Rationing by inconvenience

Posted by on Friday, Aug 6, 2010

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.

Immigrants’ Experience with Publicly Funded Private Health Insurance

The New England Journal of Medicine
August 5, 2010

To the Editor:

On October 31, 2009, Massachusetts involuntarily transferred about 30,000 legal immigrants (mostly “green card” holders) from Commonwealth Care, the state-subsidized insurance program, to a new private insurance plan. CeltiCare, a subsidiary of the out-of-state, for-profit insurer Centene, agreed to take over their care for only $1,300 per person, one third of the state’s previous cost and well below the average cost of adequate care nationally. CeltiCare excluded several hospitals (and their affiliated community health centers) that have traditionally provided safety-net care for immigrants, including Boston Medical Center and Cambridge Health Alliance (CHA), where we work.

We used internal hospital data to determine the characteristics of patients who were transferred to CeltiCare and who had formerly received their primary care at CHA. A total of 1325 patients who had visited a primary care provider at CHA during the past year were moved to CeltiCare. Of these patients, 73% speak a primary language other than English, including Portuguese (24%), Spanish (20%), and Haitian Creole (9%); 19% have hypertension, and 10% have diabetes mellitus. A psychiatric disorder has been diagnosed in at least 9%.

We then evaluated the adequacy of the provider network for these patients. During the second and third months after the switch to CeltiCare, we searched CeltiCare’s Web site for primary care providers within 5 miles of CHA’s ZIP Code. The search returned 326 providers, of whom 217 were nonduplicate adult generalists. Of these providers, 25% could not be reached at the telephone number provided. Of those available by telephone, only 37% were actually accepting new CeltiCare patients, and the average wait for an appointment was 33 days. In all, only 60 providers were accepting new CeltiCare patients, and only 38 could provide service for even one of the three major linguistic minorities.

Given these findings, we believe that patients who were switched from Commonwealth Care to CeltiCare had inadequate access to primary care 3 months into this new program. We fear that such “rationing by inconvenience” shuts patients out of care to the detriment of their health but to the benefit of CeltiCare’s bottom line. Policymakers, in Massachusetts and nationally, should reassess the role of profit-driven insurers in the provision of safety-net care.

Ruth Hertzman-Miller M.D., M.P.H.
Malgorzata Dawiskiba M.D.
Cassie Frank M.D.
Cambridge Health Alliance, Cambridge, MA

http://www.nejm.org/doi/full/10.1056/NEJMc1005451

NEJM 1989: Health Care Rationing through Inconvenience, by Gerald W. Grumet, M.D.
http://www.nejm.org/doi/full/10.1056/NEJM198908313210909

Of all of the industrialized nations, the United States has the greatest amount of health care rationing, and we do that through a unique mechanism. We ration based on ability to pay. As this NEJM report shows, our flawed financing system also results in rationing by inconvenience. This is a unique tool used by the private insurance industry – a tool that serves the interests of the insurers, at the cost of the patients.

The 1989 NEJM article by Grumet describes some of the rationing-by-inconvenience mechanisms used during the managed care revolution. Not much has changed. The Patient Protection and Affordable Care Act calls for greater regulation of the private insurance industry, but it contains only a paucity of meager safeguards against policies of inconvenience. Therefore, it will be relatively ineffective in protecting us from this unscrupulous form of rationing.

Why do we leave the private insurance industry in charge?

Quentin Young and Cory Franklin on Medicare for all

Posted by on Thursday, Aug 5, 2010

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.

Excerpts from Pro and Con op-eds on Medicare for all

Chicago Tribune
August 4, 2010

Pro: Rx for Medicare’s birthday: Expand it

By Quentin Young

I was in active medical practice on July 30, 1965, when Medicare was signed into law by President Lyndon B. Johnson. Its impact on older Americans and their families was swift and spectacular. I saw the results with my own eyes.

Almost overnight, millions of Americans age 65 and older had the doors to health care opened to them that had hitherto been closed. They streamed into our doctors’ offices seeking long-deferred and sometimes urgently needed medical attention.

Simultaneously, the specter of crushing medical debt was lifted from the shoulders of tens of millions of America’s seniors and their children. You could almost hear a collective sigh of relief.

In fact, Medicare stands like a rock in a troubled sea of waste, inefficiency and disarray in the rest of our health care system, dominated as it is by big, corporate insurers whose paramount goal is to maximize profits, often by enrolling the healthy, avoiding the sick, raising premiums and denying claims.

Medicare is not without its problems, of course. Its benefits package could be richer. It lacks authority to negotiate lower prices with drug companies. The reimbursement rate to physicians could be enhanced and stabilized, instead of depending on an annual cat-and-mouse game with Congress (the “doc fix”) over a flawed accounting formula that only erodes physician confidence in the program.

But the best way to remedy these problems — and to bring down skyrocketing health care costs at the same time — is to improve the program and, most important, to expand it to cover every person in the United States.

That’s right: Extend Medicare to everyone. By replacing our crazy-quilt, inefficient system of private health insurers with a streamlined, publicly financed single-payer program, we would reap enormous savings.

