Mirror, Mirror 2017: International Comparison Reflects Flaws and Opportunities for Better U.S. Health Care

In the United States—more than in 11 other wealthy countries—the health care you receive varies with your level of income, according to a new Commonwealth Fund report.

Source: Mirror, Mirror 2017: International Comparison Reflects Flaws and Opportunities for Better U.S. Health Care

The United States Health System Falls Short

 The United States spends far more on health care than other high-income countries, with spending levels that rose continuously over the past three decades (Exhibit 1). Yet the U.S. population has poorer health than other countries. 1 Life expectancy, after improving for several decades, worsened in recent years for some populations, aggravated by the opioid crisis. 2 In addition, as the baby boom population ages, more people in the U.S.—and all over the world—are living with age-related disabilities and chronic disease, placing pressure on health care systems to respond.

Timely and accessible health care could mitigate many of these challenges, but the U.S. health care system falls short, failing to deliver indicated services reliably to all who could benefit. 3 In particular, poor access to primary care has contributed to inadequate prevention and management of chronic diseases, delayed diagnoses, incomplete adherence to treatments, wasteful overuse of drugs and technologies, and coordination and safety problems.

This report uses recent data to compare health care system performance in the U.S. with that of 10 other high-income countries and considers the different approaches to health care organization and delivery that can contribute to top performance. We based our analysis on 72 indicators that measure performance in five domains important to policymakers, providers, patients, and the public: Care Process, Access, Administrative Efficiency, Equity, and Health Care Outcomes.

Our data come from a variety of sources. One is comparative survey research. Since 1998, The Commonwealth Fund, in collaboration with international partners, has supported surveys of patients and primary care physicians in advanced countries, collecting information for a standardized set of metrics on health system performance. Other comparative data are drawn from the most recent reports of the Organization for Economic Cooperation and Development (OECD), the European Observatory on Health Systems and Policies, and the World Health Organization (WHO).

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Counties at Risk of Having No Insurer on the Marketplace (Exchange) in 2018

This map shows the counties at risk of having no insurer on the marketplace (exchange), created by the Affordable Care Act, in 2018, based on a Kaiser Family Foundation analysis of insurer rate filings and news reports

Source: Counties at Risk of Having No Insurer on the Marketplace (Exchange) in 2018 | The Henry J. Kaiser Family Foundation

Our historical analysis of insurer participation on the marketplaces from 2014-2017 can be found here.

These data are preliminary and subject to change as more information becomes public. Insurer participation in 2018 will not be finalized until the fall of 2017. It is possible that another insurer will expand into the counties that currently appear bare, and it is also possible that insurers will exit from other counties not shown on this map.

If a county has no exchange insurer, consumers would not be able to purchase marketplace plans with federal subsidies, including advanced premium tax credits (APTCs) and cost-sharing reductions (CSR). Tax credits make coverage more affordable throughout the year by lowering consumers’ monthly premium costs; cost-sharing reductions help lower out-of-pocket costs. In 2017, 8.7 million people (84% of all marketplace enrollees) received tax credits to cover a share of their premium and 5.9 million people (57% of all marketplace enrollees) received cost-sharing reductions.

This map only shows participation by on-exchange insurers. It is possible that some people in counties with no exchange insurers in 2018 will be able to purchase individual plans off-exchange, though this coverage would not qualify for financial assistance. If no exchange insurer participates in their county, people that rely on these subsidies may be unable to afford insurance off-exchange.

Resources | Protect Our Care IL

Source: Resources | Protect Our Care IL

Protect Our Care – Illinois is a statewide coalition of health care advocates, providers, consumers, and workers, joining together to prevent the repeal of the Affordable Care Act (ACA), prevent disastrous changes to Medicaid, and protect and expand access to quality affordable health care. We know the crusade to undermine the ACA is not over whether there is a repeal vote this week, next week, or next year, so Protect Our Care – Illinois invites you to join Illinoisans across the state to defend access to quality affordable health care for all.

Protect Our Care materials

ASAN Releases Plain-Language Medicaid Toolkit

A Self-Advocate’s Guide to Medicaid

Medicaid is the biggest health care program in the country. It’s an important part of the United States health care system. But a lot of the information out there about Medicaid and attempts to change it can be difficult to understand and navigate. That’s why ASAN is proud to announce the release of our plain language resource “A Self-Advocate’s Guide to Medicaid.” This resource was developed in collaboration with the Autism Services, Education, Resources and Training Collaborative (ASERT), and with funding from the Special Hope Foundation.

The Easy Read Edition is split into parts. Each part has its own glossary, and there is also a separate glossary with all of the terms from every section. Click on the title of any of the parts below to download it:

The Impact of Health Reform Repeal on Employment

Use this interactive map to see the state-by-state impact of repeal of federal health reform on jobs.

