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.
NOTE: Wait! Don’t go away! You are not expected to read today’s message in its entirety. This is merely a sampling of the plethora of new articles that suggest that single payer may be the answer to the constitutionally-challenged Affordable Care Act. They represent the views of enthusiastic liberals, reluctant conservatives, and everyone in between. If you read only one entry, I would suggest the very last one, which is my response to today’s New York Times Economix blog by Uwe Reinhardt. Although at times it seems like we single payer activists are hollering in the wind, the profusion of responses demonstrates that single payer is now widely recognized as a model that would work for all of us. Keep hollering!
On The Individual Mandate: Towards A Single-Payer System Or Public Option?
By Renée Landers
Health Affairs Blog, March 29, 2012
Early in the arguments, in an exchange with the Solicitor General, Justice Kennedy raised the idea that one alternative available to Congress may be to “use the tax power to raise revenue and to just have a national health service, single payer.”
Toward the end of the day’s arguments, Justice Sotomayor pressed Mr. Carvin on the same point: “I want to understand the choices you’re saying Congress has. Congress can tax everybody and set up a public health care system.”
These discussions leave the Court, conservatives, and the public with a curious dilemma. Through the Affordable Care Act, Congress has tried to regulate private insurance markets to solve the market problem of making health insurance affordable for the uninsured, whatever their individual health status. If that market-based approach does not survive a Commerce Clause challenge, what alternatives are left to Congress? One alternative is to do nothing, which does not seem to be economically responsible given accelerating health care costs and certainly leaves tens of millions of Americans in a precarious and untenable situation.
The other option would be for the government, as the last resort, to create the “public option” that was so controversial during the debates over the Affordable Care Act, or to move entirely to a single-payer system, eschewing markets.
A stronger prescription for what ails health care
By Eugene Robinson
The Washington Post, March 29, 2012
Our only choice is to try to hold the costs down. President Obama tried to make a start with a modest approach that works through the current system. If this doesn’t pass constitutional muster, the obvious alternative is to emulate other industrialized nations that deliver equal or better health care outcomes for half the cost.
I’m talking about a single-payer health care system. If the Supreme Court strikes down ObamaCare, a single-payer system will go from being politically impossible to being, in the long run, fiscally inevitable.
Judicial activists in the Supreme Court
By E.J. Dionne Jr.
The Washington Post, March 28, 2012
The irony is that if the court’s conservatives overthrow the mandate, they will hasten the arrival of a more government-heavy system. Justice Anthony Kennedy even hinted that it might be more “honest” if government simply used “the tax power to raise revenue and to just have a national health service, single-payer.” Remember those words.
My Mom, the Supreme Court, and the Affordable Care Act
By Emil Guillermo
San Francisco Chronicle, March 28, 2012
My mom died before the Clintons attempted their push for reform, and before Obama came up with his intricate compromise. Before then, Mom’s old fashioned Medicare plan worked just fine.
So I know this crazy Supreme Court debate to overturn the Affordable Care Act would have surely given her chest pains.
She’d ask, “Why can’t the government just extend Medicare to all?” (Seniors have a way of getting to the point. Unlike lawyers.) Medicare is a single payer system that doesn’t have people crying “Socialism!” It doesn’t get conservatives’ dander up about individual liberty and the broad powers of the federal government.
And it works. Everyone gets the care they need.
If only mom were alive and in charge.
If Obamacare is overturned, will that lead to single payer? And would that be a good thing?
By Ezra Klein
The Washington Post, March 29, 2012
Eventually, we end up with something close to a single-payer system, as a majority of Americans — and particularly a majority of Americans who have significant health risks — are covered by the government.
Single-Payer or Bust
By Steve Erickson
The American Prospect, March 30, 2012
Striking down the individual mandate leaves only one of two options: adopt a system in which government pays for health care, or do nothing.
RedBlueAmerica: Will ‘Obamacare’ survive?
Scripps Howard News Service, March 29, 2012
Joel Mathis: The insurance mandate was a half-step toward that goal. Let’s take the full step: Single-payer health insurance, run and administered by the government, with no private-sector middlemen to add costs and reap profits from taxpayers.
Ben Boychuk: The problem with the single-payer fantasy is it makes promises the government cannot keep. The health-care budget is not unlimited. Government would make choices about your health care based not on what you need, but how much a procedure costs. In truth, that’s becoming the case more and more under our existing system, which is why reform remains essential.
What if Supreme Court strikes down Obama healthcare act?
By Mark Mardell
BBC News, March 29, 2012
(A Democrat strategist I’ve spoken to) adds that defeat might make Democrats more radical and argue that what is called here a “single payer system” – a tax-funded national health system as we have in the UK – is the only real answer, rather than President Obama’s market-sensitive half-way house.
Obamacare health-insurance exchanges are set up to fail
By Paul Mulshine
The Star Ledger, March 25, 2012
The real threat is not that Obamacare will take over Medicare. It’s the other way around, says Mike Cannon, a health-care expert with the free-market Cato Institute in Washington.
“These exchanges are built to fail,” said Cannon. “They’ll drive private insurance companies out of the market. When they do, the whole thing will collapse.”
At that point, some sort of single-payer system would be needed to cover the people the private insurers don’t want. Those who’ve been arguing Medicare should be extended to everyone would probably win at the polls.
If Health Law Is Overturned, What Will Liberals Do?
