H.R.676 reintroduced in the 112th Congress

Posted by on Monday, Feb 14, 2011

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.

112th Congress

The Library of Congress


To provide for comprehensive health insurance coverage for all United States residents, improved health care delivery, and for other purposes.

Sponsor: Rep Conyers, John, Jr. [MI-14] (introduced 2/11/2011)

Rep Baldwin, Tammy [WI-2] – 2/11/2011
Rep Capuano, Michael E. [MA-8] – 2/11/2011
Rep Christensen, Donna M. [VI] – 2/11/2011
Rep Chu, Judy [CA-32] – 2/11/2011
Rep Cohen, Steve [TN-9] – 2/11/2011
Rep Dicks, Norman D. [WA-6] – 2/11/2011
Rep Doyle, Michael F. [PA-14] – 2/11/2011
Rep Ellison, Keith [MN-5] – 2/11/2011
Rep Farr, Sam [CA-17] – 2/11/2011
Rep Filner, Bob [CA-51] – 2/11/2011
Rep Frank, Barney [MA-4] – 2/11/2011
Rep Green, Al [TX-9] – 2/11/2011
Rep Grijalva, Raul M. [AZ-7] – 2/11/2011
Rep Hinchey, Maurice D. [NY-22] – 2/11/2011
Rep Jackson, Jesse L., Jr. [IL-2] – 2/11/2011
Rep Lee, Barbara [CA-9] – 2/11/2011
Rep Lofgren, Zoe [CA-16] – 2/11/2011
Rep Maloney, Carolyn B. [NY-14] – 2/11/2011
Rep Meeks, Gregory W. [NY-6] – 2/11/2011
Rep Nadler, Jerrold [NY-8] – 2/11/2011
Rep Pingree, Chellie [ME-1] – 2/11/2011
Rep Roybal-Allard, Lucille [CA-34] – 2/11/2011
Rep Scott, Robert C. “Bobby” [VA-3] – 2/11/2011
Rep Tonko, Paul [NY-21] – 2/11/2011
Rep Weiner, Anthony D. [NY-9] – 2/11/2011

(The text of the bill has not yet been received from the Government Printing Office, but will be posted very soon.)


The “Expanded and Improved Medicare for All Act,” H.R. 676, sponsored by Rep. John Conyers Jr., D-Mich., would replace today’s private health insurers – and the Obama law’s individual mandate, which is being challenged as unconstitutional – with a single, streamlined public agency that would pay all medical claims, much like Medicare works for seniors today. (From a PNHP statement to be released later today at www.pnhp.org)

The immediate task for all of us who support an expanded and improved Medicare for all is to begin to recruit more cosponsors. Remind your Representatives that this does not eliminate the important beneficial measures of the Affordable Care Act. What it does instead is it replaces the highly flawed financing structure of ACA with a proven model that both makes health care affordable and includes everyone – the paramount goals of health care reform that have remained elusive until now.

Is ending job lock a job killer or a creator of employment opportunities?

Posted by on Friday, Feb 11, 2011

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.

CBO: Health law to shrink workforce by 800,000

By J. Lester Feder and Kate Nocera
February 10, 2011

CBO Director Douglas Elmendorf told the House Budget Committee on Thursday that the health care law will reduce employment by 0.5 percent by 2021 because some people will no longer have to work just to afford health insurance.

“That means that if the reduction in the labor used was workers working the average number of hours in the economy and earning the average wage, that there would be a reduction of 800,000 workers,” Elmendorf said in an exchange with Rep. John Campbell (R-CA).

The report, published in August, said, “The Congressional Budget Office estimates that the legislation, on net, will reduce the amount of labor used in the economy by a small amount — roughly half a percent — primarily by reducing the amount of labor that workers choose to supply … That net effect reflects changes in incentives in the labor market that operate in both directions: Some provisions of the legislation will discourage people from working more hours or entering the workforce, and other provisions will encourage them to work more.”

Republicans gleefully seized on the admission, eagerly promoting it as evidence of what they call the law’s job-killing effect.

“More bad news for American families,” was how Budget Committee Chairman Paul Ryan’s office described the report in a release.

“Since day one Republicans have opposed Obamacare for a simple reason: it would destroy jobs. Minority Leader Pelosi, Leader Reid and others said we were wrong. Guess not,” said John Murray, deputy chief of staff for Majority Leader Eric Cantor.



The Budget and Economic Outlook: An Update

Congressional Budget Office
August 2010

Effects of Recent Health Care Legislation on Labor Markets

The Patient Protection and Affordable Care Act (Public Law 111-148) and the Health Care Education Reconciliation Act of 2010 (P.L. 111-152) will affect some individuals’ decisions about whether and how much to work and employers’ decisions about hiring workers. The Congressional Budget Office (CBO) estimates that the legislation, on net, will reduce the amount of labor used in the economy by a small amount — roughly half a percent — primarily by reducing the amount of labor that workers choose to supply. That net effect reflects changes in incentives in the labor market that operate in both directions: Some provisions of the legislation will discourage people from working more hours or entering the workforce, and other provisions will encourage them to work more. Moreover, many people will be unaffected by those provisions and will face the same incentives regarding work as they do under current law.