Source: The Impact of Health Reform Repeal on Employment – The Commonwealth Fund

Contrary to a common misconception that health reform law has been a “job killer,” this study shows that repeal of these policies may cause major job losses and economic dislocation in every state -even in states that have not expanded their Medicaid programs.

While health reform repeal would dramatically increase the number of uninsured and harm access to health care, particularly for low- and moderate-income Americans, this analysis demonstrates that the consequences could be broader and extend well beyond the health care system. Repeal could trigger major reductions in employment and substantial losses in state economic activity and state and local revenues.

While health reform repeal would dramatically increase the number of uninsured and harm access to health care, particularly for low- and moderate-income Americans, this analysis demonstrates that the consequences could be broader and extend well beyond the health care system. Repeal could trigger major reductions in employment and substantial losses in state economic activity and state and local revenues.

Hover over states to see the impact of repeal of premium tax credits and Medicaid expansion on jobs.

Or click to download a state profile available under the map.

Impact of Health Reform Repeal-US Map
Impact of Health Reform Repeal-US Map

What Would Happen If Health Care in Your State Improved? – The Commonwealth Fund

This interactive tool shows the health care gains your state could achieve by improving its performance on measures of access, quality, and health outcomes. The tool draws on data from the 2015 Commonwealth Fund Scorecard on State Health System Performance.

Source: What Would Happen If Health Care in Your State Improved? – The Commonwealth Fund

The Commonwealth Fund’s Scorecard on State Health System Performance, 2017 Edition, assessed states on more than 40 indicators of health care access, quality, costs, and outcomes. Use this interactive tool to see the gains that your state could achieve by improving its performance to the level of better-performing states, as well as the losses that would result if your state failed to sustain its performance. You can also see the impact of reaching for a goal that is even better than the current best state’s performance.

In a new To the Point post, The Commonwealth Fund’s David Radley, Douglas McCarthy, and Susan Hayes show how states can use the tool to help achieve their goals. For example, by seeing the gains made in states that have already expanded Medicaid, policymakers in Georgia or another non-expansion state can calculate the improvements in insurance coverage and access to care that are within their reach.

Revised ACA Repeal and Replace Bill Likely to Increase the Uninsured Rate and Health Insurance Costs for Many

House Republicans are close to agreeing on an amended version of the American Health Care Act, their proposed repeal and replacement of the Affordable Care Act. David Blumenthal, M.D., and Sara Collins say that, based on the summaries circulated by the media, the revised bill will significantly increase the numbers of uninsured Americans while raising insurance costs for many of the nation’s most vulnerable citizens. At the same time, the bill’s restructuring of the Medicaid program is likely to hurt state economies and enrollees.

Source: Revised ACA Repeal and Replace Bill Likely to Increase the Uninsured Rate and Health Insurance Costs for Many – The Commonwealth Fund

News outlets report that House Republicans are close to agreeing on an amended version of the American Health Care Act (AHCA), their proposed repeal and replacement of the Affordable Care Act (ACA). The all-important legislative language for the revised bill is not yet available, nor are Congressional Budget Office (CBO) projections of its effects on coverage and the budget, so any analyses are necessarily tentative.

Nevertheless, the summaries leaked to the media offer insight on the amended bill. If accurate, those summaries suggest that the revised AHCA will significantly increase the numbers of uninsured Americans, raise the cost of insurance for many of the nation’s most vulnerable citizens, and, as originally proposed in the AHCA, cut and reconfigure the Medicaid program. The new amendment specifically allows states to weaken consumer protections by, for example, permitting insurers to charge people with preexisting conditions higher premiums.

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Who Gains Under Expanded Health Savings Accounts? – The Commonwealth Fund

The U.S. House of Representatives leadership’s bill to repeal and replace the Affordable Care Act (ACA) would have significantly expanded the use of health savings accounts (HSAs), which people can use to save tax-free money to pay for certain medical expenses. This effort isn’t new and it’s not likely to go away just because a vote on the House bill, the American Health Care Act (AHCA), has been tabled. Amendments to the tax code to encourage HSAs have been a staple of Republican health care proposals, and the HSA provisions in the House legislation were introduced as a standalone bill last year.

Source: Who Gains Under Expanded Health Savings Accounts? – The Commonwealth Fund

The U.S. House of Representatives leadership’s bill to repeal and replace the Affordable Care Act (ACA) would have significantly expanded the use of health savings accounts (HSAs), which people can use to save tax-free money to pay for certain medical expenses. This effort isn’t new and it’s not likely to go away just because a vote on the House bill, the American Health Care Act (AHCA), has been tabled. Amendments to the tax code to encourage HSAs have been a staple of Republican health care proposals, and the HSA provisions in the House legislation were introduced as a standalone bill last year.

Why all the interest? HSA proponents suggest the accounts offer cost savings and give consumers freedom to spend their money how they see fit. An HSA must be paired with a high-deductible health plan (HDHP), and there is evidence that the combination of an HDHP and HSA does reduce health care spending—by leading consumers to skip care, both needed and unneeded. Yet there is little basis to conclude that HSAs expand access to care, or that the tax benefits these accounts promise reach most Americans. In practice, most financial advantages have accrued to the top 5 percent of earners, who can afford to contribute to the accounts during the year and reap larger gains at tax time.

