PNHP

U.S. patients would benefit from single-payer plan

U.S. patients would benefit from single-payer plan

By Andrew Quint, M.D.
Columbia (MO) Daily Tribune, May 30, 2017

I would like to respond to Luke Davis’ recent commentary in the Tribune. Having worked as a primary care physician at Family Health Center, a federally qualified community health center, serving medically underserved patients in Columbia since 1997, I have experienced firsthand the inequality, inefficiency and warped incentives of our healthcare system.

Davis writes that treatment in a single-payer system “tends to be lower in overall quality.” For example, he cited a recent study of the Canadian health care system that found the average wait time for medically necessary treatment after seeing a specialist was 9.8 weeks. Davis’s citation of this study leaves out a critically important caveat: It was a survey of wait times for elective treatment — by definition not medically urgent care. While a longer wait time for this type of treatment is frustrating, it does not mean the Canadian system produces meaningfully lower quality care. Moreover, my uninsured patients often don’t ever get to see a specialist. One patient had a kidney stone that wouldn’t pass; he experienced pain and blood in his urine for three months. Only when he got insurance through the Affordable Care Act could I get him in to see a specialist to have the stone removed. Uninsured patients are not counted in these statistics on wait times because they often don’t even get referred to specialists.

Davis says that in the United States, “government programs and regulations also guarantee that a certain baseline level of care is provided to all residents.” This is not true unless one believes that access to an emergency room constitutes a “baseline level of care”. If you are bleeding or having a heart attack, you can go to an emergency room and be treated even if you don’t have health insurance. But emergency rooms do not provide preventative care or treat chronic diseases such as diabetes and do not provide the vast bulk of medical care that people need to avoid ending up in an emergency room with a heart attack or stroke.

The infant mortality rate in the United States is 6 per 1,000 live births; in Canada it is 4.8. Life expectancy in the United States at birth in 2012 was 81.2 years for females, 76.4 for males. In Canada it was 83.6 for females and 79.4 for males. We have higher rates of premature death for all leading causes of death than comparable countries on average. Our rates of all-cause mortality, premature death, death amenable to healthcare, and disease burden are not improving as quickly as in other comparable countries during the past 10 years. We have better short-term outcomes after treatment for certain conditions, such as 30-day mortality post-heart attack and ischemic stroke. Five-year survival rates for specific cancers (like breast and colon cancer) are higher here. But we lag behind comparable countries in prevention and other measures of quality. We have relatively higher hospital admission rates for many preventable conditions, including congestive heart failure, asthma and diabetes complications. And we have higher rates of medical errors than comparable countries.

Our per capita spending on health care is double that of other developed countries. In 2016 the United States spent $9,024 per capita on health care; Canada spent $4,506. Despite our high cost, with a few exceptions, our outcomes are generally worse than in those countries. We excel at high technology high cost care. We do not perform nearly as well on lower cost preventative care. The economic incentives in our system favor high cost medications and procedures rather than low cost educational interventions and prevention.

A colleague of mine attended a lecture on research to develop a drug to promote the growth of new blood vessels around arterial blockages. Instead of heart surgery, a patient could take this drug to grow a bypass. When it was pointed out to the speaker that exercise promotes the growth of new blood vessels around blockages, he replied “Yes, but we don’t get paid for that.”

Single-payer systems in other countries are cheaper, provide better access to care, and allow those countries to improve the financial incentives that make their health care systems more rational, with more focus on prevention of diseases and their complications.

Andrew Quint is medical director at the Family Health Center in Columbia.

http://www.columbiatribune.com…

CMS Administrator Verma is further privatizing enrollment in insurance exchanges

Consumer Advocates Wary Of New Marketplace Rules For Brokers

By Michelle Andrews
Kaiser Health News, May 30, 2017

Signing up for coverage on the health insurance marketplace should be easier for some people this fall because new federal rules will allow brokers and insurers to handle the entire enrollment process online, from soup to nuts. Some consumer advocates are concerned, though, that customers going this route won’t get the comprehensive, impartial plan information they need to make the best decision due to the financial self-interest of insurers and brokers.

“Facilitating the participation of brokers and getting web brokers involved is a good thing for the market,” said Timothy Jost, emeritus professor at Washington and Lee University School of Law in Virginia and an expert on health reform. But there are risks for consumers. “If you’re enrolling with a web broker, you could see ‘best deals’ that often aren’t the best deal for you but are the best deal for the people who are marketing them.”

The staff at online health insurance broker eHealth is thrilled with the change.

“It’s a big deal,” said Nate Purpura, vice president of consumer affairs at eHealth. “Many people, including our CEO, have been to Washington, D.C., multiple times to explain the benefits of being able to help in this way.”

Its website, which works with 180 insurance carriers nationwide, offers about 75 percent of the plans that are available on healthcare.gov, Purpura said.

That’s a problem, say some policy analysts. Federal rules require web brokers to display basic information about all the plans that are available on the federal marketplace, whether or not they actually sell them. It includes the name of the plan and insurer that offers it, the type of plan — HMO, PPO, EPO — and metal level (bronze, silver, gold or platinum). Web brokers must also publish a disclaimer that says the website information about all the available marketplace plans might not be complete and provide a link to healthcare.gov.