By Michael D. Shear
The New York Times, March 28, 2012
If Democrats make little progress on alternatives, some purists might decide it’s best to just renew the case for a single-payer system in which all Americans receive health care paid for by the government.
Sidney M. Wolfe, the director of the Health Research Group at Public Citizen, an advocacy group, has been pushing for government-run health care for decades.
Overturning health care law could lead to a single-payer system
By Peter Morici
SunSentinel, March 26, 2012
Conservatives, by persuading a majority of Justices to overturn the individual mandate, could reverse Washington’s relentless push to over regulate individual and business behavior, but they could ultimately instigate their worst nightmare — a single payer system akin to the British system.
After the Ruling
By Maggie Fox
National Journal, March 29, 2012
There is one easy solution to the issue—a single-payer health system that strictly controls costs and administrative fees, using evidence-based science to determine which interventions, drugs, and diagnostic tests are worth the money and effort.
ACA Alternatives Waiting in the Wings
By Emily P. Walker
MedPage Today, March 29, 2012
While Republicans are crafting limited-government alternatives to the Affordable Care Act (ACA), some on the other side of the political spectrum are trumpeting a single-payer, government-run system as the preferred alternative to the ACA.
The irony is that while the public option wasn’t popular enough to pass, no one disputes the Supreme Court wouldn’t be considering the case if a single-payer plan had passed, because expanding Medicare and taxing everyone more would have been well within the powers of Congress.
Experts: Medicaid Expansion Will Stand; Mandate’s Fate Unclear
By George Lauer
California Healthline, March 29, 2012
Some see the potential for a quicker move toward single payer solutions if all or part of the ACA is ruled unconstitutional.
While he didn’t go so far as to call for provisions of the ACA to be struck down, Bill Skeen, executive director of the California chapter of Physicians for a National Health Program, did see potential for progress in such a scenario.
“If the ACA is dismantled, I don’t predict there will be an easy road for single payer, but there is the sort of last-man-standing feeling that — OK, the plan Congress put together isn’t holding up. Single payer is the last best option.”
Chris Matthews, Ezra Klein Identify Strategy To Impose ‘De Facto Single Payer System’
By Noah Rothman
Mediaite, March 29, 2012
On Wednesday, Hardball host Chris Matthews and Washington Post columnist Ezra Klein discussed the potential for all or part of President Obama’s health care reform law to be ruled unconstitutional in the Supreme Court and the ways in which progressives could move forward with health care reform in a post-Affordable Care Act world. Klein confirmed conservative’s latest fear: striking down the health care law could pave the way for a single payer system that could be implemented over time through the budget reconciliation process in the Senate.
Growth & Justice lays out its case for Minnesota single-payer health care
By Beth Hawkins
MinnPost, March 29, 2012
What if single-payer were feasible?
On Wednesday, the St. Paul-based progressive-leaning think tank Growth & Justice made its case, releasing a first-of-its-kind analysis showing that a unified system of health care could provide all Minnesotans with guaranteed cradle-to-grave care at a projected savings of about $190 billion over 10 years. By 2023, overall savings could be 12 percent to 33 percent per year, it said.
During his gubernatorial campaign, Mark Dayton supported a single-payer system for Minnesota, Smith added. The advent of ACA presents a good opening to put the topic back in the public discourse.
“This option needs to stay on the table,” he said. “It is an attempt to change the conversation. … This is one of the last big hurdles for a fair and just society. You can’t just check out of the social contract.”
The Wall Street Journal: Unwitting Advocates of Single-Payer
By David Frum
The Daily Beast, March 29, 2012
The crazy thing about the litigation over the Affordable Care Act is this… nobody disputes that Congress has full authority to set in motion a national healthcare program. Congress could tax all American at any rate — or any schedule of rates, no matter how confiscatory for those at the top — and then use the money to fund a British-style National Health Service.
If Health Care Reform Falls, Look in the Mirror
By Karen Dolan
The Huffington Post, March 29, 2012
Candidate Barack Obama campaigned on universal coverage. He told would-be supporters that, if he were “starting from scratch,” single-payer would be ideal. Indeed, he even understood that the only true reform, that would sufficiently control costs and actually achieve universal coverage, was a single payer, government-sponsored health care system. The evidence is overwhelming that only such a system can achieve those goals.
Isn’t it time to fight for Medicare for all?
How Obamacare’s Rejection Would Lead to Single Payer
By Josh Barro
Forbes, March 28, 2012
Strike down Obamacare, and single payer instantly becomes the number one organizing cause for liberals in America. This Congress won’t pass a single payer insurance law, but you can bet Democrats would the next time they control both the legislative and executive branches.
Single-Payer Briar Patch
By Timothy Noah
The New Republic, March 28, 2012
The professional Obama-hater Dick Morris said today on Fox News that if President Obama is elected to a second term after the Supreme Court strikes down Obamacare (as is looking more likely) then “he’ll move to a single payer system.”
Take It From Me: Defending Obamacare is Super-Hard
By Reid Cherlin
GQ, March 27, 2012
It would have been easy for Verrilli—or any of us—to explain single-payer health care. “Look,” we could have said, “the government is paying for everyone to have coverage.” End of story. But single-payer is not what our brilliant, world-leading political system gave us.
Lawmakers Propose Single-Payer System For Mass.
