Health Policy Daily

The Century Foundation
December 15, 2015
Key Proposals to Strengthen the Affordable Care Act
By Timothy Stoltzfus Jost and Harold Pollack

The ACA undertook from the beginning an ambitious reform agenda, but
some of its approaches have turned out to be ineffective, poorly
targeted, or not ambitious enough to address deeply rooted problems.

Many of the remaining challenges in health care reform reflect the
inherent complexities and path-dependency of the American system and
were beyond the reach of any politically feasible reform. Perhaps the
most serious problem — which this report will address repeatedly — is
the inadequacy of the ACA's subsidies and regulatory structures to
address the problems of low-income Americans, for whom merely meeting
the costs of day-to-day essentials is a continuing challenge, and for
whom even modest monthly insurance premiums and cost-sharing are often
serious barriers to health coverage and care.

This report identifies problems and suggests potential solutions. Some
solutions would require federal legislation. Others could be implemented
by the administration, state law, or by private parties.

In all, we propose nineteen steps that could help fix recognized flaws
in the ACA as well as build on its accomplishments. Taken together,
these proposals would further improve the access and affordability of
health care under the ACA, create more robust provider networks, enhance
competition among insurers, improve the consumer experience, and
strengthen the Medicaid program. We understand that in the current
political climate, improvements to the ACA that require congressional
action are unlikely.

1. Expanding Access to Health Coverage for Moderate-Income Americans

* Fix the Family Glitch.

* Reduce Complexity in the Tax Credit Program.

* Increase Credits for Moderate- and Middle-Income Families.

2. Making Health Care Affordable

* Reduce Cost-sharing and Out-of-Pocket Limits and Improve Minimum
Employer Coverage Requirements.

* Increase Use of Health Savings Accounts for Moderate-Income Americans.

* Allow Use of Health Reimbursement Accounts to Purchase Health Insurance.

* Incorporate Value-based Insurance Design to Support Coverage for
High-Value Services.

* Improve State Regulation of Network and Formulary Adequacy.

* Improve Protection from Balance Billing.

3. Improving the Consumer Marketplace Experience

* Actively Guide Consumers in Coverage Selection.

* Improve Network and Formulary Transparency.

* Standardize Insurance Products.

4. Improving Medicaid for Low-Income Americans

* Have the Federal Government Permanently Assume the Entire Cost of the
Medicaid Expansion Population.

* Constrain 1115 Waivers.

* Eliminate Medicaid Estate Recoveries from the Expansion Population.

* Improve Medicaid Payment Rates.

* Ensure a Judicially Enforceable Right to Adequate Access to Medicaid
Providers and to Adequate Medicaid Payment Rates.

* Reconsider a "Public Option" Early Medicare Coverage within Health
Insurance Marketplaces.

* Raise or Eliminate Medicaid and Supplemental Security Income Asset
Limits for People Living with Disabilities.

From the Conclusion

This report offers a number of proposals for building on the ACA, to
make health coverage and health care even more affordable, accessible,
and understandable for Americans. We understand that in the current
political climate, improvements to the ACA that require congressional
action are unlikely. Yet an administration committed to improving access
could take some of the actions we recommend without new legislation,
while other proposals could be implemented by the states, marketplace,
or simply by insurers.

http://www.tcf.org/assets/downloads/TCF_KeyProposalstoStrengthenACA.pdf

***

Comment by Don McCanne

Congress is divided on what to do about our expensive but highly
dysfunctional health care system. Congressional opponents of the
Affordable Care Act (ACA) today will vote for the 62nd time to repeal
the Act without offering any replacement, and President Obama will veto
the legislation. In contrast, supporters of health care reform would
like to improve the system so that it works better for everyone.

There are two approaches to improving the system: either build on ACA
and the existing financing system, or replace it with a single payer
system. Today's report is by two highly respected professors who are
personally dedicated to health care justice - Timothy Stoltzfus Jost and
Harold Pollack - and they would build on ACA. Thus today's report
represents the best of the "repair and improve" approach.

Take a close look at the nineteen recommendations by these two revered
individuals who really care about our health care system, and then think
about what impact these recommendations would have. Most of the them
would hardly qualify as tweaks, though several of them would certainly
be beneficial if we were to support the perpetuation of the current
system. But what they do not do is to provide a new financing
infrastructure that we would need to improve efficiency, equity,
universality, access, quality, comprehensiveness, affordability,
portability, and to reduce the administrative burden through public
administration - features of a single payer national health program.

