We are not Europe. We are not Canada. We are America. This is not a single pay country. (1) This has been the uncompromising view of Senator Max Baucus (D-MT), who as chairman of the key Senate Finance Committee in 2008 and 2009 played a leading role in shaping the Affordable Care Act (ACA). As described in my 2010 book, Hijacked: The Road to Single Payer in the Aftermath of Stolen Health Care Reform, he and his committee kept a single-payer option off the table, and even called the police to arrest eight activists who showed up for a hearing before his committee on health care options. (2) Elizabeth Fowler, a former health insurance industry insider as vice president for public policy for WellPoint, was the lead author of the Senate Finance Committee bill that made sure that the industry would be well served by the legislation. (3) Conservative politicians, including both Republicans and many Democrats, have long been wary of a single-payer public financing system for national health insurance (NHI). They go out of their way to denigrate the Canadian system, even though it is extremely popular in Canada since its enactment in the 1970s, is tied to a private delivery system, and is more efficient and less bureaucratic with better outcomes than our far more expensive system. They tell us that a public financing system would be un-American and antithetical to American values, while overlooking the strengths of traditional Medicare and the Veterans Administration. Their opposition to NHI, of course, is enabled and perpetuated by extensive lobbying and campaign donations by the insurance industry. These erroneous assertions by conservatives about public opinion concerning health care financing are entirely discredited by national polls over many years, virtually ignored by the mainstream media. Three of four Americans supported NHI during the 1940s (4) Since then, a majority of respondents to many national surveys have supported NHI. A 2009 CBS/New York Times poll found that 59 percent of respondents supported NHI. (5) A 2015 Gallup poll found that satisfaction of enrollees is highest in publicly financed health insurance programs (78 percent for the VA, 77 percent for traditional Medicare, and 75 percent for Medicaid), compared to 69 percent for employer-sponsored private coverage and 65 percent for individually purchased private plans. (6) After seven years with the Romney health care reform plan in Massachusetts, upon which the ACA was based, 72 percent of respondents to a survey prefer NHI to that plan. (7) A 2015 survey by the Kaiser Family Foundation found that 84 percent of respondents support Medicare negotiating discounted prices for prescription drugs. (8) The U. S. society is in the midst of major political, demographic and cultural change. Noam Chomsky, professor emeritus of linguistics at the Massachusetts Institute of Technology, historian, philosopher and political activist, brings us this perspective of these changes: There can be no denying that the United States is undergoing a serious ideological and political realignment due to its rapid transformation into a society characterized by an immense gap between rich and poor, unprecedented economic insecurity and growing poverty, the abandonment of public investments in public infrastructure and an overall decline in the standard of living.. . . The [November 2016] elections are quite significant, whatever the outcome, in revealing the growing discontent and anger about the impact of neoliberal programs of the past generation, which, as elsewhere quite generally, have had a harsh impact on the mass of the population while undermining functioning democracy and enriching and empowering a tiny minority, largely in financial industries that have a dubious, if not harmful, role in the economy. . . . The tendencies have been clear for some time, but, in this election, the party establishments have lost control for the first time. . . . It is rather striking, for example, to see how easily the Democratic Party almost openly abandons the white working class, which drifts into the hands of their most bitter enemy, the leadership and power base of the Republican Party. (9) Health care is primarily not a left-right issue, as a December 2015 national Kaiser public opinion poll found--58 percent of adults in the U. S. supported NHI (Medicare for All), including 81 percent of Democrats, 60 percent of Independents, and 30 percent of Republicans. (10) Since we all depend on access to affordable health care on many occasions, it should not be a partisan issue. Having a large risk pool--all 320 million of us--will benefit the common good most effectively and at lowest cost to us as patients and taxpayers. All of us will need affordable access to care at various points along our journeys in life. Instead of a left-right issue, health care reform has become a top-down issue--corporate profits and oligarchy vs. democracy and the public interest. So far, democracy is losing, and the pendulum will have to swing back to best meet the needs of all Americans. Robert Reich, professor of public policy at the University of California Berkeley who was secretary of labor in the Bill Clinton administration and served in two previous administrations, sums up our current choice for the future of health care this way: The real choice in the future is either a hugely expensive for-profit oligopoly with the market power to charge high prices even to healthy people and stop insuring sick people. Or else a government-run single-payer system--such as in place in almost every other advanced economy--dedicated to lower premiums and better care for everyone. We're going to have to choose eventually. (11) John Geyman, M.D. is the author of The Human Face of ObamaCare: Promises vs. Reality and What Comes Next and How Obamacare is Unsustainable: Why We Need a Single-Payer Solution For All Americans visit: http://www.johngeymanmd.org References: 1. Baucus, M. As quoted in an interview with Karen Tumulty from Time Magazine in a Health Care Reform Newsmaker Series, March 3, 2009. Kaiser Family Foundation. 2. Robbins, K. Baucus 8 update: Single payer in the news. Healthcare-NOW! May 7, 2009. 3. Conner, K. Chief health aide to Baucus is former WellPoint executive. Eyes on the Ties Blog, September 1, 2009. 4. Steinmo, S, Watts, J. It's the institutions, stupid! Why comprehensive national health insurance always fails in America. J Health Politics, Policy and Law 20: 329, 1995. 5. Public opinion polling on single payer: Americans (still) support it! Everybody In! Healthcare NOW!'s Quarterly Newsletter on the Single-Payer Healthcare Justice Movement, 10, Spring 2016. 6. Saluja, J, Zallman, L, Nardin, R et al. Support for National Health Insurance seven years into Massachusetts healthcare reform: Views on populations targeted by the reform. Intl J Health Services. OnlineFirst--November 3, 2015. 7. Gumpert, K. Americans want Medicare to help negotiate down drug prices--poll. Reuters, July 17, 2015. 8. Polychroniou, CJ. Is the U. S. ready for socialism? An interview with Noam Chomsky. Truth-out, May 18, 2016. 9. Ibid # 6. 10. Reich, R. Why a single-payer healthcare system is inevitable. Common Dreams, August 22, 2016. -- This feed and its contents are the property of The Huffington Post, and use is subject to our terms. It may be used for personal consumption, but may not be distributed on a website.
