PNHP

Senate defeats single payer amendment

Senate defeats single payer amendment

By Don McCanne, M.D.
United States Senate, July 27, 2017

In the Senate an amendment to the Republican repeal and replace legislation was introduced by Sen. Steve Daines (R-MT) that would establish a single payer system in the United States – an expanded and improved Medicare for all – using the exact same language as in HR 676 introduced in the House by Rep. John Conyers.

The vote:
0 – Yes
57 – No
43 – Present

All Republicans, including Sen. Daines, voted against it. Democratic Senators Donnelley, Manchin, Tester, and Heitkamp, along with Independent Senator King, voted against it. All other Democrats voted Present.

Sen. Bernie Sanders had said before the vote that failure of Sen. Daines and other Republicans to vote for their amendment would demonstrate that this was a sham to be used to campaign against moderate Senators in the next election. When no Republican voted for it, most Democrats plus Independent Sen. Sanders voted Present.

It is a sad commentary that the most important health policy legislation ever introduced in Congress – legislation that would have brought health care justice to all – was used by the Republicans as a tool for political chicanery.

Do they think this was some kind of a joke? They just rejected legislation that would have prevented hundreds of thousands of people over the years from facing physical suffering due to lack of medical care, financial hardship, and even death. Death!

We could forgive them for a bad joke, but this?

Mobilize the forces. This is war! Not the guns and bombs type of war but a war against man’s inhumanity to man.

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Man was made to mourn: A Dirge

Many and sharp the num’rous ills
Inwoven with our frame!
More pointed still we make ourselves
Regret, remorse, and shame!
And man, whose heav’n-erected face
The smiles of love adorn, –
Man’s inhumanity to man
Makes countless thousands mourn!

–  Robert Burns, 1784

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Jimmy Carter on board for single payer

Jimmy Carter Believes U.S. Will Eventually Go to Single-Payer Health System

By Louise Radnofsky
The Wall Street Journal, July 23, 2017

Former President Jimmy Carter said he believed the U.S. would in time adopt a fully government-run health insurance system, or “Medicare for all,” in remarks ahead of his Sunday school class here. “I think eventually we’ll have a single-payer system,” said the former U.S. leader.

https://blogs.wsj.com…

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Comment:

By Don McCanne, M.D.

President Carter, welcome aboard.

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Should PNHP postpone single payer and advocate for incremental reform?

Single payer can’t happen in California. At least, not right away

By Steve Tarzynski
Los Angeles Times, July 25, 2017

Given the dismal state of healthcare reform in Washington, liberal Californians have rallied around the idea that the state should establish a single-payer program. Although in the future such a system would be workable and desirable, the reality is that at the moment a single-payer bill cannot pass. Fighting for one in the immediate term is a waste of time.

But by 2020, California might just be ready for single payer — if advocates achieve a string of smaller but important legislative victories to build power.

Such steps might include: a state individual mandate; a state employer mandate that also covers part-time workers and their dependents; continued guaranteed coverage for children in the country illegally; giving the state insurance commissioner the power to regulate insurance premiums; setting a process to negotiate drug and medical device pricing; administrative reforms to streamline Medi-Cal so that there is less waste and better coordination and continuity of care; engaging the state’s tech sector to assist with such streamlining; advancing nonprofit delivery systems and moving away from fee-for-service practice; and opening up Medi-Cal to everyone, which would effectively create a state public option robust enough to compete on a level playing field against private insurers.

We do not need yet another devastating loss. Time, treasure and effort would be better spent winning the series of smaller victories that create the pathway to single payer. And in four years, a substantially stronger single-payer movement could successfully lobby a new Congress and president for federal waivers.

More than a century ago, Theodore Roosevelt called for a system of national health insurance. Single-payer advocates have been working for decades. They’ll have to work a few years more.

Steve Tarzynski is a physician and president of California Physicians Alliance.

(For a fair representation of Steve Tarzynski’s views, be sure to read the full article available at the link below.)

http://www.latimes.com…

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Comment:

By Don McCanne, M.D.

How much incremental reform do we need before we are ready to enact a single payer system, whether at the state or federal level? Or are we ready now?

The California chapter of Physicians for a National Health Program (PNHP) struggled with these questions without resolve, and it was decided to split the chapter into two organizations – PNHP California and California Physicians Alliance (CaPA), CaPA having been a predecessor organization in California. PNHP is a single issue organization advocating for single payer reform whereas CaPA advocates for incremental reforms with an ultimate goal of single payer.

