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.
Right Care Series
The Lancet, January 8, 2017
Many countries struggle with the question about sustainability, fairness, and equity of their health systems. With the focus firmly on universal health coverage as a central part to the UN Sustainable Development Goals, there is an opportunity to examine how to achieve optimum access to, and delivery of, health care and services. Underuse and overuse of medical and health services exist side-by-side with poor outcomes for health and wellbeing. This Series of four papers and accompanying comments examines the extent of overuse and underuse worldwide, highlights the drivers of inappropriate care, and provides a framework to begin to address overuse and underuse together to achieve the right care for health and wellbeing. The authors argue that achieving the right care is both an urgent task and an enormous opportunity.
The full “Right Care” series is available for free through this link, though registration is required:
Right Care 1: Evidence for overuse of medical services around the world
By Shannon Brownlee, Kalipso Chalkidou, Jenny Doust, Adam G Elshaug, Paul Glasziou, Iona Heath, Somil Nagpal, Vikas Saini, Divya Srivastava, Kelsey Chalmers, Deborah Korenstein
Overuse, which is defined as the provision of medical services that are more likely to cause harm than good, is a pervasive problem. Direct measurement of overuse through documentation of delivery of inappropriate services is challenging given the difficulty of defining appropriate care for patients with individual preferences and needs; overuse can also be measured indirectly through examination of unwarranted geographical variations in prevalence of procedures and care intensity. Despite the challenges, the high prevalence of overuse is well documented in high-income countries across a wide range of services and is increasingly recognised in low-income countries. Overuse of unneeded services can harm patients physically and psychologically, and can harm health systems by wasting resources and deflecting investments in both public health and social spending, which is known to contribute to health. Although harms from overuse have not been well quantified and trends have not been well described, overuse is likely to be increasing worldwide.
• Overuse is difficult to measure and has not been well characterised
• Most studies of overuse have been done in high-income countries, but there is growing evidence that overuse is a global problem
• Overuse is likely to cause physical, psychological and financial harm to patients
• Overuse deflects resources from public health and other social spending in both low-income and high-income countries
• Overuse occurs across a wide range of medical specialties
“Though the doctors treated him, let his blood, and gave him medications to drink, he nevertheless recovered.” – Leo Tolstoy, War and Peace
Right Care 2: Evidence for underuse of effective medical services around the world
By Paul Glasziou, Sharon Straus, Shannon Brownlee, Lyndal Trevena, Leonila Dans, Gordon Guyatt, Adam G Elshaug, Robert Janett, Vikas Saini
Underuse—the failure to use effective and affordable medical interventions—is common and responsible for substantial suffering, disability, and loss of life worldwide. Underuse occurs at every point along the treatment continuum, from populations lacking access to health care to inadequate supply of medical resources and labour, slow or partial uptake of innovations, and patients not accessing or declining them. The extent of underuse for different interventions varies by country, and is documented in countries of high, middle, and low-income, and across different types of health-care systems, payment models, and health services. Most research into underuse has focused on measuring solutions to the problem, with considerably less attention paid to its global prevalence or its consequences for patients and populations. Although focused effort and resources can overcome specific underuse problems, comparatively little is spent on work to better understand and overcome the barriers to improved uptake of effective interventions, and methods to make them affordable.
• Underuse is responsible for substantial suffering, disability, and loss of life worldwide, in both high-income and low-income countries
• Underuse is prevalent across different types of health-care systems, payment models, and health services
• The causes of underuse are multi-layered:from inadequate access, health system failures, clinicians being unaware or unskilled to provide required interventions, and patients not accessing or declining them
• Underuse occurs alongside overuse, particularly in areas where there is competitive tension between profitable and low-cost interventions
• Policymakers, funders, clinicians, and civil society urgently need to recognise, invest, and resolve the slow uptake of effective, affordable, but non-promoted interventions
Right Care 3: Drivers of poor medical care
By Vikas Saini, Sandra Garcia-Armesto, David Klemperer, Valerie Paris, Adam G Elshaug, Shannon Brownlee, John P A Ioannidis, Elliott S Fisher
The global ubiquity of overuse and underuse of health-care resources and the gravity of resulting harms necessitate an investigation of drivers to inform potential solutions. We describe the network of influences that contribute to poor care and suggest that it is driven by factors that fall into three domains: money and finance; knowledge, bias, and uncertainty; and power and human relationships. In each domain the drivers operate at the global, national, regional, and individual level, and are modulated by the specific contexts within which they act. We discuss in detail drivers of poor care in each domain
The provision of care is initiated by decision making within the doctor–patient relationship, but is substantially influenced by the resources available for health care within the society, its social and political contract, the state of global and local scientific knowledge, the configuration and capacity of the delivery system, and financing mechanisms.8,22,74,214 Achievement of the right care requires an understanding of and attentiveness to all these dimensions in the development of policy choices for promotion of care that is safe, effective, sensitive to personal preferences, and just.
Although no one factor results in the provision of right care, universal health coverage should be recognised as essential at the population level. Each factor can be deemed as equally necessary but equally insufficient by itself. Reducing the role of greed by structuring financial incentives to maximise true clinical benefits and social value is key. Ensuring vigilance against error and bias, broadening research aims, and a focus on meaningful outcomes are key goals in the production of knowledge. Therefore, re-addressing imbalances of knowledge and power, not only within the clinician–patient relationship but also within delivery systems, and more broadly in society, is equally crucial. There are potentially many levers to remedy poor care, but evidence of effectiveness is very modest.
Finally, as biological creatures conscious of our susceptibilty to injury, illness, and death, deep concerns about health are universal. Public support is therefore inevitably susceptible to manipulation for private gain. Active public education, engagement, and empowerment are crucial to ensure that the forces that shape health-care delivery worldwide are truly focused on delivering the right care.