First, we would save about $400 billion annually that is presently wasted on unnecessary paperwork and bureaucracy. That’s enough money to cover everyone who is currently uninsured and to upgrade everyone else’s coverage without increasing overall U.S. health spending by a single penny.

Patients could go to the doctor and hospital of their choice. They’d be covered for all medically necessary services and medications, with no co-pays or deductibles.

Second, we’d acquire powerful cost-control tools like the ability to purchase medications in bulk, negotiate fees, develop global budgets for hospitals and coordinate capital investments. Such tools would rein in costs and help assure the program’s sustainability over the long haul.

It’s never too late to do the right thing. So when naysayers urge cuts to Medicare, don’t buy it. Tell them to ask Congress to enhance Medicare and to extend it to all.

Dr. Quentin Young is national coordinator of Physicians for a National Health Program.

http://www.chicagotribune.com/news/ct-oped-0805-pro-20100804,0,2770491.story

Con: Patients will end up receiving less care

By Cory Franklin

No physician in the United States has been a more articulate spokesman for the medically disenfranchised in the last half century than Quentin Young; his ideas on health care merit our attention. But he is simply mistaken that the best remedy for our health care problems is to expand Medicare to every American.

Medicare, adopted in 1965, has been a success — albeit a qualified one. Many of its advantages are indisputable, but some are oversold.

Medicare expansion raises the untested arguments of single-payer advocates — savings accrued through lower administrative costs, negotiating fees, global budgets, centralized planning and purchasing.

The biggest problem in expanding Medicare is essentially solving what economist Greg Mankiw calls the trilemma, the three problems of health care delivery — cost, access and quality. Any two might be achieved but the third necessarily suffers. Expanding Medicare could certainly improve access but no one has figured out how to prevent escalating costs or diminishing quality (e.g. less subspecialty care). The question must be asked: Under universal Medicare might the country pay more and see patients receive less?

Dr. Cory Franklin is a physician with NorthShore University HealthSystem.

http://www.chicagotribune.com/news/ct-oped-0805-con-20100804,0,5728796.story

Supporters of Medicare for all are already familiar with the Pro position expressed so well by Quentin Young, but you may want to download the full article anyway to share it with others who may be less informed.

The full article on the Con position, written by Cory Franklin, also provides passive support for the Medicare for all position. He argues that 1) Medicare is going broke, 2) physicians are unhappy with Medicare reimbursement rates, 3) there have been many extensive technological advances in the past 45 years, 4) aging and obesity would put a strain on Medicare, 5) patients no longer pay 50 percent of total costs out of pocket, and that 6) there are unintended consequences in a massive government assumption of costs.

The reason that his arguments support Medicare for all is that he provides no alternative to address these issues other than the “untested” policies of the single payer model. In fact, the policies listed have been tested extensively in other nations and proven to be effective in both controlling costs and ensuring health care access for everyone.

A word needs to be said about the oft-repeated common wisdom that cost, access and quality are interdependent and that an improvement in one automatically results in an impairment of one or both of the others. Improve access and costs will go up and quality will go down, they say. This meme has been repeated so often that it is no longer questioned. Even Cory Franklin advances it with his statement: “Expanding Medicare could certainly improve access but no one has figured out how to prevent escalating costs or diminishing quality.”

What is the truth? As a universal program, Medicare for all would eliminate financial barriers to access for everyone. Expanded coverage would be paid for initially by the recovery of the profound administrative waste that uniquely characterizes our dysfunctional, fragmented system of financing health care. Not only would costs not increase, but single payer policies that would be put in place would slow the growth in costs to sustainable levels far into the future. A single payer system is also much more adept at identifying and incentivizing beneficial health care practices, thereby improving the quality of care delivered.

The opponents of Medicare for all are locked into the framing of the three-legged stool of cost, access and quality – reinforce one leg and the other two destabilize. We can show them how we can use Medicare for all to reinforce all three legs – proving universal access to higher quality care while controlling costs – to provide a solid, permanent structure of affordable, high quality care for everyone.

Health is a Human Right

Posted by on Thursday, Aug 5, 2010

Dr. Oliver Fein, PNHP President, Dr. Margaret Flowers, PNHP Congressional Fellow, Mary Nichols-Rhodes, LPN and leader of the Single Payer Action Network in Ohio and also Ohio organizer of the Progressive Democrats of America in Ohio, spoke at a panel discussion on July 24 at the United National Peace Conference. We called our workshop “Health is a Human Right.”

Dr. Vic Sidel, longtime PNHP leader, Past President of the American Public Health Association, founder, past-president and current Member of the Board of Directors of Physicians for Social Responsibility and Past Co- President of International Physicians for the Prevention of Nuclear War (among many other things!) was on the panel but got sidetracked by an issue with the train from New York City. I presented Vic’s excellent slides (hope I did OK, Vic!)

Thanks to the Sanctuary for Independent Media Dr. Flowers’ remarks, sharply edited, can be seen here and in full, unedited, here.

Dr. Fein presented thoughtful remarks that, alas, are not available online. He pointed out that as we go forward single payer advocates should reach out to supporters of the “public option,” people who acknowledge single payer as the best reform, but who lack the confidence that we will win it. We ought not demonize these friends, he proposed, but rather seek their support for single payer efforts. He also called for single payer advocates to reach out for allies from other struggles, like the peace movement, the immigrant rights movement and movement for women’s rights. Single payer has been a single issue movement, Dr. Fein concluded, and perhaps the time has come to see the inter-relatedness of our issues. For example: health care, not warfare.