By Meghna Chakrabarti
WBUR, March 28, 2012
A major national story is playing out in the halls of Beacon Hill: this week’s Supreme Court hearings on the national Affordable Health Care Act.
Some lawmakers want the state to push health care reform to the next level. They’ve introduced a bill that would bring a “single-payer” system to the Bay State.
What’s really wrong with Obamacare
By Cathy Young
Newsday, March 29, 2012
If the Affordable Care Act is struck down, the eventual outcome may be better health care reform — or it may be a more socialistic road, such as a single-payer system.
Libertarian and conservative voices are essential to the health care debate. But they should be careful not to lapse into a defense of freeloading or unconstrained spending on expensive (and not always beneficial) medical procedures. Freedom is a key conservative and libertarian principle; so is responsibility.
If the Mandate Fails, Single Payer Awaits
By George Zornick
The Nation, March 27, 2012
One obvious option, besides just doing nothing and allowing health care costs to continue their exponential growth while more people lose coverage, is a single-payer health insurance plan. There is no doubt about the constitutionality here — the government is clearly allowed to levy taxes to fund public benefits.
So if health care reform goes down, the next logical step may well be just extending Medicare to everyone.
Kucinich: Single-payer healthcare on its way regardless of how Supreme Court rules
By Julian Pecquet
The Hill, March 26, 2012
The Supreme Court’s review of President Obama’s healthcare reform law is just another step on the inevitable path toward a single-payer medical system, Rep. Dennis Kucinich (D-Ohio) said Monday.
Health Care Jujitsu
By Robert Reich
The Huffington Post, March 26, 2012
But with a bit of political jujitsu, the president could turn any such defeat into a victory for a single-payer healthcare system — Medicare for all.
Individual Mandate Is Ryan Tax Credit by Other Name
By Ezra Klein
Bloomberg, March 28, 2012
The real fight is over whether the Affordable Care Act should exist at all. Republicans lost that battle in Congress, where they lacked a majority in 2010. Now they hope to win it in the Supreme Court, where they hold a one-vote advantage. The argument against the individual mandate is a pretext to overturn Obamacare. But it’s a pretext that could set a very peculiar precedent.
If the mandate falls, future politicians, who will still need to fix the health-care system and address the free-rider problem, will be left with the option to move toward a single payer system or offer incredibly large, expensive tax credits in order to persuade people to do things they don’t otherwise want to do. That is to say, in the name of liberty, Republicans and their allies on the Supreme Court will have guaranteed a future with much more government intrusion in the health-care marketplace.
The Supreme Court and the National Conversation on Health Care Reform
By Uwe E. Reinhardt
The New York Times, Economix, March 30, 2012
Once again America is having one of its “national conversations” on health care reform. This time the buzz is over arguments before the Supreme Court on the constitutionality of certain provisions in the Affordable Care Act. The justices’ rulings will be landmark decisions, because they will indirectly go much beyond the act itself to our entire system of governance.
The two major substantive decisions the Supreme Court has to make are:
1. Whether Congress has the constitutional authority to mandate every legal resident in the United States to have insurance coverage for a specified package of health benefits (hereafter the “mandate”) or whether that is an issue for the states to decide.
2. Whether Congress has the constitutional authority to expand eligibility for Medicaid benefits from the highly varied income thresholds that currently define eligibility to anyone under 133 percent of the federal poverty level.
By Don McCanne
San Juan Capistrano, CA
The intense attention being given to the constitutionality of the individual mandate and the severability of guaranteed issue and community rating and to the constitutionality of the Medicaid expansion superficially seems to have detracted from the fundamental issue of whether or not the Affordable Care Act itself should serve as a durable model for health care reform.
With the best possible outcome of the Supreme Court deliberations, we’ll still be faced with uninsurance (at least 26 million uninsured), underinsurance (low actuarial value plans with spartan essential benefits) and unaffordability (lack of effective systemic cost containment).
Right now we are seeing a surge in commentaries declaring that we will end up with single payer (Medicare for all) if the mandate and guaranteed issue and community rating are struck down by the Supreme Court, simply because that’s the only rational financing option left for us.
We will, in fact, end up with single payer, but not because of the pending Supreme Court decision. We will adopt a single payer system simply because we will not be able to continue to tolerate uninsurance, underinsurance and unaffordability.
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 Long-Term Effect of Premier Pay for Performance on Patient Outcomes
By Ashish K. Jha, M.D., M.P.H., Karen E. Joynt, M.D., M.P.H., E. John Orav, Ph.D., and Arnold M. Epstein, M.D.
The New England Journal of Medicine, March 28, 2012
Tying financial incentives to performance, often referred to as pay for performance, has gained broad acceptance as an approach to improving the quality of health care. The Centers for Medicare and Medicaid Services (CMS) recently completed a 6-year demonstration of pay for performance for hospitals through the Premier Hospital Quality Incentive Demonstration (HQID), and the Affordable Care Act calls for CMS to expand this program to nearly all U.S. hospitals in 2012. The policy of tying financial incentives to the quality of performance has strong face validity — that is, paying for better care should promote improvements in quality and, ideally, lead to better patient outcomes. Whether pay for performance will lead to better patient outcomes, however, is unclear.
Although there is evidence from the Premier HQID that pay for performance is associated with modest improvements in the processes of care, much less is known about its effect on patient outcomes.
