Coverage

IN THE STATES: San Francisco's Ride on the Health Reform Trolley

Paul Testa — Thu, 03 Jul 2008 16:54:00 -0400

Rice-A-Roni may be the San Francisco treat, but health reform has been the topic du jour of late for the Bay City. As the San Francisco Chronicle noted, yesterday marked the one-year anniversary of Healthy San Francisco—the city’s ambitious plan to make health care accessible and affordable to its uninsured residents.

Like a cable car descending Nob Hill, there have been a few bumps along the way—the growing pains health reform—as well as uncertaintity because of a pending decision from the Ninth Circuit regarding the legality of the city’s efforts. Still, the plan is an innovative effort from one of the cities described in a recent Families USA report as being on the front lines of America’s health care crisis.

The key elements of San Francisco’s plan are laid out nicely here, but we’d like to highlight two points from the initiative:

An emphasis on medical homes in which a participant chooses one of 27 participating clinics to coordinate their care.
Shared and individual responsibility represented by income-based cost-sharing on the part of individuals and an employer contribution for firms with more than 20 employees.

New America health policy program director Len Nichols provided a positive and realistic assessment of the plan for the Chronicle article:

For a city to try to do it at all is pretty amazing. Ultimately, we're going to need federal help to make health care access a reality in this nation, and it's impressive San Francisco is trying to do it in whatever patchwork way they can.

COVERAGE: Living on a Prayer

Len Nichols — Thu, 03 Jul 2008 14:35:00 -0400

If a pastor gets sick, given a choice between "a wing and a prayer" or "a wing and a prayer and health insurance," he or she would probably choose the second option—if it's available.

A recent survey by the National Association of Evangelicals found that the churches and related evangelical organizations are having the same challenges as other Americans, and jerry-rigging some of the same partial solutions. But significant numbers of pastors—the format of the NAE's survey wasn't designed to produce a precise estimate—go uninsured. Others get their coverage through their spouse's job, or by holding down a second job outside their church that gives them access to coverage. Those over 65 can get Medicare. Some are poor enough to qualify for Medicaid. Young pastors who are relatively healthy sometimes opt to get a private policy instead of buying into a church or denomination-sponsored plan, meaning the bills go up for the older and sicker.

"Only a few of our churches are adequately addressing this problem," one denominational leader was quoted as saying in an NAE report. "We tried two or three items to provide health insurance, but we have not been able to make it work," lamented another.

"This is a large and growing problem for American pastors and churches,' said Leith Anderson, NAE president, "So many churches are small and too many pastors are uninsured. There is no room in limited budgets for premiums or no way to get adequate insurance at any price. As clergy age with the rest of America's population, we may see a growing list of pastors entering retirement with bankrupting medical bills."

The NAE has been instrumental in cultivating support within the Christian community for addressing global warming and issues of environmental sustainability more generally. We have hope they might someday come to play a similar role in broadening support for a more sustainable health care system that works for all. I was in West Virginia last week for a series of meetings coordinated by the West Virginia Council of Churches. Evangelical churches are not part of the Council there, but representatives from their community did come and participate in two of the meetings in Charleston. Let's just say we all learned a lot, and hope and expect to continue dialogue about what Scripture has taught us ought to be and what health policy analysis has taught us can be.

REFORM: Kennedy Spurs Bipartisan Conversations about Health Legislation

Joanne Kenen — Wed, 02 Jul 2008 17:10:00 -0400

We perk up when we hear phrases like "bipartisan support for a major healthcare initiative," especially when the bipartisan push is coming from Senator Edward Kennedy. Today's Boston Globe reports that while Kennedy recuperates from his brain tumor surgery, his office has begun a series of bipartisan meetings with an array of health care specialists to prepare for a major push to cover all Americans when the new president takes office next year. The paper reported:

Those involved in the discussions said Kennedy believes it is extremely important to move as quickly as possible on overhauling the healthcare system after the next president takes office in January in order to capitalize on the momentum behind a new administration.