There is legitimacy for both organizations.

CaPA leadership believes that advocating for incremental reforms would establish a better working relationship with other organizations supporting health care justice. Joint advocacy efforts supposedly should reduce the resistance to the more comprehensive reform that a single payer system would bring us. More importantly, incremental reforms can be beneficial during the interim before transition to a single payer system clears the political hurdles.

PNHP leadership believes that we should do all that we can to expedite the transition to a bona fide single payer system. We have a long history of incrementalism and each step has resulted in postponement of a serious consideration of single payer. Right now the battle in Congress is between supporting the incremental policies in the Affordable Care Act or replacing them with measures that would set us back even further. Yet the concept that the government should play a greater role has gained traction amongst Americans, and we should be moving forward with a process that will accomplish that instead.

There are many individuals and organizations who support the various incremental proposals. They do not want for lack of a voice. On the other hand, there is a need for a loud, clear and unwavering voice for single payer reform, lest the message be lost in the incremental mishmash. PNHP will remain a major contributor to the clarion call. CaPA should as well though Steve Tarzynski in his op-ed says that fighting for single payer in the immediate term is a waste of time. But if we expect results by 2020, there is much work to be done now.

For full disclosure, I should say that I am a member of the transitional steering committee for PNHP California as we revitalize our chapter, and I am also a member of the advisory board for CaPA. I believe that both organizations play important but somewhat different roles in the California health care reform movement.

As a former national president of PNHP, I do have a bias. Both organizations support single payer as the ultimate goal, and I am going for that. I do support beneficial measures that may provide transitional relief, but devoting time, resources, and effort to single payer is not a waste of time; it is an absolute moral imperative. We need to go all out, now!

PNHP California
www.pnhpcalifornia.org

CaPA
http://caphysiciansalliance.org

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What does the health policy literature tell us about consumer shopping?

From The Archives: Prices And Consumer Shopping

By Rachel Dolan
Health Affairs Blog, July 19, 2017

The American Health Care Act and the proposed Better Care Reconciliation Act would both result in higher premiums and deductibles for many individuals in the private nongroup market according to the Congressional Budget Office. While the path forward for health reform is now somewhat unclear, the trend of higher consumer cost sharing will likely continue. Higher deductibles and cost sharing are often touted as ways for individuals to have “skin in the game” in health care costs and to help consumers be better shoppers. But what does the research say about the ability to truly shop for health care services? Is it possible? Does it save money? And do consumers even want to do it? Here’s what we know based on research published in the pages of Health Affairs.

Health Care Prices Vary A Lot – And Not Because Of Quality

Shopping For Health Care Has Serious Limitations

Consumers Don’t Really Use Price Tools

The trend of increased consumer cost sharing along with increased expectations that those consumers should engage in price shopping is not going away. But it’s naïve to believe that just increasing the cost burden on consumers and providing them with online tools to compare doctors is going to fix the serious cost problem we have in the US health care system.

http://healthaffairs.org…

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Comment:

By Don McCanne, M.D.

The politicians would have us believe that the health care battle is between those who would protect the policies of the Affordable Care Act and those who would replace Obamacare with a system that places a greater duty on the health care consumer to be a responsible purchaser. In fact, supporters of both approaches tout consumer price sensitivity.

The Affordable Care Act was designed specifically using lower actuarial value plans which require greater cost sharing, especially higher deductibles, supposedly driving the patient to be a more prudent health care shopper. The replacement proposals would merely magnify that – increasing cost sharing in order to reduce insurance premiums. In fact, the supporters of replacement would go so far as to require 100 percent cost sharing for the 22 million who would become uninsured – the nadir (zenith to some) of consumer-directed health care.

This article by Rachel Dolan, the Special Assistant to the Editor-in-Chief at Health Affairs, summarizes some of the studies from the Health Affairs archives, while providing links to those studies, concluding, “it’s naïve to believe that just increasing the cost burden on consumers and providing them with online tools to compare doctors is going to fix the serious cost problem we have in the US health care system.”

The intensity of the obsession with this ideology is demonstrated by the efforts of the Trump administration to introduce cost sharing into Medicaid – a program designed for low-income individuals with no discretionary income. How do they shop with money they do not have at hand?

