APRIL 26, 2006 -- Two of five working-age Americans with yearly incomes between $20,000 and $40,000 were uninsured for at least part of the past year, a "dramatic and rapid" increase from 2001 when just over a quarter of those Americans were uninsured, according to a Commonwealth Fund study released Wednesday.

The report also found that one of five adults—both insured and uninsured—currently has medical debt. Nearly two-thirds of adults with medical bills or debt problems said they or their family members were insured when they incurred the debt.

"The jump in uninsured among those with modest incomes is alarming, particularly at a time when our economy has been improving," study co-author and Commonwealth Fund President Karen Davis said in a statement. "If we don't act soon to expand coverage to the uninsured, the health of the U.S. population, the productivity of our workforce, and our economy are at risk."

Lower-income adults were still the most likely to be uninsured. Of an estimated 48 million working-age Americans uninsured during the year, 67 percent were in families where at least one person was working full time. Researchers also found that 59 percent of those adults who were without insurance in the past year and suffer from chronic illnesses such as diabetes and asthma went without or skipped their medications because they could not afford them.

How to provide coverage to the uninsured will come to the nation's attention again during Covered the Uninsured Week May 1–7, with thousands of activities scheduled across the country and in Washington to push Congress to take action on the issue.

APRIL 27, 2006 -- A group of experts whose organizations have been recognized for quality health care explained in a panel discussion Wednesday how health care systems across the nation could improve their quality of care—particularly with Congress' help.

The experts, who were called in by Rep. Patrick J. Kennedy, D-R.I., to share their experiences and advice with him and other congressional staffers, were mostly part of health care organizations that have received the Malcolm Baldridge National Quality Award, a federal award that honors American businesses, educational institutions, and health care organizations that put quality and people first. The American Society for Quality, an international professional association, sponsored the discussion, which was held on Capitol Hill.

Richard Lovering, senior vice president for operations at Robert Wood Johnson University Hospital in Hamilton, N.J., said quality health care like Baldridge Award–winning systems give is an exception in health care because most systems experience a lack of resources. He and other panelists agreed that patients these days "get what they pay for" from hospitals.

"Unless there's some push—from either the federal or state governments—to bring resources that would go across the board, I don't know how to make that common," Lovering said.

While Kennedy said that the money is in the system and the question is whether or not "we are going to channel it into getting better care," he agreed that the federal government isn't doing all it can. He suggested that it distribute more grants to the health care system so the experts can be the ones organizing how funding is being used to improve the quality of health care.

"We don't have the urgency we need up here on the Hill," he said, adding that he doesn't understand why health care isn't a bigger issue, considering it has become the number-one concern in most congressional districts.

Kennedy, however, also asked why more corporate entities aren't getting involved in pushing quality health care and better information technology in hospitals and doctors' offices.

"And yet every other industry has technology that is bringing it into the modern age," Kennedy said, adding that Congress is going to pass a "minimal" information technology health care bill. "We can do much better," he said.

William P. Thompson, senior vice president for strategic development of SSM Health Care in St. Louis, Mo., said that even though large companies, such as General Motors, have the ability to find out which health care systems are offering quality care and could announce that they would no longer pay for hospitals that give bad care, they are unlikely to because it would be limiting their employees' choices.

"If Congress wants to do something, they should mandate disclosure of information," he said, meaning comparative records of health care systems' quality ratings should be widely distributed public information to force hospitals to provide better care.

Thompson also explained what the future of health care should be like with updated technology and equipment—where appointments can be scheduled online with the patient choosing from their physicians' available times and where medical records can be accessed and updated electronically and comprehensively and forwarded to other specialists at the touch of a button.

"We can do it in other sectors," he said, pointing to the ability to buy an airline ticket and choose a seat online. "The capable systems are there, we just have to find the time and money . . . to implement them."

G. Richard Hastings, president and CEO of Saint Luke's Health System in Kansas City, Mo., said that at his hospitals every employee has a performance management plan, where the incentive is a better salary for better performance in everyday duties.

"You can't have a system without an economic incentive," he said. Deborah Baehser, senior vice president for patient care services at Robert Wood Johnson University Hospital, agreed and said that she thinks "paying for performance is moving in the right direction" of improving health care systems.

Kennedy also emphasized that aligning incentives is the key to getting health care systems to provide better care.

