Archive for May, 2009

The Public is Ahead of the Politicians

Why are our representatives in Washington so afraid of government involvement in health care that even a public plan option is being handled gingerly? A CNN/Opinion Poll issued May 29, 2009 found that an overwhelming 63 % of those polled favored an increase in the federal government’s influence over their own health care plans in an attempt to lower costs and provide coverage to more Americans. The poll indicates a split on increasing taxes to do so. This is all evidence of why a robust public plan option – which will save tax dollars, compared with private options – must be part of any health care reform solution. Are you listening Congress?

May 29, 2009 at 8:54 pm 1 comment

The Indispensible Dozen: What We Need In a Public Health Care Plan

It seems hard to believe to us, but there is actually a debate going on about whether health care reform should include a public plan option – as opposed to only private insurance plans. (Never mind whether health care reform should simply be one public plan, or a choice of public plans!)

We have discussed why a public plan is necessary. The inevitable conclusion is that any reasonable approach to health care reform must include, at the very least, a public option.

But what would a public plan look like? What elements of a public plan are essential? Here are the indispensible dozen elements:

1. Like the long-standing, public Medicare program, the plan should be available to all, throughout the United States, without exclusions for pre-existing medical conditions, and with community rating (the same base premium for all, regardless of age, medical history or other “category” that the person may fit into).

2. The public plan should resemble the traditional, public Medicare program. (Polls show that 80% of Medicare beneficiaries are either “extremely” or “very” satisfied with Medicare.) In designing health care reform policy makers should learn from the successes of traditional Medicare and the costs of privatization.

3. The public plan, as well as any other plans authorized by Congress, should receive additional payments or “risk adjustments” for sicker or more costly patients. This is necessary so no plan ends up being a default for more costly people with the result that it becomes insolvent.

4. The public plan’s benefits should be at least as broad as traditional Medicare, and should be enhanced by adding coverage for mental health, dental services, long term care, vision care and eyeglasses, hearing aides, and increased coverage for preventive services.

5. A greater emphasis should be placed on primary care, especially for manageable chronic conditions. This emphasis should be financially encouraged with incentives to providers and enrollees. Perhaps most importantly, the plans should have a clear rule that care designed to maintain (as well as to “improve”) function or health status is covered.

6. Out-of-pocket expenses should be limited. Public plan premiums (and those of private plans, if they are to be offered) should be affordable, with no co-insurance or deductibles. Although there is a school of thought that requiring patient co-pays makes them better health care consumers, studies show that when cost sharing required, many people cannot afford it and forego necessary medical care or prescription medication. The result: more serious medical conditions and more costly care down the line. (Rosenthal, What Works in Market-Oriented Health Policy, New England Journal of Medicine, May 21, 2009)

7. Subsidies should be provided for lower income persons, based on a sliding scale, which would assist with premium payments. Premium costs should capture regional costs differences, as should subsidies to lower income people.

8. The public plan should have the authority to negotiate prices with health care providers and pharmaceutical companies.

9. Enrollment procedures and time frames in the public plan should be user-friendly. Eligible persons should be able to move freely between whatever plans are offered, particularly when there has been a change in an employer’s health care coverage or a change in the individual’s circumstances.

10. There should be a simple, easy to use appeals process for (public and private) plan participants based on the Medicare appeals process, and assuring that all current due process and appeal protections guaranteed to Medicare beneficiaries are afforded to participants in plans created through health reform, including the public plan and any private plans.

11. The public plan should include financial payments to providers for offering interpreter services and for translation of materials into the major languages of the enrollees whom they serve. Education and training should be offered to providers to assure that treatment and patient education is culturally relevant, in order to assure positive health outcomes and minimize the need for more expensive care down the line.

12. US citizen-children and the parents of those children, if the parents reside in the United States, should be eligible to purchase insurance through the public plan.

These dozen essential elements of health care reform would ensure that enrollees are able to access comprehensive, affordable health care and achieve positive health outcomes at a reasonable cost to society.

Isn’t that what health care and health care reform should be all about?

May 22, 2009 at 7:13 pm Leave a comment

Private Insurance Interests Trying to Kill Key Plank of Obama Plan

A recent Washington Post article alerted us to TV ads that will be appearing on the airwaves soon. The ads, from the private insurance world, are a scare tactic to drive people off the idea of a public health care plan.

