Health Insurance

VOICES OF REFORM: Geisinger's "Experiment of Scalability"

Dr. Glenn Steele, the president and CEO of Geisinger Health System, recently co-authored an article in Health Affairs and appeared at a Health Affairs forum here in DC to talk about the innovations at Geisinger, and the ways that Geisinger's unique characteristics might limit their adaptability elsewhere. Geisinger is both a health plan and a health network spanning 41 counties in Pennsylvania, and it has an unusual mix of Geisinger and non-Geisinger physicians, of open-and closed-staff facilities. It is blazing trails on many fronts, in chronic and acute care, from medical homes to its ProvenCare initiative for certain acute inpatient conditions and procedures.

We spoke with Dr. Steele recently and turned his question around. We weren't so much interested in the limits of Geisinger's example; we wanted to know what would work elsewhere—which of those trails could be followed or adapted by others. To our relief, Dr. Steele told us that other hospitals and policy experts have been flocking to Pennsylvania recently trying to answer that precise question. And the answer is that quite a bit of it would work elsewhere.

COST: Meals or Meds?

Another reminder of the way the economic crisis is adversely affecting our nation's health. More people appear to be skimping on their prescription drugs because they can't afford them.

In the first eight months of 2008, the number of prescriptions dispensed in the United States was slightly lower than the comparable months of 2007, reversing a decade-long trend, according to a recent analysis of data from IMS Health, a research firm that tracks prescriptions.

Cost may not be the only factor. Headlines about safety concerns of a few drugs, and the over-the-counter availability of some former prescription medications may play a role, according to a New York Times story on the trend. But doctors and other experts say consumer belt-tightening is a big factor in the prescription downturn, as is the higher co-payments that insured consumers face. And these figures reach only through August, before the recent weakening of the economy and the banking crisis.

"People are having to choose between gas, meals and medication," said Dr. James King, the chairman of the American Academy of Family Physicians. A family practitioner in rural Tennessee, Dr. King said he's seen some of his own patients stop taking their medications or skip doses to stretch out a prescription.

IN THE STATES: Hawaii Cuts Back on Kids' Coverage

We usually like to point out good news from state health reformers, partly because it helps break down the mindset that fixing health care is Mission Impossible. Today however we've got some bad news: the demise of a brief experiment to make sure that every child in Hawaii has health insurance.

Gov. Linda Lingle's administration cited a budget shortfall as its reason for ending the seven-month old program. A state health official said that families were dropping private coverage so they could get into the state-subsidized plan.

The state said it would stop paying two weeks from now, on Nov. 1, but the private partner Hawaii Medical Service Association (part of Hawaii's Blue Cross Blue Shield) said it will keep the program intact through at least the end of the year, financing it from reserve funds. The state had been paying $50,000 a month, or about $25 per child, with about 2,000 children under age 18 currently enrolled. To be in the HMSA Keiki Care plan, a child had to be uninsured for the previous six moths and not be elibile for other state or federal coverage, such as Medicaid or the Hawaiian SCHIP program.

COST: Scrimping on Care

People aren't just feeling the economic crunch in their pocketbooks. They are feeling it from head to toe—literally.

The Washington Post this week had a good story showing how even insured people, facing higher co-pays and deductibles than in the past, are delaying recommended or even necessary health care. The uninsured, of course, are cutting even more deeply, or racking up debt--for themselves, and sometimes even for their kids.

The number of people who have gone without a prescription, tapped into retirement savings to pay for health care or skipped a doctor visit for themselves or a child has risen since last year, according to a survey released this summer by the Rockefeller Foundation and Time magazine. They are cutting drug doses in half, delaying screening for cancer and other conditions, and trying home remedies. Some may eventually face more serious, and more expensive, conditions if they don't catch problems early.

Ann Pietrangelo, for instance, told the Post she was skipping her MRIs and avoiding going to the doctor as much as possible for her multiple sclerosis. Her MS drugs cost her $500 a month, and there is no generic alternative. And that's with insurance.

With the economy in trouble, it's likely to get worse.

POLITICS: The $64,000 -- Er, $5,800 -- Question

For the health care cognoscenti, the most puzzling moment of last night's debate was probably when John McCain said, "The average cost of a health care insurance plan in America today is $5,800."

Where'd he get that? The figure most commonly cited—and we've heard it before on the campaign trail this year—is $12,680 for a family plan. That comes from a Kaiser Family Foundation survey. That $5,000 tax credit McCain promises doesn't go quite as far in paying for a $12,000 plan.

For a minute we wondered if McCain had just misspoken, that he was confusing the cost of a family plan with the cost of covering an individual (about $4,700, according to the same Kaiser data). Or maybe he was time-traveling (family coverage cost about $5,800 a decade ago).

COVERAGE: Into the Wild? Additional Risks of Selling Insurance Across State Lines

We used to cross state lines to buy fireworks, but recent analysis by the New America Foundation suggests that selling health insurance across state lines—far from providing more "bang for our buck"—might cause the insurance market to go up in smoke.

On Monday, we looked at the direct impact of such proposals on the insurance market. The bottom line of the de facto deregulation was not pretty, leading to higher premiums for many Americans, decreased benefits and less access to care. Today, we'll look at the effects of such proposals on market competition, as well as what would happen if selling health insurance across state lines was also paired with a proposal to eliminate the tax preference for employer-provided health coverage.

Proponents of selling insurance across state lines claim it would increase competition among insurers leading to lower premiums for consumers. Such reasoning falls short on two main accounts:

COSTS: When Belt-Tightening Means Giving Up ... Chemo

For millions of Americans, an economic slump doesn't mean belt-tightening. It means going without health insurance. Cutting back on preventive care. Foregoing chemotherapy

News stories from across the country describe how those scary gyrations on Wall Street hit health care on Main Street. USA Today reports on a study (not a random sample but still informative) that found that one-in-eight people with advanced cancer turned down recommended care because of the cost. For people with income under $40,000 the rate was one-in-four. New cancer treatments are often expensive, but more of the costs are shifted to patients, even those with insurance. From 2003 to 2006, insurers' cancer care costs rose a very steep 53 percent. But patients share of the costs more than doubled.

McClatchy newspapers profiled a couple in Pennsylvania, where both the husband and wife have chronic conditions. She's now living off Social Security disability payments because of her autoimmune disease; his rare nerve disorder causes attacks of debilitating pain that has interfered with his ability to work steadily as a carpenter. They are insured, for at least a few more months, but they are still paying about $25,000 out-of-pocket each year.

COVERAGE: Uninsured ISO Insurance

We’ve been writing this week about the ways that proposals to allow people to shop for insurance across state lines would not strengthen the individual market through choice and competition, as advocates for such policies argue. To the contrary, it would weaken that market, making it even harder for older people or those with a less than stellar health history to get affordable coverage—or even not so affordable coverage.

Along similar lines, The Wall Street Journal’s Health Blog reports on a new study that found that 15 percent of the people looking for insurance online were “uninsurable” because of preexisting conditions ranging from a past C-sections to obesity. The Health Blog added, “The report’s authors point out that the findings don’t necessarily mean the uninsurable will never get health insurance. But if they do, it would be extremely expensive and probably wouldn’t cover the pre-existing condition at issue.”

HEALTH POLITICS: Big Business Sees Flaws in McCain Health Proposals

Turns out it's not just Barack Obama and liberal Democrats finding fault with John McCain's health care proposals. According to today's New York Times, rather than thinking John McCain's health care proposals are cool, business is rather cool toward John McCain's health care plan.

Big Business and Small Business alike told the NYT's Kevin Sack that McCain's plan would accelerate the erosion of employer-sponsored health insurance that still covers 62 percent of Americans under age 65. They didn't think it would do much to cover the uninsured, and they were skeptical of his contention that his approach would stimulate competition and bring down cost. To the contrary, groups like the Chamber of Commerce said they thought that the way McCain has structured his free market approach that emphasizes families using tax credits to help pay for coverage through the individual market would be very hard on small businesses and old-line manufacturers.

HEALTH POLITICS: Still Think Health Care is Off the Table???

If you thought that the economic crisis had wiped health reform off the issues map, think again. Health care is red hot on the campaign this week.

Obama has been speaking about health care on the stump, arguing McCain has a "radical" plan that will shift costs to families. Obama is running at least four TV commercials on health care (see ads called "Coin," "Mother" "Two Extremes" and "The Ultimate Bridge to Nowhere"). We haven't spotted any health-policy focused ads from McCain, and we don't see any on his web site. (Please send us a link if we've missed it).

Obama attacks McCain's health plan on numerous fronts—how the plan to tax benefits and shift people into an individual market would probably have fewer patient protections than it has today; how McCain's plan would undermine employer-sponsored health plans, and the lack of protections for people with pre-existing conditions. In the ad called "Two Extremes" Obama also takes on the McCain campaign for accusing him of orchestrating a government-takeover of health care, and then outlines the way his own proposal will preserve the parts of the employer-based private system that work today while fixing what's broken.