PNHP

We want true Medicare for all, not today’s semi-privatized mess

We want true Medicare for all, not today’s semi-privatized mess

Don’t expand privatized system; go beyond to single-payer model.

By Rose Roach
Star Tribune (Minneapolis), Counterpoint, Aug. 5, 2016

In “What is implied by calls of ‘Medicare for all?’ ” (Aug. 2), Bryan Dowd used over-the-top rhetoric in suggesting that proponents of “Medicare for all” don’t understand Medicare. Medicare was conceived as a universal social insurance program providing health coverage to seniors regardless of income or health status, with all beneficiaries paying into the program through mandatory contributions from employees and employers. Prior to Medicare, half of seniors lacked health insurance and faced debt and poverty due to health care costs.

Unfortunately, in the last several years, the corporate health insurance lobby has tightened its grip on Medicare. Creeping privatization has made billions of dollars for the insurance industry while weakening the program.

Hefty contributions and constant lobbying on Capitol Hill by the insurance industry threatens one of the most efficient and popular universal public programs in our nation. For example, legislation passed in 2015 prohibits Medigap plans from covering Part B deductibles, forcing seniors to pay more for care, which we know tends to cause patients to delay or skip care until their illness is more serious and expensive to treat.

Another example is privatized Medicare (Medicare Advantage), which adds insurance companies as a middleman. Research has shown that Medicare Advantage costs taxpayers more than traditional Medicare and that it is less efficient.

More evidence that the Medicare system is needlessly convoluted to the advantage of the insurance companies: Kaiser Health News reported last week that health insurance companies are automatically enrolling members into their Medicare Advantage plans, rather than traditional Medicare, leaving many with surprise medical bills when they unknowingly go to out-of-network doctors and hospitals. When Dowd uses the words “turns out not to be very democratic” but rather “somewhat totalitarian,” he would be more accurately describing what is happening in Medicare Advantage than what supporters of universal health care seek. We support a system where people get to choose their doctors and medical providers, without interference from insurance companies.

Perhaps Prof. Dowd understands that we are pushing for something better than just an expansion of Medicare as it currently exists. The most efficient health care program would be a single national program, publicly financed and privately delivered, covering all Americans with one set of comprehensive benefits. No networks. No eligibility hoops or means tests. When advocates use the shorthand “Medicare for all,” that’s what we envision — not the distorted, semi-privatized, increasingly costly system seniors have to navigate today.

This is why the Minnesota Nurses Association advocates a system in which care is still provided by private providers but the government manages the finances. The current system is not sufficient: it is incredibly complex and wasteful, it is not controlling long-term health care costs, and it is not covering everyone. Your nurses think we can do better.

Rose Roach is executive director of the Minnesota Nurses Association.

http://www.startribune.com/counterpoint-we-want-true-medicare-for-all-not-today-s-semi-privatized-mess/389347521/

Insurance coverage as psychopathology; single payer as the cure

By Sharon R. Kahn, Ph.D.
The National Psychologist, July/Aug. 2016

Can you top this? “My client has PTSD and her insurance would only authorize 10 sessions.” Another adds: “My client has Major Depression and insurance will only authorize pharmacological treatment, no psychotherapy.”

Are we practicing evidence-based treatment modalities – or playing a deadly game of Go Fish? Clearly, we do not live in a sane society. How can we remediate this if we do not resurrect the zeitgeist of Erich Fromm, who drew back the curtain to show the “principle of free competition and the concomitant notion of the survival of the fittest called for individuals who were not inhibited by compassion in business dealing. Those who had the least compassion had the greatest chance of success.” Or, became insurance executives.

I became a psychologist to heal and repair the psychic ruptures in people’s souls. But I can’t repair when the access is blocked. I cannot repair when a third party is reading my notes, deliberating if it looks substantial enough to reimburse for a 45-minute session –  or if reimbursing only for the lower, 30-minute rate is justified.

It’s not just psychologists who suffer a loss of income. Over 33 percent of Americans cannot access needed medical care due to money. In fact, the United States is the only country in the world where citizens declare bankruptcy due to costs of medical treatments.

Most countries already have a national health care system. Some are socialistic in nature; others are a single­ payer system set within a capitalistic economy, such the Canadian model.

The difference between Canadian capitalism and the American is merely over who the payer is: the government, as opposed to diverse insurers. With the latter, payments are pawns to a false philosophy put forth by the insurance executives: Patients are wiser utilizers of medical services when they have “skin in the game” (i.e. copay).

