November 3, 2012

American College of Emergency Physicians: It's Time for Single-Payer

http://www.acepnews.com/index.php?id=2049&type=98&tx_ttnews[tt_news]=1564&cHash=da03e20e36

Winston Churchill’s iconic remark, reportedly issued at the dawn of America’s entry into World War II, is equally applicable to the present American health care debate and the crisis that spawned it. Regardless of whether you are elated or disappointed with June’s historic Supreme Court decision upholding the constitutionality of the Affordable Care Act, it is certainly no panacea for the problems facing U.S. health care. Even with the law intact, and despite its best intentions, it will still leave some 25 million uninsured, underinsure millions more, expand the corporatization of health care, and do little to control the escalating costs of care over the long term. So it’s clear we need to do the right thing: the creation of a national, universal, publicly funded health care system, free of the corrupting power of profit-oriented health insurance, and at the same time capable of passing constitutional muster. In short, the right thing is an expanded and improved Medicare-for-All program, otherwise known as single-payer.

Don’t be so shocked. For the last 30 years, we have tried all the alternatives, and none of them have worked. We have experimented with HMOs, PPOs, high-deductible health plans, health savings accounts, pay-for-performance, capitation, and disease management. These ideas have been promoted in various iterations, often with great fanfare, by public and private payers alike, yet none of them have shown long-term success at bending the cost curve. And the promise of the latest reforms du jour, such as Accountable Care Organizations and Patient-Centered Medical Homes, is speculative at best. American health care is unique among the world’s democracies in that it was never planned in terms of enabling legislation or explicit constitutional authority. As others have stated, our employer-based insurance system, which now covers about 160 million Americans, was an accident of history. Its lineage can be traced to FDR’s wage and price control policies during World War II, where employers were permitted to offer workers health insurance in lieu of higher wages as a job inducement. This benefit has evolved piecemeal into the Rube Goldberg complexity that is contemporary employer-sponsored health insurance, with some 1,200 private plans each doing the same things – medical underwriting, coordination of benefits, claims adjudication and denial, marketing, public relations, lobbying, litigating, and paying shareholder dividends and inflated CEO salaries while forcing individuals to pay a higher share of premiums, increased deductibles, expanded copays, or a combination of all three. Taken as a whole, private insurers’ activities are duplicative, inefficient, wasteful of scarce health care resources, conducive of job lock, and completely misdirected in supporting the 21st-century health care agenda that America needs and deserves.

November 2, 2012

First British NHS hospital privatization a massive failure

Comment by Don McCanne of PNHP: Britain's Conservative Prime Minister David Cameron has been eager to privatize their National Health Service. What a great start. Hinchingbrooke, now privately managed by former Goldman Sachs banker Ali Parsa, has racked up losses of $4.1 million and has plummeted on the Government's new patient satisfaction league table. Apparently Cameron and his Conservatives are blind as to what has happened across the Atlantic.

Of significance is that the tendering process for this arrangement began under the Labour government. Just as the Democrats here have supported an expansion of privatization through private insurers and private managed care organizations, Labour seems to be complicit in Britain's move toward privatization. Taking care of the one percenters seems to be an international phenomenon. Sad.

November 1, 2012

Cost Control in a Parallel Universe: Medicare Spending in the United States and Canada

Comment by Don McCanne of PNHP: Medicare spending has grown nearly 3 times faster in the United States than in Canada since 1980. Had US Medicare costs risen at Canadian rates, rather than a deficit of $17.1 billion in 2009, the Medicare Hospital Trust Fund would have realized a $32.3 billion surplus. Savings on Medicare Part B would have been even larger. By 2009, the $2.156 trillion in excess spending attributable to US Medicare's faster growth was equivalent to more than one-sixth of the national debt.

Several features of Canada's program help constrain costs. First, the single-payer system has simplified administration, holding administrative costs to 16.7% of overall spending vs 31.0% in the United States. Although US Medicare's internal overhead costs are low, it remains one among many payers. Hence providers' administrative costs are inflated by having to deal with a multitude of payers and track eligibility, attribute costs, and bill for individual patients and services.

Second, Canadian hospitals receive prospectively determined global operating budgets, removing incentives to provide unnecessary care while simplifying billing and administration. However, unlike accountable care organization payment schemes in the United States, capital costs are not folded into the global budgets but distributed separately through an explicit health-planning process. Canadian hospitals cannot use operating surpluses to fund new buildings or equipment but must request separate capital appropriations. Hence, they cannot expand by overproviding lucrative services, gaming the payment system through upcoding, avoiding unprofitable patients, or cost shifting.

Third, 51% of Canada's physicians are primary care practitioners vs 32% in the United States. Primary care-centered health systems are generally thriftier. Canada's outpatient fee schedules are also less technology skewed than in the United States.

Fourth, Canada's provincial plans have used their concentrated purchasing power to limit drug and device prices.

Finally, litigation and malpractice costs have remained relatively low in Canada.

Life expectancy at age 65 years is longer and has grown faster in Canada than in the United States since 1980 (and 1971), offering reassurance that cost control has not compromised quality. A meta-analysis suggests that clinical outcomes are, if anything, better for Canadians than for insured Americans.

To some, US Medicare's grim financial health suggests an even grimmer conclusion: it can no longer keep its promise of all needed care for the elderly population. Some would replace it with vouchers that seniors could use to purchase private coverage. Others suggest upending the current payment system by inverting volume-based incentives, offering instead profits to organizations that limit utilization. Yet the efficacy of these drastic solutions remains unproven. Canada's road-tested cost-containment methods offer an alternative.

My comment: Malpractice suits are comparatively rare in the rest of the developed world precisely BECAUSE health care is a guaranteed right. Because of that, people with unfavorable outcomes (regardless of wheter malpractice was involved or not) are not motiviate to sue anyone just to pay for the ensuing additional health care costs.



Comment by Don McCanne of PHNP: This study is particularly important because it compares spending in our Medicare program for beneficiaries 65 and older with Canadian Medicare spending for the same age population during the same decades studied. This apples to apples comparison reveals that there is no contest. Since 1971, we've spent almost $3 trillion more than we would have had we used Canada's payment reforms. The Medicare Hospital Trust Fund would have had a huge surplus by now, and nobody would be claiming that Medicare is "going broke."

The difference is due to economic policies that really do work. Single payer advocates already know what these are, but for those who need a reminder, they are listed in the Comment in the above article.

Not only did Canadians more effectively control their health care cost increases, their life expectancy grew more rapidly during the same time period. They benefited more under their cost efficient Medicare model.

We have enough understanding of health policy science to predict that the current proposals to control spending in the United States will either have very little impact, or, much worse, will reduce spending by making health care access even more unaffordable.

Comparing the two Medicare programs, the Canadian system pays about 80 percent of health care costs, whereas our Medicare program pays only about half. Also, Canada has banned copayments and deductibles for physician and hospital services - a mainstay of the perverse, misguided efforts to control health spending in the United States. We can control spending without imposing financial penalties on people accessing health care that we want them to have.

It is time for all of us to express our OUTRAGE! We can no longer accept inaction by our politicians because they fear the political consequences. We have to make them understand that they face dire political consequences if they don't act. As FDR said, "Make me do it."

November 1, 2012

Our Future press release on defending Medicare

The Challenge

The U.S. has a large budget deficit because the government fought two wars without paying for them; conservatives slashed taxes several times; and then the financial crisis, fueled by deregulated bank gambling, threw millions of middle-class taxpayers onto the unemployment rolls.

And now self-proclaimed “deficit hawks” have a solution: cut Medicare benefits for the most vulnerable seniors (and tomorrow’s retirees). And many (including presidential candidate Mitt Romney) want to drastically change Medicare – by giving seniors a fixed amount of money to buy insurance on the private market.

