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Ethics of equitable versus equal in health care

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:

Single Payer In California? Can We Afford It? Can We Afford Not To?

By Paul Y. Song, M.D.
HuffPost, May 24, 2017

This week, the California State Senate Appropriations Committee released their fiscal analysis of SB562 sponsored by Senators Lara and Atkins. Opponents immediately screamed that #SB562 would cost $400 billion per year, more than three times California’s $124 billion general fund budget for next year.

It is very important to understand that the author indicates that this analysis was done while much of the specific details of the proposed legislation are still not finalized, and therefore the assumptions are quite general and conservative. Still, the summary reports that annual government spending on health care is roughly $200 billion, while employers spend $100 to $150 billion towards covering their employees. Without any mention of what individuals currently pay for premiums, co-pays, deductibles, and prescription drugs, the additional required “total new spending” would therefore be $50 to $100 billion per year. So under this worse case scenario, this would be between $106 and $212 per month per Californian in additional taxes.

Now before everyone gets scared away by this daunting price tag, it is important to look at these two graphics to put this into a much needed perspective.

Fig. 1
Fig. 1

Over the past 16 years, workers have had to contribute 221 percent more toward their employer-sponsored premiums (Fig. 1), while premiums have increased 203 percent and wages and inflation have lagged far behind.

Fig. 2
Fig. 2

At the same time, in addition to contributing more towards their premiums, workers have also had to pay more (Fig. 2) in co-pays and deductibles (67 percent more over the last 5 years). Thus in reality, workers are getting squeezed on both ends while having less take home pay. Many would argue that they are already paying upwards of $106 – $212 a month towards medications, co-pays, deductibles with no end in sight. This all goes away under #SB562!!

Plus, if everyone has improved coverage, powerful hospitals can no longer gouge us upwards of 331 percent (Fig. 3) with exorbitant prices for aspirin, hospital stays, OR use, etc. (Fig. 4) under the guise that it is needed to pay for uncompensated care which many not-for-profits fail to provide inadequate amounts of (Fig. 5).

Fig. 3
Fig. 3

Fig. 4
Fig. 4

Fig. 5
Fig. 5

And when Kaiser and United Healthcare use their massive market share to negotiate steep drug discounts, it is considered good free market business sense. So why is it bad if our single payer negotiates similar discounts for all of us?!

Please do not let the sticker price scare you. Healthcare is indeed expensive and our current system is unsustainable not to mention immoral and broken. Left as is, it is estimated to consume 20 percent of our GDP by 2025 while tens of millions remain uninsured nationally unless we really do something about it. With a GOP congress which places trickle down ideology above compassion, the health of nearly 1 out of 3 Californians who are on Medicaid remains under constant threat, not to mention the millions with pre-existing conditions, women, and our older folks. SB562 is truly the only way to proactively protect our health security by fixing our badly broken system while providing every Californian with true healthcare peace of mind. And at a price which is more than reasonable in the context of no more outrageous premiums, co-pays, or deductibles.

Some say we cannot afford it. It is clear that we can no longer afford not to.

Dr. Paul Y. Song is a national board member of Physicians for a National Health Program and co-chair of the Campaign for a Healthy California.

http://www.huffingtonpost.com…

House Democrats See ‘Medicare For All’ As The Answer To Trumpcare

Rep. John Conyers’ single-payer bill has never been this popular.

By Daniel Marans
HuffPost, May 24, 2017

House Democrats on Wednesday touted unprecedented majority support for a bill that would expand Medicare to the entire U.S. population, reflecting a growing liberal consensus behind single-payer health insurance.

Rep. John Conyers (D-Mich.), who has been introducing single-payer legislation since 2003, said at a press conference that Democrats must counter the Republican bill to repeal the Affordable Care Act with support for “Medicare for all.”

“Obviously we’re all united in opposition to Trumpcare. That’s easy,” he said. “People know what we’re against, but we want to promote more what we are for.”

The press conference was scheduled to take place hours before the nonpartisan Congressional Budget Office released its assessment of the updated version of the Obamacare repeal bill that the House of Representatives passed earlier this month.

Conyers was joined by Democratic Reps. Bonnie Watson Coleman (N.J.), Steve Cohen (Tenn.), Ro Khanna (Calif.), Jamie Raskin (Md.), Keith Ellison (Minn.) and Mark Pocan (Wis.), the newly elected co-chair of the Congressional Progressive Caucus.

Like many progressives, Conyers has long said that the problems bedeviling the American health care system are rooted in its reliance on private insurance.

“We will never get universal care built on a foundation of private, for-profit insurers,” he said. “The only way we will get there is the way every other advanced country on the planet has, through a universal system like expanded Medicare.”

Critics like Conyers argue that Obamacare is flawed because of too little, not too much, government intervention.

The reform law enlarged private insurance rolls by requiring anyone in the individual market above a certain income level to seek coverage in government-regulated private insurance exchanges ― and providing them subsidies to do so. Now the number of insurance options in these markets has begun to dwindle because for-profit companies find it too costly to cover new enrollees, who tend to be sicker than the general population.

There are a number of ways that the federal government could entice insurers to stay in the exchanges, such as reimbursing them for their highest-cost cases and improving how they enforce the individual insurance mandate. But if private insurers were not part of the equation, these triage measures would be unnecessary.