Again, thanks to our friends at the Sanctuary for Independent Media you can link to a video of me saying something like this:

Agnes Smedley, in her great American autobiographical novel Daughter of Earth, observes that

“‘Deserve’ is the word which the possessors use as a weapon against those they dispossess.”

Deserve.

In the the peace movement the word “deserve” reminds us of lines by Phil Ochs:

“Show me the country where bombs had to fall.”

and

“Is there anybody here who’d like to wrap a flag around an early grave?”

For our planet and all of its species there is no reason to say that anyone, any living thing, “deserves” war.

Yet more and more in the world we’re starting to understand, as Smedley wrote, that this question of who deserves is a really a question of who possesses. And we are learning to explain just how those who possess use their weapons against those whom they dispossess, war being the most dramatic example.

When we say that health is a human right we assert that everyone deserves the best chance at health. Everyone deserves good health or the effort to make personal health good.

But when we say so we’re challenging those who possess — those who hold that some people do not deserve health, that some do not deserve care. Those who possess would have us believe, even, that there are human beings who deserve suffering, deserve to be ill, deserve, even, to die, just as they say that some people, some places, deserve war.

There is an acute and worldwide struggle, connected to the wars, a struggle for health.

In the New York Times they call it “Payback Time,” a series of business articles that aims to show, among other things, that people, especially public employees in the United States and workers in Greece and across Europe, no longer deserve to retire.

Articles like these focus on deficits to tell us that people in Spain shouldn’t have public healthcare, that those in Britain should no longer have the National Health Service, that Canada needs more hospital closings, that in the United States, perhaps 65 years old is really too young to qualify for Medicare.

Here in the United States we have articulated a method of evidence to explain that the minimum step forward to improve our health, when it comes to the delivery of healthcare, is to implement a single payer national health insurance system. It is this scientific method that we in PNHP bring to the social movement.

Certainly we all have the need for a mass movement of people, the kind of emphasis that is the focus of this peace conference. Certainly we need moral persuasion – and we know that we have the weight of ethics on our side.

But we also need science. We need science to articulate exactly how it works that those who possess benefit from the dispossession of the poor, the victims of war and those who don’t get healthcare – how those who possess benefit from the suffering of others, suffering no one deserves.

We see the shocking examples in United States, from medical deportations to needless and preventable deaths to countless daily indignities that affect almost everyone who needs care and also everyone who provides care.

In the single payer movement we will explain that our cause is just. We know that we will never win without millions of people mobilized, standing for the idea that health as a human right.

But we have learned also to understand and explain these injustices and indignities with not only politics, but economics, policy and human outcomes. The single payer movement in general and PNHP in specific contributes a method, a method of evidence – social science – to the cause of peace and justice everywhere.

Disparities within the U. S. health care system result in serious impacts on access to care for patients with cancer at all stages from screening and prevention to treatment and survival. Access barriers further lead to disparities in the quality of care received. These concerns led the American Cancer Society to launch a national effort in 2007 calling for system reform that will provide “4 As coverage”:

•  Adequate—timely access to the full range of evidence-based health care including prevention and early detection.
•  Affordable—costs are based on the person’s ability to pay.
•  Available—coverage available regardless of health status or prior claims.
•  Administratively simple—processes are easy to understand and navigate. (1) (Sack, K. Cancer society focuses its ads on the uninsured. New York Times, August 31, 2007)

Access barriers take a wide variety of forms and affect many disadvantaged groups within the U. S. population. The single most important aspect of access is the status of the patient’s health insurance coverage. (2) (Siminoff, LA, Ross, L. Access and equity to cancer care in the USA: a review and assessment. Postgrad Med J 81: 674, 2005) For all types of cancer, the uninsured are 1.6 times more likely to die within five years compared to cancer patients with insurance. (3) (Ward, E, Halpern, M Schrag, N et al. Association of insurance with cancer care utilization and outcomes. CA Cancer J Clin 58: 19-20, 2008) 8/1/9

The lack of health insurance is much more common among racial and ethnic minorities than among whites. According to the U. S. Census Bureau, when 15.9 percent of the population was uninsured in 2005, the uninsurance rate for whites was 11.3 percent compared to 19.6 percent for non-Hispanic blacks and 32.7 percent for Hispanics. (4) (Income, poverty, and health insurance coverage in the United States: 2005, update.)

These examples illustrate how the lack of insurance adversely impacts patients with cancer across the entire spectrum of care:
•  Women aged 40 to 64 without insurance are only half as likely to have had a mammogram within the last two years as those with insurance. (5) (Ibid #3)
•  One in four uninsured cancer patients delay or forego care because of cost. (6) (Ibid #3)
•  Uninsured African-American women with breast cancer have a five-year survival rate of only 63 percent compared to 89 percent for insured Caucasian women. (7) (Ibid # 3)
•  Cancer has become a chronic disease for the estimated 12 million cancer survivors in this country, many of whom have co-morbidities such as heart disease, diabetes and arthritis as well as under-recognized and under-treated anxiety and depression. A 2008 national study found that uninsured cancer patients were three times more likely than their insured counterparts to have not seen health professional in the last year, twice as likely to have no regular source of care, and five times more likely to use the emergency room for care. (8) (Wilper, AP, Woolhandler, S, Lasser, KE et al. A national study of chronic disease prevalence and access to care in uninsured U. S. adults. Ann Intern Med 149: 170-76, 2008)

Under-insurance is another big problem for many patients with cancer, since many insurance policies provide little protection against the rapidly rising costs of cancer care. Two examples illustrate the financial burdens placed on cancer patients and their families even when insured:

•  Despite being consistently insured, a 2006 study by the Kaiser Family Foundation and the Harvard School of Public Health found that almost one-half of cancer patients used up most or all of their life savings, while 8 percent were turned away or unable to get a specific treatment because of insurance issues and 3 percent ended up declaring bankruptcy. (9) (Kaiser Family Foundation. Survey of families affected by cancer shows people with and without health insurance suffer serious financial hardships. USA Today/Kaiser Family Foundation/Harvard School of Public Health National Survey of Households Affected by Cancer, November 20, 2006)
•  Some “insurance” policies are ludicrous in the extent of their undercoverage—one example is the limited-benefit basic cancer policy marketed by AllState, starting at $420 a year for family “coverage”, which pays a one-time benefit of $2,000 if diagnosed for the first time with cancer (other than skin cancer). (10) (McQueen, MP. The shifting calculus of workplace benefits. Wall Street Journal, January 16, 2007: D1)

Do patients with cancer covered by Medicare and Medicaid fare any better than their counterparts with or without private insurance? Here again, their access to care falls far short of their needs. An increasing number of physicians will not accept new patients on Medicare or Medicaid because of low reimbursement. Medicare Advantage plans may impose high cost burdens on patients who are referred to out-of-network physicians and facilities for cancer care, sometimes leading to disenrollment. (11) (Medicare Rights Center. Why consumers disenroll from Medicare private health plans. Summer 2010) Medicaid remains an underfunded porous safety net with many restrictions on coverage varying from state to state. (12) (Ramirez de Arrelano, AB, Wolfe, SM. Unsettling Scores: A Ranking of State Medicaid Programs. Washington, D.C. Public Citizen Health Research Group, April 2007)  Medicaid enrollees are more likely to have late-stage cancers when diagnosed, resulting in worse outcomes. (13) (Halpern, MT, Ward, EM, Pavluck, AL et al. Association of insurance status and ethnicity with cancer stage at diagnosis for 12 cancer sites: A retrospective analysis. Lancet Oncol 9 (3): 222-31, 2008) Many oncologists refuse to provide chemotherapy for Medicaid patients in their offices due to low reimbursement, sending them on to hospitals. (14) (Lung Cancer Connections. Caring 4Cancer. An introduction to Medicaid. Web site accessed October 31, 2008)

Because of access barriers to care and other factors in our market-based system of care (based as it is on ability to pay, not medical need), the quality of care for cancer patients in our present system leaves much to be desired for these kinds of reasons:

•  Perverse financial incentives pervade our business-oriented health care system. Hospitals and physicians make higher revenues by providing services that are often unnecessary, inappropriate or even harmful. When Medicare reduced reimbursement rates for outpatient chemotherapy drugs in 2005, oncologists switched from drugs that were most reduced in profitability to other high-margin drugs at increased cost but without good evidence of improved outcomes. (15) (Jacobson, M, Earle, CC, Price, M, Newhouse, JP. How Medicare’s payment cuts for cancer chemotherapy drugs changed patterns of treatment. Health Affairs 29 (7): 1391-99, 2010)  A 2008 study by United Health found that Procrit, a very expensive anti-anemia drug also highly remunerative to prescribing oncologists, was being prescribed for about one-third of patients who were not anemic at all. (16) (Culliton, BJ. Interview: Insurers and ‘targeted biologics’ for cancer: A conversation with Lee N Newcomer. Health Affairs Web Exclusive 27 (1): W 41-W51, 2008)  More than 30 million full-body CT scans are performed each year for screening purposes despite the lack of evidence of benefit or the approval by the FDA or the American College of Radiology. (17) (Brenner, DJ, Hall, EJ. Computed tomography—An increasing source of radiation exposure. N Engl J Med 357: 2277-84, 2007)  Over-screening, over-diagnosis and over-treatment of prostate cancer are endemic in this country, without evidence of improved outcomes. A 2009 report of a randomized ten-year trial of 76,000 American men found that widespread screening does not lower the death rate from the disease. (18)  (Andriole, GL, Grubb, RL, Buys, SS et al. Mortality results from a randomized prostate-cancer screening trial. N Engl J Med online. March 18, 2009).  Dr. Peter Bach, oncologist at Sloan-Kettering Cancer Center and former senior advisor on health care quality at the Centers for Medicare and Medicaid Services (CMS), estimates that 30 to 40 percent of spending on cancer care is of marginal value. (19) (Bach, P, as quoted in McNeil, C. Sticker shock sharpens focus on biologics. News. J Natl. Cancer Inst 99 (12): 911, 2007)
•  We have an industry-friendly system of deciding what services and treatments will be covered. Coverage policies are not rigorously evidence-based, and the use of cost-effectiveness as a criterion for coverage decisions is vigorously opposed by industry. Many expensive and toxic drugs are used for indications beyond FDA approval—so-called “off label” use. In 2009, Medicare coverage of off-label cancer drugs was expanded despite the lack of clinical evidence for effectiveness. (20) (Abelson, R, Pollack, A. Medicare widens drugs it accepts for cancer care: More off-label uses. New York Times, January 27, 2009)
•  Quality of care breaks down at the interface between primary care and oncology-related subspecialty care. A just-published monograph by the National Cancer Institute documents the scope and magnitude of this serious problem, ranging from lack of communication and collaboration to overlapping and ambiguous roles. (National Cancer Institute. Division of Cancer Control and Population Sciences. Toward Improving the Quality of Cancer Care: Addressing the Interfaces of Primary and Oncology-Related Subspecialty Care. Number 40, 2010)  For the best quality of care, cancer patients need to be followed by both groups of physicians working together in their areas of expertise. One study of almost 15,000 survivors of colorectal cancer, for example, found that patients followed by oncologists were less likely to receive influenza vaccination, cervical screening and bone densitrometry, while those followed by primary care physicians reported less screening by colonoscopy and mammography. (21) (Earle, CC, Neville, BA. Under-use of necessary care among cancer survivors. Cancer 101 (8): 1712-19, 2004) Continuity of primary care throughout the care of cancer from screening to survivorship is essential to the best outcomes. We cannot expect subspecialists to care for co-morbidities so common among cancer patients, and treatment decisions often require consideration of co-morbidities, personal and family considerations.