Kennedy is chairman of the Senate Health, Education, Labor and Pensions Committee; Obama is a member, and his Senate staff has attended the roundtable discussions, the Globe reported. But Republican staff is also involved, as Kennedy tries to identify areas of agreement, possible starting points. Kennedy has made health care a signature issue in his 45 years in the Senate, and even before his aggressive brain cancer was diagnosed he made no secret that he wants to seize the moment and act next year.

"You have got to think this will be the Ted Kennedy Health Reform Act, because he's a beloved figure and he's championed the issue for so long," said John Rother, policy director for the AARP, which has been involved in the discussions. "There are a lot of unknowns right now, but what we do know obviously is he is very close to Obama, and he also has quite a network of health policy experts that he can draw from."

The newspaper reported that Kennedy's aides have also been working with a network of Massachusetts advisers, talking about ways the state's health program could possibly be adapted to a national model.

The many lessons of the 1993–94 health care reform debacle include that it was too partisan, and that the Clinton White House did not involve Congress enough in developing its plan. Kennedy is not alone in trying to do things differently this time. The Senate Finance Committee, chaired by Montana Democrat Max Baucus, in June held a day-long bipartisan summit on health reform. Oregon Democrat Ron Wyden and Utah Republican Bob Bennett have a health reform proposal that has attracted bipartisan interest. Various nonprofit groups are running bipartisan programs to help congressional staff better understand the challenges of health care reform. We know from our conversations with people around Washington that there really is a desire to do things differently this time, so we're thrilled to see Kennedy make this a priority for his country, even as he confronts his own health ordeal.

IN THE STATES: Health Reform Blossoms in Garden State

Paul Testa — Fri, 27 Jun 2008 15:00:00 -0400

Even in a time of very tight state budgets, New Jersey's governor and legislature are taking major steps toward covering all of the state's residents, according to the Philadelpia Inquirer. This week the state Senate and Assembly both passed a measure (S-1557) that would require all children to be covered and would also cover some low-income parents. They provided $8.9 million in new funds to expand FamilyCare, (the state's health insurance program for low-income children and some adults), and moved to allow insurance premiums offered on the individual market to vary based on age to make plans more affordable for younger adults and help bring them into the health insurance pool.

The move to cover all of the state's children is the first step in a two-phase plan to cover all New Jerseyans we wrote about earlier this year. The second phase of reforms will seek to require all individuals to have coverage and create a new insurance option for uninsured residents with subsidies to ensure insurance is affordable. That second phase is still subject to more political debate.

State Senator Joseph Vitale, a leader on the reform efforts in the state who recently presented the state's work at a panel at AcademyHealth, noted "It's the only way that literally hundreds of thousands of New Jerseyans who are uninsured will ever have access to affordable health insurance... It's a gateway to care that's dependable and affordable and reliable."

COST: One in Five People Report Skipping or Delaying Health Care

Joanne Kenen — Thu, 26 Jun 2008 21:48:00 -0400

One of the myths about health care in the United States that really bugs us is that everyone gets good care, rich and poor, insured and uninsured. Well, tell that to the one-in-five people—59 million people, some of whom are insured—reported skipping or delaying care in 2007. Cost was the biggest, although not the only, factor.

It’s a big alarming jump from the one in seven who reported access problems in 2003 when the Center for the Study of Health System Change did a similar survey.

In 2007, more than 36 million reported delaying care and 23 million people skipped care. That’s 59 million people reporting access problems, according to findings from the center’s 2007 Health Tracking Household Survey. The group has done the survey five times since 1997, and this is the biggest jump in a decade, particularly among Americans with insurance.

Cost was cited as the main access problem, along with rising rates of health plan and health system barriers, such as a doctor or hospital not accepting their insurance, or a health plan not covering a treatment, the study found.

“This is the most up-to-date snapshot of the access problems Americans are facing when seeking medical care, and it’s not a pretty picture, especially for insured people, who increasingly are finding that the access to care once guaranteed by insurance is declining,” said Peter J. Cunningham, Ph.D. co-author of the study funded in part by the Robert Wood Johnson Foundation.

People in poorer or fair health had more access problems than healthy people, and uninsured had more problems than insured. No surprise there. But what’s alarming is that the rate at which the insured reported problems rose by 62 percent.

