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eridani's Journal
eridani's Journal
September 29, 2015

57% of those visiting exchange websites could not find a plan they could afford.


Exhibit 2. Just under half of the adults who have visited the marketplace enrolled in a marketplace plan or Medicaid

52% - Did not select a private plan or enroll in Medicaid

30% - Selected a private health plan

15% - Enrolled in Medicaid

2% - Don’t know/refused

Exhibit 6. Among market-place visitors who didn’t enroll, more than half said they couldn’t find an affordable plan

Can you tell me why you did not obtain a private health insurance plan or Medicaid coverage when you visited the marketplace? Was it because…?

Percent of adults ages 19-64 who visited the marketplace but did not select coverage

57% - Could not find a plan you could afford

51% - Obtained health insurance through another source

43% - Not eligible to enroll in Medicaid or for financial assistance

38% - Found the process of enrolling in a plan difficult or confusing

32% - Could not find a plan with the type of coverage you need

15% - Decided you did not need health insurance

14% - Did not know where to get help to sign up

23% - Some other reason

Affordability was a key reason people did not enroll in plans. More than half (57%) of adults who visited the marketplaces but did not enroll said they could not find a plan they could afford. Excluding the adults who also said they gained coverage elsewhere, the majority of those who did not enroll because they couldn’t find affordable plans had lower incomes. More than half (54%) had incomes in the range that made them eligible for subsidies (i.e., from 100 percent to 400 percent of the federal poverty level, or $11,670 to $46,680 in annual income for an individual). Thirty percent had incomes under 100 percent of poverty. An estimated 26 percent (and thus nearly all of those with incomes under 100 percent of poverty) were likely in the so-called Medicaid coverage gap. That is, they were living in states that had not expanded eligibility for Medicaid at the time of the survey and had incomes under 100 percent of poverty and thereby not eligible for marketplace subsidies. About 11 percent had incomes that exceeded the threshold that made them eligible for subsidies (i.e., 400 percent of poverty).

Comment by Don McCanne of PNHP: Is the Affordable Care Act a misnomer? Although half of the individuals who visited the insurance exchanges and did not enroll obtained coverage outside of the exchanges, the other half did not enroll because they found the plans unaffordable.

Making health care affordable for everyone was the primary goal of reform. It didn’t happen. But it would if we were to enact a single payer national health program.
September 26, 2015

Will US Grasp Putin's Syria Lifeline?


Russian President Vladimir Putin has thrown U.S. policymakers what amounts to a lifeline to pull them out of the quicksand that is the Syrian war, but Official Washington’s neocons and the mainstream U.S. news media are growling about Putin’s audacity and challenging his motives.

For instance, The New York Times’ lead editorial on Monday accused Putin of “dangerously building up Russia’s military presence” in Syria, even though Putin’s stated goal is to help crush the Sunni jihadists in the Islamic State and other extremist movements.

Instead, the Times harrumphs about Putin using his upcoming speech to the United Nations General Assembly “to make the case for an international coalition against the Islamic State, apparently ignoring the one already being led by the United States.”

The Times then reprises the bizarre neocon argument that the best way to solve the threat from the Islamic State, Al Qaeda and other jihadist forces is to eliminate Syrian President Bashar al-Assad and his military who have been the principal obstacles to an outright victory by the Sunni terrorist groups.

The dreamy Times/neocon prescription continues to be that “regime change” in Damascus would finally lead to the emergence of the mythical “moderate” rebels who would somehow prevail over the far more numerous and far better armed extremists. This perspective ignores the fact that after a $500 million training project for these “moderates,” the U.S. military says four or five fighters are now on the battlefield inside Syria. In other words, the members of this U.S.-trained brigade can be counted on the fingers of one hand.

But rather than rethink Official Washington’s goofy “group think” on Syria – or provide readers a fuller history of the Syrian conflict – the Times moves on to blame Putin for the mess.
September 25, 2015

Trapped in the System: A Sick Doctor’s Story


There is no bad guy here. I love the drug company that created this medication. The price is more than reasonable. I love the doctor who prescribed it to me. My insurance company has never refused to cover my care, and has always been honest with me. The laboratory personnel are professional and competent. It’s the system — the way all these things work, or fail to work, together — that’s the issue.

