Seattle Children’s Hospital excluded from most exchange plans

Posted by on Tuesday, Oct 8, 2013

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

Majority of Washington’s Health Benefit Exchange Insurance Plans Fail to Cover Care at Seattle Children’s; Hospital Sues Seeking Adequate Network Coverage for Children and Families

Seattle Children’s Hospital, October 4, 2013

Today, Seattle Children’s Hospital filed suit citing the failure of Washington state’s Office of the Insurance Commissioner (OIC) to ensure adequate network coverage in several Washington’s Health Benefit Exchange (Exchange) plans. We believe strongly that the OIC and the majority of plans on the Exchange have failed to meet their mandate, as they do not currently cover care provided at Children’s.

Children’s is the only pediatric hospital in King County and the preeminent provider of many pediatric specialty services in the Northwest. Some of these specialized services not available elsewhere in our area or region include acute cancer care, level IV neonatal intensive care and heart, liver and intestinal transplantation.

Without inclusion of Children’s, current and future patients and families who obtain insurance from several plans offered will not be able to access care at Children’s as an in-network provider. This lack of suitable access to pediatric services means that families enrolled in these plans may not receive the most timely, appropriate care, and face larger out-of-pocket amounts.

“Every child should have access to essential healthcare and the intent of the new Exchange is to make it available to all families,” said Thomas Hansen, MD, CEO, Seattle Children’s. “However, we are very concerned about the limited networks being offered by some Exchange insurance plans. Omitting coverage for care at a facility like Children’s prevents families from accessing vital services they may desperately need.”’s-Health-Benefit-Exchange-Insurance-Plans-Fail-to-Cover-Care-at-Seattle-Children’s;-Hospital-Sues-Seeking-Adequate-Network-Coverage-for-Children-and-Families/

This press release from Seattle Children’s Hospital presents only one side of the story. Children enrolled in most of the plans to be offered in Washington’s insurance exchange will not have in-network access to the crucial, highly specialized services only offered by Seattle Children’s Hospital. The financial exposure to those families could be enormous. So what is the other side to this story?

There is tremendous pressure on the exchange plans to keep premiums competitive. Although rates generally had been ratcheted down as low as the market will tolerate, they could squeeze a little more out from some providers by negotiating slightly lower rates in exchange for excluding health care competitors. These limited networks are an insurer-driven, cost-containment element of the new ACA exchanges.

Imagine a Seattle child with a major malignancy or with the need for an organ transplant. Is it really reasonable that our “reformed” health care system still exposes that family to severe financial hardship and possibly bankruptcy? This is not what we should have expected from comprehensive health care reform.

We need to go back and do it right – enact a single payer national health program that removes financial barriers to all essential care for everyone. Any child in Seattle that requires the specialized services offered by Seattle Children’s Hospital should have them. No exceptions.

Mercer update on changes in employer health benefits

Posted by on Monday, Oct 7, 2013

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

Employers Hold the Line on Health Benefit Cost Per Employee in 2014

Mercer, October 1, 2013

Based on early responses from a major survey conducted annually by Mercer, employers expect health benefit cost per employee will rise by 4.8% on average in 2014

“The recession has been one factor behind slower cost growth, by dampening utilization,” said Beth Umland, Mercer’s director of research for health and benefits. “But employers have made fundamental changes in their health benefit programs in recent years that have put the brakes on unsustainable cost growth.”

Employers estimate that if they made no changes to their current plans, health benefit cost per employee would rise by 7% on average in 2014.

One of the key strategies employers are using to manage cost growth is implementing consumer-directed health plans, which give employees financial incentives and information resources to seek more cost-effective care and are typically paired with an employee-controlled account. Another is health management (or “wellness”) programs focused on improving workforce health. And an emerging trend for 2014 that is expected to accelerate in 2015 is the use of private exchanges, such as Mercer Marketplace, which make it easier for employers to offer a range of medical plan options and voluntary benefits and which can be a tool in cost management.

About a third of all large employer health plan sponsors (those with 500 or more employees) do not currently offer coverage to all employees working 30 or more hours per week, as will be required under the Affordable Care Act (ACA) beginning in 2015. Industries that rely heavily on part-time workers will be the hardest hit by this rule. About half of respondents in retail and hospitality currently do not offer coverage to all employees working 30 or more hours per week.

Some employers will minimize the number of newly eligible employees by cutting back on hours for at least a portion of their workforce – 11% of all large employers say they will do so. But most employers affected by the rule will simply open their plans to all employees working 30 or more hours per week and brace for rising enrollment.

“Rising enrollment will be an even bigger issue in 2015 when the shared responsibility penalty goes into effect,” said Ms. Watts. “While some employers are going ahead with plans to expand eligibility in 2014 despite the delay, most of those with the big part-time populations are holding off and will feel the pinch in 2015.”

