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Gender: Female
Hometown: Washington state
Home country: USA
Current location: Directly above the center of the earth
Member since: Sat Aug 16, 2003, 01:52 AM
Number of posts: 49,490

About Me

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

Journal Archives

Insurers wait until last minute to drop hospitals from plans.


Some central Ohio consumers say a Westerville-based health insurer intended to keep quiet about its plan to drop OhioHealth hospitals and doctors from its provider network until it was too late for many of its enrollees to change their health plan.

In those complaints, the consumers, who mostly live in Franklin or Delaware counties, expressed frustration over InHealth Mutual’s last-minute notice to consumers about its plan to drop most OhioHealth providers as of March 1.

Many consumers said they were not notified of InHealth’s plan to narrow its provider network until last week, though some received robocalls on Jan. 30, the day before the deadline to sign up for health insurance through the federally run health-insurance marketplace.

During the first half of January, InHealth’s leaders decided to drop OhioHealth from the provider network. An official with the Ohio Department of Insurance said that InHealth contacted the department late on Jan. 15, triggering a required 15-day review period during which department officials review documents to ensure that insurance companies clearly explain provider-network changes to consumers.

Comment by Don McCanne of PNHP: One of the more important considerations in selecting plans offered through the healthcare.gov insurance exchanges is whether or not an individual’s physicians and hospitals are included in the provider networks selected by the insurer. Although this is supposed to place more control into the hands of the health care consumer, in fact, the insurer is free to change the provider network at any time, yet the patient is prohibited from changing insurers outside of the open enrollment period. Patients lose their providers and can’t do anything about it until open enrollment for the next year.

The Affordable Care Act does allow special enrollment periods for unavoidable circumstances wherein a person loses their coverage, but CMS is reducing these special enrollments to prevent patients from supposedly gaming the system. Apparently it is acceptable for insurers to game the system through bait and switch of their provider networks, but Andy Slavitt, the acting CMS administrator, stated that he will not open up enrollment for these victims of bait and switch.

Really, is cracking down on special enrollment periods to the detriment of the patient the type of incremental change we can expect going forward? Great for the insurers, terrible for the patients.

What is wrong here? It is that the model of health care financing that has been foisted on us is one that is designed to take good care of the insurers while treating patients as a necessary nuisance since insurers otherwise would not have a business without them.

Yesterday the citizens of New Hampshire had something to say about a government that takes good care of the wealthy but makes middle- and low-income individuals second class citizens. We have a crying need for a single payer national health program, so it has to be up to us to select politicians who will bring it to us. Most of those currently in office are not going to do it.

The President’s Proposed FY 2017 Budget: The Impact on Medicare

From the Center for Medicare Advocasy.

On February 9, 2016, President Obama unveiled his Fiscal Year 2017 Budget. With respect to Medicare, this year’s proposed budget is very similar to last year’s, both good and bad, with some notable exceptions. While not a comprehensive analysis of all of the Medicare-related provisions, the Center for Medicare Advocacy provides these comments about the budget’s potential impact on Medicare beneficiaries, including their access to services and out-of-pocket expenses.

Proposals We Support

Prescription drug rebates – The President's drug rebate proposal would restore the law to what it was before Part D, by allowing Medicare to benefit from the same rebates that Medicaid receives for brand name and generic drugs provided to beneficiaries who receive the Part D Low-Income Subsidy (LIS). Drug manufacturers would pay the difference between rebate levels already provided to Medicare Part D programs. Manufacturers would also be required to provide an additional rebate for brand name and generic drugs when their prices rise faster than inflation. Implementing drug rebates would save the Medicare program $121.3 billion over ten years.
Other drug-related provisions – Common-sense provisions aimed at bringing greater transparency to drug pricing and obtaining fair drug prices include prohibiting “pay for delay” arrangements between brand and generic drug manufacturers, which slow the entry of more affordable generics into the marketplace, and shortening the length of exclusivity for biologics from 12 years to 7 years. A proposal first introduced in last year’s budget would allow the Secretary of Health and Human Services to negotiate prices with drug manufacturers for biologics and high-cost prescription drugs covered under Part D. (While we support broader negotiation authority, this would be an important first step.)
Closing the Part D Donut Hole more quickly – The President's budget would close the Donut Hole in 2018 – 2 years sooner than under current law – by accelerating manufacturer drug rebates and increasing brand-name drug discounts in the Donut Hole.
Eliminating 190 day cap on inpatient psychiatric hospital care – As noted in the President’s budget, this limit on services “is one of the last obstacles to behavioral health parity in the Medicare benefit.” A provision in the President’s budget would remove this obstacle.
Allow Secretary of HHS to introduce Medicare primary care incentive payments – In an effort to boost access to primary care providers, the Affordable Care Act implemented a temporary 10% primary care incentive payment program. The proposed budget would allow the Secretary to introduce additional primary care payments into the Medicare physician fee schedule; such payments would be exempt from beneficiary cost-sharing.