But the information web brokers present about plans they sell and get a commission for may be much more comprehensive than the information provided about plans they don’t handle.

But some analysts remain concerned that details about how consumers’ privacy and security will be protected under the new system are still too vague.

“This is really sensitive information, people’s tax information, which needs to be highly protected,” said Jost. “There are a lot of concerns with confidentiality and privacy. I have some concerns about fraud.”

http://khn.org…

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The Centers for Medicare and Medicaid Services (CMS) announces streamlined direct enrollment process for consumers seeking Exchange coverage

CMS.gov, May 17, 2017

“This is another important step to help create stability in the health insurance market,” said CMS Administrator Seema Verma. “It is common sense to make it as simple and easy as possible for consumers to shop for and access health coverage. It is time to get the federal government out of the way and give patients the best tools to make their own healthcare decisions.”

https://www.cms.gov…

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Comment:

By Don McCanne, M.D.

CMS Administrator Seema Verma is expanding the role of private insurance brokers, such as eHealth, in enrolling individuals in plans offered by the government ACA health insurance exchanges. Not only do the private brokers promote only selected plans on the exchanges, they obviously are motivated to push the plans for which they receive a generous commission, whether or not the plans selected are in the best interests of the enrollees. This does not serve the applicants well.

In her CMS release, Verma states, “It is time to get the federal government out of the way.” Her pro-privatization, anti-government ideology is so intense that she says that it is “common sense” to add additional, wasteful private administrative services with these outside brokers, paying them fees with our tax money, and yet depriving enrollees of the full informational services that our current government-operated exchanges are providing.

Worse services, piling on of administrative excesses, and diverting public money to private vendors are a terrible price to pay simply to please the anti-government bureaucrats that are filling the positions of public trust in this administration.

In a recent Quote of the Day, it was recommended that her boss, HHS Secretary Tom Price, be replaced based on the potential havoc created by his adhering to his nutty anti-government ideology. She should be replaced for the same reason as well – ASAP.

This comment is the opinion of the author and is not an official view of Physicians for a National Health Program.

N.Y. Assembly passes universal health care bill

By Dan Goldberg
Capital New York, May 27, 2015

The state Assembly on Wednesday voted for a single-payer health bill, the first time in more than two decades the chamber has taken up the measure.

The vote was 89-47, an overwhelming but largely symbolic step toward universal health insurance. The bill now heads to the Republican-controlled Senate where it is not expected to pass.

Assemblyman Richard Gottfried, chair of the health committee, gave an impassioned speech on the floor in support of the New York Health Act, arguing that it was long past time for New Yorkers to rid themselves of the intrusive insurance companies whose goal is to deny claims rather than provide care.

“You do not have to be an Einstein to understand New York Health is the right choice for New York,” Gottfried said.

Gottfried, a Democrat from Manhattan, spent the legislative session barnstorming the state, trying to gain support for his bill, which would be funded through a progressive income tax and payroll assessments. There would be a net savings of $45 billion in health spending by 2019, Gottfried said, based on an analysis from Dr. Gerald Friedman, a professor at the University of Massachusetts at Amherst, though that figure was attacked by Republicans.

The bill, Gottfried said, would lower costs by getting rid of insurance companies. It would lower administrative costs and allow doctors to focus their time on treating patients instead of fighting for reimbursements.

“What will bring down health care costs is taking out of the equation the more than 20 percent we now spend on administrators whose job it is to fight with insurance companies,” he said.

The plan’s benefits, Gottfried said, would be more generous than any plan on the current market, and there would be no co-pays or deductibles. The bill would also require a care coordinator for every member, though that coordinator is not empowered to choose the type of care a patient receives.

For some Republicans, it was all too good to be true.

“This bill promises remarkable things for New York State residents,” said Assemblyman Andy Goodell, a Republican from Chautauqua. “It says providers, ‘you’ll be paid a lot more money,’ and it says to the employees ‘you’ll contribute a lot less money,’ and it says to the patients ‘you’ll have much broader access,’ and to the employers ‘you’ll pay $45 billion less.’ My background is in math and economics and I haven’t been able to figure out how this all works. … There is no free lunch, there is no free health care.”

Leslie Moran, spokeswoman for the New York Health Plan Association, which represents insurers, said the bill “represents an unrealistic, utopian view of a universal health care system where everyone would be covered, everything would be covered and the system would magically pay for it all.”

One problem, pointed out by Republicans, is that the offering, while generous, is the opposite of what public health officials are pushing, including those in the Cuomo administration, who have professed that insurance systems, and high deductibles and co-pays help ensure people use the health system judiciously instead of opting for more, often unnecessary, care.

“There is a role for insurance companies,” state health commissioner Dr. Howard Zucker said Wednesday before the debate.

The last time a universal health care bill was on the Assembly floor was 1992. It passed but the debate was sidelined because of federal efforts to reform health care, which ultimately failed under the Clinton administration.

The passing of the Affordable Care Act, which subsidizes private insurance for people below a certain income level, was a valid effort, Gottfried said, but ultimately served to highlight why the system needs to be entirely scrapped.