This Wednesday, Dec. 3, 2014 photo shows the Anthem logo at the company's corporate headquarters in Indianapolis. Formerly known as WellPoint, the nation's second-largest health insurer changed its corporate name to Anthem to reflect a label familiar to consumers shopping for coverage. (AP Photo/Darron Cummings) A massive experiment in California is [...]
WASHINGTON ― When celebrities, high-level party operatives and the blue blazer-and-khaki crowd of staffers and journalists join together for the highly publicized Snoop Dogg concert immediately following presumptive nominee Hillary Clinton’s acceptance speech at the Democratic National Convention, they’ll be doing so thanks to funding from two of the biggest lobbying forces in Washington. Through a fundraising committee called Unity Convention 2016, three super PACs are organizing the Snoop Dogg Unity event and a concert with the band Los Lobos. So far, the two biggest donors for the events are the Pharmaceutical Research and Manufacturers of America (PhRMA), the lobbying arm of the drug industry, and Anthem, Inc., a major health insurer. PhRMA and Anthem each contributed $50,000 to the committee, according to a filing with the Federal Election Commission. Unity Convention 2016 raises money for Priorities USA Action, the super PAC backing Clinton’s presidential campaign; Senate Majority PAC, which supports Democratic Senate candidates and is closely tied to Senate Minority Leader Harry Reid; and House Majority PAC, which is close to House Minority Leader Nancy Pelosi and is tasked with electing Democrats to the House. Each of these super PACs contributed $10,000 to help cover the cost of their convention events. PhRMA and Anthem are major lobbying forces in Washington with significant policy interests that will arise in the next administration and Congress. PhRMA and Blue Cross Blue Shield, of which Anthem is a member, are perennially two of the top 10 lobbying groups that spend the most, according to the Center for Responsive Politics. Super PACs and dark money nonprofits are closely connected to donors with important lobbying interests, The Huffington Post has previously reported. PhRMA was the key player in the Washington influence industry to help the Obama administration push the Affordable Care Act through Congress. The lobbying group made a behind-the-scenes agreement to support the legislation as long at it did not include long-standing Democratic Party policies allowing Medicare to negotiate drug prices for seniors or allow cheaper drugs to be imported from Canada and other countries. A draft of the 2016 Democratic Party platform, however, calls for Medicare to negotiate drug prices and allows for such drug importation. In addition, the platform calls for capping the price of prescription drugs, including how much Americans pay out-of-pocket for drugs, as well as expanding community health centers that can obtain cheaper drugs and increasing how quickly generics reach the market. The draft platform also includes a call for a public health insurance option to be created and offered to people using the Affordable Care Act exchanges. Clinton and President Barack Obama have both recently called for the public option to be adopted. But the public option was a controversial sticking point when Congress debated the legislation. Health insurers ― including Anthem, which was known at the time as WellPoint ― were adamantly opposed to the public option and also fought against the larger bill. In fact, health insurers played along with the Obama administration publicly to influence the legislation while working covertly with the U.S. Chamber of Commerce to defeat it. The public option was ultimately left out of the legislation after then-Sen. Joseph Lieberman of Connecticut ― a state that a number of major insurers, including Anthem, call home ― refused to back the bill if it was included. That same draft platform, however, does not include a call for a single-payer health care system. Delegates affiliated with Sen. Bernie Sanders (I-Vt.) pushed for a platform committee vote to adopt a government-run health insurance program, essentially Medicare for everyone, but were defeated by delegates connected to Clinton. Nothing scares health insurers more than efforts to replace them with government-provided insurance, as that would essentially put them out of business. Insurers, including Anthem, are currently funding the opposition to a Colorado ballot initiative to create a single-payer system for the state. Insurers have pumped $1 million into a ballot committee called Colorado for Coloradans to oppose Amendment 69, The Intercept reported. Anthem is the largest donor to the opposition, with a $500,000 donation. The Anthem-backed opposition employs a litany of Democratic Party consultants, including one employed by Priorities USA Action. Even more pressing for Anthem, though, is its pending merger with rival insurer Cigna, which comes at a time of increasing consolidation and monopolization across all industries. Democratic senators, including Connecticut Sen. Richard Blumenthal, have called for the Department of Justice to block the Anthem-Cigna deal, as well as a merger between