Health Care Now
Race is a Social Construct
To start, it’s important to understand that there is no biological basis for race. Race is purely a social construct, and racial inequities in health all have social roots (although health impacts on a social group can lead to genetic consequences for that group’s descendents, such as in sickle cell or Tay-Sachs disease).
The Role of Race Politics in the Development of the U.S. Healthcare System
The history of race politics in the U.S. is deeply intertwined with the unique development of our inequitable healthcare system, in ways that may surprise you. Gerard Boychuk’s book National Health Insurance argues that a primary reason universal healthcare passed in Canada was the national government’s attempt to prevent Quebec from seceding by instituting essential national services. In the United States on the other hand, segregationist politics in Congress blocked national healthcare for much of the 20th century – not, as is often claimed, the growth of employer-based insurance during WWII.
Treating Healthcare as a Commodity Allows Broader Racial Inequities to Impact Health
The growth and political entrenchment of a healthcare system that links access to care with ability to pay creates a dangerous dynamic in the U.S. as other large systems characterized by racial discrimination – such as access to employment, income, family wealth, housing, loans, social services, and more – translate into healthcare barriers. The literature here is vast, but we recommend Ira Katznelson’s history of how large federal programs that created the middle-class in the U.S. (Social Security, the right to unionize, the GI Bill, etc) largely excluded people of color, leading to a massive wealth gap, as well as recent studies showing the continued prevalence of racial discrimination across all areas of life – affecting employers, salespeople, doctors, legislators, and others – often due to “implicit bias” as opposed to intentional discrimination.
Experience of Racism as a Determinant of Health
These barriers to healthcare are all the worse since racial discrimination leads to greater health needs for some communities of color. In particular, a new body of a research in the last decade is showing that the daily experience of racism and the stress/self-doubt it causes, is a major cause of poor health itself, particularly for African Americans. This “embodied inequality” may also explain why immigrants, who are generally much healthier than native U.S. residents, experience declining health outcomes the longer they live here.
Racial Injustice in Medical Research and the Delivery of Care
Finally, for those who are able to access the healthcare system, medical research and the practice of medicine in the U.S. are marked by deep histories of racism as well. The Congressionally-funded 2002 study Unequal Treatment was a damning summary of the evidence that people of color are treated differently for the same medical conditions: receiving less routine care, lower-quality care, and more undesirable treatments such as lower-limb amputations.
The most notorious example of racist medical research is the Tuskegee syphilis experiment, conducted on rural African American men over the course of four decades up through the 1970s, to observe the end-of-life impacts of the disease. The men were not told they had syphilis or treated for it. Harriet Washington’s book Medical Apartheid places the Tuskegee experiment in the longer and larger context of inhumane medical experimentation on people of color – often in attempts to prove the racial basis of social behavior – which continues today.
We Can End Racial Inequities in Healthcare
We can and must end racial inequities in health. PNHP researchers have found, for example, that single-payer healthcare has almost eliminated racial gaps in unmet medical needs in Canada. Equity in health will require more than an equitable healthcare system, though: it will also require equity in the social determinants of health, such as education, housing, a healthy environment, and the equitable delivery of healthcare!
Gerald Friedman is Professor of Economics at the University of Massachusetts – Amherst. He has authored half-a-dozen economic analyses of state-single payer proposals, as well as a report on HR676, the national single-payer legislation sponsored by Rep. John Conyers.
On December 30, 2014, Vermont Governor Peter Shumlin finally released a financing proposal for “Green Mountain Care,” which would establish universal, publicly-financed healthcare for the state. Governor Shumlin’s recommendation that the legislature not enact his own proposal has shocked all those who were looking to Vermont for leadership. Below is Professor Friedman’s analysis of the report, which you can download as a pdf here. You can find Shumlin’s financing proposal here.
The report makes the case for universal public coverage in Vermont. The ultimate economic bottom line is whether better health care can be provided at a lower cost to the community. By these criteria, the Green Mountain Care (GMC) program would be a success. There would be universal coverage, an end to discrimination against Medicaid recipients, and the Governor projects savings of almost 12% per person compared with the alternative with larger increases in the future; the report projects per capita personal health spending in 2017 for the nonMedicare population of $8200 compared with $9300 under the current regime. Despite expansion in coverage and increased access, personal health care spending in Vermont will be reduced by over $550 million compared with the current system, not even including the $400 million in administrative savings in the financing system.1 Furthermore, the report projects increasing savings over time because costs will rise by only 4%, as compared with 4.8% rising to 5.2% a year under the current system; after only five years, personal health spending will be over $900 million less, with total savings over those five years over three billion dollars.
The report reaches conclusions that support implementing Act 48 even under conservative assumptions. The report understates revenues, primarily by providing for lower contributions from upper-income households and hospitals. It also has no savings from state-drug purchasing and none are explicitly included from health care administration, even though replacing private insurers with a state entity will certainly reduce health insurance administration and providers’ BIR operations. (Instead, the report projects savings through regulating prices to ACOs and other providers; this would reduce monopoly rents for high-price providers with market power as well as incorporating into lower prices some of the administrative savings.)