The net reduction in the supply of labor is largely attributable to the substantial expansion of Medicaid and the provision of subsidies that will reduce the cost of insurance obtained through the newly created exchanges, beginning in 2014. In particular:

* The legislation extends Medicaid eligibility to most nonelderly residents whose income is below 138 percent of the federal poverty level (FPL) — including childless adults who are currently ineligible for Medicaid in most states. (The FPL in 2010 is $10,830 for a single person and $22,050 for a family of four.)

* People who purchase insurance through the new exchanges will generally be eligible for tax credits to help them pay their health insurance premiums if their income is between 138 percent and 400 percent of the FPL and they are not offered coverage through an employer. (They may also be eligible for reductions in their cost-sharing requirements.) Those subsidies decline in value as income rises and can, under some circumstances, drop sharply to zero when income exceeds 400 percent of the FPL.

The expansion of Medicaid and the availability of subsidies through the exchanges will effectively increase beneficiaries’ financial resources. Those additional resources will encourage some people to work fewer hours or to withdraw from the labor market. In addition, the phaseout of the subsidies as income rises will effectively increase marginal tax rates, which will also discourage work. But because most workers who are offered insurance through their jobs will be ineligible for the exchanges’ subsidies and because most people will have income that is too high to be eligible for Medicaid, those effects on financial resources and marginal tax rates will apply only to a small segment of the population.

Other provisions in the legislation are also likely to diminish people’s incentives to work. Changes to the insurance market, including provisions that prohibit insurers from denying coverage to people because of preexisting conditions and that restrict how much prices can vary with an individual’s age or health status, will increase the appeal of health insurance plans offered outside the workplace for older workers. As a result, some older workers will choose to retire earlier than they otherwise would.

Some other provisions of the legislation may also affect decisions regarding work, but their net effect on the total labor supply will probably be small.


The Republicans in Congress have been using this report from the Congressional Budget Office (CBO) to claim that the Patient Protection and Affordable Care Act (ACA) is a “job killer,” even naming the bill that they passed to repeal health reform the “Repealing the Job-Killing Health Care Law Act.” But on reading the report from the CBO on which this claim is made, it is clear that this is not taking jobs away from the workforce; rather it is removing the shackles of job lock from these workers.

Until ACA many individuals who wanted to and were otherwise able to retire early, or wanted to pursue other less structured jobs or avocations, were unable to because they would lose their employer-sponsored health insurance and would be unable to replace it either because it was too expensive or was not available because of preexisting medical disorders. Thus this job lock was one more major defect that the reform bill was designed to correct, and it partially will once fully implemented.

The CBO explicitly states that “the legislation, on net, will reduce the amount of labor used in the economy by a small amount — roughly half a percent — primarily by reducing the amount of labor that workers choose to supply.” Note that word “choose.” These workers will not be terminated. In contrast, they will celebrate freedom, much as the Egyptians are doing today. These 800,000 jobs are not being killed, they are being abandoned voluntarily.

Which leads to a very important point that was left out of the CBO report, and certainly left out of the Republican rhetoric. These are 800,000 jobs that have been opened up to the labor market. Once these 800,000 individuals have stepped aside because they no longer need their jobs, 800,000 new jobs will have been created, not killed. And aren’t the Republicans, the Democrats and the nation at large claiming that job creation is one of our most urgent priorities?

This does not end the problems inherent in a largely employer-sponsored system. Employers are shifting more of the costs to their employees for purely business considerations, trying to control overhead expenses. Under-insurance is becoming the standard. The private plans that will be available through the exchanges will be overpriced and inadequately subsidized. Waste will be perpetuated because of administrative excesses and the lack of an efficient system of financing health care.

We should relieve employers of their employee health benefits burden, while ending job lock forever. Employees would never again have to worry about health insurance and the costs of it if we had an improved Medicare that covered everyone.

Tiered and limited networks deprive patients of choice

Posted by on Thursday, Feb 10, 2011

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.

Plans steer patients to lower-cost hospitals

By Liz Kowalczyk
The Boston Globe
February 10, 2011

Hundreds of small businesses have signed up in the past month for a new Blue Cross Blue Shield health insurance plan that charges employees hefty fees for seeking care at more expensive hospitals, in an effort to steer them to lower cost care.

