Tag: Access

Dems should unite behind Medicare for all
The Republican leadership in Congress is still planning to kill the Affordable Care Act, with no viable alternative to replace it. If the ACA is repealed, the Democrats in Congress have many compelling reasons to align around Medicare for all. Yale political scientist Jacob Hacker made the case more than a decade ago in his initial plan to expand on Medicare’s model as a way to ensure everyone in America has access to care; he built on this plan in 2007 in his Health Care for America proposal.

Here are some of the key elements of Hacker’s plan. It would create a new broad public insurance pool for people without employer coverage and not eligible for Medicare.

What benefits would this expanded Medicare proposal offer individuals?
- Like Medicare, choice of a traditional fee-for-service plan or a commercial insurance plan with the same guaranteed benefits.
- Coverage of a defined package of essential benefits with a maximum individual and family out-of-pocket cap, but with a sliding scale on these caps based on income.
- A single deductible and coinsurance rate for medical and inpatient services.
- An income-related premium, with federal premium and copay subsidies for people with low incomes, and with people earning 200 percent of the federal poverty level or less paying no premiums.
- Broad spreading of risk so that health care is affordable to everyone including people who need costly health care.
What benefits would this expanded Medicare proposal offer the health care system?
- A streamlined national system, with far less fragmentation and complexity than our current system.
- Transparency that allows for accountability and the ability to drive quality and cost improvements to the health care system.
- Substantial leverage from bargaining jointly with Medicare to secure lower prices and improved quality, reining in health care costs and delivering better care.
- Low administrative costs.
- Significant savings to employers, individuals, states and the federal government.
How would this expanded Medicare proposal work?
- Automatic coverage for all legal U.S. residents without insurance to ensure that people do not fall through the cracks, and people with insurance are not subsidizing health care for people without it.
- People with Medicaid and SCHIP are included in the program with special low-income protections and additional benefits.
- Continuous guaranteed coverage except for people who gain qualified private workplace coverage.
How would this expanded Medicare proposal be administered?
- Like Medicare, the federal government would administer the program through the Centers for Medicare and Medicaid Services at the Department of Health and Human Services, and people would have access to doctors and hospitals across the nation.
- Employers could choose to cover their workers, so long as the benefits were at least as comprehensive as Medicare, or make a small payroll contribution of a percentage of a workers’ income to cover the cost of the public insurance.
- Individuals not working could buy into the program.
Here’s more from Just Care:
February 8, 2017
Access to affordable care top priority among voters
A new Kaiser Health poll shows that Medicare’s future and access to affordable health care are top priorities for two out of three voters. More than half of voters see Medicaid, prescription drug costs and the Affordable Care Act as top issues. They want Donald Trump and Hillary Clinton to be talking about them.

Voters see Clinton as better able to address health care cost and access issues than Trump. (See chart below.) But, they are pessimistic about both candidates’ abilities to improve their access to affordable care.

Interestingly about the same percentage of older voters trust Trump on addressing the future of Medicare (44 percent) as Clinton (47 percent).

And the Affordable Care Act continues to enjoy only moderate public support, with 40 percent of the public having a positive view of it and 42 percent having a negative view of it.

Here’s more from Just Care:
September 7, 2016
Access to care issues, higher costs when hospitals merge
A recent report by Merger Watch details the access to care issues and higher costs that often arise when hospitals merge, downsize or close.

Over the last two decades, an increasing number of hospitals have merged, creating large intra and interstate health care systems that wield enormous political and financial power. There are 50 percent more for-profit hospitals in 2016 than there were 15 years ago, up from 660 to 992. Hospitals understandably are watching their bottom lines.

The 25 largest health care systems now represent 33 percent of all acute care hospitals, up from 23 percent in 2000, 15 years ago. The three largest are for-profit. State hospital oversight programs are at this point unable to keep up with monitoring hospital mergers and ensuring people are protected and able to access needed care.

