PNHP

My Turn: Republicans should choose true reform of health care

My Turn: Republicans should choose true reform of health care

By Robert S. Kiefner, M.D.
Concord (N.H.) Monitor, March 2, 2017

With the impending repeal of the Affordable Care Act, the Republican-controlled House and Senate have a unique opportunity to initiate truly universal and affordable health care through their support of “Medicare for all.”

In a commentary published last month in the Annals of Internal Medicine, Drs. Steffie Woolhandler and David Himmelstein report that a streamlined, publicly financed, privately delivered health care system would save in the realm of $500 billion annually. The breakdown includes $220 billion saved on paperwork and insurance overhead, $150 billion saved on hospital billing and administration, $75 billion saved on doctors’ billing and upward of $113 billion saved by aggressive bargaining with drug companies.

The value to the American consumer in terms of health and financial security? Priceless.

Sadly, Rep. Paul Ryan and Health and Human Services Secretary Tom Price have other ideas.

In their campaign not only to discredit Obamacare but to inadvertently make it look terrific in retrospect, the Republicans are looking to send our good citizens off on a health care scavenger hunt, equipped with a few meager tax credits and vouchers with which to purchase their overpriced and confounding private insurance policies.

The Republican proposals run the gamut from being merely inadequate to astonishingly inane, and clearly favor the wealthy. They are recommending that the age for Medicare eligibility be raised to 67 while simultaneously reducing Medicare funding, and that states accept inadequate “block grants” for their Medicaid populations.

Further, the speaker and his clueless colleagues would permit the sale of “mini-med” insurance plans with their mere illusion of coverage, and more tax breaks for health savings accounts with a wink to the more affluent taxpayer. By encouraging the interstate sale of insurance, the Republicans would undermine the already tenuous state-based consumer protections.

We have seen that for-profit models generally do not work in the world of health care. Patients cannot shop around for the “best deal” when they are ill or in crisis. Given the lack of transparency, real costs are impossible to discern and we all have had experience with a health care system that is difficult to access and impossible to negotiate. (“Your call is very important to us. The next representative will be able to serve you in approximately 34 minutes. Please enjoy another loop of music certain to make your head explode.”)

If we transition to a single-payer system, typical of all other industrialized countries, we could afford to cover everyone for outpatient and hospital care as well as medications and dental care, without the burden of increasing deductibles and co-pays.

Lobbyists for insurance companies and Big Pharma are spending billions of dollars each year to convince us (and especially Congress) that any move to publicly financed health care is wrong, as if the current system is working perfectly.

Now is the time to move forward, to build upon the gains achieved by the ACA toward a more comprehensive system with serious cost controls and universal coverage.

Relative to businesses, the taxes involved in financing this system would tend to be predictable, stable and significantly less than businesses are already paying for employee coverage. By eliminating the competitive disadvantage of our health care costs, we will be able to market our goods and services at a lower cost relative to other countries, while enjoying a healthier workforce. Sound good, Mr. President? We can even say that it’s your idea.

Building a wall of indifference between wealthy and poor patients looks to be the outcome of current “replacement” proposals. The Republican leadership must be convinced that they need to lead the effort toward true reform, and not be led like lemmings into the abyss.

Robert S. Kiefner is a family physician in Concord.

http://www.concordmonitor.com…

Obamacare meeting bends toward single-payer solutions

By Jon Kelvey
Carroll County (Md.) Times, March 2, 2017

More than 150 people packed the St. Paul’s United Church of Christ fellowship hall Thursday night for an often boisterous town hall meeting on the future of the Affordable Care Act, also known as Obamacare.

While Republican lawmakers have long been critical of President Barack Obama’s signature legislative achievement and President Donald Trump has promised to repeal and replace the law, the ACA has also seen its fair share of criticism from supporters and those on the left. Thursday’s event, organized by local progressive advocacy group Carroll CAN, was billed as a nonpartisan opportunity to discuss the law’s flaws, its virtues and its future.

That discussion began with a panel made up of local and regional health professionals and advocates: Tammy Black, executive director of Westminster-based community health clinic Access Carroll; Ed Singer, health officer at the Carroll County Health Department; Gary Honeman, assistant administrative director at Carroll County Youth Services Bureau; and Francine Hahn, a former navigator with the Maryland Health Connection, made up the local panelists. Kalie Potter, regional director regional manager for the Door to Healthcare, and Dr. Margaret Flowers, former Green Party candidate for the Senate seat now occupied by Sen. Chris Van Hollen, were the more regional representatives.

In opening remarks and in response to prepared questions, most of the panelists were in agreement — there was much to like about the Affordable Care Act, but some things it needed to do better.

“The uninsured rate has dropped by more than one-third since the [Affordable Care Act] was put in place,” Singer said. “There are, however, some flaws in the system.”

Singer’s concerns centered around the financial sustainability of the program, due to a lower than expected number of young, healthy people signing up for insurance, as well as the lack of effective coverage. Many people, he said, have purchased a lower-tier insurance plan only to find they cannot afford their deductibles if they develop a chronic condition such as cancer.

“The other thing we have had a huge problem with is the opioid crisis,” Singer said. “Low-level plans require a special waiver and it’s often difficult to get these clients into treatment to begin with.”

Hahn, who helped people sign up for insurance as a navigator, said it was gratifying to see people get insurance, especially through the expansion Medicaid programs to cover low-income people who otherwise could not afford insurance, an experience she shares with Black.

“We had [a] significant number of people who were the first people in their entire family’s history to ever have insurance,” Black said of enrolling patients at Access Carroll. “Ever. They didn’t know what to do with it.”

But even Hahn, who enthusiastically supported the health care law, said there were problems that needed to be addressed, such as what navigators called “the family glitch.”

When considering whether a family was still eligible to purchase a tax subsidized plan when one parent was offered insurance through an employer, the test was whether the cost of the employer plan was affordable for just one parent, not the entire family. This sometimes leaves one parent out in the cold.

“She has affordable health insurance,” Hahn said, “Dad is going to have to pay full price on the health exchange.”

Flowers, rather than critiquing any one piece of the Affordable Care Act, attacked it as an insufficient compromise and that the best fix would be to expand Medicare coverage to all citizens — a single payer national insurance model such as in Canada.

