National health spending in 2012 – a perspective

Posted by on Tuesday, Jan 7, 2014

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.

National Health Spending In 2012: Rate Of Health Spending Growth Remained Low For The Fourth Consecutive Year

By Anne B. Martin, Micah Hartman, Lekha Whittle, Aaron Catlin, the National Health Expenditure Accounts Team
Health Affairs, January 2014


For the fourth consecutive year, growth in health care spending remained low, increasing by 3.7 percent in 2012 to $2.8 trillion. At the same time, the share of the economy devoted to health fell slightly (from 17.3 percent to 17.2 percent) as the nominal gross domestic product (GDP) grew by 4.6 percent. Faster growth in hospital services and in physician and clinical services was mitigated by slower growth in prices for prescription drugs and nursing home services. Despite an uptick in enrollment growth, Medicare spending growth slowed slightly in 2012, mainly due to lower payment updates. For Medicaid, slowing enrollment growth kept spending growth near historic lows. Growth in private health insurance spending also remained near historically low rates in 2012, largely influenced by the nation’s modest economic recovery and its impact on enrollment.


Medicare accounted for 20 percent of national health spending in 2012, with expenditures reaching $572.5 billion (Exhibit 1). Overall, Medicare spending growth slowed slightly, increasing by 4.8 percent in 2012 compared to 5.0 percent in 2011. Growth in fee-for-service expenditures, which accounted for nearly three-quarters of total Medicare spending, slowed from 4.3 percent in 2011 to 2.7 percent in 2012. Medicare Advantage spending accounted for the remainder, increasing 10.9 percent in 2012—a faster rate than in 2011, when growth was 7.0 percent.

Enrollment in Medicare for all beneficiaries (fee-for-service and Medicare Advantage) jumped 4.1 percent in 2012—the largest one-year increase in enrollment in thirty-nine years—and more than half of these enrollees joined Medicare Advantage. The noticeable increase in total Medicare enrollment reflected the oldest members of the baby-boom generation, who became eligible to enroll in Medicare in 2011.

Total Medicare spending per enrollee grew by 0.7 percent in 2012—slower than the 2.5 percent rate of growth in 2011. This slowdown was largely due to a prominent decline in spending for nursing home care, which declined by 2.2 percent in 2012 following an increase of 9.9 percent the year before. This in turn was driven primarily by a one-time payment reduction to skilled nursing facilities, which followed a large increase in payments in 2011 corresponding to the introduction of the new payment system. In 2012 this reduction was applied to skilled nursing facility rates to recalibrate payments for the newly implemented payment system.15

For Medicare fee-for-service, per enrollee spending growth decelerated from 2.7 percent in 2011 to 0.6 percent in 2012. In addition to the decline in skilled nursing facility spending, slower growth in fee-for-service spending was influenced by spending trends for prescription drugs, physician and clinical services, and hospital care. For beneficiaries with traditional fee-for-service Medicare, prescription drug spending growth slowed because of the increased use of popular lower-cost generic drugs. Slower growth in the volume and intensity of physician services and inpatient hospital admissions contributed to slower fee-for-service Medicare physician and hospital spending in 2012. Finally, for all Part A and most Part B providers, the ACA reduced payment updates in 2012, most notably for hospitals.

The acceleration in Medicare Advantage spending growth in 2012 was driven by a 10.0 percent increase in enrollment. On a per enrollee basis, however, Medicare Advantage spending growth slowed to 0.8 percent in 2012 (from 1.6 percent growth in 2011), partially as a result of the implementation of the ACA’s new payment mechanism. That mechanism links benchmark payment rates to fee-for-service costs, and its implementation effectively lowered the increase in total Medicare Advantage payments. In addition, the ACA required quality ratings of plans to factor into payments beginning in 2012.


In 2012 the economy continued to modestly improve, and GDP grew faster than health care spending, causing the health spending share of the economy to fall slightly—from 17.3 percent to 17.2 percent. Spending growth for personal health care goods and services accelerated in 2012 as trends for hospital services and physician and clinical services more than offset one-time impacts that helped decelerate growth, such as numerous patent expirations for brand-name retail prescription drugs and a Medicare payment reduction for skilled nursing facilities. From a payer perspective, Medicaid spending growth accelerated somewhat in 2012 after experiencing low growth in 2011, while Medicare and private health insurance spending growth slowed slightly. These mixed trends produced the fourth consecutive year of low overall health spending growth and led to a relatively stable health spending share of GDP. However, this pattern is consistent with historical experience when health spending as a share of GDP often stabilizes approximately two to three years after the end of a recession and then increases when the economy significantly improves. Recently, however, the question has arisen about whether a more fundamental change is occurring within the health sector and whether this stability will endure. From our perspective, more historical evidence is needed before concluding that we have observed a structural break in the historical relationship between the health sector and the overall economy.

