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Vocapedia > Health > Health care, Health Insurance, Social security Administration

 

 

 

 

Take Care, Mr. Elson: A Hard Road to Health Insurance | Times Documentaries | The New York Times        20 June 2015

 

Times Documentaries

presents the story of one man’s hard path to health insurance

in the age of the Affordable Care Act.

 

Produced by: Emma Cott, John Woo and Abby Goodnough

Read the story here: http://nyti.ms/1JXGexO

Watch more videos at: http://nytimes.com/video

 

YouTube

https://www.youtube.com/watch?v=FG-9Qa15ybQ

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Health Care at the Bagel Shop        NYT        9 November 2014

 

 

 

 

Health Care at the Bagel Shop | The New York Times        9 November 2014

 

Reaching businesses like Bagel Grove in Utica, N.Y.,

is a priority for the new health care law.

 

But as the cost of coverage has climbed,

companies are struggling

to afford coverage for employees.

 

Produced by: Colin Archdeacon and Andrew Blackwell

Read the story here: http://nyti.ms/13IavhB

Watch more videos at: http://nytimes.com/video

 

YouTube

http://www.youtube.com/watch?
v=sjko-PHe0qU&index=2&list=UUqnbDFdCpuN8CMEg0VuEBqA

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Magoz

 

Health Policy Perspective

The Illogic of Employer-Sponsored Health Insurance

The Upshot        NYT         JULY 1, 2014

http://www.nytimes.com/2014/07/03/
upshot/the-illogic-of-employer-sponsored-health-insurance.html

 

 

 

 

 

 

 

 

 

 

 

 

 

 

health

 

 

 

 

public health        UK        2005

https://www.theguardian.com/society/
publichealth/0,11098,588173,00.html

 

 

 

 

free healthcare        UK

https://www.theguardian.com/commentisfree/2018/jun/27/
nhs-70th-birthday-universal-declaration-human-rights

 

 

 

 

France > universal health care        USA

https://www.nytimes.com/2019/01/02/
opinion/france-united-states-universal-health-care.html

 

 

 

 

get health care        USA

https://www.npr.org/sections/health-shots/2018/12/25/
671159555/a-policy-knot-leaves-oklahomans-from-marshall-islands-struggling-to-get-health-c

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mikhaela Reid

Cagle

7 November 2009

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

health care        USA

 

https://www.nytimes.com/video/health-care-america

 

 

https://www.npr.org/sections/health-shots/2019/06/24/
735432387/trump-administration-pushes-to-make-health-care-pricing-more-transparent

 

https://www.npr.org/sections/health-shots/2019/06/24/
735578519/trumps-plan-to-lower-your-hospital-costs-heres-what-you-need-to-know

 

https://www.npr.org/sections/health-shots/2019/06/17/
732497053/a-year-after-spinal-surgery-a-94-000-bill-feels-like-a-backbreaker

 

https://www.npr.org/sections/health-shots/2019/05/20/7
24468630/the-other-reasons-kids-arent-getting-vaccinations-poverty-and-health-care-access

 

https://www.npr.org/sections/health-shots/2019/05/21/
725059882/poll-many-rural-americans-struggle-with-financial-insecurity-access-to-health-ca

 

https://www.nytimes.com/2019/01/02/
opinion/france-united-states-universal-health-care.html

 

 

 

 

https://www.npr.org/sections/health-shots/2018/12/25/
671159555/a-policy-knot-leaves-oklahomans-from-marshall-islands-struggling-to-get-health-c

 

https://www.nytimes.com/2018/06/04/
upshot/reagan-deregulation-and-americas-exceptional-rise-in-health-care-costs.html

 

https://www.npr.org/sections/thetwo-way/2018/01/30/
581804474/amazon-berkshire-hathaway-and-jpmorgan-chase-launch-new-healthcare-company

 

 

 

 

https://www.nytimes.com/interactive/2017/10/16/
business/economy/trump-obamacare-arkansas.html

 

http://www.npr.org/sections/health-shots/2017/08/16/
543723927/often-missing-from-the-current-health-care-debate-womens-voices

 

https://www.nytimes.com/2017/07/15/
health/senate-health-care-obamacare.html

 

https://www.nytimes.com/2017/07/10/
opinion/health-insurance-free-market.html

 

http://www.npr.org/sections/health-shots/2017/06/30/
534773322/gop-health-bill-could-let-insurers-cap-spending-on-expensive-patients

 

https://www.nytimes.com/2017/06/19/
opinion/health-insurance-american-medical-association.html

 

http://www.npr.org/2017/05/18/
529022011/fact-check-we-dont-have-health-care-in-this-country-trump-says

 

http://www.npr.org/sections/health-shots/2017/04/20/
524881039/new-gop-health-proposal-could-ditch-protections-for-people-who-are-sick

 

http://www.npr.org/sections/health-shots/2017/04/15/
523577871/u-s-health-care-wrestles-with-the-pre-existing-condition

 

http://www.npr.org/sections/health-shots/2017/04/10/
523005353/how-u-s-health-care-became-big-business

 

https://www.nytimes.com/2017/03/18/
opinion/the-fake-freedom-of-american-health-care.html

 

http://www.npr.org/sections/health-shots/2017/03/11/
519416036/im-pregnant-what-would-happen-if-i-couldnt-afford-health-care

 

 

 

 

http://www.npr.org/sections/health-shots/2016/04/27/
475880565/that-surgery-might-cost-you-a-lot-less-in-another-town

 

http://www.npr.org/sections/health-shots/2016/04/13/
473848341/health-care-s-hard-realities-on-the-reservation-a-photo-essay

 

http://www.npr.org/sections/health-shots/2016/02/23/
467639551/sanders-health-plan-renews-debate-on-universal-coverage

 

 

 

 

http://www.nytimes.com/2010/09/23/
health/policy/23careintro.html

 

 

 

 

 

 

 

access to health care / health care access        USA

 

https://www.nytimes.com/2019/01/02/
opinion/france-united-states-universal-health-care.html

 

https://www.npr.org/sections/health-shots/2019/05/20/
724468630/the-other-reasons-kids-arent-getting-vaccinations-poverty-and-health-care-access

 

 

 

 

 

 

 

 

 

 

 

 

 

 

health care > USA > Amazon        UK / USA

https://www.theguardian.com/commentisfree/2018/feb/04/
healthcare-amazon-muscling-in

https://www.npr.org/sections/thetwo-way/2018/01/30/
581804474/amazon-berkshire-hathaway-and-jpmorgan-chase-launch-new-healthcare-company

 

 

 

 

health care in America > NYT > videos        USA

https://www.nytimes.com/video/health-care-america

 

 

 

 

afford health care        USA

http://www.npr.org/sections/health-shots/2017/03/11/
519416036/im-pregnant-what-would-happen-if-i-couldnt-afford-health-care

 

 

 

 

 free-market medicine        USA

https://www.nytimes.com/2017/07/10/
opinion/health-insurance-free-market.html

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

pre-existing condition        USA

 

https://www.npr.org/sections/health-shots/2018/10/11/
656503264/fact-check-whos-right-about-protections-for-pre-existing-conditions

 

 

 

 

http://www.npr.org/sections/health-shots/2017/05/08/
527415655/gop-health-bill-leaves-many-pre-existing-condition-protections-up-to-states

 

http://www.npr.org/sections/health-shots/2017/04/20/
524881039/new-gop-health-proposal-could-ditch-protections-for-people-who-are-sick

 

http://www.npr.org/sections/health-shots/2017/04/15/
523577871/u-s-health-care-wrestles-with-the-pre-existing-condition

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HealthCare.gov        USA

http://www.nytimes.com/2013/10/25/
opinion/getting-to-the-bottom-of-healthcaregovs-flop.html

 

 

 

 

surgery > cost > health care        USA

http://www.npr.org/sections/health-shots/2016/04/27/
475880565/that-surgery-might-cost-you-a-lot-less-in-another-town

 

 

 

 

healthcare for all        USA

http://www.npr.org/sections/health-shots/2016/02/23/
467639551/sanders-health-plan-renews-debate-on-universal-coverage

 

 

 

 

health care law        USA

http://www.nytimes.com/2011/12/17/
health/policy/health-care-law-to-allow-states-to-pick-benefits.html

 

 

 

 

 

 

 

 

 

 

 

 

 

 

subsidized health insurance        USA

http://www.npr.org/blogs/health/2015/05/11/
405183709/tales-from-3-louisianans-who-got-subsidized-health-insurance

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Children's Health Insurance Program        USA

 

federal-state program

that provides health coverage

to millions of children

in lower- and middle-class families

http://www.npr.org/sections/health-shots/2017/09/06/
548951827/congress-weighs-future-of-children-s-health-insurance

 

https://www.npr.org/sections/health-shots/2018/01/23/
580062690/after-months-in-limbo-for-childrens-health-insurance-huge-relief-over-deal

 

http://www.npr.org/sections/health-shots/2017/09/06/
548951827/congress-weighs-future-of-children-s-health-insurance

 

 

 

 

 

 

 

 

 

 

 

 

 

 

insurance > childbirth > maternity care

includes prenatal, delivery and postpartum services        USA

http://www.npr.org/sections/health-shots/2015/06/16/
414688210/insurance-still-doesnt-cover-childbirth-for-some-young-women

 

 

 

 

cartoons > Cagle > Health care repealed        USA        January 2011

http://www.cagle.com/news/HealthCareRepeal/main.asp

 

 

 

 

cartoons > Cagle > Attack on healthcare        USA        January 2011

http://www.cagle.com/news/AttackHealthcare/main.asp

 

 

 

 

Senate Passes Health Care Overhaul

on Party-Line Vote        USA        December 2009

http://www.nytimes.com/2009/12/25/
health/policy/25health.html

 

 

 

 

A History of Health Care Reform        USA        July 19, 2009

Nearly 100 years of legislative milestones and defeats.

http://www.nytimes.com/interactive/2009/07/19/us/
politics/20090717_HEALTH_TIMELINE.html

 

 

 

 

cartoons > Cagle > health care reform resistance        USA

http://www.cagle.com/news/ReformResistance/main.asp

 

 

 

 

healthcare debate > cartoons > Cagle > Bad Healthcare        USA

http://www.cagle.msnbc.com/news/HealthcareYUCK/main.asp

 

 

 

 

New York Times > Select Editorials on Health Care        USA

 

Selection of editorials published

by The New York Times Editorial Board

since March 2009

examining the policy challenges

and the politics

behind the crucial national debate

on health care reform.

http://topics.nytimes.com/topics/opinion/editorials/
select-health-care-editorials/index.html - broken link

 

 

 

 

universal health care / universal health coverage / health care reform        USA

https://www.nytimes.com/topic/subject/health-care-reform  

 

http://www.npr.org/sections/health-shots/2016/07/29/
486608543/campaign-for-universal-health-care-in-colorado-seeks-bernie-sanders-help

 

http://www.nytimes.com/2014/01/01/us/
politics/millions-gaining-health-coverage-under-law.html

 

http://www.nytimes.com/2011/09/22/us/
young-adults-make-gains-in-health-insurance-coverage.html

 

http://www.theatlantic.com/doc/200909/
health-care

http://www.nytimes.com/2009/08/27/
opinion/27kristof.html

http://www.nytimes.com/2009/06/10/
opinion/l10health.html

http://www.nytimes.com/2009/06/07/
opinion/07sun1.html

 

 

 

 

Comparing the House and the Senate Health Care Proposals        USA

 

Senate Democrats

unveiled sweeping legislation Wednesday

to overhaul the nation’s health care system.

 

Earlier this month

the House passed its own version.

 

The proposals are broadly similar

but differ on some major issues,

such as on a new government insurance plan,

abortion and immigration.

 

Many provisions of the Senate bill,

including the mandate for individuals

to obtain insurance

and the creation of insurance markets,

would take effect in 2014,

a year later

than similar provisions of the House bill.

http://www.nytimes.com/interactive/2009/11/19/us/
politics/1119-plan-comparison.html

 

 

 

 

health reform bill > cartoons > Cagle        USA        2009

http://www.cagle.msnbc.com/news/HealthReformBill/main.asp

 

 

 

 

 

 

 

health insurance / health policies / health coverage        UK / USA

 

https://www.npr.org/sections/health-shots/2018/05/30/
615156632/why-some-patients-getting-drugmakers-help-are-paying-more

 

 

 

 

https://www.npr.org/sections/health-shots/2017/12/14/
570503475/consumers-hunting-for-health-insurance-find-high-prices-and-some-great-deals

 

https://www.npr.org/sections/health-shots/2017/11/29/
567264925/health-insurers-are-still-skimping-on-mental-health-coverage

 

http://www.npr.org/sections/health-shots/2017/09/12/
550245002/what-to-do-when-your-health-insurance-won-t-pay-the-bills

 

http://www.npr.org/sections/health-shots/2017/06/06/
530846989/protected-but-priced-out-patients-worry-about-health-laws-future-in-arizona

 

http://www.npr.org/sections/health-shots/2017/04/14/
522956939/maps-show-a-dramatic-rise-health-in-insurance-coverage-under-aca

 

http://www.npr.org/sections/health-shots/2017/04/04/
522482563/trump-team-urges-skimpier-health-plans-to-lure-more-people-to-buy-insurance

 

 

 

 

http://www.npr.org/sections/health-shots/2016/05/13/
477917113/more-low-income-kids-now-have-health-coverage

http://www.npr.org/sections/health-shots/2016/03/08/
468892489/medical-bills-still-take-a-big-toll-even-with-insurance

 

http://www.nytimes.com/2014/09/16/us/
number-of-americans-without-health-insurance-falls-survey-shows.html

http://www.npr.org/blogs/health/2014/05/
05/309836437/more-health-insurance-equals-fewer-deaths-in-massachusetts

 

http://www.nytimes.com/2013/10/07/
opinion/without-health-insurance-those-left-behind.html

http://www.nytimes.com/2013/10/05/
opinion/pent-up-demand-for-health-insurance.html

 

http://www.nytimes.com/2010/09/25/
opinion/25herbert.html

http://www.guardian.co.uk/world/2010/mar/22/
health-care-vote-us-obama

http://www.nytimes.com/2010/03/22/
your-money/health-insurance/22consumer.html

http://www.nytimes.com/2010/03/22/
health/policy/22health.html

 

http://www.guardian.co.uk/society/2009/aug/21/
healthcare-provision-us-uk

http://www.nytimes.com/2009/07/01/
business/01meddebt.html

 

http://www.nytimes.com/2008/12/07/us/
07uninsured.html

http://www.usatoday.com/news/health/2008-10-28-
health-cuts_N.htm

http://www.usatoday.com/news/health/2008-07-16-
healthcoverage_N.htm

 

 

 