And—saving what's arguably the worst news for last—the plight of poor kids. Low-income kids had experienced a lot of gains between 1997 and 2003 but that progress has been wiped out. “Low-income children encountered the greatest increase in unmet needs among all children,“ the center reported, reversing the gains they experienced between 1997 and 2003.

“The deteriorating access to care, particularly for vulnerable groups—the uninsured, people in the worst health, and low-income children—are especially disturbing,” said David C. Colby, Ph.D., vice president for research and evaluation at the Robert Wood Johnson Foundation.

Read more about the survey in this Wall Street Journal story.

POLITICS: How Voters Perceive Health Care Amid Economic Slump

Joanne Kenen — Thu, 26 Jun 2008 20:37:00 -0400

In case you needed another reminder of the burden of health care costs, a new Kaiser Health Tracking Poll: Election 2008 finds that nearly six-in-ten adults report that the economic slump is causing serious problems for them—and one in four say they are having trouble paying for health care.

People surveyed were asked about seven economic stresses. Gas prices topped the list (43 percent). About one in four cited health costs and a similar number were concerned about getting a raise or a well-paid job. Next came food prices (19 percent), credit card or other personal debt (16), stock market losses, (15) and housing costs (14).

In thinking about health care, voters are more troubled by what health care costs individuals and families than the national spending levels. Almost half (47 percent) report being most worried about what the average American pays for health care and insurance. In comparison, two in ten (19 percent) say they are most concerned about how much the nation as as a whole spends. Fewer cited worries about public health insurance programs (14 percent) or increases in what employers pay for health benefits (10 percent).

"The standard that most voters will use to gauge health reform proposals is, ‘Will it make health care more affordable for me?' " said Drew Altman, Kaiser's president and CEO.

Interestingly, most of those surveyed thought we can reduce costs, which the Kaiser analysts suggested could raise expectations for Congress to act next year. Measures which resonated as potential cost-savers included eliminating waste, promoting healthier lifestyles, malpractice reform, covering all Americans, computerized medical records, reducing unnecessary care, and forcing insurers to trim administrative costs.

Voters were ambivalent about the talk in Washington and on the campaign trail about ways of moving away from job-linked health insurance (where coverage has eroded, particularly in small businesses) to some form of individual market. Of those who get coverage at work who voiced a preference, they wanted to keep it that way by a two-to-one margin (although 43 percent said it made no difference). There are a lot of different policy ideas circulating on how to make such a shift, with various degrees of government regulation, consumer protections, and low-income subsidies. Altman writes more about that today in a separate essay—and notes that it isn't just conservatives advocating a move away from the employer-based system, some liberal groups also propose versions that they see as fairer and more secure for workers in the long-run.

Kaiser also asked some questions about how we should share the cost of the sickest people. The survey authors reported:

This is a big difference in the approaches of the two major political parties: Republican policymakers generally favor less insurance regulation, potentially with high-risk pools for those who are unable to obtain coverage on their own due to pre-existing conditions. In contrast, Democratic policymakers generally favor requiring insurers to accept anyone, regardless of their health history, and to limit how much more people who are sicker could be charged.

Overall, nearly six-in-ten (59 percent) voters say that the costs should be shared across a broad insurance risk pool, while about one-third (32 percent) say that healthier people should not be asked to pay more to subsidize sicker people.

Democrats and independents were more likely than Republicans to favor sharing costs collectively.

The poll involved a nationally representative random sample of 1,206 adults (including 1,066 who say they are registered to vote), who were interviewed by telephone between June 3 and 8, 2008.

COVERAGE: New AMA President Knows More Than You'd Think About the Uninsured

Joanne Kenen — Mon, 23 Jun 2008 20:42:00 -0400

Dr. Nancy Neilsen is not the first woman president of the American Medical Association but there's a darn good chance she is the first AMA president who at one point had no health insurance for the first three of her five kids, and accepted diapers and free samples of antibiotics from a generous pediatrician.

That was back in the 1960s, when she was a microbiology graduate student, the Chicago Tribune reports. She has also been a primary care physician, an associate dean at a medical school and a health insurance executive. She has seen contemporary U.S. medicine from an unusual number of angles, and at her inaugural speech at the recent AMA annual meeting in Chicago, she put covering the uninsured as the top priority. She declared she would use "all of the power" she has at the helm of the nation's biggest doctors' group "to let the nation know that we must cover America's uninsured."