Aetna and Humana. Sen. Elizabeth Warren (D-Mass.), an increasingly influential politician who joined the push for the DOJ to reject the Anthem-Cigna merger, recently called for a new era of antitrust enforcement to prevent the consolidation of economic and political power. And for the first time since the 1980s, the Democratic Party’s platform includes a call to “enhance the antitrust enforcement arms of the Department of Justice and the Federal Trade Commission, and encourage other agencies to police anticompetitive practices in their areas of jurisdiction.” The Snoop Dogg concert is just one event planned for the week of the Democratic convention. Because a super Pac is funding it, its donors are required to be revealed to the public. There will be dozens more parties and events to fete lawmakers and other officials around Philadelphia that will be funded by undisclosed corporate interests. -- This feed and its contents are the property of The Huffington Post, and use is subject to our terms. It may be used for personal consumption, but may not be distributed on a website.
Megan McArdle, BloombergHow about a little health-care quiz to spice up your afternoon? Here are two quotes about the Obamacare exchanges, from two health insurer investor calls. Match each to the right company. 1. “We continue to expect exchanges to develop and mature over time into a strong, viable growth market for us.” A. Aetna B. UnitedHealth C. Wellpoint D. Cigna 2. “We cannot sustain these losses. We can't really subsidize a marketplace that doesn't appear at the moment to be sustaining itself” A. Aetna B. UnitedHealth C. Wellpoint D. Cigna Pencils down!
Anthem beats on earnings. Our consensus called for EPS of $2.33, and the company reported EPS of $2.73.
The rise of the Millennials over the Baby Boomers has the potential to alter the economy as a whole.
Rewards for healthy behaviors have been growing at leaps and bounds as a way to reduce healthcare costs for several years. Rewards for healthy behaviors have been growing at leaps and bounds as a way to reduce healthcare costs for several years. In 2009, employers offered employees $260 in rewards for making healthy choices. Now, companies are projecting to spend $693 per employee on wellness incentives. ObamaCare added fuel to the fire. It increased the allowable amount of rewards from 20 to 30 (and in the case of smoking cessation) 50 percent of annual insurance premium. Forbes named "health rewards" as two of the top 5 health IT trends in 2014. "Incentive Driven Healthcare" is here to stay. Why don't health plans want consumers to know this? It seems like a win-win. Well in some ways they do. Health plans win by reducing costly behavior through prevention and lifestyle changes. Consumers benefit not only by getting healthier and making better health decisions, but by receiving rewards. This is all true. But in some ways they don't. Once consumers truly realize that purchasing health insurance, while incredibly personal, is nothing more than purchasing another consumer product, the healthcare marketers of the world will be faced with a health rewards competition. ObamaCare created "exchanges" or "marketplaces" through which health insurers compete for the business of individuals and businesses. These marketplaces were established with a series of pre-packaged health plan options, which limit the variations in using traditional levers such as coverage and networks. Health plans that were used to competing on these levers are left with a single lever - price. Selecting from gold, silver and bronze hardly creates differentiation among United, Cigna, Aetna, Humana, Wellpoint, the Blues and many other plans in the United States. Think of your credit card, hotel, airline or favorite retailer. It is a sure fire way to create loyalty, brand affinity and engagement. Let's be honest, you are more inclined to use specific services or retailers if they provide a robust rewards program. When marketers of consumer products ask themselves "what tools do I need to attract, retain, and generate loyal customers?" the answer inevitably comes to reward programs. As further evidence, consumers across multiple demographics were interviewed on what they wanted from their health plan. The only item that appeared in every demographic was "rewards for healthy behavior." Would you have a more positive opinion of your health plan if they sponsored a program that rewards consumers for healthy behaviors? According to a Welltok survey, 75% of respondents agree. Furthermore, 81% said that access to such a program positively influences their decision to renew with their current plan. Not to mention, the fact that incentives are a proven means to motivate health choices and change behaviors. More than 96% of consumers would engage in healthier behaviors if rewarded. Health plans are entering a new competitive landscape. Rewards will not only be an essential component, but will also drive a healthier population - creating a win-win situation for all. -- This feed and its contents are the property of The Huffington Post, and use is subject to our terms. It may be used for personal consumption, but may not be distributed on a website.
