA
Current location: Directly above the center of the earth
Member since: Sat Aug 16, 2003, 02:52 AM
Number of posts: 40,609
Hometown: Washington state
Home country: USA
Current location: Directly above the center of the earth
Member since: Sat Aug 16, 2003, 02:52 AM
Number of posts: 40,609
Major policy wonk interests: health care, Social Security/Medicare/Medicaid, election integrity
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Mounting evidence shows that chaos in medical billing is not just affecting our health care but dinging the financial reputation of many Americans: While the bills themselves frequently take months to sort out, medical debts can be reported rapidly to credit agencies, and often without notification. And even small unpaid bills can severely damage credit ratings.
A mortgage initiator in Texas, Rodney Anderson of Supreme Lending, recently looked at the credit records of 5,000 applicants and found that 40 percent had medical debt in collection, with the average around $400; even worse, most applicants were unaware of their debt. Richard Cordray, director of the federal Consumer Financial Protection Bureau, has noted that half of all accounts reported by collection agencies now come from medical bills, and the credit record of one in five Americans is affected.
The problem is accelerating for several reasons. Charges are rising. Insurance policies are requiring more patient outlays in the form of higher deductibles and co-payments. More important, perhaps, is that while doctors’ practices traditionally worked out deals for patients who had trouble paying, today many doctors work for large professionally managed groups and hospital systems whose bills are generated far away, by computer.
Comment by Don McCanne of PNHPOur fragmented, dysfunctional system of paying medical bills is having a major impact on personal credit ratings. Half of all accounts reported by collection agencies now come from medical bills. The credit record of one-fifth of Americans is affected, and many of us are unaware of it. Are people so broke that they can’t pay their medical bills, or is something else going on here?
There are two major factors at play here. One is that with flat wages and increasing household costs, many people do have problems paying all of their essential bills, and medical bills are moved to the bottom of the stack. When payment of medical bills is postponed, or perhaps not paid at all, they are commonly sent to collection agencies, eventually appearing on the debtor’s credit report. Now that high deductibles are being used more to shift costs from payers (employers or government) to patients, this phenomenon is much more common.
The other factor is how people with good incomes who are meticulous with management of their personal finances end up with dinged credit reports because of medical bills. It is often due to the administrative complexity of the system we have of paying medical bills through private insurers who make payments based on whether the providers are in or out of network, on whether or not the products or services being billed are even covered by the plans, and on how much the deductible and coinsurance are and what charges can be credited against the deductible.
Typically the individual receives an explanation of benefits which is difficult to decipher often because some of these questions still remain unanswered. Billings may start to come in from various health care providers but without adequate explanation. When the patient inquires as to why the amount was not applied to the deductible, or why the amount seems to be for out-of-network providers when this provider is in-network, or for whatever reason, the patient is often given a temporizing response. When more statements are received that failed to address concerns such as the deductible, further efforts to correct the problem are often met with reassurance. When nothing further is heard, the patient assumes the matter was cleared up. Only later when a collection agency begins to harass them or when they find their credit report includes unpaid medical bills do they discover that the matter never was resolved.
Add in further complexities such as when a person has primary coverage perhaps through Medicare and secondary coverage through a Medigap plan, or a person had a change in coverage coinciding with the medical services provided, straightening out who is responsible for which portions of the charges can be a monumental task.
These highly responsible individuals with previously excellent credit records are understandably angry. They tend to look elsewhere for blame - the physician’s office or billing service, the hospital’s billing department, the insurer’s claim processors, the credit agency’s disregard of registered protests, or perhaps the employer who provided such a screwed up health plan.
Single payer advocates know where most of the blame really lies. It is with our political leaders who insist on perpetuating this highly inefficient, fragmented system of financing health care instead of enacting a single payer national health program. This botched up system of medical billing is only one manifestation of the profound administrative excesses that permeate our system. Ironically, all of this extra administrative detail in handling medical billings doesn’t even work well. You would think that if we are going to be paying much more in administrative costs so that the insurers could do a “better” job than a single government payer in handling our claims, we would be demanding much better performance from them. But no, keep the government out and blame everyone else.