- Revenues are lower because of provisions favoring providers and the rich. Income and payroll premiums are capped at $27,000 and $23,000 respectively, or at about $290,000 dollars of income and $200,000 of wage and salary income. This caps payments from fewer than 10,000 Vermont households, the richest in the state, and lowers revenue in 2017 by about $30 million.2 It also assumes that the shift to a state-funded universal system eliminates about $170 million in state revenue currently dedicated to the Medicaid program. While some of these lost revenues come from a claims tax on health insurers who will no longer be operating in Vermont, most are from assessments on hospitals ($131 million) and other providers ($20 million)3. It is not clear why the state would want to give a tax cut to these institutions; eliminating the benefit and restoring their current liabilities will add $150 million to available state funds.
- The report leaves out significant savings. A state drug purchasing plan that lowered drug prices to world levels, as is done in Canada, would save Vermonters over $310 million in 2017. In addition, administrative savings achieved by doing away with private insurance would save almost $400 million.4 In addition, the report includes a $44 million annual charge to fund a program reserve. This reserve could be funded through the assumption by the state of existing insurance reserve funds, funds accumulated from Vermonters’ premiums.5
- The report is missing money. Vermont is committed to spend $755 million on Medicaid in 2017 (along with $1310 million by the Federal Government). The report accounts for only $516 million. This leaves $239 million that the report assumes the GMC must fund but, without the GMC, the state would be funding out of general revenues.
Even leaving out savings and undercounting revenues, the report shows that universal public coverage can be financed. Given the conservative assumptions, the report supports the conclusion of the Hsiao-Gruber study that a universal public plan can be financed. Eliminating the tax caps, the tax cuts for providers, and the unnecessary bonding of state reserve funds will add $220 million, enough to lower the proposed payroll tax to under 10%. If the missing money were found, the proposed payroll tax could be under 8%.
The report shows the program would be equitable. Even with the cap put on income tax payments6, the proposed funding program would produce savings for Vermonters earning up to $150,000; eliminating the cap would allow lower rates and larger savings.7 Businesses with fewer than 1,000 workers that are currently providing health insurance to their workers would save money with the greatest relative savings going to small businesses.8 To be sure, businesses currently not offering health insurance will pay more; but this means that they would be required to assume a responsibility that they have avoided by riding free on public programs providing health care to their workers or on family plans provided by other employers.
- The report also shows the plan would resolve the problem of legacy costs. Few of the businesses and governments that have committed to provide retiree health insurance have put aside adequate funds to meet this responsibility. The program would end this obligation and do away with billions in unfunded liabilities.
- Sick Vermonters will pay less in out-of-pocket costs. The plan would reduce out-of-pocket costs by $260 million in 2017. Not only is this a large number, about 10% of the revenues needed to fund the program, but it is a savings targeted at the sick. The front-end savings in out-of-pocket costs for sick Vermonters creates three additional benefits: one, increased access to primary care; two, improved health outcomes before conditions worsen; and three, new financial savings by treating illnesses mostly through primary health care, as opposed to far more costly emergency care.
Points the way to interim measures. While the report provides strong arguments for a universal single payer plan as envisioned by Act 48, it does point the way to various interim steps. The governor seeks to “increase access to primary care and other vital health care services for all Vermonters, and better integrate information technology utilization and oversight statewide.”9 The report makes reasonable suggestions for giving the GMC more responsibilities in areas that would reduce the administrative waste from the current insurance system, including enrollment, claims adjudication, and reimbursement. Establishing the GMC as a single reimbursement pipeline would also give it the information base needed for effective epidemiological studies to create a streamlined single payment system. These are all good ideas and steps that will produce greater efficiencies, savings, and enhanced healthcare outcomes.10
1. This is the extra overhead in private health insurance companies compared with a single payment pipeline under the GMC. By addressing only what Centers for Medicare and Medicaid Statistics (CMS) calls “personal health expenditures,” which does not include administrative expenses among sponsors, the report neglects these savings.↩
2. This is based on my calculations of state revenue using Census data on income distribution and CBO data on sources of income. My estimates give revenues from both taxes about 9% higher than the GMC report; I have adjusted estimated revenue loss downwards by this amount.↩
3. See Appendix F of the report.↩
4. These savings are explicitly ignored in the report which focuses on personal health care expenditures which do not include administrative costs rather than health consumption expenditures including these costs. Regardless of what is included in the analysis, however, Vermonters pay the cost of administering the private health insurance system.↩
5. Assuming private insurers maintain reserves of 6 months expenditure, they hold over $700 million in reserve funds.↩
6. There is also a cap on payroll taxes at $23,000. This applies to wage and salary income above $200,000 per person and effects.↩
7. Shumlin, Green Mountain Care: A Comprehensive Model for Building Vermont’s Universal Health Care System, 53.↩
8. Ibid., 50.↩
9. Ibid., 6.↩
10. Ibid., 21.↩
Dr. Daniel Root testified before the New York Assembly Health Committee on December 4, 2014 about trying to care for the uninsured and underinsured in a rural county primary care practice. He describes a farmer, whom he has treated since childhood, losing his vision due to lack of access to basic preventive care; and another patient who had to barter free wood to pay off some of his medical bills after a heart attack. “This is a crime,” testified Dr. Root. Watch his testimony:
Gerald Friedman is Professor of Economics at the University of Massachusetts – Amherst. He has authored half-a-dozen economic analyses of state-single payer proposals, as well as a report on HR676, the national single-payer legislation sponsored by Rep. John Conyers. Below is Professor Friedman’s analysis of Governor Peter Shumlin’s announcement that single-payer reform is too expensive for taxpayers in Vermont, and that now is “not the time” to move ahead with reform in the state:
Less has changed in the economics of Vermont single payer than in the politics.