“Private health insurance companies … are actually financial institutions that are investor-owned and have a responsibility to investors to prove as much profit to investors as possible,” she said. “We have to understand that private health insurance is not here to pay for our health care — they are an obstacle.”

That was a view apparently shared by many in the crowd, who gave Flowers loud applause, if not the emissaries of elected representatives in attendance.

Sens. Ben Cardin and Chris Van Hollen sent representatives who expressed their bosses’ support for the Affordable Care Act, and Karen Robb, from Van Hollen’s office, noted the senator is in favor of a single-payer model even if not actively pursuing it at the moment.

A staff member from Rep. Jamie Raskin’s office told the crowd that the congressman not only supports a single-payer system, but that he has signed on to support HR 676, a bill in the House of Representatives that would enact such a system, to thunderous applause.

A representative of Rep. Andy Harris told the crowd she was there to listen and would take down the information of anyone interested in communicating with the congressman.

The crowd, when the time came for a question-and-answer session, were not so circumspect or bipartisan.

“When we call the police, we don’t have any expectation that when we call 911 we will have to show our Visa card,” said Mel Brennan, who lives in Westminster.

He felt there was a certain hypocrisy to accepting tax-supported public safety but not public health. “Nobody is a socialist that supports a community fire department.”

Kevin Zeese, of Baltimore, used the mic to attack Van Hollen and Cardin for not pushing harder for a single-payer system, given that they had asserted, in statements by their representatives, that they believed health care to be a human right.

“A human right is not compatible with a commodity,” he said.

And then there was Kelley Gordon, of Hampstead, whose grandson Rhett was born with cystic fibrosis and whose family lives with anxiety that the protections of the Affordable Care Act will be repealed.

She recognized, she told the crowd, that the Affordable Care Act was not enough, but even she had concerns about single payers — she’s been calling Canadian officials trying to understand how that system would work for her grandson and she’s not certain yet what it would look like.

What Gordon asked was that elected officials take a look.

“There are working systems all over the globe,” she said. “Our leaders have got to look around the world. … And do what’s right to protect people like my beautiful little grandson.”

http://www.carrollcountytimes.com…

So now what is President Trump’s position on health care reform?

Trump’s Speech to Congress

The New York Times, February 28, 2017

Transcript of section on health care (12 references to “Applause” omitted):

Tonight, I am also calling on this Congress to repeal and replace Obamacare …

… with reforms that expand choice, increase access, lower costs and at the same time provide better health care.

Mandating every American to buy government-approved health insurance was never the right solution for our country.

The way to make health insurance available to everyone is to lower the cost of health insurance, and that is what we are going to do.

Obamacare premiums nationwide have increased by double and triple digits. As an example, Arizona went up 116 percent last year alone. Gov. Matt Bevin of Kentucky just said Obamacare is failing in his state, the state of Kentucky, and it’s unsustainable and collapsing.

One third of the counties have only one insurer, and they’re losing them fast, they are losing them so fast. They’re leaving. And many Americans have no choice at all. There’s no choice left.

Remember when you were told that you could keep your doctor and keep your plan? We now know that all of those promises have been totally broken. Obamacare is collapsing, and we must act decisively to protect all Americans.

Action is not a choice; it is a necessity. So I am calling on all Democrats and Republicans in Congress to work with us to save Americans from this imploding Obamacare disaster.

Here are the principles that should guide Congress as we move to create a better health care system for all Americans.

First, we should ensure that Americans with pre-existing conditions have access to coverage and that we have a stable transition for Americans currently enrolled in the health care exchanges.

Secondly, we should help Americans purchase their own coverage, through the use of tax credits and expanded health savings accounts, but it must be the plan they want, not the plan forced on them by our government.

Thirdly, we should give our state governors the resources and flexibility they need with Medicaid to make sure no one is left out.

Fourth, we should implement legal reforms that protect patients and doctors from unnecessary costs that drive up the price of insurance and work to bring down the artificially high price of drugs and bring them down immediately.

And finally, the time has come to give Americans the freedom to purchase health insurance across state lines …

… which will create a truly competitive national marketplace that will bring costs way down and provide far better care. So important.

Everything that is broken in our country can be fixed. Every problem can be solved. And every hurting family can find healing and hope. Our citizens deserve this, and so much more, so why not join forces and finally get the job done and get it done right?

On this and so many other things, Democrats and Republicans should get together and unite for the good of our country and for the good of the American people.

https://www.nytimes.com…

***

Comment:

By Don McCanne, M.D.

Although President Trump has previously offered no specifics on his proposals for health care reform, he has said that his plan would provide “insurance for everybody…much less expensive and much better” (Washington Post, January 15, 2017). In this speech he calls for “reforms that expand choice, increase access, lower costs and at the same time provide better health care.” But then, what are the specifics of his proposal?

* Eliminate the mandate to purchase insurance: All honest policy analysts agree that would significantly increase the numbers of uninsured – not exactly a policy approach to cover everyone.

* Lower the cost of health insurance: Assuming health care costs remain the same, the only way you can reduce insurance premiums is through various innovations that shift more of the costs to the plan beneficiaries. Making an insurance plan more affordable impairs access to care because of the financial barriers created by the higher out-of-pocket expenses.

* Americans with pre-existing conditions should have access to coverage: The key word here is “access.” In December, the Republicans decided that they would drop the guarantees of health care coverage and instead insure access to coverage. They merely mean that will ensure that plans would be available in the market by relaxing the requirements that plans face today. Having access to an inadequate or unaffordable plan does not mean that you have access to affordable health care.

* Tax credits for purchasing coverage: Although he has not defined the tax credits here, the leading Republican proposal is that the tax credit would be based on age and not on income. Lower- and middle-income individuals may find that the tax credit is not adequate to make their share of the premium affordable – thus increasing the numbers of uninsured. If the tax credit is not refundable those who pay little if any taxes could not afford to purchase insurance.

