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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, 02:52 AM
Number of posts: 51,907

About Me

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

Journal Archives

Libby, Montana, has single payer health care thanks to Baucus


Yet when Senator Baucus needed a solution to a catastrophic health disaster in Libby, Montana, and surrounding Lincoln County, he turned to the nation’s single-payer health care system, Medicare, to solve the problem.

Baucus’ problem was caused by a vermiculite mine that had spread deadly airborne asbestos, killing hundreds and sickening thousands in Libby and northwest Montana. The W.R. Grace Company that owned the mine denied its connection to the massive levels of mesothelioma and asbestosis and dodged responsibility for this environmental and health disaster. When all lawsuits and legal avenues failed, Baucus turned to our country’s single-payer plan, Medicare.

The single-payer plan that Baucus kept off the table is now very much on the table in Libby. Unknown to most of the public, Baucus inserted a section into the health reform bill that covers the suffering people of Libby, not just the former miners but the whole community – all covered by Medicare.

They don’t have to be 65 years old or more. They don’t have to wait until 2014 for the state exchanges. No 10-year rollout – it’s immediate. They don’t have to purchase a plan – this is not a buy-in to Medicare – it’s free. They don’t have to be disabled for two years before they apply. They don’t have to go without care for three years until Medicaid expands. They don’t have to meet income tests. They don’t have to apply for a subsidy. They don’t have to pay a fine for failure to buy insurance. They don’t have to hope that the market will make a plan affordable. They don’t have to hide their pre-existing conditions. They don’t have to find a job that provides coverage. Baucus inserted a clause in the Affordable Care Act to make special arrangements for them in Medicare, and he didn’t wait for any Congressional Budget Office scoring to do it.

Healthcare costs top U.S. executives' concerns: Adecco survey


U.S. corporate executives are more worried about providing healthcare benefits to their employees than about issues like wages, taxes or attracting qualified workers, according to a survey by the world's No. 1 staffing company, Adecco SA.

In Adecco's poll of senior executives, 55 percent named healthcare benefits as their biggest current business challenge, and about a third say they are holding back hiring because of healthcare reforms introduced by U.S. President Barack Obama.

Healthcare's prominence as an issue has risen since the 2008-2009 recession, Adecco found: in 2007, only 35 percent called healthcare their top worry.

Comment by Don McCanne of PNHP: The Affordable Care Act (ACA) was designed to not disturb the largest sector of health insurance coverage already in existence: employer-sponsored health plans. Although costs were said to be almost intolerable for many employers, ACA included provisions to improve private health plans which will further increase costs for employers. Thus it is no surprise that health care has moved up on the executives' list of concerns as their biggest business challenge.

Before the Democrats settled on the ACA model of reform, employers were looking for better ways of controlling costs. One of the models under consideration was single payer, an attractive option because of its greater efficiencies and assured coverage of everyone.

Business executives might have been more interested in the single payer model except for two perceived drawbacks: 1) They were not assured that they wouldn't have to foot much of the bill for a national health program through higher payroll taxes, higher taxes on executive compensation, and higher corporate taxes, and 2) Many of them are ideologically conservative and did not want to see a government-run health care financing system.

With the passage of ACA health care moved from a top concern of 35 percent of the executives to a top concern of 55 percent of them. That suggests that they may believe they made a bad decision in passively allowing ACA to move forward, though there was token opposition from the U.S. Chamber of Commerce and the National Federation of Independent Business.

Another change taking place is that businesses are relying more on Medicare for their retirees as they pare back their health benefit programs for former employees. Obviously they recognize that Medicare provides a greater value for them than did their private programs, especially because of the federal funding of Medicare. It would not be much of a reach for them to decide that Medicare would also provide a greater value for them if it became the health benefit program for their active employees.

If we were to move forward with an improved Medicare that covered everyone, then the employers would need to be convinced that the taxes to fund the universal risk pool would be equitably distributed, and that they would not have to bear an unfair excessive financial burden for the program. Without getting into details on tax policy, suffice it to say that such a goal is readily achievable.

