Fwd: qotd: Never-ending rule making for ACA

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-------- Original Message --------
Subject: qotd: Never-ending rule making for ACA
Date: Fri, 29 Nov 2013 13:05:51 -0800
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>



Department of Health and Human Services

To be published in Federal Register December 2, 2013

Proposed rule.

Patient Protection and Affordable Care Act; HHS Notice of Benefit and
Payment Parameters for 2015


Executive Summary

Qualified individuals and qualified employers are now able to purchase
private health insurance coverage that begins as early as January 1,
2014, through competitive marketplaces called Affordable Insurance
Exchanges, or "Exchanges" (also called Health Insurance Marketplaces, or
"Marketplaces").1 Individuals who enroll in qualified health plans
(QHPs) through individual market Exchanges may receive premium tax
credits to make health insurance more affordable and financial
assistance to reduce cost sharing for health care services. In 2014, HHS
will also operationalize the premium stabilization programs established
by the Affordable Care Act – the risk adjustment, reinsurance, and risk
corridors programs – which are intended to mitigate the impact of
possible adverse selection and stabilize the price of health insurance
in the individual and small group markets. We believe that these
programs, together with other reforms of the Affordable Care Act, will
make high-quality health insurance affordable and accessible to millions
of Americans.

HHS has previously outlined the major provisions and parameters related
to the advance payments of the premium tax credit, cost-sharing
reductions, and premium stabilization programs. This proposed rule
proposes additional provisions related to the implementation of these
programs. Specifically, we propose certain oversight provisions for the
premium stabilization programs, as well as key payment parameters for
the 2015 benefit year.
The Patient Protection and Affordable Care Act; HHS Notice of Benefit
and Payment Parameters for 2014 final rule (78 FR 15410) (2014 Payment
Notice) finalized the risk adjustment methodology that HHS will use when
it operates risk adjustment on behalf of a State. This proposed rule
proposes minor updates to this risk adjustment methodology for 2014 to
account for certain private market Medicaid expansion plans, and seeks
comment on how to adjust the geographic cost factor in the payment
transfer formula to account for less populous rating areas in future
benefit years. In this proposed rule, we also propose to clarify the
counting methods for determining small group size for participation in
the risk adjustment and risk corridors programs.

Using the methodology set forth in the 2014 Payment Notice for
determining the uniform reinsurance contribution rate and uniform
reinsurance payment parameters, we propose in this rule a 2015 uniform
reinsurance contribution rate of $44 annually per capita, and the 2015
uniform reinsurance payment parameters – a $70,000 attachment point, a
$250,000 reinsurance cap, and a 50 percent coinsurance rate. We also
propose to decrease the attachment point for 2014 from $60,000 to
$45,000. Additionally, in order to maximize the financial effect of the
transitional reinsurance program, we propose that if reinsurance
contributions collected for a benefit year exceed the requests for
reinsurance payments for the benefit year, we would increase the
coinsurance rate on our reinsurance payments, ensuring that all of the
contributions collected for a benefit year are expended for claims for
that benefit year.

We also propose several provisions related to cost sharing. First, we
propose a methodology for estimating average per capita premium and for
calculating the premium adjustment percentage for 2015 which is used to
set the rate of increase for several parameters detailed in the
Affordable Care Act, including the maximum annual limitation on cost
sharing and the maximum annual limitation on deductibles for health
plans in the small group market for 2015. We also propose to set the
same reduced maximum annual limitations on cost sharing for the 2015
benefit year as we established for the 2014 benefit year for
cost-sharing reduction plan variations. Additionally, we are proposing
certain modifications to the methodology for calculating advance
payments for cost-sharing reductions for the 2015 benefit year. We also
propose standards for updating the actuarial value (AV) calculator.

This proposed rule provides for a 2015 Federally-facilitated Exchange
(FFE) user fee rate of 3.5 percent of premium. Additionally, we propose
a user fee adjustment allowance for administrative costs in the 2015
benefit year to reimburse third party administrators that provide
payment for contraceptive services for enrollees in certain self-insured
group health plans that receive an accommodation from the obligation to
cover these services in 2014.

On November 14, 2013, the Federal government announced a policy under
which it will not consider certain non-grandfathered health insurance
coverage in the individual or small group market renewed between January
1, 2014, and October 1, 2014, under certain conditions to be out of
compliance with specified 2014 market rules, and requested that States
adopt a similar non-enforcement policy.

Issuers have set their 2014 premiums for individual and small group
market plans by estimating the health risk of enrollees across all of
their plans in the respective markets, in accordance with the single
risk pool requirement at 45 CFR 156.80. These estimates assumed that
individuals currently enrolled in the transitional plans described above
would participate in the single risk pools applicable to all
non-grandfathered individual and small group plans, respectively (or a
merged risk pool, if required by the State). Individuals who elect to
continue coverage in a transitional plan (forgoing premium tax credits
and cost-sharing reductions that might be available through an Exchange
plan, and the essential health benefits package offered by plans
compliant with the 2014 market rules, and perhaps taking advantage of
the underwritten premiums offered by the transitional plan) may have
lower health risk, on average, than enrollees in individual and small
group plans subject to the 2014 market rules.

If lower health risk individuals remain in a separate risk pool, the
transitional policy could increase an issuer's average expected claims
cost for plans that comply with the 2014 market rules. Because issuers
would have set premiums for QHPs in accordance with 45 CFR 156.80 based
on a risk pool assumed to include the potentially lower health risk
individuals that enroll in the transitional plans, an increase in
expected claims costs could lead to unexpected losses.

To help address the effects of this transitional policy on the risk
pool, we are exploring modifications to a number of programs. We have
outlined various options under consideration throughout this proposed
rule, including adjustments to the reinsurance and risk corridors
programs. We are seeking comment on these proposals, as well as
soliciting suggestions for alternate proposals. As the impact of the
transitional policy becomes clearer, we will determine what, if any,
adjustments are appropriate.

The success of the premium stabilization programs depends on a robust
oversight program. This proposed rule expands on provisions of the
Premium Stabilization Rule (77 FR 17220), the 2014 Payment Notice (78 FR
15410), and the first and second final Program Integrity Rules (78 FR
54070 and 78 FR 65046). In this proposed rule, we propose that HHS may
audit State-operated reinsurance programs, contributing entities, and
issuers of risk adjustment covered plans and reinsurance eligible-plans.
We also clarify participation standards for the risk corridors program,
and outline a proposed process for validating risk corridors data
submissions and enforcing compliance with the provisions of the risk
corridors program.

We also propose several provisions regarding the HHS-operated risk
adjustment data validation process. On June 22, 2013, we issued "The
Affordable Care Act HHS-operated Risk Adjustment Data Validation Process
White Paper" and on June 25, 2013, we held a public meeting to discuss
how to best ensure the accuracy and consistency of the data we will use
when operating the risk adjustment program on behalf of a State. In this
proposed rule, we propose standards for risk adjustment data validation,
including a sampling methodology for the initial validation audit and
detailed audit standards. These proposed standards would be tested for 2
years before they are used as a basis for payment adjustments. This
proposed rule also includes a proposal to implement, over time, the
requirements related to patient safety standards that QHP issuers must
meet, and proposes reducing the time period for which a State electing
to operate an Exchange after 2014 must have in effect an approved, or
conditionally approved, Exchange Blueprint and operational readiness
assessment from at least 12 months to 6.5 months prior to the Exchange's
first effective date of coverage. We also propose provisions related to
the privacy and security of personally identifiable information (PII),
the annual open enrollment period for 2015, the annual limitation on
cost sharing for stand-alone dental plans, and the meaningful difference
standards for QHPs offered through an FFE. We also propose certain
standards for the Small Business Health Options Program (SHOP) and for
composite rating in the small group market.

Proposed rule (255 pages):
https://s3.amazonaws.com/public-inspection.federalregister.gov/2013-28610.pdf


Comment: Thousands of pages of rules regarding the Patient Protection
and Affordable Care Act have already been published. This proposed rule,
which updates previous rules, is being published in the Federal Register
to allow a period of comment before the rule becomes final.

As you review these and other rules, it becomes ever more evident that
the process is inordinately complicated for one overriding reason: These
rules are established to try to squeeze private insurers in between
patients and their health care professionals and institutions. They do
not fit.

As an example of how ridiculous the process is, just look at the
proposal for reinsurance payments for 2014. A previous rule set the
attachment point (when reinsurance would begin) at $60,000. This rule
reduces the attachment point to $45,000. Thus, once the insurer reaches
$45,000 in claims for an individual, the insurer is insured for further
losses, though a coinsurance is applied along with a $250,000
reinsurance cap.

With the higher deductibles that characterize these new plans and with a
reinsurance attachment point of $45,000, the private insurer seems to be
much more of a superfluous intermediary that introduces profound
administrative waste. Yet the rule states that "these uniform
reinsurance payment parameters will support the reinsurance program's
goals of promoting nationwide premium stabilization and market
stability." By all means, let's stabilize markets for the benefit of the
private insurers. Forget the turmoil for the rest of us.

Go ahead and read the 255 pages of this rule and then just imagine how
that would extrapolate to the many thousands of pages of other rules
that have been advanced, with more to come. Then tell us why we should
continue with these acrobatic, bureaucratic twists and turns that are
designed merely to keep the private insurers in the action, especially
with all of their waste and unwanted intrusions.

Enough. As those from the right and left are now saying, single payer is
coming. Let's not wait any longer. Let's do it now.

Fwd: qotd: Major physician organizations concerned about impaired access through exchange plans

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-------- Original Message --------
Subject: qotd: Major physician organizations concerned about impaired
access through exchange plans
Date: Wed, 27 Nov 2013 13:02:57 -0800
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>



The Wall Street Journal
November 26, 2013
Doctors: New Health Care Plans Raise Red Flags
By Louise Radnofsky

Physicians groups told Obama administration officials Tuesday that they
are worried that new insurance plans under the Affordable Care Act offer
only limited networks of providers and low reimbursement rates for
doctors, and that could make it difficult for millions of those enrolled
to actually get health care.

As the Journal has reported, some health plans don't include big
brand-name health providers in their networks and are slashing how much
they'll pay medical practices for treating the newly covered.

Representatives from the major physician lobbying groups raised these
issues Tuesday in a White House meeting with health officials including
Chris Jennings and Jeanne Lambrew of the White House, and Chiquita
Brooks-LaSure of the Centers for Medicare & Medicaid Services.

"Some of the things were not a surprise to them… they're acutely aware,"
Shawn Martin, a top lobbyist for the American Academy of Family
Physicians, said after the noon meeting.

The American Medical Association, the American Academy of Family
Physicians, American Academy of Pediatrics, and American College of
Physicians, the American Osteopathic Association, the American Medical
Group Association and the American Association of Nurse Practitioners
were among the groups present, participants said.

http://blogs.wsj.com/washwire/2013/11/26/doctors-new-health-care-plans-raise-red-flags/


Comment: The new health plans to be offered in the exchanges are
avoiding excessive premium increases by using narrow networks of
physicians and by lowering payment rates for health services. The
leaders of our nation's leading organizations of health care
professionals are concerned enough about what this might do to patient
access that they met with Obama administration officials at the White House.

The administration officials were already "acutely aware" of these
problems. Of course, they were. They result from fundamental design
flaws in the financing model of the Affordable Care Act. The model was
designed by and for the private insurance industry.

It is likely that members of these professional organizations are not
only concerned about the patients, narrow networks and lower payments
have a direct effect on their livelihoods. In a well designed system,
patients must always come first, but the professionals taking care of
the patients should be content as well. Grumpy doctors and nurses
detract from an optimal patient care environment.

There will be more discontentment as the Obamacare model of
high-deductibles, narrow networks, and payment restrictions extend to
employer-sponsored private plans. These trends will no doubt expand with
the proliferation of private insurance exchanges catering to employers -
exchanges outside of the government-operated Obamacare exchanges. Even
the private Medicare Advantage plans are being modified in response to
their overpayments being pared back. UnitedHealth, the nation's largest
private insurer, has notified thousands of physicians that they are
being dropped from their Medicare Advantage network.

Do we really want to keep headed in this direction?

The traditional Medicare program does not use narrow networks. Patients
have their choice of their health care professionals. Medicare payment
rates are higher than the rates expected to be offered by most of the
exchange plans. It would not take much to improve Medicare, and then it
would be an ideal program for covering everyone.

You can bet that the representatives of these professional groups didn't
ask for single payer to be put on the table. Too bad.

Fwd: qotd: Can we talk about single payer? (Flowers, Baker & Folbre)

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-------- Original Message --------
Subject: qotd: Can we talk about single payer? (Flowers, Baker & Folbre)
Date: Mon, 25 Nov 2013 12:47:07 -0800
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>



The Real News
October 1, 2013
Obamacare Debate: Flowers vs. Baker

JESSICA DESVARIEUX, TRNN PRODUCER: With us to discuss the Affordable
Care Act are Dean Baker and Dr. Margaret Flowers. Dr. Flowers joins us
in-studio. She's a pediatrician in the Baltimore area and the Maryland
chapter of Physicians for a National Health Program cochair, and she's
the secretary of health for the Green Shadow Cabinet… And joining us
from Washington, D.C., is Dean Baker. He's the codirector of the Center
for Economic and Policy Research.

DEAN BAKER, CODIRECTOR, CEPR: There's lots of grounds for criticizing
the ACA. But this is a huge step forward. We're going to have tens of
millions of people that will be able to get insurance who haven't had it
previously. And, again, for the 100-plus million who are now insured,
they will actually have real insurance, because if they do get sick,
lose their job, they'll still in most cases be able to get affordable
insurance through the exchanges. So I have to see that as a big step
forward.

DESVARIEUX: Okay. Let's have Dr. Flowers respond to that. Do you see
that as a step forward?

DR. MARGARET FLOWERS, COCHAIR, PNHP: No, I actually see the Affordable
Care Act as a step backwards. It takes us farther in the direction of
privatized health care. And the way that we really need to go is towards
greater--a publicly financed universal health care system. That's the
most efficient and most equitable way to provide health care…

BAKER: Well, it'd be great to have, you know, universal Medicare, but
that wasn't about to be coming. So basically our choice is having health
care provided through private insurers or not having it at all. And the
fact is, we have 100-plus million people who get most of their health
care through private insurers now. And yeah, they do lots of bad things,
but the alternative is not getting it all. So I can't somehow tell
people they're better off not getting health care than having it
provided through private insurers, as much as I may not like them.

DESVARIEUX: But is that true? Is that really the alternative? We only
have two choices here?

FLOWERS: No. And, actually, during the health reform debate, a point
that we were making, especially towards the end when it looked like the
Affordable Care Act was going to go through, was don't give hundreds of
millions of dollars in subsidies to private insurance companies where
they're going to hang on to a lot of that and still deny people care. We
should be giving that to our public programs to expand them more and
really shift us in the direction we need to go, towards a greater
publicly financed health care system.

Part of the reason that the Affordable Care Act went through is that it
wasn't challenged by people on the left, by people that supported
single-payer. People were told, well, this is all that we can get, and
so they accepted that.

http://therealnews.com/t2/index.php?option=com_content&task=view&id=31&Itemid=74&jumival=10805


The New York Times
November 25, 2013
The Single-Payer Alternative
By Nancy Folbre

Rush Limbaugh's take on the disastrous rollout of the Affordable Care
Act could, ironically, warm the hearts of those at the other end of the
political spectrum. He contends that President Obama knew all along that
the Affordable Care Act would crash and burn, but pushed it through so
that the conflagration would clear the way for single-payer health
insurance.

Yet one of the greatest advantages of a single-payer system — its
relatively low administrative costs — has been thrown into sharp relief
by problems registering with the new health exchanges.

In theory, competition and choice should increase efficiency. In
practice, health insurance companies are able to take advantage of the
complexity and uncertainty surrounding health care choices to make
comparison shopping very difficult.

The process of negotiating relationships with new health care providers
because old ones are "out of network" is physically and emotionally
exhausting. Insurance companies benefit from promoting policies that are
difficult to understand and make consumers fearful of any change in
their coverage.

David Himmelstein and Steffie Woolhandler, co-founders of Physicians for
a National Health Program, regularly assert that elimination of the huge
paperwork and overhead imposed by private insurance companies could save
enough to cover the estimated 31 million of Americans who will remain
uninsured under the Affordable Care Act.

My fellow Economix blogger Uwe E. Reinhardt, expanding on this theme,
notes that the Institute of Medicine of the National Academy of Sciences
recently estimated excess administrative costs of $191 billion, again
more than enough to attain truly universal health care coverage.

Most such estimates are limited to the monetary costs incurred by
insurers, doctors and hospitals and don't include the value of the time
that health care consumers must devote to managing a torrent of
inscrutable paperwork that can become truly frightening for the
critically ill.

A single-payer insurance system, whether based on an extension of
Medicare or on the Canadian model, promises many profoundly important
benefits. Right off the mark, it promises simplicity.

No wonder conservative pundits are afraid of it.

(Nancy Folbre is professor emerita of economics at the University of
Massachusetts, Amherst.)

http://economix.blogs.nytimes.com/2013/11/25/the-single-payer-alternative/


Comment: Experts across the political spectrum have long understood how
much more effective a single payer system would be in achieving our
goals of universality, comprehensiveness and affordability than is our
current financing infrastructure that was left in place by the
Affordable Care Act. When this fact was so obvious at the time reform
was being crafted, even to President Obama, then why did we reject
single payer in favor of our highly flawed system?

It was the progressive community, of all people, that took it off of the
table. The words of Dean Baker echo the prevailing view of many
progressives at that time: "Well, it'd be great to have, you know,
universal Medicare, but that wasn't about to be coming. So basically our
choice is having health care provided through private insurers or not
having it at all."

So the view was, single payer is the system that will work for us, so
let's choose between expanding our current dysfunctional system of
private insurers or let's have nothing at all. Talk about a non sequitur!

