Is primary care relinquishing acute care?

Posted by on Tuesday, Sep 7, 2010

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

Where Americans Get Acute Care: Increasingly, It’s Not At Their Doctor’s Office

By Stephen R. Pitts, Emily R. Carrier, Eugene C. Rich and Arthur L. Kellermann
Health Affairs
September 2010


Historically, general practitioners provided first-contact care in the United States. Today, however, only 42 percent of the 354 million annual visits for acute care — treatment for newly arising health problems — are made to patients’ personal physicians. The rest are made to emergency departments (28 percent), specialists (20 percent), or outpatient departments (7 percent). Although fewer than 5 percent of doctors are emergency physicians, they handle a quarter of all acute care encounters and more than half of such visits by the uninsured. Health reform provisions in the Patient Protection and Affordable Care Act that advance patient-centered medical homes and accountable care organizations are intended to improve access to acute care. The challenge for reform will be to succeed in the current, complex acute care landscape.

When you say “my physician,” what do you mean? For most of us, that means the physician whom you call when you have a medical need. It’s the physician who will always be there for you, or who will at least ensure that a colleague is available when taking an off-call breather or when on vacation. Yet, as this study shows, personal physicians or their associates provide care for only 42 percent of acute problems. Increasingly, patients can no longer rely on their doctor’s office when they need acute care.

The policy community certainly recognizes the crisis in primary care. Much attention has been directed toward improving chronic care management within the primary care environment. Unfortunately, much of these efforts remain in the discussion phases, and only limited improvement has been made in the application of these relatively imprecisely defined concepts.

Yet what the primary care professional should be really good at – timely care of acute problems – has been almost completely ignored by the policy community. Physicians are too busy and don’t have time to take care of their patients. (Although that thought certainly can be expanded upon, the irony is inescapable.)

What are some of the solutions?

*  Emergency departments (EDs) already are bearing the largest portion of the overload. Queues in EDs are enough of a problem without adding to the waiting room backlog of many individuals who would be more appropriately cared for in a less intensive environment, such as a primary care practice. Adding to the problems with our overcrowded EDs is the burden of having to care for over one-half of all uninsured individuals with acute care problems.

*  Patients in the next largest sector directly access specialists for their acute problems. Sometimes this may be quite appropriate, yet many times it may result in more expensive care for problems that would be more appropriately managed in a less expensive primary care environment. Also some patients who should be cared for by specialists may not be able to access them for several reasons, and, once again, the primary care physician would be in a better position to enable that access for the patient.

*  Outpatient departments of integrated health systems appropriately may fulfill the role as the acute care provider as long as arrangements are made for access outside of clinic hours. These departments are usually associated with larger institutions, and, as such, would never be much more than a niche provider of acute care services.

*  Retail clinics are capable of providing only the most basic of acute care services, and further fragment the coordinated care that should be provided in the primary care environment. Further, retail clinics skim off the easy, cash paying “customers” (a more appropriate term than “patients” in this retail environment). The same is true of urgent care centers and their customers, though they are usually capable of caring for a greater variety of problems.

*  Concierge physicians do provide greater personal attention, but for very high fees that most of us cannot afford. To provide this higher level of accessibility, they sharply reduce the number of patients in their practices, further compounding the problem of the critical shortage of primary care physicians.

*  Community health centers (CHCs) fulfill an important role in primary care, especially because they usually provide access for underserved patients in underserved communities. They provide acute care services during clinic hours, though patients often must rely on EDs when the clinics are closed. Most CHCs continue to struggle with finances. Also, most have difficulties in obtaining the cooperation of an adequate variety of specialists in providing care for more complex problems.

Members of Congress are quite aware of the profound deficiencies in our primary care infrastructure, so they included some measures in the Patient Protection and Affordable Care Act (PPACA) designed to address this issue. Will they help?

Funds are being allocated for primary care training programs. That is certainly a step in the right direction, but the funds are quite limited and will hardly make a dent in the problem.

More funds are being allocated for community health centers, again certainly a beneficial measure, but one which falls far short of meeting the need.

Some Medicare funds are being shifted from other services to primary care but not enough to even begin to narrow the compensation gap between primary care and the surgical specialists. Why would medical students, saddled with education debt, choose primary care with its long hours and modest pay, when specialties promise higher pay and more free time?

PPACA contains measures to promote the medical home model – theoretically the ideal primary care model. Although medical home demonstration projects are under way, it will be a long time before the specifics of the model will be precisely defined and ready for universal application. Further, the logistics of permeating the nation with medical homes may be beyond the capabilities of our public and private stewards working within the limitations of our dysfunctional financing system. Though the medical home model shows great promise, we need a financing system that will make it much more feasible.

The great hope of PPACA has been pinned on accountable care organizations (ACOs). This Health Affairs article defines ACOs as “integrated or virtually integrated delivery systems that will provide care for a defined population in a range of settings, linked by health information technology.” The supporters of ACOs have described everything from full service integrated health care delivery systems to “virtual” systems that are not connected by much more than an information technology system.

