Obamacare Sign-Ups Surge as Threat of Repeal Looms

A record number of Americans signed up for Obamacare Thursday on what they thought would be the last day to enroll in health insurance coverage that starts in the new year, President Barack Obama said Friday.

So many people visited the federal government website that the administration extended the deadline until early next week to give more people time to sign up for what could be the last year of Obamacare coverage.

The Republicans who will control Congress and the White House starting next month say they'll repeal the law that provides the insurance markets as soon as they can — although there's no clear plan for how, when or what to put in its place.

Obama plugged the health insurance marketplace, the centerpiece of the 2010 Affordable Care Act, in his last press conference of the year before heading to Hawaii for vacation.

"Yesterday was the biggest day ever for Healthcare.gov. More than 670,000 Americans signed up to get coverage," Obama said.

That's compared to 600,000 sign-ups last year on the Dec. 15 deadline.

Obama said when he took office, 44 million Americans lacked health insurance. "Today, we have covered more than 20 million of them," he said. "For the first time in history, more than 90 percent of Americans are insured."

Republican opponents of Obamacare don't dispute the coverage numbers but say the law has failed to bring down costs for consumers, as had been promised.

Premiums have risen as insurance companies taking part in the exchanges have struggled to make the profits they seek with the other restrictions imposed by the law. Obamacare limits the ability to charge higher premiums for women and older people, and it forces insurers to take all comers, even people who are already sick.

But the publicity over higher premiums didn't seem to scare off new customers. The Department of Health and Human Services said more than 4 million people have signed up for coverage on Healthcare.gov, compared to about 2.8 million enrollments by the first week of December last year. That includes 1.1 million people not covered before and 2.9 million renewals.

Most people who buy private insurance on the health insurance marketplaces get a hefty federal subsidy to help pay the premiums. An analysis by the Center for Health and Economy found those subsidies would cost $42.6 billion next year, an increase of nearly $10 billion over this year.
The enrollment numbers do not include 12 health insurance marketplaces run by states and Washington, D.C. independently of the federal government.

The new demand could help improve profitability for insurers, said Larry Levitt of the nonpartisan Kaiser Family Foundation. "If the current (Affordable Care Act) open enrollment period is successful and enrollment grows, it means the insurance market is not collapsing," he said via Twitter.

"Because of the extraordinary demand, we extended the deadline to sign-up for January 1 coverage by two business days until 11:59 pm PST December 19. We don't yet know how many people will take advantage of this extension, but nearly a million consumers left their contact information to hold their place in line," HHS said in a statement.

Obama on Friday took a shot at critics who said the law would hurt business and employment by requiring larger employers to cover their workers.

"Since I signed Obamacare into law, our businesses have added more than 15 million new jobs," he said.

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In ACO era, physicians will still play a leading—but changing—role

Commentary by David Dranove, an economist and professor of health industry management at the Kellogg School of Management, Northwestern University, Evanston, Ill.

More than 8 million Americans have signed up for health insurance thanks to the Patient Protection and Affordable Care Act. Significantly increasing access to care, the 4-year-old healthcare reform law also creates incentives for providers to reorganize the delivery of healthcare.

The ACA has promoted the growth of accountable care organizations. Where successful, ACOs have the potential to bend the cost curve and improve quality. They are taking many forms, with some led by large multispecialty group practices and others by vertically integrated hospital systems with cadres of employed physicians.

Physicians will always remain central to patient care. Yet the ACA challenges the traditionally, if not fiercely, independent practice of medicine. The 21st-century physician is increasingly employed by a large provider organization with accountability to management, subject to standardized treatment protocols and required to interact with complex electronic health records.

Just how physicians will transform medical care in this new environment engenders much conversation, as was recently demonstrated at a healthcare management symposium held last month at Northwestern University's Kellogg School of Management on “The Future of the Physician.”

Health industry leaders offered their perspectives on the ACA's impact on the business of healthcare. Among the distinguished speakers, presidential adviser Dr. Ezekiel Emanuel provided several provocative predictions, ranging from the end of employer-sponsored health insurance to the closure of 1,000 hospitals. Dr. Ardis Dee Hoven, then-president of the American Medical Association, shared strategies physician groups are using to reduce the economic and social burden of chronic diseases.

                 

Insurance companies still serve a purpose. Integrated health systems have entered the insurance marketplace, leading some to speculate the end of the Blues, Aetna and UnitedHealthcare. However, early attempts to provide insurance and provider services in one organization have shown only limited success. Insurers continue to have the risk prediction know-how and data capacity to identify best practices to steer patients toward cost-effective providers. They aren't going anywhere for now.

ACOs can and do listen to doctors. It's a myth that ACOs are physician control freaks, compromising patient care to dollars and cents. ACOs do offer contractual relationships between various parties to control costs and improve quality. Ideally, they encourage physician participation in governance and work closely with them to develop protocols. ACOs may be a modern-day version of HMOs, but this time around, they may afford better access and fewer administrative snafus. If they can provide coordinated quality care and save money in the process—the jury is still out with regard to these goals—it will be a win for everyone involved.

Digital medicine will drive the cost/quality equation. Physicians complain that user “unfriendly” EHRs take time away from the patient-physician interaction—a major reason cited for their increasing job dissatisfaction. Agreed. EHRs are frustrating. We are currently in the Wild West here with multiple record systems sold by a variety of vendors whose products remain largely incompatible. Yet as a country, we spend close to $3 trillion annually on healthcare without much to show in the way of quality. Electronic documentation offers a solution: it provides the data required to begin linking the quality of care to the cost of care. EHR systems are evolving. We all need to be patient. We'll get there because we must.

Only cost-conscious physicians need apply. In the 1970s, television character Marcus Welby, M.D., epitomized the family doctor who did everything that was medically possible for his patients, sometimes stepping outside of standard practice if he felt it necessary. Dr. House, an opiate addict with a borderline personality disorder, replaced the beloved Dr. Welby, only to show even less concern for costs and standard practice. This model is no longer sustainable.

Physicians must own up to the economic consequences of their decisions, whether through employment or contractual models. Physicians must also come to accept treatment protocols, however rigid they may appear. We have tolerated widespread practice variations for too long. And medical schools must seriously consider a curriculum overhaul that teaches physicians how to manage the care-delivery process.

The future of physicians remains secure. With the newly insured accessing care, physicians—primary-care specialists in particular—are in high demand. The ones who can adapt to a post-ACA world and participate in the coordinated delivery of care will likely thrive. They may even find greater job satisfaction, if healthcare reform provisions truly result in saving lives and money.

  

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Deaths fell after Massachusetts healthcare overhaul: study

(Reuters Health) - When Massachusetts blazed the trail of healthcare reform in 2006 by expanding coverage for the poor and requiring all residents to have health insurance, it may have done more than serve as a model for nationwide reform: it also seemed to save lives, according to a study released on Monday.

The findings, reported in the Annals of Internal Medicine, are the first to provide a detailed analysis of the effects of systematically expanding healthcare coverage. Increasing access to Medicaid, the government-run insurance program for the poor, and mandating that everyone have health insurance were the two centerpieces of Massachusetts' healthcare reform.

They are also central to President Barack Obama's 2010 Patient Protection and Affordable Care Act, and remain its most controversial elements. Half the states have refused to expand Medicaid under the law known as Obamacare, for instance, and Republican opponents of the law regularly rail against the individual mandate requiring that individuals buy insurance or pay a penalty.