“I think the A.C.A. has made it clear to people … there are profound problems in our health care system that cannot be addressed by incremental change in that system,” Gottfried said.

Wiping out an industry — even the insurance industry — was not seen as popular by many Republicans who worried about the loss of jobs and what might happen should this plan fail.

Goodell asked why the state should go down this road when when Medicaid — a government run insurance program for lower-income residents — is expensive, burdensome and not well liked.

“Why would we want to expand that type of approach,” he asked.

Gottfried responded that his bill would improve Medicaid by putting everyone into one pot. He would, he said, eliminate the two-tiered system. There’d be no greater risk of fraud under this law than in the current Medicaid program.

Republicans also pointed out how much was left to be done. The income tax rates have yet to be decided, but would likely cost the highest earners more than they currently pay for health insurance, while subsidizing lower income residents.

The analysis provided by Gottfried estimates no income tax on the first $25,000, an income tax of 9 percent on income between $25,0001 and $50,000, graduating to 16 percent tax for income over $200,000.

The legislation is also not specific on how to deal with residents of New York State who retire to another state.

That would have to be resolved at a later date, Gottfried said.

“Though we have numerous pages on this legislation, we have numerous holes also,” said Al Graf, a Republican from Holbrook. “There is no way I can go back to my constituents and tell them you may have coverage in the future. … This is an exercise in insanity.”

Moran said there is no certainty that providers would accept government set reimbursement, though Gottfried said almost all would receive more for their services than they are currently being paid.

The bill also “completely disregards the economic contribution of health plans — both to the state and to local communities,” Moran said.

Joseph Borelli, a Republican from Staten Island, cited Vermont, which tried and failed to enact a single-payer health system.

Vermont’s collapse has been a cautionary tale for even the most enthusiastic supporters of government sponsored health insurance, but Gottfried was having none of it.

“New York … bears no resemblance to Vermont,” Gottfried said. “The bill bears very little resemblance to Vermont. Their financing system is different. The two have absolutely nothing to do with one another, nothing! Why don’t you ask me whether New York will flood Just like Texas flooded if we enact this plan. The weather in Texas has as much to do with this as Vermont does.”

Read the bill here: http://bit.ly/1JVUg1I

http://www.capitalnewyork.com/article/albany/2015/05/8568890/assembly-pa…

N.Y. Assembly votes for universal health coverage

By Michael Virtanen, Associated Press
Democrat & Chronicle (Rochester, N.Y.), May 27, 2015

ALBANY – The New York Assembly voted 89-47 on Wednesday for legislation to establish publicly funded universal health coverage in a so-called single payer system.

All New Yorkers could enroll. Backers said it would extend coverage to the uninsured and reduce rising costs by taking insurance companies and their costs out of the mix.

With no patient premiums, deductibles or co-payments for hospital and doctor visits, testing, drugs or other care, New York Health would pay providers through collectively negotiated rates. It would be funded through a progressive payroll tax paid 80 percent by employers and 20 percent by employees.

Also, waivers would be sought so federal funds now received for New Yorkers in Medicare, Medicaid and Child Health Plus would apply.

“Employers are shifting more and more health care costs to workers or are dropping it entirely,” said Assemblyman Richard Gottfried, chief sponsor. “The only ones who benefit are the insurance companies.”

The Manhattan Democrat estimated universal care would save New Yorkers more than $45 billion annually, cutting the statewide total cost for health care to about $255 billion in 2019.

Assembly Republicans doubted Gottfried’s estimate and questioned what would happen to everyone now employed by insurance companies.

“All I can say right now I think this is the last think New York state needs as far as an additional cost,” said Assemblywoman Jane Corwin, an Erie County Republican. She said they’re still trying to grapple now with the cost of the federal Affordable Care Act. That extended health care coverage to about 1 million New Yorkers, more than half in Medicaid and the others in private insurance with possible tax subsidies to offset costs.

An identical bill hasn’t advanced in the state Senate and isn’t expected to before the legislative session ends in June. Senate Health Committee Chairman Kemp Hannon said Wednesday that Gottfried’s bill faces two major hurdles, resistance from senior citizens to giving up Medicare for a new state program and obtaining federal waivers to apply Medicaid and Medicare funding to support it.

http://www.democratandchronicle.com/story/news/local/2015/05/27/assembly…

I’m a Kansas City doctor in Australia. Trump is right about Australian health care

By Marie Shieh
The Kansas City Star, May 27, 2017

President Donald Trump, I heartily agree with you when you told Australian Prime Minister Malcolm Turnbull, “You have better health care than we do.”

You see, I have been both a patient and a doctor in the U.S. and Australia. After working and studying as a family physician in the U.S. for almost 20 years, I landed my dream job working in Australia in 2015. I love working within this excellent health care system where doctors and patients are supported by a program called Medicare. It is similar to American Medicare but covers every Australian of every age for most health care costs.

Patients pay a small out-of-pocket fee, based on income, for things like medications ($7-$30), doctor visits ($0-$30) or X-rays ($0-$40). As their primary care physician, I can decide to charge a copay (children and seniors are always free) or stick with the basic Medicare reimbursement. For example, I might not charge patients I feel might not return for a follow-up visit. The choice is mine. Unlike working in the U.S., I never worry about bringing people back to the office to be sure they are getting the best care.

My Australian patients are not afraid to come see me and get tests done. They can visit physical therapists, dietitians, exercise physiologists, diabetes educators, chiropractors, podiatrists and osteopaths. I do not worry about patients not being able to afford an electrocardiogram, blood tests, radiology tests or medications like I did in the U.S. I can send my Australian patients to the hospital and emergency room, and unlike in the U.S., they are not afraid to go for fear of medical bankruptcy. The hospitals here are of excellent quality.

My Australian patients get care when they need it, not when they can afford it. By contrast, my American patients would routinely avoid care and treatments for fear of cost, leading to complications and extended sickness.

Australian Medicare provides high-quality, compassionate care to the elderly and disabled, which allows my patients to live with dignity at home, not in nursing homes. Take two of my patients, an elderly couple: The husband is 90 years old and the wife 81 years old, with mild dementia. They receive regular home visits from nurses who conduct assessments and dispense medication. They might get a cleaner every two weeks if they cannot get down to scrub floors or bathtubs. And speaking of bathtubs, they get handrails installed for a substantial discount, to keep them safe from falls. These common-sense measures keep patients healthy and cut down dramatically on hospital costs.

My Australian patients with advanced or terminal illness get home visits from me if they are too weak to come to the office. They receive palliative care in their homes, on par with the best treatments I have seen in U.S. hospice care.

Compare this to my experience as a patient in the U.S. I had my first baby in 1992 while in medical school. Even though I carried insurance and enjoyed a normal, unmedicated delivery, we got hit with a bill that was five times our monthly rent. Instead of enjoying our first weeks home with our new son, we spent that time haggling with the insurance company and being threatened by a collection agency. On top of that, our son wasn’t covered for the care he received right after being born, and we received a bill for the newborn check, none of which was covered by our insurance. This would never happen in Australia.

President Trump, you were right. We do have better health care here in Australia. Don’t you think Americans deserve the same?

Marie Shieh, M.D., is an American physician who now works in Australia. She was born in Salt Lake City and raised in Kansas City.

original op-ed:
http://www.kansascity.com…

follow-up interview with Dr. Shieh:
http://www.kansascity.com…

Robert Borosage on paving the way to Medicare for All

Will the Republican Health-Care Debacle Pave the Way for ‘Medicare far All’?

By Robert L. Borosage
The Nation, May 25, 2017

This week, the Congressional Budget Office confirmed what was already apparent: The revised House Republican health-care bill will still deprive millions of Americans — 23 million in the CBO estimate — of health insurance. Senate Republicans are devising their plan in secret, because it too will likely deprive millions of health coverage. In contrast with Republican horrors, Obamacare has grown in popularity, but premiums are rising as insurance companies consolidate monopolies in various states and Trump works to sabotage it. Surely, now is the time for progressives to wage a fierce campaign for Medicare for All.

Americans are more than ready. The popularity of expanding Medicare is surprising, given how little support it has received from the political class.

Will Republican efforts to repeal and replace Obamacare pave the way to Medicare for All? Only if progressives force the debate. Americans are looking for sensible reform. Medicare for All is the right answer. Now is the time for progressives to educate and enlist to take on the entrenched interests that stand in the way.

https://www.thenation.com…

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Comment:

By Don McCanne, M.D.

With the backlash against the Republicans for their ongoing failure to deliver effective health care reform, and with the failure of ACA to provide affordable health care for everyone, the pathway to Medicare for All may now have been paved.

Robert Borosage suggests that it is time for progressives to push the process – force the debate, educate, and enlist. But that should not be limited to progressives in the Democratic party. We should work with Republican progressives, independent progressives, Democratic Socialist progressives, and even, albeit rare, libertarian progressives. By forcing the debate, educating, and enlisting, even conservatives and others who do not usually assign to themselves the “progressive” label, should be ready for a serious consideration of single payer.

Assured health care, at a price we could all afford, who could be against that? Neither ACA nor AHCA would bring us that. Members of Congress will be home on a break this next week. Let them hear from you, though you may not want to announce yourself using the “progressive’ label.

Health Care Financing: It’s a tape worm

By Ewell Scott, M.D., F.A.C.P.
The Morehead (Ky.) News, May 26, 2017

When Warren Buffett talks, everybody who is anybody sits right up and listens.

Mr. Buffett, living in Oklahoma in a modest ranch house situated in a middle class neighborhood, demands the attention of Wall Street Tycoons and Hedge Fund Managers as he has the uncanny ability of predicting the future in economic terms. He picks out the winners. His reputation for honesty, plain speaking and accuracy are legendary.

Well, just last week he described our current health care financing system a “tape worm.” WOW. I do not want to have a tape worm. Since childhood the image of a silent grisly creature eating away, living in my gut, was scary.

But I am afraid the shoe fits, as our private health insurance based system is literally wasting huge amounts of money.

We in the USA spend twice as much as any other civilized country but get less. Our military, the best and largest, consumes 5 percent of our gross domestic product while total health care spending is responsible for 18 percent. We needlessly spend ours on an inefficient, fragmented, confusing system.