HSAs: The Basics

HSAs were created in 2003 in legislation establishing a Medicare prescription drug benefit. They are tax-preferred savings accounts funded by consumers and sometimes their employers. Consumers can contribute to an HSA only if they are enrolled in an HDHP, which in 2017 is an individual or group health plan that has a deductible of at least $1,300 ($2,600 for a family plan). Unlike other savings vehicles established under federal law, HSAs provide what amounts to triple tax benefits: contributions are tax-deductible; account funds are invested and grow tax-free; and withdrawals are tax-exempt (if they are used for qualified medical expenses).

HSAs are far more attractive to higher-income individuals, who are more likely to have sufficient income to fund the accounts and gain a greater tax benefit than are lower-income individuals subject to lower tax rates. In 2013, tax filers with income above $200,000 were 10 times more likely to claim a tax deduction for HSA contributions than those with incomes below $50,000, and the tax-advantaged contributions these high earners made were, on average, more than twice as large. A study of HSA take-up in the group market from 2005 to 2012 found similar results and observed, perhaps unsurprisingly, that high-income households were substantially more likely to fund their HSAs fully (with their own dollars and contributions from employers) than were middle- and lower-income filers.

Enhanced HSAs on the Horizon?

The AHCA would have expanded use of HSAs by authorizing higher tax-free contributions (increasing the amount from $3,400 to $6,550 for an individual plan) and more tax-free uses for funds. The AHCA also would have cut in half the penalty for withdrawals for nonmedical expenses.

Other proposals would provide similar and sometimes greater benefits to account holders. Legislation previously authored by Health and Human Services Secretary Tom Price would increase HSA contribution limits while also making it easier to shelter those funds and other retirement savings from taxes when they are transferred to heirs. Senator Rand Paul’s (R–Ky.) ACA replacement bill would go still further, erasing the requirement that HSAs be linked to a high-deductible plan and eliminating contribution limits altogether.

There is little doubt these expansions would encourage HSA take-up. Likewise, the proposals would make HSAs even more attractive as savings and estate planning vehicles for high-income households—particularly those who earn too much to contribute to other tax-advantaged retirement accounts and those who have maxed out such contributions. At the same time, the financial services companies that manage these accounts would reap substantial benefits, too.

Looking Ahead

HSAs are already growing under current law: by 2017, nearly 21 million accounts held more than $41 billion in assets, while the cost of the program to taxpayers has steadily increased and will nearly double by 2020. The AHCA would have dramatically accelerated this trend, causing federal spending to shoot up nearly 50 percent over the first three years following enactment and by a total of more than $19 billion by 2026.

The Congressional Budget Office estimated that the AHCA would have reduced insurance coverage dramatically, especially among Americans with low incomes. Moreover, the people most likely to need assistance paying for coverage and out-of-pocket costs—those with incomes under 200 percent of poverty, or around $24,000 for a single person—are the least likely to benefit from the bill’s approach to making coverage more affordable: HSAs. Given an ACA replacement’s potential impact on federal spending and coverage, spending billions of dollars on a program that primarily helps those least likely to need assistance purchasing coverage and paying out-of-pocket costs warrants scrutiny.

Medicaid Work Requirements – Legally Suspect

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Source: Medicaid Work Requirements – Legally Suspect

Executive Summary

Legal Director Jane Perkins, and Policy Analyst Ian McDonald detail why adding a work requirement to Medicaid is “legally suspect.” They explain that currently the Medicaid Act has four requirements that an individual must meet that do not include a mandatory work requirement. “A number of courts,” Perkins and McDonald write, “have recognized that states may not ‘add additional requirements for Medicaid eligibility’ that are not set forth in the Medicaid Act.” They also note that the purpose of Medicaid is to “furnish medical assistance to low-income individuals who cannot afford the costs of medically necessary services and to furnish ‘rehabilitation and other services to help [such individuals] attain or retain capability for independence or self-care. A mandatory work requirement is not medical assistance; it is not a service provided to Medicaid beneficiaries.”

Medicaid Work Requirements – Not a Healthy Choice

Executive SummaryIn an effort to win conservative members’ support for the Affordable Care Care Act repeal bill, House Republicans have added a work requirement for Medicaid to the measure. In this issue brief, NHeLP Managing Attorney of the DC office Mara Youdelman,  Legal Director Jane Perkins, and Policy Analyst Ian McDonald detail why such work requirements “run counter to the purpose of Medicaid.” They conclude, “Work requirements would stand Medicaid’s purpose on its head by creating barriers to coverage and the pathway to health that the coverage represents.”DOWNLOAD PUBLICATION

Source: Medicaid Work Requirements – Not a Healthy Choice