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POLICY: Uninsured number will rise, but maybe not enough

In an article in Health Affairs today called It’s The Premiums, Stupid Gilmer and Kronick project the numbers of the uninsured through 2013. Kronick, BTW was a co-author with Alain Enthoven of some of his market-based consumer choice articles, though he seems to have moved leftwards since the early 1990s.   Essentially they forecast that there will be a continued price effect with low and middle-income workers continuing to be squeezed out of insurance as the costs go up.  For the human side of this, take a look at the LA Times article which assessed this phenomenon yesterday. For the numbers, Kronick and Gilmer say:

Based on the
projected growth rates for health spending and personal income, we
estimate that the rate of uninsured non elderly workers will increase by
4.0 percentage points to 27.8 percent in 2013. We estimate that the
uninsurance rate among all nonelderly Americans will increase by 3.3
percentage points to 20.5 percent in 2013. With an expected population
of 271 million people under age sixty-five in 2013, we estimate that
there will be fifty-six million uninsured Americans in this age group,
an increase of thirteen million over the CPS estimate for 2002. Of this
estimated increase, 8.6 million occurs because of the expected increase
in the proportion of the population that is uninsured, and 4.4 million
because of an increase in population size.

The problem is that while there are countless stories of misery behind these numbers, and some real costs to being uninsured in terms of both access to care and worse health status —  not to mention the corresponding increase in people being severely underinsured — this may not be enough to change things.  Vic Fuchs at Stanford always used to say that we needed a national crisis to change the health system.  Adding a couple more million people — and they are poorer, more marginalized people than the typical voter — to the uninsured numbers each year isn’t going to change too much.  If however, things are getting worse, and we see these numbers increase at a faster rate — particularly amongst white middle income males in their 50s (i.e. Republican voters) — then there might be some real change coming up in 4-8 years.  I think that’s an equally plausible scenario, but if Gilmer and Kronick are right, then it’s probably more of the dreary same.

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13 replies »

  1. Sue,
    I think all of your points are valid. As you say, the fact that something doesn’t appear on your MIB report doesn’t mean that you’re insurance company won’t contact your previous insurers to dig for dirt.
    Gadfly,
    If you’re rejected for insurance, you have a right to a free copy of your MIB report.

  2. Two questions about the MIB Database.
    1) Why isn’t is subject to HIPAA? If the Seattle case established that HIPAA could be extended beyond Health Plans and Providers, then it seems to me that MIB Database should be high on the list of Other Privacy Concerns. The information in the MIB could adversely affect the lives of thousands of people, skewing against people with genetic disorders and the elderly.
    2) It bothers me that people have to pay to see a copy of the MIB report. When a person reports a credit card theft or gets rejected for a loan, they are entitled to check their credit report. It seems that if a person is rejected for insurance (or charged a high rate for mysterious reasons), then that person should be able to verify the facts on their health record. People shouldn’t have to pay for correct documentation.

  3. Great infomation newbiewonk and I’ve requested a report copy to see what is there.
    The challenge is that health questionnaires are worded very carefully. The one I’m looking at now wants a list of every medication I’ve taken in the past five years in addition to detail on potential health conditions. It even has a catch-all question that asks if you’ve “sought advice” at an emergency room in the last five years. The one before wanted detail on every doctor’s visit over the past five years. Plus both want lists of previous insurers and ask if an insurance company has ever rated me higher for a premium. In short there are a lot of questions that try to identify flags that would indicate higher risk, which might not have been reported to MIB. Let’s say I check my MIB record and see that nothing significant is listed. I then only write safe answers in my questionnaire. I get insurance at reasonable rates. Then one day I have an expensive accident or develop a serious health condition. The insurance company seeing a large claim and a “clean” questionnaire goes back to that questionnaire and contacts my old insurers directly to verify data more thoroughly and finds things I didn’t disclose. Based on the statement at the bottom of the application, they can cancel my insurance and keep all those premiums. In short, if I seek routine medical care, I’m likely to always be posting “red flag” answers because as I age, conditions will be documented. If I lie on the questionnaire I give insurers a “get out of jail free card” on paying any expensive claims. It’s not a good system right now for anyone not in perfect health and my situation underscores that the definition of “perfect health” is pretty narrow. Even when fully insured with a low deductible, I didn’t take anything but occasional prescription medication and typically only saw doctors for routine diagnostic tests like annual exams or age-specific cancer screening like mammograms, etc. In short, my health expense incidence rate was extremely low. With car insurance, you have the ability to let the good side of your driving record counter any short term issues like an isolated accident or moving violation. With health insurance there is no ability balance risk indicators with behavior that documents lower cost medical care consumer behavior. That’s a problem.

  4. Sue,
    Why don’t you request a copy of your health record from the Medical Information Bureau (MIB). The MIB is a centralized database used by the health insurance companies to keep tabs on whether you’re being truthful on your health insurance applications, etc…
    Here’s a description of the MIB excerpted from the Privacy Rights Clearinghouse (http://www.privacyrights.org/fs/fs8-med.htm).
    “The Medical Information Bureau (MIB) is a central database of medical information shared by insurance companies. Approximately 15 million Americans and Canadians are on file in the MIB’s computers. About 600 insurance firms use the services of the MIB primarily to obtain information about life insurance and individual health insurance policy applicants.When you apply for life or health insurance as an individual, you are likely to be asked to provide information about your health. Sometimes you are required to be examined by a doctor and/or to have your blood and urine tested. If you have medical conditions that insurance companies consider significant, the insurance company will report that information to the MIB.The information contained in a typical MIB record is limited to codes for specific medical conditions and lifestyle choices. Examples include codes to indicate high blood pressure, asthma, diabetes, or depression. A code can signify participation in high-risk sports such as skydiving. A file would also include a code to indicate that the individual smokes cigarettes. The MIB uses 230 such codes.It’s important to remember the following about the MIB:
    The MIB is not subject to HIPAA.MIB files do not include the totality of one’s medical records as held by your health care provider. Rather it consists of codes signifying certain health conditions.
    A decision on whether to insure you is not supposed to be based solely on the MIB report.
    The MIB is a consumer reporting agency subject to the federal Fair Credit Reporting Act (FCRA). If you are denied insurance based on an MIB report, you are entitled to certain rights under the FCRA, including the ability to obtain a free report and the right to have erroneous information corrected. See the Federal Trade Commission’s web site on insurance decisions, http://www.ftc.gov/bcp/conline/pubs/buspubs/insurers.htm.
    The MIB does not have a file on everyone. But if you have an MIB file, you will want to be sure it is correct. You can obtain a copy ($9.50) by writing to the Medical Information Bureau, P.O. Box 105, Essex Station, Boston, MA 02112, or by calling (617) 426-3660. Web: http://www.mib.com.”

  5. //I don’t think I have any health problems, but I’m sure not going to do anything to document them//
    This seems to me to be a very interesting corrolary to physician’s practicing “defensive medicine” and trying to avoid diagnosis.
    Another discouraging factor for the uninsured is just having to discuss your financial situation with some judgmental and/or skeptical bureaucrat. The thought of this indignity was enough to make me hesitate about going to the ER when I was at risk of legal blindness in one eye. Hemhorraging eyes vs. patronizing ER clerk: actually a tough decision.
    Maybe we’re moving toward the Health Denial Society.
    I do have a pre-existing genetic condition that can lead to costly medical problems. I don’t know whether this would prevent me from getting my own health insurance, but I’ve never been excluded from employer-sponsored health insurance. If an entrepreneurial model of health care ultimately prevails, then I suppose I would be excluded from health insurance coverage all together. I think it all comes down to pop-Darwinism: society would rather slough off a contributing member than pay to keep a member contributing.

  6. Gadfly,
    I am insured (with high premimum and high deductible) and I avoid doctors, not because of the cost, but because I’d like to switch insurers and am afraid of what I may have to answer on the next health questionnaire if I see a doctor. I made the mistake of doing a lot of diagnostic tests in my mid-40s thinking that recommended preventative screening was a good idea. It didn’t uncover any major problems, but listing those visits cost me a 25% upcharge in premiums because it showed a hereditary hiatal hernia. I have had the the condition all my life and never needed any treatment–my mother, grandfather and great-aunt have too. If I hadn’t confirmed it was there with a routine endoscopy I’d be insurable at regular rates. I don’t think I have any health problems, but I’m sure not going to do anything to document them until I get past my five-year look back period. I’d love to see a limit on what questions that can be asked AND also a time limit on premium upcharges for conditions that aren’t being treated. There is a time limit on pre-existing conditions, why not a time limit on premium upcharges based solely on health questionnaire questions. When you multiply what I’m doing times all the other people afraid to see doctors (not because of health costs) but because of impact on premium cost or insurability it creates another potential healthcare crisis.

