SUMMARIES OF  Jan-June 2009 REPORTS

• Massachusetts' Health Care Reform Efforts Continue To Evolve
• Trends In Underinsurance
• Profiles Low-Income Adults
• Bidding In Medicare Advantage
• $31 Billion A Year On Health Insurance Plan Interaction
• Medicare Comes At A High Price
• Up To 66 Million Americans Could Be Uninsured By 2019
• Problems Of Low-Income Individuals
• Family Put Off Medical Care
• Transform Safety-Net Clinics
• Women Skipping Health Care
• Cost Growth Can Be Slowed
• Medicare Advantage Plans Get Extra $11.4 Billion
• Coverage For All Could Reduce Health Disparities
• Views And Experiences With Nation’S Health Care System
• Struggle To Get Patients Mental Health Services
• Medical Homes
• U.S. Economy
• Reforming Provider Payment
• A High Performance U.S. Health System
• Most Families Skimped on Medical Care Because Of Cost In Past Year
• Controlling Cost Growth
• Medicaid Physician Fees
• Women’s Health Disparities
• Employer Coverage Does Not Shield Workers
• Ensuring That Health Reform Puts People First
• Out-Of-Pocket Spending In Medicaid And Chip
• Health Care Delivery Overhaul
• Cancer Patients Confront Holes
• Cancer Patients Problems With Private Health Coverage
• A Transformed U.S. Health System
• Swiss And Dutch Health Insurance Systems
• Leading Congressional Health Care Bills, 2007-008
• Health Care Expenses Strain Family Budgets
• Impacts of a Recession
• Cost-Sharing Requirements And Limits
• Unnecessary Hospitalizations
• The Way We Pay For Health Care
• Transforming Health Care
• KAISER HEALTH TRACKING POLL
• Alternative Paths To A High Performance U.S. Health System/a> Care
• Medical Bills Linked To Nearly Two-Thirds Of All Bankruptcies

MASSACHUSETTS' HEALTH CARE REFORM EFFORTS CONTINUE TO EVOLVE

MASSACHUSETTS' HEALTH CARE REFORM EFFORTS CONTINUE TO EVOLVE, OFFERING IMPORTANT LESSONS FOR NATIONAL REFORM. Commonwealth Fund

Key Findings

1. Cost remains a key barrier to expanding the role of private insurance. People who shop for, but do not buy, long-term care insurance cite cost as the most important reason for their decision.7 Premium amounts vary by age of purchase. For individuals age 60 with no partner, the annual premiums for a typical policy averaged $2,329 across three products offered by three major carriers (Figure 1). For a couple the same age, premiums for the same policy design averaged $3,096 combined for the two people.8 If purchased at age 70, premiums would cost, on average across these products, $4,515 per year for an individual and $6,010 for a married couple. Policymakers seeking to increase the purchase of long-term care insurance will have to address its cost and the ability of consumers to pay premiums.
   
2. Health risk can deny consumers coverage. Before purchasing insurance, many consumers must undergo a detailed health screening and evaluation to determine their insurability and risk rating. Industry experts estimate that 15 to 20 % of those who apply do not get coverage.9 Policymakers interested in promoting the role of private long-term care insurance will need to seek ways to reduce coverage denial rates or provide private financing alternatives for individuals denied coverage.
3. Buyers face complex product design issues. The complexity of today’s long-term care insurance products reflects a market in which consumers traditionally have worked with individual agents to tailor products along multiple dimensions such as how much they will receive in daily benefits, how long the coverage will last, and how their benefits will be protected from inflation. Even policies with the same design elements can differ from one insurance carrier to another in even more subtle ways such as the definition of certain services. Any policy effort to expand the marketing and appeal of long-term care insurance to a broader group will require product simplification and consumer education.

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TRENDS IN UNDERINSURANCE

TRENDS IN UNDERINSURANCE AND THE AFFORDABILITY OF EMPLOYER COVERAGE, 2004-007 COMMONWEALTH FUND Commonwealth Fund June 2, 2009 Jon R. Gabel, M.A., Roland McDevitt, Ph.D, Ryan Lore, Jeremy Pickreign, M.S., Heidi Whitmore, M.P.P., Tina Ding

A study of trends in employer-sponsored health insurance found that plan enrollees’ out-of-pocket expenses grew by more than one-third between 2004 and 2007, affecting some 161 million Americans in all types of plans. Those who are sicker and poorer are often underinsured.

For many workers, health insurance is becoming prohibitively expensive, with premium shares and out-of-pocket medical expenses steadily rising. Some economists and actuaries claim, however, that employees do not have enough "skin in the game" -that higher patient cost-sharing is needed to prevent overuse of health services and keep health costs under control. Jon Gabel and colleagues analyzed medical claims and health benefits survey data to better understand changes in the financial protection workers with insurance have, their out-of-pocket expenses, the affordability of coverage, and underinsurance rates.

Key Findings

1. Among adults with employer-sponsored health coverage, out-of-pocket (OOP) spending -including premium shares, deductibles, copayments, and coinsurance -increased by 34 % between 2004 and 2007, from $545 to $729. Out-of-pocket spending rose 42 % for the 1 % of adults with the greatest medical expenses
   
2. The number of individuals living at 200 % of the federal poverty level whose expected OOP spending on premiums and medical services exceeded 10 % of income (an affordability threshold used for the study) rose from 13 % to 18 %. Affordability decreased at all incomes levels between 2004 and 2007.
   
3. Gabel and colleagues considered individuals underinsured if their OOP spending on medical services (excluding premiums) would be expected to exceed 5 % or 10 % of income. For people at 200 % of the poverty level, about 20.3 % of those with employer-sponsored insurance exceeded the 5 % threshold in 2007, up from 16.5 % in 2004.
   
4. Fifty-seven % of the increase in workers’ OOP payments was attributable to higher cost-sharing for medical services and 43 % to higher premium contributions.
   
5. While most of the increase in OOP costs resulted from growth in overall health care spending, the actuarial value of employer-sponsored insurance declined slightly as the percentage of plans with deductibles -and the average size of deductibles -grew.

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COMPARATIVE EFFECTIVENESS RESEARCH

COMPARATIVE EFFECTIVENESS RESEARCH AND EVIDENCE-BASED HEALTH POLICY: EXPERIENCE FROM FOUR COUNTRIES Commonwealth Fund June 5, 2009 Journal: Milbank Quarterly, June 2009, Kalipso Chalkidou, M.D., Ph.D., Sean Tunis, M.D., M.Sc., Ruth Lopert, M.D., Lise Rochaix, Ph.D., Peter Sawicki, M.D., Ph.D., Mona Nasser, Ph.D., and Bertrand Xerri, M.D.

This study examines the key features of government agencies created in Australia, France, Germany, and the United Kingdom to lead research into the comparative effectiveness of medical treatments, procedures, and technologies. In each of the four countries studied, the agencies have a clear mandate to produce information that will inform clinical and health policy decisions. By contrast, comparative effectiveness legislation under consideration in the U.S. Senate explicitly separates the generation of knowledge from health care decision-making. A part of the recent discussions about U.S. health system reform has focused on the need for better evidence on the comparative effectiveness of various clinical treatments. Other countries’ experiences in creating and operating comparative effectiveness research agencies may provide useful lessons to inform these discussions.

Key Findings

1. In Australia, France, Germany, and the U.K., comparative effectiveness research is driven by demand for information by those making health care policy and practice decisions, including public and private payers, patients, clinical professionals, and policymakers.
   
2. In the four countries, comparative effectiveness research agencies produce information that affects clinical and health policy decisions. By contrast, the Baucus-Conrad bill in the U.S. Senate -the leading comparative effectiveness legislation proposed -states that research findings should not be "construed as mandates, guidelines, or recommendations for payment, coverage, or treatment . . . for any public or private payer."
   
3. The international agencies rely mainly on syntheses of existing studies, rather than prospective research, owing to time and resource constraints. By contrast, the Baucus-Conrad bill would support primary research, in addition to synthesis and evaluation.
   
4. Over time, the international agencies have begun to consider cost-effectiveness, as well as clinical effectiveness.

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PROFILES LOW-INCOME ADULTS

KAISER BRIEF PROFILES LOW-INCOME ADULTS UNDER AGE 65 Kaiser Family Foundation

. As Congress and the Obama administration consider comprehensive health reform, one group likely to draw policymakers’ attention is low-income adults under age 65. The more than 50 million members of this demographic are more likely to be in poor health than other Americans, but are the least likely to have health insurance and therefore have the poorest access to health care.

A new policy brief from the Kaiser Family Foundation’s Commission on Medicaid and the Uninsured provides a window into the characteristics and insurance coverage of this important, largely uninsured population. Among the key findings:

1. Nearly a third of adults under 65 are from families earning less than twice the poverty level. Fifteen % live in poverty.
   
2. The chance of being healthy declines with income. Among the uninsured, the poorest are more likely to be in worse health and adults without dependent children are more likely to have multiple chronic conditions than others.
   
