Tag Archives: health insurance

The Truth Hearing Report: Testimony on Healthcare

As promised, I am reporting back to you about our Truth Hearing held July 31 in Huntsville, Alabama.  It took a little longer than I anticipated—I wanted to be sure you could view all the video segments for yourself.


The purpose of our event was to obtain direct testimony from members of the public about difficulties getting necessary healthcare, without adding political commentary that might close off our thinking in regards to solutions.  In that spirit, I am going to provide limited commentary of my own and trust you to form your own opinions.   This will enable you to share it with friends across the political spectrum.


We had a few technical glitches—this was definitely a learning experience, and we will know better next year how to avoid similar problems.  I hope to do this event annually, so we can learn what is happening as our healthcare insurance environment changes.  Our volunteer videographer had a broken camera on the day of the event and so was unable to help.  I have to thank my husband, who stepped up to find and hire Brian Pitts of Pinnacle Video Services (does legal video depositions) at the last minute.  The sound was not as good on the first segments, and fortunately Brian realized there was a problem and fixed it.  My friend Sara Crocker and her husband Charlie also volunteered to video, and I used their broader angle for the opening segment. 


Here is the opening.  We invited several elected leaders—of those, Representative Laura Hall (Alabama Legislature) and Kenny Anderson (representing Mayor Battle) attended.  Dr. Richard Showers of Huntsville City Council had planned to come but was unable to do so.  Our two US senators, our County Commissioners, US Fifth District Congressional Representative, Regional Health and Human Services Office (will run our state Exchange), Alabama Medicaid Office and Governor’s office declined to attend. All were given the option of attending in person or selecting a proxy.


Community leaders who rose to fill the empty chairs:  Benard Simelton (Alabama NAACP President), Sara Crocker (Huntsville’s Human Relations Commission), Ann Denbo (board member National Alliance on Mental Illness, Alabama), and James Robinson (GLBT Advocacy and Youth Services). 


I counted 52 in the room, although I may have missed a few who entered after the beginning.  By sharing this blog with your friends, you can help keep attendance at our event growing.


I’m going to present the speakers somewhat out of order, in case you only watch a few, because it took us a bit to warm up to more personal stories. 


Bonnie Roberts, a fellow poet, told me later she had never imagined she would cry and was not looking for sympathy.  I am grateful that she did feel moved to share her deep feelings with us.  As you will imagine after viewing the video, she received offers of help (and help) after the event—she wanted most for you to know that she is by no means the only person in this situation.  Her story, to me, shows that for extreme medical expenses, most of us even with good jobs will not be able to plan well enough to avoid severe financial consequences.   It’s also a reminder that you may know people who need help and who will not tell you about it.  They are ashamed. Most of us want to be self-sufficient and to be givers, not receivers.  By talking about her situation, Bonnie is giving us valuable information—could this happen to us?  What would we do?  How would you respond to a person in her position? Bonnie has insurance—Medicare.  It did not keep her from having medical debt and ongoing medical expenses so high that she runs out of food at the ends of months.


Benard Simelton, in addition to serving on the listening panel, read Callie Greer’s testimony about her daughter’s death from cancer.  Callie so much wanted to attend herself but was unable.  I am grateful that she sent us her words and to Benard for reading them. Callie’s daughter was uninsured—she was sent home from the ER with early breast cancer, no physical exam, and a prescription for pain medicine.   When you hear it said that uninsured people can always get free care from the ER, this is the story you need to remember. 


Thomasin Cates told us how her insurance tried to refuse authorization for surgery to remove a football-sized, life-threatening tumor from her chest by saying it was cosmetic.  This sort of thing is more common than you’d think.  Here is the description of the policy that will form the benchmark for Alabama’s Exchange coverage—note page 41 where it says coverage excludes services “we determine are not medically necessary.”  All insurance policies I’ve seen have this clause.  All insurers I’ve worked with drag their feet and deny coverage with it, even when they know they will eventually have to give in.  During that foot-dragging time, illnesses can progress irreversibly.