In addition, the Center supports repeal of the 36 month rental for oxygen equipment as a better alternative for beneficiaries who have been left without services and equipment between months 37 and 60 in the event they moved from a service area or had unmet maintenance needs.

We also support the proposal to eliminate beneficiary coinsurance for screening colonoscopies with polyp removal, but urge expansion of this concept to other medically necessary services received at the time of, and obtained as a result of, preventive services or screenings.

One provision would suspend coverage and payment for questionable Part D prescriptions. If the Secretary uses this new authority to require additional information about nursing home residents who are prescribed antipsychotic drugs under Part D, this proposal could lead to a necessary reduction in the inappropriate, off-label, and life-threatening prescribing of these drugs. Conversely, adequate safeguards would be required in order to ensure that proposed conditions of coverage do not restrict access to medically necessary medications.

The Budget proposes to achieve over $77.2 billion in savings over 10 years by reforming Medicare Advantage (MA) payments through competitive bidding. The Center is generally in favor of leveling the playing field between traditional Medicare and MA, and addressing wasteful payments such as MA “upcoding” (plans reporting enrollees as being more sick than they actually are for purposes of receiving higher risk-adjusted payments). However, it is unclear how this provision would play out, and whether it would adequately address wasteful spending on MA plans above traditional Medicare levels.

The Budget proposes setting a national standard for income and asset definitions for the Medicare Savings Programs. Currently, the eligibility criteria are federal standards; states may have more, but not less, generous standards. For example, Connecticut currently has no asset limit for the Qualified Individual Program (QI). It is unclear from the proposal whether the national standards would be made more generous, or if the new standards would be more restrictive than what some states currently use. Therefore, more details are needed to determine if this budget proposal would be helpful or harmful for low income beneficiaries.

Proposals of Concern

The FY 2017 Budget includes a number of Medicare legislative proposals that would reduce net Medicare spending by $419.4 billion over 10 years. Unfortunately, approximately $56.4 billion of the total would be saved by implementing “structural reforms” that would shift additional costs directly onto Medicare beneficiaries. The Center continues to oppose these proposals. We note that one provision that would have added a surcharge on Part B premiums for new beneficiaries who purchase Medigap policies with low cost-sharing, included in previous budgets, was excluded from the FY 2017 budget. Presumably, this is because Congress passed a physician payment bill in 2015 that imposes limitations on Medigaps purchased by new beneficiaries beginning in 2020. Thus the concept is unfortunately already in the law.

Implementing a Co-Payment for Home-Health Care. Starting in 2020, this proposal would create a home health co-payment of $100 per 60-day home health episode, applicable for episodes with five or more visits not preceded by a hospital or other inpatient post-acute care stay. As the Center has argued in the past, this provision is misguided. It will create a barrier to home-and-community based services, encourage hospitalization and decrease home care for people with long-term and chronic conditions. Further the cost-savings are minimal.

Increasing the Part B Deductible for New Beneficiaries. The President's plan would increase the Part B deductible ($166 in 2016) for new beneficiaries by $25 dollars in 2020, 2022 and 2024 (for a total $75 increase). This proposal continues efforts to increase out-of-pocket costs for Medicare while beneficiary incomes remain low. According to the Kaiser Family Foundation, 50% of Medicare beneficiaries’ annual incomes are below $24,500.