APRIL 26, 2008 -- The National Federation of Independent Businesses came to the Hill on Wednesday with 450,000 signed petitions supporting legislation by Sen. Michael B. Enzi that would make it easier for small businesses to join together to offer health insurance.

However, a key moderate Republican signaled that the bill would be difficult to pass without some changes, and state governments contend it would usurp their right to regulate health insurance.

Enzi, a Wyoming Republican who is chairman of the Health, Education, Labor and Pensions Committee, said his bill (S 1955) would give small businesses "the power to negotiate together for the health benefits they want and need, at prices they can afford."

But Maine Republican Olympia J. Snowe has been a leading champion of her own small-business health legislation (S 406) and has not yet thrown her full support behind Enzi's measure. Most Democrats oppose the legislation.

Snowe was unable to attend Wednesday's news conference because she was chairing a committee meeting at the time, her spokesman said. But in a statement, she said, "We're further along on this issue than we ever have been."

Compromise for Support
She nonetheless called for changes in Enzi's proposal. "Only a compromise that has bipartisan support will be able to pass the Senate," Snowe wrote.

Enzi said he was running ideas by other senators to gather input and test out proposals. "It's been a very difficult process," he said, but predicted the final bill would have enough votes to surmount a filibuster and pass the Senate.

Support from Snowe, who pressed her case on small business health care in a meeting with President Bush on Wednesday, will be essential, so she is likely to win some changes to align the bill more closely to her version before the Senate takes up the issue in mid-May.

But even if Snowe and Enzi can agree on language, they will still need to convince Democrats to join them to get to 60 votes for cloture. To win over Democrats, they would most likely need to give some ground on the overriding of state coverage mandates.

During the markup of Enzi's bill last month, Democrats offered more than 20 amendments—most of which were aimed at preserving insurance coverage guarantees for specific diseases.

Enzi's legislation would retain state insurance oversight and enforcement, rather than shifting those duties to the federal Department of Labor, as Snowe has proposed.

Enzi's bill would allow small-business health plans to bypass state coverage mandates only if they also sell at least one policy that matches a benefit plan offered to state employees of one of the five most populous states—California, Texas, New York, Florida, or Illinois. Snowe's plan has no such requirement.

Coalition of Opposition
Opposition to Enzi's bill has drawn together an unusual coalition of interest groups.

On Tuesday, 39 state attorneys general sent a letter to Enzi to convey their "strong opposition" to the bill.

"Consumers rightfully expect their state government to require a minimum of health benefit protections. . . . Elimination of strong state protections in exchange for weak federal oversight fails consumers," they wrote.

State insurance commissioners also have lined up against the legislation.

The liberal Center on Budget and Policy Priorities released a report Wednesday saying that instead of making coverage more affordable across the board for small businesses, the Enzi bill would create winners and losers in that segment of the market.

Small businesses with older and sicker employers, or those who had just one employee who is sick or has a history of costly illness, would be particularly vulnerable to sharp premium hikes, the report said.

Sweep Away the Rules
The Enzi bill would "sweep away the rules that most states use to limit the degree of variation in the insurance premiums that small employers are charged," according to the report.

In a separate report released Wednesday, the group found that after New Hampshire adopted measures similar to the Enzi bill, 65 percent of employers with between two and nine workers saw premium hikes of 30 percent or more.

New Hampshire repealed the law because of complaints received from small business, said Edwin Park, speaking for the group.

APRIL 28, 2006 –- Requiring California residents to purchase health insurance could cost the state between $6.8 billion and $9.4 billion per year, according to a new study by the non-partisan Institute for Health Policy Solutions.

The idea of an individual mandate came to the forefront when Massachusetts passed legislation earlier this month that aims to provide near universal coverage for the state's 6.4 million residents—550,000 of whom are uninsured—as well as subsidize premiums on a sliding scale for people earning below 300 percent of the federal poverty level. Republican Gov. Mitt Romney signed the legislation into law April 12.

An individual mandate in California would cost more because the state has a far higher proportion of uninsured and low-income residents, the study notes. Redirecting existing state funding for the uninsured also wouldn't provide as much money to subsidize the purchase of insurance in California as it would in Massachusetts. Massachusetts' plan relies on redirecting $1 billion in existing funding to pay for new subsidies to low-income residents to buy insurance—about $1,300 to $1,800 per uninsured resident annually. Were California to similarly redirect $2 billion in existing state funds, doing so would yield only $300 per uninsured resident annually.