Skin in the game restricts access, as between patients and practitioners when patients wonder whether practitioners recommend treatments based on what insurers will pay or patients reject recommended praxis due to fiscal concerns.

Access is further restricted when insurers use clerical personnel to review records and decide to reduce reimbursements based on their assessment of what best praxis should cost. Throw in a lack of true parity for mental health, vision and dental care and one can only wonder why a latter-day Samuel Adams (a disabled American) has not thrown all health insurers into some harbor.

The hypothesis of “skin in the game” has been disproven over and over. Medical costs become a de facto method to ration care, not rationalize it. A single-payer system would restore trust, increase access and reduce health care costs by paying hospitals, clinics and professionals a lump sum monthly.

Single payer is not socialistic, as professionals and hospitals remain privatized – they negotiate patient care with the patient – not with a third party. Professionals bill and are reimbursed by the state health department. Never again would clients hear that their insurance will not cover additional sessions. Or that their insurance insists that they take medications. No one receiving in-patient care will be harassed when their insurer calls and informs them they don’t merit that level of care.

Under the Affordable Care Act (ACA), states are encouraged to innovate in health care systems. Every legal state resident would be covered regardless of age, income, savings or employment. A person desirous of medical care would simply flash an eligibility card in front of the receptionist to receive services. There are no co-pays or deductibles. Professionals bill the health department for services. Tests and prescriptions are all covered. True parity would be offered, not only medical, but mental health, dental and vision care.

The money is there, via the state’s payroll taxes (paid 80 percent by employers, 20 percent by employees and I 00 percent by the self-employed). Non­ payroll income, such as capital gains, dividends and interest would also be used to fund single payer. Perhaps overall, taxes would rise – however, overall, costs for the individual would decrease – no more premiums, deductibles, co-pays and out-of-network minimums.

The average cost of an employer­provided family plan today is over $17,500 with an average family deductible of over $2,200. The average individual spends over $6,000 a year for health care premiums.

Overall health care costs will decrease as the profit that insurance companies demand (up to 30 percent of the health care dollar) will disappear. Administrative costs will decrease, as there will be no billing specialists whose job is to negotiate with insurance companies.

Under single payer, federal funds currently utilized for Medicare, Medicaid, Family Health Plus and Child Health Plus would be combined with the state revenue in a health trust.

The ACA (Obamacare) has failed to ensure universal coverage. It was based on the notion that federal aid would enable citizens to buy insurance via subsidies – it did not predict that insurance companies would then raise premiums to ensure profits would never be used to pay for health care costs, a perpetual game of keep away. Keep away does not bring down health care costs, as insurers are for-profit ventures with no incentives to make costs transparent.

The growth in the net cost of health insurance is due to administrative waste and executive profits. A single-payer plan would reduce spending by 15 percent by terminating billing expenses, administrative waste and fraud.

ACA further assumed that states would expand Medicaid coverage – and approximately half did not. One-third of Americans report they are now unable to access needed medical care due to cost. Thus current practice only serves to ration care; single payer offers a rational path to the sane society.

There is no justification for what passes for psychotherapeutic praxis today. True therapeutic conditions arise when clients and psychologists are freed to discuss all the empirically proven options. Psychologists once more could heal psychic deficits, offering the intensity of care individually titrated to the client’s needs. It will happen when psychologists become so frustrated as to make their desires known to elected state and federal representatives. Single payer offers the route to a saner society replete with life, liberty and the pursuit of happiness.

References available from author.

Sharon R. Kahn, Ph.D., is a medical expert for the Social Security Administration and a consultant to the New York Metropolitan Transit Authority s Access-A-Ride program. She completed post-doc studies in narcotic and drug research. She resides and practices in New York, N.Y., where she advocates for a single-payer plan. Her email address is drsrkalm@gmail.com.

Tory plans for NHS privatization revealed

Tory plans for NHS privatisation released during parliamentary recess

By Alex Scott-Samuel
The BMJ, August 5, 2016

July 2016 saw the very quiet publication of two key documents charting the route to the privatisation of the NHS in England. Firstly, from NHS England, came Strengthening Financial Performance and Accountability in 2016-17. This is the latest set of instructions on the implementation of NHS chief executive Simon Stevens’s Five Year Forward View (5YFV).