We can be thankful that we have individuals like Timothy Jost and Harold
Pollack who have dedicated themselves to improve what we have. Until we
can enact a single payer system, we need their efforts to continue. Yet
they concede that "improvements to the ACA that require congressional
action are unlikely." That is the same reason given for not advocating
for a single payer system - it supposedly is not politically feasible.
But you don't compromise policy for politics. You change politics so
that you can achieve optimal policy.

Unfortunately Harold Pollack has a problem with PNHP. He has written, "I
happen to dislike PNHP leaders' unhelpful stance in the current debate,"
and "I wish the group would talk and act rather differently in this
debate," and "Indeed its leaders denigrate important provisions of ACA
that expand access for 32 million people and protect millions against
catastrophic financial risks." In fact, we have supported the beneficial
gains of ACA as important transitional improvements until we can move
the political process to achieve single payer. This matters because this
abrasiveness has reduced the framing to incremental changes or nothing,
when the framing should be incremental changes or single payer.

From the list in this report, the proposed incremental changes are far
too feeble when compared to the need. I feel certain that Timothy Jost
would be on board if there were a politically feasible path to single
payer. I just wish Harold Pollack would join us as well.

http://pnhp.org/blog/2015/07/09/seidman-and-pollack-aca-versus-medicare-for-all/

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Kaiser Family Foundation
December 2015
The Burden of Medical Debt: Results from the Kaiser Family
Foundation/New York Times Medical Bills Survey
Prepared by: Liz Hamel, Mira Norton, Karen Pollitz, Larry Levitt, Gary
Claxton and Mollyann Brodie

Previous Kaiser surveys have found that about a quarter of people say
they or someone in their household had problems paying medical bills in
the past year, and a 2014 Kaiser report provided a qualitative look at
some of the circumstances and consequences of unpaid medical bills
through interviews with people who had sought credit counseling for
medical debt. But to date, there has been little research providing a
quantitative look at the causes of medical bill problems and the impacts
they have on people's families, their finances, and their access to
health care.

To fill this gap, the Kaiser Family Foundation and The New York Times
conducted an in-depth survey with 1,204 adults ages 18-64 who report
that they or someone in their household had problems paying or an
inability to pay medical bills in the previous 12 months.

Prevalence of problems paying medical bills among different groups

Insurance status has a strong association with
medical bill difficulties, with over half (53 percent) of the uninsured
saying they had problems paying household medical bills in the past
year. However, as previous surveys have shown, insurance is not a
panacea against these problems. Roughly one in five of those with health
insurance through an employer (19 percent), Medicaid (18 percent), or
purchased on their own (22 percent) also report problems paying medical
bills. In fact, overall among all people with household medical bill
problems, more than six in ten (62 percent) say the person who incurred
the bills was covered by health insurance, while a third (34 percent)
say that person was uninsured. Among those with private insurance
(either through an employer or self-purchased), their plan's deductible
makes a difference in ability to afford health care bills, with those in
higher deductible plans more likely to report medical bill problems than
those in plans with lower deductibles (26 percent versus 15 percent).

To explore these relationships further, we used a statistical technique
called logistic regression analysis to isolate which demographic
characteristics are the strongest predictors of problems paying medical
bills when holding other factors constant. In that analysis, income,
insurance status, and all 3 measures of health status (being in fair or
poor health and having a disability or chronic condition) had a
significant and strong association with problems paying medical bills,
even after accounting for the influence of the other demographic
factors. Having a private insurance plan with a high deductible also
remained a significant predictor, even after controlling for other
factors, as did being under age 25 and having minor children at home.

Circumstances leading to problems paying medical bills

Among those who report problems paying medical bills, two-thirds (66
percent) say the bills were the result of a one-time or short-term
medical expense such as a hospital stay or an accident, while 33 percent
cite bills for treatment of chronic conditions that have built up over
time. These shares are similar for people who faced medical bill
problems with and without insurance coverage.

Asked which types of bills made up the largest share of what they owed,
the most common responses are emergency room visits (21 percent) and
hospitalization (20 percent), followed by dental care (12 percent) and
diagnostic tests like X-rays and MRIs (11 percent).