Mr. Buffett’s co-executive at Berkshire Hathaway, Charlie Munger has recently called for adopting a single payer health care system with progressive financing to get rid of this unwanted situation. Medicare for All, new and improved, would do it.

Let’s tell our politicians we want a truly universal, affordable and comprehensive health care financing system.

http://www.themoreheadnews.com…

Take action to rein in pharmaceuticals

By Robert Blake, M.D.
The Missourian, May 26, 2017

Pharmaceutical companies are among the most profitable companies in the world, and their executives are among the highest paid. In recent years, drug prices have markedly increased, rendering more and more Americans unable to afford essential medications.

Companies incur legitimate expenses for research and development of new drugs; however, their combined expenditures for lobbying, contributions to political campaigns, direct advertisements to consumers and promotional efforts, including free gifts, targeting physicians far exceed what they devote to research and development. Furthermore, the National Institutes of Health and other federal sources provide significant funding for research of many drugs that become highly profitable for companies. Taxpayers subsidize the development of drugs that they later must pay high prices to obtain or cannot afford to buy.

The film, “Big Pharma – Market Failure,” recently shown at the Columbia Public Library, documents the failure of the market to supply many medications at a reasonable price. The film emphasizes the devastating effects of escalating drug prices on small businesses that provide health insurance for employees.

We can take actions to address this serious problem.

• The federal law that prohibits Medicare from negotiating drug prices with pharmaceutical companies must be repealed. By negotiating prices, the Veterans Affairs  provides essential drugs to veterans at lower prices; Medicare should be allowed to do this.

• American consumers should be legally able to purchase medications from legitimate foreign sources. Prices of the same drugs are much lower in countries like Canada. The ensuing competition will reduce prices in the U.S.

• The public should have input into the pricing of drugs that were developed with taxpayer assistance.

• We need effective limitations on lobbying and campaign contributions from wealthy corporations, which unduly influence lawmakers to the benefit of the companies and the detriment of the public.

• Patent laws should be reformed to prevent companies from perpetuating monopolies on drugs by making trivial changes that confer no therapeutic advantage.

We should no longer passively submit to harmful practices of drug companies.

Dr. Robert Blake is a Columbia resident.

http://www.columbiamissourian.com…

HHS Secretary Price on the CBO Report

H.R. 1628, American Health Care Act of 2017

Congressional Budget Office, May 24, 2017

CBO and JCT estimate that enacting the American Health Care Act would reduce federal deficits by $119 billion over the coming decade and increase the number of people who are uninsured by 23 million in 2026 relative to current law.

CBO Summary:
https://www.cbo.gov…

CBO Full Report (41 pages):
https://www.cbo.gov…

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HHS Secretary Price Statement on CBO Report

U.S. Department of Health and Human Services, May 24, 2017

Following the release of the Congressional Budget Office (CBO) report analyzing the American Health Care Act, Health and Human Services (HHS) Secretary Tom Price, M.D. released the following statement:

“The CBO was wrong when they analyzed Obamacare’s effect on cost and coverage, and they are wrong again. In reality, Americans are paying more for fewer healthcare choices because of Obamacare, and that’s why the Trump Administration is committed to reforming healthcare. In a new analysis released just last night, HHS reported that premiums in the individual market have more than doubled since many of Obamacare’s regulations and mandates were implemented.”

HHS released a new analysis yesterday that shows premiums have doubled for individual health insurance plans since 2013, the year before many of Obamacare’s regulations and mandates took effect.

https://www.hhs.gov…

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Comment:

By Don McCanne, M.D.

Even though we spend far more on health care than other nations, the market has not been effective in allocating our funds in a manner that would ensure adequate health care for all. This is a time and circumstance wherein we clearly need government leadership.

In response to a Congressional Budget Office report showing that the current proposed health reform legislation – American Health Care Act of 2017 – would likely cause another 23 million people to lose their health insurance, besides its other deleterious effects, HHS Secretary Tom Price fails to acknowledge the severe deficiencies of the legislation and instead condemns the report as being “wrong.” This is not a casual comment; he distributes this through an official HHS release of the U.S. government.

Of course, the report isn’t wrong; it’s a prediction, based on the best available information.

What is wrong is that we have in place a public servant who would destroy whatever he can of the important public health role served by the Department of Health and Human Services. He is driven by his nutty anti-government ideology and would sacrifice the health services of tens of millions of Americans simply for the expediency of implementing his destructive agenda.

Although there are some checks and balances, nevertheless he is in a position to do considerable harm to America’s health care. He should not be left in office for four to eight years while we wait for the next president to replace him. Citizen action is required – now.

This is the opinion of the author is not an official view of Physicians for a National Health Program.

The US healthcare system is at a dramatic fork in the road

By Adam Gaffney, M.D.
The Guardian, May 25, 2017

The US healthcare system – and with it the health and welfare of millions – is poised on the edge of a knife. Though the fetid dysfunction and entanglements of the Trump presidency dominate the airwaves, this is an issue that will have life and death consequences for countless Americans.