As is clear from the above, access and quality of care are closely entwined and multi-dimensional. Addressing these problems is a complex challenge since they are embedded in a dysfunctional health care system. But that is the subject of our next post, which will consider to what extent the new health care reform law, the Patient Protection and Affordable Care Act of 2010, can remedy these problems.

Adapted in part from The Cancer Generation: Baby Boomers Facing a Perfect Storm, 2009, with permission of the publisher, Common Courage Press.

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The impact of Taiwan’s single payer system on amenable mortality

Posted by on Wednesday, Aug 4, 2010

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 universal National Health Insurance on population health: the experience of Taiwan

By Yue-Chune Lee, Yu-Tung Huang, Yi-Wen Tsai, Shiuh-Ming Huang, Ken N Kuo, Martin McKee and Ellen Nolte
BMC Health Services Research
August 4, 2010

Background

Taiwan established a system of universal National Health Insurance (NHI) in March, 1995. Today, the NHI covers more than 98% of Taiwan’s population and enrollees enjoy almost free access to healthcare with small co-payment by most clinics and hospitals. Yet while this expansion of coverage will almost inevitably have improved access to health care, however, it cannot be assumed that it will necessarily have improved the health of the population. The aim of this study was to determine whether the introduction of National Health Insurance (NHI) in Taiwan in 1995 was associated with a change in deaths from causes amenable to health care.

Methods

Identification of discontinuities in trends in mortality considered amenable to health care and all other conditions (non-amenable mortality) using joinpoint regression analysis from 1981 to 2005.

Results

Deaths from amenable causes declined between 1981 and 1993 but slowed between 1993 and 1996. Once NHI was implemented, the decline accelerated significantly, falling at 5.83% per year between 1996 and 1999. In contrast, there was little change in non-amenable causes (0.64 percent per year between 1981 and 1999). The effect of NHI was highest among the young and old, and lowest among those of working age, consistent with changes in the pattern of coverage. (This result is consistent with our expectations as 77% of the working age population were already covered by the pre-existing social insurance; thus they were inevitably going to be affected less by the introduction of NHI.) NHI was associated with substantial reductions in deaths from circulatory disorders and, for men, infections, whilst an earlier upward trend in female cancer deaths was reversed.

Conclusions

NHI was associated in a reduction in deaths considered amenable to health care; particularly among those age groups least likely to have been insured previously.

Policy Implications

These findings have implications for other countries that do not have universal health insurance coverage. The implementation of NHI in Taiwan was associated with a sustained reduction in deaths from causes amenable to health care, which surpassed the underlying decline in other causes. It is reasonable to expect that the introduction of universal coverage elsewhere might also have beneficial effects.

Looking ahead, while the Taiwanese NHI has succeeded in terms of cost (3.4% of GDP), satisfaction (77.5% satisfied in 2007), low administrative cost (1.49%), and equitable financial burden, the system is not without problems. For example, as a publicly-managed program, it is difficult to insulate it from political interference, a factor that has contributed to a continuing financial deficit. Thus, the existing budget may be inadequate to sustain the current level of performance.

http://www.biomedcentral.com/1472-6963/10/225/abstract

Full article (provisional):
http://www.biomedcentral.com/content/pdf/1472-6963-10-225.pdf

United States has worst rate of amenable mortality:
http://www.pnhp.org/news/2008/january/united_states_has_wo.php

Taiwan’s 1995 introduction of a single payer system of universal National Health Insurance provides us with a natural experiment on the impact of single payer reform on health outcomes. The results are dramatic. The rate in reductions of deaths due to disorders that are amenable to health care were nine times the reductions in deaths from non-amenable causes. Nine times!