  7. //The number of uninsured hoping to stay healthy who aren’t seeking medical care is probably much larger//
    I’m wondering what segment of the uninsured realize they aren’t healthy (or, in economic terms, “optimally productive”) but regard their health problems as “not acute”. These are the people who end up weighing their tolerance for various physical problems against their willingness to go into debt.
    In my own case, I’m currently able to work, and I’d describe my only medical problems as uncomfortable. When I was insured, however, I took several medications: I don’t know if they are still necessary, and any emerging problems related to the same underlying condition will of course remain undiagnosed unless something “acute” happens. When I take into account my own values as well as the social pressures I will have to live with, I’d rather deal with deferred treatment and an acceptable level of risk to my health than accumulate debts that I know I won’t be able to pay (Collections Agencies, bankruptcy, random social judgments for letting myself get into debt). I’d be really surprised if I’m the only uninsured person to follow this line of reasoning.

  8. To me, simply implementing common sense billing and having larger deductibles should ensure better premiums. But the medical community and insurers don’t want to see that happen. A few years ago my dog had cancer. We were able to discuss every option with the vet and figure out the best course of action with a full understanding of costs and benefits. Why? Because vets recognize that people won’t use their services if the costs aren’t kept reasonable and understandable. The vets in that area (East SF Bay area) actually created a consortium that shared high dollar diagnostic equipment throughout the Bay area instead of everyone getting their own machines (imagine if hospitals in a region actually developed sharing strategies to minimize fixed costs instead of tried to see who could purchase the best of the best to attract the highest paying patients). The ultrasound (on a mobile diagnostic van) was $80. They also had some programs with UC Berkeley vet school to offer lower cost options relative to surgery and treatment options. In short, they created a system that was user-friendly. The for profit mentality in the health care industry today recognizes that people don’t want to die and can be sold services with very little “shopping” if costs are hard-to-understand. Insurance programs have very little legislative incentive to provide access to coverage to all at reasonable prices and charge outrageous rates to healthy, older Americans foolish enough to honestly answer their health questionnaires (and if you lie they can cancel your policy). Tort reform won’t solve either of those issues. I don’t understand why the tort reform issue can’t be resolved with a worker’s comp like scenario. Workman’s comp is an exclusive remedy. That means that if your employer has workman’s comp, you can’t sue for an on-the-job injury. Workman’s comp pays for the care and has an arbitration policy for appeal on claims. Not as lucrative as legal lotto for the injured, but it provides a way for employers and employees to cover workplace injury risk widely. If we did the same thing with health insurance relative to arbitration on malpractice claims (plus billed patients direct, provided uniform cost schedules and offered a true higher deductible/lower premium option), we’d have affordable, private healthcare. We might not be able to pay radiologists $500K a year anymore, have hospitals renting billboards to discuss why their equipment or capabilities are the best in the region and insurance stocks wouldn’t be over $50/share, but healthcare consumers would be happier when they could actually buy affordable health care (plus maybe doctors could afford to make less if they weren’t paying $100K a year in malpractice insurance premiums). Lawyers would feel pain, but at least they could get it treated at reasonable rates. The old system worked when everyone was insured, but in today’s world, more and more people are going to be shut out of any health care. I don’t think current reports capture the number of middle-class Americans dropping health care. I think instead they are measuring people who identify themselves as uninsured when buying healthcare services. The number of uninsured hoping to stay healthy who aren’t seeking medical care is probably much larger and it represents a hugh liability for taxpayers and financial institutions long-term.

  9. I have yet another tale of hospital billing mystification…
    While I was dealing with my recent ER bills, it came to light that I had an ER bill in collections from 2001. At that time I was insured by Blue Cross. I remember something very similar to my recent problems occured: I had to go to the ER twice, I got a series of bills, and I assumed Blue Cross was taking care of it. As it turned out my insurance information was only processed for the physician bills and not the ER bills. I eventually got a Collections call for the ER bill. I immediately followed up with Blue Cross, and Blue Cross told me they would take care of the problem.
    Now, 4 years later, I discover that Blue Cross only took care of *one* of the ER bills, and the left over bill has been haunting my credit record all this time. I have no idea whether Blue Cross would have been willing to address this after all this time, but I was told I could write Summit’s administrative offices and explain that my insurance information hadn’t been applied correctly.
    As much as I hate the idea of grovelling to a corporation to resolve a problem that wasn’t my fault, I was planning on going through this – I was just distracted by recent events. Fortunately, though, a very kind representative from Summit did just step in and take care of the 2001 bill for me. I even got a letter that apologized for the “untimely response to my concerns”. I still have to clear up my credit record myself, though it’s probably not worth the effort since I’m going to be hit with non-payment of my current Physician Group bills anyway. I’m happy Summit finally looked into this for me, though. Sadly, I think I only got the help in light of the notoriety of my recent misfortunes. So I’m under the impression that for the normal person on the street, these problems would just remain unaddressed.