With the release of this annual report on health care spending in the United States, many are celebrating the fourth consecutive year of a slow down in spending increases, with some even suggesting that this is a new permanent trend due in a large part to the implementation of the Affordable Care Act (ACA). However, according to this report, ACA “had a minimal impact on overall national health spending growth through 2012.”

The reasons for increases in spending are complex and change from year to year. The excerpt on Medicare, selected above, demonstrates some of these variabilities. Spending in Medicare is important to understand since it is often held up as a program that could serve us all well as a single payer national health program. However, under our fragmented system of financing health care, it is difficult to use the current Medicare data to predict what spending might be under an Improved Medicare for All program, particularly with the split in Medicare between the traditional fee-for-service program and the private Medicare Advantage plans, but also because Medicare has little control over most of our health care spending. It is even more difficult to predict total future health spending for the entire nation with our current administratively complex, fragmented financing system.

If we had a unified single payer system, we could look at the variables that really count when we try to predict future spending. These include elements such as demographics, inflation, prices, legitimate costs, access, new technology, elimination of ineffectual technology, and the health of the economy. When you look at this list, it cries out for adopting public policies that would ensure future value in our health care spending. Many of these policies would be extremely difficult if not impossible to implement under our current financing system. That is perhaps the most important reason for replacing our dysfunctional system with a single payer national health program – an improved Medicare that covers everyone.

NBC’s chief medical editor, Nancy Snyderman, endorses single payer

Posted by on Monday, Jan 6, 2014

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.

Top Health Stories of 2013

By Nancy Snyderman, M.D., NBC’s chief medical editor
Morning Joe, MSNBC, December 30, 2013

Dr. Nancy Snyderman:  I think there should be a single payer system. And increasingly you’re seeing physicians in their late 50s, 60s and 70s who are saying, you know what, we got it wrong; we should have taken Medicare, expanded it and done it smarter.

YouTube clip of segment:

The endorsement of single payer by NBC’s chief medical editor, Dr. Nancy Snyderman, is a welcome addition to the many voices of those who have long understood the superiority of the single payer/improved Medicare for all model of reform but who now believe that it is finally time to speak out in support of it.

It is interesting that this video clip of Dr. Snyderman has been circulated widely on conservative blogs. We are hearing “single payer” from the conservatives so frequently now that it’s almost as if they are trying make the term a pejorative much as Reagan, Thatcher and others did with the term “socialism.” Another example just this weekend was on Fox News – six minutes of meaningless jabber, with the exception of one token, fair and balanced panelist who supports single payer:…

Why does Medicaid increase patients’ use of Emergency Departments?

Posted by on Friday, Jan 3, 2014

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.

Medicaid Increases Emergency-Department Use: Evidence from Oregon’s Health Insurance Experiment

By Sarah L. Taubman, Heidi L. Allen, Bill J. Wright, Katherine Baicker, Amy N. Finkelstein

Science, Published Online January 2, 2014


In 2008, Oregon initiated a limited expansion of a Medicaid program for uninsured, low-income adults, drawing names from a waiting list by lottery. This lottery created a rare opportunity to study the effects of Medicaid coverage using a randomized controlled design. Using the randomization provided by the lottery and emergency-department records from Portland-area hospitals, we study the emergency-department use of about 25,000 lottery participants over approximately 18 months after the lottery. We find that Medicaid coverage significantly increases overall emergency use by 0.41 visits per person, or 40 percent relative to an average of 1.02 visits per person in the control group. We find increases in emergency-department visits across a broad range of types of visits, conditions, and subgroups, including increases in visits for conditions that may be most readily treatable in primary care settings.

From the Discussion

These findings speak to one cost of expanding Medicaid, as well as its net effect on the efficiency of care delivered, and may thus be a useful input for informed decision-making balancing the costs and benefits of expanding Medicaid.

How Obamacare will change the emergency room

By Dan Gorenstein

Marketplace, January 2, 2014

And the report already has pundits worked up, especially with 9 million Americans projected to newly sign up for Medicaid this year under the Affordable Care Act.

The reason this is so hot – at least politically – is because the report over turns conventional healthcare thinking. Harvard health economist Amitabh Chandra describes the theory.

“If we insure the uninsured, they are not going to use the emergency room and they are going to use less healthcare. So in the long run, insuring the uninsured saves us money,” says Chandra.

Affordable Care Act advocates have used this argument to say insurance should be expanded.

There’s just one thing: that’s not what happens.

“Its basic economics that I would teach my students,” says MIT economist Amy Finkelstein – one of the report’s authors.