The popularity of the plan — Blue Cross Blue Shield of Massachusetts says it is the fastest launch ever of a new product — is the latest sign that the once radical idea has been embraced as a way to control soaring health care costs, even as pricier hospitals warn of a possible backlash and cuts in services.

Other Massachusetts insurers also report brisk business in plans that offer lower premiums in exchange for limits on use of high-cost care. The plans either charge consumers extra for receiving care from popular but expensive hospitals or doctors, or bar them altogether from seeking treatment at those institutions and practices.

The Blue Cross Hospital Choice plan, which went on sale last month, charges members, for example, an extra $1,000 for an inpatient stay or outpatient surgery, and $450 more for an MRI, at 15 higher-cost hospitals, including Massachusetts General and Brigham and Women’s hospitals, Children’s Hospital Boston, and UMass Memorial Medical Center in Worcester.

In Massachusetts, insurers traditionally have offered wide-open networks, meaning members can check into a pricey teaching hospital to deliver a baby rather than go to a less expensive community hospital, and can schedule MRIs in a hospital outpatient department, even when freestanding clinics provide similar service for less money. But amid intense scrutiny into why health care costs in Massachusetts are climbing 7.5 percent a year, “tiered” and “limited” networks have emerged as an immediate way to control costs.

But executives at Partners HealthCare, the parent organization of Massachusetts General and Brigham and Women’s, said that while these new policies are making providers more sensitive to price, they have pitfalls.

Dr. Thomas Lee, head of Partners’ physician group, said some people will become seriously ill and realize they can’t go to, or can’t afford, their first-choice hospital.


Although private insurers in California have led the way in innovative product changes in an attempt to keep insurance premiums competitive (at the great cost of impairing the protection afforded by their products), Massachusetts is now serving as the laboratory for what we might expect under the Affordable Care Act (ACA), since Massachusetts got a jump start on the ACA model.

What determines which insurance policy people will select for themselves or for their families? The premiums or the benefits? If they are relatively healthy, which most people are, they may look at both, but the decision will most likely come down to choosing a plan with a premium that they can barely afford over a plan with a premium that is totally beyond their means. They are less likely to study the fine print on the benefits that states, for instance, the less expensive plan uses “tiered” or “limited” networks.

As this Boston Globe article indicates, the financial penalties for using a higher tiered facility can be very severe. And limited networks? The plan pays nothing outside of the network. Plan-approved provider networks have been used by the insurers as a tool to leverage the negotiations for provider rates. The expansion in the use of tiered or limited networks now uses the patient as a tool – contrary to their own interests – in an attempt to reduce spending so that premiums remain affordable, if only barely so.

Tiered and limited plans are growing rapidly in Massachusetts. Some of the most prestigious academic medical centers in the nation are being targeted and could face serious budget constraints. In using these tools of the marketplace, financial decisions are not being made based on what services should be provided and paid for; instead they are being made on the basis of what will best support the market of private insurance plans. As a result, serious damage could be inflicted on the infrastructure of our health care delivery system.

Imagine Medicare engaging in this behavior. You really can’t. Although always a work in process, Medicare includes the entire health care delivery system as its network, and reimburses at rates that have some semblance of maintaining the financial viability of the delivery system, while reining in waste. It can do better, and would do so if it were purchasing essentially all care provided in the United States, through an improved Medicare for all. The multiple tools of a single payer system would dramatically improve the efficiency of our health care purchasing.

Will Mayo Clinic save money as an ACO?

Posted by on Tuesday, Feb 8, 2011

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.

Some insurance companies pushing plans with Mayo Clinic out of network

By Christopher Snowbeck
February 5, 2011

Bloomington-based HealthPartners last year started marketing health plans that feature a network of hospitals and doctors that doesn’t include the Mayo Clinic. In exchange for not having access with low co-payments to the iconic Rochester, Minn., clinic, subscribers pay lower premiums when they select a HealthPartners plan with Mayo as an out-of-network option.

Last year, Eagan-based Blue Cross and Blue Shield of Minnesota also started emphasizing health insurance products for individuals in which Mayo isn’t in the network of providers.

Mayo has been celebrated nationally for providing high-quality and low-cost health care, but health insurance brokers say the local reputation is different as far as cost goes.

“Mayo is cheap only compared to other national care centers, but in general is a higher-cost center when compared to its Minnesota peers,” said Christopher Schneeman, a health insurance broker with SevenHills Benefit Partners in St. Paul.

“The Mayo Clinic is world-class,” said Greg Sailer of Sailer Benefit Services in Lake Elmo. “But it’s expensive, and you’re going to pay for it.”

Mayo Clinic officials argue that the Rochester center offers greater value by providing comprehensive care that steers patients to the most-effective treatments. That ultimately adds up to lower overall cost, the clinic says.

“When we looked at Mayo’s total cost of care — the combination of price and utilization — they, on average, have a higher total cost of care than other health systems that are seeing comparable groups of patients,” said (Andrea Walsh, chief marketing officer of HealthPartners).