The Affordable Care Act, which seems so complicated to so many, was almost entirely about getting more people in the United States health insurance. That was just a first step, arguably an easy one, and we’re still fighting about it. Reforming the ways in which we actually deliver care and try to improve outcomes? That’s so much more important, and we barely talk about that at all. But that’s what matters to the people who use the system, and it’s why so many of them are frustrated.

Because of my job, I probably know more about the health care system and how it works than most people in the United States. Yet if this is how much trouble I have navigating a simple refilling of my medication, I don’t know how the rest of America does it, especially those with much more complicated issues than mine.

Answers to your questions about “Trapped in the System: A Sick Doctor’s Story”


I received more than my usual share of feedback from this week’s Upshot column. I thought I might answer some of the most common comments and questions here:

1. If we only had a single payer system. That would fix this, right?

Well, I’m not sure. I understand your impulse, but that would only solve some of the insurance problems. Medicare for all wouldn’t make it so that the lab, pharmacy, and doctor’s office shared an information system, or could even reliably share information. It wouldn’t change the fact that I need to jump through the order hoops, or the authorization hoops. It might make things easier, but it wouldn’t solve all of the problems. Ask people who have Medicare (which is much closer to single payer) if things are seamless. I doubt you’ll get a universally positive response.

Comment by Don McCanne of PNHP: Dr. Aaron Carroll’s frank discussion of his chronic medical problem and the nuisances he faces in interacting with our health care system struck a chord with many - both for the empathy engendered because of his medical condition, and especially for the crying shame that this prominent physician has to go through hoops to make our health care system work for him, suggesting that it might not work well for any of us.

Of the over 700 responses that he received, a common theme was that he wouldn’t have these problems if we had a single payer system. He responds that he is not sure. He suggests that people on Medicare, as a proxy for single payer, may find that their care is not so seamless either. Well, he hasn’t experienced Medicare as a patient since he is still on his employer-sponsored plan, and he hasn’t experienced Medicare directly as a physician either since he is a pediatrician.

I think that I can help him on this. I am a family physician, now retired from practice, and I never had the problems with my Medicare patients that I had with my managed care patients - problems similar to those he describes. I also have a few chronic disorders myself that require interaction with the health care system. I am covered under the traditional Medicare program with a Medigap supplement. I have had none of the problems that Dr. Carroll describes, except for nuisance requirements and limitations for my Part D drug coverage - but then Part D, by design, is much more like the managed care coverage that creates barriers to care (restrictive formularies, limited choice of pharmacies, logistical hurdles in filling prescriptions, etc.).

He is correct that interoperability of computer systems remains a problem, but that is a failure of George Bush and David Brailer in insisting that interoperability issues be left to the private sector to address. Players in the private sector strive for dominance and depend on a lack of interoperability to keep competitors out. The government is now encouraging improvements in interoperability, but how do you fix the mess that has been created? At any rate, the prospects for improving interoperability would be much greater under a single payer - improved Medicare for all - than they are under our fragmented, competitive multi-payer system.

Dr. Carroll says there is no bad guy here, but that “It’s the system — the way all these things work, or fail to work, together — that’s the issue.” But that’s the point. Having our entire health care delivery system integrated under a well-designed single payer model would make the system work far better for all of us - patients and physicians alike.

(Aaron Carroll is a professor of pediatrics at Indiana University School of Medicine. He is a highly respected authority in health policy who blogs in The New York Times, The Incidental Economist, and JAMA. He is co-author of a widely-quoted study demonstrating that three-fifths of physicians "support government legislation to establish national health insurance.&quot
September 23, 2015

It's the deductibles, stupid!!

Employer Family Health Premiums Rise 4 Percent to $17,545 in 2015, Extending a Decade-Long Trend of Relatively Moderate Increases


Single and family premiums for employer-sponsored health insurance rose an average of 4 percent this year, continuing a decade-long period of moderate growth, according to the Kaiser Family Foundation/Health Research & Educational Trust (HRET) 2015 Employer Health Benefits Survey released today.

The average annual premium for single coverage is $6,251, of which workers on average pay $1,071. The average family premium is $17,545, with workers on average contributing $4,955.

The survey also finds that 81 percent of covered workers are in plans with a general annual deductible, which average $1,318 for single coverage this year. Covered workers in smaller firms (three to 199 workers) face an average deductible of $1,836 this year. That’s 66 percent more than the $1,105 average deductible facing covered workers at large firms (at least 200 workers).