3. Medicaid currently covers most low-income children, but has limited coverage for their parents, and generally does not cover childless adults unless they are disabled, leaving uninsured a large share of low-income adults with significant health needs.
   
4. For those adults Medicaid does cover, the program improves access to care substantially and levels are comparable to those with private insurance.

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BIDDING IN MEDICARE ADVANTAGE

COMPETITIVE BIDDING IN MEDICARE ADVANTAGE June 5, 2009 By: Jaffe S Robert Woods Johnson Foundation

President Obama proposes to save $177 billion over 10 years through a new competitive-bidding system for [lucrative] "Medicare Advantage" plans. These are the private health plans that serve nearly one in four Medicare beneficiaries. In 2009 these private plans will receive an average 14% or $12 billion - more than the govern­ment would pay if beneficiaries enrolled in those plans had remained in the traditional Medicare program.

The Obama administration’s plan goes beyond other proposals to cut payments to Medicare Advantage plans. Under the Obama administration’s proposal, companies in a given geographic area would submit bids to cover Medicare beneficiaries, as they do now. But they would then be paid the average of their bids, plus some additional amounts as de­tailed below. Insurers submitting below-average bids would receive the average payment; they could use the difference between their bids and the average payment amount to provide addition­al benefits to enrollees. Companies with above-average bids would charge members a premium to make up the shortfall between the average payment and their bids.

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$31 BILLION A YEARON HEALTH INSURANCE PLAN INTERACTION

PHYSICIAN PRACTICES SPEND $31 BILLION A YEAR ON HEALTH INSURANCE PLAN INTERACTION Commonwealth Fund

The average physician spends nearly three weeks a year interacting with health insurance plans, at an estimated annual cost to practices of $31 billion, or $68,274 on average per physician per year, according to a study published as a Health Affairs Web Exclusive.

Physicians reported spending nearly three weeks per year interacting with plans, while nursing staff spent more than 23 weeks per physician per year, and clerical staff spent 44 weeks per physician per year interacting with health plans. When converted to dollar estimates, the time accounts for as much as $31 billion a year, or 6.9 % of all U.S. expenditures for physician and clinical services.

A separate study published as a Health Affairs Web Exclusive found billing and insurance tasks in a large medical group practice consume $85,276 per full-time equivalent physician -or 10 % of operating revenue. The study found that clinicians spent more than 35 minutes per day performing these tasks and that these activities required the equivalent of 0.67 nonclinical, full-time staff per full-time physician.

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EDICARE COMES AT A HIGH PRICEM

FOR THOSE WITH DISABILITIES, THE WAIT FOR MEDICARE COMES AT A HIGH PRICE Commonwealth Fund Gina Livermore and David Stapleton and Henry Claypool

The goal of the Social Security Disability Insurance (SSDI) program is to provide a safety net for workers who must stop working because of a disability. But there is a major catch: although Medicare coverage is available to people with disabilities, most beneficiaries must wait 24 months after their eligibility for SSDI for coverage to begin.

Compared with the period before their entry into the program, SSDI beneficiaries are more than twice as likely to live in families with incomes below the federal poverty level. While about 12 % of individuals in the second year prior to SSDI entry report being in poor health, that percentage more than doubles among those in the year prior to SSDI entry and rises substantially for those in the first year after disability. People who will become eligible for SSDI benefits are significantly more likely to be uninsured than other workers

In a new "Perspectives on Health Reform" essay, the Fund's Stuart Guterman and Heather Drake say that although the cost of eliminating the waiting period -estimated to be $12 billion a year -seems high, it represents only a small percentage increase in Medicare spending. Moreover, eliminating the waiting period could bring important benefits to the program and to beneficiaries, while helping states reduce their spending on public programs.

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UP TO 66 MILLION AMERICANS COULD BE UNINSURED BY 2019

UP TO 66 MILLION AMERICANS COULD BE UNINSURED BY 2019 UNLESS HEALTH REFORM IS ENACTED Robert Woods Johnson Foundation

If federal reform efforts are not enacted -within 10 years the cost of health care for businesses could double, and the number of uninsured Americans could reach 65.7 million -with middle-income families hardest hit. Researchers from the Urban Institute prepared the analysis using the Institute's Health Insurance Policy Simulation Model, estimating how coverage and cost trends would change between now and 2019.

Under any economic scenario, the analysis shows a tremendous strain on business owners and their employees over the next decade if reform is not enacted. There would be a dramatic decline in the percentage of people insured through their employers, and millions more would become uninsured. There would be large growth in public programs, and major increases in health care spending and levels of uncompensated care. While all income levels would be affected, middle-class working families would be hardest hit.

The report shows that if health care reform is not enacted:
1. Individuals and families would see health care costs dramatically increase. Total individual and family spending on premiums and out-of-pocket costs could increase 68 % by 2019 in the worst-case scenario. Even under the best case scenario, health care costs would likely increase at least 46 %.
2. Businesses could see their health care costs double within 10 years. The model shows that employer spending on premiums would more than double - from $429.8 billion in 2009 to $885.1 billion in 2019. Even under best-case economic conditions, employer spending on health insurance premiums would increase 72 %. The result would likely be far fewer Americans being offered or accepting employer-sponsored health insurance (ESI). Estimates suggest a drop from 56.1 % of Americans being covered by ESI in 2009, to as few as 49.2 % by 2019.
3. Spending on government insurance programs could double. In the worst case scenario, spending on Medicaid and the Children’s Health Insurance Program could increase from $251.2 billion this year to $519.7 billion in 2019, as more people are priced out of private insurance and become eligible for government programs. Enrollment in these programs could increase to 20.3 % in 2019 in the worst case, or one in every five Americans. That’s an increase of 13.3 million people from current figures.
4. Millions more people would be uninsured. The model projects that without reform, 65.7 million people could be uninsured by 2019, compared to 62.2 million in the intermediate case and 53.1 million under the best case.
5. The amount of uncompensated care in the health system would increase. In the worst case scenario, totals for uncompensated care could more than double, from $62.1 billion in 2009 to $141.4 billion in 2019 in the worst case, and even $106.6 billion in the best case -putting a tremendous strain on health systems, hospitals, providers of clinical care and local municipalities.

[EINO: Actually in more accurate real numbers more than 66 million Americans were already uninsured at time of this report. Official Census numbers on uninsured only count as uninsured, those who were uninsured entire calendar year from Jan - Dec 31. Thus those uninsured from Feb 2002 through Nov 2003 -20 months- are not counted as uninsured IN EITHER YEAR.]

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PROBLEMS OF LOW-INCOME INDIVIDUALS FACE

WHAT PROBLEMS DO LOW-INCOME INDIVIDUALS FACE IN TODAY’S HEALTH CARE SYSTEM? Kaiser Family Foundation

As debate on national health reform moves forward, expanding coverage to the uninsured as well as addressing health care cost and quality issues have emerged as the dominant drivers for system reform. Extensive research shows that coverage is key to securing access to needed health care services. Leading health reform proposals rely on a combination of public and private approaches to expand coverage, control costs and improve quality with shared responsibilities across employees, employers, government, consumers and insurance markets.

1. Two-thirds of the 45 million uninsured are low-income individuals (below 200% of the poverty level or $36,620 for a family of three in 2009), and many have significant health needs.
2. Many low-income individuals do not have access to employer coverage and cannot afford or access private coverage through the individual market. Why build on Medicaid?
   
3. Medicaid already serves 60 million Americans and provides a base of affordable and comprehensive coverage that is well suited for low-income and high-need populations. The costs of private health care and Medicare premiums are lessened by having Medicaid insure these highneed populations and provide key services not covered by private plans or Medicare.
   
4. Most Medicaid enrollees receive care through private managed care plans that are designed to promote access to care, enhance quality and control costs. Medicaid also helps support community health centers and other safety-net providers in medically underserved areas.
   
5. Medicaid enrollees fare as well as the privately insured populations on important measures of access to primary care even though they are sicker and more disabled. Accounting for the health needs of its beneficiaries, Medicaid is a low-cost program with lower per capita spending than private insurance; thus covering Medicaid enrollees in private coverage would be more costly.
   
6. Medicaid has a well developed administrative structure in every state that has enabled it to be a cornerstone in federal and state efforts to expand coverage. Medicaid plays an important role for some disadvantaged populations and the program has broad public support.

How can Medicaid be a stronger platform for health reform?
1. Expand Medicaid’s reach to more low income individuals by basing eligibility on income alone with federal minimum standards and making additional progress to increase participation rates.
   
2. Ensure that current and new enrollees receive Medicaid’s benefit and cost-sharing protections, and promote better access by addressing payment rates to help boost provider participation.
   
3. Provide adequate Medicaid financing by having the federal government assume the costs of expanding Medicaid coverage or by shifting some current Medicaid costs to the federal government; and provide stable financing by establishing a countercyclical financing mechanism during economic downturns.
   