 

people covered by health insurance        USA

http://www.npr.org/sections/health-shots/2017/04/14/
522956939/maps-show-a-dramatic-rise-health-in-insurance-coverage-under-aca

 

 

 

 

Children’s Insurance / Health Care for America’s Kids        USA        2015

http://www.nytimes.com/2015/02/13/
opinion/hillary-clinton-and-bill-frist-on-health-care-for-americas-kids.html

 

 

 

 

“junk insurance”        USA

https://www.nytimes.com/2017/07/15/
health/senate-health-care-obamacare.html

 

 

 

 

 

 

 

 

 

 

 

 

 

 

“socialized medicine”        USA

http://www.nytimes.com/2009/08/27/
opinion/27kristof.html

 

 

 

 

health officials        UK

http://www.guardian.co.uk/world/2009/may/05/
swine-flu-cases-britain

 

 

 

 

Health Protection Agency    HPA

http://www.hpa.org.uk/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

health insurance companies / insurance companies        USA

 

http://www.npr.org/sections/health-shots/2016/07/25/
481765235/single-mom-s-search-for-therapist-hampered-by-insurance-companies

 

http://www.npr.org/sections/health-shots/2016/04/27/
475880565/that-surgery-might-cost-you-a-lot-less-in-another-town

 

 

 

 

http://www.nytimes.com/2010/05/16/
health/policy/16health.html

 

 

 

 

 

 

 

health insurers        USA

 

https://www.npr.org/sections/health-shots/2018/07/17/
629441555/health-insurers-are-vacuuming-up-details-about-you-and-it-could-raise-your-rates

 

https://www.npr.org/sections/health-shots/2018/05/25/
613685732/why-your-health-insurer-doesnt-care-about-your-big-bills

 

http://www.npr.org/sections/health-shots/2015/06/08/
408190121/insurer-uses-personal-data-to-predict-who-will-get-sick

 

http://www.nytimes.com/2011/05/14/
business/14health.html

 

http://www.nytimes.com/2010/09/25/
opinion/25sat1.html

http://www.nytimes.com/2010/09/23/
business/23insure.html

 

 

 

 

 

 

 

UnitedHealth Group - one of the largest commercial insurers        USA

 

https://www.nytimes.com/topic/company/unitedhealth-group-inc 

 

http://www.nytimes.com/2011/05/14/
business/14health.html

 

 

 

 

 

 

 

premiums        USA

 

http://www.nytimes.com/2010/09/25/
opinion/25sat1.html

 

 

 

 

 

 

 

 

 

 

 

 

 

 

the uninsured        UK

http://www.guardian.co.uk/society/2009/aug/21/
healthcare-provision-us-uk

 

 

 

 

the uninsured        USA

http://www.nytimes.com/interactive/2015/10/31/
upshot/who-still-doesnt-have-health-insurance-obamacare.html

 

http://www.nytimes.com/2009/09/05/
health/policy/05uninsured.html

 

http://www.nytimes.com/2008/12/09/
business/09emergency.html

 

 

 

 

Interactive map > Mapping Uninsured Americans        USA        2013

Census data released Dec. 17

show where the uninsured live.

http://www.nytimes.com/newsgraphics/2013/12/18/
uninsured-map/

 

 

 

 

U.S. Health Insurance Cost        USA        2011

http://www.nytimes.com/2011/09/28/
business/health-insurance-costs-rise-sharply-this-year-study-shows.html

 

 

 

 

afford health insurance        USA

http://www.nytimes.com/2010/04/17/
health/policy/17health.html

 

 

 

 

health tourism        UK

http://www.theguardian.com/society/2003/dec/21/
asylum.medicineandhealth 

 

 

 

 

health disaster

http://www.economist.com/agenda/displayStory.cfm?story_id=2786168

 

 

 

 

Health Protection Agency    HPA        UK

http://www.theguardian.com/society/2005/apr/19/
health.medicineandhealth 

 

 

 

 

health index        UK

http://www.theguardian.com/society/2005/jun/15/
hospitals.medicineandhealth 

 

 

 

 

private healthcare        UK

http://www.theguardian.com/society/2004/jun/23/
nhs2000.politics3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

health bills / medical bills / hospital bills        USA

 

https://www.npr.org/sections/health-shots/2019/02/26/
697786766/cat-bites-the-hand-that-feeds-hospital-bills-48-512

 

http://www.npr.org/sections/health-shots/2016/03/08/
468892489/medical-bills-still-take-a-big-toll-even-with-insurance

 

http://www.npr.org/blogs/health/2015/03/27/
395586203/medical-bills-linger-long-after-cancer-treatment-ends

 

http://www.nytimes.com/2013/10/19/
your-money/out-of-network-not-by-choice-and-facing-huge-health-bills.html

http://www.nytimes.com/2013/10/19/
opinion/paying-for-health-care-on-credit.html

http://www.nytimes.com/2013/10/14/
business/economy/patients-mired-in-costly-credit-from-doctors.html

 

 

 

 

 

 

 

 

 

 

 

 

 

 

medical debt        USA

 

http://www.npr.org/sections/health-shots/2016/03/17/
470109362/medical-debt-rains-pain-on-families-even-in-the-sunshine-state

 

 

 

 

 

 

 

 

 

 

 

 

 

 

UK > National Health Service    NHS        UK

 

http://www.nhs.uk/pages/home.aspx

https://www.theguardian.com/society/nhs

 

 

https://www.nytimes.com/2018/01/16/
opinion/nhs-britain-crisis.html

 

https://www.theguardian.com/politics/2007/oct/05/uk.health 

 

https://www.theguardian.com/uk/2006/jun/15/health.politics 

https://www.theguardian.com/lifeandstyle/2006/may/11/healthandwellbeing.health  

https://www.theguardian.com/theguardian/2006/may/11/features11.g2 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

American Medical Association        USA

http://www.ama-assn.org/ama 

 

http://www.nytimes.com/2009/06/25/
opinion/25kristof.ready.html

http://www.nytimes.com/2009/06/27/
opinion/l27health.html

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

social security        USA

 

https://www.nytimes.com/topic/subject/social-security-us

 

 

http://www.npr.org/sections/health-shots/2017/06/13/
531207430/people-with-unseen-disabilities-could-suffer-under-new-government-rules

 

http://www.npr.org/2016/10/06/
496067982/the-issues-hillary-clinton-and-donald-trump-on-social-security-and-medicare

 

http://www.nytimes.com/2004/12/21/
business/21lobby.html

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Randy Bish

The Tribune-Review

Pittsburgh, PA

Cagle

26 October 2010

 

Related > Halloween

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Millions of Poor Are Left Uncovered

by Health Law

 

October 2, 2013

The New York Times

By SABRINA TAVERNISE

and ROBERT GEBELOFF

 

A sweeping national effort to extend health coverage to millions of Americans will leave out two-thirds of the poor blacks and single mothers and more than half of the low-wage workers who do not have insurance, the very kinds of people that the program was intended to help, according to an analysis of census data by The New York Times.

Because they live in states largely controlled by Republicans that have declined to participate in a vast expansion of Medicaid, the medical insurance program for the poor, they are among the eight million Americans who are impoverished, uninsured and ineligible for help. The federal government will pay for the expansion through 2016 and no less than 90 percent of costs in later years.

Those excluded will be stranded without insurance, stuck between people with slightly higher incomes who will qualify for federal subsidies on the new health exchanges that went live this week, and those who are poor enough to qualify for Medicaid in its current form, which has income ceilings as low as $11 a day in some states.

People shopping for insurance on the health exchanges are already discovering this bitter twist.

“How can somebody in poverty not be eligible for subsidies?” an unemployed health care worker in Virginia asked through tears. The woman, who identified herself only as Robin L. because she does not want potential employers to know she is down on her luck, thought she had run into a computer problem when she went online Tuesday and learned she would not qualify.

At 55, she has high blood pressure, and she had been waiting for the law to take effect so she could get coverage. Before she lost her job and her house and had to move in with her brother in Virginia, she lived in Maryland, a state that is expanding Medicaid. “Would I go back there?” she asked. “It might involve me living in my car. I don’t know. I might consider it.”

The 26 states that have rejected the Medicaid expansion are home to about half of the country’s population, but about 68 percent of poor, uninsured blacks and single mothers. About 60 percent of the country’s uninsured working poor are in those states. Among those excluded are about 435,000 cashiers, 341,000 cooks and 253,000 nurses’ aides.

“The irony is that these states that are rejecting Medicaid expansion — many of them Southern — are the very places where the concentration of poverty and lack of health insurance are the most acute,” said Dr. H. Jack Geiger, a founder of the community health center model. “It is their populations that have the highest burden of illness and costs to the entire health care system.”

The disproportionate impact on poor blacks introduces the prickly issue of race into the already politically charged atmosphere around the health care law. Race was rarely, if ever, mentioned in the state-level debates about the Medicaid expansion. But the issue courses just below the surface, civil rights leaders say, pointing to the pattern of exclusion.

Every state in the Deep South, with the exception of Arkansas, has rejected the expansion. Opponents of the expansion say they are against it on exclusively economic grounds, and that the demographics of the South — with its large share of poor blacks — make it easy to say race is an issue when it is not.

In Mississippi, Republican leaders note that a large share of people in the state are on Medicaid already, and that, with an expansion, about a third of the state would have been insured through the program. Even supporters of the health law say that eventually covering 10 percent of that cost would have been onerous for a predominantly rural state with a modest tax base.

“Any additional cost in Medicaid is going to be too much,” said State Senator Chris McDaniel, a Republican, who opposes expansion.

The law was written to require all Americans to have health coverage. For lower and middle-income earners, there are subsidies on the new health exchanges to help them afford insurance. An expanded Medicaid program was intended to cover the poorest. In all, about 30 million uninsured Americans were to have become eligible for financial help.

But the Supreme Court’s ruling on the health care law last year, while upholding it, allowed states to choose whether to expand Medicaid. Those that opted not to leave about eight million uninsured people who live in poverty ($19,530 for a family of three) without any assistance at all.

Poor people excluded from the Medicaid expansion will not be subject to fines for lacking coverage. In all, about 14 million eligible Americans are uninsured and living in poverty, the Times analysis found.

The federal government provided the tally of how many states were not expanding Medicaid for the first time on Tuesday. It included states like New Hampshire, Ohio, Pennsylvania and Tennessee that might still decide to expand Medicaid before coverage takes effect in January. If those states go forward, the number would change, but the trends that emerged in the analysis would be similar.

Mississippi has the largest percentage of poor and uninsured people in the country — 13 percent. Willie Charles Carter, an unemployed 53-year-old whose most recent job was as a maintenance worker at a public school, has had problems with his leg since surgery last year.

His income is below Mississippi’s ceiling for Medicaid — which is about $3,000 a year — but he has no dependent children, so he does not qualify. And his income is too low to make him eligible for subsidies on the federal health exchange.

“You got to be almost dead before you can get Medicaid in Mississippi,” he said.

He does not know what he will do when the clinic where he goes for medical care, the Good Samaritan Health Center in Greenville, closes next month because of lack of funding.

“I’m scared all the time,” he said. “I just walk around here with faith in God to take care of me.”

The states that did not expand Medicaid have less generous safety nets: For adults with children, the median income limit for Medicaid is just under half of the federal poverty level — or about $5,600 a year for an individual — while in states that are expanding, it is above the poverty line, or about $12,200, according to the Kaiser Family Foundation. There is little or no coverage of childless adults in the states not expanding, Kaiser said.

The New York Times analysis excluded immigrants in the country illegally and those foreign-born residents who would not be eligible for benefits under Medicaid expansion. It included people who are uninsured even though they qualify for Medicaid in its current form.

Blacks are disproportionately affected, largely because more of them are poor and living in Southern states. In all, 6 out of 10 blacks live in the states not expanding Medicaid. In Mississippi, 56 percent of all poor and uninsured adults are black, though they account for just 38 percent of the population.

Dr. Aaron Shirley, a physician who has worked for better health care for blacks in Mississippi, said that the history of segregation and violence against blacks still informs the way people see one another, particularly in the South, making some whites reluctant to support programs that they believe benefit blacks.

That is compounded by the country’s rapidly changing demographics, Dr. Geiger said, in which minorities will eventually become a majority, a pattern that has produced a profound cultural unease, particularly when it has collided with economic insecurity.

Dr. Shirley said: “If you look at the history of Mississippi, politicians have used race to oppose minimum wage, Head Start, all these social programs. It’s a tactic that appeals to people who would rather suffer themselves than see a black person benefit.”

Opponents of the expansion bristled at the suggestion that race had anything to do with their position. State Senator Giles Ward of Mississippi, a Republican, called the idea that race was a factor “preposterous,” and said that with the demographics of the South — large shares of poor people and, in particular, poor blacks — “you can argue pretty much any way you want.”

The decision not to expand Medicaid will also hit the working poor. Claretha Briscoe earns just under $11,000 a year making fried chicken and other fast food at a convenience store in Hollandale, Miss., too much to qualify for Medicaid but not enough to get subsidies on the new health exchange. She had a heart attack in 2002 that a local hospital treated as part of its charity care program.

“I skip months on my blood pressure pills,” said Ms. Briscoe, 48, who visited the Good Samaritan Health Center last week because she was having chest pains. “I buy them when I can afford them.”

About half of poor and uninsured Hispanics live in states that are expanding Medicaid. But Texas, which has a large Hispanic population, rejected the expansion. Gladys Arbila, a housekeeper in Houston who earns $17,000 a year and supports two children, is under the poverty line and therefore not eligible for new subsidies. But she makes too much to qualify for Medicaid under the state’s rules. She recently spent 36 hours waiting in the emergency room for a searing pain in her back.

“We came to this country, and we are legal and we work really hard,” said Ms. Arbila, 45, who immigrated to the United States 12 years ago, and whose son is a soldier in Afghanistan. “Why we don’t have the same opportunities as the others?”

Millions of Poor Are Left Uncovered by Health Law,
NYT,
2.10.2013,
http://www.nytimes.com/2013/10/03/
health/millions-of-poor-are-left-uncovered-by-health-law.html

 

 

 

 

 

Health Care Law

Will Let States Tailor Benefits

 

December 16, 2011

The New York Times

By ROBERT PEAR

 

WASHINGTON — In a major surprise on the politically charged new health care law, the Obama administration said Friday that it would not define a single uniform set of “essential health benefits” that must be provided by insurers for tens of millions of Americans. Instead, it will allow each state to specify the benefits within broad categories.

The move would allow significant variations in benefits from state to state, much like the current differences in state Medicaid programs and the Children’s Health Insurance Program.

By giving states the discretion to specify essential benefits, the Obama administration sought to deflect one of the most powerful arguments made by Republican critics of President Obama’s health care overhaul — that it was imposing a rigid, bureaucrat-controlled health system on Americans and threatening the quality of care. Opponents say that the federal government is forcing a one-size-fits-all standard for health insurance and usurping state authority to regulate the industry.

