Important RAND study of single payer and other options for Oregon

Posted by on Friday, Jan 20, 2017

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Oregon faces obstacles expanding health insurance to all residents, study finds

By RAND Corporation
Medical Xpress, January 19, 2017

Researchers from the RAND Corporation and Health Management Associates were asked by the Oregon Health Authority to analyze three proposals put forward by policymakers as potential ways to expand health coverage among the uninsured and compared the likely outcomes to the existing health care system.

Researchers used several modeling techniques to analyze how each of the options would affect outcomes on insurance enrollment, payments from households to support health care, total health spending in the state and other impacts. They also assessed the regulatory aspects of each of the proposals.

The single-payer option, introduced as a bill in the Oregon House, would use public financing to provide privately delivered health care to all Oregon residents, including those currently enrolled in Medicare and Medicaid. The proposal would pool state and federal outlays for current public programs, and add additional revenue from new state income and payroll taxes. The plan would cover 100 percent of health care costs for residents with incomes under 250 percent of the federal poverty line and 96 percent of health costs for other residents.

The Health Care Ingenuity Plan would pool revenue from state and federal outlays for Medicaid and ACA marketplaces with addition revenue generated from a new state sales tax. The plan would create a public financing pool to provide basic health insurance for most nonelderly Oregon residents. Medicare would continue to cover seniors and the disabled.

Cost sharing of the private health plans would vary depending on enrollees’ incomes, with the average share of costs covered by the plan ranging from nearly 100 percent for those with incomes below 138 percent of the federal poverty level to 70 percent for those with incomes above 250 percent of poverty. Enrollees could purchase private supplemental insurance to cover cost sharing and additional benefits.

The third proposal, a so-called public option, would create a state-run health plan to cover essential health benefits outlined by the Affordable Care Act and would compete with private plans in the ACA marketplaces. Enrollees in the public option would be eligible for federal advance-premium tax credits and cost-sharing reductions. The public option would set provider reimbursements levels equal to Medicare fee-for-service rates and would require providers who participate in other state health programs to participate in the plan.

Researchers found that both the single-payer option and the Health Care Ingenuity Plan increase coverage relative to the status quo and reduce financial barriers to care.

Under the single-payer plan, researchers assumed the state would have power as the sole purchaser of health care to set payment rates for most providers at 10 percent below the status quo. Overall, there would be little change in health system costs because the increase in patient demand would be offset by lower payments rates and administrative savings.

Under the Health Care Ingenuity Plan, researchers expect there would be higher system costs because Medicaid enrollees and the uninsured would be shifted into private insurance plans, which typically reimburse providers at significantly higher rates than the Medicaid program. These higher payment rates would increase system costs, expand the supply of providers and ease congestion. Researchers also estimate that under the plan, three-fifth of state residents would purchase supplementary insurance to reduce their individual cost sharing.

Researchers estimate that the public option would cover about 9,000 additional Oregon residents, leaving the share of the population who are uninsured at 5 percent. But many people already buying coverage through the ACA marketplaces would likely shift to the public option, saving the average enrollee about $850 per year.…

A Comprehensive Assessment of Four Options for Financing Health Care Delivery in Oregon:…

Download full report (147 pages total; Summary is 12 pages):…

This study can be very helpful to those who are considering comprehensive health care reform on a state level. RAND has shown that a single payer system would cover everyone without increasing total health care spending; private health insurance for the nonelderly plus Medicare for seniors and the disabled would cover everyone but would increase total spending; and providing a state-run health plan (public option) would have only a negligible impact on coverage and spending.

Health policy wonks should read the full study, and reform activists should read at least the 12 page summary. As with any study of this type, certain assumptions are made and differing emphases can be placed on various features of the reform models. For these reasons this study warrants at least the following comments.

For the single payer model, the authors assumed that payment rates for health care providers would be reduced ten percent below the current average Oregon rates. That supposedly would keep total spending at the same level by offsetting the increased volume of care for those who are newly insured and for those who have a significant decrease in their cost sharing.

The authors assume that services would be less available because of the payment reductions, contending that some providers would reduce their supply of care or perhaps even leave the state. They state that this would lead to “congestion” – greater consumer demand with diminished provider availability. This could result in excessive queues or in the need to travel greater distances for care.

This conclusion derives partly from the fact that they assumed that the administrative savings would be much smaller than several other studies have shown. Although a study demonstrating the tremendous administrative burden placed on the providers was included in the appendix, the authors did not factor in the savings that would accrue for the providers by eliminating the private insurers and simplifying the public payment procedures through a single payer. In fact, one of the reasons for reducing payments is that the amount recovered by eliminating the administrative waste is quite significant.

Another factor is that when the volume increases more room is made for the more pressing problems which partially displaces care that is of little or no value. Thus health care value actually increases when there is some pressure on the schedule. Also the use of other health care professionals such as nurse practitioners and physician assistants can help meet the increased demand at a lower marginal cost.

Also their modeling at a ten percent reduction in average payments is still quite a bit above the Medicare rates that are paid in Oregon. Most providers would not find that having absolutely everyone covered with higher than Medicare rates to be particularly onerous. Besides, most dedicated professionals would be satisfied with reasonable payments for their services. Those who are not perhaps should look for income opportunities that would shift them into the one-percenters – a breed not really welcome in health care.

Another point that should be made is that the two comprehensive models are characterized as a public model that would cause “congestion” (queues for non-urgent services) versus a private model that would increase spending. But the two most objectionable features of the private insurance model are given only fleeting acknowledgment in this study. Those are the very high deductibles and other cost sharing and the limited choice in care because of narrow provider networks. In the single payer model, cost sharing is dramatically reduced or eliminated, and there is only one provider network that includes the entire legitimate health care delivery system. Although high cost sharing and narrow networks may reduce spending in the private insurance model, they are not needed in a publicly administered single payer model.

This study also has important lessons for those who insist that we must enact single payer on the state level before we attempt to enact a national program. For those who believe that enacting a state-level public option will eventually lead to single payer, this study shows that it would have only a negligible impact in reducing the uninsured and in controlling costs. Pass it and then nothing else will happen for years to follow.

The other lesson for state reform activists is that there are major barriers to enacting a bona fide single payer system at the state level – barriers that will most likely require federal legislation. As long as we need to carry the battle to the national level, we might as well go for a national single payer program – an improved Medicare for all. Please do continue to work for beneficial changes at the state level, but please do not let it diminish your advocacy for health care justice for the entire nation.

