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eridani

Profile Information

Gender: Female
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: 42,314

About Me

Major policy wonk interests: health care, Social Security/Medicare/Medicaid, election integrity

Journal Archives

No cannabis in Seattle, but there is in Bellingham



The only Seattle cannabis store had every one of its varieties marked (out of stock) the last time I checked. This weekend I was in Bellingham for the state Democratic Party quarterly meeting, and took advantage of their pot store. They had plenty of varieties and also edibles. I didn't see any high CBD/low THC varieties, though. Those interested in serious pain relief will be dependent on medical marijuana clinics for the forseeable future as far as I can tell.

For myself I got an Indica-dominant strain with the highest gamma-cannabinoid content I could find--this if for my insomnia (not considered a condition rating a medical marijuana card in WA, unfortunately--though it is in CA).

For my husband I got a 95% Sativa-dominant strain for computer programming creativity. Don't know for sure if he really is more creative on the stuff, but he thinks he is.

I think it's time for another serious try at a state bank--the shops deal in cash only. This puts them at risk for theft, IMO. Not only that, but I would have gotten larger amounts if I had had more cash--so many people these days carry little cash and depend on credit or debit cards, and stores would sell more if a bank would accept credit. The state's tax revenue would be considerably higher.

People in Seattle are probably still relying on the underground economy. I've heard from the grapevine that prices have dropped a lot since legalization, and are certainly lower without all the taxes. But if street dealers even know whether their product is Indica or Sativa dominant (let alone more detailed information), I'd be seriously surprised.

I'd rather get mine from state-approved stores for two reasons. I approve of the boost to the state's revenues from marijuana taxation. Also, I'm a geek looking for marijuana with very specific components, and I like seeing a solid chemical analysis with as many components of interest quantified as possible. Date of harvesting is listed, and the material must be mold-free.

Implementing Health Reform: Tax Form Instructions

http://healthaffairs.org/blog/2014/08/29/implementing-health-reform-tax-form-instructions/

On August 28, 2014, the Internal Revenue Service re-released the draft forms that will be used by employer, insurers, and exchanges for reporting Affordable Care Act tax information to individuals and to the IRS for 2014 and 2015, as well as the instructions for completing those forms. The IRS also released in the Federal Register requests for public comments on three of those forms – the 1094-B, the 1094-C, and the 1095-C – under the Paperwork Reduction Act. This post reports on these forms and instructions and on a guidance released by the Centers for Medicare and Medicaid Services.

The tax forms had been published earlier and are described in an earlier post. The instructions for the forms, however, had not been available and had been eagerly awaited by employers, insurers, exchanges, and tax professionals. Forms 1094-C and 1095-C will be used by large employers with more than 50 full-time or full-time-equivalent employees to determine whether the employer is responsible for penalties under the employer shared responsibility requirements of the ACA. They will also be used to determine whether employees have received an affordable and adequate offer of coverage, rendering them ineligible for premium tax credits. Employers are required to provide each full-time employee with a form 1095-C and to file each of these together with a transmittal form 1095-B form with the IRS.

The instructions for the 1094-C and 1095-C are by far the most complex of the instructions released on August 28, filling 13 pages with dense, two column, print. Most of the complexity derives from the options for complying with the employer mandate and the transition exceptions to that mandate that the administration has created…

Comment by Don McCanne of PNHP: If you enjoy minutia, click on the links to the full blog post and the draft instructions and read away.

Although today’s message deals with only one minor provision of the Affordable Care Act - the instructions for tax forms used to report ACA tax information to individuals and to the IRS - the administrative detail required is mind-boggling. Extrapolate that to all aspects of ACA and it becomes obvious that, instead of gaining administrative simplicity, ACA greatly increased administrative complexity - on top of the most administratively complex health financing system in the world. What a waste!

Timothy Jost’s comment from yesterday’s message can be repeated again today: “We are doomed to continue to struggle with this complexity as long as we stubbornly cling to a private health insurance-based health care financing system.”

Single payer!!

The existence of private insurance strongly correlates with higher health care costs

http://theconversation.com/creating-a-better-health-system-lessons-from-norway-and-sweden-30366

Private insurance, however, is an expensive way to fund health care. When we look at the relationship between private insurance and a nation’s total health-care costs, we find a strong positive relationship: the more a country relies on private insurance the more it pays for health care, without any extra benefit.

