Where the ACA Should Go Next?
On Tue, Sep 9, 2014 at 1:47 PM, Dan <firstname.lastname@example.org> emailed:
Rortybomb, New Piece on Where the ACA Should Go Next Rorty touts the 2009 House Bill which calls for a Public Option and described here To improve ‘Obamacare,’ reconsider the original House bill
Maggie Mahar replies:
Originally I favored a public option, but in fact, at the time, no one really spelled out who would run the public option–or how it would be run.
One of the best things about the ACA is that lets both HHS and CMS make end-runs around Congress. I would never want a public option that was run by Congress.
Here is the comment I just posted in reply to the post “Where the ACA Should Go Next”
I would need to know far more about the public option—and how it would be different from Medicare– before voting for it.
Medicare is extraordinarily wasteful– 1/3 of Medicare dollars are squandered on unnecessary treatments that provide no benefit to the patient. Why? Because Congress is Medicare’s board of directors, and lobbyists representing various specialist’ groups, hospitals, device-makers and drug-makers control Congress.
Meanwhile, Medicare does not cover much needed care, ie. vision checks are just one example. This is why the vast majority of Medicare beneficiaries must buy separate private insurance (MediGap or Medicare Advantage) to supplement what medicare doesn’t cover.
Finally, I favor narrow networks. They keep costs down. The doctors and hospitals that are not included in the networks are those that refuse to negotiate prices. By excluding them we remind doctors and hospitals that we can no longer afford letting providers charge whatever they wish. No other developed nation allows doctors and hospitals to simply set prices.
As for the notion that a network might not include the specialist a patient needs to treat a particular disease, that’s simply not true. Under the ACA if a patient suffered from a rare disease and no doctor in the network was qualified to treat it, the patient can appeal at two levels and under the ACA, must get a speedy response.
Also keep this in mind: all of the medical research on cost and quality reveals that more expensive care is no better and often it is worse. Doctors and hospitals that are money-driven are likely to over-treat, putting their patients at risk without benefit.
Finally, I would favor a public option only if it were very different from Medicare. Ideally it would be run by an independent board and its decisions would not have to be approved by Congress. Instead, that board would use medical evidence to decide what to cover–and what not to cover.
Best, Maggie Mahar Health Beat Blog
From your mouth to God’s ears.
And I do not believe in God, so that’s going some.
I had Medicare and Medicaid. But Illinois shifted patients on those two to narrow networks.
With Medicare and Medicaid your PCP may refer you to any doctor who takes both. Typically this results in your family doctor keeping all referrals in one contiguous place — the same hospital or office building.
With a narrow network this may not be possible. Problem is that you are dealing with patients over 65 years old. As they get older — and more infirm — they need to see more and more specialists — just as they are less and less able to move around.
* * * * * *
I know a low income employee who was finally able to get medical coverage under ACA — but only under the cheapest monthly payment plan. Problem was that the cheapest plan had a the highest deductible: $3,000. Luckily a better paid family member volunteered to come up with the deductible — otherwise said employee would have been out of luck; $3,000 might as well have been a million.
Someways it all sounds like a worse and worse mess to me.
And before the ACA what would your friend have done?
“Ideally it would be run by an independent board and its decisions would not have to be approved by Congress.”
Devil’s advocate asks, what board is ever independent? Someone or some entity decides who sits on a board. How does such a group maintain independence? By definition an appointed group that is obliged to make significant decisions is required to be dependent. That is, such a group is responsible to the appointing authority.
“Devil’s advocate asks, what board is ever independent? ”
It is a matter of degree.
Any board would be more independent that one composed of members of Congress.
E (if I may use the familiar):
My measuring stick is other modern countries — not our sad one.
And you ask the right questions:
What would Drew’s low-income friend have done pre-Obamacare?
(Also if he really is as low-income as Drew suggests, his out of pocket
spending would be subsidized–see my reply to Drew.
Also when it comes to “independent boards,” independence is a matter of degree.
But virtually any board is more independent than members of Congress.