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Harris Poll on profits and ethics in health care

Posted by on Thursday, Jan 19, 2017

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Only Nine Percent of U.S. Consumers Believe Pharma and Biotechnology Put Patients over Profits; Only 16 Percent Believe Health Insurers Do

The Harris Poll, January 17, 2017

Only nine percent of U.S. consumers believe pharmaceutical and biotechnology companies put patients over profits, while only 16 percent believe health insurance companies do, according to a Harris Poll study released today. Meanwhile, 36 percent of U.S. adults believe health care providers (such as doctors and nurses) put patients over profits, compared to hospitals (23%).

More consumers rate health insurance (24%) and pharmaceutical and biotechnology companies (20%) with low reputations, compared to hospitals (6%), health care providers (doctors and nurses) (5%) and technology (2%). Fifty-eight percent rate the reputation of the technology industry as high, compared to health care providers (43%), hospitals (37%), pharmaceutical and biotechnology companies (20%), and health insurance companies (15%).

Consumer Skepticism High Across Health Care – But to Varying Degrees

Nearly half of consumers say they think store pharmacists (49%) and health care providers (48%) offer high quality products and services, compared to hospitals (44%), pharmaceutical companies (31%), and health insurance companies (26%). Roughly half of consumers believe providers (51%) and hospitals (49%) make a positive difference in the country, compared to store pharmacists (39%), health insurance companies (26%) and pharmaceuticals (26%).

Consumers See Providers, Patients Solving Health Care Challenges

When asked where solutions to the health care industry’s challenges will come from, more than half of U.S consumers (55%) say health care providers, such as doctors or nurses. Nearly half (47%) see patients and consumers solving health care challenges, while 38 percent cite the government. Other responses include health insurance companies (34%), pharmaceutical and biotechnology companies (32%), hospitals (31%), academics, non-profits or think tanks (29%), technology companies (25%), and retail pharmacies (7%).

Ethics Deemed Important Trait to Solve Health Care Challenges

The Harris Poll study finds that in order to be a part of the solution in addressing U.S. health care needs, consumers believe it is most important for organizations to demonstrate ethics (62% say very important) and quality (57%). Other critical factors include efficiency (51%), a long-term view versus a short-term gain (49%), collaboration (47%), flexibility (47%), and transparency (47%).…

While pharmaceutical firms and insurers stand out for having reputations of placing profits over patients, the rest of the health care industry has not totally escaped the perception of this blemish in its ethics.

It is reassuring that health care professionals – physicians and nurses – still have enough respect that the poll respondents believe that these professionals working with patients are best suited to provide solutions to our health care industry challenges. They believe that it is important to demonstrate ethics above all in addressing these problems.

Since ethics is integral to organizations such as Physicians for a National Health Program and National Nurses United/California Nurses Association, they and other sectors that operate on the same ethical plane are well positioned to work with the people of the nation to bring health care justice to all. We, along with the people, need to lead.

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Pew poll confirms support of government responsibility in health care

Posted by on Wednesday, Jan 18, 2017

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

More Americans say government should ensure health care coverage

By Kristen Bialik
Pew Research Center, January 13, 2017

As the debate continues over repeal of the Affordable Care Act and what might replace it, a growing share of Americans believe that the federal government has a responsibility to make sure all Americans have health care coverage, according to a new Pew Research Center survey.

Currently, 60% of Americans say the government should be responsible for ensuring health care coverage for all Americans, compared with 38% who say this should not be the government’s responsibility. The share saying it is the government’s responsibility has increased from 51% last year and now stands at its highest point in nearly a decade.

More than eight-in-ten Democrats and Democratic-leaning independents (85%) say the federal government should be responsible for health care coverage, compared with just 32% of Republicans and Republican leaners.

While about three-quarters of those with family incomes of less than $30,000 per year (74%) say the government should ensure coverage, only about half (53%) of those with incomes of $75,000 or higher say the same.

The belief that the government has a responsibility to ensure health coverage has increased across many groups over the past year, but the rise has been particularly striking among lower- and middle-income Republicans.

Currently, 52% of Republicans with family incomes below $30,000 say the federal government has a responsibility to ensure health coverage for all, up from just 31% last year. There also has been a 20-percentage-point increase among Republicans with incomes of $30,000-$74,999 (34% now, 14% last year). But there has been no significant change among those with incomes of $75,000 or more (18% now, 16% then).

Overall, 43% of Democrats and Democratic leaners support a so-called single payer approach, but this approach is more popular among liberal Democrats (51%) than among conservative and moderate Democrats (38%).

Most of those on the other side of the issue – people who say the government does not have a responsibility to ensure health coverage – say on a subsequent question that the government should continue Medicare and Medicaid (32% of the overall public), while just 5% of the public says the government should have no role in health care.









Once again about 60 percent of Americans say that the government should be responsible for ensuring health care coverage for everyone. There are a couple of observations in this particular poll worth considering.

As the health care reform process began, there was a decline in support of a government responsibility in health care coverage. That decline has reversed and is now back to 60 percent (see graph).

Last year, 31 percent of Republicans with family incomes below $30,000 supported a government responsibility for coverage and now that has increased to 52 percent. This suggests that the prospects for bipartisan support are greater, including Trump voters.

The poll also suggests that the term “single payer” has not gained as much traction, though a previous Kaiser Health Tracking Poll has demonstrated much stronger support for the “Medicare for all” framing.

Regardless, the ground is fertile to advance the cause of health care justice for all. Let’s do it.

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The recent first step by the Republicans for repeal of the ACA (by a vote of 51-48 in the Senate and 227-198 in the House) (1) opens up an intense debate among Republicans as to how and when to replace it. President-elect Donald Trump is pressing Congress to replace it concurrently, or nearly so, with its actual repeal, with which House Speaker Paul Ryan now seems to agree. Recent talk of a two to four-year delay is quickly fading away. Having embarked on the budget reconciliation process, the GOP can expect to pass repeal with just a bare majority vote in Congress, thereby avoiding filibuster by Democrats, but knows it will need 60 votes in the Senate to pass any real replacement package, thus requiring some help from the Democrats.

Some say the GOP still has no replacement plan, after almost seven years contesting the ACA, But they actually have published their principles, and have somewhat similar competing plans on the shelf, with some variation as to details. Republicans now realize the political dangers of a two to four-year delay after repeal, and are now trying to gain consensus among these plans as two House committees report out by the end of this month. The question of Tom Price’s role in the outcome lingers as his committee hearings are delayed into February, when we will learn if he is to be confirmed as incoming head of the Department of Health and Human Services (DHHS).