It’s not just the bureaucratic cost of private insurance; it’s also the distortions it introduces, for when there is a private insurer in the market, able to pay premium prices for priority access to care, prices throughout the health system rise, both for the public insurer and for those who pay for health care from their own pockets.

The graph below shows the relationship between countries’ health-care costs (as a proportion of GDP) and reliance on private insurance. These are all countries with only minor differences in their health outcomes. (For the statisticians, R Squared = 0.66.)



At one end of the scale, the United States stands out. At the other end are three countries – Sweden, Norway and Iceland, where private insurance is either absent or plays a minuscule role in funding health care. And these countries contain their total health-care costs (as does Australia for now), to around 9% of GDP. This is in spite of the fact that Sweden, the largest of these countries, has a significantly older population than Australia.

Insurance companies go for profitable tests, but not for more doctor time spent with patients

Cardiologist Speaks From The Heart About America's Medical System

http://www.npr.org/blogs/health/2014/08/19/341632184/cardiologist-speaks-from-the-heart-about-americas-medical-system

As a young doctor working at a teaching hospital, Sandeep Jauhar was having trouble making ends meet. So, like other academic physicians, he took a job moonlighting at a private practice, the offices of a cardiologist. He noticed that the offices were quick to order expensive tests for their patients — even when they seemed unnecessary.It was "made very clear from the beginning" that seeing patients alone was not financially rewarding for the business, he says."Spending 20-30 minutes with a patient might be reimbursed $80, $90, but sending the patient for a nuclear stress test was much more profitable," Jauhar tells Fresh Air's Terry Gross. "A nuclear stress test, at the time when I started working, was reimbursed roughly $800 to $900."

Jauhar was supervising the tests that had been ordered by a physician — and some physician assistants."So even though I wasn't ordering the tests, I was in the office while these tests were being performed — and I felt really dirty about it," Jauhar says.Jauhar's new memoir, Doctored: The Disillusionment of an American Physician, is about how doctors are growing increasingly discontent with their profession. And they're facing more pressures: As the number of patients they're expected to see increases, so does the amount of paperwork. While some doctors who perform a lot of procedures may be paid too much, he writes, many doctors, such as primary care physicians, aren't paid enough.And, he adds, "the growing discontent has serious consequences for patients.

Health care plans worth even less than bronze? Yep--meet copper.

Probably "lead" would have been more appropriate. If you get sick on a plan like that, you are instantly bankrupt.

Council for Affordable Health Coverage
Study Shows “Copper Plan” Would Lower Premiums by 18 Percent
http://cahc.net/press-release-study-shows-copper-plan-would-lower-premiums-by-18-percent/

The Council for Affordable Health Coverage today released an estimate by Avalere Health LLC showing that legislation to permit a new, less expensive tier of insurance coverage under the Affordable Care Act would lead to an additional 350,000 Americans keeping their employer sponsored health insurance in 2016. Because fewer people would lose their coverage, taxpayers would spend $5.8 billion less on exchange subsidies, while employers would pay about $5.5 billion less in penalties under the employer mandate


Avalere
Estimated Impact on the Federal Deficit and Insurance Premiums from Creating a New Health Plan Tier with an Actuarial Value Level of 50 Percent

http://cahc.net/wp-content/uploads/2014/08/20140605-CAHC-New-50-AV-Tier-Score.pdf

Summary

The Council for Affordable Health Coverage requested Avalere Health to estimate the impact on the federal deficit of a legislative proposal that would allow a new type of plan tier for consumers in the new health insurance marketplace as well as small employers. Plans on this new tier would have an actuarial value (AV) of 50 percent. As originally passed in the Affordable Care Cat (ACA), commercial health insurance plans in the individual and small group markets must cover at least 60 percent of the estimated health costs of enrollees starting in 2014.

We estimate tht creating a new tier with an AV of 50 percent would reduce the federal deficit by $0.3 billion between FY 2015 and FY 2024. This estimate assumes that the new tier would be available to consumers starting in plan year 2016. The reduction is due to a net $5.8 billion decrease in subsidies paid by the federal government for individuals in the new health insurance marketplace, primarily due to an increase in the estimated number of employers who will offer affordable coverage to employees. Counteracting this reduction in federal spending is an estimated $5.5 billion decrease in revenues collected by the federal government, again primarily due to fewer employers paying the employer mandate penalty.