“When you lower the price of something, people buy more of it,” says Finkelstein. “That’s true of apples and bananas and it turns out it’s true of healthcare too.”

Co-author Katherine Baicker says… “That doesn’t mean that it’s inefficient, good or bad. It just means that insurance makes healthcare more affordable, and that has both financial consequences and health consequences.”

Perhaps most important, Harvard’s Amitabh Chandra says when it comes to money, this isn’t where the action is.

“The spending is not in the emergency room. The spending is on high cost patients. These are cancer patients. Many of them in the end of life,” he says.

Chandra says it would be easy to use this report and argue that the Affordable Care Act is too costly.

He says the big question – the tough question – is how to limit the care everyone agrees is inefficient and expensive, regardless of who gets it or where that care is received.…

New Oregon Data: Expanding Medicaid Increases Usage Of Emergency Rooms, Undermining Central Rationale For Obamacare

By Avik Roy

Forbes, January 2, 2014

(The authors) found that those on Medicaid used the emergency room 40 percent more than the uninsured did—1.43 ER visits per Medicaid enrollee, as against 1.02 for the uninsured. More to the point, a majority of the emergency room visits were unnecessary, because they involved conditions that could easily have been managed outside of the ER.

Because Medicaid was nearly free to the program’s enrollees, those enrollees ended up seeking—and receiving—lots of inappropriate care. That led to massive cost overruns that, even today, are bankrupting state governments. The one thing they have been able to do is pay doctors and hospitals less and less to provide the same care.

That trend, in turn, has led many doctors to stop accepting new Medicaid patients. So it’s extremely difficult for Medicaid enrollees to get appointments with primary care physicians. They have to spend weeks on the phone to find someone who will treat them.

Put yourself in the shoes of that Medicaid enrollee. Why would you bother calling primary care docs all day and all week, if you can go to the emergency room and get the same care for the same price? So that’s what Medicaid patients do.

Many hospitals say that they lose money on every Medicaid patient they see. But somehow, if we have more Medicaid patients, taxpayers will be better off?

It was bunk in 2009, and it’s bunk today. It’s why the states that have chosen to forego Obamacare’s Medicaid expansion were wise to do so…

National Study of Health Insurance Type and Reasons for Emergency Department Use

By Roberta Capp MD, MHS, Sean P. Rooks BA, Jennifer L. Wiler MD, MBA, Richard D. Zane MD, Adit A. Ginde MD, MPH

Journal of General Internal Medicine, December 2013


We evaluated the association between health insurance type and self-perceived acuity or access issues among individuals discharged from the ED.

Key Results

Overall, 65.0 % of adults reported ≥ 1 acuity issue and 78.9 % reported ≥ 1 access issue. Among those who reported no acuity issue leading to the most recent ED visit, 84.2 % reported ≥ 1 access issue. Relative to those with private insurance, adults with Medicaid (OR 1.05) and those with Medicare (OR 0.98) were similarly likely to seek ED care due to an acuity issue. Adults with Medicaid (OR 1.50) and Medicaid + Medicare (dual eligible) (OR 1.94) were more likely than those with private insurance to seek ED care for access issues.


Variability in reasons for seeking ED care among discharged patients by health insurance type may be driven more by lack of access to alternate care, rather than by differences in patient-perceived acuity. Policymakers should focus on increasing access to alternate sites of care, particularly for Medicaid beneficiaries, as well as strategies to increase care coordination that involve ED patients and providers.

There has been extensive media coverage of this new study which confirms that uninsured individuals who become covered under the Medicaid program will increase their use of Emergency Department (ED) services. Is this good or bad? Conservative physician/columnist Avik Roy writes, “It’s why the states that have chosen to forego Obamacare’s Medicaid expansion were wise to do so.” Really? Let’s try to make some sense of this.

Medicaid patients have learned that access to care is impaired because far too many physicians refuse to accept patients who are on this program. Patients have also learned that they will be seen when they present themselves to the ED, and that they won’t have to pay for the care because of their Medicaid coverage. Even Avik Roy concedes that.

The study by Roberta Capp et al shows that all patients, including Medicaid patients, who perceive the acuity of their condition to warrant ED services will go to the ED for care. Yet Medicaid patients who have impaired access will also use the ED simply because of the access issues. This applies as well to dual eligible patients who have both Medicare and Medicaid, indicating that Medicare patients stigmatized with Medicaid will also have impaired access, except in the ED.

Clearly, the problem is with inadequate access to primary care within the community, largely because of the refusal of too many physicians to accept Medicaid as a payment source.