That would leave only ideology as a hurdle. Successful businessmen certainly place great importance on value. When it is demonstrated to them that an improved Medicare for all would control their health care costs well into the indefinite future, they would be very foolish to reject such a good deal. They really wouldn't have to give up their ideology. They could take it to the smoking lounge and vent with their business colleagues, over a cigar and a snifter of brandy, how terrible it is that they had to accept the terms of a single payer system, but, after all, business is business.

George McGovern: What It Means to Be a Democrat

Blue Rider Press, Penguin Group

What It Means to Be a Democrat
By George McGovern

Universal Health Care

In 2010, Barack Obama and the Democrats in Congress did an outstanding job in passing the Patient Protection and Affordable Care Act to make health insurance available for every American. The bill passed without a single Republican vote.

The law is being phased in over five years, but it already has eliminated some of the major shortcomings of the private insurance system. It has made health care coverage available to more children and young adults, ended
lifetime limits on coverage, made more preventive services available at no cost, improved pharmaceutical coverage for seniors on Medicare, and provided tax credits to small businesses that insure their employees. The law also prohibits insurers from the heinous practice of denying coverage to children who have preexisting conditions, a provision that later will be extended to adults. It offers much-needed discipline to the insurance companies, which have called the shots for far too long.

But I think we should go further.

We should replace the 906-page bill, which I'm sure many lawmakers and most citizens haven't read, with a seven word sentence that reads: "Congress hereby extends Medicare to all Americans."

My firsthand experience with Medicare has convinced me that a Medicare-like plan, or single-payer system such as Canada enjoys, should apply to everyone, not just to old duffers like me.

Future of Medicare is top concern for 61% of seniors


Thinking about retirement, are any of the following concerns for you?

61% - Future of Medicare
52% - Having enough money to enjoy retirement
43% - Paying for long-term care
41% - Paying for health care
38% - Outliving money
24% - Paying for housing

In general, how satisfied are you with your current Medicare coverage?

45% - Extremely satisfied
44% - Somewhat satisfied
6% - Not satisfied
5% - Not sure

As you may know, costs for the Medicare program are rapidly increasing. New funding or benefit restructuring will likely be needed. To keep the Medicare coverage you have right now, would you be willing to pay: 20% more/10% more/5% more/1% more?

32% - Pay 20% more
19% - Pay 10% more
10% - Pay 5% more
10% - Pay 1% more
23% - Pay nothing more
4% - Don't know
2% - Medicare won't need new funding

Comment by Don McCanne of PHHP: This survey confirms what we already knew. Most seniors are satisfied with Medicare, but a majority of them also are concerned about the future of Medicare, doubtlessly provoked by the current political threats to convert Medicare into a defined contribution (voucher) under the rubric of the imperative for entitlement reform. An intriguing inquiry in this survey is whether or not Medicare beneficiaries would be willing to pay more in order to keep their current Medicare coverage.

Sixty-one percent of responders indicated that they would be willing to pay five to twenty percent more to keep their current Medicare coverage. This probably does not communicate their belief that they should be paying more, but rather expresses the view that they are protective of Medicare and would be willing to reach deeper into their pockets to preserve the program.

It would not surprise anyone if the politicians used this result to decide to increase the out-of-pocket expenses for Medicare beneficiaries, again in the name of entitlement reform. But this would be a mistake. In a recent
Quote of the Day message, we discussed Medicare's failure to protect personal finances (http://www.pnhp.org/news/2012/september/medicares-failure-to-protect-personal-finances). Instead of increasing out-of-pocket costs, financial barriers should be removed by providing first-dollar coverage. You could do that by adopting a single payer system. Health care costs can be controlled by using the other economic tools of a well-designed single payer system.

Rather than using premiums, deductibles and coinsurance assigned to the individual Medicare beneficiary, an improved Medicare program that covered everyone should be separately funded through progressive taxes. The current proposal to adjust Medicare premiums based on income would seem like a step in the right direction, but it would add more unnecessary administrative complexity to Medicare financing. It would be far better to establish a single, separate universal risk pool, funded based on ability to pay, and then to provide health services based on need regardless of the individual's financial status. We should totally separate health care funding from the delivery of health care services, just like we do with police protection, fire protection, highway systems, public education and the many other government functions that we rightfully take for granted.