Although the providers of health care may seek to create innovative ACO systems that theoretically would improve patient care, it is likely that the emphasis will be on, not just controlling, but actually reducing spending. The ghost of managed care past will be embellished through the “integrated and accountable” efforts of the insurers partnering with health delivery entrepreneurs. Only the patients, patient-oriented health care professionals, and the patient-oriented hospitals will be losers.

Whatever you need – preventive services, continuing care for your chronic condition, or timely management of an acute problem – wouldn’t it be nice if you always had available your own personal physician’s team to meet your needs? With our fragmented, dysfunctional system of financing health care, it is unlikely that in the future this will be more than a dream for the majority of us.

If we had our own Medicare-for-all monopsony (single purchaser of health care) it could become a reality for all of us. We would simply insist that a primary care system coordinating a full complement of specialized services is all that we’re going to pay for. The insurers and health profession entrepreneurs can take a hike.

A message from Sen. Mark Leno on the California single payer bill

Posted by on Friday, Sep 3, 2010

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

A special message from Senator Mark Leno on SB 810, the California Universal Health Care Act:

September 3, 2010

Dear Friends,

By now most of you have heard the disappointing news that our bill, SB 810, the California Universal Health Care Act, was held on the Assembly Floor on the last night of session, effectively killing the measure until next year. Over my strong objections, Assembly leadership decided to hold the bill. Although we are greatly disappointed, we are determined to come back even stronger next year.

I want to thank and recognize the work of the California School Employees Association and California Nurses Association who worked hard to lobby members all year. I also want to recognize Health Care for All, California Physicians for a National Health Plan, Single Payer Now, California Alliance for Retired Americans, California Health Professional Student Alliance, League of Women Voters and the other dozen organizational members of our statewide alliance. Most importantly, I thank the thousands of advocates who made phone calls, requested meetings, attended rallies, and sent letters, faxes and emails, making it clear to legislators that the single payer health care movement is vibrant, strong and growing larger every day.

Our movement has always acknowledged that it is founded on a long-term vision and strategy. This setback does not change our work, it only emboldens it. For decades we have found the courage to speak out for single payer, even when others around us told us that now is not the right time. We have learned that fear and hesitation can only be overcome by courage and commitment – something with which our movement is rich. That is how we have come so far, and that is why we will win.

Without question, I commit to reintroducing this bill again next year, and to work ever harder with you to achieve the only real solution to our health care crisis – Medicare for All.

I encourage you to begin our work today to ensure the passage of this bill next session. Now is the time to educate your current representatives, and those who are seeking office, about the need for single payer universal health care and to ask for their support. More importantly, now is the time for you to educate your co-workers, neighbors, friends, and family members about why their elected officials should take a strong stance in support of Medicare for All.

We’ve always said that the closer we come, the harder our work will become. So often, it’s “two steps forward, one step back.” Let this temporary detour enliven us to work even harder to see single payer become a reality in California. With term limits, it is clear that each new class of representatives needs to be educated and reminded of how important this issue is to our state. Next year will bring a new governor and a new legislature – and consequently, new opportunities and challenges. To win, we must come closer together as allies, fight smarter, and work even harder.

As the author of SB 810, I believe deeply in you, this cause and this movement. Until every Californian has health care and no family faces medical bankruptcy, we will not be deterred. Until our state budget and entire economy are no longer being swallowed by health care costs, we will not cease. Until we have “Medicare for All,” we will not stop fighting. We’re the fastest growing grassroots movement in America, and we will win universal health care. Let’s dig deep, redouble our efforts and get back to work.


Senator Mark Leno

Uwe Reinhardt on the details of the medical loss ratio

Posted by on Friday, Sep 3, 2010

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

On Health Care, the Devil’s in the Details

By Uwe E. Reinhardt
The New York Times
September 3, 2010

The recently passed Affordable Care Act requires heath insurance issuers to use at least some minimum fraction of revenue from the premiums it receives on medical services. While the idea might sound straightforward, this fraction, known as the “medical-loss ratio,” is open to all sorts of creative arithmetic, and you can bet that interest groups from every corner are trying to get the math to add up in their favor.

Under the new law,  health insurers are supposed to spend at least 85 percent of premiums collected from large groups of insured on something defined as “medical benefits and activities that improve health care quality.” For small groups and individually sold policies, the standard is lower, at 80 percent.

Put yourself in the shoes of the health care providers.

They would like to put as many of an insurer’s outlays – other than provider payments – as can be justified into the denominators as “selling or administrative expense.” That would put pressure on insurers to increase payments to providers or to spend less on administration to meet the ratio requirement. Therefore, providers typically plead for a very narrow definition of an insurer’s outlays for “health care quality improvement” that, by statute, are to go into the numerator.

Health insurers, on the other hand, would like to pack as many of their outlays as possible into the numerator of the ratio.