We found little evidence that participation in the Premier HQID program was associated with declines in mortality above and beyond those reported for hospitals that participated in public reporting alone, even when we examined care over a period of 6 years after the program’s inception. Furthermore, we found no differences in trends in mortality between conditions for which outcomes were explicitly linked to incentives and conditions for which outcomes were not linked to incentives.
Prior studies of the Premier HQID showed that the early gains in process quality had mostly dissipated after 5 years under the program. Werner et al. found that the modest benefits in adherence to process measures were most perceptible for hospitals that were eligible for larger bonuses, that were well financed, or that operated in less competitive markets. We failed to find that these factors were associated with a significantly greater effect on outcomes.
In summary, we found little evidence that participation in the Premier HQID program led to lower 30-day mortality rates, suggesting that we still have not identified the right mix of incentives and targets to ensure that pay for performance will drive improvements in patient outcomes. Even though Congress has required that the CMS adopt pay for performance for hospitals, expectations with regard to programs modeled after Premier HQID should remain modest.
Pay for performance (P4P) is one of the measures in the Affordable Care Act (Sec. 3001) that supposedly is designed to improve quality and reduce costs. The recommendation was based on data such as this Medicare Hospital Quality Incentive Demonstration (HQID) which had shown that providing financial bonuses and penalties improves processes of care. But does it improve outcomes?
This large study of hospital performance had already shown early but non-sustained improvement in processes, but it turns out that paying for this performance did not improve patient outcomes. P4P did not improve 30 day nor 6 year mortality for the conditions studied – three medical conditions (acute myocardial infarction, congestive heart failure, and pneumonia) and two surgical procedures (coronary-artery bypass grafting [CABG] and total knee or total hip replacement). Yet the Affordable Care Act requires that all hospitals participate in the value-based purchasing (VBP) program, which provides financial incentives for both high achievement and improvement in performance – an approach closely modeled after the Medicare HQID.
This “teach to the test” P4P experiment did, in fact, result in rewards and penalties for hospitals based solely on process measures, though having no impact on outcomes. Such programs seem to promote gamesmanship much more than they promote actual improvements in quality – appealing to hospitals that were “eligible for larger bonuses, that were well financed, or that operated in less competitive markets.” It is yet another example of the multitude of unproven or minimally effective quality and cost measures in the Affordable Care Act.
The tragedy is that Congress and the President rejected the proven model of reform that would have achieved these goals – a single payer national health program. One benefit of the Supreme Court hearings this week is that there has been a resounding response that single payer is the answer. If only we could convert that perception into action. If only…
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.
Hardball with Chris Matthews
MSNBC, March 27, 2012
Chris Matthews: Professor Gruber, I’ve got a curve ball for you, from the left field, all right? I’m mixing my metaphors here. If the Supreme Court strikes down the individual mandate today, which is the most conservative way to have national health for everybody, requiring people to take responsibility as individuals. If that fails, and the progressive left of the Democratic Party says, no, now’s our chance to go for single payer, or what’s called the public option – I guess they’ll wind up being the same thing because there won’t be another option really. Is that a better economic proposition? That the government simply provides health insurance for the country? Single payer. Is that a better economic deal with no profit motive?
Jonathan Gruber: I think that single payer, if you could start over, I think that single payer has a lot to recommend it, but we can’t, and I think the bottom line is…
Chris Matthews: But we might have to start over after tonight.
Jonathan Gruber: No. I agree, but if we start over, the problem with failing, if this ruling goes against… this law fails, we’ll see the same pattern we’ve seen for the past century, which when we start over again which will on average be about seventeen years from now, because it’s about every seventeen years we start over, it’s going to be further to the right of where we are. Every seventeen years… Remember Richard Nixon proposed something to the left of the Affordable Care Act. Every seventeen years we move to the right. If this fails, the next round is not going to be single payer. It’s going to be even more conservative than what we have now.
What is the basis for this conversation about starting over if the Affordable Care Act (ACA) is struck down by the Supreme Court? Implicit is the concept that the Affordable Care Act actually accomplished the reform that we need. Of course, it didn’t. So, regardless of the decision, we wouldn’t be starting over since no iteration of ACA would hardly even begin to complete the process of reform.
For those who believe that ACA is the most feasible path to reform, there are some issues in this debate that would have the appearance of a make-or-break outcome (even though ACA itself isn’t a make-or-break model).
Based on the first two days of deliberation before the Supreme Court, it appears that the individual mandate to purchase private insurance may well be struck down. If it is, then both sides (plus an amicus from America’s Health Insurance Plans) agree that guaranteed issue and community rating should be declared inseverable and struck along with the individual mandate.
Though an intact ACA falls intolerably short on reducing uninsurance, underinsurance, and unaffordability, a decision eliminating guaranteed issue (eliminates pre-existing condition exclusions) and community rating (prevents insurers from gouging those with greater health care needs) would leave yet many more uninsured, especially those with greater health care needs plus the healthy invincibles whose funds are needed for the insurance risk pools. That should be enough to cause ACA supporters to take another look at single payer, though the mess we have with an intact ACA should make them reconsider anyway. ACA did not turn out to be the affordable-care-for-everyone model that supporters had hoped for at the beginning.
So we wouldn’t be starting over again since ACA was merely a misfire that gained us very little. A misfire is not enough to restart the seventeen year clock, not to mention that the clock is only an illusion anyway.
