PNHP

Look who says health care is a right

Look who says health care is a right

Health Care in the United States: A Right or a Privilege

By Howard Bauchner, M.D., Editor in Chief, JAMA
JAMA, Editorial, January 3, 2017

The United States is about to embark on a great challenge: how to modify the current system of providing health care coverage for its citizens. However, the fundamental underlying question remains unanswered and was rarely mentioned during the past 8 years—Is health care coverage a basic right or a privilege (regardless of how that coverage is provided or who provides it)? Until that question is debated and answered, it may not be possible to reach consensus on the ultimate goal of further health care reform. Without agreeing to the goal, measuring success will be nearly impossible.

The months and years ahead are filled with uncertainty regarding how the US health care system will evolve.

The ACA needs to be modified, even though it has accomplished a great deal, principally by expanding the number of newly insured individuals. However, much remains to be accomplished, including how to ensure high-quality, affordable health insurance for all residents and how to control the continual increases in annual health care spending, now exceeding $3 trillion.

Sorting out the most effective way to provide health care coverage in the United States is a work in progress and will require careful assessment and likely repeated changes. If the goals of further health care reform are clear and are measured but are not reached, then it will be necessary to return to previous discussions that have included a public option, a single-payer system, lowering the eligibility for Medicare, or further privatization of the health care system.

I hope that all physicians, including those who are members of Congress, other health care professionals, and professional societies would speak with a single voice and say that health care is a basic right for every person, and not a privilege to be available and affordable only for a majority. The solution for how to achieve health care coverage for all may be uniquely American, but it is an exceedingly important and worthy goal, emblematic of a fair and just society.

JAMA is granting free access to the full editorial at this link:
http://jamanetwork.com…

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Comment:

By Don McCanne, M.D.

Did you get that? Howard Bauchner, the Editor in Chief of JAMA – the Journal of the American Medical Association – says that “all physicians, including those who are members of Congress, other health care professionals, and professional societies (should) speak with a single voice and say that health care is a basic right for every person, and not a privilege to be available and affordable only for a majority.”

If we get this one right, improved Medicare for all follows.

Congress stumbles in its effort to abandon ethics

House Republicans Back Down on Bid to Gut Ethics Office

By Eric Lipton and Matt Flegenheimer
The New York Times, January 3, 2017

House Republicans, facing a storm of bipartisan criticism, including from President-elect Donald J. Trump, moved early Tuesday afternoon to reverse their plan to kill the Office of Congressional Ethics. It was an embarrassing turnabout on the first day of business for the new Congress, a day when party leaders were hoping for a show of force to reverse policies of the Obama administration.

The reversal came less than 24 hours after House Republicans, meeting in a secret session, voted, over the objections of Speaker Paul D. Ryan, to eliminate the independent ethics office.

http://www.nytimes.com…

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Comment:

By Don McCanne, M.D.

It is astonishing that a new Congress that has promised to reduce the government’s support of some of the most important social programs in our nation took as their first action, behind closed doors, approval of “their plan to kill the Office of Congressional Ethics.”

Although they rejected the advice of Speaker Paul Ryan not to do this, President-elect Trump also expressed his view through a tweet that this should not have been “their number one act and priority.” We can only speculate as to whether Trump and Ryan were truly concerned about preserving the function of the ethics committee or if it was just that they were concerned about the negative public image that might ensue. It did not take long for the expression of public outrage to convince them that they needed to reverse this action.

The damage is done. The Congressional majority has made a clear statement that they will not let ethics interfere with their attack on our social programs, beginning with the Affordable Care Act. It will be our duty to continue to express our outrage at the unethical implications of making health care less and less affordable for an ever growing number of residents, not to mention all of the other social injustices they intend to advance through their attack on existing programs.

Voters indicated that they wanted to clean up Congress. They must be perplexed that the first action was to try to throw Congressional ethics out the window. It should be a clarion call to all of us to watch very closely every other policy that this Congress attempts to enact.

The Republican New Year’s Resolution: Destroy Medicare

Republicans hide their true intentions behind euphemisms about “saving” it. The truth is that Medicare doesn’t need saving.

By Nancy Altman
The Huffington Post, Dec. 30, 2016

New Year’s is a time for resolutions. Consistent with this tradition, powerful Republicans have made clear that they are resolving, in the New Year, to dismantle Medicare, ending it as we know it.