The flurry of recent merger announcements from the handful of remaining national health insurance providers is cause for alarm for all Americans. The Affordable Care Act (ACA) has taken nearly full effect and it is clear that staggering annual increases in health insurance premium costs are still with us. The skyrocketing costs of health insurance and health care treatment are pushing working American families well past the breaking point. There is a limit to what working people can afford to pay for what should be a human right. The most recent corporate advances down the road of health insurance monopolization are the announcements that the enormous Aetna intends to absorb rival Humana, and at the same time the Anthem corporate giant -- formerly Wellpoint -- is maneuvering to swallow Cigna. Should these latest anti-competitive takeover moves go unchallenged by the Obama Justice Department when there is little doubt that the trend of double digit premium increases will accelerate? In many areas of the country today there are frequently only one or two health insurers available when workers try to grapple with the dramatically rising premiums and costs. Their frequently identical plan offerings and prices raise the obvious suspicion that the insurers have fixed prices and rigged market share somehow. And while these latest insurance company combinations and practices will be scrutinized by some states, that level of review is uneven and forced on reluctant state insurance departments ill-equipped to deal with such enormous corporations and their armies of legal and lobbying representatives. Must Confront Corporate Criminality It is urgent that the Obama Administration act swiftly and decisively to confront corporate criminality. The Department of Justice (DOJ) has recently awoken from its slumber on the antitrust front, and has begun preliminary moves to investigate the obvious price fixing of the major airlines. They are likewise reviewing the sale of the General Electric appliances division to the European Electrolux corporation. But while both of these are cases are critical to the restoration of some semblance of an antitrust enforcement policy, the potential damage to working people from greater monopolization of the key health insurance sector is incalculable. Until the United States Congress finds the political will to abolish our costly and badly broken health insurance industry the monopoly racketeers must at least be confronted and restricted from free rein. A single payer system is urgently needed to solve this catastrophic crisis for working people. Until then it is imperative that the Obama Administration utilize its full DOJ resources to investigate and stop the trend towards complete monopolization in the health insurance industry. This action takes no act of Congress, but merely requires the political leadership to commit the Justice Department to enforce existing laws on an industry that has demonstrated its intention to defy the law and rob working people in the process. -- This feed and its contents are the property of The Huffington Post, and use is subject to our terms. It may be used for personal consumption, but may not be distributed on a website.
Anthem (ANTM) Beats on Q2 Earnings, Memberships Increase
The combination will push Aetna close to Anthem Inc's (ANTM.N) No.2 insurer spot by membership, and would nearly triple Aetna's Medicare Advantage business. The deal will face antitrust scrutiny but if it goes through it would dwarf the previous largest insurance deal announced just this week, where Swiss property and casualty giant ACE Ltd (ACE.N) announced it was buying Chubb Corp (CB.N) for $28 billion.
Zacks Industry Rank Analysis Highlights: UnitedHealth, Anthem, Aetna, Humana and Cigna - Press Releases
Zacks Industry Rank Analysis Highlights: UnitedHealth, Anthem, Aetna, Humana and Cigna
The new conventional wisdom on corporate structure is that companies can do better by organizing themselves around customer groups. The logic sounds compelling: A customer-centric structure, as the approach is known, can help a company understand its customers better, develop deeper relationships with them, and improve customer satisfaction. Some 30% of Fortune 500 firms, including Intel, Dell, IBM, and American Express, are already on board, and the numbers are growing all the time. But customer alignment doesn’t work for everyone. Cisco and Xerox, for example, have seen poor results. And even when it does work, a company can go through years of poor performance before the benefits kick in. Is there a flaw in the logic? Our analysis of Fortune 500 firms shows that the strengths of the strategy are real: Customer-centricity does allow divisions to focus on specific customer segments, and this narrower focus increases their knowledge of those groups. But it introduces greater complexity into communication and decision making and leads to duplication of certain functions across divisions. Details of the competition and of customer segments determine whether the positives outweigh the negatives, and years can pass before customer-centricity bears fruit. We’ll show how companies can use our findings to estimate whether — and when — a customer-centric structure is likely to work. But first a little background. The idea that companies should adopt customer-centric structures has been around in both academia and practice for a while, but it was George S. Day of Wharton who reignited interest in the concept. In his 2006 survey of U.S. managers, he said the proportion of U.S. firms with structures organized around customers would grow from 32% to 52% as firms raced to build customer-centric organizations, and he interviewed companies including IBM and Systems Group that had announced customer-centric restructurings. He also emphasized in a 1999 book that “the wrong structure can doom all other market-driven initiatives in the organization to failure.” A good example of customer-centricity is Tumi, the innovative U.S.