 

 

 

The study's authors cautioned that their analysis does not prove that Massachusetts's healthcare overhaul caused the decline in deaths; all it can show is that the two are correlated.

Previous studies that examined whether expanding access to health insurance resulted in fewer deaths got mixed results.

The new study compared deaths among people aged 20 to 64 years old in Massachusetts counties before and after "Romneycare" (as the health insurance overhaul is known, since Republican politician Mitt Romney was governor when it became law) to counties in other states.

The years compared were 2001-2005 and 2007-2010.

For every 830 people who became insured as a result of Massachusetts' mandatory coverage and Medicaid expansion, they calculated, one fewer person died each year.

That represents "a 3 percent decline in the death rate in the first few years after implementation," lead author Dr Benjamin Sommers of Harvard School of Public Health in Boston told Reuters Health.

In particular, there were fewer deaths from cancer, heart disease and infections, all of which benefit from preventive and regular healthcare, said Sommers. He has served as a senior advisor to the U.S. Department of Health and Human Services, the lead Obamacare agency, and continued to serve part-time in an advisory role in 2013-2014.

"The decline in the death rate of Massachusetts was focused in those areas where you would think reform would make the biggest difference," he said.

The drop in deaths was also larger in poorer communities that had a high number of uninsured residents before 2006.

Austin Frakt, a health economist with the Department of Veterans Affairs in Jamaica Plain, Massachusetts who was not involved in the new study but wrote an editorial accompanying it, called it "one of the most relevant studies pertaining to the Affordable Care Act."

Most such studies do show that health insurance has a positive effect on death rates and health, Frakt told Reuters Health: "Those findings are out there and the findings are really robust."

Sommers cautioned that the findings may not apply nationwide. For one thing, Massachusetts has an abundance of doctors and hospitals, many of whom accept the newly insured. Under Obamacare, people whose new insurance is not accepted by many healthcare providers might have coverage on paper but not easy access to healthcare.

The Congressional Budget Office estimates that 37 million people will gain health insurance by 2018 through the Affordable Care Act.

Annals of Internal Medicine Study

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Americans at Risk: One in Three Uninsured

A Report from Familes USA, March 2009

Key Findings:

One in Three Uninsured: 2007-2008

86.7 million people under the age of 65 went without health insurance for some or all of the two-year period from 2007 to 2008.

One out of three people (33.1 percent) under the age of 65 were uninsured for some or all of 2007-2008.

Number of Months Uninsured

Of the 86.7 million uninsured individuals, three in five (60.2 percent) were uninsured for nine months or more. Nearly three-quarters (74.5 percent) were uninsured for six months or more.

Among all people under the age of 65 who were uninsured in 2007-2008, one quarter (25.3 percent) were uninsured for the full 24 months during 2007-2008; 19.5 percent were uninsured for 13 to 23 months; 15.4 percent were uninsured for nine to 12 months; 14.3 percent were uninsured for six to eight months; and 20.1 percent were uninsured for three to five months. Only 5.4 percent were uninsured for two months or less.

Work Status of the Uninsured

Four out of five individuals (79.2 percent) who went without health insurance during 2007-2008 were from working families: 69.7 percent were in families with a worker who was employed full-time, and 9.5 percent were in families with a worker who was employed part-time.

In addition, 4.6 percent were looking for work.

Of the people who were uninsured during 2007-2008, only 16.2 percent were not in the labor force—because they were either disabled, chronically ill, family caregivers, or not looking for employment for other reasons.

Income Level of the Uninsured

Three out of five individuals (58.7 percent) in families with incomes below the federal poverty level ($21,200 a year for a family of four in 2008) went without health insurance in 2007-2008.

More than half (52.0 percent) of individuals in families with incomes between 100 and 199 percent of poverty (between $21,200 and $42,400 a year for a family of four in 2008) went without health insurance in 2007-2008.

The likelihood of being uninsured decreases considerably with increased income, but nearly one in five (17.9 percent) people in families with incomes at four times the poverty level or above went without health insurance in 2007-2008.

Every Racial and Ethnic Group Is Affected

Hispanics/Latinos, African Americans, and people of other racial or ethnic minorities were much more likely to be uninsured than whites: 55.1 percent of Hispanics/Latinos, 40.3 percent of African Americans, and 34.0 percent of other racial and ethnic minorities went without health insurance in 2007-2008, compared to 25.8 percent of whites.

Although racial and ethnic minorities are more likely to be uninsured, whites accounted for nearly half (49.8 percent) of the uninsured in 2007-2008.

Every Age Group Is Affected

Of the total 86.7 million uninsured people in 2007-2008, 60.1 million were uninsured adults (between 19 and 64 years of age).

The likelihood of being uninsured declined among adults as they grew older. The percentage who were uninsured was highest among 19- to 24-year-olds (49.5 percent) and 25- to 44-year-olds (36.3 percent). The percentage who were uninsured declined for 45- to 54-year-olds and 55- to 64-year-olds, to 25.5 percent and 21.2 percent, respectively.

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Obama reaffirms commitment to healthcare reform

President Barack Obama told a joint session of the U.S. Congress on Tuesday his budget plan this week would include a "down payment" on the principle that all Americans should have access to affordable healthcare.

Obama said money from the $787 billion economic stimulus plan approved by Congress would be used for research to fight cancer and to computerize health records.

But he said the rapidly rising cost of health care made broader changes an economic imperative.

"Health care reform cannot wait, it must not wait, and it will not wait another year. This budget builds on these reforms," he said.

"It includes an historic commitment to comprehensive health care reform -- a down payment on the principle that we must have quality, affordable healthcare for every American."

Obama promised during his campaign to work to extend health insurance to many of the 46 million Americans who do not now have it. His budget for the 2010 fiscal year, due out on Thursday, will begin to lay out a timeline for this.

The United States spends more than $7,400 per person on healthcare each year. That amounted to 18 percent of gross domestic product in 2009, according to the Centers for Medicare and Medicaid Services.

The CMS, which administers federal and state health insurance plans, says healthcare spending will hit more than $2.4 trillion this year.

Yet studies show Americans in general do not get better care than people in countries that spend less.

Improving medical care will help stimulate the economy as well as to reduce the $1 trillion budget deficit, Obama said.

"It's a commitment that's paid for in part by efficiencies in our system that are long overdue."

This includes eliminating fraud and waste but also by promoting prevention that can save lives by stopping people from getting expensive diseases in the first place. Electronic medical records and prescriptions can also save money and reduce costly errors, according to many experts.

Obama noted that high medical bills are one of the main causes of bankruptcy in the United States. "By the end of the year, it could cause 1.5 million Americans to lose their homes," he said.

The cost of health insurance premiums has grown four times faster than wages and the cost is crippling small businesses and driving jobs to countries with lower costs and national health insurance systems, he said.

Republican Senator John McCain, who also made healthcare reform an issue his losing presidential campaign against Obama, said he would help.

A member of the Senate Committee on Health, Education, Labor and Pensions, McCain said in an interview after the speech that he felt an accord is reachable this year.

"I do think it's possible, because I think that the inflation associated with health care is so severe, as the president correctly stated, it's affecting all of our economy," McCain said. "Certainly a lot of us are eager to work with the president on that issue."