What does this greater use of EDs do to health care costs? Harvard’s Amitabh Chandra says, “The spending is not in the emergency room. The spending is on high cost patients.” Although many state that ED costs are too high to warrant providing ED care for these patients that should have been served by primary care professionals within the community, in fact it is only the ED prices that are high, and Medicaid doesn’t pay those high prices anyway. The actual marginal costs for taking care of these low acuity patients are almost negligible.

There are some obvious solutions to this problem. The most important is to establish a single payer system so that patients are not sorted out by their payment source. Along with that it is crucial to reinforce the primary care infrastructure so that access is always available. For night and weekend hours, the ED could serve a triage function with primary care services being provided as a community service. If that would overload the ED staff, the community physicians could rotate weekend and night call to back up the ED staff for these lower acuity problems. Also, free standing 24 hour clinics could be established, though in most communities a triage function in the ED would be more appropriate.

What we don’t need is more blaming the victims – condemning Medicaid patients who “overuse” EDs, when they are simply trying to access care that they should have. We also need physicians with a heart, but, unfortunately, medical schools don’t seem to include that requirement amongst their admissions criteria.

Contrasting the rollout of Medicare and Obamacare

Posted by on Thursday, Jan 2, 2014

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.

Medicare’s Rollout vs. Obamacare’s Glitches Brew

By David Himmelstein and Steffie Woolhandler
Health Affairs Blog, January 2, 2014

The smooth and inexpensive rollout of Medicare on July 1, 1966 provides a sharp contrast to the costly chaos of Obamacare.

We won’t rehearse the chaos part here, just the costs.

As of March, 2013, federal grants for Obamacare’s state exchanges totaled $3.8 billion.  Spending for the federal exchange is harder to pin down because funding has come from multiple accounts, including: the $1 billion Health Insurance Implementation Fund; DHHS’ General Departmental Management Account and General Departmental Management Account; CMS’s Program Management Account and the Prevention and Public Health Fund.  CMS estimates fiscal 2014 spending for the federally-operated exchanges at $2 billion.  So it’s safe to say that the costs of getting the exchanges up and running, and (hopefully) enrolling 7 million people in the program’s first year will exceed $6 billion.

Bear in mind that the exchanges won’t actually pay any medical bills, just sign people up for coverage.  So billions more in overhead costs will show up on the books of the private insurers and state Medicaid programs that will actually process medical claims.

Back in 1966, Medicare started paying bills for 18.9 million seniors (99 percent of those eligible for coverage) just 11 months after Pres. Johnson signed it into law.  Overhead costs for the first year totaled $120 million (equivalent to $867 million in 2013).  But that figure includes the cost of processing medical bills, not just the enrollment costs

Moreover, Medicare and Medicaid (which was passed at the same time) displaced several smaller federal health assistance programs, saving about $376 million on their overhead costs (2013 dollars).

Signing up most of the elderly for Medicare was simple; they were already known to Social Security Administration, which handled enrollment.  To find the rest, the feds sent out mailings to seniors, held local meetings, and asked postal workers, forest rangers and agricultural representatives to help contact people in remote areas.  The Office for Economic Opportunity spent $14.5 million to hire 5,000 low income seniors who went door-to-door in their neighborhoods.

Despite predictions of chaos, and worries that the newly-insured seniors would flood the health care system, there were few bottlenecks.  Hospitals continued to operate smoothly and no waiting lists materialized.  The only real “glitch” was that many hospitals in the Deep South initially refused to integrate their facilities – which Medicare required for certification and payment.  But by the end of the first month, 99.5 percent of hospitals had signed on.

Obamacare’s start-up has been rocky because complexity is “baked in” to the design, just as simplicity was “baked in” to Medicare.  Obamacare’s exchanges must coordinate thousands of different plans, with premiums, co-payments, deductibles and provider networks that vary county-by-county; Medicare offered a single, uniform plan.  The exchanges must calculate subsidies for each applicant after first verifying income, family size and immigration status; Medicare offered free hospital coverage, with a minimal ($22) uniform premium for doctor coverage.  Instead of setting up a new bureaucracy to collect premiums from millions of enrollees and funnel them to private insurers, Medicare relied on the existing payroll and income tax system to garner funds.

Obamacare’s byzantine complexity reflects the contortions required to simultaneously expand coverage and appease private insurers.  And private insurers will exact a steep ongoing toll.  Medicare’s overhead is just 2 percent, vs. an average of 13 percent for private plans (on top of the Exchanges’ costs, roughly 3 percent of premiums).  A single payer plan that excluded private insurers could save hundreds of billions in transaction costs.