This criticism has inspired legal challenges to the new law — with the Supreme Court set to decide next year whether the government can require Americans to buy health insurance — and helps explain why public opinion of the law remains deeply divided.

The law is looming as a central issue in the 2012 presidential race, with Republican presidential candidates being evaluated on the strength of their opposition to it. The announcement by the administration follows its decision this year to jettison a program created in the law to provide long-term care insurance, a move that disappointed liberal backers of the program championed by the late Senator Edward M. Kennedy.

The action Friday prompted questions among supporters of the new health care law. Prof. Timothy S. Jost, an expert on health law at Washington and Lee University, said, “The new bulletin perpetuates uncertainty about what benefits an insurer will be required to cover under the Affordable Care Act.” From the consumer’s point of view, Professor Jost added, “I wish the Department of Health and Human Services had signaled that there would be more uniformity and less flexibility.”

Chris Jacobs, a health policy analyst for Senate Republicans, said the new policy “gives states the flexibility to impose more benefit mandates, not fewer,” and would lead to higher insurance premiums, contrary to what Mr. Obama promised in the 2008 campaign.

The new law lists 10 categories of “essential health benefits” that must be provided by insurance offered in the individual and small-group markets, starting in January 2014. These include preventive care, emergency services, maternity care, hospital and doctors’ services, and prescription drugs.

Kathleen Sebelius, the secretary of health and human services, had been expected to provide details of what services and benefits must be provided in each category. Instead, in an insurance bulletin issued Friday, Ms. Sebelius said the federal government would respect the states’ role, giving them “the flexibility to design coverage options that meet their unique needs.”

Under this approach, each state would designate an existing health insurance plan as a benchmark. The benefits provided by that plan would be deemed essential, and all insurers would have to provide benefits of the same or greater value. Plans could modify coverage within a benefit category so long as they did not reduce the value of coverage.

Each state would choose one of the following health insurance plans as a benchmark:

¶ One of the three largest small-group plans in the state.

¶ One of the three largest health plans for state employees.

¶ One of the three largest national health insurance options for federal employees.

¶ The largest health maintenance organization operating in the state’s commercial insurance market.

While working on health care legislation in 2009 and 2010, Congress spent many hours debating how to balance the goals of comprehensive benefits and affordable coverage.

Sherry A. Glied, an assistant secretary of health and human services, said the administration’s approach “builds off the experience of today’s marketplace and will minimize disruption to it.”

Steven B. Larsen, deputy administrator of the federal Centers for Medicare and Medicaid Services, said, “The state is always in control of what the essential benefits package is in that state.”

In recent months, federal health officials have taken a number of steps that could help inoculate Mr. Obama against charges that he was foisting a rigid, inflexible model of health care on the nation.

Several states have received temporary waivers from tough new federal standards that require insurers to spend more of each premium dollar for the benefit of consumers. Federal officials have also provided temporary exemptions from some provisions of the law for some employers and labor unions offering bare-bones coverage.

The new law says that the scope of essential health benefits must be “equal to the scope of benefits provided under a typical employer plan.” But the law itself specifically requires some benefits not widely available in employer-sponsored health plans, like “habilitative services” for people with conditions like autism or cerebral palsy.

Under the new law, each state is supposed to have an insurance exchange or marketplace where consumers can compare options and buy insurance. Health plans must offer the essential benefits, regardless of whether the coverage is sold inside or outside the exchange.

The government will offer subsidies to help low-income people buy insurance through exchanges. The subsidies will help cover the cost of essential benefits. States can require insurers to provide additional benefits, but states will have to pay much of the extra cost.

The law also says that the definition of essential benefits must not “discriminate against individuals because of their age, disability or expected length of life.”

 

Sara Rosenbaum, a professor of health law and policy

at George Washington University,

said the new bulletin “does not offer any guidance

on this crucial part of the law.”

    Health Care Law Will Let States Tailor Benefits, NYT, 16.12.2011,
    http://www.nytimes.com/2011/12/17/health/policy/
    health-care-law-to-allow-states-to-pick-benefits.html

 

 

 

 

 

The Smokers’ Surcharge

 

November 16, 2011
The New York Times
By REED ABELSON

 

More and more employers are demanding that workers who smoke, are overweight or have high cholesterol shoulder a greater share of their health care costs, a shift toward penalizing employees with unhealthy lifestyles rather than rewarding good habits.

Policies that impose financial penalties on employees have doubled in the last two years to 19 percent of 248 major American employers recently surveyed. Next year, Towers Watson, the benefits consultant that conducted the survey, said the practice — among employers with at least 1,000 workers — was expected to double again.

In addition, another survey released on Wednesday by Mercer, which advises companies, showed that about a third of employers with 500 or more workers were trying to coax them into wellness programs by offering financial incentives, like discounts on their insurance. So far, companies including Home Depot, PepsiCo, Safeway, Lowe’s and General Mills have defended decisions to seek higher premiums from some workers, like Wal-Mart’s recent addition of a $2,000-a-year surcharge for some smokers. Many point to the higher health care costs associated with smoking or obesity. Some even describe the charges and discounts as a “more stick, less carrot” approach to get workers to take more responsibility for their well-being. No matter the characterizations, it means that smokers and others pay more than co-workers who meet a company’s health goals.

But some benefits specialists and health experts say programs billed as incentives for wellness, by offering discounted health insurance, can become punitive for people who suffer from health problems that are not completely under their control. Nicotine addiction, for example, may impede smokers from quitting, and severe obesity may not be easily overcome.

Earlier this year, the American Cancer Society and the American Heart Association were among groups that warned federal officials about giving companies too much latitude. They argued in a letter sent in March that the leeway afforded employers could provide “a back door” to policies that discriminate against unhealthy workers.

Kristin M. Madison, a professor of law and health sciences at Northeastern University in Boston, said, “People are definitely worried that programs will be used to drive away employees or potential employees who are unhealthy.”

Current regulations allow companies to require workers who fail to meet specific standards to pay up to 20 percent of their insurance costs. The federal health care law raises that amount to 30 percent in 2014 and, potentially, to as much as half the cost of a policy.

When Wal-Mart Stores, the nation’s largest employer, recently sought the higher payments from some smokers, its decision was considered unusual, according to benefits experts. The amount, reaching $2,000 more than for nonsmokers, was much higher than surcharges of a few hundred dollars a year imposed by other employers on their smoking workers.

And the only way for Wal-Mart employees to avoid the surcharges was to attest that their doctor said it would be medically inadvisable or impossible to quit smoking. Other employers accept enrollment in tobacco cessation programs as an automatic waiver for surcharges.

“This is another example of where it’s not trying to create healthier options for people,” said Dan Schlademan, director of Making Change at Walmart, a union-backed campaign that is sharply critical of the company’s benefits. “It looks a lot more like cost-shifting.”

Wal-Mart declined to make an official available for an interview and provided limited answers to questions through an e-mail response. “The increase in premiums in tobacco users is directly related to the fact that tobacco users generally consume about 25 percent more health care services than nontobacco users,” said Greg Rossiter, a company spokesman.

Wal-Mart requires an employee to have stopped smoking to qualify for lower premiums. The company, which has more than one million employees, started offering an antismoking program this year, and says more than 13,000 workers have enrolled.

Some labor experts contend that employers can charge workers higher fees only if they are tied to a broader wellness program, although federal rules do not define wellness programs.

Employers cannot discriminate against smokers by asking them to pay more for their insurance unless the surcharge is part of a broader effort to help them quit, said Karen L. Handorf, a lawyer who specializes in employee benefits for Cohen Milstein Sellers & Toll in Washington.

Many programs that ask employees to meet certain health targets offer rewards in the form of lower premiums. At Indiana University Health, a large health system, employees who do not smoke and achieve a certain body mass index, or B.M.I., can receive up to $720 a year off the cost of their insurance. “It’s all about the results,” said Sheriee Ladd, a senior vice president in human resources at the system.

Initially the system also rewarded employees who met cholesterol and blood glucose goals, but after workers complained that those hurdles seemed punitive, Indiana shifted its emphasis a bit.

Workers who do not meet the weight targets can be eligible for lower premiums if a doctor indicates they have a medical condition that makes the goal unreasonable, Ms. Ladd said. “There are not many of those who come forward, but it’s available,” she said, adding that workers must be nonsmoking to get the other discount. About 65 percent of roughly 16,000 workers receive a discount.

Some benefits consultants say companies may be increasingly willing to test the boundaries of the law because there has been little enforcement, even though there is a provision requiring employers to accommodate workers with medical conditions limiting their ability to meet certain standards. “They are thumbing their nose at the accommodation provision,” said Michael Wood, a consultant at Towers Watson.

Still, “The employer is going to win not by cost-shifting but by getting people to stop smoking,” said Barry Hall, an executive at Buck Consultants, which advises employers.

Some versions of tougher standards have already been abandoned. The UnitedHealth Group, for example, had introduced a health plan called Vital Measures, which allowed workers to reduce the size of their deductible by meeting various health targets, but discontinued the offering three years ago because of insufficient demand, according to a spokesman. The insurer now offers plans that allow employees to earn rewards by either achieving health targets or participating in a coaching program to improve their health.

Wal-Mart’s decision to start charging smokers more for insurance came abruptly, according to some employees who say they had no chance to quit or consult a doctor. Jerome Allen, who works for Wal-Mart in Texas, says he realized he was paying $40 a month more as a smoking surcharge only when he saw a printout of his insurance coverage.

“Forty dollars is a lot of money,” said Mr. Allen, 63, who works part time. He says he has now quit smoking.

Wal-Mart says it mailed information about benefits changes weeks in advance of the enrollment deadline.

Under Wal-Mart’s programs, employees who want to enroll in some of the company’s more generous plans, which offer lower deductibles and out-of-pocket maximums, can pay as much as $178 a month, or more than $2,000, a year more if they smoke.

Many other companies charge smokers a smaller, flat amount, and have kept any financial penalties under the 20 percent threshold set by the federal rules, according to benefits experts. Target, a Wal-Mart competitor, does not charge smokers more for insurance, while Home Depot charges a smoker $20 a month. PepsiCo requires smokers to pay $600 a year more than nonsmokers unless they complete an antismoking program.

Some critics say Wal-Mart’s surcharge may have the effect of forcing people to opt for less expensive plans or persuade them to drop coverage altogether. Dr. Kevin Volpp, the director of the Center for Health Incentives and Behavioral Economics at the Leonard Davis Institute at the University of Pennsylvania, pointed out that surcharges and stringent health targets might wind up endangering those whose health was already at high risk. “There is this potentially very significant set of unintended consequences,” he said.

    The Smokers’ Surcharge, NYT, 16.11.2011,
    http://www.nytimes.com/2011/11/17/health/policy/
    smokers-penalized-with-health-insurance-premiums.html

 

 

 

 

 

U.S. Health Insurance

Cost Rises Sharply,

Study Finds

 

September 27, 2011
The New York Times
By REED ABELSON

 

The cost of health insurance for many Americans this year climbed more sharply than in previous years, outstripping any growth in workers’ wages and adding more uncertainty about the pace of rising medical costs.

A new study by the Kaiser Family Foundation, a nonprofit research group that tracks employer-sponsored health insurance on a yearly basis, shows that the average annual premium for family coverage through an employer reached $15,073 in 2011, an increase of 9 percent over the previous year.

“The open question is whether that’s a one-time spike or the start of a period of higher increases,” said Drew Altman, the chief executive of the Kaiser foundation.

The steep increase in rates is particularly unwelcome at a time when the economy is still sputtering and unemployment continues to hover at about 9 percent. Many businesses cite the high cost of coverage as a factor in their decision not to hire, and health insurance has become increasingly unaffordable for more Americans. Over all, the cost of family coverage has about doubled since 2001, when premiums averaged $7,061, compared with a 34 percent gain in wages over the same period.

How much the new federal health care law pushed by President Obama is affecting insurance rates remains a point of debate, with some analysts suggesting that insurers have raised prices in anticipation of new rules that would, in 2012, require them to justify any increase of more than 10 percent.

In addition to increases caused by insurers getting ahead of potential costs, some of the law’s provisions that are already in effect -- like coverage for adult children up to 26 years of age and prevention services like mammogram screening -- have contributed to higher expenses for some employers.

The Kaiser survey includes both big and small companies using employer-sponsored coverage representing about 60 percent of all insured Americans of working age. The annual growth in premiums, according to the survey, had slowed in recent years to 5 percent, rising just 3 percent in 2010, in part due to the lingering effects of the recession. After years of double-digit increases, the moderation was a welcome relief.

The unexpected increase in premiums raises questions about whether health care costs are, in fact, stabilizing at all, as people have postponed going to the doctor or dentist and have put off expensive procedures. “No one quite knows,” said Mr. Altman.

Throughout this year, major health insurers have defended higher premiums — and higher profits — saying that their expenses would rise once the economy recovered and people believed they could again afford medical care. The struggling economy will probably keep suppressing demand for medical care, particularly as people pay a larger share of their own medical bills through higher deductibles and co-payments, according to benefits consultants and others. About three-quarters of workers now pay part of the bill when they go see a doctor, and nearly a third have a deductible of at least $1,000 if they have single coverage, up from just one in 10 in 2006, according Kaiser.

Although demand for care appears to be growing relatively slowly, insurers and benefit consultants also say prices for medical care continue to climb as prescription drug makers and hospitals charge more. “If they’re a popular brand or anchor hospital, they’re going to negotiate a significant increase if they can,” said Edward A. Kaplan, a benefits expert with the Segal Company, which recently surveyed insurers about medical costs.

The question for employers and insurers is whether the lackluster economy, as well as recent efforts by employer and insurers to better manage the medical care of workers, will keep premiums increasing at a more moderate level. Early responses to a survey by Mercer, a consulting firm, suggest employers are expecting the cost of providing health benefits to go up about 5 percent next year, according to Beth Umland, Mercer’s director of research for health and benefits. These companies may be factoring in the more pessimistic view of the economy, she said, where any recovery seems further off than it did a few months ago.

Employers are reporting that their workers are using less medical care, said Ms. Umland, but they and insurers have been slow to estimate costs that reflect the lower demand. “It always takes a while for underwriting to catch up with reality,” she said.

Some small business say they expect their premiums to moderate, but only because of changes in their work force — partly caused by younger, healthier employees — that make it less likely that the companies will incur high medical claims. “Up until last year, we saw very hefty increases -- double digits,” said Heather Gombos, an executive for R. M. Jones & Company and affiliated businesses in New Britain, Conn., a group that insures about 50 of its 80 employees.