The Congressional Budget Office’s (CBO) dismal “scoring” of the revised American Health Care Act (AHCA) on Wednesday made clear just how dire America’s healthcare prospects are under Trump’s administration. But while the healthcare debate is often framed as a choice between Obamacare and the new Republican plan, there are actually three healthcare visions in competition today. These can be labelled healthcare past, healthcare present, and healthcare future.

Let us begin with healthcare past, for the dark past is precisely where Republicans are striving to take us with the AHCA. The bill – narrowly passed by the House on 4 May – is less a piece of healthcare “reform” than a dump truck sent barreling at high speed into the foundation of the healthcare safety net.

Wednesday’s CBO score reflects the modifications made to the AHCA to pacify the hard-right Freedom Caucus, changes that allowed states to obtain waivers that would relieve health insurers of the requirement that they cover the full spectrum of “essential healthcare benefits”, or permit them to charge higher premiums to those guilty of the misdemeanor of sickness, all purportedly for the goal of lowering premiums.

In fairness, the CBO report did find that these waivers would bring down premiums for non-group plans. This, however, was not the result of some mysterious market magic, but simply because, as the CBO noted, covered benefits would be skimpier, while sicker and older people would be pushed out of the market.

In some states that obtained waivers, “over time, less healthy individuals … would be unable to purchase comprehensive coverage with premiums close to those under current law and might not be able to purchase coverage at all”. Moreover, out-of-pocket costs would rise for many, for instance whenever people needed to use services that were no longer covered – say mental health or maternity care.

Much else, however, stayed the same from the previous reports. Like the last AHCA, this one would cut more than $800bn in Medicaid spending over a decade, dollars it would pass into the bank accounts of the rich in the form of tax cuts, booting about 14 million individuals out of the program in the process. And overall, the new AHCA would eventually strip insurance from 23 million people, as compared to the previous estimate of 24 million.

It’s worth noting here that Trump’s budget – released Tuesday – proposed additional Medicaid cuts in addition of those of the AHCA, which amounted to a gargantuan $1.3tn over a decade, according to the Center on Budget and Policy Priorities.

The tax plan and budget – best characterized as a battle plan for no-holds-barred top-down class warfare drawn up by apparently innumerate xenophobes – would in effect transform the healthcare and food aid of the poor into bricks for a US-Mexico border wall, guns for an already swollen military, and – more than anything – a big fat payout to Trump’s bloated billionaire and millionaire cronies.

What becomes of this violent agenda now depends on Congress – and on the grassroots pressure that can be brought to bear upon its members.

But assuming the AHCA dies a much-deserved death – quite possible given the headwinds it faces in the Senate – we will still have to contend with healthcare present.

Last week, the Centers for Disease Control released 2016 results from the National Health Interview Survey, giving us a fresh glimpse of where things stand today. And on the one hand, the news seemed good: the number of uninsured people fell from 48.6 to 28.6 million between 2010 and 2016.

On the other hand, it revealed utter stagnation: an identical number were uninsured in 2016 as compared with 2015, with about a quarter of those with low incomes uninsured last year (among non-elderly adults). It also suggested that the value of insurance is declining, with “high-deductible health plans” rapidly becoming the rule and not the exception: for the privately insured under age 65, 39.4% had a high-deductible in 2016, up from 25.3% in 2010.

Healthcare present, therefore, is an unstable status quo: an improvement from healthcare past, no doubt, but millions remain uninsured and out-of-pocket health costs continue to squeeze the insured.

Which takes us to the third vision, that of healthcare future. As it happens, another recent development provided a brief glimmer of hope for that vision. As the Hill reported, the Democratic congressman John Conyers held a press conference yesterday (Physicians for a National Health Program, in which I am active, participated) to announce that his universal healthcare bill – the “Expanded & Improved Medicare For All Act” – had achieved 111 co-sponsors, amounting to a majority of the House Democratic Caucus and the most in the bill’s history.

This bill – like other single-payer proposals – is the precise antithesis of Paul Ryan’s AHCA. Rather than extract coverage from millions to provide tax breaks for the rich, it would use progressive taxation to provide first-dollar health coverage to all.

Which of these three visions will win out is uncertain, but the outcome of the contest will have a lasting impact on the country. We can only hope that the thuggish, rapacious vision championed by Trump and his administration does not prevail.

https://www.theguardian.com…

Single Payer Benefits

By Jack Mayer, M.D., M.P.H.
Vermont Public Radio, May 25, 2017

Winston Churchill once quipped that, You can always count on Americans to do the right thing – after they’ve tried everything else.

I like that quote because it allows me to be cautiously optimistic that in the end, the current chaotic health care debate may actually result in a Medicare-for-All, single payer system.

We already have a limited form of this in Medicare and Medicaid. Both work very well and provide excellent care for all who are eligible.

I’ve been a Vermont pediatrician for decades and I’ve been advocating for a single payer system since medical school. Obamacare – also known as the Affordable Care Act or the ACA – was a modest step towards universal coverage, but its repeal and the Republican bill to replace it will be dangerous for my patients, because there are multiple problems with the American Health Care Act – or what I prefer to think of as Trumpcare.