Alix Morehouse has two stories, first about herself and then about her son.  She describes a classic Catch-22 in our healthcare system—she needs insurance to have surgery done which would allow her to work at a better paying job—with insurance.  She could probably get disability—but she doesn’t want to be disabled.  She wants to work.  Her son, who is insured, has had ongoing treatment for precocious puberty denied because the insurer dropped the only drug off their approved list and no longer covers it.  During the appeals process, his disorder has progressed for lack of treatment.  I am seeing more of this problem in my practice—dropping effective treatments off the formulary.  Alix’s son has an insurance card that is broken.  How many of us have broken cards and don’t know it yet?   How will we know?


Margaret Melton, who is insured, tells us how insurance rules have created barriers to getting her kidney stones diagnosed and treated and interfered with physician practice.  Her physician has told her that her insurance won’t “allow” primary care doctors to get diagnostic testing for the stones, only specialists.  I can’t speak to this, since I’ve not encountered it for stones—I wonder if the issue has to do with the red tape of getting prior authorizations for CT scans and if her doctor is tired of wasting time and getting denied.  It certainly does happen with me in my own practice for treatment of minor depression and ADHD, where many insurers will not certify me to do what I’ve been trained and licensed to do.  These children must wait for a psychiatrist appointment instead.  Bottlenecks occur at the specialist level, delaying care and saving insurers money.


Robert Partlow tells about his struggles to care for his wife through her serious illnesses.  Despite their attempts to be proactive, he and his wife have felt shut out of the process of choosing treatments.  She is now in a nursing home 100 miles away from him. What would have to change about our healthcare system to be more respectful, responsive and inclusive of the Partlows and others like them?  Have you encountered this access barrier of a different sort—inability to find meaningful care where your wishes were sought out and respected?


Don Ramsey tells about his difficulty getting healthcare, and his relief at learning he could get high quality care through the VA.  I appreciate his enthusiasm and desire to let others know—certainly any veteran who is eligible should take advantage of the care.  Unfortunately, about 1.8 million US veterans are not eligible for services through the VA.


Meg Tilden struggles with insurance that barely allows her to cover her costs and tells of her efforts to help others in our community with their healthcare.  She has encountered the world of Medicare Advantage insurers recruiting patients who then learn that their existing physicians and medications are not covered.   More competition without transparency means more confusion, and healthcare is not like a toaster we can return if it malfunctions.


Finally, John Jeter, who was actually the first speaker at the Truth Hearing, tells his story of being diagnosed in his youth with Type I diabetes. Good quality healthcare and personal responsibility have been critical to his survival.  Mr. Jeter puts his medication and hospital charges under much deserved scrutiny and offers his thoughts on healthcare reform.


In closing, I want to thank everyone who attended our hearing and who volunteered to help.  We had volunteers to run the sound system, to set up/clean up and to welcome guests.  This event would not have happened without them.  


Now you have attended our Truth Hearing.  What did you learn?  Did anything surprise you?  How can we do a better job informing each other of healthcare in the trenches?  What could we do differently, armed with the truth?


Filed under citizen responsibility, Healthcare reform

HR 676, Part 2: Tell me what you want, what you really, really want!

Let’s look at Section 102 of HR 676 (Expanded and Improved Medicare for All), Benefits and Portability, on page 5.  If you followed my suggestion last week, you can get out your wish list of medical services —if you didn’t, please take a couple of minutes to jot down any service you or a family member has needed that your insurance didn’t pay for.

To quote directly from the bill, the “health care benefits under this Act cover all medically necessary services, including at least the following:  1) Primary care and prevention ; 2) Approved dietary and nutritional therapies; 3) Inpatient care; 4) Outpatient care; 5) Emergency care; 6) Prescription drugs; 7) Durable medical equipment ; 8 ) Long-term care; 9) Palliative care; 10) Mental health services;  11) The full scope of dental services, including periodontics, oral surgery, and endodontics but not including cosmetic dentistry; 12) Substance abuse treatment services; 13) Chiropractic services, not including electrical stimulation; 14) Basic vision care and vision correction (other than laser vision correction for cosmetic purposes); 15) Hearing services, including coverage of hearing aids; 16) Podiatric care.”