Two developments stem from this unwise choice in reform, both related to
how unsatisfactory the policies are - costly but all too ineffective. On
the one hand, the conservatives opposed to any effective reform are
telling us that things are in such a mess that we will have to resort to
single payer to bail us out. On the other hand, many progressives, like
Professor Nancy Folbre, are now motivated to speak up in favor of single
payer since the Affordable Care Act clearly is going to fall intolerably
short of our goals. Most moderates and even some conservatives
understand the imperative of single payer.

The point is that now is the time to talk about single payer, with a
loud and clear voice. As the deficiencies in the Affordable Care Act
become ever more obvious to the public at large, they need to know that
there is a way out. Let's hear it, loud and clear now: *We should have
gone for single payer… and we still can!*

Fwd: qotd: Kip Sullivan on “If you like your plan…”

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-------- Original Message --------
Subject: qotd: Kip Sullivan on "If you like your plan…"
Date: Fri, 22 Nov 2013 07:30:12 -0800
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>



Columbia Journalism Review
October 31, 2013
Too little, too late on "You can keep it."
By Trudy Lieberman

I have a question for all the reporters busy asking whether Obama misled
Americans with his oft-repeated line that "if you like your health plan,
you can keep it": Where have you been? You should have challenged this
claim well before now. You should have been reporting that some people
in the individual insurance market might receive cancellation letters …
well before it started happening to them….

http://www.cjr.org/the_second_opinion/reporting_too_little_too_late_on_obamas_you_can_keep_it.php?page=all


The origins of, "If you like your health insurance you can keep it":

Huffington Post
November 1, 2013
By Richard Kirsch

There are good reasons why President Obama's leading message on health
care during the 2008 campaign … was "if you like your health insurance,
you can keep it." That message was created to overcome the
fear-mongering that had blocked legislative efforts to make health care
a government-guaranteed right in the United States for a century....

As one of the people who engaged early on in building the effort that
led to the passage of the Affordable Care Act, I am keenly aware of this
history. ...

As we predicted, the opponents of reform used fear-mongering … to try to
kill the Affordable Care Act....

The opponents of reform have used reckless, baseless charges to try to
kill reform. I'm glad that President Obama used a slight exaggeration to
finally provide secure health coverage for all Americans.

http://www.huffingtonpost.com/richard-kirsch/the-origins-of-if-you-lik_b_4190922.html


Comment by Kip Sullivan:

As Trudy Lieberman noted in her article for Columbia Journalism Review,
and as some noted as early as 2008 (1), it has been known for a long
time that millions of Americans would not be able to keep their health
insurance under the Affordable Care Act. Yet President Obama and many
other proponents of the ACA claimed this would not happen. They said
people who liked their health insurance could keep it.

If Obama et al. had made this claim once or twice in the heat of a
debate, few would be questioning their integrity now. But they made this
claim repeatedly, both before and after the ACA was enacted. The
chickens are coming home to roost. Obama and other Democrats are taking
a terrible beating for having made a promise they knew or should have
known they couldn't keep.

What explains such irrational behavior?

In his essay for the Huffington Post, Richard Kirsch takes a stab at an
answer. Kirsch is in an ideal position to give us one. He was present at
the creation of the marketing strategy that was supposed to neutralize
the inevitable attacks on the ACA from the right. Kirsch was the
chairman of the "health policy refinement committee" of the Herndon
Alliance, a coalition formed in 2005 to promote whatever it was the
Democrats decided to put forward in the name of "health care reform,"
and he later became the campaign director for Health Care for America
Now, the leading organization in the fight to enact whatever it was the
Democrats decided they could get through Congress.

Kirsch tells us the mantra was invented to "overcome … fear-mongering"
that he and the entire rest of the world predicted conservatives would
use to stop the ACA. But this argument merely begs another question: Why
would the public be reassured by an argument that was so easily
rebutted, at first by commonsense and eventually by reality as well? Why
wasn't it obvious to Kirsch et al. that inaccurate statements would come
back to haunt the makers of those statements?

The answer can be found in the "framing" and "messaging" craze that
erupted late in 2004 after John Kerry lost to George Bush.(2) George
Lakoff and other "framing" gurus claimed that conservatives were winning
elections liberals should have won because conservatives were
"messaging" better than liberals. More specifically, the argument was
that voters respond to emotions, not "facts," and if voters and
conservatives don't care about facts, liberals shouldn't either.
Instead, liberals should convene focus groups and conduct polls to
determine what buzzwords and claims "resonate" with voters' emotions –
their "frames" – and use those buzzwords and make those claims.

In this comment I don't propose to take sides on whether Lakoff and
other "framing" proponents were promoting science or pseudoscience. I do
argue that "framing" theology was easily interpreted as an excuse to say
anything regardless of the evidence, regardless of whether a proposal or
legislation actually existed, and, after legislation had been
introduced, regardless of the actual language in that legislation. I
argue that that's what happened to Kirsch, the Herndon Alliance, and
other advocates of the ACA.

Consider this memo published by the Herndon Alliance and others in June
2008.(3) The memo urged advocates of "health care reform" to claim that
"reform" ("reform" was not explained) would:

• guarantee "choice among plans,"
• guarantee that Americans could "keep our current doctor,"
• "make insurance companies compete to keep costs down and quality up,"
• stop insurance companies from "overriding doctors' decisions about
what their patients need,"
• keep "deductibles low," and
• save "billions by cutting administrative waste and moving to
electronic medical records."

The memo made no attempt to document the truthfulness of these claims.
That is not surprising, because not one of these claims was accurate
then, and not one is accurate now.

So how did the Herndon Alliance et al. justify urging advocates to make
these claims? They cited "framing" theology. They said these claims had
been "market-tested" on focus groups and "online dial groups" of "swing
voters" to determine what "frames" lurked in the minds of the
participants and what "messages" were consistent with those "frames." In
short, the Herndon Alliance et al. convinced themselves that
misrepresentation is moral and effective if the misrepresentation has
been shown to elicit positive responses in focus groups and surveys.

Several factors contributed to the widespread acceptance of this flimsy
rationale for inaccuracy among the leaders of the pro-ACA movement. One
was the failure of the media to question the buzzwords and claims
concocted by the Herndon Alliance and promoted by HCAN and eventually
Obama and members of Congress. Trudy Lieberman criticized the media for
this failure even before the ACA was enacted. In a 2009 article she
called the Herndon Alliance's buzzwords "hollow as straw" and
"Orwellian" and recommended that reporters "avoid quoting someone who
uses those words unless they have something more significant to say."(4)

But the media did not do that, and the Herndon Alliance's claims quickly
mutated into conventional groupthink among leaders of the pro-ACA
movement. To those leaders and members of Congress who could have warned
Democrats not to repeat "if you like your health insurance etc." and now
lament the fallout from the constant repetition of that canard, I repeat
Ms. Lieberman's question: Where have you been?


(1)
http://pnhp.org/blog/2013/11/08/editorial-who-first-said-you-can-keep-the-insurance-you-have

(2)
http://www.nytimes.com/2005/07/17/magazine/17DEMOCRATS.html?pagewanted=all&_r=0G

(3)
http://familiesusa2.org/assets/pdfs/drew-and-celinda-short-memo-revised-6-11-08.pdf

(4)
http://www.cjr.org/campaign_desk/what_journalists_can_learn_fro_1.php?page=all

Fwd: qotd: Why we shouldn't be celebrating the slowdown in health care spending

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-------- Original Message --------
Subject: qotd: Why we shouldn't be celebrating the slowdown in health
care spending
Date: Thu, 21 Nov 2013 12:58:32 -0800
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>



The White House
November 20, 2013
New Report from the Council of Economic Advisers: The Recent Slowdown in
Health Care Cost Growth and the Role of the Affordable Care Act
By Jason Furman

The Affordable Care Act (ACA) was passed against a backdrop of decades
of rapid growth in health care spending, and one of the ACA's key goals
was to root out serious inefficiencies in the United States health care
system that increase costs and compromise patients' quality of care.
Recent data show that health care spending and prices are growing at
their slowest rates in decades; it appears that something has changed
for the better. While this marked slowdown likely has many causes, and
these causes are not yet fully understood, the available evidence
suggests that the ACA is contributing to these trends, and, moreover, is
helping to improve quality of care for patients. Today the White House
Council of Economic Advisers released a new report analyzing recent
trends in health costs, the forces driving those trends, and their
likely economic benefits.

http://www.whitehouse.gov/blog/2013/11/20/new-report-from-council-economic-advisers-recent


Executive Office of the President of the United States
November 2013
Trends in Health Care Cost Growth and the Role of the Affordable Care Act

While final conclusions about the causes of the recent slow growth and
its persistence await additional data and analysis, some conclusions are
possible with the data currently available.

The Role of the 2007-2009 Recession

Some have identified the 2007-2009 recession and its aftermath as a
potential driver of system- wide changes.

However, the theory that the slowdown in the growth of health care costs
is simply a result of the recession is inconsistent with several pieces
of evidence.

* The slowdown has persisted well beyond the end of the recession.

* The slowdown appears in Medicare, which is more insulated from the
business cycle, not just the private sector.

* The slowdown appears in health care prices in addition to health
spending.