For many years, the most common example given of the variations in the costs of health care demonstrated by the Dartmouth Atlas was the high costs of health care in Boca Raton, Florida when compared to Rochester, Minnesota, home of the Mayo clinic. These observed variations throughout the nation have led to the recommendation – now enacted in the Affordable Care Act (ACA) – to establish accountable care organizations (ACOs).

Although the precise details of what constitutes an ACO have not yet been released by HHS, the law states that the ACO will be “accountable for the quality, cost, and overall care of the Medicare fee-for-service beneficiaries assigned to it.” Payment will be based on a “Medicare Shared Savings Program,” in which the ACO shares with the government the savings for which it is accountable. It is a program designed to reduce health care spending.

Since Mayo Clinic certainly has the capability of providing overall care of the patient, it would seem to be an ideal institution to serve as an ACO. In fact, the authors of the legislation had in mind institutions such as Mayo as important models that could provide high quality care at a lower cost.

But will Mayo deliver at a lower cost? Not according to the current experience in Minnesota. Mayo argues that they provide greater value because they provide “comprehensive care that steers patients to the most-effective treatments,” even if that care is more expensive than elsewhere in Minnesota. (Time for a little soft shoe?)

The point is that the cost savings in ACA, such as the ACOs, are not much more than a fantasy at this point. And for this we gave up universal coverage and have established under-insurance as the new standard. We can still reach our goals of comprehensive, affordable care for everyone by replacing ACA’s financing system with an improved Medicare for all.

Individual mandate falls short in Massachusetts

Posted by on Monday, Feb 7, 2011

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.

Lack Of Access Due To Costs Remains A Problem For Some In Massachusetts Despite The State’s Health Reforms

By Cheryl R. Clark, Jane Soukup, Usha Govindarajulu, Heather E. Riden, Dora A. Tovar and Paula A. Johnson
Health Affairs
February 2011

Did the Massachusetts health reforms, which provided near-universal insurance coverage, also address problems of unmet need resulting from the cost of care and of inadequate preventive care for diverse patient groups? We found that nearly a quarter of adults who were in fair or poor health reported being unable to see a doctor because of cost during the implementation of the reforms. We also found that state residents earning less than $25,000 per year were much less likely than higher earners to receive screening for cardiovascular disease and cancer.



More get waivers of health insurance

By Kay Lazar
The Boston Globe
February 7, 2011

Massachusetts regulators granted more exemptions last year to residents who said they could not afford the health insurance required by the state, waiving the tax penalty for more than half of those who appealed, according to state data.

That is prompting regulators to take a fresh look at how Massachusetts defines affordable when it comes to mandatory health insurance.

Massachusetts residents with the lowest family incomes, less than $33,075 for a family of four, make up the largest share — 43 percent — of the uninsured, according to state data.

“We may want to let them in [to government subsidized health insurance], but it would cost money, and we would have to decide if the state wants to spend money that way,” said committee member Jonathan Gruber, an economics professor at the Massachusetts Institute of Technology.


Does an individual mandate to purchase private insurance with cost-sharing requirements ensure that citizens will have health care access and be able to afford it? It hasn’t in Massachusetts, and it will not throughout the United States because it is an irreparably flawed mechanism of financing health care.

The literature is replete with policies that would nudge us a little bit closer to the goals of affordability and expanded coverage, but, as Jonathan Gruber, an advocate of the private insurance mandate model, says, “we would have to decide if the state wants to spend money that way.”

But it’s the model, stupid! Dump it and replace it with an improved Medicare for all and then health care will be affordable for everyone. Why does Gruber and the others insist on separating state money from personal money, as if state money is sacred and personal money isn’t? It all belongs to us anyway.

qotd weekend special: The Super Bowl and a Crystal Stair

Posted by on Saturday, Feb 5, 2011

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.

Well here we are. Super Bowl weekend! Hurrah! What could be more American than this? Billions of dollars and the nation’s full attention directed to a couple dozen men playing a game. And this is no sandlot game. No. This is our nation at its finest – honoring in unparalleled splendor those great Americans who prevail and are declared winners of this historic rough-and-tumble fracas. And what more could our nation be than about winners?

Let me digress for a moment. I have a little story to tell.

I was still in practice during the Clinton effort to reform health care. Although practicing in an affluent community, I was experiencing great frustrations in trying to obtain specialized health care services for not only our indigent patients, but also for our insured patients who were facing increasing managed-care barriers to care.

Previously, in 1989, a life-changing event had occurred for me. It was simply that I read an article in The New England Journal of Medicine titled “A National Health Program for the United States,” written by a team led by David Himmelstein and Steffie Woolhandler, representing a group called Physicians for a National Health Program. I was stoked! I joined PNHP.