Further expanding Means-Testing of Medicare Part B and D Premiums. Certain Medicare beneficiaries already pay higher Part B and D premiums based upon their income. Starting in 2020, this proposal would increase the amount of premiums paid by higher income individuals and also freeze the income level for higher payments at $85,000, not adjusting for inflation, cost of living, or any other such factors, until 25% of beneficiaries were paying the higher premiums.

Encouraging the Use of Generic Drugs by Low-Income Beneficiaries.
Starting in 2018, this proposal would force the increased use of generic drugs by Part D Low-Income Subsidy (LIS) enrollees by doubling copayments for brand name drugs from their current low level, while lowering specified copayments for generic drugs. We generally support promoting the use of generic drugs as long as individuals are not denied access to medically necessary brand name drugs. We do not support doing so by correspondingly increasing the cost-sharing for brand name drugs paid by low-income individuals.

Part D “lock-in” proposal – In an effort to prevent prescription drug abuse, the budget includes a proposal to allow the Secretary of HHS to establish a program in Part D that “would require that high-risk Medicare beneficiaries only utilize certain prescribers and/or pharmacies to obtain controlled substance prescriptions”. While the proposal notes that the program would be “required to ensure that beneficiaries retain reasonable access to services of adequate quality” we are concerned that, among other things, such a program might be overly restrictive on beneficiaries without adequate focus on potential provider-side solutions.

Various payment reforms
– While we support paying providers accurately for high-quality services, we are concerned about how access to care might be negatively impacted by several proposals aimed at delivery system and payment reforms. For example, one proposal focuses on Budget-Neutral Value-Based Purchasing for Skilled Nursing Facilities, Home Health Agencies, Ambulatory Surgical Centers, Hospital Outpatient Departments, and Community Mental Health Centers. Value-based purchasing (VBP) demonstrations in Medicare Advantage, hospitals, and skilled nursing facilities did not find improved quality of care for Medicare beneficiaries or reduced Medicare costs. Extending VBP in a budget-neutral manner also perpetuates racial disparities. Another proposal seeks to Reinstate the 75% Rule for Inpatient Rehabilitation Hospitals. By increasing from 60% to 75% the percentage of inpatient rehabilitation hospital (IRH) patients who must meet one of 13 conditions, the proposal would restrict the availability of IRHs for Medicare beneficiaries who need the intensive rehabilitation that only IRHs can provide.

Providing Authority to Expand Competitive Bidding for Certain Durable Medical Equipment -- The Budget proposes to expand the competitive bidding program (CBP) to additional categories, including (but apparently not limited to): inhalation drugs (which are already included in the CBP); ostomy, tracheostomy, and urological supplies (which makes sense given their recurrent, standard, and general nature); and all prosthetics and orthotics. The category of “all” prosthetics and orthotics is cause for great concern. Straying far from the standard and general nature of current CBP categories into customized prosthetics and orthotics is a mistake. Uniquely tailored items should not be included in a volume driven, non-customized competitively bid program. Access and availability for customization that is medically necessary will be reduced when suppliers are not compensated for the extra labor and unique equipment. Customized orthotics and prosthetics should not be included in the CBP.

Reforming the Medicare Appeals Process - the Center has considerable experience representing beneficiaries in the Medicare administrative appeals process. Regrettably, we have witnessed greatly diminished success rates at the lower levels of review, and significant delays in obtaining administrative law judge (ALJ) hearings ─ where beneficiaries receive the fairest review of their claims. Given this experience, we are greatly alarmed at proposals first introduced in last year’s budget and reintroduced this year that would further restrict access to meaningful review of individuals’ claims. These proposals include:
Establishing a refundable filing fee for providers, suppliers, and State Medicaid agencies, including those acting as a representative of a beneficiary, at each level of Medicare appeal;

Increasing the amount in controversy (AIC) for ALJ hearings (the 3rd, and most meaningful, stage in the appeals process) to equal the amount required for judicial review in federal court (the 5th and final stage in the appeals process). The ALJ AIC would increase ten-fold (from $150 in 2016 to $1,500);
Allowing attorney adjudicators (presumably with less experience and training than ALJs) to hear appealed claims below the higher AIC threshold;

Remanding appeals to the redetermination level if new evidence is introduced. As noted above, beneficiaries, who often have problems obtaining timely documents and other support for their appeals, experience an almost non-existent success rate at these lower appeal levels (a denial rate of about 98%).