We also estimate that the premium for the new plan with a 50 percent AV would be nearly 18 percent lower than the premium for an average bronze tier plan in 2016. The lower premium would result in a slight increase in estimated enrollment in the new marketplace.


http://www.modernhealthcare.com/article/20140819/BLOG/308199995
'Copper plans' could cut subsidies, lower deficit, but would consumers bite?
Allowing cheaper health plans designed to cover just half of medical costs to be sold on the exchanges would result in 350,000 additional individuals enrolling in coverage in the next decade, according to an analysis by Avalere Health.

The lower actuarial threshold also would convince some employers to maintain coverage, according to the Avalere analysis. The Society of Actuaries has predicted that 3% of employers will stop providing coverage under the ACA. But if the copper plan option existed, Avalere estimates that 4% of that group would continue offering coverage to workers. That increase represents just 0.1% of the current employer-sponsored market.

America's Health Insurance Plans, the primary industry group, supports allowing what are often referred to as “copper plans” to be sold on the exchanges. The organization has argued that it would entice more people—particularly younger, healthier individuals – into the marketplaces.


Comment by Don McCanne of PNHP: One of the major problems with the Affordable Care Act is that it has established underinsurance as a new standard. It was bad enough when the decision was made to allow insurers to offer products that covered an average of only 60 percent of estimated health care costs, but now there is a serious proposal to reduce that to 50 percent. What does this do?

From the insured’s perspective, it would fulfill the requirement to purchase insurance, while keeping premiums as low as possible, with a tradeoff that you must accept the risk of paying on average the other half of health care costs that the insurer does not pay for (plus all costs for services not covered and for the balance of charges for out-of-network services). For the majority, such costs would create a financial hardship should significant medical problems develop - the reason this is labeled underinsurance.

From the insurers’ perspective, while discounting the premium by only 18 percent below that of a 60 percent actuarial value bronze plan, they can attract healthier individuals who are more likely to be willing to gamble that they may not need much health care. This would be a great deal for the insurers.

A 50 percent actuarial value copper plan would be appealing to libertarian conservatives for a few reasons. It uses a consumer-directed approach to health care purchasing by exposing the patient to significant out-of-pocket costs, requiring the patient to became an informed price shopper (even though the out-of-pocket expenses may not be affordable). It also allows consumers to exercise choice over market originated insurance products, rather than defaulting to a more comprehensive single payer program administered by the government that would actually work. Furthermore, the Avalere study shows that adding a copper level choice would reduce the federal deficit by about 30 million dollars a year. Little does it matter that 30 million dollars would not even qualify as a footnote in our federal budget, it is fulfilling an ideological goal of reducing federal spending that is compelling to conservatives.

What about fulfilling the goal of advocates of health care justice? Obviously this proposal was not written for them. Creating a plan that exposes the sick to financial hardship is the opposite of what insurance should be doing.

Rather than talking about insurance, we should be talking about prepaid health care - removing the financial barriers to the health care that you need, when you need it. This is precisely what a single payer national health program would do.

I can’t wait to see their proposal for a health plan with a 10 percent actuarial value. You doubt it? If AHIP can get clearance for private insurers to produce such a plan and have it count as fulfilling the insurance requirement thereby avoiding the penalties for being uninsured, I guarantee you that they will find a market for it. It would be ideal for insurers since it would eliminate 90 percent of their risk while allowing them to continue to sell us a profusion of wasteful administrative services. And our bureaucrats? “If that’s a product that the people want…”

Insurance companies offer discriminatory benefits to actual sick people

Letter
July 28, 2014
To: Sylvia Burwell, Secretary of Health and Human Services
From: Over 300 patient advocacy groups

http://www.theaidsinstitute.org/sites/default/files/attachments/IAmStillEssentialBurwellltr_0.pdf

Based on reports of enrollee experiences during the first year of Marketplace implementation, we have identified a number of concerns. These include discriminatory benefit designs that limit access, such as restrictive formularies and inadequate provider networks; high cost-sharing; and a lack of plan transparency that may deprive consumers of information that is essential to making informed enrollment choices.