"Her background allows her to speak the language of every physician in the country," Dr. Robert Goldberg, a fellow AMA member and friend of Nielsen's from the New York State Medical Society, told the Chicago paper.

We aren't sure exactly how next year's health reform debates will play out in Washington; we know there will be many domestic and foreign policy challenges facing the next president, whoever he may be. We look forward to hearing the AMA's voice loud and clear, keeping attention focused on the families, like Neilsen's 40 years ago, who need more from our health care system than the kindest of pediatricians can provide.

REFORM: America's Most Wanted? Sustainable Health Reform (Part II)

Paul Testa — Fri, 13 Jun 2008 12:21:00 -0400

We mentioned bank robber Willie Sutton earlier this week in our initial recap of the Partnership to Fight Chronic Disease's recent policy symposium. Sutton was one of the first criminals on the FBI's Ten Most Wanted Fugitives list. We heard another infamous list during former Senate Majority Leader Tom Daschle's symposium keynote speech when he listed the major myths standing in the way of health reform. His top three:

We have the best health care in the world. Not always. The care you'd get at the Mayo Clinic is a far cry from what you'd find at small hospital in rural Mississippi. As we've heard Daschle say before, a better description of the U.S. system would be "islands of excellence in a sea of mediocrity."
Health reform would lead to rationing. Rationing already happens in the U.S., according Daschle, but it's based on person's ability to pay.
Any new reform would cost too much. The whole reason to pursue health reform, according to Daschle, is because we can't possibly continue to spend what we do on health care in our broken system.

Daschle's last myth especially resonates. Excuse our double negative but it's not that we can't afford health reform. It's that we can't afford not to do health reform. So how do we change our system to make high quality affordable health care a reality for all Americans? Last week's symposium featured a variety of experts, including former Speaker of the House Dick Gephardt and former Congresswoman Nancy Johnson. The discussions were insightful and we'd like present what we saw as major areas of consensus:

The current system is inefficient and unsustainable. You've probably heard this for a while from a variety of sources, but Kenneth Thorpe, the Partnership's executive director, added his own take. He emphasized that our current system has been geared toward treating acute illnesses—conditions requiring urgent or immediate care—but the majority of mortality and spending in this country can be attributed to chronic diseases.

Payment reform is crucial to changing the system. Patrick Mattingly, of the disease management firm Health Dialog (no relation to our blog), emphasized that " chronic disease management and cost control won't happen without payment reform." Nancy Nielsen, MD, president-elect of the American Medical Association noted that we pay for interventions, but not for doctors to educate and motivate their patients to manage chronic disease. She stressed the need to cover everyone, adding "a patient who doesn't have insurance won't manage their disease."

There is a great deal of common ground for bipartisan reform. As Thorpe noted, there seems to be growing agreement on the health reform agenda, particularly the need to control costs and improve quality. Further, everyone seemed to agree on the need for more health IT and evidence-based medicine. Gephardt said he was impressed with the level of bipartisanship seen in the Healthy Americans Act (S. 334), a bill sponsored by Senators Ron Wyden (D-OR), Bob Bennett (R-UT), and a list of 12 other Democrats and Republicans—a list that sure beats the one that Willie Sutton was on.

VOICES OF REFORM: Consumers Union Jim Guest on the Push For Change

Joanne Kenen — Thu, 12 Jun 2008 15:08:00 -0400

We had a little e-mail chat with James Guest, president of Consumers Union, the other day about the organization's activities in educating (or empowering) health care consumers, and its role in the efforts for comprehensive national health reform. We liked that he mentioned the underinsured, a topic that's been getting a lot of deserved attention in the last few days (for instance, see today's New York Times editorial) since the recent Commonwealth Report which we wrote about earlier this week. Here's what Guest had to say:

A lot of people think of Consumers Union as a place you turn for help buying a car or a household appliance. Can you explain why national health reform is a consumer issue?