Right Care 4: Levers for addressing medical underuse and overuse: achieving high-value health care
By Adam G Elshaug, Meredith B Rosenthal, John N Lavis, Shannon Brownlee, Harald Schmidt, Somil Nagpal, Peter Littlejohns, Divya Srivastava, Sean Tunis, Vikas Sain
The preceding papers in this Series have outlined how underuse and overuse of health-care services occur within a complex system of health-care production, with a multiplicity of causes. Because poor care is ubiquitous and has considerable consequences for the health and wellbeing of billions of people around the world, remedying this problem is a morally and politically urgent task. Universal health coverage is a key step towards achieving the right care. Therefore, full consideration of potential levers of change must include an upstream perspective—ie, an understanding of the system-level factors that drive overuse and underuse, as well as the various incentives at work during a clinical encounter. One example of a system-level factor is the allocation of resources (eg, hospital beds and clinicians) to meet the needs of a local population to minimise underuse or overuse. Another example is priority setting using tools such as health technology assessment to guide the optimum diffusion of safe, effective, and cost-effective health-care services. In this Series paper we investigate a range of levers for eliminating medical underuse and overuse. Some levers could operate effectively (and be politically viable) across many different health and political systems (eg, increase patient activation with decision support) whereas other levers must be tailored to local contexts (eg, basing coverage decisions on a particular cost-effectiveness ratio). Ideally, policies must move beyond the purely incremental; that is, policies that merely tinker at the policy edges after underuse or overuse arises. In this regard, efforts to increase public awareness, mobilisation, and empowerment hold promise as universal methods to reset all other contexts and thereby enhance all other efforts to promote the right care.
The modern history of health care is littered with policy and practice inaction in the face of inappropriate care, often justified by an absence of evidence or uncertainty about what might result—Machiavelli’s “new order of things”. This lack of action should no longer be acceptable. Although the scale of the problem is vast and complex, a range of potentially effective remedies are available, with many more needed. Evidence-based medicine, HTA (health technology assessment), shared decision making, and countless other movements have surely nudged health systems to a point whereby we must ultimately acknowledge that a decision not to act is still a decision, and one with implications for people’s health. As efforts to improve the delivery of care continue worldwide, we must recognise that if the objective is to improve health, delivery systems need to be properly scaled and adapted to local needs and socioeconomic conditions to be maximally effective. Furthermore, delivery system leaders should remain humble about their systems’ contributions to health and should be unburdened from the task of substituting less effective medical spending for social spending. Transitions from the norm invariably cause conflict, but if efforts to achieve the right care are able to capture the full opportunity in front of us, the benefits to the wellbeing of patients, professionals, and the public as a whole are too great to condone inaction.
Considering the amount of money we spend on health care in the United States, we should be making special efforts to see that we spend it right. This Lancet series, “Right Care,” is helpful because it defines for us where we are not providing enough care (underuse), leaving too many with unmet health care needs, and where we are providing excess care (overuse), wasting resources that could be used elsewhere, not to mention that excessive care is sometimes harmful.
Although many factors are involved in our misuse of health care, the financing system plays a significant role. We leave far too many people uninsured and underinsured which creates financial barriers to essential health care services. We have a maldistribution of our health care resources which impairs access to care in underserved areas.
By using a finance system that is based on business principles instead of public service, we are using financial disincentives, such as high deductibles, supposedly to discourage overuse but which, in fact, inappropriately incentivizes underuse. A well designed financing system, such as single payer, should go a long way toward addressing the problem of underuse, though other social factors would have to be addressed as well.
Overuse is a more difficult problem. Most health care is in a gray area. Obviously, expensive high-tech care that provides no benefit and is harmful is overuse and should be ferreted out of the system. But when high-tech care is beneficial it may be that it is no more beneficial than less expensive traditional care, but there inevitably would be disagreement on that, even after comparative effectiveness studies are completed. Many treatment regimens have potential adverse consequences, but that is often difficult to balance against the benefits that the patient may experience. Some low cost diagnostic and therapeutic interventions may lack scientific validation but if the interventions are essentially harmless and the patient is improved if for no other reason than reassurance, would this be considered overuse of our health care system? Although some might consider gray area medicine to be overuse, it would be very difficult to recover the costs of this care.
The “Right Care“ series addresses much more than the financing systems of health care, so it would be worthwhile to set time aside to read the articles (4 papers, 3 comments, and 1 perspective). It is imperative that we make “right care” a goal of reform.
But we really do need to get the financing system right. If we don’t, we’ll continue to see money wasted in more affluent areas where there is an excess capacity in high-tech care, and we’ll continue to see deficiencies in care for those who are not well served by our fragmented, dysfunctional system, market-based system.
Once we establish a publicly-financed and publicly-administered financing system, then we can work to improve the distribution and allocation of our resources to reduce waste while being sure that health care is there for people when they need it.
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.
Remarks by the President in Vox Live Interview
By Ezra Klein and Sarah Kliff of Vox
The White House, Office of the Press Secretary, January 6, 2017
Excerpts of the President’s comments:
“…the challenge of getting it passed was always the fact that, unlike other advanced countries, we didn’t start with a system in which everybody was covered, and we have a very complicated marketplace, and we have third-party insurers. And what that meant was that even after we got the law passed anything that dissatisfied people about the health care system could be attributed to — quote, unquote — “Obamacare,” even if it had nothing to do with Obamacare.”
“…whenever you look at polls that say 40-something percent are supportive of the law and 40-something percent are dissatisfied — in the dissatisfied column are a whole bunch of Bernie Sanders supporters who wanted a single-payer plan. (Laughter.) And so the problem is not that they think Obamacare is a failure; the problem is that they don’t think it went far enough and that it left too many people still uncovered, that the subsidies that people were getting weren’t as rich as they should have been, that there’s a way of dealing with prescription drug makers in a way that drives down those costs.”
“If it works, I’m for it. If something can cover all Americans, make sure that if they have a preexisting condition they can still get coverage, make sure that prescription drugs are affordable, encourage preventive measures to keep people healthy, that makes sure that in rural communities people have access to substance abuse care or mental health care, that Medicare and Medicaid continue to function effectively — if you can do all that cheaper than we talked about, cheaper than Obamacare achieves and with better quality and it’s just terrific, I’m for it.”
“In fact, if you look at how this law evolved — and I’ve said this publicly before, if I was starting from scratch, I probably would have supported a single-payer system because it’s just easier for people to understand and manage. And that’s essentially what Medicare is, is a single-payer system for people of a certain age. And people are very satisfied with it and it’s not that complicated to understand or to access services. But that wasn’t available; we weren’t starting from scratch.”