Then Bill Clinton was elected, and the nation was ready for a national health program. As masters of health policy science, PNHP was there and ready to help guide the process. But President Clinton decided that they would follow the path of political expediency and build reform based on the existing private insurers/managed care entities. Thus, in a political maneuver, to be repeated years later, PNHP was denied a seat at the table.

I watched the process closely. I listened as the opposition proposed a model almost identical to that of the Patient Protection and Affordable Care Act. I saw the effort go down in flames. I decided that we couldn’t just walk away.

I felt then that a pure single payer program, as much as I wanted it, could never pass. But I thought that there was enough agreement on fundamental principles that almost everyone would be able to support some model of social insurance, if we just had the right one. So I crafted a model. It was brilliant – just the right balance to achieve our goals while pleasing everyone.

I sent it in to PNHP. The task of reviewing it was handed to PNHP’s new president, Claudia Fegan. It required more postage to return it to me, because it was newly laden with red ink.

My lesson? I was passionate about reforming our system so that everyone would have the health care that they need, but I knew nothing about health policy science. I am forever indebted to Claudia for showing me the light, and resetting my course in my advocacy for reform. The principle she taught me is that you change policy recommendations only when policy science has demonstrated that there are better policies available. You do not ever change policy recommendations simply to conform to politics.

Claudia has continued to be a great inspiration to me. And that brings us to a crystal stair. On this glittering Super Bowl weekend, we should take a look at that crystal stair. You will understand what I mean when you read the Claudia’s remarks that she delivered to the Louisville, Kentucky Urban League on January 15, 2011. After reading her comments maybe we can think about what it really takes to make winners in America.

Cladia Fegan’s remarks to the Louisville Urban League:

Half of <200 FPL adults will have unstable shifting eligibility between Medicaid and exchanges

Posted by on Friday, Feb 4, 2011

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.

Issues In Health Reform: How Changes In Eligibility May Move Millions Back And Forth Between Medicaid And Insurance Exchanges

By Benjamin D. Sommers and Sara Rosenbaum
Health Affairs
February 2011

The Affordable Care Act will extend health insurance coverage by both expanding Medicaid eligibility and offering premium subsidies for the purchase of private health insurance through state health insurance exchanges. But by definition, eligibility for these programs is sensitive to income and can change over time with fluctuating income and changes in family composition. The law specifies no minimum enrollment period, and subsidy levels will also change as income rises and falls. Using national survey data, we estimate that within six months, more than 35 percent of all adults with family incomes below 200 percent of the federal poverty level will experience a shift in eligibility from Medicaid to an insurance exchange, or the reverse; within a year, 50 percent, or 28 million, will.

Income fluctuation raises issues for all subsidy-eligible individuals or families up to 400 percent of the federal poverty level, which includes those whose incomes place them squarely within the exchange system. For those purchasing coverage with subsidies through exchanges, income changes may trigger the obligation to repay some or all subsidies received; the amounts subject to repayment were significantly increased recently by Congress. But income fluctuations pose a particular challenge for individuals and families who cross the Medicaid-exchange divide, because this change may trigger a shift between plans and provider networks. In short, for this group, income fluctuation carries both financial and health care consequences.

Our multivariate analyses show that income fluctuations were common even among adults initially with incomes below the poverty level. This is particularly troubling because many of these people will often have incomes low enough to exempt them from the federal insurance mandate, which means that fatigue with frequent coverage changes may lead them to simply stop signing up for insurance over time. This is a problem on two fronts. First, it is uninsured low-income adults who have the most to gain from health reform. Second, this group includes millions of healthy adults whose participation in the exchanges is crucial to robust risk pools. We found that income changes were more common among adults who were younger, more educated, and white—characteristics that correlate with a lower burden of illness. Indeed, these results are consistent with previous findings on changes in Medicaid coverage among adults.


We have previously made the point that fluctuations in eligibility for Medicaid and for the income-related subsidies in the exchange plans create instability in coverage. Impaired outcomes occur because of gaps in coverage, and disruptions in provider networks. This new study puts a number on the degree of instability. Within one year, over 50 percent of adults with a family income under 200 percent of the federal poverty level (FPL) will experience a shift in eligibility from Medicaid to an insurance exchange, or vice versa.

The article discusses some of the implications of this, including problems with shifting eligibility levels for exchange subsidies for those with incomes over 200 percent of the FPL. Though eligible for one program or another, many individuals will have incomes that exempt them from the mandate to purchase insurance, and, assuredly, the healthier ones who are needed to round out the risk pools will go without coverage as a result of fatigue over multiple ejections by one program or another.

The authors offer policy options that might reduce this instability in coverage, but these options can never eliminate it. Our fragmented financing system of various private and public programs will never ensure that everyone is covered at all times, and it will continue to waste funds on administrative excesses such as trying to keep up with eligibility shifts due to income fluctuations.