Assuming large administrative savings, Hsiao-Gruber had estimated that a single-payer program with comprehensive benefits (like the 94% actuarial value in the Governor’s statement) would require payroll tax of about 17% in 2017 to raise $2.7 b. Last year, I estimated that a single payer plan with a comprehensive package and administrative savings like those of Hsiao-Gruber would require a payroll tax of 10% and a tax on dividends, rents, profits of 10%; without the tax on non-wage income, it would require a payroll tax of 16%. My proposal (back-of-the-envelope) anticipated raising $2.3 b in 2015 and $2.5 b in 2017.
The Governor’s report discounts administrative savings by an unspecified amount, and anticipates less federal support than previous Green Mountain Care reports, albeit more than I had anticipated. It concludes that in 2017 the program would require $2.8 b to be raised from a payroll tax of 11.5% and a sliding scale income tax. While $300 million more than I would expect from my funding plan and $100 million more than Hsiao-Gruber anticipated. The Governor is abandoning Vermont’s single payer plan because it is slightly more expensive than expected.
The Governor also mentions various unspecified transition costs, notably the need to give discounts to small businesses during the transition. No details are given but there is talk of added costs of $500 m. While these would add 3-4 percentage points to the needed tax rate, they would also be savings in reduced payroll taxes to some Vermonters; while throwing around large numbers gives the Governor more political cover, these expenses are a wash economically.
The Governor’s decision is political not economic.
Since his election, he has avoided discussing financing and the need for a very large increase in state taxes to fund an enormous government program. He did nothing to prepare the public for a program that would replace larger private insurance premiums with smaller taxes.
Lessons for our movement.
- This does not mean that state single payer cannot be done. In terms of the economic analysis, nothing has changed; the Governor has abandoned Vermont’s single-payer plan on the basis of almost the same economic analysis that was used to support its enactment in the first place. Nothing has changed in the economics supporting single payer, either in Vermont or elsewhere.
- We cannot avoid discussing economics and costs. We can win public support on the virtues of universal coverage but we will still lose if we cannot match their arguments about the costs of coverage and the need for public taxes to support public spending.
Lieutenant Gary Pudup, a police officer for 30 years, testified to the New York Assembly Health Committee on December 8, 2014, about his haunting memories of investigating suicides – only to find out that the victims had ended their lives to protect their families from crushing medical expenses. In a just healthcare system, no officer would have this job – listen to Lt. Pudup’s testimony here:
We spoke with leaders of the Living Hope Wheelchair Association, based in Harris County (which includes Houston), Texas, which is a member of our affiliate Health Care for All Texas. Raymundo Mendoza (board secretary and Living Hope member), Francisco Cedillo (board treasurer and Living Hope member), and Francisco Arguelles (Executive Director of Living Hope Wheelchair Association) answered our questions. You can learn more about Living hope at www.lhwassociation.org or by calling 281-764-6251.
1. Why was the Living Hope Wheelchair Association formed, and can you tell us a bit about the situation faced by its members?
Living Hope is an organization formed by immigrants with spinal cord injuries working to improve our quality of life through services, advocacy, and community organizing. We formed in 2005 when the Harris County Hospital District decided to stop providing basic medical supplies to immigrants who were not eligible for Medicaid. We had to organize to find ways to help one another raise funds to buy catheters, diapers, and other supplies, and after some years evolved to become a small non–profit organization operated by us with the help of some volunteers.
Suffering a catastrophic spinal cord injury has a brutal impact on a person’s life. If this person is an immigrant or a low-wage worker in the United States then he or she is in an extremely vulnerable situation. During our existence as an organization we have been able to help each other first to survive the depression that comes after the accident, then to survive the problems that come with not having resources to buy medical supplies and equipment. We have learned to improve our quality of life through hope and solidarity, sharing what we have and organizing to get what we need.
2. What does the experience of Living Hope members tell us about the healthcare system in the United States?
Our experience with the healthcare system in the United States is a mixed one. We are grateful to doctors and nurses in the emergency services that took care of us after we were victims of a crime or suffered car or workplace accidents. We are grateful to therapists and rehabilitation specialists that have helped us along the years. On the other hand it is very frustrating not having access to regular healthcare. It is very painful to see our members needing attention and having to wait until they are in very bad shape because they can only be treated as emergencies. We have a member that needed dialysis treatment three times a week due to the kidney damage he suffered when he was shot in a drive-by shooting and he could only receive treatment every week or every ten days when his potassium reached critical levels; even though we were able to get him more regular treatment in a clinic, the damage to his health was devastating.