The United States should be especially interested in these results since, in a study of nineteen industrialized nations, we have the worst rate of amenable mortality (link above). We have over 100,000 excess deaths per year due to disorders amenable to health care.

Will the Patient Protection and Affordable Care Act (PPACA) erase this blemish on our health care system? Most of our dysfunctional financing system will remain in place. Some will receive care under an expansion of Medicaid, but as a chronically underfunded program with insufficient numbers of willing providers, access problems are inevitable. Others will receive care under the private plans in the insurance exchanges, but financial barriers to access will remain because of the low actuarial values of the plans and inadequate subsidies. There is little reason to believe that the tweaks of PPACA will have much impact on amenable mortality.

After enacting a single payer system, Taiwan not only greatly reduced amenable mortality, but it was done at a fraction of our spending, with great patient satisfaction, with extremely low administrative costs, and with a financing system that is equitable. Maybe Taiwan needs to spend more, but just think of what we could have with the amount that we are already spending. Besides, saving 100,000 lives a year seems to be a worthy policy goal.

Threat of destabilization of the private insurance market

Posted by on Tuesday, Aug 3, 2010

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.

Covering New Ground in Health System Shift

By Robert Pear
The New York Times
August 2, 2010

Administration officials are eager to demonstrate and deliver what they see as the benefits of the new law (Patient Protection and Affordable Care Act). But they face a delicate task: they do not want to destabilize or disrupt the existing market in a way that makes insurance less available or more expensive to consumers.

For the moment, President Obama has the upper hand. Congress gave him sweeping power to regulate the industry for the benefit of consumers. Administration officials said they would be tough on the industry, but, for the law to succeed, they need large numbers of insurance companies to compete in the new regulated marketplace.

Sabrina Corlette, a research professor at the Health Policy Institute of Georgetown University, said: “In 2014, we can say good riddance to bottom-feeder insurance plans, which have built a business around selling policies to healthy young people. They often provide inadequate coverage when people get sick. But if these plans pull out of the market before 2014, we want to be sure that viable alternatives are available.”

http://www.nytimes.com/2010/08/03/health/policy/03insurance.html?hp

“…bottom-feeder insurance plans, which have built a business around selling policies to healthy young people (and which) often provide inadequate coverage when people get sick…” That quotation describes the products being sold in the individual insurance market by WellPoint, the largest insurer in the nation.

Imagine WellPoint improving those plans so that they do provide adequate benefits, with a choice of physicians and hospitals, without excessive cost sharing, and that they would include everyone regardless of preexisting conditions. Imagine the premiums that they would have to charge. Then imagine many companies developing similar quality insurance products to create a robust market of plan choices within the insurance exchanges.

Keep imagining because these products will have to exist only in our minds since the private insurance industry will never again be able to make them a reality if they are going to cover everyone with premiums we can afford.

For those who have employer-sponsored plans that seem to be working, keep in mind that these plans have cherry picked the large but highly select group of the inexpensive healthy workforce and their young healthy families. Also keep in mind that the employee cost of these plans is not only the payroll deduction, but also the forgone wage increases that pay for the employer contribution, and now to be added are the taxes that will be paid to support the subsidies for those who purchase their plans through the exchanges. Nobody is getting off cheap.

If the Obama administration is going to “regulate the industry for the benefit of consumers,” then they can’t help but “destabilize or disrupt the existing market in a way that makes insurance less available or more expensive to consumers.”

Why should we worry about a destabilized market of private plans, when our real concern is how are we going to pay for the health care that any of us might need? The obvious solution would be to replace the private plans with a single payer national health program – an improved Medicare for all. The fate of the private insurers should be the least of our concerns.

Sen. Sanders to introduce bill for single payer waiver

Posted by on Monday, Aug 2, 2010

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.

Sanders promises to seek health care waiver from Obama for Vermont

By Susan Smallheer
Rutland Herald
August 1, 2010

U.S. Sen. Bernard Sanders, I-Vt., pledged to personally take Vermont’s case for a statewide single-payer health care system to President Obama if the Legislature authorizes it next year.

Sanders, speaking at a health care rally at the Hetty Green Park in downtown Bellows Falls on Saturday afternoon, said that he and other members of Congress would also introduce legislation that would roll back to 2014 the current 2017 restriction for states to apply for a waiver in order to implement their own systems. He said Democratic Reps. Dennis Kucinich of Ohio and John Conyers of Michigan would be co-sponsoring the legislation with him.

http://www.rutlandherald.com/article/20100801/NEWS02/708019832/1003/NEWS02

Although the Patient Protection and Affordable Care Act would allow states to apply for waivers to implement their own systems, they cannot do so until 2017, three years after they are required to implement the private insurance exchanges. Many have asked if Sen. Sanders still intends to introduce legislation to move that date up so that states would not have to set up the exchanges only to replace them soon thereafter with a single payer system. The answer is yes.

Happy birthday, Medicare

Posted by on Monday, Aug 2, 2010

Originally published in the Berkshire Eagle.