My comment: A 20% increase in Medicare costs would be a financial disaster for many seniors. However, given the shitty expensive individual policies available to people 50-64, it's no surprise that seniors don't want to go back to that situation.

The US is two different countries, with two different approaches to health care


In all kinds of real and practical ways, the United States today is not one nation, but two.

By nearly every measure, people who live in the blue states are healthier, wealthier, and generally better off than people in the red states. It's impossible to prove that this is the direct result of government spending.

But the correlation is hard to dismiss. The four states with the highest poverty rates are all red: Mississippi, Louisiana, Alabama, and Texas. (The fifth is New Mexico, which has turned blue.) And the five states with the lowest poverty rates are all blue: New Hampshire, New Jersey, Vermont, Minnesota, and Hawaii. The numbers on infant mortality, life expectancy, teen pregnancy, and obesity break down in similar ways.

Advocates for the red-state approach to government invoke lofty principles: By resisting federal programs and defying federal laws, they say, they are standing up for liberty. These were the same arguments that the original red-staters made in the 1800s, before the Civil War, and in the 1900s, before the Civil Rights movement. Now, as then, the liberty the red states seek is the liberty to let a whole class of citizens suffer. That's not something the rest of us should tolerate. This country has room for different approaches to policy. It doesn't have room for different standards of human decency.

Miss. says no thanks to Medicaid expansion dollars


Mississippi has long been one of the sickest and poorest states in America,with some of the highest rates of obesity, diabetes and heart disease and more than 1 in 7 residents without insurance. And so you might think Mississippi would jump at the prospect of billions of federal dollars to expand Medicaid.

You'd be wrong.

Leaders of the deeply conservative state say that even if Mississippi receives boatloads of cash under President Barack Obama?s health care law, it can?t afford the corresponding share of state money it will have to put up to add hundreds of thousands of people to the government health insurance program for the poor.

Commentby Don McCanne of PNHP: One strategy in the Affordable Care Act that was introduced to help cover everyone was to expand the Medicaid program for low-income individuals. To encourage state participation, the federal government would pay the full costs of care for three years and then taper down to 90 percent, leaving the states responsible for only 10 percent of the costs. Yet Governors Bryant, Scott, Jindal, Deal, Haley, and Perry have rejected the program, decisions which will surely leave many otherwise qualified individuals with no coverage.

Those of us who supported single payer reform - an improved Medicare for all - warned repeatedly that the model enacted in the Affordable Care Act could never cover everyone. Current predictions are that 30 million people will remain uninsured (CBO).

This is shocking and fills with grief those of us who have been fighting so long and hard for health care justice in America. It is worth repeating the last paragraph in Jonathan Cohn's article because he states it so well:

Advocates for the red-state approach to government invoke lofty principles: By resisting federal programs and defying federal laws, they say, they are standing up for liberty. These were the same arguments that the original red-staters made in the 1800s, before the Civil War, and in the 1900s, before the Civil Rights movement. Now, as then, the liberty the red states seek is the liberty to let a whole class of citizens suffer. That's not something the rest of us should tolerate. This country has room for different approaches to policy. It doesn't have room for different standards of human decency.

Raising the Medicare Eligibility Age Would Increase Total Health Care Costs

In a recent blog post, Paul Van de Water of the Center on Budget and Policy Priorities (CBPP) discusses why raising the Medicare eligibility age from 65 to 67 would save the federal government money only by shifting expenses to older adults and employers. In fact, Van de Water explains, this change would cause total health care costs to increase, as costs to consumers would be twice as large as any net federal savings. Citing a study conducted by the Kaiser Family Foundation, Van de Water pinpoints the reasons for these increased costs: http://www.kff.org/medicare/med032911nr.cfm

•65- and 66-year-olds, who could no longer depend on Medicare, would pay more on average for premiums and cost-sharing;
•Employers who provide retiree coverage would become primary payers for their retirees under the age of 67;
•Medicare beneficiaries over the age of 67—as well as younger people who purchase health insurance through the state exchanges that will be implemented in 2014—will have higher premiums. As 65- and 66-year-olds seek insurance through the exchanges, the beneficiary pools of both the exchanges and Medicare itself would be older, sicker and more costly;
•State Medicaid costs would rise, as people without Medicare would depend on Medicaid for coverage.