Limited Benefits:

Due to the manner in which Essential Health Benefits (EHBs) are defined for plan years 2014 and 2015, select plans do not include all the medications that enrollees may be prescribed to address their health care needs. Plans are further restricting access to care by imposing utilization management policies, such as prior authorization, step therapy and quantity limits. Tying plan formulary requirements to the number of drugs in each class in the state benchmark has resulted in some plans not covering critical medications, including combination therapies. Additionally, there is no requirement for plans to cover new medications and plans can remove medications during the plan year as long as the plan continues to meet the state’s benchmark requirements. Narrow provider networks and a lack of access to specialists are also negatively impacting access to quality care for enrollees.

These design elements appear to affect certain patient populations disproportionately – many of the same populations that were subject to pre-existing condition restrictions prior to ACA implementation.


High Cost-Sharing:

Despite enrollee out-of-pocket limits that are included in the ACA and reduced cost-sharing for people with very low income levels, some plans are placing extremely high co- insurance on lifesaving medications, and putting all or most medications in a given class, including generics, on the highest cost tier. This creates an undue burden on enrollees who rely on these medications. Unlike employer-sponsored plans, where enrollees usually experience reasonable co- pays, enrollees in the Marketplace are being subject to plans that impose 30%, 40% and even 50% co-insurance per prescription. Such high co-insurance is shocking enrollees and will lead to reduced medication adherence and medical complications as people are unable to afford to begin or stay on medications. Some plans are also imposing high deductibles for prescription medications and high cost-sharing for accessing specialists.

We believe these practices are highly discriminatory against patients with chronic health conditions and may, in fact, violate the ACA non-discrimination provisions.

Transparency and Uniformity:

Individuals must have access to easy-to-understand, detailed information about plan benefits, formularies, provider networks, and the costs of medications and services. Unfortunately, individuals cannot access this information easily through an interactive web tool such as a plan finder or benefit calculator that matches an individual’s prescriptions and provider needs with appropriate plans (such as the one utilized by the Medicare Part D program). Most troubling is the practice of requiring co-insurance without information for an individual to understand what their actual cost-sharing will be. Transparent, easy-to-navigate grievances and appeals processes are needed, along with special enrollment procedures when patients lose access to a medication due to formulary changes during a plan year


Comment by Don McCanne of PNHP: In spite of regulations defining the essential health benefits to be covered, actuarial values of the health plans, and adequacy of plan descriptions, the private insurers continue to use deceit in implementing these regulations to avoid enrolling individuals with greater health care needs. Even if some of the current deceptions are patched, they will always use the marketplace tool of innovation in order to advantage themselves over patients.

Though the government may try to revise regulations as problems arise, no regulation can ever alter the innate amorality of the industry - no, make that immorality. The private insurers need to be replaced with a single payer national health program.

Medicare Advantage continues to steal from taxpayers

http://www.publicintegrity.org/2014/08/07/15216/how-medicare-advantage-plans-code-cash

A new federal study shows that many Medicare Advantage health plans routinely overbill the government for treating elderly patients — and have gotten away with doing it for years.

Analyzing government data never before made public, Department of Health and Human Services researchers found that many plans exaggerate how sick their patients are and how much they cost to treat. Medicare expects to pay the privately run plans — an alternative to traditional Medicare — some $160 billion this year.

The HHS study does not directly accuse any insurers of wrongdoing or name specific plans that were scrutinized. But the researchers offer the most comprehensive evidence to date that suspect billing practices have been common across much of the Medicare Advantage industry and are likely to get worse unless officials crack down.

Medicare pays the Advantage health plans higher rates for sicker patients and less for healthy people using a complex formula called a “risk score.” But the HHS study spells out several ways health plans have inflated those scores, from reporting implausibly high levels of medical conditions such as alcohol or drug dependence to billing for an inordinately high number of patients with complications of diabetes.

Despite its broad implications for Medicare spending, the study by HHS researchers Richard Kronick and W. Pete Welch has attracted scant notice in Washington. It was quietly posted late last month on an online research site run by the Centers for Medicare and Medicaid Services, part of HHS.

Kronick directs the HHS Agency for Healthcare Research and Quality, whose mission is to improve health care delivery. Welch works for the HHS Office of the Assistant Secretary for Planning and Evaluation.


