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  • Lewin vs Stark: How Many Americans Will End Up on the Public Plan?

    Earlier this week, in conjunction with The Lewin Group, we released an analysis of the House health bill showing that if the public plan component became law:

    • Approximately 103 million people would be covered under the new public plan and, as a consequence, about 83.4 million people would lose their private insurance. This would represent a 48.4 percent reduction in the number of people with private coverage.
    • About 88.1 million workers would see their current private, employer-sponsored health plan go away and would be shifted to the public plan.
    • Yearly premiums for the typical American with private coverage could go up by as much as $460 per privately-insured person, as a result of increased cost-shifting stemming from a public plan modeled on Medicare.

    Long-time single payer advocate Rep. Pete Stark (D-CA) has since responded to the Lewin study claiming “The Congressional Budget Office Trumps the Lewin Group.” The Lewin Group now has a point by point rebuttal of Stark’s statement. The is the text of the Lewin response, also available here:

    Stark Claim #1. Enrollment: The CBO predicts 12 million people in the public plan compared with the Lewin estimate of 103.4 million people.
    Lewin Response: As explained above, we estimate that the public plan will save more than CBO assumed. The CBO also assumes that eligibility for the public plan is never extended beyond firms with fewer than 20 workers, while we assume the Commissioner would exercise his/her authority to extend eligibility to all employers so that all can take advantage of the projected premium savings.

    Stark Claim #2: The CBO estimates an increase in employer-sponsored insurance of 2.0 million people while we estimate that 88 million workers and dependents enroll in the public plan.
    Lewin Response: In Figure 4 of our paper, we show that the number of people with coverage sponsored by employers increases by 1.4 million people. The difference is that we estimate that about 88 million people would be in firms that decide to purchase coverage for their workers in the exchange and then elect the public plan option.

    Stark Claim #3: Lewin assumes that providers would participate in the public plan regardless of what it pays.
    Lewin Response: We assume that provider participation in the public plan would be similar to participation under Medicare, where the same payment levels are used (In fact payments in the public plan for physicians will often be Medicare plus five percent). We also assumed that providers would not be subject to the same utilization management controls that are used by private plans. The cost of the resulting increase utilization of health services in the public plan is reflected in our public plan premiums and discussed in Appendix A of our paper.

    Stark Claim #4: Lewin estimates that premium savings in the public plan will be lower than CBO assumes, because private insurers will step up their cost containment efforts.
    Lewin Response: The assumption that private insurers could close the premium gap with enhanced cost containment is unrealistic in the context of how insurers control costs.
    a. Insurer bargaining leverage is diminished under the program. Insurers typically negotiate “volume” discounts with providers. Thus the more people a plan covers the more bargaining leverage it has in obtaining these discounts. Because millions of people move to the public plan, private plan enrollment drops, thus diminishing private insurer bargaining leverage.
    b. Consolidations across hospitals and physician groups have eliminated provider competition in some areas, thus reducing the plan’s ability to leverage discounts. For example, a plan has little leverage in negotiating discounts if there are no other hospital systems in the area.
    c. The effectiveness of provider networks is diminished by the program. Key to the effectiveness of networks is the plan’s ability to channel patients to the providers who are participating in the plan’s cost containment efforts. However, provider network formation is experienced by patients as restrictions on access. Increased reliance on these approaches would further alienate patients resulting in a greater shift to the public plan.
    d. Intensification of insurer utilization management practices would also further alienate patients and providers.

    Stark Claim #5: Experience with FEHBP and other programs show that price is not the only factor in choosing a health plan.
    Lewin Response: This is basically true, although in the FEHBP experience, the coverage provided differs across each plan offered. There are differences in co-insurance, covered services and network availability etc. This differs from the exchange model where people pick among competing plans with virtually the same co-pays and coverage. This will increase the relative importance of price and quality indicators in selecting a plan.

    Also, as discussed in Appendix A of our paper, we do account for differences in price response by age and health status, which controls for some of these issues raised by the critique. For example, we account for the fact that when faced with a lower cost coverage option, older and sicker individuals are less likely to change coverage than are younger and healthier people.

    Stark Claim #6: Lewin assumes that the Commissioner exercises his/her option to extend public plan eligibility to all employers.
    Lewin Response: At this time, the only thing in the House bill that results in savings for workers is the public plan. If the Commissioner does not extend eligibility to all, most people would see no cost containment. In our next study, we show the impacts with and without extending eligibility to firms with over 20 workers.

    Posted in Obamacare [slideshow_deploy]

    3 Responses to Lewin vs Stark: How Many Americans Will End Up on the Public Plan?

    1. Pingback: » Financial News Update - 07/22/09 NoisyRoom.net: Where liberty dwells, there is my country…

    2. George Pinell, Zilla says:

      Would you be so kind as to let me know how this plan would effect Seniors who are on Medicare? Especially in regards to Medicare advantage plans. We now have coverage with a zero premium. With this plan we get annual check ups at no cost to us.

      Thanks for you time.


      George Pinell

    3. John Jaye says:

      It is not stated in the reform bill if preventative care for seniors on Medicare will be affected. Medicare will be cut by an estimated 500 billion.

      Seniors on Medicare cannot receive medical treatment, beyond preventative care and or minor treatment, without prior authorization from the "Commissioner" who will have panels of individuals who will review the request from the physician.

      In making their decision they are held to take certain factors into consideration to determine the economic viability of the treatment:

      Age,life threatening disease or injury and life limiting conditions.

      They do not specify what they consider life threatening or life limiting, as such it is left to their discretion.


      The medical treatment requested is a hip replacement.

      AGE: 69 the life expectancy table will be utilized/ average life span 72.

      Life expectancy: 4 years

      Life Threatening Condition:


      Life Limiting condition: NONE


      There is a fee schedule which has the allowable amount that they will pay for each and every procedure or service. Every thing is itemized and coded with a dollar amt assigned to the particular code.

      The figures used in this example are totals and not itemized, and are not true or actual costs.

      Surgery,surgeon, anesthesiologist,hospital stay,medication,primary physician services,Physical Therapy.

      Out patient care: Physical therapy

      medication, Primary physician Services.

      Possible complications due to life threatening disease or life limiting condition? yes / diabetes

      Additional costs: Extended hospital stay,medication, physician services, in home care.


      LIFE EXPECTANCY: 4 years

      Palliative Treatment:

      Wheelchair purchase,or wheelchair rental



      Which is the most economically viable?

      You do the math.

      Palliative care would be more expensive if this was a 40 year old with no other health problems.

      If this was a disabled child, or a child with cystic fibrosis, or any special needs child the cost estimate for a surgical procedure would be higher. Also, their life expectancy is not the normal average.

      As such, when these factors are taken into consideration for authorizing medical procedures and or treatment for

      Older, and/or disabled individuals it results in denial of treatment as it would not be "economically viable."

      This bill is ambiguous and open ended.

      Also, congress has decided that once the bill is law medicare will not be under their control. This also takes away any recourse seniors on medicare have.

      I strongly suggest that all seniors read the articles Mr. Ezekiel Emanuel has published in medical journals. He advocates withholding medical care for disabled individuals. He has also stated that individuals with dementia are nothing more than useless eaters.

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