4. Bolster Medicaid with broader efforts to contain costs across the health system (public and private) to help ensure long term sustainability; develop strategies to expand the primary care workforce to provide better access to primary and preventive care, and establish system-wide quality standards along with the implementation of health information technology to promote an efficient health care system based on positive outcomes.

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FAMILY PUT OFF MEDICAL CARE

SIX IN TEN SAY FAMILY PUT OFF MEDICAL CARE DUE TO COST Kaiser Family Foundation

As economic conditions remain poor, a majority of the public continues to say that they or a member of their household have delayed or skipped health care in the past year, according to the Kaiser Family Foundation’s April health tracking poll. Perhaps because Americans continue to struggle with the cost of medical care in their own lives, the country’s overall economic problems have not dampened their interest in pursuing health care reform: a solid majority of the public (59%) believes health care reform is more important than ever compared with the thirty-seven % who say we can’t afford health reform because of economic problems.

"Our polls suggest strong general support for health reform, but the public can be swayed on the key details," said Kaiser President and CEO Drew Altman. "There is still a tremendous opportunity for leadership but also for interest groups to define the direction of the health reform debate." The most common actions taken due to costs were substituting home remedies or over-the-counter drugs for doctors visits (42%) and skipping dental care or check ups (36%). Additionally, three in ten (29%) did not fill a prescription for medicine and two in ten (18%) cut pills in half or skipped doses. Not everyone can forgo care, and overall one in four (26%) Americans say someone in their household has had trouble paying medical bills in the past year.

Seven in ten (71%) Americans strongly or somewhat favor increasing income taxes for those in families making more than $250,000 per year, but there is much less support for increasing income taxes on all taxpayers (28%). The poll indicates some support for taxing unhealthy behaviors, sometimes called "sin" taxes. When asked if they would favor or oppose increasing taxes on a package of items including soda, alcohol, junk food, and cigarettes to pay for health reform and provide coverage for the uninsured, six in ten (61%) favor such taxes while roughly four in ten (37%) are opposed. Asked about each of these items specifically, the poll suggests there is somewhat more support for increasing taxes on cigarettes, wine and

Another way to measure Americans’ views on the public plan debate is giving the public a choice of two methods and asking which would better encourage price competition among health plans. When asked whether private plans competing with just each other or with a government-administered public insurance plan similar to Medicare would do a better job of lowering costs and improving quality, Democrats favor including a public plan by more than 3 to 1 (71% to 19%), and political independents back this approach 53 % to 40 %. A majority of Republicans, on the other hand, prefer having private plans compete without a public plan (54% to 39%).

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TRANSFORM SAFETY-NET CLINICS

NATIONAL INITIATIVE TO TRANSFORM SAFETY-NET CLINICS INTO MEDICAL HOMES IN FIVE STATES

The Commonwealth Fund, in collaboration with eight cofunders, is launching a national Safety Net Medical Home Initiative, which will provide $6 million to help 68 community health centers in five states transform into patient-centered medical homes. Health centers in Colorado, Idaho, Massachusetts, Oregon, and Pennsylvania will be given training and ongoing support to improve how they deliver care to patients.

"In order to have a truly high performing health care system in this country we must have high-quality, well-coordinated, patient-centered primary care," said Commonwealth Fund President Karen Davis. "This initiative is an investment in the long-term health of these clinics as well as this model of care. With safety-net clinics leading the way, we hope to show how all primary care practices can transition into true medical homes providing the best care possible."

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WOMEN SKIPPING HEALTH CARE

WOMEN SKIPPING HEALTH CARE BECAUSE OF COSTS -Women at Risk: Why Many Women Are Forgoing Needed Health Care, by Commonwealth Fund researchers Sheila Rustgi, Michelle Doty, Ph.D., and Sara Collins, Ph.D

Women are more likely than men to have trouble getting needed care because they cannot afford it, with about half (52%) of working-age women, compared with 39 % of men, reporting problems such as not being able to fill a prescription, go to the doctor, or get a medical test. Seven of 10 working-age women have no health insurance coverage or inadequate coverage, medical bill or debt problems, or problems getting needed health care because of cost.

Women who are insured but have inadequate coverage are especially vulnerable: 69 % of underinsured women have problems accessing care because of costs, compared with half (49%) of underinsured men. Women are more affected by high health care costs because they have lower average incomes and use the health care system more frequently, and therefore face higher out-of-pocket health costs than men.

Because of high health care costs, women and their families are faced with making difficult choices between health care and purchasing basic necessities or making payments on mortgages or credit card debt. The researchers say the study understates the scope of this problem, as it is based on data from the Commonwealth Fund's 2007 Biennial Health Insurance Survey. The current economic recession has led to greater unemployment and loss of insurance coverage.

"Health reforms that would expand access to affordable, high-quality coverage are critical -for women and men, and the families they care for," the authors say.

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COST GROWTH CAN BE SLOWED

HEALTH CARE COST GROWTH CAN BE SLOWED, EXPERTS SAY Commonwealth Fund

Nearly all respondents to the latest Commonwealth Fund/Modern Healthcare Health Care Opinion Leaders Survey agree that the U.S. must rein in the growth of health care spending, and most believe it is possible to hold steady the current percentage of gross domestic product (GDP) devoted to health care over the next decade. In addition, large majorities expressed support for a range of strategies to reduce costs, including many of those outlined in President Obama's budget blueprint.

Currently, the nation as a whole spends 17 % of GDP on health care; that proportion is projected to grow to 21 % by 2020. Opinion leaders voiced strong support for various aspects of payment reform, including moving away from "fee-for-service" payment toward "bundled" payment (70%), aligning rates for Medicare Advantage private plans with those paid in traditional Medicare (77%), and providing greater incentives for high performance care (87%). Having Medicare negotiate prescription drug prices was supported by 82 % of respondents.

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MEDICARE ADVANTAGE PLANS GET EXTRA $11.4 BILLION

PRIVATE MEDICARE ADVANTAGE PLANS GET EXTRA $11.4 BILLION IN GOVERNMENT FUNDS FOR 2009 Commonwealth Fund

Private health insurance plans serving Medicare beneficiaries will be paid $11.4 billion more in 2009 than what the same beneficiaries would have cost if covered by the traditional Medicare fee-for-service program. [More precisely the private insurance companies are awarded extra public dollars.]

Since the program was enacted in 2004, a total of $43 billion in extra payments have been made to private plans. The bulk of these extra payments were mandated by the Medicare Modernization Act of 2003, which was intended to expand the role of private plans in Medicare "in an effort to reduce growth in Medicare spending" (no one believed that really, it was a GW Bush effort to bolster insurance profits). The Congressional Budget Office estimates that bringing payments to private Medicare Advantage (MA) plans in line with fee-for-service Medicare would save $157 billion over the next 10 years.

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COVERAGE FOR ALL COULD REDUCE HEALTH DISPARITIES

STUDY FINDS INSURANCE COVERAGE FOR ALL COULD REDUCE HEALTH DISPARITIES Commonwealth Fund by J. Michael McWilliams, M.D., Ph.D., and colleagues at Harvard University

Obtaining Medicare coverage is associated with significant reductions in racial, ethnic, and socioeconomic health disparities in adults with diabetes and cardiovascular disease. Universal coverage is a possible means of reducing these types of health disparities in the general population.

The authors reviewed health data from more than 6,000 people aged 40 to 85 with least one of the following conditions: diabetes, hypertension, coronary heart disease, or stroke. They found that while overall improvements have been made in controlling the diseases, racial, ethnic, and socioeconomic differences have remained the same or in some cases worsened in the pre-Medicare population. However, at age 65, when people become eligible for health care coverage under the Medicare program, differences in health by race, ethnicity, and socioeconomic status were reduced significantly: For blood sugar levels with diabetes, educational disparities decreased by 83 %, while racial and ethnic disparities fell by 78 %. For total cholesterol levels, educational disparities disappeared altogether. For systolic blood pressure, racial disparities decreased by 60 %.

The full article may still be available CLICK HERE

VIEWS AND EXPERIENCES WITH NATION’S HEALTH CARE SYSTEM

PUBLIC’S VIEWS AND EXPERIENCES WITH NATION’S HEALTH CARE SYSTEM, INCLUDING ATTITUDES TOWARDS HEALTH CARE DELIVERY REFORMS NPR/Kaiser/Harvard Survey

The survey’s findings include:
1. While three in four Americans say it is important for their health care providers to use electronic records and large proportions see a broad range of benefits in terms of better coordination of care, improving quality, avoiding unnecessary care and medical errors, a majority of the public do not think it will lower health care costs. More than half have little or no confidence that EMR systems would be able to protect the confidentiality of their personal health information.
   
2. While half of the public say it isn’t a problem at all, a substantial proportion of Americans report at least minor problems (44%) with coordinating care between their different doctors. Those who see more doctors report experiencing more coordination of care challenges.
   
