Deterioration in employer-sponsored health plans

Center for American Progress
March 3, 2015
The Great Cost Shift
Why Middle-Class Workers Do Not Feel the Health Care Spending Slowdown
By Topher Spiro, Maura Calsyn, Meghan O'Toole

In recent years, the growth in overall health care costs has slowed
dramatically. But for millions of Americans with employer-sponsored
insurance, or ESI, this slowdown is illusory. From 2008 through 2013,
the average annual growth rate of employees' monthly premium
contributions and out-of-pocket expenses, adjusted for inflation, was
more than double that of average annual growth in real per-capita
national health care spending, which was less than 2 percent per year.
This growth has also outpaced employers' costs of offering these
benefits by more than 40 percent.

Employees experiencing higher health care costs tend to blame the
Affordable Care Act, or ACA, even though the law largely leaves the
employer-based system alone. In fact, many employers report that the ACA
has had only a negligible influence on their health care costs.

The actual reason why employee and employer costs are increasing at
different rates is because employers have, over time, shifted greater
responsibility for health care expenses to their employees through
higher deductibles, higher copayments, and higher coinsurance — a
practice that began long before the passage of the ACA. Other employers
pay smaller shares of their employees' health care premiums.

To some degree, this long-term cost shifting has contributed to the
overall health care slowdown. Increased cost sharing discourages the use
of health care — individuals tend to spend less on their health care
when they are subjected to higher fees or deductibles — which has
lowered overall health care spending. Employees with higher cost sharing
are more likely to avoid or delay even beneficial and cost-effective
care. Employers, insurers, and public health care programs benefit from
these savings, while individual employees with significant health care
needs face greater out-of-pocket costs. Employees have increasingly
reported that their health care costs are unaffordable. In other words,
almost everyone in the health care system is realizing savings, but
employees' costs are rising.

Unlike changes to wages, which are straightforward and transparent,
these types of changes to employees' health benefits can be hard to
understand, making cost-shifting efforts difficult for employees to detect.

The Great Cost Shift (full 31 page report can be downloaded at this page):
https://www.americanprogress.org/issues/healthcare/report/2015/03/03/105777/the-great-cost-shift/

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Comment by Don McCanne

One of the most important goals of the Affordable Care Act was to
preserve the part of our health care financing system that supposedly
was working quite well: employer-sponsored insurance. However, in a
process that had already begun and has further intensified since the
beginning of ACA implementation, the coverage for employees has
deteriorated, with costs being shifted from the employer to the employee
without a commensurate increase in wages, leaving employees considerably
worse off - especially those employees with greater health care needs.

This report from the Center for American Progress provides an excellent
explanation of the mechanisms of this shift in spending from the
employer to the employee. Unfortunately, their neoliberal
recommendations for correcting this problem are grossly inadequate. Not
only would they leave in place the otherwise highly flawed model of
financing health care through a multitude of private health plans, they
would merely increase transparency of this shift that has been taking
place, while increasing administrative complexity by requiring employers
to return half of the savings to the employee, and, yes, they would
throw in three free primary care visits per year - big deal!

This problem is serious and requires truly transformative change.
Instead of allowing employers to continue to implement their current
agenda of introducing further relatively opaque changes that will
compound the deterioration of the effectiveness of their health plans,
we should terminate these plans and replace them with a far more
efficient, equitable, and effective single payer national health program.

A single payer system would end employers' concerns about excessive
increases in health care costs, not to mention relieving them altogether
from the need to maintain a health benefit program. Much more
importantly, it would ensure truly affordable, reasonably comprehensive
health care benefits not only for all of their employees, but for
everyone else in the nation as well.

Tsung-Mei Cheng on the success of Taiwan’s single payer system

Health Affairs
March 2015
Reflections On The 20th Anniversary Of Taiwan's Single-Payer National
Health Insurance System
By Tsung-Mei Cheng

Abstract

On its twentieth anniversary, Taiwan's National Health Insurance (NHI)
stands out as a high-performing single-payer national health insurance
system that provides universal health coverage to Taiwan's 23.4 million
residents based on egalitarian ethical principles. The system has
encountered myriad challenges over the years, including serious
financial deficits. Taiwan's government managed those crises through
successive policy adjustments and reforms. Taiwan's NHI continues to
enjoy high public satisfaction and delivers affordable modern health
care to all Taiwanese without the waiting times in single-payer systems
such as those in England and Canada. It faces challenges, including
balancing the system's budget, improving the quality of health care, and
achieving greater cost-effectiveness. However, Taiwan's experience
with the NHI shows that a single-payer approach can work and control
health care costs effectively. There are lessons for the United States
in how to expand coverage rapidly, manage incremental adjustments to the
health system, and achieve freedom of choice.