Since 2010, both the share of workers with deductibles and the size of those deductibles have increased sharply. These two trends together result in a 67 percent increase in deductibles since 2010, much faster than the rise in single premiums (24%) and about seven times the rise in workers’ wages (10%) and general inflation (9%).

“With deductibles rising so much faster than premiums and wages, it’s no surprise that consumers have not felt the slowdown in health spending,” Foundation President and CEO Drew Altman said.

Comment by Don McCanne of PNHP: For Quote of the Day subscribers who go straight to the comment (and many of you do), today’s message is presented instantly in a single visual - merely click on the link above and check out the graph accompanying the news release.

In words, the graph shows that, for the past five years, inflation is flat, workers earnings are flat, employer-sponsored health insurance premiums are continuing to increase, and health insurance deductibles are skyrocketing!

That explains why so many patients with “good” employer-sponsored health plans feel that health care costs are out of control, even though we’re told they’re not - their deductibles have increased at seven times the rate of increase in their wages!

We have the wrong model of health care financing in the United States. We need single payer.
September 13, 2015

New data reveals that higher Social Security income helps the memory and mental functioning of older


Other factors associated with higher income could of course be involved.


As the population ages, it’s important that our policies help to prevent, reduce or delay cognitive impairments. We want to be sure that for as long as possible people can carry out daily activities. And, we want to avoid the financial and emotional costs that come with dementia. New research by Padmaja Ayyagari and David Friswold suggests that higher Social Security income helps the memory, knowledge, language and overall cognition of older adults.

Ayyagari and Friswold’s August 2015 National Bureau of Economic Research paper reveals the positive impact of Social Security income on cognitive function for older adults. It looks at whether the 1977 reduction in Social Security income for those born after 1917 led to a reduction in cognition.

Specifically the research shows that a $1,000 increase in Social Security annual income improves working memory 2.2%, knowledge, language and orientation 1.1%, and overall cognition 1.4%. It also shows that a $1,000 increase in Social Security annual income reduces the chance of being diagnosed as demented by 1.9% and the change of being diagnosed as cognitively impaired by 1%.

The authors suggest that the cost of increasing Social Security benefits could be offset by lower Medicare and Medicaid costs; higher Social Security benefits would mean fewer people needing costly treatment for cognitive impairments.

Prior research has shown that higher income can mean less financial stress and better access to care, both of which are associated with better cognition. Stress has been shown to reduce cognition for older adults. There is also a strong link between depression and reduced cognition. Stress and depression cause higher levels of corticosteroids that can affect memory.

September 10, 2015

Health Savings Accounts benefit the healthy rich and harm the sick and poor

Health Savings Accounts: Growth Concentrated Among High-Income Households And Large Employers


Between 2005 and 2012, the share of employers whose employees had health savings accounts (HSAs) and the share of employees working at these employers grew more than tenfold. High-income and older tax filers both established HSAs and fully funded their HSAs at least four times as often as did low-income and younger filers.

Although suggestive, the evidence to date on the take-up of HSAs has been limited to surveys, which rely on modest samples of several thousand individuals or employers that have chosen to participate. In this study we examined US tax records to offer a definitive depiction of the growth and ownership patterns of HSAs.

Comment by Don McCanne of PNHP: Although there are innumerable surveys available on health savings accounts (HSAs), this is the definitive word since it used actual US tax records of filings on these tax-advantaged accounts. We can now say with absolute certainty that four times as many high-income and older tax filers both established and fully funded their HSAs as did low-income and younger filers.

This is what was predicted by many of us since the tax expenditures associated with these accounts (taxes not paid since the contributions are deducted from taxable income) are regressive tax policies benefiting higher income individuals with little or no benefit for those with low incomes. It is patently unfair to use our tax funds to subsidize the rich but not the poor.

But there is another consequence of HSAs that has a much greater negative impact. That is that an HSA must be combined with a high-deductible health plan. Many studies have confirmed that these high-deductible plans have left many middle- and low-income individuals and families underinsured. They face financial hardship should they need health care, because of the high out-of-pocket expenses associated with these insurance plans that shift health care costs from the insurers to patients in need.

Although HSAs are designed to pay for care received before reaching the deductible, this study confirms that the HSA accounts of lower-income individuals contain few if any funds at all. An empty HSA account doesn’t open doors to health care.

Another annoying feature is that these accounts can be used for retirement expenses once reaching age 65. What is fair about supporting these accounts for wealthier individuals with our tax expenditures that lower income individuals do not receive, even if they do have some funds in their accounts? Because of these regressive tax policies, the charge that they work for the wealthy and healthy but not the sick and poor really is true.

Many conservatives recognize that we need public policies to help support those with lower incomes. It is difficult to reconcile that view with their current push to expand the use of HSAs that are designed primarily to benefit the rich.

This issue would go away if we enacted an improved Medicare for all.
September 6, 2015

Are hospitals driving up costs for people with Medicare to improve quality ratings?


Medicare’s new payment incentive system financially penalizes hospitals with high readmission rates. To meet quality standards imposed by the Centers for Medicare and Medicaid services, some hospitals have been reclassifying patient visits within 30 days after discharge so they do not count as readmissions. They either classify patients as outpatients, on “observational” status, or they admit these patients to the emergency room.

As a result, hospital quality improvement is likely not as significant as the Medicare readmission data would suggest. What’s worse, hospitals that fail to “readmit” patients who have been discharged within 30 days may be penalizing those patients financially. Even if they remain on observational status for several days, they will be ineligible for Medicare skilled nursing or rehab services. (To qualify for Medicare skilled nursing or rehab coverage, patients must be admitted to hospital as inpatients for at least three days in the 30 days prior to getting that care.) And, their out-of-pocket costs could be significantly higher while in hospital.

To support their claims, Himmelstein and Woolhandler reveal that hospital outpatient stays increased 96 percent in the seven years between 2006 and 2013. The rise in outpatient stays represents more than half of the decline in reported hospital readmission rates. There has also been a notable increase in hospital emergency department visits.
September 3, 2015

Is your spouse actually a member of your family? Not in Ohio, it would seem


In a decision that could have far-reaching effects, a federal appeals court ruled Tuesday that Ohio must count an applicant’s spouse as a member of his family when determining eligibility for financial assistance to pay Medicare bills.

A three-judge panel of the Cincinnati-based U.S. 6th Circuit Court of Appeals told the state it can’t exclude a beneficiary’s spouse when it comes to income calculations simply because the federal law doesn’t define the word “family.”

At issue is a program under Medicaid, the federal-state insurance program for the poor, that helps low-income Ohioans pay their premiums, co-payments, and deductibles under Medicare, the federal health insurance for senior citizens.

The larger the family, the more a beneficiary may earn and be eligible for that financial help.

“Ask 100 Americans whether a 74-year-old man’s ‘family’ includes his wife who lives with him, and every one of those Americans will likely say yes,” 6th Circuit Judge Raymond M. Kethledge wrote. “But the Ohio Department of Medicaid answered no, with the result that it denied Joe Turner’s application for benefits under the Medicaid Act.”

“It should have been clear to Ohio that the word ‘family,’ as used in the provisions here, does not mean whatever the state’s officials want it to mean, but instead includes at least a beneficiary’s resident spouse,” Judge Kethledge wrote.

Comment by Don McCanne of PNHP: What kind of bureaucrat would make a decision that Medicaid benefits can be denied to an applicant by arbitrarily declaring that the applicant’s spouse is not part of the family and thus the family is too small to qualify? Perhaps Ohio’s family-values Governor John Kasich could explain, if he weren’t so busy running for President.

The real lesson here is that we really need to question the wisdom behind the multitude of health reform proposals that would provide federal grants to states and allow them to craft their own health care financing policies. It’s bad enough that states can refuse to participate in the Medicaid expansion, depriving millions of the health care that they should have. Just imagine the liberties they could take if allowed to make decisions such as redefining a family as having only one spouse when there are actually two.

Although a single payer system would be administered on a state or regional basis, the basic requirements would be established at the federal level. An example is the Canada Health Act which simply requires public administration, comprehensiveness, universality, portability and accessibility. Although their single payer systems are administered on the provincial level, there are no provinces that exclude a spouse from the definition of a family.

In the United States, it would not work to have federal legislation defining a national health program that is as simply stated as in the Canada Health Act. We have a track record of shameless gaming of the system to the detriment of patient care. That’s why we need greater specifications of the requirements - such as those in HR 676, the Expanded and Improved Medicare for All Act, by Rep. John Conyers with 51 cosponsors. We really can’t turn the decisions over the bureaucrats in supposed family-values states who actually don’t believe in family values.
September 2, 2015

Turkey’s phenomenal success with socialized medicine


Over the past decade, Turkey has implemented remarkable health-care reforms, achieving universal coverage in 2003, and dramatically expanding access to care for the population. Accompanied by significant investment in the hospital sector and the establishment of a family physician system, the Health Transformation Programme (HTP) has delivered a high level of activity in the health system. The reforms benefited from ambitious leadership and a clear set of priorities (focused on expanding health insurance and improving access and, in the clinical domain, on maternal and child health). An evaluation culture built in from the beginning and a willingness to open up the reform process to external scrutiny were also fundamental elements. Centralisation and rationalisation of the health system’s governance was critical in achieving recent health-care successes.


Over the past decade, the Turkish healthcare system has undergone a major transformation marked by significant investments in infrastructure, education of healthcare personnel, modernization of patient tracking and payment systems, and most importantly, the launching of the Family Medicine Program (FMP). With the introduction of the FMP in 2005, Turkey has essentially established a socialized healthcare system for primary healthcare services, under which every Turkish citizen is ensured a comprehensive package of healthcare service that is free-of-charge irrespective of the citizen’s ability to pay. This paper provides the first comprehensive analysis of the impact of the FMP on the outcomes of age-specific birth and mortality rates using province level data between 2001 and 2013.

Our results indicate that the FMP has caused reductions in both mortality and birth rates. The benefits associated with the FMP appear to be the strongest among the most vulnerable populations, i.e., the infants and the elderly for the mortality rate, and the teenagers for the birth rate. Furthermore, the results indicate that the program resulted in a more rapid reduction in mortality in provinces with a higher baseline mortality rate. This implies that the FMP might have also contributed towards an equalization of the mortality disparities across provinces.

A handful of recent studies highlight the importance of supply-side reforms in improving public health and reducing disparities in health outcomes in countries like Brazil and Thailand. The current study builds upon this growing strand of literature by documenting evidence on the effectiveness of a nationwide supply-side intervention from Turkey, which emphasizes direct service provision and effective government oversight. The findings in this paper provide further compelling evidence in favor of the view that extending healthcare services to all citizens is critical to achieving universal coverage and improving public health.

The signature feature of the Turkish FMP is the assignment of every citizen to a new category of “family physicians,” who are the central and first point of contact for patients. Every Turkish citizen is required to register with a particular family physician, who is in charge of providing a wide range of healthcare services at neighborhood clinics that operate on a walk-in basis.

Comment by Don McCanne of PNHP: Turkey’s phenomenal success in health care reform is largely due to the establishment of the supply-side Family Medicine Program - a socialized health care system for primary health care services. Maybe we in the United States should be thinking beyond a single payer social insurance program. A single payer socialized medicine program built on a primary care infrastructure offers many advantages that may never be realized if we stop short with mere insurance reform. Just a thought.
September 1, 2015

No Social Security increase in 2016 at substantial cost to most older adults


However, people who are just joining Medicare, have an income-adjusted Medicare premium, or have Medicare and Medicaid, can face premium increases. And, because the law requires Medicare Part B premiums to cover 25 percent of program costs, the 30 percent of people with Medicare for whom premiums can rise will have monthly premiums of at least $159.30, up from premiums as low as $104.90. Couples with incomes of more than $428,000 will have monthly premiums of $509.80.

Less disposable income for non-health-related expenses for most people receiving Social Security benefits: Because health care costs are rising faster than non-medical costs, people with Medicare who rely on Social Security for some or all of their income, receive lower net Social Security benefits after health care expenses each year. (People with Medicare spend an average of $5,000 on health care costs Medicare does not pay for.) Also, Medicare premiums have been rising more than twice as fast as the Social Security benefit, even with the cost-of-living adjustment. As a result, each year, people with Medicare have less disposable income for non-health-related expenses.

Every year but two for the last 40 years, people have seen a cost-of-living increase in their Social Security checks, an inflation adjustment. But, they will see no increase at all in their Social Security benefit in 2016. To make matters worse, a new report from the Center for Retirement Research, reveals that, unless there is a work-around, some people with Medicare will see almost a 50 percent increase in their Medicare Part B monthly premium. And, most people with Medicare will have less disposable income for non-health care related expenses.

Significant Medicare premium increase for about 15 million people: About three in ten people with Medicare will have to absorb the full 25 percent of Medicare Part B program costs in their premiums that the other 70 percent of people with Medicare will be exempt from paying. Under the law, Medicare premiums cannot increase for most older adults and people with disabilities if their Social Security benefits do not also increase.

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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 eridani

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