In the meantime, we already know a lot about what to expect in the final Republican post-ACA replacement plan. First, these are the principles upon which it will be based:

  1. States, not the federal government, should have primary responsibility for health policy;
  2. Patients and doctors should be in control;
  3. There should be more competition among health plans to give patients more choices; and
  4. Small business should have more discretion and flexibility to configure health benefits for their employees. (2)

Released last summer, Paul Ryan’s 37-page white paper, A Better Way, includes continuation of consumer-directed health care (CDHC) (with patients having “more skin in the game”), health savings accounts, high-risk pools, selling insurance across state lines, association health plans among businesses, and further privatization of Medicare and Medicaid (3) Tom Price (R-GA), as leader of the House Budget Committee, proposed in 2015 the complete repeal of the ACA, as well as privatization of Medicare, sharp cuts in Medicaid funding, and defunding of Planned Parenthood. (4)

The problem with all of these proposals is—they won’t work. Each of these directions has been used for years, and have all failed to assure Americans with better access to affordable health care. They have been discredited by long experience.

Here are four fatal flaws to these proposals:

  1. Market failure. Like the ACA, any of their replacement plans are still based mainly on the private for-profit market place. Insurers, the drug industry, and other parts of the medical-industrial complex, including their shareholders, have enjoyed bonanza years on Wall Street under the ACA without any significant cost containment. Most people are unaware of how extremely privatized and for-profit the current health care system is, as these examples show: free-standing laboratory and imaging centers (100 %), surgical-centers (95 %), dialysis centers (90 %), home care (76 %), nursing homes (65 %), and hospice (63 %) (1) (2016 Annual Survey by the Commerce Department or most recent available data for share of establishments.) Instead of increased competition, we have seen increasing consolidation and less competition under the ACA.
  2. Failure to learn from past failed health care policies. Republicans conveniently forget that the ACA was modeled on a health plan brought forward by the Heritage Foundation and enacted as the Massachusetts Health Plan by Governor Romney in 2006. Three years later, a study comparing safety net hospitals with non-safety net hospitals found that the former played a disproportionately large role in caring for disadvantaged patients and were hurting financially. (5) Many reasons for the ACA’s failure have been discussed elsewhere, including its reliance on a failing multi-payer financing system with some 1,300 private insurers, mostly dedicated to profits rather than coverage of patients’ health needs. How they continue to discriminate against the sick, profiteer, and inflate their overhead has been described elsewhere, to the point where the industry is not sustainable without taxpayer support. (6)
  3. Further privatization. Contrary to experience, evidence and GOP ideology, privatization is less competitive, less efficient, and more expensive for patients than the public sector, as already demonstrated by private Medicare and Medicaid plans. Privatized plans offer less choice, are more volatile and less accountable than their public counterparts. They game the system and demand ongoing overpayments (e.g. more than $173 billion to Medicare Advantage between 2008 and 2016 (7) All that amounts to corporate welfare at taxpayer expense.
  4. Dependence on larger role of states. There are already wide variations in states’ definitions of eligibility and coverage, which are likely to increase further as more restrictive federal block grants to states become widespread. Safety net resources will be hit hard, seriously impacting the most vulnerable among us.

The GOP is taking us over a cliff, not yet realizing it may well be political suicide for the party. We can expect that any GOP replacement plan will cost patients, families, and taxpayers more, and that we will all get less. This is all so foolish since there is a real solution in plain sight—single-payer national health insurance (NHI) if Republicans were not so blinded by ideology and unaware of the failed policies already proven by the last 25-plus years’ experience, including those of the ACA, much of which are still baked into their supposed “better way.” They also seem to be unaware of the most recent public polls strongly favoring NHI, regardless of political party. As just one example, a Gallup poll in May 2016 found that 41 percent of Republicans and leaners favored replacing the ACA with NHI. (8)

Defying experience and reason, we can anticipate that the GOP’s principles and approaches will make an imploding ACA system even worse. We can then expect a huge backlash from the public and even the private insurance industry when it doesn’t get all that it wants.

John Geyman, M.D. is the author of  The Human Face of ObamaCare: Promises vs. Reality and What Comes Next and How Obamacare is Unsustainable: Why We Need a Single-Payer Solution For All Americans


1.    Robert Pear, Obamacare Repeal Moves a Step Closer to Reality, The Atlantic Online, Jan. 13, 2017 –
2.    Senate Republican Leaders Vow to Begin Repeal of Health Law Next Month, New York Times Online, December 6, 2017 –
3.    Rovner, J. House Republicans unveil long-awaited plan to replace health law. Kaiser Health News, June 22, 2016 –
4.    Petito, J, Hyatt, A, Zingman, M. We condemn the AMA and AAMC endorsements of Tom Price for HHS secretary. Common Dreams, December 12, 2016 –
5.    Mohan, A, Grant, J, Batalden, M et al. The health of safety net hospitals following Massachusetts health care reform: Changes in volume, revenue, costs, and operating margins from 2006 to 2009. Intl J Health Services 43 (2): 321-335, 2013 –
6.    Geyman, JP. How Obamacare Is Unsustainable: Why We Need a Single Payer Solution for all Americans. Friday Harbor, WA. Copernicus Health Care, 2015 –
7.    Geruso, M, Layton, T. Upcoding inflates Medicare costs in excess of $2 billion annually. UT News. University of Texas at Austin, June 18, 2015 –
8.    Republican support for single-payer. Gallup poll, May 16, 1016. Keith Ensminger. Kramer Translation, Merced, CA. Personal communication, September 8, 2016 –

CBO update of estimates of premiums and coverage under repeal of ACA

Posted by on Tuesday, Jan 17, 2017

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

How Repealing Portions of the Affordable Care Act Would Affect Health Insurance Coverage and Premiums

Congressional Budget Office, January 2017

A little more than a year ago, the Congressional Budget Office and the staff of the Joint Committee on Taxation (JCT) estimated the budgetary effects of H.R. 3762, the Restoring Americans’ Healthcare Freedom Reconciliation Act of 2015, which would repeal portions of the Affordable Care Act (ACA) — eliminating, in two steps, the law’s mandate penalties and subsidies but leaving the ACA’s insurance market reforms in place. At that time, CBO and JCT offered a partial assessment of how H.R. 3762 would affect health insurance coverage, but they had not estimated the changes in coverage or premiums that would result from leaving the market reforms in place while repealing the mandate penalties and subsidies. This document—prepared at the request of the Senate Minority Leader, the Ranking Member of the Senate Committee on Finance, and the Ranking Member of the Senate Committee on Health, Education, Labor, and Pensions—provides such an estimate.

In brief, CBO and JCT estimate that enacting that legislation would affect insurance coverage and premiums primarily in these ways:

* The number of people who are uninsured would increase by 18 million in the first new plan year following enactment of the bill. Later, after the elimination of the ACA’s expansion of Medicaid eligibility and of subsidies for insurance purchased through the ACA marketplaces, that number would increase to 27 million, and then to 32 million in 2026.