Family coverage is now running $12,000 a year, Ms. Gombos said, and she is waiting to see what rate increases her insurer proposes for the coming year. She thinks premiums will not rise as sharply in 2012. “What it comes down to is we’ve had some good luck,” she said.

Some businesses say they anticipate relief from higher costs in the coming year for a variety of reasons. At Ogilvy & Mather, the New York advertising firm, the company believes its efforts to encourage wellness and better oversee its employees’ health through an on-site medical clinic are paying off. "We are not anticipating any cost increase for employer and employee," said Gerri Stone, the senior partner who oversees the firm’s benefits strategy.

Ms. Stone acknowledged that the firm’s 3,600 employees were relatively young and healthy, helping it avoid some of the sharp increases experienced by other businesses. "We’ve never gone into the double digits," she said. Family coverage runs about $16,000 a year, she said.

Insurers and benefits consultants say, however, it is difficult to predict whether health care demand will again take off when the economy rebounds or whether some other factor is at play. "We’ve seen a moderation in the increase in health services, particularly in discretionary services," said Tom Richards, an executive with Cigna. While he attributes some of the moderation to the poor economy, he says the increase in cost-sharing by employees and programs that more closely monitor their health could be having a more permanent impact.

The question, he said, is "what is the economy going to be and what is the new normal."

Obama administration officials argue that new regulations are forcing insurers to be more circumspect about raising rates. Insurers seeking to raise premiums next year by more than the 10 percent maximum will have to publicly justify their rate increases, and the new law requires the companies to spend at least 80 cents of every dollar they collect in premiums on medical care. If they end up taking too much in premiums, they will have to refund the money to consumers.

But employers and others say much more still needs to be done to control overall costs, especially when workers’ wages are essentially flat. Of the $15,073 in average premiums paid for family coverage, Kaiser found that employees paid $4,129 towards the cost, in addition to whatever out-of-pocket costs they shouldered.

“We’re going to continue to have this yawning gap,” said Helen Darling, the chief executive of the National Business Group on Health, which represents employers that provide health coverage to their workers. Health care costs continue to climb much faster than overall inflation, she noted.

“The health economy acts as if it’s a boom economy,” she said.

U.S. Health Insurance Cost Rises Sharply, Study Finds,
NYT, 27.9.2011,
http://www.nytimes.com/2011/09/28/
business/health-insurance-costs-rise-sharply-this-year-study-shows.html

 

 

 

 

 

Young Adults Make Gains

in Health Insurance Coverage

 

September 21, 2011

The New York Times

By KEVIN SACK

 

Young adults, long the group most likely to be uninsured, are gaining health coverage faster than expected since the 2010 health law began allowing parents to cover them as dependents on family policies.

Three new surveys, including two released on Wednesday, show that adults under 26 made significant and unique gains in insurance coverage in 2010 and the first half of 2011. One of them, by the Centers for Disease Control and Prevention, estimates that in the first quarter of 2011 there were 900,000 fewer uninsured adults in the 19-to-25 age bracket than in 2010.

This was despite deep hardship imposed by the recession, which has left young adults unemployed at nearly double the rate of older Americans, with incomes sliding far faster than the national average.

The Obama administration, intent on showcasing the benefits of a law that has been pilloried by Republicans, attributes the improvement to a provision of the Affordable Care Act that permits parents to cover dependents up to their 26th birthdays. Until that measure took effect one year ago this week, children typically had to roll off their parents’ family policies at 18 or 21 or when they left college.

Some twentysomethings adopted a posture of “young invincibility,” forgoing health insurance they could afford while gambling that they would not incur steep medical expenses. But others, like Kylie R. Logsdon, who credits the provision for enabling her heart transplant in July, were living with chronic or life-threatening conditions and had no prospects for coverage.

“I honestly don’t know what we would have done,” said Ms. Logsdon, 23, of Gerlaw, Ill., who gained coverage under her father’s policy after losing her job as a legal secretary. “There was no way we could have afforded it. I might not be here right now.”

Last week, the Census Bureau reported that the share of young adults without health insurance dropped in 2010 by 2 percentage points, to 27.2 percent. That decline meant that 502,000 fewer 18- to 24-year-olds were uninsured. Most gained coverage through private policies, not government programs.

For every other age group, the proportion without insurance increased, as high unemployment and contractions in employer coverage continued to take their toll. For the first time in more than 10 years, 18- to 24-year-olds were not the least insured group, having been overtaken by those 25 to 34.

Kathleen Sebelius, the secretary of health and human services, accentuated the silver lining in an otherwise grim census poverty report by declaring: “The Affordable Care Act is working.”

On Wednesday, the C.D.C. released its survey showing that the trend might have accelerated in the first quarter of 2011. That report, the National Health Interview Survey, which differs in methodology from the census count, estimates that 900,000 fewer adults ages 19 to 25 were uninsured in the first quarter of this year than in 2010. Also released Wednesday, a Gallup survey found similar rates in the second quarter of 2011.

The Department of Health and Human Services had projected last year that 650,000 uninsured would gain coverage in 2011 because of the provision.

Although cause and effect have not been proved, government officials and health industry analysts said they could not imagine another explanation for the change. In the census numbers, young adults were the only age bracket with an increasing share insured by employers (albeit presumably their parents’ employers).

“It would be hard to construe it to be anything but the Affordable Care Act,” said Mark F. Olson, a senior actuary with Towers Watson, the human resources consulting firm.

There have been no studies of the provision’s impact on cost. But Mr. Olson and several insurance industry spokesmen credited it for raising enrollments and premiums by between 1 percent and 3 percent at many firms.

“It’s a basic principle of economics that when more benefits are added to a policy or more people are covered under that policy there are additional costs incurred,” said Robert Zirkelbach, a spokesman for America’s Health Insurance Plans, the industry trade group. “The cost impact is even greater to the extent ‘adverse selection’ occurs, meaning that only people who need health care services choose to enroll in their parents’ plan.”

The dependent coverage provision allows parents to insure adult children even if the children are married. Children are not eligible if they have an offer of employer-based coverage.

Although the provision did not take effect until Sept. 23, many insurers voluntarily extended their dependent coverage months earlier. A majority of states had recently passed similar laws, but they had varying age limits and did not apply to some large insurance plans.

Advocacy groups have worked assiduously to educate students about the new provision. One of the groups, Young Invincibles, is running a campaign this week on 16 college campuses under the inevitable banner of “Friends With Benefits.”

Miriam A. Brand, a senior at the University of Maryland, said it gave her profound peace of mind to know she could remain on her father’s group insurance policy for several years while attending graduate school or searching for a first job, preferably in counseling. Ms. Brand, 22, has been managing Type 1 diabetes since she was 6, and she said her medications and supplies cost at least $8,000 a year.

“I’m not like most college students,” Ms. Brand said. “I don’t have the luxury of putting medical care to the wayside. Now I have the gift of time in finding a job in this scary job market.”

Ms. Sebelius reinforced that point. “In a world where great inventors, entrepreneurs and C.E.O.’s can be young or old,” she told reporters on Wednesday, “we can’t take the chance that the next Facebook will never happen because its creator took a desk job just to get health insurance.”

The young adults provision is one of several measures in the health law designed as a stopgap until 2014, when the number of uninsured is expected to drop significantly.

Providing the act is not struck down by the Supreme Court or repealed by Congress, most Americans at that point will be required to obtain insurance. Pre-existing condition exclusions will be eliminated for adults, Medicaid eligibility will be expanded and government subsidies will make private coverage more affordable for many.

Not all of the stopgap measures have proved as popular as young adult coverage. The pre-existing condition insurance plans created under the law were projected to cover 375,000 otherwise uninsurable people in 2010. Only 30,000 had signed up as of July.

Because entry-level jobs frequently do not have health benefits, and individual policies can be unaffordable on a starting salary, the rate of young adults without coverage is nearly double the national average. A Commonwealth Fund survey found that 45 percent of young adults reported delaying medical care because of cost in 2010, up from 32 percent in 2001.

    Young Adults Make Gains in Health Insurance Coverage, NYT, 21.9.2011,
    http://www.nytimes.com/2011/09/22/us/
    young-adults-make-gains-in-health-insurance-coverage.html

 

 

 

 

 

Health Insurers

Making Record Profits

as Many Postpone Care

 

May 13, 2011
The New York Times
By REED ABELSON

 

The nation’s major health insurers are barreling into a third year of record profits, enriched in recent months by a lingering recessionary mind-set among Americans who are postponing or forgoing medical care.

The UnitedHealth Group, one of the largest commercial insurers, told analysts that so far this year, insured hospital stays actually decreased in some instances. In reporting its earnings last week, Cigna, another insurer, talked about the “low level” of medical use.

Yet the companies continue to press for higher premiums, even though their reserve coffers are flush with profits and shareholders have been rewarded with new dividends. Many defend proposed double-digit increases in the rates they charge, citing a need for protection against any sudden uptick in demand once people have more money to spend on their health, as well as the rising price of care.

Even with a halting economic recovery, doctors and others say many people are still extremely budget-conscious, signaling the possibility of a fundamental change in Americans’ appetite for health care.

“I am noticing my patients with insurance are more interested in costs,” said Dr. Jim King, a family practice physician in rural Tennessee. “Gas prices are going up, food prices are going up. They are deciding to put some of their health care off.” A patient might decide not to drive the 50 miles necessary to see a specialist because of the cost of gas, he said.

But Dr. King said patients were also being more thoughtful about their needs. Fewer are asking for an MRI as soon as they have a bad headache. “People are realizing that this is my money, even if I’m not writing a check,” he said.

For someone like Shannon Hardin of California, whose hours at a grocery store have been erratic, there is simply no spare cash to see the doctor when she isn’t feeling well or to get the $350 dental crowns she has been putting off since last year. Even with insurance, she said, “I can’t afford to use it.” Delaying care could keep utilization rates for insurers low through the rest of the year, according to Charles Boorady, an analyst for Credit Suisse. “The big question is whether it is going to stay weak or bounce back,” he said. “Nobody knows.”

Significant increases in how much people have to pay for their medical care may prevent a solid rebound. In recent years, many employers have sharply reduced benefits, while raising deductibles and co-payments so people have to reach deeper into their pockets.

In 2010, about 10 percent of people covered by their employer had a deductible of at least $2,000, according to the Kaiser Family Foundation, a nonprofit research group, compared with just 5 percent of covered workers in 2008.

Doctors, for one, say patients’ attitudes are changing. “Because it’s from Dollar 1 to Dollar 2,000, they are being really conscious of how they spend their money,” said Dr. James Applegate, a family physician in Grand Rapids, Mich. For example, patients question the need for annual blood work.

High deductibles also can be daunting. David Welch, a nurse in California whose policy has a $4,000 deductible, said he was surprised to realize he had delayed going to the dermatologist, even though he had a history of skin cancer. Mr. Welch, who has been a supporter of the need to overhaul insurance industry practices for the California Nurses Association union, said he hoped his medical training would help him determine when to go to the doctor. “I underestimated how much that cost would affect my behavior,” he said.

Dr. Rebecca Jaffe, a family practice doctor in Wilmington, Del., said more patients were asking for the generic alternatives to brand-name medicines, because of hefty co-payments. “Now, all of a sudden, they want the generic, when for years, they said they couldn’t take it,” she said.

The insurers, which base what they charge in premiums largely on what they expect to pay out in future claims, say they still expect higher demand for care later this year. “I think there’s a real concern about a bounce-back, a rebound, in utilization,” said Dr. Lonny Reisman, the chief medical officer for Aetna.

Because they say they expect costs to rebound, insurers have not been shy about asking for higher rates. In Oregon, for example, Regence BlueCross BlueShield, a nonprofit insurer that is the state’s largest, is asking for a 22 percent increase for policies sold to individuals. In California, regulators have been resisting requests from insurers to raise rates by double digits.

Some observers wonder if the insurers are simply raising premiums in advance of the full force of the health care law in 2014. The insurers’ recent prosperity — big insurance companies have reported first-quarter earnings that beat analysts expectations by an average of 30 percent — may make it difficult for anyone, politicians and industry executives alike, to argue that the industry has been hurt by the federal health care law. Insurers were able to raise premiums to cover the cost of the law’s early provisions, like insuring adult children up to age 26, and federal and state regulators have largely proved to be accommodating.

But 2014 and 2015 are likely to be far more challenging, as insurers are forced to adjust to the law’s greatest changes, like providing coverage to everyone regardless of whether they have an expensive pre-existing condition. “I think they’re going to go through a winter,” said Paul H. Keckley, executive director of the Deloitte Center for Health Solutions, a research unit of the consulting firm Deloitte.

And while the slowing down of demand is good for insurers, at least in the short term, the concern is that patients may be tempted to skip important tests like colonoscopies or mammograms. The new health care law will eventually prevent most policies from charging patients for certain kinds of preventive care, but some plans still require someone to pay $500 toward a colonoscopy.

In recent times, insurers have prospered by pricing policies above costs, said Robert Laszewski, a former health insurance executive who is now a consultant in Alexandria, Va. The industry goes through underwriting cycles where the companies are better able to predict costs and make room for profits. “They’re benefiting from a very positive underwriting cycle,” he said.

“Maybe managed care is finally working,” he said. “Maybe this is the new normal.”

Still, he emphasized, health care costs, even if they are rising at 6 percent or 7 percent a year, are increasing at a much faster pace than overall inflation. “We haven’t solved the problem,” Mr. Laszewski said.

    Health Insurers Making Record Profits as Many Postpone Care,
    NYT, 13.5.2011,
    http://www.nytimes.com/2011/05/14/business/14health.html

 

 

 

 

 

Faces of Health Care Debate

Point to New Law’s Complexity

 

April 16, 2010
The New York Times
By DAVID M. HERSZENHORN

 

WASHINGTON — They were the human faces of the nation’s wrenching, yearlong health care debate.

Natoma Canfield of Medina, Ohio, sent a letter to President Obama about no longer being able to afford her health coverage, and he read it aloud to a group of insurance executives at the White House. Then Ms. Canfield learned she had leukemia, helping Mr. Obama illustrate the life-and-death stakes of the often mind-numbing policy fight.

Marcelas Owens, an 11-year-old boy from Seattle, whose mother could not get some treatment for lack of insurance and died at age 27 from pulmonary hypertension, met Senator Patty Murray, Democrat of Washington, at a rally and ended up by the president’s side at the bill-signing ceremony. “I don’t want any other kids to go through the pain our family has gone through,” Marcelas said.

And Molly Secours, a filmmaker from Nashville, who battled uterine cancer, nearly lost her home because of medical bills — even though she had health insurance. Told that she would need a radical hysterectomy, chemotherapy and radiation treatment, Ms. Secours said, “I was consumed with the fear that I’ll have to declare bankruptcy.”

But if their stories helped the Democrats pass the health care overhaul, a more complicated question is: What will the health care law do for them?

Revisiting their cases illustrates both the enormous potential benefits of the new law, which seeks to insure some 32 million people, and also how the complexity of the health system will continue to pose a formidable challenge for patients and health care providers in the months and years ahead.

Of the cast of Americans who made appearances in the health care debate, Ms. Canfield, who is undergoing chemotherapy and preparing for a bone marrow transplant at the Cleveland Clinic, may have had the biggest role.

Her story led Mr. Obama to hold a rally in Ohio, not far from her home, which helped secure the vote of Representative Dennis J. Kucinich, a Democrat who had opposed the bill. Then, Ms. Canfield’s congressman, Representative John Boccieri, a freshman Democrat, cited her in announcing that he, too, would support the bill.

As it turns out, Ms. Canfield’s grave illness means that her time as one of the roughly 50 million uninsured Americans was brief. In recent days, she was approved for Social Security disability benefits and Medicaid, the federal-state insurance program for low-income people.

“She is no longer able to work,” said her sister, Connie Anderson. “She has kind of dropped down into a different category.”

Supporters of the legislation say that proves one of their main points — the existing system provides little help until catastrophe strikes and, even then, it entails a maze of bureaucracy.

But for some critics, the Cleveland Clinic’s quick reassurance that Ms. Canfield need not worry about losing her home to medical costs showed that Mr. Obama exaggerated her case. On Fox News, Sean Hannity accused Mr. Obama of lying about Ms. Canfield’s situation.

Ms. Canfield got a break. Her local hospital, Medina General, was taken over last year by the Cleveland Clinic, a prominent hospital system with a sophisticated patient-support structure.

In interviews, Ms. Canfield and her sister credited the hospital with helping secure government aid. Leukemia is on Social Security’s list of “compassionate allowances” for an expedited disability ruling. Were she not disabled, Ms. Canfield could not qualify for Medicaid in Ohio under current rules even though she earned well below the federal poverty limit.

That will change as a result of the new law, which will expand Medicaid in 2014. Between now and then, Ohio residents may benefit from the creation of a high-risk insurance pool, either at the state or national level. While other states already have such programs, Ohio does not.

But while the bill provides $5 billion to create or expand such programs, it is not clear how they will work. Premiums are often expensive, and payment rates for providers have not been set. That makes it impossible for a hospital to know if it would be paid more by a high-risk policy or by the state’s existing Hospital Care Assurance Program, which reimburses for care of the uninsured.

In the current system, Lyman Sornberger, the executive director of patient financial services at the Cleveland Clinic, said that Ms. Canfield had good reason to worry about being forced to sell her home to pay medical bills.

“Facilities or health care systems have an option to decide what their charity care is,” Mr. Sornberger said. “They could put a lien against her home. They could harm her credit. They could ask her to sell all of her assets and sell her home and pay that bill off to that health care system before they agree to give her any charity.”

Even with Medicaid paying the hospital bills, Ms. Canfield’s sister said she was worried about how she would pay her basic expenses, like property taxes and utility bills. Her disability payments do not begin until July, and even then will not cover all her expenses, Ms. Anderson said.

In the case of Marcelas Owens’s mother, Tiffany Owens, it is unclear that the health care legislation would have prevented her from falling into a gap in coverage that prompted her to forgo treatment and may have contributed to her death.

Ms. Owens briefly had private insurance through her restaurant management job. But in October 2006, when she could no longer work because she was sick, she lost both her job and her benefits.

She applied for Medicaid but was rejected because she had earned too much earlier in the year. She was told to reapply in January, but by then she was hospitalized. Six months later, she was dead.

“There was that lapse of time where the sickness was still progressing and there was nothing she could do until she could go back and reapply again,” said Gina Owens, her mother. “It’s just crazy that people fall through the cracks.”

It is not clear if the new health care law will help when a person’s employment, insurance and health status change so rapidly.

Beginning in 2014, low-income Americans who do not qualify for Medicaid could get subsidies to help buy private insurance. But a new system could have pitfalls.

For Marcelas himself, the most immediate benefit of the new law may be a provision barring states from cutting Medicaid rolls. Even when his mother was alive, Marcelas and his two sisters were on Medicaid.

Under the new law, primary care doctors will be paid higher rates to treat Medicaid patients for at least two years. The bill will also provide billions of dollars in additional aid to community health centers, like the Seattle Indian Health Board, where Marcelas gets his pediatric care.

In Nashville, Molly Secours thought she had the system figured out. She had health insurance from Blue Cross, a house and a film company. But after uterine cancer left her with huge bills, she nearly lost her home.

Congress came to the rescue, not with legislation but in the form of Representative Jim Cooper, Democrat of Tennessee, who helped her negotiate a new mortgage. Ms. Secours joined Speaker Nancy Pelosi at a news conference at the Capitol in July.

She is still paying off some bills to Baptist Hospital, but her home is secure. As someone with a pre-existing medical condition, Ms. Secours, under the new law, is assured of being able to find coverage. And as someone who buys her policy on the individual market, she may find better insurance or at least more options.

“People like me who have a major diagnosis aren’t going to get turned down because they had cancer,” she said.

Ms. Secours said she hoped to one day be able to take advantage of tax credits that the new health care law will give to small businesses to help them provide insurance to employees. “A couple of years from now I might be able to hire people and offer them something,” she said.

    Faces of Health Care Debate Point to New Law’s Complexity, NYT, 16.4.2010,
    http://www.nytimes.com/2010/04/17/health/policy/17health.html

 

 

 

 

 

For Consumers,

Clarity on Health Care Changes

 

March 21, 2010
The New York Times
By TARA SIEGEL BERNARD

 

American consumers, who spent a year watching Congress scratch and claw over sweeping health care legislation, can now try to figure out what the overhaul would mean for them.

The uninsured are clearly the biggest beneficiaries of the legislation, which would extend the health care safety net for the lowest-income Americans.

The legislation is meant to provide coverage for as many as 32 million people who have been shut out of the market — whether because insurers deem them too sick or because they cannot afford ever-rising insurance premiums.

For people already covered by a large employer — most Americans, in other words — the effect would not be as significant. And yet, just about everyone might benefit from tighter insurance regulations.

“We think it’s a big step forward,” said Bill Vaughan, a policy analyst at Consumers Union. “It’s going to provide a peace of mind that many Americans who really want or need health insurance will always be able to get a quality product at a reasonable price regardless of their health or financial situation.”

There would be costs to consumers, too. Affluent families would be required to pay additional taxes. Most Americans would be required to have health insurance and face federal penalties if they do not buy it. And it is still unclear what effect, if any, the legislation would have on rising out-of-pocket medical costs and premiums.

But there is no question that the legislation should benefit consumers in various ways. Beginning in 2014, for example, many employers — those with 50 or more workers — could face federal fines for not providing insurance coverage. Several of the other changes would take effect much sooner.

Six months after the legislation is enacted, many plans would be prohibited from placing lifetime limits on medical coverage, and they could not cancel the policies of people who fall ill. Children with pre-existing conditions could not be denied coverage.

And dependent children up to age 26 would be eligible for coverage under their parents’ plans — instead of the current state-by-state rules that often cut off coverage for children at 18 or 19.

And within three months of the law’s taking effect, people who have been locked out of the insurance market because of a pre-existing condition would be eligible for subsidized coverage through a new high-risk insurance program.

That special coverage would continue until the legislation’s engine kicks into a higher gear in 2014, when coverage would be extended to a wider part of the population through Medicaid and new state-run insurance exchanges.

Those exchanges, or marketplaces, are meant to provide much more competitive, consumer-friendly online shopping centers of private insurance for people who are not able to obtain coverage through an employer.

In 2014, people with pre-existing conditions could no longer be denied insurance, all lifetime and annual limits on coverage would be eliminated and new policies would be required to meet higher benefit standards.

Even sooner, in 2013, affluent families with annual income above $250,000 would be required to pay an additional 3.8 percent tax on their investment income, while contributing more to the Medicare program from their payroll taxes. And eventually, the most expensive insurance policies would be subject to a new tax.

Here is a look at some of the main ways the health care overhaul might affect household budgets.

 

The Uninsured

Although most Americans who do not obtain health insurance would face a federal penalty starting in 2014, many experts question how strict the enforcement of that penalty would actually be.

The first year, consumers who did not have insurance would owe $95, or 1 percent of income, whichever is greater. But the penalty would subsequently rise, reaching $695, or 2 percent of income.

Families who fall below the income-tax filing thresholds would not owe anything. Nor would people who cannot find a policy that costs less than 8 percent of their income, said Sara R. Collins, a vice president at the Commonwealth Fund, an independent nonprofit research group.

EXPANDED MEDICAID More lower-income individuals under the age of 65 would be covered by Medicaid, the federal health insurance plan for the poor. Under the new rules, households with income up to 133 percent of the federal poverty level, or about $29,327 for a family of four, would be eligible.

EXCHANGES AND SUBSIDIES Most other uninsured people would be required to buy insurance through one of the new state-run insurance exchanges. People with incomes of more than 133 percent of the poverty level but less than 400 percent (that’s $29,327 to $88,200 for a family of four) would be eligible for premium subsidies through the exchanges.

Premiums would also be capped at a percentage of income, ranging from 3 percent of income to as much as 9.5 percent.

EMPLOYMENT FLEXIBILITY The exchanges would also help people who lose their jobs, quit or decide to start their own businesses.

“If you lose your employer-related insurance, you will be able to move seamlessly into the exchange,” said Timothy Stoltzfus Jost, a professor at the Washington and Lee University School of Law.

Moreover, people of any age who cannot find a plan that costs less than 8 percent of their income would be allowed to buy a catastrophic policy otherwise intended for people under age 30.

 

Those With Insurance

EMPLOYER COVERAGE People who receive coverage through large employers would be unlikely to see any drastic changes, nor should premiums or coverage be affected. But almost everyone would benefit from new regulations, like the ban on pre-existing conditions that would apply to all policies come 2014.

There might even be cases where people would be eligible to buy insurance through an exchange instead of through their employer, Professor Jost said: those who must pay more than 9.5 percent of their income for premiums, or those whose plans do not cover more than 60 percent of the cost their benefits.

CHANGES IN MEDICARE One of the biggest changes involves the Medicare prescription drug program. Its unpopular “doughnut hole” — a big, expensive gap in coverage that affects millions — would be eliminated by 2020. Starting immediately, consumers who hit the gap would receive a $250 rebate. In 2011, they would receive a 50 percent discount on brand name drugs.

HIGH-COST INSURANCE Starting in 2018, employers that offer workers pricier plans — or those with total premiums of $10,200 or more for singles and $27,500 for families — would be subject to a 40 percent tax on the excess premium, said C. Clinton Stretch, managing principal of tax policy at Deloitte. Retirees and workers in high-risk professions like firefighting would have higher thresholds ($11,850 for singles, or $30,950 for families), pegged to inflation.

Although the taxes would be levied on the insurer, experts expect the assessment to be passed on to the consumer in the form of higher premiums or reduced benefits.

    For Consumers, Clarity on Health Care Changes, NYT, 22.3.2010,
    http://www.nytimes.com/2010/03/22/your-money/
    health-insurance/22consumer.html

 

 

 

 

 

House Approves Health Overhaul,

Sending Landmark Bill to Obama

 

March 21, 2010
The New York Times
By ROBERT PEAR and DAVID M. HERSZENHORN

 

WASHINGTON — House Democrats approved a far-reaching overhaul of the nation’s health system on Sunday, voting over unanimous Republican opposition to provide medical coverage to tens of millions of uninsured Americans after an epic political battle that could define the differences between the parties for years.

With the 219-to-212 vote, the House gave final approval to legislation passed by the Senate on Christmas Eve. Thirty-four Democrats joined Republicans in voting against the bill. The vote sent the measure to President Obama, whose yearlong push for the legislation has been the centerpiece of his agenda and a test of his political power.

After approving the bill, the House adopted a package of changes to it by a vote of 220 to 211. That package — agreed to in negotiations among House and Senate Democrats and the White House — now goes to the Senate for action as soon as this week. It would be the final step in a bitter legislative fight that has highlighted the nation’s deep partisan and ideological divisions.

On a sun-splashed day outside the Capitol, protesters, urged on by House Republicans, chanted “Kill the bill” and waved yellow flags declaring “Don’t Tread on Me.” They carried signs saying “Doctors, Not Dictators.”

Inside, Democrats hailed the votes as a historic advance in social justice, comparable to the establishment of Medicare and Social Security. They said the bill would also put pressure on rising health care costs and rein in federal budget deficits.

“This is the Civil Rights Act of the 21st century,” said Representative James E. Clyburn of South Carolina, the No. 3 Democrat in the House.

Mr. Obama celebrated the House action in remarks at the White House.

“We pushed back on the undue influence of special interests,” Mr. Obama said. “We didn’t give in to mistrust or to cynicism or to fear. Instead, we proved that we are still a people capable of doing big things.”

“This isn’t radical reform,” he added, “but it is major reform.”

After a year of combat and weeks of legislative brinksmanship, House Democrats and the White House clinched their victory only hours before the voting started on Sunday. They agreed to a deal with opponents of abortion rights within their party to reiterate in an executive order that federal money provided by the bill could not be used for abortions, securing for Democrats the final handful of votes they needed to assure passage.

Winding up the debate, Speaker Nancy Pelosi said: “After a year of debate and hearing the calls of millions of Americans, we have come to this historic moment. Today we have the opportunity to complete the great unfinished business of our society and pass health insurance reform for all Americans that is a right and not a privilege.”

The House Republican leader, Representative John A. Boehner of Ohio, said lawmakers were defying the wishes of their constituents. “The American people are angry,” Mr. Boehner said. “This body moves forward against their will. Shame on us.”

Republicans said the plan would saddle the nation with unaffordable levels of debt, leave states with expensive new obligations, weaken Medicare and give the government a huge new role in the health care system.

The debate on the legislation set up a bitter midterm campaign season, with Republicans promising an effort to repeal the legislation, challenge its constitutionality or block its provisions in the states.

Representative Paul D. Ryan, Republican of Wisconsin, denounced the bill as “a fiscal Frankenstein.” Representative Lincoln Diaz-Balart, Republican of Florida, called it “a decisive step in the weakening of the United States.” Representative Virginia Foxx, Republican of North Carolina, said it was “one of the most offensive pieces of social engineering legislation in the history of the United States.”

But Representative Marcy Kaptur, Democrat of Ohio, said the bill heralded “a new day in America.” Representative Doris Matsui, Democrat of California, said it would “improve the quality of life for millions of American families.”

The health care bill would require most Americans to have health insurance, would add 16 million people to the Medicaid rolls and would subsidize private coverage for low- and middle-income people, at a cost to the government of $938 billion over 10 years, the Congressional Budget Office said.

The bill would require many employers to offer coverage to employees or pay a penalty. Each state would set up a marketplace, or exchange, where consumers without such coverage could shop for insurance meeting federal standards.

The budget office estimates that the bill would provide coverage to 32 million uninsured people, but still leave 23 million uninsured in 2019. One-third of those remaining uninsured would be illegal immigrants.

The new costs, according to the budget office, would be more than offset by savings in Medicare and by new taxes and fees, including a tax on high-cost employer-sponsored health plans and a tax on the investment income of the most affluent Americans.

Cost estimates by the budget office, showing that the bill would reduce federal budget deficits by $143 billion in the next 10 years, persuaded some fiscally conservative Democrats to vote for the bill.

Democrats said Americans would embrace the bill when they saw its benefits, including some provisions that take effect later this year.

Health insurers, for example, could not deny coverage to children with medical problems or suddenly drop coverage for people who become ill. Insurers must allow children to stay on their parents’ policies until they turn 26. Small businesses could obtain tax credits to help them buy insurance.

The Democratic effort to secure the 216 votes needed for passage of the legislation came together only after last-minute negotiations involving the White House, the House leadership and a group of Democratic opponents of abortion rights, led by Representative Bart Stupak of Michigan. On Sunday afternoon, members of the group announced that they would support the legislation after Mr. Obama promised to issue an executive order to “ensure that federal funds are not used for abortion services.”

Mr. Stupak described the order as a significant guarantee that would “protect the sanctity of life in health care reform.” But supporters of abortion rights — and some opponents — said the order merely reaffirmed what was in the bill.

The vote to pass the Senate version of the bill means that it will become the law of the land as soon as Mr. Obama signs it, regardless of when — or even whether — the Senate acts on the package of changes the House also passed.

In his remarks, shortly before midnight in the East Room, Mr. Obama urged the Senate to complete the final pieces of the legislation. “Some have predicted another siege of parliamentary maneuvering in order to delay it,” he said. “I hope that’s not the case.”

He continued, “It’s time to bring this debate to a close and begin the hard work of implementing this reform properly on behalf of the American people.”

Mr. Obama watched the roll call with Vice President Joseph R. Biden Jr. in the Roosevelt Room in the White House.

The House galleries were full, and the floor was unusually crowded, for the historic debate on health care.

Working together, Mr. Obama and Ms. Pelosi revived the legislation when it appeared dead after Democrats lost their 60th vote in the Senate and with it their ability to shut off Republican filibusters.

Republicans said they would use the outcome to bludgeon Democrats in this year’s Congressional elections. The White House is planning an intensive effort to convince people of the bill’s benefits. But if Democrats suffer substantial losses in November, Mr. Obama could be stymied on other issues.

The campaign for a health care overhaul began as a way to help the uninsured. But it gained momentum when middle-class families with health insurance flooded Congress with their grievances. They complained of soaring premiums. They said their insurance had been canceled when they got sick.

“It’s not just the uninsured,” said Representative Jim McGovern, Democrat of Massachusetts. “We also have to worry about people with insurance who find, for crazy reasons, that they are somehow going to be denied coverage.”

In the end, groups like the United States Chamber of Commerce and the National Federation of Independent Business tried to stop the bill, saying it would increase the cost of doing business. But other groups, including the American Medical Association and AARP, backed it, as did the pharmaceutical industry.

Lawmakers agreed that Sunday’s debate was historic, but they were poles apart in assessing the legislation.

Representative Rodney Alexander, Republican of Louisiana, said, “You cannot expect to expand coverage to millions of individuals and to curb costs at the same time.”

Republicans said the picture painted by the budget office was too rosy, because the new taxes and fees would start immediately, while the major costs would not show up for four years.

Moreover, Republicans said Democrats would pay a price for defying public opinion on the bill.

“Are you so arrogant that you know what’s best for the American people?” Representative Paul Broun, Republican of Georgia, asked the Democrats. “Are you so ignorant to be oblivious to the wishes of the American people?”

Lawmakers spoke with deep conviction in explaining their votes.

“Health care is not only a civil right, it’s a moral issue,” said Representative Patrick J. Kennedy, Democrat of Rhode Island, who invoked the memory of his father, Senator Edward M. Kennedy, a Massachusetts Democrat and a lifelong champion of health care for all.

After the legislation passed, Mr. Obama sought to place the day in perspective.

“In the end what this day represents is another stone firmly laid in the foundation of the American dream,” the president said. “Tonight, we answered the call of history as so many generations of Americans have before us. When faced with crisis, we did not shrink from our challenges. We overcame them. We did not avoid our responsibilities, we embraced it. We did not fear our future, we shaped it.”


Carl Hulse contributed reporting.

    House Approves Health Overhaul, Sending Landmark Bill to Obama,
    NYT, 22.3.2010,
    http://www.nytimes.com/2010/03/22/health/policy/22health.html

 

 

 

 

 

Senate Passes Health Care Overhaul

on Party-Line Vote

 

December 25, 2009

The New York Times

By ROBERT PEAR

 

WASHINGTON — The Senate voted Thursday to reinvent the nation’s health care system, passing a bill to guarantee access to health insurance for tens of millions of Americans and to rein in health costs.

The 60-to-39 party-line vote, starting at 7:05 a.m. on the 25th straight day of debate on the legislation, brings Democrats closer to a goal they have pursued for decades and brings President Obama a step closer to success in his signature domestic initiative. When the roll was called, with Vice President Joseph R. Biden Jr. presiding, it was the first time the Senate had gathered for a vote on Christmas Eve since 1895.

If the bill becomes law, it would be a milestone in social policy, comparable to the creation of Social Security in 1935 and Medicare in 1965. But unlike those programs, the initiative lacks bipartisan support. Only one Republican supported a broadly similar bill that the House approved last month 220 to 215, and no Republicans backed the Senate version.

After the vote, lawmakers and Mr. Obama wasted no time leaving for their holiday break, well aware that their return to Washington would mean plunging into negotiations to reconcile the measures passed by the two chambers.

If a deal can be struck, as seems likely, the resulting law would vastly expand the role and responsibilities of the federal government. It would, as lawmakers said repeatedly in the debate, touch the lives of nearly all Americans.

The bill would require most Americans to have health insurance, would add 15 million people to the Medicaid rolls and would subsidize private coverage for low- and middle-income people, at a cost to the government of $871 billion over 10 years, according to the Congressional Budget Office.

The budget office estimates that the bill would provide coverage to 31 million uninsured people, but still leave 23 million uninsured in 2019. One-third of those remaining uninsured would be illegal immigrants.

Mr. Obama hailed the Senate action. “We are now incredibly close to making health insurance reform a reality,” he said, before leaving the White House to celebrate Christmas in Hawaii.

The president, who endorsed the Senate and House bills, said he would be deeply involved in trying to help the two chambers work out their differences. But it is unclear how specific he will be — if, for example, he will push for one type of tax over another or try to concoct a compromise on insurance coverage for abortion.

Senator Olympia J. Snowe of Maine, a moderate Republican who has spent years working with Democrats on health care and other issues, said she was “extremely disappointed” with the bill’s evolution in recent weeks. After Senate Democrats locked up 60 votes within their caucus, she said, “there was zero opportunity to amend the bill or modify it, and Democrats had no incentive to reach across the aisle.”

Like many Republicans, Ms. Snowe was troubled by new taxes and fees in the bill, which she said could have “a dampening effect on job creation and job preservation.” The bill would increase the Medicare payroll tax on high-income people and levy a new excise tax on high-premium insurance policies, as one way to control costs.

When the roll was called Thursday morning, the mood was solemn as senators called out “aye” or “no.” Senator Robert C. Byrd, the 92-year-old Democrat from West Virginia, deviated slightly from the protocol.

“This is for my friend Ted Kennedy,” Mr. Byrd said. “Aye!”

Senator Kennedy of Massachusetts, a longtime champion of universal health care, died of brain cancer in August at age 77.

Senator Jim Bunning, Republican of Kentucky, did not vote.

The fight on Capitol Hill prefigures a larger political battle that is likely to play out in the elections of 2010 and 2012, as Democrats try to persuade a skeptical public of the bill’s merits, while Republicans warn that it will drive up costs for those who already have insurance.

“Our members are leaving happy and upbeat,” said the Senate Republican leader, Mitch McConnell of Kentucky. “The public is on our side. This fight is not over.”

After struggling for years to expand health insurance in modest, incremental ways, Democrats decided this year that they could not let another opportunity slip away. As usual, lawmakers were deluged with appeals from lobbyists for health care interests who have stymied similar ambitious efforts in the past. But this year was different.

Lawmakers listened to countless stories of hardship told by constituents who had been denied insurance, lost coverage when they got sick or seen their premiums soar. Hostility to the insurance industry was a theme throughout the Senate debate.

Senator Sherrod Brown, Democrat of Ohio, said insurance companies were often “just one step ahead of the sheriff.” Senator Dianne Feinstein, Democrat of California, said the industry “lacks a moral compass.” And Senator Sheldon Whitehouse, Democrat of Rhode Island, said the business model of the industry “deserves a stake through its cold and greedy heart.”

The bill would establish strict federal standards for an industry that, since its inception, has been regulated mainly by the states. Under it, insurers could not deny coverage because of a person’s medical condition; could not charge higher premiums because of a person’s sex or health status; and could not rescind coverage when a person became sick or disabled. The government would, in effect, limit insurers’ profits by requiring them to spend at least 80 to 85 cents of every premium dollar on health care.

The specificity of federal standards is illustrated by one section of the bill, which requires insurers to issue a benefits summary that “does not exceed four pages in length and does not include print smaller than 12-point font.”

Another force propelling health legislation through the Senate was the Democrats’ view that it was a moral imperative and an economic necessity.

“The health insurance policies of America, what we have right now is a moral disgrace,” said Senator Tom Harkin, Democrat of Iowa. “We are called upon to right a great injustice, a great wrong that has been put upon the American people.”

Costs of the bill would, according to the Congressional Budget Office, be more than offset by new taxes and fees and by savings in Medicare. The bill would squeeze nearly a half-trillion dollars from Medicare over the next 10 years, mainly by reducing the growth of payments to hospitals, nursing homes, Medicare Advantage plans and other providers.

Republicans asserted that the cuts would hurt Medicare beneficiaries. But AARP, the lobby for older Americans, and the American Medical Association ran an advertisement urging senators to pass the bill, under which Medicare would cover more of the cost for prescription drugs and preventive health services.

Karen M. Ignagni, president of America’s Health Insurance Plans, a trade group, said the bill appeared to be unstoppable. But she added: “We are not sure it will be workable. It could disrupt existing coverage for families, seniors and small businesses, particularly between now and when the legislation is fully implemented in 2014.”

Senate Passes Health Care Overhaul on Party-Line Vote,
NYT,
25.12.2009,
http://www.nytimes.com/2009/12/25/
health/policy/25health.html

 

 

 

 

 

Editorial

The Uninsured

 

August 23, 2009

The New York Times

 

One of the major goals of health care reform is to cover the vast numbers of uninsured. But how vast, really, is that pool of people? Who are they? And how important is it to cover all or most of them?

Critics play down the seriousness of the problem by pointing out that the ranks of the uninsured include many people who have chosen to forgo coverage or are only temporarily uninsured: workers who could afford to pay but decline their employers’ coverage; the self-employed who choose not to pay for more expensive individual coverage; healthy young people who prefer not to buy insurance they may never need; people who are changing jobs; poor people who are eligible for Medicaid but have failed to enroll. And then there are the illegal immigrants, a favorite target of critics.

All that is true, to some degree. But the implication — that lack of insurance is no big deal and surely not worth spending a trillion dollars to fix — is not.

No matter how you slice the numbers, there are tens of millions of people without insurance, often for extended periods, and there is good evidence that lack of insurance is harmful to their health.

Scores of well-designed studies have shown that uninsured people are more likely than insured people to die prematurely, to have their cancers diagnosed too late, or to die from heart failure, a heart attack, a stroke or a severe injury. The Institute of Medicine estimated in 2004 that perhaps 18,000 deaths a year among adults could be attributed to lack of insurance.

The oft-voiced suggestion that the uninsured can always go to an emergency room also badly misunderstands what is happening. By the time they do go, many of these people are much sicker than they would have been had insurance given them access to routine and preventive care. Emergency rooms are costly, and if uninsured patients cannot pay for their care, the hospital or the government ends up footing the bill.



So how many uninsured people are out there, facing those risks? The most frequently cited estimate, 45.7 million in 2007, comes from an annual census survey. That number was down slightly from the year before, but given the financial crisis, it is almost certainly rising again.

Some or even many of those people may have only temporarily lost or given up coverage, but even that exposes them to medical and financial risk. And many millions go without insurance for extended periods.

The Agency for Healthcare Research and Quality in the Department of Health and Human Services estimates that 28 million people were uninsured for all of 2005 and 2006 and that 18.5 million of them were uninsured for at least four straight years. That does not sound like a “temporary” problem, and the picture today is almost certainly bleaker.

Various analyses have tried to decipher just who the uninsured are. These are the main conclusions, with the caveat that there is overlap in these numbers:

THE WORKING POOR The Kaiser Family Foundation estimates that about two-thirds of the uninsured — 30 million people — earn less than twice the poverty level, or about $44,000 for a family of four. It also estimates that more than 80 percent of the uninsured come from families with full-time or part-time workers. They often cannot get coverage at work or find it too expensive to buy. They surely deserve a helping hand.

THE BETTER OFF About nine million uninsured people, according to census data, come from households with incomes of $75,000 or more. Critics say that is plenty of money for them to buy their own insurance. But many of these people live in “households” that are groups of low-wage roommates or extended families living together. Their combined incomes may reach $75,000, but they cannot pool their resources to buy an insurance policy to cover the whole group.

Still, about 4.7 million uninsured people live in families that earn four times the poverty level — or $88,000 for a family of four — the dividing line that many experts use to define who can afford to buy their own insurance.

Those people who could afford coverage but choose not to buy it ought to be compelled to join the system to lessen the possibility that a serious accident or illness might turn them into charity cases and to help subsidize the coverage of poorer and sicker Americans.

YOUNG ADULTS Some 13 million young adults between the ages of 19 and 29 lack coverage. These are not, for the most part, healthy young professionals making a sensible decision to pay their own minimal medical bills rather than buy insurance that they are unlikely to need. The Kaiser foundation estimates that only 10 percent are college graduates, and only 5 percent have incomes above $60,000 a year, while half have family incomes below $16,000 a year. Many of these younger people would be helped by reform bills that would provide subsidized coverage for the poor and an exchange where individuals can buy cheaper insurance than is now available.

ALREADY ELIGIBLE Some 11 million of the poorest people, mostly low-income children and their parents, are thought to be eligible for public insurance programs but have failed to enroll, either because they do not know they are eligible or are intimidated by the application process. When such people arrive at an emergency room, they are usually enrolled in Medicaid, but meanwhile they have lost out on routine care that could have kept them out of the emergency room. They will presumably be scooped up by the mandate under reform bills that everyone obtain health insurance.

THE UNDERINSURED The Commonwealth Fund estimates that 25 million Americans who had health insurance in 2007 had woefully inadequate policies with high deductibles and restrictions that stuck them with large amounts of uncovered expenses. Many postponed needed treatments or went into debt to pay medical bills.

NON-CITIZENS Some 9.7 million of the uninsured are not citizens; of those, more than six million may be illegal immigrants, according to informed estimates. None of the pending bills would cover them.

If nothing is done to slow current trends, the number of people in this country without insurance or with inadequate coverage will continue to spiral upward. That would be a personal tragedy for many and a moral disgrace for the nation. It is also by no means cost-free. Any nation as rich as ours ought to guarantee health coverage for all of its residents.

    The Uninsured, NYT, 23.8.2009,
    http://www.nytimes.com/2009/08/23/opinion/23sun1.html

 

 

 

 

 

Many With Insurance

Still Bankrupted by Health Crises

 

July 1, 2009
The New York Times
By REED ABELSON

 

Health insurance is supposed to offer protection — both medically and financially. But as it turns out, an estimated three-quarters of people who are pushed into personal bankruptcy by medical problems actually had insurance when they got sick or were injured.

And so, even as Washington tries to cover the tens of millions of Americans without medical insurance, many health policy experts say simply giving everyone an insurance card will not be enough to fix what is wrong with the system.

Too many other people already have coverage so meager that a medical crisis means financial calamity.

One of them is Lawrence Yurdin, a 64-year-old computer security specialist. Although the brochure on his Aetna policy seemed to indicate it covered up to $150,000 a year in hospital care, the fine print excluded nearly all of the treatment he received at an Austin, Tex., hospital.

He and his wife, Claire, filed for bankruptcy last December, as his unpaid medical bills approached $200,000.

In the House and Senate, lawmakers are grappling with the details of legislation that would set minimum standards for insurance coverage and place caps on out-of-pocket expenses. And fear of the high price tag could prompt lawmakers to settle for less than comprehensive coverage for some Americans.

But patient advocates argue it is crucial for the final legislation to guarantee a base level of coverage, if people like Mr. Yurdin are to be protected from financial ruin. They also call for a new layer of federal rules to correct the current state-by-state regulatory patchwork that allows some insurance companies to sell relatively worthless policies.

“Underinsurance is the great hidden risk of the American health care system,” said Elizabeth Warren, a Harvard law professor who has analyzed medical bankruptcies. “People do not realize they are one diagnosis away from financial collapse.”

Last week, a former Cigna executive warned at a Senate hearing on health insurance that lawmakers should be careful about the role they gave private insurers in any new system, saying the companies were too prone to “confuse their customers and dump the sick.”

“The number of uninsured people has increased as more have fallen victim to deceptive marketing practices and bought what essentially is fake insurance,” Wendell Potter, the former Cigna executive, testified.

Mr. Yurdin learned the hard way.

At St. David’s Medical Center in Austin, where he went for two separate heart procedures last year, the hospital’s admitting office looked at Mr. Yurdin’s coverage and talked to Aetna. St. David’s estimated that his share of the payments would be only a few thousand dollars per procedure.

He and the hospital say they were surprised to eventually learn that the $150,000 hospital coverage in the Aetna policy was mainly for room and board. Coverage was capped at $10,000 for “other hospital services,” which turned out to include nearly all routine hospital care — the expenses incurred in the operating room, for example, and the cost of any medication he received.

In other words, Aetna would have paid for Mr. Yurdin to stay in the hospital for more than five months — as long as he did not need an operation or any lab tests or drugs while he was there.

Aetna contends that it repeatedly informed Mr. Yurdin and the hospital of the restrictions in policy, which is known in the industry as a limited-benefit plan.

The company says such policies offer value by covering some hospital expenses, like surgeons’ fees or a stay in the intensive care unit. Aetna also says all of its policyholders receive significant discounts on the overall cost of hospital care. But Aetna also acknowledges that a limited-benefit plan was inappropriate in Mr. Yurdin’s case because his age and condition — an irregular heartbeat — made him likely to require more comprehensive coverage.

“Limited benefits aren’t right for everyone, and it clearly wasn’t right for Mr. Yurdin,” said Cynthia B. Michener, an Aetna spokeswoman.

Charles E. Grassley, the ranking Republican on the Senate Finance Committee, which is taking a lead on health legislation, says Congress needs to make “meaningful” insurance coverage more affordable and accessible. But “until that happens,” he said, “any presentation of limited-benefit plans ought to be completely straightforward, and not misleading in any way.”

Insurers like Aetna generally defend limited-benefit policies as a byproduct of the nation’s flawed health care system, which they say makes it too expensive to adequately insure someone like Mr. Yurdin.

If everyone in the country were required to have insurance, the industry says — a mandate that Congress is contemplating — the costs and risks of insurance would be spread over a large enough pool of people to let insurers provide full, affordable coverage even to people with pre-existing medical conditions.

Mr. Yurdin worked at TEKsystems, which employs people for short periods as contractors for other companies. TEKsystems says it does not pay for the contract workers’ health benefits, but it does enable them to purchase individual policies with limited benefits so they have at least some coverage.

“There’s no way we make this sound like regular coverage,” said Neil Mann, an executive vice president at Allegis Group, which owns TEKsystems.

Although Mr. Mann acknowledged that the plan Mr. Yurdin purchased excluded routine hospital care, he said he thought it still provided value to employees who wanted “peace of mind.”

True peace of mind, however, comes with a much higher price tag. When Mr. Yurdin no longer qualified for the Aetna coverage after he left TEKsystems and his eligibility eventually ended, his only option was a special state plan in Texas for people who are at high risk for expensive medical care. He has been paying more than $1,000 a month for comprehensive coverage, compared with the roughly $250 a month he was paying for the Aetna plan.

But as of Wednesday, his future insurance problems are largely solved: he qualifies for

 because he turns 65.

Many insurers, as part of the Congressional overhaul of their business, say they expect the demand for limited-benefit policies to fall. “Until the nation achieves the universal coverage that we strongly support, some individuals will want to be able to choose limited indemnity products, but with comprehensive health reform we think that need should diminish,” said Simon Stevens, an executive at UnitedHealth.

UnitedHealth drew criticism last year for selling policies with sharply limited coverage through AARP, the advocacy group for older people. One of the plans capped reimbursement for an operation at $5,000, for example, although many procedures cost at least several times that amount. After Senator Grassley began investigating its sales practices, UnitedHealth agreed to stop offering the limited AARP plans.

Mr. Yurdin and his wife say it was not clear that he was liable for tens of thousands of dollars in hospital bills until after he had the first two of what would eventually be four operations. St. David’s says it tried to persuade them to apply for charity care, under which the hospital would absorb much, or all, of the unpaid bills.

But the couple says a lawyer advised them to turn to bankruptcy as the way to be certain they would not be left with too much debt. “I knew we were getting way, way over our heads,” Mrs. Yurdin said.

While Aetna disputes the Yurdins’ and the hospital’s version of events, it also says it has tried to clarify the language it uses to describe the coverage. In its most recent brochure, the fine print describing the limits to “other” hospital services now defines what they are in a footnote on the same page and warns that the excluded expenses could be “significant.”

Senator John D. Rockefeller IV, Democrat of West Virginia, who is also on the Finance Committee, has introduced legislation that would require insurers to be more clear about what they do — and do not — cover. He says he advocates such a change, even if Congress cannot agree to a more sweeping overhaul of the health insurance industry.

But advocates for broad changes to the health care system say Congress can succeed only by making sure health reform goes beyond giving every American a buyer-beware insurance card. One such person is Len Nichols, a health economist for the New America Foundation.

“Conceptually,” he said, “insurance means normal people should not go bankrupt from serious medical conditions.”

    Many With Insurance Still Bankrupted by Health Crises, NYT, 1.7.2009,
    http://www.nytimes.com/2009/07/01/business/01meddebt.html

 

 

 

 

 

Uninsured Put a Strain on Hospitals

 

December 9, 2008
The New York Times
By REED ABELSON

 

As increasing numbers of the unemployed and uninsured turn to the nation’s emergency rooms as a medical last resort, doctors warn that the centers — many already overburdened — could have even more trouble handling the heart attacks, broken bones and other traumas that define their core mission.

Even before the recession became evident, many emergency rooms around the country were already overcrowded, with dangerously long waits for some patients and the frequent need to redirect ambulances to other hospitals.

“We have no capacity now,” said Dr. Angela F. Gardner, the president-elect of the American College of Emergency Physicians, which represents 27,000 emergency doctors. “There’s no way we have room for any more people to come to the table.”

In a report to be released Tuesday, her group warns that the nation’s system of emergency rooms is in “serious condition.” Dr. Gardner argues that any public discussion of overhauling the current health system must include the nation’s emergency departments.

The number of patients coming to emergency departments has been steadily increasing. Helping push up that volume have been the growing ranks of the uninsured, because emergency rooms are legally obliged to see all patients who enter their doors, regardless of their ability to pay. But even insured patients who have no quick access to regular doctors are also showing up — among them older people, who represent the fastest growing population of emergency room visitors.

So far, there are no firm figures on the recent influx. But even two years ago, when a government survey found that the annual volume of visits to emergency departments had reached 120 million — a third higher than a decade earlier — doctors considered many emergency rooms overburdened.

Now the recession, whose full impact is yet to be seen, threatens to make conditions even worse, emergency doctors say. Hospitals are absorbing increasing amounts in unpaid medical bills, and some are already experiencing much higher numbers of patients without insurance.

For example, Denver Health, a public hospital system, had a 19 percent increase in emergency visits by uninsured patients in November — to 3,325, up from 2,792 a year earlier.

“Virtually every time I work a nine-hour shift, I encounter a couple of patients who have never been here before because they’ve just lost their insurance,” said Dr. Vincent J. Markovchick, the director of the hospital’s emergency medical services.

They include patients like Matthew Armijo, 29, who was laid off from his client services job at a technology company in August and could continue his health insurance only through October. He showed up at Denver Health’s urgent care center, a part of the emergency department, suffering from increasing abdominal pain. Mr. Armijo said he went there because he would not have to pay anything.

Denver Health expects the amount of care it delivers for which it will never be paid to grow to more than $300 million this year, compared with $276 million in 2007.

Some patients are people who have delayed seeking medical care as long as they can, like those who arrive during an asthma attack after deferring treatment.

“I am definitely seeing patients coming in presenting worse in their illness because they are further along,” said Dr. Katherine A. Bakes, the director of the program’s emergency services for children.

Other doctors around the country also report treating people who seem to have no other option. One emergency room doctor in Iowa, Dr. Thomas E. Benzoni, said he recently saw a mother come in with her two children for what he thought was routine care. When he asked her why she had not gone to her family doctor, she said she did not have health insurance.

“I don’t know what else she was supposed to do,” Dr. Benzoni said.

The increase is not affecting all emergency rooms. Some emergency physicians, in fact, said there had actually been a recent decline in visits. A report by the American Hospital Association for July, August and September found a slight overall decrease in hospital traffic, including emergency visits, as some people apparently sought to avoid spending money on anything they did not deem absolutely essential.

But as the recession continues, many officials of the college of emergency doctors predict it is only a matter of time until the rising number of uninsured and the delays in getting primary care create a crisis.

“I think we’re seeing the tip,” said Dr. Nicholas J. Jouriles, the group’s current president. Patients, he said, will have no choice but to come to the emergency department when they have no money or insurance. “They will get turned away elsewhere,” he said.

One of the doctors’ major concerns is the long waits by patients requiring a hospital bed. The doctors group, surveying its members last year, learned of at least 200 deaths related to the practice of “boarding” — in which patients on stretchers line the corridors until they can be moved into a bed.

“Crowding is a national public health problem,” said Dr. Jesse M. Pines, an emergency physician in Philadelphia.

Patients forced to wait for hours on end for a bed clearly suffer.

“It was pure hell,” recalled Robert Roth, whose 90-year-old mother, Kato, last year spent 36 hours at the emergency department of a Queens hospital, near her home in Jackson Heights, waiting for a room after going to the emergency room in the middle of the night. Mrs. Roth, who had a recent series of falls, said she had been hearing music in her ears, and both her son and the doctor he called were worried about a possible stroke.

After the first five hours of waiting, she became increasingly disoriented and delusional. Mr. Roth was unable to stay with her during the entire wait. After he left and returned, he said, the hospital staff told him they had no idea where she was. She turned up in an empty room off the emergency department, and her physical and mental condition had clearly deteriorated, Mr. Roth said. She believed that she had been kidnapped.

When she had to go several weeks later to another emergency department in Manhattan, she endured a 20-hour wait for a room, again becoming disoriented after several hours, forcing her to be sedated.

The emergency staffs “just seemed overwhelmed, overwhelmed,” said Mr. Roth, who wondered why emergency departments could not handle the elderly in a special fashion.

Dr. Ann S. O’Malley is a physician and senior researcher for the Center for Studying Health System Change, a nonprofit group in Washington that has studied emergency services in different communities. While some hospitals have taken steps to reduce crowding and move patients more efficiently from the emergency department into rooms, Dr. O’Malley said, others have responded by expanding their facilities — attracting more patients.

“Emergency departments,” she said, “are a kind of barometer of the general health of the rest of the system.”

Dr. Eric J. Lavonas, an emergency physician in Denver, said: “The nation’s emergency rooms are the end of the line. We will strain and stretch and bulge under the weight.”

Dr. Gardner, of the emergency doctors’ group, said the question now is whether the emergency room safety net will break — how often people with heart attacks will not be able to get care in time to be saved. Her group’s report, she said, is meant to alert people to the precarious nature of the system.

“What they don’t understand,” she said, “is that the system is fundamentally flawed and will fail.”



Melinda Sink contributed reporting from Denver.

    Uninsured Put a Strain on Hospitals, NYT, 9.12.2008,
    http://www.nytimes.com/2008/12/09/business/09emergency.html

 

 

 

 

 

When a Job Disappears,

So Does the Health Care

 

December 7, 2008

The New York Times

By ROBERT PEAR

 

ASHLAND, Ohio — As jobless numbers reach levels not seen in 25 years, another crisis is unfolding for millions of people who lost their health insurance along with their jobs, joining the ranks of the uninsured.

The crisis is on display here. Starla D. Darling, 27, was pregnant when she learned that her insurance coverage was about to end. She rushed to the hospital, took a medication to induce labor and then had an emergency Caesarean section, in the hope that her Blue Cross and Blue Shield plan would pay for the delivery.

Wendy R. Carter, 41, who recently lost her job and her health benefits, is struggling to pay $12,942 in bills for a partial hysterectomy at a local hospital. Her daughter, Betsy A. Carter, 19, has pain in her lower right jaw, where a wisdom tooth is growing in. But she has not seen a dentist because she has no health insurance.

Ms. Darling and Wendy Carter are among 275 people who worked at an Archway cookie factory here in north central Ohio. The company provided excellent health benefits. But the plant shut down abruptly this fall, leaving workers without coverage, like millions of people battered by the worst economic crisis since the Depression.

About 10.3 million Americans were unemployed in November, according to the Bureau of Labor Statistics. The number of unemployed has increased by 2.8 million, or 36 percent, since January of this year, and by 4.3 million, or 71 percent, since January 2001.

Most people are covered through the workplace, so when they lose their jobs, they lose their health benefits. On average, for each jobless worker who has lost insurance, at least one child or spouse covered under the same policy has also lost protection, public health experts said.

Expanding access to health insurance, with federal subsidies, was a priority for President-elect Barack Obama and the new Democratic Congress. The increase in the ranks of the uninsured, including middle-class families with strong ties to the work force, adds urgency to their efforts.

“This shows why — no matter how bad the condition of the economy — we can’t delay pursuing comprehensive health care,” said Senator Sherrod Brown, Democrat of Ohio. “There are too many victims who are innocent of anything but working at the wrong place at the wrong time.”

Some parts of the federal safety net are more responsive to economic distress. The number of people on food stamps set a record in September, with 31.6 million people receiving benefits, up by two million in one month.

Nearly 4.4 million people are receiving unemployment insurance benefits, an increased of 60 percent in the past year. But more than half of unemployed workers are not getting help because they do not qualify or have exhausted their benefits.

About 1.7 million families receive cash under the main federal-state welfare program, little changed from a year earlier. Welfare serves about 4 of 10 eligible families and fewer than one in four poor children.

In a letter dated Oct. 3, Archway told workers that their jobs would be eliminated, and their insurance terminated on Oct. 6, because of “unforeseeable business circumstances.” The company, owned by a private equity firm based in Greenwich, Conn., filed a petition for relief under Chapter 11 of the Bankruptcy Code.

Archway workers typically made $13 to $20 an hour. To save money in a tough economy, they are canceling appointments with doctors and dentists, putting off surgery, and going without prescription medicines for themselves and their children.

Archway cited “the challenging economic environment” as a reason for closing.

“We have been operating at a loss due largely to the significant increases in raw material costs, such as flour, butter, sugar and dairy, and the record high fuel costs across the country,” the company said. At this time of year, the Archway plant is usually bustling as employees work overtime to make Christmas cookies. This year the plant is silent. The aromas of cinnamon and licorice are missing. More than 40 trailers sit in the parking lot with nothing to haul.

In the weeks before it filed for bankruptcy protection, Archway apparently fell behind in paying for its employee health plan. In its bankruptcy filing, Archway said it owed more than $700,000 to Blue Cross and Blue Shield of Illinois, one of its largest creditors.

Richard D. Jackson, 53, was an oven operator at the bakery for 30 years. He and his two daughters often used the Archway health plan to pay for doctor’s visits, imaging, surgery and medicines. Now that he has no insurance, Mr. Jackson takes his Effexor antidepressant pills every other day, rather than daily, as prescribed.

Another former Archway employee, Jeffrey D. Austen, 50, said he had canceled shoulder surgery scheduled for Oct. 13 at the Cleveland Clinic because he had no way to pay for it.

“I had already lined up an orthopedic surgeon and an anesthesiologist,” Mr. Austen said.

In mid-October, Janet M. Esbenshade, 37, who had been a packer at the Archway plant, began to notice that her vision was blurred. “My eyes were burning, itching and watery,” she said. “Pus was oozing out. If I had had insurance, I would have gone to an eye doctor right away.”

She waited two weeks. The infection became worse. She went to the hospital on Oct. 26. Doctors found that she had keratitis, a painful condition that she may have picked up from an old pair of contact lenses. They prescribed antibiotics, which have cleared up the infection.

Ms. Esbenshade has two daughters, ages 6 and 10, with asthma. She has explained to them why “we are not Christmas shopping this year — unless, by some miracle, mommy goes back to work and gets a paycheck.”

She said she had told the girls, “I would rather you stay out of the hospital and take your medication than buy you a little toy right now because I think your health is more important.”

In some cases, people who are laid off can maintain their group health benefits under a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1986, known as Cobra. But that is not an option for former Archway employees because their group health plan no longer exists. And they generally cannot afford to buy insurance on their own.

Wendy Carter’s case is typical. She receives $956 a month in unemployment benefits. Her monthly expenses include her share of the rent ($300), car payments ($300), auto insurance ($75), utilities ($220) and food ($260). That leaves nothing for health insurance.

Ms. Darling, who was pregnant when her insurance ran out, worked at Archway for eight years, and her father, Franklin J. Phillips, worked there for 24 years.

“When I heard that I was losing my insurance,” she said, “I was scared. I remember that the bill for my son’s delivery in 2005 was about $9,000, and I knew I would never be able to pay that by myself.”

So Ms. Darling asked her midwife to induce labor two days before her health insurance expired.

“I was determined that we were getting this baby out, and it was going to be paid for,” said Ms. Darling, who was interviewed at her home here as she cradled the infant in her arms.

As it turned out, the insurance company denied her claim, leaving Ms. Darling with more than $17,000 in medical bills.

The latest official estimate of the number of uninsured, from the Census Bureau, is for 2007, when the economy was in better condition. In that year, the bureau says, 45.7 million people, accounting for 15.3 percent of the population, were uninsured.

M. Harvey Brenner, a professor of public health at the University of North Texas and Johns Hopkins University, said that three decades of research had shown a correlation between the condition of the economy and human health, including life expectancy.

“In recessions, with declines in national income and increases in unemployment, you often see increases in mortality from heart disease, cancer, psychiatric illnesses and other conditions,” Mr. Brenner said.

The recession is also taking a toll on hospitals.

“We have seen a significant increase in patients seeking assistance paying their bills,” said Erin M. Al-Mehairi, a spokeswoman for Samaritan Hospital in Ashland. “We’ve had a 40 percent increase in charity care write-offs this year over the 2007 level of $2.7 million.”

In addition, people are using the hospital less. “We’ve seen a huge decrease in M.R.I.’s, CAT scans, stress tests, cardiac catheterization tests, knee and hip replacements and other elective surgery,” Ms. Al-Mehairi said.

When a Job Disappears, So Does the Health Care,
NYT,
7.12.2008,
http://www.nytimes.com/2008/12/07/us/07uninsured.html

 

 

 

 

 

A Decline in Uninsured

Is Reported for 2007

 

August 27, 2008

The New York Times

By IAN URBINA

 

Correction Appended

 

WASHINGTON — After climbing steadily for six years, the number of Americans without health insurance dropped by more than a million in 2007, to 45.7 million, the Census Bureau reported Tuesday.

The drop was the result of growth in government-sponsored health insurance programs, officials said, most of them focused on children. At the same time, the number of people covered by private insurance continued to decline.

Experts cautioned that the report, which also included data on income and poverty, did not take into account the economic downturn that began late last year, and therefore it probably presents a rosier picture than the current economic reality.

According to the report, the nation’s median household income rose by 1.3 percent in 2007, to $50,233, the third consecutive annual increase. The nation’s poverty rate remained flat at 12.5 percent, the report said.

“The data in this report refer to last year, when everything was different,” said Jared Bernstein, a senior economist at the Economic Policy Institute, a liberal policy group in Washington. “This year, we’re losing jobs on a monthly basis, inflation is running well over 5 percent, and unemployment was last seen at 5.7 percent and rising.”

Health-care experts and advocates for the poor said the report also presented an outdated picture regarding health insurance. The rate of people without health insurance declined to 15.3 percent in 2007, from 15.8 percent a year earlier.

“In 2007, at least 26 states made efforts to expand coverage, but as the economy has turned downward so have state efforts,” said Diane Rowland, executive vice president of the Kaiser Family Foundation.

Ms. Rowland added that insurance premiums had risen faster than wages and inflation, causing more people to seek insurance from public programs.

The census report, she said, highlights the importance of expanding government health-care plans like the State Children’s Health Insurance Program.

In December, President Bush signed legislation that extends federal financing for the program through the end of March 2009. That action came after he vetoed two Congressional attempts to expand the program.

David Johnson, chief of the Housing and Household Economic Statistics Division at the Census Bureau, said that the number of people covered by private insurance declined in 2007, but that the overall number of people who were uninsured went down because of federal and state programs.

“The fall in private insurance was similar to recent years,” Mr. Johnson said. “That fall was offset by the rise in government insurance.”

The number of people under 18 without insurance dropped to 11 percent, or 8.1 million, in 2007, from 11.7 percent, or 8.7 million, a year earlier.

Over all, the percentage of people covered by government programs rose to 27.8 percent in 2007 from 27 percent the year before. The percentage and number of people on Medicaid, the government health insurance program for low-income people, rose to 13.2 percent, or 39.6 million, in 2007, up from 12.9 percent, or 38.3 million, in 2006.

Private health insurance fell, covering 67.5 percent of Americans in 2007, down from 67.9 percent in 2006. Employment-based coverage also continued its long decline in 2007, dropping to 59.3 percent from 59.7 percent.

“States such as Massachusetts have also played an important role in stemming the rising tide of uninsured, and thanks to their health reform law they now have one of the lowest uninsured rates,” said Karen Davis, president of the Commonwealth Fund, a private foundation supporting independent health policy and health care research. “But 45.7 million uninsured people are far too many, and we need a national solution to this crisis.”

Changes in economic circumstances varied regionally and by race and age.

Douglas J. Besharov, a resident scholar at the American Enterprise Institute, a conservative research group, said one of the most noteworthy statistics in the report concerned foreign-born residents.

While households led by someone who was native-born had an increase of 1 percent in median income, the income of households headed by foreign-born persons who are noncitizens dropped 7.3 percent in 2007, according to the report.

Real median income (adjusted for inflation) for black and non-Hispanic white households rose between 2006 and 2007, representing the first measured real increase in annual household income for each group since 1999, according to the report. Real median household income remained statistically unchanged for Asians and Hispanics.

Mr. Besharov said an increase in poverty among Hispanics in the construction trade stemmed largely from the bursting of the housing bubble and the ensuing mortgage crisis.

“With more current data, we would see that the type of the poverty that we see among Latinos has actually already spread to the general population,” Mr. Besharov said.

Mr. Bernstein, from the Economic Policy Institute, agreed and said that while comparisons to 2006 showed some improvement, in order to understand the difficulties facing middle- and low-income families, it was important to consider these results in the context of the economic expansion since 2000.

For the first time on record, real household income is no higher at the end of an economic expansion than it was when the cycle began, Mr. Bernstein said.

The median income of working-age households — with household heads under age 65 — rose insignificantly in 2007, when adjusted for inflation, and was $2,010 below its 2000 level.

“Working households helped bake a bigger economic pie but ended up with thinner slices,” Mr. Bernstein said.

The report also found other disparities.

Women earned 78 cents for every $1 earned by men. But that is the highest percentage ever reported for women, when compared with men.

Texas led the nation with the highest percentage of uninsured residents, 24.4 percent, while Massachusetts and Hawaii, at 8.3 percent, had the lowest.



This article has been revised

to reflect the following correction:

Correction: August 28, 2008


A map on Wednesday with an article about the percentage of Americans without health insurance erroneously highlighted a state in some copies. The label for Massachusetts, the state with the lowest percentage of uninsured people, pointed to Pennsylvania.

A Decline in Uninsured Is Reported for 2007,
NYT,
27.8.2008,
http://www.nytimes.com/2008/08/27/washington/27census.html

 

 

 

 

 

CDC:

About 2M More Americans Uninsured

 

June 26, 2007

Filed at 8:36 p.m. ET

The New York Times

By THE ASSOCIATED PRESS

 

ATLANTA (AP) -- The number of adults without health insurance jumped by 2 million from 2005 to 2006, according to a new federal report. Uninsured Americans numbered 43.6 million last year, a 6 percent increase from 2005, according to the U.S. Centers for Disease Control and Prevention.

Almost all the increase was in the non-elderly adult population -- a trend attributed to diminishing employer coverage and pricier private insurance.

The change in non-elderly adults was significant, but the overall increase was not, CDC officials said. The overall count of the uninsured has been fluctuating between 41 and 44 million over the last five years and is not really trending up, they said.

''It's kind of bobbled around,'' said Robin Cohen, a CDC statistician who is lead author of the report released Monday.

The CDC is one of at least three federal agencies that estimate the number of Americans without health insurance. The U.S. Census Bureau puts out what is perhaps the best-known number, but that agency's 2006 estimate is not to be released until August.

Like the Census Bureau, the CDC's estimate is based on a survey. The CDC interviewed about 75,000 Americans last year, asking if they were uninsured at that point in time. About 15 percent said yes, leading to the estimate that 43.6 million Americans were uninsured.

The number was 41.2 million in 2005; the figure has fluctuated between that mark and 43.6 million for the past five years.

But there was more than a bobble in the number of adults age 18 to 64 without health insurance. That estimate rose to 36.5 million in 2006, from 34.5 million the year before.

Rising health insurance costs have caused employers to drop coverage, and stopped people from buying it privately, experts said.

''The real key issue is we've got to find means to make health care more affordable,'' said Ken Thorpe, an Emory University health policy professor.

Meanwhile, the number of uninsured children has dropped from about 10 million to about 7 million from 1997 to 2006. The State Children's Health Insurance Program -- a federal program to expand public health insurance programs for kids that started in 1997 -- seems to be the main explanation, said Sherry Glied, a Columbia University professor who studies the uninsured.

In past policy debates, some worried that the SCHIP program would merely shift children from private coverage to public insurance without actually diminishing the number of uninsured. But the new CDC report shows that wasn't the case, Glied said.

''The kids result was interesting. I haven't really seen that in other studies,'' Glied said.

Between 2005 and 2006, however, there was actually a slight increase in the number of uninsured kids -- from 6.5 million to 6.8 million.

Glied and others said the CDC numbers are roughly comparable to the Census Bureau estimates. The Census Bureau estimated that in 2005, 44.8 million people or 15.3 percent of the population were without health insurance.

CDC: About 2M More Americans Uninsured,
NYT,
26.6.2007,
http://www.nytimes.com/aponline/us/AP-Uninsured.html - broken link

 

 

 

 

 

 

 

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