In typical D.C. fashion, our legislators continue to look for solutions that would increase regulatory oversight to prevent unfair damage to the credit ratings of conscientious individuals, though the legislators are receiving expected push back from the credit industry. What we do not need is more administrative oversight piled on top of an administrative boondoggle. Instead we need to replace it with an efficient improved Medicare, with first dollar coverage, that covers everyone. Credit scores dinged by medical bills then would become a quaint historical oddity.
Posted by eridani | Tue Mar 11, 2014, 06:42 AM (1 replies)
Hundreds of thousands of Americans in poorer counties have few choices of health insurers and face high premiums through the online exchanges created by the health-care law, according to an analysis by The Wall Street Journal of offerings in 36 states.
Consumers in 515 counties, spread across 15 states, have only one insurer selling coverage through the online marketplaces, the Journal found. In more than 80% of those counties, the sole insurer is a local Blue Cross & Blue Shield plan. Residents of wealthier, more populated counties in the U.S. receive lower-priced choices than those living in counties with a single insurer.
The price differences reflect the strategy of insurers to pick markets where they believe they can turn a profit—and avoid areas of high unemployment and a concentration of unhealthy residents they deem more risky.
Aetna Inc. and UnitedHealth Group Inc., for instance, have limited their participation in the new health-insurance marketplaces, where consumers shop for coverage, to a much smaller map than their traditional business. They offer coverage in more counties outside of the marketplaces, where plans are sold directly to consumers and federal subsidies aren't available.
Aetna targeted areas with stable levels of employment and income to attract desirable customers to its marketplace offerings, Chief Executive Mark Bertolini said last fall. "We were very careful to pick the markets" where the insurer could succeed, he said.
Reversing the trend presents a challenge because low-population areas are unlikely to draw more insurers, said Glenn Melnick, a health-care economist at RAND Corp: "I don't think the health law can overcome those economics."
Comment by Don McCanne of PNHP: We’ve always know that insurers market their plans in areas where there is the greatest potential for business success. As USC Health Finance Professor Glen Melnick explains, the Affordable Care Act cannot overcome those economics.
Clearly we have the wrong model for reform. Private insurers respond to business opportunities. Public insurance, such as a single payer national health program, simply enrolls everyone; there are no market decisions to be made.
So is it going to continue to be about private insurance markets, or will it be about patients - all patients? An improved Medicare for all would be about the latter
Posted by eridani | Sat Feb 15, 2014, 08:45 AM (5 replies)
On his first day as governor of Massachusetts, Donald Berwick promises to set up a commission tasked with finding a way to bring single payer to the Bay State. It'll have report back to him within a year -- ideally sooner.
Having run Medicare and Obamacare in Washington for 17 months, he has concluded that the existing hybrid system is too cumbersome and expensive, and that single payer is the right fix. And he's the only candidate in this year's contest who dares to go there.
"The Affordable Care Act is a majestic step forward for this country -- for the only nation that hasn't made health care a human right yet. But luckily I'm in a state that's able to take even a bigger step," Berwick told TPM in an interview. "And a single payer option -- even if the country is not ready for it, I think Massachusetts is ready and it's worth exploring."
A political novice, Berwick is an underdog candidate for the Democratic nomination in the 2014 elections -- the most outspoken progressive in the race. A pediatrician, Harvard health policy professor and former health care executive, his talent for -- and obsession with -- health management caught the eye of President Barack Obama, who in 2010 appointed him to be the Administrator of the Center for Medicare & Medicaid Services, which was tasked with getting Obamacare off the ground in its infancy. Berwick left in December 2011, after his recess appointment expired and Senate Republicans refused to confirm him.
"I've been looking hard at the Massachusetts budget and I've become more aware than ever of how the rising costs of health care are taking opportunity away from other investments," he said. "I saw it in Washington, and I see it in Massachusetts. We need to find money for transportation, education, the social safety net. ... And so I feel a sense of urgency about getting costs under control without harming patients at all."