The institute's model for a health insurance mandate in California, however, only focuses on an individual mandate. The Massachusetts law contained a provision requiring payment of a fee of $295 per employee by employers with 11 or more full-time workers who do not offer or contribute to workers' health coverage. Massachusetts lawmakers were expected to override a Romney veto of the provision.

Were California able to redirect all $2 billion of its existing funds to a subsidy program, the cost of an individual mandate in the state would fall to somewhere between $4.8 billion and $7.4 billion per year, the study calculated.

The institute's brief is part of a larger ongoing analysis to be released this summer.

APRIL 28, 2006 -- While lawmakers have focused on giving Medicare beneficiaries increased access to prescription drugs, low-income, uninsured people under age 65 are struggling to get the medications they need, according to a report released this week by a Washington health policy research group.

The report published Wednesday by the Center for Studying Health System Change (HSC) documents that 26 percent of uninsured adults in 2003 did not buy at least one prescription because of its cost, compared with 8.7 percent of people with employer coverage.

The report further reveals a lack of new federal and state resources specifically targeting that population's access to prescriptions.

Faced with a shortage of resources, safety net providers such as local hospitals and community health centers have developed several strategies to help low-income, uninsured patients overcome the hurdles, the report details.

According to visits in 2005 to 12 communities such as Boston, Greenville, S.C., and Syracuse, N.Y., safety net providers have made acquiring free or reduced-cost medications part of their routine, doing so by applying for discounts on brand-name and generic prescription drugs through the federal 340B Drug Pricing Program, trying to increase the amount of free drugs available in pharmaceutical manufacturer assistance programs, and relying more heavily on funding from state charity pools and private organizations.

Many also have obtained access to a federal prescription drug discount program.

The policy research organization is funded primarily by the Robert Wood Johnson Foundation.

APRIL 28, 2006 -- Insurance giant UnitedHealth Group has enrolled the largest number of Medicare beneficiaries in both stand-alone drug plans and Medicare Advantage plans with drug coverage, according to data the Centers for Medicare and Medicaid Services (CMS) released Friday.

UnitedHealth plans account for nearly 3.8 million, or 27 percent, of the 13.9 million Medicare beneficiaries enrolled in prescription drug plans and about 1.2 million, or 20 percent, of the nearly 6 million beneficiaries enrolled in Medicare Advantage plans, according to the CMS statistics.

UnitedHealth plans offered to AARP members comprise about 2 million of that 5 million enrollment figure, AARP officials said earlier this week.

Other top prescription drug plan (PDP) players include Humana Inc. (2.4 million or 18 percent of enrollees), Wellpoint, Inc. (just over 1 million or 7 percent of enrollees), and Member Health Inc. (924,100, or 7 percent of enrollees).

Kaiser Permanente plans have enrolled nearly 822,000, or 14 percent, of beneficiaries in Medicare Advantage plans with drug coverage and Humana has captured 13 percent with 792,500 enrollees.

According to preliminary analysis by Avalere Health, a health care consulting firm, the top 10 PDP plans represent 80 percent of the beneficiaries who have enrolled in those plans. National PDPs claim 61 percent of that enrollment.

Avalere analysts also found that the top 10 Medicare Advantage plans that offer drug coverage (MA-PDs) account for 64 percent of the enrollment so far in those plans.

Forty-two percent of enrollment nationally is concentrated in the Humana and UnitedHealth PDP and MA-PD products combined, said Avalere president Dan Mendelson.

"There is a high degree of concentration among a relatively smaller number of plans," Mendelson said. In the long run, he said, it will help produce market stability and concentration. "It means that these plans will probably be able to leverage better prices over some period of time . . . It could help keep premiums low."

As of March 31, Medicare beneficiaries in stand-alone drug plans had filled 46.4 million prescriptions while Medicare Advantage plans with drug coverage filled just over 46 million, according to the CMS data.

Medicaid beneficiaries automatically enrolled into the Medicare drug plan as a "dual eligible" have filled 88 million prescriptions while retirees covered by the Medicare drug subsidy have filled 58 million prescriptions. Federal retirees have filled nearly 30 million prescriptions.