-based maker of suitcases, which has been customer-centric since its founding in 1975. Each division focuses on one customer group — premium customers or young adults, for example — and, through research, designs products for that segment. Surveys commissioned by the company show that it does a good job of satisfying customers by matching their needs. Intel, whose top-level divisions had been organized around product groups or functional areas, adopted customer-centricity in 2005, and its improved knowledge of and commitment to customers has resulted in greater customer satisfaction. Dell, which adopted customer-centricity in 2009, has seen positive results too: After aligning its corporate business units around customer groups, such as large enterprises and consumers, the company learned to operate seamlessly in the new structure and improved its financial performance. Examples like these, as well as the seemingly bulletproof logic of making customers’ needs central, have helped sell customer-centricity to many corporate leaders. And there’s no doubt that a customer-centric structure helps organizations amass rich depositories of customer knowledge and expertise and thereby uncover unmet needs. But our research, conducted with Conor M. Henderson of the University of Oregon and Irina V. Kozlenkova of Michigan State University, tells us that there are situations in which discovering and acting on unmet customer needs either amounts to mere table stakes or contributes little to profitability: Prevalence of customer-centricity and high competitive intensity. When competitors already have customer-centric structures or otherwise do a very good job of meeting customer needs, any one company’s customer-centric structure is less valuable. Customer-centric firms with many customer-centric competitors exhibited 11% lower performance than peer firms with product-centric structures. Moreover, customer-centric firms that operated in highly competitive markets had 69% lower performance, compared with product-centric peers. Low industry profitability. When few customers value greater customization or responsiveness, the headaches of restructuring around customer segments aren’t worth the trouble. Customer-centric firms in less-profitable industries performed 20% lower than firms whose structures were not aligned with customers. Take, for example, two exponents of the customer-alignment philosophy: the for-profit health-care company Anthem and software and services firm SunGard. Anthem implemented a customer-centric structure in 2008 when it was known as WellPoint and when few of its competitors had adopted the approach. It was able to use its new organizational structure to discover and meet new customer needs such as better quality of care, enhanced transparency, and lower health-care costs. Its adoption of customer-centricity yielded a 36% increase in return on assets over the four-year period after the restructuring. The company has maintained and still benefits from its structure, even though some of its competitors have adopted customer-centricity. SunGard’s competitive environment was different. Its competitors, such as Affiliated Computer Services and Leidos Holdings, were already doing a good job of discovering and addressing unmet customer needs. Its 2002 restructuring offered little incremental benefit while adding cost and complexity. Its ROA dropped 81% over the four years after the restructuring. There’s also a gray area in which customer-centricity provides significant advantages while simultaneously dragging down results. Tumi, for example, has recently struggled with the drawbacks of customer-centricity. With each division focusing on only its own customer segment, the structure appears to be poorly suited for generating widespread corporate brand awareness. Customer-centricity appears to be a reason for the company’s high marketing and coordinating costs: Its customer-focused structure has entailed a division of resources, capabilities, and people; raised organizational barriers to sharing and communicating; and led to greater complexity-related costs and losses of economies of scale. These high marketing and coordinating costs may be the cause of its problems today. In cases where customer-centricity is an appropriate structure, we found that it takes more than two years after a restructuring, on average, for companies’ performance to exceed prior levels. During that period, performance typically deteriorates significantly as the firm incurs coordinating costs due to internal conflicts and confusions. Among 37 Fortune 500 firms that went through customer-centric restructurings, the performance drop averaged 39% from companies’ pre-restructuring levels; it was only after 10 quarters that performance exceeded those levels — at which point it exceeded them by 11%, on average. Before initiating adoption of a customer-centric structure, companies should look carefully at the extent to which this approach has permeated the competition. Firms should also gauge the industry’s competitive intensity and take a close look at their industries’ profitability. There are no simple rules of thumb for these assessments — every industry is different — but a predominance of customer-centricity, high competitive intensity, and high commoditization and a prevalence of low margins all suggest that restructuring around customer segments may not pay off. And if executives determine that a customer-oriented restructuring is a good gamble, they should enter into the process with eyes wide open, establishing clear expectations that performance will sag before it rises. In addition, CEOs and functional heads need to talk to each other about proposed changes in organizational structure. Top executives should get guidance from marketing, sales, and R&D before making structural-design decisions, and managers from those functions should weigh in on the harm that could be done by the greater complexity and duplication that are so often a consequence of customer-centricity.
The American health care system is particularly troubling for transgender people, but there are some insurance plans without blanket exclusions. Here are 24.
Anthem (ANTM) Beats on Q1 Earnings, Memberships Increase
Take a look at these three health insurers this earnings season.
