Florida Health Insurance Topic April 4, 2009:
"Room for Negotiation?"

Obama Firm On Health Insurance

In his televised news conference, President Obama said, "that he was willing to be flexible on negotiating with Congress on the budget for the 2010 fiscal year, but that he would stand firmly by his commitment to 'health care reform.'" It sets off the question of what he and others mean by that term.

Here is a brief explanation of what he's probably referring to.

As a horizontal economist lying in a hospital bed, I, like most patients, tend to think of health care as a caring human activity in which I repose my trust.

As a vertical economist, however, I naturally think of health care as just another economic sector with the following distinct facets:

  1. a demand side (by which I mean patients or their agents, private and public health insurers, who procure health care and pay for that care)
  2. a supply side (the providers of health care and of health care products)
  3. a health-insurance system, intended to protect individuals and households from excessive financial loss due to medical bills, and also to help patients procure health care at negotiated prices
  4. an information infrastructure supporting and linking patients, insurers and providers of care with one another, and
  5. a regulatory infrastructure intended to keep transactions in this market honorable, fair to both sides, and oriented toward the ultimate social goals of a health system.

Ambitious as he is, the president would like to reform all of these facets of the health sector.

First, on the demand side, he would like to move the United States closer to the almost-century-old goal of attaining universal health-insurance coverage. The idea is to endow with adequate purchasing power the rapidly growing number of low-income Americans who cannot afford to pay for health care of a satisfactory quality.

On the demand side, the president would like to reform the manner by which we pay the providers of health care. The general idea is to align payments with actual "performance" through what is now known as "pay-for-performance" or simply P4P. Ideally such a system would be based on so-called "bundled payments" for an entire medical case treated in accordance with evidence-based clinical practice guidelines. Although an old idea, it has eluded implementation so far, because it is horrendously difficult to achieve in practice.

The ultimate objective of this demand-side policy, however, is to goad the supply side through financial incentives into delivering genuinely clinically integrated health care, in place of the traditionally fragmented care they now deliver. It would require a major realignment of professional and economic power on the supply side.

Third, on the health insurance facet, the president would like to develop a well-functioning market for individually purchased health insurance, as an alternative to the employment-based system which covers most insured non-elderly Americans.

There now is such a market, but it covers only a small fraction of non-elderly Americans, primarily because it is highly fragmented and, moreover, in most states pegs the individual's insurance premiums to that individual's health status. To reform this market, the president would establish a National Insurance Exchange.

This can be thought of as the analogue to a farmers' market on which competing insurers offer their products, subject to a set of regulations that make transactions in the market transparent and honorable, and the competition among insurers fair.

A major contentious issue here is whether the insurers competing in this market should include a newly established public insurance plan like Medicare, but for the non-elderly. --read more == Española

Free Healthcare Offered By Awesome South Florida Doctor

With the number of uninsured rising daily, a prominent South Miami radiologist is offering free mammogram screenings for women who have lost their jobs and health insurance. ''In the spirit of Barack Obama, we need to volunteer to help our country,'' said Nilza Kallos, who operates the Breast Health Center and Diagnostic Ultrasound.

She challenged other physicians to make similar offers. ''This could be like an invitation to other doctors to step up,'' she said. ``I've heard surgeons say they don't have enough work. Well, how about helping those who need help?''

Kallos' offer comes as many financially pressed patients are curtailing care because they can't afford it. Some are insured and can't even afford the co-payments. Few doctors in South Florida are matching Kallos' free offer, but many in Broward and Miami-Dade are offering discounts to those who need them. ''The situation has reached the crisis stage,'' says Bernd Wollschlaeger, a North Miami Beach physician and president of the Dade County Medical Association. ``I think we need to do something.''

He says he and others are lowering their prices for their uninsured patients or giving them other help if they can't afford to pay. ''If you donate some of your time, it comes back to help you,'' because patients will remember helpful doctors when the economy improves.

Tony Prieto, president of the Broward County Medical Association, said in a statement: ``Patients need to understand that doctors have bills to pay, staff salaries, and office expenses, but we are compassionate, reasonable people who want to help our patients. ``Patients who have lost their insurance should know that most doctors are willing to work with their patients, set up payment plans and give cash discounts so that the patients can still have access to care.''

Those doctors include Barbara Martin, a Tamarac internist. ''In my office we are not charging for any visits to patients who are in bad situations,'' Martin wrote in an e-mail. ``Also we are trying to get them medications that they can afford at Wal-Mart, and samples at the office.'' ''I would be happy to offer services discounted to anyone who has lost a job,'' wrote Richard Rubenstein, a Tamarac dermatologist, in an e-mail.

Some doctors note they have always offered help to the uninsured. Alan Routman, a Fort Lauderdale orthopedic surgeon, said: ``I've been giving patients without insurance 30 percent discounts for cash or credit-card payments forever.''

