Medicare's 50th birthday is something to celebrate | Duluth Budgeteer
Great arguments for single payer via Medicare for All.
Friday, July 31, 2015
Views mixed as Medicare, Medicaid turn 50 | Duluth News Tribune
Views mixed as Medicare, Medicaid turn 50 | Duluth News Tribune
Great article showing the arguments. Market driven argument seems to be based on for profit backers of the proponents rather than on facts.
Great article showing the arguments. Market driven argument seems to be based on for profit backers of the proponents rather than on facts.
Tuesday, July 28, 2015
Monday, July 27, 2015
Sunday, July 26, 2015
[Report] | Wrong Prescription?, by Trudy Lieberman | Harper's Magazine
[Report] | Wrong Prescription?, by Trudy Lieberman | Harper's Magazine
Comment by Don McCanne
Harper’s Magazine
has now moved Trudy Lieberman’s “Wrong Prescription?” out from behind
the paywall, making it available for free.
has now moved Trudy Lieberman’s “Wrong Prescription?” out from behind
the paywall, making it available for free.
It
is an extraordinary article that explains the what, why and how we ended
up with the wrong prescription for our sick health care financing
system. Though a fairly long article, reading it and sharing it with
others is an imperative.
is an extraordinary article that explains the what, why and how we ended
up with the wrong prescription for our sick health care financing
system. Though a fairly long article, reading it and sharing it with
others is an imperative.
The article does not dwell on what is the right prescription, but there are basically three options:
1.
Live with ACA, and try to patch the the defects. The problem with this
is that the fundamental infrastructure cannot be repaired. Patches are
inadequate in that the same basic structural flaws would be perpetuated.
Live with ACA, and try to patch the the defects. The problem with this
is that the fundamental infrastructure cannot be repaired. Patches are
inadequate in that the same basic structural flaws would be perpetuated.
2.
Although the Republicans keep telling us that they have a replacement
plan, after five years they have been unable to agree within themselves
on the specifics. That said, they have telegraphed their ideas, and,
combined, they are basically a weaker version of the market-driven
principles already incorporated in the Affordable Care Act. They would
merely weaken oversight of the plans and shift even more responsibility
to the patient-consumer. Being uninsured, underinsurance, and lack of
affordability of adequate coverage would all worsen under their
proposals.
Although the Republicans keep telling us that they have a replacement
plan, after five years they have been unable to agree within themselves
on the specifics. That said, they have telegraphed their ideas, and,
combined, they are basically a weaker version of the market-driven
principles already incorporated in the Affordable Care Act. They would
merely weaken oversight of the plans and shift even more responsibility
to the patient-consumer. Being uninsured, underinsurance, and lack of
affordability of adequate coverage would all worsen under their
proposals.
3. A single payer national health
program - an improved Medicare for all - would finally achieve our goals
of universality, affordability and accessibility while removing
financial barriers through an equitable system of financing. It is the
prescription we desperately need.
program - an improved Medicare for all - would finally achieve our goals
of universality, affordability and accessibility while removing
financial barriers through an equitable system of financing. It is the
prescription we desperately need.
Take a moment
this weekend to read this article and then share it with others. At the
50th anniversary of Medicare, this article is very timely. We have to
fix this system once and for all, but that means that everyone must
understand why ACA was the wrong prescription.
this weekend to read this article and then share it with others. At the
50th anniversary of Medicare, this article is very timely. We have to
fix this system once and for all, but that means that everyone must
understand why ACA was the wrong prescription.
Saturday, July 25, 2015
Friday, July 24, 2015
Anthem acquiring rival Cigna in $54.2 billion deal - StarTribune.com
Anthem acquiring rival Cigna in $54.2 billion deal - StarTribune.com
My God! Soo much of our money goes to corporate profits and so much of our health care is controlled by them based on profit motivation - not on a motivation to improve our health.
My God! Soo much of our money goes to corporate profits and so much of our health care is controlled by them based on profit motivation - not on a motivation to improve our health.
Thursday, July 23, 2015
Tuesday, July 21, 2015
Monday, July 20, 2015
Sunday, July 19, 2015
Changes to WI Budget Impacting Elderly and Disabled
Wisconsin State Budget Overview:
Just over one year ago, the Governor
issued a letter to all state agency heads instructing most agencies
to prepare 2015-2017 budgets using zero-growth targets and
encouraging them to reform or eliminate obsolete or outdated programs
to free up funding for new initiatives within their current base.
Agency budgets were due to the State Budget Office by mid Sept. ’14.
On Feb. 3, 2015, Governor Walker delivered his budget address and
released his 2015-’17 Executive Budget.
We immediately began a review of the
budget to assess its impact on older adults and aging
programs/services. Significant changes proposed to SeniorCare, ADRCs
and long term care, BadgerCare Plus and transportation (among others)
made it clear there was much advocacy work to be done!
The aging network immediately
prioritized a SeniorCare campaign as their starting point.
Communications directly with members of the Joint Finance Committee,
heavy contacts with all state legislators, over 13,000 petitions to
save SeniorCare, a motion from the SeniorCare Advisory Council, and
engagement of the media led to announcements from key legislative
leaders by the end of March that the SeniorCare program would not be
changed and would continue operating as it does now!
Proposed changes to Wisconsin’s
homegrown long-term care system led to the formation of new
coalitions and advocacy and social media groups –WI Long-Term Care
Coalition, ADRC Core Team, Save IRIS, and Save Wisconsin ADRCs - to
help raise up the voice of older adults and people with disabilities
and their advocates.