Speaker of the House Paul Ryan has said that destroying Medicare is part of the Republican plan to repeal Obamacare, another Republican resolution for 2017. And Representative Tom Price, powerful chairman of the House Budget Committee, Ryan ally, and likely next Secretary of Health and Human Services, has explained that the Republicans will enact Medicare legislation in the first six to eight months of 2017, since it is probably too big a task to include it in the planned January repeal of Obamacare.

These Republicans are people who carry through on their New Year’s resolutions. In discussing the goal of destroying Medicare in the New Year, Ryan explained, “With a unified Republican government, we can actually get things done.”

These Republicans never say, straightforwardly, that their plan is the repeal and replacement of Medicare. Because of Medicare’s overwhelming popularity, Republicans hide their true intentions behind euphemisms about “saving” it. But no one should be fooled. Their idea of saving Medicare is to destroy it, just as, during the Vietnam war, a U.S. military officer explained, “It became necessary to destroy the town to save it.”

The truth is that Medicare doesn’t need saving. There is no question that, as the wealthiest nation in the world at the wealthiest moment in our history, the United States can afford not just today’s Medicare, but a greatly expanded Medicare. In 1965, when Medicare was enacted, the nation’s Gross Domestic Product was, in real terms, a quarter of what it is today ($4.1 trillion in 1965 versus $16.7 trillion today.) Moreover, Medicare covers the most expensive part of the population – seniors and people with disabilities. Covering the rest of us is easier and cheaper.

Indeed, other industrialized countries spend a small fraction of what the United States spends on health care with better outcomes, despite older populations. Japan, for example, has a much older population than we do, and theirs is aging more rapidly than ours. In 2010, seniors represented 23 percent of the Japanese population, but just 13 percent of the U.S. population. In 2050, American seniors will compose just under 21 percent of the population ― less than Japan’s percentage of seniors today! Yet, the United States today spends three times more per capita than Japan on health care. Despite the additional spending, our health outcomes are worse. Indeed, Japan’s average life expectancy is more than four years longer than that of Americans!

The Republican plan to destroy Medicare will make American costs and health outcomes worse. Despite Medicare covering the most expensive part of the population, it is much more efficient than the rest of the American health care system. Japan and other industrialized countries have what amounts to Medicare for all. No other nation has the crazy patchwork system we have, which includes employer-sponsored private insurance, means-tested insurance, and individual private insurance, in addition to government-run Medicare.

Ryan proposes to make the patchwork system even more of a hodgepodge, with less coverage and higher costs. He wants to end Medicare as we know it and, instead, simply give seniors and people with disabilities fixed cash stipends to fend for themselves, unprotected, on the private market. But before the enactment of Medicare, many seniors and people with disabilities couldn’t get health insurance at any price. And those that managed to find an insurance company willing to cover them paid much higher prices than other Americans.

So why do the Republicans want to destroy Medicare and make our health care system less efficient and more expensive, with less coverage and poorer outcomes? Ideology, pure and simple. Republicans believe that the private sector is always superior to the government. But there are some things the government does better than the private sector. And Medicare is one of them.

Insurance is most inexpensive when everyone is covered under the same plan as the result of mandatory coverage. Only the federal government has the power and the ability to cover everyone, spreading the risk and responsibility as broadly as possible. Indeed, we should be expanding Medicare, not destroying it.

But, driven by ideology, Ryan and his fellow Republicans want to end Medicare as we know it. Ryan proposes to raise the initial age of eligibility for Medicare from its current age 65 to age 67, and to simply give everyone now under the age of 55 cash to buy insurance on their own, eliminating the efficiency of a single, large risk pool.

While those now on Medicare may think that they will be spared, they are wrong. Republicans always say, about their efforts to end Social Security and Medicare, that those aged 55 and over will not be affected, because those politicians recognize that seniors are most concerned about the programs and they vote. This assurance, of course, is insulting, because it assumes seniors are only concerned about themselves and not their children and grandchildren.