Progressive single-payer advocates say that these challenges, along with the unprecedented political threat to Obamacare from President Donald Trump and congressional Republicans, have created the right political moment to push their ideal into the party’s mainstream.

Sen. Bernie Sanders (I-Vt.), who turned “Medicare for all” into a progressive rallying cry with his insurgent presidential campaign, plans to introduce companion legislation to Conyers’ bill in the Senate this summer. His single-payer bills have not attracted any co-sponsors in the past.

The growing level of support for Conyers’ bill suggests this time might be different. The legislation, known as the Expanded and Improved Medicare for All Act, has 111 co-sponsors ― including Dels. Eleanor Holmes Norton of D.C. and Gregorio Sablan of the Northern Mariana Islands, who can’t vote on legislation on the House floor. Still, it is a solid majority of the 193-member House Democratic Caucus and the most support such legislation has ever received. The bill has even attracted support from some fiscally conservative members like Rep. Jim Cooper (D-Tenn.).

The previous high-water mark for Conyers’ bill was in 2008, when 93 of his colleagues got behind it. The Democratic caucus was much larger at the time, however, so the bill’s supporters constituted a smaller proportion. Last Congress, the bill attracted just 63 co-sponsors.

House Assistant Minority Leader James Clyburn (D-S.C.) and Democratic Caucus Chair Joseph Crowley (D-N.Y.), both members of leadership, have co-sponsored the bill.

Yet single-payer legislation would undoubtedly face a steep climb, even if Democrats took back the House in 2018. Currently, Medicare requires co-payments from seniors and people with disabilities above a certain income level.

House Minority Leader Nancy Pelosi (D-Calif.) said earlier this month that “the comfort level with a broader base of the American people is not there yet,” and encouraged activists to try to enact single-payer plans at the state level first.

In addition to extending Medicare coverage to the whole population, Conyers’ bill would improve on Medicare’s coverage levels by having the government pick up the entire tab for everything from preventive care visits to dental care.

To pay for this expansion, the law would increase personal income taxes by 5 percent for higher earners, institute a new tax on worker payroll, and levy new taxes on investment income and financial transactions.

But Conyers’ bill is also deliberately vague on some of the details. Aside from the income tax hike, the legislation does not specify the levels of all the new taxes, or the earnings thresholds where they would take effect. But a 2013 analysis of the bill by Gerald Friedman, an economist at the University of Massachusetts, Amherst, assumed that the new high-income surtax would increase taxes on households earning $225,000 or more by 6 percent, and the payroll tax would levy new 3 percent or 6 percent taxes on employers of all workers.

Ultimately, the taxes on workers and employers would be a net financial win for the country, saving Americans nearly $600 billion a year in lower health care costs, according to Friedman.

But when the reality of those upfront tax increases sets in for members of Congress, it could be a tough sell.

What’s more, several efforts to wring savings from private health care providers during the crafting of Obamacare collapsed as Democrats succumbed to industry pressure en masse. Since Conyers’ bill envisions that the government will use its bargaining power to bring costs into line with those of other countries, it could face similar resistance from providers.

State-level experiments with single-payer health insurance face similar if not greater challenges due to the size of their risk pool. Vermont tried to adopt a single-payer health insurance plan in lieu of Obamacare, but gave up when the costs of transitioning to the the new system proved too great.

Some progressive groups, including the National Nurses United, are now throwing their weight behind a serious effort to create a single-payer health insurance system in California. The plan could cost as much as $400 billion a year, according to a legislative analysis released Monday and conducted at the request of state lawmakers promoting the policy. Half of that amount would have to be raised through new taxes.

Challenges notwithstanding, progressive activists and Democratic lawmakers are tired of asking for less than what they really want and encountering unified Republican opposition anyway.

Even if it stands no chance of approval in the short-term, they say that a push to expand the popular Medicare program is a political winner that can help Democrats take back Congress.

At Wednesday’s press conference, Pocan observed that town hall discussions about implementing “Medicare for all” draw a more enthusiastic response than any other issue. He said the issue was widely praised at a town hall he recently held in in Kenosha, Wisconsin, which is in Republican House Speaker Paul Ryan’s district.

Indeed, 60 percent of Americans favor extending Medicare to the entire population, according to an Economist/YouGov poll from April.

Ellison, who is deputy chair of the Democratic National Committee, emphasized that no one in the DNC would tell lawmakers and candidates what position to take on a given issue ― but the power of suggestion is fair game.

“I recommend that you win your election, and I think a good way to do it is to support the Conyers bill,” he said.

http://www.huffingtonpost.com…

Townie right on AHCA provisions

By Thomas O’Rourke, Ph.D., M.P.H.
The (Champaign, Ill.) News-Gazette, May 23, 2017

Kudos to Ryan Jackson (the Reluctant Townie) for his recent excellent article. “Rodney Davis voted for your death panel” by supporting the American Health Care Act that barely passed the House, 217-213.

Let me add a few other points. Besides taking $880 billion out of Medicaid, it would take another $312 billion out of subsidies that help working families buy private coverage through the Affordable Care Act exchanges. Instead of helping people get care, this money would be diverted to give an $800 billion tax break to people with incomes over $200,000.

Davis’s vote threatens to strip coverage from 57,300 people in our district.

But it doesn’t end there. If the ACA is entirely or partially repealed, 413,700 individuals in the district with employer-sponsored sponsored health insurance are at risk of losing important consumer protections such as coverage of pre-existing conditions and the prohibition on annual and lifetime limits.

Also, 377,200 individuals in our district with health insurance covering preventive services like cancer screenings and flu shots without any copay, coinsurance or deductibles stand to lose their access if the Republican Congress eliminates ACA provisions requiring health insurers to cover important preventive services without cost-sharing.

Undeniably, the ACA is flawed. It left 28 million Americans uninsured and millions more with unaffordable premiums, deductibles and copayments.

But the GOP plan would make things much worse.

Instead of moving backward, we should move forward and go from the ACA to a Medicare for All plan like the one proposed by Rep. John Conyers (H.R. 676).

http://www.news-gazette.com…

U.S. Health Care is Profiteered to Death

Interview with Susan Rogers, M.D.
Black Agenda Report, May 23, 2017

The following is an unofficial, lightly edited transcript of an interview that Dr. Susan Rogers, PNHP national board member, gave to Glen Ford, executive editor of the Black Agenda Report, on May 23. You can listen to the interview above.

Glen Ford: Obamacare remains in a kind of limbo in the U.S. Congress, having been repealed in the House but with no action pending in the Senate. On the single-payer health care front, a majority of House Democrats have finally signed on to Congressman John Conyers’ Medicare for All bill. However, Democratic Party leaders have not gotten behind the measure. And Bernie Sanders has not introduced a single-payer bill in the Senate. In Chicago we spoke with Dr. Susan Rogers, a board member of Physicians for a National Health Program.

Dr. Susan Rogers: I think that it’s just politically difficult for a lot of these congressmen to take a stand for single payer, although, clearly, they cannot support the Republican bill that has been passed in the House. And even the Affordable Care Act: many people know that there are some significant issues with that. There are some positives in the ACA, of course: the fact that people can get coverage for preexisting conditions, that kids can stay on their parents policy till they’re 26. But the Affordable Care Act doesn’t eliminate the whole issue of private-insurance-sponsored health care, which is – that’s the biggest problem. That’s where all the high deductibles are coming from, the copays, the tiered drugs and all of the expenses that are being shifted onto patients. That, the Affordable Care Act does not fix.

GF: I was surprised to see even a Republican seem to admit that single payer’s time has come. That person was defending the Republican bill that would allow states to opt-out or opt-into plans, as this congressman mentioned, “so they could have their single payer or they could have our plan,” which seemed to be an admission that single payer is on the horizon anyway.

SR: That is true. I think a lot of people will say that. However, to have just a small segment of the population in a single-payer system won’t work. That’s been the problem with the public option: the people who would end up being in the public option are people who couldn’t get affordable insurance elsewhere. So here you end up with a pool of people who have a lot of medical issues at high cost. And that’s why that public option or small single-payer systems would not work. I mean, if you look at Medicare, it covers everybody over 65. We all know that’s a very heterogeneous group, in terms of some people who are very, very healthy, and some people who are high utilizers of health care. The pool works because you’ve diluted the risk: you have healthy people and sick people in the same large pool. And that’s the way a single-payer system would work. Everybody has to be in it.

GF: Single payer seems to work in every industrialized country in the world. But folks in the United States, Democrats as well as Republicans, act as if the U.S., the richest country in the world, can’t afford it.

SR: Well, we still have this assumption that health care is a commodity and that the markets dictate how it functions. Buying health care isn’t like buying a car. Everybody needs the same coverage and health care. Everybody doesn’t need the same kind of car. Everybody doesn’t need the same kind of house. So that’s where the market comes in, it’s when people have choices with things. But people talk about choice of health care, which really, when you think about it, makes no sense. Do you know what your health care needs are going to be next week? You have no clue. You assume they’re going to be what they are today, but you don’t know. That’s the whole point of insurance, is to cover you for the unexpected. So to make buying health insurance a matter of choosing what’s best for you – the whole basis of that argument is false. It’s not applicable, because you don’t know what you’re going to need. So you have to be covered for everything. And that’s why people who buy private insurance often end up being exposed to the phenomenal bills, these high deductibles these co-pays, that send them into bankruptcy.

GF: And the net result is that the United States pays more per capita for health care than anybody else in the world – without assuring insurance for everybody

SR: Yes we do. And an interesting part of that number, too, is that the majority of those dollars are already government dollars. So the government is already paying the majority of that per capita expense. Not just Medicaid, not just Medicare, but in terms of the premiums for government employees – all teachers, all policemen, all firemen. All these people get their health premiums paid for in large part with government dollars. And then when you look at the tax write-off by employers for what they spend on employees’ premiums – that’s an additional cost to the government. So the government is already spending more than other countries, and that’s without the additional cost of the costs they’re putting on patients so they have so-called skin in the game. So the government is already paying more than everybody else, so the whole idea that there isn’t money is not true. We would save so much money by eliminating all the administrative costs. It’s ridiculous the amount of time and money that gets spent in administering a system like this that is so complex and so tedious. It’s difficult even for me as a physician who had some medical issues this last year. I found it difficult to navigate the system. So I can’t even imagine how someone who does not understand health care can figure a way through it. It’s impossible.

GF: So it’s not a question of expense which is already exorbitant, but who gets paid and who profits.