Public budget hearings conducted by the
Joint Finance Committee (JFC) began in mid-March. Older adults and
aging advocates turned out in droves not only for the JFC public
hearings, but for town hall meetings and listening sessions conducted
by legislators all across the state. Despite the many other budget
areas challenged in the biennial budget, thanks to the experience,
talents, and resources of the aging network and our partners in the
disability and long term care communities, issues of importance to
older adults and people with disabilities were among those in the
forefront.
The JFC began meeting in Executive
Session to take action on the budget in mid-April and continued to
meet and act on the budget through July 2, 2015. Note the state
fiscal year ends on June 30; however, Wisconsin has automatic
continuing appropriations statutes that keep existing appropriations
in effect in the new fiscal year and all subsequent fiscal years
until amended or eliminated. Once the budget was approved by JFC, it
was taken up by the full Senate and passed on July 7th with no
further changes made to the issues taken up by the aging network. The
Assembly passed an identical budget on July 9th, exactly one year to
the day from when the Governor first issued his budget instructions.
After making 104 vetoes, Governor Walker signed the 2015-17 budget
into law on Sunday, July 12, 2015.
Our advocacy efforts do not end with
the passage of the budget. Many of the important implementation
details related to changes authorized in the budget have yet to be
worked out and will be left to legislative committees, state
departments, and/or federal agencies (where federal waivers are
required) to work out. It is critically for stakeholders, including
most importantly the consumers/citizens impacted by the changes, to
be involved in and providing input/feedback throughout the
implementation processes. Stay tuned for updates on additional
opportunities for continued involvement. See below for further
details on specific budget issues of interest to the aging network.
State Budget issues impacting older
adults:
A. SeniorCare – Aging advocates
request “no changes” to the current program.
1) Governor’s budget requires adults
aged 65 and older needing prescription drug coverage to apply for,
and if qualified, enroll in a Medicare Part D plan versus just
automatically enrolling in SeniorCare (Wisconsin’s prescription
drug program). Uses SeniorCare as a wrap- around program only and
reduces state funding by over $15 million in the biennium.
2) JFC budget deletes the Governor’s
recommendations to require SeniorCare enrollees to apply for and
enroll in Medicare Part D and leaves the programs as it is now.
3) Senate/Assembly make no further
changes to budget approved by JFC.
4) Gov. Walker does not veto changes
made by JFC. SeniorCare continues as it is now!
B. MA Personal Care – Aging advocates
request removing the requirement for an independent assessment for
personal care and provide funding for a Medicaid Personal Care Rate
increase (no increase since July ’08).
Governor’s budget requires an
independent assessment for all prescribed fee-for-service (FFS)
personal care services and allows third-party agencies to develop a
consumer’s care plan.
1) JFC budget approves the Governor’s
recommendation to require an independent assessment (which is
associated with an estimated reduction in expenditures) and delays
the start date for the third-party personal care assessment contract.
No increase in funding for a rate increase approved (FYI a 1% nursing
home rate increase was approved).
2) Senate/Assembly make no further
changes to budget approved by JFC.
3) Gov. Walker does not veto changes
made by JFC. MA personal care rate was not increased and FFS personal
care services will require an independent assessment of personal care
needs.
C. BadgerCare – Medicaid (MA) for
Childless Adults – aging advocates request accepting Medicaid
Expansion which would keep childless adults enrolled in BadgerCare
Plus without requiring premiums or other proposes program changes and
would provide coverage for all childless adults between 100%- 138% of
the Federal Poverty Level (FPL)
1) Governor’s budget seeks a waiver
from the federal government to impose monthly premiums, as well as
premiums for “risky” behaviors for childless adults enrolled in
Medicaid, requires childless adults to have a health risk assessment
and to be screened for drug use to receive benefits and calls for
limiting enrollment to no longer than 48 months.
2) JFC budget approves the Governor’s
recommendations.
3) Senate/Assembly make no changes to
budget approved by JFC.
4) Gov. Walker approves budget
recommendations as final. The Department of Health Services (DHS) is
directed to seek a federal waiver to impose monthly premiums and
additional
“risk based” premiums for
childless adults in Medicaid. In addition, childless adults enrolled
in MA will be required to have a health risk assessment and be
screened for drug use. Their enrollment will be limited to 48 months
(if the waiver request to CMS is approved).
D. ADRCs - Aging advocates seeking to
keep ADRCs local, nonprofit, and “one-stop” comprehensive
community resources.
1) Governor’s budget eliminates the
current structure that gives counties first right of refusal to
operate the ADRC and opens the door for the state to contract with
other entities to operate the ADRC (county, non-profit, for-profit,
etc.), allows the state the flexibility to contract with single or
multiple entities to operate ADRCs in regions or statewide,
eliminates long-term care districts as eligible ADRC operators
(currently ADRC of the Northwoods is the only ADRC in the state
organized as a LTC district), allows the state the flexibility to
contract with multiple entities to provide ADRC services, eliminates
ADRC governing boards and regional advisory committees, allows the
state Department of Health Services (DHS) to contract with a resource
center or a private entity for some or all of the
services—anticipates bidding out the administration of the Family
Care functional screen via a statewide contract, and provides funding
at the same level (no increases in cost or savings anticipated from
this change).