Almost 50 years ago Medicare was created to guarantee seniors affordable health care. It has been an amazing success story, assuring that more than 50 million older Americans and people with disabilities have health care – and are not pushed into poverty by the costs of illness and hospitalization. Now, conservatives are vowing to replace Medicare with a voucher system that would force older people to try to buy insurance from a welter of private insurance companies whose failure to serve seniors made Medicare necessary in the first place.

If they are successful, seniors would lose the comprehensive national coverage and financial protection that Medicare offers them no matter which doctors and hospitals they use, anywhere in the country. The Republican plan would force them to pay more for health care seniors now get from Medicare – and jeopardize their access to care.

Despite its success, Medicare has been targeted by conservatives who don’t want to take on the real drivers of growing deficits. Instead, they see an opportunity to bolster the profits of private insurance companies, even if this means ignoring the needs of Medicare enrollees. And, for all their talk about deficits, conservatives don’t want to make investments that would put Americans to work and bring down the deficit through an expanding tax base.

Calling Medicare an out-of-control “entitlement” whose costs are rising dramatically and unsustainably, they claim we just can’t afford Medicare as we know it any more. They ignore the experience of history that demonstrates private insurance is more costly. They are really making the case for a giant step backward as a nation and as a civilized community. And it would avoid the real causes of deficits.

Make the Case

Medicare enjoys almost universal support. Most working Americans have seen how Medicare takes a huge load of worry off their parents and grandparents because at 65 this national, comprehensive program offers health and financial security.

But conservatives first tell us we can no longer afford it; we need to privatize it. Then they promise not to change anything for today’s seniors, imposing cuts on future retirees. Don’t you believe it. Many of the changes that they want to make right away – such as repealing health care reform – will cut the health benefits and raise out-of-pocket costs for your mother or grandfather now on Medicare.

But here’s the big flaw in their case: Medicare is actually better at controlling costs than the private health insurance industry. And cost-control experiments pioneered by Medicare – requiring, for example, that hospitals get paid for health care results and not just for every procedure – have the potential to control costs for Medicare and for every other public and private health insurance plan.

It is the inefficient and wasteful private health care system that is driving the costs of Medicare. Conservatives fixate on public plans like Medicare because the federal government pays. But if they get their way and turn Medicare into a voucher program, those costs wouldn’t go down; they would just shift and increase, devastating the savings of elderly individuals and their families.

Every other developed country has done a much better job of controlling health care costs without cutting benefits. Economist Dean Baker has repeatedly pointed out that if our system were as efficient as most European countries, America’s private health care costs would flatten out, Medicare costs would stabilize and the long-term federal deficit problem would disappear. Baker’s think tank documents this with new charts here.

Case in Point
? Conservatives want to force people in their 60s, 70s and 80s to buy less comprehensive private health insurance with a voucher (a set amount of money each year) the government would give them. Voucher supporters pretend the government would save money because those insurance companies would compete to provide the best coverage at the lowest cost. But insurance companies make their money by finding ways to insure only the healthiest people and avoid the oldest and the sickest. If competition leads to efficiency, why is Medicare far better than private insurance at holding down costs?

? The real way these conservative voucher plans would save money for the government is by having the value of the voucher rise more slowly than the cost of health insurance policies. This will shift costs to seniors and their families. Economist David Cutler found the plan supported by Republican presidential candidates Mitt Romney and Paul Ryan plan would raise costs for current seniors by $11,100 and by as much as several hundred thousand dollars for future seniors. This infographic shows how today’s younger workers would fare. Another source is this Kaiser Family Foundation fact sheet.

? Some conservatives who don’t want to support vouchers instead propose to put a cap on overall Medicare spending. That would mean that seniors end up paying more out of pocket for their care.

? Other conservatives want to raise the age when people can get Medicare, which they claim is fair because people are living longer. But that would saddle older adults with big health care bills for months or years longer, at a time when millions of people are hanging on by their fingernails and many unemployed people are going without insurance until they turn 65 and can get Medicare. Raising the eligibility age means that the next wave of (older) seniors to enroll have more health problems due to postponing doctor visits at that advanced age. That means higher Medicare costs, not lower. And research shows the only people living longer these days are the wealthy.