Say “Happy Birthday” to Medicare, signed into law by President Lyndon Johnson 45 years ago, on July 30, 1965.

This national program provides health insurance coverage for everyone 65 years and older, regardless of income or health status, as well as covering people with disabilities. Our senior citizens love Medicare, which, along with Social Security, has substantially lowered poverty among the elderly, providing a secure safety net for our most vulnerable citizens.

Medicare is an example of a “single payer” health insurance program, in which health care dollars are administered by only one payer, the federal government. Medicare patients love the program for a number of reasons. Their premiums, deductibles and co-payments are reasonably priced. No one 65 and older can be denied coverage due to pre-existing conditions. Patients have their choice of doctors and hospitals, and are able to make decisions with their doctors about the care they need.

This safety net is now being threatened. President Obama has appointed a committee, the “National Commission on Fiscal Responsibility and Reform,” to make recommendations to Congress for reducing our federal deficit. Unfortunately, some members of this commission are already considering cuts to Medicare and Social Security benefits. Other solutions for reducing the deficit, like cutting the military budget, taxing the rich, negotiating drug costs, and eliminating the waste of the private health insurance industry by enacting a single-payer health insurance program, are not being considered. The commission is expected to make its recommendations to the House of Representatives after the fall elections, with a vote anticipated in December during a lame duck period of Congress.

Instead of cutting Medicare benefits, a better solution is to eliminate the failed and very costly for-profit “multiple payer” model, that includes hundreds of private health insurance companies with their high administrative costs and exorbitant CEO salaries, as well as their intrusion into the doctor-patient relationship. A much more cost-effective insurance approach would be to improve and expand Medicare to include everyone. At a time when our nation faces high unemployment, and fiscal crises, an expanded Medicare program would be a boon for individuals, small businesses, towns and states.

How would such a program produce savings and control health care costs? First, with Medicare, administrative costs are much lower than for private insurance companies. Administrative savings would be about $400 billion/year, enough money to provide coverage for everyone. Second, prescription drug prices would be negotiated, and drug costs could be lowered by 40 percent, bringing U.S prices in line with other developed countries. Third, an expanded Medicare system could establish global budgets for health care facilities.

The majority of Americans support Medicare and an expansion of this program to provide single-payer health insurance for everyone. Last week this was demonstrated again when participants in town meetings sponsored by “America Speaks” demanded single-payer as the option to solve the health care crisis, and 71 percent voted to not cut Medicare and Medicaid.

Our public and private dollars are flowing into the coffers of the private health insurance industry. These insurance companies continue to squeeze patients and health care providers financially, while paying their executives enormous salaries and bonuses. In 2009, the United Health Group, one of the biggest health insurance companies, paid CEO Stephen Helmsley a compensation package of over $107. 5 million. A recent conference of health economists in Chicago concluded that increasing consolidation in the health insurance industry has led to higher premiums, fewer jobs for health care workers, and reduced physician earnings.

Obama’s commission should not recommend cutting Medicare benefits. Write to your senators and representatives, and let them know how you feel about preserving, and expanding Medicare. Ask them to improve and strengthen Medicare by making it available to everyone, so that in coming years we will all be able to enjoy and celebrate the birthday of this life-saving health insurance program.

Susanne L. King, M. D., is a Lenox-based practitioner.

By Margaret Flowers, M.D.

Today we celebrate the 45th anniversary of the enactment of Medicare. Events are happening across the nation to mark this significant occasion, and yesterday I and about 10 other single-payer health reform advocates walked the halls of Congress and distributed literature to underscore its importance.

Medicare is a true American legacy which has brought health security to many of the most vulnerable members of our society. Because of Medicare, fewer senior citizens are living in poverty. Because of Medicare, health disparities which are growing in younger populations begin to decline after the age of 65. Medicare serves as a model of a universal (for those 65 and older) health system which operates with significantly lower administrative costs as compared to commercial health insurance so that a greater proportion of Medicare dollars pay for direct patient care.

During the recent health reform process, it was puzzling to health advocates to hear members of Congress and the president say that we must keep what works and fix what doesn’t and then see them keep what doesn’t work – commercial insurance. It was puzzling to hear legislators say that we needed to keep the American legacy of employer-sponsored health insurance while they ignored the true American legacy of Medicare.

We took every opportunity to let legislators know that the most effective solution to our health care crisis is to improve and expand a Medicare-like health system to everybody. To the detriment of the people in this nation, while the single-payer movement did grow, our arguments were largely ignored by Congress. The result was increased privatization of health care with its inherent inequities and soaring costs.

Now that a health bill has passed, we face a new challenge altogether. Instead of pushing to expand Medicare, we will have to struggle just to keep our current Medicare, and other social insurances, from being further weakened and privatized. This is a struggle that must not be ignored. We cannot cede any more ground to those who profit at the expense of our human lives.

The president appointed a new commission in April of this year, close on the heels of the passage of the health bill. Known as the National Commission for Fiscal Responsibility and Reform, this group of 18 is packed with and sponsored by those who will gladly use this opportunity to gut our feeble social safety nets. The same marketing tools used so successfully in the health reform process are being employed again: scripted public events used to create the illusion of popular support, public hearings designed to give the appearance of public input and co-optation of progressive institutions in support of neoliberal policies.