SR: That is exactly true. And the ones who are going to get paid are the health insurance companies. There’s no question about that. And if you look at a large hospital, I bet they’ve got more billing clerks than they do nurses per patient. That just tells you where the money is going. It’s not going to health care, it’s going to billing. And if you look at the electronic medical record, which was supposed to be developed to make health care better – so that if you go to a hospital in New York and then see somebody in California, the two doctors should be able to talk, but they often can’t or don’t. The drive for electronic health records, EHRs, was really driven by billing. It was not driven by the need to improve health care or clinical care. It was driven by a way to bill, and that’s the whole concept. So it really isn’t helping health care. It may be a little bit because we can read the notes now of physicians with poor penmanship, but it’s not lowering medical costs. In fact it’s driving costs up.

GF: As a physician, as a person as an activist medical person, what would you like to see happen to get the Congress off the dime on single payer?

SR: I would like to see Congress get educated about this. I have talked with many people who have gone to town hall meetings and had firsthand discussions with representatives across the country. I can speak mostly to people I know who have done so in Illinois. One thing that’s clear. They talk about is just how the congresspeople are so – they don’t know what the system is. They’re actually ignorant about the problems. I hate to use that word because it’s a strong word, but some of the comments that have been made, like “Nobody has died because they didn’t have access.” I mean, where does this person live? What bubble are they living in? And that’s part of the problem – these congressmen are living in bubbles and have no idea of what everyday people go through just to get their health care needs met. And then there is this other assumption too, that the biggest driver of costs in health care are the unhealthy lifestyles of people. That may be true in the sense that some behaviors do lead to more cardiovascular disease, for example, but we have to remember we are all mortal. We are all going to get sick whether we lead a perfectly healthy lifestyle or not. So we all are going to need health care.

GF: That’s right. Almost all of us will die of disease at some point.

SR: Exactly. And even if we die of trauma, there’s still health care in that issue. So the whole idea that staying healthy will prevent you from using health care dollars is a falsehood, because we will all eventually need health care. I know very healthy people who have gotten cancer. I know very healthy people who have gotten heart disease. I know very healthy people who unfortunately lived in an area with bad air and ended up with lung disease. So it’s not just because of poor lifestyles, because obesity is a big problem. Clearly that’s a factor. I’m not denying that. But that’s not what’s necessarily driving up health care costs.

GF: That sounds like the ever-present factor of prejudice in American political thought.

SR: Well, yes, if you look at the health care industry lobby, it’s a huge lobby that has poured billions and billions into congressional races and stuff. And so that’s who people are beholden to. And unfortunately it’s been clearly shown that the congressmen are voting for their donors, not for their constituents.

GF: That was Dr. Susan Rogers of Physicians for a National Health Program.

https://soundcloud.com…

Would California’s proposed single payer system bankrupt businesses?

California Senate Committee on Appropriations: SB 562 (Lara) – The Healthy California Act

By Brendan McCarthy (Consultant)
May 22, 2017

Bill Summary: SB 562 would create a universal, single-payer health care system in California.

Fiscal Impact: The fiscal estimates below are subject to enormous uncertainty. Completely rebuilding the California health care system from a multi-payer system into a single payer, fee-for-service system would be an unprecedented change in a large health care market.

The projected costs and revenue needs for the proposed Program are as follows. For a discussion of the underlying assumptions, see Staff Comments (link below).

* Total annual costs of about $400 billion per year, including all covered health care services and administrative costs, at full enrollment.

* Existing federal, state, and local funding of about $200 billion could be available to offset a portion of the total program cost.

* About $200 billion in additional tax revenues would be needed to pay for the remainder of the total program cost. Assuming this tax was raised through a new payroll tax (with no cap on the wages subject to the tax), the additional payroll tax rate would be about 15% of earned income.

It is important to note that the overall cost of those new tax revenues would be offset to a large degree by reduced spending on health care coverage by employers and employees. Although precise estimates of total spending for employer sponsored health insurance are not available, the best available information indicates that existing spending is between $50 and $100 billion per year. Therefore, total new spending required under the bill would be between $50 and $100 billion per year.

Administrative cost savings would be real, but limited

Under a single payer system, the overall administrative cost of the system would likely be lower than it is in the current multi-payer system. In the United States, the cost of the health insurance industry is about 7% of total costs. In addition, providers, such as hospitals and physicians, incur significant administrative costs to negotiate contracts and comply with health insurer billing requirements. If we assume that the costs on the provider side are equal to the costs of the insurance industry, then current administrative costs are likely to be about 15% of total spending. Administrative costs in the Medi-Cal fee-for-service system and Medicare are about 6% of spending. Assuming that dealing with a single payer system reduced provider administrative costs by half, total administrative costs of the system in the bill would likely be about 9-10% of total spending. This does represent a significant savings in a $400 billion health care system. However, administrative savings are not likely to substantially lower the overall cost of providing health care to the state, compared to costs associated with expanding coverage to the uninsured and increased utilization of services under the bill.

https://ww2.kqed.org…

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Comment:

By Don McCanne, M.D.

With the release of this fiscal analysis of SB 562 – The Healthy California Act – the expected loud protests to the high costs of a single payer system have been forthcoming, especially that the costs would exceed the California state budget and that raising the additional funds required through a 15% payroll tax would bankrupt businesses. The opponents conveniently ignore the opening caution that “the fiscal estimates below are subject to enormous uncertainty.”