Policymakers who support raising the Medicare eligibility age argue that under the Affordable Care Act (ACA), older adults no longer covered by Medicare would have adequate insurance through state exchanges or Medicaid. Many proposals to raise the Medicare eligibility age assumed that states would be required to expand Medicaid coverage to everyone with incomes below 133 percent of the federal poverty limit up to age 67. However, according to Van de Water, the recent Supreme Court decision that upheld the constitutionality of the ACA, but ruled that the federal government could not withhold states’ existing Medicaid funds for not expanding Medicaid coverage, means a significant number of poor 65- and 66-year-olds would lack affordable health insurance. Moreover, Van de Water writes, more states may refuse to expand Medicaid coverage because they would bear the costs for these individuals, putting the health and financial security of low-income older adults at risk.

Health Affairs: Financial incentives may sap motivation, undermine quality

Physicians for a National Health Program (PNHP)
Press Release
October 12, 2012
Financial incentives may sap motivation, undermine quality: Health Affairs

A leading authority on behavioral economics has teamed up with two health policy experts in an article at the Health Affairs blog to argue that pay-for-performance (P4P) schemes in medicine may do more harm than good by ?crowding out? altruism and other intrinsic motivations to do a good job.

Such P4P schemes, which are being quickly adopted by Medicare and many private insurers under the new federal health law, typically involve giving bonuses to doctors and hospitals for hitting specific, numerical targets in such matters as prescribing certain drugs or ordering screening tests.

However, despite the widespread rush to embrace P4P, a growing body of research has found no evidence that these schemes actually benefit patients, write professor Dan Ariely and physicians Dr. Steffie Woolhandler and Dr. David Himmelstein. Their article was posted to the blog late Thursday afternoon.

Moreover, it's likely the introduction of such schemes into the cognitively complex work of medicine will backfire, they say.

"Traditionally, economists have viewed extrinsic (i.e. monetary) reward as either the only motivator or as simply additive to intrinsic motivators such as purpose, altruism, mastery, or autonomy," the authors write.

"According to this view, higher pay induces better performance. But this simple model of reward-induced performance ignores the complexity of human drive, particularly the role of intrinsic motivation--the desire to perform an activity for its own inherent rewards.

"Offering your dinner-party host a $10 reward for cooking a wonderful meal isn?t likely to motivate future invitations."

The authors cite multiple research studies--involving blood donors in the United States, volunteer workers in Switzerland, and Israelis with children in day care, to name just a few--that show how introducing financial incentives into the picture led to diminished motivation to do the right thing.

They also cite a meta-analysis summarizing 128 studies that show such findings are representative of a consistent body of research.

In addition, the authors warn that 'crowd-out' of doctors' intrinsic motivation may be particularly severe when contracts are more detailed and controlling. P4P incentives may also lead providers to game the system by checking boxes or exaggerating diagnoses when they know that doing so will garner bonuses.

Pay-for-performance programs also increase administrative costs, they say, citing the extensive economics literature on the downsides of overly detailed contracts.

The authors are recognized experts in their respective fields. Dan Ariely is the James B. Duke Professor of Psychology and Behavioral Economics at Duke University. He is the author of numerous research studies and three bestselling books on behavioral economics, including "The (Honest) Truth about Dishonesty"

Dr. Steffie Woolhandler and Dr. David Himmelstein are physicians and professors at the City University of New York's School of Public Health at Hunter College and visiting professors of medicine at Harvard Medical School. They have published many articles in leading medical journals on health insurance and mortality, medical bankruptcy and administrative costs in health care, among other subjects. They are also co-founders of Physicians for a National Health Program, a single-payer advocacy group. PNHP provided no financial or other support for their research.

Health Affairs Blog

Will Pay For Performance Backfire? Insights From Behavioral Economics

Paying for performance (P4P) has strong intuitive appeal. Common sense and rigorous studies tell us that paying more for, say, angioplasties or immunizations yields more of them. So paying doctors and hospitals for better care, not just more of it, seems like a no-brainer. Yet while Medicare and many private insurers are charging ahead with pay-for-performance (P4P), researchers have been unable to show that it benefits patients.