A policy option that would work, not mentioned by the authors, would be to dump our dysfunctional multi-payer system and enact an improved Medicare that includes everyone. The problem of fluctuating incomes is greatly simplified because it impacts only the contribution through the tax system, without moving the individual in or out of Medicare.

Will ACOs be used to further privatize Medicare?

Posted by on Thursday, Feb 3, 2011

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.

Berwick Indicates CMS Still Plans To Mix Private Payers, Medicare In ACO Demo

By John Wilkerson
Inside Health Reform
February 3, 2011

CMS Administrator Donald Berwick indicated on Feb. 1 that CMS still plans to use a demonstration to let accountable care organizations include Medicare beneficiaries and patients with private insurance. Specifically, he said the CMS innovation center will make room for the “vanguards” of accountable care organizations so CMS can test ACO models that go beyond what is called for under the ACO program.

Sources say CMS had been planning to announce a demonstration program late last year to assign Medicare and possibly Medicaid beneficiaries to existing clinically integrated entities in the private insurance market. That announcement was delayed, they said, leaving them to wonder whether CMS had backed off the plan – but Berwick seemed to say at a Brookings Institution conference that the plan is still in the works.

CMS is talking to private payers about public-private partnerships and about how clinically integrated organizations can align what they are doing for patients with private insurance with the goals of ACOs, Berwick told reporters after his presentation. (The Federal Trade Commission has warned that broad-based ACOs involving private payers could raise antitrust concerns, but the FTC has been working out those matters with CMS.)

Berwick said the proposed rule on the ACO program should be published soon, but when asked by Inside Health Policy whether a demonstration would be announced before the proposed rule, Berwick said only that the innovation center would move “quickly” on ACO demonstrations. The health reform law created an ACO program, which is permanent and separate from the temporary demonstrations that the innovation center approves. However, CMS could approve ACO demonstrations that would later be wrapped into the ACO program, sources say.


Brookings Institution Conference: ACHIEVING BETTER CARE AT LOWER COSTS

This Brookings Institute conference on accountable care organizations (ACOs) provides important insights as to what we might be facing. These experts, including Donald Berwick, Elliott Fisher and Mark McClellan, provide abstractions as to policies that might achieve the quality and cost-containment goals of the ACOs that are mandated by the Patient Protection and Affordable Care Act (PPACA).

The Medicare Shared Savings Program will begin on January 1, 2012, less than one year from now. At that time, “groups of providers of services and suppliers meeting criteria specified by the Secretary may work together to manage and coordinate care for Medicare fee-for-service beneficiaries through an accountable care organization” (PPACA). Details as to the requirements can be found in Sec. 3022 and Sec. 10307 of PPACA.

If you read the transcript of the Brookings presentations of the experts and the panel discussions following, you should be concerned – very concerned. Within months, these somewhat nebulous abstractions are to be transformed into real life organizations of health professionals and facilities that supposedly will deliver higher quality care at a lower cost, while splitting the savings with the government.

Obviously, these ACOs will not spring up de novo; there isn’t enough time. We already know that the early demonstration projects are using existing entities that can best be categorized as managed care organizations. According to the report from Inside Health Reform, “CMS is talking to private payers about public-private partnerships and about how clinically integrated organizations can align what they are doing for patients with private insurance with the goals of ACOs, Berwick told reporters after his presentation.”

As recorded in the transcript of the Brookings conference, CMS Administrator Donald Berwick stated, “Now, I’m in a little bit of an awkward moment, aren’t I? The Notice of Proposed Rulemaking isn’t out yet. It will be out very soon, but I can’t tell you what’s in it yet because I guess I’m not supposed to, but you’ll see it soon. And then there’ll be a comment period, which I hope you’ll all take seriously.”

Be ready. When the Notice of Proposed Rulemaking is released for public comment, peruse it to determine if Medicare is going to be turned over to private insurer/managed care organizations in the name of higher quality and lower costs through accountable care organizations. We need to find out if this is merely new rhetoric that will mask the further privatization of Medicare, intended or not. If so, we cannot let it stand.

On Suppressing Ideas

Posted by on Thursday, Feb 3, 2011

On Friday, January 28, 2011, President Obama cautioned Egyptian President Hosni Mubarak that, “suppressing ideas never succeeds in making them go away.”

One year earlier, on January 25, 2010, our President said in his State of the Union address “If you have a better idea (for health care reform) let me know, let me know, let me know.”

So on January 29, 2010, Dr. Margaret Flowers and I went to the Harbor Hotel in Baltimore, where the President was meeting with the GOP leadership, in an attempt to deliver a letter to the President, outlining how a National Health Program IS a better idea.

We got arrested. Again.