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Healthcare's Nine Most Pressing Issues

NEW YORK (GlobeNewswire via COMTEX) -- The financial downturn, a new President and growing public demand for health reform will force health organizations to react quickly in 2009, according to the Top Nine Health Industries Issues in 2009, published today by the Health Research Institute at PricewaterhouseCoopers LLP (PwC).

In its annual review of the top concerns for health executives and policy makers, PwC says the health industry will face a plethora of challenges in the year ahead, including how to deal with more underinsured Americans; adapt to new coding and payment methods; and fund new cures in a capital-starved market.

"The coming year will be a watershed for healthcare in the United States," said David Chin, M.D., PricewaterhouseCoopers' Health Research Institute Leader. "Severe economic conditions are placing pressure on hospitals, insurers, employers and patients alike.

"President-elect Obama has called for significant reform for healthcare and will have a Democratic Congress supporting him. The convergence of market and political forces will drive the greatest change in healthcare in a generation, changes that could benefit patients and make the health system stronger."

The report is an annual review of the most pressing issues for health executives and policy makers. According to PricewaterhouseCoopers' Health Research Institute, the top nine health industry issues in 2009 are:

1. The Economic Downturn Will Hit Healthcare

Although the health industry historically has been less vulnerable to economic downturns than other industries, the disrupted economy will hit healthcare in 2009. Hospitals and other providers, from family physicians to dentists, will experience an increase in bad debt and a drop in elective procedures.

Investment portfolios for all health organizations have been affected. The payer mix is shifting away from relatively lucrative commercial insurers, as they are seeing a drop in enrollment and premium revenue, a trend that will likely continue if employment drops further.

Charitable donations and investment income are down, and improvement projects involving capital outlays for IT, facilities and equipment have been put on hold. Pharmaceutical and biotech companies have seen their valuations drop, which could further affect their access to raise additional capital. Health organizations that need to find new sources of capital will have to demonstrate that they're improving their core businesses, improving efficiencies and delivering value.

2. The Underinsured Will Surpass the Uninsured as Healthcare's Biggest Headache

The uninsured draw most of the attention, but the number of underinsured is growing even faster. An estimated 25 million adults qualify as underinsured, an increase of 60 percent since 2003. With some but not enough health insurance, the underinsured often can't or won't pay the high deductibles and co-pays for the services they need.

In 2009, the US could see more bad debts for hospitals, more cost-shifting to commercial plans and more patients delaying or foregoing care. With growing unemployment, self-pay is becoming a major part of providers' revenue cycle processes. Many hospitals have begun to pre-qualify patients. Some are using credit card-like swipe machines to verify eligibility and estimate insurance coverage. Others are using credit cards and extending their own lines of credit.

Not-for-profit hospitals must tread carefully, as they don't want to further complicate the credit for uninsured and low-income patients. Business operations will likely look to technology and processes from the retail, banking and credit industries to manage self-pay patients and the underinsured.

3. Big Pharma turns to M&A to build the drug pipeline

With revenue from existing pharmaceuticals slowing down and the decrease of approved new drugs in the pipeline, Big Pharma is focusing on acquisitions of smaller biotech firms to re-energize the drug pipeline. Cash-rich pharmaceutical companies may be able to find bargains in the mergers and acquisition market as the financial markets continue to hit turbulence.

4. From Vaccines to Regulation, Prevention is on the Rise

Prevention will get a boost from drug makers, regulators and nonprofit benefactors, making vaccines one of the few bright spots for pharma sales. In addition, more state and local governments are regulating health-related behaviors, such as banning smoking in public areas and trans-fats in foods. Next up for consideration: Nutritional posting requirements for fast-food restaurants, limits on where cigarettes may be sold and fees for sugary sodas.

5. Genetic Testing is Reaching a Price Point for the Masses

The direct-to-consumer market for genetic testing may begin to take off in the year ahead as costs drop, enabling people to purchase a complete map of their DNA to identify markers for specific diseases such as Alzheimer's.

A federal ban on discriminating the use of genetic data could accelerate the use of these tests by the public. Research will focus on how genetics can affect pharmaceuticals and enable personalized medicine. The marketing of these tests bypasses traditional clinicians, raising questions about how the information will affect diagnosis and treatment. Regulations regarding genetics at a state and federal level will continue to develop.

6. The Internet and Social Networking is a Powerful Health Extender

Technology will empower patients in new ways during 2009. The increased information and growing patient-to-patient interaction over social networking platforms and web sites such as patientslikeme.com and americanwell.com are changing how healthcare is navigated and experienced by consumers, especially as electronic health records become more common.

7. Hospitals Must Perform to Get Paid

Medicare, Medicaid and insurance companies are increasingly basing reimbursement to hospitals on performance, and, despite resistance to it, pay for performance isn't going away. In 2009, healthcare providers will have to get serious about not only improving performance but documenting it.

The Centers for Medicare & Medicaid Services (CMS) has proposed adding a new index: the total performance score. It's part of Medicare's move to value-based purchasing. If Congress approves this measure, CMS would replace the current quality reporting system with one in which Medicare withholds between 2 percent and 5 percent of its reimbursements to hospitals. They will need to focus on process improvements to improve safety and avoid unreimbursed medical errors, known as "never events."

8. Payers and Employers to Give Incentives for Wellness Programs

More employers will give incentives to encourage responsible health behaviors and participation in wellness and disease management programs. Wellness programs don't work if employees don't participate, and most of them don't, according to research by PricewaterhouseCoopers' Health Research Institute which found that less than 15 percent of eligible individuals enrolled in wellness programs actually participate.

However, they found that workers are two to four times more likely to enroll in wellness programs if they receive gift cards or other incentives. In 2009, health plans will begin to play a more active role in wellness program design, tools and support.

9. ICD-10 Will Require a Major Resource Investment

The conversion to a new International Classification of Disease code sets, known as ICD-10, will be a painful and costly process that health organizations will begin in 2009. The federal government has proposed an accelerated timetable for increasing the number of code sets used for billing and clinical classifications from 17,000 to 150,000. In addition to clinical process changes, the entire healthcare system-- from quality of care, to medical records, to incentive salary systems, to reimbursement-- will have to be adapted.

The good news: When it's done, providers and payers will have far more data on which to document diagnosis, decisions and reimbursement.

A full copy of PricewaterhouseCoopers' Health Research Institute's Top Nine Health Industry Issues in 2009 is available online at http://www.pwc.com/hri/top9.

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When a Job Disappears, So Does the Health Care

ASHLAND, Ohio (NY Times)— As jobless numbers reach levels not seen in 25 years, another crisis is unfolding for millions of people who lost their health insurance along with their jobs, joining the ranks of the uninsured.

The crisis is on display here. Starla D. Darling, 27, was pregnant when she learned that her insurance coverage was about to end. She rushed to the hospital, took a medication to induce labor and then had an emergency Caesarean section, in the hope that her Blue Cross and Blue Shield plan would pay for the delivery.

Wendy R. Carter, 41, who recently lost her job and her health benefits, is struggling to pay $12,942 in bills for a partial hysterectomy at a local hospital. Her daughter, Betsy A. Carter, 19, has pain in her lower right jaw, where a wisdom tooth is growing in. But she has not seen a dentist because she has no health insurance.

Ms. Darling and Wendy Carter are among 275 people who worked at an Archway cookie factory here in north central Ohio. The company provided excellent health benefits. But the plant shut down abruptly this fall, leaving workers without coverage, like millions of people battered by the worst economic crisis since the Depression.

