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Gender: Female
Hometown: Washington state
Home country: USA
Current location: Directly above the center of the earth
Member since: Sat Aug 16, 2003, 02:52 AM
Number of posts: 51,907

About Me

Major policy wonk interests: health care, Social Security/Medicare/Medicaid, election integrity

Journal Archives

Will the US health care system be tiered forever?


Rather than embracing a single-payer system, the United States is more likely to stumble, in fits and starts, toward something resembling officially sanctioned tiering of the American health care experience by income class, as follows:

FOR MEDICAID BENEFICIARIES AND THE UNINSURED, a budget-constrained system of public hospitals and public clinics. It would allow politicians to ration health care (through tight budgets) without ever having to acknowledge that they were doing so. In other words, it would reduce the price of being kind.

FOR THE EMPLOYED MIDDLE CLASS, a mixed system with defined contributions by employers, private health insurance exchanges and reference pricing by insurers. Under a restructured Medicare program also based on a defined contribution model, reference pricing would be likely to apply to Medicare beneficiaries as well. Depending on how it is operated – e.g., if it were solely based on cost, in abstraction of quality – reference pricing also permits tiering of the health care experience by income class, without anyone having to say so openly.

FOR THE UPPER-INCOME GROUPS, boutique medicine, which is already growing in the United States. Here the sky will be the limit.

Comment by Don McCanne of PNHP: Uwe Reinhardt, an astute observer of the U.S. health care system, does not see single payer in our future, but rather sees an “officially sanctioned tiering of the American health care experience by income class.” We already have the three tiers that he describes, but the middle tier is rapidly evolving in a way that may provoke a renewed and more intense interest in single payer.

The lowest tier - Medicaid beneficiaries and the uninsured - have never had much of a political voice. Nevertheless, even the most heartless of politicians recognize that we must provide care for indigent pregnant women and children. Thus we have the chronically underfunded Medicaid program plus safety net hospitals and community health centers. Some states also have included other low-income adults, though they still make up the largest percentage of the uninsured. Except for the most basic of primary care services and care for events that threaten life or limb, access to health care for this sector is limited, especially for specialized services. As Professor Reinhardt indicates, politicians are able to ration health care for Medicaid beneficiaries and the uninsured without admitting that they are doing it, merely by placing restraints on the budget. Since it is unAmerican to ration health care, they would never do that, but rather they merely refuse to budget spending that we can’t afford. (Of course, inadequate funding of health care is rationing, and we actually can afford to pay for health care for all, though we do need more efficiency in our financing system.)

The highest tier - the upper-income groups - have never had problems with gaining access to the best care available. That is true now, and will be true no matter what health care financing system we will have. Some have expressed concerns that in a truly egalitarian system, such as a single payer system, the wealthy would have to give up some of the finer amenities of health care and stand in line with the rest of us, but that will never happen. The wealthy are not hampered by noblesse oblige when it comes to moving to the front of the line for health care. Besides, a well designed system should not have an excessive queue anyway.

The middle tier - the employed middle class - will see greater changes in health care access and affordability, changes that have already begun. Although the plans to be offered in the state exchanges will include many of these changes, employers are already following by modifying their plans to reduce their own exposure to costs. Higher deductibles and other forms of cost sharing are shifting more costs to the pockets of those who need health care. Although ten categories of benefits will be required under the plans, the insurers have considerable flexibility in the composition of benefits within each category and will leave out selected benefits that some individuals will need, especially some of the more expensive benefits. Insurers are reducing their networks of physicians and hospitals, further limiting patient choice of their health care providers, unlike the traditional Medicare program, which allows free choice. Patents may still face catastrophic losses since the maximum out-of-pocket expenditures apply only to covered benefits provided within the networks. Care unavoidably obtained out of network and health care services not included as a plan benefit can result in costs that threaten personal bankruptcy. Even the allowed maximums would create a hardship for many. Employers are beginning to switch to defined benefit contributions to health plans that would be selected from private (not state) health exchanges. This voucher approach allows employers to shift the future increases in health care costs disproportionately to the employees. Reference pricing is the process of setting a low price for given health care services and requiring the patient to pay the full difference in prices if the patient selects a more expensive provider. This is another method of shifting more costs to the patient, not to mention that it further limits choice of providers since these extra costs may be truly unaffordable. A shift in control of Congress and the White House to conservatives may well result in premium support of Medicare (vouchers - a defined contribution), thereby allowing Medicare to adopt some of these same policies that shift more costs to patients in need.

The obvious point is that the exchange plans and now even employer-sponsored plans will cause the employed middle class to become quite dissatisfied with our health care financing system. Once they or their families and friends have enough negative experiences with our health care financing, and once they understand single payer - an improved Medicare for all - it will be the middle class workers that will be the loudest in demanding change.

In the meantime, under our present three-tiered system, we will be able to obtain a basic level of care for Tiny Tim, just not the specialized services that he really needs. And Ebenezer Scrooge will be able to access his boutique providers, with the sky as the limit. But what about the people of the village? Once Scrooge gains control of the insurance industry, will he further advance the current agenda of making health care more expensive to increase profits, and less accessible to reduce costs? Will another visit from the Ghost Of Christmas Yet To Come be adequate? Or will he be hardened enough to carry on, as Reinhardt writes, “the age-old reluctance among many of the nation’s haves and the healthy to help purchase for America’s lower-income families and the chronically ill the super-expensive health care that the haves enjoy themselves.”