Few large employers – just 5% – say it’s likely they will terminate their health plans within the next five years, even though public insurance exchanges will provide another source of health coverage. About a fifth of employers with fewer than 200 employees say it’s likely they will terminate their plans; employers of this size are much less likely to offer coverage to begin with.

Under the ACA, beginning in 2018 employers will pay a 40% tax on the cost of health coverage in excess of $10,200 for an individual or $27,500 for a family. “This tax has been dubbed the ‘Cadillac tax’ but that’s really a misnomer,” said Ms. Watts. “Health coverage can often be expensive without being overly generous.”

Based on cost data collected in 2011, Mercer estimates that about 40% of employers would have to pay the tax on at least one plan if they made no changes to current plan design. Nearly a third of all large employers say they are taking steps in 2014 to avoid the tax in 2018 – in many cases, by adding a high-deductible consumer-directed health plan or taking steps to increase enrollment in an existing plan.

These preliminary findings just released by Mercer indicate that employers will continue to take steps to reduce their own costs of their health benefit programs, by shifting even more costs to their employees.

One of the more shocking new numbers is that nearly a third of large employers are taking steps in 2014 to avoid the 40 percent excise tax on expensive plans – a tax that will be assessed in 2018. These expensive plans do not have overly generous benefits, but they are expensive only because health care has become so expensive. To avoid the tax, most employers will be offering high-deductible, consumer-directed health plans which expose employees to greater out-of-pocket expenses.

Although only 5 percent of large employers say that they will terminate their plans within the next five years, the deterioration in coverage will surely cause a backlash from those who need care and cannot afford the out-of-pocket expenses. It may be that those who currently feel secure with the plans they get through their work may be the ones who will eventually clamor for single payer once they see how exposed their plan revisions will leave them.

Congress gets the gold, and the people get silver? bronze?

Posted by on Friday, Oct 4, 2013

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

Changes in Health Coverage FAQs

U.S. Office of Personnel Management

Members of Congress and Designated Staff

How will Members of Congress and designated congressional staff obtain health coverage in 2014?

House of Representatives and Senate offices will provide health coverage to Members of Congress and designated staff through the Marketplace.  OPM has determined the most appropriate Marketplace is the Small Business Health Options Program (SHOP). SHOPs were established to administer group health benefits to employees of small businesses. Given the location of Congress in Washington D.C., OPM has determined that the DC SHOP, known as the DC Health Link Small Business Market administered by the DC Health Benefit Exchange Authority, is the appropriate SHOP from which Members of Congress and designated congressional staff will purchase health insurance in order to receive a Government contribution.

From which “Metal Level” on the DC SHOP will Members of Congress and designated congressional staff choose their plans?

Members of Congress and designated staff will choose from plans on the Gold Metal Level of the DC SHOP, which currently includes 112 choices. While all plans have the same “essential health benefits” (EHB), plans vary in copays, coinsurance, deductibles, and benefits beyond the EHB. Plans include fee-for-service, HMOs, Point of Service, and HSA-compatible plans.…

Supposedly requiring Members of Congress and their staffs to participate in the insurance exchanges established by the Affordable Care Act was to make their coverage comparable to what the rest of us would have (an oversimplification since most of us will not be enrolled in the exchanges). Yet the benchmark plans setting the subsidies in the exchanges are silver tier plans with an actuarial value of 70 percent, and the plans which qualify for Federal Employees Health Benefits (FEHB) premiums for Members of Congress are limited to the gold tier plans with an actuarial value of 80 percent. This is much more significant than it appears to be.

The gold plans for the Members of Congress pay about 80 percent of their health care costs, and about three-fourths of their premiums are paid by the taxpayers. This is comparable to the more traditional employer-sponsored plans that most of us considered to be good insurance coverage. In essence, as members of Congress and their staffs move into the exchanges, they are being assured that they will have coverage very close to that which they now have in the FEHB program.

The standard silver tier for individuals selecting their plans though the exchanges will leave the patient responsible for paying 30 percent of costs out-of-pocket, though lower income individuals will qualify for subsidies that are considered to be inadequate. Also the narrow networks of the exchange plans risk exposing patients to 100 percent of sometimes unavoidable out-of-network costs, with no cap on spending. Further, because of their lower premiums, many will choose the bronze plans at 60 percent actuarial value, risking greater financial hardship should significant health care be required.

This is a huge difference since the 80 percent actuarial value plans for Congress are considered to be standard insurance, whereas the 60 to 70 percent actuarial value plans for the general public are considered to be underinsurance – plans that do not provide adequate financial security in the face of medical need.

We didn’t get this right. A gold standard for Congress and a lesser standard for the people? Let’s “Occupy Congress” by replacing those in Congress who don’t seem to get it with legislators who will bring us what we need – a single payer, improved Medicare that covers everyone.