3. Patients generally do not ask about the costs of medical or lab tests they receive. Only 22 % say they have done so in the past two years.
   
4. Half of the public believes the American health system has a "major problem" with patients receiving unnecessary tests and treatments and even more, two-thirds, say the system has a major problem with "too many patients not getting medical tests and treatments they need."
   
5. Seven in ten Americans believe that there is not always clear scientific evidence about which treatment is likely to work best for any one patient. And about half report that they have talked to their doctor about scientific evidence (48%) or how well a treatment works compared to other less expensive treatments (46%) as reasons for their doctors’ treatment recommendations. But less than half (41%) would trust experts from an independent scientific organization appointed by the federal government "a great deal" or "a fair amount" to make such a recommendation.

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STRUGGLE TO GET PATIENTS MENTAL HEALTH SERVICES

PRIMARY CARE PHYSICIANS STRUGGLE TO GET PATIENTS MENTAL HEALTH SERVICES Commonwealth Fund Peter J. Cunningham, Ph.D

About two-thirds of U.S. primary care physicians reported in 2004-05 that they could not get outpatient mental health services for their patients -a rate that was at least twice as high as for other services, according to a Commonwealth Fund-supported study published by Health Affairs.

More than half of the primary care physicians reporting problems getting mental health services for their patients cited lack of or inadequate insurance coverage, health plan barriers, and shortages of mental health providers as "very important" reasons for the difficulty in accessing this care.

Although the survey data used for the study preceded passage of the 2008 Wellstone-Domenici Mental Health Parity and Addiction Equity Act of 2008 -which mandated mental health parity in private insurance benefits nationally -the researchers found that existing state mental health parity laws had only a modest effect on reducing mental health access disparities.

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READMISSIONS TO HOSPITAL ARE FREQUENT AND COSTLY

READMISSIONS TO HOSPITAL ARE FREQUENT AND COSTLY Commonwealth Fund

One of five Medicare beneficiaries discharged from the hospital is readmitted within 30 days, and half of patients admitted for reasons other than surgery are readmitted without having seen a doctor in follow-up. All told, unplanned rehospitalizations cost Medicare $17.4 billion in 2004. The researchers also found wide variation in rehospitalization rates among states. Between October 2003 and December 2004, the five states with the highest rehospitalization rates (Maryland, New Jersey, Louisiana, Illinois, and Mississippi) had rates 45 % higher than the five states with the lowest rates. "You have to worry about a system in which patients are rehospitalized soon after discharge with no bill for a physician visit in between," said Stephen Jencks, M.D., M.P.H., the study's lead author. "If we want to prevent unplanned rehospitalizations, we have to help hospitals and community healthcare providers implement transition procedures that are more patient-centered."

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MEDICAL HOMES

TRANSFORMING HEALTH CARE DELIVERY WITH MEDICAL HOMES Commonwealth Fund Melinda K. Abrams, Karen Davis, and Christine Haran

Overhauling our fragmented health care delivery system will be critical to the success of any national health reform initiative. A new delivery system must be built on a solid foundation of primary care, and the medical home -with its emphasis on the relationship between patient and clinician -should be its cornerstone.

"Creating medical homes throughout the country will clearly require a significant restructuring of our existing health care delivery 'system,'" the authors say. "Whereas most doctors' offices and hospitals are currently isolated from each other -electronically and otherwise -providing patients with around-the-clock access to coordinated care will require that providers are linked and working together."

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U.S. ECONOMY

Tough Economic Times NEJM

These are tough economic times. Since December 2007, the U.S. economy has shed 4.4 million jobs, and as of February 2009, the unemployment rate had risen from 4.9% to 8.1%. Millions of Americans have seen their jobs disappear, incomes decline, and health care coverage become increasingly remote. Many have sought public coverage from the states through Medicaid, but Medicaid's ability to fill the gap is becoming increasingly constrained, as state revenues decline and states turn to Washington for help in paying their share of the Medicaid bill.

Perhaps most obviously, the recession jeopardizes health coverage for millions of Americans - both those who have Medicaid coverage today and those who are losing job-based coverage - and leaves more families uninsured. In 2007, before the recession began, officially [counting less than 2 of every 3 people actually without insurance that month] 45 million Americans under 65 years of age were without health insurance. Eight in 10 of America's uninsured are from working families, and two thirds come from families with incomes below 200% of the poverty level ($44,000 for a family of four in 2009). Health insurance is generally not offered to these families through their jobs, nor is it affordable for them to purchase on their own, since the average health insurance plan for a family costs more than $12,000 a year.

When the economy is in recession, as it has been since December 2007, coverage quickly unravels further. When insured workers lose their jobs, they also lose their job-based health insurance coverage; without a job, few have the resources to use the COBRA option) to extend their employer-sponsored coverage by paying the full health insurance premium themselves. Coverage through Medicaid is far more limited, with a cutoff below 100% of the poverty level in 33 states - meaning that children are often covered while their parents remain uninsured. For adults without dependent children, no matter how poor, Medicaid coverage is largely unavailable unless they qualify on the basis of a severe disability.

The effects of the deepening recession underscore the importance of tackling health care reform to achieve greater stability and broader health coverage of the U.S. population. Medicaid can serve as a platform for broadened coverage of the low-income population, but achieving this goal will require new policies that establish a minimum eligibility threshold for adults (including those without dependent children), promote greater access to primary care and equity in payment rates across payers, provide more automatic countercyclical federal financing during economic downturns, and restructure federal and state responsibilities to ensure that financing for coverage remains secure. These changes can help to alleviate the crisis in health care coverage and financing that we're now facing.

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REFORMING PROVIDER PAYMENT

REFORMING PROVIDER PAYMENT: ESSENTIAL BUILDING BLOCK FOR HEALTH REFORM Commonwealth Fund

The Commission-recommended payment reforms seek to:

1. strengthen primary care by enhancing Medicare payment for services and ensuring annual increases that keep pace with the cost of efficient practice
   
2. encourage adoption of the medical home model and promote more accessible, coordinated, patient-centered care, with a focus on health and disease prevention
   
3. promote more effective, efficient, and integrated care delivery through "bundled payment" approaches that reimburse providers for care delivered over a period of time or for the duration of an illness, with rewards for quality, outcomes, and efficiency
   
4. correct price signals in health care markets to align payments with value.

The report shows that by increasing emphasis on primary care, improving coordination, and eliminating unnecessary and duplicative services, specific policies based on the Commission's recommendations could slow growth in total health care spending by a cumulative $1 trillion through 2020. This represents one-third of the overall system savings of $3 trillion projected for the Commission's integrated set of health care reform recommendations.

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A HIGH PERFORMANCE U.S. HEALTH SYSTEM

THE PATH TO A HIGH PERFORMANCE U.S. HEALTH SYSTEM: February 19, 2009 | Volume 105 Commonwealth Fund Cathy Schoen

The time has come for comprehensive health reform that will put the nation on a path to a high performance health system. The nation's health and economic security are at risk: rising costs are putting pressure on families, businesses, and governments, and sharp increases in the number of uninsured and underinsured are leaving millions without access to care or essential financial protection when sick. The U.S. health care system is already the most expensive in the world, by far, and total health spending is projected to double by 2020 -rising from a projected $2.6 trillion in 2009 to $5.2 trillion by 2020 to consume 21 % of the nation's economic resources (gross domestic product). To achieve more affordable coverage and ensure access for everyone in the country, we must change the way health care is delivered and the way we pay for care. We must focus on value. Despite having centers of excellence, our health care system falls short. It fails to produce the outcomes and care it could, wastes resources, often fails to provide the right care at the right time, and delivers unacceptably wide variations in quality and safety. Unless we move to a high performance delivery system and improve the value of care that is delivered, efforts to expand coverage will be difficult, if not impossible, to sustain over time.

The USA needs to be on a different path, one guided by a positive vision of what should be possible and by policies leading to outcomes we should expect. This is a historic political opportunity -with a majority of the public seeking profound change and a new administration and Congress taking office -for taking bold steps to ensure the health security of all.

In this report, the Commission recommends an integrated set of policies to extend coverage to all by: establishing a national insurance exchange that offers a choice of private plans and a new public plan; requiring everyone to have coverage, with income-related premiums to make coverage affordable; and instituting insurance market reforms that focus competition on outcomes and value. On this foundation, payment policies would change the way we pay for care to enhance the value of primary care and move from fee-for-service to more "bundled" methods of paying that encourage coordinated care and hold providers accountable for improving health outcomes and prudent use of resources. Investment policies would accelerate the spread and use of health information technology and establish a center for comparative effectiveness to enhance knowledge and appropriate use of evidence-based care. Population health policies would promote health and disease prevention, with benchmarks and goals to spur a culture of innovation and continuous improvement.

This integrated approach could achieve access for all, improve population health, and provide more positive patient experiences. Moreover, an analysis of specific policies consistent with this approach indicates that they could slow the growth in national health spending by a cumulative $3 trillion through 2020, compared with current projections (Exhibit ES-1) -if we start now.