In fact, this 8 page analysis is loaded with assumptions and uncertainties based on the lack of detail specified in the proposed legislation, as the author indicates. Health care is almost one-fifth of our gross domestic product, and, by any accounting, that is very expensive. But this does not change fundamental single payer principles. All of the health care funds are moved into a single, publicly-administered system which is administered much more efficiently and which is funded on an equitable basis (which requires progressive taxes because of the decades-long shift of income and wealth to the top).

The opponents have already declared that this legislation is a failure based on the high global costs and the assumption that a payroll tax would replace current private spending. Reading the full report would provide a more objective perspective, in spite of the multitude of uncertainties.

At any rate, those who dismiss this legislation based on spending greater than the California state budget and a 15% payroll tax must be challenged. Our response? This bill would provide each Californian with all essential health care services at a price that each can afford.

Why Won’t More American Corporations Support Single-Payer Health Care?

Warren Buffett is rare among CEOs in publicly recognizing the economic benefits of Medicare for All.

By Helaine Olen
The Nation, May 22, 2017

Talk of single-payer health care in the United States popped up in an unexpected place recently: the most recent Berkshire Hathaway annual meeting. “The whole system is cockamamie,” the company’s vice chair, Charlie Munger, declared. “I think we should have single-payer medicine eventually.” As for partner Warren Buffett, the man known by his fans as the Sage of Omaha, he called health-care costs “the tapeworm of American economic competitiveness” and claimed he “personally” supported a single-payer system.

Those of us who cover individual investing know that the utterings of Buffett and Munger are generally repeated, and repeated again. They turn into aphorisms—how many times have you heard it said of the stock market, “It’s only when the tide goes out that you learn who’s been swimming naked?” But when it comes to health care, it’s something else. There is a day or so of attention, and then it’s nothing but crickets.

What’s going on? You can thank a toxic stew of ideological blindness, fear of controversy, and rampant cost shifting for the silence. The size and power of the industry is a factor too. Healthcare “is the military industrial complex of the 21st century,” says Richard Master, the chief executive officer of MCS Industries, a supplier of picture frames based in Pennsylvania, and the rare C-suiter to publicly support single-payer.

The United States spends more than $3.3 trillion on health care annually. Employer-based insurance covers about half the non-elderly population. The cost is not unsubstantial. Medicare spends less than 2 percent of its budget on administration vs. 18 percent for private insurers. According to the Kaiser Family Foundation, the average premium for a family was $18,142 in 2016. The typical employer picked up about two-thirds of that total. The numbers are adding up, and the politically vaunted small-business sector is yowling. The National Federation of Independent Business’s 2016 Problems and Priorities survey found more than half of those they polled claimed the cost of health insurance was “a critical issue,” they faced.

Healthcare costs also eat away at American business competitiveness. Prior to the Great Recession, General Motors claimed that providing health-care coverage adds another $1,500 onto the sticker price of every new model sold. Starbucks reported around the same time it spent more on health care than on coffee beans. The Affordable Care Act has slowed the overall pace of health-care spending, which nonetheless still exceeds the rate of inflation.

Buffett’s economic point—one he’s made for a number of years—is that corporate honchos obsess about the weight of taxes on their bottom line when they should be pondering the impact of skyrocketing health-care costs instead. For years, he’s pointed out that health-care expenditures were approximately 5 percent of the gross domestic product in the 1960s. Now they are at about 17 percent. Other countries spend significantly less. Healthcare costs make up 11 percent of Canada’s gross domestic product. In Australia—about which Donald Trump recently said, “you have better health care than we do”—it’s approximately 9 percent.

But all this spending isn’t exactly doing wonders. About one in ten American adults still doesn’t have health insurance. Our reputation for world-class care might be a tad exaggerated; our maternal mortality rate has increased substantially since 2000. Never mind the moral argument for health care for a moment. Pay more money for lesser results? Surely, no sane businessman or businesswoman would want to deal with this, not for one blasted moment. In this environment, business and corporate support for single-payer/Medicare For All/whatever you want to call it should be the proverbial no brainer.

But it’s not. Many in the United States business world remain in thrall to a marketplace ideology, mixed with a whiff of self-help. The glory of the market is paramount, and any attempt to enhance the role of government—even when it is in the best interests of the players to do so—is looked on with suspicion. For example, when runaway medical costs caused mass business agita, former Safeway CEO Steve Burd founded a group called the Coalition to Advance Health Care Reform. It endorsed universal coverage but argued it needed to be “market-based” and offer “universal coverage with individual responsibility.” These days, people needing insurance or medical care are routinely referred to as “shoppers” who should compare the price of medical services like they would a can of peas.

The American Sustainable Business Council, a left-leaning business trade group, is now seeking to change things. It recently debuted, in conjunction with a documentary, Big Pharma: Market Failure, an action group called Business Leaders Transforming Healthcare that is making the case for single-payer as a business imperative. More than 150 businesses have signed on to the campaign, including Richard Masters’s MCS Industries, who is also in the film. But it’s going to be a battle. Many of the American Sustainable Business Council’s most recognizable corporate partners have yet to join in.

In an effort to find out why, I contacted Ben & Jerry’s, Eileen Fisher, Patagonia, Seventh Generation, Dansko, Etsy, and The Honest Company—all members of the council who have yet to sign onto the health care campaign. A spokeswoman for Ben & Jerry’s told me, “We all know the US health-care system is broken,” adding, “We believe strongly that everybody should have access to quality care” and that the company could not make a decision on whether or not to sign on to the initiative “until we have formulated our position.”