And Gruber’s contention that our next reform efforts will move further to the right because that’s the way history has led us? Really? Was Social Security a move to the right? Was Medicare a move to the right? Was the Civil Rights Act a move to the right?
Does health care really fall at some point along a linear, bipolar, one-dimensional span between right and left? Of course not, though we should tell the ideologues in Congress who believe this that such in-the-box thinking is why we are replacing them in the forthcoming election. We want not just the elderly but everyone in America to be able to say, “Leave my Medicare alone!”
NHS reforms finally become law
By Andrew Woodcock, Tim Schulthorpe
The Independent, March 27, 2012
The Government’s controversial reforms to the NHS became law today after a tortuous 14-month passage through Parliament, when the Queen granted Royal Assent to the Health and Social Care Bill.
The new rules mean the Government can create GP commissioning groups to buy health care for patients and scrap Primary Care Trusts (PCTs).
Labour has bitterly opposed the passage of the new law, insisting it threatens the foundation of the NHS and paves the way for private services to get too involved.
A draft risk register leaked today showed that ministers were warned 18 months ago of the risk that the reforms could lead to a loss of financial control, reduced productivity and emergencies being less well managed.
The Department of Health, which refused to comment on today’s leak, has resisted a ruling from the Information Commissioner that it should release the final version of the risk register in response to a freedom of information request from Labour.
Shadow health secretary Andy Burnham said today’s document showed that ministers were warned before they launched the Bill that it was “likely to cause major damage to the NHS”.
Identifying 43 separate areas of potential risk, the draft register rates each on a scale of one to five, where a rating of one means little likelihood and very low impact and five means almost certain to occur and very high impact.
The likelihood and impact figures are multiplied together to give an overall risk rating, with a maximum score of 25.
Among 13 areas given a risk rating of 16 – with likelihood and impact each assessed at four out of five – were:
* Parliamentary amendments creating “unforeseen consequences for the system”;
* Costs being driven up by GP consortia using private sector organisations and staff;
* Implementation beginning before adequate planning has been done;
* Loss of financial control;
* “Unhelpful conflict” between the NHS commissioning board and regulator Monitor;
* GP consortia going bust or having to cut services for financial reasons;
* GP leaders being drawn into managerial processes which end up driving clinical behaviour.
Other dangers, considered to have a lower rating of 12, included the risk that “NHS role in emergency preparedness/responsiveness is more difficult to manage through a more devolved organisation, and so emergencies are less well managed/mitigated”.
Staff concerns and union action over the reforms could lead to “deterioration in relations, lower productivity in the Department of Health/NHS and delays in programme”, the document said.
And there was a warning that strategic health authorities and primary care trusts might lose “good people” who then have to be re-employed to run the new system.
Mr Burnham told the Guardian: “Now we know why David Cameron refused to publish the risk register before the Bill was through Parliament – it’s because civil servants were telling him his reorganisation was likely to cause major damage to the NHS.
“David Cameron will never be forgiven for knowingly taking these risks with the country’s best-loved institution.”
David Cameron’s conservative government has succeeded in dismantling the National Health Service, turning it over to “GP consortia using private sector organisations and staff,” with “GP leaders being drawn into managerial processes which end up driving clinical behaviour.” The process became final today when the Queen granted Royal Assent.
As a sign of the nefarious process involved, the Cameron government refused an order to release the “risk register” that described the dangers inherent in this legislation that were “likely to cause major damage to the NHS.” Only on the day that the Queen granted her Royal Assent was a draft of the risk register leaked.
The lesson for the United States? Without greater citizen involvement, nominal democracies are, in fact, plutocracies. We bear the consequences of our inaction.
What greater example could there be than the fact that the most watched Supreme Court decision in decades evolves around a consideration as to how large the private insurance industry’s market will be, rather than the consideration that should be under review: whether the people have the right to join together as a nation to ensure health care justice for all.
Health law, constitutional or no, fails to remedy ailment: doctors group
Press Release, March 26, 2012
Leaders of Physicians for a National Health Program, an organization of 18,000 doctors who advocate for single-payer national health insurance, released the following statement today:
Regardless of whether the Supreme Court upholds or overturns the Affordable Care Act in whole or in part, the unfortunate reality is that federal health law of 2010 will not work: (1) it will not achieve universal coverage, as it leaves at least 26 million uninsured, (2) it will not make health care affordable to Americans with insurance, because gaps in their policies will leave them vulnerable to bankruptcy in the event of major illness, and (3) it will not control costs.
Why? Because the ACA perpetuates a dominant role for the private insurance industry. That industry siphons off hundreds of billions of health care dollars annually for overhead, profit and the paperwork it demands from doctors and hospitals; it denies care in order to increase insurers’ bottom line; and it obstructs any serious effort to control costs.
In contrast, a single-payer, improved-Medicare-for-all system would achieve all three goals – truly universal, comprehensive coverage; health security for our patients and their families; and cost control. It would do so by replacing private insurers with a single, nonprofit agency like Medicare that pays all medical bills, streamlines administration, and reins in costs for medications and other supplies through its bargaining clout.
The major provisions of the ACA do not go into effect until 2014. Although we will be counseled to “wait and see” how this reform plays out, we’ve seen how comparable reforms in Massachusetts and other states have worked over the past few decades. They have invariably failed our patients, foundering on the shoals of skyrocketing costs – even as they have profited the big private insurers and Big Pharma.