The 5YFV is increasingly coming to resemble one of Stalin’s Five Year Plans from the 1950s. As the new guidance makes clear, Stevens’s latest collectivisation strategy, the Sustainability and Transformation Plans (STPs), is being rigidly imposed across England.

My alternative title for the guidance document would be “Policing the government’s privatisation plans.” Having constructed, with help from the Treasury, a universal set of NHS trust financial deficits based on arbitrarily imposed cash limits, NHS England is now using those deficits to legitimise impossibly tight controls on hospital trusts, clinical commissioning groups (CCGs), and other NHS agencies to ensure they conform to central proposals for cuts and mergers between NHS institutions.

At the same time, private sector and insurance friendly “new models of care” are being imposed in community settings, further undermining NHS hospitals. The ultimate intended outcomes of this massive, dictatorial reorganisation process are privatisation, co-payments, charges, and insurance funded care.

These intentions are made clearer in a second policy paper, similarly released during the parliamentary recess when it is least likely to be noticed: the NHS Improvement Business Plan 2016/17. The plan states that providers will be required “to transform services in line with the 5YFV and this will include making use of new care models and innovative organisational forms.” A priority for 2016/17 is “to facilitate independent sector providers to form NHS partnerships.”

We are told that: “We intend to bring together the most promising potential areas for formal collaboration between NHS Improvement, providers, independent sector partners, NHS England, and other key stakeholders into a new work programme. The key elements of this programme in the first instance will examine the opportunities in the areas of:

  • mainstreaming clinical capacity for elective, outpatient, and diagnostic care;
  • joint ventures and/or outsourcing of new, novel, or restructured clinical services;
  • joint ventures and novel financing for facilities and/or technology;
  • independent sector management models to support capability and leadership challenges.”

In other words, before the end of the 2016-17 financial year, we will see the new Conservative government start to impose the large scale privatisation of clinical services, foreshadowed in the Health and Social Care Act 2012. In the event of any doubts regarding the obligatory nature of these policies, the NHS England report referred to earlier makes it clear that “special measures” (central takeover of local management) will be imposed if agencies fail to balance the books or deviate in any way from the government’s plans.

In this context, it’s ironic to recall all the fluffy political spin about “putting GPs in the driving seat” when CCGs were launched in 2012. By contrast, we are now told by NHS England that CCGs that fail to follow Stevens’s diktat will be disbanded and/or forced to become US style accountable care organisations (ACOs). This is with the aim of promoting mergers, cuts, and closures in the publicly provided NHS and introducing community based “integrated packages of care,” which are readily amenable to private sector provision and insurance funding—as occurs in the US ACOs on which this particular “new model of care” is based.

It is no coincidence that the House of Lords is currently calling for evidence to be submitted to its new select committee on the long term sustainability of the NHS.

This inquiry, supported by government ministers, is likely to make recommendations that will legitimise the aims of Stevens’s five year plan, including the “inevitability” of top-ups, co-payments, charges, and of the short term personal health budgets and longer term health insurance system that would be required to fund them. This toxic combination of an increasingly insurance based and increasingly privately provided health service will signal the final dismantling of what was once our National Health Service in England—a horrific and destructive act, which we now know to have been first proposed by Prime Minister Theresa May’s predecessor Margaret Thatcher in 1982.

http://blogs.bmj.com/bmj/2016/08/05/tory-plans-for-nhs-privatisation-released-during-parliamentary-recess/

***

Comment:

By Don McCanne, M.D.

We’ve been concerned for some time about the privatization of England’s National Health Service. The process is now underway. The Tory government is threatening the conversion of their delivery system into US style accountable care organizations, ignoring the fact that they have failed to improve quality or control costs. As we stumble along with our grossly inadequate efforts to reform our system, we can learn from the British how not to do it, which, as we see, bears an uncanny resemblance to what we are already doing.

Tory plans for NHS privatization revealed

Tory plans for NHS privatisation released during parliamentary recess

By Alex Scott-Samuel
The BMJ, August 5, 2016

July 2016 saw the very quiet publication of two key documents charting the route to the privatisation of the NHS in England. Firstly, from NHS England, came Strengthening Financial Performance and Accountability in 2016-17. This is the latest set of instructions on the implementation of NHS chief executive Simon Stevens’s Five Year Forward View (5YFV).

The 5YFV is increasingly coming to resemble one of Stalin’s Five Year Plans from the 1950s. As the new guidance makes clear, Stevens’s latest collectivisation strategy, the Sustainability and Transformation Plans (STPs), is being rigidly imposed across England.

My alternative title for the guidance document would be “Policing the government’s privatisation plans.” Having constructed, with help from the Treasury, a universal set of NHS trust financial deficits based on arbitrarily imposed cash limits, NHS England is now using those deficits to legitimise impossibly tight controls on hospital trusts, clinical commissioning groups (CCGs), and other NHS agencies to ensure they conform to central proposals for cuts and mergers between NHS institutions.

At the same time, private sector and insurance friendly “new models of care” are being imposed in community settings, further undermining NHS hospitals. The ultimate intended outcomes of this massive, dictatorial reorganisation process are privatisation, co-payments, charges, and insurance funded care.

These intentions are made clearer in a second policy paper, similarly released during the parliamentary recess when it is least likely to be noticed: the NHS Improvement Business Plan 2016/17. The plan states that providers will be required “to transform services in line with the 5YFV and this will include making use of new care models and innovative organisational forms.” A priority for 2016/17 is “to facilitate independent sector providers to form NHS partnerships.”

We are told that: “We intend to bring together the most promising potential areas for formal collaboration between NHS Improvement, providers, independent sector partners, NHS England, and other key stakeholders into a new work programme. The key elements of this programme in the first instance will examine the opportunities in the areas of:

  • mainstreaming clinical capacity for elective, outpatient, and diagnostic care;
  • joint ventures and/or outsourcing of new, novel, or restructured clinical services;
  • joint ventures and novel financing for facilities and/or technology;
  • independent sector management models to support capability and leadership challenges.”

In other words, before the end of the 2016-17 financial year, we will see the new Conservative government start to impose the large scale privatisation of clinical services, foreshadowed in the Health and Social Care Act 2012. In the event of any doubts regarding the obligatory nature of these policies, the NHS England report referred to earlier makes it clear that “special measures” (central takeover of local management) will be imposed if agencies fail to balance the books or deviate in any way from the government’s plans.

In this context, it’s ironic to recall all the fluffy political spin about “putting GPs in the driving seat” when CCGs were launched in 2012. By contrast, we are now told by NHS England that CCGs that fail to follow Stevens’s diktat will be disbanded and/or forced to become US style accountable care organisations (ACOs). This is with the aim of promoting mergers, cuts, and closures in the publicly provided NHS and introducing community based “integrated packages of care,” which are readily amenable to private sector provision and insurance funding—as occurs in the US ACOs on which this particular “new model of care” is based.

It is no coincidence that the House of Lords is currently calling for evidence to be submitted to its new select committee on the long term sustainability of the NHS.

This inquiry, supported by government ministers, is likely to make recommendations that will legitimise the aims of Stevens’s five year plan, including the “inevitability” of top-ups, co-payments, charges, and of the short term personal health budgets and longer term health insurance system that would be required to fund them. This toxic combination of an increasingly insurance based and increasingly privately provided health service will signal the final dismantling of what was once our National Health Service in England—a horrific and destructive act, which we now know to have been first proposed by Prime Minister Theresa May’s predecessor Margaret Thatcher in 1982.

http://blogs.bmj.com/bmj/2016/08/05/tory-plans-for-nhs-privatisation-rel…

We’ve been concerned for some time about the privatization of England’s National Health Service. The process is now underway. The Tory government is threatening the conversion of their delivery system into US style accountable care organizations, ignoring the fact that they have failed to improve quality or control costs. As we stumble along with our grossly inadequate efforts to reform our system, we can learn from the British how not to do it, which, as we see, bears an uncanny resemblance to what we are already doing.

Healthcare inequality on the rise

By Steffie Woolhandler and David U. Himmelstein
The Hill, Aug. 2, 2016

In healthcare, as in the rest of American life, the gap between rich and poor is growing. That’s the take-home message from our analysis of 50 years of data on healthcare use and expenditures that appears in the July issue of the journal Health Affairs.

In the bad old days of the 1960s—before Medicare and Medicaid—the wealthy got twice as much care as the poor. But those programs changed things. By 1977, the poor were getting 14 percent more care than the wealthy— an appropriate difference since the poor are sicker and need more care.
The pattern changed again in 2004. Over the next eight years, use of care by the wealthiest fifth of Americans grew by 19.7 percent, outpacing growth for the middle class by 57 percent. Meanwhile, care for the poorest fifth actually fell.