Blacks disproportionately being left uninsured

Posted by on Thursday, Oct 3, 2013

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

Millions of Poor Are Left Uncovered by Health Law

By Sabrina Tavernise and Robert Gebeloff
The New York Times, October 2, 2013

A sweeping national effort to extend health coverage to millions of Americans will leave out two-thirds of the poor blacks and single mothers and more than half of the low-wage workers who do not have insurance, the very kinds of people that the program was intended to help, according to an analysis of census data by The New York Times.

Because they live in states largely controlled by Republicans that have declined to participate in a vast expansion of Medicaid, the medical insurance program for the poor, they are among the eight million Americans who are impoverished, uninsured and ineligible for help.

Those excluded will be stranded without insurance, stuck between people with slightly higher incomes who will qualify for federal subsidies on the new health exchanges that went live this week, and those who are poor enough to qualify for Medicaid in its current form, which has income ceilings as low as $11 a day in some states.

The 26 states that have rejected the Medicaid expansion are home to about half of the country’s population, but about 68 percent of poor, uninsured blacks and single mothers. About 60 percent of the country’s uninsured working poor are in those states. Among those excluded are about 435,000 cashiers, 341,000 cooks and 253,000 nurses’ aides.

“The irony is that these states that are rejecting Medicaid expansion — many of them Southern — are the very places where the concentration of poverty and lack of health insurance are the most acute,” said Dr. H. Jack Geiger, a founder of the community health center model. “It is their populations that have the highest burden of illness and costs to the entire health care system.”

The disproportionate impact on poor blacks introduces the prickly issue of race into the already politically charged atmosphere around the health care law. Race was rarely, if ever, mentioned in the state-level debates about the Medicaid expansion. But the issue courses just below the surface, civil rights leaders say, pointing to the pattern of exclusion.

Every state in the Deep South, with the exception of Arkansas, has rejected the expansion. Opponents of the expansion say they are against it on exclusively economic grounds, and that the demographics of the South — with its large share of poor blacks — make it easy to say race is an issue when it is not.

Blacks are disproportionately affected, largely because more of them are poor and living in Southern states. In all, 6 out of 10 blacks live in the states not expanding Medicaid. In Mississippi, 56 percent of all poor and uninsured adults are black, though they account for just 38 percent of the population.

Dr. Aaron Shirley, a physician who has worked for better health care for blacks in Mississippi, said that the history of segregation and violence against blacks still informs the way people see one another, particularly in the South, making some whites reluctant to support programs that they believe benefit blacks.…

When the Supreme Court relieved the states of the requirement to expand their Medicaid programs as a condition of continuing to receive federal Medicaid contributions, it was understood that, in those states that did not voluntarily participate, many low-income people who were not eligible for plans to be offered in the exchanges (since they were to have been covered by Medicaid) would now also remain ineligible for Medicaid. Thus the most vulnerable are to be left with no coverage at all. What this New New York Times analysis adds to our understanding is that the sector hardest hit is poor blacks, especially those living in the South.

State politicians must carry much of the blame for this egregious health care injustice. If they agreed to participate, the states eventually would be required to fund only ten percent of this expansion, and none of the costs at the beginning. These politicians fully understood the demographics of the populations they refused to cover. So why did they refuse to authorized the quite modest expenditures that would bring health care to these people? Was it because they are poor? Or is it because they are predominantly black?

Regardless, we can blame not only these politicians, but also the voters who keep them in office. It is heartbreaking to realize that that so much of Martin Luther King’s Dream remains only a dream.

We still desperately need reform that is truly equitable and egalitarian. The Affordable Care Act didn’t get us there.

Truthdig article on a new prescription for health care for all

Posted by on Wednesday, Oct 2, 2013

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

Health Care for All: Why We Need a New Prescription

By Scott Tucker
Truthdig, October 1, 2013

The right-wing assault on Obamacare is a distraction, but the “progressive” (or rather party line) defense of the Affordable Care Act is also a dead end.

This conversation between one doctor (Don McCanne) and one writer (Scott Tucker), both of us active in the reform of our health care system, is not a detailed map of that terrain, and far less a scripture for those looking for a new religion. Any proposals for public policy must, of course, be discussed before the widest public. Within the secular horizon of the public realm, we must not lose our sense of balance and common sense, nor our sense of right and wrong. The right to health care is a human right, but the political will to win that right as a daily fact of life begins with a moral commitment to care for the poor, the sick and the dying, and for all of us without exception.…

The editors of Truthdig strategically selected October 1 to post this article – the day that the insurance exchanges opened for business. It is important to understand where we are headed and where we should be headed instead. This conversation between a writer and a doctor (5 pages) tries to provide perspective on the need for better policies than those in the Affordable Care Act and the need for social activism to achieve those policies.

Comments are welcome on the Truthdig website.