Board members don’t have to campaign for their position on a board,
and do not need millions of dollars in political donations. All too often, campaign contributions determine how they vote.
For examples of relatively independent boards, see my reply to Jack
Were you intending to reply to Jack and Drew?
How subsidized; by a tax break on an income too low to owe substantial taxes? I may misunderstand how the subsidy is paid; I understand you are not here to tutor me.
In any event the subsidy would have to wait until next year even if a check would be in the mail.
* * * * * *
Any comment on narrow networks not being ideal — possibly being deadly — to the elderly sick who are less and less able to trek around as they need more and more care?
When I was a Chicago cab driver it would take me 30 seconds looking through the six county atlas at the airport to find your street on your page and I didn’t have to think about how to get there. Not all the elderly fit that description.
As e-Michael says, “independence” is relative: some independent boards are more independent than others. But all are more independent than Congress-. Board members don’t need millions in campaign contributions in order to run for a seat on a board.
One example of a very independent board is FASB— the board that
sets accounting standards. It’s located in Norwalk CT, and some
ascribe its independence to the fact that it’s not in D.C.
Board members are beholden to the “appointing authority” only if there is one appointing authority.
But it is possible to let the President appoint several members of a board,
and let other groups also appoint board members. What is essential is that the board members have NO Financial Interest in their decisions.
For example, if a board is going to regulate what doctors or hospital can charge, you would want retired doctors on the boards, or doctors who work
Also board members should not be allowed to take money (or services)
from anyone who might have an interest in the board’s decisions.
For example, if you are a doctor who works for the VA, you are not allowed to take consulting fees from drug companies, device companies etc.
VA docs work on salary, and one or two on an independent board that
oversaw a public option would be a good idea.
Individuals and families with incomes between 100 percent of the federal poverty line ($23,550 for a family of four) and 250 percent ($58,875 for a family of four) are eligible for cost-sharing reductions (or CSRs) if they are eligible for a premium tax credit and purchase a silver plan through the health insurance marketplace in their state. People with lower incomes receive the most assistance.
If they buy a silver plan, the insurer will pay 94% of their medical bills.
The low-income person might have an annual deductible of just $250.
Cost-sharing subsidies have nothing to do with tax credits.
People eligible for cost-sharing reductions who enroll in a silver plan will automatically receive a version of the plan with reduced cost-sharing charges, such as lower deductibles, out-of-pocket maximums or copayments. Unlike the premium subsidies, cost-sharing reductions are not provided as a tax credit and they do not have to be “reconciled” when people file their taxes for the year the cost-sharing reductions were received.
Apparently your low-income friend (and his wealthy relative) didn’t call the Exchange to get full information on what is available for low-income people. Of, if the relative just Googled “cost sharing” and Obamacare eh subsidies he would find a great many articles describing them.
As for elderly people and narrow networks: I have never known a doctor who referred patients only to specialists located in his building. Docs refer patients to other docs they know and like. It’s a network– and often just as narrow as an insurer’s narrow network. The only difference is that your GP doesn’t worry about how much the specialist will charge you–he’s just doing a favor for a colleague.
If a person is seeing a doctor who works for a hospital, he may refer you to
other docs who work for that hospital. But in that case, if one doc from the hospital is part of the insurer’s narrow network, all of them are.
Insurers contract with the hospital, not with individual doctors.
Bottom line: older people have trouble getting around, especially if they are sick. But in general, insurers’ networks don’t make the problem any worse.
Also, narrow networks existed long before Obamacare. Employers and insurers have been using narrow networks to keep a lid on costs for many years
CSRs are something I either forgot about or did not know. It does make sense and it is useful in response to those who complain about high deductibles and out-of pocket costs. I will add this Kaiser explanation of CSRs:
The federal cost-sharing subsidies essentially increase the insurance company’s share of covered benefits, resulting in reduced out-of-pocket spending for lower-income consumers. A family of four whose income is between 100 and 150 percent of the federal poverty level ($23,550 to $35,325) will be responsible for paying 6 percent of covered expenses out-of-pocket compared with the 30 percent that a family not getting subsidized coverage would owe in a silver plan. A family with an income between 150 and 200 percent of the poverty level ($35,325 to $47,100) will be responsible for 13 percent of expenses, and one with an income between 200 and 250 percent of the poverty level will be responsible for 27 percent ($47,100 to $58,875).