* Expanded health savings accounts: People who do not have enough income to save some for cash reserves would not have enough to make deposits into a health savings account (HSA). The only distinguishing feature of HSAs over other savings is that HSA deposits are deductible from income for tax purposes. This form of “tax expenditure” is highly regressive since the wealthy benefit and the poor do not. Expanding the amount of the allowable contributions to HSAs benefits the wealthiest of us, using our tax money to reduce their net out-of-pocket expenses. This is a tax policy that directs the benefit to exactly the wrong place.

* Americans purchase the plan they want, not the plan forced on them: They would eliminate essential health benefits and actuarial floors, making much less expensive plans available, but plans that would expose many to financial disaster should significant health needs develop.

* Give our state governors the resources and flexibility they need with Medicaid: They would convert state payments for Medicaid to block grants or per capita caps, either of which enable the federal government to reduce transfers to the states. “Resources and flexibility they need” apparently means granting the states fewer resources so they can have the flexibility to throw more patients off of their Medicaid programs.

* Implement legal reforms that protect patients and doctors from unnecessary costs: This is the old saw that somehow malpractice costs are a major contributor to our national health care spending; they are not, though we do need tort reform. But that needs to be reform that protects patients who are harmed, not reform that allows physicians to escape their responsibilities. Rather we need to civilize the process through alternate dispute resolution.

* Bring down the artificially high price of drugs: Yes, but that requires a regulatory role of government, whereas the Republicans are reducing regulation, pretending that somehow the magic of the marketplace will put a lid on drug prices. But it is the market that is bringing us six figure drug prices.

* Freedom to purchase health insurance across state lines: Not only does this reduce plans to their lowest common denominator, preventing state insurance commissioners from exercising adequate control over renegade insurers, but also the insurers do not want to face the administrative costs of setting up provider networks and marketing their plans in regions that would not be profitable to them.

If Trump’s plan looks familiar, it is. These proposals are the same old proposals that the Republicans have been tossing around for years. These are the proposals of Ryan’s two white papers and the recent “leaked” legislative draft that the Republicans quickly dismissed because of the blow back they received. Also it resembles the previous legislation introduced by HHS Secretary Tom Price when he was in Congress.

Trump has been meeting with Price and has promised releasing his formal proposals in three or four weeks, though Trump wants them in two weeks. These meetings have led Trump to say that reforming health care is “unbelievably complex… nobody knew that health care could be so complicated.” But this speech is ominous. The Republican/Price/Trump proposals will reduce the federal guarantees of affordable health care, resulting in greater numbers of uninsured and in greater out-of-pocket costs that will be unaffordable for many more.

It looks like Trump’s promise of “insurance for everybody… much less expensive and much better” is deceptive. Insurance for everybody means access to insurance, not actually being insured. Much less expensive means insurance that does not protect your financial assets, it you have any. Much better means that you have a choice of purchasing worthless plans, if you call that better.

This deception reaches a plane that we have to call it for what it is…a lie. He could have fulfilled his promise by bringing us an improved Medicare for all.

Chicago UAW Local 551 endorses H.R. 676, Improved Medicare for All

Single Payer News, Feb. 28, 2017

At its February meeting, UAW Local 551, which represents workers at Ford’s Chicago Assembly Plant, endorsed H.R. 676, Congressman John Conyers’ national single-payer legislation, the Expanded and Improved Medicare for All Act.

UAW Local 551 Vice President Scott Houldieson reports that the local “made note that negotiations over healthcare continue to consume a large portion of the money the union negotiates over. This holds back wages and pensions.”

“We also believe in Social Justice for all workers,” said Houldieson. “Because of this we know that a single-payer system covering every American from cradle to grave is the moral thing to do.”

Houldieson says that the local “took guidance from the delegates to the 35th Constitutional Convention which set International UAW policy. At that convention we debated our support for the Affordable Care Act, noting that while the Act was a step in the right direction, we still believe National Single-Payer Health Care is the proper remedy.”

The Chicago Assembly Plant, where UAW Local 551 workers build the Ford Taurus, Ford Explorer, and the Police Interceptor, is the company’s oldest continually-operated automobile manufacturing plant. The local also represents workers at Voith, ABM, and USA.

Hale Landes of IBEW Local 134 reports that the Labor Outreach Committee of the Illinois Single-Payer Coalition initiated the discussion of endorsement of H.R. 676 with the UAW local.

The resolution passed the UAW Local 551 Executive Board unanimously and was approved by the membership with the approval of the Board minutes. The full resolution is below:

UAW Local 551 Resolution to Support Single-Payer Health Care

WHEREAS, the delegates to the 35th Constitutional Convention while supporting the Affordable Care Act (ACA) as a good beginning step stated; We remain convinced that a single-payer system is the best way to control costs while providing universal access to high quality care; and we are committed to building an aggressive strategy to educate lobby and mobilize to achieve that goal; and

WHEREAS, many in Congress have called for the repeal and replacement of the ACA; and

WHEREAS, workers, their families, and their unions are waging an increasingly difficult struggle to win or keep good health benefits; and

WHEREAS, almost every union at every contract deadline must battle and sacrifice merely to sustain health insurance benefits; and

WHEREAS, the rising cost of health insurance premiums are blocking worker progress in wages, job growth, and other areas. All of our unions face a health care crisis; and

WHEREAS, economic necessities and moral conscience compel us to seek a better way; and

WHEREAS, Congressman John Conyers Jr. has introduced H.R. 676, the United States National Health Insurance Act. A.K.A. “Expanded and Improved Medicare for All;” and

WHEREAS, H.R. 676 will cover every person in the United States for all necessary medical care from birth to death; therefore be it

RESOLVED that UAW Local 551 endorses Congressman Conyers H.R. 676 Bill “Expanded and Improved Medicare for All”; and be it further

RESOLVED that UAW Local 551 will work with other unions and community groups to build support and action for H.R. 676 until we make what is morally right for our nation into what is also politically possible; and be it finally

RESOLVED that UAW Local 551 will take other actions to mobilize our members and the community at a grassroots level, to encourage other members of the House to sign on as co-sponsors of H.R. 676 and to encourage Senators to introduce a companion bill in the Senate.