More recently one of our members, who is also our board treasurer, had to wait fourteen hours seated in his wheelchair in the waiting room at the county hospital before a doctor saw him. They didn’t even give him a bed during those fourteen hours so he could lie down and avoid developing a bedsore ulcer that can be very dangerous because they take months to heal. We know this is not the fault of doctors and nurses but a consequence of terrible public health policies that exclude so many people from having access to health care.
We believe that the fact that we are not included is a great injustice because we have contributed to the economy of this country and this is very frustrating. We want equality for all, health is a human right, and we don’t go to the emergency room because we enjoy it!
The situation in Texas is particularly bad, we are the state with more uninsured people and recently Governor Perry refused to take advantage of available resources to expand Medicaid, ignoring the negative impact this has on the whole system; we believe it is outrageous that he and other politicians don’t see that while they count the votes they win with these decisions, we have to count the hours we spend waiting in the emergency room, the hours we spend in severe pain because we don’t have access to treatment and medicine, and we count those who die and could have lived if their right to health care would be respected before the profits of insurance companies or the electoral interests of politicians that have never suffered like regular people.
3. Advocates for a single-payer healthcare system will often hear the question: “Will this cover undocumented immigrants?” How does Living Hope make the case that access to health services and goods should be available to all, regardless of documentation status? What can advocates for truly universal health care learn from Living Hope’s experience speaking with the broader community in Texas?
For us this is very simple: We are human beings, we have human rights, just like the rest of people in the U.S. Including undocumented immigrants in the healthcare system makes sense from a public health point of view and also from an economic point of view, it has been demonstrated by many different well respected studies; but that shouldn’t be the main reason why we are included: human dignity should be.
Texas is the state with more uninsured people and so many groups defending human rights in our state are working for a Medicaid expansion so we can have a better healthcare system. Ours is a very religious state and we think that those who want to deny our rights and humanity need to ask themselves: If we are not their brothers and sisters, how can they say that God is their Father?
So to advocates all over the country we have one advice: do not try to convince your opponents only with cost-benefit analysis, or seductive talking points; it is better to share stories that show the humanity, suffering and dignity of our communities and then let our opponents and the undecided do their homework with their consciences and beliefs, most people will do the right thing when they can connect with their own humanity and not just with ideological noise.
4. If a national, single-payer system was implemented that included all residents, how would that affect the lives of Living Hope members?
Having access to a single-payer system would have a great positive impact in our lives, it would mean opening the possibility of regular health care services that would help us prevent problems instead of having to live in a constant state of emergency. We are clear that a single-payer system would not solve all of our problems, we will still be in our wheelchairs, we will still have to face the discrimination we encounter both as immigrants and as persons with a disability, but what people who have health insurance and good health need to understand is that for us this is not an issue, this is a battle of life and death, and having access to health care will reduce the amount of pain we have to live with every day, it will help us live longer. So, paraphrasing our friend Ken Kenegos from the Health Care for All coalition here in Houston: those who prevent us from entering hospitals are today’s version of Alabama Governor George Wallace standing in the door of the University of Alabama in 1962. We know we are human beings and have rights and dignity; the question is if many of our current politicians in Texas are ready to acknowledge this and be on the right side of history.
John N. Lozier has been executive director of the National Health Care for the Homeless Council since its founding in January 1990. The Council is a network of more than 10,000 doctors, nurses, social workers, patients and advocates who share the mission to eliminate homelessness. John lives in Nashville, TN with his wife Joceline, and sits on the Board of Healthcare-NOW!
Question 1: Can you start off by talking about how people come to experience homelessness, and whether the healthcare industry plays a role in that?
Medical debt, deeply rooted in the current system, is a major and often overlooked contributor to homelessness. PNHP research shows that over 60% of personal bankruptcies in the US are the result of medical debt. From bankruptcy there is a well-worn path through eviction, followed by temporary stays with family or friends, to sleeping in a car, a shelter or outdoors.
Beyond that driver of homelessness, untreated illnesses play a huge role in selecting who will experience homelessness in an economy that is sorely lacking in affordable housing. Those who are most quickly squeezed out onto the streets tend to be those with so-called “behavioral health” problems – addictions and mental illnesses. Without minimizing the difficulties in treating these diseases, very helpful treatment approaches do exist, but are far from universally available. Uninsurance and underinsurance play a central role in excluding people who need and want treatment. Even when one has a payment source, system insufficiencies create wait lists for people who need to enter treatment at the point when they are ready.
Question 2: Does homelessness and housing insecurity create particular challenges for accessing needed healthcare?