In December 2015, the Audit & Appeal Fairness, Integrity, and Reforms in Medicare (AFIRM) Act of 2015 (S. 2368) was introduced in the Senate. Working from these appeals proposals in last year’s Budget, the Senate Finance Committee improved several issues of concern to beneficiaries, but left others in place when marking up the AFIRM Act in June 2015. The Center remains concerned that rather than addressing the underlying reasons for the appeals backlog, (including the dreadful quality of review at the first two levels of appeal, and the enormous volume of inappropriate classification of inpatient hospital stays as outpatient Observation), these proposals would hinder beneficiary appeal rights.


The Center supports a number of provisions of the President’s proposed budget that would improve the program’s finances without harming beneficiaries or reducing access to care. We remain concerned, however, about provisions that would shift additional costs to beneficiaries and hinder access to both care and meaningful review of coverage denials.

Licking Wounds, Insurers Accelerate Moves To Limit Health-Law Enrollment


Stung by losses under the federal health law, major insurers are seeking to sharply limit how policies are sold to individuals in ways that consumer advocates say seem to discriminate against the sickest and could hold down future enrollment.

In recent days Anthem, Aetna and Cigna, all among the top five health insurers, told brokers they will stop paying them sales commissions to sign up most customers who qualify for new coverage outside the normal enrollment period, according to the companies and broker documents.

Last year, these “special enrollment” clients were much more expensive than expected because lax enforcement allowed many who didn’t qualify to sign up, insurers said. Nearly a million special-enrollment customers selected plans in the first half of 2015, half of them after losing previous coverage.

In addition, Cigna and Humana, another big health insurer, have ceased paying brokers to sell many higher-benefit “gold” marketplace plans for individuals and families while continuing to pay commissions on more-profitable, lower-benefit “bronze” plans, according to documents and interviews.

Comment by Don McCanne of PNHP: No matter what legislation, regulations, rules or advisories our government produces, the private insurance industry will always find ways to skirt the intent of this oversight in order to maximize their business goals, usually at a cost to patients and public and private payers. The current efforts of insurers to manipulate the brokers are a prime example of how they will continue to work the system to advance their own interests.

As the Affordable Care Act was being crafted and then implemented, there was a push to include brokers as intermediaries who would provide customer access to the exchange plans. The argument was that brokers were highly qualified to provide guidance on what the best plans would be for their clients. But little was said about how insurers might find ways to use the brokers to to their own advantage.

As this article shows, insurers can heavily influence broker behavior through the commissions they grant. The insurers found that people who were signed up during special enrollment periods had greater health care needs and also were more likely to drop out after their needs were met. That’s easy. The insurers stopped paying commissions for most of the plans sold during these special enrollment periods. Also, people enrolling in gold plans, with their higher actuarial values (covered more of the costs), were also using more health care. Again, no problem. Many insurers quit paying commissions for gold plans but continued to pay them for lower actuarial value plans that required patients to pick up more of the costs of health care. Will the broker sell plans without a commission, when an insurer offers a commission for selling their more profitable plans?

Discrimination in the offering of private insurance plans is prohibited, but AHIP - the insurance lobby - says that insurers are not discriminating but rather are merely adjusting to market realities. Clare Krusing - AHIP’s spokesperson - said that there was no way “to offer the kind of coverage as they had in the past (gold or platinum plans) without sustaining huge losses.” It really is about profits, not patients.

And now many politicians and progressive pundits are telling us to build on Obamacare. Forget about single payer because it will “never, ever come to pass.” Instead let’s control costs through higher deductibles and other cost sharing, narrower networks, greater administrative hassles through ACOs and EHRs that keep professionals from tending to their patients, more opaque obstructions that keep sicker patients out of the private plans, more managed care that reduces access, especially to specialized services, *** **** ****, ***** ** ****, and ** ****** *****.