The benefits are fully portable, to be available with any “licensed healthcare clinician anywhere in the United States that is legally qualified to provide the benefits.”  No more COBRA!  And a biggie—“No deductibles, copayments, coinsurance or other cost-sharing shall be imposed with respect to covered benefits.”  We will pay in advance, not at the door.

Primary care and prevention means your family doctor, internist, pediatrician, or ob-gyn doctor, nurse practitioners, midwives and physician assistants, as well as the labs and other tests we need.  Our current health insurance law attempted to cover those items, but far too many policies have remained “grandfathered” and don’t have to cover well person care, including my own insurance.   

Approved dietary and nutritional therapies—I hope this makes a lot of you happy!  This should cover not just formulas for tube- feeding people who can’t eat but also nutritionists and supplements.

Inpatient care means care given in a hospital, and outpatient covers care anywhere else, including home health, physical therapy, occupational therapy, speech therapy and specialist care.  Some hospital services are currently coded as “outpatient” even when patients stay overnight in the physical building of the hospital —a complicated bit of footwork insurers use to get out of paying fairly.  I don’t know that the bill needed to specify emergency care separately, but that’s fine.   Same with primary care, already part of both outpatient and inpatient care.  I do like the symbolism of listing primary care first, setting it as the cornerstone of our proposed system.

Long term care—that’s nursing homes and sometimes rehab hospitals.  Palliative care isn’t designed to cure an illness but to relieve symptoms.  Hospice, one type of palliative care, would be included.  

I’m interested that chiropractors get specific mention, since all categories of licensed providers are already included.   What is the electrical stimulation we won’t get, and why?  I don’t know—TENS units are mainstream, so I wonder if this is another type of device?  Anyway, if enough of you don’t like that part and want some sort of electrical stimulation, beneficial or not, feel free to insist on coverage.   I know right now some of my friends are going to have fun with that one—TMI.

We will have brains (mental health and addiction), teeth, eyes, ears and feet finally become legitimate body parts—hurray!  Reminds me of one of my husband’s favorite funnies.  What do you call a deer with no eyes?  No eye deer.  What do you call a deer with no eyes and no legs?  Still no eye deer.  What do you call a deer with no eyes, no legs and which is on fire?  Still no flaming eye deer!  Yeah, I know the R rated version.   What do you call a person in our current insurance system with depression, a cracked tooth, TMJ, nearsightedness, hearing loss, and bunions?  SOL!  And that’s no joke.

Comparing your own wish lists to HR 676, do you see anything left out?  If so, speak up now—we have time to get it in there.  Do you see anything included but think we don’t need it?  Let’s talk.  Next week, we’ll take up section 103, Qualification of Participating Providers.


Filed under HR 676 Analysis

The Health Insurance Twilight Zone

I’ve written before about how insurers give us the runaround.  Just yesterday, I got a wonderful example from my own insurer—thought I’d share it while I’m still fuming.  A few months ago, I paid too much up front for medical services a family member received.  At the time, I didn’t have my contract booklet in hand and was in an emergency situation.  Plus, of course, I was distraught over my family member’s illness. I didn’t want to delay treatment, so I paid and figured I’d be able to sort it out later. Wrong.

I contacted Insurer X several times over the following weeks, not about the overpayment but because we were concerned they might not cover the full treatment Provider Y recommended.  As is common during a hospital stay, Insurer X certified only a few days at a time, putting us in a panic at least twice a week.  Insurer X’s website has no contact information for subscribers other than one general phone number.  Because of this, I spent hours playing phone tag with their staff.  At one point, to my own surprise, I was so worried about my family member that I cried on the phone to a staffer (I’ll call her Ms. B).  She took pity on me and gave me her work email, which I then used to send requests for information.  I sent Ms. B a total of only 5 emails, 2 during the treatment period and 3 afterwards.

During treatment, Provider Y told us that if Insurer X wouldn’t pay for the full therapy, we could still pay out of pocket.  So I left the overpaid amount as a deposit.  In the end, we made other arrangements and did not exceed Insurer X’s benefits.  I asked Provider Y to refund the overpaid amount and was told I would get it after Insurer X finished processing the claim.