Moreover, the blatant assurance is not even true. Many Republican Social Security proposals cut current beneficiaries’ cost of living proposals. And, in the case of Medicare, the impact on current beneficiaries is likely to be even more substantial. If Ryan and his fellow Republicans have their way, Medicare will become increasingly expensive per enrollee, covering an aging and shrinking group, with high medical costs. As the group shrinks, they will have less and less political clout. Everyone not on traditional Medicare, will, by that time, be forced to fend for themselves with private insurance companies. It is extremely foreseeable that at some point, someone will propose treating this very old, small, and expensive population like everyone else. And then their Medicare will be gone, as well.

If we want a health care system in this country that provides everyone with access to the best medical care possible at the lowest possible cost, the way to achieve that is not to end Medicare, but to expand it. That, indeed, was the idea of the program’s founders. They saw Medicare as simply a first step, to be followed soon after by expanding it to include all children, and then more and more of the population, until the United States had Medicare for All.

We should follow that wise plan. As a next step, we should lower the initial age of Medicare eligibility, when people can first claim Social Security retirement benefits, from age 65 to 62. We certainly should not raise the age to 67 and then end the program as we know it, as the Republicans resolve to do. Unfortunately, they are now in control of all branches of government, and so have the political power to do what they want.

To stop them, I urge everyone who is old or hopes to be old someday to make your own Medicare resolution for 2017. Tell your elected leaders: Hands off Medicare except to expand it. And ask your friends to join you. Mobilize and make your voices heard. Then, as a resolution for 2018, we can all resolve to elect leaders who listen to us and have the good sense to expand, not destroy, Medicare.

Nancy Altman is founding co-director of Social Security Works.

http://www.huffingtonpost.com…

Quietly, Trump and Republicans Are Gunning to Destroy Medicaid

As Democrats focus on Obamacare and Medicare, there’s a “quieter war” on Medicaid brewing

By Deirdre Fulton
Common Dreams, Dec. 29, 2016

Medicaid, the nation’s healthcare program for the poor and disabled, is on the chopping block under President-elect Donald Trump and a Republican-controlled Congress—and it will take “intense focus by progressives” to ensure it doesn’t meet a dire fate.

In fact, former National Economic Council director Gene B. Sperling wrote Sunday in a New York Times op-ed, “if Democrats focus too much of their attention on Medicare, they may inadvertently assist the quieter war on Medicaid—one that could deny health benefits to millions of children, seniors, working families, and people with disabilities.”

As Democrats prepare for battles over the two programs, “the Republican effort to dismantle Medicaid is more certain,” Sperling warned—a prediction echoed this week by multiple news outlets.

“Neither Mr. Trump nor Senate Republicans may have the stomach to fully own the political risks of Medicare privatization,” he continued. “But not only have Speaker Paul D. Ryan and Tom Price, Mr. Trump’s choice for secretary of health and human services, made proposals to deeply cut Medicaid through arbitrary block grants or ‘per capita caps,’ during the campaign, Mr. Trump has also proposed block grants.”

Just this month, Vice President-elect Mike Pence told ABC: “With regard to Medicaid…there’s a real opportunity, there’s a real opportunity as we repeal and replace Obamacare to do exactly what the president-elect also said on the campaign, and that is block granting Medicaid back to the states.”

Block-granting can mean funding cuts, The Hill explained:

Block grants would mean limiting federal Medicaid funds to a set amount given to the states, rather than the current federal commitment, which is more open-ended.

Indeed, Sperling pointed to 2012 study (pdf) from the Kaiser Family Foundation, which found that a Medicaid block-grant proposal from Speaker Ryan “would lead to 14 million to 21 million Americans losing their Medicaid coverage by the 10th year, and that is on top of the 13 million who would lose Medicaid or children’s insurance program coverage under an [Affordable Care Act, or Obamacare] repeal.”

A separate Center for Rural Affairs report (pdf), also from 2012, found that “changes in Medicaid are likely to have a disproportionate effect on rural areas.”

Pence’s tenure as governor of Indiana could provide more clues about where the critical safety net program is headed. As governor, Pence implemented a policy requiring poor Medicaid recipients to make monthly payments for their insurance, or else lose benefits.

“That idea could soon be going national,” The Hill wrote, noting that “Trump’s nominee to run the Centers for Medicare and Medicaid Services, Seema Verma, helped Pence develop the changes to Medicaid in Indiana.”

While negotiating this arrangement, one federal official told NPR this week, Verma was “very committed to a particular ideology. That ideology is very much focused on personal responsibility.”