Most assuredly. The Institute of Medicine of the National Academy of Sciences recognized this as early as 1988 in its seminal publication, Homelessness, Health and Human Needs. Beyond the very high uninsurance rates in the homeless population, competing survival priorities can take precedence over seeking health care. Just as people a bit higher in society’s pecking order might have to choose between paying for medicine and heating the house, people experiencing homelessness may have to choose between standing in line for a meal or a chance for a shelter bed and standing in line or waiting for a health care visit. Think about Maslow’s hierarchy of human needs, and what choice you would make.
Transportation is another problem. While public transportation and safety-net services sometimes help, may people without homes must walk to get places, and services are not always located close to areas where people stay. In Health Care for the Homeless, we see terrible foot problems, a result of all that walking, of sleeping sitting up (fluids pool in the lower extremities), and of high rates of diabetes.
Poor provider attitudes toward people who are obviously homeless and distressed – perhaps with poor personal hygiene (hard to control when you’re on the streets!), bad odors and strange behaviors – create new barriers to care. People are pushed away in ways ranging from subtle to brutal.
Question 3: If a single-payer healthcare system were implemented in the United States, how would that effect homelessness?
It would help to end mass homelessness by dramatically improving access to care. It would reduce immense human suffering.
Medical debt would be a thing of the past, closing a front door into homelessness. At the primary care level, the barrier of co-pays and deductibles (an oddly emerging barrier for dispossessed people as they become auto-enrolled in Medicaid managed care programs under the Affordable Care Act) would be eliminated. Specialty care and non-emergency procedures would become available – no longer would people living under bridges have to forego oncology services or cancer surgery for lack of a payer. And reasonable health planning would help ensure appropriate geographical distribution of services.
Question 4: Adequate housing and access to healthcare are both fundamental to quality of life and human dignity, but they are also two massive industries in the United States. Do you see parallels between the social movements to recognize healthcare and housing as rights? Are there spaces where these two movements could work together?
We do work together. We share the theoretical perspective that housing and health care are both human rights, and as such are interdependent and inseparable. Moreover, we recognize on a very practical level that housing is health care: one cannot expect to get well or stay well when living without housing, exposed to all sorts of infectious agents, the harsh elements, parasites, violence, poor nutrition, and poor rest.
One way that insight takes form is in the widely accepted “housing first” approach to homelessness interventions. Usually focusing on people whose health status makes them particularly vulnerable to homelessness, “housing first” moves homeless people into housing without expecting sobriety, employment or other indicators of “housing readiness.” Housing becomes the foundation upon which a person can begin to become healthy.
The National Health Care for the Homeless Council enthusiastically participates in the work of the National Low Income Housing Coalition for a National Affordable Housing Trust Fund to increase the actual supply of housing. The Corporation for Supportive Housing helps to bring our expertise in health care delivery into housing first developments.
Of course, I describe a relatively narrow focus on homelessness, the place where the extremes of poor housing and poor health intersect and offend the conscience. The collaborations among organizations are mostly focused on services and housing initiatives. The challenge is broadening this work to bring the human rights perspective to our well-intentioned colleagues who may have less expansive visions. Ultimately in a democracy, the strength of the profiteers in industry must succumb to a mobilized constituency insisting on basic human rights.
Question 5: Where can we learn more?
Below is testimony from Michael Lighty, Director of Public Policy for National Nurses United, to the California Assembly Health Committee regarding Ebola preparedness in a fragmented healthcare system with cost-barriers to care and declining investment in public health.
This is a proud moment for California Nurses Association/National Nurses United, whose members have taken the lead in blowing the whistle for Ebola preparedness. From a die-in on the Las Vegas Strip in September to the 50,000 strong national day of action on November 12th, the nurses of CNA/NNU have made history.
Contrary to what their hospital administrators have said about their adherence to the CDC guidelines—nurses reported quite the opposite in a survey of over 3500 nurses from every state in the US. So this new guidance in California creates a real level of security for nurses, and we thank Governor Brown and Director Baker, and the staff who worked so diligently to set this new national standard.
But what about the patients in a fragmented, under resourced “non-system” who are at the mercy of their insurance company’s high-deductible, minimal benefit, narrow network, sparse drug formulary health plan? And those on Medi-Cal who can’t find a doctor to accept them, or those undocumented workers and others who must rely solely on ER visits and a decimated public health system?
Funding for public health preparedness and response activities in the US was $1billion less in 2013, than in 2002, according to a CDC report from earlier this year.
According to CMS data collected in 2013, patients in California Emergency Departments faced waits that are 23 minutes longer than the national average. Specifically, California patients waited on average more than two-and-a-half hours in the ED.
Further, if a patient is admitted to the hospital, the average wait increased to:
- About five hours and 18 minutes from arrival to the time a patient is admitted; and
- Nearly an additional two hours before a patient is moved to a bed.
At least 5% of patients at 20 of the state’s EDs left before being treated because of the long waits, according to Center for Health Reporting/Daily News.
Let’s make a distinction between an integrated, well-resourced system that guarantees a single standard of care for all with a dedicated funding source and real public accountability – known as single-payer – verses the existing fragmented approach that seeks to regulate behavior sometimes with the force of law as in the case of this new guidance, and mostly as monetary incentives and voluntary guidance. Now, the treatment response to Ebola, for example, as other in other pandemics is largely governed by private healthcare corporations who are only accountable to their shareholders or board of directors, not the public.