In a letter to the commissioners, the president of America’s Health Insurance Plans, which represents about 1,300 member companies that provide insurance for more than 200 million Americans, pleads for inclusion in “activities to improve health care quality” such items as fraud prevention and detection, utilization review, costs associated with administrative simplification and health-information technology expenses, and the cost of implementing the new International Classification of Diseases, or ICD-10, codes.

Finally, there are the commissions that insurers pay to brokers, who currently play an important role in the small-group and individual market for health insurers.

The commissions usually range between 4 and 8 percent of the premium, depending on the state, but sometimes are 20 percent of the premium in the first year of a policy before dropping to the normal range.

How these commissions are incorporated into the ratio can have a significant impact on the economics of insurance brokers, whose future role in health care is of great concern to the commissioners.

My response, also posted at the link here:

10.  Don McCanne, San Juan Capistrano, CA
September 3rd, 2010

Focusing on narrow issues such as whether the administrative cost of brokers’ fees somehow represents patient care or quality improvement as opposed to being an administrative expense distracts us from the much more important overriding issue of the profound administrative waste throughout our health care system that is related to the dysfunctional, fragmented manner in which we allocate health care spending.

The first consideration is the administrative cost of the private insurers. Should we really be allocating 15 to 20 percent of the insurance premiums to the private insurers for them to use for their own intrinsic purposes – funds that never make it to paying for health care? When you consider the very high health care expenditures in our nation, 15 to 20 percent is a huge allocation for non-medical purposes.

Another very important diversion of health care dollars is the cost of the administrative burden placed on hospitals and physicians merely to deal with our fragmented system of a multitude of public and private plans – especially in claims processing, including not only the protracted process of managing disputed claims, but also other administrative diversions such as negotiating and managing insurance company contracts.

This administrative burden on the providers has been estimated to consume about 12 percent of premium dollars. Thus the combined administrative costs merely for the insurance function will be about 27 to 32 percent of the insurance premium – a very high percentage of our very high priced system. That does not include all of the other essential administrative functions that hospitals and physicians face. What a waste!

It is unfortunate that consideration of a single publicly-financed and publicly-administered financing system was excluded before the reform negotiations began. Such a financing system – a single payer or an improved Medicare for all – would have dramatically reduced this profound administrative waste.

Even more important, a single financing system would have created our own public monopsony (single buyer of health care) in which we could ensure that we would be receiving maximum value in our health care purchasing – avoiding excessively high prices while ensuring that enough funds are available to maintain adequate capacity in the system. That is the cost control that we really need. And, oh yes… everyone is included!

Wasn’t that the goal of reform? Cover everyone and control costs?

Medicare then and now

Posted by on Friday, Sep 3, 2010

By Charles R. Mathews, M.D.

This pulmonologist was plying his profession in upstate New York some 44 years ago when his receptionist announced, “The White House is calling!” I assumed it was a hoax, since my only direct contact with that eminent residence had been limited to passing through as a tourist.

But my receptionist persisted and connected me to the caller, who inquired whether I’d be available for a “presidential meeting on Medicare’s implementation” to take place in Washington on June 15, 1966.

The invitation, which was shortly confirmed by telegram, was not to be declined. I was more than a bit surprised, since I’d been actively supporting the American Medical Association’s campaign to stave off the inroads of government into our medical domains, decrying and demonizing Medicare as “socialized medicine.”

But President Lyndon B. Johnson, the consummate politician, was able to draw me and many others into the orbit of his Great Society programs by dint of his overwhelming electoral triumph in 1964. His formidable political capital helped win passage of civil rights and anti-poverty legislation, aid to education, and, of most consequence to us physicians and our patients, Medicare and Medicaid.

About 200 of us from all 50 states attended the meeting. We were whisked into the East Room, where, because of its small size, we barely had room to breathe. (Take it from a lung doctor.) Minutes later, the president took the podium and delivered a moving half-hour address.

“For the first time in the history of America,” Johnson said, “every senior citizen will be able to receive hospital care – not as a ward of the state, not as a charity case, but as an insured patient.”

The changes had been breathtaking. Medicare had been enacted into law just one year before, on July 30, 1965, and here we were, assessing its progress. But certainly more remained to be done.

For example, the president noted that some 20 percent of the nation’s hospitals were not in compliance with the Civil Rights Act. Over 90 percent of hospitals in the South were still segregated.

“We believe the answer to that problem is a simple one,” LBJ said, noting that hospitals had been put on notice that their Medicare reimbursement payments would be contingent on their compliance with the Civil Rights Act’s ban on any discrimination based on race, color or national origin.

While the desegregation process was sometimes slow, “whites only” hospital wards were ultimately consigned to the dustbin of history, and Medicare had played an honorable part in their abolition.

Forty-five years have passed since Medicare became the law of the land. It’s hard to overstate the beneficial effect it’s had on the health and financial security of our nation’s seniors and their families. It remains absolutely essential for persons over 65 and for those with severe disabilities or end-stage renal disease.