Other factors driving slower growth in health spending unrelated to the ACA

* Increased cost-sharing may be reducing utilization in private plans

* Many blockbuster drugs are coming off patent

The Role of the Affordable Care Act

* Reductions in Medicare overpayments to providers and health plans

* Deployment of new payment models to increase efficiency and improve
quality of care

* Penalties for hospitals with high readmission rates

* Accountable Care Organizations

The evidence is clear that recent trends in health care spending and
price growth reflect, at least in part, ongoing structural changes in
the health care sector. The slowdown may be raising employment today,
and, if continued, will substantially raise living standards in the
years ahead. The evidence also suggests that the ACA is already
contributing to lower spending and price growth and that these effects
will grow in the years ahead, bringing lower cost, higher quality care
to Medicare and Medicaid beneficiaries and to the health system as a whole.

Full report (28 pages):
http://www.whitehouse.gov/sites/default/files/docs/healthcostreport_final_noembargo_v2.pdf


Los Angeles Times
November 19, 2013
Drew Altman, Obamacare's ref
By Patt Morrison

Drew Altman, President and CEO of the Henry J. Kaiser Family Foundation:

"We are in a historic slowdown in healthcare spending right now, mostly
due to the weak economy but also due to changes in health delivery —
more cost-sharing, higher deductibles, more out of pocket. Nobody knows
when healthcare spending will shoot up again and by how much."

http://www.latimes.com/opinion/commentary/la-oe-morrison-altman-20131119,0,1829401.column#axzz2lBRuAToy


Democracy
Summer 2006
Our Unhealthy Tax Code
By Jason Furman

In the final diagnosis, the tax code is literally making America sick -
squandering taxpayer dollars on a health care subsidy system that is
failing to provide quality health care to all Americans.

A single-payer national health care system would, by definition, remedy
the problem, but it is unlikely to happen any time soon, if ever at all.
Beyond the political limitations, it is also an open question whether a
single-payer system would be the most efficient way to provide quality
health care for all Americans. In the meantime, reforming health care
will come down to a set of incremental changes that build on the current
system.

http://www.democracyjournal.org/1/6466.php


Comment: The White House has released a new report from the Council of
Economic Advisers, chaired by Jason Furman, celebrating the fact that
health care spending has finally come under control, and it is due
primarily to implementation of the Affordable Care Act, or so it seems
that is what they want us to believe.

Although there are multiple factors why health care spending has slowed,
the two most important are those mentioned by Kaiser Foundation's Drew
Altman: the weak economy that persists since the Great Recession, and
the expansion of health insurance products that place more of the burden
of paying for health care on patients themselves.

Prices and volume determine the level of spending. The continuing
weakness in the economy has created a reluctance to increase prices, and
the cost sharing barriers such as high-deductibles have decreased the
volume of services accessed. Spending slows.

Furman tends to minimize these two important factors as he touts the
great benefits of the Affordable Care Act. He cites the reduction in
Medicare overpayments while remaining silent on the fact that HHS used
two devious schemes to offset some of those reductions (overpaying
quality bonuses, and using an accounting gimmick that will provide a
3.3% increase in Medicare Advantage payments, replacing a scheduled 2.2%
decrease - a 5.5% net gain). He cites new payment models such as
value-based purchasing, the shared savings program, innovation
experimentation, and outcomes research, all of which are largely
experimental and could not have had any significant impact to this date
on slowing spending. He cites the penalties for hospital readmissions,
but Medicare readmissions have been reduced from 19% to 18%, a very
small percentage of overall Medicare admissions and hardly an
explanation for any significant reduction in the rate of spending
increases (not to mention that he fudges the numbers to predict another
undocumented 0.5% decrease). And, finally, he cites the great promise of
spending reduction - the accountable care organizations. Though he touts
their success, only 13 of the 32 Pioneer ACOs saved enough money to
receive shared savings from CMS. ACOs simply do not explain the slowing
of spending on health care.

We need to understand that Jason Furman is an avowed incrementalist who,
in 2006, was dismissive of single payer reform. As such, he has become a
great "company man" for President Obama. Rather than being dismissive of
single payer, we can be dismissive of Jason Furman. If we really want
spending control, we need to adopt the proven model of a single payer
national health program - an Improved Medicare for All.

So should we nevertheless be celebrating the slowdown in health care
spending? Let's look at the score sheet:

Protracted weak economy - No celebration

Impaired access to care through cost barriers - No celebration

Ineffective policies of the Affordable Care Act - No celebration

Good grief!

Fwd: qotd: Low payment rates for exchange plans threaten adequacy of provider networks

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-------- Original Message --------
Subject: qotd: Low payment rates for exchange plans threaten adequacy
of provider networks
Date: Wed, 20 Nov 2013 12:40:56 -0800
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>



Kaiser Health News
November 19, 2013
Doctors Complain They Will Be Paid Less By Exchange Plans
By Roni Caryn Rabin

Many doctors are disturbed they will be paid less -- often a lot less --
to care for the millions of patients projected to buy coverage through
the health law's new insurance marketplaces.

Some have complained to medical associations, including those in New
York, California, Connecticut, Texas and Georgia, saying the discounted
rates could lead to a two-tiered system in which fewer doctors
participate, potentially making it harder for consumers to get the care
they need.

"As it is, there is a shortage of primary care physicians in the
country, and they don't have enough time to see all the patients who are
calling them," said Peter Cunningham, a senior fellow at the nonpartisan
Center for Studying Health System Change in Washington D.C.

If providers are paid less, "are [enrollees] going to have difficulty
getting physicians to accept them as patients?"

Physicians are uncomfortable discussing their rates because of antitrust
laws, and insurers say the information is proprietary. But information
cobbled together from interviews suggests that if the Medicare pays $90
for an office visit of a complex nature, and a commercial plan pays $100
or more, some exchange plans are offering $60 to $70.

Insurance officials acknowledge they have reduced rates in some plans,
saying they are under enormous pressure to keep premiums affordable.
They say physicians will make up for the lower pay by seeing more
patients, since the plans tend to have smaller networks of doctors.

http://www.kaiserhealthnews.org/Stories/2013/November/19/doctor-rates-marketplace-insurance-plans.aspx


Comment: Insurers will be paying physicians less through their exchange
plans than they do through their existing commercial plans. If the rates
turn out to be typically 30 or 40 percent less, as this article
suggests, they will have problems maintaining adequate provider
networks. An insurance card is of little value if you cannot find
physicians who will accept it.

As we said from the start, those designing health care reform were
making a terrible mistake when they decided to make health insurance
premiums affordable while largely ignoring health care costs.

Look what they did:

* They assigned very low actuarial values to the plans that most
individuals will select, leaving 30 to 40 percent of health care costs
to be paid by the patient, though some will receive inadequate subsidies.

* They designed plans with very high deductibles, causing the large
percentage of patients who need less care to receive virtually no
sickness or injury benefits from their plans.

* They reduced the size of their provider networks which will reduce
spending by making care less accessible, especially specialized care.

* Now it appears that they will be reducing provider payments to levels
that will be rejected by many physicians. Although employer-sponsored
plans are moving in the same direction, it is likely that many
physicians will limit their practices to these plans and cash-paying
patients, while avoiding patients in the exchange plans and the
chronically-underfunded Medicaid program.

* As part of the SGR fix, legislators are considering not allowing any
inflationary increases in the Medicare program for the next ten years -
keeping the payment rates flat. If so, physicians are apt to leave the
Medicare program as payment rates approach that of Medicaid.

As we approach $3 trillion in health care spending, this is criminal!
For that kind of spending, everyone could have high quality health care.
Instead, we get a system that perpetuates disparities in health care
while creating financial burdens for precisely those individuals who
most need health care.

The entire health care system will not collapse, but this experiment
will perform so miserably that most will consider it to be a failure. We
don't need to go back to the drawing boards. We merely need to enact a
system that we already know will achieve our goals - an improved
Medicare for all.

Fwd: qotd: Obamacare is the Trojan horse for what!?

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-------- Original Message --------
Subject: qotd: Obamacare is the Trojan horse for what!?
Date: Mon, 18 Nov 2013 12:47:28 -0800
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>



Bloomberg View
November 18, 2013
A Conservative Cure for Obamacare
By Paul Howard & Yevgeniy Feyman

The Patient Protection and Affordable Care Act is floundering.

Conservatives who take satisfaction in that should be careful not to get
ahead of themselves. The rollout problems - however serious and
continuing - shouldn't be confused with the law's outright collapse.

The reality is that large constituencies are in place to work to
preserve Obamacare.

What strategy, then, would move us closer to the patient and
consumer-focused health-care system that conservatives desire while also
recognizing the facts on the ground?

The answer might be simple: Propose changes that will make plans more
affordable and drive enhanced competition among insurers and providers.
In other words, make Obamacare a Trojan horse for conservative
health-care reform. The administration of President Barack Obama has
quietly introduced regulatory decisions that have made the exchanges a
viable market for high-deductible, health-savings-account-eligible
health plans.

Shortly after the law passed, it looked like the administration would
use regulatory rule-making to kill health savings accounts. But
subsequent rules clarified that HSA-qualified plans were actually the
default structure for bronze plans on the exchanges. (Some silver plans
qualify, too.)