Suppressing true health care reform isn’t going to make it go away. It’s an idea that is thriving, thanks to independent media like Democracy Now!, Huffington Post, Firedog Lake, Counterpunch, Common Dreams and OpEd News. And thanks to social networking sites like Facebook and Twitter. And thanks to the grassroots work of Single Payer healthcare reform activists around the country.

We have only to look at what is happening in

Vermont where they have a governor, Peter Shumlin, who campaigned on a state Single Payer platform, a Congressional delegation including Sen. Bernie Sanders, Rep. Peter Welch and Sen. Patrick Leahy, who support state Single Payer legislation, and a state legislature that is listening to the ideas of the people of Vermont, who are saying loudly and clearly, “we want comprehensive, publicly funded, single payer healthcare for all Vermonters.”

Mr. President, actions speak louder than words.

Dr. Paris is a psychiatrist and a member of the Maryland Chapter of PNHP, Physicians for a National Health Program  She was one of the “Baucus 8″ arrested with Dr. Margaret Flowers, Attorney Kevin Zeese and others for protesting the absence of representation for single payer universal health care on the Baucus Senate Panel hearings.

Honoring Dr. King in Louisville by demanding health care for all
An interview with Dr. Garrett Adams

By Andrew D. Coates, MD

To celebrate Martin Luther King Jr.’s birthday, January 15, Dr. Garrett Adams, president of Physicians for a National Health Program, invited Dr. Claudia Fegan to speak in Louisville, Kentucky.

Dr. Fegan is a prominent figure in Chicago’s medical community and a nationally recognized authority on single-payer health care systems. She currently serves as associate chief medical officer for the Ambulatory and Community Health Network for the Cook County Health and Hospital System, and is a past president of Physicians for a National Health Program (PNHP).

Dr. Fegan spoke at the Louisville Urban League at a Jan. 15 meeting to honor and celebrate Dr. King’s life and work. The text of her remarks, “‘The time is always right to do what’s right’: Dr. King and health reform,” has been posted at the Network of Spiritual Progressives.

During her visit to the city, Dr. Fegan also met with students and faculty at the Louisville Presbyterian Theological Seminary and with local physicians and medical students.

Dr. Adams, a specialist in infectious diseases of children, is the new president of PNHP. He has retired from full-time teaching at the University of Louisville School of Medicine. His previous duties included serving as medical director of communicable diseases at the Louisville Metro Health Department. He recently established a not-for-profit volunteer clinic on the Cumberland Plateau in Tennessee (www.beershebaclinic.org).

Thank you, Dr. Adams, for taking time to speak with us. To begin, would you please share with us some thoughts about how your recent efforts in Louisville connect with the overall effort for a national health program, and why you invited Dr. Fegan to speak?

One of the reasons that I was invited to be the new president of the Physicians for a National Health Program is because I am from Kentucky, a southern state. PNHP has recognized the contradiction that in the very areas of the United States where some of the worst health outcomes exist – areas that particularly would benefit from national health insurance – we have the lowest number of members. I have taken it upon myself to make an effort to expand the knowledge and understanding of the value of single-payer health reform in the South. I want especially to bring this message to African-American and Latino people who disproportionately suffer poor health results from the current system based on private health insurance.

That is why I invited Dr. Claudia Fegan, a highly respected African-American physician and a past president of PNHP, to help us celebrate the birthday of Dr. Martin Luther King Jr. in Louisville.

So to answer your question, Dr. Fegan’s visit was targeted for Louisville’s African-American community, and it was a great success.

Before we get to the big meeting at the Urban League, please tell us about the discussion at the Louisville Presbyterian Theological Seminary.

Dr. Fegan was invited to speak at the Louisville Seminary by a seminary professor. Several faculty members with significant health concerns have had unfortunate personal experiences with private health insurance and are convinced of the moral imperative that health care is a right to which all are entitled. Last year the Presbyterian Church USA made a formal endorsement of publicly funded national health insurance, so the subject is not unfamiliar. Dr. Fegan’s presentation was the first in a new series of health care discussions at the seminary sponsored by two professors, one of whom happens to be African-American.

It was an informal meeting over lunch attended by a racially mixed audience of about 30 students and professors. Dr. Fegan had new slides specially prepared for this audience, and she engaged the audience from start to finish; there were lots of questions and interaction. Many stayed later to talk and to ask her more questions.

When you met with medical students and physicians, did they bring similar concerns to your dialogue?

This meeting was targeted to bring together PNHP-Kentucky members, medical students, and the membership of the Falls City Medical Society, the area’s association of African-American physicians. Once again, Dr. Fegan was right on target with her presentation, including a selected group of fresh slides for this audience. A surgeon member of the Falls City Medical Society described his experience with French medicine and the “carte vitale.” A resident physician, who had driven all the way from eastern Kentucky, and a medical student were especially interested in the discussion. There were several new faces at the meeting. Dr. Fegan’s talk was informative and inspiring, but the opportunity to meet and talk with colleagues from a broader spectrum of our community was a memorable aspect of this meeting.