Findings from the new field of behavioral economics may explain these negative results. They challenge the traditional economic view that monetary reward is either the only motivator or is simply additive to intrinsic motivators such as purpose or altruism. Studies have shown that monetary rewards can undermine motivation and worsen performance on cognitively complex and intrinsically rewarding work, suggesting that P4P may backfire.

PNHP press release: Private insurers have cost Medicare $282.6 billion in excess payments since 1985

NHP press release: Private insurers have cost Medicare $282.6 billion in excess payments since 1985


October 10, 2012

Ida Hellander, M.D.
Steffie Woolhandler, M.D., M.P.H.
David Himmelstein, M.D.
Mark Almberg, communications director PNHP, (312) 782-6006, [email protected]

Researchers say privately run Medicare Advantage plans have undermined traditional Medicare’s fiscal health and taken a heavy toll on taxpayers, seniors and the U.S. economy

In the first study of its kind, a group of health policy experts has determined the amount of money that Medicare has overpaid private insurance companies under the Medicare Advantage program and its predecessors over the past 27 years and come up with a startling figure: $282.6 billion in excess payments, most of them over the past eight years.

That’s wasted money that should have been spent on improving patient care, shoring up Medicare’s trust fund or reducing the federal deficit, the researchers say.

The findings appear in an article by Drs. Ida Hellander, Steffie Woolhandler and David Himmelstein titled “Medicare overpayments to private plans, 1985-2012.” The article was released online today and is forthcoming in the International Journal of Health Services.

Hellander is policy director at Physicians for a National Health Program (PNHP), a nonprofit research and advocacy group. Woolhandler and Himmelstein are professors at the City University of New York School of Public Health, visiting professors at Harvard Medical School and co-founders of PNHP.

The article appears at a time when some lawmakers, including vice presidential candidate Paul Ryan, have proposed a dramatic expansion of private Medicare plans and criticized the Obama administration for the modest cuts in the overpayments contained in the Affordable Care Act (ACA). However, the administration has also touted the fact that private plans are on the upswing.

Private Medicare plans – previously referred to as Medicare HMOs and now called Medicare Advantage plans – have been in existence for about three decades. Such plans, most of them for-profit, currently cover about 27 percent of Medicare enrollees and have been growing at a fast clip. UnitedHealth and Humana are among the largest players in this market, and together operate about one-third of such plans.

Medicare pays these privately run plans a set “premium” per enrollee for hospital and physician services (averaging $10,123 in 2012) based on a prediction of how costly the enrollee’s care will be.

The authors find that private insurers have exploited loopholes to garner overpayments above and beyond what it costs them to care for their enrollees. For instance, Medicare gives private insurers a full premium for each enrollee, even for those who get most of their care for free at the Veterans Health Administration.

In addition, through heavy lobbying, the insurance industry induced Congress and the Bush administration to add bonus payments to Medicare Advantage premiums beginning in 2003.

Finally, private plans cherry-pick by enrolling seniors whose care will cost far less than the premiums, guaranteeing large profits. Although private plans must accept all seniors who choose to enroll, they cherry-picked by selectively recruiting the healthiest seniors through advertising, office location, etc., and induced sicker ones to disenroll by making expensive care inconvenient.

After Medicare began risk adjusting the premium payment for each patient’s diagnoses in 2004, the plans began cherry-picking in a new way. They recruited otherwise healthy seniors with very mild (and inexpensive) cases of sometimes serious conditions – automatically triggering higher premiums from the risk-adjustment scheme, but escaping payments for expensive care. For instance, many seniors have very mild cases of arthritis, heart failure and bronchitis that require little or no treatment.

The full report includes further details on these and other schemes that private insurers have used to increase their Medicare payments.

“We’ve long known that Medicare has been paying private insurers more than if their enrollees had stayed in traditional free-for-service Medicare, but no one has assessed the full extent of these overpayments,” said Dr. Ida Hellander, lead author of the study. “Nor has anyone systematically examined the many ways that private insurers have gamed the system to maximize their bottom line at taxpayers’ expense.”

“In 2012 alone, private insurers are being overpaid $34.1 billion, or $2,526 per Medicare Advantage enrollee,” Hellander said.