Oversight is needed. Some of these mergers are leading to restrictions in care. For example, when hospitals merge with religiously-sponsored health systems, which restrict care based on their religion, the newly formed hospital may continue to restrict care even though the new entity is a secular hospital or health system. Restrictions may limit reproductive health services, even when medically necessary. Or, they may deny women suffering a miscarriage emergency services, forcing them to go to another hospital that may be far away at great risk to them.

And, while you might imagine these larger hospitals are able to deliver more cost-effective care, hospital rates have for the most part risen significantly. Hospital mergers are not appearing to drive the efficiencies one might expect. Or, if they are, patients and health insurers are not benefiting from them. (Of note, at the same time these mergers are happening, many hospitals are closing; 60 rural hospitals have closed since 2010, making it harder for people in their communities to access care.)

A new study reveals that two of the largest hospitals in California are charging about 25 percent more for each patient admission than other hospitals in the area. They are not charging based on cost but, rather, based on their market power, providing evidence that hospital mergers are driving up consumer health care costs. Sutter and Dignity, two big hospital chains, are getting an average of $4,000 more for each person who is admitted than smaller hospitals. And according to the study’s authors, this gap has nothing to do with wage differences or treating sicker patients.

Based on ten years of claims data from Blue Shield of California, one of the largest insurers, prices were about the same for all the hospitals in 2004. Ten years later, prices from these two hospital chains increased 113 percent as compared to 70 percent for other hospitals. The average cost at Sutter and Dignity was $19,606 and $15,642 at the other hospitals.

According to Kaiser Health News, the California Attorney General is currently investigating Sutter for possible harm to consumers; it is also looking at Dignity. To be sure, prices have risen substantially across all California hospitals “during a period of low overall price inflation, low economic growth, and declining demand for inpatient care.” The higher prices for the larger hospital systems may be leading the smaller hospitals to raise their prices.

Merger Watch argues that significantly more state oversight is needed to ensure patient and community access to needed care. It gave only six of the 50 states and the District of Columbia an A or A- for their oversight process. Twenty states received an F.

Here’s more from Just Care:
July 5, 2016
Why traditional Medicare remains so popular
Uwe Reinhardt, PhD, writes Why Many Medicare Beneficiaries Cling to an Allegedly Worse Deal in JAMA Forum earlier this month. In a nutshell, he argues that traditional Medicare remains so popular because it offers people the choice of doctors and hospitals they want.

Reinhardt points out that the government spends more per person for Medicare Advantage enrollees (people enrolled in a commercial insurance plan that offers Medicare benefits) than on traditional Medicare. In addition, because Medicare Advantage plans generally rely on networks that restrict access to doctors and hospitals, they can offer seemingly more benefits and lower out-of-pocket costs to their enrollees than are available to people in traditional Medicare. But, still only 3 in 10 people with Medicare choose to enroll in one of these plans.

Most older adults, says Reinhardt, like the freedom of choice available through traditional Medicare exclusively. People value the ability to see almost any doctor and use virtually all hospitals and other health care facilities anywhere in the country. Indeed, the U.S. Government Accountability Office issued a report in September 2015 addressing concerns raised about the narrow networks in many Medicare Advantage plans that can limit access to needed care. It recommended greater oversight of these plans.

Reinhardt also posits that people trust the government more than the commercial Medicare Advantage plans. People value traditional Medicare for the same reason they value Social Security–it is “an always faithful and reliable companion.” In sharp contrast the commercial insurers that offer Medicare Advantage are nothing more than “ephemeral companions.”

Medicare Advantage plans can morph and change at any time. The insurer who offers the Medicare Advantage plan can change many terms of the agreement whenever it wishes. Doctors and hospitals can move in and out of the network throughout the year, changing the network and undermining continuity of care. And benefits, copays and deductibles can change from year to year. Protocols for accessing care can also change. In addition, the Medicare Advantage plan can stop offering coverage altogether or the insurer offering the coverage could be bought by another insurer who changes the rules.