The single-payer movement has once again, come together to stand united to oppose the actions of the deficit commission. Four representatives of organizations who are members of the Leadership Conference for Guaranteed Health Care (LCGHC) testified at the deficit commission public hearing in June. However, given the extent of influence being wielded by the billionaire Peter G. Peterson Foundation, it is unlikely that our testimony will influence the commission members.

Our greatest strength as a movement is to hold our legislators accountable by urging them to oppose changes that weaken Medicare, Medicaid and Social Security. To that end, members of the LCGHC spent July 29 walking the halls of Congress. We delivered a letter from the LCGHC, copies of our testimony to the commission, a pledge for members to sign and information about single payer to each of the 435 members in the House and to most of the senators.

In addition, we met with staff in the offices of the co-chairs of the Congressional Progressive Caucus to present them with nearly 1,000 postcards signed by people from across the nation asking them to oppose cuts to Medicare and instead to create improved Medicare for All. We asked that the caucus make a public statement confirming their commitment to not only oppose such cuts, but to actively work to defeat such recommendations.

The deficit commission is charged with the task of submitting their plan to Congress in early December and Congress has committed to vote on their recommendations. The timing of these events has been arranged to occur after the November elections when there will be a lame duck Congress. Such timing makes the task of holding elected officials accountable more difficult but it remains crucial that we attempt to do so.

The struggle for health justice will go on. We must plan now for the future. For this reason, I urge you to meet with your member of Congress and senators during the August break. They will be campaigning in their home districts. You can find information to use in these visits at www.pnhp.org. Ask your legislators to sign the pledge available at www.healthcare-now.org. Publicize the results. And let your legislators know that you will be watching. If they pledge to oppose cuts before the election and then turn around and vote for cuts, no matter what excuse they give, then you must pledge to withhold your vote for them in the 2012 election.

This is the power that we the people possess: the power of the vote. And having the courage to use this power, this tool, at this point in time will bend the arc of justice to the needs of the people of this country.

So, on this day of celebration, Medicare’s 45th, please pledge to yourself to be a defender of our much needed social insurance programs. Step up and join with us to preserve and protect Medicare, a true American legacy.

Margaret Flowers, M.D., is congressional fellow for Physicians for a National Health Program (www.pnhp.org).

Lawmakers vow to continue fight for Medicare for All

Posted by on Friday, Jul 30, 2010

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 following text is an open letter to the single-payer community from Rep. Dennis Kucinich of Ohio, Rep. John Conyers Jr. of Michigan and Sen. Bernie Sanders of Vermont. It was released on the eve of Medicare’s 45th anniversary.

Congress of the United States
July 29, 2010

Dear friends of health care for all,

Now that a new health care bill has been signed into law, it has never been more important to have a strong movement behind Medicare for All.

Many health care experts have expressed concern that the Patient Protection and Affordable Care Act does not adequately contain costs for American families and businesses. If they are correct, and we believe they are, additional legislative cost containment measures will be necessary in the future.

When it is time for Congress to try to control health care costs again, the demand for Medicare for All must be undeniable. There is substantial support for a federal Medicare for All solution, embodied by H.R. 676, the National Health Care Act, and S. 703, the American Health Security Act, in the Congress and around the country. We believe that this support can and will continue to grow.

The truth is not enough. We already know that such a health care system has repeatedly proven to control costs more effectively, cover everyone or almost everyone, and deliver care of significantly higher quality than health care systems that tolerate the presence of private health insurance companies. Now we must make it so that the truth can no longer be ignored.

During the health care debate, the movement created significant momentum on which to build. Its voice was heard in multiple Congressional hearings – it won historic victories in a House vote to grant an ERISA waiver to a state that passes a Medicare for All-like plan and in a Senate provision allowing a waiver from the Exchanges for states to innovate with health coverage such as a state-based Medicare for All-like system that was included in the new law.

The latter victory created a new opening. Though the effective date for the Exchange waiver was pushed back to 2017 by the Congressional Budget Office to avoid driving up the estimated cost of the bill, the waiver’s presence sent a clear message: if a state thinks it can do better, Congress wants to see it.

We are encouraged by the progress already garnered in multiple states toward guaranteed health care and we will continue to work hard in Congress to clear any obstacles in the way. The 2017 date can be changed at the same time Congress considers all of the other waivers from federal laws that will be required for the state to move forward. That can happen either before or after a state passes a Medicare for All-like bill.

Regardless of the legislative path, we vow to continue to fight alongside you for health care justice at the both the federal and state levels. We believe that Medicare for All is inevitable in the United States. It is up to all of us to determine when the inevitable becomes the reality.

Sincerely,

Rep. Dennis J. Kucinich

Rep. John Conyers Jr.

Sen. Bernie Sanders

http://www.pnhp.org/news/2010/july/lawmakers-vow-to-continue-fight-for-medicare-for-all

On the 45th anniversary of Medicare it is reassuring to know that the vision of President Lyndon Johnson and the 89th Congress for an America that ensures health care for everyone, through a comprehensive Medicare for all, not only still lives, but is an inevitability.

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