Two weeks after the end of treatment, I emailed Insurer X’s staffer to see when I would get an EOB (explanation of benefits).  Text of my email: “Hi Ms. B– I have not gotten an EOB yet for my Family Member’s services from Provider Y– how do I get it?” She responded that it would be 30 to 45 days.  I waited over 2 months and never got anything, so I emailed again: “Hi, Ms. B– I still haven’t gotten it. I waited a little longer just in case.”

The EOB came yesterday, 90 days past the end of treatment, and I was correct– I had overpaid.  Having already unsuccessfully requested a refund from Provider Y, I decided to ask Insurer X for help. (I had tried getting help from my own HR department and was told to contact Insurer X first).

Insurers and providers have contracts stipulating patients can’t be charged over the contract amount unless we agree in writing to pay non-covered charges.  If providers break that agreement, insurers can remove them from the preferred list.  It seemed to me that a little pressure on that front might help, so I sent the following email to Insurer X’s staffer (Ms. B), Provider Y, and my family attorney (ok, I admit I copied my husband—but he is an attorney and he is family).

“Dear Insurance Company X (Ms.B), 

I received the detailed remittance I requested regarding services by Provider Y from 3 months ago.  I am copying Provider Y’s billing office.  I am also copying our family attorney. 

It looks like the total amount I should have paid Provider Y was $250, according to your fee arrangement with them and my contract booklet.  I was told by Provider Y that my estimated payment was $800, which I paid on the date of service.  I have not received a refund of the overpayment, nor have I received any account statements from Provider Y to date.

I don’t know why I was charged $800 up front, unless there was a misunderstanding on Provider Y’s part about their contract with you. I am letting you know about this, because I am probably not the only subscriber that has been billed incorrectly– you may need to clarify your arrangements with them.  Can you please assist me in getting my money refunded?

Thank you,

 Pippa Abston”

And here is the email I received in response:

“Pippa, I’m sorry you feel like you have to go to such drastic measures. It was my understanding that Ms. A explained the benefits to you beforehand. Claims is not my specialty. I have just been trying to help you out. You need to contact them. Under the circumstances, I feel it’s best for me not to communicate with you anymore. 

Ms. B

Services Coordinator

Insurance Company X”

I admit to being baffled.  I do not know Ms. B personally, in case you’re wondering about her use of my first name.  I’m not sure what sounds so drastic about my letter, and if claims are not the specialty of an insurance employee, what does she do?  Maybe she gets paid as a “medical expense” to listen to crying family members, who knows.  As for just trying to help me out—I pay hefty premiums every month and don’t think I am a charity case.  Not sure who the “them” is I’m supposed to contact.  If it’s Claims, why not forward my email or give me theirs?  The Ms. A she refers to was the case manager, who never gave me an email and who is very difficult to get on the phone.  Apparently I have upset Ms. B so much that now I have no email contact with my insurer at all (I quoted my emails so you wouldn’t think I had somehow been harassing her).  Looks like I’m on my own with their “preferred provider.” 

So, back to the frustrating phone tag.  I don’t have time for it, but I want my money back.

This sort of lunacy is not one bit unusual—it’s actually a fairly mild example of insurer dealings. They throw up every barrier they can think of to keep patients from communicating with them, understanding their benefits, and getting services.  The more we try to regulate them, the more tricks they find.  I’m mad as hell—are you?  When are we going to finally decide not to take it anymore?  I’d love to follow Insurer X’s plan of not communicating further “under the circumstances.”  We don’t need them, folks—we can have publicly funded, improved Medicare for All.


Filed under Healthcare reform

A Consumer By Any Other Name….

Recently, Paul Krugman took on the use of the word “consumer” as applied to patients, in his blog post “Patients are not consumers” http://www.nytimes.com/2011/04/22/opinion/22krugman.html?_r=1.  You should read it, and then come back here.

First, let me tell you that I agree with almost everything Mr. Krugman says.  It is indeed a travesty to treat medical care as a commodity.  I’ve written about that before.  As a member of Physicians for a National Health Program, I am working to bring about national health insurance, with lifelong medical care for all of us — everybody in, nobody out.  But I’d like to address a particular question Mr. Krugman posed, one he may have intended rhetorically: “How did it become normal, or for that matter even acceptable, to refer to medical patients as ‘consumers’?”