Medical quality improvement experts often advise hospitals to “avoid workarounds”; fix system defects rather than force doctors and nurses to sidestep problems like faulty equipment, understaffing, or illegible handwritings.  This advice is equally valid for health reform.  To avoid glitches and wasteful expense, design the system right; eliminate private insurers and cover everyone under a single payer program.…

PNHP’s press release:…

“Obamacare is a giant workaround crafted to keep private insurers at the center of the health care system,” said co-author Dr. David Himmelstein, a primary care physician, professor of public health at the City University of New York and lecturer in medicine at Harvard Medical School.

“The simple single-payer, Medicare-for-all approach would save more than $400 billion annually on bureaucracy, enough to give every American first-dollar coverage. But to get those savings you have to break private insurers’ stranglehold on health care and on Washington,” he said, adding, “The glitches in Obamacare’s rollout don’t come from government incompetence, but from political cowardice.”

4,832,000 of the most vulnerable remain in the coverage gap

Posted by on Tuesday, Dec 31, 2013

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.

The Impact of the Coverage Gap in States not Expanding Medicaid by Race and Ethnicity

Kaiser Family Foundation, December 17, 2013

Medicaid eligibility for adults is very limited. Many states limit Medicaid eligibility for parents to below poverty, and adults without dependent children have historically been excluded from the program. The ACA’s Medicaid expansion to adults with incomes at or below 138% FPL would significantly increase eligibility for parents in many states and end the exclusion of adults without dependent children from the program. The expansion was intended to occur nationwide as of January 2014 and serve as the base of coverage for low-income individuals, with premium tax credits available to moderate-income individuals above Medicaid limits to purchase Marketplace coverage. However, as a result of the Supreme Court decision on the ACA, implementation of the Medicaid expansion is now effectively a state choice. As of December 11, 2013, 26 states, including DC, are moving forward with the Medicaid expansion in 2014, while 25 states are not moving forward at this time.

In states that do not expand Medicaid, nearly five million poor uninsured adults will fall into a “coverage gap.” These individuals would have been eligible for Medicaid if their state had chosen to expand coverage. In the absence of the expansion, they remain ineligible for Medicaid and do not earn enough to qualify for premium tax credits to purchase Marketplace coverage, which begin at 100% FPL. Most of these individuals have very limited coverage options and are likely to remain uninsured.

These continued coverage gaps will likely lead to widening racial and ethnic as well as geographic disparities in coverage and access.

Table 1: Nonelderly Poor Uninsured Adults in the Coverage Gap in States Not Expanding Medicaid by Race/Ethnicity

Total, United States

4,832,000  –  All races/Ethnicities
2,248,000  –  White
1,327,000  –  Black
992,000  –  Hispanic
265,000  –  Other
2,584,000  –  People of Color…

Since it was decided to reject reform that would have been truly universal, you would think that at least we would be covering the most vulnerable segments of our population. But no, half of our states rejected federal funding for Medicaid expansion, leaving almost 5 million otherwise qualified individuals out of the Medicaid program, even though their incomes ironically are too low to qualify them for subsidies to purchase plans in the state insurance exchanges.

Over half of these people left out are people of color, resulting in a widening of the unjust disparities in care already plaguing our nation.

What a terrible way to start the first year of what is essentially the full implementation of the Affordable Care Act. It seems pretty obvious what our New Year’s resolution should be: Let’s bring health care to everyone through an improved and expanded Medicare for all.

Mayo Clinic’s Eric Matteson endorses tax-supported universal healthcare

Posted by on Monday, Dec 30, 2013

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.

10 Questions: Eric Matteson, MD

By Nancy Walsh
MedPage Today, December 27, 2013

Eric L. Matteson, MD, of the Mayo Clinic, is the chair of rheumatology and professor of medicine.

1. What’s the biggest barrier to your practicing medicine today?

Without a doubt, it is lack of access for many patients, especially the un- and underinsured.

2. What is your most vivid memory involving a patient who could not afford to pay for healthcare (or meds, tests, etc.) and how did you respond?

I have a young woman with severe erosive RA who has limited mental ability who works 20 hours a week in a rural recycling center at a minimum wage job sorting recyclables. I see her in another state at a small clinic that’s 80 miles away. She has only Medicaid. She is able to afford methotrexate and hydroxychloroquine. We accept losses with the cost of monitoring, and also for the orthopedic surgeries she has required and she cannot afford. I have sought drug and assistance from every company with biologics on the market, some on more than one occasion, and to date have been turned down by all of them. She is not able to even afford gas, or the time off, to come to our center to participate in drug studies.

4. If you could change or eliminate something about the healthcare system, what would it be?

I would have a tax-supported universal healthcare for at least minimum services.