Posted by eridani | Thu Feb 13, 2014, 08:28 AM (8 replies)
As counterintuitive as it may sound, time after time American Communists such as Seeger were on the right side of history - and through their leadership, they encouraged others to join them there.
Communists ran brutal police states in the Eastern bloc, but in Asia and Africa they found themselves at the helm of anti-colonial struggles, and in the United States radicals represented the earliest and more fervent supporters of civil rights and other fights for social emancipation. In the 1930s, Communist Party members led a militant anti-racist movement among Alabama sharecroppers that called for voting rights, equal wages for women and land for landless farmers. Prominent and unabashedly Stalinist figures such as Mike Gold, Richard Wright and Granville Hicks pushed Franklin D. Roosevelt's New Deal to be more inclusive and led the mass unionization drives of the era. These individuals, bound together by membership in an organization most ordinary Americans came to fear and despise, played an outsize and largely positive role in American politics and culture. Seeger was one of the last surviving links to this great legacy.
"Stateside Communists were the underdogs, fighting the establishment for justice - the victims of censorship and police repression, not its perpetrators."
American communism was different during those years. It wasn't gray, bureaucratic and rigid, as it was in the U.S.S.R., but creative and dynamic. Irving Howe thought it was a put-on, a "brilliant masquerade" that fought for the right causes but in a deceptive, opportunistic way. But there was an undeniable charm to the Communist Party - an organization that hosted youth dances and socials, as well as militant rallies - that first attracted Seeger. One need only reread the old transcripts from his 1955 run-in with the House Un-American Activities Committee to see the difference between the stodginess of the interrogators and the crackling wit of the young firebrand.
Posted by eridani | Thu Jan 30, 2014, 08:02 AM (4 replies)
These are the people that get charged three times as much under the ACA
The US Government Accountability Office (GAO) recently published a report that examines how continuous health insurance before enrolling in Medicare relates to a beneficiary’s reported health status and use of medical services. The study included only people who were eligible for Medicare due to age, not people who were eligible due to disability. It examines the time span from six years before someone was eligible for Medicare to six years after someone had Medicare.
GAO found that people with prior continuous insurance reported being in better health throughout their first six years on Medicare. Additionally, they had lower Medicare spending during their first year on Medicare, translating to approximately $2,300 less in Medicare spending in their first year of coverage.
The study also found that beneficiaries with continuous prior insurance had less institutional outpatient care (e.g., hospital outpatient care) than those who did not during their first two years of Medicare coverage. Those with and without prior continuous insurance had similar noninstitutional outpatient care spending (e.g., physicians and labs) at first. However, beneficiaries with prior continuous insurance surpassed their counterparts in noninstitutional outpatient spending in the fourth and fifth year. This coincides with the finding that those with prior continuous insurance having more physician office visits during the first five years on Medicare.
GAO’s report suggests that beneficiaries with prior insurance are in better health and use fewer or less expensive Medicare services during their first years on Medicare. The care spending and usage patterns also suggest that people with and without prior continuous insurance may access healthcare in different ways. Overall, GAO’s report shows that, while Medicare can help those who are 65 and older access the care they need, their health status and use of services can be largely impacted by their health insurance status prior to Medicare.
Posted by eridani | Mon Jan 27, 2014, 10:54 PM (0 replies)
Health care costs are at levels never before seen anywhere in the world and are increasing in an uncontrolled and unsustainable way. Despite our high per-person costs — double those of other developed countries — tens of thousands of Americans die every year from lack of timely access to health care.
The degree of interference with doctors’ and patients’ health care decisions that exists in America today would not be tolerated anywhere else in the world. “Death panels” do exist in America, but they are run not by government but by private corporations. Their purpose is to maximize profits.
Americans are unique in the world in thinking about health care as a business. In no other country is that notion so widely and unquestioningly accepted.