Far from being driven to extinction, high-deductible, HSA-eligible plans
have an opportunity to capture significant new market share on the
exchanges.

Conservatives aren't going to repeal or replace Obamacare anytime soon.
But they can propose smart fixes that build on the HSA-friendly exchange
architecture to make the law more consumer- and patient-friendly. Reform
from the inside can set the stage for even bigger changes in the
not-too-distant future.

http://www.bloomberg.com/news/2013-11-18/a-conservative-cure-for-obamacare.html


Comment: In recent months, many conservatives have been attacking
Obamacare as being a Trojan horse that will open up health care to
single payer, even though actually it has taken us further in the wrong
direction to a private insurance-dominated market. This article from the
Manhattan Institute more accurately describes Obamacare as a Trojan
horse taking us to high-deductible, health-savings-account-eligible
health plans, often referred to as consumer-directed health plans. But
let me clarify that.

The low actuarial value plans that will dominate the Obamacare exchanges
are high-deductible plans that already are or with very little tweaking
will be eligible for associated health savings accounts (HSAs). HSAs
work well for wealthier people who can take advantage of the tax
incentives, and who remain healthy so that they can use the accumulated
tax-advantaged funds in retirement. But families with more modest
incomes will be selecting the low-actuarial value bronze and silver
plans only because of the lower premiums. They will receive little or no
tax benefit, and if major illness strikes, they may not be able to
afford the out-of-pocket expenses, even if qualified for subsidies.

From a health policy perspective, the HSA component can be ignored.
Except for tax incentives for the rich, the HSA is really only cash to
be used for out-of-pocket payments. Even if funded by the employer, it
is still paid by the employee in the form of forgone wage increases. So
it is the high-deductible and not really the HSA that has such perverse
consequences - patients forgoing care because of not having the money to
pay the deductible, - whether having an empty pocket or an empty HSA.

What is particularly disconcerting is that it always was intended that
the exchange plans be high-deductible plans, simply to control premium
costs. Also, employers are now rapidly converting to high-deductible
plans for the same reason. The consumer-directed advocates no longer
need to hide in a Trojan horse since the deductibles are already highly
visible. Right before our eyes, it has been the Trojan army of
deductibles that has been conquering our health security, placing those
with health care needs in servitude.

The Trojan horse came, and the neo-liberals pretend they didn't even see it.

Fwd: qotd: The United States is worse in access, affordability and insurance complexity

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-------- Original Message --------
Subject: qotd: The United States is worse in access, affordability and
insurance complexity
Date: Fri, 15 Nov 2013 04:49:47 -0800
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>



Health Affairs
December 2013 (online November 13, 2013)
Access, Affordability, And Insurance Complexity Are Often Worse In The
United States Compared To Ten Other Countries
By Cathy Schoen, Robin Osborn, David Squires, and Michelle M. Doty

The United States is in the midst of the most sweeping health insurance
expansions and market reforms since the enactment of Medicare and
Medicaid in 1965. Our 2013 survey of the general population in eleven
countries — Australia, Canada, France, Germany, the Netherlands, New
Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United
States — found that US adults were significantly more likely than their
counterparts in other countries to forgo care because of cost, to have
difficulty paying for care even when insured, and to encounter
time-consuming insurance complexity. Signaling the lack of timely access
to primary care, adults in the United States and Canada reported long
waits to be seen in primary care and high use of hospital emergency
departments, compared to other countries. Perhaps not surprisingly, US
adults were the most likely to endorse major reforms: Three out of four
called for fundamental change or rebuilding.

Insurance Design And Affordability

In this study, US adults — both the insured and the uninsured — were
more likely than adults in other countries to report going without care
because of costs, having high out-of-pocket costs, and having difficulty
paying medical bills.

Reforms scheduled under the Affordable Care Act provide for subsidies to
lower cost sharing for those with incomes below specified thresholds as
well as reductions in premiums for people with low or modest incomes.
However, by international standards, cost-sharing exposure will remain
high for those with low incomes. Also, states will have considerable
leeway in insurance design for middle- and high-income families, with
annual out-of-pocket maximums and deductibles that will continue to be
high compared to those in other countries. For people with chronic,
ongoing conditions, the result could be continued high medical cost burdens.

Insurance And Primary Care

Insurance design and payment policies also matter for access and
countries' primary care infrastructure.

The high rates of ED use associated with long waits for primary care in
the United States (including among insured patients) and several other
countries underscore the importance of 24/7 primary care coverage in
terms of overall system cost and resource allocation.

Insurance Complexity

The experiences of patients and physicians in other countries regarding
the time-consuming complexity of insurance also provide potential
insights for the United States.

A recent Institute of Medicine study estimated that administrative
layers throughout the US health insurance and care system add as much as
$360 billion per year to the cost of health care — and much of that sum
was deemed to be wasted, with little or no return in value. Evidence
from other countries suggests opportunities to reduce such costs.

Cost Control

A key challenge for the United States is its already high level of
health spending, which is 50–167 percent higher per capita than in the
other study countries. These costs undermine the financial protections
offered by insurance and drive premiums up.

Support For Reform

Polls in the United States show mixed public support and lack of
knowledge about the provisions of the Affordable Care Act. Yet in the
survey most US adults called for major change, with a minority
preferring the status quo. People who had experienced problems with
access to or affordability of care or who had time-consuming insurance
problems had more negative views than people who had not had such problems.

http://content.healthaffairs.org/content/early/2013/11/12/hlthaff.2013.0879.full.pdf+html?ijkey=7LvT


Comment: This 2013 survey sponsored by the Commonwealth Fund is very
helpful during the Affordable Care Act transition because it tells us
how the United States is doing compared to ten other industrialized
nations with universal systems. Our results are terrible, and when we
look ahead at the changes yet to be implemented, it is clear that they
will have an almost negligible impact on correcting the serious
deficiencies in the United States.

Our per capita costs will remain far higher than those of other nations.
Our insurance products will remain very expensive yet highly flawed in
design since they leave those individuals who have significant health
care needs with high medical cost burdens. The excessive complexity of
our insurance products will continue to waste hundreds of billions of
dollars that could be used on health care. Measures intended to provide
much needed reinforcement of our primary care infrastructure are all too
meager, so timely access to care will remain impaired for too many.

Three-fourths of Americans believe that we need fundamental changes or
complete rebuilding of our health system. We have a far greater
percentage dissatisfied than are in the other developed nations.
Although it will be several weeks before the exchange plans and the
Medicaid expansions will be in effect, most Americans will not be able
to detect any improvements in their health care financing and access.

In fact, many will have greater out-of-pocket costs because of increased
shifting of costs to patients through measures such as high deductibles,
and others will lose access to their current health care professionals
and institutions because of the greater use of narrow provider networks
- further reducing choices in health care. In spite of the noble
intentions of the Affordable Care Act, most of us will not see any
correction of the serious flaws demonstrated in this international
survey which shows how costly and dysfunctional our system is, and too
many of us will be even worse off.

As we watch the 2014 implementation unfold, we have to keep in mind that
it didn't have to be this way. We could have had and still can have a
single payer national health program - an improved Medicare covering
everyone. With what we spend, we should be at the top in these
international comparisons. Single payer would get us there.

Fwd: qotd: Deloitte’s take on hospital mergers and acquisitions

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-------- Original Message --------
Subject: qotd: Deloitte's take on hospital mergers and acquisitions
Date: Tue, 12 Nov 2013 12:41:31 -0800
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>



Deloitte
Health Care Current
November 12, 2013
My Take: The art of becoming big: the dilemma of mergers & acquisitions
in health care
By Mitch Morris, MD, Vice Chairman and National Health care Provider
Lead, Deloitte LLP

Consolidation has transformed nearly every U.S. industry—manufacturing,
retail, life sciences and hospitality — you name it.

The U.S. health care industry is well into another round of
consolidation. Already, according to the American Hospital Association,
3,007 hospitals (roughly 53 percent) are part of a health system. The
industry went through a round of consolidation in the 1990's but many
would say that, other than better access to the debt market, the
resulting health systems were, for the most part, holding companies and
not operators that had a focus on economies of scale or reduced costs.

According to Irving Levin Associates, in 2012 there was twice the number
of hospital mergers as compared to 2009 and this shows no sign of
slowing down. The Affordable Care Act (ACA) has served as a catalyst to
accelerate the consolidation movement, which seems to have taken on a
life of its own. Several trends are beginning to emerge across the industry:

* As reimbursement rates continue their downward trend and the costs of
maintaining infrastructure and regulatory compliance march ever higher,
the acute care industry seeks scale to better manage costs. Many acute
care players are beginning to reduce costs through economies of scale,
including the implementation of shared services, programmatic
integration and consolidation, selective sourcing and addressing
clinical effectiveness. The hope is that costs can be shaved by as much
as 30 percent, which is certainly not a goal that can be achieved simply
by headcount reduction.