In a statement following Verma’s nomination, Physicians for a National Health Program president Robert Zarr said Verma’s “actions in Indiana signal that she will inflict cruel and unusual punishment on America’s most vulnerable citizens.”

As Common Dreams reported, leading Democrats are planning nationwide rallies for January 15 to gird against this gutting of the U.S. healthcare system.

Deidre Fulton is a staff writer at Common Dreams.

This work is licensed under a Creative Commons Attribution-Share Alike 3.0 License

http://www.commondreams.org…

A slightly different end-of-year request

Dear Quote of the Day list members,

Your email inboxes are no doubt inundated with end-of-year requests for donations “to keep this publication going” or whatever.

This is not a request to donate to Quote of the Day, but it is something much more important.

Regarding the Quote of the Day, I self-fund my activities and am able to do so quite comfortably. I do not receive funds from PNHP, so no dues are diverted to the qotd messages. In my role as senior health policy fellow of PNHP I serve as a volunteer, receiving no pay nor benefits. In fact, I am a monthly contributor to PNHP instead.

So what am I asking that is so important?

At this time when threats to our already inadequate health care system are intensifying we need an increase in people power to help carry to the nation the message of health care justice for all through a single payer national health program – an improved Medicare for all.

A great vehicle that supports the movement is membership in Physicians for a National Health Program. We need to achieve a critical mass of activists and supporters. Although membership is predominantly composed of physicians, medical students and other health care professionals, we also include activists and others who are dedicated to health care justice through single payer reform.

* If you are not a member, please consider joining (click here to join).

* If you are a member but have not recently renewed your membership, please consider doing so now (click here to renew).

* If you are a medical or other health professional student, membership is free (click here to join).

* Considering our national presence, PNHP operates on a remarkably spartan budget funded by dues and individual contributions, thus donations by those who can afford them are greatly appreciated and are put to good use (Contributions to PNHP are tax deductible under section 501(c)(3) of the IRS code – click here to donate).

This is not a message from PNHP but it is simply a personal request, from me to each of you, to join or renew your support for a cause to which I have devoted the remaining productive years of my life.

Peace, love and good health for all,

Don

***

Don McCanne, MD
Senior Health Policy Fellow
Physicians for a National Health Program
www.pnhp.org
don@mccanne.org

Why single payer makes sense

By Michael Huntington, M.D.
Corvallis (Ore.) Gazette-Times, Letters, Dec. 29, 2016

My friend, a business owner in Corvallis in his early 50s, tells me the following.

There are now only two health care “insurers” available to him in Benton County. His premium for a single person in 2017 would be about $9,500 per year for a “Gold” plan or about $6,500 for a “Bronze” plan. If he has a heart attack, he would pay an additional $5,000 for a total of about $14,500 (under Gold) or well over $7,000 for a total of well over $13,500 (under Bronze) before reaching his out-of-pocket cap.

One of the insurers, Providence, has no contract with, and will not pay, the emergency room doctors’ fees in this county — so add considerably more for that. Add thousands more dollars after scanning pages of fine print for each policy (or learning by sticker-shock experience) which specialists, services, and medications are not covered.

Premiums for individual policies are rising at a rate of 18 percent to 40 percent per year. My friend can barely afford to pay for his own insurance this year and regrets that he cannot afford coverage for his staff and their families. He feels he shouldn’t have to pay a fifth of his adjusted gross income or half his staff’s wages on health insurance, especially “insurance” that seems intent on preventing his access to health care.

This businessman feels we should have a single payer system as most other developed countries have. It would be good for business owners and everyone else.

Dr. Mike Huntington lives in Corvallis.

http://www.gazettetimes.com…

Preferring single payer health care over Partners

By Samuel Shem, M.D.
The Boston Globe, Letters, Dec. 29, 2016

Re “First, do no harm” by David Torchiana, president and CEO of Partners HealthCare (Opinion, Dec. 19): In understanding Partners, a touch of history may be relevant. There never was a need for a “Partners.” It was created to make an alliance between Massachusetts General Hospital and Brigham and Women’s Hospital — but also to make money.