But it faces new challenges. The basic Medicare program worked well for many years as an efficient, not-for-profit system with a standard benefit package for all enrollees. However, beginning with the passage of the Balanced Budget Act of 1997, the private, for-profit health insurance companies began to more aggressively bore their way into the program with the aim of siphoning off public and beneficiary dollars.

They’ve succeeded in doing so through their Medicare Advantage plans (which offer some additional benefits but which don’t improve overall quality, even as they rack up much higher overhead expenses than traditional Medicare) and through a prescription drug program that boosts insurance and drug company profits.

Partially as a consequence, health costs continue to skyrocket.

It is clear to me that President Johnson’s original vision of providing universal access to health care through an equitable, publicly financed plan is one that we must turn to again. It’s the only approach that is sustainable and just.

We need an improved Medicare for all. Research shows the $400 billion in savings we’d reap from eliminating all the excess paperwork and bureaucracy associated with the private insurance industry, plus the cost-control tools we’d acquire have like bulk purchasing of medications, would be enough to assure high quality, affordable and comprehensive care for everyone over the long haul.

It remains to be seen how long the health care oligarchs, particularly the private insurers and Big Pharma, can forestall this badly needed solution. They managed to do so this round of reform. But its day must come.

Charles R. Mathews is a Tallahassee, Fla., physician and a member of Physicians for a National Health Program (

Should we leave employers in charge of health benefits?

Posted by on Thursday, Sep 2, 2010

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

Employer Health Benefits

The Kaiser Family Foundation and Health Research and Educational Trust
September 2, 2010

The average annual premiums for employer-sponsored health insurance in 2010 are $5,049 for single coverage and $13,770 for family coverage.

Twenty percent of covered workers are in plans with an annual total premium for family coverage of at least $16,524 (120% of the average premium).

Covered workers on average contribute 19% of the total premium for single coverage (up from 17% in 2009) and 30% for family coverage (up from 27% in 2009).

Fifty-one percent of workers with family coverage pay more than 25% of the total premium.

Among workers with a deductible, the average general annual deductible for single coverage is $675 for workers in PPOs, $601 for workers in HMOs, $1,048 for workers in POS plans, and $1,903 for workers in HDHP/SOs.

For the last two years we have asked employers about changes that they made to their health benefits in response to the poor economy. Among large firms (200 or more workers), 38% reported reducing the scope of benefits or increasing cost sharing, up from 22% in 2009, while 36% reported increasing their workers’ premium share, up from 22% in 2009.

Tracking whether and how worker out-of-pocket costs continue to grow will be an important focus for the survey over the next few years. The slow economic recovery and continuing high unemployment suggests that this trend of increasing out-of-pocket costs will persist, as workers have little clout to demand better benefits or lower costs in the current labor environment.

Full report (226 pages):

By design, the Patient Protection and Affordable Care Act (PPACA) will have the least impact on employer-sponsored health plans. Congress did not want to disturb these plans that seemed to be working reasonably well, in that they covered more of us than all other programs, and were already generously funded with employer contributions. This annual report on employer health benefits is even more relevant this year since Congress, through PPACA, has deemed that we will be living with these plans for decades to come.

The report brings us terrible news. Premiums continue to rise at intolerable rates, and more of the premium costs are being shifted to the employees. Employers also are requiring greater cost sharing on the part of their employees, especially in the form of higher deductibles. Employees are paying more for less protection.

With the poor economy employees need greater relief, yet employers are seeking relief for themselves by placing an even greater financial burden on their own employees.

This is a one-way trend. Employers will continue to seek ways to reduce the costs of their health benefit programs, and an ever increasing amount of the burden will be borne by the employees. Should we really be leaving these decisions in the hands of the employers?

Drew Altman, president and CEO of the Kaiser Family Foundation, said, “The new law helps a lot of people in a lot of ways… but in general it left employer-based coverage alone. That is what the politics of health care dictated and what the American people asked for.” (Kaiser Health News, Sep 2)

If Americans really prefer their employer-sponsored plans, then why are they so relieved when they get to go on Medicare? How much more burden will Americans have to bear before they change the politics and start demanding Medicare for all?

Democrats Block California Single Payer Bill

Posted by on Wednesday, Sep 1, 2010

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

By Don McCanne
September 1, 2010

Speaker John Perez of the California State Assembly, on the very last day of the legislative session, pulled SB 810, the single payer bill, from the Assembly floor.

This highly unusual move of pulling a bill that had cleared all legislative hurdles except for the final Assembly floor vote was to protect Democrats from having to cast a health care reform vote in a difficult political environment three months before the next election.

Democrats feared a backlash from those who are opposed to the recently enacted federal health care legislation should they vote for the bill, and they feared offending their progressive base should they vote against the bill. Since a veto by Gov. Schwarzenegger was a given, it was decided that it would be safer to avoid the political risks by simply pulling the bill.

But did they really avoid that risk? Are the single payer advocates expendable? Don’t think so.