The changing role of government in financing health care

Posted by on Tuesday, Oct 1, 2013

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

The Changing Role of Government in Financing Health Care: An International Perspective

By Mark Stabile (University of Toronto) and Sarah Thomson (London School of Economics and Political Science)
National Bureau of Economic Research, September 2013

7. Implications for health system efficiency, costs, quality

Lessons Learned

What lessons can we draw from the evidence summarized above and what questions remained unanswered? In terms of collection, many countries are exploring new ways of generating revenues for health care to enable them to cope with significant cost growth. However, there is little evidence to suggest that collection mechanisms alone are effective in managing the cost or quality of care. First, the traditional classification of tax‐financed versus social insurance systems does not determine how countries organize health financing functions to achieve policy goals (the authors use a narrower definition of “social insurance” to differentiate it from “tax-financed” systems – DMc). The evidence available on the relationship between financing and outcomes suggests that health systems financed through social insurance (as opposed to general tax revenues) tend to be more regressive and have smaller tax bases. Some evidence suggests that financing through social insurance versus general tax revenues is associated with higher cost growth over time, although it is difficult, using such a broad classification, to separate collection mechanisms from other characteristics more often found in tax‐financed jurisdictions such as budget and price controls and quasi‐hard budget constraints. Public health care funding in tax‐based systems tends to track GDP more closely than in countries that collect funds through social insurance. Perhaps unsurprisingly, many jurisdictions are moving towards a diversity of funding streams (adding tax‐based funding to social insurance) to manage health care expenditure growth and maintain universality. Theory and evidence on cost sharing through standard user fees suggests that for the purpose of revenue collection it is not clear, given the administrative costs involved, that user fees are an optimal means of supplementing taxes and contributions in developed health systems. The evidence on value‐based cost sharing (using cost sharing selectively to encourage patients to use medication, services, and providers that offer better value than other options, rather than simply applying user fees across the board) suggests some efficiency improvements in use of care.

European systems with competitive health insurance (historically only found in countries that use social insurance to finance health care) have multiple risk pools, which can lead to selection issues and inefficiencies. All have significantly improved their risk equalization schemes in the last ten years and many now have relatively sophisticated formulas that include health‐based risk adjusters. In spite of this, insurers’ incentives to select risks are substantial and there continues to be (largely circumstantial) evidence of risk selection and hence potential inefficiencies in risk pooling. In some cases such as Switzerland, the voluntary insurance market seems to exacerbate risk selection and it would make sense to segment these markets to avoid this behavior. Recent evidence from the United States offers two reasons for optimism on this front. The first is that risk adjustment continues to improve and there is evidence that more detailed data on use, coupled with restrictions on ability to change insurer, can significantly mitigate risk selection. As a result, there is likely to continue to be convergence across countries towards better risk selection strategies. Second, recent empirical evidence examining insurance choice by individuals in the United States has found that preferences, in addition to risk, are important determinants of insurance choice, so the welfare implications of adverse selection by individuals in many markets may be smaller than previously thought.

Where purchasing is concerned, there has been some convergence among OECD health systems towards more use of market‐like mechanisms, particularly the adoption of DRGs to pay hospitals (keep in mind that DRG is a creation of our public Medicare program, hardly “market-like” – DMc). Some countries have also attempted to encourage hospital competition and, more recently, a growing number of countries have tried to link provider payment to performance. The evidence on hospital competition suggests that where outcomes are easily observable or targeted (such as wait times) hospitals compete on price and quality (wait times), leading to improved outcomes. In some cases improvements have been at the expense of quality measures that are more difficult to observe, suggesting that it would be useful to have further comparable, well‐defined measures of quality beyond wait times. However, where prices are set administratively, competition has improved productivity and quality. DRG payment also appears to have improved productivity and quality, although its effect on overall system costs is mixed. There is some evidence (mainly from the United Kingdom) of improved physician productivity and patient outcomes following the introduction of P4P, although the evidence also suggests a degree of gaming to maximize financial incentives.

A number of the health systems we explore continue to use wait times as a source of non‐price rationing. The evidence on the effects of wait times on health outcomes is mixed, with more recent studies finding negative effects on patient health and readmission rates, and older studies finding little effect on health outcomes. The United Kingdom in particular, and to some extent Canada, have significantly reduced wait times by increasing volumes using forms of DRG funding loosely modeled on US Medicare and through targeted budgets. Wait times are therefore not inherent in tax‐financed systems but can be fairly successfully manipulated by policy levers such as targets, DRGs, and non‐price competition between hospitals.

Unresolved Questions

Our review has revealed some areas where there is a need for a greater evidence base. First, while efforts to be more systematic about defining the publicly provided or mandated benefits package have increased over the past decade, there is a lack of evidence on how effective these changes have been. Organizations such as NICE in the United Kingdom, the Canadian Agency for Drugs and Technologies, the German Institute for Quality and Efficiency in Health Care, or the French National Health Authority, have emerged in many countries in the last decade, showing how jurisdictions increasingly recognize the importance of economic evaluation of best practice and technologies. However, we found little evidence on the extent to which these bodies have achieved their goals and some evidence to suggest they struggle with implementation.