As Melody Petersen has documented in her book “Our Daily Meds,” instead of embracing George Merck’s philosophy, pharmaceutical companies have become huge marketing machines. They now are focused far more on their profitability than on their healing mission. Producing medicine that cures diseases instead of just treating symptoms has become a bad business model. Once a disease is cured the customer disappears and profits decline.
Posted by eridani | Sat Jan 25, 2014, 07:13 AM (4 replies)
Medicare’s Rollout vs. Obamacare’s Glitches Brew
The smooth and inexpensive rollout of Medicare on July 1, 1966 provides a sharp contrast to the costly chaos of Obamacare.
As of March, 2013, federal grants for Obamacare’s state exchanges totaled $3.8 billion. Spending for the federal exchange is harder to pin down because funding has come from multiple accounts, including: the $1 billion Health Insurance Implementation Fund; DHHS’ General Departmental Management Account and General Departmental Management Account; CMS’s Program Management Account and the Prevention and Public Health Fund. CMS estimates fiscal 2014 spending for the federally-operated exchanges at $2 billion. So it’s safe to say that the costs of getting the exchanges up and running, and (hopefully) enrolling 7 million people in the program’s first year will exceed $6 billion.
Bear in mind that the exchanges won’t actually pay any medical bills, just sign people up for coverage. So billions more in overhead costs will show up on the books of the private insurers and state Medicaid programs that will actually process medical claims.
Back in 1966, Medicare started paying bills for 18.9 million seniors (99 percent of those eligible for coverage) just 11 months after Pres. Johnson signed it into law. Overhead costs for the first year totaled $120 million (equivalent to $867 million in 2013). But that figure includes the cost of processing medical bills, not just the enrollment costs.
Signing up most of the elderly for Medicare was simple; they were already known to Social Security Administration, which handled enrollment. To find the rest, the feds sent out mailings to seniors, held local meetings, and asked postal workers, forest rangers and agricultural representatives to help contact people in remote areas. The Office for Economic Opportunity spent $14.5 million to hire 5,000 low income seniors who went door-to-door in their neighborhoods.
Obamacare’s byzantine complexity reflects the contortions required to simultaneously expand coverage and appease private insurers. And private insurers will exact a steep ongoing toll. Medicare’s overhead is just 2 percent, vs. an average of 13 percent for private plans (on top of the Exchanges’ costs, roughly 3 percent of premiums). A single payer plan that excluded private insurers could save hundreds of billions in transaction costs.
PNHP oress release
“Obamacare is a giant workaround crafted to keep private insurers at the center of the health care system,” said co-author Dr. David Himmelstein, a primary care physician, professor of public health at the City University of New York and lecturer in medicine at Harvard Medical School.
“The simple single-payer, Medicare-for-all approach would save more than $400 billion annually on bureaucracy, enough to give every American first-dollar coverage. But to get those savings you have to break private insurers’ stranglehold on health care and on Washington,” he said, adding, “The glitches in Obamacare’s rollout don’t come from government incompetence, but from political cowardice.”
Posted by eridani | Fri Jan 3, 2014, 03:41 AM (15 replies)
Rather than embracing a single-payer system, the United States is more likely to stumble, in fits and starts, toward something resembling officially sanctioned tiering of the American health care experience by income class, as follows:
FOR MEDICAID BENEFICIARIES AND THE UNINSURED, a budget-constrained system of public hospitals and public clinics. It would allow politicians to ration health care (through tight budgets) without ever having to acknowledge that they were doing so. In other words, it would reduce the price of being kind.
FOR THE EMPLOYED MIDDLE CLASS, a mixed system with defined contributions by employers, private health insurance exchanges and reference pricing by insurers. Under a restructured Medicare program also based on a defined contribution model, reference pricing would be likely to apply to Medicare beneficiaries as well. Depending on how it is operated – e.g., if it were solely based on cost, in abstraction of quality – reference pricing also permits tiering of the health care experience by income class, without anyone having to say so openly.