What do you find doctors and medical students saying about the Affordable Care Act? The national news media refers to it “the health care overhaul” or sometimes “sweeping health care legislation.” Is that their sense of the president’s reform?

I did not meet anyone over this weekend of health reform discussions that thinks that the ACA will resolve America’s health care dilemmas. Most recognize the advantages that are coming from it and appreciate the fact that something has been done, but they know that it’s not enough. The people with whom I met like the prospect of a single-payer national health plan.

How did the meeting at the Urban League come about?

We chose the Louisville Urban League as the venue for our signature remembrance of Dr. Martin Luther King Jr. for several reasons. First, it is located in the section of the city where many African-Americans live; it is a building with which local residents are familiar. It was a logical place to hold an event celebrating the life and work of Dr. King because the Louisville Urban League’s mission is “to assist African-American and disadvantaged persons in the achievement of social and economic equality primarily through education, employment, housing, family development and community development.”

Can you describe the Urban League event for us? Who spoke besides Dr. Fegan?

My feeling about the meeting was that it was exciting and joyous. The participation of community leaders was incredible. There were over 100 attendees. The first welcome was by Mr. Ben Richmond, the president and CEO of the Louisville League.

Mr. Richmond was followed by our own congressman, Rep. John Yarmuth. The congressman, distressed by the horror of the recent shooting of his friend and colleague Rep. Gabrielle Giffords, complimented us by his presence. A friend of the single-payer movement, Mr. Yarmuth struggled with the health reform debate in Washington last year. He told us that many times during the discussions he pointed out to his colleagues that an issue they were debating could be solved by single payer. Congressman Yarmuth stated, “I’m a single payer guy.”

Following Rep. Yarmuth’s remarks, Louisville’s newly elected mayor, Greg Fischer, welcomed the crowd. Mayor Fischer’s motto for the city is, “One City, One Community, One Family.” Mayor Fischer’s inaugural address emphasized the great importance to the city of addressing health problems. So, as he looked out at the crowd of faces of all ages and races at the Urban League, he was looking at his “One Family.” He praised our work for better health care for all. His presence and welcome was not only an acknowledgment of Dr. King’s legacy, but a tribute to those who continue to work for better health for all.

Finally, before Dr. Fegan’s address, Triza Cox led us in singing together the Black national anthem, “Lift Every Voice and Sing.”

Would you like to say something about how celebrating the life of Martin Luther King Jr. connects with the struggle for national health insurance?

Dr. King understood 40 years ago that gross inequities in health care existed in America and that they were linked to poverty and racism. The subtitle of Dr. Fegan’s address was “Remembering Dr. King’s cry for justice in health care.” Dr. King said, “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” On this occasion, in Louisville, Kentucky, we responded to that declaration with a loud affirmative, that we demand justice in health care for all Americans, and we will not relent until it is a reality.

Shortly after Dr. Fegan’s visit to Louisville, the House of Representatives, with a new Republican majority, passed a symbolic bill that would repeal the Affordable Care Act. Did the events “inside the beltway” in Washington seem to be on the minds of the people at the Urban League?

Not much. The American people are amazingly prescient. They recognize political grandstanding for what it is. These audiences understand clearly that the recent health law is incomplete, but they appreciate the progress it represents, and they are very supportive of President Obama.

What do you think the significance of the Louisville meetings was for the future of our efforts to win single-payer national health insurance?

We took a giant step forward for single payer in Louisville on Dr. Martin Luther King’s birthday. Many discouraged people were informed and inspired by the single-payer message that Dr. Fegan and the members of PNHP-Kentucky and Kentuckians for Single Payer Healthcare brought.

Do you have any advice for people who might want to try to emulate your work in Louisville and reach out in other places around our country?

Yes. “Reach out” is the right phrase. That is exactly what we need to do. As Dr. Arthur Sutherland of Memphis has said, we need to replace charity with social justice. There is no better way to eliminate inequities in health care than with single-payer national health insurance, an improved Medicare for all.

In December a panel of four PNHP-Kentucky physicians made a presentation in the African-American community. We were multicultural – one white, one black, one Latino and one Indian. An African-American gentleman in the audience said to me, “I didn’t know people like you existed.”

These events were meant to reach African-Americans. It is necessary for those of us who are not African-American or members of minority groups to try to recognize the subtleties of racism in ourselves, so that we can connect and share the single-payer message of “Everybody In, Nobody Out.”

(Andrew D. Coates, MD, is an internist and professor at Albany Medical College (N.Y.) and a member of the national board of PNHP.)

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