Because he never mentioned the original history of this usage, I’m going to guess Mr. Krugman doesn’t realize where it started.  I only found out a few years ago, when I became a member of NAMI, the National Alliance on Mental Illness.  NAMI is an advocacy organization started by family members of persons with serious mental illnesses (SMI)– diseases like schizophrenia and bipolar.  In NAMI, I learned that “consumer” was a label patients chose for themselves back in the 1980’s.  Initially, it was part of the anti-psychiatry movement–some people even called themselves “survivors” of the psychiatric system.  Later, the term evolved into common usage among people who did seek traditional psychiatric care.

So why did they pick that word?  If you do not suffer from mental illness or have a family member who does (I don’t mean mild depression– I mean the illnesses people get committed to institutions with), perhaps you haven’t experienced the loss of dignity so commonplace for those with SMI.  In many ways, it is better today, partly through the efforts of NAMI– but some aspects remain the same.  Can you imagine being stripped of your belongings, forced to take medications with miserable side effects, and deprived of most freedoms the rest of us enjoy?  And having this treatment called medical care?  It is true that because severely psychotic people often don’t recognize their own illnesses, treating them without their consent may be the only way to save their lives.   The psychiatrists who deliver the unwanted but desperately needed care are often quite compassionate and empathetic.  None of which removes the degradation and humiliation entirely.  Or the anger.

Angry patients called themselves consumers for a very specific reason– to remind healthcare professionals who paid them.  It was a way of taking back a measure of autonomy and personhood, in the midst of a patronizing system.  Now, 30 years after the consumer movement began, organized groups of persons with SMI still proudly call themselves consumers, as they work to erase the misconceptions and stigma of their diseases.  When I posted a comment to this effect on Facebook, one person in the mental health field responded that she calls her patients “clients.”  Here’s my first question, and this one is definitely rhetorical– since when do we have the right to choose labels for other people?

Yes, the term consumer is distasteful in my mouth.  I hate the idea of my patients seeing me as some sort of saleswoman.  But  other than in my personal role as an occasional patient, I have no standing to criticize any word chosen by others to describe themselves.  I would be especially unwilling to attack usage by persons with mental illness. 

Now for my real questions.   Has the word consumer simply been hijacked by insurers, grossly insensitive to the consumer movement history?  Or have patients themselves– those without mental illness–begun to see themselves as consumers too?   Will some begin to call themselves “survivors”, not of their illnesses but of our medical system? Perhaps physicians, by putting their bank accounts before the needs of their patients and failing to defend them against corporate insurer greed, have helped injure the very meaning of our profession.  Last year in a debate with two conservative doctors, I was aghast when one stood up and said “I am a businessman”, followed by loud applause from an audience of community leaders.  My response that I saw myself as a professional drew little interest.

Before we try to reverse the renaming of our patients, we need to listen.  In medical parlance, we need to take a real history.  If the people we care for in our offices believe they are consumers, our healthcare system doesn’t just need therapy.  It needs a heart transplant.


Filed under Healthcare reform

The Competition Conundrum

The meme of competition underlies every conservative healthcare reform proposal, so much so that it has taken on a sacred nature. I notice that many progressives tend to side-step this one—yes, they argue outcomes, but not necessarily the fundamental concept that competition is the root of all good, in every transactional system. Maybe that’s because it’s just hard to fight a meme like this. When it comes to varieties of flat-earthers, facts can be beside the point.

I had a comment on my last post that I was ignoring basic economics by not understanding that the laws of supply and demand, with enough competition, would by necessity result in lower prices and higher quality. So I thought it would be worth a try to look at a few factors in health insurance that are different from the basic market principles for things like pizza or haircuts. Remember I’m not an economist, so I’m going to stick to the easy stuff—the basics.

First of all, when someone is trying to sell us pizzas, the goal is to balance the price and quality to maximize the chance most of us will come back. If organic tomatoes, at a higher price, don’t affect our desire for more, they won’t be in the sauce. The sellers also need us to eat as much pizza as possible. In contrast, a smart health insurance company wants us to buy their product but not to actually use it. That is the only way they can make the increasing profits shareholders demand. Remember we aren’t their only customers—shareholders count too. This is really an unusual economic setup, when you think about it, so it would be simplistic to think “basic” economics would work.