Jessica Alba’s The Honest Company—a self-described “mission-driven company” dedicated to, among other things, “corporate social responsibility” and “taking selfless actions that benefit others”—wrote back that they work with the American Sustainable Business Council on “issues related to chemical safety and ingredient disclosure” and aren’t “currently engaged” in other initiatives with them.

The others ignored me. I can’t say I am surprised. Corporations are notoriously loath to endorse controversial positions, especially ones that have the potential to put them in the firing line of activists on one side or the other. Then there is the power of the health-care industry, which is responsible for the largest number of jobs added since the last economic downturn. Business leaders stick to the powerful until it’s all but unsupportable.

In lieu of asking for government help, many American corporations are dealing with the health-care expense in a time honored capitalist fashion: they’re sticking it to the workers. A majority of those with employer provided health insurance now have a deductible of at least $1,000, which partly explains why out-of-pocket health-care spending for someone with employer provided health insurance has increased by more than 50 percent since the beginning of the decade. Little wonder recent Congressional Town Halls feature many plaintive pleas for single-payer or a Medicare expansion.

Masters told me he thinks the comments at the Berkshire Hathaway meeting are a game changer. “It’s a remarkable green light for business leaders to start thinking about single-payer.” Maybe he’s on to something: The week that began with Munger endorsing single-payer ended with Aetna Healthcare’s chief executive officer Mark Bertolini saying the United States needed to “debate” single-payer but stopping short of endorsing it. “If the government wants to pay all the bills, and employers want to stop offering coverage, and we can be there in a public-private partnership,” he told a group of Aetna employees in a private conversation subsequently leaked to Vox, “then let’s have that conversation.”

https://www.thenation.com…

What do leaders of the medical-industrial complex think about reform?

Healthcare Strategy in the Year of Uncertainty; Even amid significant legislative ambiguity, reform remains a market-driven issue.

By Aamer Mumtaz, Alan London, MD, and David Fairchild, MD
Healthcare Financial Management Association, May 2017

Among the dozen C-suite leaders from leading health systems and AMCs in nine states who we interviewed over the past two months, most believe that the healthcare market has many of the same characteristics and challenges as it did in 2011: Cost growth is an issue, quality and value are ongoing concerns, and breaking even on government programs is a challenge. With some critical caveats, the appropriate short-term provider response thus will not be fundamentally different from the past seven years:

• The search for value will continue, with clinical integration, care coordination, and high-quality care still the paths to get there.

• Scale will become even more important as systems look for ways to reduce the per unit cost of care.

• Commercial insurance will remain the main engine of growth for providers, with Medicare Advantage the most attractive government program financially.

• Medicaid and the ACA marketplaces are wild cards. What happens in those spaces will be felt disproportionately by systems serving high numbers of underprivileged patients, including systems operating in rural areas.

• The move toward quality will continue despite the potential waning of government support for innovation.

• Speed to market for new initiatives in the pipeline will be important.

• Cost reduction and asset redeployment will be essential in an increasingly cash-strapped environment.

“No regret” moves

Providers are focused on moves that transcend the ongoing legislative and regulatory uncertainty and instead address more fundamental economic forces. Such moves include:

• Achieving scale through partnerships and alliances

• Commercial market growth (e.g., through targeted ambulatory expansion)

• Continued focus on Medicare Advantage

• Aggressive cost control

• Partnerships with health plans to share more risk

• Building the clinical network

• Slowdown or halt on long-term investments

Economics overshadows politics

Our preliminary discussions with leaders from major health systems around the country have cofirmed that healthcare reform remains driven primarily by market forces as opposed to legislative initiatives. As one West Coast executive told us, “The challenges facing health care are more economic than political.”

Just as in 2011, imperatives to reduce costs and to achieve profitable growth through the delivery of value remain key. In fact, cutting costs, improving clinical integration, and addressing quality and customer service needs — all while focusing on profitable markets for growth — arguably will be even more important strategies in 2017 and going forward than they were in 2011.

http://www.bdcadvisors.com…

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Comment:

By Don McCanne, M.D.

So who really determines the nature and scope of the health care delivery system? Is it the doctors and nurses? They are busy trying to make the system we have work for their patients, and they are having difficulties with that. Is it the politicians? They continue to feed the largest share of money into the system (taxes – often opaque – to pay for health care) while turning much of it over to the medical-industrial complex.

The medical-industrial complex is composed of interwoven, overlapping organizations and their executives that make spending decisions through various financing vehicles such as commercial insurance, managed care organizations, accountable care organizations, health plan administrators for public and private programs, and the like. According to this survey of C-suite leaders, they want more of it – more integration (anti-competitive consolidation), more care coordination (care management prioritizing executive business decisions), shifting care to where the money is (outpatient services now epitomized by the most expensive of all – free-standing emergency departments), more programs to promote “quality” (think MACRA and MIPS), more government financing of private insurance (prominent examples being Medicare Advantage and Medicaid managed care), while achieving scale in all of this (more and more of it), and they want it right now (before the social movement for health care as a right – single payer – can gain traction).