Understaffing, access to treatment based on ability to pay, technology replacing hands-on care, difficulty gaining admission: it could and does happen everyday in our fragmented corporate health care system. All this happened to Ebola patient Thomas Eric Duncan in a Dallas hospital, and in his case, it was fatal and two nurses infected.
We know what works, Canada has done it: A province-based single-payer system and federal agency that has the responsibility and authority to ensure local, state and national coordination to detect, respond and treat outbreaks.
The Ebola epidemic reveals the fissures and fatal inadequacies of our healthcare “non-system.” Only greater integration, planned and directed resources, and authority to a public health system can protect people in California from the dangers of pandemics like Ebola.
This new guidance issued by Cal/OSHA stands out as a clear mandate for precaution and protection establishing a national standard. Let us a create system where that is the rule, rather than the exception.
The Health Committee of the New York Assembly has announced that it will be hosting a historic series of six public hearings across New York state to receive testimony on the “New York Health,” bill which would establish a single-payer healthcare system for the state. Below is the announcement from the NY Assembly Health Committee, along with the dates of the hearings:
“New York Health”, a universal “single payer” health coverage bill, would replace insurance company coverage, premiums, deductibles, co-pays, limited provider networks and out-of-network charges. Instead, it would provide comprehensive, universal health coverage for every New Yorker, with a benefit package more comprehensive than commercial or other health plans, with full choices of doctors and other providers. The program would be funded by broad-based taxes based on ability to pay. It would eliminate the local share of Medicaid (which would become part of New York Health). The bill, A.5389-A/S.2078-A, was introduced by Assembly Health Committee Chair Richard N. Gottfried and Senator Bill Perkins.
This series of public hearings around the state will review the effects and costs of the current health coverage system on patients, health care providers, employers, labor, taxpayers and health and health care. It will review how the single-payer system would work in New York.
The Campaign for New York Health – a coalition of organizations advocating for single-payer legislation in the state – is spearheading the grassroots campaign, and they’ve set up a new web-site here: www.nyhcampaign.orgSchedule of Hearings (UPDATED):
Thursday, Dec.4, 10 AM
Medical Alumni Auditorium, Weiskotten Hall
Upstate Medical University, 766 Irving Avenue
Monday, Dec. 8, 10 AM
City Council Chambers
Rochester City Hall
“A” Building, 3rd Floor
30 Church Street
Wednesday, Dec. 10, 10 AM
Roswell Park Cancer Institute
Research Studies Center
Elm & Carlton Street
NEW YORK CITY
Tuesday, Dec. 16, 10 AM
New York University
Grand Hall, 5th Floor
Global Center for Academic and Spiritual Life
238 Thompson Street
Wednesday, Dec. 17, 10 AM
Nassau County Legislative Chambers
Theodore Roosevelt Executive and Legislative Building
1550 Franklin Avenue
Tuesday, Jan. 13, 10 AM
Hearing Room B
Legislative Office Building
Patricia Wanderlich got insurance through the Affordable Care Act this year, and with good reason: She suffered a brain hemorrhage in 2011, spending weeks in a hospital intensive care unit, and has a second, smaller aneurysm that needs monitoring.
But her new plan has a $6,000 annual deductible, meaning that Ms. Wanderlich, who works part time at a landscaping company outside Chicago, has to pay for most of her medical services up to that amount. She is skipping this year’s brain scan and hoping for the best.
“To spend thousands of dollars just making sure it hasn’t grown?” said Ms. Wanderlich, 61. “I don’t have that money.”
About 7.3 million Americans are enrolled in private coverage through the Affordable Care Act marketplaces, and more than 80 percent qualified for federal subsidies to help with the cost of their monthly premiums. But many are still on the hook for deductibles that can top $5,000 for individuals and $10,000 for families — the trade-off, insurers say, for keeping premiums for the marketplace plans relatively low. The result is that some people — no firm data exists on how many — say they hesitate to use their new insurance because of the high out-of-pocket costs.
Insurers must cover certain preventive services, like immunizations, cholesterol checks and screening for breast and colon cancer, at no cost to the consumer if the provider is in their network. But for other services and items, like prescription drugs, marketplace customers often have to meet their deductible before insurance starts to help.
While high-deductible plans cover most of the costs of severe illnesses and lengthy hospital stays, protecting against catastrophic debt, those plans may compel people to forgo routine care that could prevent bigger, longer-term health issues, according to experts and research.
“They will cause some people to not get care they should get,” Katherine Hempstead, who directs research on health insurance coverage at the Robert Wood Johnson Foundation, said of high-deductible marketplace plans. “Unfortunately, the people who are attracted to the lower premiums tend to be the ones who are going to have the most trouble coming up with all the cost-sharing if in fact they want to use their health insurance.”