The Supreme Court’s ruling is not expected until June. Regardless of how it rules, we cannot wait for an effective remedy to our health care woes any longer, nor can our patients. The stakes are too high.
We pledge to continue our work for the only equitable, financially responsible and humane cure for our health care mess: single-payer national health insurance, an expanded and improved Medicare for all.
The attention to the Supreme Court deliberations on the Affordable Care Act is an unfortunate distraction since, regardless of the outcome, intolerable levels of uninsurance, undersinsurance, and unaffordability will still be with us. We need to replace the Affordable Care Act with single-payer national health insurance, an expanded and improved Medicare for all.
Please share this pivotal message with others, and feel free to use it as a basis for other communications such as letters to the editor, op-eds, reports to community organizations, and any other modality that can educate others on this crucial issue.
PNHP statement on the passage of the Affordable Care Act (March 2010):
Fact sheet on single payer, improved Medicare for all:
Many other resources are available at www.pnhp.org
California seeks limits on small-business self-insurance trend
By Chad Terhune
Los Angeles Times, March 23, 2012
Self-insurance, in which employers pay medical providers for their workers’ care, has traditionally been used only by large employers that have the financial resources to pay for expensive medical claims.
Now some insurers are chasing after much smaller customers with new plans designed to limit employer payouts for big claims using what’s called stop-loss policies. This guarantees that businesses won’t be responsible for anything over a certain amount per employee, perhaps as low as $10,000 or $20,000, with the rest paid by an insurer. Regulators and health-policy experts say this arrangement undercuts the notion of self-insurance since employers aren’t bearing much of the risk, and it allows companies to circumvent some state insurance rules.
“This is not real self-insurance. This is clearly a sham,” said Mark Hall, a professor of law and public health at Wake Forest University who has studied the small-business insurance market.
Critics said insurers such as Cigna Corp. are using these new plans to game the system and cherry-pick companies with healthier workers. They said this could undermine a key goal of the federal Affordable Care Act to lower premiums by pooling together more healthy and sick Americans into insurance exchanges. Premiums could continue to escalate without a diverse pool of consumers.
Insurance officials say that they are responding to employer demands for more affordable coverage and that regulators shouldn’t interfere in the market.
Self-insurance is attractive for many reasons, particularly the prospect of lower costs. It’s exempt from state insurance regulations such as mandated benefits, granting employers the flexibility to design their own benefit package and the opportunity to reap some of the savings from employee wellness programs. A federal law, the Employee Retirement Income Security Act, or ERISA, governs self-funded plans. Some aspects of the Affordable Care Act do apply to self-insurance, such as the elimination of caps on lifetime benefits and some preventive care at no cost.
Anthem Blue Cross, California’s largest for-profit insurer and a unit of WellPoint Inc., began selling these self-insured plans to employers with as few as 35 workers March 1, down from its previous minimum of 250 employees. Assurant Inc., a New York-based insurer, is selling plans to companies in California and other states with as few as 10 workers.
Marc Neely, vice president for Cigna’s self-insured business in 14 Western states, said his sales to small businesses with as few as 25 people are growing at a double-digit rate because employers are fed up with annual rate hikes of 10% to 15% on their traditional plans. Neely said Cigna offers stop-loss coverage as low as $20,000 per employee. “We’re excited about California as a growth market for us,” Neely said.
Now that the Affordable Care Act (ACA) is law, we can be assured the the private insurers will be team players in helping to craft regulated insurance markets that will serve the interests of patients first. Right? Wrong! Just read this article about how they are dumping much of the risk onto employers through these phony “self-insured” plans, while using ERISA to escape some of the regulatory provisions of ACA.
These crooks will never change. It is in their corporate DNA. No matter how much they are regulated, they will always find a way around to cheat the payers and avoid paying for the sick. This is what insurance market innovation is all about – screw the patients and take the money and run.
(For more, this topic was covered in a previous message: http://www.pnhp.org/news/2011/november/exemptions-for-self-insured-plans…)
2012 Progress Report: Health Reform is Opening the Insurance Market and Protecting Consumers
HealthCare.gov, March 22, 2012
The Affordable Care Act’s Rate Review policies bring an unprecedented level of scrutiny and transparency to health insurance rate increases. They ensure that, in every state, every proposed increase of 10% or more is evaluated by independent experts to assess whether they are based on reasonable assumptions and sound data.
Rate review is expected to help moderate premium increases and provide consumers with greater value for their premium dollar. Additionally, health insurance companies must provide easy to understand information to their customers about their reasons for significant rate increases, as well as publicly justify and post on their website any unreasonable rate increases.
The Affordable Care Act’s Rate Review program started for most individual and small group plans on September 1, 2011.
Through March 10, 2012, 186 increases affecting more than 1.3 million people have been posted on companyprofiles.healthcare.gov. Each provides an explanation from the insurer, including the rate increases determined to be unreasonable rate increases.
States are taking a strong lead in reviewing proposed rate increases. Of the 186 requested increases posted on HealthCare.gov as of March 10, 2012, two-thirds (125 filings) of these are being reviewed by rate review programs in the states. Only one-third (61 filings) is under review by HHS.
In the 61 instances to date where HHS is charged with conducting reviews, the Department has completed 28 determinations. HHS has determined that 20 of the 28 proposed rate increases are unreasonable. The most common reason for this determination is that the proposal would result in projected medical loss ratios (MLRs) below the 80% applicable threshold.