Lessons Learned

The most important lesson of Taiwan's experience is that the
single-payer approach can offer all citizens timely and affordable
access to needed health care on equal terms, regardless of the patient's
social, economic, and health status; sex; age; place of residence; and
employment status.

A second lesson is that a single-payer model such as Taiwan's can
control costs effectively. It is administratively simple and inexpensive
and is the ideal platform for a powerful health IT system. It also
facilitates global budgeting, if that is the only way to keep health
spending in line with the growth of GDP.

A third lesson is the importance of investing heavily, up front, in a
modern IT infrastructure. A modern IT system such as Taiwan's allows the
government to have information about health utilization and spending in
almost real time.

Fourth, Taiwan's case illustrates that health policy makers should not
miss windows of opportunity for major health reform. Enabling factors
include rapid economic growth, which makes it easier to redistribute
resources; strong popular demand for reform; strong political
leadership; a broad social and political consensus on the ethical
principles that guide the health system; and the availability of a cadre
of competent civil servants motivated and able to implement reform.

Lessons For The United States

Taiwan's experience demonstrates that with competence and goodwill, the
challenge of adding a large influx of newly insured citizens can be met.
Health systems appear to be adaptive, and the case of Taiwan illustrates
that incremental improvements on reform are possible.

Taiwan's experience also might induce Americans to think more deeply
about the term freedom of choice. In health care, freedom of choice
could mean choice among health insurance carriers and health insurance
contracts, choice among health care providers, or both. For Taiwan's
citizens, freedom of choice among providers of health care trumped
freedom of choice among insurance carriers and contracts. These
citizens' high satisfaction with their health system suggests that they
still endorse that choice. By contrast, in the United States freedom of
choice among insurance carriers and products ranks above freedom of
choice among health care providers, which often is limited to narrow
networks of providers.

A growing body of literature has shown that by international standards,
enormous human resources are used in the United States to facilitate
choice among insurers and insurance products, process claims, and
annually negotiate a payment system that results in rampant and
bewildering price discrimination. Relative to the less complex health
systems elsewhere in the industrialized world, the US system is a poor
platform for the effective use of modern health IT.

According to a recent report by the Institute of Medicine, the US system
has excessive administrative costs that in 2009 amounted to $190
billion. That is more than it would cost to attain true universal health
care in the United States.

It is not this author's role to prescribe what Americans should or
should not do in regard to freedom of choice. But it is appropriate to
invite readers to think more deeply about the relative benefits and
costs of their choices. It is remarkable that in cross-national surveys,
Americans have consistently given their health care delivery system
relatively high marks, but their health system relatively poor ones.

(Tsung-Mei Cheng is a health policy research analyst at the Woodrow
Wilson School of Public and International Affairs, Princeton University,
in Princeton, New Jersey.)

http://content.healthaffairs.org/content/34/3/502.abstract

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Comment by Don McCanne

The people of the United States have continued to watch our health care
spending increase far beyond that of all other nations. We have watched
the quality of our insurance coverage deteriorate as insurers take away
our choices of physicians and hospitals and shift more costs to those
with health care needs, often causing the very financial hardships that
health insurance should be preventing. And we have continued to tolerate
leaving tens of millions uninsured.

For the past generation we also have been observing the natural
experiment in single payer healthcare financing taking place in Taiwan -
Taiwan serving as the experimental subject and the United States as the
control. As Tsung-Mei Cheng explains in this Health Affairs article, it
has been a spectacular success for Taiwan. Had we adopted a similar
program twenty years ago, today everyone would be covered, no one would
face financial hardship because of medical bills, we would have freedom
of choice of our physicians and hospitals, we would have eliminated much
of our profound administrative waste, and our total national health
expenditures would have followed a lower trajectory and thus would be
much less than they are today.

What is it about American exceptionalism? In our stubbornness, we are
going to continue our feeble search for policy solutions to our
intolerable deficiencies and inequities in health care, when we have
before us one of the nearest to perfect natural experiments ever
completed - in precisely the reform that we need. By the definition,
"much better than average," exceptional we are not. Or by the
definition, "deviating from the norm," we should have no pride in either
our health care system or in our obstinate refusal to apply proven
health policies that would inject much needed remedies into our sick system.

At our PNHP meetings and in the health policy literature, Tsung-Mei
Cheng has provided us with an abundance of observations and data that
should illuminate for us a clear path forward for reform. We just have
to make good use of her contributions. We can begin by sharing this
Health Affairs article with others who care about the future of our
health care system.

