A piece of the health care reform issue we don’t hear much about is the very serious shortage of primary care physicians:
The annual number of American medical students who go into primary care has dropped by more than half since 1997. It’s hard to get an appointment with the doctors who remain. In some surveys, as many as half of primary-care providers have stopped taking new patients. The other half are increasingly overworked and harried. Clearly we need to find a way to increase their ranks, and both the congressional health-care bills and President Obama’s reform proposal make moves in that direction. But those efforts are somewhat limited, and a more comprehensive solution could be thwarted by the same thing that’s stalled the rest of health-care reform so far: politics.
The reason behind America’s doctor gap is a matter of money. The average income in primary care is somewhere in the mid-$100,000s, which sounds like a lot but is less than half what specialists such as radiologists and dermatologists make. Given that doctors may graduate with as much as $200,000 in med-school debt, it’s easy to see why primary care started hemorrhaging recruits more than a decade ago and why radiology and other well-paid, high-tech specialties took off in popularity.
The field has since entered a vicious cycle. As fewer people have entered primary care, the doctors who are left have been forced by tight schedules to shortchange some patients, forgoing the long, meandering chats that used to be a big part of checkups in favor of 15-minute, checklist-style appointments. The close relationships that general practitioners once had with patients drew many idealistic students into the field. Now recruiters face an extra-tough sell: they have to convince bright young would-be docs to pursue a career that won’t pay very well and won’t be as emotionally fulfilling as it once was.
Some medical schools around the country now have programs that pay a portion of the med student’s tuition, in exchange for them doing their training in rural areas. There is also the National Health Service Corps where scholarships and loan repayment are available to medical professionals who go to work in an underserved area. Programs like this are especially important in rural areas. From their website:
About the National Health Service Corps
Since 1972, more than 30,000 clinicians have served in the Corps, bringing high quality health care to places and people without access to even basic services.
Nearly 80 percent stay in the underserved area after fulfilling the NHSC service commitment; more than half make a career of caring for underserved people.
Last year, about 3,500 NHSC providers cared for 4 million people — changing their own and their patients’ lives.
Average hours dropped from about 55 to 51 hours per week from 1996 to 2008, according to the analysis, appearing in Wednesday’s Journal of the American Medical Association.
That’s the equivalent of losing 36,000 doctors in a decade, according to the researchers. And it raises policy questions amid a looming primary care doctor shortage and Congress considering an expansion of health insurance coverage that would mean more patients.
One can certainly suppose (correctly) that overwork and burnout may be reasons why doctors are working fewer hours, but money also seems to be a big motivator:
Payment issues may have played more of a role. The overall decrease in hours coincided with a 25% decline in pay for doctors’ services, adjusted for inflation. And when the researchers looked closely at U.S. cities with the lowest and highest doctor fees, they found doctors working shorter hours in the low-fee cities and longer hours in the high-fee cities.
One way to address the problem of doctor shortages is to have patients see nurses, physician’s assistants, and nurse practitioners for routine care – all of whom can detect a serious problem and pass it on to a doctor. In some rural areas this is already happening, out of necessity.
The American Medical Association and doctors groups don’t like this. Even though there is a serious shortage of primary care docs, the AMA is opposed to letting nurse practioners have a greater role in primary care.
The American Medical Association sparked harsh criticism from nursing groups when it released a report in October bluntly questioning whether nurse practitioners “are adequately trained to provide appropriate care.” To back up its claims, the report cites recent studies that question the prescription methods of some nurse practitioners, as well as a survey that reported only 10 percent of nurse practitioners questioned felt well prepared to practice primary care.
The nurses are fighting back:
Responding to the AMA in December, the American Nurses Association and more than two dozen other nurses’ organizations termed the report “misleading,” saying it “contains numerous factual misrepresentations.” Their letter rebuked the AMA for its “attempt to change the perceptions of NP practice as anything other than fully qualified professionals working within a legally established scope of practice.”
In addition to the common sense aspect, using nurse practitioners also saves money:
In September, the nonpartisan Brookings Institution’s Engelberg Center for Health Care Reform issued a report by 10 experts that said one way to curb health care spending is to encourage states to permit “greater use of nurse practitioners, pharmacists, physician assistants, and community health workers.” Meanwhile, a blue-ribbon committee working under the aegis of the Institute of Medicine and Robert Wood Johnson Foundation is planning to make extensive recommendations later this year on the future of nursing.
Instead of big, howling egos, it would be nice to see more creative solutions. A small town in northern NH was fortunate enough to have one solution given to them. A wealthy summer resident of Tamworth, NH started the Tamworth Community Nurses Association. Mrs. Elizabeth Whittemore left behind an endowment, so that all residents of Tamworth could have access to health care. That was over 80 years ago. The town of Tamworth still has a nurse that sees patients in her office or makes house calls. Free.