Deductibles for the most popular health plans sold through the new marketplaces are higher than those commonly found in employer-sponsored health plans, according to Margaret A. Nowak, the research director of Breakaway Policy Strategies, a health care consulting company. A survey by the Kaiser Family Foundation found that the average deductible for individual coverage in employer-sponsored plans was $1,217 this year.
In comparison, the average deductible for a bronze plan on the exchange — the least expensive coverage — was $5,081 for an individual and $10,386 for a family, according to HealthPocket, a consulting firm. Silver plans, which were the most popular option this year, had average deductibles of $2,907 for an individual and $6,078 for a family.
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Jon R. Gabel, a health economist at NORC, a research organization affiliated with the University of Chicago, said that employer-sponsored plans had lower deductibles, in part, because they provided more generous coverage than the most popular exchange plans. The typical employer-sponsored health plan would qualify as a gold-level policy under the standards of the Affordable Care Act, Mr. Gabel said.
The website for the federal insurance marketplace serving 36 states, HealthCare.gov, strongly encourages consumers to focus on premiums: When consumers search for a plan online, the results are ranked by premium price, with plans offering the lowest premiums listed first.
But insurance plans with lower premiums generally have higher deductibles. Gina Brown, 37, of Nashville, was paying about $155 a month for a Blue Cross Blue Shield of Tennessee plan, after taking account of her subsidy. But her deductible was $4,000, she said, and so she avoided going to the doctor even when she got an ear infection over the summer.
“I attempted to treat it with over-the-counter and homeopathic meds,” she said. “Eventually it went away.”
Ms. Brown recently got a job with health benefits, so she canceled the marketplace plan. Her new insurance has a deductible of $1,000, but primary care visits and prescriptions are not subject to the deductible.
“Now that I know I can go and safely just pay a co-pay,” she said, “it makes me feel better.”
Mark Yuschak, 57, of Jackson, N.J., said he had a silver plan with an annual deductible of $3,000. He discovered its limits in March.
“My wife had an incident, a digestive disorder, and we had to go to the emergency room of a hospital in Freehold, N.J.,” Mr. Yuschak said. “We presented our insurance card and filled out all the forms. They told us, ‘You don’t have a co-payment, you’re free to go.’ ”
Later, though, they received a bill “that could choke a horse,” Mr. Yuschak said — for more than $1,000. “Our insurance wouldn’t cover any of it because we had not met our deductible.”
Carol Payne, a respiratory therapist in Gilbert, Ariz., signed up through HealthCare.gov for a Blue Cross Blue Shield plan with a $6,000 deductible. She pays $91 toward her monthly premium and gets a subsidy of $353 to cover the rest.
The plans she could have chosen with lower deductibles were from insurers that “were not as reputable,” Ms. Payne said. She has used the insurance for preventive care and an emergency room visit after a car accident.
“I’m just doing what I can to keep myself healthy,” she added. “I mean, $6,000 — do they think I’ve just got that under my mattress?”
People with low incomes may qualify for subsidies that reduce their deductibles, co-payments and other out-of-pocket costs. The assistance is available to people with incomes from 100 percent to 250 percent of the poverty level (from $23,550 to $58,875 for a family of four), but only if they choose a silver plan.
Consumers also benefit from a provision of the Affordable Care Act that limits out-of-pocket costs, which include deductibles. The limit this year is $6,350 for an individual and $12,700 for a family plan. But in general, the limits apply only to care provided by doctors and hospitals in a plan’s network and do not cap charges for out-of-network care.
Dr. Rebecca Love, of Moab, Utah, is well on her way to passing that limit. Dr. Love, 63, who has degenerative arthritis and a host of other health problems, pays $422 a month in premiums for a plan that has a deductible of $6,000. But she has already paid more than $6,000 in medical costs this year that did not count toward her deductible because the doctors and hospitals — more than 100 miles away in Grand Junction, Colo. — were not in her network.
To see certain specialists in her network, Dr. Love said, she would have had to travel to Salt Lake City, which is much farther away and requires driving through a treacherous mountain pass.
“Medical care costs too much and health insurance as it stands doesn’t address this,” she said. “What have we become?”
Ms. Wanderlich, who had suffered the brain hemorrhage, was even avoiding preventive care until last month, when she had to get a prescription renewed and her doctor’s office required her to be seen first. Grudgingly, she went for an annual physical exam on Sept. 12. She was relieved to learn that she owed only $30 for the visit; the provider billed her insurer more than $1,200.
When the next open enrollment period begins on Nov. 15, Ms. Wanderlich said, she will probably switch to a plan with a narrower network of doctors and a smaller deductible. It will probably mean losing her specialists, she said, but at this point she is resigned.
“A $6,000 deductible — that’s just staggering,” she said. “I never thought I’d say this, but how many minutes until I get Medicare?”
After his recent herniated-disk surgery, Peter Drier was ready for the $56,000 hospital charge, the $4,300 anesthesiologist bill, and the $133,000 fee for orthopedist. All were either in-network under his insurance or had been previously negotiated. But as Elisabeth Rosenthal recently explained in her great New York Times piece, he wasn’t quite prepared for a $117,000 bill from an “assistant surgeon”—an out-of-network doctor that the hospital tacked on at the last minute.