About 10.3 million Americans were unemployed in November, according to the Bureau of Labor Statistics. The number of unemployed has increased by 2.8 million, or 36 percent, since January of this year, and by 4.3 million, or 71 percent, since January 2001.

Most people are covered through the workplace, so when they lose their jobs, they lose their health benefits. On average, for each jobless worker who has lost insurance, at least one child or spouse covered under the same policy has also lost protection, public health experts said.

Expanding access to health insurance, with federal subsidies, was a priority for President-elect Barack Obama and the new Democratic Congress. The increase in the ranks of the uninsured, including middle-class families with strong ties to the work force, adds urgency to their efforts.

“This shows why — no matter how bad the condition of the economy — we can’t delay pursuing comprehensive health care,” said Senator Sherrod Brown, Democrat of Ohio. “There are too many victims who are innocent of anything but working at the wrong place at the wrong time.”

Some parts of the federal safety net are more responsive to economic distress. The number of people on food stamps set a record in September, with 31.6 million people receiving benefits, up by two million in one month.

Nearly 4.4 million people are receiving unemployment insurance benefits, an increase of 60 percent in the past year. But more than half of unemployed workers are not receiving help because they do not qualify or have exhausted their benefits.

About 1.7 million families receive cash under the main federal-state welfare program, little changed from a year earlier. Welfare serves about 4 of 10 eligible families and fewer than one in four poor children.

In a letter dated Oct. 3, Archway told workers that their jobs would be eliminated, and their insurance terminated on Oct. 6, because of “unforeseeable business circumstances.” The company, owned by a private equity firm based in Greenwich, Conn., filed a petition for relief under Chapter 11 of the Bankruptcy Code.

Archway workers typically made $13 to $20 an hour. To save money in a tough economy, they are canceling appointments with doctors and dentists, putting off surgery, and going without prescription medicines for themselves and their children.

Archway cited “the challenging economic environment” as a reason for closing.

“We have been operating at a loss due largely to the significant increases in raw material costs, such as flour, butter, sugar and dairy, and the record high fuel costs across the country,” the company said.

At this time of year, the Archway plant would usually be bustling as employees worked overtime to make Christmas cookies. This year the plant is silent. The aromas of cinnamon and licorice are missing. More than 40 trailers sit in the parking lot with nothing to haul.

In the weeks before it filed for bankruptcy protection, Archway apparently fell behind in paying for its employee health plan. In its bankruptcy filing, Archway said it owed more than $700,000 to Blue Cross and Blue Shield of Illinois, one of its largest creditors.

Richard D. Jackson, 53, was an oven operator at the bakery for 30 years. Mr. Jackson and his two daughters often used the Archway health plan to pay for doctor’s visits, imaging, surgery and medicines. Now that he has no insurance, he takes his Effexor antidepressant pills every other day, rather than daily, as prescribed.

Another former Archway employee, Jeffrey D. Austen, 50, said he had canceled shoulder surgery scheduled for Oct. 13 at the Cleveland Clinic because he had no way to pay for it.

“I had already lined up an orthopedic surgeon and an anesthesiologist,” Mr. Austen said.

In mid-October, Janet M. Esbenshade, 37, who had been a packer at the Archway plant, began to notice that her vision was blurred. “My eyes were burning, itching and watery,” Ms. Esbenshade said. “Pus was oozing out. If I had had insurance, I would have gone to an eye doctor right away.”

She waited two weeks. The infection became worse. She went to the hospital on Oct. 26. Doctors found that she had keratitis, a painful condition that she may have picked up from an old pair of contact lenses. They prescribed antibiotics, which have cleared up the infection.

Ms. Esbenshade has two daughters, ages 6 and 10, with asthma. She has explained to them why “we are not Christmas shopping this year — unless, by some miracle, Mommy goes back to work and gets a paycheck.”

She said she had told the girls, “I would rather you stay out of the hospital and take your medication than buy you a little toy right now because I think your health is more important.”

In some cases, people who are laid off can maintain their group health benefits under a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1986, known as Cobra. But that is not an option for former Archway employees because their group health plan no longer exists. And they generally cannot afford to buy insurance on their own.

Wendy Carter’s case is typical. She receives $956 a month in unemployment benefits. Her monthly expenses include her share of the rent ($300), car payments ($300), auto insurance ($75), utilities ($220) and food ($260). That leaves nothing for health insurance.

Ms. Darling, who was pregnant when her insurance ran out, worked at Archway for eight years, and her father, Franklin J. Phillips, worked there for 24 years.

“When I heard that I was losing my insurance,” she said, “I was scared. I remember that the bill for my son’s delivery in 2005 was about $9,000, and I knew I would never be able to pay that by myself.”

So Ms. Darling asked her midwife to induce labor two days before her health insurance expired.

“I was determined that we were getting this baby out, and it was going to be paid for,” said Ms. Darling, who was interviewed at her home here as she cradled the infant in her arms.

As it turned out, the insurance company denied her claim, leaving Ms. Darling with more than $17,000 in medical bills.

The latest official estimate of the number of uninsured, from the Census Bureau, is for 2007, when the economy was in better condition. In that year, the bureau says, 45.7 million people, accounting for 15.3 percent of the population, were uninsured.

M. Harvey Brenner, a professor of public health at the University of North Texas and Johns Hopkins University, said that three decades of research had shown a correlation between the condition of the economy and human health, including life expectancy.

“In recessions, with declines in national income and increases in unemployment,” Mr. Brenner said, “you often see increases in mortality from heart disease, cancer, psychiatric illnesses and other conditions.”

The recession is also taking a toll on hospitals.

“We have seen a significant increase in patients seeking assistance paying their bills,” said Erin M. Al-Mehairi, a spokeswoman for Samaritan Hospital in Ashland. “We’ve had a 40 percent increase in charity care write-offs this year over the 2007 level of $2.7 million.”

In addition, people are using the hospital less. “We’ve seen a huge decrease in M.R.I.’s, CAT scans, stress tests, cardiac catheterization tests, knee and hip replacements and other elective surgery,” Ms. Al-Mehairi said.

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Women Buying Health Policies Pay a Penalty

Striking new evidence has emerged of a widespread gap in the cost of health insurance, as women pay much more than men of the same age for individual insurance policies providing identical coverage, according to new data from insurance companies and online brokers.

Some insurance executives expressed surprise at the size and prevalence of the disparities, which can make a woman’s insurance cost hundreds of dollars a year more than a man’s. Women’s advocacy groups have raised concerns about the differences, and members of Congress have begun to question the justification for them.

The new findings, which are not easily explained away, come amid anxiety about the declining economy. More and more people are shopping for individual health insurance policies because they have lost jobs that provided coverage. Politicians of both parties have offered proposals that would expand the role of the individual market, giving people tax credits or other assistance to buy coverage on their own.

“Women often fare worse than men in the individual insurance market,” said Senator Max Baucus, Democrat of Montana and chairman of the Finance Committee.



Insurers say they have a sound reason for charging different premiums: Women ages 19 to 55 tend to cost more than men because they typically use more health care, especially in the childbearing years.

But women still pay more than men for insurance that does not cover maternity care. In the individual market, maternity coverage may be offered as an optional benefit, or rider, for a hefty additional premium.