So how can they entice us to buy a product but not use it? You might think they would try to keep us healthy, but other tactics are far quicker and more lucrative. First, they use tricky wording to hide the fact that they don’t cover certain services we might assume would be covered. Some diagnoses, unless we are medically trained, would be completely unfamiliar to us. So we might see an illness in the contract under excluded conditions and have no idea this mattered. Then they throw multiple layers of roadblocks in our way. Provider networks and formularies keep their costs low partly because some customers will decide to pay a higher price out of pocket for a better doctor or medicine. Denying claims or authorizations initially and then “realizing” there was an error if challenged lets insurers cheat customers who never catch the error. Even those long, convoluted phone trees to get prior authorization or protest a claim denial (“press one if you want to bite someone”) make some patients give up in frustration. I could go on and on about these tactics but have discussed many in previous posts.

Now let’s look at haircuts. Same thing as pizzas, in that my barber (yes, I have a barber and think she is awesome) is motivated to give me a haircut that makes me want to come back, and also hopes I’ll tell my friends about her. But the price of a haircut, if you ask any woman, does not depend only or maybe even primarily on quality. It depends instead on the cache of the salon—the area of town, the type of clientele (helps if some big-wigs go there, pun intended), the décor. I’ve seen plenty of women walk out of trendy salons with very ordinary hair. If they were bad cuts, of course people wouldn’t go back—but ordinary turns into glamorous if you get to share hairdressers with the women who buy $500 shoes. Or maybe with John Edwards. This same principle holds true with pricey wines. Tasters who drink wine poured from a fancy bottle give much higher ratings than they do to the same wine poured from a bottle labeled Mad Dog.

So competition does not always result in the best quality, even in non-insurance products—there are too many factors other than quality that play into demand. Insurers borrow this principle in their Medicare Advantage plans, marketing products that have great names or have cool perks like health club membership discounts but fail to offer quality coverage for serious illnesses. I’ve seen a recent insurance commercial talking up the friendly nurse a new cancer patient can call to get treatment options (I guess instead of talking to the oncologist). Never mind that this nurse has an interest in keeping your care cheaper for his company. The company doesn’t care if the sickies leave and don’t come back—it works just fine to keep only the customers who don’t have to use their product. Apparently negative feedback does not lower insurance market value much. Maybe the dissatisfied customers are too sick or too dead to make noise.

Risk pool size also makes competition an ineffective way to lower prices. If we had a very competitive market with lots of insurers, and no large companies dominated, each risk pool would be smaller and more vulnerable to effects of a few unlucky customers with expensive illnesses. Premiums would have to increase to compensate in those pools, and healthy customers without pre-existing conditions would migrate to another pool at lower cost. Using the pizza analogy again, customers who didn’t eat the pizza would try to find pizza places where no one else ate it either. If someone did eat it, the others would be better off if that person got food poisoning and never came back. Eventually we’d wind up with sick people in plans they couldn’t afford anymore. Of course, free market proponents would remove all the new health insurance reform features, including protection for pre-existing conditions and price controls, in the service of the god Competition.

Do folks really want the natural outcome of competition in health insurance—products the sellers don’t want them to be able to use? Do they value a principle like competition, whether it works or not, more than coverage when they are sick? Are they ready to constantly scramble from risk pool to risk pool when prices rise? And to pay through the nose when they get sick and the well folks run away, along with their premiums?

All this reasoning has limitations. I know from experience in medicine that things don’t always work the way it seems they should. We used to think babies were safer sleeping on their stomachs, until we looked at the data and found out they were 10 times more likely to die. So if you want to ignore everything I just said, fine—look at what happens in the real world. We have plenty of examples of states with multiple competing products and states like Alabama with one heavily dominating company. And insurance is expensive everywhere.