Many of the measures are touted as methods of controlling costs when the real cost containment efforts are directed to reducing volume and price as a method of ratcheting down the growth of spending on the actual health care delivery system. Although excessive prices and over-utilization are problems, so are under-utilization and inadequate pricing. Establishing barriers to care and not compensating the delivery system adequately do a disservice to patients and their health care professionals, especially when there are far more patient-friendly methods of containing spending, which also reduce the abuses.

Our current bearing will leave these people in charge, with more of the same. So what should we do? What should be our strategy and tactics? Is sticking placards in the faces of politicians and shouting “single payer” enough? Can we truly organize and coordinate with the greater social justice movement? Can we convince the medical-industrial complex that they need to be active participants and even leaders in a sincere movement for health care justice for all? They are going to be there whether or not we want them involved, though we should be able to cull those who really care for patients from those who are simply after acquisition of substantial personal wealth.

Regardless, take another look at what these C-suite executives have in store for us. It is terrible for health care professionals who really do care and even worse for patients. We can do far better with the $3.2 trillion we are already spending on health care (it’s our money!) than to turn it over to the medical-industrial complex and let them do with it what they will. As these authors state, “reform remains a market-driven issue” when we know that markets are anathema to health care justice.

No more feeble organizing. Let’s have the real thing.

A majority of physicians favor a single-payer health system

By Elizabeth Hakas, M.D.
Pittsburgh Post Gazette, May 21, 2017

As a person with 30 years of experience working in health care (first, as a medical assistant during college, and later, as a physician), I am very concerned about the GOP’s American Health Care Act. It will remove $880 billion in funding from Medicaid and remove the subsidies that help millions of Americans buy private health insurance. I must admit that I was not a huge fan of the Affordable Care Act (Obamacare), but the AHCA is much worse — a disaster in the making.

I will tell you my bias upfront: I am in favor of a single-payer system for our country, in which the government acts as “insurer” or “payer” and the care is provided through various means (private practices, community clinics, academic and community hospitals, etc. — just like now!) such as is the case in Canada. It would reduce administrative costs, and we could use the saved money to pay for care, rather than to line the pockets of insurance company executives. Such a system should be unconnected to one’s employment status and funded by taxes.

If we took all of the money that employers and workers pay toward their health “insurance” now, and instead called that “taxes,” it would be more than enough to provide excellent coverage for every single American. It just makes sense.

When I discuss this issue with my physician friends and colleagues, I am amazed at how many of them agree with this. I have yet to talk to a single physician who favors the AHCA over the ACA, and I have talked to many who favor single payer. This is in line with multiple national polls of physicians, which indicate that a national single-payer system (such as the Expanded & Improved Medicare for All Act, HR 676) is the most favored option among a majority of practicing physicians in this country. It is fair and morally correct that everyone in the U.S. have access to decent health care and that it be available consistently despite the changes that occur occasionally in most people’s lives: periods of unemployment, financial challenges, pre-existing conditions, etc.

I hope to see a single-payer health care system instituted in this country in my lifetime. In the meantime, we should all be vigorously rejecting the AHCA, which is a terrible step backward.

http://www.post-gazette.com…

America’s ranking on amenable mortality is an embarrassment

First-ever global study finds massive health care inequity

By the Institute for Health Metrics and Evaluation (IHME)
EurekAlert, May 18, 2017

A first-ever global study finds massive inequity of access to and quality of health care among and within countries, and concludes people are dying from causes with well-known treatments.

“What we have found about health care access and quality is disturbing,” said Dr. Christopher Murray, senior author of the study and Director of the Institute for Health Metrics and Evaluation (IHME) at the University of Washington. “Having a strong economy does not guarantee good health care. Having great medical technology doesn’t either. We know this because people are not getting the care that should be expected for diseases with established treatments.”

Professor Martin McKee, from the London School of Hygiene & Tropical Medicine, who participated in the study, commented: “Using deaths that could be avoided as a measure of the quality of a health system is not new but what makes this study so important is its scope, drawing on the vast data resources assembled by the Global Burden of Disease team to go beyond earlier work in rich countries to cover the entire world in great detail, as well as the development of a means to assess what a country should be able to achieve, recognizing that not all are at the same level of development. As the world’s governments move ahead to implement the goal of universal health coverage, to which they committed in the Sustainable Development Goals, these data will provide a necessary baseline from which they can track progress.”

The United States had an overall score of 81, tied with Estonia and Montenegro. As with many other nations, the US scored 100 in treating common vaccine-preventable diseases, such as diphtheria, tetanus, and measles. But the US had nine treatment categories in which it scored in the 60s: lower respiratory infections (60), neonatal disorders (69), non-melanoma skin cancer (68), Hodgkin’s lymphoma (67), ischemic heart disease (62), hypertensive heart disease (64), diabetes (67), chronic kidney disease (62), and the adverse effects of medical treatment itself (68).

“America’s ranking is an embarrassment, especially considering the US spends more than $9,000 per person on health care annually, more than any other country,” Dr. Murray said. “Anyone with a stake in the current health care debate, including elected officials at the federal, state, and local levels, should take a look at where the US is falling short.”

The study was published today in the international medical journal The Lancet, and represents the first effort to assess access and quality of services in 195 countries from 1990 to 2015. Researchers used a Healthcare Access and Quality (HAQ) Index, based on death rates from 32 causes that could be avoided by timely and effective medical care, known as “amenable mortality.”

https://www.eurekalert.org…

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Healthcare Access and Quality Index based on mortality from causes amenable to personal health care in 195 countries and territories, 1990–2015: a novel analysis from the Global Burden of Disease Study 2015

The Lancet, May 18, 2017

Drawing from GBD 2015 (Global Burden of Diseases, Injuries, and Risk Factors Study), we constructed a novel measure of personal health-care access and quality — the HAQ Index (Healthcare Quality and Access Index) — by using highly standardised estimates of 32 different causes that are amenable to personal health care. Compared with previous efforts, the HAQ Index provides a clearer signal on personal health-care access and quality over time and place because GBD provides enhanced comparability of cause of death data, helps to account for variation due to behavioural and environmental risk factors, and includes 195 countries and territories over time. Our analysis showed large differences in personal health-care access and quality, spanning from a low of 23·1 in Ethiopia in 1990 to higher than 90 in Andorra, Iceland, Switzerland, Norway, and Sweden in 2015. The global HAQ Index improved from 40·7 in 1990 to 53·7 in 2015, and 167 of 195 countries and territories significantly increased their HAQ Index during this time. Although the HAQ Index and SDI (Socio-demographic Index) were highly correlated, we noted substantial heterogeneity for geographies at similar SDI.

The Healthcare Access and Quality Index (HAQ Index) for the highest quartile of the Socio-demographic Index (SDI):

95  Andorra
94  Iceland
92  Switzerland
90  Sweden
90  Norway
90  Australia
90  Finland
90  Spain
90  Netherlands
89  Luxembourg
89  Japan
89  Italy
88  Ireland
88  Austria
88  France
88  Belgium
88  Canada
87  Slovenia
87  Greece
86  Germany
86  Singapore
86  New Zealand
86  South Korea
86  Denmark
86  Israel
85  Cyprus
85  Qatar
85  Malta
85  Czech Republic
85  United Kingdom
85  Portugal
82  Kuwait
82  Croatia
81  Estonia
81  United States
81  Montenegro
80  Lebanon
80  Hungary
80  Poland
79  Saudi Arabia
79  Bermuda
79  Bahrain
79  Slovakia
78  Latvia
78  Taiwan
77  Puerto Rico
77  Lithuania
76  Macedonia
76  Chile
75  Serbia
74  Romania
74  Belarus
74  Cuba
73  Ukraine
72  United Arab Emirates
72  North Mariana Islands
72  Russia
71  Bulgaria
71  Greenland
70  Virgin Islands
70  Brunei
68  Argentina
68  Armenia
67  Barbados
67  Antigua and Barbuda
67  Malaysia
66  Seychelles
64  Azerbaijan
64  The Bahamas
63  Guam
62  Georgia
62  Trinidad and Tobago
61  Kazakhstan
58  Grenada
58  Turkmenistan

The full PDF of this Lancet article (36 pages) can be downloaded for free at this link:
http://www.thelancet.com…

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Comment:

By Don McCanne, M.D.

This study establishes a new landmark in health policy research. It provides a basis of determining how all nations are doing in reducing premature deaths by providing timely and effective health care, that is, in improving their “amenable mortality” rates.

To no surprise for those who follow health policy, the Healthcare Access and Quality Index (HAQ Index) for the United States falls about in the middle of nations in the highest quartile of the Socio-demographic Index (SDI). Although our per capita spending on health care is about twice the average of these nations, our access and quality are only average. We do not have the best health care system in the world, in spite of what reform opponents say.

As Christopher Murray, a senior author of this study, states, “America’s ranking is an embarrassment.” Look at the countries that rank above us. If, like them, we used our public resources more effectively we would no longer have to be ashamed of our performance. Just through the tax system alone we are already spending more per capita than almost all of the other nations do in both public and private spending combined.

It’s not that we need to make a decision to finance health care through our taxes; we already largely do that. Instead we need to improve the allocation of our tax funds plus our private spending. We can do that best by enacting and implementing a well-designed single payer national health program – an improved Medicare for all. With all that we are spending, we should be at the top of the list.

Yoho’s ACA vote

By F. Douglas Stephenson, LCSW
Ocala Star Banner, May 18, 2017

I’m a retired clinical social work psychotherapist and have seen many patients worried about the future of health/mental health care. Congressman Ted Yoho’s recent vote for the GOP’s American Healthcare Act (AHCA) that repeals much of the Affordable Care Act (the ACA or Obamacare) gravely threatens the health of thousands of his District 3 constituents.

The GOP bill would take $880 billion out of Medicaid, and another $312 billion out of subsidies that help working families buy private coverage through the ACA exchanges. Instead of helping people get care, this money would be diverted to give an $800 billion tax-break windfall to people with incomes over $200,000, as well as big insurance and drug companies. The rest of us would get virtually no tax relief.

If Rep. Yoho had supported expansion of Medicaid, many could now afford new coverage through the exchange. All told, his vote threatens to strip coverage from thousands of people in our district, would weaken protections for people with pre-existing conditions, boost premiums for people over 40, and take tens of millions of dollars from our hospitals and clinics.

The ACA is deeply flawed. It left 28 million Americans uninsured and millions more with unaffordable premiums, deductibles and copayments. But the GOP plan would make things much worse. Instead of moving backward, we should move forward from the ACA to a “Medicare for All” plan like the one proposed Rep. John Conyers (H.R. 676).

http://www.ocala.com…