Crystal D. Kilpatrick, a healthy 33-year-old real estate agent in Austin, Tex., said: “I’ve delayed having a baby because my insurance policy does not cover maternity care. If I have a baby, I’ll have to pay at least $8,000 out of pocket.”

In general, insurers say, they charge women more than men of the same age because claims experience shows that women use more health care services. They are more likely to visit doctors, to get regular checkups, to take prescription medications and to have certain chronic illnesses.

Marcia D. Greenberger, co-president of the National Women’s Law Center, an advocacy group that has examined hundreds of individual policies, said: “The wide variation in premiums could not possibly be justified by actuarial principles. We should not tolerate women having to pay more for health insurance, just as we do not tolerate the practice of using race as a factor in setting rates.”

Without substantial changes in the individual market, Ms. Greenberger said, tax credits for the purchase of insurance will be worth less to women because they face higher premiums.

The disparities are evident in premiums charged by major insurers like Humana, UnitedHealth, Aetna and Anthem, a unit of WellPoint; in prices quoted by eHealth, a leading online source of health insurance; and in rate tables published by state high-risk pools, which offer coverage to people who cannot obtain private insurance.

Humana, for example, says its Portrait plan offers “ideal coverage for people who want benefits like those provided by big employers.” For a Portrait plan with a $2,500 deductible, a 30-year-old woman pays 31 percent more than a man of the same age in Denver or Chicago and 32 percent more in Tallahassee, Fla.

In Columbus, Ohio, a 30-year-old woman pays 49 percent more than a man of the same age for Anthem’s Blue Access Economy plan. The woman’s monthly premium is $92.87, while a man pays $62.30. At age 40, the gap is somewhat smaller, with Anthem charging women 38 percent more than men for that policy.

Todd A. Siesky, a spokesman for WellPoint, declined to comment on the Anthem rates.

Thomas T. Noland Jr., a senior vice president of Humana, said: “Premiums for our individual health insurance plans reflect claims experience — the use of medical services — which varies by gender and age. Females use more medical services than males, and this difference is most pronounced in young adults.”

In addition, Mr. Noland said, “Bearing children increases other health risks later in life, such as urinary incontinence, which may require treatment with medication or surgery.”

Most state insurance pools, for high-risk individuals, also use sex as a factor in setting rates.

Thus, for example, in Dallas or Houston, women ages 25 to 29 pay 39 percent more than men of the same age when they buy coverage from the Texas Health Insurance Risk Pool.

In Nebraska, a 35-year-old woman pays 32 percent more than a man of the same age for coverage from the state insurance pool.

Representative Xavier Becerra, Democrat of California, said that “if men could have kids,” such disparities would probably not exist.

Elizabeth J. Leif, a health insurance actuary in Denver who helps calculate rates for Nebraska and other states, said: “Under the age of 55, women tend to be higher utilizers of health care than men. I am more conscious of my health than my husband, who will avoid going to the doctor at all costs.”

“Many state insurance laws require insurance policies to cover complications of pregnancy, even if they do not cover maternity care,” Ms. Leif said. Insurers say those complications generate significant costs.

Representative Lloyd Doggett, Democrat of Texas, asked, “How can insurers in the individual market claim to meet the needs of women if maternity coverage is so difficult to get, so inadequate and expensive?”

Cecil D. Bykerk, president of the Society of Actuaries, a professional organization, said that if male and female premiums were equalized, women would pay less but “rates for men would go up.”

Mr. Bykerk, a former executive vice president of Mutual of Omaha, said, “If maternity care is included as a benefit, it drives up rates for everybody, making the whole policy less affordable.”

The individual insurance market is notoriously unstable. Adults often find it difficult or impossible to get affordable coverage in this market. In most states, insurers can charge higher premiums or deny coverage to people with health problems.

In job-based coverage, civil rights laws prohibit sex discrimination. The Equal Employment Opportunity Commission says employers cannot charge higher premiums to women than to men for the same benefits, even if women as a class are more expensive. Some states, including Maine, Montana and New York, have also prohibited sex-based rates in the individual insurance market.

Mila Kofman, the insurance superintendent in Maine, said: “There’s a strong public policy reason to prohibit gender-based rates. Only women can bear children. There’s an expense to that. But having babies benefits communities and society as a whole. Women should not have to bear the entire expense.”

And that expense can be substantial.

In Iowa, a 30-year-old woman pays $49 a month more than a man of the same age for one of Wellmark’s Select Enhanced plans. Her premium, at $151, is 48 percent higher than the man’s.

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Economic woes force people to put off health care needs

'HEARTBREAKING' | Sick economy forces Americans to put off needed health care

When two of his six children came down with fevers and sore throats several weeks ago, Donald Hendricks of west suburban Lombard didn't take them to the doctor because he couldn't afford gas money to drive them there.

Hendricks, who lost his job over the summer, gave his kids soup and soda instead, and they got better. But Hendricks said he's worried what will happen the next time someone in his family gets sick.

"I never felt the crunch like this before," he said.

Hendricks isn't alone.

The ailing economy is leading many Americans to skip doctor visits, skimp on their medicine and put off elective surgeries and outpatient procedures. And physicians worry the result will be sicker patients who need more expensive treatment later.

"It's really hard to get around the fact that people do have to choose between a $300 gas bill and coming to the doctor, which might cost them $50 or $100 for preventive care," said Dr. Tamarah Duperval, a family physician who works at a clinic near the United Center. "Even that $3 co-pay is too much for some people."

Duperval said she's already seeing a growing number of patients coming in with advanced illnesses that could have been treated earlier. And many aren't taking their medication as often as prescribed.

"It's heartbreaking," she said.

The numbers show Americans are increasingly putting their health at risk:

• Thirty-six percent of people surveyed this month by the Kaiser Family Foundation said they or a family member have put off needed care, compared with 29 percent in April. Almost one-third had skipped a recommended test or treatment, up from 24 percent. And about one-fifth said their condition got worse as a result.

• The number of prescriptions filled dropped 0.4 percent for the quarter ending in June -- the first time it hasn't risen, according to IMS Health, which has been tracking such data for 12 years.

• A July survey by the National Association of Insurance Commissioners found that 11 percent of Americans had either reduced the number of prescription medicines they take or cut the dosage by such means as splitting pills in half.

• Elective surgeries like hip and knee replacements, diagnostic tests and outpatient procedures fell roughly 1 percent to 2 percent in recent months at many hospitals, said Dick Clarke, president of the Healthcare Financial Management Association. While the decline seems small, the numbers typically climb 2 percent to 4 percent a year as the population ages.

• U.S. hospitals are reporting an uptick in emergency room patients, according to the American Hospital Association. Clarke said that includes a rise in uninsured patients with conditions that could have been treated elsewhere, and he expects that number to increase.

The U.S. unemployment rate has climbed from 4.7 percent to 6.1 percent over the past year, costing many newly jobless people their health insurance. But the uninsured are not the only patients feeling the economy's sting.

At Sutcliffe Pharmacy in Lake View, owner Kevin Winston said he's seen a 10 percent drop in sales over the last four months, primarily because customers aren't filling prescriptions as often.

"I've never seen it this bad before," he said. "People should be due for a refill, but they're sort of letting it go."

Winston tries to work out payment arrangements with cash-strapped customers, so they don't have to go without their medication. But he said, "It's a very, very difficult position to be in."

Meanwhile, Walgreen Co. pharmacies have been calling customers, making emotional arguments for why they should be getting prescriptions refilled.

"For example, do they want to be around when their kids grow up, or their grandkids?" Jeff Rein, Walgreen's chief executive, told analysts last month.

At Ohio State Medical Center in Columbus, Dr. Andrew Thomas said one of his patients put off having an MRI done for severe back pain "because literally she didn't have the gas money to drive across town."

Patients are often too embarrassed to admit they are struggling financially, he said. He offered them this advice: "If you're on a bunch of different medications, ask your doctor, 'Which one of these could I get by on for six months without taking?' "

"Your doctor might say, 'Some of these are imperative, but if you really need to save money, these are the ones I could cut out or change the dosage.' "

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Nonprofit Hospitals Leave The City for Greener Pastures

DETROIT -- Ascension Health, the country's largest nonprofit hospital system, says its mission is to serve all, "with special attention to those who are poor and vulnerable." But in this city, where one in four people don't have health insurance, it's become harder for the poor and vulnerable to find Ascension.

Last year, Ascension's local subsidiary closed Riverview Hospital, the third hospital it has shut down in Detroit in the past 10 years and the only hospital that remained on the city's blighted east side.

Meanwhile, 30 miles away, in a suburb of multimillion-dollar homes, Ascension is opening a new $224 million hospital.

Dwindling Options in Detroit (click here)
Of the 42 hospitals in the city in 1960, fewer than 10 are left. See a demographic breakdown of Detroit, a map of the city's open and shuttered hospitals, and a look at Ascension's system.

Ascension's approach to the Detroit market is an increasingly common strategy among nonprofit hospital systems: Close money-losing facilities in poor areas where a large share of patients are uninsured, and build or refurbish hospitals in affluent places where people have private insurance coverage.

Nonprofit hospital systems have shuttered facilities from Los Angeles to Chicago to Newark, N.J., while spending billions on suburban expansions. This all comes as large nonprofit chains have been enjoying some of their most prosperous times ever.

Net income at Ascension, which owns 67 hospitals located mostly in the Midwest, South and Northeast, nearly tripled to $1.2 billion between 2004 and 2007 thanks largely to investment gains. With financial markets struggling over the past year, Ascension reported net income of $351 million for the year ended June 30.

Shutting down unprofitable operations and expanding profitable ones is a common business maneuver, but nonprofit hospital systems aren't ordinary businesses. They're required to provide benefits to their communities, such as free care for the indigent, in exchange for the billions of dollars in annual tax exemptions they receive.

Ascension, which is affiliated with the Roman Catholic Church, says its more profitable subsidiaries can't be used to subsidize those that are struggling. "Such an approach would mean that needs in other communities may not be met," says Ascension spokeswoman Trudy Barthels. The 38 subsidiaries, which Ascension calls "health ministries," operate with a large degree of independence and have to be "self-sustaining," she says. Ascension adds that it ties how much capital it allocates each subsidiary, in part, to its profitability.

St. John Health System, Ascension's Michigan subsidiary, says Riverview lost $16 million in 2006, just before it announced the closing. Uninsured patients were using Riverview's emergency room for non-emergencies -- an expensive and inefficient way to deliver routine care, says Robert Hoban, St. John's chief strategy officer. The neighborhood's real need, he says, is not for a hospital but for more primary-care doctors. He says St. John is studying ways to provide more of that kind of care there.

Abandoned Patients Search for Care
Catering mostly to the poor and elderly, Detroit Riverview was the only hospital open on the downtrodden eastside of the city, but shuttered its doors recently. Now the hospital's former patients search for a new hospital to call their own. This, despite the former owners of the hospital opening a new facility in affluent Novi, Mich.

But critics of the closure, including neighborhood residents and former employees, say shutting down Riverview had the effect of driving doctors away. Of the 50 doctors who worked in office buildings on the Riverview campus, at least a third have left or cut back their office hours since the hospital closed, including all but one of the pediatricians and the sole oncologist.

Malaz Alatassi, an internal-medicine doctor who had office hours once a week at Riverview, has since cut down to twice a month and is considering leaving the area for good. "The message patients got was that all doctors have left," said Dr. Alatassi. "It was a bad thing for the community. I feel bad giving up my patients."

St. John officials say that there hasn't been a large-scale exodus and that they are finalizing negotiations to add another primary-care doctor to the campus.

Ascension traces its roots to 17th-century France, where a group of nuns known as the Daughters of Charity traveled from city to city to care for the poor. In the early 1800s, the order found its way to the U.S., creating one of its first hospitals in a three-room log cabin in St. Louis.

In 1999, the Daughters of Charity National Health System and the Sisters of St. Joseph Health System merged to create Ascension, a nonprofit giant with facilities in 20 states and the District of Columbia.

Many Ascension meetings still begin with a prayer and nuns hold some management roles. Ascension is also a well-oiled money machine with sterling credit ratings. Its cash and investments totaled $7.3 billion for the year ended June 30, including about $1 billion restricted to self-insurance trust funds or limited by donors for specific uses or to be maintained in perpetuity. Ascension's chief executive, Anthony Tersigni, earned $2.4 million in total compensation in 2006, according to the hospital system's latest filing with the Internal Revenue Service. Ascension declined to provide more recent compensation figures.

Ascension spent $320 million on charity care in its hospitals in the year ended June 30, or 2.5% of its patient revenue -- the highest percentage among the nation's five largest nonprofit hospital systems. But its St. John subsidiary devotes a much smaller percentage to traditional charity care, with 0.8% going to it in the 2008 fiscal year.

Ascension and St. John say their traditional charity care numbers don't take into account all the other money they spend on helping the poor in the community, such as health education, writing off bad debts and their losses on Medicaid, the government health-insurance program for the poor.

A St. John spokeswoman said it's unfair to compare St. John's figures to Ascension's because more patients in Michigan qualify for Medicaid than some of the other states where Ascension operates. In those states, more people receive charity care because fewer people are eligible for Medicaid.

Before its closing, Riverview was one of the few remaining hospitals in the Detroit city limits. Of the 42 hospitals that dotted this 139-square-mile city in 1960, only four are now left. At the same time Detroit's hospitals have dwindled, its number of uninsured has grown. An estimated 200,000 of the city's 800,000 residents have no health insurance.

Located in one of Detroit's poorest wards, Riverview sits among empty buildings on East Jefferson Avenue, a thoroughfare sprinkled with subsidized senior housing, empty and overgrown lots, partially burned homes, and graffiti-stained shops.

Even in a struggling city, Riverview's neighborhood stands out for its abysmal statistics: Thirty-four percent of the population lives below the poverty line, infant mortality is more than double the national average and the rate of AIDS deaths is five times higher, according to Richard Lichtenstein, an associate professor at the University of Michigan's School of Public Health. Its poor patient base made Riverview a perennial money-loser.

In 2003, St. John executives campaigned to persuade local regulators to let it build a new hospital in the wealthy suburb of Novi (pronounced no-vie), 30 miles to the northwest. The new facility's profits, they said, would help ensure the survival of St. John's operations in Detroit by subsidizing their losses.

"We are very, very committed to staying in Detroit," St. John's Mr. Hoban said at a public hearing on the new hospital plan, according to a transcript. "We wouldn't be here today if we weren't committed to staying in Detroit."