Issued by:
All Unions Committee for Single Payer Health Care–HR 676
c/o Nurses Professional Organization (NPO)
1169 Eastern Parkway, Suite 2218
Louisville, KY 40217
(502) 636-1551
nursenpo@aol.com
unionsforsinglepayer.org
facebook.com/unionsforsinglepayer

H.R. 676 would institute a single-payer health care system by expanding a greatly improved Medicare to everyone residing in the U.S. Patients will choose their own physicians and hospitals. H.R. 676 would cover every person for all necessary medical care including prescription drugs, hospital, surgical, outpatient services, primary and preventive care, emergency services, dental (including oral surgery, periodontics, endodontics), mental health, home health, physical therapy, rehabilitation (including for substance abuse), vision care and correction, hearing services including hearing aids, chiropractic, durable medical equipment, palliative care, podiatric care, and long-term care. H.R. 676 ends deductibles and co-payments. H.R. 676 would save hundreds of billions annually by eliminating the high overhead and profits of the private health insurance industry.

H.R. 676 has been endorsed by 628 union organizations including 152 Central Labor Councils/Area Labor Federations and 44 state AFL-CIOs (KY, PA, CT, OH, DE, ND, WA, SC, WY, VT, FL, WI, WV, SD, NC, MO, MN, ME, AR, MD-DC, TX, IA, AZ, TN, OR, GA, OK, KS, CO, IN, AL, CA, AK, MI, MT, NE, NJ, NY, NV, MA, RI, NH, ID).

The list of union endorsers.

The sample endorsement resolution.

Achieving Universal Coverage Without Turning to a Single Payer

Lessons From 3 Other Countries

By Regina E. Herzlinger, DBA; Barak D. Richman, JD, PhD; Richard J. Boxer, MD
JAMA, February 27, 2017

The most popular parts of the Affordable Care Act (ACA) are the most expensive. Universal coverage is a top priority not only for Democrats but also for President Trump. Both Republicans and Democrats want to preserve many costly coverage features of the ACA, including those that prevent insurers from precluding people with preexisting conditions and those that eliminate lifetime or annual coverage limits. The challenge is how to preserve these features and make insurance affordable.

A primary obstacle to achieving affordable universal coverage is the high costs of those with diseases or costly traumatic events — approximately 20% of individuals accounting for approximately 80% of health care spending. So, a key question is how to pay for their care.

Some nations in the Organisation for Economic Co-operation and Development (OECD) rely on a governmental single-payer model to achieve universal coverage, but this approach is politically infeasible in the United States. As the United States relies on private-sector insurance, 3 other countries that use private-sector insurance to offer affordable universal coverage provide some potentially helpful lessons.

Paying for Costly Patients

Some advocate creating risk pools for enrollees with preexisting conditions. This strategy removes individuals with high health care costs from the broad pool of enrollees and uses government funds to subsidize their insurance premiums. In turn, the cost of insurance is substantially reduced for the rest of those who are insured. This strategy, however, requires substantial infusions of funds.

If high-risk pools are part of the solution to attaining universal coverage, federal funding is essential. But federal policy makers are unlikely to commit a sufficient amount of funds to make this approach successful.

Another strategy to pool costly patients would channel them into Medicare and rely on the federal government as the ultimate risk bearer. But Medicare premiums are artificially controlled by passing some present spending onto future generations. Trustees project Medicare’s 75-year total spending in excess of dedicated revenues at $27.9 trillion, and the Centers for Medicare & Medicaid Services Office of the Actuary projects this amount at $36.8 trillion. Adding costly individuals to Medicare would only exacerbate these intergenerational problems.

This leaves a third strategy: the individual mandate — or as the Supreme Court characterized it, an annual tax assessed against individuals who have not purchased qualified health insurance within the calendar year. Although vilified by some, the mandate is attractive for several reasons. It is relatively easy to implement, is effective in pooling risk, and reflects the values of individual responsibility. Coverage is primarily funded by the enrollees rather than by general taxation. For these reasons, some nations that are committed to a private health insurance sector have achieved universal coverage and effective risk pooling by mandating the purchase of insurance.

Examples of the Individual Mandate and Penalties

Switzerland, Singapore, and Germany have achieved universal coverage and made insurance affordable even for their citizens with highest health care costs by instituting an individual mandate. One major difference, however, is that unlike the ACA, the mandates instituted by these countries are reinforced with effective penalties for nonparticipation, thus ensuring that lower-cost enrollees — generally healthier individuals — balance out the costs of the others who require more medical resources.

* In Switzerland, citizens must purchase health insurance. If they do not, government authorities automatically enroll them, selecting the insurance provider on the individuals’ behalf. Moreover, insurers can implement debt enforcement proceedings against anyone failing to pay their premiums and collect a penalty in addition to back premiums. The Swiss government subsidizes premium payments for more than a quarter of the population, including retirees who purchase the same insurance as workers.

* Singapore institutes compulsory contributions from employers on behalf of their employees to create medical savings accounts. Employees maintain these accounts for health care expenses such as health and disability insurance premiums, hospitalization, surgery, rehabilitation, end-of-life care, and outpatient services. Those failing to pay their premiums are subject to garnished wages and other legal actions that can force payment of back premiums, penalties, and interest. Unemployed or low-income individuals are eligible for government subsidies that enable them to pay for the premiums.

* In Germany, insurance is funded by compulsory contributions to private insurers levied as 7.3% of income. Unemployed individuals have their contribution taken out of their unemployment benefits coupled with means-based sliding-scale subsidies, and uninsured self-employed persons who later attempt to purchase insurance face payment of back premiums for the period in which they were uninsured.

In sum, health insurance models in Switzerland, Singapore, and Germany suggest that an individual mandate, with adequate subsidies, can achieve affordable universal coverage. But the recipe for their success also includes firm penalties. Achieving universal coverage, like these 3 nations, requires a more forceful approach.

From the Conclusions

If the goal is universal health coverage that provides care even for patients with the highest health care costs without relying on public insurance programs, the financial burden must be spread across the whole population. This requires either massive government spending, whether through high-risk pools or Medicare, or requiring individuals to purchase insurance.