Americans are not demanding a health care financing system in which they have to look into their own pockets to see what health care they can afford. They want a system that removes financial barriers to care so they can receive the care they actually need. Many Americans were relatively unhappy with the inadequacies of the Affordable Care Act, creating support for repeal and replacement. But when they learned that the proposed replacement would be even worse, they realized more than ever that government programs that have been successful in other nations may be just what we need.

Instead of price shopping it would be much better to have government oversight to make sure that our health care spending is fair, and to leave to the patient-consumers choices in the selection of their health care professionals and institutions, just as we now have with our traditional Medicare program. Tell the politicians to forget consumer price shopping; it doesn’t belong in health care. We can do far better with an equitable, publicly financed program.

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Charlie Gard’s case is tragic. But it’s not a warning about public health care.

Conservatives are using a sick baby’s story for their own political purposes.

By Adam Gaffney, M.D.
The Washington Post, July 24, 2017

The saga of Charlie Gard — the critically ill 11-month-old boy with a spectacularly rare genetic disorder, who is on life support in a London hospital — seems to be coming to a close. Charlie has been at the center of a highly politicized imbroglio with international reach as a result of a disagreement between his parents and physicians over his fate. On Monday, however, that appears to have ended, after his parents learned of the results of an MRI performed last week and decided it was “too late” for an experimental therapy that had been offered in the United States.

This is, more than anything, an utterly heart-rending situation for Charlie’s family. Looking back at the controversy over his medical care from an American prospective, however, one is also struck by how Charlie was used politically in this nation: Right-wing politicians and commentators have wielded his tragic case as a crude cudgel against the public provision of health care, essentially accusing the British National Health Service of sentencing him to die.

“I stand with Charlie Gard and his parents,” House Speaker Paul D. Ryan (R-Wis.) posted on Facebook on July 13. “Health care should be between patients and doctors. Government has no place in the life or death business.” President Trump, meanwhile, offered to “help” the child via Twitter. On Rush Limbaugh’s show, Vice President Pence opined, “We hope and pray that little Charlie Gard gets every chance, but the American people oughta reflect on the fact that for all the talk on the left about single-payer, that’s where it takes us.” Just last week, the House Appropriations Committee moved unanimously on an amendment that would grant Charlie residency status in the United States to facilitate his transfer here to receive experimental treatment, as his parents were hoping (until Monday), but his doctors opposed. The latter felt that the evidence was scant that the therapy would do him any good and that continuing life support would just prolong his suffering.

There’s a serious hypocrisy in the conservative rhetoric, as others have pointed out. After all, Republicans are simultaneously attempting to dismantle the health-care safety net, which helps ensure that people don’t die simply because they are poor. Perhaps Ryan’s talk about the “death business” was actually a form of projection. Regardless, Ryan didn’t frame the debate quite right in his Facebook post. Health care should be between physicians and patients, he said — but it was Charlie’s own doctors who were pushing for a palliative care-only approach. Ultimately, it wasn’t Ryan’s government bureaucrats, but rather Charlie’s health-care providers who decided that his condition was beyond treatment. (British courts agreed with them.)

Charlie had the terrible misfortune of inheriting a pair of genetic mutations that deplete his body of mitochondria, the minute structures that produce energy molecules that cells need to live. As a result, he has for months suffered — according to the hospital — “catastrophic and irreversible brain damage.” He cannot breathe, he essentially cannot move, and he cannot hear. He has been kept alive because of the miracle — and sometimes the curse — of life support.

To be clear, there would have been no debate — and no controversy — whatsoever if Charlie’s physicians and parents had been in agreement: The physicians would have already proceeded to withdraw life support some time ago, and we would never have heard of the case. This happens in ICUs in the United States and Britain every day. In other words, this case was never about what many people thought it was about. It was not about “euthanasia.” It was not about “death panels.” It was not about the “value of life.” And although the case captivated “conservative groups from the United States led by Catholics and evangelicals,” it was not really about religion. In Catholic doctrine, for instance, it is permissible to cease life support when an individual is overcome with disease. “We may reject life-prolonging procedures that are insufficiently beneficial or excessively burdensome,” as medical directives from the United States Conference of Catholic Bishops note.

Finally, it was never about “socialized medicine.” The means by which a health-care system is funded neither creates nor resolves these difficult situations: They are instead the inevitable consequence of the mid-20th–century invention of the ICU and of life-support tools like ventilators. I would wager that most, if not nearly all, critical-care clinicians have found themselves in scenarios where they felt they were doing a true disservice to another human being — performing invasive procedures, maintaining life support, prolonging suffering — because they were compelled to push ahead by a sick patient’s family. I most certainly have.