* Premiums in the nongroup market (for individual policies purchased through the marketplaces or directly from insurers) would increase by 20 percent to 25 percent—relative to projections under current law — in the first new plan year following enactment. The increase would reach about 50 percent in the year following the elimination of the Medicaid expansion and the marketplace subsidies, and premiums would about double by 2026.

If the Congress considers legislation similar to H.R. 3762 in the coming weeks, the estimated effects could differ from those described here. In particular, the response of individuals, insurers, and states would depend critically on the particular specifications contained in such legislation.…


Trump vows ‘insurance for everybody’ in Obamacare replacement plan

By Robert Costa and Amy Goldstein
The Washington Post, January 15, 2017

“It’s not going to be their plan,” he said of people covered under the current law. “It’ll be another plan. But they’ll be beautifully covered. I don’t want single-payer. What I do want is to be able to take care of people,” he said Saturday.

Trump did not say how his program overlaps with the comprehensive plan authored by House Republicans. Earlier this year, (Tom) Price suggested that a Trump presidency would advance the House GOP’s health-care agenda.…

So far Congress has initiated a process to eliminate health plan subsidies and eliminate individual and employer mandates authorized by the Affordable Care Act. This update estimates the numbers who would be uninsured and estimates the increase in non-group insurance premiums that would occur if insurance reforms such as guaranteed issue remained in place. In the next decade another 32 million people would be without insurance and premiums for exchange plans would double.

It is highly unlikely that Congress would stop here since they have promised a replacement plan. We do not know what that is but President-elect Trump now says that he does not want single payer, and the Republicans in Congress do not either. Trump does say that he has a plan and that people will be “beautifully covered.”

Beautiful coverage is not a standard health policy term, but if it means that everyone will be covered with plans that are affordable and provide access, we can see problems ahead. Expanding coverage to everyone, reducing financial barriers such as high deductibles, and ensuring access while rejecting the efficiencies of a single payer system will be very expensive. Most Americans will not be able to afford the cost of such coverage which means that Congress must authorize massive subsidies to help pay for the very high costs. This Congress?

You can see that this tale is not finished. The people are going to have to watch closely as it unfolds and then be prepared to thrust our wrath onto our elected representatives as they begin to move down the wrong path on reform. Although our signs will say SINGLE PAYER, our pitchforks should have more than the traditional two or three tines since forks with four or five tines are crafted to pitch manure.

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What would Martin Luther King Jr say?

Posted by on Monday, Jan 16, 2017

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

By Dr. Martin Luther King Jr.
Medical Committee for Human Rights, March 25, 1966

“Of all the forms of inequality, injustice in health is the most shocking and inhuman.”…


Noam Chomsky: The US Health System Is an “International Scandal” — and ACA Repeal Will Make It Worse

By C.J. Polychroniou
Truthout, January 12, 2017

Selected quotes of Noam Chomsky:

First, it is important to remember that the US does not accept the Universal Declaration of Human Rights — though in fact the UDHR was largely the initiative of Eleanor Roosevelt, who chaired the commission that drafted its articles, with quite broad international participation.

The UDHR has three components, which are of equal status: civil-political, socioeconomic and cultural rights. The US formally accepts the first of the three, though it has often violated its provisions. The US pretty much disregards the third. And to the point here, the US has officially and strongly condemned the second component, socioeconomic rights, including Article 25.

Rejection of Article 25, then, is a matter of principle. And also a matter of practice. In the OECD [Organization for Economic Cooperation and Development] ranking of social justice, the US is in 27th place out of 31, right above Greece, Chile, Mexico and Turkey. This is happening in the richest country in world history, with incomparable advantages.


All of this is part of the background for the US departure in health care from the norm of the OECD, and even less privileged societies. But there are deeper reasons why the US is an “outlier” in health care and social justice generally. These trace back to unusual features of American history. Unlike other developed state capitalist industrial democracies, the political economy and social structure of the United States developed in a kind of tabula rasa. The expulsion or mass killing of Indigenous nations cleared the ground for the invading settlers, who had enormous resources and ample fertile lands at their disposal, and extraordinary security for reasons of geography and power. That led to the rise of a society of individual farmers, and also, thanks to slavery, substantial control of the product that fueled the industrial revolution: cotton, the foundation of manufacturing, banking, commerce, retail for both the US and Britain, and less directly, other European societies. Also relevant is the fact that the country has actually been at war for 500 years with little respite, a history that has created “the richest, most powerful, and ultimately most militarized nation in world history,” as scholar Walter Hixson has documented.

For similar reasons, American society lacked the traditional social stratification and autocratic political structure of Europe, and the various measures of social support that developed unevenly and erratically. There has been ample state intervention in the economy from the outset — dramatically in recent years — but without general support systems.

As a result, US society is, to an unusual extent, business-run, with a highly class-conscious business community dedicated to “the everlasting battle for the minds of men.” The business community is also set on containing or demolishing the “political power of the masses,” which it deems as a serious “hazard to industrialists” (to sample some of the rhetoric of the business press during the New Deal years, when the threat to the overwhelming dominance of business power seemed real).


As for reasons, we can return to the more general question of social justice comparisons, but there are special reasons in the health care domain. To an unusual extent, the US health care system is privatized and unregulated. Insurance companies are in the business of making money, not providing health care, and when they undertake the latter, it is likely not to be in the best interests of patients or to be efficient. Administrative costs are far greater in the private component of the health care system than in Medicare, which itself suffers by having to work through the private system.

Comparisons with other countries reveal much more bureaucracy and higher administrative costs in the US privatized system than elsewhere. One study of the US and Canada a decade ago, by medical researcher Steffie Woolhandler and associates, found enormous disparities, and concluded that “Reducing U.S. administrative costs to Canadian levels would save at least $209 billion annually, enough to fund universal coverage.”


The facts about public support for universal health care receive occasional comment, in an interesting way. When running for president in 2004, Democrat John Kerry, The New York Times reported, “took pains .. to say that his plan for expanding access to health insurance would not create a new government program,” because “there is so little political support for government intervention in the health care market in the United States.” At the same time, polls in The Wall Street Journal, Businessweek, The Washington Post and other media found overwhelming public support for government guarantees to everyone of “the best and most advanced health care that technology can supply.”

But that is only public support. The press reported correctly that there was little “political support” and that what the public wants is “politically impossible” — a polite way of saying that the financial and pharmaceutical industries will not tolerate it, and in American democracy, that’s what counts.