The private health insurance industry in the U.S. has had a long run since shifting to medical underwriting and a for-profit status in the early 1960s. It finds itself increasingly dependent on the government as the costs and prices of health care have continued upward since the 1980s. Its many perks from government include tax exemptions for employer-sponsored insurance (ESI), privatized Medicare and Medicaid programs, and longstanding over-payments to Medicare Advantage programs. The Affordable Care Act (ACA) has added to these perks since 2010 with subsidized premiums through the exchanges, a "risk corridor system" to protect insurers from losses, and allowing automatic self-renewal for 2015 plans. (1) Incremental attempts to contain health care costs and reform the system since the 1990s have built upon our current multi-payer financing system. After five years' experience with the ACA, we now know that insurers themselves are a major barrier to achieving the kind of access to affordable care that our population so desperately needs. Here are some of the major reasons why private health insurers warrant no further bailout by government and taxpayers. 1. Continued discrimination against the sick. Despite the supposed consumer protections in the ACA, a 2014 letter from more than 300 patient advocacy groups to the Secretary of Health and Human Services described continuing ways that insurers still discriminate against the sick, including benefit designs that limit access, high cost-sharing, restrictive drug formularies, inadequate provider networks, and deceptive marketing practices. (2) A recent study by Kaiser Family Foundation found that only one-third of households with incomes between 100 percent and 250 percent of poverty have enough liquid assets to pay their deductibles, while only about one-half can meet out-of-pocket limits. (3) As other examples, Wellpoint developed an algorithm to search its database for patients with breast cancer with an intent to cancel their policies (4), while many insurers place all drugs used to treat such complex diseases as cancer, multiple sclerosis and HIV in the highest drug formulary cost-sharing tiers, thereby reducing insurers' costs but making the drugs unaffordable for many patients. (5) 2. Fragmentation, inefficiency, and exorbitant administrative overhead. There are some 1,300 private insurers still trying to maximize their income by avoiding the costs of sicker patients. Their administrative overhead is more than five times higher than that of the single-payer program in two Canadian provinces (6); the overhead of private Medicare Advantage plans averages 19 percent vs. the 1.5 percent for traditional Medicare. (7) Although the ACA set limits of 20 percent for overhead in the individual market and 15 percent in large-group markets, a recent study has found that those requirements had no effect on insurers' overhead spending over the first three years of the ACA. (8) 3. Increasing costs for less coverage The ACA provided insurers with four levels of coverage -- the so-called "metals" -- with actuarial values (what insurers pay vs. what patients pay) ranging from 60 percent (bronze) 70 percent (silver) to 80 percent (gold) and 90 percent (platinum). Not content with those levels of coverage, the industry through its trade group, America's Health Insurance Programs (AHIP), has been lobbying hard for copper plans with only 50 percent actuarial value. (9) Silver plans have been the most popular on the exchanges, so that patients are left with almost one-third of their costs, plus the cost-sharing that was required to get and maintain their policies. All this has led to an epidemic of underinsurance, whether the plans are purchased through the ACA exchanges or through the private insurance markets. The ACA has made the mistake of focusing on raising the numbers of Americans with "insurance", but has not been effective in containing prices or costs of health care, with the result that an increasing proportion of these costs are shifted to patients and families. One-half of bronze plans in seven large U.S. cities requireenrollees to pay the deductible (often $5,000) before covering a doctor's visit. (10) 4. Gaming the ACA for profits more than service to patients There are many examples of this, starting with Medicare Advantage. Many insurers have been cited by the Centers for Medicare & Medicaid Services (CMS) for serious violations of Medicare's patient protection requirements, including inappropriate denial of coverage and failure to consider physicians' clinical information. (11) Humana, one of the largest Medicare Advantage insurers in the country, is facing scrutiny from the U.S. Department of Justice for its risk-adjustment practices, which "upcode" the severity of patients' illnesses in order to gain increased reimbursement, even as they lobby Congress for continued high over-payments. (12) Meanwhile, some insurers are marketing short-term plans that last less than 12 months, evading any of the ACA's requirements. (13) 5. Private insurance has priced itself out of the market. Premiums keep going up at rates much higher than the cost of living, with little or no containment by regulators. As examples, MetroPlus, a popular new entrant on the New York exchange in 2014, has requested rate hikes of up to 28 percent in 2015 for some of its enrollees (14), while Florida Blue, the state's largest insurer, has announced an average rate increase of 17.8 percent for 2015. (15) One can argue that the private insurance industry should be regarded as obsolete and not worth saving. However, the ACA has extended its life, including almost $2 trillion in federal subsidies over the next ten years (16) (if these subsidies survive a U.S. Supreme Court ruling on their legality in coming months). Insurers have focused on attracting enrollees with low premiums, high cost-sharing, and low levels of actual