By 2012 the wealthy were getting 40 percent more doctor visits than other Americans. Overall, after adjusting for differences in age and health, the wealthy got 43 percent more care than the poor— $1,743 per person— and left the middle class in the dust too; the latter got $1,082 less care than the rich.

What’s behind widening healthcare inequality?

Ballooning copayments and deductibles are the most likely culprits.

As healthcare costs soared, employers shifted more and more of the burden to their workers.  Over the past decade, the average deductible in employer-sponsored health plans has risen 255 percent.

Where the copay for a trip to the doctor used to be a few dollars, now it’s often $50. An MRI or night in the hospital? We’re talking hundreds, or even thousands of dollars out of pocket.

With incomes of the poor and middle class stagnant or worse, many Americans don’t have that kind of money; half can’t afford an unplanned $400 expense without borrowing money or selling off a possession. That leaves many facing a choice between debt and care. Medical bills have become collection agencies’ biggest business.

Health policy wonks have applauded rising deductibles and copayments as the right way to get healthcare inflation under control —they call it giving patients more skin in the game.

But as doctors we’ve seen the human toll these policies exact: Women who waited and hoped that their breast lump would just disappear. Men with strokes because they couldn’t afford high blood pressure treatment.

Obamacare offered a partial solution to healthcare inequity by covering about half of the uninsured. But the health law is also part of the problem. The new insurance policies demand punishing deductibles—an average of $3,064 per person in the exchanges’ silver plans, and even more, $5,765, in the bronze plans. And after paying that, patients still face steep copayments.

That kind of insurance is akin to a hospital gown: it gives the impression that you’re covered, but doesn’t actually cover your butt.

The healthcare inequality we found is uniquely American. In every other wealthy nation, people are shielded from the costs of illness by a comprehensive and truly universal national health insurance program.

Every Canadian, for instance, has first-dollar coverage through a Medicare-for-all system (they actually call it “Medicare”) that distributes care according to need, not wealth. As a result, poor Canadians get 26 percent more care (and the middle class 11 percent more) than the wealthy.

The growing inequality in healthcare use in America is reflected in worsening outcomes for those with lesser incomes. While the health gap between rich and poor Canadians has been closing, ours has been widening. Today, the wealthiest American men live 15 years longer than their poor counterparts.

For the past decade or more U.S. health policy has blamed patients for skyrocketing health costs, and sought solutions in ever-skimpier insurance coverage and market-based competition.

Those policies have fueled a boom for giant insurers, drug firms and hospital chains. But they’ve been a bust for poor and middle-class Americans.

Drs. Steffie Woolhandler and David U. Himmelstein are primary care physicians, professors of health policy at the City University of New York at Hunter College, and lecturers in medicine at Harvard Medical School. They co-founded Physicians for a National Health Program (pnhp.org), a nonpartisan organization that advocates for single-payer health reform.

This article originally appeared at The Hill. The views expressed by contributors are their own and not the views of The Hill.

http://thehill.com/blogs/pundits-blog/healthcare/290128-healthcare-inequality-on-the-rise

Should we require providers to accept Medicaid?

California’s Public Hospitals Face New Medi-Cal Mandate

By Pauline Bartolone
California Healthline, August 4, 2016

Public hospitals in California will be required to contract with at least one Medi-Cal managed care plan starting in 2018.

But advocates for low-income Californians say one regional contract with a Medi-Cal insurer is not enough to ensure adequate access to care. In addition, public hospitals may be exempted from the mandate if “good faith” contract negotiation efforts have failed.

The Western Center on Law and Poverty, an advocacy group, lobbied lawmakers to require that public hospitals contract with all Medi-Cal managed care plans in their region.

But such a mandate was not included in the hospital financing arrangement, which is part of what’s known as the “Medi-Cal 2020 waiver” — a $6.2 billion agreement between state officials and the federal government to facilitate programs related to health care quality, access and cost.

The agreement is intended to improve the quality of care and enhance access to it for the state’s 13 million-plus Medi-Cal enrollees, about 80 percent of whom are in managed care plans.

The Western Center said it decided to advocate for broader Medi-Cal coverage after hearing about the challenges Medi-Cal enrollees face trying to get specialized care at some University of California health systems.

Public hospitals like San Francisco General Hospital and Harbor-UCLA Medical Center often serve Medi-Cal enrollees, but they are not obligated to provide all services to these patients. The hospitals say that Medi-Cal managed care reimbursements often do not cover the costs they incur caring for those patients.