Fortunately, Senator Mark Leno is not to be deterred. He has vowed to reintroduce the bill in the next legislative session which begins in January.

The Democrats are worried about their political base, but maybe that’s not the framing we should be looking at. Perhaps the single payer advocates should be reassessing their own base instead.

Not all Democrats have been supportive of single payer, and several Republicans who are not part of the prevailing lock-step bloc do understand the benefits of the single payer model. The Patient Protection and Affordable Care Act is proof that we can’t rely on the Democrats to do the right thing. Most importantly, everyone understands the benefits of Medicare as a social insurance program (even if there is a fringe reactionary element that would emasculate it).

The Tea Party is proving that passionate voices can be heard. Maybe we can learn from them, though our message should contain more than simple platitudes. Our message needs to convey the principled substance of health care justice, and it needs to be loud, clear and highly infectious.

Private insurers shifting support to Republicans

Posted by on Monday, Aug 30, 2010

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

Health Insurer Cash Shifts to Favor Republicans Before Election

By Drew Armstrong
August 26, 2010

Health insurers led by WellPoint Inc. are backing Republicans with campaign donations by an 8-to-1 margin, favoring the party that’s promised to repeal President Barack Obama’s health-care overhaul if it wins back Congress.

WellPoint, Humana, Aetna, Cigna and UnitedHealth Group Inc. have also been considering a $20 million-plus campaign fund to reward friends and punish enemies in Congress. That fund would target vulnerable Democrats who have spoken out against the industry, and would support candidates who are likely to argue for the industry’s positions during future debate on the health overhaul.

With private insurers supporting Republicans by an 8-to-1 margin, there is no question but that the insurers are supporting their own financial interests, regardless of the negative impact on people who need health care.

The Republicans remain opposed to all forms of social insurance that would make health care accessible and affordable for everyone (not that the Democrats did much better this time around). Instead Republicans support measures such as high-deductible health plans, health savings accounts, elimination of mandated benefits such as mental health and maternity care, and promoting interstate sale of less regulated, Spartan plans.

Insurers prefer these plans because they are the most profitable. Many individuals in the large healthy sector of our population tend to prefer these plans because the premiums are lower. Unfortunately for the sick, these plans shift a burdensome amount of the health care costs to the patients in need, not to mention the fact that the insurers have been relatively successful in avoiding these higher-cost individuals in the first place.

Republicans support these proposals because of their ideological stance, believing that each person should be responsible for their own welfare, making exceptions only for those who are the most destitute, not of their own making. They oppose the social solidarity of “collectivist” approaches such as universal insurance programs, whether public or private.

A distinction should be made between the current, lock-step, obstructionist, party-of-NO Republicans, and the nearly extinct species of progressive Republican – many of whom have become independent. It is this obstructionist Republican bloc that serves so well the interests of the private insurers.

It’s sad that the Democrats got into bed with these people. The Democrats ended up supporting the right-wing private insurance model of Mitt Romney and the Heritage Foundation to appease the Republicans and the private insurers. That resulted in the enactment of a terribly flawed program that will not adequately control costs, and will leave tens of millions uninsured and many more underinsured.

The insurers now want to send us more of these reactionary politicians. Aren’t there enough of us who care about the health of all of our people to step up and counter this? Or is it merely all words (for the pollsters), and no action (on behalf of those with health care needs)?

Where are our activists?

By Kip Sullivan

The campaign to create a “public option” ended in failure last March when Congress passed the Patient Protection and Affordable Care Act with no “option” in it.

This failure occurred even though the “option” campaign happily allowed their proposal to be transformed from one that would have taken 130 million customers away from the insurance industry and given the insurance industry no subsidies, to one that took zero to 10 million customers away and gave hundreds of billions of dollars to the insurance industry. Even after “option” advocates had degraded the “option” to a sad little token of a program, Congress refused to incorporate it into PPACA.

There are several useful lessons to be learned from the failure of the “option” campaign. However, you won’t find them in an August 17 article in The American Prospect entitled “Health Reform 2.0” by Jacob Hacker, the most visible scholar in the “option” campaign.

Rather than give us his assessment of what went wrong, Hacker celebrates PPACA and issues recommendations for improving it that are so vague they amount to platitudes. Here are examples:

  • “reformers will need to call plainly for a greater government role;”
  • “Insurers and providers will be doing everything they can to shape what states do. Reformers… will need to push back;”
  • “[reformers should] build on the existing law to fill in its gaps;”
  • “progressives [should] rehabilitate American government;” and, of course,
  • “reformers should revive the public option.”

Any questions?

The following two sentences are the only ones in Hacker’s article that resemble analysis:

[T]he public-option debate was a case study in why cost control is so hard: Conservative Democrats first effectively stripped out the tools of cost control that would have allowed the public option to compete aggressively with private insurers. Then they complained that the public option wouldn’t control costs!