  10. There is no longer any reason for a patient to get seriously involved in the billing and payment for his/her medical care until well after that care has been delivered. Because Medicare and 3rd party payors have effectively removed the patient from any immediate payment responsibility, by the time the bill gets down to the patient, it is very difficult to determine what has been paid, when it was paid, and what is left for the patient to pay.
    I feel that it is time for us to go back to the system of billing the patient first. That eliminates the insurers’ ability to play delaying and denial games, and lets the consumers actually understand what their insurer does for their money. Imagine what would happen if you didn’t pay for your groceries when you left the store!
    As far as the uninsured go, we will never have lower premiums until [1] there is adequate tort reform to eliminate a large amount of defensive medicine and [2] states allow insurers to sell less comprehensive coverage, i.e., eliminate coverage for chiropractic care, aromatherapy, etc.

  11. It’s unfortunate that our political system rarely deals with the most serious problems until they become crises. not enough political will means more bandages on top of bandages…
    I think many hospitals are aware of these difficult billing situations. HFMA has come out with http://www.patientfriendlybilling.org/ to help hospital administrators “de-mystify” billing as much as possible. still a long way to go, but a step in the right direction.

  12. This is silly in light of gadfly’s post above … but his name really couldn’t be Kronick, could it?

  13. I’m wondering what will happen when unpaid medical bills (which I see as a form of predatory lending) collide with expanding use of credit checks and tougher personal bankruptcy laws.
    I’d like to raise the example of what I see as a deliberate attempt of Hospitals to exploit a loophole in the Patients Bill of Rights and use collections agencies to manage billing of the poor. When I went to Alta Bates (a Summit Hospital) ER for an eye problem, I explained up front that I didn’t have an income, and I asked what I should do about paying for medical treatment. I was given forms for the Hospital Charity Program, but no one explained to me that the Charity Program didn’t cover the Physician’s bills. I believe the separation of Physician’s bills is deliberately hidden at this point to prevent people from being denied medical care when they realize the cost is too prohibitive to proceed. I was not shown any sort of list of physician fees or given any counselling for payment plan options. I was led to believe that if I qualified for the Charity Program, the bills would be taken of.
    I received several bills from the Physician’s group, but I ignored them for the same reason I ignored such bills when I was insured: I assumed some slow bureaucratic process was goint on in the background, and the bills would ultimately be adjusted. Apparently the last bill included a remark in the small print that the indicated that the bill would go into collections. There was no separate letter or phone call to make sure that I understood the bill was going to go into collections: I believe this is because the Physicians Group doesn’t want people to be able to negotiate with them for payment: they want people to negotiate with the collections agency – an extremely dubious collections agency according to the Better Business Bureau.
    As soon as I started getting calls from the Collections Agency, I called the Physicians Group to explain I didn’t even understand that I owed them money and that I thought the Charity Program was taking care of it. The Physicians Group told me that I had to negotiate with the Collections Agency and there was “nothing they could do”.
    I’d like to make it clear that I’m not complaining about the lack of free care for the indigent or the Physician’s desire to be paid. What bothers me here is what looks to me like a deliberate attempt to mystify the billing process until it goes to the Collections Agency – which is free to use various means of intimidation and coercion that I’m sure the Hospital, that bastion of service to mankind, wouldn’t want to be directly associated with. The Patients Bill of Rights was put in place to make delivery of medical services more humane. Many people have pointed out that it makes to treat an injured person and only to subject him or her to overwhelming financial stress that could trigger a return trip to the hospital. I would also argue that it doesn’t do society any favors to drive people who are already in desperate straits into bankruptcy. Or, those same people could chose the fiscal prudence of avoiding medical treatment while the economy suffers from a decline in productivity – a glut of unhealthy people and rising rates disability.
    I would honestly be surprised if Alta Bates/Summit is the only hospital that attempts to hide billing practices and ultimately shift the burden to more “effiient” Collections Agencies. As far as I know, I’m the only one who has pointed this problem out, or at least the only one calling it a conspiracy to distance the Hospital from a predatory lending scam behind the curtains. If anyone thinks that “conspiracy” is a melodramatic way of putting it, I challenge them to do some research on the Alta Bates intake process themselves.

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