May 21, 2009 at 8:35 pm Leave a comment

A New Day Dawns for Oversight of Private Medicare Plans

With the advent of the Obama Administration, we have seen a new philosophy towards the private insurance plans that contract with Medicare under the Medicare Part C (Medicare Advantage) and Medicare Part D (prescription drug) programs.

No longer will the Medicare agency “partner” with the Medicare Advantage and prescription drug plans “to design and provide a variety of high quality health care products…..” as the agency said in 2009. This Administration is not about partnering with the private entities that it pays to provide health coverage to Medicare beneficiaries. Instead, Medicare will be looking closely at how these plans operate and what they do with the billions of federal dollars they receive. For example:

• Medicare has told current and potential Part C and Part D plan sponsors that it will no longer accept (during the application process for 2010) the incomplete applications, blank documents and spread sheets, and late filings that it has accepted in past years.

• Medicare announced that it is reducing Medicare Advantage payments for 2010 to account for “up-coding” by Medicare Advantage plans. Plans “up-code” the disease codes for their enrollees, i.e., claim that their enrollees have gotten sicker, in order to receive higher payments. The problem is that the private Medicare Advantage plans claimed an increase that was actually greater than the increase for the Medicare population.

• The President’s budget, released today, May 7, 2009, includes a focus on private Medicare plans and additional funding for greater oversight of the Medicare Advantage and Medicare prescription drug plans, as part of the overall effort to reduce fraud, waste and abuse in the federal government.

These changes are good for the fiscal integrity of the Medicare program, for the older people and people with disabilities who are served by the program, and for all Americans. What a breath of fresh air.

May 7, 2009 at 7:23 pm Leave a comment

Private Insurers Desperate to Avoid Public Plan

The following is from the National Health Law Program ( It illustrates very clearly that a public option for health care is the most efficient solution to our nation’s health care woes, as evidenced by the insurance industry’s desire to derail such a plan.

We offer the following for the benefit of anyone who might still be even slightly in doubt about the best way to provide people with health coverage that they want and need. Everyone involved in health care reform (and a 2 to 1 majority of the American people, whose opinion will apparently not be terribly involved in health care reform) knows that providing coverage through a public plan is the right answer. This is vividly demonstrated below by the quite remarkable testimony of the insurance industry, and Republican public plan opponents… The former is now begging to be regulated, and promising to abandon some (but of course not all) of its worst current abusive practices, rather than face the specter of a public plan option with which it knows it cannot compete. The private insurance industry’s Republican apologists (here embodied by Sen. Cornyn of Texas), for their part, have suddenly lost their stomach for market competition if one of the options is a plan not premised on maximizing profits (and therefore minimizing those things that eat into profit, like coverage, e.g.). At any rate, the following should brighten the day of all those who have known the right answer all along and watched with dismay as those in Washington engage in their Kabuki theater aimed at avoiding the obvious.

Cong Daily 5.6.09 AM
By Anna Edney

In a rare sight on Capitol Hill for any industry, health insurers practically begged senators Tuesday to regulate their livelihood rather than subject them to the fierce, and potentially lethal, competition that would ensue if lawmakers unleash a government-run public insurance option on them.

“We accept the premise that the system is not working today and needs to be reformed and, in fact, we need very clear, specific government regulation,” Karen Ignagni, president of America’s Health Insurance Plans said.

AHIP also said insurers would stop discriminating based on gender, which typically leaves women paying more than men.

AHIP has suggested insurers are willing to drop conditions for insurance
coverage and variations in premium costs depending on how sick a person is.

Ignagni spoke at a roundtable discussion with the Senate Finance Committee and other stakeholders. She elaborated after the event that she envisions the government setting a minimum health benefit package and enforcing the limits through penalties she said AHIP would help design. She admits the request is unusual.

“It’s radical for an industry working in a market to say ‘Renovate the
rules. Here’s the road map,'” Ignagni said.

Much of Tuesday’s three-hour discussion focused on the public option. It’s a vexing topic for Finance Chairman Max Baucus, who is trying to find compromise for some Democrats who insist on one and Republicans who vehemently object. Showing how the rhetorical flourishes will be shaped, a few Democrats Tuesday renamed the public option the “consumer-oriented health” plan, while Sen. John Cornyn, R-Texas, dubbed it the “Washington-directed unfair competition” plan.

Democrats and many patient and consumer groups argue a public option will increase competition and hold private insurance companies accountable, while Republicans and insurers maintain a public option would drive insurance companies out of business.

Ignagni contends the public option idea stems from thinking formed before insurers came to the negotiating table. Instead, she says, healthcare coverage can expand and insurance companies can be held more accountable with changes that negate the need for a public option.

“What we are proposing is a wholesale change and a complete overhaul of existing regulation, so it would be set out at the federal level, clearly, transparently hitting the mark with respect to: No one falls through the cracks; no one is discriminated against because of pre-existing condition; no one has to pay according to health status and there would not be gender differentiation,” Ignagni said. “That essentially is the thrust of what folks have quite correctly talked about needs to be done.”

Baucus posed the critical question of who should be responsible for coming up with a minimum health benefit package. “There’s those over the last couple, three years that have suggested a medical board that would insulate members of Congress from the onslaught of every group under the sun that wants to be covered,” Baucus said. “Others say, ‘No, no, no, no, no that’s too much big government. That’s socialism.'”

Even though they could not agree on a public plan, participants at the
roundtable agreed for the most part that Congress should not be involved in making such policy decisions.

“Anyone other than the people here, because I think it is an incredibly
important decision and politics shouldn’t play a role,” Andy Stern,
president of the Service Employees International Union, said.

Ron Pollack, executive director of FamiliesUSA, echoed Stern but suggested Congress take an active role in setting limits on out-of-pocket costs to keep health coverage affordable.

May 6, 2009 at 3:25 pm Leave a comment

The Cart Before The Horse?

It’s time to change the conversation about health care reform from protecting private insurance companies to protecting the American people. Senator Charles Schumer is quoted in today’s New York Times as saying any public plan included in health care reform must comply with private insurance requirements.

Senator Schumer has it backwards. Since when is health care for Americans about making things work for private, profit-making insurance companies? Isn’t the moral imperative to provide for the medical needs of American citizens? If we are looking to equalize public and private offerings, how about eliminating profits for private companies, requiring standardized benefits, notices, appeal rights, and full due process, with full and complete access by the public to all their records – as would be the case with a public plan.

May 5, 2009 at 4:57 pm 1 comment

Encore: More About the Costs of Private Medicare

Once again we hear that private Medicare, euphemistically known as “Medicare Advantage,” costs billions of dollars more than the traditional public program. A report issued by the Commonwealth Fund on May 4th finds that the private plan model is draining Medicare and taxpayers – and providing little in exchange. This nonsense must end as soon as possible. Why, with all we always hear about Medicare fraud, do these outrageous subsidies continue?
And please, remind policy makers not to repeat this unaffordable waste in Health Care Reform!


Medicare Advantage plans will receive $11.4 billion extra: report
By Rebecca Vesely
Posted: May 4, 2009 – 5:59 am EDT

Medicare Advantage plans this year will receive $11.4 billion in extra payments above the cost of traditional fee-for-service Medicare, a 34% increase over 2008, according to a report released by the Commonwealth Fund.

Since Medicare Advantage plans became available in 2004, the federal government has made $43 billion in supplemental payments to private health insurers administering these plans, according to the study by Brian Biles, professor of health policy at George Washington University, and colleagues. Extra payments this year averaged $1,138 per member, or 13% above Medicare fee-for-service costs, for the total 10 million Medicare Advantage members.
The 34% year-over-year increase was because of higher payment rates and increasing enrollment in Medicare Advantage plans, according to the study, which used Medicare and Commonwealth Fund data. “We have to ask ourselves whether this is the best use of our healthcare dollars,” Biles said in a written statement.
Visit for additional information.

May 4, 2009 at 6:01 pm Leave a comment

Health Policy Expertise

We provide effective, innovative opportunities to impact federal Medicare and health care policies and legislation in order to advance fair access to Medicare and quality health care.

Judith A. Stein, Executive Director

Contact us by email
for a free consultation,
Or call at (202) 293-5760.
Se habla español
May 2009


%d bloggers like this: