21% of People in MA Still Forgo Necessary Medical Care
I tweeted this factoid yesterday, but wanted to post on it too, because I think it illustrates the difference bewteen health insurance and health care.
A number of supporters of the current Senate bill have been pointing to RomneyCare to argue that mandates and exchanges can be wildly successful in providing care. But a September 2009 Kaiser Commission review of the MA experience had this to say:
According to a March 2009 Urban Institute report, health reform has improved access to health care services for newly insured and previously insured adults. Over ninety percent of adults in Massachusetts have a usual source of care and most reported seeing a doctor in the previous year. However, the affordability of health care remains a barrier to receiving care for some residents. Of the total population, 21 percent went without needed care in the previous year because of cost. People with disabilities and those in fair and poor health experienced the greatest barriers to accessing care.
There is some good in this snippet. It says that people–presumably some of them for the first time in a while–are getting primary care. But it’s also saying that more than one-fifth of them are forgoing medically necessary care because the health insurance they have is too stingy to make that medically necessary care affordable.
The MA program is not dissimilar to the Senate bill. It allows for policies with deductibles of up to $4000 for families and other out-of-pocket fees, though it actually has lower out-of-pocket limits than the Senate bill. What MA considers to be an affordable premium is not all that different from what would be required under the Senate bill. (While I don’t think all the Senate subsidy levels have been released, making a one-to-one comparison impossible, it appears that the Senate bill offers an affordability opt-out for the affluent–families making $114,401–that the MA program doesn’t have, but requires the middle class to pay higher premiums–$441/month versus $364/month for a family making $66,150; go figure, the House of Lords screwed the Middle Class again).
So we should assume that the Senate bill would have similar outcomes as the MA program (though with a much weaker mandate, it would achieve much lower levels of coverage). And one outcome appears to be that the middle class is being forced to buy insurance, but that insurance is not making health care affordable when people need it the most.
It’s one thing to require people to buy insurance if it is affordable and it guarantees that it’ll actually get them the care they need. But if it doesn’t (and the Senate bill wouldn’t for the middle class), then it just becomes a wealth shift from the middle class to the health care industry.
Please keep hitting these facts, EW. Truth might set you free, but facts will help get you there, too. And right now we need all the facts we can get our hands on in order to counter what so many in the U.S. Senate are saying as they defend the travesty called “health care reform” they are trying to impose on the nation.
Howard Dean in today’s WaPo.
re on the MA program. in many ways it’s much better than the house bill (last i looked). use of subsidized exchange instead of medicaid expansion, women’s reproductive health coverage, etc.
when i spoke to my rep’s aide about it (just after passage of house bill), she agreed and i was assured that because we (MA) already had a waiver from the hhs, we would be allowed to keep our exchanges and not be forced to use the fed’s. don’t know what the story is re the senate bill (especially since i haven’t seen it and can’t get info from my senator’s offices like i can from rep).
costs are killing us now (apparently the good thing about the house bill is that we’d get a bit more fed money). and as a result, coverage is being cut back. legal immigrants, annual limit to insurance coverage ($50K iirc) for cheapest plans for the young and healthly. and last i saw, being considered is no auto annual re-enrollments for people on the subsidized exchange even if they still qualify (apparently not covering them while they file paper work, etc will save money). don’t know what that will mean for those who are too sick to actually do the paperwork.
lack of significant cost control is a real killer for any type of reform. because without it costs get controlled by denying care. and that can happen with gov plans as well as private.
(and imo the po-in-multi-payer-market was and is very stupid policy for that reason, among others)
Something I read said the DID take away the auto-reenrollment.
The Senate bill does state-level exchanges, so I imagine yours would remain untouched.
But yeah, if you guys–a relatively affluent state, for all that’s worth–can’t find a way to pay for this, the US can’t.
We’re paying for it now, it’s just not itemized as such. Instead of insurance, we’re paying hospitals to care for the indigent. And we’re paying them so little that some have dumped patients. Hospital stays open by raising rates for everybody so insurance goes up and we pay for it.
I’m in favor trashing the current attempt and starting over. At the end of the day, the burden on the US economy from a single payer system will be little different from the current system.
It will cost a large number of good jobs in the insurance and medical billing areas, though.
Boxturtle (Heck, just open medicare up to everybody and work within that system)
thanks for the info re senate bill. i will try to follow up on the issue of auto-reenrollment (only read about in some commission hearing report when i was looking for something else). also, i forgot to mention, something which happened early on, was the decrease in $$ to hospitals that provide care to the needy (everything from insulin for diabetics to treatment for addicts who showed up off the street). it’s the people most in need and with the least political power who are being harmed the most.
i would like to think that results of MA experiment could be useful to the country (if policy was evidence based). some short term good has come from our 2006 reform, but also some people have been harmed and the good is not sustainable. and in addition to being a relatively well off state, we have, in comparison to much of the country, a decent regulatory environment. for example, pre 2006 we had rules to prevent denial of coverage due to pre-existing conditions and modified community rating (rates based on age, gender and location) — this stuff mattered to me pre reform so i paid a bit of attention even then.
so, must agree with you: if it can’t work here, i don’t think it’s workable. (although on the fed level at least there is the operational possibility of spending not constrained by revenue or borrowing, but politically there are constraints – just watched some of lieberman’s hearing with greenspan and walker on the need for a cat food commission because of “out of control federal deficits”)
You know I’d love to see a diary from you on your view of the MA experience.
yikes! i’d have to really study up then. (i’ve been threatening to it for almost a year, and probably should…. but being a lazy assed wimp instead and hoping some other MA resident would beat me to it).
btw, love you post. thank you very much for it.
I’m from MA, too, but unfortunately have little to contribute to the ins/outs of the MA system. I should study up, too, but think you are better versed in the details than I, so I look forward to your post as well. Hoping that a public option can be reattempted if the current Senate version of the Health Care bill can be put down.
I can address your impression @40 that MA has a shortage of primary care physicians.
Without PCPs to treat patients, universal health insurance will not quickly translate into health care for all.
Dr. John Goodson, internist from the Massachusetts General Hospital has been studying the disappearance of primary care physicians. His JAMA article in 2007 Unintended Consequences of Resource-Based Relative Value Scale Reimbursement may be available at most libraries, but is probably hidden behind a fire wall on the internet. (Journal of the American Medical Association, Vol. 298 No. 19, November 21, 2007)
Goodson indicates that reimbursement/salaries for primary care physicians have remained flat while specialists’ physician salaries have increased. He believes this wage gap has contributed to fewer medical school grads entering primary care in favor of higher paying subspecialties.
Goodson finds the wage gap between generalist and specialist is increasing, correlated in time with the adoption by Medicare of the physician relative value scale pay rates. These reimbursement rates are determined and updated by a committee called the RUC (pronounced “ruck”). The ‘RUC’ stands for ‘Resource-based relative value scale’ Update Committee, which is sponsored by the American Medical Association (AMA), a national doctor’s group that is specialist-dominated.
Per Goodson:
note: CMS stands for Centers for Medicare & Medicaid Services
Most for-profit insurance companies tie their own physician reimbursement to the Medicare/Medicaid reimbursement rates, so the RUC’s recommendations have influence over the entire landscape of physicians’ salaries, including primary care.
Goodson also points out that the RUC’s recommendations are not reviewed or revised by Congress and that such a review should be part of our health care reform. As the RUC’s rules currently work, any change to the reimbursement recommendations of the RUC requires a majority vote among members of the RUC. Primary care (this easily includes medicine, pediatrics, family medicine, and psychiatry) makes up a minority of the RUC at all times.
rcentor at DB’s Medical Rants has a whole series on this topic.
If medical insurance is mandated – to avoid fines and being deemed a criminal, a record that will haunt background and credit checks required for most jobs – it will be paid, with usuriously expensive borrowed money. That makes families even poorer, with little relief in bankruptcy for a fresh start.
If that expensively purchased insurance is poor – it is sure to be without far more regulation than the Senate has in its bill – then it will too expensive to use. Which is like buying a traveler’s check or prepaid card and never using it. A nominal liability on the seller’s books eventually becomes significantly greater profits. Another way for this novel, legal mandate to become a public subsidy of private profits. Three-dimensional chess, indeed.
I gather from bmaz that not complying with this government mandate is a civil, not criminal wrong, but that the government can still recover from you a fine, in order to persuade you that joining the queue to buy fraudulent private insurance company products rather than to obtain better health care is a great idea – and he thought of it.