The title of today’s message, “Controlling costs through HHS rate reviews,” is deliberately deceptive to make a point. Supposedly, the Affordable Care Act (ACA) was designed to help control spending in health care, and the insurance premium Rate Review process was a component of cost containment. In fact, not only does the process have no impact on health care spending, it doesn’t even have any federal control over increases in health insurance premiums.
ACA regulations require that any plan with premium increases of 10 percent or more be reviewed. Although states may have some influence over rate increases, the federal government has no authority to do anything about the increases other than expose the insurers to public ridicule.
In the last six months, 20 rate increases reviewed by the federal government have been found to be unreasonable, primarily because they exceeded the 20 percent of the premium that they could use for administrative services and profits. Many of these insurers in the individual market will find that their inefficiencies are so great that they will be unable to comply with this requirement, so they really don’t need ridicule to drive home this point.
In the meantime, insurers will be able to increase their premiums 9.9 percent each year with no questions asked, at least not by the federal government. Compound that rate over several years, and then where will we be?
Obviously this ACA measure to “control costs” will have very little impact, if any, on insurance premiums and absolutely no impact on total health care spending.
There is a much more efficient model of health care financing that actually would slow the increase in health care spending while ensuring health care for everyone. Instead of playing ACA games, we should move forward with an improved Medicare for everyone.
Utah fifth state to join Health Care Compact
By Kirsten Stewart
The Salt Lake Tribune, March 20, 2012
Utah Gov. Gary Herbert on Tuesday signed a controversial measure to replace Medicare and Medicaid with a block grant to the states.
SB208 would have Utah join an interstate “Health Care Compact” designed to allow states to opt out of federal health reform without forgoing billions in federal funding.
But hospitals and consumer advocates warned the bill risks tying Utah’s fate to states with poorer health and higher health costs.
It also would also mean sacrificing $132 million in federal funding by 2014 because the block grants are not designed to keep pace with medical inflation, they said.
To date, four states have pledged to join the compact: Texas, Missouri, Oklahoma and Georgia. Two governors have vetoed the idea, including Arizona Gov. Jan Brewer.
Indiana Gov. Mitch Daniels Signs Health Care Compact Into Law
By Shonda Werry
Health Care Compact Blog, March 21, 2012
Gov. Mitch Daniels Monday signed the Health Care Compact into law, paving the way for restoring state control over health care policy and providing Hoosiers an alternative to the federally-run system.
The Health Care Compact is an initiative of the Health Care Compact Alliance, a nonpartisan organization dedicated to providing Americans more authority over decisions that govern their health care. It does not make suggestions on what policies individual states should pursue but advocates that health care policy decisions be made at the state level.
The Compact has been introduced in 13 states since February of 2011 and has been adopted in Texas, Georgia, Oklahoma, Missouri, and now Indiana.
For the Health Care Compact to become law, it must be approved by Congress. Once it is ratified, states will then be responsible for crafting their own policies.
Since the political barriers to enacting a national single payer program seem to be insurmountable, at least for the near future, many single payer activists are pursuing state level single payer models of reform. To be truly single payer, federal legislation would be required to free up funds from federal programs. The Health Care Compact should give us pause as to whether or not we want to give states that much control over our federal tax funds.
Under the Health Care Compact, Medicare and Medicaid funds would be transferred to the states under a block grant. To understand the significance of block grants for programs such as these, one need look no further than the House Budget proposal introduced yesterday by Congressman Paul Ryan. His proposal for block grants for Medicaid would eventually cut the federal contribution in half, leaving the states to fill in the gap.
With the budget problems that states already face, what would happen to coverage for Medicaid-eligible beneficiaries under a block grant? Even if all funds were combined into a single risk pool, these Medicaid cuts would result in either benefit reductions or in the need for higher state-based revenues, whether as taxes or premiums.
Six states – Texas, Georgia, Oklahoma, Missouri, Indiana, and Utah – have now passed the Health Care Compact. They are asking to use funds from existing federal programs to establish their own state health care programs. With their tight budgets and a further decrease in federal funding, would any of these states pass a single payer program that provided all necessary health care services for everyone? Of course not. Instead they seek to establish insurance markets that cross state lines, promoting the sale of low-premium, lowest-common-denominator plans that would destroy the financial security that health plans should be offering.
Keep this in mind as you work on state single payer solutions. When we ask for waivers (federal legislation) to allow states to use existing federal funds for state single payer programs, that process would also allow other states that are in the process of crushing unions, destroying retirement security, wiping out public primary and secondary education, driving up state college tuition to unaffordable levels, and so forth, to use their freedom to wipe out health security for their own people.
That seems like too dear of a price for our fellow Americans to pay. We can avoid that simply by enacting a national single payer program – an improved Medicare for everyone.