“We hear from our local legal aid partners that there are significant specialty access problems for some Medi-Cal members who would like to be able to access services at UC hospitals,” the Western Center’s director of public advocacy, Elizabeth Landsberg, wrote in a letter to lawmakers.

Landsberg’s group wants the new requirement for Medi-Cal contracting to provide for the full scope of health care services, including primary and specialty care.

California Senate Health Committee Chairman Ed Hernandez (D-West Covina) authored one of the bills that formally turned the new public hospital funding rules into state law. He says the Western Center’s suggested contracting requirements weren’t included because of the financial difficulty they would impose.

“Ideally, I would love to see all the public hospitals, including the UCs, see any and every Medi-Cal patient that comes in the door,” said Hernandez.

“The dilemma is…you can’t force people to see Medi-Cal patients because of the poor reimbursement rates.”

http://californiahealthline.org/news/californias-public-hospitals-face-new-medi-cal-mandate/

***

Obamacare Expansion A Bumpy Ride For Rural Health Clinics

By Pauline Bartolone
Kaiser Health News, August 3, 2016

When Medi-Cal, California’s version of Medicaid, was first expanded under the Affordable Care Act in early 2014, the number of people insured under the program doubled to around 40,000 people in the region served by Shasta Community Health. Not only did the clinics see new patients, but the demand for services soared from existing ones who were newly insured.

The clinic network already had a shortage of doctors and nurses. — a problem shared by many other rural health clinics in California.

“The … more new patients we brought in, the more stress on the providers, the more likely [they] were going to leave, the deeper the crisis went,” said Shasta Community Health Center CEO C. Dean Germano. So he decided to close the network’s five clinics to new adult Medi-Cal patients, though they continued to serve all of their existing patients and accepted new children.

Q: Were you able to meet the demand for all these new services?

Germano: No, not at all. We quickly became overwhelmed, although there were a couple of things happening all at once. One was certainly the growth in Medicaid coverage, but at the very same time, the state of California expanded Medi-Cal managed care into 28 rural counties. We are one of them. We did not have Medi-Cal managed care prior to this.

We were assigned patients, then assigned more patients. We quickly reached a point where we could not take on more new adult patients to our practice. We had to essentially constrain and at one point close the practice to new adult Medicaid patients.

It was a very big hit [to] the community because adult patients had to go further afield to find services outside of the emergency room. Under managed care, it’s [the health plan’s] responsibility to find a medical home and some of the medical homes were 30 to 40 miles into the mountains.

http://khn.org/news/obamacare-expansion-a-bumpy-ride-for-rural-health-clinics/

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Medi-Cal Managed Care: An Overview and Key Issues

By Margaret Tatar, Julia Paradise, and Rachel Garfield
Kaiser Family Foundation, March 2, 2016

Access to care

Problem with access to care in Medi-Cal FFS carry over into managed care, challenging Medi-Cal health plans to establish adequate provider networks and improve care. Gaps in access to certain specialists, including psychiatrists and other behavioral health providers, and long-term care services, are the most significant gaps. Providers have cited Medi-Cal’s low payment rates as a barrier to their participation in the program and sued the state on the basis that the fees violate federal Medicaid payment standards. Language and cultural gaps in access to care and gaps in rural access are additional issues.

Major current issues

Two recent developments – CMS’ proposed modernization of the Medicaid managed care regulations and the approval of “Medi-Cal 2020,” the renewal of California’s section 1115 waiver – can be expected to bear on the Medi-Cal managed care program, by increasing plan- and state-level requirements and state oversight responsibilities, and by setting the stage for potential changes in the role and operation of managed care plans in a transforming health care delivery and payment system.

http://kff.org/medicaid/issue-brief/medi-cal-managed-care-an-overview-and-key-issues/

***

Comment:

By Don McCanne, M.D.

One of the great successes of the Affordable Care Act is the expansion of Medicaid coverage for low-income individuals. But how do you define success? Let’s look at California.

One-third of Californians are on Medi-Cal – California’s Medicaid program. Yes, one-third! Yet California has one of the lowest Medicaid provider payment rates in the nation and frequently does not cover the costs of care provided. California has now transferred about four-fifths of the Medi-Cal patients into managed care. Managed care plans have significant additional administrative costs, yet payment rates were not increased over what was being paid under the fee-for-service program. That means that the actual health care providers have had a further net decrease in payment rates.

