One of my professors years ago was a round little man who liked to warn us, with a twinkle in his eye, “Making predictions is very difficult, especially predictions about the future.” Will a bill pass, in what form, and then what will the long term implications be? It’s hard to predict.
The incomparable Dr John Geyman, former president of PNHP, makes another strong case [below] that whatever bill this Congress is able to pass will likely set the cause of single payer healthcare back because it “would leave in place an inefficient, exploitive insurance industry that is dying by its own hand, even as [the bill] props it up with enormous future profits through subsidized individual and employer mandates.”
But below that, Sam Stein writing in the Huffington Post reveals the Goldman Sachs analysis for the health insurance behemoths is that no reform would benefit them the most, and if we end up with a version close to the House bill, that would cause the industry the most financial difficulty.
It is clear that many of the supporters and opponents of the bills, both in Congress and the general public, are clearly deluded, and single payer is what has them flummoxed.
On the Left I keep talking to supporters of the public option who claim to be “single payer at heart”, and they believe that whatever passes will be the camel’s nose under the tent, the slippery slope to single payer. Seems delusional. If only they are right….
Speaking of the Right, many of them also believe that any bill this Democratic Congress will pass will become the same camel’s nose, the same slippery slope to socialism. Could they be right, too?
There is still work to do. The handwriting was on the wall Saturday 10/31 when anti-abortion Democrats had enough political oomph to get their Stupid Amendment debated and passed while the Progressive Caucus couldn’t muster enough support to bring either the Kucinich or Weiner Amendments to the floor.
No matter what happens, one thing is certain: we have to continue to build our movement. Next time around we have to get all those Representatives and Senators who voted for reform this time, to vote for real single payer reform. And that would prove the delusional ones were right after all.
by John Geyman
As we know, the House passed its health care reform bill on October 29, 2009 after many months of contentious debate. By a narrow margin, 220-215, the 1,990 page, almost 20 pound bill was passed. It laid out the most liberal health care reform that might be expected out of Congress this year, since any bill that may clear the Senate will certainly be more restrictive.
In order to answer our question as to the value of the House bill, we need to re-state the original major goals of reform: (1) contain skyrocketing costs of health care and health insurance; (2) expand access to care by including everyone; and (3) improve the quality of care.
At a gross cost of $1.055 trillion over ten years, the House bill would do some good things, including reduction of the uninsured by up to 30 million; helping many Americans to pay for insurance through government subsidies; helping small business to provide coverage to their employees; expanding Medicaid and community health centers; establishing a new Center for Comparative Effectiveness Research to study and recommend the most effective treatments; initiating limited reforms of the health insurance industry, such as termination (four years hence) of its common practice of denying coverage based on health status and pre-existing conditions; phasing out government overpayments to private Medicare Advantage plans; revoking a decade-old anti-trust exemption for insurance companies; and creating a new long-term care program (CLASS ACT) to supplement Medicaid and/or private long-term care insurance.
However, the negatives far outweigh the positives, and adopting this bill would delay real reform for years to come. Despite a chorus of accolades about the bill by its supporters, even comparing it with the historic importance of Social Security and Medicare, this monster bill instead bears the heavy imprint of corporate stakeholders who themselves are largely responsible for out-of-control health care costs. After months of lobbying and campaign contributions to legislators crafting the legislation, their multiple conflicts of interest and political compromises, this bill ends up being a bailout for the insurance industry and a bonanza for stakeholders in the medical industrial complex.
Here are some of the major problems with the bill:
• It will not “bend the cost curve” for many reasons—with the exception of a provision that the government negotiate drug prices with manufacturers (as the VA does so effectively), there are no real restraints on the prices of health insurance or health care services; insurers have already warned that premiums will continue to surge in future years; perverse incentives would remain in the system to continue providing large amounts of inappropriate and unnecessary services, especially by specialists in more highly reimbursed areas; and recommendations based on studies by the new Center for Comparative Effectiveness Research could not be used to mandate coverage or reimbursement policies.
• As the crisis in declining access to care only grows (with already 46 million uninsured and at least another 30 million underinsured), expansion of Medicaid, subsidies, and limited restrictions on insurers would not take place for four more years. And as many states struggle with their deficits during the recession, access and benefit levels available to patients on Medicaid will be seriously jeopardized in many parts of the country. Meanwhile 45,000 Americans are dying each year as a result of being uninsured—one every 12 minutes.
• Because of a number of small-print provisions in the bill, bought by industry interests and crafted by their representatives, we would see a growing epidemic of underinsuranceamong the newly insured. These are some of the reasons: low requirements for actuarial value, the proportion of health care costs that insurers are required to pay for care (probably ending up as low as 65 or 70 percent when further compromises are made with the Senate); restricted levels of benefits to be covered (the minimal essential benefits package would be in four tiers, has yet to be developed, and we can expect that it will fall far short of all necessary care); in a last-ditch effort to pass the bill and assuage pro-life legislators, new anti-choice language was added by the Stupak amendment that would deny coverage of abortion care to millions of women; and coverage shortcomings of private plans already in force will be grandfathered in without reform.
• Even after the expenditure of more than $1 trillion, the bill would still leave some 18 million Americans uninsured.