Efforts in systems such as Canada’s to expand coverage beyond hospital and physician services, or to promote voluntary insurance through tax subsidies have been mixed. A combination of tax deductions and subsidies has resulted in high levels of voluntary private insurance coverage for non‐publicly financed services but these subsidies have led to substantial and poorly targeted tax expenditures and continued reliance on the firm as the provider of voluntary coverage. Attempts to provide public coverage selectively to older people have also been expensive, while reforms aimed at re‐targeting benefits based on income have lowered public costs and had some positive redistributive consequences. The countries we examine therefore provide evidence of the inefficiencies of tax subsidies and of inefficiencies associated with voluntary insurance alongside publicly financed coverage, but do not provide particularly helpful evidence on the efficient mix of public and private finance.

The past ten to fifteen years have seen high health care cost growth in many countries, including all those reviewed here, with average health care cost growth exceeding the average growth in GDP (Haigst and Kotlikoff, 2005). In considering the success of different health systems in controlling costs, the evidence suggests that while policies that effectively limit demand through rationing and fixed budgets appear still to be effective at holding down costs at a point in time, there has been a discernible shift in policies employed by the countries we review away from these types of cost containment strategies, and away from other strategies that simply shift costs to households, towards policies that focus more on the cost‐benefit ratio and efficiency, such as greater use of health technology assessment and activity‐based funding with administratively set prices. While there are high hopes that these strategies will produce a more efficient use of health care resource and, ideally, control cost growth, further research is needed to determine the extent to which these policies achieve their goals.…

Although this paper from Canada and England is very heavy reading and frames some of the issues differently from what we might, nevertheless, the authors conclude that “while the United States remains an outlier among OECD countries, a number of policy changes across jurisdictions suggest significant convergence in the role of the state in financing health care.”

When you read the nature of the improvements, they are quite meager compared to what we need, but they did come predominantly from the government rather than from the private sector. More than a convergence, we need a new infrastructure in the United States – a single payer national health program.

Is tailoring enrollment strategies to match dynamics of uninsured a solution?

Posted by on Monday, Sep 30, 2013

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

Understanding State Variation In Health Insurance Dynamics Can Help Tailor Enrollment Strategies For ACA Expansion

By John A. Graves and Katherine Swartz
Health Affairs, September 2013 (online)


The number and types of people who become eligible for and enroll in the Affordable Care Act’s (ACA’s) health insurance expansions will depend in part on the factors that cause people to become uninsured for different lengths of time. We used a small-area estimation approach to estimate differences across states in percentages of adults losing health insurance and in lengths of their uninsured spells. We found that nearly 50 percent of the nonelderly adult population in Florida, Nevada, New Mexico, and Texas—but only 18 percent in Massachusetts and 22 percent in Vermont—experienced an uninsured spell between 2009 and 2012. Compared to people who lost private coverage, those with public insurance were more likely to experience an uninsured spell, but their spells of uninsurance were shorter. We categorized states based on estimated incidence of uninsured spells and the spells’ duration. States should tailor their enrollment outreach and retention efforts for the ACA’s coverage expansions to address their own mix of types of coverage lost and durations of uninsured spells.

Policy Implications

The planning for implementing the ACA’s coverage expansions has largely focused on the percentage of people in each state who are uninsured at a certain point in time. In particular, attention has centered on decomposing these state percentages into people eligible for Medicaid coverage and people eligible for premium subsidies if they purchase plans in an exchange. Two states with the same percentage of uninsured people could have quite different proportions of people who are eligible for Medicaid, for premium subsidies, or neither.

Two states with similar uninsurance rates could also have very different uninsured populations in terms of how long adults had been without coverage. Differences in length of time without insurance are just as important as differences in income for policy makers. They must determine whether to focus more on efforts to minimize possible Medicaid churning or on efforts to reduce potential adverse selection—that is, efforts to encourage healthy uninsured people to buy exchange plans, so the plans do not have a disproportionate share of enrollees who require expensive medical care in the near future. States with a high incidence of people losing public coverage, for example, could have more reason to worry about Medicaid churning than states with a high proportion of uninsured spells that last more than two years, where possible adverse selection in their exchanges would be a more likely problem.…

This study shows that it is not only the income level but it is also the length of time that an individual has been uninsured that affects the probability of whether the individual would be eligible for Medicaid or for the state insurance exchanges instead. Since there is considerable variation between states, the authors suggest that enrollment strategies be tailored to target the uninsured based not just on the types of coverage lost but also on the duration of being uninsured. What?

The dynamics of public or private insurance eligibility are forever changing. Eligibility depends on employment, income, age, geographical location, level of state participation in Medicaid, immigration status, and other factors that are frequently in flux. The navigator program was established to help individuals sort out the eligibility criteria in order to move them into appropriate health care coverage.

It does not seem logical that states should measure durations of being uninsured and then change enrollment strategies simply because people who previously had been in public programs had shorter periods of being uninsured. Navigators help all uninsured (except the tens of millions not able to enroll in any program) whereas targeted programs are aimed at only selected populations of the uninsured, tacitly acknowledging the difficulties of getting everyone covered and retaining that coverage.