In addition, people who earn 250 percent of the federal poverty level or less will also have their maximum out-of-pocket spending capped at lower levels than will be the case for others who buy plans on the exchange. In 2014, the out-of-pocket limits for most plans will be $6,350 for an individual and $12,700 for a family. But people who qualify for cost-sharing subsidies will see their maximum out-of-pocket spending capped at $2,250 or $4,500 for single or family coverage, respectively, if their incomes are less than 200 percent of the poverty level, and $5,200 or $10,400 if their incomes are between 200 and 250 percent of poverty. In Addition To Premium Credits, Health Law Offers Some Consumers Help Paying Deductibles And Co-Pays
See my replies to Jack & Drew above.
Given that Medicare costs have increased 61% less since its inception then private insurance its really astonishing that it still spends 1/3rd on inefficient/wasteful treatments
The lowest deductible for my friend that I can find at the EHEALTH online calculator is $3000 with a $163 monthly premium. $250? Perhaps not easily found by the non-expert.
[for some reason cannot upload web address]
I cited Kaiser http://www.kaiserhealthnews.org/features/insuring-your-health/2013/070913-michelle-andrews-on-cost-sharing-subsidies.aspx so you would have a reference in which too read. If you are over 400% FPL, you are on your own pretty much; but in any case, there is a wealth of preventative care you can receive free-of-charge. Take a moment and read kaiser
Once again. What did your friend do before the ACA?
Ya’ think if if he walked into the ER(let’s forget about preventative care) with a problem he would leave without a bill for $3000 plus $163 a month?
Or have a cap on his costs?
Be serious when you talk about healthcare in here. There are people(not me) that know what is going on, and they are not going to waste their time(or mine) answering someone that just mopes along.
You are not going to find the reduced deductible on e-health.
Your friend has to APPLY for a cost-sharing subsidy based on his income:
How to Apply for the Cost-Sharing Subsidy
“Apply for the reduced cost-sharing subsidy through your state’s health insurance exchange while you’re shopping for health insurance. You can apply for the premium tax-credit subsidy and the reduced out-of-pocket-maximum subsidy at the same time. Be prepared to give the exchange information about your income, family size, and employer if you have a job”.
Here’s more detail on the cost-sharing subsidy:
The reduced cost-sharing subsidy doesn’t actually pay you money. Instead, it saves you money by lowering your cost-sharing expenses. How much money it saves you depends on your income and on how much you use your health insurance.
The poorer you are, the more your cost-sharing is reduced. The amount of this reduction is based on comparing your income to federal poverty level. Federal poverty level changes every year, and is based on both your income and your family size.
Keep in mind that to get a cost-sharing subsidy, you must buy a Silver plan
Without the cost-sharing subsidy, your health insurance company would pay roughly 70 percent of your total covered health care expenses. With the cost-sharing subsidy, your health insurance company will pay:
94 percent of your expenses if your income is 100-150 percent of FPL
For individuals with a 2013 income from $11,490-$17,235.
For couples with a 2013 income from $15,510-$23,265.
87 percent of your expenses if your income is 150-200 percent of FPL
For individuals with a 2013 income from $17,235-$22,980.
For couples with a 2013 income from$23,265-$31,020.
73 percent of your expenses if your income is 200-250 percent of FPL
For individuals with a 2013 income from $22,980-$28,725.
For couples with a 2013 income from $31,020-$38,775.
Your health insurance company can structure the cost-sharing reduction however it wants as long as the health plan pays the correct percentage of your health care expenses. For example, it could decide to lower your deductible by a lot, but leave your copayments unchanged. Or, it could barely reduce your deductible, but eliminate your copayments and lower your coinsurance.
Thanks for the additional info on CSRs.
When journalists write about high high out of pocket costs are under the Obamacare, they rarely mention these cost-sharing subsidies.