In the interest of full disclosure, I know JoAnn Rainville, the Tamworth Community Nurse. I live in a nearby town. The kind of care she provides, saves money. In rural areas, duplicating this kind of service makes sense, especially as we face a shortage of primary care doctors and the possibility of millions of Americans becoming insured.
So, Anthem Blue Cross totally needed to raise rates on individual policy holders in California by up to 39%. They were losing money, people! (On the individual market in California, while making giant profits overall.) Just trying to staunch the bleeding! (They told us.)
Internal emails tell a different story. You might need to sit down before reading this, but: The rate increases were to increase profits, not minimize loss. Who could’ve guessed?
This came out yesterday at a hearing held by the House Energy and Commerce Health Subcommittee, where Representatives Waxman and Stupak read out some internal Anthem emails.
– “The average increase is 23 percent and is intended to return California to a target profits of 7 percent, versus 5 percent this year.” [WellPoint email, October 7, 2009]
– “We’re asking for premiums that would put us $40 million favorable…if we get the increases on time, we will see an opt gain upside of $30 million downgrades and rate cap.” [WellPoint email, November 2, 2009]
– “[W]e needed to reach agreement on filing strategy quickly — specifically in the area of do we file wth a cushion allowed for negotiations.” [WellPoint email, 10/24/2009]
Company-wide profits aren’t enough for them. Profits in California aren’t enough for them. No, every single area of business has to be profitable for them. What’s next? How far does it get subdivided? “Well, yes, we were making money on individual policyholders, but we weren’t making money on individual policyholders over 60, so we had to raise their rates by 73%”?
This is why there needs to be meaningful competition and meaningful cost controls. This is why a public insurance option is the best choice – because when individual policy holders got their letters announcing a 39% increase, they’d have somewhere to go. And don’t you think maybe that would make Anthem rethink whether to send the letters to begin with?
In advance of the planned bipartisan meeting on health care reform, the White House released a health care reform proposal. You can read the proposal here; mcjoan at Daily Kos writes that:
The strong message from the White House is that they are prepared to use reconciliation to pass this bill, with Pfeiffer reiterating their need for an “up or down” vote on reform, breaking a Republican filibuster as needed.
Jason Rosenbaum summarizes the bill at HCAN, while ThinkProgress has a table laying out the key differences between this bill, the Senate bill, and the House bill.
Both point to improved subsidies for lower- and middle-income people; the closing of the Medicare Part D donut hole; an increase in the value of insurance plans that will be exempted from the excise tax, and a delay in when the excise tax starts hitting people’s policies. According to ThinkProgress,
The White House explained that it paid for its changes (which cost approximately $75 billion) by levying higher penalties on individuals and employers that don’t meet the legislation’s requirements, extending the payroll tax to unearned income, $10 billion in fees on branded pharmaceuticals, and increased savings from Medicare Advantage.
The proposal also eliminates the so-called Cornhusker kickback and provides full federal funding for Medicaid expansion for four years starting in 2014. Between 2018 and 2019, the federal government will pay 90% of the cost of the expansion and provide extra funds to states with generous Medicaid programs.
The question, of course, is “will it pass?” If it gets through the Senate using reconciliation to bypass the inevitable Republican filibuster, is it a strong enough bill to pass the House? That we’ll have to wait to see, but after being stalled for months, any movement toward the health care reform this country so badly needs is more than welcome.
Anthem’s rate hikes in California are only the beginning. Dramatic rate hikes are expected in a number of other states. HHS Secretary Kathleen Sebelius is releasing a report today. From TPM:
Among the findings:
Anthem of Connecticut requested an increase of 24 percent last year, which was rejected by the state.
Anthem in Maine had an 18.5-percent premium increase rejected by the state last year as being “excessive and unfairly discriminatory” – but is now requesting a 23-percent increase this year.
In 2009, Blue Cross/Blue Shield of Michigan requested approval for premium increases of 56 percent for plans sold on the individual market.
Regency Blue Cross Blue Shield of Oregon requested a 20-percent premium increase.
UnitedHealth, Tufts, and Blue Cross requested 13- to 16-percent rate increases in Rhode Island.
And rates for some individual health plans in Washington increased by up to 40 percent until Washington State imposed stiffer premium regulations.
You might think that in a time of deep recession, with over 10% unemployment that they might scale back a little – but clearly these companies have no shame.
This says it all:
“[P]rofits for the ten largest insurance companies increased 250 percent between 2000 and 2009, ten times faster than inflation,” the report finds.
And this really sums it up: Pirates of the Health Care-ibean
Anthem Blue Cross has just raised rates in California, anywhere from 25-39% – at least 4 times the rate of medical inflation. Health and Human Services Secretary Kathleen Sebelius asked Anthem (and parent company WellPoint) to justify the huge increase. They said (in part):
In statements and letters, Anthem and WellPoint have explained what the industry calls a recessionary death spiral: as unemployment and declining wages prompt healthy people to drop their insurance, the remaining risk pool becomes sicker and more expensive to insure, which in turn forces up prices and pushes more people out of the market.
That sounds almost reasonable, until we learn:
A study released this week found that the five largest health insurance companies collectively lost 2.7 million customers last year, including 1.4 million by WellPoint. Yet they reported record profits of $12.2 billion.
The difference in health care spending between the U.S. and other advanced nations is breathtaking, and thanks to the practices of Big Insurance it has climbed to a level never before seen in the developed world. For every dollar spent in the U.S. last year, 17.3 cents was devoted to health care, up 1.1 percentage points from the previous year and the largest single-year increase on record, according to actuaries at the U.S. Centers for Medicare and Medicaid Services (CMS).37 Such rapid growth in relative spending, especially at a time when the economy is sputtering, is a hidden tax on families and businesses. It reduces the U.S. standard of living, keeps wages down, drains family bank accounts and weakens our ability to compete with other countries. Without comprehensive national health insurance reform that will make quality, affordable care available to all, the portion of our economic output devoted to health care is projected to rise to a staggering 19.3 percent in 2019.
Just as the health care reform debate had bogged down, and seemed to be going nowhere, this news has invigorated the discussion, and reenergized those who are in favor of a public option.
Senators Michael Bennet (D-CO) Senators Kirsten Gillibrand (D-NY), Jeff Merkley (D-OR), and Sherrod Brown (D-OH) have sent a letter to Majority Leader Harry Reid, calling upon him to use reconciliation to pass the public option. You can see the letter here and sign on yourself. As the letter points out:
The overwhelming majority of Americans want a public option. The latest New York Times poll on this issue, in December, shows that despite the attacks of recent months Americans support the public option 59% to 29%. Support includes 80% of Democrats, 59% of Independents, and even 33% of Republicans.
Much of the public identifies a public option as the key component of health care reform — and as the best thing we can do to stand up for regular people against big insurance companies. In fact, overall support for health care reform declined steadily as the public option was removed from reform legislation.
The need for a robust public option has never been more apparent.
Just as dealings with the Obama administration and congressional Democrats soured last summer, six of the nation’s biggest health insurers began quietly pumping big money into third-party television ads aimed at killing or significantly modifying the major health reform bills moving through Congress.
That money, between $10 million and $20 million, came from Aetna, Cigna, Humana, Kaiser Foundation Health Plans, UnitedHealth Group and Wellpoint, according to two health care lobbyists familiar with the transactions. The companies are all members of the powerful trade group America’s Health Insurance Plans.
The funds were solicited by AHIP and funneled to the U.S. Chamber of Commerce to help underwrite tens of millions of dollars of television ads by two business coalitions set up and subsidized by the chamber. Each insurer kicked in at least $1 million and some gave multi-million dollar donations.
This was at the same time the insurers were claiming they supported reform.
For the record, that’s enough money to provide up to 3,000 families health insurance for a year, if the insurance companies had any interest in actually providing health care to people.
This reflects poorly on everyone involved. The Chamber of Commerce – ostensibly a principles interest group with its own constituency and goals – is revealed to be nothing more than a front group for hire. And the insurance companies and AHIP not only lied about their support for reform (as we’ve known all along), but lacked the courage of their convictions to put their money into their opposition publicly.
You can help shape the health care reform bill in Congress by making your voice heard today, as part of the National Call-in Blitz.
It’s important to do this today, because tomorrow the House Democratic caucus will hold a policy session, which President Obama is scheduled to attend. Your call today can help the House and the President to get the health reform bill right.
Just call toll-free 1-877-3-AFLCIO (1-877-323-5246). You’ll be prompted to press 1 to connect to your Senators, press 2 to connect to your member of the House of Representative, or press 3 to receive mobile text updates. So you can call several times, all toll-free.
Leaders of a dozen of America’s largest labor unions met yesterday with President Obama and administration health care officials to deliver the message that the Senate’s proposed excise tax on working families’ health benefits is bad policy and bad politics.
As Congress and the White House work to craft a final health care reform bill, a key question remains how major components will be funded. The Senate’s bill currently includes a 40% excise tax on the costs of health benefit plans in excess of $8,500 for individuals and above $23,000 for family plans. The House health care reform measure would place a 5.4% surcharge on the 1% highest incomes — $1 million for joint filers and $500,000 for individuals.
The AFL-CIO, other major labor organizations, and their progressive allies including Health Care for America Now strongly favor the approach supported in the House health reform bill — to tax the wealthy, not the middle class.
As the union leaders prepared to meet with the President at the White House, The New York Timesreported:
Union leaders said Monday afternoon that they planned to tell President Obama in a meeting later in the day that it would be a costly political mistake to enact an excise tax on high-priced, employer-sponsored health benefits.
They said they would warn the president that enacting the tax, which the president favors and is part of the Senate health bill, would give Republicans lots of political ammunition — enabling them to run ads saying that Mr. Obama and the Democrats had imposed a tax on the middle class after Mr. Obama had promised during his presidential campaign not to raise taxes on average Americans.
During his campaign, Mr. Obama said he would not raise taxes on households earning less than $250,000 a year.
Union leaders also said it would be politically unwise for Mr. Obama to back the excise tax because his presidential campaign had run ads attacking John McCain for proposing to tax health benefits.
In a speech at the National Press Club earlier Monday, Richard Trumka, president of the A.F.L.-C.I.O., said the labor federation could not support the Senate version of the health legislation, largely because it contains the excise tax, which would affect individual insurance policies with annual premiums more than $8,500 and family policies more than $23,000.
According to one union survey, the tax would affect one in four union members.
There’s only one big remaining issue on health care reform: how to pay for it. The House wants a 5.4 percent surtax on couples earning at least $1 million in annual income. The Senate wants a 40 percent excise tax on employer-provided “Cadillac plans.” The Senate will win on this unless the public discovers that a large portion of the so-called Cadillacs are really middle-class Chevys, expensive not because they deliver more benefits but because they have higher costs.
… by taxing so-called Cadillac plans, the Senate bill would actually end up taxing the Chevy plans of a large portion of the middle class. And as time goes by, a still larger portion, since the Senate plan is geared to the overall rate of inflation rather than to the (much higher) rate of increases in health-care costs.
Some say the Senate’s excise tax is the only way to control long-term health care costs. Baloney. If a portion of the middle class loses their health care, they won’t get the preventive care that’s so crucial to containing long-term costs.
Reports following the White House meeting between union leaders and the President indicate that labor’s message may be making headway.
President Obama told union leaders at a private White House meeting on Monday that he remained committed to taxing high-cost insurance policies as a way to drive down health costs. But he also signaled that he was willing to amend the proposal to “make this work for working families,” a senior administration official said.
Mr. Obama’s remarks, at an hourlong session with a dozen labor leaders in the White House Roosevelt Room, came just hours after the new president of the A.F.L.-C.I.O., Richard L. Trumka, delivered a speech at the National Press Club in which he criticized the tax as a “policy that benefits elites” and warned that Democrats would pay a price at the polls if it was enacted.
“Instead of taxing the rich, the Senate bill taxes the middle class by taxing workers’ health plans — not just union members’ health care,” Mr. Trumka said. “Most of the 31 million insured employees who would be hit by the excise tax are not union members.”
House and Senate negotiators are considering applying for the first time the Medicare payroll tax to investment income as part of a compromise to pay for a health overhaul.
The extra Medicare tax would apply only to the wealthy and could allow congressional Democrats to reduce the sting of a tax on high-cost insurance plans, said Democratic aides and others briefed on the negotiations.
Currently, the Medicare tax applies only to wages, without any limits. The 2.9% tax is divided in half, with workers and employers each paying 1.45%. The health bill passed by the Senate would raise the worker contribution to 2.35% for individuals making more than $200,000 a year and couples making more than $250,000 a year.
Under the proposal now being considered, people making more than those amounts would also pay the Medicare tax on dividends and other income from investments, the people familiar with the talks said. Income from pensions and retirement accounts, including 401(k) accounts, would be exempt.
The proposal would also bring the Senate closer to the House version of the health bill, which contains a 5.4% income surtax on the wealthy.
“It’s an obvious compromise,” said Chuck Marr, director of federal tax policy at the left-leaning Center on Budget and Policy Priorities. “They need to find something between the House and Senate versions. The advantage of this proposal is that, like the House surtax, it is broad-based.”
If organized labor and many Democrats in the House get their way, that proposed tax on high-end health-care plans will be heading for the body shop before lawmakers come up with a final health-care overhaul bill for President Barack Obama to sign.
But if Obama was swayed by labor leaders’ salvos against the tax during a meeting at the White House on Monday, he’s not saying — White House Office of Health Reform spokeswoman Linda Douglass described the meeting only as “productive” and gave no indication if Obama had changed his mind about the tax.
While it appears that the White House may be looking at remodeled excise tax-Medicare payroll tax hybrid, still Bob Reich asks:
But why even take these chances when the House bill simply and cleanly goes after the top 1 percent? It’s not as if couples earning over a million can’t afford to pay the tax. When I last looked, the top 1 percent was taking home a record 23 percent of total income. If anything, the Great Recession is widening the gap. It’s bonus time on Wall Street again. But the middle class is taking a beating.
This is the last big fight on health care reform. It’s being fought right now. Make your voice heard.
So a Republican member of Congress breaks a bone, gets good medical care, and says this shows the health care system works.
Of course it does — for him. Coffman, who has great taxpayer-subsidized insurance as a member of Congress, went for X-rays, found that he’d broken a bone, and received a cast and some painkillers. It cost him a $30 co-pay. A friend of a friend is a specialist, who saw Coffman on short notice and concluded that the conservative lawmaker would not need surgery. The visit to the specialist — at an exclusive clinic in Vail — wasn’t covered by his insurance, but Coffman, who makes $174,000 a year as a House member, had no trouble paying the $350 out-of-pocket expense.
Can we get him to break another bone and deal with it on the median income and insurance of his constituents? I’d sure like to hear what he’d say then.
House Democrats are slated to caucus today on a phone conference as they pursue efforts to improve the health care reform bill approved by the Senate.
As we reported in an earlier post today, one of the most contentious issues is the excise tax on so-called ‘Cadillac’ health insurance plans in the Senate bill. Rather than impacting only wealthy policy holders and the highest-priced insurance plans, the Senate’s excise tax would hit even the modest plans of millions of middle-class Americans.
Opposition to the Senate’s health benefits tax is strong in the House, where Rep. Joe Courtney (D-CT) has gotten 190 of his Democratic colleagues to sign his letter (pdf) against the excise tax.
“One-hundred-ninety House Democrats have joined my effort to stop the proposed ‘Cadillac’ tax on health care plans, which is a number that cannot be ignored during health care reform negotiations,” Rep. Courtney said in a statement released yesterday. Calling the Senate-backed excise tax “misguided”, Courtney said “there is no question that the tax will hurt the wages of working families. The House must stand firm in its opposition to the tax.”
“The real origin of the Senate’s benefits tax was John McCain’s campaign,” Courtney told me in a phone interview yesterday. “And President Obama vociferously opposed that plan during the campaign.” Noting that the McCain plan would have put a cap on the deductibility of health insurance plans, Courtney added “you could make an argument that the Senate’s excise tax is actually worse than McCain’s plan.”
An aide to the Congressman cited this report from Roll Call (subscription) which included quotes from an Obama campaign ad:
In the runup to the presidential election, Obama was a frequent critic of a similar tax endorsed by the GOP nominee, Sen. John McCain (Ariz.). In October 2008, Obama’s campaign bought national television ads to criticize McCain for his proposal.
“McCain would tax health benefits … for the first time ever, meaning higher income taxes for millions,” a narrator said in an ad run by Obama’s campaign. “His plan would raise costs for employers offering health care, so your coverage could be reduced.”
Referring to President Obama’s oft-repeated reform pledge that if you like your current health care plan you can keep it, Courtney said “there’s no way you can square that pledge with an excise tax on benefits that the Joint Committee on Taxation says will impact 27% of family plans and 22% of individual plans by 2019.”
Asked how the benefits tax made its way into the Senate bill, given its pedigree, Courtney said “there is no question that this excise tax was floated in the Senate Finance Committee during the ‘Gang of Six’ discussions as a means of attracting Republican support,” adding that of course that support never materialized.
Courtney pointed to numerous polls showing broad opposition to the Senate’s tax and strong support for the House version’s alternative, a progressive surtax on the top 1% of incomes. For example, the most recent Rasmussen poll results showed 59% of voters opposing the Senate’s benefits excise tax and 64% supporting the House’s highest incomes surcharge.
Despite the clear political dangers for Democrats posed by the health benefits excise tax, House Democrats opposing the Senate’s tax face an uphill battle according to the latest reports from the White House.
President Obama told House Democratic leaders at a meeting on Wednesday that they should include a tax on high-priced insurance policies favored by the Senate in the final version of far-reaching health care legislation, aides said.
“But the House gets first crack at the bill,” Rep. Courtney said, noting that the process of amending the Senate’s version had just begun.