? Beyond the bogus arguments about costs, imagine a 75-year-old senior with multiple health problems having to do battle with a private insurance company to get them to pay for hospital care, tests, or even doctor visits. Imagine being older, on a limited income, and needing a lot of health care. Then imagine having to figure out which private policy would allow you to use the doctors you know and trust and meet your health and financial needs, now and in the unforeseeable future. Medicare is better.

Counterpoint



Public Pulse
? By a margin of 3 to 1, voters in the swing states of Ohio, Florida and Virginia don’t believe Social Security and Medicare need to be cut to reduce our deficits (The Washington Post-Kaiser Family Foundation).

? Given choices for reducing the deficit, including raising taxes on the wealthy and reducing Medicare benefits, 83 percent of Americans oppose cutting Medicare (13 percent supported those cuts) and 68 percent favored raising taxes on households with incomes higher than $250,000 per year (The Washington Post-Bloomberg News).

? An August 2012 Pew Poll finds 72 percent of Americans have heard a lot or a little about a proposal to change Medicare into a voucher. And among those who are aware, the idea remains unpopular; by a 49 percent to 34 percent margin, more oppose than favor the idea. This is virtually unchanged from public reactions a little more than a year ago, when Republicans in the House voted in favor of this proposal as part of the “Ryan plan” (Pew Research Center).

? A July poll shows the popularity of Medicare among seniors. The poll found that 89 percent of seniors are satisfied with the coverage they currently have through Medicare. (Richard Day Research for Allsup Medicare Advisor)

? 66 percent of Americans, including 45 percent of Republicans and 64 percent of independents, favor increasing income taxes for upper-income Americans, compared with 42 percent of Americans who support making “significant changes” to Social Security (Gallup).

? 66 percent of Americans said they were very worried about “not having enough money for retirement,” making it the issue that the largest number of Americans are concerned about (Gallup).

Tweet This

Don’t cut #Medicare benefits. Make drug cos charge same prices in US as in France or Canada. Deficit will come down. #smarttalk @OurFuture

Americans love #Medicare. Private insurance costs more. Voucherizers = same people who wrecked our economy. #smarttalk via @OurFuture

Tell Congress: Protect #Medicare and health needs of our parents and grandparents, not profits of health insurance and drug companies.

Congress, ignore Wall St. Listen to Main Street. Voucherizing #Medicare will hurt today’s seniors & young people when they need it.

Pew poll: Medicare Voucher Plan Remains Unpopular http://tinyurl.com/ca2lrv2 #smarttalk via @OurFuture

It's the health care prices, stupid. Give #Medicare option to all and health care costs in US will come way down. #smarttalk via @OurFuture

RT Sandra Fluke?@SandraFluke New study on problems with #Romney's #medicare plan. http://tinyurl.com/8h389bl

Learn More

» Health Care for America Now – Medicare and Medicaid page
» Economic Policy Institute’s Retirement research page
» Center for Economic and Policy Research’s Social Security and retirement issue page
» Fixing our Fiscal Health: Budget Deficits and Health Care Costs

Get this and other Smart Talks on the Web at http://OurFuture.org/SmartTalk

October 30, 2012

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

http://www.pnhp.org/news/2011/june/how-libby-montana-got-medicare-for-all

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

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

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

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

October 25, 2012

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

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

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

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

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

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

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

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

October 22, 2012

George McGovern: What It Means to Be a Democrat

Blue Rider Press, Penguin Group
http://www.amazon.com/What-Means-Democrat-George-McGovern/dp/B007F7QA5K

What It Means to Be a Democrat
2011
By George McGovern

Universal Health Care

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

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

But I think we should go further.

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

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

October 21, 2012

Future of Medicare is top concern for 61% of seniors

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

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

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

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

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

October 19, 2012

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

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

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

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

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

October 14, 2012

Raising the Medicare Eligibility Age Would Increase Total Health Care Costs

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

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

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