It is time to stabilize the premiums of the universal insurance market by neutralizing the political disagreements surrounding the ACA’s mandate and penalties. As these 3 countries demonstrate, maintaining the popular aspects of the ACA requires keeping its less popular part, and achieving the stated goal of universal coverage requires a serious commitment to individual responsibility.

http://jamanetwork.com…

***

A Conversation With Regina E. Herzlinger, PhD: A New Individual Market on the Horizon

Managed Care, July 2011

Quotes from the interview:

“I have always supported universal coverage for personal and economic reasons. There are 40 million people who are uninsured. Typically, in any pool, 20 percent are sick. That’s 8 million people. How are we going to cover these 8 million sick people? The only way we can pay for them is to raise taxes — which is not going to happen — or to have universal coverage. Universal coverage is in many ways much more acceptable than a tax in which the well subsidize the sick.”

Are we headed toward a single payer system?

“I wouldn’t say that. I think we are going to a Swiss system. Employers will drop their health insurance coverage, not solely for reasons of cost. Many employers find buying health insurance onerous, and they would rather it be a consumer purchase.”

Accountable care organizations — does this concept have any legs?

“It’s like the Affordable Care Act itself — great idea, poorly thought through. Fee-for-service payment is perverse because it penalizes integration. The problem is the scope of the ACO, which is not just one disease or one condition, but everything for everybody. It’s not feasible to excel in managing every kind of care. It’s too complicated.”

Will the consumer model make its way to Medicare?

“Consumer-driven health care started in the commercially-insured population. I would hope it would go to Medicaid so that the poor aren’t stuck in this terrible program. And eventually it will go to Medicare because we have to solve the Medicare problem.”

The Congressional Budget Office thinks that senior citizens will be worse off under a voucher system from Medicare, which is Rep. Ryan’s plan.

“What the CBO failed to think about is, if 50 million seniors go out in the insurance market, is that market going to remain the same, or is it going to become more competitive in ways the Swiss insurers are competitive, by reducing administrative costs? The CBO’s mistake was assuming that nothing would change. If 50 million seniors show up in the insurance market, they are going to force insurers to become more competitive.”

Providers talk about the difficulty of dealing with so many insurance companies. Is it going to get worse for them as more health plans enter a consumer-driven market?

“Well, either you are going to have a lot of insurers breathing down your neck, or it’s going to be single payer. Our last gasp is consumer-driven health care. Take your choice.”

https://www.managedcaremag.com…

***

Comment:

By Don McCanne, M.D.

The theme of this article is somewhat astonishing. The authors recommend that we modify the most unpopular element of the Affordable Care Act – the mandate to purchase private health insurance or face penalties – by increasing the severity of the penalties to a degree that they will drive people to purchase plans, thereby forcibly achieving near universal coverage. This, as the title of the JAMA article implies, is to avoid the inevitability of single payer, as if single payer were so terrible that it is worth it for us to make being uninsured an unconscionable act warranting severe punishment.

The intent of this approach to health care financing is to avoid “massive government spending” as they say might occur with high-risk government insurance pools or by enrolling high-risk patients in Medicare (or, of course, single payer). By instead requiring individuals to purchase insurance the costs would shift to the individuals. But considering our very high national health expenditures, who could afford to pay for plans that include all of the high-risk individuals in the insurance pools? Of course, only wealthier, higher-income individuals. That puts us back into the position of either providing government subsidies that are more generous than those currently offered under ACA, or opening the market to barebones plans that would make health care access unaffordable.

Harvard Business School Professor Regina Herzlinger has been a long-time advocate of consumer-directed health care. She believes that “the stated goal of universal coverage requires a serious commitment to individual responsibility” with the individual functioning as an informed consumer in the private health insurance marketplace. Her opposition to single payer is ideological, preferring markets over governments.

She has repeatedly threatened us with single payer if we don’t establish policies that promote consumer-driven health care. In spite of her disdain for single payer, she does recognize that “either you are going to have a lot of insurers breathing down your neck, or it’s going to be single payer. Our last gasp is consumer-driven health care. Take your choice.”

Some choice: Market-driven hell or single payer nirvana.

Health insurance fix: Medicare-for-all

By Jack Kotecki
Green Bay (Wis.) Press-Gazette, Feb. 28, 2017

Health care reform is a high priority on the newly elected Congress’ to-do list.

As a University of Wisconsin medical student who grew up in northeastern Wisconsin, I am concerned that the proposals being put forward by Republicans in Congress will harm Wisconsinites’ ability to access and receive the care they need.

It has been well-documented that the Affordable Care Act has failed to significantly control health care costs; I’ve heard firsthand from patients, family members, and friends about the unbelievable increases in insurance premiums they now face. This, then, presents the new Congress with an opportunity to vastly improve the health insurance infrastructure in America.

So far, their plans have been a conglomeration of conservative ideas like health savings accounts and interstate insurance markets. Such plans will fall well short of the true affordability and health care access that Americans deserve. It may seem like we are mired in a hopeless situation, but there is a way to create better more affordable health insurance: Medicare-for-all.

Medicare-for-all (sometimes referred to as “single-payer”) is a simple program. It requires the elimination of for-profit health insurance companies in favor of a nonprofit government entity that covers all medical expenses. Health care payments would be financed through progressive taxation and fully offset by the elimination of premiums and out-of-pocket expenses. Single-payer systems would cover every American, and they would pay less, to boot.

The strength behind Medicare-for-all lies in its ability to control administrative costs. For example, private health insurance companies take between 12 percent and 25 percent of patient premiums to pay for overhead (advertising, underwriting costs, etc.). This is money that doesn’t pay for care and would be all but eliminated in a Medicare-for-all program (traditional Medicare’s overhead was 1.6 percent in 2013). Instead, that money would stay in patients’ pockets, to be used as they see fit.

Medicare-for-all leads to more freedom and control for patients. It eliminates the concept of “provider networks”; patients can choose to see any doctor and hospital they prefer. Departing from the current private insurance provider networks, profit will not fuel decisions surrounding your care, so there is little incentive to deny insurance claims.

Businesses and workers would both benefit tremendously from this program. Businesses would no longer be legally obligated to provide health insurance to their employees and could put more money toward growing their business. Conversely, since health insurance wouldn’t be tied to your job, workers could change careers without worrying about losing their coverage. This would lead to a much more dynamic labor market and help businesses fill job openings.