American health care at first was a two-party system: doctor and patient. The next step was a third party: private insurance. Partners was born as a new third party, wedged between doctor-patient and private insurance (which became “a new 4th party”). Partners became a middleman and fee broker between doctor-patient-hospital and private insurance.

No wonder this added corporate giant added to health care costs, and has recently suffered record losses from ventures such as the installation of a new electronic medical records system and from running its own insurance company, Neighborhood Health Plan.

There’s no need for a “Partners.” The need, and solution, is for a national single-payer Medicare for all. Many, if not most, doctors want it. And ask any of us Medicare insurance patients: It’s cheap, and it works.

Dr. Samuel Shem is the author of the novel “The House of God” and is professor of medicine in medical humanities and psychiatry at New York University Medical School. He resides in Newton.

https://www.bostonglobe.com…

PNHP note: This letter was originally published under the title “He’d take single payer health care over Partners.”

Dr. Samuel Shem understands

He’d take single payer health care over Partners

By Samuel Shem, M.D.
Boston Globe, Letters, December 29, 2016

RE “FIRST, do no harm” by David Torchiana, president and CEO of Partners HealthCare (Opinion, Dec. 19):

In understanding Partners, a touch of history may be relevant. There never was a need for a “Partners.” It was created to make an alliance between Massachusetts General Hospital and Brigham and Women’s Hospital — but also to make money.

American health care at first was a two-party system: doctor and patient. The next step was a third party: private insurance. Partners was born as a new third party, wedged between doctor-patient and private insurance (which became “a new 4th party”). Partners became a middleman and fee broker between doctor-patient-hospital and private insurance.

No wonder this added corporate giant added to health care costs, and has recently suffered record losses from ventures such as the installation of a new electronic medical records system and from running its own insurance company, Neighborhood Health Plan.

There’s no need for a “Partners.” The need, and solution, is for a national single-payer Medicare for all. Many, if not most, doctors want it. And ask any of us Medicare insurance patients: It’s cheap, and it works.

The writer is the author of the novel “The House of God” and is professor of medicine in medical humanities and psychiatry at New York University Medical School.

https://www.bostonglobe.com…

Dr. Samuel Shem (Stephen Bergman, MD):
http://www.samuelshem.com…

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Comment:

By Don McCanne, M.D.

In health care, those receiving the funds will design their systems to maximize revenues. The financing system can be designed to optimize the private market business model, as it is now, or it can be optimized to obtain maximum value for patient care, as it would be under a well-designed single payer national health program – an improved Medicare for all. Samuel Shem describes it as it should be.

Medicare for All will help solve health care crisis

By Richard A. Damon, M.D.
Bozeman (Mont.) Daily Chronicle, Letters, Dec. 28, 2016

In contrast to other advanced countries of the world, health care as a human right is still controversial in the United States. Our market-based system still treats health care as a commodity for sale on the open market with access to care based on ability to pay.

The inadequate and shoddy debate over health care is closely linked to the thousands of ill-informed Americans who do not seem to possess even the most rudimentary understanding of the benefits of universal health care reform. John Geyman, M.D., author of “The Human Face of Obamacare,” has suggested three alternatives to consider how health care will be financed and how Americans will pay for it under the Trump administration:

1) Repeal the ACA and replace with a vague GOP plan with total privatization, ill-defined subsidies, health savings accounts, and cross-state insurers.

2) Continuation of the unsustainable ACA with changes, but with private insurers, drug makers and big corporate medical stake holders continuing control of costs.

3) Enactment of a single-payer Medicare for All system of National Health Insurance (NHI).

Comparison of the three alternatives gives obvious conclusion:

* The ACA has restricted access, choice, and accountability, no cost containment, unimproved quality of care, increased bureaucracy, no universal coverage, and no financial sustainability.

* The privatized GOP plan has restricted access, choice, and accountability, no cost containment, unimproved quality of care, increased bureaucracy, no universal coverage, and no financial sustainability.

* The NHI plan (Medicare for All) has unrestricted access, complete choice, cost containment, improved quality of care, reduced bureaucracy, universal coverage from birth to death, full accountability and is financially sustainable.

Check it out. How much more comparison is necessary to convince Americans which is the best plan? H.R. 676, Expanded and Improved Medicare for All overwhelmingly wins out.