“From the very start, in the earliest negotiations in 2009, 2010, I made clear to Republicans that, if they had ideas that they could show would work better than the ideas that we had thought of, I would be happy to incorporate them into the law. And rather than offer ideas, what we got was a big no, we just don’t want to do this.”
“After the law passed, for the last six, seven years, there has been the argument that we can provide a great replacement that will be much better for everybody than what the Affordable Care Act is providing. And yet, over the last six, seven years, there has been no actual replacement law that any credible health care policy experts have said would work better. In fact, many of them would result in millions of people losing coverage and the coverage being worse for those who kept it.
“And so now is the time when Republicans, I think, have to go ahead and show their cards. If, in fact, they have a program that would genuinely work better and they want to call it whatever they want — they can call it Trumpcare, they can call it McConnellcare, or Ryancare. If it actually works, I will be the first one to say, great, you should have told me that back in 2009. I asked. (Laughter.) I suspect that will not happen.”
“I am saying to every Republican right now, if you, in fact, can put a plan together that is demonstrably better than what Obamacare is doing, I will publicly support repealing Obamacare and replacing it with your plan. But I want to see it first. (Applause.) I want to see it first.”
“This idea that somehow, oh, this is about Obama preserving his legacy — keep in mind, I’m not the one who named it Obamacare. (Laughter.) They were the ones who named it Obamacare, because what they wanted to do was personalize this and feed on antipathy towards me in their party as an organizing tool, as politics.
“But I don’t have a pride of authorship on this thing. If they can come up with something better, I’m for it. But you have to show — and I would advise every Democrat to be for it — but you have to show that it’s better. And that’s not too much to ask.”
“…the answer is the Republicans, yes, will own the problems with the health care system if they choose to repeal something that is providing health insurance to a lot of people, and providing benefits to every American who has health insurance even if they’re getting it through the job, and they haven’t shown us what it is that they’re going to do. Then they do own it. Because that is irresponsible. And even members of their own party, even those who are opposed to me, have said that that is an irresponsible thing to do.”
“So if you look at the things that people are frustrated about with Obamacare, the Affordable Care Act, the big things are the subsidies aren’t as high as they’d like and they don’t have as many options as they’d like. And I’m happy to provide both those things. I’d sign on to a Republican plan that said we’re going to give more subsidies to people to make it even cheaper, and we’re going to have a public option where there isn’t an option.
“Here’s the problem. I don’t think that’s the thing that they want — (laughter) — to do.“
“And my advice to the President-elect — in fact, we talked about this when I met with him for an hour and a half right after he got elected — I said make your team and make the Republican members of Congress come up with things that they can show will actually make this work better for people. And if they’re convincing, I think you would find that there are a lot of Democrats out there — including me — that would be prepared to support it. But so far, at least, that’s not what’s happened.”
“Well, look, this is the irony of this whole debate, is the things that people are most dissatisfied with about Obamacare, about the Affordable Care Act, are things that essentially in other countries are solved by more government control, not less. (Laughter.) And so Republicans are pointing at these things to stir up dissatisfaction, but when it comes to, all right, what’s the solution for it, their answer is less government regulation and letting folks charge even more and doing whatever they want and letting the marketplace work its will.”
“If we want to control prices for consumers more, then the marketplace by itself will not do that. And the reason is because health care is not exactly like other products. It’s not like buying a flat-screen TV. If you’re sick, or if your kid is sick, most of the time you’re not in a position to negotiate right there and then. You can’t walk out of the store and say, well, I’m going to see if I can get a better deal.”
“The problem is, is that that’s not what’s being proposed by Mitch McConnell, the senator from Kentucky. Instead what he’s proposing, I gather, is you’re going to repeal the law, then you’re going to come up with something, except you will have taken away all the — the way we pay for the subsidies for working people is we’re taxing wealthier folks at a little bit higher. So he wants to cut those taxes, and that money would be gone right away. And then he’s going to promise you, or those people who you’ve been signing up, better health care, except there’s not going to be any money to pay for it. And nobody has explained to me yet how that’s going to work.”
“…then at the very least you should be putting pressure on your members of Congress to say, show us exactly what the deal is going to be for us before you take away the deal that we got.”
“The way this process is going to work, there’s this rushed vote that’s taking place this week, next week to — quote, unquote — “repeal Obamacare.” But really all that is, is it’s a resolution that is then instructing these committees in Congress to start actually drafting a law that specifically would say what’s being repealed and what’s not. Then, after that, they’d have to make a decision about what’s going to replace it and how long is that going to take. And that stretches the process out further.
“And so I think, whether you originally supported Obamacare or you didn’t, whether you like me or you don’t, the one thing I would just ask all the American people to do is adopt the slogan of the great state of Missouri — “Show me.” (Laughter.) Show me. Do not rush this process.
“And to Republicans, I would say: What are you scared of? If you are absolutely convinced, as you have been adamant about for the last seven years, that you can come up with something better, go ahead and come up with it. And I’ll even cut you some slack for the fact that you’ve been saying you can come up with something better for seven years and I’ve never seen it. (Laughter.) But we’ll restart the clock.”
Video (1 hour, 9 minutes):
What is the point of today’s message? Virtually everyone wants affordable access to health care, for themselves at least. Most want a better system than what we have under the Affordable Care Act. But the nation is divided as to whether ACA needs to be repealed prior to improving the functioning of our health care financing system.
So the point is that there is broad agreement that we want the system improved, but the Republicans, who are in control, are hamstrung by their anti-government ideology which prevents them from offering the government solutions that we would need that would actually be effective in improving the system.
Repealing ACA would further impair the functioning of our system, so the Republicans would have to introduce effective policies that would more than compensate for the deficiencies that would be created by repeal. Almost any piecemeal solution would require greater regulation and more government spending, anathema to the Republicans. Suggestions to date coming from their camp would leave us worse off than what we currently have. It is no wonder that they refuse to tell us what their replacement proposal would be.
If they really do want to improve the system, and they say they do, then they have two choices. Either provide beneficial tweaks to the current system, which will cost more and require greater regulation, yet fall far short of reform goals, or replace the current system with a single payer national health program – an improved Medicare for all. The latter would greatly improve the financing of health care, ensuring true universality, improved access, greater choice in care, and affordability for each and every individual. And we could do that without increasing spending above our current level.
The Republicans have an opportunity to provide us with a replacement program that would be vastly superior to building on our current dysfunctional system. Both President Obama and President-elect Trump have acknowledged the clear superiority of a single payer system. Most progressives, a majority of moderates and a plurality of conservatives agree. Now all the Republicans need to do is show us.
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.
Repealing the ACA without a Replacement — The Risks to American Health Care
By Barack H. Obama, J.D.
The New England Journal of Medicine, January 6, 2017
Health care policy often shifts when the country’s leadership changes. That was true when I took office, and it will likely be true with President-elect Donald Trump. I am proud that my administration’s work, through the Affordable Care Act (ACA) and other policies, helped millions more Americans know the security of health care in a system that is more effective and efficient. At the same time, there is more work to do to ensure that all Americans have access to high-quality, affordable health care. What the past 8 years have taught us is that health care reform requires an evidence-based, careful approach, driven by what is best for the American people. That is why Republicans’ plan to repeal the ACA with no plan to replace and improve it is so reckless. Rather than jeopardize financial security and access to care for tens of millions of Americans, policymakers should develop a plan to build on what works before they unravel what is in place.
Thanks to the ACA, a larger share of Americans have health insurance than ever before. Increased coverage is translating into improved access to medical care — as well as greater financial security and better health. Meanwhile, the vast majority of Americans still get their health care through sources that predate the law, such as a job or Medicare, and are benefiting from improved consumer protections, such as free preventive services.
We have also made progress in how we pay for health care, including rewarding providers who deliver high-quality care rather than just a high quantity of care. These and other reforms in the ACA have helped slow health care cost growth to a fraction of historical rates while improving quality for patients. This includes better-quality and lower-cost care for tens of millions of seniors, individuals with disabilities, and low-income families covered by Medicare, Medicaid, and the Children’s Health Insurance Program. And these benefits will grow in the years to come.
That being said, I am the first to say we can make improvements. Informed by the lessons we’ve learned during my presidency, I have put forward ideas in my budgets and a July 2016 article to address ongoing challenges — such as a lack of choice in some health insurance markets, premiums that remain unaffordable for some families, and high prescription-drug costs. For example, allowing Medicare to negotiate drug prices could both reduce seniors’ spending and give private payers greater leverage. And I have always welcomed others’ ideas that meet the test of making the health system better. But persistent partisan resistance to the ACA has made small as well as significant improvements extremely difficult.
Now, Republican congressional leaders say they will repeal the ACA early this year, with a promise to replace it in subsequent legislation — which, if patterned after House Speaker Paul Ryan’s ideas, would be partly paid for by capping Medicare and Medicaid spending. They have yet to introduce that “replacement bill,” hold a hearing on it, or produce a cost analysis — let alone engage in the more than a year of public debate that preceded passage of the ACA. Instead, they say that such a debate will occur after the ACA is repealed. They claim that a 2- or 3-year delay will be sufficient to develop, pass, and implement a replacement bill.
This approach of “repeal first and replace later” is, simply put, irresponsible — and could slowly bleed the health care system that all of us depend on. (And, though not my focus here, executive actions could have similar consequential negative effects on our health system.) If a repeal with a delay is enacted, the health care system will be standing on the edge of a cliff, resulting in uncertainty and, in some cases, harm beginning immediately. Insurance companies may not want to participate in the Health Insurance Marketplace in 2018 or may significantly increase prices to prepare for changes in the next year or two, partly to try to avoid the blame for any change that is unpopular. Physician practices may stop investing in new approaches to care coordination if Medicare’s Innovation Center is eliminated. Hospitals may have to cut back services and jobs in the short run in anticipation of the surge in uncompensated care that will result from rolling back the Medicaid expansion. Employers may have to reduce raises or delay hiring to plan for faster growth in health care costs without the current law’s cost-saving incentives. And people with preexisting conditions may fear losing lifesaving health care that may no longer be affordable or accessible.
Furthermore, there is no guarantee of getting a second vote to avoid such a cliff, especially on something as difficult as comprehensive health care reform. Put aside the scope of health care reform — the federal health care budget is 50% bigger than that of the Department of Defense. Put aside how it personally touches every single American — practically every week, I get letters from people passionately sharing how the ACA is working for them and about how we can make it better. “Repeal and replace” is a deceptively catchy phrase — the truth is that health care reform is complex, with many interlocking pieces, so that undoing some of it may undo all of it.
Take, for example, preexisting conditions. For the first time, because of the ACA, people with preexisting conditions cannot be denied coverage, denied benefits, or charged exorbitant rates. I take my successor at his word: he wants to maintain protections for the 133 million Americans with preexisting conditions. Yet Republicans in Congress want to repeal the individual-responsibility portion of the law. I was initially against this Republican idea, but we learned from Massachusetts that individual responsibility, alongside financial assistance, is the only proven way to provide affordable, private, individual insurance to every American. Maintaining protections for people with preexisting conditions without requiring individual responsibility would cost millions of Americans their coverage and cause dramatic premium increases for millions more. This is just one of the many complex trade-offs in health care reform.
Given that Republicans have yet to craft a replacement plan, and that unforeseen events might overtake their planned agenda, there might never be a second vote on a plan to replace the ACA if it is repealed. And if a second vote does not happen, tens of millions of Americans will be harmed. A recent Urban Institute analysis estimated that a likely repeal bill would not only reverse recent gains in insurance coverage, but leave us with more uninsured and uncompensated care than when we started.
Put simply, all our gains are at stake if Congress takes up repealing the health law without an alternative that covers more Americans, improves quality, and makes health care more affordable. That move takes away the opportunity to build on what works and fix what does not. It adds uncertainty to lives of patients, the work of their doctors, and the hospitals and health systems that care for them. And it jeopardizes the improvements in health care that millions of Americans now enjoy.
Congress can take a responsible, bipartisan approach to improving the health care system. This was how we overhauled Medicare’s flawed physician payment system less than 2 years ago. I will applaud legislation that improves Americans’ care, but Republicans should identify improvements and explain their plan from the start — they owe the American people nothing less.
Health care reform isn’t about a nameless, faceless “system.” It’s about the millions of lives at stake — from the cancer survivor who can now take a new job without fear of losing his insurance, to the young person who can stay on her parents’ insurance after college, to the countless Americans who now live healthier lives thanks to the law’s protections. Policymakers should therefore abide by the physician’s oath: “first, do no harm.”
The negative consequences of repealing the Affordable Care Act without replacing it with measures that address some of the problems that ACA was designed to fix have been well publicized. President Obama is right to warn us about repealing ACA without replacing it. But the full story is more complex.
Although the Republicans are moving ahead with including repeal of ACA in the budget reconciliation process, we do not have any details about what is being repealed nor when the repeal would actually take place, if ever. And the Republicans have no clue as to what their replacement would be, especially since it is obvious that their favored proposals such as health savings accounts and selling insurance across state borders would not effectively address the deficiencies that would be recreated by repeal.
Of greater concern, President Obama’s warning about repealing without replacement misses the bigger picture. ACA only tweaked our dysfunctional financing system when we needed comprehensive reform.
Obama touts ACA measures that supposedly saved money by replacing quantity with quality, but, in fact, such measures have not had even a negligible impact on overall cost containment. What they have done is to increase administrative complexity and waste, resulting in an epidemic of physician burnout.
He touts the increase in the numbers of individuals insured, but ignores the deterioration in quality of the coverage through the increase in financial barriers to care, especially high deductibles, and the impaired access that is resulting from expanded use of ever narrower provider networks.
He expresses regret that guaranteeing coverage to individuals with preexisting disorders requires a very unpopular individual mandate to purchase insurance (to prevent adverse selection), and yet he remains silent on the fact that social insurance programs such as Medicare are extremely popular and they rely on automatic coverage instead on an individual decision on whether or not to comply with a mandate.
He repeats the tag line that he used when he rejected single payer reform: we need to “build on what works and fix what does not.” Yet ACA patched only a few problems but did not begin to address the major deficiencies of our health care financing infrastructure, especially those resulting in profound administrative waste. ACA provided tweaks when we needed a new infrastructure.
And then – Primum non nocere – First do no harm. A system in which people are suffering, going broke, and sometimes even dying, is a system which is doing great harm. Reform should not be slogan driven. It should be built on what really does work to actually reduce harm. A single payer national health program – improved Medicare for all – does precisely that.
By Drew Altman
The New York Times, January 5, 2017
This week Republicans in Congress began their effort to repeal and potentially replace the Affordable Care Act. But after listening to working-class supporters of Donald J. Trump — people who are enrolled in the very health care marketplaces created by the law — one comes away feeling that the Washington debate is sadly disconnected from the concerns of working people.
Those voters have been disappointed by Obamacare, but they could be even more disappointed by Republican alternatives to replace it. They have no strong ideological views about repealing and replacing the Affordable Care Act, or future directions for health policy. What they want are pragmatic solutions to their insurance problems. The very last thing they want is higher out-of-pocket costs.
The Kaiser Foundation organized six focus groups in the Rust Belt areas — three with Trump voters who are enrolled in the Affordable Care Act marketplaces, and three with Trump voters receiving Medicaid. The sessions, with eight to 10 men and women each, were held in late December in Columbus, Ohio, Grand Rapids, Mich., and New Cumberland, Pa. Though the participants did not agree on everything, they expressed remarkably similar opinions on many health care questions. They were not, by and large, angry about their health care; they were simply afraid they will be unable to afford coverage for themselves and their families. They trusted Mr. Trump to do the right thing but were quick to say that they didn’t really know what he would do, and were worried about what would come next.
They spoke anxiously about rising premiums, deductibles, copays and drug costs. They were especially upset by surprise bills for services they believed were covered. They said their coverage was hopelessly complex. Those with marketplace insurance — for which they were eligible for subsidies — saw Medicaid as a much better deal than their insurance and were resentful that people with incomes lower than theirs could get it. They expressed animosity for drug and insurance companies, and sounded as much like Bernie Sanders supporters as Trump voters.
The Trump voters in our focus groups were representative of people who had not fared as well. Several described their frustration with being forced to change plans annually to keep premiums down, losing their doctors in the process. But asked about policies found in several Republican plans to replace the Affordable Care Act — including a tax credit to help defray the cost of premiums, a tax-preferred savings account and a large deductible typical of catastrophic coverage — several of these Trump voters recoiled, calling such proposals “not insurance at all.” One of those plans has been proposed by Representative Tom Price, Mr. Trump’s nominee to be secretary of Health and Human Services. These voters said they did not understand health savings accounts and displayed skepticism about the concept.
When told Mr. Trump might embrace a plan that included these elements, and particularly very high deductibles, they expressed disbelief. They were also worried about what they called “chaos” if there was a gap between repealing and replacing Obamacare. But most did not think that, as one participant put it, “a smart businessman like Trump would let that happen.”
There was one thing many said they liked about the pre-Affordable Care Act insurance market: their ability to buy lower-cost plans that fit their needs, even if it meant that less healthy people had to pay more. They were unmoved by the principle of risk-sharing, and trusted that Mr. Trump would find a way to protect people with pre-existing medical conditions without a mandate, which most viewed as “un-American.”
If these Trump voters could write a health plan, it would, many said, focus on keeping their out-of-pocket costs low, control drug prices and improve access to cheaper drugs. It would also address consumer issues many had complained about loudly, including eliminating surprise medical bills for out-of-network care, assuring the adequacy of provider networks and making their insurance much more understandable.
Republican health reform plans would probably increase deductibles, not lower them. And providing the more generous subsidies for premiums and deductibles that these voters want would require higher taxes, something the Republican Congress seems disinclined to accept.
In general, the focus among congressional Republicans has been on repealing the Affordable Care Act. There has been little discussion of the priorities favored by the Trump voters who spoke to us. But once a Republican replacement plan becomes real, these working-class voters, frustrated with their current coverage, will want to know one thing: how that plan fixes their health insurance problems. And they will not be happy if they are asked to pay even more for their health care.
This survey of focus groups composed of Trump supporters confirms the anecdotal reports that many of them have been disappointed by Obamacare, but they want health insurance that is affordable and that works. They believe that President Trump will do the right thing even though they have no idea what that is.
Although they have a poor understanding of the complexities of insurance, what they do want is to keep their out-of-pocket costs low, control drug prices, improve access to cheaper drugs, eliminate surprise medical bills for out-of-network care, adequate provider networks, and make their insurance more understandable. What they seem to want are the policies of a single payer national health program. What they certainly would not want would be any of the replacement proposals of the Republican party if they understood how much worse affordability and access would be.
What we need are the replacement bills so that we can explain the damage they would do, but it appears that those bills are not forthcoming.
What we will probably see is a resolution, but not a requirement, to repeal features of Obamacare at some time in the distant future. The Republicans may then introduce replacement bills which they will tout as reform but will actually advance intolerable changes (privatizing Medicare, slashing Medicaid funding through block grants, establishing high risk pools without adequately funding them, etc.) that the Democrats will have to filibuster. Then the Republicans will be able to claim that they tried to replace Obamacare, but the Democrats blocked their reforms. They can then walk away, hoping everyone will have forgotten their resolution to repeal Obamacare.
The problems that people are blaming on Obamacare will still be there, even though they are mostly problems inherent in the highly flawed, fragmented financing infrastructure that was only minimally patched by Obamacare. When they see that the “repeal and replace” rhetoric was all hot air, they may be ready to accept an insurance program that they can understand and that will meet their needs – a single payer, improved Medicare for all.
Health Care in the United States: A Right or a Privilege
By Howard Bauchner, M.D., Editor in Chief, JAMA
JAMA, Editorial, January 3, 2017
The United States is about to embark on a great challenge: how to modify the current system of providing health care coverage for its citizens. However, the fundamental underlying question remains unanswered and was rarely mentioned during the past 8 years—Is health care coverage a basic right or a privilege (regardless of how that coverage is provided or who provides it)? Until that question is debated and answered, it may not be possible to reach consensus on the ultimate goal of further health care reform. Without agreeing to the goal, measuring success will be nearly impossible.
The months and years ahead are filled with uncertainty regarding how the US health care system will evolve.
The ACA needs to be modified, even though it has accomplished a great deal, principally by expanding the number of newly insured individuals. However, much remains to be accomplished, including how to ensure high-quality, affordable health insurance for all residents and how to control the continual increases in annual health care spending, now exceeding $3 trillion.
Sorting out the most effective way to provide health care coverage in the United States is a work in progress and will require careful assessment and likely repeated changes. If the goals of further health care reform are clear and are measured but are not reached, then it will be necessary to return to previous discussions that have included a public option, a single-payer system, lowering the eligibility for Medicare, or further privatization of the health care system.
I hope that all physicians, including those who are members of Congress, other health care professionals, and professional societies would speak with a single voice and say that health care is a basic right for every person, and not a privilege to be available and affordable only for a majority. The solution for how to achieve health care coverage for all may be uniquely American, but it is an exceedingly important and worthy goal, emblematic of a fair and just society.
JAMA is granting free access to the full editorial at this link:
Did you get that? Howard Bauchner, the Editor in Chief of JAMA – the Journal of the American Medical Association – says that “all physicians, including those who are members of Congress, other health care professionals, and professional societies (should) speak with a single voice and say that health care is a basic right for every person, and not a privilege to be available and affordable only for a majority.”
If we get this one right, improved Medicare for all follows.
House Republicans Back Down on Bid to Gut Ethics Office
By Eric Lipton and Matt Flegenheimer
The New York Times, January 3, 2017
House Republicans, facing a storm of bipartisan criticism, including from President-elect Donald J. Trump, moved early Tuesday afternoon to reverse their plan to kill the Office of Congressional Ethics. It was an embarrassing turnabout on the first day of business for the new Congress, a day when party leaders were hoping for a show of force to reverse policies of the Obama administration.
The reversal came less than 24 hours after House Republicans, meeting in a secret session, voted, over the objections of Speaker Paul D. Ryan, to eliminate the independent ethics office.
It is astonishing that a new Congress that has promised to reduce the government’s support of some of the most important social programs in our nation took as their first action, behind closed doors, approval of “their plan to kill the Office of Congressional Ethics.”
Although they rejected the advice of Speaker Paul Ryan not to do this, President-elect Trump also expressed his view through a tweet that this should not have been “their number one act and priority.” We can only speculate as to whether Trump and Ryan were truly concerned about preserving the function of the ethics committee or if it was just that they were concerned about the negative public image that might ensue. It did not take long for the expression of public outrage to convince them that they needed to reverse this action.
The damage is done. The Congressional majority has made a clear statement that they will not let ethics interfere with their attack on our social programs, beginning with the Affordable Care Act. It will be our duty to continue to express our outrage at the unethical implications of making health care less and less affordable for an ever growing number of residents, not to mention all of the other social injustices they intend to advance through their attack on existing programs.
Voters indicated that they wanted to clean up Congress. They must be perplexed that the first action was to try to throw Congressional ethics out the window. It should be a clarion call to all of us to watch very closely every other policy that this Congress attempts to enact.
Donald Trump has blatantly disregarded his supposedly “populist” campaign and promises to “drain the swamp” of money in politics. He has shown himself as a self-promoter, con man, and the most unpopular presidential candidate in modern political history. According to Wall Street Journal/NBC News polls, he was viewed positively by just 29 percent of voters in mid-October and only 41 percent in mid-December after the election. (1)
Trump’s Cabinet picks give us alarm that his administration will be deeply connected with Wall Street and big money. As of December 22, his 17 appointees have more wealth than the bottom 43 million American households combined, according to the End Citizens United Action Network. Examples include Steve Bannon, his chief strategist, former chairman of the far-right media group Breitbart and Goldman Sachs veteran, and Gary Cohn, Director of the National Economic Council, previously second in command at Goldman Sachs. Four of his picks are billionaires, while most have donated millions to his campaign and helped to finance super PACs on his behalf. (2)
Trump’s political appointees further show how unlikely it is that any swamp will be drained—instead, we can expect quite the opposite, and that doesn’t bode well for health care. Rep. Tom Price (R-GA), an orthopedic surgeon and incoming appointee to head the Department of Health and Human Services (DHHS), has long called for repeal of the ACA, privatization of Medicare, sharp cuts in Medicaid funding, and defunding Planned Parenthood. He has claimed that every woman in the country has access to affordable contraception. Over the last two years, he has traded more than $300,000 in shares of health-related companies while sponsoring and advocating legislation that could affect those companies’ stocks, a possible violation of the Stop Trading on Congressional Knowledge (3) In his new role, he will have oversight of Medicare, Medicaid, the FDA, the Centers for Disease Control and Prevention, and the NIH. Andrew Puzder, Trump’s pick for Secretary of Labor, CEO of the parent company of fast-food chains, lobbyist and top Trump campaign donor, has tried for years to overturn Roe v. Wade. (4) Billionaire investor Carl Icahn is expected to be named special advisor to the president on overhauling federal regulations. (5)
All this shouldn’t come as a surprise, given the long history of big money influencing health care and policy. Noam Chomsky, professor of linguistics at the Massachusetts Institute of Technology and a leading voice of conscience, brings us this historical perspective:
Beginning in the 1970s, partly because of the economic crisis that erupted in the early years of that decade and the decline in the rate of profit, but also because of the view that democracy had become too widespread, an enormous, concentrated, coordinate business offensive was begun to try to beat back the egalitarian efforts of the post-war era, which only intensified as time went on. The economy shifted itself to financialization. Financial institutions expanded enormously. By 2007, right before the crash for which they had considerable responsibility, financial institutions accounted for
a stunning 40 percent of corporate profit. A vicious cycle between concentrated capital and politics accelerated, while increasingly wealth concentrated in the financial sector. Politicians, faced with the increasing costs of campaigns, were driven ever deeper into the pockets of wealthy backers. And politicians rewarded them by pushing policies favorable to Wall Street and other powerful business interests. Throughout this period, we have a renewed form of class warfare directed by the business class against the working people and the poor, along with a conscious attempt to roll back the gains of the previous decades. (6)
In the run-up in 2008 and 2009 to the passage of the ACA in 2010, the Center for Congressional and Presidential Studies at American University estimated that there were about 168 influence peddlers, most representing big corporate stakeholders, for every member of Congress. (7) As Bill Allison, senior fellow at the Sunshine Foundation, said at the time about the ACA:
When you have a big piece of legislation like this, it’s like ringing the dinner bell for K Street . . . There’s a lot of money at stake and there are a lot of special interests who don’t want their ox gored. (8)
In a recent blog, I described the problems involved in whatever the Republicans do about health care in the early days and weeks of the incoming Trump administration. Whatever they do, today’s government run by billionaires poses an increasingly dire threat to the health care of ordinary Americans. Health care is still being viewed as a largely for-profit enterprise oriented towards financial returns to corporate stakeholders, not the needs and best interests of patients and families. The stock market is surging as Wall Street learns more about how president-elect Trump is likely to govern. According to the Tax Policy Center more than one half of Trump’s tax cuts will be to the richest 1% of the population, with the richest 0.1% receiving tax cuts averaging almost $1.5 million per year. (9)
Ignored by the current debate and the mainstream media, what should be standing in plain sight is a more efficient and affordable system for universal coverage in the public interest—single-payer national health insurance. Instead we are being led by politicians beholden to big money serving the greed of today’s medical-industrial complex. Ironically, almost two-thirds of national health care spending is already financed by taxpayers, much more than what would be needed to provide full coverage for all necessary care for all Americans. Whatever comes next in this new Republican administration—whether the ACA (with or without modification) or a more fully privatized GOP “system”—many millions of Americans will have little or no access to affordable health care. We should be able to do better in this “democratic” society, as other advanced industrial countries around the world have done for many years.
John Geyman, M.D. is the author of The Human Face of ObamaCare: Promises vs. Reality and What Comes Next and How Obamacare is Unsustainable: Why We Need a Single-Payer Solution For All Americans
Dear Quote of the Day list members,
Your email inboxes are no doubt inundated with end-of-year requests for donations “to keep this publication going” or whatever.
This is not a request to donate to Quote of the Day, but it is something much more important.
Regarding the Quote of the Day, I self-fund my activities and am able to do so quite comfortably. I do not receive funds from PNHP, so no dues are diverted to the qotd messages. In my role as senior health policy fellow of PNHP I serve as a volunteer, receiving no pay nor benefits. In fact, I am a monthly contributor to PNHP instead.
So what am I asking that is so important?
At this time when threats to our already inadequate health care system are intensifying we need an increase in people power to help carry to the nation the message of health care justice for all through a single payer national health program – an improved Medicare for all.
A great vehicle that supports the movement is membership in Physicians for a National Health Program. We need to achieve a critical mass of activists and supporters. Although membership is predominantly composed of physicians, medical students and other health care professionals, we also include activists and others who are dedicated to health care justice through single payer reform.
* If you are not a member, please consider joining (click here to join).
* If you are a member but have not recently renewed your membership, please consider doing so now (click here to renew).
* If you are a medical or other health professional student, membership is free (click here to join).
* Considering our national presence, PNHP operates on a remarkably spartan budget funded by dues and individual contributions, thus donations by those who can afford them are greatly appreciated and are put to good use (Contributions to PNHP are tax deductible under section 501(c)(3) of the IRS code – click here to donate).
This is not a message from PNHP but it is simply a personal request, from me to each of you, to join or renew your support for a cause to which I have devoted the remaining productive years of my life.
Peace, love and good health for all,
He’d take single payer health care over Partners
By Samuel Shem, M.D.
Boston Globe, Letters, December 29, 2016
RE “FIRST, do no harm” by David Torchiana, president and CEO of Partners HealthCare (Opinion, Dec. 19):
In understanding Partners, a touch of history may be relevant. There never was a need for a “Partners.” It was created to make an alliance between Massachusetts General Hospital and Brigham and Women’s Hospital — but also to make money.
American health care at first was a two-party system: doctor and patient. The next step was a third party: private insurance. Partners was born as a new third party, wedged between doctor-patient and private insurance (which became “a new 4th party”). Partners became a middleman and fee broker between doctor-patient-hospital and private insurance.
No wonder this added corporate giant added to health care costs, and has recently suffered record losses from ventures such as the installation of a new electronic medical records system and from running its own insurance company, Neighborhood Health Plan.
There’s no need for a “Partners.” The need, and solution, is for a national single-payer Medicare for all. Many, if not most, doctors want it. And ask any of us Medicare insurance patients: It’s cheap, and it works.
The writer is the author of the novel “The House of God” and is professor of medicine in medical humanities and psychiatry at New York University Medical School.
In health care, those receiving the funds will design their systems to maximize revenues. The financing system can be designed to optimize the private market business model, as it is now, or it can be optimized to obtain maximum value for patient care, as it would be under a well-designed single payer national health program – an improved Medicare for all. Samuel Shem describes it as it should be.
By Jeff Bendix, Charlotte Huff, Rose Schneider Krivich, Chris Mazzolini, Mary Pratt, Todd Shryock
Medical Economics, December 25, 2016
For the fourth consecutive year, Medical Economics reveals its list of obstacles physicians will face in the coming year and, more importantly, how to overcome them. For this latest presentation, we asked readers to tell us what challenges they face each day and where they needed solutions.
Here are their responses, starting with the biggest challenge of the coming year.
Challenge 1: MACRA
Healthcare reimbursements are migrating from volume to value. MACRA will most likely serve as the road map for other payers, so get used to the reporting requirements.
The law directs physicians to choose one of two reimbursement paths—advanced alternative payment models (APMs) or the Merit-based Incentive Payment System (MIPS).
Challenge 2: Prior authorizations
Prior authorization requirements have increased steadily in recent years, and the growth trend shows no signs of abating in 2017.
A 2015 Kaiser Family Foundation analysis of Medicare data found that 23% of drugs in private drug plans covered by Medicare Part D required prior authorizations, up from 8% in 2007. During the same period, the percentage of drugs carrying some type of utilization management restriction more than doubled, from 18% to 39%.
Challenge 3: Negotiating with payers
As payers move to consolidate, physicians find themselves facing the prospect of declining reimbursement and narrowing provider networks. Many doctors lament that payers now come to the table with a “take it or leave it” approach, forcing physicians to agree to one-sided contracts to maintain their patient head count.
Challenge 4: Staying motivated to practice medicine
Like everyone else, doctors want to enjoy their work, but they are finding it harder to do so. Physician professional dissatisfaction has been steadily growing in recent years, driven by increasing workloads and frustration at being unable to spend sufficient time with patients.
By now the causes of physician unhappiness are well known. They include ever-increasing amounts of time spent on administrative tasks and documentation, frustration with the demands imposed by electronic health records and the feeling they are having to cede control of their practices to government regulators and third-party payers.
Challenge 5: Maintenance of certification
More changes are on the way for physicians certifying in their sub-specialties through the American Board of Internal Medicine’s (ABIM) maintenance of certification (MOC) process.
Physicians feel as though a “board certification industrial complex” has been created by ABIM and MOC, says Christopher Unrein, DO, an internist and hospice/palliative care practitioner in Parker, Colorado. “Our profession’s very own medical societies, that we pay significant amounts of membership dues to, turn around that membership to sell us products in order to pass the exams and/or gain MOC points,” he says. “So not only is MOC a busy-work, anxiety-laden process, it is also one of financial opportunism. Physicians preying upon physicians — it disgusts me, as we are supposed to be a profession that cares and looks out for others.”
Challenge 6: Lack of EHR interoperability
Very few physicians have complete interoperability, which the nonprofit advocacy organization Center for Medical Interoperability defines as “the ability to share information across multiple technologies.”
In fact, a study released by KLAS Research in October finds that a mere 6% of healthcare providers can effectively and efficiently share patient data with other clinicians who use an electronic health record (EHR) system different than their own.
Challenge 7: Patient frustration with rising costs
The rapid rise in copays, deductibles and prescription drug prices is causing concern among physicians who see patients skipping care as a result of these increasing healthcare costs.
Challenge 8: The non-adherent patient and “quality” care
Patients who dismiss medical advice are nothing new, but that attitude increasingly threatens to cost doctors as quality metrics become tied to compensation.
Challenge 9: Changing patient attitudes
Today’s patients are educating themselves more, presenting both a challenge and an opportunity for primary care physicians.
Some, newly insured by the Affordable Care Act, may be coming to the doctor for the first time, and have questions and concerns they expect their new physician to answer. Other patients are angry. A recent Medical Economics reader poll suggests physicians are seeing that anger manifested during office visits as frustration with the cost of healthcare, from deductibles to surprise charges. Other patients are taking a consumerist approach to healthcare, looking for convenience and quick access.
“Patients feel more empowered to take control over their own health and consider the doctor an adviser. Doctors have to adjust from being in an elevated position to more of a coaching and advising role,” says Joseph E. Scherger, MD, a primary care physician in La Quinta, California, and member of the Medical Economics editorial advisory board.
Challenge 10: Patient satisfaction scores
Patient satisfaction has become an increasingly important factor in how physicians are treated by their employers and insurers, thanks in part to government regulations.
Dealing with the internet-savvy patient—but also attempting to make a personal connection with them—all while entering the data correctly into the practice’s electronic health record (EHR) system is a daunting but necessary task because of value-based care.
Who’s in charge here? Would physicians choose to include these challenges in our health care system? What is the benefit/hassle-factor ratio in these challenges?
These intrusions are not originating with health care professionals and their patients. Instead they are emanating from insurers, from public and private administrators, from legislative bodies, and from vested interests in the medical-industrial complex.
A well-designed single payer system would eliminate some of these hassles and would modify others to more clearly benefit patients, providing a much more congenial practice environment for themselves and their health care professionals.
Our current system is designed to promote business principles, with an inevitable fight over where health care dollars end up. In contrast, a publicly-administered and publicly-financed single payer system would be designed to promote patient service, with dollars directed to health care delivery rather than to administratively-complex intermediaries and their rent-seeking puppeteers.
It seems like physicians have enough challenges in working with their patients to seek the best clinical outcomes. They really don’t need these other burdensome challenges injected by inefficient insurers, superfluous administrators, bureaucrats and legislative bodies. They need a well designed single payer system instead – an improved Medicare for all. In fact, some of the challenges listed explain why we need to improve Medicare when we convert it to a system serving all of us.
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