Mayo Clinic’s Eric Matteson is yet another prominent physician who supports “tax-supported universal healthcare,” though he qualifies that with “for at least minimum services.” From his example, it seems that he would include most of his field of rheumatology as “minimal services,” though others might say “all essential services.” Nevertheless, there continues to be an increase in those who now are willing to speak out on the need for a publicly-financed health care system that covers everyone. There is a growing consensus that financial barriers to care need to be removed.

Incrementalism predicted for 2014

Posted by on Friday, Dec 27, 2013

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.

With Health Law Cemented, G.O.P. Debates Next Move

By Jonathan Weisman
The New York Times, December 26, 2013

Senator Kelly Ayotte, Republican of New Hampshire, said she was teaming up with Democrats on a host of incremental changes to the law, such as expanding health savings accounts and repealing a tax on medical devices. And other Republicans are wondering aloud how long they can keep up the single-minded tactic of highlighting what is wrong with the law without saying what they would do about the problems it was supposed to address.…

Democrats want to repair some of the defects in the Affordable Care Act. Republicans want to include some of their favorite proposals such as expansions of health savings accounts and catastrophic plans, and loosening restrictions on sale of insurance products across state lines. Members of both parties wish to curry the favor of the voters before the November elections. This is a setup for mediocre incrementalism when what we really need is… well, the most popular NYT reader response (out of 475 at moment) says it well:

Atikin – North Carolina
The only logical solution: single-payer.

Don’t forget New York

Posted by on Thursday, Dec 26, 2013

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.

Single Payer for New York

The New York Times, December 23, 2013

To the Editor:

Re “Under Health Law, Independent Practitioners in City Face Canceled Policies” (news article, Dec. 14):

The Affordable Care Act makes important repairs to our broken health care system. The problem is that it leaves insurance companies in charge — with high premiums, high deductibles and co-pays; too much control over which doctors or hospitals we can go to and what care they can provide; and high administrative costs.

The exchanges are complicated because the system requires means-testing to see who is eligible for Medicaid or subsidies, and then requires people to select from multiple plans.

We could cover everyone, provide better coverage and save billions through publicly sponsored, single-payer health coverage, like an improved version of Medicare for everyone — and no insurance companies.

Washington might not be ready to act, but individual states have long been the “laboratories of democracy.” New York can do better.

Richard N. Gottfried

New York, Dec. 14, 2013

(The writer, chairman of the New York State Assembly Health Committee, is the author of a bill in the New York Legislature to establish a state single-payer health plan.)…

A.5389/S.2078, New York Health – an act to establish a single payer health program:

As the Affordable Care Act unfolds it becomes all too obvious that the repairs in our system of financing health care are falling far too short of the goals of universality, affordability, administrative simplicity, and accessibility with free choice of hospitals and health care professionals. Clearly we need a single payer system that would easily achieve these goals. New York, with the leadership of Assemblyman Richard Gottfried, has joined other states in attempting to enact a state-based single payer system.

What we desperately need is a federal government that partners with states – all states – in enacting legislation that will bring single payer to all of us. With the surge in a renewed interest in single payer, we need grassroots and coalition efforts to be sure that people understand the single payer approach and then will demand it when they go to vote. Let’s pull out all stops between now and next November.

Commodification harms not only our health care

Posted by on Thursday, Dec 26, 2013

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.

Do bigger governments lead to happier people?

An interview by Dylan Matthews
The Washington Post, December 23, 2013

Benjamin Radcliff is a professor of political science at the University of Notre Dame. His current research focuses on how public policy affects human happiness.

Dylan Matthews: You argue that social democratic or left-leaning policies are more conducive to happiness. What sorts of things are you talking about? Government spending? Regulations? Both?

Benjamin Radcliff: I have organized my research around two dimensions of policy. The first is the size of government, i.e. of what it is government does, from the tax burden to the generosity of the welfare state to the total impact of the government in terms of its overall consumption on GDP. The second involve institutions that protect people in labor markets, which means labor unions and economic regulations (the minimum wage, mandated vacation time, etc.), which provide a degree of sovereignty and power for workers in their employment relationships. Two sides of the coin: the general scope of what government does to make life more secure for people and the stuff that works specifically in terms of peoples’ work conditions.

Both types of policies contribute to what social theorists call “decommodification,” meaning limiting the degree to which in a capitalist economy people have to act as commodities in order to survive. You have to sell your labor power on the market. Decommodification measures how much people can opt out of the labor market, whatever the reason, and provides a way of judging to what extent have we made them free of market commodification.

More decommodification makes people happier, and it does so for rich and poor people, men and women, and controlling for just about any other thing. Similar empirical results obtain when considering total social spending on education, health care, total government consumption, the tax burden, a well-known OECD measure of employee protection legislation, even indices on the size of government and labor market regulation from the conservative Fraser Institute. The smaller the government, the less happy people are.