And those asterisks? They are the hidden future policies of the insurers that will further enhance their business models - policies that we can’t even conceive of since they can only be conjured up by the nefarious minds that are currently in control of our health care financing system. Do we really have to have a health care future that will eventually reveal to us what is behind the magic asterisks? Or shall we tell them on their way out the door where to put their asterisks, as we take over and set up our own single payer national health program?

Insurance companies losing money on ACA

Now that they have to cover actual sick people.


Blue Cross and Blue Shield of NC is expecting to lose more than $400 million on its first two years of Obamacare business. In response to its bleak experience with the Obamacare exchange, the company has decided to eliminate sales commissions for agents, terminate advertising of Obamacare policies, and stop accepting applications on-line through a web link that provides insurance price quotes–all moves calculated to limited Obamacare enrollment.


Aetna has joined other major health insurers in sounding a warning about the Affordable Care Act's public insurance exchanges.

The nation's third-largest insurer said Monday that it has been struggling with customers who sign up for coverage outside the ACA's annual enrollment window and then use a lot of care. This dumps claims on the insurer without providing enough premium revenue to counter those costs.

Comment by Don McCanne of PNHP: The losses experienced by Blue Cross and Blue Shield of North Carolina represent a problem prevalent throughout the nation wherein patients, when they become ill, enter the system during special enrollment periods and then exit once their health care needs are met. The insurers along with CMS have diagnosed the problem. There is nothing wrong with our system of private insurers. It is the patients who are to blame because they are gaming the system.

The solution? Reduce special enrollment periods that were designed to assist patients who fell through the cracks. Instead, protect the insurers by preventing these people from getting coverage for the care that they need. Bankrupt them. That’ll show them.

Reducing special enrollment periods is being touted as one of the improvements that we need in the Affordable Care Act - the type of incrementalism that we should pursue as we reject overtures to establish a single payer national health program. We should pay no regard to the fact that this incremental tweak is designed to assist the private insurers and enhance their profits, at a cost of impairing access and affordability for far too many patients.

Wasn’t the Affordable Care Act designed to provide everyone with affordable access to health care? No. Single payer has such a design, but that was rejected to the benefit of the private insurers.

So now we are supposed to tweak the system to make it work better for patients? No. We are tweaking it to make it work better for private insurers. Damn those patients who try to cheat the insurers by gaming the system.

Oh wait. Under single payer the goal is to deliberately include absolutely everyone. The idea that someone is cheating by trying to sneak into the system is totally foreign to the stewards of egalitarian universal systems. How could anyone even think about devising methods of keeping people out? Perhaps it’s American Exceptionalism at work.

Donna Smith:: What Will We Do With People Like Me?


It all seems an unlikely scenario. It also seems unlikely that a person such as me will have a piece published on Monday morning, February 1, 2016. I don't hold the sway or nearly the level of expertise that so many, many others do in the political world. It also seems such a pivotal time for the nation.

Years ago when Michael Moore filmed my family for his 2007 documentary, SiCKO, one my sons was filmed asking me, "What do we do with people like you?" He was wondering aloud what to do about aging parents who were drowning financially due to medical debt. He was making it clear that his generation didn't want to sweep up the mess that was my life. My heart broke. My spirit was crushed. My child saw me as a failure and worse, my child saw me as a problem to be solved.

That is what this election is all about. To the extent that Iowa sets the stage for what is to come down the road of this election season, the Iowa caucuses may begin to answer the question my child asked so many years ago. What do we do with people like me?

When I view the current candidates for president of the United States, I can see only one who answers the question in a way that prevents any mother from ever hearing that from her son again. You see, I had become such a drain. As the profit-crazed U.S. healthcare system ground away at us with insidious persistence, I fought to make sure my children had access to as many opportunities as I could so that they might never have their dreams deferred or destroyed. I was only partly successful. While I could protect my kids from some of the financial trauma for a time by working more and more, I forever altered their paths forward.