Among who say their bill problems were the result of a one-time or
short-term medical expense, just under one in five (18 percent) cite an
accident as the main cause. Most of the others name illnesses, pain,
dental issues, or surgery, suggesting that although most bill problems
are caused by one-time events, these events are often acute episodes of
illness or expensive surgeries, medications or tests, rather than
injuries caused by accidents.

Financial status of those with bill problems

About three in ten (31 percent) of those with medical bill problems say
the total amount of the bills they had problems paying was $5,000 or
more, including 13 percent who report bills adding to at least $10,000.

Many of those with medical bill problems report struggling with bills of
lower amounts, including 24 percent of the insured and 22 percent of the
uninsured who say their bills amounted to less than $1,000. While these
lower amounts may seem small, even a bill of $500 or less can present a
major problem for someone who is living paycheck to paycheck. In fact,
when asked to describe their financial situation, about six in ten (61
percent) of those who've had problems paying medical bills say they
either just meet their basic expenses (43 percent) or don't have enough
to meet basic expenses (18 percent).

Even among the insured, those who have faced medical bill problems are
significantly more likely than their counterparts who haven't had such
problems to say they are either just getting by or don't have enough to
make ends meet (55 percent versus 22 percent).

Compared to those without medical debt, those who've had medical bill
problems are also less likely to say they have a credit card (53 percent
versus 77 percent), a retirement savings account (43 percent versus 62
percent), or some other type of savings (17 percent versus 38 percent).

About three in ten (29 percent) say that someone in their household had
to take a cut in pay or hours as a result of the illness that led to the
medical bills, either because of the illness itself or in order to care
for the person who was sick.

Medical bill problems among those with health insurance

While problems paying medical bills are more common among the
uninsured, more than six in ten (62 percent) of those who had problems
paying medical bills say the person who incurred the bills was covered
by health insurance when treatment began.

Of those who were insured when the bills were incurred, three-quarters
(75 percent) say that the amount they had to pay for their insurance
copays, deductibles, or coinsurance was more than they could afford.

About three in 10 (32 percent) of those who had problems paying medical
bills while insured say they received care from an out-of-network
provider that their insurance wouldn't pay for. For many, these bills
came as a surprise.

About a quarter (26 percent) of the insured who had medical bill
problems say they had a claim denied by their insurance company.

The impact of medical bills on families

Among those with medical bill problems, almost identical shares of the
insured (44 percent) and uninsured (45 percent) say the bills have had a
major impact on their families.

A few groups among those with medical bill problems are more likely to
say the medical bills have had a major impact on their families,
including people with bills amounting to $5,000 or more (66 percent),
those who say the family member who generated the bills has a disability
(57 percent), and those who describe their financial situation as not
having enough to meet basic expenses (56 percent).

Sacrifices made to pay medical bills

Even among those with health insurance, people who've faced medical bill
problems report making various sacrifices in order to pay these bills,
including significant changes to their employment, financial situation,
or lifestyle. Overall, about seven in ten report cutting back or
delaying vacations or major household purchases (72 percent) as well as
reducing spending on food, clothing and basic household items (70
percent). About six in ten (59 percent) say they used up all or most of
their savings in order to pay medical bills. Substantial shares say that
someone in their household took on an extra job or worked more hours (41
percent), borrowed money from family and friends (37 percent), or
increased their credit card debt (34 percent). Roughly a quarter (26
percent) say they took money out of a retirement, college, or other
long-term savings account. Smaller – but not inconsequential – shares
say they changed their living situation (17 percent), took out another
type of loan (15 percent), borrowed from a payday lender (13 percent),
or sought the aid of a charity or non-profit (12 percent) in order to
pay medical bills.

These sacrifices are reported by people in all walks of life, and not
just the uninsured or those with precarious financial situations.

Effects of medical bills on ability to get needed health care

Overall, about three in ten (31 percent) of those who faced problems
paying medical bills say they had problems getting other health care
they needed directly as a result of these problems.

More broadly, many of those with medical bill problems report delaying
or skipping health care over the past 12 months because of the cost – at
rates 2 to 3 times those of their counterparts who did not have problems
paying medical bills, regardless of their insurance status.