* The stand-alone hospital may be an endangered species—many smaller
organizations simply cannot afford to invest in keeping up with
facilities, upgrading IT capabilities, attracting the best clinicians,
or playing an active role in the emerging payment model innovation game.
Nor do they all have the market clout to be considered essential players
in narrow health plan networks. As margins shrink and access to capital
becomes more difficult, even hospitals in affluent communities are
feeling the pinch.

* Health plans, which also continue to consolidate, are dipping their
toes into the provider business through the acquisition of medical
groups. Many are also developing capabilities to manage population health.

So is bigger better? How big is big enough? And can a system be too big?

It's not uncommon for mergers to fail to produce expected benefits for
the new organization or the communities they serve. But there is some
data to suggest that, by some measures of performance, hospital
acquisitions do produce a benefit. A Deloitte Center for Health
Solutions report, Hospital Consolidation: Analysis of Acute Sector M&A
Activity, recently studied hospitals that were acquired in 2007 and 2008
and found that, over several years, the acquired hospitals had increased
volumes and improved margins compared to a cohort of similar size (case
mix adjusted) that was not acquired. The benefit was most pronounced
when the acquirer was a national chain as compared to a regional system.

We are quickly moving toward needing a larger scale to successfully
compete. In the 90's we did not have the same economic or legislative
imperative to achieve higher value in a lower cost structure. Now we do.
And those organizations that don't get both the art and science of this
transition are likely to find themselves in a difficult position.

****

An online poll of Health Care Current readers (results as of 11/12/13,
1:47 PM EST):

There are many factors driving consolidation in health care, but I
believe the greatest is...

37.84% Margin constraints such as declining reimbursement rates and
costs of infrastructure

10.81% The increasing complexity of regulatory compliance

51.35% Companies vying to remain in a competitive market position

00.00% Consumer demand

00.00% Innovation and new technologies

http://www.deloitte.com/view/en_US/us/Insights/Browse-by-Content-Type/Newsletters/health-care-current/4a2992c0bab42410VgnVCM3000003456f70aRCRD.htm

Deloitte report: "Hospital Consolidation: Analysis of Acute Sector M&A
Activity" (26 pp):
http://www.deloitte.com/assets/Dcom-UnitedStates/Local%20Assets/Documents/Center%20for%20health%20solutions/us_dchs_2013HospitalConsolidation_05292013.pdf


Comment: This Deloitte report reveals that hospital merger and
acquisitions are occurring at an accelerated pace. Is that good or is
that bad? The answer depends on whether you believe that hospitals
should be run like businesses, trying to obtain competitive advantages
in the health care marketplace, or if you believe that they should be
run as a service organization, emphasizing patient care as its
predominant role in the community.

Consolidation through merger and acquisition increases market clout. It
is anti-competitive, giving the merged entity a larger share of the
market. Because of the ability to negotiate better rates, prices go up
without the need to provide additional services and amenities that might
be more attractive to patients. There is less need to improve quality
when competitors are less able to increase revenues that might be
allocated for their own quality improvements. Private sector
consolidation leading to oligopolies or monopolies result in the
opposite of what markets are supposed to bring us. They result in lower
quality and higher costs. Yet health care reform is supposed to bring us
higher quality at lower costs.

Maybe we overuse the example of a fire department, but it is a useful
analogy. We think of the fire department as a service organization,
always there when we need it to put out fires or to perform other
community service functions. We don't think of it as a business that
competes in the marketplace. We don't shop for fire services based on
price and quality. We simply pay for them through the tax system, and we
expect that the fire personnel will continue to take pride in the
services that they provide to the community.

Health care should be the same. Hospitals should be service
organizations, always there for when we need them. Instead of us
shopping prices, whether directly or through our insurers, they should
be financed through the tax system - using global budgets just as fire
departments do. And quality? That is automatic and stems from the
fundamental moral fiber of dedicated health care professionals, as long
as they are not corrupted by the business element that is increasing its
presence to fulfill its mission of using private market business tools,
such as consolidation, to maximize market share. Yet, consolidation of a
public service entity can be used to improve efficiency, quality, and value.

The readers of Deloitte's Health Care Current likely represent the
business oriented element in health care. It is interesting to see the
response of the online poll of what they believe is the greatest factor
driving consolidation. A majority believe that it is due to the business
goal of trying to achieve a better market position. A large minority
believes that it is due to declining margins - lower payment rates and
higher infrastructure costs. A few believe that it is due to greater
regulatory complexity. In general, these concerns that encourage greater
consolidation are more business concerns rather than patient service
concerns.

What is particularly revealing is what these health care businessmen do
not believe are contributing to efforts to consolidate. They do not
believe that innovation and new technologies are primary drivers, though
they continually tout them as being one of the great products of a
business economy. When service is the goal, new innovation would be
adopted based more on patient benefit rather than on business
opportunities afforded by the technology. In a service model, efficiency
could be improved by consolidation if efforts are made to improve
efficiency by assuring optimal capacity - neither excess nor deficient
capacity.

Most impressive in the current phase of health care evolution, wherein
the health care business community is foisting on us consumer-driven
health care, is that not one of these businessmen believe that consumer
demand is a major reason for consolidation. It is not about the patient;
it's about businesses and markets. We need to change that. We could if
we adopted our own single payer national health program, dedicated to
patient service.

Fwd: qotd: Editorial: Who first said, “You can keep the insurance you have”?

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-------- Original Message --------
Subject: qotd: Editorial: Who first said, "You can keep the insurance
you have"?
Date: Fri, 8 Nov 2013 11:53:35 -0800
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>



November 8, 2013
Editorial: Who first said, "You can keep the insurance you have"?
By Don McCanne

Considering our national health expenditures, our health care financing
and delivery systems are a disaster. It is fully apparent that the
Affordable Care Act will fall woefully short of what is needed, and even
offset some of the minimal gains with changes that will make many of us
worse off by passing more costs directly onto us when we become ill
(higher deductibles and other cost sharing), and by further limiting our
choices of physicians and hospitals (shifting to narrow provider networks).

At a time that it is imperative that we address policy issues to try to
straighten up our system, we abandon reason and propel forward with
politics as usual.

President Obama's political enemies, well supported by the media -
including editorialists - are now expressing shock, shock that he lied
to us when he told us that we could keep the insurance we have, if we
like it. He was not the author of this sound bite provided to him for
political campaigning, so where did it come from?

Let's go back five years, beginning before Sen. Obama was even the
Democratic nominee for president, and look at some of our Quote of the
Day messages beginning then:


February 6, 2008
Is "keeping the insurance you have" your choice?
By Don McCanne

How many of you, under age 85, have the same health insurance plan that
you had twenty years ago? None?

Why did you change? (Several possibilities listed.)

What is the obvious conclusion? Health insurance coverage on a continual
basis is practically non-existent in the private insurance market. In
almost all of the instances listed, the insured individual was not
granted the option of "keeping the insurance you have."

Most polls on health care reform continue to ask many of the same
questions as they have over the past couple of decades, but there is one
new question. The pollsters are now asking if you support reform that
would allow you "to keep the insurance you have." For healthier
individuals who believe that they have good insurance, this concept
polls very well. In fact, the other questions in the polls are now
tailored to reinforce this simple concept.

http://www.pnhp.org/news/2008/february/is-keeping-the-insurance-you-have-your-choice


Health Care for America Now!
(Undated, but referenced in 2008)
Statement of Common Purpose

A choice of a private insurance plan, including keeping the insurance
you have if you like it…

http://healthcareforamericanow.org/about-us/statement-of-common-purpose/


July 11, 2008
"Keeping the insurance you have" - Don't believe it!
By Don McCanne

Pause for a minute. Think back to the insurance you had twenty years
ago. Remember? Now do you still have precisely that same coverage?
Unless you are over 85 and have been in the traditional Medicare program
for the past twenty years, it is highly likely that you do not.

So why do you no longer have the better coverage that you had twenty
years ago? You may have changed jobs, likely more than once, and lost
the coverage that your prior employer provided. Your employer may have
changed plans because of ever-increasing insurance premiums. Frequently
your insurer introduces plan innovations such as larger deductibles, a
change from fixed-dollar co-payments to higher coinsurance percentages,
tiering of your cost sharing for services and products, reduction in the
benefits covered, dollar caps on payouts, and other innovations all
designed to keep premiums competitive in a market of rapidly rising
health care costs. You may have lost coverage when your age disqualified
you from participating in your parents' plan. You may have found that
health benefit programs have been declining as an incentive offered by
new employers. Your children may have lost coverage under the Children's
Health Insurance Program when your income, though modest, disqualified
your family from the program. Your union may not have been able to
negotiate the continuation of the high-quality coverage that you
previously held. Your employer may have reduced or eliminated the
retirement coverage that you were promised but not guaranteed. Your
employer may have filed for bankruptcy without setting aside the legacy
costs of their pensions and retiree health benefit programs. You may
have decided to start your own small business and found that you could
not qualify for coverage because of your medical history, even if
relatively benign, or maybe your small business margins are so narrow
that you can't afford the premiums. You may have been covered previously
by a small business owner whose entire group plan was cancelled at
renewal because one employee developed diabetes, or another became HIV
infected. Your COBRA coverage may have lapsed and you found that the
individual insurance market offered you no realistic options. You may
have retired before Medicare eligibility, only to find that premiums
were truly unaffordable or coverage was not even available because of
preexisting medical problems.

http://www.pnhp.org/news/2008/july/keeping-the-insurance-you-have-dont-believe-it


June 23, 2010
Will grandfathering save our current private plans?
By Don McCanne

The opponents of reform, especially the Republicans in Congress, are
making a big deal out of the fact that the Affordable Care Act breaks
President Obama's promise that you will be able to keep the insurance
plan you have. The Obama administration is countering by publicizing the
new regulations that will allow plans in place on March 23, 2010 to be
grandfathered, supposedly assuring that you will be able to keep your
plan if you had it on that date.