And of course Republicans don’t even acknowledge that they exist !
That claim that one-third of Medicare spending is wasted sounds pretty questionable to me. I doubt that treatment protocols in the U.S. are all that different from other countries. The real difference, it would seem, is in the level of compensation demanded by providers, doctors in particular.
A great start on a public option (and a big plus right now as a proposal for Democratic candidates in tight races): people aged 50-65 who cannot get insurance through an employer should be allowed to buy into Medicare. That option could be available in all the exchanges. Does anyone think that would not be an enormously popular proposal from anyone between ages 40 and 65? That’s a hell of a lot of voters.
You write: “That claim that one-third of Medicare spending is wasted sounds pretty questionable to me.”
This is your opinion. If you had spent the last 20 years working as a medical researcher investigating unnecessary treatment, your opinion would be of great interest to all of us; but, I’m assuming you have not done so.
Thus, you might be interested in some facts:
Dr. Donald Berwick, who headed up Medicare and Medicaid during the 1st half of the Obama administration has said, repeatedly, that at least 1/3 of Medicare dollars ware wasted on unnecessary tests, procedures and drugs that provide no benefit for the patient. He is only one of dozens of health policy experts who have made the same statement. (Google “Health Affairs” the leading medical journal that focuses on health policy and “unnecessary treatments” Over the past 30 years, researchers at Dartmouth have provided stacks of evidence documenting unnecessary care in the U.S.
You also write: “I doubt that treatment protocols in the U.S. are all that different from other countries.”
Again, this is your opinion. Unfortunately, you are wrong.
In other countries, doctors and hospitals tend to follow evidence-based guidelines. In the U.S. a great many doctors object to the idea of someone telling them how to practice medicine. (Even though “someone” is “science”) They value their autonomy and prefer to do things the way they have always done them.
Of course, this is not true of all doctors.
But even when you look at protocols at our academic medical centers, you find that the way they treat similar patients varies widely.
Here , I’m not talking about how much they charge for a procedure (which also varies widely) but how many tests they order, how often they
prescribe spine surgery for someone suffering from low-back pain, how often they tell a woman she needs a C-Section . . .
One big problem is that our doctors and hospitals are paid “fee -for service;” in other words, the more they do, the more they are paid.
As Dartmouth’s Dr. Eliot Fisher points out: “U.S. patients are not hospitalized more often than patients in other countries; but in the U.S., a lot more happens to you while you’re there.”
In addition, traditionally our medical schools have trained doctors to practice very aggressive medicine. The resident who orders a battery of
tests is praised. Students are told “Don’t just sit there (and think) Do Something!”. Traditionally our medical culture has been a very macho culture and it is just beginning to change.
Finally, Americans tend to think that “more is always better”. Larger servings in a restaurant, bigger cars, bigger homes, etc. And when it comes to healthcare, patients in the U.S. tend to think that “more care is better care.” They are wrong. Every medical product and service carries some risk. If it provides no or little benefit, the patient is exposed to risk without benefit.
When medical protocols in the U.S. are compared to how medicine is practiced in other countries, researchers have found: —- Much unnecessary spine surgery. The rate of back surgery in the U.S. is five times higher than in the UK. Studies have shown little difference in long-term outcomes for patients who undergo back surgery compared to those who select non-surgical treatment.
The U.S. does more testing than other countries. For instance, the number of MRI and CT tests for every 1,000 people in 2010 was double the average in other OECD countries. Comparatively, there were also more tonsillectomies, caesarean sections and knee replacements. Regardless of how much more nearly every procedure, scan and drug costs; it’s nothing compared to how out-of-whack the medical heroics thrown at Americans in the last stages of life The Cost of Health Care: A Country-by-Country Comparison
Colonoscopies are prescribed and performed more frequently than medical guidelines recommend and are given preference over less invasive tests that screen for colon cancer. Those less invasive tests are not only routinely performed in other countries, they’ve also been proven to be just as effective by the U.S. Preventative Services Task Force.
“We’ve defaulted to by far the most expensive option, without much if any data to support it,” said Dr. H. Gilbert Welch, a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice.
In the U.S. many more patients die in ICU’s getting futile care. This is a painful, lonely way to die. In other countries, more patients are treated in hospices or allowed to go home where nurses and even doctors visit them.
Half of all heart surgeries (using stents) do no good. We know which half! But stent-makers and other providers have turned this into a big business.
– Our drug companies enjoy 20% profit margins.
– Our device-makers boast 16% profit margins.
We are over-medicated (particularly older people), and undergo too many surgeries that involve very expensive devices. Medicare covers virtually everything (even drugs that have been shown to be dangerous–until they are taken off the market). If it does not cover all of the newest treatments and products lobbyists would howl– and Congress makes sure that heads roll.
This is one reason why we don’t want to give everyone 40 to 65 a chance to enroll in Medicare. No one could afford it. (This idea was considered in the late 1990s. Do you have any idea how much 40-65 year olds would have to pay for our extraordinarily inefficient and wasteful Medicare system? On top of that and like people over 65, they would have to pay hefty sums for MediGap to Medicare advantage — private insurance plans
that cover all of the things that Medicare doesn’t.
Medicare is now beginning to cut back, and over time it will refuse to pays for unnecessary surgeries (heart surgeries, unproven prostate cancer surgeries, and some hip and knee replacements, unless the patient has tried physical therapy first–and losing weight, if possible. (Some people just can’t lose weight, even under a doctor’s supervision.)
Medicare will also stop covering every new drug that comes on market, setting up a formulary and only paying for drugs that are effective — and cost-effective. The same will be true of devices.
Then — and only then — we might talk about letting people 40-65 sign up for Medicare, though in many cases, research on quality of care suggests that they would be better off with the best of our non-profit insurers: Kaiser, Geisinger, etc.
Medicare is a highly politicized bureaucracy and inevitably, Congress dictates what it can and can’t do. Medical guidelines should be set by medical researchers and doctors who have no financial interest in the outcome.
For instance, the number of MRI and CT tests for every 1,000 people in 2010 was double the average in other OECD countries.
I wonder why this would be. Perhaps it has something to do the practice of defensive medicine as a result of the the risks neurologists face for having to defend against malpractice claims? http://www.rand.org/pubs/research_briefs/RB9610/index1.html
“Each year during the study period, 7.4% of all physicians had a malpractice claim, with 1.6% having a claim leading to a payment (i.e., 78% of all claims did not result in payments to claimants). The proportion of physicians facing a claim each year ranged from 19.1% in neurosurgery, 18.9% in thoracic–cardiovascular surgery, and 15.3% in general surgery to 5.2% in family medicine, 3.1% in pediatrics, and 2.6% in psychiatry. ” [emphasis mine]
“The United States had 50 percent more malpractice claims filed per 1,000 population filed than the United Kingdom and Australia, and 350 percent more than Canada . . .
“Defensive medicine—tests or procedures ordered by physicians to protect against the risk of being sued—could contribute more to health spending than malpractice payments do. Several attempts have been made to quantify the amount spent on defensive medicine, but estimates vary widely. The difficulty lies in determining what services are purely “defensive”—that is, both inappropriate overuse and motivated by fear of litigation. For example, a physician might ask for a second opinion on a difficult diagnosis, mindful of the potential of litigation, but that second opinion could be considered appropriate care. Other services could be considered inappropriate overuse but were motivated by incentives other than the litigation threat, such as payment policy. These gray areas make precise estimates of the cost of defensive medicine extremely difficult. . . .
“One estimate of this cost has come from HHS, which estimates that $70–126 billion (5–9 percent) in health spending per year would be saved if malpractice tort reform, similar to policies in California, were passed at the national level.”
Medicare does not cover much needed care, ie. vision checks are just one example.
Vision checks (in contrast with comprehensive eye examinations that can identify some chronic diseases early) strike me as a great example of the type of procedure that should not be covered by insurance, at least if insurance is defined as *insurance* as opposed to defined as a pre-paid financing mechanism.