Dr. Richard A. Damon resides in Bozeman.

http://www.bozemandailychronicle.com…

Top 10 challenges facing physicians in 2017

By Jeff Bendix, Charlotte Huff, Rose Schneider Krivich, Chris Mazzolini, Mary Pratt, Todd Shryock
Medical Economics, December 25, 2016

For the fourth consecutive year, Medical Economics reveals its list of obstacles physicians will face in the coming year and, more importantly, how to overcome them. For this latest presentation, we asked readers to tell us what challenges they face each day and where they needed solutions.

Here are their responses, starting with the biggest challenge of the coming year.

Challenge 1: MACRA

Healthcare reimbursements are migrating from volume to value. MACRA will most likely serve as the road map for other payers, so get used to the reporting requirements.

The law directs physicians to choose one of two reimbursement paths—advanced alternative payment models (APMs) or the Merit-based Incentive Payment System (MIPS).

Challenge 2: Prior authorizations

Prior authorization requirements have increased steadily in recent years, and the growth trend shows no signs of abating in 2017.

A 2015 Kaiser Family Foundation analysis of Medicare data found that 23% of drugs in private drug plans covered by Medicare Part D required prior authorizations, up from 8% in 2007. During the same period, the percentage of drugs carrying some type of utilization management restriction more than doubled, from 18% to 39%.

Challenge 3: Negotiating with payers

As payers move to consolidate, physicians find themselves facing the prospect of declining reimbursement and narrowing provider networks. Many doctors lament that payers now come to the table with a “take it or leave it” approach, forcing physicians to agree to one-sided contracts to maintain their patient head count.

Challenge 4: Staying motivated to practice medicine

Like everyone else, doctors want to enjoy their work, but they are finding it harder to do so. Physician professional dissatisfaction has been steadily growing in recent years, driven by increasing workloads and frustration at being unable to spend sufficient time with patients.

By now the causes of physician unhappiness are well known. They include ever-increasing amounts of time spent on administrative tasks and documentation, frustration with the demands imposed by electronic health records and the feeling they are having to cede control of their practices to government regulators and third-party payers.

Challenge 5: Maintenance of certification

More changes are on the way for physicians certifying in their sub-specialties through the American Board of Internal Medicine’s (ABIM) maintenance of certification (MOC) process.

Physicians feel as though a “board certification industrial complex” has been created by ABIM and MOC, says Christopher Unrein, DO, an internist and hospice/palliative care practitioner in Parker, Colorado. “Our profession’s very own medical societies, that we pay significant amounts of membership dues to, turn around that membership to sell us products in order to pass the exams and/or gain MOC points,” he says. “So not only is MOC a busy-work, anxiety-laden process, it is also one of financial opportunism. Physicians preying upon physicians — it disgusts me, as we are supposed to be a profession that cares and looks out for others.”

Challenge 6: Lack of EHR interoperability

Very few physicians have complete interoperability, which the nonprofit advocacy organization Center for Medical Interoperability defines as “the ability to share information across multiple technologies.”

In fact, a study released by KLAS Research in October finds that a mere 6% of healthcare providers can effectively and efficiently share patient data with other clinicians who use an electronic health record (EHR) system different than their own.

Challenge 7: Patient frustration with rising costs

The rapid rise in copays, deductibles and prescription drug prices is causing concern among physicians who see patients skipping care as a result of these increasing healthcare costs.

Challenge 8: The non-adherent patient and “quality” care

Patients who dismiss medical advice are nothing new, but that attitude increasingly threatens to cost doctors as quality metrics become tied to compensation.

Challenge 9: Changing patient attitudes

Today’s patients are educating themselves more, presenting both a challenge and an opportunity for primary care physicians.

Some, newly insured by the Affordable Care Act, may be coming to the doctor for the first time, and have questions and concerns they expect their new physician to answer. Other patients are angry. A recent Medical Economics reader poll suggests physicians are seeing that anger manifested during office visits as frustration with the cost of healthcare, from deductibles to surprise charges. Other patients are taking a consumerist approach to healthcare, looking for convenience and quick access.

“Patients feel more empowered to take control over their own health and consider the doctor an adviser. Doctors have to adjust from being in an elevated position to more of a coaching and advising role,” says Joseph E. Scherger, MD, a primary care physician in La Quinta, California, and member of the Medical Economics editorial advisory board.