We might not be able to overcome the religion of competition. Maybe we’ll just have to borrow it for our own purposes. If we had a national health insurance, an improved Medicare for all of us, we could access it for preventive medical care or early treatment. Paying well for this type of care, and maybe even treatment for obesity and nicotine addiction, would become the best way to lower overall costs. We wouldn’t have to pay part of our premiums for advertising brochures and commercials, customer service people who get paid to confuse us, high-salary executives or shareholder profits. We could have the largest risk pool possible, making our individual payments the cheapest. Because of this, our pizza businesses, hair salons and automobile makers could save money, by not having to fund private insurance and by having healthy, productive employees. They could—guess what? Compete!


Filed under Bad solutions for the uninsured

Medicare for None?

There has already been a great deal of commentary on the new plan for Medicare– I doubt if I can add much but would like to at least join in the chorus.  The latest cost-cutting idea on Medicare is to turn it into a voucher program.  Instead of having care insured through the government, seniors would get vouchers to apply to private health insurance.  Proponents freely admit that the vouchers would not cover the cost of care currently provided by Medicare but insist that it would save money.

That’s true– it would initially save the government some money.  Right now, we are wasting large sums on Medicare Advantage plans, which are funded by Medicare money and administered by private insurers at far higher overheads, so that would stop. (We’d still be paying extra overhead for privately insured government employees though, including Congress).   The cost would be passed on directly to seniors.

To purchase private health insurance, seniors would have to pay an extra 20% or more in overhead (vs the 3% of Medicare overhead) for a generally poorer quality product.  I’ve discussed the inferior coverage and higher cost of Medicare Advantage plans in prior posts so won’t repeat all that.  As private insurance premiums rise, the voucher amounts will increasingly fall short– the inevitable result is that many grandmas and grandpas will have no health insurance at all.  But they will still need medical care.  Instead of getting early, less expensive care and preventive care, they will go to the ER when they get really sick.  This will cost even more, and they often won’t be able to pay the hospital bills– eventually, some hospitals will be forced to shut down.  As we lose medical resources in our communities, the pain will spread to every age group.  Talk about pulling the plug on Granny!

Bankruptcies and foreclosures would increase again.  The “sandwich” generation, caring for both children and elderly parents, would certainly try to help cover the unpaid costs– at risk to their own homes.  And the overall economy would take another big hit when we can least afford it.  What good will it do to save government money on the front end if our economy tanks later?

In some ways, I’m glad this bizarre plan came up.  It gives us a chance to look harder at the enormous value we get from our current Medicare and perhaps some will begin to seriously reconsider the possibility of Medicare for all of us.  Will the seniors who have chimed in that “government can’t do anything right” suddenly realize that isn’t true, once faced with the prospect of trying to buy private insurance? 

I am always surprised to hear some of my friends and family on Medicare tell me they have earned the benefits they are getting, because they paid their Medicare taxes during their working lives.  But this is simply not true.  Medicare, like Social Security, is an intergenerational covenant– I won’t say contract because if it falls through, it is not enforceable.  The current generation on Medicare agreed to have some of their income go towards the medical expenses of their elders.  The money didn’t get put into a savings account set aside for their own use– it has been spent.  They did this with the expectation that the next working generation would continue to be willing to fund Medicare when it was their turn.  At the same time, too many seniors have actively fought against the possibility that the current working generation, the ones paying for the seniors’ care, could also contribute a little more in Medicare taxes and get the same public insurance for themselves and their children, without having to wait for retirement age.   This is so shockingly selfish to me.

But maybe the selfishness has now come back on them, like a boomerang.  Apparently some current workers are not so willing to keep funding the medical care of their elders.  They’re saying what’s good for the goose is good for the gander.  This is fair retribution for AARP members who failed to support expanding Medicare to younger generations.  Unfortunately there are also many unselfish seniors who will suffer the same backlash.  Will we have to actually experience the wretched consequences of privatizing Medicare– will we have to witness our beloved elders suffering unnecessarily and dying prematurely?  Or can we use a little imagination?  Let’s be pro-active!  Tell your legislators to sign on to HR 676, Improved Medicare for All.  AARP members, you need to get busy.  At our current growth rate of medical expenditure, we really can’t afford to keep assisting you much longer, no matter how generous we are.  With Medicare for All, we can and will.