And therein lies the crux of the Charlie case: There was no consensus between family and physicians. His physicians have firmly and consistently held that his condition makes discontinuing life support — and instead providing only palliative care so he was as comfortable as he could be — the appropriate medical decision, and they have been supported in this by multiple court decisions. Charlie’s parents wanted life support continued to take him to the United States, where Columbia University neurologist Michio Hirano had initially offered to provide an experimental treatment (“nucleoside bypass therapy”) that had never been tried, as STAT notes, on someone with his particular genetic mutation. Though it’s now a moot point, the question lingers: Had Charlie’s doctors been wrong to prevent his transfer, and withhold the treatment, earlier?

One cannot know from the sidelines, but it is worth noting that the April High Court judgment refers to Hirano, at least at that time, as “the only expert in this case who has been suggesting that there is any potential benefit in nucleoside therapy” and notes that the physician himself once said, “I can understand the opinion that he is so severely affected by encephalopathy [brain dysfunction] that any attempt at therapy would be futile. I agree that it is very unlikely that he will improve with that therapy.” More recently, Hirano testified with what sounded like odd precision that there might be an “11 percent to 56 percent chance of clinically meaningful improvement” in the strength of Charlie’s muscles. With claims about new evidence, the case went back to court, and the controversy became only more heated.

The Great Ormond Street Hospital, where Charlie is being cared for, did, in fact, consider this therapy but ultimately determined “that the experimental treatment, which is not designed to be curative, would not improve Charlie’s quality of life” and could not “reverse the brain damage that has already occurred.”

There is simply nothing to suggest that the hospital was motivated at any point by anything other than what it saw as Charlie’s best interest. This was never about cost-cutting or rationing; Charlie is simply not, as the headline of Washington Examiner put it, “a baby … condemned to death by socialized medicine.” He is a baby tragically condemned to death by a fatal illness, which would be true in any country.

Admittedly, the landscape of who gets to make the critical decisions about stopping life support is different in the United States compared with Britain. As bioethicist Michael Dauber wrote in STAT, in the United States, when doctors and “surrogate” decision-makers disagree on continuing life support, the wishes of the surrogates — in a case like Charlie’s, where the patient is both too young and too ill to make medical decisions, his parents — take precedence. In Britain, the matter can be resolved in courts (and a guardian is appointed to represent children). Charlie’s case essentially revolved around the proper balance of power between surrogates and physicians over medical decision-making.

The British approach may strike many here as problematic: The core principle around which so many of our bioethics debates revolve is autonomy, which is to say the sovereignty of the individual over his or her own body, the right to be at the center of all medical decisions. Paradoxically, however, the principle of autonomy is often of limited applicability in critical care, as during a moment of an overwhelming illness, many people are unable to engage in the complex, necessary discussions (in Charlie’s case, he is obviously also too young).

There is simply no ideal solution, contrary to Ross Douthat’s assertion in the New York Times that the situation is an “easy question, whose answer makes the case a moral travesty.” Some may be horrified at the notion of physicians making decisions “over” family members, but this happens frequently. For instance, if parents insist that their child not receive a lifesaving treatment for religious reasons, they can — and should — be ignored. Obviously, the Charlie case is different: There is nothing to suggest improper motivations on the behalf of his parents, and they were trying to provide, and not deprive him of, care, albeit of questionable utility.

But look at it from the perspective of Charlie’s physicians, who have been receiving a torrent of death threats and abuse. Continuing life support — and sustaining his potential suffering — so that he could cross the Atlantic to obtain experimental therapy that they believed has no chance of curing him and little chance of significantly palliating him would have constituted a form of real harm.

However we answer it, the question of how decisions about the cessation of life support are made is an issue that is separate from how we structure and fund our health-care system. Attempts to link universal health care with one particular approach to end-of-life decision-making are disingenuous and dangerous. Chalie’s doctors have wanted to withdraw life support from him for months because they believe that is the best way they can help him. Those who denounced them are today fighting fervently to withdraw health coverage from millions to make way for tax cuts for the rich.

Which one is the real moral travesty?