• The public option, diminished as it has been to the point where it could only include 2 percent of Americans by 2019, would not have enough market clout to “keep the insurers honest.” The Congressional Budget Office (CBO) has already concluded that the public option would not offer real competition to private insurers, and that its premiums would even have to be higher than private premiums. It would not be available until 2013 through the new Health Insurance Exchange, and then only to the uninsured and some employees of small businesses without coverage. Moreover, such Exchanges have no track record of success. After 15 years of experience in California, that Exchange failed, mostly due to lack of pricing power and adverse selection by attracting sicker enrollees.
• The CBO has projected that rising insurance costs could mean that middle-income families would spend 15 to 18 percent of their income on premiums and co-payments.
• This bill would not reverse the unraveling of the employer-sponsored insurance system because of rising health care costs that outpace the rest of our economy; despite subsidies to small business, employer-sponsored insurance would remain unsustainable.
• This bill would only add to the already large burden of complexity and bureaucracy, together with their additional costs. At the same time, it would forego savings of some $400 billion a year that could otherwise be achieved through a simplified, more efficient single-payer system.
So in sum, this bill, while well intentioned, is fatally flawed. It would not effectively address the three major system problems demanding urgent reform, and would delay real reform by letting much of our population falsely think that reform is at hand. It would leave in place an inefficient, exploitive insurance industry that is dying by its own hand, even as it props it up with enormous future profits through often subsidized individual and employer mandates.
The most fundamental single question about how to reform our health care system should be whether or not we abandon our multi-payer, mostly investor-owned financing system or move to a not-for-profit single-payer system, Medicare for All, which this year’s political process has carefully kept off the table. The lesson of history in this country tells us that, as long as we retain private health insurance at the core of our health care system, we can never achieve universal access to affordable, comprehensive high-quality care.
John Geyman, M.D. is Professor Emeritus of Family Medicine at the University of Washington, past President of Physicians for a National Health Program, author of a number of books on health policy, and a member of the Institute of Medicine.
First Posted: 11-12-09 05:12 PM | Updated: 11-13-09 12:02 AM
A Goldman Sachs analysis of health care legislation has concluded that, as far as the bottom line for insurance companies is concerned, the best thing to do is nothing. A close second would be passing a watered-down version of the Senate Finance Committee’s bill.
A study put together by Goldman in mid-October looks at the estimated stock performance of the private insurance industry under four variations of reform legislation. The study focused on the five biggest insurers whose shares are traded on Wall Street: Aetna, UnitedHealth, WellPoint, CIGNA and Humana.
The Senate Finance Committee bill, which Goldman’s analysts conclude is the version most likely to survive the legislative process, is described as the “base” scenario. Under that legislation (which did not include a public plan) the earnings per share for the top five insurers would grow an estimated five percent from 2010 through 2019. And yet, the “variance with current valuation” — essentially, what the value of the stock is on the market — is projected to drop four percent.
Things are much worse, Goldman estimates, for legislation that resembles what was considered and (to a certain extent) passed by the House of Representatives. This is, the firm deems, the “bear case” scenario — in which earnings per share for the top five insurers would decline an estimated one percent from 2010 through 2019 and the variance with current valuation is projected to be negative 36 percent.
What the firm sees as the best path forward for the private insurance industry’s bottom line is, to be blunt, inaction.
The study’s authors advise that if no reform is passed, earnings per share would grow an estimated ten percent from 2010 through 2019, and the value of the stock would rise an estimated 59 percent during that time period.
The next best thing for the insurance industry would be if the legislation passed by the Senate Finance Committee is watered down significantly. Described as a “bull case” scenario — in which there is “moderation of provisions in the current SFC plan” or “changes prior to the major implementation in 2013” — earnings per share for the five biggest insurers would grow an estimated ten percent and the variance with current valuation would rise an estimated 47 percent.
The report, a Goldman official stressed, was analytic not advocacy-based. Their job was to provide a sober assessment of the market realities facing private insurers under various versions of health care reform.
“If no reform at all happens you would see the largest rise in EPS,” a Goldman official acknowledged. “But what we are doing is just analyzing what the stocks would do under different scenarios.”
The study does note on the front page that the firm “does and seeks to do business with companies covered in its research reports.” Those companies include Aetna, Wells Point and United Health.
In the context of the current health care debate, the findings provide a small window into the concerns that have driven the private insurance industry’s opposition to reform legislation. Simply put: health care reform is going to hurt their bottom line. No less a prestigious voice than Goldman Sachs is telling them so.
Some insurers, in the end, will be hit harder than others. CIGNA is the lowest of the big five, for instance, because it does little business providing insurance plans to Medicare patients, individuals and families buying health plans directly, or small employers that offer health plans to their workers.
In addition, some reforms are going to hurt the industry more than others. Regulatory changes — such as prohibiting the prejudice against consumers with pre-existing conditions — will have an impact across the board, as will the funding cuts to Medicare Advantage.
Overall, Goldman calculates the probability of reform passing Congress at 75 percent. Though the limitations of Goldman’s political prognostications were on full display earlier in the document:
By mid-late October, we expect a cloture vote (60 votes) to bypass a potential filibuster followed by several weeks of debate over proposed amendments on the Senate floor (with a similar process under way in the House). If both the Senate and House are able to pass legislation (perhaps before the Thanksgiving recess), a House-Senate conference negotiation should produce combined legislation for final approval (perhaps by mid-December).