Approval for the Novi hospital was granted. That year, St. John shut down its hospital in northeast Detroit, reducing its presence in the city proper to Riverview and St. John Hospital and Medical Center. St. John had already closed another Detroit hospital, Saratoga Hospital, in 1998.

Mr. Hoban says today that even with the closure of those hospitals and Riverview, "we still have the same number of beds per population" in the city after a recent expansion of St. John Hospital and Medical Center.

Riverview continued to be a drag on St. John's financial performance. Nearly 50% of its patients were uninsured or on Medicaid and another 42% were on Medicare, the federal program for the elderly. Unlike Medicare, Medicaid reimburses hospitals at much lower rates than private insurance plans and often not enough to cover costs.

In 2006, Dr. Cheryl Gibson-Fountain, Riverview's former chief of staff, says she was told by St. John that the hospital could not afford the less than $5,000 Riverview was planning to spend on its annual health-and-immunization fair. The point of the fair was to screen area residents for early signs of disease. A spokeswoman for St. John said the hospital participated in other health fairs.



















Even as it eliminated the fair, St. John spent $9 million in design and architecture fees for its new construction projects in the year ended June 30, 2006, according to its IRS filings.

In February 2007, a potential lifeline materialized for Riverview. St. John officials were in talks with Michigan State University about making it one of the university's teaching hospitals, Riverview's president told employees in a letter. Under the proposed deal, the state would have taken ownership of the hospital with St. John receiving a fee to manage it. But the deal fell through when Michigan State chose to link up with another hospital.

"We were looking for teaching space for our students," said Randy Hillard, the university's associate provost for human health. "They wanted to give us the whole hospital, and we needed to pay them a $10 million management fee on a hospital that was losing millions of dollars."

St. John closed Riverview in June 2007. That year, St. John paid then-Chief Executive Elliot Joseph $1 million. Mr. Joseph defends the closing of the hospital, pointing out that the population of the metro areas had shifted from the shrinking city to the growing suburbs.

"At the time we closed Riverview, the state of Michigan said that there were an excess of 1,200 hospital beds in the city of Detroit," Mr. Joseph said through a spokesman. "We believed, accurately, that the best way to improve the health of the community in the Riverview area was by helping people establish relationships with primary-care physicians."

Shortly after Riverview closed, St. John's critics seized on renovations at the system's lone remaining city hospital as a symbol of their anger. St. John moved the lobby of St. John Hospital and Medical Center to overlook the wealthy, almost exclusively white suburb of Grosse Pointe Woods rather than Detroit, which it had faced for more than 50 years.

William Anderson, who was director of medical education at Riverview, says he believes St. John was saying, "We do not want to be in Detroit where there are so many poor, black people."

St. John denies that race and wealth had anything to do with it; the change was dictated by simple geography. The lobby-moving project was part of a $163 million upgrade to the hospital that added 144 private-room beds and more parking. Maureen Petrella, a St. John spokeswoman, says the expansion was added "to the north part of the property because that is the only space that was available on this landlocked site." Patients can still enter the Detroit side of the hospital.

To ease the impact of Riverview's closure, St. John maintained a bare-bones emergency room there for 12 months. The hospital's ER had always been bustling, handling 30,000 patient visits a year.

In February, a 60-year-old barber named Alfred Gaut was on his routine exercise walk in nearby Belle Isle Park when he was shot in the leg by teenagers playing with a gun. The police took Mr. Gaut to the shrunken Riverview ER, his daughter and two of his sisters say. Mr. Gaut, who was on Medicaid, was told he had flesh wounds and sent home with crutches and painkillers, the family says.

Mr. Gaut had been training to become a barber instructor. When he didn't show up for a ceremony at which he was to receive his instructor's license two weeks later, his family and friends went looking for him. They discovered his badly decomposed body in his apartment. The medical examiner's office listed the cause of death as "indeterminate."

Tia Gaut, Mr. Gaut's 38-year-old daughter, wonders if things might have turned out differently if there had been a hospital to admit him. "I want to know, why did they release him?" she asks.

Ascension and St. John declined to comment about Mr. Gaut, citing patient-privacy laws. But Ascension notes that every 52 seconds one of its hospitals nationwide treats an uninsured patient, and it provides care for many Medicaid patients.

St. John shut Riverview's ER for good on June 30. It's now an "urgent care" center only equipped to handle small emergencies such as cuts or burns. Unlike full-fledged emergency departments, urgent-care clinics aren't required to treat all patients regardless of their ability to pay.

A sign at the reception desk reads: "Attention all Riverview urgent care patients: There is a $50 charge if you do not have insurance." Ms. Petrella says patients who say they can't pay can "request free care or installment payments." St. John wouldn't say how many people request such accommodations nor how many get them.

Sister Mary Ellen Howard, the executive director of the Cabrini Clinic, a free clinic located just a few miles away that treats about 1,600 uninsured patients, says the health-care situation in Detroit is desperate. Even before Riverview closed, her clinic periodically limited the number of new patients it accepts. Another nearby free clinic for the uninsured says it continues to turn away about 30 callers a day looking for help.

A few months ago, Sister Howard met with Cynthia Taueg, vice president of community health for St. John, to ask if she could send a few of her uninsured patients to a St. John hospital for minor procedures or surgery. The Cabrini Clinic operates only with volunteer family-medicine doctors. The nun says she was turned down. "We're doing enough already," she says Ms. Taueg told her. St. John and Ascension donated $43,000 to the Cabrini Clinic last year.

In an email, Ms. Taueg said Sister Howard's account of the meeting "is not entirely accurate," but she didn't respond to subsequent emails and phone messages asking her to elaborate. Ms. Petrella says St. John only makes its specialists available to uninsured patients within its own network of affiliated hospitals and clinics "due to limited resources."

While East Detroit adjusts to the reality of not having a hospital, Ascension's state-of-the-art Providence Park Hospital opened last month in Novi with private rooms that feature flat-screen televisions and large windows for viewing what the St. John Web site describes as "green space, wetlands, foliage and wildlife habitat" on a campus "rich in natural beauty."

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Healthcare Costs Outpace Wisconsin Wages

In addition to current burdens of the economy, Wisconsin family health care premiums have gone up almost 75% since 2000. That's according to a new report from the group Families USA.

The report shows health care costs have gone up an estimated 4.8 times faster than the earnings of Wisconsin workers.

The high premiums leave some employers with little choice but to drop their employees' coverage, driving up the number of uninsured workers, and if employees are still covered through their company, they're being asked to pay greater premiums while getting less coverage.

"We don't blame the employers for thiseither, they've got a bottom line they have to look at just like every family does and it's an unfair choice for them to have to make," said Ann Vogel with Citizen Action of Wisconsin.

Citizen Action recently launched its "got healthcare?" campaign which educates and asks candidates running for office in 2008 to take action on the health care crisis.

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Marrying for Health Benefits

AMERICANS RANK HEALTH CARE NEAR THE TOP OF THEIR ECONOMIC WOES, NEW POLL FINDS

Almost Four In 10 Report Serious Financial Burden Caused By Medical Bills; 7 Percent Say Someone In Their Household Got Married So They or Their Spouse Could Get Health Benefits

Menlo Park, CA – Health care costs rank among Americans’ top personal economic problems, and their struggles to deal with those costs have affected both their financial well-being and their family’s health care, a new Kaiser Family Foundation poll finds.

Conducted by the Foundation’s public opinion researchers, the April poll probes into the economic concerns facing Americans and the ways they have dealt with the cost of health care.