So why were “conservative Democrats” successful in stripping the “option” of its alleged cost-containment tools? Hacker doesn’t say. We may infer from Hacker’s silence that he would prefer his readers not question the decisions the “option” campaign made.

But the decision by Hacker and the leadership of Health Care for America Now (HCAN, the coalition that led the “option” campaign) to abandon single-payer legislation in favor of the “option” on “political feasibility” grounds ought to be questioned. Over the last five years, Hacker has repeatedly argued that single-payer legislation is not “feasible” because the American public is “stubbornly attached” to the current system. By the same logic, he also argued that “option” legislation could pass because it leaves the current multiple-payer system intact.

Here is a particularly condescending example of Hacker’s argument taken from an article he published in 2007 the New England Journal of Medicine in which Hacker criticizes Michael Moore for supporting a single-payer system:

Moore wants to do away with it all. His “prescription for change,” available on the Sicko Web site, calls for giving every U.S. resident “free, universal health care for life” [and] abolishing “all health insurance companies….” Moore clearly does not think much of the health plans being offered by Democratic presidential candidates Barack Obama and John Edwards. The Sicko site directs us to a new vehicle for “netroots” organizing sponsored by Physicians for a National Health Program … which warns, “Beware of Phony Universal Coverage: Many political candidates say they support ‘universal health care,’ but usually this just means making more Americans insurance company customers. Real universal coverage means evicting insurance companies and establishing a national health program instead.” It is an appealing vision, in many ways…. But it is also unrealistic. Sadly most Americans … can be frightened into believing that changing [the current] entrenched and inadequate system means paying more for less.

(“Healing our Sicko health care system,” New England Journal of Medicine 2007;357:733-735, 734.)

Having criticized Moore for being “unrealistic,” Hacker went on to urge his readers to abandon single-payer and support the version of the “option” he was promoting back then, a version he called the “Health Care for America Plan.”

We all know what happened over the next two years. Single payer was taken “off the table” because it was “unrealistic” and an utterly innocuous version of the “option” was placed on the table. But, alas, even this “option” turned out to be “unrealistic,” and so it was also removed from the table. What remained on the table was the centerpiece of what became PPACA – a mammoth insurance industry bailout. The PNHP warning that Hacker scoffed at in 2007 turned out to be 100 percent accurate.

As PNHP had warned, the legislation Obama supported (and that Hacker now celebrates) turned out to be a scheme to turn even more Americans into “insurance company customers.” Under PPACA, the insurance industry will get 20 million to 25 million new customers (16 million directly, and a few more million through the expansion of privatized state Medicaid programs), and the premiums of most of these customers will be subsidized by the taxpayer.

The net result of Hacker’s strategy: A “reform” bill with no “option” and no cost control which will leave half the uninsured uninsured a decade from now and which enriches the insurance industry.

This outcome begs for analysis. The “option” campaign was one of the most well-funded campaigns for a left-of-center proposal in American history (HCAN alone spent at least $51 million over the past two years). Moreover, the campaign took place at one of the more propitious moments for health reform in American history. And yet it failed completely. (This assessment assumes that Hacker and HCAN weren’t all along promoting an insurance industry bailout under the guise of promoting an “option.” I have questioned this assumption in a previous comment on this blog.)

But Hacker offers no analysis other than to blame “conservative Democrats” for whacking his “option.” If it had been a single-payer bill that conservative Democrats successfully opposed in 2009 and early 2010, we know exactly what Hacker would be saying: He would be saying single-payer advocates are “unrealistic” people who don’t understand Americans as well as he does. He would be saying, “Of course conservative Democrats killed the single-payer bill. They represent mainstream Americans who are stubbornly attached to the current system.”

But, of course, it wasn’t single-payer that got killed last year, it was Hacker’s “option” – the completely gutted version – that got killed.

The lesson that Hacker and all of us who care about universal coverage should draw from the “option” debacle is that the “option” never was the Northwest Passage to universal health insurance in America. It will turn out to be more like the Donner Pass – a path that seemed from afar to lead over a mountain range of obstacles, but which turned out to be a trap.

It is imperative that the American universal coverage movement arrive at an accurate interpretation of the history of PPACA, including the “option” campaign’s criticism of single-payer and its support for an insurance industry bailout. The interpretation I hope we all arrive at some day is that the “option” campaign squandered a golden opportunity to achieve real reform or to at least set the stage for the achievement of real reform in the near future.

The year 2009 was one of those rare windows of opportunity for fundamental reform of our health care system. Two-thirds of Americans supported a single-payer system. The nation’s large and seasoned single-payer movement was chomping at the bit to fight for single-payer legislation.

But the “option” campaign squandered it all for an insurance industry bailout. Hacker’s timid and inaccurate analysis of what was possible played a key role in this tragedy.

Kip Sullivan is a member of the steering committee of the Minnesota chapter of Physicians for a National Health Program (

Two year Medicare waiting period for those with disabilities

Posted by on Friday, Aug 27, 2010

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

Groups Press Congress To End Patients’ Wait For Medicare

By Jessica Marcy
Kaiser Health News
August 27, 2010

Under federal rules, most people with disabilities who are younger than 65 aren’t eligible for Medicare until more than two years after they qualify for Social Security disability income. A coalition of more than 65 organizations led by the Medicare Rights Center has been pushing Congress to do away with the waiting period. But the effort has stalled because of the high cost to the federal government – an estimated $113 billion over 10 years, according to the Congressional Budget Office. That takes into account a $32 billion reduction in federal spending on Medicaid, the state-federal program for the poor and the disabled. Many people with disabilities go on Medicaid while they wait to become eligible for Medicare.

When Medicare expanded in 1972 to cover the disabled, Congress created the waiting period to help control costs and ensure that only people with severe, ongoing disabilities received coverage. About 17 percent of Medicare’s total 47 million beneficiaries – just over 8 million people in 2010 – receive disability benefits, according to the Kaiser Family Foundation.

Still, the patient groups are pushing to end the Medicare waiting period because many people may still need government help. Currently, nearly 39 percent of patients are uninsured for at least some of the time during the Medicare two-year waiting period while 26 percent have no insurance for the entire time.

Discarding the Medicare waiting period “is always going to be an issue in Congress,” said Edmund Haislmaier, senior health policy research fellow at the Heritage Foundation. “Some of it is money, some of it is politics, too. For members of Congress, irrespective of party or where they stand on the issue, it’s kind of all-or-nothing because if they did it for some diseases, then they’re immediately going to be inundated with ‘Why didn’t you do it for us?'”

Joseph Antos, health care policy scholar at the American Enterprise Institute, said that a total elimination of the waiting period was not going to happen. “Across the board eliminating the two years just doesn’t seem practical,” he said. “This really is a money issue.”

When Congress expanded Medicare to cover individuals under 65 with long-term disabilities, they specified a two year waiting period to be certain that only those with truly permanent disabilities would be admitted to the program. Obviously this creates a hardship for precisely those for whom the eligibility was established. Will the Patient Protection and Affordable Care Act (PPACA) adequately address this injustice?

PPACA did not include any adjustments in the two year waiting period. Consequently different groups representing specific chronic disorders are lobbying for exceptions to the two year wait. Even if some of these groups achieve legislative success, it will not help the others who must wait the two years.

Since many lose their insurance and their income during that two year wait, some may become eligible for the expanded Medicaid program. Yesterday’s message explained how Medicaid may leave those with chronic disorders underinsured with impaired outcomes, so this is certainly not a satisfactory solution. Besides, many with inadequate incomes may still fall above the threshold for Medicaid eligibility.

For those who lose their insurance during the two year wait, the individual mandate would require that they purchase private plans. Even with premium subsidies, these plans may still not be affordable. Besides, their low actuarial values will not provide adequate protection for these individuals with high health care costs, even with out-of-pocket spending subsidies.

PPACA included the CLASS Act (Community Living Assistance Services and Supports Act) designed to provide long-term care insurance. Though you might think that this provides an out, there are significant problems with CLASS. The program is voluntary and the individual must pay premiums for five years before benefits are available. That alone will exclude those with modest incomes who might consider the premiums to be unaffordable, especially for a program they can’t use for five years and may never need. Furthermore, the benefits are anticipated to be quite meager and likely will provide only a modest daily cash benefit. The CLASS Act will not fulfill the insurance need for the two year gap.

The comments from the representatives of the Heritage Foundation and the American Enterprise Institute describe the real hurdles: politics and money. It’s not that we can’t find the money, but the anti-government politics of today is driven by the philosophy that the government has been drained dry so that no funds are available. That is ridiculous. Our national health expenditures are already adequate, but the funds are inequitably and inefficiently distributed. We need more government involvement, not less, in providing stewardship over our health care funds.

The two year waiting period is yet one more example of the profound injustices inherent in our fragmented, dysfunctional health care financing system – a unsound and iniquitous system perpetuated by Congress through the enactment of PPACA. All of this evil nonsense would go away if they instead would enact a single payer, improved Medicare for all.

Rampant underinsurance in children

Posted by on Thursday, Aug 26, 2010

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

Underinsurance among Children in the United States

By Michael D. Kogan, Ph.D., Paul W. Newacheck, Dr.P.H., Stephen J. Blumberg, Ph.D., Reem M. Ghandour, Dr.P.H., Gopal K. Singh, Ph.D., Bonnie B. Strickland, Ph.D., and Peter C. van Dyck, M.D., M.P.H.
The New England Journal of Medicine
August 25, 2010



Recent interest in policy regarding children’s health insurance has focused on expanding coverage. Less attention has been devoted to the question of whether insurance sufficiently meets children’s needs.