Critics who argue Medicare-for-all is “socialized medicine” don’t realize, or mention, that the U.S. already has the largest government-run health insurance program in the world, our Medicare program. This program does an excellent job controlling costs, especially considering they insure one of the most expensive subsets of patients, the elderly. Medicare patients also are happier with their insurance, consistently having higher levels of satisfaction with their insurance coverage than those with private insurance plans.

Admittedly, the United States health care system is a complex, economic juggernaut with myriad vested interests. But we do have a cure for the expensive, inadequate health insurance Americans now experience. Medicare-for-all is the insurance program that Americans deserve. It will guarantee affordable coverage for everyone. It will lend more freedom to patients over which doctors and hospitals they use. In the coming weeks, I will be contacting my Congressional representatives’ office and voicing my support for a Medicare-for-all insurance program. I hope that you will consider doing the same.

Jack Kotecki is a first-year medical student at the University of Wisconsin School of Medicine and Public Health and a graduate of Coleman High School.

http://www.greenbaypressgazette.com…

Does the Democratic Party really believe that health care is a right?

By Brian Cooney
The (Danville, Ky.) Advocate-Messenger, Feb. 28, 2017

Over the past seven years, Republicans have regularly voted to repeal all or part of the Affordable Care Act (ACA/Obamacare). Those repeal votes were cheap talk as long as Republicans could count on a Democratic president’s veto. But now, to their surprise, they have their very own President Trump eager to fulfill his campaign promise to eliminate the ACA, and they can’t agree on a replacement.

They know the American public won’t tolerate going back to the status quo before Obamacare (back when we had what Mitch McConnell ignorantly described as “the finest health care system in the world”). Obamacare brought several major improvements to America’s health care system, and most people today want to keep them.

It banned insurance companies from denying coverage or charging higher premiums for pre-existing conditions, and from setting a lifetime limit on how much an insurer has to pay for covered benefits. In the good old days, many people were unaware that a single bout of cancer could leave them bankrupt after their policies maxed out.

Obamacare also required allowing adult children to stay on their parents’ policies until age 26. It put a cap on insurance company profits and limited premium differences between old and young. Through its subsidized insurance exchanges and expansion of Medicaid eligibility, it “reduced the number of uninsured Americans by an estimated 20 million people from 2010 to 2016” (NYT 1/13/17). However, it still left more than 27 million uninsured (more than the combined populations of Belgium and the Netherlands).

The problem for Republicans is that these very popular features of Obamacare require a lot of government supervision and expensive subsidies for those who cannot afford the care they need. The current GOP is an anti-government party that does not believe health care is a right that should be guaranteed by the government.

The problem for Democrats is that, although their 2016 Party platform reaffirms the traditional Democratic belief that health care is “a fundamental right for every American,” they haven’t been willing to commit to reforms that would implement this right. Instead, the platform suggested tweaking Obamacare. However, if health care is a right, then a system that leaves 27 million uninsured fails to respect that right. “Additionally, underinsurance is an increasing, often overlooked problem,” says Dr. Jessica Schorr Saxe of Physicians for a National Health Program:

“According to the Commonwealth Fund, this included 21 percent of adults below Medicare age in 2014. More than one-third of Americans did not get needed care due to financial barriers, and more than one-third have trouble paying a medical bill. Free clinics, which expected declining numbers after the ACA, are seeing an influx of insured patients who cannot afford co-pays or deductibles.”

The U.S. pays much more for health care than other high-income nations, but gets much less. In its recent survey of health care in 11 high-income countries (Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom and the United States), the Commonwealth Fund reached this conclusion:

 “In comparison to adults in the other 10 countries, adults in the U.S. are sicker and more economically disadvantaged.  . . .Although the U.S. has made significant progress in expanding insurance coverage under the Affordable Care Act, it remains an outlier among high-income countries in ensuring access to health care. The authors point out that all of the other countries surveyed provide universal insurance coverage.”

The argument over retaining, tweaking or repealing the ACA is a distraction. If health care is a right, then we must have a national program to secure health care for everyone. There is a bill in Congress that would do just that: H.R.676 — Expanded & Improved Medicare For All Act, introduced by Rep. John Conyers (D-MI) with 59 cosponsors.

Medicare as it now exists is a program for the elderly that 77 percent of Americans consider “very important” (second only to Social Security), and 75 percent of recipients say is working well. It is (mostly) a single-payer system in which a government-administered fund pays for services delivered by private hospitals and practitioners. H.R. 676—Medicare for All would create a universal and much more comprehensive single-payer system.

Like the Canadian single-payer system and our current Medicare, it would drastically reduce (by hundreds of billions of dollars) the administrative costs imposed on doctors’ offices and hospitals by the multiple forms and rules of competing private insurers. It would also (as in Canada and Europe) help patients by reducing drug prices through direct negotiation with pharmaceutical companies. These savings would enable the U.S. to cover those uninsured 27 million, and greatly expand coverage for everyone.

Even Donald Trump saw this back in 2000, when he wrote in his book “The America We Deserve” that “We must have universal health care. Just imagine the improved quality of life for our society as a whole. … The Canadian-style, single-payer system in which all payments for medical care are made to a single agency (as opposed to the large number of HMOs and insurance companies with their diverse rules, claim forms and deductibles) … helps Canadians live longer and healthier than Americans.”

According to a recent Gallup poll (5/16/16), 58 percent of Americans (73 percent of Democrats and 41 percent of Republicans) favor replacing the ACA “with a federally funded healthcare system that provides insurance for all Americans.” Yet Hillary Clinton’s majority in the Democratic National Platform Committee voted against single-payer, ignoring the overwhelming preference of Democrats.

The DNC’s vote, and Hillary’s refusal to endorse single-payer, were a vivid reminder that the Democratic Party was still the servant of the health care industry and not of the people. Can it reform before 2018?

https://www.amnews.com…

Should health insurance options control retirement decisions?

If Obamacare Exits, Some May Need to Rethink Early Retirement

By Austin Frakt
The New York Times, February 27, 2017

Here’s another possible consequence of repealing the Affordable Care Act: It would be harder for many people to retire early.