Here’s more from Just Care:
June 22, 2016
Health plan networks limit access to care
One of the biggest problems with health insurance companies is that they generally offer health plans that limit coverage to doctors and hospitals in their networks. And, too often their networks of doctors and hospitals are inadequate, even though they may seem adequate at first glance. So, what you see is not what you get, and people have access to care problems. Two recent reports reveal problems with the adequacy of health plan networks, as well as a high frequency of people in private Medicare Advantage plans switching to traditional Medicare when they need costly care because access to care is so much easier.

Traditional Medicare offers people the choice of coverage from virtually any doctor or hospital in the United States. That’s why about seven out of 10 people with Medicare are enrolled in traditional Medicare. People with employer coverage or enrolled in a state health exchange plan do not have the choice of a plan like traditional Medicare. (Bernie Sanders is proposing to give everyone that option.)

People in HMOs and other commercial health plans face four key problems with in-network care.
1. Many of the doctors listed in their network may no longer be in their network or, if they are, they may not be taking new patients. So, protect yourself, and don’t trust your health plan’s provider directory;
2. The doctors listed may have offices that are difficult to access;
3. The doctors listed may not have the skills to treat people with a range of serious and complex conditions; and,
4. Doctors in network at the start of the year may leave the network any time during the year. (Notice is required.)
Moreover, a recent study from the Government Accountability Office (GAO) found that the Centers for Medicare and Medicaid Services does not do a good job of ensuring that the Medicare Advantage plans have adequate networks. For example, while there are standards to help ensure Medicare Advantage plans have adequate networks, CMS has approved 90 percent of requests from these health plans to be relieved of the responsibility of ensuring that people do not have to travel more than five miles (10 minutes) to see a doctor or use a hospital.

Why are Medicare Advantage and other commercial health plan networks often inadequate? Another Health Affairs study by Rahman, Keohane, Trivedi and Mor, High-Cost Patients Had Substantial Rates of Leaving Medicare Advantage and Joining Traditional Medicare, explains that commercial health plans that contract with Medicare have a financial incentive to keep patients with costly needs from both joining their plans and remaining in their plans. As a result, their networks are likely not to meet the needs of high-cost patients, particularly patients needing home health care, skilled nursing care and acute inpatient care.

People with costly health care needs enrolled in Medicare Advantage plans are more likely to leave a Medicare Advantage plan for traditional Medicare. Fortunately, they can switch plans. (Here’s how to choose.) But, unfortunately, they can only do so once a year during open enrollment season. So, if they need specialty services that they cannot get from their Medicare commercial health plan, they will either need to pay out of pocket for the care or forego it until they are able to switch to traditional Medicare.
February 10, 2016
Medicare and Medicaid at 50: Their roles in our health care system
A 2015 article in Health Affairs by Drew Altman and Bill Frist speaks to Medicare and Medicaid at 50, looking at the numbers, their roles in our health care system, the challenges they face and emerging issues. Medicare, a federal social insurance program, helps ensure older adults and people with disabilities have affordable access to the care they need. Medicaid, a joint state and federal program, covers older adults, people with disabilities and people with low incomes.

The Medicare and Medicaid numbers:
- Collectively, they serve 111 million people, one in three Americans
- By 2025, they will serve 139 million people
- Ten million people have Medicare and Medicaid
- They are responsible for $1 trillion in annual health spending, 39 percent of national health spending and 23 percent of the federal budget
- They generate 43 percent of hospital revenues
- Median income for people with Medicare is $23,500 and with Medicaid is $15,000
The emerging issues:
- Will Medicare and Medicaid continue to be “open-ended” programs, with guaranteed benefits and no spending cap?
- Will they become increasingly privatized? Today, less than a third of people with Medicare are in private Medicare Advantage plans, but the number could increase. And, more than half of people with Medicaid are in private managed care plans.
- Will they shift more costs onto the people they serve?
- Will they continue to play a role in reshaping delivery of care and reform of our health care system?
To date:
- Expansion of Medicare and Medicaid eligibility and benefits; Medicare now covers people with disabilities and people with ALS and ESRD; Medicaid now covers people with incomes up to 138 percent of the federal poverty level in most states.
- Stronger financial incentives to improve quality and efficiency
- Polling data show both Medicare and Medicaid remain very popular. 72 percent of Americans have a favorable view of Medicare and 90 percent of adults 65 and older.
January 20, 2016
Will your health plan cover the drugs you need?