coverage. Large insurers such as Wellpoint (Anthem) and Humana expect to receive $5.5 billion in 2015 through the ACA's "risk corridor" provision that protects them from "losses." (17) 6. As their business plan dictates, insurers are leaving unprofitable markets without regard for patients' needs. Private health insurers are all about making money, so they leave unprofitable markets regardless of the public's needs. A recent example is Blue Shield of California (which just lost its state tax-exempt status with a surplus of more than $4 billion), which withdrew from 250 zip codes in California throughout the state in 2014. (18, 19). Based on the above, the time has come for us to replace private health insurers with a more efficient, not-for-profit single-payer financing system--national health insurance (NHI)--which could be enacted by passage of H. R. 676, Expanded and Improved Medicare for All. _____ Read more at http://www.johngeymanmd.org. References: 1. Geyman, JP. How Obamacare Is Unsustainable: Why We Need a Single Payer Solution for All Americans. Friday Harbor, WA, Copernicus Healthcare, 2015, p. 170. 2. Patient advocacy groups. Letter to Sylvia Burwell, Secretary of Health and Human Services, July 28, 2014. 3. Claxton, G, Rae, M, Panchal, N. Consumer assets and patient cost sharing. Kaiser Family Foundation, March 11, 2015. 4. Tillow, K. Health care law did not end discrimination against those with pre-existing conditions. Firedoglake, MyFDL, March 6, 2015. 5. Pearson, C. Exchange benefit designs increasingly place all medications for some conditions on specialty drug tier. Avalere, February 11, 2015. 6. Woolhandler, S, Campbell, T, Himmelstein, DU. Costs of health care administration in the United States and Canada. N Engl J Med 349: 768-775, 2003. 7. Healthcare-NOW! Single-Payer Activist Guide to the Affordable Care Act, 2013. p. 22. Available at www.healthcare-now.org 8. Day, B, Himmelstein, DU, Broder, M et al. The Affordable Care Act and medical loss ratios: No impact in first three years. Intl J Health Services 45 (1), 2015. 9. Andrews, M. Proposal to add skimpier "copper" plans to marketplace raises concerns. Kaiser Health News, July 1, 2014. 10. Appleby, J. Consumers beware: Not all health plans cover a doctor's visit before the deductible is met. Kaiser Health News, December 23, 2013. 11. Pear, R. U.S. finds many failures in Medicare health plans. New York Times, October 12, 2014. 12. Herman, B. CMS pitches 1.1 % boost to Medicare Advantage payments. Modern Healthcare, February 20, 2015. 13. Andrews, M. Short-term plans can skirt health law requirements. Kaiser Health News, October 28, 2013. 14. Hartocollis, A. Insurers on New York State's exchange seek significant rate increases. New York Times, July 2, 2014. 15. Galewitz, P. Florida's largest insurer is raising exchange rates average of 17.6 percent. Kaiser Health News, August 1, 2014. 16. Pear, R. Health law turns Obama and insurers into allies. New York Times, November 17, 2014. 17. Wayne, A. Insurers' Obamacare losses may reach $5.5 billion in 2015. Bloomberg News Businessweek, March 4, 2014. 18. Terhune, C. With billions in the bank, Blue Shield of California loses its tax-exempt status. Los Angeles Times, March 18, 2015. 19. Bartolone, P., Capital Public Radio. Insurance choices dwindle in rural California as Blue Shield pulls back. Kaiser Health News, January 30, 2015. Adapted in part from my recently released book, How Obamacare Is Unsustainable: Why We Need a Single Payer Solution for All Americans. -- This feed and its contents are the property of The Huffington Post, and use is subject to our terms. It may be used for personal consumption, but may not be distributed on a website.
Having assessed in the last three posts the impacts of the Affordable Care Act (ACA) over the last five years, we have seen that the ACA will not bring universal access, contain health care costs for patients and taxpayers, or improve the quality of care. These are some of the main lessons we have already learned from the ACA's initial five years. 1. Health care "reform" through the ACA was framed and hijacked by corporate stakeholders, themselves in large part responsible for our system problems of health care. Although deregulated markets in our medical-industrial complex were largely responsible for problems of access, costs and quality of health care for many years, policy makers and framers were unwilling to confront corporate stakeholders of the existing system where the business "ethic" prevails. Thus the interests of insurers, the drug and medical device industries, hospitals and organized medicine took precedence over the needs of patients throughout the political process. By the time the ACA was enacted, some 1,750 organizations and businesses had hired about 4,525 lobbyists, eight for every member of Congress, at a cost of $1.2 billion, to get the kind of legislation they wanted. (1) Drafters of the ACA often had conflicts of interest; Elizabeth Fowler, for example, as the lead author of the Senate Finance Committee's bill, had served as vice president for public policy for Wellpoint, the country's second largest insurer. (2) 2. We can't contain health care costs by letting for-profit health care industries pursue their business "ethic" in a deregulated marketplace. All of the corporate stakeholders in health care have seen a bonanza of profits through new subsidized markets with no significant price controls. Health insurer stocks have soared, as illustrated by UnitedHealth Group, the nation's largest insurer, which saw its share price rise from $30.40 in March 2010, to $113.85 this month, a 375 percent increase. The other five of the six top insurers more than doubled or tripled their stock value. (3) The ACA has rewarded hospitals with several million more paying customers through the individual mandate and Medicaid expansion as they merge and consolidate with