Access to Mental Health Care — US worst among wealthy countries

Summary: World Mental Health Day was October 10th. How is the US doing on access to care? Terribly. Therapists often don’t take insurance, and we lead wealthy nations in financial barriers to care: fully 50% of those in need. Single payer would provide a strong behavioral health benefit.

Why It’s So Hard to Find a Therapist Who Takes Insurance
The Wall Street Journal
October 5, 2021
By Andrea Petersen

Especially in big cities such as Los Angeles, New York and Washington, D.C., demand for mental-health care is so strong that many experienced therapists don’t accept any insurance plans, they say. They can easily fill their practices with patients who would pay out of pocket, they add. Therapists who do take insurance are often booked up. And in many smaller towns and rural areas, there are few mental-health professionals at all.

Mental Health Care Needs in US and 10 Other High-Income Countries The Commonwealth Fund
October 8, 2021
By Reginald D. Williams II, Arnav Shah

The following charts show that, across the countries, large shares of people with mental health needs: … have high rates of cost-related problems accessing care, especially among US Black and Latinx/Hispanic adults.

Comment by: Isabel Ostrer

World Mental Health Day was on October 10, so we ought to look at mental health care access in the United States. The findings are, unfortunately, discouraging.

As the WSJ article points out, finding a therapist who will take your insurance is difficult. There’s no requirement for mental health providers to accept insurance. And, in fact, they often make more by not taking it, thus incentivized to accept only patients who have the means to pay out of pocket.

It’s no wonder that the US fares poorly among peer high-income nations when it comes to mental health. The Commonwealth Fund survey finds that white and Black US adults have the highest rates of mental health needs in these countries. And US adults with mental health needs were the most likely to report a cost-related problem accessing health care. Black US adults with mental health needs use the emergency room – a suboptimal setting – at disproportionately high rates.

As we reflect on World Mental Health Day, the US has plenty to learn from peer countries. Perhaps most fundamentally is that we must broaden access to mental health treatment and providers. A single payer system would achieve this by ensuring all Americans have access to a standardized package of behavioral health care services. 


Racism in health – medical debt

Summary: “Columbus Day” is a holiday that invites us to reflect on another source of pervasive racism in our health system – the debt that arises when health insurance is absent or inadequate. This problem would be resolved with, yes, single payer.

The racial implications of medical debt: How moving toward universal health care and other reforms can address them
Brookings Institute
October 5, 2021
By Andre M. Perry et al.

17.4% of households with insurance have medical debt compared to 27.9% of households without insurance. Conditional on having medical debt, households with health insurance have an average of $18,827.25, while households without health insurance have an average of $31,947.87.

[R]oughly half of all collections tradelines are due to medical bills, affecting nearly one in five consumers in the credit reporting system. … In 2007, at least 62% of bankruptcies were, at least partially, attributable to medical debt. Even after the advent of the Affordable Care Act in 2010, that number has not decreased significantly.

Twenty-seven percent of Black households hold medical debt compared to 16.8% of non-Black households.

Comment by: Jim Kahn

Today is still officially designated “Columbus Day” despite the racist implications of naming the “discovery” of this continent for a European who arrived to find inhabitants already quite aware of its existence. Thus started racism in our land.

Racism permeates our systems. Recently I wrote in HJM about two reports on racism in health. In this post I add a third: medical debt.

The Brookings Institute examined census data and found that medical debt rates are far higher among Blacks than Whites. This is related to a greater chance of being uninsured, but even insured Blacks are as likely as uninsured whites to hold medical debt.

Who’s got this medical debt? Almost entirely people with zero or negative net worth. Not people who can afford it.

How much do they have? A mean of $20,500, a median of $2000.

The racism links work, in part, like this:

  1. Blacks were historically shunted to occupations and jobs that paid less.
  2. Blacks were deprived of government subsidies, such as federally insured mortgages.
  3. Black families thus have a net worth about one-tenth that of whites.
  4. The jobs Blacks hold are less likely to provide health insurance.
  5. Safety net insurance like Medicaid is very restricted and stingy in many states.
  6. Blacks are left with poor access to health care and more medical debt, which they can’t afford.
  7. Financial barriers to healthcare cause serious health consequences.