Across a series of economic concerns, health care costs rank near the top. Nearly three in 10 Americans (28 percent) report that they or their families have had a serious problem paying for health care and health insurance as a result of recent changes in the economy, behind paying for gas (44 percent) and about tied with getting a good-paying job or raise in pay (29 percent). Smaller shares report serious problems paying their rent or mortgage (19 percent), dealing with credit card or other personal debt (18 percent), paying for food (18 percent) or losing money in the stock market (16 percent).

Reports of families facing serious economic problems extend up into middle-income families, with almost three in 10 (28 percent) of those earning between $30,000 and $75,000, reporting a serious problem paying for health care or health insurance as a result of recent changes in the economy.

Health care costs are also having ripple effects on family budgets. In a separate series of questions asking about the personal economic consequences of medical bills, nearly four in 10 (37 percent) report at least one of six financial troubles over the past five years as a result of medical bills: having difficulties paying other bills (20 percent); being contacted by a collections agency (20 percent); using up all or most of their savings (17 percent); being unable to pay for basic necessities such as food, heat or housing (12 percent); borrowing money (10 percent); or declaring bankruptcy (3 percent).

“Many people view health and the economy as separate issues, but the cost of health care is a significant pocketbook issue for many families and paying for health care has become a key dimension of the public's economic concerns,” Kaiser President and CEO Drew E. Altman said.

The poll also finds that health benefits play a key role in people’s decisions to switch jobs or stay in their current job. Nearly a quarter (23 percent) say that, within the past year, they or a member of their household have either taken a new job or stuck with their current job (instead of taking a new one) primarily because of better health benefits.

Perhaps surprisingly, health coverage is also a factor in some people’s decisions to get married. Among all adults, 7 percent say that, in the past year, they or someone in their household decided to get married in order to have access to their spouse’s health care benefits, or so their spouse could have access to their benefits.

The high cost of health care also caused a significant number of Americans to delay or go without medical care. When asked about the impact of costs on their families’ health care, more than four in 10 (42 percent) say that, within the past year, they or a family member living in their household have experienced at least one of five specific consequences due to cost: put off or postponed getting needed care (29 percent); skipped a recommended medical test or treatment (24 percent); not filled a prescription (23 percent); cut pills in half or skipped doses of medicine (19 percent); or had problems getting mental health care (8 percent).

People generally are more likely to report taking these actions now than in the past – for instance, 24 percent now report skipping a recommended medical test or treatment in the past year because of the cost, up from 17 percent in 2005.

Kaiser also released the results of its April Kaiser Health Tracking Poll: Election 2008, the seventh in a series tracking voters’ views about where health care fits as an issue in the 2008 presidential election, as well as their views on potential approaches to health reform. The latest survey finds voters are most likely to name the economy as one of the two most important issues for the candidates to discuss, followed by Iraq and health care. The three issues rank in the same order among Democrats, Republicans and independents. Early polls in the series have also looked at the ways health care costs contribute to voters’ concern about the economy.




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Health costs hit farmers - Woodland, California

In light of a new report on the increasing burden of health care costs on California's family farmers and ranchers, Yolo County policymakers are discussing ways to better protect area residents and the agriculture-dominated local economy.

At a meeting in Woodland on July 31, a group of 14 individuals that included three county supervisors, as well as the county's health department director and its agricultural commissioner, gathered to learn more about the report and start brainstorming ways to ease the financial burden on the ag community.

The report was issued in May by the Access Project, a Boston-based group that works with cities and counties around the country to promote health access. The findings were based on a survey last year of nearly 1,800 family farmers and ranchers throughout California, where 98 percent of farms are family-owned and operated.

The authors found that roughly one-third of the respondents have no access to group health coverage and do not qualify for government sponsored programs, and must therefore purchase insurance through the individual market. Among those whose principal occupation was farming or ranching, that figure jumped to 48 percent.

Those numbers are significantly higher than the national average; a mere eight percent of insured Americans purchase individual insurance.

Buying direct comes at a significant cost: The survey found that families with non-group health coverage spent nearly $4,700 more per year on premiums and out-of-pocket expenses than those who got their insurance through employment outside the family farm or ranch.

"These costs end up eating up a family's savings, increasing their credit card debt or taking away from their retirement funds," said Bill Lottero, the Access Project's field director and a co-author of the report, which was funded by the California Endowment, a private health foundation. "When I speak to young people from farming families, they name this as a barrier to getting into farming."

California's family farms produce $32 billion per year in value and support 1.1 million jobs, according to the U.S. Department of Agriculture and the California Farm Bureau Federation.

Lottero, who led the Woodland discussion, noted that farm and ranch operators have higher incomes and are insured at much higher rates than the general population; 90 percent of the respondents to Lottero's survey said all members of their household had been continuously insured during the previous year.

Yet 13 percent of respondents said they were saddled with medical debt and some families reported that as much as 44 percent of their income went toward health care-related expenditures. In addition, 16 percent of respondents said they or a family member had delayed seeking medical care, mainly because they could not afford the anticipated cost.

Woodland farmer Robert Ramming, whose family owns and operates Pacific Star Gardens, an organic "U-pick" farm and fruit stand, is all too familiar with the financial burden of health care, which costs him roughly $8,000 per year, he said. His family of six purchased health insurance through the individual market, and insurance premiums alone eat up about $6,000 annually, he said.

"Our family is in good health and we have a high-deductible policy, and even so, we're spending a huge amount of money on premiums," he said. "If we had anything like a preexisting (medical) condition or a string of bad luck, we'd be up a creek."

Ramming, who is 52, said he hopes that when he and his wife turn 65, Medicare will still be there to take care of them. Then, he said, they can finally start putting some money into a retirement fund - a fund that is currently nonexistent, thanks to the family's health care bills and other pressing business and personal expenses.

The pain of individual farming families like Ramming's trickles outward through the economy, said John Karatzas, the California project director for the Small Business Majority, a national nonprofit organization of business entrepreneurs.

"Research tells us that most small businesses are getting killed by health care costs," he said. "It's going to stifle economic development. We really can't survive this way."

Yolo County Supervisor Helen Thomson expressed concern that prohibitive health care costs would harm not only patients but also local health care providers and clinics.

"The situation is becoming very scary," she said at the Woodland discussion, held at the county health department headquarters on N. Cottonwood Street.

Lottero said he viewed the informal gathering as a jumping-off point, a way to raise concern among local policymakers and spur them to take action on behalf of Yolo County's large - and profitable - agricultural community. Local farmers and ranchers produced more than $370 million worth of goods in 2006, according to the Yolo County Farm Bureau.

Lottero also encouraged the attendees to reach out to other influential individuals and groups, including the farm bureau and state-level lawmakers, some of whom have important health care reform bills pending in the Legislature.

Ultimately, Lottero said, he hopes to see California's agricultural businesses community connect with the broader small business community and come together for a statewide health care summit about a year from now. He plans to continue meeting with county leaders around the state to help make that happen.

Ramming, who attended the Woodland discussion and took extensive notes, said he hoped to see fewer policy meetings and more concrete action in the coming months and years.

"The local 'powers that be' seem to be on same page understanding the problem," he said in a phone interview Monday. "They seem to be realizing that the problem (of health care costs) isn't just affecting underemployed people, lower-income folks. It has expanded to the middle class and the upper-middle class, and something has to be done."