Actually, this is a silly debate. As explained in my comment two years
ago, except for those individuals on Medicare or other fiscally sound
retiree programs, almost no one gets to keep the insurance he or she
has. Rather than stabilizing existing coverage, the regulations that
would grandfather plans make it less likely, in an environment of
increasing health care costs, that existing plans would continue to be
offered without significant changes.

In an effort to make the insurance plans more affordable, further
adjustments in deductibles and coinsurance are almost inevitable, and
the ever-changing insurance marketplace will surely result in changes in
insurance companies selected. Insurance price shoppers, who are mostly
healthy, will be much more sensitive to size of the premiums than they
would be to cost sharing; this is precisely what has happened throughout
the individual market. These pressures would accelerate the decline in
grandfathered plans.

"Keeping the insurance you have" was only a slogan used to market the
reform proposal. It wasn't a serious long term strategy. Instead of
wasting time in another political dogfight - this time over
grandfathering - we should move forward with supporting policies that
will work for everyone - like a single payer national health program.

http://www.pnhp.org/news/2010/june/will-grandfathering-save-our-current-private-plans


Comment, November 8, 2013:

"Liar!"

Is that the best lesson that we can learn from President Obama's
decision to accept the recommendation of his political advisers to use
the sound bite, "You can keep the insurance you have, if that's what you
want"?

The fact that this is the framing of the current
keep-the-insurance-you-have discourse demonstrates not only how
acrimonious the Washington political environment has become, it also
shows the ineptitude of the media. Not only do they buy this framing
when there is a far more compelling message in this mess, they also
serve as dupes, propagating the biting, counter-productive message of
the Obama opponents.

Repeating my comment from 2010, "Instead of wasting time in another
political dogfight… we should move forward with supporting policies that
will work for everyone - like a single payer national health program."
That's the lesson we should learn.

Fwd: qotd: Geraldo Rivera supports single payer

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-------- Original Message --------
Subject: qotd: Geraldo Rivera supports single payer
Date: Wed, 6 Nov 2013 10:47:58 -0800
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>



Geraldo Rivera
November 1, 2013

"You know, it's great that people get health care. I want everyone to
have health care. I want single payer. I want Medicare for everybody. I
want it to be like Sweden. I want it to be like the United Kingdom or
Canada. I want everyone to have health care. This program (Obamacare),
though, is deeply flawed, and I think part of the problem is we let the
insurance industry write the legislation, and when the insurance
industry, like they did for the prescription plan, Part B (D), when they
write the legislation, they stack the deck so they're the beneficiaries.

Geraldo Rivera Radio, 11/1/2013 - at the 48:55 mark:
http://www.wabcradio.com/common/page.php?pt=Geraldo+Podcasts&id=512&is_corp=0


Comment: Geraldo Rivera was quite sincere when, on his radio show, he
discussed briefly the serious flaws of Obamacare and then explicitly
supported single payer - Medicare for everybody. This is from a
Republican who also has a show ("Geraldo-at-Large") on the Fox News Channel.

Recently, much of the media attention on single payer has been coming
from conservatives who seem to be threatening us with the prospect of
single payer as an inevitable outcome of expanded coverage through the
Affordable Care Act. They may be correct, but not for the reasons they
imply. Rather than ACA being a step closer to single payer, it moves in
the direction of expansion of enrollment in private plans, whereas
single payer would essentially eliminate private plans.

The real reason that ACA moves us closer to single payer is that the
plans are further limiting our choices of physicians and hospitals, and
they are shifting an unbearable amount of the costs to patients. Once a
critical threshold of patients experience these abuses, the public will
demand that everyone be covered with a public program like Medicare.

During our PNHP meeting in Boston last weekend, Fox News broadcast an
attack on single pager (likely only coincidental that it was during our
meeting). It represents what seems to be an orchestrated attempt to
discredit single payer before it gains further traction. If you watch
the 7 minute video at the following link, you may find disconcerting
the fact that media professionals apparently believe that the intellect
of the average American is so low that they would be swayed by their
framing. Anyway, I report, you decide:

http://www.youtube.com/watch?v=AS_eKBjW5QM

On a more positive note, there are many Republicans, such as Geraldo
Rivera, who do understand and support the single payer model. We need to
expand our message beyond the progressive community by increasing our
efforts to communicate with Republicans and with the business community.

Tomorrow, November 7, Geraldo Rivera is going to have as a guest on his
program, PNHP co-founder David Himmelstein:

WABC at 10:00 AM Eastern (Click on "Listen Live" or listen later to the
podcast):
http://www.wabcradio.com/common/page.php?pt=Geraldo+Podcasts&id=512&is_corp=0

Fwd: qotd: Exchange plans hide your true financial exposure

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-------- Original Message --------
Subject: qotd: Exchange plans hide your true financial exposure
Date: Tue, 5 Nov 2013 10:14:28 -0800
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>



Center for American Progress Action Fund
May 2009
Coverage When It Counts
How much protection does health insurance offer and how can consumers know?
By Karen Pollitz, Eliza Bangit, Jennifer Libster, Stephanie Lewis, and
Nicole Johnston

Knowing whether insurance provides adequate coverage can be a challenge.
Health insurance policies are complex products, highly variable in their
design, and key information about how coverage works is not always
disclosed during marketing. Further, health insurance promises
protection against future, unknown events. Consumers who are healthy
today can find it difficult to anticipate future medical problems and
costs and harder still to evaluate how insurance might cover those needs.

Using simulated claims scenarios for different types of patients we
analyzed the content of coverage under a variety of health insurance
policies sold to individuals and small employers in Massachusetts and
California and estimated out-of-pocket costs for care that patients
might face.

This project estimated cost scenarios for patients with serious medical
conditions: breast cancer, heart attack, and diabetes.

Massachusetts is unique in requiring residents to have health insurance
that meets minimum creditable coverage (MCC) standards — a state
criteria for ensuring adequate coverage. As a result of this individual
mandate and minimum coverage rule, health coverage tends to be much more
standardized and comprehensive in Massachusetts compared to most other
states. MCC standards for 2009 include inpatient and outpatient hospital
and physician care, emergency services, mental health and substance
abuse treatment, and prescription drug coverage.

The Commonwealth Connector (i.e., exchange) offers plans with high,
medium, and low tiers of coverage — characterized as gold, silver, and
bronze. Policies offered by competing insurers within each tier are
supposed to be "actuarially equivalent." Policies are said to be
actuarially equivalent if, for the same population covered, they would
each pay the same share of the population's total expected medical
bills. However, for any given patient, actuarially equivalent policies
might offer different protection.

To illustrate how coverage can vary — and how challenging it might be
for consumers to appreciate the differences — we mapped the simulated
claims scenarios against specific health insurance policies.

Figure 2. Seemingly similar Massachusetts policies work differently

Plan C - Bronze
Deductible $2,000
Patient out-of-pocket costs
Breast cancer $12,907
Heart attack $8,400
Diabetes management $960

Plan G - Bronze
Deductible $2,000
Patient out-of-pocket costs
Breast cancer $7,983
Heart attack $6,237
Diabetes management $4,383

Massachusetts has made great strides toward assuring that all residents
will have basic health insurance protection, and the Commonwealth
Connector has surpassed other states in the amount and quality of
comparative health plan information provided to consumers. Yet even in
that state, gaps in coverage persist and consumers may not easily
appreciate what those gaps could cost if they get seriously ill.

http://www.americanprogressaction.org/wp-content/uploads/issues/2009/05/pdf/CoverageWhenItCounts.pdf


Comment: These boring minutiae on benefits of two actuarially
equivalent plans offered through the Massachusetts health insurance
exchange seem like they would have little relevance compared to the
major features of the Affordable Care Act. Quite the opposite. These
numbers demonstrate that the concept of transparency in shopping for
plans in the ACA exchanges is a cruel fiction. It is impossible to know
what your out-of-pocket expenses will be for any given plan that you select.

In ACA, just as in the Massachusetts exchange, plans in the same metal
tier (bronze in the example above) must be actuarially equivalent; that
is, they must pay the same average percentage of covered expenses,
leaving the balance to be paid the patient. But the definition of what
is covered can vary, even while maintaining actuarial equivalency. Thus,
even though the plans have an annual out-of-pocket limit, that applies
only to covered services, which can vary by plan.

This study looked at expected expenses for three serious conditions and
then calculated what each plan would cover. The out-of-pocket expenses
often exceeded the plan limit because of the cost of essential services
that were not covered.