Since its founding in 1936, Consumers Union's mission has been to advocate for a fair, just, and safe marketplace for all consumers. Today, there is probably no marketplace that consumes the attention—or the pocketbooks—of the American public more than the health care system. We spend 16 percent of the gross national product on healthcare, yet 47 million Americans remain uninsured. At Consumer Reports, we're seeing through our surveys a growing new class of health-care consumers— the underinsured—-those who have insurance but not enough to cover their basic needs. In our survey, nearly one-third of people who had health insurance were underinsured with coverage so meager they often postponed medical care because of costs. Twenty-two percent of respondents who were underinsured lived in households making more than $100,000 per year.

As a result, our research also shows that more than 1-in-3 consumers have taken steps, at the risk of their welfare, to control cost by doing things like putting off a doctor's visit, declining a medical test, skipping filling a prescription, skipping a scheduled dose of a medication or cutting prescribed pills in half. These are staggering statistics that make it quite clear why this issue has become such a primary focus for a group like ours who regularly speaks to—and hears from—millions of consumers.

In the early 1990s, CU leaders advocated a single-payer health care system, and some were quite critical of President Clinton's reform efforts. But in the last few years, CU has cited several ways of achieving coverage for all Americans—single payer, employer mandate, individual mandate all among the options. Have you chosen one of these paths as the organization's main focus? And why have you broadened your approach from the early 90s?

Right now, Consumers Union is focused on the outcomes we know from our in-depth surveys, our research, our participation on various quality committees, and our activism that consumers would like to see in the health-care system rather than on the various approaches to getting there. Namely, we have three primary objectives. They are to:

Lower Health Care Costs. Contain costs for individuals and families and in the overall health care system without compromising quality of care.
Improve Quality of Care. Ensure that medical care is appropriate, high-quality, and safe.
Guarantee Coverage for Life. Ensure that every individual and family automatically has healthcare coverage for life regardless of their medical problems and at a price they can afford.

We've learned in the last 15 years that our work to improve Americans' health care involves more than just lobbying for federal reform legislation. It involves fighting for marketplace change such as getting more health care data disclosed so consumers have meaningful comparative information, pushing for doctors to exercise greater accountability and evidence-based decision making, pushing players in health care to address the misplaced incentives, providing public education, and much more.

We've all seen your Best Buy Drugs and now your new hospital ratings. How much can we really "shop" for our health care, given that plans may limit our choices, or we may be facing emergencies? And how do these consumer tools link to the broader questions of national health reform?

There's no question that rating health care providers such as insurance companies, hospitals, and doctors is not the same as rating toasters, but what we know first-hand from our 70-plus years of experience is the value publicly available comparative data has in improving the safety and performance of products and services. In the case of health care providers, we know from our focus groups that most consumers are unable to make an informed decision about a private health insurance policy that meets their needs. On the one hand, they are unaware of some valuable information resources (e.g., from state insurance departments), and on the other, information from insurance companies often is impenetrable. One participant summed it up by saying: "It's scary we are paying so much and don't understand what we are getting." In the case of doctors, we had one tirelessly crusading activist (she lost her son to a medical error) say it best when she said, "You can call up the Better Business Bureau to check on complaints with your roofer or your plumber, but right now, you have no easy way of checking on the background of your doctor." This is why our efforts at Consumers Union aren't just focusing on transforming the healthcare system, but also on helping consumers navigate it. It's not just about educating consumers about the problems but making it easier for consumers to make more informed choices—through transparent, credible (free from conflict of interest), fully disclosed (performance outcomes should be available to the public) and standardized information. Consumers are—right now— almost completely in the dark. If we help them see the light, they'll be far better advocates for change.

There are many lessons from the failures of 1993-94 health reform efforts, but what do you see as the most pertinent one for Consumers Union? How do you make sure we don't miss another opportunity?