Filed under Healthcare reform

Patient Protection and Affordable Care Act, Part 33

If you have been following along with these posts, you may have noticed it has been several weeks since I’ve done an installment on PPACA.  It seemed to me that many of the sections were becoming fairly repetitive.  I’ve decided to continue reading the original text as before but blogging mainly  on the high points– the changes I think may be more significant to our actual care.  Please post a comment if you ever have a question on one of the original points.

Today I’ll cover Section 3201 regarding Medicare Advantage (MA) plans.  This is a long, complicated section!  It will make some changes to how we pay these privately administered plans, in an attempt to save money.  In case you don’t know what MA plans are, they are alternative choices to traditional Medicare run by private corporations.  Remembering that the average traditional Medicare overhead runs about 3%, you may guess that the cost per person of MA plans to our country is higher, to account for the always higher overhead of private plans– and you would be correct.  On average they cost at least 12% more per person (to our government) than traditional Medicare plans.  If the changes made by PPACA do save money as hoped, do you expect the corporations to roll over and accept lower profits?  That was a rhetorical question.  They will accomplish their steadily increasing profit margin by raising premiums to enrollees and/or cutting services (which can often, as you’ve learned, be accomplished by underhandedly making the payment process for some services more difficult for patients rather than changing any of the official policies). 

You might think these obstacles and frustrations would deter patients from choosing an MA plan.  What actually happens is that healthy people who rarely have to seek care and thus don’t encounter difficulties pay for these plans, enjoying some of the perks like health club discounts and so on.  Those who get sick tend to return to traditional Medicare, so the MA plans can indirectly cherry pick enrollees.  This is a completely losing situation for us as taxpayers and to me it demonstrates how powerful corporations can get legislation favorable to them that hurts the country overall.

Before PPACA, MA plans bid for payment by the government against a benchmark.  If they bid more than the benchmark, they had to issue a rebate to the government (but remember, even the benchmark cost per person is higher than traditional Medicare).  If they bid less, they got the extra money to keep as profit, so we didn’t save anything at all in the national budget.  Again, they could bid less both because they got more money anyway than traditional Medicare and because they found ways to not pay for services.  With PPACA, the extra money from “underbidding” won’t be given out automatically but will be used as incentive payments for care coordination (which has been demonstrated not to save money) or to get higher quality ratings.  MA plans will also have to give rebates to enrollees if they save money.  Since they will certainly raise premiums, this will be like a clothing store raising prices and then having a sale with a little bit of that price raise marked off.

MA plans are rated on a 1 to 5 star scale based on a combination of measures given by HEDIS (healthcare effectiveness data and information set), CAHPS (consumer access of healthcare provider systems), CMS (Center for Medicare and Medicaid Services), HOS (Health outcomes survey) and IRE (independent review entity).  These include consumer opinions of quality– whether all these ratings really measure quality of care is very much in question.  Be that as it may, MA plans getting 4 or 5 stars are rare only about 15%.  In Alabama, less than 1% of MA plans make it to 4 stars or more.

So how do the star ratings of MA plans compare to traditional Medicare?  I don’t know the answer– www.medicare.gov lists the star rating for Medicare as “not available.”  I googled it also to see if anyone else had by chance estimated a star rating and couldn’t find one.  But maybe we can take as a proxy the rating comparison of Medicare plus a prescription drug plan versus MA plus a prescription drug plan, since the only variable is Medicare vs MA.  In my zipcode, MA plus drug plans have star ratings from 2.5 to 3.  Traditional Medicare has ratings from 2.5 to 5!  That implies that the quality rating of traditional Medicare is very high and that the lower end of those ratings has more to do with the chosen drug plan.  You can go to this website and search for the same information by your own zipcode.

Did you know that a single MA plans can be sole in multiple states?  Even with this supposed cost-cutting strategy to consumers of selling across state lines, costs have just continued to rise.

We had a chance in PPACA to just get rid of these expensive MA plans and didn’t do it.  Traditional Medicare offers both lower cost and higher quality than private plans.  This is the best example of a head to head test of government managed payment and private corporation payment– and we have the answer.  Private corporate Medicare insurers just can’t do anything right (other than rake in the big bucks).  Now I’ll sing my favorite refrain– it’s time to throw out the private insurers and have one improved Medicare for All.

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Filed under Healthcare reform