We estimated underinsurance among U.S. children on the basis of data from the 2007 National Survey of Children’s Health (sample size, 91,642 children) regarding parents’ or guardians’ judgments of whether their children’s insurance covered needed services and providers and reasonably covered costs. Data on adequacy were combined with data on continuity of insurance coverage to classify children as never insured during the past year, sometimes insured during the past year, continuously insured but inadequately covered (i.e., underinsured), and continuously insured and adequately covered. We examined the association between this classification and five overall indicators of health care access and quality: delayed or forgone care, difficulty obtaining needed care from a specialist, no preventive care, no developmental screening at a preventive visit, and care not meeting the criteria of a medical home.


We estimated that in 2007, 11 million children were without health insurance for all or part of the year, and 22.7% of children with continuous insurance coverage — 14.1 million children — were underinsured. Older children, Hispanic children, children in fair or poor health, and children with special health care needs were more likely to be underinsured. As compared with children who were continuously and adequately insured, uninsured and underinsured children were more likely to have problems with health care access and quality.


The number of underinsured children exceeded the number of children without insurance for all or part of the year studied. Access to health care and the quality of health care are suboptimal for uninsured and underinsured children. (Funded by the Health Resources and Services Administration.)

From the Discussion

We found that inadequate coverage of charges was far and away the most common source of underinsurance. We also found that children enrolled in private plans were more than three times as likely as their counterparts in public plans to have inadequate coverage of charges. This dramatic difference is probably the result of federal rules that permit only very limited cost sharing under Medicaid and modest cost sharing under the Children’s Health Insurance Program.


Treating Underinsurance

By James M. Perrin, M.D.
Editorial, The New England Journal of Medicine
August 25, 2010

Health care reform, through the Patient Protection and Affordable Care Act of 2010, may improve access to needed health care services for people with chronic health conditions, including children. Key private insurance reforms, including the removal of provisions imposing lifetime limits or unreasonable limits on annual benefit, the removal of discriminatory premium rates, guaranteed availability of coverage, and dependent coverage for young people up the age of 26 years, may go a long way toward improving coverage for Americans and lowering out-of-pocket costs.

However, the growth in child and adolescent disability, combined with the problem of underinsurance and its effects on the quality of care and access to care, also highlights gaps that will remain in public insurance coverage even after the institution of safeguards affecting private coverage. The basic Medicaid program, unlike Medicare, includes long-term care benefits, such as care at home or in nursing homes and specialized therapies, and it serves as a vital source of financing for nursing home care (about 41% of current total nursing home support). The assumption that most children are healthy, however, has led policymakers to limit long-term care and coverage of a number of other benefits for chronic conditions in other programs for children. SCHIP provided a less generous benefit package — and excluded coverage of services for many chronic conditions (e.g., respiratory therapy, speech and language services, and home-based services) on the basis of the belief that the SCHIP population would not need such benefits. Research conducted since the enactment of SCHIP has indicated that substantial numbers of enrolled children have chronic conditions and could benefit from these services.

The Affordable Care Act calls for a major expansion in Medicaid, especially to provide insurance for a large number of currently uninsured and ineligible adults — that is, those under 65 years of age who have incomes below 133% of the federal poverty line (an estimated 12 million to 17 million people). Here, too, the benefit package will resemble the SCHIP (now CHIP) benefit, with an emphasis on coverage of care for acute conditions and less generous coverage of long-term care. Yet the members of the low-income adult population who will become eligible under this Medicaid expansion include substantial numbers of people with chronic conditions, especially mental health conditions. Here, too, for cases in which long-term care is needed, the Medicaid expansion may leave many newly insured people underinsured. For those instances in which the major epidemics of chronic conditions among adolescents have already begun to affect the young adult population, it is unlikely that many of these young people, even with their new Medicaid coverage, will receive the coverage they need for long-term care.

Being underinsured often results in the same or similar adverse outcomes as not being insured at all. This study demonstrates that the problem of underinsurance amongst children is even more widespread than being uninsured. Does the Patient Protection and Affordable Care Act (PPACA) adequately address this shameful injustice?

PPACA does expand coverage for children through the individual mandate to purchase private insurance, though this study demonstrates that private insurance plans were three times as likely as public insurance plans to have inadequate coverage of charges. Thus PPACA, while reducing the numbers who are uninsured, actually increases the incidence of underinsurance. Most will still be insured through private employer-sponsored plans. For those purchasing their plans through the exchanges, the subsidies will provide some relief but still will not be not adequate to eliminate underinsurance.

PPACA also expands Medicaid, though primarily for adults. Although Medicaid and CHIP cover out-of-pocket expenses better than do the private plans, the editorial by James Perrin explains how lower-income individuals in these programs may still be underinsured. This is particularly true of those with chronic conditions who may need long-term care.

An appropriately designed single payer system eliminates the problem of underinsurance by eliminating significant cost sharing for all appropriate health care services. The efficiencies and policies of the single payer model create enough savings to pay these costs equitably without increasing our national health expenditures.

As long as we remain content with merely tweaking PPACA, we will continue to live in a society that tolerates exposing individuals and families to the hardships created by underinsurance or by having no insurance at all. Certainly we must be a better nation than that.

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