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MOST FAMILIES SKIMPED ON MEDICAL CARE BECAUSE OF COST IN PAST YEAR

MORE THAN HALF OF AMERICANS SAY FAMILY SKIMPED ON MEDICAL CARE BECAUSE OF COST IN PAST YEAR; WORRIES ABOUT AFFORDABILITY AND AVAILABILITY OF CARE RISE Kaiser Family Foundation

Public Strongly Supports Action on Health Care Reform, But Majority Think It Can Be Done Without Additional Spending

As economic conditions continue to worsen, the public is increasingly worried about the affordability and availability of care, with many postponing or skipping treatments due to cost in the past year and a notable minority forced into serious financial straits due to medical bills, according to the Kaiser Family Foundation’s first health care tracking poll of 2009.

Slightly more than half (53%) of Americans say their household cut back on health care due to cost concerns in the past 12 months. The most common actions reported are relying on home remedies and over-the-counter drugs rather than visiting a doctor (35%) or skipping dental care (34%). Roughly one in four report putting off health care they needed (27%), one in five say they have not filled a prescription (21%), and one in six (15%) say they cut pills in half or skipped doses to make their prescription last longer.

The 27 % of the public that reported they had "put off or postponed getting health care [they] needed" were asked about the specific types of care they had foregone. The most common responses were delaying going to the doctor for a temporary illness (19%) or for preventive care (19%). But nearly as many -- 16 % -- report putting off care for a more serious problem, either postponing a doctor’s visit related to a chronic illness such as diabetes or delaying major or minor surgery.

Not all medical care can be postponed, however, and the survey indicates that roughly one in five (19%) people experienced serious financial problems recently due to family medical bills. Specifically, 13 % say they have used up all or most of their savings trying to pay off high medical bills in the past 12 months, and just as many say their medical debt means they have difficulty paying other bills. A similar proportion (12%) say they have been contacted by a collection agency, while a smaller share (7%) report being unable to pay for basic necessities like food, heat or housing.

The share of Americans who say that the country’s economic problems make it more important than ever to take on health care reform has remained remarkably stable over the past five months at roughly six in 10 (62%). However, the partisan divide also remains large with Democrats overwhelmingly (79%) saying reform is more important than ever and most Republicans (58%) saying the nation cannot afford to tackle health care reform at this point. Independents tilt the balance by being in favor of reform now (57%).

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CONTROLLING COST GROWTH

EFFICIENCY AND QUALITY: CONTROLLING COST GROWTH IN HEALTH CARE REFORM June 11, 2009 By: Ginsburg P and Center for American Progress Robert Woods Johnson Foundation

The Center for American Progress released a new report that identifies reforms that have the greatest potential" for controlling health care costs. explains five specific reforms:
1. increasing the amount Medicare pays for primary care;
   
2. pay for episodes of care instead of individual procedures;
   
3. encourage Medicaid and private insurers to adopt Medicare’s payment methods;
   
4. reform the tax treatment of employer-based health benefits; and
   
5. expand research that identifies best practices in treating diseases effectively and affordably.

According to the report, the current system results in government programs that pay too little for primary care and too much for specialty care, which the authors say leads poor quality and higher costs. The report also states that the current way in which health benefits are taxed results in consumers using too much health care and suggests guidelines to curb the over-use of new, expensive procedures that may not yet be proven to be most effective.

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MEDICAID PHYSICIAN FEES

MEDICAID PHYSICIAN FEES ROSE MORE THAN 15 % FROM 2003 TO 2008, Kaiser Family Foundation

As policymakers consider health reform options that include improvements and expansions to Medicaid - the health insurance safety net for nearly 60 million of the nation’s poorest and sickest individuals [conservatively counted]- many have raised concerns that the program’s physician payment levels contribute to difficulties accessing care. Medicaid has historically reimbursed physicians under fee-for-service at levels below what Medicare and private health insurers would pay for the same services.

Medicaid fees grew by more than 15 % from 2003 to 2008, but fell in real terms because the gains did not keep pace with inflation. Medicaid fees did grow faster than Medicare fees during that period, however, rising from 69 % of Medicare in 2003 to 72 % by 2008. Increases were greatest in Medicaid fees for primary care and obstetrical services.

Conducted by researchers at the Urban Institute in partnership with the Kaiser Family Foundation's Commission on Medicaid and the Uninsured and the California HealthCare Foundation, the study also explores state variation in Medicaid fees, comparing each state’s fees to the national averages. Although findings are based only on Medicaid fee-for-service physician reimbursement, nearly two-thirds of program spending still occurs in the fee-for-service setting, where elderly and disabled enrollees with the greatest health needs primarily receive their care.

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WOMEN’S HEALTH CARE DISPARITIES

PUTTING WOMEN’S HEALTH CARE DISPARITIES ON THE MAP: EXAMINING RACIAL AND ETHNIC DISPARITIES AT THE STATE LEVEL Kaiser Family Foundation

A decade after U.S. Surgeon General David Satcher called for the elimination of racial disparities in health, women of color in every state continue to fare worse than white women on a variety of measures of health, health care access and other social determinants of health.

Disparities persist on 25 indicators between white women and women of color, including rates of diseases such as diabetes, heart disease, AIDS and cancer, as well as insurance coverage and health screenings. Women of color fared worse than white women on most measures and in some cases the disparities were stark. National statistics mask substantial state-by-state variation in disparities. The report moves beyond national figures to quantify where disparities are greatest, providing new information to help determine how best to combat the problem. "This report demonstrates that disparities in health are not one problem but many and vary from state to state -- and that a variety of strategies will be needed if we hope to turn things around".

American Indian and Alaska Native Women Experience Some of the Greatest Challenges

Among different racial and ethnic groups, American Indian and Alaska Native women had among the worst outcomes on many health indicators, often twice as high as white women. The percentage of American Indian and Alaska Native women in serious psychological distress was more than 1.5 times that of white women.

At the same time, the report reveals tremendous variation among states within racial and ethnic groups. For example, among white women, the rate of diabetes was 7.5 times as high in West Virginia (6.0%) as in the District of Columbia (0.8%). Among women who are Asian American, Native Hawaiian and other Pacific Islander, 10% in Ohio had late or no prenatal care compared to 34% in Utah. Forty-three % of Hispanic women in Oklahoma had not had a mammogram in the past two years, compared to 14.5% in Massachusetts.

Many forces contribute to the levels of disparities in the states. The report examined underlying factors such as poverty levels and high school graduation rates that are often beyond the control of state health officials. It also looked at some factors that officials do have a hand in shaping, such as the scope of states’ Medicaid programs, which can influence how many people have health coverage in a state.

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UPDATED PRIMER ON HEALTH CARE COSTS

UPDATED PRIMER ON HEALTH CARE COSTS Kaiser Family Foundation

The annual growth in national health spending has exceeded the growth of the economy as a whole by an average 2.4 % from 1970 to 2007. During this period, the share of the economy devoted to health care grew from 7.2 % to 16.2 %, and it is projected to increase to one-fifth by 2018.

The primer describes the types and sources of health care spending [OTHER THAN direct and indirect costs of high uninsurance and underinsurance rates], the demographic factors associated with higher or lower levels of spending, and the impact of higher premiums and out-of-pocket costs on families and employers. It also discusses factors that influence health care spending growth, including the use of new medical technology, population changes, and changes in disease prevalence ­ and highlights some of the challenges policymakers face in trying to slow the rise in health care costs.

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EMPLOYER COVERAGE DOES NOT SHIELD WORKERS

EMPLOYER COVERAGE HELPS, BUT IT DOES NOT SHIELD WORKERS FROM HEALTH CARE COSTS DEEMED "UNAFFORDABLE" AS A PERCENTAGE OF THEIR INCOMES. Kaiser Family Foundation Health Affairs June 2, 2009by Jon R. Gabel, Roland McDevitt, Ryan Lore, Jeremy Pickreign, Heidi Whitmore, and Tina Ding

Health plans from 2004 to 2007 covered slightly fewer expenses in 2007 than in 2004, but out-of-pocket spending grew more than one-third because of growth in overall health spending. For people at 200 % of poverty, the percentage spending more than 10% of their income out of pocket increased from 13 % to 18 % (by one definition of underinsurance the percentage rose by nearly 40% in these few years).

In the USA, if you are sick and earn a modest income, then you are probably underinsured - even if you have employer-based health coverage. In 2007, among people at 200 % of poverty ($41,300 for a family of four in 2007) who were among the top 25 % of spenders on health care services, 71 % were underinsured.

