Tuesday, January 31, 2023

Pervasive Greed Destroying US Health Care

Summary: Esteemed medical care quality leader Donald Berwick condemns the pervasive and crippling role of financial gain-seeking in US health care. As he said recently, single payer is the solution. Salve Lucrum: The Existential Threat of greed in US Health Care Link to Article

Sunday, January 22, 2023

Galluping In the Wrong Direction: Higher Cost Barriers & Lower Quality

Health Justice Monitor - January 21, 2023 No Commentson Galluping In the Wrong Direction: Higher Cost Barriers & Lower Quality Summary: National polls show that the US is losing ground on two major indicators of health system performance: access to care and perceived quality. Who thought it could get worse? Gallup shows we’re galloping to disaster. Record High in U.S. Put Off Medical Care Due to Cost in 2022 Gallup January 17, 2023 By Megan Brenan The percentage of Americans reporting they or a family member postponed medical treatment in 2022 due to cost rose 12 points in one year, to 38%, the highest in Gallup’s 22-year trend. Americans were more than twice as likely to report the delayed treatment in their family was for a serious rather than a nonserious condition in 2022. In all, 27% said the treatment was for a “very” or “somewhat” serious condition or illness, while 11% said it was “not very” or “not at all” serious. [This] 16-point gap in the perceived seriousness of forgone treatment in 2022 is the second largest on record … Americans Sour on U.S. Healthcare Quality Gallup January 19, 2023 By Lydia Saad For the first time in Gallup’s two-decade trend, less than half of Americans are complimentary about the quality of U.S. healthcare, with 48% rating it “excellent” or “good.” The slight majority now rate healthcare quality as subpar, including 31% saying it is “only fair” and 21% — a new high — calling it “poor.” Americans’ evaluations of the quality of healthcare they personally receive are also at a low ebb — albeit higher than their U.S. rating — with 72% giving it excellent or good marks. This low reading has been two years in the making, with the metric falling six points to 76% in 2021 and another four points in the past year. Comment by: Jim Kahn This pair of national Gallup polls demonstrates our health care is headed in the wrong direction. The care is less affordable and lower quality. Why less affordable? In brief, under-insurance. As the Kaiser Family Foundation showed in its 2022 annual survey of job-based insurance, deductibles continue increasing (Fig. 7.18), even as employee premium contributions rise or stay flat (Fig. 6.23). Drug prices are extraordinarily high due to the industry’s relentless pursuit of profit, and cost controls in the Inflation Reduction Act are anemic. A commentary from last week noted that drug cost-sharing under the now ubiquitous pharmacy benefit managers (PBMs) can be devastating for patients who depend on expensive brand-name medicines with no generic options. Two main causes: First, a shift from fixed co-payments to percentage-of-cost coinsurance, which is based on inflated list prices. Second, exclusion of manufacturer patient assistance from deductible credit. The difference for patients can be tens of thousands of dollars a year (see sample calculations here). Wendell Potter wrote recently on the painful results for patients. Financial barriers have clinical consequences. Research by Gaffney et al in late 2022 found rationing of insulin by 17% of patients or 1.3 million US adults. Research by Chandra et al in 2021 found that a 34% ($10) rise in out-of-pocket cost for seniors reduces drug use by 23% and increases mortality by one-third, specifically for statins and antihypertensives. Why lower quality? It’s multi-factorial. Clearly COVID has burdened health care capacity, leading to worker stress, burnout, and staffing shortages. But I believe patient frustration also carries over from the financial challenges. When people have to pay more – which they can barely afford – they demand and expect more. When the system is failing in multiple ways, it feels like it’s completely falling apart. Which it is. Saddle up for single payer.

Thursday, January 5, 2023

The Problems with Job-Based Insurance

http://healthjusticemonitor.org/2023/01/05/the-problems-with-job-based-insurance/ January 5, 2023 No Commentson The Problems with Job-Based Insurance Summary: The Chamber of Commerce uses the results of its online poll to claim overwhelming worker support for job-based health benefits. However, the methods and reporting are biased. Survey findings by the Commonwealth Fund tell a far more worrisome story. New Poll of American Workers Reveals Tremendous Value Placed on Workplace Health Benefits U.S. Chamber of Commerce December 15, 2022 Health insurance is the most important benefit an employer can offer workers and their families, according to a new survey on how American workers view employer-sponsored health coverage. Workers report that they overwhelmingly prefer to receive health insurance directly from an employer rather than through other means. The poll found that as high as 96% of Americans believe it is important that a job offer health insurance. Ninety-three percent of respondents said they were satisfied with their insurance. Employer-sponsored health insurance remains far more popular than insurance plans available on the individual market: 89% of Americans expressed a preference for obtaining their health coverage through an employer than through other means. 81% of respondents reported that they would rather receive their insurance from an employer than a government-provided health plan. “I expected there to be a high level of satisfaction with employer health benefits, but I was stunned by the level of intensity,” said Matt George of Seven Letter Insight, who ran the survey. “It is not an exaggeration to say Americans love, trust, and rely on their workplace health care coverage.” The survey was commissioned by the Protecting American’s Coverage Together (PACT) campaign, a coalition including the U.S Chamber of Commerce, Business Roundtable, Vermeer Corporation, The National Association of Manufacturers and Council for Affordable Health Coverage. PACT represents leading employer voices focused on strengthening the ESI system and protecting the coverage and benefits that American families depend on for their health. The State of U.S.Health Insurance in 2022 The Commonwealth Fund September 29, 2022 By Sara R. Collins, Lauren A. Haynes, Relebohile Masitha Forty-three percent of working-age adults were inadequately insured in 2022. These individuals were uninsured (9%), had a gap in coverage over the past year (11%), or were insured all year but were underinsured, meaning that their coverage didn’t provide them with affordable access to health care (23%). Twenty-nine percent of people with employer coverage and 44 percent of those with coverage purchased through the individual market and marketplaces were underinsured. Among the world’s high-income countries, the U.S. stands alone for the complexity of its health insurance system. Americans are eligible for different types of coverage depending on whether their employer offers it, what their income level is and what their age and health care needs are. There is no national enrollment mechanism for people who don’t have employer coverage; they must know which program they are eligible for and then sign up for coverage. Consequently, people can experience insurance gaps at different points in their lives, like when they lose a job. The average insurance deductible for employer health plans with single coverage is more then $1,000 ($1,434 for all covered workers in 2021), and out-of-pocket maximums average $4,272 for single coverage in employer plans. Half of survey respondents said they would not have the money to cover an unexpected $1,000 medical bill within 30 days. Comment by: Don McCanne & Jim Kahn With our inordinately high costs of health care and persistent gaps and inequities in access, many hope that 2023 is going to be the year that we finally start to enact and implement health care justice for all. Remarkably, however, there is still resistance to the tested and proven concept that will get us there: single payer Medicare for All. Some argue that Medicare has too many defects, but we know what they are and can revise the program to meet widely accepted standards of care. Other nations have shown that to achieve the goals of equity, accessibility, and affordability for all, the government must have a central role. To those who advocate for reliance on a private sector strategy, we point to its clear failings. Our health system failings reflect the shift of health care funds from patient care to wealthy investors, such as through public fund privatization (eg Medicare Advantage and Medicaid managed care) and the massive acquisition of providers by private equity. That’s why we must pay for health care through public insurance on the model of traditional Medicare. Employers and insurer organizations tout the benefits of employer-sponsored health insurance. Admittedly, these plans provide a welcome financial backstop for expensive medical problems, such as a heart attack or a fracture requiring surgery. Unsurprisingly, workers value getting health benefits with a significant employer contribution. Yet most job-based plans have large deductibles (thousands of dollars) and provider networks are limited. This mixed picture is evident in the Commonwealth poll and reports by the Kaiser Family Foundation and others. The Chamber of Commerce poll and report grossly exaggerate the level of support for job-based coverage. It’s biased, in four ways (please excuse geek detour): 1) Biased sample of respondents: it’s an online survey, with no sampling frame or response rate specified. This is a red flag for self-selection: the individuals who see and participate in the poll have a special perspective. The report doesn’t indicate the recruitment message, but if it was something like “What do you like about your health insurance?” or “Do you appreciate your health benefits?”, who do you think would click over to the survey? 2) Biased presentation: Statistics are presented in a way that favors the pro-benefits view. E.g., 52% do NOT strongly agree that insurance is affordable, and a similar % do NOT say that it’s high quality. More than 70% do NOT say it’s comprehensive or convenient. 3) Unfair comparison with public insurance like single payer. Respondents are asked if they prefer private work-based coverage or “government insurance”. No hint at what that means – is it Medicaid? The responses would be quite different if phrased fairly, e.g., “an improved Medicare for All, with coverage for all medical needs; no premiums, deductibles, or copays; and increased taxes only if you earn >$250,000”. 4) Omission. They don’t ask if workers are pleased that employer contributions to health benefits come out of wage or salary levels. (They do, to a very large degree.) Polling as advocacy isn’t real information. Ok geek mode off. Single payer would enable access to the entire health care system whenever needed. In contrast, employer insurance depends, first of all, on employment status and employer benefit plans. Second, details of the insurance contract matter: there may not be freedom to choose health care providers, hospitals, pharmacies, or even what care is covered. Workers may fall prey to job lock, required to stay in a job because insurance may not be available if they quit. Voluntary and highly varied job-based insurance guarantees that coverage is inequitable and unreliable, in contrast to the equity and universality of single payer. It is understandable how, through the years, individuals have liked employer sponsored plans, since they have been among the better options to provider, under the right circumstances, heath care for workers and for their families. (Less true these days due to the skyrocketing deductibles, and obscuring the lower wage effect.) Also, taking solace in decent job-based insurance undermines a principle that most of us care about: solidarity. Most of us really would like to see health care for everyone. Not long ago, we experimented on a large scale with trying to fix the private insurance approach. The Affordable Care Act aimed to preserve, improve, and expand employer sponsored insurance as a pillar of our health care coverage, filling in the voids with a regulated market for private insurance and more Medicaid. The ACA seemed to enhance solidarity while preserving employment sponsored plans. The problem, as reviewed well recently, is that this experiment in health policy was a dismal failure in providing decent coverage for everyone, and thus a failure in the solidarity we seek. Tens of millions remain uninsured, and under-insurance exploded with the rapid growth of high deductible plans. If solidarity is building, it’s of the wrong variety: shared pain. Other nations provide us with ample highly successful examples of single payer. They are effective in providing affordable care for everyone and thus also fulfill the goal of solidarity. We really can have high performance universal health care, and save money in the process. A single payer system would guarantee better health care choices than in employer sponsored plans, for workers and for everyone. We have the opportunity to reject the current, fragmented, dysfunctional employer-sponsored system and adopt policies of social solidarity that would bring affordable, comprehensive high quality health care to everyone. Look around you. This really seems to be the year to fix the health care financing system in the United States. We can use our ingenuity to create a uniquely American system of social and economic justice. Let’s do it. In solidarity, single payer for all!