Implicit submission is not imposed by laws of nature or political theory. It is a choice, at least in societies such as ours, which enjoys the legacy provided by the struggles of those who came before us. Here power is indeed “on the side of the governed,” if they organize and act to gain and exercise it. That holds for health care and for much else.…

Of the OECD nations, the United States ranks near the bottom in health care justice. And yet Congress is moving forward with legislative action that likely would further diminish justice within our health care system. On this day dedicated to Martin Luther King Jr, it seems appropriate to ask what he would say. Well, we already know because he did say, “Of all the forms of inequality, injustice in health is the most shocking and inhuman.”

Noam Chomsky explains the appalling truth of how this could be in the United States – the wealthiest nation on earth. Yet, he explains, we do not have to accept health care injustice since power is on the side of the governed if we organize and act to gain and exercise it.

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High premiums in non-group insurance markets

Posted by on Friday, Jan 13, 2017

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Identifying Causes and Possible Remedies

By Linda J. Blumberg and John Holahan
Urban Institute, January 2017

The Issue

The authors note that premiums are not high in all areas, and that many areas with large recent premium increases reflect needed corrections to very low premiums in the early years of reform. However, in sources with high premium levels, the causes differ, as should appropriate solutions.

Key Findings

The first potential problem is that sicker people are more likely to enroll in marketplace plans;

The second, premiums tend to be higher if an insurer or provider group has a monopoly in their area; and

Third, inadequate risk adjustment, i.e., moving premium dollars from insurers with low-cost enrollees to insurers with high-cost enrollees, may also be a factor leading to high premiums in some areas.


Marketplaces in many areas throughout the United States have experienced high premiums and insurer attrition for the 2017 plan year. In this brief, we identify three potential sources of these difficulties, not all of which exist in all markets, and we emphasize that some markets continue to work competitively and without any significant difficulties.

First, some ACA-compliant nongroup insurance markets have enrolled a population with above-average health care risks relative to a broad cross section of the nonelderly population (e.g., the population enrolled in employer-based insurance). In these cases, above-average claims have led to high and increasing premiums and losses for some insurers that were large enough to force them out of the market. Second, some markets have high insurer and/or provider concentration. The exercise of monopoly or near-monopoly power in these markets can lead to high provider payment rates and high premiums. Third, in some markets, the risk-adjustment system may not have sufficiently shared health care risk across insurers within the nongroup insurance market, either moving too much money away from lower-cost insurers or moving too little money toward higher-cost insurers. In such cases, insurers may have increased premiums to compensate for their losses. An inadequate risk-adjustment system could also induce all insurers in a market to increase premiums because they fear that they may be selected against but not receive appropriate compensation through the risk-adjustment mechanism.

In this paper, we argue that each problem requires a different approach. Some policies may be implemented in some states and substate areas and not in others. However, a more uniform national strategy could incorporate a range of policies that collectively could address all these problems, with policies designed to be binding only in the specific areas where they are warranted. Because different markets have different problems, some policy solutions will be essential in some markets and have little or no impact in others. Implementing these policies nationally would obviate the need to design and legislate policies on an ongoing basis as market conditions change over time.

To address the problem of low enrollment and adverse selection against the entire nongroup market in an area, first, we suggest a significant increase in outreach and enrollment assistance and more generous premium tax credits and cost-sharing assistance. Second, penalties for not obtaining health insurance may also be increased, once coverage is made more affordable with increased financial assistance. Third, there should be a permanent reinsurance program funded from a broad-based source (e.g., general revenues or a tax on all insurance plans and stop-loss plans sold to self-insuring employers) that would subsidize nongroup insurance market plans with extremely high claims (e.g., $1 million or more).

Fourth, there should be increased regulation of sales of non-ACA-compliant nongroup insurance products (e.g., short-term policies, disease-specific policies, indemnity plans). These products are most attractive to those in relatively good health. Phasing them out, eliminating them entirely, or assessing them in order that they share in the risk of the ACA compliant market, will make individuals more likely to purchase ACA compliant plans and improve the risk pool. Finally, fixing the family glitch and lowering the Medicaid eligibility threshold to 100 percent of the FPL would also increase marketplace enrollment while improving the private nongroup insurance pools’ risk profiles.

In principle, the problems of insurer and provider concentration could be solved with a public insurance option, but this would be extremely difficult to implement. For starters, the government would have to develop a large new organization, and the approach is certain to face opposition from the insurance industry. An alternative that could be more politically palatable (at least to insurers) is a cap on provider payment rates paid by any ACA-compliant nongroup insurer within a particular market (e.g., Medicare plus some percentage). Insurers could develop networks at lower provider payment rates, but providers would be prohibited from charging nongroup insurers above the statutory limit. This would be more attractive than a public option to insurers, though many providers would probably be opposed to any legislation limiting their payment rates (even though these limits would apply to the fairly small population enrolled in nongroup coverage). In markets where provider payment rates are already low (e.g., those with high levels of competition), this policy would have little or no effect. But it could have a significant effect in markets where few insurers compete or where providers have significant market power and insurers have little or no negotiating leverage.

Problems with the risk-adjustment mechanism may persist even after CMS implements improvements in 2017. The inclusion of prescription drug use in the risk-adjustment formula is a step in the right direction. Other improvements are beyond the scope of this paper and require additional research. However, we believe the approach proposed by the Obama administration for 2018, which would add a reinsurance-type component for insurers incurring extremely high claims in a given year, could be very helpful.

Ideally, the federal government would adopt an array of these policies and apply them nationwide. As noted above, not all would be binding in all markets in any particular year. But implementing each policy on an as-needed basis in each particular time and place would leave the overall program vulnerable to political challenges, market instability, and logistical delays. However, in the face of federal inaction, individual states could choose to implement the specific policies that apply to them. These mechanisms should lead to increased enrollment, a fairer distribution of risk among insurers, greater insurer participation in ACA-compliant nongroup markets, more stable risk pools, and more predictable increases in premiums year to year.…

Full report (9 pages):…

Linda Blumberg and John Holahan explain why premiums in non-group insurance markets can be high, and they suggest policies that can improve the stability of premiums. The proposals would increase the administrative complexity in our system when we are already tremendously overburdened with administrative excesses, and, further, they are designed to protect the private insurance industry – an approach in which providers and patients are considered a nuisance which must be accommodated to benefit the insurers.

The key findings – adverse selection, insurer or provider monopolies, and inadequate risk adjustment – would not be issues under a well designed single payer national health program. Our policy community is well meaning when they try to fix the the serious faults with our fragmented, dysfunctional financing system, but they do a disservice to all of us when they continue to exclude the single payer model from their policy briefs.

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What would states do with greater flexibility through Medicaid block grants?

Posted by on Thursday, Jan 12, 2017

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Both State, Feds May Seek Changes To Medicaid

By Shamane Mills
Wisconsin Public Radio, January 11, 2017

Wisconsin hopes to change Medicaid in several ways. The Walker administration would like participants to undergo drug testing, charge smokers more and put time limits on how long people could use Medicaid.

Gov. Scott Walker’s entitlement reforms come as top Republicans in Washington, D.C. are pushing for states to get federal block grants they could spend as they wish on Medicaid.…


Missouri lawmakers seek to convert Medicaid to block grant

By David A. Lieb, AP
St. Louis Post-Dispatch, January 11, 2017

Not waiting for President-elect Donald Trump to act first, some Missouri Republican lawmakers are pressing for a health care overhaul that could convert the state’s Medicaid program into a block grant from the federal government.

Missouri Sen. David Sater said the state’s more than $9 billion Medicaid program — called MO HealthNet — is beset by “runaway spending” and lacks “personal accountability and responsibility.”

The Missouri legislation seeks to address that by requesting federal approval for the block grant to be adjusted for inflation, growth in the Medicaid rolls and other economic and demographic factors. It also seeks approval to potentially implement work requirements for able-bodied Medicaid enrollees and to require co-payments, premiums or health savings accounts for patients to “reward personal responsibility.”…

There are two main reasons that the Republicans want to convert Medicaid to block grants for the states. Instead of paying a percentage of Medicaid costs, block grants can be set at an amount of payment that is lower and that does not increase at the same rate as health costs, thus shifting Medicaid costs from the federal government to the states. Also, the states are given much greater leeway on how the block grant funds can be spent, reducing federal regulatory oversight.

Many state governments are concerned about the reduced funding that would be available for health care for the low-income sector. Most states operate on very tight budgets and would have difficulty assuming a significantly greater proportion of the costs. Some states simply do not have an adequate tax base that would support the needs of these individuals. Federal funding is much more equitable and egalitarian.

Granting greater leeway on how the Medicaid funds would be spent is very appealing to state ideologues. There is a push today to require greater personal responsibility through policies such as drug testing, penalizing smokers, failure to meet work requirements, requiring financial responsibility through premiums, cost sharing, and required contributions to health savings accounts in this population that has no discretionary income, and perhaps ejecting individuals from the program simply because they have been on it long enough.

These politicians seem to look upon Medicaid beneficiaries as people who are less  deserving because of their welfare status that they believe is due to their own volition. They believe that simply requiring more personal responsibility is the solution, except for those more severely handicapped. Most health professionals who work with these patients know differently and understand why they qualify for Medicaid.

But think of how it would be under a single payer national health program. Everyone would receive essential health care services regardless of socioeconomic status. The politicians certainly expect to have their care when they need it. Why shouldn’t everyone have the same expectation?

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Social risk factors and performance measurements

Posted by on Wednesday, Jan 11, 2017

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Report to Congress: Social Risk Factors and Performance Under Medicare’s Value-Based Purchasing Programs

United States Department of Health and Human Services
Office of the Assistant Secretary for Planning and Evaluation, December 2016


There is growing recognition that social risk factors – such as income, education, race and ethnicity, employment, community resources, and social support – play a major role in health. Despite ongoing efforts, significant gaps remain in health and in life expectancy based on income, race, ethnicity, and community environment.

At the same time, the health care system is increasingly moving towards higher levels of provider accountability for the quality, outcomes, and costs of care. Value-based or alternative payment models, which tie payment to the quality and efficiency of health care delivered, are in place in nearly all Medicare settings, including in hospitals, outpatient settings, and post-acute facilities.

These two issues are intersecting. If beneficiaries with social risk factors have worse health outcomes because the providers they see provide low-quality care, value-based purchasing could be a powerful tool to drive improvements in care and reduce health disparities. However, if beneficiaries with social risk factors have worse health outcomes because of elements beyond the quality of care provided, such as the social risk factors themselves, value-based payment models could do just the opposite. If providers have limited ability to influence health outcomes for beneficiaries with social risk factors, they may become reluctant to care for beneficiaries with social risk factors, out of fear of incurring penalties due to factors they have limited ability to influence.

This report, mandated by the Improving Medicare Post-Acute Care Transformation Act of 2014 or the IMPACT Act (P.L. 113-185), shares empirical analysis using existing Medicare data to help address these questions and provides considerations for policymakers while additional work using other data sources continues.


FINDING 1: Beneficiaries with social risk factors had worse outcomes on many quality measures, regardless of the providers they saw, and dual enrollment status was the most powerful predictor of poor outcomes.

FINDING 2: Providers that disproportionately served beneficiaries with social risk factors tended to have worse performance on quality measures, even after accounting for their beneficiary mix. Under all five value-based purchasing programs in which penalties are currently assessed, these providers experienced somewhat higher penalties than did providers serving fewer beneficiaries with social risk factors.

Strategies and Considerations

STRATEGY 1: Measure and Report Quality for Beneficiaries with Social Risk Factors

Consideration 1: Consider enhancing data collection and developing statistical techniques to allow measurement and reporting of performance for beneficiaries with social risk factors on key quality and resource use measures.

Consideration 2: Consider developing and introducing health equity measures or domains into existing payment programs to measure disparities and incent a focus on reducing them.

Consideration 3: Prospectively monitor the financial impact of Medicare payment programs on providers disproportionately serving beneficiaries with social risk factors.

STRATEGY 2: Set High, Fair Quality Standards for All Beneficiaries

Consideration 1: Measures should be examined to determine if adjustment for social risk factors is appropriate; this determination will depend on the measure and its empirical relationship to social risk factors.

Consideration 2: The measure development community should continue to study program measures to determine whether differences in health status might underlie the observed relationships between social risk and performance, and whether better adjustment for health status might improve the ability to differentiate true differences in performance between providers.

STRATEGY 3: Reward and Support Better Outcomes for Beneficiaries with Social Risk Factors

Consideration 1: Consider creating targeted financial incentives within value-based purchasing programs to reward achievement of high quality and good outcomes, or significant improvement, among beneficiaries with social risk factors.

Consideration 2: Consider using existing or new quality improvement programs to provide targeted support and technical assistance to providers that serve beneficiaries with social risk factors.

Consideration 3: Consider developing demonstrations or models focusing on care innovations that may help achieve better outcomes for beneficiaries with social risk factors.

Consideration 4: Consider further research to examine the costs of achieving good outcomes for beneficiaries with social risk factors and to determine whether current payments adequately account for any differences in care needs.


Social factors are powerful determinants of health. In Medicare, beneficiaries with social risk factors have worse outcomes on many quality measures, including measures of processes of care, intermediate outcomes, outcomes, safety, and patient/consumer experience, as well as higher costs and resource use. Beneficiaries with social risk factors may have poorer outcomes due to higher levels of medical risk, worse living environments, greater challenges in adherence and lifestyle, and/or bias or discrimination. Providers serving these beneficiaries may have poorer performance due to fewer resources, more challenging clinical workloads, lower levels of community support, or worse quality.