Comment by Don McCanne of PNHP: We have discussed before the ways in which the private Medicare Advantage (MA) plans have been cheating the taxpayers, including cheating the beneficiaries in the traditional Medicare program who are paying higher premiums to support these private MA plans. Today’s message is especially significant since it cites a detailed 19 page report from the director of AHRQ and his colleague - a report which further confirms the private insurers’ distortion of Hierarchical Condition Categories (HCC) to receive extra risk adjustment payments based on upcoding that reports their patients as being more ill than they actually are (i.e., they pad the diagnoses).

The history of Medicare Advantage is that of a steady string of abuses. The program began with overpayments of about 14 percent over the cost of caring for Medicare patients in the traditional program. That overpayment was a deliberate ploy of Congress to give the private plans a competitive market advantage in an effort to privatize Medicare. The plans then selectively enrolled healthier, less expensive patients through deceptive marketing practices. When an effort to correct this favorable selection was made through risk adjustment using Hierarchical Condition Categories, the insurers then padded the diagnoses, as mentioned above. Further, since the Affordable Care Act included adjustments to correct the overpayments, the insurance industry heavily lobbied Congress and the Obama Administration to use three years of accounting gimmicks to reduce the impact of these adjustments. Cheat, cheat, cheat.

What can we expect now? Richard Kronick and W. Pete Welch are reserved in their language when they state, in a footnote, “Some would expect that MA plans will react to the 2013 and 2014 model changes by finding other HCCs on which to focus their efforts, and the success of coding intensity efforts may well increase in the future.”

I’ll be more frank. These crooks will continue to cheat the American taxpayers. They will surely use other HCCs to upcode their patients, until that door is finally slammed shut. What then? The private insurers continually tout to their shareholders the importance of “innovation” in health care coverage. They will always be able to find new and more effective ways to cheat us.

Medicaid premiums significantly reduce signup rates.

http://www.bloombergview.com/articles/2014-08-04/you-qualify-for-medicaid-don-t-sign-up

"The biggest effects in my data were at the margin where folks start having to pay premiums at all," she told me by phone last week. She wasn't sure why that was -- perhaps the difficulty of paying another monthly bill or the psychology of having to pay in the first place.

What makes these papers relevant is that at least four states -- Indiana, Iowa, Michigan and Pennsylvania -- have expanded or are trying to expand Medicaid access in a way that imposes premiums on those making from 101 percent to 138 percent of poverty. Those premiums aren't high: $25 a month in Indiana, $10 in Iowa, $25 in Pennsylvania ($35 for a household) and 2 percent of income in Michigan. But these new studies show that even those small amounts can significantly reduce the number of people who sign up.

That seems to be the point. After all, Medicaid spending per beneficiary will reach almost $6,400 in 2014, against which $120 in premiums each year generates additional revenue that's barely significant. And as Dague notes, imposing a premium at all means spending money to obtain and process those payments.

"If the administrative costs of collecting premiums are high relative to revenue collected," she wrote, "small premiums seem difficult to justify as anything other than a measure to discourage enrollment."


Children’s Health Insurance Program Premiums Adversely Affect Enrollment, Especially Among Lower-Income Children
http://content.healthaffairs.org/content/33/8/1353.abstract

In this article we have examined the effects of public premiums on insurance coverage of children who were eligible for Medicaid or CHIP and whose family incomes were above 100 percent of the federal poverty level in 1999–2010. Higher public premiums are associated with lower public coverage and with increases in private coverage and uninsurance. The magnitudes of these premium effects vary considerably by poverty level and by parental coverage offers.

Among lower-income children, premium increases are associated with larger reductions in enrollment in public coverage, and a larger share of the decline in enrollment takes the form of increased uninsurance. The association between premiums and uninsurance is particularly strong among lower-income children who lack access to employer-sponsored insurance through parental offers.


The effect of Medicaid premiums on enrollment: A regression discontinuity approach
http://www.sciencedirect.com/science/article/pii/S0167629614000642

This paper estimates the effect that premiums in Medicaid have on the length of enrollment of program beneficiaries. Whether and how low income-families will participate in the exchanges and in states’ Medicaid programs depends crucially on the structure and amounts of the premiums they will face.


Comment by Don McCanne of PNHP: The obsession of the policy and political communities with requiring even low income families to experience consumer sensitivity to costs has crossed the bounds into blatant psychopathology, as these studies confirm.

The Medicaid and CHIP programs were specifically designed to provide health care coverage for low income families - a goal with which most caring individuals agree. The very modest Medicaid and CHIP premiums extracted from these families are so small that they have no impact on the overall financing of the programs. Yet they are enough that these families with no discretionary income find these programs to be unaffordable, and so they remain uninsured.