larger market shares. All this has led to higher prices. As one example, charges for medical procedures rose four times faster than the rate of inflation in 2012. (4) 3. We can't reform the delivery system without reforming the financing system. Drafters of the ACA never questioned the multi-payer financing system which is a big part of our problems. Ignoring the experience of most other advanced countries, they kept not-for-profit, single-payer public financing off the table. Private insurers have successfully avoided costlier, sicker patients for many years. While the ACA sets some limits on this behavior, the industry has found new ways to continue to game the new system for their business interests, as we shall see in our next post. Today, the "partnership" is still close between government and the private insurance industry. They both need each other -- the Obama administration, which counts on private insurers to participate in expanding their markets, and insurers, who welcome nearly $2 trillion in subsidies expected over the next ten years. (5) 4. It is futile to embark on unproven and untested incremental tweaks to our present system while ignoring health policy and experience around the world. As we have seen in recent posts, the ACA embarked on various new initiatives that were either untested or had failed in earlier years, including increased cost-sharing with patients, changes in payment policies, accountable care organizations, and further privatization. All of those initiatives ignored the role of the deregulated marketplace in perpetuating our access, cost and quality system problems. 5. In order to have the most efficient insurance coverage, we need the largest possible risk pool to spread the risk and avoid adverse selection. It is well known that the larger and more diverse the risk pool is, the more efficient and affordable insurance can be. About 20 percent of the population accounts for 80 percent of all health care spending. But the ACA has opted to leave some 1,300 private insurers in place, with continued increased fragmentation of risk pools. Risk pools under the ACA are made smaller by many young people not signing up through the exchanges, one-third of middle-aged men opting to stay uninsured (6), and many exemptions to the individual mandate given by the Department of Health and Human Services (HHS). 6. The ACA has been much more disruptive to our system than a simplified single payer alternative would have been. The key question that was never asked or answered by the framers and promoters of the ACA was who is the system for -- corporate interests or patients? Instead of minimizing disruption by corporate stakeholders, the ACA brings us increased disruption for patients: a more confusing and unstable system, more discontinuity of insurance coverage, disruption of many doctor-patient relationships, less choice of hospitals and physicians through narrowed (and changing) networks, and more uncertainty. As one example of how ineffective accountable care organizations (ACOs) have been, a recent study found that two-thirds of office visits to specialists were provided outside of assigned ACOs, especially for higher-cost patients with more office visits and chronic conditions. (7) 7. We can't trust many states to assure an adequate safety net for the uninsured and underinsured. Red states and those that have opted out of Medicaid expansion give us no confidence that they will assure that the uninsured and underinsured will receive sufficient essential health care. Many states are cutting already low Medicaid reimbursement, with the result that more physicians will not accept new Medicaid patients. (8) The ACA gives states wide latitude to determine what "adequate access to covered services" is. Churning in coverage will continue -- a 2014 study found that 40 percent of adults likely to enroll in Medicaid or subsidized marketplace coverage will have a change of eligibility within 12 months. (9) And at the national level, the GOP is targeting big cuts in Medicaid and food stamps. (10) Can this trajectory be changed going forward? Based on the lessons above, the answer has to be "No," though many supporters are not yet prepared to acknowledge this. It is unfortunate that we will have to see ongoing profiteering and administrative waste at patients' and taxpayers' expense before we can get health care right in this country. Our next blog will address one of the main culprits perpetuating our dysfunctional health care system -- the private insurance industry itself. References: 1. Center for Public Integrity, as cited by Moyers, B, Winship, M. The unbearable lightness of reform. Truthout, March 27, 2010. 2. Connor, K. Chief health aide to Baucus is former Wellpoint executive. Eyes on the Ties blog, September 1, 2009. 3. Potter, W. Health insurers' stock soars as they dump small business customers. The Progressive Populist, March 1, 2015. 4. O'Leary, W. On the road to corporate health care. The Progressive Populist, March 1, 2015. 5. Pear, R. Health law turns Obama and insurers into Allies. New York Times, November 17, 2014. 6. Flavelle, C. Obamacare's dropouts are middle-age men. Bloomberg News, March 17, 2014. 7. McWilliams, JM, Chernew, ME, Dalton, JB et al. Outpatient care patterns and organizational accountability in Medicare. JAMA Internal Medicine, April 21, 2014. 8. Pear, R. For many new Medicaid enrollees, care is hard to find, report says. New York Times, September 14, 2014. 9. Summers, BD, Graves, JA, Swartz, K et al. Medicaid and marketplace eligibility changes will occur often in all states; policy options can ease impact. Health Affairs 33 (4): 700-707, April 2014. 10. Peterson, K. GOP targets Medicaid, food stamps. Wall Street Journal, March 13, 2015: A 5. Adapted in part from my new book, How Obamacare Is Unsustainable: Why We Need a Single Payer Solution for All Americans. Buy a copy from Amazon.com