From HMOs to ACOs: The Quest for the Holy Grail in U.S. Health Policy
By Theodore Marmor, PhD and Jonathan Oberlander, PhD
Journal of General Internal Medicine, March 13, 2012 (Online)
The United States has been singularly unsuccessful at controlling health care spending. During the past four decades, American policymakers and analysts have embraced an ever changing array of panaceas to control costs, including managed care, consumer-directed health care, and most recently, delivery system reform and value-based purchasing. Past panaceas have gone through a cycle of excessive hope followed by disappointment at their failure to rein in medical care spending. We argue that accountable care organizations, medical homes, and similar ideas in vogue today could repeat this pattern. We explain why the United States persistently pursues health policy fads — despite their poor record — and how the promotion of panaceas obscures critical debate about controlling health care costs. Americans spend too much time on the quest for the “holy grail” — a reform that will decisively curtail spending while simultaneously improving quality of care — and too little time learning from the experiences of others. Reliable cost control does not, contrary to conventional wisdom, require fundamental delivery system reform or an end to fee-for-service payment. It does require the U.S. to emulate the lessons of other nations that have been more successful at limiting spending through budgeting, systemwide fee schedules, and concentrated purchasing.
Emulation, Not Innovation
We do not know how far ACOs will spread or what impact they, medical homes or other delivery system reforms will have on health care spending. But our history of failed cost control offers sobering lessons about exaggerated expectations, the limits of organizational reforms, and the recurring temptation to oversell reform ideas like ACOs as panaceas and the harbingers of a new, radically transformed, and vastly improved health care system. Such ideas should be seen as supplements, rather than the basis for a national strategy of health care cost control.
We believe that the U.S. needs less innovation and more emulation. That is, in order to control costs effectively Americans should focus less on (re)inventing the latest delivery system or payment method, and instead pay more attention to what other countries do to slow health care spending. Global budgets, fee schedules, systemwide payment rules, and concentrated purchasing power may not be modern, exciting or “transformational”. But they have the advantage of working.
Why have we spent decades trying to circumvent the obvious? We need to emulate the health care policies that do work in other nations, and give up on pursuing our many innovations that haven’t worked. Haven’t we had enough of modern, exciting and transformational failures?
By James G. Kahn, M.D., M.P.H.
Sunday night’s CNN special narrated by journalist Fareed Zakaria titled “Global Lessons — The GPS Road Map for Saving Heath Care” was interesting and initially promising, but ultimately disappointing.
It started out with superb references to other countries, then became illogical and gutless. In the end, the “solutions” offered by Zakaria to cure our broken health care system didn’t flow from the evidence presented earlier in the program. Remarkably, the U.S. implications of successful single-payer models were ignored.
Zakaria started out with a reasonable report on Britain’s single-payer National Health Service: its good quality, universal access and low cost. He also gave a fair account of the evidence-based, evaluative work of the National Institute for Health and Clinical Excellence, NICE (which is being undermined now, something he failed to mention).
He interjected a few comments about long wait times in Britain for non-urgent care, and raised the bogey of high taxes as the price one has to pay for such a system. But on balance the account was generally favorable.
Taiwan’s adoption of single-payer national health insurance was treated next. Zakaria noted that with Taiwan’s shift to a single-payer system in 1995, the proportion of the country’s uninsured dropped from 41 percent to 8 percent within a year. He also described other positive aspects of the Taiwanese health system. Overall, this segment was quite favorable and accurate.
Then came Switzerland. Here he gave a reasonable report about the country’s system of highly regulated private insurers (who can’t profit from selling basic health insurance policies and must offer insurance to all comers). He was incorrect, however, in equating the Swiss reform with the Affordable Care Act in the U.S.
Then the logical connections fell apart.
Zakaria proceeded directly to a segment on “consumer-driven care,” interviewing a corporate CEO who recently wrote in praise of free-market medicine in The Atlantic. Here Zakaria at least pointed out that there’s no evidence that a free-market approach will control costs, saying that the only evidence of competition working is for elective procedures like Lasik surgery, whereas most health care costs arise unpredictably or stem from chronic disease.
He then looked at ACOs, accountable care organizations, in the form of an uncritical interview with Dr. Atul Gawande, the surgeon and writer for The New Yorker. Gawande emphasized how uncoordinated and excessive care contribute importantly to our nation’s high health care costs. Zakaria noted that there are ACO experiments, but failed to emphasize the lack of evidence that we can scale up ACOs.
Next was also an uncritical, indeed quite favorable, report on efforts in Camden, N.J., to provide case management care for high utilizers in “hot spots.” Zakaria glossed over the lack of solid evaluation data on the Camden experiment.
In his wrap-up, Zakaria offered his own views. He endorsed individual mandates (noting that they were first proposed by the Heritage Foundation). He said the ACA won’t control costs, and said we need a “cost control board” to decide what’s covered and what isn’t.
He explicitly rejected a pure market solution as inappropriate to health care, noting we’re not buying cars, we’re buying something for which we have little choice when it’s needed. The pure market solution won’t control costs and will leave many without care, he said.
Inexplicably, Zakaria failed to point out the implications for the U.S. of the successful British and Taiwan experiences, and instead said that we need to “acknowledge what’s on the ground” in the U.S. (read: path dependence), and thus need to fix the current “messy mixed model” we currently have.
As I said at the beginning: promising opening, but ultimately disappointing in acceptance of our current structurally defective health care financing system. Viewers deserve a more coherent and brave progression from evidence to action.
Dr. James G. Kahn is a professor at the Philip R. Lee Institute for Health Policy Studies at the University of California, San Francisco. Dr. Kahn is an expert in policy modeling in health care, cost-effectiveness analysis, evidence-based medicine, and administrative costs in U.S. health care. He is also a board member and immediate past president of Physicians for a National Health Program – California.
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