FOR THE UPPER-INCOME GROUPS, boutique medicine, which is already growing in the United States. Here the sky will be the limit.
Comment by Don McCanne of PNHP: Uwe Reinhardt, an astute observer of the U.S. health care system, does not see single payer in our future, but rather sees an “officially sanctioned tiering of the American health care experience by income class.” We already have the three tiers that he describes, but the middle tier is rapidly evolving in a way that may provoke a renewed and more intense interest in single payer.
The lowest tier - Medicaid beneficiaries and the uninsured - have never had much of a political voice. Nevertheless, even the most heartless of politicians recognize that we must provide care for indigent pregnant women and children. Thus we have the chronically underfunded Medicaid program plus safety net hospitals and community health centers. Some states also have included other low-income adults, though they still make up the largest percentage of the uninsured. Except for the most basic of primary care services and care for events that threaten life or limb, access to health care for this sector is limited, especially for specialized services. As Professor Reinhardt indicates, politicians are able to ration health care for Medicaid beneficiaries and the uninsured without admitting that they are doing it, merely by placing restraints on the budget. Since it is unAmerican to ration health care, they would never do that, but rather they merely refuse to budget spending that we can’t afford. (Of course, inadequate funding of health care is rationing, and we actually can afford to pay for health care for all, though we do need more efficiency in our financing system.)
The highest tier - the upper-income groups - have never had problems with gaining access to the best care available. That is true now, and will be true no matter what health care financing system we will have. Some have expressed concerns that in a truly egalitarian system, such as a single payer system, the wealthy would have to give up some of the finer amenities of health care and stand in line with the rest of us, but that will never happen. The wealthy are not hampered by noblesse oblige when it comes to moving to the front of the line for health care. Besides, a well designed system should not have an excessive queue anyway.
The middle tier - the employed middle class - will see greater changes in health care access and affordability, changes that have already begun. Although the plans to be offered in the state exchanges will include many of these changes, employers are already following by modifying their plans to reduce their own exposure to costs. Higher deductibles and other forms of cost sharing are shifting more costs to the pockets of those who need health care. Although ten categories of benefits will be required under the plans, the insurers have considerable flexibility in the composition of benefits within each category and will leave out selected benefits that some individuals will need, especially some of the more expensive benefits. Insurers are reducing their networks of physicians and hospitals, further limiting patient choice of their health care providers, unlike the traditional Medicare program, which allows free choice. Patents may still face catastrophic losses since the maximum out-of-pocket expenditures apply only to covered benefits provided within the networks. Care unavoidably obtained out of network and health care services not included as a plan benefit can result in costs that threaten personal bankruptcy. Even the allowed maximums would create a hardship for many. Employers are beginning to switch to defined benefit contributions to health plans that would be selected from private (not state) health exchanges. This voucher approach allows employers to shift the future increases in health care costs disproportionately to the employees. Reference pricing is the process of setting a low price for given health care services and requiring the patient to pay the full difference in prices if the patient selects a more expensive provider. This is another method of shifting more costs to the patient, not to mention that it further limits choice of providers since these extra costs may be truly unaffordable. A shift in control of Congress and the White House to conservatives may well result in premium support of Medicare (vouchers - a defined contribution), thereby allowing Medicare to adopt some of these same policies that shift more costs to patients in need.
The obvious point is that the exchange plans and now even employer-sponsored plans will cause the employed middle class to become quite dissatisfied with our health care financing system. Once they or their families and friends have enough negative experiences with our health care financing, and once they understand single payer - an improved Medicare for all - it will be the middle class workers that will be the loudest in demanding change.
In the meantime, under our present three-tiered system, we will be able to obtain a basic level of care for Tiny Tim, just not the specialized services that he really needs. And Ebenezer Scrooge will be able to access his boutique providers, with the sky as the limit. But what about the people of the village? Once Scrooge gains control of the insurance industry, will he further advance the current agenda of making health care more expensive to increase profits, and less accessible to reduce costs? Will another visit from the Ghost Of Christmas Yet To Come be adequate? Or will he be hardened enough to carry on, as Reinhardt writes, “the age-old reluctance among many of the nation’s haves and the healthy to help purchase for America’s lower-income families and the chronically ill the super-expensive health care that the haves enjoy themselves.”