PNHP release on King v. Burwell

Physicians for a National Health Program (PNHP)
Press Release
March 3, 2015
Health law's complexity invites attack, even as it fails to cure
ailment: doctors group

King v. Burwell shows how Affordable Care Act's corporate-inspired,
convoluted structure makes it an easy target for opponents

Latest legal challenge threatens to add more than 8 million people to
the ranks of the tens of millions who are currently uninsured, leading
to an additional 8,000 'excess deaths' annually linked to lack of insurance

'This case is yet another reason to swiftly move beyond the failing ACA
to a simpler, publicly financed, improved-Medicare-for-All system that
would cover everyone, make care affordable, and control costs,' says
president of single-payer physicians' group

FOR IMMEDIATE RELEASE
March 3, 2015

Contact:
Mark Almberg, PNHP communications director, (312) 782-6006,
mark@pnhp.org <mailto:mark@pnhp.org>

The following statement was released today by leaders of Physicians for
a National Health Program, a research and educational organization of
19,000 doctors who support single-payer national health insurance, or
"an improved Medicare for all."

This week's arguments before the Supreme Court in the case of King v.
Burwell demonstrate once again how the Affordable Care Act's
administrative complexity and flaws – largely reflecting its
accommodation to the private health insurance industry and other
corporate, profit-oriented interests in U.S. health care – make it
vulnerable to legal attacks by its opponents.

The ACA clearly lacks the simplicity and legal robustness that a
single-payer plan would have. Single payer would be simple: everyone in
the U.S. would be covered for all medically necessary care in a single
program financed by equitable taxes.

If the court upholds King and his fellow plaintiffs' challenge to
premium subsidies in over 30 states, the health and financial harms to
our patients will be considerable. By some estimates, more than 8
million people will quickly lose insurance coverage, increasing the
intolerable suffering we already see today.

One consequence of this loss of coverage would be an additional 8,000
"excess deaths" each year – deaths linked to lack of insurance. That
figure is over and above the estimated 30,000 annual preventable deaths
that are currently occurring under the ACA due to its having left 30
million people uninsured. This is completely unacceptable.

Regardless of how the court rules, the unfortunate reality is that the
ACA won't be able achieve universal coverage. It won't make care
affordable or protect people from medical bankruptcy. Nor will it be
able to control costs.

The ACA is fundamentally flawed in these respects because, by design, it
perpetuates the central role of the private insurance industry and other
corporate and for-profit interests (e.g. Big Pharma) in U.S. health care.

In contrast, a single-payer system – an improved Medicare for All –
would achieve truly universal care, affordability, and effective cost
control. It would be simple to administer, saving approximately $400
billion annually by slashing the administrative bloat in our
private-insurance-based system. That money would be redirected to
clinical care. Copays and deductibles would be eliminated.

A growing section of the insured population is already facing very high
copays, deductibles and coinsurance, deterring them from seeking needed
care. This trend is toxic and unsustainable.

Physicians can't wait for an effective remedy any longer, nor can our
patients. The stakes are too high.

Dr. Robert Zarr, a Washington, D.C.-based pediatrician who will be in
front of the Supreme Court building on Wednesday at 10 a.m. Eastern, is
president of Physicians for a National Health Program.

Zarr said today: "The King v. Burwell case is yet another reason to
swiftly move beyond the failing ACA to a simpler, publicly financed,
improved-Medicare-for-All system. Such a system would cover everyone,
make care affordable, and control costs. Based on our experience with
the Medicare program and the experience of other nations, we know it
will work. It's the only moral and fiscally responsible thing to do."

http://www.pnhp.org/news/2015/march/health-law's-complexity-invites-attack-even-as-it-fails-to-cure-ailment-doctors-grou

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Comment by Don McCanne

The Supreme Court case of King v. Burwell is appropriately receiving
extensive coverage in the media since the decision of the Court has the
potential to cause perhaps 8 million individuals to lose their health
insurance, plus it would adversely impact health insurance markets
through spiraling premiums due to adverse selection.

Even though a decision prohibiting subsidies in federally-administered
state exchanges would be disastrous, the hype over this case obscures
the much more intolerable disaster of perpetuating the inequities and
injustices of our current health care financing system. The consequences
of continued inaction on single payer reform constitutes proportionately
a much greater disaster, regardless of the outcome of King v. Burwell.
Over 30 million will still remain uninsured, tens of millions will
experience financial hardship in the face of medical need, perhaps even
personal bankruptcy, while private insurers will continue to take away
our choices of physicians and other health care professionals, take away
our choices of hospitals, and take away our choices of pharmaceuticals
that our physicians say we should have.

Merriam-Webster includes as two of the definitions of "state": "a
politically organized body of people usually occupying a definite
territory; especially one that is sovereign," and "the operations or
concerns of the government of a country." It would be tragic if the
court ruled that this silly argument on the meaning of "state" had
enough substance to allow a few ideologically-driven Supreme Court
justices to deprive 8 million people of insurance coverage. But it would
be a much greater tragedy if we allow this to divert us from
accomplishing the imperative: establishing a single payer national
health program - an improved Medicare for all.