Think about this. When electing a plan you have to decide in advance
whether or not you are going to have breast cancer or develop diabetes
or have a heart attack next year. Then you have to see how much
out-of-pocket expenses you will be left with after the plan makes its
payments.

In the case of breast cancer, even though Plans C and G are actuarilly
equivalent, you would choose Plan G with out-of-pocket expenses
estimated to be $7,983 since Plan C would have out-of-pocket expenses of
$12,907.

But wait. Suppose you are going to develop diabetes instead. Then you
need to pick Plan C with out-of-pocket expenses of $960, since Plan G
would entail $4,383 in expenses. Or if you are going to have a heart
attack, you would save some with Plan G at $6,237 as opposed to C at $8,400.

But then consider this. These numbers were not available in the plan
information provided by the exchanges. They were not even available in
the detailed insurance contracts that you receive after you purchase a
plan. These numbers had to be calculated by policy experts who
meticulously reviewed each plan. They didn't even include costs incurred
because of care unavoidably obtained out-of-network. Further, because
the calculations are quite laborious, they did not provide them for the
hundreds or thousands of other disorders you could develop next year.
But then, really, who knows what next year holds for us?

For ACA, the calculations would be even more difficult. Although there
are ten categories of essential health benefits that must be included in
the coverage, the insurers are allowed to vary the benefits within each
of the ten categories as long as they remain actuarially equivalent.
Imagine the calculating tool that would be required to compare plan
coverage. It would challenge the Obamacare exchange computer systems in
complexity.

The bottom line? Because of private health plan chicanery, it is
impossible to know what expenses you may face in the next year. But if
you develop a major disorder, there is a great risk that you will have
to pay more than the out-of-pocket limit that is posted on the exchange
plan descriptions.

For no more than our current national health expenditures, we could have
had prepaid health care with first dollar coverage for everyone. We
still can by enacting a single payer national health program - an
expanded and improved Medicare for all.

(Those attending the Boston meeting of PNHP this past weekend will
recognize the numbers presented in Figure 2 above. Our thanks to Steffie
Woolhandler and David Himmelstein for bringing them to our attention.)

Fwd: qotd: Drug and device studies being withheld illegally

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-------- Original Message --------
Subject: qotd: Drug and device studies being withheld illegally
Date: Mon, 4 Nov 2013 14:28:36 -0800
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>



BMJ
October 29, 2013
Non-publication of large randomized clinical trials: cross sectional
analysis
By Christopher W Jones, Lara Handler, Karen E Crowell, Lukas G Keil,
Mark A Weaver, Timothy F Platts-Mills

Randomized clinical trials are a critical means of advancing medical
knowledge. Clinical trials depend on the willingness of participants to
expose themselves to the risks of randomization, blinding, and unproven
interventions. The ethical justification for these risks is that society
will eventually benefit from the knowledge gained from the trial.
Because the risks involved in trial participation may be significant,
and because individual trial participants often do not benefit directly
from trial participation, substantial safeguards have been implemented
to protect the interests of study participants both prior to and during
the trial. These safeguards take multiple forms, including oversight by
institutional review boards, the informed consent process, and data and
safety monitoring boards. Until recently, the protection of the
interests of study participants after trial completion has received
significantly less emphasis. This began to change in 1997 with the
signing of the Food and Drug Administration Modernization Act in the
United States, which mandated that the US Department of Health and Human
Services establish a registry of clinical trials, thereby providing
permanent, public access to information on the conduct of both publicly
and privately funded clinical trials.

In 2005 the International Committee of Medical Journal Editors (ICMJE)
required that prospective trials involving human participants be
registered prior to the beginning of study enrollment in order to be
considered for publication in member journals. This requirement was
later incorporated into the ICMJE's "uniform requirements for
manuscripts submitted to biomedical journals," along with the updated
CONSORT 2010 statement for the reporting of randomized controlled
trials. The prospective registration of phase II-IV clinical trials
subsequently became federal law in the United States in 2007 with the
passage of the Food and Drug Administration Amendments Act. This
legislation also expanded the scope of ClinicalTrials.gov to include a
database of trial results. Results from all registered studies may be
posted to ClinicalTrials.gov, including studies completed prior to
enactment of the Food and Drug Administration Amendments Act. In
addition, reporting results is now mandatory for many trials. Failure to
comply with this mandate can result in substantial penalties, including
civil fines of up to $10 000 (£6200; €7400) per day and withholding of
funds from investigators sponsored by the National Institutes of Health.

The registration of clinical trials serves an important role in
protecting the interests of study participants after trial completion.
In addition to discouraging investigators from preferentially choosing
to report statistically significant positive outcomes, trial
registration can increase awareness of possible publication bias within
the medical literature by allowing the public to compare the subset of
trials with published results to the total number of trials that were
registered and conducted. Publication bias can distort the apparent
efficacy of interventions, which complicates the interpretation of the
medical literature. The non-publication of trial data also violates an
ethical obligation that investigators have towards study participants.
When trial data remain unpublished, the societal benefit that may have
motivated someone to enroll in a study remains unrealized. Systematic
trial registration provides a tool that can help to assess both the
magnitude and the causes of these problems.

Data sources

PubMed, Google Scholar, and Embase were searched to identify published
manuscripts containing trial results. The final literature search
occurred in November 2012. Registry entries for unpublished trials were
reviewed to determine whether results for these studies were available
in the ClinicalTrials.gov results database.

Results

Of 585 registered trials, 171 (29%) remained unpublished. These 171
unpublished trials had an estimated total enrollment of 299 763 study
participants. The median time between study completion and the final
literature search was 60 months for unpublished trials. Non-publication
was more common among trials that received industry funding (150/468,
32%) than those that did not (21/117, 18%), P=0.003. Of the 171
unpublished trials, 133 (78%) had no results available in
ClinicalTrials.gov.

From the Discussion

Trial investigators and sponsors have an ethical obligation to study
participants to publish trial results. This principle is implicit in the
US Federal Policy for the Protection of Human Subjects, also known as
the "Common Rule," which outlines the scope and responsibilities of
institutional review boards for overseeing research using human
participants. The Common Rule states that institutional review board
approval requires demonstration that "risks to subjects are reasonable
in relation to anticipated benefits, if any, to subjects, and the
importance of the knowledge that may reasonably be expected to result."
Similarly, the Declaration of Helsinki, which was instrumental in
developing the modern system of oversight by institutional review
boards, also acknowledges the importance of disseminating research
results, stating "Authors have a duty to make publicly available the
results of their research on human subjects and are accountable for the
completeness and accuracy of their reports." By directing institutional
review boards to assess the societal importance of resulting knowledge
in addition to the possible risks and harms to individual research
participants, the Common Rule provides justification for institutional
review board oversight of results reporting, including trial
registration and publication. Because the involvement of institutional
review boards with clinical trial oversight begins prior to participant
enrollment, these institutions are uniquely positioned to protect the
rights of study participants throughout all stages of trial conduct,
from study planning to reporting results. Given the persistent problem
of unpublished trial results despite continued emphasis on trial
registration from governmental agencies, funding organizations, and the
editorial community, increased institutional review board attention
toward this issue may be needed.

Conclusions

We observed that non-publication is common among large randomized
clinical trials. Furthermore, the sponsors and investigators of these
unpublished trials infrequently utilize the ClinicalTrials.gov results
database. The lack of availability of results from these trials
contributes to publication bias and also constitutes a failure to honor
the ethical contract that is the basis for exposing study participants
to the risks inherent in trial participation. Additional safeguards are
needed to ensure timely public dissemination of trial data.

http://www.bmj.com/content/347/bmj.f6104

NIH: ClinicalTrials.gov


Comment: Publication bias of drug and device studies has bordered on
the criminal. Industry funded studies in particular were often withheld
from publication if the results were not favorable for the future
marketing of the product; that is, if the studies showed no benefit or,
worse, if they showed that the products were harmful.

Recognizing the problem, in 2005 medical journal editors began to
require that studies be registered before clinical trials began or the
studies would not be published in peer reviewed journals. In 2007 the
federal government began to mandate the reporting of studies with the
threat of civil fines for failing to comply. Many of us recognized that
this failure of the private sector required government intervention, and
we were relieved to finally see it.

Alas, this study shows that non-compliance is still common, especially
with industry funded studies. Not only does this corrupt the data bases
on which our knowledge of new drugs and devices relies, it is also a
failure of ethics by withholding results of human experimentation
consented to by individuals who placed their health at stake to advance
our understanding of the benefits and potential harms of these products.
That ethical failure extends to future individuals who might be exposed
to ineffective or harmful interventions merely because this adverse
information was withheld from the medical community.

There is an analogy with single payer. Private sector enthusiasts insist
on exposing us to the waste, inefficiencies, and sometimes harm
inflicted on us by the private insurance industry and its marketplace
applications. The administrators of a government single payer program do
not experiment with patients in order to expand the market for health
care. However, they do collect generic data, rather than hiding it, to
help advance our understanding of beneficial health care interventions.

Whether it's drug and device research or health care financing, we need
more government involvement, not less.