The Real Healthcare Debate We Should Be Having


Recently, a fierce debate has been ignited within the Democratic Party regarding the merits and feasibility of a single-payer Medicare-for-All universal healthcare system. Some liberal commentators have summarily dismissed Senator Sanders' proposal as politically unrealistic or as greatly lacking in details while championing a slightly improved status quo, and other political surrogates have spread GOP-like untruths that have no place in any honest discussion.

Regardless of ones' individual beliefs on Medicare-for-All, it is crucial to note some indisputable facts regarding the Affordable Care Act (ACA) and the current status quo:

1. While the ACA did indeed do some very positive things like end lifetime caps on medical coverage and do away with discrimination for pre-existing conditions, it was never intended to cover every uninsured individual. In fact, after the ACA is fully implemented, the Congressional Budget Office estimates that up to 29 million residents will still remain uninsured.

2. The only area of the ACA that both Democrats and Republicans found mutual agreement on was to exclude our undocumented brothers and sisters.

3. The average insured family still pays an extra $1,017 in premiums (hidden tax) to cover the cost of care for the uninsured.

4. A recent Commonwealth Fund study revealed that 31 million people with insurance had such high out-of-pocket costs or deductibles relative to their incomes that they were UNDER-insured and that 51% of these adults reported problems with their medical bills, while 44% of all adults reported not getting care because of high co-pays and deductibles despite being insured.

5. Even after a significant decrease in the total number of uninsured, there were still 1.7 million medical related bankruptcies in 2014 of which 75% were actually insured, and this is only expected to get worse.

6. Most individuals in the U.S. cannot afford an annual deductible of $6,850 and most families of four cannot afford an annual deductible of $13,700.

7. Despite premiums increasing over 150% over the past 9 years, there is no federal insurance rate regulation.

8. Despite the fact that average branded drug prices have increased 127% during the past 8 years to the point that 73% of Americans now find the cost of drugs unreasonable, there was no mechanism to control drug prices.

9. Many states have huge underfunded retiree healthcare liabilities. California's alone is $150 Billion.

10. Healthcare costs are currently 17.5% of GDP with over 1% of GDP spent on Prescription drugs alone, and will only continue to climb as mandatory federal health spending is projected to double in the next 10 Years.

11. Recent data from the American Journal of Public Health found that tax-funded expenditures accounted for 64.3% of all U.S. health spending. U.S. health spending for 2013 was $9,267 per capita, with government's share being $5,960.

12. Prior to the bailout, GM spent more on healthcare for its employees than it did on steel. Rising healthcare costs are making U.S. companies less competitive and taking money away from wages and capital investments.

13. Most Americans continue to get employer-sponsored healthcare but worker's contributions to premiums have increased 212% since 2000 while wages have only increased 54% during the same period.

14. Healthcare benefits have become the biggest source of labor negotiation strife.

So if anything, most health policy experts believe that our current healthcare system is unsustainable for individuals, businesses, states and our federal government, and to continue this status quo is what is really unrealistic.

The real debate Democrats should be having should not be about whether single payer, a highly successful proven system in so many industrialized nations, is the solution, but rather how we can collectively come together to overcome the corporate forces that derailed the ACA from providing a public option, drug price controls and insurance rate regulation, and how we get to the ultimate goal of Medicare for All.

PBS Newshour Lies About Single-Payer Health Care


According to a 2014 Program for Consultation study analyzing public polling occurring between 2008 and 2013, majorities in both "red" (Republican-dominated) and "blue" (Democratic-dominated) congressional districts prefer government to play a greater role in health care.

When presented with the statement, “Healthcare is a right, not a privilege,” 62.3% of respondents in red districts agreed, compared to 62.9% of respondents in blue districts.

When presented with the statement, “Government should be responsible for ensuring health care needs of its citizens,” 55.6% of respondents in red districts agreed, compared to 64.1% of respondents in blue districts.

The Program for Consultation study even found 47.8% of respondents from red districts to agree that they, “Favor government paying for all necessary medical care for everyone.” That compared to 54.9% of respondents in blue districts.