It’s practices like these that contribute to Americans’ widespread medical-debt woes. Roughly 40 percent of Americans owe collectors money for times they were sick. U.S. adults are likelier than those in other developed countries to struggle to pay their medical bills or to forgo care because of cost.
California patients paid more than $291,000 for the procedure, while those in Arkansas paid just $5,400.
Earlier this year, the financial-advice company NerdWallet found that medical bankruptcy is the number-one cause of personal bankruptcy in the U.S. With a new report out today, the company dug into how, exactly, medical treatment leaves so many Americans broke.
Americans pay three times more for medical debt than they do for bank and credit-card debt combined, the report found. Nearly a fifth of us will hear from medical-debt collectors this year, and they’ll gather $21 billion from us, collectively.
Types of Debt Collected From Consumers in 2013
The company also found that 63 percent of Americans have received a medical bill that was more than they expected to pay. Some of that is a result of hospital errors: Nearly half of the Medicare insurance claims NerdWallet examined contained billing mistakes.
Another contributing factor is that hospitals charge wildly different amounts for the same procedures. In the most extreme example NerdWallet analyzed, the highest charge for an inpatient stay for severe intestinal bleeding was 54 times higher than the lowest charge. At most, California patients paid more than $291,000 for the procedure, while those in Arkansas paid just $5,400.
It’s worth noting that the Affordable Care Act’s individual mandate and Medicaid expansion might alleviate some of this debt strain over the coming years. But otherwise, patients have few options beyond attempting to research hospital charges ahead of time—which is probably the furthest thing from a person’s mind when they are most in need of a hospital.
Walmart Stores, the world’s largest retailer and the nation’s largest private employer, said on Tuesday that it would terminate health insurance coverage for about 30,000 part-time workers, joining a string of retailers that have rolled back benefits in response to the Affordable Care Act.
Starting on Jan. 1, Walmart will no longer offer insurance to employees working less than an average of 30 hours a week, a move the retailer said was in response to an unexpected rise in health care costs.
“This year, the expenses were significant and led us to make some tough decisions,” Sally Welborn, Walmart’s senior vice president for global benefits, said in a blog post announcing the changes.
The workers losing their coverage make up about 5 percent of the company’s part-time work force of about 600,000, including in-store, logistics and corporate workers, said Brooke Buchanan, a company spokeswoman. Walmart did not disclose what percentage of the part-time work force would be left without coverage. Many part-time employees were never covered for a variety of reasons.
Over all, Walmart employs about 1.3 million people in the United States, and provides health coverage to about 1.2 million workers and workers’ family members, Ms. Buchanan said.
In scaling back coverage for part-time employees, Walmart joins retailers including Home Depot, Target and Trader Joe’s, which have dropped benefits in response to the Affordable Care Act, the health care overhaul enacted by the Obama administration. In 2011, Walmart eliminated health insurance for employees working fewer than 24 hours a week.
The company said that the health law’s introduction had prompted larger-than-expected numbers of employees to enroll in its health plans, driving up expenses.
The retailer expects to spend an additional $500 million on health care costs in the United States this year, it said in a filing in August, far more than the $330 million increase it forecast in February.
The Affordable Care Act, the most comprehensive overhaul of the nation’s health care system in decades, requires most Americans to enroll in health insurance or face a tax penalty. From Jan. 1, 2015, it will require companies with 50 or more employees to offer health insurance coverage to employees working at least 30 hours a week, or pay a penalty.
Employees working less than that can apply for subsidies in new government-run insurance exchanges that opened last year. But some experts say that the exchanges make it easier for employers like Walmart to eliminate health care coverage for part-time workers.
Walmart said that it would work with a health coverage specialist to guide workers through the process of finding alternative coverage.
It also said that it would raise health insurance premiums in 2015. But it said that its premiums remained lower than the industry average, citing figures from the human resources consulting firm Aon Hewitt. Representatives at Aon Hewitt were not immediately available to confirm that.
Stuart Appelbaum, president of the Retail, Wholesale and Department Store Union, called Walmart’s move “shameful.”
“Not only do they deny their workers full-time jobs, now they’re denying them health care coverage,” Mr. Appelbaum said.
Still, health benefits for part-timers are the exception rather than the rule among retailers. Last year, 62 percent of large retail chains offered no health care benefits to their part-time workers, up from 56 percent in 2009, according to the New York-based consulting firm Mercer.
Beth Umland, Mercer’s director of research for health and benefits, said that more retailers were likely to eliminate health care coverage for part-timers. “Now employees can go somewhere else to get coverage,” she said. “It’s an easier decision to make than before.”
Nancy Reynolds, 67, who has worked part time at the Walmart store in Merritt Island, Fla., for the last six years, said she worried that losing her insurance would mean higher costs for treatment of her diabetes, glaucoma and arthritis. Ms. Reynolds is covered by Medicare, but she said that she relied on company coverage to supplement it.
“I depend on Walmart’s health care,” Ms. Reynolds said. “I’m not sure what I’m going to do.”