Challenge 10: Patient satisfaction scores

Patient satisfaction has become an increasingly important factor in how physicians are treated by their employers and insurers, thanks in part to government regulations.

Dealing with the internet-savvy patient—but also attempting to make a personal connection with them—all while entering the data correctly into the practice’s electronic health record (EHR) system is a daunting but necessary task because of value-based care.

http://medicaleconomics.modernmedicine.com…

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Comment:

By Don McCanne, M.D.

Who’s in charge here? Would physicians choose to include these challenges in our health care system? What is the benefit/hassle-factor ratio in these challenges?

These intrusions are not originating with health care professionals and their patients. Instead they are emanating from insurers, from public and private administrators, from legislative bodies, and from vested interests in the medical-industrial complex.

A well-designed single payer system would eliminate some of these hassles and would modify others to more clearly benefit patients, providing a much more congenial practice environment for themselves and their health care professionals.

Our current system is designed to promote business principles, with an inevitable fight over where health care dollars end up. In contrast, a publicly-administered and publicly-financed single payer system would be designed to promote patient service, with dollars directed to health care delivery rather than to administratively-complex intermediaries and their rent-seeking puppeteers.

It seems like physicians have enough challenges in working with their patients to seek the best clinical outcomes. They really don’t need these other burdensome challenges injected by inefficient insurers, superfluous administrators, bureaucrats and legislative bodies. They need a well designed single payer system instead – an improved Medicare for all. In fact, some of the challenges listed explain why we need to improve Medicare when we convert it to a system serving all of us.

Improving health care for the homeless

Improving Health Care for Homeless People

By Howard K. Koh, MD, MPH; James J. O’Connell, MD
JAMA, December 27, 2016

Addressing the medical issues of homeless people is the health equity challenge of our time. The most recent US Department of Housing and Urban Development (HUD) report on homelessness, published in 2015, estimated that about 564,000 homeless people in the United States live in shelters and on the streets. This figure, based on a point-in-time snapshot on a single night each January, may well be an underestimate, given varying definitions of homelessness, peripatetic populations, and the lack of robust surveillance systems.

Some estimate as many as 2.3 million to 3.5 million individuals experience homelessness each year; persons of color are disproportionately affected, with one-third unsheltered.

This vulnerable population comprises a human kaleidoscope of people often excluded from mainstream society: runaways, LGBT (lesbian, gay, bisexual, and transgender) youth, those targeted by domestic violence, struggling veterans, displaced factory workers, migrant laborers, refugees, illiterate individuals, fragile elderly persons, and those discharged from mental hospitals or overcrowded prisons. For many, the daily struggle for food, shelter, clothing, and safety relegates health to a distant priority which, in turn, exacerbates disease, complicates treatment, and drives excess mortality. One recent analysis shows death rates for homeless youth are more than 10 times greater than for the general population.

More than 250 health care for the homeless (HCH) projects, funded by the Health Resources and Services Administration as federally qualified health centers, now feature multidisciplinary teams of clinicians that use an array of dedicated care strategies.

A decade ago, strategies for housing usually involved a treatment-first, continuum-of-care approach, in which clients were required to progress through milestones (such as sobriety, psychiatric treatment, and independent living skills) before being offered a home. Current federal efforts now favor “low-threshold supportive housing.” This is particularly true of Housing First, which offers timely access to a home without such requirements, thereby providing clients opportunities to link quickly with caregivers who can help address mental and physical health needs.

Insurance and Health Care Financing

Medicaid expansion in 32 states as part of the Affordable Care Act now provides new insurance options for people experiencing homelessness, especially previously ineligible single adults. In expansion states, health coverage rates for patients in HCH projects increased from 45% in 2012 to 67% in 2014 vs 26% to 30% in nonexpansion states during the same period. Through various waiver and plan options, states can request that the CMS approve Medicaid plans that cover housing costs, as long as the plans are cost-saving or cost-neutral.

The US Interagency Council on Homelessness coordinates national efforts with 19 federal agencies, state and local governments, and service providers. Other leading groups to address homelessness and its associated health challenges include the National Alliance to End Homelessness, the National Coalition for the Homeless, the National Health Care for the Homeless Council, the Corporation for Supportive Housing, and the Mayors Challenge to End Veterans Homelessness.