We are making this too complicated. Much of this is due to the fact that we are merely expanding a highly fragmented and dysfunctional system of financing health care that is too costly and doesn’t work very well. It is ridiculous that we should consider looking at all of the fluid variables and then target some individuals while leaving others behind. Instead of trying to sort all of this out we should merely switch to a single payer national health program in which everyone is simply enrolled once, for life.

Peter Morici on an American National Health Service

Posted by on Friday, Sep 27, 2013

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

First Obamacare, Then a Single Payer System

By Peter Morici
Breitbart, September 27, 2013

Republicans must live with Obamacare. They have few prospects for electing 60 senators needed to repeal the law, and unless they work to make it more palatable — something they have few ideas to accomplish — the nation is headed for socialized medicine.

The burden to find solutions will take congress to places that Republicans are very reluctant to go.

The German and other European systems accomplish lower costs and universal coverage by imposing tight controls on prices for services, drugs, and devices. Britain’s National Health Service doesn’t bother with insurance companies and claims forms — by eliminating insurance company overhead it accomplishes much lower costs than even the German system.

Even before Obamacare, federal and state governments, through Medicare, Medicaid, and other programs, paid more than 50 percent of U.S. health care bills. That was more than the 9 percent of GDP, and the amount Britain spends to accomplish universal coverage — without the additional $4,600 per person American businesses and individuals pony up.

Reducing U.S. doctors fees and drug and device prices down to German levels won’t be easy or likely possible, but politicians, providers, and businesses still providing health insurance will need a solution — likely a scapegoat.

Enter the insurance companies that have been screwing down doctor’s fees, hassling everyone with mindless paperwork, and paying executives like royalty.

The federal government could probably pay doctors, drug companies, and device manufactures pretty reasonably directly, and without the insurance company middlemen, through an American National Health Service.

(Peter Morici is an economist and professor at the Smith School of Business, University of Maryland, and a widely published columnist.)…

Professor Peter Morici, an expert on international trade, is known for holding no punches. Here he suggests that Republican intransigence could lead us to an American National Health Service – true socialized medicine.

In the full article, available at the link above, he explains why Obamacare is unsatisfactory, likely with the intent of cajoling Republicans into working with Democrats to improve it. He seems to be using the prospect of a national health service as a threat to Republicans as to what could happen if they failed to cooperate. In doing so, he does present some very persuasive arguments for making the change.

Maybe he’s serious. He does make private insurance companies the scapegoat. Get rid of them and then what options do we really have?

Where are our professional boundaries?

Posted by on Thursday, Sep 26, 2013

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

Crossing Boundaries—Violation or Obligation?

By Gordon D. Schiff, MD
JAMA, September 25, 2013

It is 5 pm on Friday afternoon. After 2 hours on the telephone trying (and failing) to get her insurance plan to pay for her medication refill, I reached into my pocket and handed the patient $30 so she could fill the prescription. It seemed both kinder and more honest than sending her away saying, “I’m sorry I can’t help you.” While I hardly expected a commendation for such a simple act of kindness, I was completely surprised to find myself being reprimanded for my “unprofessional boundary-crossing behavior” after the resident I was supervising shared this incident with the clinic directors. This allegation of an ethics violation was not only personally painful; it also raised important, controversial, and timely questions about appropriate professional roles.

Physicians must indeed respect certain boundaries. A growing literature and guidelines have admonished physicians and other health professionals to strictly respect boundaries to avoid improper expectations, dependency, legal liabilities, and confusion of personal and professional relationships. Most concerning were data documenting sexual relationships between physicians (often psychiatrists) and their patients.

However, some interpretations of these restrictions risk constructing a misguided model—one that discourages physicians from humanly caring for and about their patients. This new paradigm risks encouraging detached, arms-length, uncaring relationships. When do “boundaries” become barriers to meaningful caring relationships? And will such bounded thinking serve to rationalize abdication of our professional and personal responsibilities to humanely respond to patient suffering and underlying injustices?

While I had rarely paid for a patient’s medication as I did on that Friday afternoon, in this situation it seemed reasonable and appropriate. Various ethics and conflict of interest rules prohibiting physicians from having “financial relationships” with patients may be appropriate when it comes to physicians taking or soliciting money from patients. But what about the propriety of giving money to a needy patient in this particular situation? While other alternatives such as using a special fund might be preferable, when I found that no such fund existed at my hospital (and the drug insurance plan denied coverage due to a technical glitch in the patient’s enrollment), was it wrong to personally help a patient in such a moment of need?

Everything we do in medicine has risks. Whether prescribing a medication or performing surgery, we, in consultation with the patient and family, must weigh potential benefits and risks. When considering reaching out to help patients in need, possible adverse effects should be weighed against the benefits in that particular context and situation.

In weighing such risks, however, we need to be clear whose risks we are considering. Many of these risks are actually more risks to physicians, rather than to patients. Thus, those insisting on stricter boundaries need to rethink what they mean by “limits.” Who are those limits designed to protect? Are “limits” protecting the patient, or are they protecting us—protecting our time or even protecting our consciences, allowing us to avoid painful questions of inequality or taking needed moral action? While there is nothing inherently wrong with protecting caregivers against overwhelming time demands or burnout, let’s not pretend we are imposing limits for patients rather than our own best interests.

The American Medical Association’s Code of Medical Ethics states: “The practice of medicine … is fundamentally a moral activity that arises from the imperative to care for patients and to alleviate suffering. … The relationship between patient and physician is based on trust and gives rise to physicians’ ethical obligations to place patients’ welfare above their own self-interest … and to advocate for their patients’ welfare.” The type of caring relationships embodied in this statement, and the kindness I believe most patients and physicians yearn for, has been pejoratively dubbed “nostalgic professionalism.” This outmoded model of professionalism, it is argued, needs to be replaced by a more dispassionate business-like model where limitations and boundaries are more circumscribed and it is clear that we are not our patients’ friends, neighbors, or personal advocates for issues beyond their medical problems. Short of avoiding caring for poor patients entirely or not being part of the community in which our patients live and work (both unfortunately not rare), personal engagement with patients as people, not just as “clients” or “consumers,” is inevitable, and even desirable. For many of us (particularly primary care physicians), more than any P4P (pay-for-performance) financial incentives, our most fulfilling rewards and professional satisfactions come from having meaningful relationships with our patients, as well as our ability to broadly ameliorate their problems and suffering. Of course we have to make daily compromises with reality, especially the realities of suffering and hardships poor and underserved patients face—problems we obviously can’t personally cure. Nonetheless, we should try within the limitations of our time, resources, and abilities to help where we can.

The real danger of personal engagement is not that we further complicate already complicated relationships with our patients by doing too much. Rather it is that of tokenism—of doing too little and feeling satisfied and excused from addressing the social and economic injustices that underlie poor patients’ suffering. It is here we have to be mindful of the fundamental distinction between charity and solidarity. Yes, we need to be charitable in every way possible, but we also need to stand alongside our patients in striving for a fairer, more caring world. If physicians want to stand aloof, addressing only the biomedical problems, ignoring and seemingly indifferent to the social circumstances of our patients, then patient/relation-centered medical homes are likely to feel more like gated communities than places where people live and work together. Fortunately, the two strands of genuine “caring DNA” are closely intertwined. Collective advocacy for societal change and personal advocacy and helping of individual patients cross-fertilize and nourish each other. Minimizing barriers for professionals and patients working together for this shared agenda represents true patient-centered medical care.

For my home office that I use for my health reform advocacy work, I had put away all of my credentials and hung on the wall only one item: The Oath of Hippocrates. Regarding today’s message, one sentence stands out: “Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and, further, from the seduction of females or males, of freemen and slaves.” Boundaries are as old as the profession.

But what has happened with boundaries now that we seem to have transitioned from the profession of medicine to the business of medicine? “Care providers” are to turn to the clinic directors or whatever entity is representing the business to learn about redefined boundaries that are best for… the business?

What about establishing boundaries between the healing arts professions and the financial accounting functions for health care that should be relegated to the virtual back office? How about allowing the health care professionals to revert to the traditional Hippocratic concepts of boundaries?

In fact, instead of limiting boundary considerations strictly to the one-on-one interaction between patients and professionals, shouldn’t we be exploring the boundaries that Gordon Schiff implies when he refers to “collective advocacy for societal change and personal advocacy and helping of individual patients”?

If we were to use that collective advocacy for societal change to establish a single payer system, we could break down barriers, allowing us to come closer to achieving optimal care for all patients. As Schiff says, “Minimizing barriers for professionals and patients working together for this shared agenda represents true patient-centered medical care.”

After reading Gordy Schiff’s commentary and seeing that his moral compass is set on the primacy of the patient, it should come as no surprise to readers that he has been very active in Physicians for a National Health Program, having served as its president. Thank goodness he understands as much as anyone where our professional boundaries should be. Sadly, the stewards of the new business world of medicine will never understand.

Canadian businessmen perplexed by U.S. health care

Posted by on Wednesday, Sep 25, 2013

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

Canadians don’t understand Ted Cruz’s health care battle

By Matt Miller
The Washington Post, September 25, 2013

When you’re being forced to endure another rabid Sen. Ted Cruz (R-Tex.) soliloquy on Obamacare’s threat to human freedom, it’s easy to forget how absurd our health-care debate seems to the rest of the civilized world. That’s why it’s bracing to check in with red-blooded, high testosterone capitalists north of the border in Canada — business leaders who love Canada’s single-payer system (a regime far to the “left” of Obamacare) and see it as perfectly consistent with free market capitalism.