The biggest lesson we learned from the health care reform effort in the 1990s is that while Americans were certainly united on the problem, they were not united on the solutions. And back in 1994, there was no powerful enough countervailing force to the "consumer" faces of "Harry and Louise" to convince the American public that reform wouldn't mean giving up choice or quality. Now we know that we can't develop messages on solutions until people really understand the depth of the problems. Now we know that in order to speak for consumers, we need to speak directly with them. We need this effort to come from the ground up—-not from the top down. That's why five years ago we launched a grassroots activism program at Consumers Union that, in its short tenure, has helped us pass landmark federal drug safety legislation and laws in more than 20 states to reduce hospital-acquired infections. It's also why we're spending the summer driving an RV around the country (www.coveramericatour.org) collecting compelling stories of people's troubles with the healthcare system—everyone from small business owners who can't afford to give their staff raises and continue to pay their healthcare to consumers who are waiting until they are eligible for Medicare to get the treatment they actually need now. As part of this effort, we're posting videos online, writing a blog, and holding events, and eventually some of these people will make their way with us to Capitol Hill. In order to be successful in passing meaningful health care legislation, we need to broaden consumers' understanding of the issues so that they're educated advocates for reform. And then we need to ensure that the consumer voice is heard. We intend to use everything in our arsenal to amplify that voice—through lobbying, activism, surveys, focus groups, strategic partnerships and alliances, and investigative research and journalism to name a few. For every dollar the health care industry spends lobbying, we intend to match it with consumer stories pushing for change.

REFORM: If You Hold It, They Will Come

Paul Testa — Wed, 11 Jun 2008 19:39:00 -0400

Forget about the Nationals' new stadium (you already had?), the hardest seat to get in town this summer has been at the Senate Finance hearings on health reform. We arrived 20 minutes early yesterday to find the halls of the Senate's Dirksen building packed. And for good reason, as the day's testimony on 47 Million & Counting: Why the Health Care Marketplace is Broken was as refreshing as the room's AC (68.2 degrees!)

The hearing opened with video testimony from Lisa Kelly, of Lake Jackson, Texas. Kelly is one of the 25 million underinsured Americans we wrote about yesterday. Kelly purchased a limited benefit plan with a $189 monthly premium that provided fine coverage for her allergy pills but was woefully inadequate when she was diagnosed with leukemia in 2006. Kelly's trials were the subject of a recent piece in the Wall Street Journal. Forced to dip into her savings and currently saddled with nearly $137,000 in medical debt, Kelly, was asked what she thought Congress should do. Her answer was particularly moving:

"I don't know what's the right or wrong thing to do. I know health care is expensive and that doctor's time and medicine is expensive. But they were charging me for things I didn't need. Everybody should be able to go in and get health care whether you have money or not."

Kelly's testimony set the tone for a particularly interesting hearing that focused on why our current system fails to meet the needs of so many Americans and what to do about it.

Raymond Arth, president and CEO of Phoenix Products, in Avon Lake, Ohio, presented the plight of small businesses on behalf of the National Small Business Association. Until 2003, Arth said, he was able to provide acceptable coverage for his employees while managing to keep costs down. But then, the numbers started to catch up with him. In 2007, his firm faced a 22 percent increase when he tried to renew the insurance plan, He switched to a high deductible plan and was "forced to pay a little more to cover much less." This year renewal rate is 35 percent above last year's, and Arth says he's run out options to deal with what amounts to a $40,000 increase in premiums.

Aetna's CEO Ron Williams, presented the insurers' perspective, stressing that rising premiums and deductibles were a reflection of rising health care costs. He came out in support of an individual coverage requirement, and suggested if such a system could be achieved, bringing everyone into the system, insurers could abandon the current business model of medical underwriting and risk selection and instead focus on improving their members health and managing the quality of care they receive.

Mark Hall, a professor of law and public health at Wake Forest University, rounded out the testimony by emphasizing the "80-20 rule" of health care, which is that about 80 percent of the costs come from 20 percent of the population (for a more academic examination of this distribution check out this recent Health Affairs article). Such a distribution creates incentives for medical underwriting and leads to natural risk segmentation as healthier people select plans with the benefits (and costs) they expect to need. The key, Hall said, was to achieve risk pooling independent of health status.

With all likelihood, the Nationals' season ends in September and D.C.'s Southeast sluggers would do well to add a lefty-righty combination similar to Senate Finance chairman Max Baucus (D-MT) and ranking member Chuck Grassley (R-IA), whose bipartisan leadership on health reform has been impressive early on. Of course, there's no offseason for health reform, and we hope Baucus, Grassley, and all of Congress will continue to step up to the plate.