The Brookings authors mention single payer as one potential solution to these problems. We think single payer is the only reasonable option that meets their own prescription that “American health insurance systems need a radical restructuring”.


Medicare Privatization is Failing Seniors

Summary: Seniors face much greater financial barriers to medical care in the US than in other wealthy countries. Why? Because we’re handing Medicare over to business interests, which prioritizes profits over medical care and health.

When Costs Are a Barrier to Getting Health Care: Reports from Older Adults in the United States and Other High-Income Countries
The Commonwealth Fund
October 1, 2021


Older Americans pay more for health care and are more likely to postpone or skip care because of the cost than people in other high-income countries.

Despite the financial protection Medicare offers, the program’s significant cost-sharing requirements leave many older adults exposed to high health care costs.

Policy Implications

Overall, our analysis shows that the affordability of health care remains a concern for older adults and is leading American seniors to forgo care. Survey data show that older Americans pay more for health care and are more likely to postpone or skip care because of the cost than people in other high-income countries. Countries where more comprehensive coverage is available have fewer people skipping or missing care. Dental care illustrates the key role coverage plays in access to care: in those countries that carve out dental care from medical coverage, or fail to cover it at all, many people avoid getting their oral health needs addressed.

Care that is postponed or never received could have cost implications for Medicare. Evidence shows that forgoing health care is associated with poor health outcomes and increased risk of hospitalization.

Congress is currently considering legislation that would add dental, vision, and hearing coverage to traditional Medicare. This change could lead to an increase in U.S. older adults visiting the dentist.

Comment by: Don McCanne

In spite of the popularity of the concept of Medicare for All, what gains have we actually made in expanding Medicare to provide more financial protection for seniors, much less expanding Medicare to cover more individuals than those over 65 (except for people with disabilities)? This Commonwealth Fund study indicates that, compared to other countries, Medicare is falling short of providing adequate financial protection to seniors with health care needs.

Although there has been considerable discussion about using proposed reconciliation legislation to expand Medicare coverage by adding dental, vision, and hearing services, insider information from Congress reveals that it has already been decided that these services will not be included as efforts are being made to compromise on the cost of the legislation.

Actually, it is worse than that. As we continue to advocate for Medicare for All, a greater percentage of Medicare beneficiaries have moved into the privatized Medicare Advantage plans, and, even worse, there is considerable momentum to involuntarily shift even more of the traditional Medicare beneficiaries into privatized plans through the deceptive direct contracting entities (DCE). Those who are trying to escape into the Medigap policies are finding that they may not be available to them if they did not sign up when they first became eligible for Medicare.

So not only is Medicare coverage not nearly as generous as many of us need, the private insurance industry is operating behind the scenes to even further reduce the coverage provided while using celebrities to promote sales through false images of expanded coverage when actually they are taking away coverage and diverting profits though restricted provider lists, prior authorization barriers, illegitimate risk-adjustment upcoding, and other private insurer deceptions.

For decades now, we’ve been sitting in the aisles, supporting “Medicare for All,” while the various administrations have been moving in the direction of turning health care over to the business interests. Those physicians who were in practice, like me, before Medicare and Medicaid were enacted – just think back about how the programs were when they began and how they have been transformed over the decades, right under our supposed supervision, giving ever more power to the MBAs. Now look at where we are with the pending involuntary privatization of the traditional Medicare program, with structural changes being made to take good care of the business interests while neglecting the needs of patients. Think of the various policies that have been and will be put in place, and you will see that they are based on what is taught in business schools and not on what is taught in medical, nursing, and other health professional schools. There we are taught how to take care of patients.

Do we really want to continue to promote Medicare for All when Medicare itself is transforming into an industry that primarily serves the financial interests of insurers to the detriment of the health care interests of patients? Are we going to end up with Medicare Advantage for All? That’s a label that might assist the private insurers with their marketing, but it can only compound the deficiencies hinted at in this Commonwealth Fund report on current health cost barriers for our seniors on Medicare.

Maybe we’d better reset our public education campaign and go back to promoting SINGLE PAYER – Health Care for All.


Dental care for Medicare!

Summary: Medicare has always lacked dental services. Some dentists are now offering dental practice “memberships”. But dental health is too important to be handled piecemeal and unregulated. It’s time for dental coverage in Medicare!