Meanwhile, a 2015 Progressive Change Institute poll found over 50% of Americans support a single-payer health care system like that proposed by Sanders, including 80% of Democrats.

Given all this, a Newshour viewer may have reasonably hoped that at the very least Marcus, the segment's "left" perspective, would have interjected to correct Woodruff with any of the above. But, alas, Woodruff's complete distortion of reality, whether a result of a confounding ignorance or ideological blindness, passed without comment.

It seems that not even a "trusted news program" on an ostensibly public channel is capable of conceding the progressive views of the American public.

How and Why Medicare for All Is a Realistic Goal


Those two expansions -- lowering the Medicare age and adding children -- would have been easy to explain and popular. They constitute excellent policy, and would have been easily understood by the electorate. A newly-elected Clinton administration, laser-focused on an incremental expansion of Medicare, would have had an excellent chance of success. President Obama could have built on that success, proposing lowering the Medicare age further, raising the Medikids age, and allowing those with pre-existing conditions and others to buy into Medicare at a reasonable price. Eventually, more and more people would have opted in, getting us ever closer to the goal of Medicare for All.

This strategy is still likely to work. It is completely compatible with Obamacare. Medicare is popular among conservatives and liberals alike. Many seniors, who have been a growing part of the Republican base, are hanging on until they reach their 65th birthdays. A Medicare expansion, polls show, is overwhelmingly popular, just as Social Security expansion is. As part of the expansion effort, a new push for a public option, in the form of a Medicare buy-in, would help reach the ultimate goal.

An incremental approach only works if one has a vision of where the incremental steps are leading. In a campaign, candidates present the ultimate goals, not a blueprint for incremental change. But to attack the ultimate goal as unrealistic, when incremental steps can get you there, is a disservice. It is a disservice to all of the millions of Americans who believe that high quality, affordable health care should be a right, not a privilege. It is a disservice to all those who want a more efficient health care system in order to have resources to spend on other pressing domestic needs. It is a disservice to those who see that a more efficient health care system will allow more compensation to be paid in the form of cash wages, as opposed to health insurance.

Claiming that such a noble, important and popular goal -- Medicare for all -- is unrealistic does not show pragmatism. Rather, it shows a lack of imagination.

Study: Some Marketplace Customers Spend 25 Percent of Income on Health Expenses


Even with subsidies to make coverage more affordable, many people who buy health insurance on the marketplaces spend more than 10 percent of their income on premiums, deductibles and other out-of-pocket payments, a recent study found. Among those hit hardest, the researchers said, are people who spend nearly a quarter of their income on health care expenses.

“There’s been a lot of talk about how high deductibles and out-of-pocket costs are in the Affordable Care Act, and a lot of anecdotes about that, and this quantifies that in a more systematic way,” said John Holahan, a fellow at the Urban Institute’s Health Policy Center who co-authored the study.

The study used a model to estimate expected household spending on health insurance premiums and out-of-pocket expenses by individuals and families at different income levels using the marketplaces in 2016.

The analysis incorporated tax credits that are available on a sliding scale to people with incomes between 100 and 400 percent of the federal poverty level ($11,770 to $47,080 for an individual) to help subsidize the cost of premiums. It also included cost-sharing reductions that lower out-of-pocket spending for people with incomes up to 250 percent of the federal poverty level ($29,425 for one person) if they purchase silver plans on the online marketplaces.

Despite the financial assistance provided by the health law, people with modest incomes and average medical expenses have relatively heavy financial burdens for health care, the study found.

LTE from doctors to Krugman.on single payer


I’m glad to see that Paul Krugman acknowledges that “if we could start from scratch, many, perhaps most, health economists would recommend single-payer, a Medicare-type program covering everyone.” His argument that we should not work for it now is unconvincing.

Just because private insurers are powerful doesn’t mean a concerted national campaign can’t overcome their well-funded opposition. Already a majority of the general public (58 percent in a recent Kaiser poll) supports single-payer. Cost will never be controlled until we do away with the bloated administrative expenses of our hopelessly complex financing arrangements and for-profit medicine.
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