Adam Gaffney is an Instructor in medicine at Harvard Medical School and a pulmonary and critical care physician at the Cambridge Health Alliance and serves on the board of directors of Physicians for a National Health Program.

https://www.washingtonpost.com…

Bruce Trigg, MD

Dr. Trigg is a pediatrician who worked 23 years with the New Mexico Department of Health until his retirement in 2011. He served as medical director of the Sexually Transmitted Disease (STD) Program and worked in correctional health care and with harm reduction approaches to injecting drug use.

Dr. Trigg is currently a clinician providing methadone and buprenorphine treatment for people who are addicted to opiates. He also has recently worked as an international consultant in addiction treatment in several Southeast Asian countries.

A long time advocate for a single-payer, national health program for the US, he is an active member of Physicians for a National Health Program and is the C0-Chair of the New Mexico chapter; the New Mexico Network of Health Professionals for a National Health Program (NHP Squared).

Dr. Trigg is Clinical Assistant Professor with the Department of Pediatrics and Associate Professor of Nursing at the University of New Mexico Health Sciences Center.

He graduated from George Washington University School of Medicine in 1981 and did his residency training at Albert Einstein College of Medicine in NYC and the University of New Mexico Health Sciences Center. From 1983 to 1986 he worked as a general medical officer with the Indian Health Service of the US Public Health Service in Native American communities in New Mexico and Arizona.

Ayana Jordan

Ayana Jordan is a fifth year MD/PhD student at the Albert Einstein College of Medicine of Yeshiva University. Ayana had the pleasure to co-chair the past two student forums sponsored by PNHP entitled Medical Student Activism, Past, Present, and Future and medical student activism: Reforming Healthcare Through Student Action with participation from the American Student Medical Association, Student National Medical Association, Einstein Community Health Outreach (ECHO) free clinic and New York University’s free health clinic. Currently, Ayana serves as the president for the Einstein chapter of PNHP. She looks forward to continuing the work of building partnerships between communities of color, medical students and PNHP.

Laura S. Boylan, MD

Dr. Laura S. Boylan is member of Physicians for a National Health Program, a non-profit research and education organization of 17,000 physicians, medical students and health professionals who support single-payer national health insurance. She is a Clinical Associate Professor of Neurology at New York University School of Medicine and practices at the Department of Veteran’s Affairs and in Pennsylvania. She completed her medical training at Columbia University College of Physicians & Surgeons.

William Thar, MD, MPH

Dr. Thar is a physician who has experience in many sectors of health care. A graduate of Michigan State University College of Human Medicine, he did his residency at the University of Michigan, where he also received his MPH in Health Care Administration and Epidemiology. He has operated a private primary care practice, been the Medical Director of rural public health programs, directed epidemiology programs at a major U.S. corporation, where he also provided medical consultation to their health care benefits programs, and was a developer and Medical Director of a health care management company before his retirement. Dr. Thar has seen the fragmented, expensive, and highly variable care provided in the United States and is committed to the development of a National Health Program based on HR 676 that can serve all of the people of the United States.

Alan L. Kenwood, MD, FACEP

MD, FACEP

Dr. Alan Kenwood has been a practicing emergency physician for over 30 years. More than any other specialists, emergency medicine physicians see the faults of our health care system.  Prior to becoming an emergency physician, he served in the US Army Special Forces at Fort Bragg, North Carolina. As a member of PNHP-NJ Dr. Kenwood has spoken all over the state about the benefits of single payer healthcare.

Sean Lehmann, DPM

Dr. Sean Lehmann attended the College of Podiatric Medicine and Surgery at Des Moines University (Iowa) where he earned both a Doctor of Podiatric Medicine and a Master’s degree in healthcare administration. He then completed a surgical residency program at Lakewood Regional Medical Center near Long Beach, California. Soon after opening his practice in the summer of 2000, Sean and his wife Michelle bought a home in Carson City, Nevada. Sean is an avid runner, currently coaches track at Carson High School, and particularly enjoys running with his wife and their two sons. He is also a member of the Carson City Parks and Recreation Commission, and further enjoys skiing, hiking, basketball, traveling, and flying.

John D. Bower, MD

Dr. John Bower is Chief of the Division of Nephrology at the University of Mississippi in Jackson, Mississippi. His practice includes many patients in the publicly financed and highly successful end-stage renal disease program. Dr. Bower has been a PNHP member for six years, and is the founder of PNHP’s Mississippi chapter. He brought a single-payer resolution before the the state medical society, and is active in speaking and writing editorials and letters on the need for universal access to health care.