Dentists Chip Away at Uninsured Problem by Offering Patients Membership Plans
Kaiser Health News
September 17, 2021
By Phil Galewitz

A quarter of dentists nationwide [offer] memberships, according to a 2021 survey of 70,000 dentists by the American Dental Association.

These in-office plans are largely targeted to the 65 million Americans who lack dental insurance and have to pay out-of-pocket for all their care. Dentists also like the plans better than handling insurance plans because they don’t have to deal with insurers’ heavily discounted reimbursement rates, waits to get preapprovals to provide services and delays in getting their claims paid.

Comment by: Allison K. Hoffman & Hannah Leibson

Congressional Democrats continue to battle over the size and scope of the 2022 budget reconciliation bill. The $3.5 trillion version of the bill proposed in September adds dental, vision, and hearing benefits to the traditional Medicare program. But if the total spending decreases to levels that moderate Democrats like Joe Manchin (WV) and Kyrsten Sinema (AZ) currently demand, these benefits are at risk.

Since Medicare’s passage in 1965, dental coverage has not been part of traditional Medicare benefits, despite strong evidence that poor oral health can exacerbate other health conditions. As noted in an earlier HJM post, without this benefit, approximately 24 million Medicare enrollees lack access to dental coverage. In turn, many do not seek out needed dental care, a problem disproportionately affecting communities of color and low-income beneficiaries. For Medicare beneficiaries who did seek dental care in 2018, average out-of-pocket spending neared almost $1000 a year.

Today’s options for beneficiaries are not great. Some people enroll in Medicare Advantage, which generally includes some dental benefits. Moving into a managed care plan with a private insurer can be unappealing in various other ways, however.

This recent Kaiser Health News article highlights another alternative, one that also falls short. It describes how up to 25 percent of dental practices nationwide have begun to offer independent membership plans to their patients. These prepaid care plans provide, for a fixed monthly fee, access to basic services like an annual exam, coverage for an emergency visit, and discounts on procedures. The yearly cost to enroll in one of these plans is about $300-400. 

These plans may chip away at the number of people who forgo needed preventive care, but they are far from a replacement for dental benefits. Someone enrolled in a prepaid plan who needs more than routine care could still face substantial bills for procedures, even with discounted rates. The plans, unlike dental insurance plans, are unregulated, so no one is ensuring they deliver as promised. And, Galewitz reports, the discounts offered on services are typically less than in dental insurance plans. In addition, dental insurance plans negotiate lower rates with dentists, which also reduces patients’ share of the bills.

Dentists who offer these prepaid plans gain confidence that their bills will be paid, and at the rates they want—rather than the ones that dental insurance plans negotiate. But these plans are not a good long-term policy solution for seniors, even if they encourage them to seek out routine dental care. As Galewitz notes, however, many seniors are enrolling in them.

What is tragic is that the American Dental Association (ADA), the largest industry association for dentists and, as the Wall Street Journal describes, “one of Washington’s most powerful health professional organizations,” has urged its members to oppose a broad dental benefit. At its core, the ADA fears Medicare would reimburse dentists less than what many patients currently pay for services. Their opposition is reminiscent of the American Medical Association’s opposition to Medicare’s initial passage, and the ADA’s opposition to including dental benefits in the program from the start. It is not a position that puts patients’ interests first.  

On the other hand, the Center for Medicare Advocacy and various others, including the National Dental Association, an organization of minority dentists who promote oral health equity in communities of color, are putting patients’ needs first and have signaled strong support.

This lineup of interests casts a clear message to Senators who care about the health and financial wellbeing of seniors: it is past time for traditional Medicare to include dental benefits.  


Racism in US health, two reminders

Summary: Racism in US health manifests in multiple guises and scales. Today we report on two diverse country-wide phenomena most severely harming Blacks: thousands of deaths due to police violence, and millions burdened by social stresses and substandard insurance for the poor.

Fatal police violence by race and state in the USA, 1980–2019: a network meta-regression
October 2, 2021
By GBD 2019 Police Violence US Subnational Collaborators

From the abstract:
We compared data from the USA National Vital Statistics System (NVSS) to three non-governmental, open-source databases on police violence: Fatal Encounters, Mapping Police Violence, and The Counted.

Across all races and states in the USA, we estimate 30 800 deaths from police violence between 1980 and 2018; this represents 17 100 more deaths than reported by the NVSS. Over this time period, the age-standardised mortality rate due to police violence was highest in non-Hispanic Black people (0·69 per 100 000), followed by Hispanic people of any race (0·35), non-Hispanic White people (0·20), and non-Hispanic people of other races (0·15). This variation is further affected by the decedent’s sex and shows large discrepancies between states. Between 1980 and 2018, the NVSS did not report 55·5% of all deaths attributable to police violence. When aggregating all races, the age-standardised mortality rate due to police violence was 0·25 per 100 000 in the 1980s and 0·34 per 100 000 in the 2010s, an increase of 38·4% …

Racism, Chronic Disease and Mental Health: Time to Change Our Racialized System of Second‐Class Care
September 27, 2021
By Judith Albert et al.

The “weathering hypothesis” was first proposed by Arline Geronimus in 1992: “Namely, that the health of African American women may begin to deteriorate in early adulthood as a physical consequence of cumulative socioeconomic disadvantage.” Now, nearly 30 years later, a large body of literature has expanded upon this hypothesis. There is accumulating evidence that structural as well as interpersonal racism contribute to the significant increases in Black maternal and infant morbidity and mortality compared to that of whites.

Blacks use about half the outpatient care and fewer psychiatric medications as white adults, yet are hospitalized at twice the rate as their white counterparts for mental illness

From the abstract:
Medicaid … while passed alongside Medicare during the Civil Rights era, was Congress’s concession to Southern states unwilling to [permit] federal oversight and funds to the provision of equal healthcare for poor and Black people. Medicaid, which covers 33% of all Blacks in the US and suffers from chronic underfunding and state efforts to weaken it through demonstration waivers, is a second‐class system of healthcare with eligibility criteria that vary by state and year.

Comment by: Jim Kahn

Racism in US health is structural, pervasive, and multi-faceted. Two articles published this week together convey this devastating point.

The article in Lancet is an impressive national comparison of databases of more than 30,000 deaths from police violence with government vital statistics. The official statistics 50% under-report violent deaths by police. These deaths are 3.5 times more common for Blacks than for Non-Hispanic Whites. It’s not healthcare, but it certainly is health-related. And these vast racial differences constitute highly suggestive evidence of systemic racism in attitude and approach.

The article in Healthcare reviews social and health burdens disproportionally faced by millions in Black populations. These include social stressors, poor access to mental health care, and the Medicaid insurance for impoverished populations – under-funded and manipulated to impede access to care. Our health insurance system is profoundly structurally inequitable.

And what for? We know that the simplest, most equitable insurance systems – covering everyone with the same insurance — are also the most efficient and effective.

Single payer would not only eliminate insurance and care inequities, it would foster social cohesion, and thus help reduce policing bias.

Who’s gaining with our current bloated, lopsided system? Mainly the rich, so they can stash more money overseas (that’s another story this week!).


No relief from private insurance market concentration

Summary: The American Medical Association finds rising health insurer concentration. That’s bad, because powerful private insurers undermine the healthcare experience. What we need is fully concentrated insurance: a single payer, committed to the public good.

AMA publishes new study monitoring competition in U.S. health insurance markets
AMA press release
September 28, 2021

The American Medical Association (AMA) today published the newest annual edition of Competition in Health Insurance: A Comprehensive Study of U.S. Markets with findings demonstrating the rise of highly concentrated markets for health insurance.

The study’s findings show most health insurance markets in the U.S. are highly concentrated leaving millions of Americans with more limited health insurer options.

Between 2014 and 2020, the share of highly concentrated markets rose from 71% to 73%.

[This report] is a vital element of AMA’s continued antitrust advocacy to protect patients and physicians from competitive harm.

Comment by: Don McCanne

For two decades, the AMA has been publishing these annual reports on highly concentrated markets for health insurance, indicating that “consolidation involving health insurers may cause competitive harm to consumers and providers of care.”

With all of the problems in health care today, you would think that these reports would have led to interventions reducing the concentration. Instead, concentration actually rose from 71% to 73%. This demonstrates the ineffectiveness of current legislative, administrative, and private market sector control over private insurance abuses.

It is true that a single payer Medicare for All would maximally concentrate insurer function, but it would do that with a program that would operate on behalf of the public good for all of us rather than what we have now – a system that operates on behalf of a private sector that is draining funds for its own benefit rather than for the health of us all.

For those waiting for the AMA to do something, two decades of inertia is enough. We claim we have a democracy. It’s high time that we invoke its power to change policy for the public good. We can begin by electing legislators who understand and support policies that will lead to health care justice for all. No more delay!


Medicare Advantage & DCEs: How Corporate Investors Deplete Medicare

Summary: Private investors have devised and exploit clever mechanisms to obtain massive payments and outlandish profits from Medicare. These manipulations started with Medicare Advantage, and now threaten traditional Medicare via Direct Contracting Entities. DCEs must be stopped.

Medicare Advantage, Direct Contracting, and The Medicare ‘Money Machine’
Part 1 & Part 2

Health Affairs Blog
September 27 & 28, 2021
By Richard Gilfillan Donald M. Berwick

In this two-part post, we … explain the perverse MA business model that underlies this elevated level of investment, and we will explore its connection to the Direct Contracting model now being tested by CMS. The story is complex, but we think it is worth telling because the stakes for beneficiaries, the public treasury, and our health care system are very high. This business model is distorting health care delivery, creating excessive costs for taxpayers and Medicare beneficiaries, draining the Medicare Trust Fund, obstructing the badly needed value transformation of American health care, and diverting the money needed to fund other social services and goods.

The Medicare Payment Advisory Committee (MedPAC) has documented approximately $140 billion in MA overpayments over the past 12 years. MedPAC further concludes that risk adjustment overpayments are currently increasing [and may rise to $355 billion over the next eight years].

Given an Orwellian title, Direct Contracting, launched by Center for Medicare and Medicaid Innovation (CMMI), was anything but direct. “Indirect Contracting” would have been a far more accurate name, since the cornerstone of the program was CMS’s opening the door to non-provider-controlled “Direct Contracting Entities (DCEs)” to become the fiscal intermediaries between patients and providers.

Comment by: Jim Kahn

Why are investors paying $87,000 per “covered life” for Medicare-focused health companies? That’s more than seven years of care costs for one beneficiary. Where’s the profit to justify those prices?

That’s the question that this very important Health Affairs blog addresses. It lays out in gory detail just how cleverly corporate investors have refined techniques to influence and manipulate Medicare rules to massively profit, thereby threatening the principles and finances of this valued program. My comment today is long, to provide a proper tour of the blog’s major points.

Part 1 focuses on Medicare Advantage. That’s the part of Medicare in which private insurance companies set up care networks and serve as financial intermediaries.

“Upcoding” is the name of the game. The secret to high profits is to exploit the diagnostic coding system set up to adjust for differences in clinical severity (and costs) between traditional fee-for-service Medicare and Medicare Advantage. The diagnosis codes used to design this system years ago relied on sparse coding practices, mainly of more severe disease instances. Now codes have multiplied. Medicare Advantage companies actively seek and add diagnoses – even minor or equivocal ones – to gain the high payments. And thus they earn much higher premium payments from Medicare, even several times higher.

This strategy has three versions: (1) Pay Providers for Submitting More Codes, (2) Share the Risk Premium with Providers, and (3) Own the Providers. Option 3 is the most profitable, but requires buying up providers. That’s exactly what’s happening. And that’s why the valuations are so high.

Part 2 focuses on “Direct Contracting Entities” or DCEs.

DCEs are the mechanism devised by the Center for Medicare and Medicaid Services (CMS) to bring private insurers and investor-controlled provider firms – those driving Medicare Advantage profiteering – into traditional Medicare. CMS structured DCEs very similarly to Medicare Advantage, to ease the transition.

And, indeed, DCEs provide several routes for participating companies to manipulate clinical severity coding to raise payments and profits. These include changing the codes prior to DCE entry and allowing re-coding for several years for a large category of DCE entrants.

The scope is huge. Initial DCE contracts with investor (not provider) owners will reach 60% of traditional Medicare beneficiaries.

The effects for beneficiaries will be hassles. Payment arrangements will be more complicated, with a role for the DCE, CMS, and Medigap.

Thus, magically, seniors who chose traditional Medicare will find themselves in a Medicare Advantage-like situation.