The screwball idea that these premiums somehow make these low income families better consumers is totally void of reason. These premiums merely defeat the purpose of the programs - getting these people the coverage that they need. The psychopathology rests with those who insist that cash payments, no matter how small, are absolutely essential for these families to appreciate the benefits of actively participating in markets rather than passively accepting a government handout. This is ideology gone mad!

Under a well designed single payer system, premiums and cost sharing are eliminated. People simply get the heath care they need when they need it. Paying for the system is totally removed from the delivery of care since it is financed through progressive taxes that everyone can afford.

Weight gain in the American population 1960-2000

http://www.cdc.gov/nchs/data/ad/ad347.pdf

The definitive data are in the above paper. I used the Excel chart function to see how the numbers came out visually. What really jumped out at me was that the crucial dividing year was 1980. Any discussion of possible causes must use this year as a reference. The internet was not in widespread use until the late 90s, so that isn't it. What about HCFS? Was 1980 a turning point of some sort nutritionally? One obvious point to make is that that year is the start of the destruction of the American middle class.

The NHANES studiess are by decade--1960, 1970, 1980, 1990 and 2000. Do a linear regression on 1960, 1970 and 1980, and then on 1980, 1990, and 2000. You get pretty straight lines as indicated by the correlation coefficients. The slopes are an indication of the rate of increase in average weight gain.

Men 1960-1980
Slope = 3.75
R2 = 0.7899

Women 1960-1980
Slope = 2.56
R2 = 0.9204

Men 1980-2000
Slope = 8.6
R2 = 1.000

Women 1980-2000
Slope = 9.4
R2 = 0.9976

For men, after 1980 the rate of increase increased by a factor of 2.3 times.
For women, after 1980 the rate of increase increased by a factor of 3.6 times.

Why Improving Access to Health Care Does Not Save Money

http://www.nytimes.com/2014/07/15/upshot/why-improving-access-to-health-care-does-not-save-money.html

One of the most important facts about health care overhaul, and one that is often overlooked, is that all changes to the health care system involve trade-offs among access, quality and cost. You can improve one of these – maybe two – but it will almost always result in some other aspect getting worse.

You can make the health care system achieve better outcomes. But that will usually cost more or require some change in access. You can make it cheaper, but access or quality may take a hit. And you can expand access, but that will increase cost or result in some change in quality.

More people being able to get care was the point of the A.C.A. It’s possible that overall health care spending may remain flat or even decrease because of other changes to the health care system, or economic factors outside the system entirely. But with respect to emergency care, prevention and procedures, we should expect that increasing access will lead to more spending, not less.

It’s understandable that supporters of the law want it to increase access, increase quality and decrease spending all at the same time, but that’s very unlikely. Trade-offs occur; we need to be honest, and prepared, for what’s likely to happen.


Reader Comments:

Don McCanne

San Juan Capistrano, CA

The supposedly inevitable trade-offs between access, quality and cost ignore one important intervention regarding cost. The health care financing system in the United States is unique in its profound, costly administrative waste due to the highly inefficient, fragmented financing through a multitude private insurers and public programs (and no programs at all for the uninsured).

Merely changing to a universal single payer program or a national health service model dramatically reduces costs without having a negative impact on access and quality. The future trajectory of cost increases would be shifted downward - achieving that elusive bending of the cost curve. That is one way other nations provide truly universal health care at a per capita cost averaging only half of that of the United States.

In fact, the monopsonistic purchasing of a public program can actually improve quality by obtaining greater value in health care purchasing.

Some of the savings that would accrue by changing to a universal program such as an improved Medicare for all would be redirected to much needed improvements in access.

The important bottom line is that we really can achieve improved access, improved quality, and lower costs by structural reform of our highly dysfunctional financing system - a system that was only expanded by the Affordable Care Act.


Darlene
Albuquerque, NM


This author makes a compelling case that the ACA will not decrease costs because there are trade-offs among access, quality and cost. What he ignores is that we also have another system, Medicare, operating simultaneously, that provides good access and quality and manages to limit cost with little trade-off. In addition, it serves the population that consumes the greatest share of health care. You, good reader, know the difference. This article shows, once more, why we need a single payer system for all.





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