Health plans often make it hard for people to know which drugs they cover before they sign up for the plan and even harder to find out what out-of-pocket costs will be for a particular drug. Yet, different drugs in a particular class may work better or worse for a particular person.

If you have Medicare, you should be able to find out online quite quickly whether a Part D prescription drug plan covers the anti-depressant you need. But, a new Urban Institute study suggests that people in the health insurance exchanges may have difficulty knowing whether a health plan meets their drug needs.

The study looked at health plan coverage of anti-depressants in five state health exchanges and found significant differences among them in drugs covered and willingness to disclose which drugs were covered. Antidepressants are the third most commonly used prescription drug. More than one in 10 Americans over 12 take them.

Out of 35 health plans studied, nine excluded more than five antidepressants from coverage and some excluded up to 15.

Allowing the plans to list drugs they cover in whatever way they choose can make it extremely hard for people to determine whether a drug is covered. And, even when people can see a drug they take is covered, it can be hard for them to know what their out-of-pocket costs will be in advance of enrolling in a plan. People in plans that charge co-insurance for drugs are generally left in the dark.

The study recommends that the state exchanges offer direct links to easily searchable lists for each plan, make it easier for an individual to appeal the non-coverage of a drug, and monitor the process to ensure its fairness; it also recommends that out-of-pocket costs be predictable.

December 16, 2015
John Oliver: Republicans are blocking access to health insurance in 20 states

In this video segment, John Oliver explains how the Supreme Court hurt millions of Americans by not upholding the Affordable Care Act in its entirety, why elections matter, and how Republicans in 20 states are turning away millions of dollars from the federal government. The government money is intended to cover 90 percent of the cost of health insurance for people with low incomes.

By rejecting these funds designed to pay for an expansion of Medicaid to people with incomes up to 138 percent of the federal poverty level ($27,724 for a family of three), the states deprive more than three million of their residents 0f health care coverage. The median Medicaid eligibility income in the states that have not expanded Medicaid is 44 percent of the federal poverty level ($8, 840 for a family of three) and childless adults are not eligible even at that income level. And, unfortunately, the ACA did not contemplate that the Supreme Court would allow states to reject Medicaid expansion, so it does not offer subsidies to people with incomes up to 138 percent of the federal poverty level.

There are few options for people caught in this health insurance coverage gap, other than moving to a state that has expanded Medicaid or taking on more work. For a primer on Medicaid and why it’s important to all of us, click here.

November 13, 2015
The Affordable Care Act: What happens between now and the November 2016 elections?

The Supreme Court’s decision last month affirming, yet again, the legality and structure of Obamacare (the Affordable Care Act) could signal an end to the 5-year slog of bitter political divisiveness over the law. Or not.

As I see it, one of two divergent scenarios could play out between now and November, 2016:

(1) The number of people benefiting from the law grows briskly, premium increases remain modest, and Americans finally accept the law as permanent and worth it; that leads Republicans (and their presidential candidates) who have vigorously opposed the law to back off, realizing they’re fighting a losing battle that could cost them control of Congress and their bid for the White House in 2016.

(2) The number of people benefiting from the law plateaus, premiums in the state-based exchanges increase 15% a year in 2015 and 2016, deductibles and co-pays increase, concern about restricted provider networks grows, and the public remains deeply divided over the wisdom and impact of the law. Skating off that and sensing blood in the water, Republicans double-down on their opposition to the law and make the election a referendum on it.

These scenarios are oversimplified, of course.   Other events and factors could come into play, such as a foreign crisis that diverts attention from health care.

But there’s little doubt we are now (sorry for the tired metaphor) at a crossroads.   The Supreme Court’s ruling pretty much means that the only route to dismembering the law is political.

As a reminder, the Republican-controlled House of Representatives has voted along party lines over 50 times to repeal parts or all of the law.   In the Senate, also controlled by Republicans since the 2014 elections, efforts by members of that party to repeal the law have been bogged down by rules that require 60 votes to get major legislation to a full Senate vote. The Republicans hold 54 seats in the Senate, to the Democrats’ 44, plus 2 independents. Obama has also pledged to veto any bill that undermines the law.

So the 2016 elections could well decide Obamacare’s fate. If Republicans win the White House and maintain their majorities in Congress, the only way Democrats could block repeal of the law—assuming Republicans pursue that—is through the 60-vote rule in the Senate to break a legislative filibuster.   That assumes Republicans don’t top 60 seats in the Senate in the 2016 elections, a pretty safe bet.

Your role in all this?   Polls by the Kaiser Family Foundation, (“KFF”), since 2011 show Americans have been persistently sharply divided on the merits of the law, and that opinion is strongly party-affiliated. That is, a large majority of Republicans oppose the law while a large majority of Democrats support it.   This has always signaled to me and many other observers that the bulk of opinion on the law as a whole is driven by a combination of party and ideological loyalty, with a generous dollop of sentiment about the role of government in our lives.

Results from deeper-dive KFF surveys bear that out: a majority of Americans irrespective of political party affiliation support several major components of the ACA, such as requiring insurers to cover people with pre-existing medical conditions, without making them pay more.

I might be whistling into the wind, tilting at a big windmill or pushing the proverbial Sisyphian bolder up a steep hill, but I believe this crossroads is a time for opponents of the law (and those on the fence, about 10-15% of the population) to take a step back from the partisan political divide we all say we hate and reassess the ACA on the merits of what it has done to date, its actual provisions, and the concrete arguments pro and con. There’s no dearth of intelligent and easy-to-understand information on the internet, from both sides.

In short, make up your own mind and don’t be led by your political nose.   This is an issue that should transcend lock-step politics.

If premiums and costs rise, there’ll likely be more than a few registered Democrats who’ll need to shore up their support of Obamacare, too.

In very practical terms, take 2 to 3 hours some evening or weekend and learn how the law is actually constructed. Talk to trusted friends on the opposite side of the debate. Read behind the headlines and ignore the political rhetoric—from both sides. Be engaged.

Every so often, big social changes are needed. Health reform was such a moment (well, it actually took 20 years). Keep in mind that Republicans agree that the old system was broken and unsustainable. The ACA is not a perfect law.   Indeed, the tragedy of the 5-year senseless political fight over the ACA is that it’s made sensible fixes over the last few years impossible.

Be part of the solution to that, and refuse to perpetuate the problem.

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To understand how repeal of the ACA would drive the deficit up and leave 19 million uninsured, click here.

June 30, 2015
Access to care a serious problem in Medicaid managed care plans

A recent report by the HHS Office of the Inspector General reveals that private companies offering Medicaid managed care are failing to ensure adequate access to care to their enrollees. Each state has its own law regarding standards for access to care in managed care plans—both appointment availability and wait times for appointments—and different ways of determining compliance with standards.

Given that the federal government is paying the full cost or a significant part of the cost of these plans, the report makes a strong case for the federal government to step in and create a baseline standard with enforcement mechanisms for managed care plans in every state.

Disturbingly, the OIG found that appointments were not available from more than half of providers (51 percent) surveyed. More than one-third of providers (35 percent) surveyed were not even at the office listed by the plan. Another 8 percent were not in the plan’s network. And yet another 8 percent were simply not taking new patients.

Of the providers with whom appointments were available, the median wait time was two weeks and more than 25 percent of them required enrollees to wait more than a month for an appointment.The OIG surveyed 1,800 providers of care, both primary care physicians and specialists.

March 5, 2015