Another variable I find of interest is labor union membership and density, i.e. do you belong, and the percentage of all workers who belong the unions. People who belong to unions are happier, and, more importantly, union density is strongly related to levels of happiness for union members and non-members.

Dylan Matthews: How does that compare to the effects on happiness of non-policy things like, say, the effect of being married or unemployed?

Benjamin Radcliff: The literature would tell you that being married has a huge positive impact on wellbeing, while unemployment has an equally powerful negative effect. They thus make nice benchmarks for comparing the effect of other variables. My results suggest that the effect of the political variables is much larger by orders of magnitude.

Dylan Matthews: Can you talk a bit more about what you mean by “decommodification”? Do you mean not being reliant on work to live — not being a commodity yourself — or the carving out of certain things (human organs, say) that just aren’t commodities you can buy and sell?

Benjamin Radcliff: A society is decommodified to the degree to which people are not entirely dependent on labor market participation in order to survive — principally because they are aged, because they are ill, or simply because jobs are scarce, but also, potentially, so that they can take time to care for a new child or an ailing family member, etc. My research suggests people lead better lives in those societies that are the most decommodified. The reasons are easy enough to understand: There’s a famous quotation observing that a capitalist economy, whatever its many positive aspects, creates a situation in which people have to behave as commodities in order to survive. It doesn’t take great insight to realize that people do not enjoy being reduced to commodities, so a society that limits that necessity is likely to be a better one in which to live.

Now, to be sure, the market economy absolutely contributes to human well-being in other ways — no one can deny that — but we have a macro- vs. micro-problem. At the macro level, capitalism works well. I would agree that the market society is one of humanity’s greatest achievements. But at the micro level it depends at the very core of its logic, as even Adam Smith was at pains to point out, on the idea of using other people (employees) as a means to making profits for oneself. The people we hire to do work are just mere commodities in the profit-loss calculations, no more worthy of special concern than barrels of oil or bushels of grain. The last chapter of my book (“The Political Economy of Human Happiness”) discusses these moral tensions that capitalism creates. My conclusion is that the social safety net, labor market regulations and labor unions all limit the degree to which people become mere commodities, and thus are more likely to lead fulfilling lives.…

On a positive note just in time for the Holiday Season, we can be assured that we have it within our power to increase happiness throughout the nation by joining together, as a government, in decommodifying ourselves within our own society, but that means that we cannot leave power in the hands of those who would commodify us.


Uwe Reindardt on the U.S. path to three-tiered health care

Posted by on Thursday, Dec 26, 2013

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.

The Economics of Being Kinder and Gentler in Health Care

By Uwe E. Reinhardt
The New York Times, December 20, 2013

In the late 1980s, about 35 million respondents to large nationwide surveys declared that they lacked health insurance of any kind. The comparable number now is close to 50 million.

Then, as now, the endless “national conversation” went on and on, pondering ways to achieve truly universal health insurance coverage, a feat most other developed nations accomplished long ago.

Then, as now, news organizations and the health services research community reported on the financial and physical hardship that many low-income, uninsured Americans face when they fall ill.

And then, as now, the prices for identical health care goods and services were more than twice as high in the United States as they were – and still are – in the member nations of the Organization for Economic Cooperation and Development.

For all the wonderful things the United States health system has done for the American people, then, as now, it has also helped price some degree of kindness out of our souls, a side effect of their treatments that the leaders of American health care at some point must begin to contemplate.

My interpretation is that opposition to the Affordable Care Act largely reflects the age-old reluctance among many of the nation’s haves and the healthy to help purchase for America’s lower-income families and the chronically ill the super-expensive health care that the haves enjoy themselves. That attitude is all the more striking because of the generous federal indirect subsidies enjoyed by many of the haves, especially high-income Americans. (I am thinking specifically of the generous tax preference accorded employment-based health insurance, the largest tax expenditure in the federal budget.)

Some people on both the extreme left and right seem to believe that the current travails of implementing the Affordable Care Act and the possibility of a so-called “death spiral” in the market for individual health insurance may usher in single-payer health insurance in the United States – say, Medicare for all.

I do not find that a likely prospect. Rather than embracing a single-payer system, the United States is more likely to stumble, in fits and starts, toward something resembling officially sanctioned tiering of the American health care experience by income class, as follows:

FOR MEDICAID BENEFICIARIES AND THE UNINSURED, a budget-constrained system of public hospitals and public clinics. It would allow politicians to ration health care (through tight budgets) without ever having to acknowledge that they were doing so. In other words, it would reduce the price of being kind.