How similar is the private mandate senate bill to the Romney-care in Massachusetts? If it is similar maybe we should start calling it national Romney-care since that is a known failure. It might make it even harder for them to pass it. I posted a diary on DailyKos trying to get this meme going…
http://www.dailykos.com/story/2009/12/17/114934/93?new=true
(Replying to earlofhuntingdon @4)
Poorer families, with little relief in bankruptcy?
It brings to mind an older solution . . .
Perhaps the legislation to bring them back is buried in the fine print somewhere.
Or they’ve tasked Bob Cratchet to write it – when he’s done with his real work for the day.
That Dickensian conditions are emerging in 21st century America is true. Spend a day in Canton, Ohio, or California’s Central Valley, where unemployment is well into double digits and likely to stay there for far longer than was true in the Reagan recession of the early 1980’s. In Reagan’s day, Americans returned to career quality jobs. Today, the WaPoop and employers want to pay a lower minimum wage to those still able to get it.
The food bank business in the area is WAY up. Further, the GM workers are losing their benefits as of Jan 1 and that’s going to hit the area even harder. There are 50 year old’s moving back into their parents houses. With their wives.
Boxturtle (But the important thing is that New GM can attract investors)
That’s for that comment. And that’s just the start of winter and the deepening decline of middle class America. We are all former auto and steel workers now. Mr. Obama is not our union rep, he works for management.
Who cares about health care, Palin is wearing a hat that disses Mccain!
Boxturtle (This has been a mainstream media moment. We now return you to your regular content)
the distinction between insurance reform and health care reform is very important.
as best i can tell, what the president and the senate have been dicking around with is insurance “reform”.
better health care outcomes for the nation’s population are apparently supposed to flow from insurance reform.
better pre-natal care?
better dental care?
reduced obesity?
reduced smoking?
better care for nursing home residents?
more comprehensive vaccination coverage for children and adults?
maybe.
i suppose we’ll have some data to decide in five to ten years.
and now that i think of it,
isn’t it basic economics that if the u.s. pumps tens of billions more dollars into a health care system that cannot respond quickly with additional doctors, nurses, technicians, medical equipment, hospital beds, etc.
that we will have the worst imaginable inflation in health care costs over the next decade.
what insurance “reform” is doing is assuring access without assuring capacity.
from nov 13 cms report:
don’t mean to be a broken record, but one of the benefits of single payer is not only the cost savings due to massive decrease in administrative costs, it’s also the amount of time healthcare providers now spend on useless insurance administrative matters. at least that time could be freed up for, you know, actual healthcare. there are other things that must imo be done (healthcare should not be run to maximize efficiency — we need surge capacity), but that would be a start.
I just called this number:
202-456-1414
Left my brief message (Medicare-for-all, the American people deserve no less, we’re going to lose big time in 2010 if we don’t do what’s right for the American people). Very nice volunteer. Told me I had lots of company today. !!
selise @18
thanks, selise.
that was a very informative comment.
re:
[…Price reactions—that is, providers successfully negotiating higher fees in response to the greater demand—could result in higher total expenditures or in some of this demand being unsatisfied. Alternatively, providers might tend to accept more patients who have private
insurance (with relatively attractive payment rates) and fewer Medicaid patients, exacerbating existing access problems for the latter group. Either outcome (or a combination of both) should be considered plausible and even probable…]
i know it’s a technical report, but they don’t seem very bothered by these possibilities.
even as we speak,
and well before any federal bill takes effect,
health care inflation is unchecked and much above the economy’s base level of inflation,
a situation made all the worse by the deflation in family incomes some of the middle-class are experiencing.
MA plan is still better than nothing. I haven’t done research, but from empirical experience with two kids who graduated college in last few years (and their friends), I can attest that low-income young people can get an affordable subsidized plan (somewhere around $150-200 per month). It takes effort, and paperwork, and persistence to qualify, but you CAN get it.
In NY state, on the other hand, even the subsidized individual plans (they have something called Healthy NY) are much more expensive, and offer less in benefits than MA.
If you’re an individual, freelancing, in NY as one kid is, you can get on a group plan through Freelancer’s Union. The problem is that the premiums are high enough that even the lowest price plan (I think hospitalization only), isn’t affordable once you factor in the extremely high cost of NYC rents. (somewhere north of $350 per month)
So, just to compare MA and NY, in terms of premiums and benefits for lower-income young healthy individuals, MA is better. At least there is SOME access. And the exchange (Connector), at the very least lays out the options fairly clearly.
The thing that is missing from the proposed plans in the Senate is a mandate for employers. (Correct me if I’m wrong, facts keep changing so quickly it’s hard to keep track). I’m not sure about the House plan.
If there were an employer mandate–with a decent tax on those not providing insurance for their employees–I’d probably favor passage even with the really awful flaws in the rest of the bill.
Without that, the onus seems to be solely on the middle and lower-middle class folks who can least afford it.
devils and details.
from the dec 14 Federal Times:
[… A Senate health care reform proposal would put the Office of Personnel Management in charge of extending medical coverage to uninsured Americans. But some experts warn the plan may overwhelm the tiny agency and risk undermining federal pay and benefits programs that OPM is responsible for overseeing… ]
http://www.federaltimes.com/article/20091213/BENEFITS04/912130302/1041/BENEFITS
the independent federal agency OPM (office of Personnel Management) would be asked to administer an insurance exchange
and might be asked to open up the federal employee health benefits program to uninsured americans.
That’s pretty much what you do when you want to demonstrate the failure of a specific proposal and of the government in general to do what manifestly only private, profit-driven companies can do well. The Dutch and French are medical socialists, so let them lose their souls by getting quality medical care for half to two-thirds what it costs us not to get it.
This all goes to the “real” pony versus “fake” pony aspect of the healthcare fiasco.
It isn’t coverage if you fkn can’t afford it.
Now the big sell on the Senate bill is “at least it gets rid of the pre-existing conditions exclusion.”
Right. But no one finishes the sentence. The Senate bill replaces the pre-existing conditions exclusion with a pre-existing conditions penalty.
I’m an unemployed Massachusetts resident, and I get my health care through the commonwealth’s Medical Security Program. The program pays for a Blue Cross policy, and the insurance has been pretty good.
Since there are way too many unemployed people right now, however, it turns out that the program can’t continue to provide the same level of coverage. Earlier this week, I got a letter saying that while my premiums will still be paid for under the program, the benefits will be reduced (increased co-pays, etc.) and my choices will be limited.
I have asthma, so I need regular check-ups and prescriptions. I’m thinking that I’m going to send my bills to Senator Lieberman. Clearly, he can afford to pay the difference.
The Massachusetts program wouldn’t exist if not for the fact that we have a strong, proud Democrat in Deval Patrick keeping it viable (and he’s fighting a losing war). It’s continually getting chipped away — and forcing other necessary programs to get eliminated to save the health care bill. This year, they were forced to remove dental treatment for those with heavily subsidized (or free) health care through the system, as well as “medically unnecessary” treatments, like medicine to cure severe acne from teenagers, which would prevent lifelong facial (and emotional) scarring.
And Massachusetts has it better than most — with higher incomes and a larger existing base of insured people. This CANNOT work at a federal level. It will be a disaster.
“And Massachusetts has it better than most — with higher incomes and a larger existing base of insured people. This CANNOT work at a federal level. It will be a disaster.”
Absolutely right. MA had a lower percentage of uninsured before reform than the USA will have after. TX and CA both have more uninsured than MA has people. RomneyCare will not work for the country as a whole. And progressives should not support reform that we know won’t work. This is too important.
I’d add that the Mass. healthcare costs are strangling our municipal budgets. I’m a public library trustee in Massachusetts. We’re paying more for employee health insurance now than we are for books. Single-payer would eliminate most of what may the world’s highest medical administrative overhead. This would be about $9,000,000,000 for Mass. annually if single-payer just got our administrative overhead down from 34% to the 17% that Ontario has. That would be a godsend to public budgets.
a couple of studies to back you up (have to scroll down to MA):
http://www.pnhp.org/facts/single_payer_system_cost.php?page=all
CHRIS MATTHEWS JUST SAID WE AREN’T REAL DEMOCRATS, WE ARE JUST PEOPLE WHO LIKE TO COMPLAIN!!!! He said we don’t vote. WTF??????????????????
Does ANYBODY have an email address for Matthews or his boss at MSNBC??????
I am late 40’s and have voted in every presidential election since I turned 18 and I am reading FDL and contributing money because I care about my fellow residents who DONT have insurance/ can’t afford it/ can’t get it due to pre-existing conditions.
I’M GONNA TO GET A STROKE IF I DON’T CALM DOWN BUT HE OWES US ALL A HUGE APOLOGY, WHAT AN IGNORANT SLAP IN THE FACE.
You mean this?
Try [email protected] not sure if it’s right.
Matthews also thinks Obama is suffering in the polls because he’s too far left. Hahahahahaha.
demos are timid
they elect timid politicans
and so it goes
chris is right
the demos hide in fear of the repubs
just look at nancy and reid they represent you demos
ie spinless and they always fold like a deck of cards
they are a reflection of the demo voters that put them into office.
ie spineless.
are you people nuts
if we cannot make mega profits off the sick and needy what good is it to be an american.
we are americans and we know how to make mega profits off the sick and needy and our wars for profits and even our prisons.
god bless america we are god’s chosen nation
god and jesus were capitalists that is what they had in common. ie capitalism.
we are a christian nation and we are the greatest nation on earth in everything just ask us.
how many other nations can claim to make mega profits off the sick and needy and can make such profits off our wars for profits for the few.
and the more people we can put in prisons in texas the more profits we can make for the few.
god I love this country.$$$$$$$$$$$$$$$$$$$$$
The entire notion of deductibles is poisonous with respect to people seeking necessary screening and treatment EARLY when it does the most good.
It encourages people instead to put things off until the situation becomes intolerable…by which time it’s often too late.
It’s especially bad for those living near the edge, who are simply trying to maintain coverage — because they end up paying hundreds or even (in the worst cases) thousands of dollars a month for a health insurance policy they then lack the means to use. “Let’s see… $800 to pay this month’s premium. Or if I kept it and just dropped the insurance, maybe I could see a doctor about these chest pains I keep having.”
Of course, it’s a Hobson’s Choice either way. Keep the insurance, and you might die. Drop the insurance and see the doctor, and you still might die. Either way, you die broke.
Mathews is a joke and an embarrassment. His ratings are mediocre at best. I truly do not understand why MSNBC continues to put tweety bird on the air. They could do much, much better.
EW, you might want to change your leading paragraph. A “factoid” is a “statement formed and asserted as a fact, but with no veracity”. I suspect you meant “factlett“.
Two pertinent factors regarding the MassHealth system, especially as it relates to the pending legislation in the Senate:
MassHealth has a strong public option.
MassHealth legislation on cost-containment continues apace: That is to say, as a comprehensive approach to healthcare management it is unfinished. This was done for two reasons:
first (and perhaps foremost) implementation was delayed to let Romney flee the scene before he could muck it up, veto, or otherwise try to stamp it with his personal brand of financial “expertise”.
and secondly, to provide for continuity of a care AFTER first having put in place the individual mandate and the exchanges. It was deemed to chaotic to have done all at a once…
If anything ought to have been copied about the Ma approach it ought to have been the piecemeal nature of the implementation. Frankly, I think the one-shot, winner-take-all omnibus approach of the current Congress is an engraved invitation to epic failure. Coverage, exchanges, cost-controls, universality… All this could be achieved in pieces, instead of a go-for-broke handjob for Joes Lieberman…
masshealth is our medicaid, not the subsidized exchange. is it really that good? i’ve been hearing complaints about difficulty finding providers (due to the lower reimbursement rates), but that’s just hearsay.
i will say though that paying full price bcbs, i had to wait over 6 months to get a “new patient” appointment with my current primary care doc (we have way too few pcps in my area, and i’ve heard similar stories from other parts of MA – but again have no data, just hearsay). waits for some specialists are long also, but nothing like for pcps: my experience is 2-5 months if not immediately life theatening. although i was told at one point there was a 4 month wait for a biopsy. needless to say, i spent a couple of weeks being a very loud asshole until i got an appoint to go to boston (4 day wait).
grok @38
[ …If anything ought to have been copied about the Ma approach it ought to have been the piecemeal nature of the implementation. Frankly, I think the one-shot, winner-take-all omnibus approach of the current Congress is an engraved invitation to epic failure. Coverage, exchanges, cost-controls, universality… All this could be achieved in pieces, instead of a go-for-broke handjob for Joes Lieberman… ]
yeah.
your comment articulates the bad feeling creeping over me about this legislation:
done with too little forethought and prior planning. dumping millions of folks into a medical system that appears to be fully engaged as of now and in no way prepared for the tsunami of patients that may appear
done with far too much political horse trading and far too little focused concern on the national interest – economic, moral, and political
done with little or no regard for the political consequences to the democratic party.