Take David Beatty, a 70-year-old Toronto native who ran food processing giant Weston Foods and a holding company called the Gardiner Group during a career that has included service on more than 30 corporate boards and a recent appointment to the Order of Canada, one of the nation’s highest honors. By temperament and demeanor, Beatty is the kind of tough-minded, suffer-no-fools wealth creator who conservatives typically cheer.

Yet over breakfast in Toronto not long ago, Beatty told me how baffled he and Canadian business colleagues are when they listen to the U.S. health-care debate. He cherishes Canada’s single-payer system for its quality and cost-effectiveness (Canada boasts much lower costs per person than the United States). And don’t get him started on the system’s administrative simplicity — you just show your card at the point of service, and that’s it. Though he’s a well-to-do man who can pay for whatever care he wants, Beatty told me he’s relied on the system just as ordinary Canadians do, including for a recent knee replacement operation. The one time he went outside the system was to pay extra for a physical therapist closer to his home than the one to which he’d been assigned.

It’s just “common sense” in Beatty’s view that government takes the lead in assuring basic health security for its citizens. He’s amazed at the contortions of the debate in the United States, and wonders why big U.S. companies “want to be in the business of providing health care anyway” (“that’s a government function,” he says simply). Beatty also marvels at the way the U.S. regime’s dysfunction comes to dominate everyday conversation. He shakes his head recalling how much time and passion American friends devoted one evening to comparing notes on their various supplemental Medicare plans. Talk about your sparkling dinner conversation.

Roger Martin, another Toronto native and avowed capitalist, spent years as a senior partner at the consulting firm Monitor before becoming dean of the Rotman School of Management at the University of Toronto, where he recently completed a 15-year stint. He advises U.S. corporate icons like Proctor & Gamble and Steelcase. He lived in the United States for years and has experienced both systems first hand.

Martin told me that Canada’s lower spending, better outcomes and universal coverage make it superior by definition. Plus, it’s “incredibly hassle-free.” In the United States every time he took his kids in for an earache his wife spent hours fighting with the health plan or filling out reams of paperwork. In Canada, he says, “the entire administrative cost is pulling your card out of your pocket, giving it to them and putting it back.”

There’s more. Canadian divisions of multinational firms love Canada’s system because when they bid on projects they have no health costs to load in. Also, there’s no crazy “job lock” as with the employer-based system in the United States — where people with (say) a sick child cling to their job for fear of being pronounced uninsurable. His peers, he says, view the U.S. debate as “ideological and not based on economics.”

“The whole single payer thing just makes sense,” Martin adds. “You don’t spend time trying to shift costs.” It’s hardly perfect: a few folks go to the United States to jump the line on certain elective procedures, and Canada, like others, free rides on American’s investment in pharmaceutical innovation (funded by higher U.S. drug prices). But, he adds, “I literally have a hard time thinking of what would be better than a single-payer system.”

The moral of the story? Don’t let the rants of cynical demagogues like Cruz confuse you — it is entirely possible to be a freedom loving capitalist and also believe in a strong government role in health care. Remember, Obamacare features a much smaller such role than does Canada’s approach — or England’s, where Margaret Thatcher would have been chased from office for proposing anything as radically conservative as the Affordable Care Act.

One well-known billionaire told me a few years back that the right answer for the United States was single payer for basic coverage, with the ability for folks to buy additional private supplements atop that. But he won’t say this in public; the gang at the club just wouldn’t understand. Maybe when U.S. business leaders muster the common sense of their Canadian counterparts, they’ll deliver the message the Ted Cruzes of the world need to hear: sit down and shut up.

Matt Miller writes a weekly column on economic and other domestic policy issues. He is a senior fellow at the Center for American Progress, the voice of the political “center” on public radio’s “Left, Right & Center,” the host of the new podcast “This…Is Interesting.”

Businessmen in the United States need to listen to their colleagues in Canada.  They see single payer as being “perfectly consistent with free market capitalism.” “The whole single payer thing just makes sense.”

It should be noted that this Washington Post article was written by a “voice of the political center” – Matt Miller. That single payer is appropriately a centrist concept is demonstrated by the fact that it fulfills the fundamental business principles of being efficient (lower costs per person), effective (everyone is included), and of high quality (better health outcomes).

(As an aside, regarding the well-known billionaire who recommended single payer for basic coverage with private supplementary coverage for other care, I should say that I wrote such a proposal right after the failure of the Clinton reform effort. I submitted it to Claudia Fegan, then president of PNHP, and she returned it smothered in red ink. That is when I learned that I knew very little about health policy, so I have studied it on a daily basis since. Simply stated, single payer needs to be comprehensive enough such that no supplemental coverage would be necessary.)

Incidentally, the hotlinks in the article on “Canada’s single payer system” and “lower costs per person” lead to two great articles on these topics. If the links are not live in this email, they can be accessed in the original article at the link above.

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