According to the Congressional Budget Office, if the proposed Trump/Republican health care plan passes, 23 million will lose insurance, premiums will rise, pre-existing condition protections will be at risk, Medicaid will be slashed, costs will be shifted to hospitals, clinics and states, and huge tax-breaks will accrue to people with incomes over $200,000, as well as big insurance and drug companies – while the rest of us get virtually no tax relief.

Almost every medical organization and AARP opposes this Republican plan.

But any insurance-based system will be dependent on the obsolete medical insurance industry, as it acts as an intermediary between providers and patients, without providing even one iota of care. And this places enormous administrative burdens on providers, while producing dubious outcomes. No other country pays as high a proportion of GDP towards health care and gets less quality and access than the United States.

A single payer plan would simplify the delivery of health care – and would do so with greater equity and fairness. Every other industrialized country provides a system of inexpensive, universal access to health care in recognition that health care is a human right, not a free-market commodity.

Without affordable access, children born into struggling families lose health insurance, and families go into debt or bankruptcy. Untreated children and adults suffer, thousands die.

Perhaps after trying everything else, Americans will finally see the wisdom in a system that would be equitable, simpler, less expensive, and provide excellent care for everyone.

audio here:
http://digital.vpr.net…

Ethics of equitable versus equal in health care

Health Insurance Benefits Should Be Equitable, Not Necessarily Equal

By Betsy Q. Cliff, Michael Rozier, and A. Mark Fendrick
Health Affairs Blog, May 22, 2017

As policy makers grapple with potentially undoing or modifying the largest expansion of health insurance in a generation, the cost and generosity of benefits hold center stage. Traditional underpinnings of insurance plans — premiums, deductibles, copayments, and coinsurance — frequently create barriers to the optimal use of these plans by consumers. They also can exacerbate inequities in health care, by inhibiting the use of services known to benefit health. Novel approaches to insurance plan design to produce a more equitable and efficient distribution of health care expenditures are warranted.

Following the principle of equality, insurance benefit designs traditionally have offered the same benefit structure to all enrollees. Consumer cost sharing at the point of service is typically uniform regardless of need or potential clinical benefit — often it’s based on the acquisition cost. This one-size-fits-all mentality seems like a great idea on the surface but can create deeply unfair outcomes.

Instead, we should be designing insurance coverage in a way that provides access to care for people who need it, when they need it. That requires a subtle but important shift from equal access to equitable access. The first approach treats all people, regardless of clinical need, the same. The second recognizes that clinical need is an essential factor in determining where to direct resources and does not apologize for treating people with different needs differently.

A feasible and effective approach to better aligning expenditures with patient-centered outcomes is value-based insurance design (VBID). VBID structures consumer cost sharing around the idea of clinical nuance, which recognizes that the value of medical services depends on who receives it, who provides it, and where it is provided. This nuanced strategy supports the goals of equity by reducing financial barriers to specific services for targeted populations who need them most. This approach can also be used to deter the use of services when there is low or no expected clinical benefit to the patient.

Equity Versus Equality

The concept of equity is most often applied to health outcomes, in terms of addressing the burden of disease borne by one group compared to another. The solution to these inequities often involves assessing the distribution of health determinants and allocating resources accordingly.

Equity is also embedded in the financing of our health system. For example, Medicaid Disproportionate Share Hospital payments follow the principle of equity rather than equality: Health care organizations that bear the greatest share of uninsured or underinsured patients receive the largest share of funds from this program.

In most situations, a fair health care system ought to concern itself more with equity than equality. If people responded identically to, and had equal need for, clinical services, then access to those services should be equal. Since this is clearly not the case, it makes sense to discriminate based on the likelihood of clinical benefit. In other words, we should not let the potential negative effects of “bad” discrimination (for instance, failing to prescribe a drug based on a person’s racial or sexual identity) obscure the potential advantages of “good” discrimination, which would make it easier for some groups to obtain a service based on clinical need. Equity is premised on the idea that some types of discrimination — treating unequals unequally — is not only good but also necessary.

In particular, tailoring insurance benefits in this way allows individuals to access the best care for their clinical situation. To help ameliorate disparities, patients who are in the most need and services shown to have the most benefit should be supported by their insurance coverage at the most generous levels.

Ensuring Access Through Equitable Benefits

Allowing benefit programs to adapt to those who are most likely to benefit from care could allow physicians to better tailor treatment to each patient and allow patients to better respond to evidence-based recommendations. Using VBID promotes this goal in three distinct ways.

First, VBID reduces cost sharing for specific services that are shown to have the highest clinical benefit.

Second, VBID enhances benefits for specific patient populations.

Third, whereas traditional benefit designs can keep people from accessing innovative medications due to higher cost, VBID can help tailor cost sharing to the specific clinical circumstance.

Coverage arrangements in most insurance plans are designed under principles of equality rather than equity. To fully realize the benefits of medical advances, ensure access for those who could benefit most, and enhance the efficiency of our health care expenditures, we need to change this paradigm. Equitable benefit design recognizes that many chronic conditions often require tailored therapies for achieving results and allows for discrimination based on clinical need. Better health outcomes, especially for those most in need, require us to apply principles of equity in all aspects of our health care system, including benefit design.

http://healthaffairs.org…

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Comment:

By Don McCanne, M.D.

The concepts of equitable and equal, as applied to health care, are certainly crucial. It is imperative that health care and the financing of it be equitable – fair – but it does not necessarily have to be equal. This article discusses these concepts in regard to value-based insurance design (VBID), appropriately reflecting the biases of a University of Michigan health management and policy professor (and a partner in V-BID Health), A. Mark Fendrick, and two of his graduate students.

It is clear that our fragmented, multi-payer health care system is neither equitable nor equal. Because of the great variety of health care financing systems in the United States, or lack thereof, people certainly do not have equal access to health care services and products. Nor is the system equitable since some are served very well when in need, and others are served poorly, if at all. There is an inherent unfairness in having impaired access to the most expensive health care system in the world.

The authors recognize that insurance design contributes to these inequities. They suggest that they could be diminished by redesigning benefits so that they are value-based. But they limit their considerations by adhering to the ideology of consumer-directed health care in which patients share in the costs of health care services as they are accessed (deductibles, copayments, coinsurance, tiering of benefits, penalties for out-of-network care, etc.). Thus their emphasis is on insurance design rather than on more direct financing of essential health care services.

This approach perpetuates and adds to the complexity and waste of our uniquely American health care financing system that is weighted down by profound administrative excesses. Tweaking benefits within an individual plan certainly does not make the benefits equal to those in a multitude of other private and public plans. Even if value-based tweaks were adopted by many other plans and programs, the overall impact on health care would be almost infinitesimal compared to the great needs we have in health care reform.

Much more important than not creating equality, VBID also would have too small of an impact on health care equity. Jiggering benefits would not begin to address the deficiencies that the uninsured and underinsured face, perpetuating our profound unfairness in health care access and affordability.

So let’s set private insurance plans aside and look at these concepts in the single payer model of health care financing. How do you make the system equitable – fair? You make it accessible and affordable for everyone. Central planning and budgeting of capital improvements ensures that health care facilities and professionals are as available as the logistics and resources would allow.

Affordability? Considering the profound inequality in income and wealth and the very high costs of health care, payment into the common risk pool must be based on ability to pay if financing of the system is to be equitable. This is accomplished through progressive tax policies. There could not be a more ethical example on why our health care system must be equitable, but not necessarily equal. An equitable system would be designed to make sure that essential health care benefits are available to all, and thus equal (though benefits that should not be funded by a public system would not be equal), but the financing, to be equitable, must not be equal.

We can forget about the value-based benefit tweaks for private consumer-directed health plans. We need real fixes in our health care system that are universally equitable.

Dr. Phil Verhoef speaks at Medicare-for-all press conference

Transcription by Kay Tillow
Daily Kos, May 24, 2017

A few hours before the CBO announced that 23 million Americans would lose their health insurance under the Republican health care bill passed by the House, Congressman John Conyers, seven co-sponsors of HR 676, and representatives of physicians and nurses groups gathered near the Capitol to announce the amazing growth of both public and Congressional support for single payer.

The following remarks were made by PNHP board adviser Dr. Phil Verhoef:

So I’m an ICU physician at the University of Chicago and as an ICU physician I depend on research and evidence to help inform me about how to practice medicine, how to take care of critically ill kids and adults in the ICU.

But I look at our current health care system, and when I look at the evidence and when I look at the research, I’m pretty sure that our health care system is also critically ill. Why do I say that? Well, look, based on research published last week we ranked 80th out of 195 countries and that is by far the worst of the developed countries in this world.

But more importantly we have 30 million uninsured patients in this country. What that means based on research and evidence is that we will have no less than 20,000 deaths this year because of that lack of insurance. That is unacceptable.

On top of that costs are out of control.

We spend the most per person out of pocket on health care. We spend the most per person per GDP. We spend the most on every possible measure that you can think of.

And so we are failing on every front…this is a critically ill health system. So I say, as a critical care physician, What’s the solution?

Well, one solution has been proposed in Trumpcare and I can tell you that I’m pretty sure, even without CBO’s report which we expect later today, that this is actually going to make our critically ill system even worse.

It’s a little bit like giving grandma a heart attack when she is already in the ICU for pneumonia And so ultimately why would that happen? So look, if 24 million people lose health insurance, that’s another 20,000 deaths that we can lay at the feet of the architects of this awful bill.

Second, this bill (Trumpcare) achieves financial responsibility by providing a humongous tax cut to actually destabilize Medicare at same time that it guts Medicaid. So what that really means is that we are balancing the books on the backs of senior citizens, children, people with disabilities and the poor.

And this just doesn’t make any sense to me.

But we have a solution, we have a therapy for this critically ill patient, our health care system, and that is HR 676, improved and expanded Medicare for All.

Again I turn to research and evidence based on studies from other countries around the world that use similar systems, it saves lives, it saves money, it improves health outcomes.

The thing that burns me up is that we have a solution on the books and there is not political will to move forward with it except for Congressman Conyers and the 111 cosponsors that have been supportive.

As an ICU physician, I know what the solution to our critically ill system is and that’s HR 676 Improved and Expanded Medicare for All and I hope to see political will to stop the deaths of people for lack of health insurance.

full press conference transcription:
http://www.dailykos.com…

full press conference video: