Wednesday, August 31, 2022

New for Medicare

https://indivisible.actionkit.com/mailings/view/79847?t=8&akid=79847%2E513975%2Ef7Z75T

Friday, July 8, 2022

What’s Wrong With Health Insurance? Deductibles Are Ridiculous, for Starters. July 7, 2022 By Aaron E. Carroll, NYT

Dr. Carroll is the chief health officer of Indiana University and writes often on health policy. More than 100 million Americans have medical debt, according to a recent Kaiser Health News-NPR investigation. And about a quarter of American adults with this debt owe more than $5,000. This isn’t because they’re uninsured. More often, it’s because they’re underinsured. The Affordable Care Act was supposed to improve access to health insurance, and it did. It reduced the number of Americans who were uninsured through the Medicaid expansion and the creation of the health insurance marketplaces. Unfortunately, it has not done enough to protect people from rising out-of-pocket expenses in the form of deductibles, co-pays and co-insurance. Out-of-pocket expenses exist for a reason; people are less likely to spend their own money than an insurance company’s money, and these expenses are supposed to make patients stop and think before they get needless care. But this moral-hazard argument assumes that patients are rational consumers, and it assumes that cost-sharing in the form of deductibles and co-pays makes them better shoppers. Research shows this is not the case. Instead, extra costs result in patients not seeking any care, even if they need it. Cost-sharing isn’t set up in a thoughtful way such that it might steer people away from inefficient care toward efficient care. Deductibles are, frankly, ridiculous. The use of deductibles assumes that all medical spending is the same and that the system should disincentivize all of it, starting over each Jan. 1. There is no valid argument for why that should be. Flu season peaks in the winter. We were in an Omicron surge at the beginning of this year. Making that the time when people are most discouraged from getting care doesn’t make sense. Co-pays and co-insurance aren’t much better. They treat all patients the same, and they assume that all patients should be treated the same way. In a National Bureau of Economic Research working paper published last year, researchers looked at how increases in cost-sharing affected how older adults, who are more likely to need care, pay for and use drugs. Remember, people age 65 and older in the United States are insured with what most consider to be rather comprehensive coverage: Medicare. The researchers claimed, however, that a simple $10 increase in cost-sharing, which many would consider a small amount of money, led to about a 23 percent decrease in drug consumption. Worse, they said it led to an almost 33 percent increase in monthly mortality. In other words, making seniors pay $10 more per prescription led to people dying. These seniors weren’t taking optional, esoteric, exceptionally expensive medications. This finding was for drugs that treat cholesterol and high blood pressure. In fact, they were considered “high value” drugs because they were proven to save lives. Further, those at higher risk of a heart attack or stroke were more likely to cancel their prescriptions than people at lower risk. People are not smart shoppers or rational spenders when it comes to health care. When you make people pay more, they consume less care, even if it’s for lifesaving treatment. Moreover, a $10 increase in drug cost-sharing is small potatoes compared with what most people have to pay out of pocket for care each year. The average deductible on a silver-level plan on the A.C.A. exchanges rose to $4,500 in 2021. If people tried to buy plans with a lower premium, at a bronze level, the average deductible rose to more than $6,000. Granted, some cost-sharing reductions are available for those who make less than 250 percent of the federal poverty line, but even after accounting for those, the average deductible was more than $3,100 for silver plans. Those who receive insurance from their employers aren’t much better off than those who buy on the A.C.A. marketplaces. The average deductible for insurance offered by large companies in the United States was more than $1,200. At small companies, it was more than $2,000. Those are only the deductibles. After they are paid, people must still cover co-pays and co-insurance until they hit the out-of-pocket maximums. The good news is that the A.C.A. limits these in plans sold in the exchanges. The bad news is that they’re astronomical: $8,700 for an individual and $17,400 for a family. A large majority of Americans don’t have that kind of money sitting in accounts, certainly not after paying an average of about $5,000 in premiums each year for a benchmark individual silver plan. Half of U.S. adults don’t have even $500 to cover an unexpected bill. Anyone who requires significant health care will be out the entire deductible, meaning thousands of dollars, and if severely ill, is likely to hit the out-of-pocket maximum. Of course Americans are in medical debt. The Kaiser Family Foundation estimates the country’s collective medical debt is almost $200 billion. It’s worth noting that the cost of health care in the United States is so high that even expensive premiums are not enough to cover the full amount without significant out-of-pocket spending. That doesn’t mean no better options exist for cost-sharing. We could treat those with diagnosed chronic diseases differently, as many countries in Europe do. It makes sense to try to disincentivize healthy people from overtreatment, but lots of people, including me, need care that costs money every day. It makes no sense to try to persuade me to rethink that. U.S. leaders could also consider adapting a reference pricing system, where the health system determines what constitutes the lowest-cost, highest-quality care and makes that available without any out-of-pocket spending. Cost-sharing can then be applied to other options that might cost more or have less evidence behind them. The purpose of insurance is to protect people from financial ruin if they face unexpected medical expenses. Reducing the amount that they need to pay from six figures to five is necessary, but not sufficient. It’s not enough to give people insurance. That insurance must also be comprehensive.