The scope, reach, and financial risk associated with value-based and alternative payment models continue to widen. There are three key strategies that should be considered as Medicare aims to administer fair, balanced programs that promote quality and value, provide incentives to reduce disparities, and avoid inappropriately penalizing providers that serve beneficiaries with social risk factors. Measuring and reporting quality for beneficiaries with social risk factors, setting high, fair quality standards for all beneficiaries, and the provision of targeted rewards and supports for better outcomes for beneficiaries with social risk factors, may help ensure that all Medicare beneficiaries can achieve the best health outcomes possible.

Next Steps

The findings outlined in this report represent only the beginning of a body of necessary work around fair and accurate quality measurement in the context of Medicare’s increasing use of value-based purchasing programs. The IMPACT Act lays out specific additional requirements for Study B, including the examination of specific social risk factors not currently available in Medicare data such as health literacy, limited English proficiency, and Medicare beneficiary activation (the degree to which beneficiaries have the knowledge, skill, and confidence to manage their health and health care). Based on the findings in this report, future work may also include examining the impact of measuring and accounting for functional status or frailty on the relationship between social risk factors and performance, and identifying care innovations associated with the achievement of good health outcomes for beneficiaries with social risk factors.

Full report (374 pages):…

One of the problems with the various pay-for-performance schemes is that social risk factors play a major role in health care outcomes. Dedicated physicians and hospitals who take care of patients with greater social risks tend to be penalized for factors over which they have no direct control. This 374 page ASPE report was generated at the request of Congress to define this problem and consider solutions.

Skim reading this report leads to the conclusion that the approach to evaluating the role of social risk factors in payment systems using value-based purchasing, alternative payments models and other forms of payment innovation results in profound administrative complexity, with all of its waste, and yet it is still not very effective in correcting payment injustices. And this 374 pages is only the bare beginning of a “a body of necessary work around fair and accurate quality measurement in the context of Medicare’s increasing use of value-based purchasing programs.”

We continue to head down the wrong path. Our target should be to establish universality in health care while financing the system equitably with a system that reduces administrative waste. Instead you would think, based on the responses of the policy community and government bureaucrats, that the problem is that we do not have enough administrative oversight, so they propose more and more and more!

Instead we should reduce administrative waste by establishing a single payer national health program and improve value through global budgets, negotiated payment rates, and administered pricing, plus separate budgeting of capital distribution and system capacity. The latter should help to improve care for patients with higher social risk factors, though we do need to improve social programs that would better address the fundamental factors resulting in otherwise amenable social risks.

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Overuse and underuse of health care

Posted by on Tuesday, Jan 10, 2017

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Right Care Series

The Lancet, January 8, 2017

Many countries struggle with the question about sustainability, fairness, and equity of their health systems. With the focus firmly on universal health coverage as a central part to the UN Sustainable Development Goals, there is an opportunity to examine how to achieve optimum access to, and delivery of, health care and services. Underuse and overuse of medical and health services exist side-by-side with poor outcomes for health and wellbeing. This Series of four papers and accompanying comments examines the extent of overuse and underuse worldwide, highlights the drivers of inappropriate care, and provides a framework to begin to address overuse and underuse together to achieve the right care for health and wellbeing. The authors argue that achieving the right care is both an urgent task and an enormous opportunity.

The full “Right Care” series is available for free through this link, though registration is required:…


Right Care 1: Evidence for overuse of medical services around the world

By Shannon Brownlee, Kalipso Chalkidou, Jenny Doust, Adam G Elshaug, Paul Glasziou, Iona Heath, Somil Nagpal, Vikas Saini, Divya Srivastava, Kelsey Chalmers, Deborah Korenstein

Overuse, which is defined as the provision of medical services that are more likely to cause harm than good, is a pervasive problem. Direct measurement of overuse through documentation of delivery of inappropriate services is challenging given the difficulty of defining appropriate care for patients with individual preferences and needs; overuse can also be measured indirectly through examination of unwarranted geographical variations in prevalence of procedures and care intensity. Despite the challenges, the high prevalence of overuse is well documented in high-income countries across a wide range of services and is increasingly recognised in low-income countries. Overuse of unneeded services can harm patients physically and psychologically, and can harm health systems by wasting resources and deflecting investments in both public health and social spending, which is known to contribute to health. Although harms from overuse have not been well quantified and trends have not been well described, overuse is likely to be increasing worldwide.

Key messages

• Overuse is difficult to measure and has not been well characterised
• Most studies of overuse have been done in high-income countries, but there is growing evidence that overuse is a global problem
• Overuse is likely to cause physical, psychological and financial harm to patients
• Overuse deflects resources from public health and other social spending in both low-income and high-income countries
• Overuse occurs across a wide range of medical specialties

“Though the doctors treated him, let his blood, and gave him medications to drink, he nevertheless recovered.” – Leo Tolstoy, War and Peace…


Right Care 2: Evidence for underuse of effective medical services around the world

By Paul Glasziou, Sharon Straus, Shannon Brownlee, Lyndal Trevena, Leonila Dans, Gordon Guyatt, Adam G Elshaug, Robert Janett, Vikas Saini

Underuse—the failure to use effective and affordable medical interventions—is common and responsible for substantial suffering, disability, and loss of life worldwide. Underuse occurs at every point along the treatment continuum, from populations lacking access to health care to inadequate supply of medical resources and labour, slow or partial uptake of innovations, and patients not accessing or declining them. The extent of underuse for different interventions varies by country, and is documented in countries of high, middle, and low-income, and across different types of health-care systems, payment models, and health services. Most research into underuse has focused on measuring solutions to the problem, with considerably less attention paid to its global prevalence or its consequences for patients and populations. Although focused effort and resources can overcome specific underuse problems, comparatively little is spent on work to better understand and overcome the barriers to improved uptake of effective interventions, and methods to make them affordable.