Though should we really expect a different outcome? We now have a society that when Bob Cratchit pulls himself up by his bootstraps and runs for mayor, we elect Ebenezer Scrooge instead.
Posted by eridani | Thu Dec 26, 2013, 11:24 PM (20 replies)
That said, plenty of single payer supporters are thankful that the ACA at least broke the logjam preventing action on changing our system.
Could anger at the Obamacare rollout make Americans more receptive to a kind of Medicare-for-all system? That’s what activists are hoping—and they’re plotting a state-by-state fight.
As the rollout of Obamacare clunks forward, activists who opposed the law from the beginning say it is time to seize the moment, to tear down the current health-care edifice and start anew, especially now as frustration with the law’s implementation is reaching a peak.
These are not Tea Party activists but advocates for a single-payer health-care system who say some of the problems with the launch of the Affordable Care Act—in addition to built-in problems with the law itself—have made the American public more receptive than ever to a Medicare-for-all kind of coverage system.
On Monday, Sen. Bernie Sanders (I-VT) introduced the American Health Security Act, which would require each state to set up a single-payer health-care system and would undo the exchanges that have plagued Obamacare. Meanwhile, various state-led efforts are under way that advocates hope will sweep the country statehouse by statehouse, as soon as lawmakers see the advantage of a single-payer system. In Vermont, for example, lawmakers have set aside the financing and are already preparing to adopt a single-payer system when the federal government permits it, which according to provisions of the Affordable Care Act will be in 2015. In Massachusetts, Don Berwick, a former top Obama administration health official, is basing his campaign for governor on bringing a single-payer system to the commonwealth. And advocates in New York, Maryland, Oregon, and around the country say they see new energy around their cause.
“As the president fully understands, the rollout has been a disaster, the website has been a disaster, said Sanders in an interview moments after his bill was introduced in the Senate. “But the truth is, even if all of those problems were corrected tomorrow and if the Affordable Care Act did all that it was supposed to do, it would be only a modest step forward to dealing with the dysfunction of the American health-care system. When you have a lot of complications, it is an opportunity for insurance companies and drug companies and medical equipment suppliers to make billions and billions of profits rather than to see our money go into health care and making people well.”
Posted by eridani | Tue Dec 24, 2013, 12:28 AM (9 replies)
* On a national level, Medicare patients have good access to physicians. The vast majority (96%) of Medicare beneficiaries report having a usual source of care, primarily a doctor’s office or doctor’s clinic.
* Most people with Medicare — about 90 percent — are able to schedule timely appointments for routine and specialty care. Medicare seniors are more likely than privately insured adults age 50-64 to report “never” having to wait longer than they want for timely routine care appointments.
* A small share of Medicare beneficiaries say they looked for a new physician in the past year, and only 2 percent of seniors with Medicare report problems finding one when needed — comparable to rates reported by privately insured adults age 50-64.
Comment by Don McCanne of PNHP: This comprehensive report lays to rest once and for all the the rumor that physicians are leaving Medicare in droves. Most physicians accept new Medicare patients, and less than 1 percent have formally opted-out of the Medicare program.
An improved Medicare would be even more attractive to physicians, especially if it covered everyone. It would dramatically reduce hassles with intrusive third party payers so that physicians could spend most of their time doing what they devoted their lives to - taking care of their patients.
As far as th threat that physicians would quit if we enacted an improved Medicare for all, first of all, very few would leave - likely less than 1 percent - and, second, since most of those who would leave seem to be more interested in money rather than patients (think concierge), we really don’t want them around anyway. It would be a great way to clean up our profession.
Posted by eridani | Tue Dec 17, 2013, 05:26 AM (0 replies)