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ENSURING THAT HEALTH REFORM PUTS PEOPLE FIRST

FRONT AND CENTER: ENSURING THAT HEALTH REFORM PUTS PEOPLE FIRST Commonwealth Fund by Karen Davis, Ph.D., Kristof Stremikis, M.P.P., Cathy Schoen, M.S., Sara R. Collins Ph.D., Michelle M. Doty, Ph.D., Sheila D. Rustgi, and Jennifer L. Nicholson, M.P.H

The health system has to work for the people it is designed to serve. Report describes the difference comprehensive, integrated health reform would make in the lives of the 116 million working-age adults who are uninsured or underinsured, have medical bill or debt problems, or experience difficulties obtaining needed care.

In a nation replete with modern medical centers, there are countless stories of Americans whose lives could have been saved or disabilities averted if they had been able to afford medical care or had timely access to high-quality, safe care. In today’s health system both the insured and the uninsured are at risk. Even families whose incomes place them solidly in the middle class worry that they will not be able to afford to get sick, that they will see their children lose the protection of family coverage, or that they will exhaust a lifetime of savings paying off medical debt.

This report examines the multiple ways in which the current health insurance and care delivery systems fail people when they need it. And it describes the people who would benefit from health reforms aimed at providing secure, comprehensive coverage and enabling the delivery of accessible, safe, patient-centered health care, even when people get sick [private insurers specialize in covering enrollees while they are healthy and problem-free].

The most important outcome of health system reform that puts people first would be the health benefits to the American people. If the achievable targets included in the Path framework are reached, by the year 2020 an estimated 100,000 lives per year would be saved, 68 million more adults would receive recommended preventive care, and 37 million more adults and 10 million more children would receive care from physician practices that ensure easy access to care and are accountable for providing patients all essential health services. Avoidable hospitalizations would decline each year as well: 640,000 fewer Medicare beneficiaries would be hospitalized for ambulatory care-sensitive conditions, and 180,000 fewer Medicare beneficiaries would be readmitted within 30 days following their initial hospital discharge. In addition, there would be 70,000 fewer children hospitalized for asthma-related complications each year, and 250,000 fewer adults hospitalized for diabetes-related complications.

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OUT-OF-POCKET SPENDING IN MEDICAID AND CHIP

COST SHARING IN MEDICAID AND CHIP: HOW DOES IT AFFECT OUT-OF-POCKET SPENDING? Health Affairs June 2, 2009 by Thomas M. Selden, Genevieve M. Kenney, Matthew S. Pantell, and Joel Ruhter

Rapidly rising spending has prompted debate about increasing cost sharing in Medicaid and the Children's Health Insurance Program (CHIP). Many low-income families would face high health spending burdens even with minimal cost sharing for their publicly insured children. Adding even modest cost sharing for such children could greatly increase high financial burdens.

Our survey of state policies reveals that a growing number of states are using cost sharing in the form of premiums or copayments, or both, for services in their public coverage programs for children. Most states have provisions that specify caps on family spending - generally at 5 % of family income - and premiums are capped in most states for families with more than three children. Yet our analysis of state policies suggests that systems to track family spending and to ensure free access once caps have been reached are generally not well developed.

Higher cost sharing in public programs may reduce public spending. However, half of all publicly insured children in our analysis were poor, and even modest cost sharing can be burdensome for many poor families. Exempting poor children reduces budgetary savings unless much larger cost-sharing burdens are imposed on the remaining families. Optimal targeting of cost sharing is difficult, moreover, when family incomes fluctuate from month to month and when health needs, such as the presence of a an SHCN (Special Health Care Needs) child or a parent in poor health, vary so widely across families.

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HEALTH CARE DELIVERY OVERHAUL

KAREN DAVIS: INSURANCE REFORM SHOULD BE PAIRED WITH HEALTH CARE DELIVERY OVERHAUL

"As the nation turns to the issue of reforming our health insurance system, it is important to address simultaneously how we organize and deliver health services--to ensure that we are obtaining the best possible health outcomes for Americans and the most value for the money we spend on health care," Commonwealth Fund president Karen Davis told the U.S. Senate Committee on Health, Education, Labor, and Pensions at a hearing held yesterday afternoon.

Davis said that "the nation will not have the health system it wants if the federal government does not lead and implement a series of coordinated strategies to close the quality chasm," including:

• extending health insurance to all
  
• aligning financial incentives to reward the outcomes we want to achieve
  
• changing the organization and delivery of care to ensure that it is accessible, coordinated, and patient-centered;
  
• investing in the infrastructure and support necessary to reach attainable levels of quality and efficiency; and
  
• xercising the leadership and collaboration among all parts of the health system necessary to achieve health goals for the nation.

Davis called attention to models of high performance in health care delivery that already exist in states and regions across the U.S., like Geisinger Health System in Pennsylvania, a leading innovator that has combined an electronic health record system with quality incentives and policies to encourage care coordination. Looking abroad, she also cited the health systems of the Netherlands and Denmark--both of which emphasize accessible primary care boosted by information systems that assist physicians in coordinating health services--as international leaders from whom the U.S. could learn.

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CANCER PATIENTS CONFRONT HOLES

CANCER PATIENTS CONFRONT HOLES IN THE HEALTH INSURANCE SYSTEM Commonwealth Fund By Karyn Schwartz, Gary Claxton, Kristi Martin, and Christy Schmidt Kaiser Family Foundation American Cancer Society February 2009

Facts on cancer care and current insurance system:

1. High cost-sharing, caps on benefits and lifetime maximums leave cancer patients vulnerable to high out-of-pocket health care costs
   
2. People who depend on their employer for health insurance may not be protected from catastrophically high health care costs if they become too sick to work
   
3. Cancer patients and survivors are often unable to find adequate and affordable coverage in the individual market.
   
4. While high-risk pools are designed to help cancer patients and others who are uninsurable, they are not available to all cancer patients and some find the premiums difficult to afford.
   
5. Waiting periods, strict restrictions on eligibility, or delayed application for public programs can leave cancer patients who are too ill to work without an affordable insurance option.

It is impossible to determine exactly how many privately insured individuals in the USA are at risk for high out-of-pocket health costs. HGaps in the current private health insurance system leave cancer patients and others with serious illnesses vulnerable even when they have coverage.

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CANCER PATIENTS PROBLEMS WITH PRIVATE HEALTH COVERAGE

EXPERIENCES OF CANCER PATIENTS ILLUSTRATE POTENTIAL PROBLEMS WITH PRIVATE HEALTH COVERAGE Kaiser Family Foundation

Cancer patients can face severe challenges in paying for life-saving care -- running up large debts, filing for personal bankruptcy and even delaying or forgoing potentially life-saving treatment -- even when they have private health insurance, according to a new report by the Kaiser Family Foundation and the American Cancer Society. This report profiles 20 patients and illustrates the potential difficulties people diagnosed with cancer or other serious illnesses have in maintaining affordable health insurance and paying for their health care.

For these patients, having private health insurance at the time of their cancer diagnosis did not protect them from high out-of-pocket costs -- leaving them with large debts to cover their treatment costs and forcing some to skip or delay necessary treatments. "Cancer patients too often find out that their insurance doesn't protect them when they need care the most," said John R. Seffrin, Ph.D., national chief executive officer of the American Cancer Society. "High out-of-pocket costs coupled with the high cost of insurance premiums can force cancer patients to incur huge debt, and to delay or forgo life-saving treatments."

Some key points:
1. High cost-sharing, caps on benefits leave cancer patients vulnerable. The various types of cost-sharing and limits on benefits found in some insurance plans may quickly lead to high out-of-pocket costs once cancer treatment begins.
   
2. Those with employer-sponsored coverage may not be protected from catastrophically high health care costs if they become too sick to work. Most people get their health coverage through their employers, which often pay most of the premiums. Under existing law, people who lose their jobs because they are unable to work generally must decide within 60 days whether to temporarily retain their employer-sponsored coverage through COBRA by paying the full premium costs.
   
3. Cancer patients and survivors are often unable to find adequate and affordable coverage in the individual market. Cancer survivors who have been in remission for years and have a good long-term prognosis may still have trouble finding coverage or pay higher premiums in the individual market.
   
4. High-risk insurance pools are not available to all cancer patients, and some find the premiums difficult to afford. High-risk pools, which are designed to help cancer patients and others who are uninsurable, are not available in all states, and when they are available, they are often much more expensive than most other plans in the individual market. For exam.
   
5. Waiting periods, strict restrictions on eligibility, or delayed application for public programs can leave people who are too ill to work without an affordable insurance option. Cancer patients too sick to work may qualify for Social Security Disability Insurance income and, after two years of receiving this income, may qualify for Medicare coverage. During the waiting period, patients typically have reduced incomes and may not be able to afford private insurance coverage [if they manage to survive the period].

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A TRANSFORMED U.S. HEALTH SYSTEM

YOU CAN GET THERE FROM HERE: MAPPING THE WAY TO A TRANSFORMED U.S. HEALTH SYSTEM Kaiser Family Foundation

"The potent combination of recent events in the USA has presented the nation's leaders with a historic opportunity to fix our broken health care system," writes Commonwealth Fund president Karen Davis. The poor performance of the U.S. health system adds to our current economic crisis. As a nation we spend twice as much per person on health care as other major industrialized countries do--saddling businesses with high expenses, burdening taxpayers, and squeezing other public priority needs, from education to the nation's aging infrastructure. Meanwhile, two-thirds of all adults under age 65 report they are uninsured or underinsured, forgo needed care, or struggle to pay medical bills or related debt.

Davis maps out a way for the nation to transform and revitalize its health care system:
• Change the financial incentives for hospitals, physicians, and other health care organizations so that they become more accountable for patient health outcomes and the prudent use of resources.
  
• Leverage Medicare's purchasing power to help keep costs down.
  
• Create a more organized delivery system that taps the expertise of teams of health professionals, from primary care and specialist physicians to nurses and pharmacists.
  
• Meet and continually raise benchmarks for care, and help providers get the tools they need to reach the highest attainable levels of performance.
  
• Ensure accountable national leadership, constant innovation, and closer coordination between the public and private sectors by granting greater authority to the Secretary of Health and Human Services or an independent board to move quickly on new payment policies that reward value and quality.

"Such reforms, taken together, have the potential to achieve near-universal coverage, improve quality, and expand access--all while generating health system savings," Davis says.

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SWISS AND DUTCH HEALTH INSURANCE SYSTEMS

THE SWISS AND DUTCH HEALTH INSURANCE SYSTEMS: UNIVERSAL COVERAGE AND REGULATED COMPETITIVE INSURANCE MARKETS Commonwealth Fund January 16, 2009 | Volume 104 Robert E. Leu, Ph.D., Frans F. H. Rutten, Ph.D., Werner Brouwer, Ph.D., Pius Matter, and Christian Rütschi,

While the U.S. spent $6,700 per capita on health care in 2006, Switzerland spent $4,300 and the Netherlands just $2,800. Even while spending less, both countries ensure health coverage for most of their populations and also enjoy better health outcomes than the U.S. Administrative costs in the Netherlands and Switzerland, meanwhile, average about 5 % of total health care costs, compared with 7 % in the U.S. The Dutch and Swiss systems feature patient choice, broad access to care, and low rates of disparities in care. "These countries can serve as idea labs for health reform in the U.S., and we should seek to learn from their successes and failures, just as we learn from the experiences of states like Massachusetts," says Karen Davis, The Commonwealth Fund's president. "There are examples of universal, comprehensive, high-quality, efficient health care . Attention has turned to countries that combine universal coverage with private insurance and regulated market competition. The systems in Switzerland and the Netherlands, in particular, have drawn attention for their use of individual mandates combined with public oversight of insurance markets. Prepared at the request of the Swiss and Dutch national governments, this paper provides an overview of the Swiss and Dutch health insurance systems with a focus on insurance markets. The health insurance systems in the Netherlands and Switzerland embody some of the same concepts that have guided the health reforms adopted in Massachusetts and that have been considered in other states and at the federal level:

• Universal coverage attained through a mandate that every individual purchase a basic insurance plan.
  
• National standards for basic coverage for private insurance.
  
• In both countries, benefits are comprehensive in scope for acute care services (doctors, hospitals, prescription drugs, and lab/diagnostic tests).
  
• In both countries, the majority of the population buys supplemental policies, often purchased from the insurer providing basic coverage.
  
• Tight regulation of basic health insurance markets, with requirements for open enrollment and community rating.
  
• Both countries require that insurers accept all applicants and prohibit variations in premiums by health status­community rating, with guaranteed offer and renewal.
  
• The Swiss insurance system (7.5 million people) is highly decentralized, with plans operating and setting premiums at the canton level (26 divisions). In Switzerland, only nonprofit insurers may participate.
  
• Risk equalization systems are intended to reduce incentives for insurers to seek healthier enrollees.

The Swiss and Dutch health systems provide real-world prototypes for a regulated competitive model with multiple insurance plans, which many believe is the most likely route to universal coverage in the USA.

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LEADING CONGRESSIONAL HEALTH CARE BILLS, 2007-008

AN ANALYSIS OF LEADING CONGRESSIONAL HEALTH CARE BILLS, 2007-008 Commonwealth Fund By Sara R. Collins, Ph.D, Jennifer L. Nicholson, and Sheila D. Rustgi The Commonwealth Fund January 2009

This report analyzes and compares leading bills of the 110th Congress aimed at expanding and improving health insurance coverage. Bills and proposals from members of Congress and President-elect Barack Obama include plans to fundamentally reform the health insurance system through mixed private-public approaches that build on our current system; a public insurance option available to the entire population; bills to change the tax treatment of employer benefits; federal-state partnership to provide grants to states to expand coverage; and bills that would expand coverage for children or disabled individuals, among others. Using analysis from the Lewin Group, the authors provide coverage and cost estimates for the proposed bills, which range from 48.9 million uninsured people gaining coverage to a net loss of coverage for 283,000 people; proposals could increase national health spending by as much as $64.1 billion or create savings of $58.1 billion.

[Comments from Don McCanne, PNHP: For those who would like to have a better understanding of the various Congressional approaches to reform, this report is very helpful. The Lewin Group analysis brings reality to the claims being made by the proponents of each approach. The proposals vary considerably in how effective they are (or are not) in expanding coverage to include everyone. Only one of the proposals evaluated, Representative Pete Stark's AmeriCare Health Care Act, would be effective in covering everyone. The closest to this would be the Commonwealth (Obama/Baucus) and the Wyden proposals, but they would leave a few million without coverage.

Not only is Stark's AmeriCare proposal the most effective in expanding coverage, it is also the least expensive in terms of our total National Health Expenditures, actually reducing spending by about $58 billion. The results are no surprise. Many studies, such as the California Health Care Options Project (a study of nine models of reform) have shown that those models that build on our current system of private and public plans are the most expensive models of reform, and fall short on goals of universality, comprehensiveness, and equity. In contrast, the single payer model and health service model actually accomplish those goals while being the least expensive models of reform.

To be clear, Pete Stark's AmeriCare is not a single payer model. AmeriCare, an improved and expanded Medicare-like program, would cover 85 % of us. The existing Medicare program would be improved and cover another 10 % of us. Qualified employer-sponsored plans would cover 1 % (yes, only one percent). Dual Eligible and TRICARE would cover the balance. Of the proposals studied, AmeriCare is the closest to single payer, though many single payer advocates would have preferred that Representative John Conyers' HR 676 single payer bill be included in the analyses.]

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HEALTH CARE EXPENSES STRAIN FAMILY BUDGETS

LIVING ON THE EDGE: HEALTH CARE EXPENSES STRAIN FAMILY BUDGETS By Peter J. Cunningham, Carolyn Miller, and Alwyn Cassil Center for Studying Health System Change December 2008 Center for Studying Health System Change

Affordability of medical care is a central focus of health care reform efforts. As health care costs continue to increase and the economy declines sharply, there is very little cushion in family budgets for health care costs, even for families with insurance coverage. Financial pressures on families from medical bills increase sharply when out-of-pocket spending for health care services exceeds 2.5 % of family income. Low-income families and people in poor health experience financial pressures at even lower levels of spending, largely because they have already accumulated large medical debts they are unable to pay off.

There is little consensus among policy makers on how to set affordability standards in medical care, in part because there is little empirical evidence to guide these decisions. In addition, most of the policy focus has been on identifying affordability standards for insurance premiums, such as in the Massachusetts health reform, with much less attention on affordability standards for out-of-pocket spending on medical services. Some analysts propose setting affordability standards based on the current distribution of out-of-pocket spending for services, such as typical spending levels for a privately insured, middle-income population.

However, a limitation with this approach is that unlike spending for premiums, mortgages, rents, and other household necessities, out-of-pocket spending on medical care is much less predictable, often unexpected and not entirely discretionary. [Duh !! And its the reason anyone wants to be insured for their health.] While families may be able to budget for preventive and routine health care needs, high out-of-pocket medical spending by families is more often associated with urgent or serious health conditions, as well as provider recommendations for treatment, rather than discretionary patient choices. Thus, what people actually spend out of pocket on medical care reflects -at least in part -what they need or are prescribed, not necessarily what they can afford.

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IMPACT OF A RECESSION

REPORTS SHOW IMPACT OF A RECESSION, RISING UNEMPLOYMENT ON HEALTH COVERAGE AND STATE BUDGETS January 9, 2009 Kaiser Family Foundation

The analysis projects that if the unemployment rate rises to 7 % in early 2009 from an average of 4.6 % in 2007, Medicaid and State Children's Health Insurance Program (SCHIP) enrollment would increase by 2.4 million and an additional 2.6 million people would become uninsured. If the unemployment rate climbed even further to 10 %, Medicaid and SCHIP enrollment would increase by 5.4 million and the uninsured would increase by 5.8 million. At the same time, states face increased budget pressure to finance care for the uninsured and to cut program spending as revenues declines.

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COST-SHARING REQUIREMENTS AND LIMITS

BRIEF EXAMINES COST-SHARING REQUIREMENTS AND LIMITS IN THREE EUROPEAN NATIONS January 12, 2009 Kaiser Family Foundation

As policymakers in the USA weigh options for reform to the nation’s health care system, the level of cost sharing that consumers face when they receive services covered by their health plans is a major consideration, especially for those with serious health conditions.

A new background brief authored by Kaiser Family Foundation researchers examines how three European countries ­ France, Germany, and Switzerland ­ have dealt with cost sharing in their health systems. While cost sharing is required in each of these countries, each has a number of specific policies to limit the impact on people and families with significant health care needs and low incomes. The brief provides an overview of each country’s health care system, its cost-sharing policies, and the cost-sharing exemptions and limits that help protect people with low incomes, certain medical conditions or high medical costs, and other characteristics from burdensome, excessive costs.

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UNNECESSARY HOSPITALIZATIONS

INTERRUPTIONS IN MEDICAID COVERAGE TRIGGER UNNECESSARY HOSPITALIZATIONS researchers led by Andrew Bindman, M.D

Interruptions in health insurance coverage are common in the USA. This stems in part from the voluntary nature of employer coverage, as well as the multiplicity of state rules governing eligibility for public insurance programs like Medicaid. To continue qualifying for benefits, Medicaid beneficiaries must demonstrate eligibility each year and, in some states, as often as every three months. These requirements can make people especially vulnerable to disruptions in coverage--and less likely to get regular primary and preventive care.

Adult California Medicaid beneficiaries who experienced interruptions in their benefits had a substantially higher risk of hospitalization for ambulatory care-sensitive conditions than did patients with continuous coverage. These conditions include asthma, congestive heart failure, chronic obstructive pulmonary disease, diabetes, and pneumonia. While public insurance programs provide coverage to people who would otherwise not have any, the administrative burdens they often place on beneficiaries can impede success in reaching those in need. Policies that reduce the frequency of coverage interruptions, the authors say, could prevent hospitalizations and other events that trigger negative health consequences and high costs.

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THE WAY WE PAY FOR HEALTH CARE

CHANGE THE WAY WE PAY FOR HEALTH CARE, EXPERTS SAY Commonwealth Fund

More than two-thirds of respondents to the latest Commonwealth Fund/Modern Healthcare Health Care Opinion Leaders Survey believe the way we pay for health care in the USA must be fundamentally reformed. Fee-for-service payment--the most prevalent system throughout the country--is not effective in encouraging high-quality, efficient care.

In the survey, there was strong support for a move toward bundled approaches--that is, making a single payment for all services provided to a patient during the course of an episode or period of time. Under fee-for-service, providers are reimbursed for individual services, like hospital stays and medical procedures, rather than for providing the most appropriate care for the patient over the course of an illness. This creates incentives for providing more technical and more expensive--but not necessarily more effective--care.

When asked their opinions about policies for improving U.S. health system performance, 85 % of survey respondents cited fundamental provider payment reform, including incentives to provide high-quality and efficient care over time, as an effective strategy.

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TRANSFORMING HEALTH CARE PAYMENT AND DELIVERY SYSTEMS

TRANSFORMING HEALTH CARE PAYMENT AND DELIVERY SYSTEMS Robert Woods Johnson Foundation

A major cause of the quality and cost problems in U.S. health care today is attributed to the current payment system built to reward the quantity of treatment, not the quality of care. A summit of more than 100 leaders from across the country -doctors, hospitals, insurers, academics, foundations, government, regional health care collaboratives and others -generated the recommendations.

This report is the first in the NRHI Healthcare Payment Reform Series, funded by the Robert Wood Johnson Foundation. The series examines ways to reform payment systems, improve quality and reduce costs in the health care system.

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KAISER HEALTH TRACKING POLL

KAISER HEALTH TRACKING POLL April 2-8, 2009 Kaiser Family Foundation

Now I'm going to read you some different ways to increase the number of Americans covered by health insurance. As I read each one, please tell me whether you would favor it or oppose it.

1. Requiring employers to offer health insurance to their workers or pay money into a government fund that will pay to cover those without insurance 71% favor 25% oppose .
   
2. Offering tax credits to help people buy private health insurance
   67% favor
   29% oppose
   
3. Expanding Medicare to cover people between the ages of 55 and 64 who do not have health insurance
   79% favor
   18% oppose
   
4. Creating a government-administered public health insurance option similar to Medicare to compete with private health insurance plans
   67% favor
   29% oppose
   
5. Expanding state government programs for low-income people, such as Medicaid and the State Children’s Health Insurance Program
   77% favor
   20% oppose
   
6. Requiring all Americans to have health insurance, either from their employer or from another source, with financial help for those who can’t afford it
   72% favor
   25% oppose
   
7. Having a national health plan in which all Americans would get their insurance from a single government plan
   49% favor
   47% oppose
   
8. Creating a public health insurance option similar to Medicare to compete with private health insurance plans
   67% favor
   29% oppose

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FORK IN THE ROAD

FORK IN THE ROAD: ALTERNATIVE PATHS TO A HIGH PERFORMANCE U.S. HEALTH SYSTEM Cathy Schoen, M.S., Karen Davis, Ph.D., Stuart Guterman, and Kristof Stremikis, M.P.P. June 24, 2009

A controversial part of the health reform debate is whether a new public insurance plan choice should be offered to the under-65 population. Alternative paths to reform were analyzed to estimate the impacts on health spending 2010-2020. The three alternatives that were considered include: 1) a public health plan paying providers at Medicare rates, offered alongside private plans in a national health insurance exchange; 2) a public plan paying providers at rates set midway between Medicare and private plan rates, offered alongside private plans in an insurance exchange; and 3) no public plan, with only private plans offered to employers and individuals through an insurance exchange. A single payer system for everyone was not included. All three approaches, if combined with Medicare payment and system reform, would produce substantial savings over time compared to our current chaotic system, but option 1 would yield the most savings ($3.0 trillion) followed by $2.0 trillion savings (option and $1.2 trillion savings (option 3).

The U.S. health system is traveling down a fiscally dangerous road. By 2020, over one-fifth of the nation’s economic resources, a full 21.3 percent of the gross domestic product will go toward providing health care without commensurate return in access, health outcomes, or value. In spite of all that spending, an estimated 61 million people will be uninsured in 2020 (counting only those continually uninsured jan 1 - dec 31 for the calendar year) and ath very least 30 million more will be underinsured. National debate is currently centered on the question of how to slow the growth of health care costs to sustain coverage while ensuring quality of care. A controversial component of this debate is whether to offer a new public plan choice to the under-65 population

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MEDICAL BILLS LINKED TO NEARLY TWO-THIRDS OF ALL BANKRUPTCIESUSE

ILLNESS AND MEDICAL BILLS LINKED TO NEARLY TWO-THIRDS OF ALL BANKRUPTCIES www.pnhp.org David Himmelstein, M.D. Steffie Woolhandler, M.D., M.P.H. Elizabeth Warren, J.D. Deborah Thorne, Ph.D.

Medical problems contributed to nearly two-thirds (62.1 percent) of all bankruptcies in 2007, according to a study in the August issue of the American Journal of Medicine. The data were collected prior to the current economic downturn and hence likely understate the current burden of financial suffering. Between 2001 and 2007, the proportion of all bankruptcies attributable to medical problems rose by 49.6 percent.

Surprisingly, most of those bankrupted by medical problems had health insurance. More than three-quarters (78%) were insured at the start of the bankrupting illness, including 60% who had private coverage. Most of the medically bankrupt were solidly middle class before financial disaster hit. Two-thirds were homeowners and three-fifths had gone to college. In many cases, high medical bills coincided with a loss of income as illness forced breadwinners to lose time from work. Often illness led to job loss, and with it the loss of health insurance.

Even apparently well-insured families often faced high out-of-pocket medical costs for co-payments, deductibles and uncovered services. Medically bankrupt families with private insurance reported medical bills that averaged $17,749 vs. $26,971 for the uninsured. High costs - averaging $22,568 - were incurred by those who initially had private coverage but lost it in the course of their illness. Individuals with diabetes and those with neurological disorders such as multiple sclerosis had the highest costs, an average of $26,971 and $34,167 respectively. Hospital bills were the largest single expense for about half of all medically bankrupt families; prescription drugs were the largest expense for 18.6 percent.

"We need to rethink health reform. Covering the uninsured isn't enough. Reform also needs to help families who already have insurance by upgrading their coverage and assuring that they never lose it. Only single-payer national health insurance can make universal, comprehensive coverage affordable by saving the hundreds of billions we now waste on insurance overhead and bureaucracy. Unfortunately, Washington politicians seem ready to cave in to insurance firms and keep them and their counterfeit coverage at the core of our system. Reforms that expand phony insurance - stripped-down plans riddled with co-payments, deductibles and exclusions - won't stem the rising tide of medical bankruptcy."

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