And maybe headed to Medicare Advantage. DCE enrollees may be recruited into Medicare Advantage owned by the same company. The company has a huge incentive to make life in the DCE less attractive.

All of these contractual details are complicated and confusing. I’m confused, and I think about this for a living. The complexity is not a bug, it’s a feature – provide lots of room to maneuver, and obscure what’s really going on.

Who wins? Investors. “From early April, 2010 through the end of August, 2021, the average stock price for five MA-focused insurers—United Health, Humana, Cigna, Anthem, and CVS/Aetna—increased 825 percent (compared to 280 percent for the entire S&P 500).”

The authors offer a long list of policy solutions. As readers of HJM know, I’m not a big fan of ACOs. But their other suggestions resonate. For example:

— Replace the defective risk adjustment system, so that it can’t be manipulated through upcoding to shift tens of billions of dollars in profits to investors and deplete the Medicare Trust Fund. There are alternatives, such as the Medicare Beneficiary Survey.

— End DCEs. Or, if they must continue, drastically lower the scale to just enough for testing, and then use the results to decide what to do. And limit DCEs to provider-owned, not insurer-owned, companies.

The huge Medicare health insurance ship is headed in the wrong direction. Let’s turn the rudder toward traditional Medicare, traditionally implemented, and then on to an improved Medicare for All.


NYT: The multifaceted failings of US health insurance

Summary: The New York Times, the most respected US daily newspaper, over the last week prominently published three stories about startling failings in our health insurance system. Are the reporters and editors sending us a message – time to change health insurance system?

Their Baby Died in the Hospital. Then Came the $257,000 Bill
New York Times
September 21, 2021
By Sarah Kliff

Last summer, Ms. Lane started receiving debt collection notices. The letters, sent by the health plan Cigna, said she owed the insurer over $257,000 for the bills it accidentally covered for Alexandra’s care after Ms. Lane switched health insurers.

Ms. Lane was flummoxed: It was Cigna that had received the initial bill for care and had paid Mount Sinai West. Now, Cigna was seeking the money it had overpaid the hospital by turning to the patient.

“For them, it’s just business, but for us it means constantly going through the trauma of reliving our daughter’s death,” said Clayton Lane, Alexandra’s father and Ms. Lane’s husband. “It means facing threats of financial ruin. It’s so unjust and infuriating.”

Medicare Expansion Clashes with Health Care for the Poor as Budget Bill Shrinks
New York Times
September 20, 2021
By Jonathan Weisman & Sheryl Gay Stolberg

Democrats are facing tough moral and political decisions over how to pursue their century-old dream of universal health care now that their ambitious $3.5 trillion social safety net bill will almost certainly have to be trimmed back.

As they try to reduce the bill’s cost, members of the party disagree over whether to prioritize expanding coverage to more poor adults in states whose leaders have refused to do so or to give new Medicare benefits to older people across income levels.

This Lab Charges $380 for a Covid Test. Is That What Congress Had in Mind?
New York Times
September 26, 2021
By Sarah Kliff

At the drugstore, a rapid Covid test usually costs less than $20.

Across the country, over a dozen testing sites owned by the start-up company GS Labs regularly bill $380.

There’s a reason they can. When Congress tried to ensure that Americans wouldn’t have to pay for coronavirus testing, it required insurers to pay certain laboratories whatever “cash price” they listed online for the tests, with no limit on what that might be.

Comment by: Isabel Ostrer

Three stories in one week on the front page of the preeminent US newspaper. Three stark examples of just how diversely broken the American health insurance system is.

1) A family being harassed by an insurer who accidentally paid for a hospital bill after the family had already switched insurance providers. Now the family relives the tragedy of their infant daughter dying each time they contend with these outrageous and illegitimate bills.

2) Congress debating whether to expand coverage to low-income adults who were left out during the piecemeal expansion offered by the Affordable Care Act or to give seniors more comprehensive health coverage. A terrible choice.

3) A lab gaming the system to change exorbitantly high prices for Covid tests, which is only possible because the US government refuses to take an active role in controlling such prices.

Together, these very different stories offer a glimpse of the myriad ways that American health care fails the American people. Single payer could fix all these problems. A unified insurer would mean the Lane family would not have to contend with multiple for-profit insurers debating which bills they covered. A unified insurer would cover all Americans instead of leaving poor individuals in ACA-non-expansion states by the wayside, and provide comprehensive coverage. A unified insurer would regulate prices and eliminate price-gouging, and control the unhinged growth of American health spending.  


High Uninsurance post-ACA for Low-Income, Black, Hispanic

Summary: This study used a national survey to document high levels of uninsurance among vulnerable populations after ACA implementation, especially in states not choosing to expand Medicaid – up to 40-60% for some groups in some states. Sadly, but unsurprisingly, the ACA falls far short.

States’ Performance in Reducing Uninsurance Among Black, Hispanic, and Low-Income Americans Following Implementation of the Affordable Care Act
Health Equity
July 21, 2021
By G. Lines et al.

From the abstract:

Purpose: To assess state-level variation in changes in uninsurance among Black, Hispanic, and low-income Americans after implementation of the Affordable Care Act (ACA) [in 2014].

Methods: We analyzed data from the Behavioral Risk Factor Surveillance System from 2012 to 2016 …

Results: The range in the percentage point reduction in uninsurance varied substantially across states: 19-fold for Black (0.9–17.4), 18-fold for Hispanic (1.2–21.5), and 23-fold for low-income (1.0–27.8) adults. … In some states, more than one quarter of Black, one half of Hispanic, and approaching one half of low-income adults remained uninsured after full implementation of the ACA. Compared with states in the lowest quintile of change in coverage, states in the highest quintile experienced greater improvements in ability to see a physician.

From Fig 3, for Low Income individuals. Dark bars are states that expanded Medicaid.

Comment by: Jim Kahn

National averages for uninsurance don’t do justice to the dismal post-ACA shortfalls for vulnerable groups – Blacks, Hispanics, and low-income. Especially in states that failed to expand Medicaid, but also in states that did expand. As this study demonstrates, these shortfalls impair ability to see a physician, and that, we know, worsens health outcomes.

How long will our country continue its commitment to highly inefficient convoluted health insurance schemes when there is a simple, efficient, equitable solution waiting for us to pluck it off the shelf and put it in place?

Single payer would not need studies or graphics like this. We’d just cover everyone.



Californians Crave Single Payer!

Summary: Three diverse California groups – doctors in training, low income populations, and leaders of community-based organizations — recently showed high support for single payer. Very encouraging trend, invigorating! Let’s harness that energy.

Health reform debate
USC Keck School of Medicine
September 21, 2021
Single Payer presenter Paul Song MD

See Paul’s ppt deck here.

Community Voices Priorities and Preferences of Californians with Low Incomes for Health Care Reform
September 2021
By The Healthy California for All Commission

From the Executive Summary:

Both the public opinion poll and the CBO leader interviews and surveys conducted show strong support for a single, statewide, government-run health care program that covers all people who live in California. The poll suggests that 65% of Californians with low incomes support the concept, with people of color showing greater support: 76% of African Americans, 71% of Latinos, 73% of Asian/Pacific Islanders, 65% of Native Americans and 54% of whites. Similarly, a majority of CBO leaders indicated support for the concept of a single statewide government-run health care program.

Comment by: Jim Kahn

Look what’s happening in California: So much support for single payer, from different corners … two diverse examples arrived in the last couple of days.

All of us who educate and advocate for single payer have been in debates, arguing the merits of single payer versus strategies that are pure market (“skin in the game”) and blended (like the ACA). Usually we’re quite pleased to swing opinion 10-20%. Look what happened when Paul Song spoke at USC Keck School of Medicine – a 41-point swing! To 89% support! Paul is a brilliant presenter. But, also, the times are changing … more and more people in health care and out recognize the gaping flaws in the current health care non-system, and the excellent performance of single payer.

Who recognizes it especially well? The population that is most vulnerable and in need. In statewide polling of low income populations and of community-based organization leaders, the Health California for All Commission found a clear consensus: “strong support for a single, statewide, government-run health care program that covers all people who live in California”. That sounds like … single payer.

There’s lots of work left to do. Lots more people to convince, including importantly our legislators. Bills to write, battles to wage. But I think we’ve turned a corner … to widespread recognition of what is known so well outside our country’s borders: single payer is a stunningly efficient and effective solution.