FOR THE EMPLOYED MIDDLE CLASS, a mixed system with defined contributions by employers, private health insurance exchanges and reference pricing by insurers. Under a restructured Medicare program also based on a defined contribution model, reference pricing would be likely to apply to Medicare beneficiaries as well. Depending on how it is operated – e.g., if it were solely based on cost, in abstraction of quality – reference pricing also permits tiering of the health care experience by income class, without anyone having to say so openly.

FOR THE UPPER-INCOME GROUPS, boutique medicine, which is already growing in the United States. Here the sky will be the limit.

And what do readers think?…

Uwe Reinhardt, an astute observer of the U.S. health care system, does not see single payer in our future, but rather sees an “officially sanctioned tiering of the American health care experience by income class.” We already have the three tiers that he describes, but the middle tier is rapidly evolving in a way that may provoke a renewed and more intense interest in single payer.

The lowest tier – Medicaid beneficiaries and the uninsured – have never had much of a political voice. Nevertheless, even the most heartless of politicians recognize that we must provide care for indigent pregnant women and children. Thus we have the chronically underfunded Medicaid program plus safety net hospitals and community health centers. Some states also have included other low-income adults, though they still make up the largest percentage of the uninsured. Except for the most basic of primary care services and care for events that threaten life or limb, access to health care for this sector is limited, especially for specialized services. As Professor Reinhardt indicates, politicians are able to ration health care for Medicaid beneficiaries and the uninsured without admitting that they are doing it, merely by placing restraints on the budget. Since it is unAmerican to ration health care, they would never do that, but rather they merely refuse to budget spending that we can’t afford. (Of course, inadequate funding of health care is rationing, and we actually can afford to pay for health care for all, though we do need more efficiency in our financing system.)

The highest tier – the upper-income groups – have never had problems with gaining access to the best care available. That is true now, and will be true no matter what health care financing system we will have. Some have expressed concerns that in a truly egalitarian system, such as a single payer system, the wealthy would have to give up some of the finer amenities of health care and stand in line with the rest of us, but that will never happen. The wealthy are not hampered by noblesse oblige when it comes to moving to the front of the line for health care. Besides, a well designed system should not have an excessive queue anyway.

The middle tier – the employed middle class – will see greater changes in health care access and affordability, changes that have already begun. Although the plans to be offered in the state exchanges will include many of these changes, employers are already following by modifying their plans to reduce their own exposure to costs. Higher deductibles and other forms of cost sharing are shifting more costs to the pockets of those who need health care. Although ten categories of benefits will be required under the plans, the insurers have considerable flexibility in the composition of benefits within each category and will leave out selected benefits that some individuals will need, especially some of the more expensive benefits. Insurers are reducing their networks of physicians and hospitals, further limiting patient choice of their health care providers, unlike the traditional Medicare program, which allows free choice. Patents may still face catastrophic losses since the maximum out-of-pocket expenditures apply only to covered benefits provided within the networks. Care unavoidably obtained out of network and health care services not included as a plan benefit can result in costs that threaten personal bankruptcy. Even the allowed maximums would create a hardship for many. Employers are beginning to switch to defined benefit contributions to health plans that would be selected from private (not state) health exchanges. This voucher approach allows employers to shift the future increases in health care costs disproportionately to the employees. Reference pricing is the process of setting a low price for given health care services and requiring the patient to pay the full difference in prices if the patient selects a more expensive provider. This is another method of shifting more costs to the patient, not to mention that it further limits choice of providers since these extra costs may be truly unaffordable. A shift in control of Congress and the White House to conservatives may well result in premium support of Medicare (vouchers – a defined contribution), thereby allowing Medicare to adopt some of these same policies that shift more costs to patients in need.

The obvious point is that the exchange plans and now even employer-sponsored plans will cause the employed middle class to become quite dissatisfied with our health care financing system. Once they or their families and friends have enough negative experiences with our health care financing, and once they understand single payer – an improved Medicare for all – it will be the middle class workers that will be the loudest in demanding change.

In the meantime, under our present three-tiered system, we will be able to obtain a basic level of care for Tiny Tim, just not the specialized services that he really needs. And Ebenezer Scrooge will be able to access his boutique providers, with the sky as the limit. But what about the people of the village? Once Scrooge gains control of the insurance industry, will he further advance the current agenda of making health care more expensive to increase profits, and less accessible to reduce costs? Will another visit from the Ghost Of Christmas Yet To Come be adequate? Or will he be hardened enough to carry on, as Reinhardt writes, “the age-old reluctance among many of the nation’s haves and the healthy to help purchase for America’s lower-income families and the chronically ill the super-expensive health care that the haves enjoy themselves.”

Though should we really expect a different outcome? We now have a society that when Bob Cratchit pulls himself up by his bootstraps and runs for mayor, we elect Ebenezer Scrooge instead.

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