Effects of medical bills on household finances and ability to afford
basic needs

Medical bills can also lead to problems meeting other financial
obligations and paying for basic necessities. Among those with medical
bill problems, about six in ten of both the insured (62 percent) and the
uninsured (62 percent) say they've had difficulty paying other bills as
a result of medical debt. Over a third in each group (34 percent of the
insured and 39 percent of the uninsured) say they were unable to pay for
basic necessities like food, heat, or housing as a result of medical bills.

Most of those with medical bill problems report having other kinds of
debt, including credit card debt (56 percent), car loans (46 percent),
student loans (33 percent), mortgages (32 percent), payday loans (17
percent), and other outstanding loans (31 percent).

For some of those with problems paying medical bills, medical debt makes
up a large share of their total debt. About one in five (22 percent,
including 17 percent of the insured and 34 percent of the uninsured) say
their medical bills represent all or almost all of their total
non-mortgage debt.

The survey also finds that once medical bill problems start, it can be
difficult to make them stop, and that for some, medical bills can start
a cascade of other bill problems.

While almost half (47 percent) say they've also had problems paying
other unrelated bills in the past year, medical bills appear to be
either the sole problem or the main trigger of bill problems for the
other half, including 31 percent who say they've only had problems with
medical bills, not other types of bills, and 19 percent who say their
problems paying other bills started as a result of their medical bills.

Financial consequences of struggling to make payments

Once a person has problems paying medical bills, their insurance status
appears to make little difference in their ability to pay bills on time.
Among those with medical bill problems, similar shares of the insured
and uninsured say they've been late on a payment (62 percent and 63
percent, respectively) or missed a payment (55 percent and 61 percent)
for a medical bill in the past year.

Likely as a result of missed or late payments, almost six in ten (58
percent) of those with medical bill problems say they've been contacted
by a collection agency in the past year, mostly because of medical bills
alone (25 percent) or a combination of medical bills and some other type
of debt (20 percent).

Overall, 11 percent say they've declared bankruptcy at some point and
that medical bills were at least a partial contributor to their bankruptcy.

From the Conclusion

Insurance features like cost-sharing, provider networks, and confusing
billing practices can all lead to medical bill problems among the
insured. While higher deductibles and other forms of cost-sharing have
helped to keep health insurance premium growth at historically low
levels in recent years, the survey highlights the consequences these
changes can have for people.

The survey also shows that medical bill problems can have real and often
lasting impacts on individuals and families in terms of their standard
of living, their financial stability, and their ability to access needed
health care. While insurance provides some protection against incurring
medical bill problems in the first place, once these problems occur, the
effects on individuals and families are often as serious for the insured
as they are for the uninsured.

Full report (32 pages):
https://kaiserfamilyfoundation.files.wordpress.com/2016/12/8806-the-burden-of-medical-debt-results-from-the-kaiser-family-foundation-new-york-times-medical-bills-survey1.pdf

***

Comment by Don McCanne

These excerpts from the Kaiser Family Foundation/New York Times Medical
Bills Survey of adults 18 to 64 confirm once again that our multi-payer
health insurance system falls far short in preventing financial
insecurity for those with medical needs. This survey expands on our
knowledge base by demonstrating the deplorable consequences of the
financial hardships created by this system.

These deficiencies cannot be corrected by merely tweaking our current
dysfunctional financing system. A massive infusion of funds would be
required under the current system if we wish to reduce the negative
financial consequences, but the political and policy communities
currently oppose any increase in spending. In fact, their current
approach is to control spending by increasing barriers to care through
unaffordable cost sharing and narrower networks designed to reduce
access. Obstructing access to care might reduce spending, but preventing
beneficial health care is the opposite of what a health care financing
system should be doing.

Think of that. It is bad enough that people have the misfortune to
suffer medical disorders, yet we add to that grief by perpetuating a
system that dumps personal financial hardship on top of their medical
misfortunes.

The efficiencies of a single payer system would save enough to more
assuredly enable access to appropriate health care services by removing
cost-sharing barriers to care, not to mention the benefit that
absolutely everyone would be included. What are we waiting for? The
status quo is unequivocally unacceptable.

Health Policy Daily

Thursday, January 7, 2016

qotd: Thomas Friedman endorses single payer

Wednesday, January 6, 2016

qotd: Jost and Pollack’s proposals to strengthen ACA

Tuesday, January 5, 2016

qotd: KFF/NYT survey demonstrating the burden of medical debt, even with insurance

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