Key messages

• Underuse is responsible for substantial suffering, disability, and loss of life worldwide, in both high-income and low-income countries
• Underuse is prevalent across different types of health-care systems, payment models, and health services
• The causes of underuse are multi-layered:from inadequate access, health system failures, clinicians being unaware or unskilled to provide required interventions, and patients not accessing or declining them
• Underuse occurs alongside overuse, particularly in areas where there is competitive tension between profitable and low-cost interventions
• Policymakers, funders, clinicians, and civil society urgently need to recognise, invest, and resolve the slow uptake of effective, affordable, but non-promoted interventions…


Right Care 3: Drivers of poor medical care

By Vikas Saini, Sandra Garcia-Armesto, David Klemperer, Valerie Paris, Adam G Elshaug, Shannon Brownlee, John P A Ioannidis, Elliott S Fisher

The global ubiquity of overuse and underuse of health-care resources and the gravity of resulting harms necessitate an investigation of drivers to inform potential solutions. We describe the network of influences that contribute to poor care and suggest that it is driven by factors that fall into three domains: money and finance; knowledge, bias, and uncertainty; and power and human relationships. In each domain the drivers operate at the global, national, regional, and individual level, and are modulated by the specific contexts within which they act. We discuss in detail drivers of poor care in each domain


The provision of care is initiated by decision making within the doctor–patient relationship, but is substantially influenced by the resources available for health care within the society, its social and political contract, the state of global and local scientific knowledge, the configuration and capacity of the delivery system, and financing mechanisms.8,22,74,214 Achievement of the right care requires an understanding of and attentiveness to all these dimensions in the development of policy choices for promotion of care that is safe, effective, sensitive to personal preferences, and just.

Although no one factor results in the provision of right care, universal health coverage should be recognised as essential at the population level. Each factor can be deemed as equally necessary but equally insufficient by itself. Reducing the role of greed by structuring financial incentives to maximise true clinical benefits and social value is key. Ensuring vigilance against error and bias, broadening research aims, and a focus on meaningful outcomes are key goals in the production of knowledge. Therefore, re-addressing imbalances of knowledge and power, not only within the clinician–patient relationship but also within delivery systems, and more broadly in society, is equally crucial. There are potentially many levers to remedy poor care, but evidence of effectiveness is very modest.

Finally, as biological creatures conscious of our susceptibilty to injury, illness, and death, deep concerns about health are universal. Public support is therefore inevitably susceptible to manipulation for private gain. Active public education, engagement, and empowerment are crucial to ensure that the forces that shape health-care delivery worldwide are truly focused on delivering the right care.…


Right Care 4: Levers for addressing medical underuse and overuse: achieving high-value health care

By Adam G Elshaug, Meredith B Rosenthal, John N Lavis, Shannon Brownlee, Harald Schmidt, Somil Nagpal, Peter Littlejohns, Divya Srivastava, Sean Tunis, Vikas Sain

The preceding papers in this Series have outlined how underuse and overuse of health-care services occur within a complex system of health-care production, with a multiplicity of causes. Because poor care is ubiquitous and has considerable consequences for the health and wellbeing of billions of people around the world, remedying this problem is a morally and politically urgent task. Universal health coverage is a key step towards achieving the right care. Therefore, full consideration of potential levers of change must include an upstream perspective—ie, an understanding of the system-level factors that drive overuse and underuse, as well as the various incentives at work during a clinical encounter. One example of a system-level factor is the allocation of resources (eg, hospital beds and clinicians) to meet the needs of a local population to minimise underuse or overuse. Another example is priority setting using tools such as health technology assessment to guide the optimum diffusion of safe, effective, and cost-effective health-care services. In this Series paper we investigate a range of levers for eliminating medical underuse and overuse. Some levers could operate effectively (and be politically viable) across many different health and political systems (eg, increase patient activation with decision support) whereas other levers must be tailored to local contexts (eg, basing coverage decisions on a particular cost-effectiveness ratio). Ideally, policies must move beyond the purely incremental; that is, policies that merely tinker at the policy edges after underuse or overuse arises. In this regard, efforts to increase public awareness, mobilisation, and empowerment hold promise as universal methods to reset all other contexts and thereby enhance all other efforts to promote the right care.


The modern history of health care is littered with policy and practice inaction in the face of inappropriate care, often justified by an absence of evidence or uncertainty about what might result—Machiavelli’s “new order of things”. This lack of action should no longer be acceptable. Although the scale of the problem is vast and complex, a range of potentially effective remedies are available, with many more needed. Evidence-based medicine, HTA (health technology assessment), shared decision making, and countless other movements have surely nudged health systems to a point whereby we must ultimately acknowledge that a decision not to act is still a decision, and one with implications for people’s health. As efforts to improve the delivery of care continue worldwide, we must recognise that if the objective is to improve health, delivery systems need to be properly scaled and adapted to local needs and socioeconomic conditions to be maximally effective. Furthermore, delivery system leaders should remain humble about their systems’ contributions to health and should be unburdened from the task of substituting less effective medical spending for social spending. Transitions from the norm invariably cause conflict, but if efforts to achieve the right care are able to capture the full opportunity in front of us, the benefits to the wellbeing of patients, professionals, and the public as a whole are too great to condone inaction.

Considering the amount of money we spend on health care in the United States, we should be making special efforts to see that we spend it right. This Lancet series, “Right Care,” is helpful because it defines for us where we are not providing enough care (underuse), leaving too many with unmet health care needs, and where we are providing excess care (overuse), wasting resources that could be used elsewhere, not to mention that excessive care is sometimes harmful.

Although many factors are involved in our misuse of health care, the financing system plays a significant role. We leave far too many people uninsured and underinsured which creates financial barriers to essential health care services. We have a maldistribution of our health care resources which impairs access to care in underserved areas.

By using a finance system that is based on business principles instead of public service, we are using financial disincentives, such as high deductibles, supposedly to discourage overuse but which, in fact, inappropriately incentivizes underuse. A well designed financing system, such as single payer, should go a long way toward addressing the problem of underuse, though other social factors would have to be addressed as well.

Overuse is a more difficult problem. Most health care is in a gray area. Obviously, expensive high-tech care that provides no benefit and is harmful is overuse and should be ferreted out of the system. But when high-tech care is beneficial it may be that it is no more beneficial than less expensive traditional care, but there inevitably would be disagreement on that, even after comparative effectiveness studies are completed. Many treatment regimens have potential adverse consequences, but that is often difficult to balance against the benefits that the patient may experience. Some low cost diagnostic and therapeutic interventions may lack scientific validation but if the interventions are essentially harmless and the patient is improved if for no other reason than reassurance, would this be considered overuse of our health care system? Although some might consider gray area medicine to be overuse, it would be very difficult to recover the costs of this care.

The “Right Care“ series addresses much more than the financing systems of health care, so it would be worthwhile to set time aside to read the articles (4 papers, 3 comments, and 1 perspective). It is imperative that we make “right care” a goal of reform.

But we really do need to get the financing system right. If we don’t, we’ll continue to see money wasted in more affluent areas where there is an excess capacity in high-tech care, and we’ll continue to see deficiencies in care for those who are not well served by our fragmented, dysfunctional system, market-based system.

Once we establish a publicly-financed and publicly-administered financing system, then we can work to improve the distribution and allocation of our resources to reduce waste while being sure that health care is there for people when they need it.

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