Co-author Dr. Steffie Woolhandler said: “It’s clear that having Medicare Advantage programs compete with Medicare doesn’t save us money. In fact the opposite is the case. The private plans only add waste, and the aggregate waste is staggering – enough to be a significant drag on the economy.

“Unfortunately, recent legislative and technical attempts to reduce Medicare’s overpayments to these insurance firms have had little or no impact,” she said.

“It’s time we look to proven, cost-effective ways of providing high-quality care to Medicare’s beneficiaries and to the entire population,” Woolhandler said. “That means taking a fresh look at the single-payer model of reform.”

After Millions of Californians Gain Health Coverage Under the Affordable Care Act, Who Will Remain--



* 3.1 to 4 million Californians are predicted to remain uninsured in 2019.

* Almost three-quarters of the remaining uninsured in California will be U.S. citizens or lawfully present immigrants.

* Half of all remaining uninsured, or two million Californians, will be eligible for Medi-Cal or Exchange subsidies but remain unenrolled under the base scenario. Barriers to enrollment could include lack of awareness about the programs, challenges in the enrollment process, or inability to afford subsidized coverage.

* 72 percent of remaining uninsured Californians will be exempt from paying tax penalties under the minimum coverage requirements of the ACA due to income, lack of an affordable offer of coverage or immigration status. Approximately three percent of all Californians will owe a tax penalty due to not obtaining minimum coverage.

* Nearly 40 percent of the remaining uninsured will lack an offer of affordable coverage with premiums costing eight percent of household income or less. Some uninsured Californians will be ineligible for subsidized coverage due to income or immigration status, while others will be eligible for subsidized plans in the Exchange with premiums that exceed the affordability standard.

* Some of the remaining uninsured will lack coverage for short time periods due to life transitions.

* 57 percent of Californians who remain uninsured will have household incomes at or below 200 percent of the Federal Poverty Level.

Comment by Don McCanne PNHP: The projected numbers and demographics of the uninsured after full implementation of the Affordable Care Act in California are shameful. Although there would be regional differences in demographics, the national numbers would be roughly tenfold. We can do far better by enacting an improved Medicare for all.

My comment: ACA will help, but not enough. We need to be thinking ahead to single payer, most likely to be achieved on a state-by-by state basis.

Only in America--health status and whether or not one is insured

United States Census Bureau
Health Status, Health Insurance, and Medical Services Utilization: 2010

There is a U-shaped relationship between health status and having any type of health insurance coverage. Among all people who reported excellent health, 85.0 percent were insured. For those who reported good health, 80.2percent had health insurance coverage. Finally, 85.1 percent of people who reported poor health also had health insurance coverage.

This U-shaped relationship for the overall insurance rate is partially attributable to trends in the type of health insurance coverage. For example, 15.7 percent of people with excellent health reported having only public insurance, compared with 44.7 percent of people with poor health. On the other hand, the percentage of people with excellent health who had private health insurance was 69.3 percent, compared with 40.4 percent of people in poor health.

Comment by Don McCanne of PHNP: This seemingly mundane observation from this Census Bureau report provides great insight into the problems with health care financing in the United States.

It is astonishing that a country that spends so much on health care would have a U-shaped curve, or any curve for that matter, on the relationship between health status and whether or not one is insured.

Considering our financing system, the curve is easy to understand. People in excellent health also tend to have favorable socioeconomic circumstances that would result in higher enrollment in private insurance plans. Likewise, people in poor health tend to have less favorable socioeconomic circumstances that would result in higher enrollment in public insurance programs. People in good health would fall in between and thus would lie in the trough of the U-shaped curve, with lower rates of insurance than those well off and those benefiting from government programs.

If we had a decent health care financing system, wouldn't those in good health be as well covered as those in excellent health and those with public programs? More importantly, shouldn't either end of the U-shaped curve reach 100 percent coverage? And wouldn't the trough be wiped out so everyone with good health were covered as well?

The Affordable Care Act might shift the entire curve up as more are covered, but the 30 million who will remain uninsured will perpetuate the bizarre U-shape of the curve. We need a flat line, at the top, with 100 percent coverage. That's everyone, like we would have in an improved Medicare for all.
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