Thursday, June 9, 2022

Analysis of the 2022 Senate Medicare-for-All legislation

From PNHP: What’s in the Bill? Benefits: Covers all medically-necessary services including primary and preventive care, mental health care, reproductive care including abortion (with a ban on the Hyde Amendment), vision and dental care, prescription drugs, and home- and community-based long-term services and supports. Patient Choice: Provides full choice of any participating doctor or hospital. Providers may not dual-practice within and outside the Medicare system. Patient Costs: Provides first-dollar coverage without premiums, deductibles, or copays for medical services, and prohibits balance billing. Does require small copays for some brand-name prescription drugs. Eligibility: Covers everyone residing in the U.S. regardless of immigration status. Cost Controls: Prohibits duplicative coverage, negotiates drug prices with manufacturers, and funds hospitals through global operating budgets. Timeline: Provides for a four-year incremental transition to Medicare for All. What’s different in this year’s version? The 2022 bill includes some major improvements from the 2019 version, bringing it closer to the PNHP’s gold standard as established by the Physicians Proposal. Global budgeting of hospitals and other institutional providers: Global budgets would fund hospitals with annual lump sum payments which can be used for patient care — not for profits, advertising, or executive bonuses — with separate funding for capital projects. PNHP estimates that global budgets would save $220 billion per year; they would also prevent hospital closures by providing facilities in rural and other underserved communities with stable funding, which can be quickly supplemented during public health emergencies. Global budgets also promote health equity by funding services and capital projects based on community health needs (i.e., mental health, obstetrics, and HIV care), not what’s most profitable for hospitals (i.e., elective surgeries). Standardized fee-for-service payments to providers: Establishes a national fee-for-service schedule for individual and group providers, similar to language in the House bill (H.R. 1976). Expanded benefits: Provides transportation for seniors with functional limitations, and expands mental health care by covering licensed marriage and family therapist and licensed mental health counselor services. Office of Health Equity: Establishes an Office of Health Equity to monitor and eliminate health disparities, and promote primary care. How could the bill be improved? Cover all long-term care (LTC): While community-based LTC supports would be covered by Medicare for All, institutional LTC remains within Medicaid, preserving the state-based variations that contribute to inequities, injustice, and complexity. PNHP recommends moving all LTC services into Medicare for All. Shorten transition period: The four-year transition period gradually expands Medicare’s benefits and lowers the eligibility age, along with a “buy in” scheme that includes commercial Medicare Advantage plans. The transition period is needlessly complex, delays access to care for the most vulnerable patients, and could exacerbate inequalities. PNHP recommends a one-year transition. Eliminate prescription drug costs and strengthen price negotiations: While drug co-pays are lower than the 2019 bill, even modest cost-sharing is a proven barrier to care. PNHP recommends eliminating all patient cost-sharing. While the bill does authorize Medicare to negotiate drug prices, it lacks certain safeguards if negotiations fail, such as direct procurement of drugs. PNHP recommends competitive drug licensing, direct procurement of drugs, and other safeguards if price negotiations fail. Ban (and buyout) investor-owned health facilities: This bill does not explicitly ban for-profit health facilities and agencies, which provide lower-quality care at higher costs than nonprofits. PNHP recommends an orderly conversion of investor-owned, for-profit providers to not-for-profit status.