Despite some progress over the last several decades, the obstacles remain monumental. Accelerating efforts to reduce health disparities will require even greater societal commitment to improve health for this most vulnerable population.

JAMA is providing free access to the full article:
http://jamanetwork.com…

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Comment:

By Don McCanne, M.D.

Many of us are concerned about the unmet medical needs of the homeless, yet we fail to see adequate attention being paid to supporting public policies that would better address these needs. As Koh and O’Connell indicate, that means providing housing as well as access to health care and to programs that pay for these needs.

An egalitarian single payer healthcare system with first dollar coverage – an improved Medicare for all – obviously would go a long way toward providing access to health care. But providing housing and other essential needs would also be required for those who do not have the capability of meeting their own needs.

It is interesting that Medicaid waivers can be granted to include housing “as long as the plans are cost-saving or cost-neutral.” Wow. Considering that Medicaid is already severely underfunded, you would think that the government would have problems with the concept of drawing down Medicaid funds even further just to help fund housing. You might think that, but apparently not.

Holiday season seems to have become a time to pity the homeless, maybe a time to even donate a couple dollars to a soup kitchen, but not really a time for action. But as Koh and O’Connell remind us, the obstacles for progress remain monumental. “Accelerating efforts to reduce health disparities will require even greater societal commitment to improve health for this most vulnerable population.” Societal commitment means all of us, including Mr. Trump.

With Obamacare out of the way, what can GOP do?

By Robert Stone, M.D.
The Journal Gazette (Fort Wayne, Ind.), Dec. 26, 2016

There is the story of the dog that chases a bus down his street day after day, barking furiously. One day the bus stops. The dog catches it. Now what?

The Republicans have been barking furiously chasing Obamacare (the ACA) and now are about to catch it. They have promised to repeal it on Inauguration Day. You may not recall that the original idea for the ACA came from the conservative Heritage Foundation and first became law as Romneycare in Massachusetts. President Barack Obama chose this Republican-created idea as a compromise, hoping to find some Republican support, but met uncompromising resistance.

Here in Indiana, almost 600,000 Hoosiers have health insurance through the ACA, more than 390,000 in HIP 2.0 and more than 196,000 through the exchange. Nationally, there are 22 million at risk of losing ACA coverage. There is no historical precedent for taking something this vital from so many Americans. That many losing access to health care would be a catastrophe and would translate into 22,000 preventable deaths a year.

We can’t tell what is actually going to happen. We know they have promised to repeal it and replace it, but the ideas floated about replacement are vague, and although much of the ACA could be effectively repealed in January, replacement would take longer. They say they want to keep the pre-existing condition protection, the part of the ACA that says that you can’t be denied insurance just because you have some sort of illness. However, if you take away the mandate to purchase insurance, which has been unpopular, it becomes impossible for insurance companies to sell insurance at an affordable price. The ACA was complicated for a reason. They never considered the elegantly simple alternative of expanding our existing Medicare to cover everyone.

The ACA was deeply unpopular from two directions – those who saw it as government overreach, and those who felt it didn’t go far enough by leaving 28 million uncovered and keeping the corporate interests (the insurance industry and drug companies) in control of the system. Now this originally Republican idea is going to be owned by the party that birthed it.

They will probably try to re-brand it the same way Gov. Mike Pence expanded Medicaid in Indiana under the ACA while insisting he wasn’t expanding Medicaid. He called it HIP 2.0, the Healthy Indiana Plan. Paul Ryan, the speaker of the House, has suggested they replace “premium subsidies” in the ACA with “tax credits.” No matter what we get, it will likely cover fewer people and include more “skin in the game” (a term I find offensive) – higher deductibles and out-of-pocket expenses. It will not bring down insurance premiums or make health care more affordable.

We have work to do at the state and national level to protect the 22 million at risk of losing their Obamacare. Indiana’s legislature, new governor and congressional delegation must work to guarantee that 586,000 Hoosiers are protected. We all know someone who could be given the boot.

Dr. Robert Stone is director of Hoosiers for a Commonsense Health Plan and state coordinator and national board adviser for Physicians for a National Health Program. He is medical director for the Palliative Care Program, Indiana University Health Bloomington, and assistant clinical professor, Indiana University School of Medicine.

http://www.journalgazette.net…