The burden of more people seeking cheaper healthcare often falls on publicly-funded health centers, who take all patients regardless of whether they have insurance. Jennifer Capezzuti, a primary care doctor at Broward Health, notes that she has been spending ``excessive amounts of time evaluating patient's prescriptions and switching to generic alternatives.'' At the Breast Center in South Miami, Kallos has long been known as a doctor who reached out to help the community. In 2008, she was honored as a ''Woman of Vision'' by the American Committee for the Weizmann Institute of Science. -- more

Cancer Patient Loses Coverage

Here is a health insurance nightmare we all wish we could avoid. A New Jersey Woman (Denise Prosser, 39) can't afford her next cancer treatment — a radioactive therapy that she's supposed to receive once a year — because she and her husband lost their jobs in December. Without insurance, she has postponed the radiation indefinitely and is taking only half of her asthma medications — sacrifices that often leave her gasping for air and could allow her cancer to come surging back. "I can't walk more than 100 feet without sounding like I just ran a marathon," says Prosser, of Galloway, N.J.

Prosser is among millions of Americans who struggled last year to pay for health care or medications, the largest poll ever conducted by Gallup shows.

As the economy fell, the percentage who reported having trouble paying for needed health care or medicines during the previous 12 months rose from 18% in January 2008 to 21% in December, according to the poll of 355,334 Americans. Each percentage point change in the full survey represents about 2.2 million people, says Jim Harter, Gallup's chief scientist for well-being and workplace management.

Gallup, along with disease management company Healthways, surveyed a random sample of about 1,000 people nearly every day during 2008 about their physical, emotional and economic well-being.

The poll, the Gallup-Healthways Well-Being Index, shows that struggles to pay crossed all socioeconomic lines but hit some Americans harder than others: More than half of the uninsured had trouble paying for health care or medications during the year. So did more than 30% of blacks and Hispanics, compared with 17% of whites and 13% of Asians. Overall, women had more trouble than men. Those who were divorced, widowed or in domestic partner arrangements fared less well than those who were married.

Among other key findings:

  • As the year progressed, fewer Americans reported getting health coverage through their jobs, dropping from 59% in the first quarter to 58% by the last.
  • The number of African Americans reporting trouble paying for health care or medications rose six percentage points from the first quarter to the last, to 34%. People ages 25-34 also saw a big increase, up five points to 28%.
  • Among the states, Hawaii had the smallest percentage of residents who had trouble paying for health care in the previous 12 months at 12%, and Mississippi the most at 29%.

"The biggest problem that the country has is actually the cost of health care," says Jim Clifton, Gallup's CEO. "It's a lot bigger problem than war and a bigger problem than the current meltdown because there are no fixes to it on the horizon right now. … You can't just throw money at it. That's still not a fix."

The increasing trouble people have paying for medical care comes as Congress begins its most serious health care overhaul debate in 15 years — and as the economy continues to shed jobs. Because most people still get health insurance through their jobs — rather than buying it themselves or being covered by a government program such as Medicare — the loss of a job can mean the loss of insurance.

Nearly 4.4 million people have lost jobs since the recession began in December 2007, the U.S. Department of Labor reports. Nearly one in 10 children and one in five adults under age 65 are uninsured, says a February report on the uninsured from the Institute of Medicine, part of the National Academy of Sciences, which advises the government on health care.

People without insurance are at much higher risk for a host of medical problems, the institute's report shows. They're less likely to get preventive care, more likely to be diagnosed with later-stage cancers and more likely to die if they suffer a heart attack, stroke, lung problem, hip fracture, seizure or trauma. "The evidence clearly shows that lack of health insurance is hazardous to one's health," says report co-author Lawrence Lewin. "And the situation is getting worse."

Lower-income residents are more likely to have trouble paying medical bills and to lack insurance. Income also plays a role in how people feel about their own physical well-being. The Gallup-Healthways poll found that 40% of those making $500 to $1,000 a month said they were dissatisfied with their health. By comparison, only 10% of wealthy people — those making at least $10,000 a month — are dissatisfied with their health. --- more

Your Health or Insurance Company Profits

We all know that people have different ideologies about the proper role of government. Some people, who tend to be left of center, think that the government's role is to try to promote the general good, by providing basic services, protecting the poor and the sick, and ensuring a well-working economy. On the other hand, there are others, who usually place themselves right of center, who believe that the proper role of government is to redistribute as much income as possible to the wealthy.

These competing views of government are coming to a head in the debate over national health care reform. Those who think that the role of government is to serve the public good are likely to favor some form of universal Medicare. Such a system would almost certainly save a huge amount in administrative costs at the level of insurers, providers and government oversight.

Private insurers spend more than 15 percent of the money they collect in premiums on administrative costs. By contrast, Medicare spends about 2 percent. Part of the insurers' administrative expenses go toward marketing -- an expense that would be unnecessary in a universal Medicare system. more

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