Americans reaching 65 become eligible for Medicare. Before reaching that age, some can get retiree coverage from their former employers. But not very many companies, especially small ones, offer medical insurance to retirees. If early retirees are poor enough, they could turn to Medicaid. To retire early, everybody else would need to turn to the individual health insurance market. Without the subsidies and protections the A.C.A. put in place, health care coverage would be more difficult to obtain, cost consumers more where available, and provide fewer benefits than it does today.

But it is clear that with A.C.A. repeal on the table, people contemplating early retirement may need to reconsider.

***

NYT Reader Comments:

By Don McCanne, M.D.
San Juan Capistrano, CA

It seems that our goal should be to remove financial barriers to health care for all of us so we can get the health care we need when we need it.

So why do we make it difficult by establishing such arbitrary qualifications for health coverage: employment status (employer-sponsored plans), older age (65 for Medicare), younger age (CHIP), income (Medicaid), prior military service (VA), ethnic heritage (Indian Health Service), temporary unemployment (COBRA), or whatever?

This complexity contributes greatly to the profound administrative waste in our system – now over a half a trillion dollars a year that could be recovered, according to a report this month in the Annals of Internal Medicine. It also increases instability in our health care with ever-changing provider networks, creating a degree of fragmentation that is unique in the U.S. health care system.

It would be so much simpler and efficient to improve Medicare so that it is appropriate for all ages, and then automatically include everyone, using an equitable method of funding that would be affordable for all.

With the difficulty that Congress is having with decisions on how to improve health care financing, why don’t they finally take a serious look at a proven model that has worked well in other nations – a single payer national health program – in the form of an improved Medicare for all?

https://www.nytimes.com…

Amid GOP Attacks on Health Care, the Movement for Single Payer Is Growing

By Michelle Chen
Truthout, Feb. 27, 2017

This could be the moment that the country finally comes to its senses on single payer, according to Dr. David Himmelstein, co-founder of the advocacy network Physicians for a National Health Program (PNHP).

Facing the inevitable collapse of an unsustainable system, “now there’s much more…appetite for addressing the fundamentals,” Himmelstein said.

One proposal for enacting single payer is simply extending and fortifying the basic infrastructure of Medicare, the centralized plan covering seniors over 65. Even Medicare in its current form is not a pure single-payer program: It suffers from its own funding gaps and contains major coverage deficits patched by semi-privatized or market-based care. (Republicans are now poised to exacerbate these gaps with post-ACA reforms that would replace it with more private, fee-based programs, which could destroy publicly subsidized care generally, endangering both Medicare for seniors and Medicaid for low-income families.)

However, as a blueprint for a workable single-payer network, the popular program could form a politically acceptable foundation for a universal health plan.

According to a recent cost analysis published by Drs. Himmelstein and Steffie Woodhandler, another PNHP co-founder, an enhanced “Medicare for all” system, which would consolidate private insurance schemes into a single, unified care network covering every patient, would save the public a total of more than $610 billion in 2017 alone, including more than $100 billion in reduced drug costs, primarily by cutting administrative waste and bloat, and integrating all services under a transparent, uniform cost structure. Patients, meanwhile, would be guaranteed lifetime coverage without insurance fees or premiums, and no risk of exclusion from coverage.

full article:
http://www.truth-out.org…

Appalachia needs a single-payer health system

By Katie Lee
Johnson City (Tenn.) Press, Feb. 26, 2017

We are all aware that the recent election is likely to bring change in the health care system of this nation, but we have a choice to make. During these tumultuous times in health care policy, the way forward is not to strip 20 million Americans of their health care by repealing the Affordable Care Act  without a replacement. Instead, we should pursue the most equitable and just option — a single payer health care system.

No, this is not “socialized medicine,” which would mean both the financing and delivery of care are government funded. We already have a form of this system for our veterans, and it leaves much to be desired. What a coalition of 20,000 physicians, medical students, and other health professionals propose is a “Medicare-for-all” system.

The ACA has taken necessary steps toward a universal system, but it has fallen short. Among the most popular components are the right to remain free from discrimination for a pre-existing condition, young people remaining on their parents’ plans until they turn 26, and equity in plan cost between men and women.

Yet, approximately 27 million people remained uninsured after the landmark legislation was passed and an acceptable reduction in cost was not truly achieved. Supporters of the ACA aimed to bend the curve on ever-increasing health care expenditures and while this was accomplished, they still accounted for 18 percent of GDP last year.

The United States remains the only developed country with for-profit insurance companies and only one of three developed nations that does not guarantee health care. We are spending the largest amount per capita ($8,000 plus) on health care expenditures of any nation in the world, but without the best outcomes.

The leading cause of bankruptcy in the United States is medical bills, and an estimated 45,000 deaths annually can be attributed to lack of health insurance. Over 100 million Americans forgo professionally recommended medical care due to cost each year. Clearly, we have work to do. A single-payer system by way of a Medicare-for-All structure would allow coverage for all Americans and would actually reduce spending.

Not all states chose to expand Medicaid, including approximately half of those traditionally included in the Appalachian region, leaving lower income earning adults in a gap between Medicaid and marketplace subsidies. Americans were left with artificial lines between states that create headaches for Tri-Cities area patients daily, when the nearest hospital to rural dwellers may be across state lines.

Social workers in our local hospitals work tirelessly to coordinate care for patients leaving Tennessee hospitals, but needing follow-up in West Virginia, Virginia or Kentucky where their health insurance coverage and state law differs. Paying employees to navigate these complexities is currently unavoidable, but it is my hope that a more streamlined, simple system could render these duties unnecessary.

Today we waste about a third of our health care dollars to overhead, administrative costs and insurance profits. Physicians cite administrative burden as one of the leading causes of burn out, leading to decreased quality of care.

With a single-payer system for all Americans, we reduce this waste and instead direct these funds toward medical care. There is an additional benefit of freeing up physicians to spend longer appointments with patients as needed or increase patient volume.

Moreover, Americans living in rural areas face a physical access to care issue in addition to cost barriers. This makes seeking appropriate preventive care visits and screening tests even more important. It is a well-known fact that it is cheaper to prevent a chronic illness than to treat it long-term.

Consequently, removing the cost barrier to preventive services in Appalachia while we work to improve the number of physicians and hospitals in rural areas is morally imperative but also cost effective.

Uninsured Americans cited lack of affordability and unemployment as their top two reasons for their insurance status. While the national unemployment rate in 2014 was around 6 percent, in the more economically depressed parts of Appalachia that figure reached as high as 14 percent. Increased levels of unemployment in the region together with state policies declining Medicaid expansion contribute to higher uninsured rates, and consequently poorer health outcomes.

Our mixed system including employer-based health coverage is a relic of a time when most employees remained in the same job for decades and is inappropriate for the more dynamic, shifting workforce of today. Transition away from employer-based care would prevent workers from fearing a job change lest they lose their insurance, freeing workers to pursue innovative, entrepreneurial positions they might otherwise have foregone.

The 45th President of the United States has praised the concept of universal health care multiple times in the past, citing the improved mortality rates and reduced costs per capita in countries with this structure. In order to capitalize on his promise to take care of “the forgotten” in the United States, including those living in the impoverished communities of coal country, I urge the president to reconsider a Medicare-for-all system.

Not only will it help make this country “great,” it is the right thing to do.

Katie Lee is an aspiring medical professional with a passion for social justice issues. She is a graduate of Vanderbilt University and lives in Johnson City.

http://www.johnsoncitypress.com…

We Represent the Future

By Adam Gaffney, M.D.
Jacobin, Feb. 26, 2018

When future historians chronicle how Medicare for All was finally won, the current moment may prove to be a crucial turning point in their narratives, albeit one contained, most likely, in the earlier chapters. Scholars will have to probe why single payer emerged with such potency at this moment. Proponents have been steadfastly advancing the cause for decades, but it took Bernie Sanders’s insurgent primary campaign to push single payer into the political spotlight.

And it was only last year, amid all the lurid dysfunction and savagery of Trump’s first months in office, when activists helped thwart the Republicans’ Obamacare repeal efforts while simultaneously achieving a historic advance for Medicare for All. For the first time, single-payer bills won support from a majority of Democrats in the House, and — after Sanders’s new bill launched in September — more than a third of those in the Senate. More and more legislators, it seems, knew which way the wind was blowing.

Why now? Because, as historians might one day note, we are at the intersection of two related crises: one in health care, the other in politics.

The first of these may seem like nothing new. There have been health care injustices in America for as long as America has had a health care system. Hospitals once turned away the poor and uninsured in the throes of illness; facilities were once viciously segregated; reproductive rights were once not much more than aspirations. But we also made progress: from the civil rights era, which realized Medicare and Medicaid, to the passage of the Affordable Care Act (ACA), which expanded insurance coverage to twenty million people. But if American health care used to be so much worse, why is it in crisis now?

In part because, despite such wide-ranging reform, the system’s injustices remain unresolved, pervasive, and deadly.

The figures tell the story. Even without Republican rollbacks, twenty-eight million have no insurance, and, according to the Commonwealth Fund, some forty-one million are underinsured. A substantial portion of the nation — predominantly those of low and middle income and disproportionately people of color — cannot afford to see doctors, pay for medicine, or go to the emergency room.

Families who bought silver plans on the Obamacare marketplace still have $8,292 deductibles, but less than half of American households can cover even a $4,000 deductible. Patients take twice-a-day medications only once, skip doses, or fail to fill their prescriptions to save on co-payments. And of course, people die — tens of thousands of people a year — because they lack coverage.

But the crisis in American health care isn’t simply that the aca didn’t go far enough: it’s that there’s no aca 2.0 available to finish the job. Real progress has been made, but the incremental reforms left us with a deeply inhumane system. Meanwhile, the Right is on the prowl, offering a slew of tired, malicious nostrums about personal responsibility, while liberal reformers have mostly run out of ammunition. But the Left has not, and single payer is now the only potent policy weapon still on the table.

Today’s second crisis comes from the larger political economy. Decades of rising inequality have left a substantial proportion of the population wondering if any politician actually represents them. The unequal health care system only exacerbates the problem: wage stagnation has come with rising health care costs, further squeezing workers’ take-home pay. A recent study in the American Journal of Public Health found that, after accounting for income devoted to health care expenditures, economic inequality is even worse than we thought: these costs effectively push an additional seven million people into poverty.

Discontent with the status quo helps explain the unprecedented success of a democratic socialist in the 2016 primary. But the neoliberal crisis has sparked a resurgence in right-wing populism as well. An odious billionaire has risen to power at the head of a right-wing government that spews pollution, slashes the safety net, vilifies immigrants, and redistributes wealth upwards with great efficiency and vengeance.

We should see the Medicare-for-all movement as a powerful response to both crises. It will transform health care, mandating a social right to equitable care, free at point of use. Everyone in the nation will enjoy comprehensive benefits without provider networks, co-pays, or deductibles.

Almost everyone — sick and well, insured and uninsured — has something to gain from this system. Single payer’s universalism is its strength, and the reason we can win it. But the Medicare-for-all movement is both a means and an end: it will clearly make for a happier and healthier nation, but it can also can become a unifying issue within a larger egalitarian political project at a moment of political crisis.

One day, when we read the history of how, against incredible odds, a single-payer national health program was finally created, we will come upon an early chapter that chronicles how Medicare-for-all advocates survived in the political wilderness. We’ll hear about how activists cut their teeth, built coalitions, crafted policy, drafted bills, won over politicians, launched campaigns, swayed opinions, and mobilized the grassroots. It will tell the story of ordinary people forging a powerful movement; it will tell the story of our present.

Fortunately, the next chapter isn’t so far in the future. It will describe how the movement was tempted by — but ultimately rejected — weak and diversionary counterproposals, how it broadened its base, how it skirmished with powerful corporate lobbies with near-bottomless war chests, and how it finally pushed a robust single-payer health care program onto the national legislative agenda.

Let’s forge ahead, confident as the architect of the National Health Service, Nye Bevan, was when he said that “the tides of history are flowing in our direction, that we are not beaten, that we represent the future…”

https://jacobinmag.com…