2) JFC budget deletes all of the
Governor’s recommendations to modify the statutory requirements of
ADRCs and to eliminate the ADRC governing boards, requires DHS to
evaluate the functional screen and options counseling functions for
reliability and consistency among ADRCs and provide a report
regarding these activities by Jan. 1, 2017 and requires DHS to assess
which responsibilities of ADRC governing boards are duplicative with
current DHS procedures and to propose changes to the statutory
requirements of these boards to remove duplication no later than July
1, 2016. In addition JFC deletes the Governor’s recommendation to
eliminate the long-term care advisory committee and requires DHS to
study the integration of income maintenance consortia and ADRCs and
present a report no later than April 1, 2016 with recommendations
regarding potential efficiencies that may be gained and whether such
a merger would be appropriate.
3) Senate/Assembly make no further
changes to budget approved by JFC.
4) Gov. Walker does not veto changes
made by JFC. DHS is required to: evaluate the functional screen and
options counseling functions for reliability and consistency among
ADRCs and provide a report regarding these activities by Jan. 1,
2017; assess which responsibilities of ADRC governing boards are
duplicative with current DHS procedures and propose changes to the
statutory requirements of these boards to remove duplication no later
than July 1, 2016; and study the integration of income maintenance
consortia and ADRCs and present a report no later than April 1, 2016
with recommendations regarding potential efficiencies that may be
gained and whether such a merger would be appropriate.
E. Family Care/IRIS – Aging advocates
are seeking to make the current Family Care program available in
every county and to maintain the current level of legislative
oversight and meaningful involvement of stakeholder that has occurred
throughout the redesign process.
1) Governor’s budget expands a new
version of the Family Care program (2.0) statewide by January 1,
2017, allows DHS the ability to choose whether managed care
organizations (MCOs) include both acute and primary care services
along with the current long-term care services, eliminates the IRIS
(“Include, Respect, I Self-Direct”) program as an alternative to
the Family Care program for those who wish to fully self-direct their
long-term services and supports and provides all enrollees a
“self-directed services option” within Family Care and within
guidelines established by the department, eliminates long-term care
districts as eligible MCO entities (currently 4 MCOs are LTC
districts), moves some of the administrative functions and oversight
of Family Care and MCOs from DHS to the Office of the Commissioner of
Insurance (OCI), regulates CMOs as insurance entities under OCI, and
eliminates the state requirement to solicit proposals for CMO
contracts under a competitive sealed proposal process.
2) JFC budget deletes all of the
statutory changes recommended by the Governor, but retains the
projected cost-savings from statewide expansion and requires DHS to
submit a waiver to CMS requesting changes to the Family Care and IRIS
waiver and if the new waiver is approved to eliminate COP, CIP, and
CORP when the new Family Care benefit is available statewide (by
Jan. 1, 2017 or date determined by DHS,
whichever is later). In addition, to statewide expansion, require the
waiver submitted by DHS to: specify that consumers receive both
long-term care and acute care services, include Medicare-funded
services to the extent allowable by CMS from integrated health
agencies (IHAs), increase the size of the regions currently served by
MCOs – no less than five regions, require multiple IHAs in all
regions of the state, require IHAs to make available a
consumer-directed option under the long-term care program which shall
include the ability to select, direct and/or employ persons offering
any of the services currently available under the IRIS program and
the ability to manage (utilizing the services of a IHA serving as a
fiscal intermediary) and individual home-and community-based service
budget allowance, allow for audits of providers, preserve the “any
willing provider” requirement for long-term care providers for a
minimum of three years after the implementation date of the program
in each region, establish an open enrollment period for the program
that coincides with the open enrollment period for Medicare, and
require the rates paid to IHAs to be set through an independent
actuarial study. Later action taken by JFC in a clean-up bill (motion
#999) requires DHS to submit, as part of the MA quarterly reports
submitted by September 30, 2015, and December 30, 2015, progress
reports regarding the development of the waiver proposal. The reports
must include, but are not limited to, information regarding outcomes
from discussions with representatives of consumers of long term care,
long term care providers, and the federal Centers for Medicare and
Medicaid Services. DHS is also required to hold no less than two
public hearings regarding the proposed Family Care waiver prior to
its submission to JFC.
3) Senate/Assembly make no further
changes to budget approved by JFC.
4) Gov. Walker does a partial veto of
the changes made by JFC. The Governor: vetoes the language requiring
no less than 5 managed care regions and gives DHS the authority to
determine the number of managed care regions (no minimums)- (This
makes it possible for DHS to move forward with one statewide area or
2-3 large regions, but does not prevent DHS
from recognizing and securing the
current managed care regions.); vetoes the requirement for rates paid
to Integrated Health Agencies (IHAs) to be set by actuarial study;
and vetoes the requirement for the Family Care open enrollment period
to coincide with the Medicare open enrollment period and gives DHS
the authority to set the period. DHS is required to submit a waiver
to CMS requesting changes to the Family Care and IRIS waiver and if
the new waiver is approved to eliminate COP, CIP, and CORP when the
new Family Care benefit is available statewide (by Jan. 1, 2017 or
date determined by DHS, whichever is later). Prior to submission of
the waiver, DHS is required to submit, as part of the MA quarterly
reports submitted by September 30, 2015, and December 30, 2015,
progress reports regarding the development of the waiver proposal and
hold no less than two public hearings regarding the proposed Family
Care waiver prior to its submission to JFC. (Advocacy will be needed
throughout the waiver application and implementation process to
ensure meaningful involvement and input opportunities for consumers
and other stakeholder.) In addition, to statewide expansion, require
the waiver submitted by DHS to: specify that consumers receive both
long-term care and acute care services, include Medicare-funded
services to the extent allowable by CMS from integrated health
agencies (IHAs), require multiple IHAs in all regions (number to be
determined by DHS) of the state, require IHAs to make available a
consumer-directed option under the long-term care program which shall
include the ability to select, direct and/or employ persons offering
any of the services currently available under the IRIS program and
the ability to manage (utilizing the services of a IHA serving as a
fiscal intermediary) and individual home-and community-based service
budget allowance, allow for audits of providers, pres erve the “an
y willing provider” requirement for long-term care providers for a
minimum of three years after the implementation date of the program
in each region.
F. LTC Ombudsman – Aging advocates
support providing funding and position authority to the Wisconsin
Board on Aging & Long Term Care for a lead ombudsman specialist
and two additional
ombudsman specialists to provide
services and assistance to some of Wisconsin’s most vulnerable
citizens - residents of long-term care facilities and consumers of
home and community-based services.
1) Governor’s budget recommends
providing expenditure and position authority for a lead ombudsman
specialist and two ombudsman specialists to provide services and
assistance to residents of long-term care facilities and consumers of
home and community-based services.
2) JFC budget approves the Governor’s
recommendations.
3) Senate/Assembly make no changes to
budget approved by JFC.
4) Gov. Walker approves budget
recommendations as final.
G. Dementia Care Specialists (DCS) –
Aging advocates support funding of these valuable DCS positions and
support expansion of Dementia Care Specialists into the remaining 46
counties. (There are currently 20 DCS positions serving 26 counties –
This budget item relates to 16 DCS positions currently funded by
DHS.)
1) Governor’s budget recommends
providing one-time funding to support the costs of dementia care
specialists in selected ADRCs across the state. (Funds 12 grant
positions in FY ‘17).
2) JFC budget approves the Governor’s
recommendation. (*This approval leaves the funding allocation short
four positions and a six month gap between the current funding for
DCS positions and funding available in the next biennial budget.)
3) Senate/Assembly make no changes to
budget approved by JFC.
4) Gov. Walker approves budget
recommendations as final.
H. Health Aging Grants – Aging
advocates are seeking a $600,000 annual appropriation to fund a
private, non-profit entity (such as WIHA) to serve as a statewide
clearinghouse for evidence-based disease prevention and health
promotion programs in healthy aging.
1) Governor’s budget does not include
funding for Healthy Aging Grants.
2) JFC budget includes $200,000 in
one-time GPR funding in each year of the biennium (2015-2017) to fund
a private, non-profit entity to coordinate implementation of health
promotion programs in healthy aging, coordinate research on healthy
aging, serve as a statewide clearinghouse on evidence-based disease
prevention and health promotion programs, provide training and
technical assistance to county departments/administering agencies and
other providers of service to aging populations, collect and
disseminate information, coordinate public awareness activities, and
advise DHS on public policy issues concerning disease prevention and
health promotion in aging. In addition, JFC calls for DHS to create
an annual GPR appropriation for “Healthy Aging; evidence-based
training and prevention.”
3) Senate/Assembly make no further
changes to budget approved by JFC.
4) Gov. Walker does a partial veto of
the changes made by JFC. The Governor: removes the grant
administration requirements from the budget language and provides DHS
the flexibility to "best address healthy aging issues."
Funding for Healthy Aging Grants remains in the budget ($200,000 in
each year of the budget). DHS will have increased flexibility in how
the funds are used, including support for an evidence-based
clearinghouse for healthy aging programs and training and technical
assistance to aging units and other aging service providers as
originally proposed.
I. Specialized Transportation – Aging
advocates request an increase in funding to the Elder and Disabled
Transportation Assistance Program (s.85.21) of 10% ($1.36 million)
with ongoing annual increases to account for growth in the older
adult population in Wisconsin.
1) Governor’s budget increases
funding by $438,000 (1%) for elderly and disabled aids to local
governments and nonprofit organizations and renames the program
“Seniors and Individuals with Disabilities Specialized
Transportation Aids.”
2) JFC budget approves the Governor’s
recommendation.
3) Senate/Assembly make no changes to
budget approved by JFC.
4) Gov. Walker approves budget
recommendations as final.
J. Mass Transit – Aging advocates
support investment in public transit to provide a 4% increase in
calendar year 2016 equaling $5,537,100 for the biennium and to fully
fund the 4 new tier C transit programs ($485,900).
1) Governor’s budget funds Mass
Transit Operating Aids at current levels.
2) JFC budget approves the Governor’s
recommendation.
3) Senate/Assembly make no changes to
budget approved by JFC.
4) Gov. Walker approves budget
recommendations as final.
K. Complete Streets – Aging advocates
support Complete Streets policy which ensures pedestrian and bike
ways are considered in all new and reconstructed road projects and
therefore are requesting the legislature to remove the repeal of the
Complete Streets policy from the budget.
1) Governor’s budget repeals the
policy commonly known as Complete Streets.
2) JFC budget repeals the Complete
Streets policy and replaces current law with a provision specifying
that the Department would be required to give due consideration to
establishing bikeways and pedestrian ways in all new highway
construction and reconstruction projects funded in part or in whole
with state or federal funds. Specify that the Department may not
establish a bikeway or pedestrian way as part of a new highway
construction or reconstruction project if either of the following
apply: (a) bicyclists or pedestrians are prohibited by law from using
the highway that is the subject of the project; or (b) the project is
funded in whole or in part from state funds, unless the governing
body of each municipality in which a portion of the project will
occur has adopted a resolution authorizing the Department to
establish the bikeway or pedestrian way. JFC also deleted $190,500
annually from the appropriation for the program to reflect
anticipated savings from the modification of the law.
3) Senate/Assembly make no changes to
budget approved by JFC.
4) Gov. Walker makes a partial veto of
the requirement prohibiting DOT from constructing bike or pedestrian
facilities unless municipalities pass resolutions approving such
projects. This requirement will no longer apply to projects that are
already underway. For all new highway construction and reconstruction
projects (excluding those currently underway), the Department of
Transportation must give due consideration to establishing bikeways
and pedestrian ways if the project is funded in part or in whole with
state or federal funds. However, DOT may not establish bike- or
pedestrian ways as part of the project if bicyclists or pedestrians
are prohibited by law from using the highway that is the subject of
the project or the project is funded in whole or in part from state
funds, unless the governing body of each municipality in which a
portion of the project will occur has adopted a resolution
authorizing the DOT to do so.
L. Non-emergency Medical Transportation
(NEMT) – Aging network advocates support a regional brokerage model
operating on a fee-for-service basis.
1) Governor’s budget makes no changes
to NEMT.
2) JFC budget requires DHS to modify
the current NEMT contract, to the extent permitted by the contract to
exclude Jefferson, Kenosha, Milwaukee, Ozaukee, Racine, Walworth,
Washington and Waukesha county MA beneficiaries from the contract and
make alternative arrangements for the provision of NEMT services for
beneficiaries in those counties.
3) Senate/Assembly make no changes to
budget approved by JFC.
4) Gov. Walker does a partial veto of
the JFC changes by removing the language excluding the specific
counties (8 SE) from the current NEMT contract. No changes have been
made to the NEMT contract or services. MTM’s original three year
contract expires in July 2016, with an option to extend it for two
additional one year periods. Aging network advocates, in cooperation
with disability advocates and transportation advocates and providers,
continue to work with legislators and DHS to address issues
identified in the recent LAB audit report and make recommendations
for a longer term solution to improving customer satisfaction,
financial sustainability and CMS compliance by considering a new
regional brokerage model.
Thursday, July 16, 2015
Report: ACA plans have a third fewer providers than employer-based plans - The Washington Post
Report: ACA plans have a third fewer providers than employer-based plans - The Washington Post
The Managed Care model in ACA plans just keeps making the restrictions on who can be used as a vendor worse and worse.
The Managed Care model in ACA plans just keeps making the restrictions on who can be used as a vendor worse and worse.
1 in 4 adults had insurance but still couldn’t afford medical care - The Washington Post
1 in 4 adults had insurance but still couldn’t afford medical care - The Washington Post
Some good examples of how and why high deductibles/co-pays do not improve health care outcomes.
Also, some good examples of how ACA can be done differently to better benefit the patients.
Some good examples of how and why high deductibles/co-pays do not improve health care outcomes.
Also, some good examples of how ACA can be done differently to better benefit the patients.
Wednesday, July 15, 2015
Friday, July 10, 2015
[Report] | Wrong Prescription?, by Trudy Lieberman | Harper's Magazine
Full article in PDF
Comments from Kip Sullivan:
"I'm passing along an article in the latest Harper's that you must read.
The author is Trudy Lieberman, a writer I have long enjoyed reading.
Trudy's
main argument is that the ACA has given Republicans what they have
always wanted -- a health care system that forces Americans to buy
high-deductible policies from the insurance industry. She quotes Obama
saying the ACA reflects Republican principles.
Her secondary
point is that the Republican/ACA system is doing nothing to lower costs,
and is shifting more and more costs onto the backs of patients.
This
article confirms my belief that the ACA is going to become even more
unpopular in a few years than it is now, which is to say it's going to
become an even heavier albatross around the necks of Democrats than it
is now. The question is how badly the ACA will damage Democrats and the
movement for universal coverage in any form -- single- or
multiple-payer. I entertain the possibility that the backlash could be
so severe Republicans will take control of the White House and both
houses of Congress in 2020 and repeal whatever is left of the ACA. To
forestall the backlash, Democrats must do more than run from the ACA or
dig in their heels and defend it.
Kip"
Comments from Kip Sullivan:
"I'm passing along an article in the latest Harper's that you must read.
The author is Trudy Lieberman, a writer I have long enjoyed reading.
Trudy's
main argument is that the ACA has given Republicans what they have
always wanted -- a health care system that forces Americans to buy
high-deductible policies from the insurance industry. She quotes Obama
saying the ACA reflects Republican principles.
Her secondary
point is that the Republican/ACA system is doing nothing to lower costs,
and is shifting more and more costs onto the backs of patients.
This
article confirms my belief that the ACA is going to become even more
unpopular in a few years than it is now, which is to say it's going to
become an even heavier albatross around the necks of Democrats than it
is now. The question is how badly the ACA will damage Democrats and the
movement for universal coverage in any form -- single- or
multiple-payer. I entertain the possibility that the backlash could be
so severe Republicans will take control of the White House and both
houses of Congress in 2020 and repeal whatever is left of the ACA. To
forestall the backlash, Democrats must do more than run from the ACA or
dig in their heels and defend it.
Kip"
Tuesday, July 7, 2015
Health Insurance Companies Seek Big Rate Increases for 2016 - The New York Times
Health Insurance Companies Seek Big Rate Increases for 2016 - The New York Times
Comment by Don McCanne
Although it will be
about three months before we have the final health insurance premiums
for 2016, the information we have already can warrant a few preliminary
observations.
about three months before we have the final health insurance premiums
for 2016, the information we have already can warrant a few preliminary
observations.
* The Affordable Care Act
appears to have failed on delivering its promise of controlling global
health care costs. The primary reason given by the insurers when
submitting requests for much higher premiums for 2016 is that health
care costs were much higher than their actuaries anticipated.
appears to have failed on delivering its promise of controlling global
health care costs. The primary reason given by the insurers when
submitting requests for much higher premiums for 2016 is that health
care costs were much higher than their actuaries anticipated.
*
Some complain that new enrollees were less healthy and thus drove
spending up, but under the individual mandate, increases in enrollment
were across the board and not concentrated amongst the less healthy.
Some complain that new enrollees were less healthy and thus drove
spending up, but under the individual mandate, increases in enrollment
were across the board and not concentrated amongst the less healthy.
*
There may have been some pent up demand amongst new enrollees (e.g.,
joint replacement) but that is only a transient surge which does not
warrant long term premium increases. Much of the pent up demand will
have been ventilated as most of the remaining uninsured are ineligible
by immigration status or by personal hardship. The numbers who are
eligible but decline coverage will only trickle in as health care needs
develop.
There may have been some pent up demand amongst new enrollees (e.g.,
joint replacement) but that is only a transient surge which does not
warrant long term premium increases. Much of the pent up demand will
have been ventilated as most of the remaining uninsured are ineligible
by immigration status or by personal hardship. The numbers who are
eligible but decline coverage will only trickle in as health care needs
develop.
* It appears that the increases in
the benchmark silver plans will not be as great as the increases
currently receiving considerable publicity. Requests over a ten percent
increase were required to be made public whereas increases under ten
percent will not be known until plans are marketed prior to the November
1 beginning of open enrollment.
the benchmark silver plans will not be as great as the increases
currently receiving considerable publicity. Requests over a ten percent
increase were required to be made public whereas increases under ten
percent will not be known until plans are marketed prior to the November
1 beginning of open enrollment.
* Because
rate increases vary considerably amongst the plans, many individuals
will be forced to choose between paying higher rates by staying in their
current plans or changing to plans with lower rates but with different
narrow provider networks thereby potentially sacrificing continuity of
care.
rate increases vary considerably amongst the plans, many individuals
will be forced to choose between paying higher rates by staying in their
current plans or changing to plans with lower rates but with different
narrow provider networks thereby potentially sacrificing continuity of
care.
* Respected institutions such as
Geisinger in Pennsylvania and Scott and White in Texas are asking
staggering premium increases, indicating that the supposed cost
containment features of ACA are having a negligible impact on legitimate
spending.
Geisinger in Pennsylvania and Scott and White in Texas are asking
staggering premium increases, indicating that the supposed cost
containment features of ACA are having a negligible impact on legitimate
spending.
* Little is being said about the
insurance underwriting cycle. Large, well capitalized insurers are able
to price their products more competitively, decreasing the market
presence of less competitive insurers. Once market dominance is
established, insurers are free to drive up premiums as much as 20 to 40
percent, as reported in this New York Times article. The regulated
medical loss ratios are generous enough to allow market performance
(profits) to excel, as confirmed by current Wall Street activity in
health insurance equities.
insurance underwriting cycle. Large, well capitalized insurers are able
to price their products more competitively, decreasing the market
presence of less competitive insurers. Once market dominance is
established, insurers are free to drive up premiums as much as 20 to 40
percent, as reported in this New York Times article. The regulated
medical loss ratios are generous enough to allow market performance
(profits) to excel, as confirmed by current Wall Street activity in
health insurance equities.
So are we going to
wait until October when the premium rates are announced, and then do
nothing other than continue to stand back and observe because the
insurers will reassure us that silver benchmark plans didn’t go up that
much - maybe 4.4 percent - even if it means that the enrollees have to
switch plans and find new providers in a different narrow network? Is
this the good that’s coming out of all of this? What about those who
want to continue with their current providers, but face a 20 to 40
percent premium increase? Will the death spiral bleed over from insurers
to patients?
wait until October when the premium rates are announced, and then do
nothing other than continue to stand back and observe because the
insurers will reassure us that silver benchmark plans didn’t go up that
much - maybe 4.4 percent - even if it means that the enrollees have to
switch plans and find new providers in a different narrow network? Is
this the good that’s coming out of all of this? What about those who
want to continue with their current providers, but face a 20 to 40
percent premium increase? Will the death spiral bleed over from insurers
to patients?
Enough. Single payer.
Monday, July 6, 2015
Great Comment was Posted to the Last Article Below
From: doktada
Medicare is a nice term like Medicaid or NHS (National Health Service), but they been under siege in recent decades. I went to a recent retirement planning event and Medicare was explained. It's better than basic insurance but still has holes in it. A lot of money can be saved by using the single payer concept. Let's put it in terms a business can understand. How does it work ? 4 simple rules:
1. Who is covered? Everyone
2. What is covered ? Everything
3. Who controls care ? Patient and doctor (provider)
4. Who pays ? Government pays providers (workers pay Medicare tax)
What's in it for business (those job creators) ?
1. No more health insurance part of benefits department
2. No more negotiating for corporate healthplans
3. No more training employees on how their plan works
4. No corporate health insurance premium subsidies.
How's it save money ?
1. The trillion dollar insurance middleman eliminated
2. Government has larger economies of scale.
3. Less or no profit points saves employers and employees money
4. Results in healthier population. Tens of thousands less deaths annually from postponing care until too late.
Medicare is a nice term like Medicaid or NHS (National Health Service), but they been under siege in recent decades. I went to a recent retirement planning event and Medicare was explained. It's better than basic insurance but still has holes in it. A lot of money can be saved by using the single payer concept. Let's put it in terms a business can understand. How does it work ? 4 simple rules:
1. Who is covered? Everyone
2. What is covered ? Everything
3. Who controls care ? Patient and doctor (provider)
4. Who pays ? Government pays providers (workers pay Medicare tax)
What's in it for business (those job creators) ?
1. No more health insurance part of benefits department
2. No more negotiating for corporate healthplans
3. No more training employees on how their plan works
4. No corporate health insurance premium subsidies.
How's it save money ?
1. The trillion dollar insurance middleman eliminated
2. Government has larger economies of scale.
3. Less or no profit points saves employers and employees money
4. Results in healthier population. Tens of thousands less deaths annually from postponing care until too late.
Saturday, July 4, 2015
Insurance Companyies' Warped Approach to Competition
The Commonwealth Fund
June 24, 2015
How Insurers Competed in the Affordable Care Act's First Year
By Katherine Swartz, Mark Hall, Timothy S. Jost
Abstract
Prior to the Affordable Care Act (ACA), most states’ individual health insurance markets were dominated by one or two insurance carriers that had little incentive to compete by providing efficient services. Instead, they competed mainly by screening and selecting people based on their risk of incurring high medical costs. One of the ACA’s goals is to encourage carriers to participate in the health insurance marketplaces and to shift the focus from competing based on risk selection to processes that increase consumer value, like improving efficiency of services and quality of care. Focusing on six states — Arkansas, California, Connecticut, Maryland, Montana, and Texas — this brief looks at how carriers are competing in the new marketplaces, namely through cost-sharing and composition of provider networks.
From the Conclusions
The ACA reforms will surely stimulate continuing adaptations by carriers, providers, and policymakers, and we expect the competitive strategies in the marketplaces to evolve as consumers and carriers gain more experience with marketplace competition.
****
Comment by Don McCanne
What should the consumer expect from marketplace competition? Business experts tell us that competition is the key to higher quality at lower cost. So what has competition between private health insurance plans brought us?
Based on international comparisons, our health care quality is mediocre and our health care costs are by far the highest of all nations. The insurers have been ineffective in improving either of those. Okay, but what about the health plans themselves? Are we receiving high quality insurance products at low prices?
Before the Affordable Care Act (ACA), insurers competed primarily on the prices of their insurance premiums, and they still do. Before ACA, the most effective method of keeping their premiums from increasing more than they did was to exclude people from coverage who actually needed health care. The most important purpose of insurance is to make health care access affordable by diluting risk through insurance risk pools. Yet the insurers instead excluded risk by attempting to insure only those who could pass underwriting standards in the individual market, or by pricing group plans out of the market if they experienced high health care utilization.
A quality risk pooling program would be designed to ensure that everyone receives essential health care, yet by excluding those who have the greatest needs for care, the insurers abandoned any effort to ensure quality in their insurance products.
As far as costs are concerned, health care costs continued to escalate out of control, demonstrating that the insurers could not deliver on the promise of lower costs either.
What has happened since ACA was implemented?
Although the act prohibits medical underwriting, the insurers are still using devious methods to discourage individuals with greater heath care needs from enrolling. As an example, drugs used for certain chronic conditions are placed in upper tiers of drug coverage which require greater coinsurance payments, pricing these products out of reach for the patients, which deters them from joining the plan in the first place. Plans also are still selectively marketed to healthier populations. Professionals and institutions noted for providing care to high needs patents are frequently left out of the insurers’ networks, chasing away patients who use these providers. Again, these efforts to exclude those with needs confirm that the insurers are still marketing low quality insurance products that fall short of the health care needs of the community.
This new report from The Commonwealth Fund shows that the insurers are using two innovations to improve their competitive positions in the marketplace: cost sharing and narrow provider networks.
Cost sharing through deductibles, co-payments, coinsurance, and exclusion of coverage erects financial barriers to care, reducing the use of beneficial services and thus allowing the insurers’ premiums to be priced more competitively. An insurance product that is designed to keep people away from care that they need is a low quality product.
Narrow provider networks reduce health care utilization by preventing coverage of health care professionals and institutions that may be the most appropriate for the patients’ conditions, requiring them to turn to lesser care or no care at all. Also, care may be made less accessible simply by increasing the distances needed to travel to network providers while excluding nearby providers from the networks. Again, insurance products designed to impair access to appropriate health care providers are low quality products.
Thus, with ACA, insurers are impairing quality through the use of the barriers of cost sharing and narrow networks. And regarding costs, it appears that they are again on an upward trajectory. Health care prices have not been controlled. The only slowing has been due to a modest reduction in the use of beneficial health care services caused by these barriers that the insurers have erected. The insurers have failed again on their promise of higher quality at lower cost.
What about the future? The Commonwealth Fund report states, “we expect the competitive strategies in the marketplaces to evolve as consumers and carriers gain more experience with marketplace competition.” We know what this means. The insurers will not be looking for ways to pay for more beneficial health care services. They will be introducing more innovations that prevent patients from getting the care that they need. That’s the way that the marketplace for health insurance products works.
Medicare doesn’t work that way. Instead, efforts are made to include everyone who is qualified and to include all health care professionals and institutions. At the same time, payments are based on legitimate costs and fair margins - a system that is less costly because of administrative efficiencies.
If we really want higher quality at a lower cost, we need to improve Medicare and expand it to cover everyone. The private insurance industry certainly is never going deliver on quality and cost since they will do better for themselves with their warped approach to competition.
Is it Time to Nationalize the Drug Industry?
Reuters
June 30, 2015
Novartis to test new pricing model with heart failure drug
By Ben Hirschler
Novartis plans to test a novel pricing model with some customers when it launches its keenly awaited new heart failure drug Entresto, the Swiss company's head of pharmaceuticals said on Tuesday.
Entresto, also known as LCZ696, is the first new drug in decades for helping patients whose lives are in danger because their hearts cannot pump blood efficiently. As a result, it is widely expected to generate billions of dollars in annual sales.
How the product should be priced, however, is a dilemma for Novartis, since the company wants to reach as many patients as possible and it knows it will be competing with very cheap - though less effective - older medicines.
David Epstein said he was talking to several healthcare customers about a system under which they would get the drug at a discount but then pay Novartis more if, as expected, it successfully reduces the need for costly hospital visits.
"We are beginning to share the risk," he said in an interview.
The idea of moving from a simple pay-per-pill model to one based on clinical outcomes is being considered by several drugmakers, and Novartis already has such a system in place for one customer using its multiple sclerosis drug Gilenya.
But Entresto could be an important test case because the drug will push up immediate drug costs markedly for a large number of patients, while having the potential to reduce their long-term medical bills.
The issue of drug pricing has come to a head recently, thanks to the launch of extremely expensive new medicines for cancer and hepatitis C, which are straining healthcare systems and adding to co-payment costs for patients.
Epstein, whose team is in the final stages of deciding the price for Entresto, declined to detail a likely cost per pill. But he said it would take into account "cost offsets", such as fewer hospitalizations, as well as the value added from improving patients' lives.
"We going to try and be fair and reasonable," he said.
****
Health Economics
October 2014
Cost-Offsets of Prescription Drug Expenditures: Data Analysis Via a Copula-Based Bivariate Dynamic Hurdle Model
By Partha Deb, Pravin K. Trivedi and David M. Zimmer
Summary
In this paper, we estimate a copula-based bivariate dynamic hurdle model of prescription drug and nondrug expenditures to test the cost-offset hypothesis, which posits that increased expenditures on prescription drugs are offset by reductions in other nondrug expenditures. We apply the proposed methodology to data from the Medical Expenditure Panel Survey, which have the following features: (i) the observed bivariate outcomes are a mixture of zeros and continuously measured positives; (ii) both the zero and positive outcomes show state dependence and inter-temporal interdependence; and (iii) the zeros and the positives display contemporaneous association. The point mass at zero is accommodated using a hurdle or a two-part approach. The copula-based approach to generating joint distributions is appealing because the contemporaneous association involves asymmetric dependence. The paper studies samples categorized by four health conditions: arthritis, diabetes, heart disease, and mental illness. There is evidence of greater than dollar-for-dollar cost-offsets of expenditures on prescribed drugs for relatively low levels of spending on drugs and less than dollar-for-dollar cost-offsets at higher levels of drug expenditures.
****
Comment by Don McCanne
With the marketing success of outrageously priced drugs, the pharmaceutical industry is now devising schemes to be sure that their new products that are protected by patents will continue to be introduced with similar outrageous prices. This concept of adding “cost offsets” to the pricing is not new, but it now has a label that supposedly legitimizes its inclusion in pricing decisions.
In the past, pharmaceutical firms have cited the high costs of drug research as an excuse for high prices of new products (though the high prices of the past were nothing compared to the five and six digit prices of today’s new products). As the public discovers that the drug industry's advertising budgets are typically three times their research budgets, and much of the research is funded through government programs such as those of the NIH, the firms apparently have decided that this argument is no longer as persuasive, and so they have to find another reason to justify outrageous pricing.
“Cost offsets” is a convenient label for adding to the the research, marketing, administration and profit costs of the products. These “cost offsets” include such concepts as money saved by fewer hospitalizations, fewer expensive interventions for progression of disease processes, and for the added value of prolonged lives or the added value of higher quality lives.
Think about that. What gall it takes for these pooh-bahs of the pharmaceutical world to suggest that they are entitled to capture, for themselves, not just the costs and legitimate profits, but the value of the benefits of their products, through higher consumer prices, whether paid individually or through some form of public or private insurance.
This perverse type of thinking is not limited to Novartis’ David Epstein. Bayer’s Marijn Dekkers 18 months ago said, about their expensive cancer drug, Nexavar, “we did not develop this product for the Indian market - let’s be honest - we developed this product for Western patients who can afford this product, quite honestly.”
Perhaps more despicable is this entry from a draft of the infamous Trans-Pacific Partnership Agreement, which contains the following in its statement of principles: “(d) the need to recognize the value of pharmaceutical products and medical devices through the operation of competitive markets or by adopting or maintaining procedures that appropriately value the objectively demonstrated therapeutic significance of a pharmaceutical product or medical device.”
Not only did the pharmaceutical industry buy off Congress when they went the route of the market-based Affordable Care Act instead of an efficient single payer Medicare for all, they have demonstrated to us that their primary goal is to achieve the greatest returns for their executives and shareholders no matter the cost to the ultimate consumers - the patients.
There could not be an industry that cries out more for government intervention to protect consumers than the pharmaceutical industry (oh wait, the private insurance industry, of course, but that's another topic). Many suggest that it is time to demand negotiation of drug prices, or even to dictate fair prices. But should that be our opening position? How about calling for nationalization of the industry, at least their U.S. subsidiaries. That should get their attention. They have to know that we're serious about wanting relief from their greed.
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