Though should we really expect a different outcome? We now have a society that when Bob Cratchit pulls himself up by his bootstraps and runs for mayor, we elect Ebenezer Scrooge instead.

Single Payer Is Getting a Second Life as Obamacare Frustration Peaks

That said, plenty of single payer supporters are thankful that the ACA at least broke the logjam preventing action on changing our system.


Could anger at the Obamacare rollout make Americans more receptive to a kind of Medicare-for-all system? That’s what activists are hoping—and they’re plotting a state-by-state fight.

As the rollout of Obamacare clunks forward, activists who opposed the law from the beginning say it is time to seize the moment, to tear down the current health-care edifice and start anew, especially now as frustration with the law’s implementation is reaching a peak.

These are not Tea Party activists but advocates for a single-payer health-care system who say some of the problems with the launch of the Affordable Care Act—in addition to built-in problems with the law itself—have made the American public more receptive than ever to a Medicare-for-all kind of coverage system.

On Monday, Sen. Bernie Sanders (I-VT) introduced the American Health Security Act, which would require each state to set up a single-payer health-care system and would undo the exchanges that have plagued Obamacare. Meanwhile, various state-led efforts are under way that advocates hope will sweep the country statehouse by statehouse, as soon as lawmakers see the advantage of a single-payer system. In Vermont, for example, lawmakers have set aside the financing and are already preparing to adopt a single-payer system when the federal government permits it, which according to provisions of the Affordable Care Act will be in 2015. In Massachusetts, Don Berwick, a former top Obama administration health official, is basing his campaign for governor on bringing a single-payer system to the commonwealth. And advocates in New York, Maryland, Oregon, and around the country say they see new energy around their cause.

“As the president fully understands, the rollout has been a disaster, the website has been a disaster, said Sanders in an interview moments after his bill was introduced in the Senate. “But the truth is, even if all of those problems were corrected tomorrow and if the Affordable Care Act did all that it was supposed to do, it would be only a modest step forward to dealing with the dysfunction of the American health-care system. When you have a lot of complications, it is an opportunity for insurance companies and drug companies and medical equipment suppliers to make billions and billions of profits rather than to see our money go into health care and making people well.”

Medicare Patients’ Access to Physicians: A Synthesis of the Evidence


Main findings:
* On a national level, Medicare patients have good access to physicians. The vast majority (96%) of Medicare beneficiaries report having a usual source of care, primarily a doctor’s office or doctor’s clinic.

* Most people with Medicare — about 90 percent — are able to schedule timely appointments for routine and specialty care. Medicare seniors are more likely than privately insured adults age 50-64 to report “never” having to wait longer than they want for timely routine care appointments.

* A small share of Medicare beneficiaries say they looked for a new physician in the past year, and only 2 percent of seniors with Medicare report problems finding one when needed — comparable to rates reported by privately insured adults age 50-64.

Comment by Don McCanne of PNHP: This comprehensive report lays to rest once and for all the the rumor that physicians are leaving Medicare in droves. Most physicians accept new Medicare patients, and less than 1 percent have formally opted-out of the Medicare program.

An improved Medicare would be even more attractive to physicians, especially if it covered everyone. It would dramatically reduce hassles with intrusive third party payers so that physicians could spend most of their time doing what they devoted their lives to - taking care of their patients.

As far as th threat that physicians would quit if we enacted an improved Medicare for all, first of all, very few would leave - likely less than 1 percent - and, second, since most of those who would leave seem to be more interested in money rather than patients (think concierge), we really don’t want them around anyway. It would be a great way to clean up our profession.

Payment Due: The Obamacare Deadline No One is Talking About


“There is also a lot of worrying going on over people making payments,” industry consultant Robert Laszewski wrote in an email. “One client reports only 15% have paid so far. It is still too early to know for sure what this means, but we should expect some enrollment slippage come the payment due date.”

Another consultant Kip Piper, agreed. “So far I’m hearing from health plans that around 5% and 10% of consumers who have made it through the data transfer gauntlet have paid first month’s premium and therefore truly enrolled,” he wrote me.

“It naturally varies by insurer and will hopefully increase as we get close to end of December and documents flow in the mail,” added Piper, a former official at the Centers for Medicare and Medicaid Services. “But overall I’m hearing it’s a small portion so far. And that, of course, is a fraction of an already comparatively small number of people who have made it through setting up an account, getting verified, subsidy eligibility determined, plan selected, complete and correct data transferred to the insurer, and insurer set out the confirmation with invoice for consumer’s share of the first month’s premium.”


One additional point to keep an eye on: If consumers pay their first month’s premium but then stop paying, insurers cannot drop them from their plans for 90 days.

“Under the rule interpreting the law, insurers offering plans on the exchanges must provide a three-month grace period to individuals who have enrolled and who have stopped paying their premiums. In the first 30 days, the insurer must continue to pay incurred claims. But for subscribers who ultimately fail to pay premiums within the 90 days and whose coverage is terminated, payers are not required to pay for claims incurred during the last 60 days of the 90-day period,” Modern Healthcare reported in August.

Healthcare providers are nervous that they will be on the hook for services delivered to patients who haven’t paid their premiums.
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