So who is going to see these patients? Do you send them to local community health centers? These centers have had problems recruiting enough primary care professionals and thus have had difficulties accepting more Medi-Cal patients. The Shasta Community Health Center even had to temporarily close the practice to new adult Medi-Cal patients. Where do they go?

Taxpayer-supported public hospitals and clinics, including the University of California health systems, seem like a logical place to refer these patients. But they have the same capacity issues. Further, many specialists in the community refuse to accept Medi-Cal patients and thus a greater burden would be placed on the academic center specialists. Most of these specialists are not advocates of noblesse oblige. They particularly do not want to be overworked and underpaid.

Just as emergency departments no longer have the right to refuse patients, some suggest that physicians, hospitals and clinics also be required to accept Medi-Cal patients. Although this was considered, the California legislature decided to take a lesser step. As of 2018, all public hospitals in California will be required to contract with at least one Medi-Cal managed care plan.

This may not seem like that big of a deal, but it does expand the principle beyond emergency departments that the government can mandate that providers be required to see patients while refusing to adequately fund their care. Will it be private hospitals next? Outpatient centers? Private medical practices? Real problem, wrong solution.

What we need instead is an equitable system of financing health care – a single payer national health program. A patient’s access to care should not depend on the payment source, as it does now. Access should be based strictly on health care needs, backed up by an automatic, equitable payment system.

Should we require providers to accept Medicaid?

California’s Public Hospitals Face New Medi-Cal Mandate

By Pauline Bartolone
California Healthline, August 4, 2016

Public hospitals in California will be required to contract with at least one Medi-Cal managed care plan starting in 2018.

But advocates for low-income Californians say one regional contract with a Medi-Cal insurer is not enough to ensure adequate access to care. In addition, public hospitals may be exempted from the mandate if “good faith” contract negotiation efforts have failed.

The Western Center on Law and Poverty, an advocacy group, lobbied lawmakers to require that public hospitals contract with all Medi-Cal managed care plans in their region.

But such a mandate was not included in the hospital financing arrangement, which is part of what’s known as the “Medi-Cal 2020 waiver” — a $6.2 billion agreement between state officials and the federal government to facilitate programs related to health care quality, access and cost.

The agreement is intended to improve the quality of care and enhance access to it for the state’s 13 million-plus Medi-Cal enrollees, about 80 percent of whom are in managed care plans.

The Western Center said it decided to advocate for broader Medi-Cal coverage after hearing about the challenges Medi-Cal enrollees face trying to get specialized care at some University of California health systems.

Public hospitals like San Francisco General Hospital and Harbor-UCLA Medical Center often serve Medi-Cal enrollees, but they are not obligated to provide all services to these patients. The hospitals say that Medi-Cal managed care reimbursements often do not cover the costs they incur caring for those patients.

“We hear from our local legal aid partners that there are significant specialty access problems for some Medi-Cal members who would like to be able to access services at UC hospitals,” the Western Center’s director of public advocacy, Elizabeth Landsberg, wrote in a letter to lawmakers.

Landsberg’s group wants the new requirement for Medi-Cal contracting to provide for the full scope of health care services, including primary and specialty care.

California Senate Health Committee Chairman Ed Hernandez (D-West Covina) authored one of the bills that formally turned the new public hospital funding rules into state law. He says the Western Center’s suggested contracting requirements weren’t included because of the financial difficulty they would impose.

“Ideally, I would love to see all the public hospitals, including the UCs, see any and every Medi-Cal patient that comes in the door,” said Hernandez.

“The dilemma is…you can’t force people to see Medi-Cal patients because of the poor reimbursement rates.”

http://californiahealthline.org/news/californias-public-hospitals-face-new-medi-cal-mandate/

***

Obamacare Expansion A Bumpy Ride For Rural Health Clinics

By Pauline Bartolone
Kaiser Health News, August 3, 2016

When Medi-Cal, California’s version of Medicaid, was first expanded under the Affordable Care Act in early 2014, the number of people insured under the program doubled to around 40,000 people in the region served by Shasta Community Health. Not only did the clinics see new patients, but the demand for services soared from existing ones who were newly insured.

The clinic network already had a shortage of doctors and nurses. — a problem shared by many other rural health clinics in California.

“The … more new patients we brought in, the more stress on the providers, the more likely [they] were going to leave, the deeper the crisis went,” said Shasta Community Health Center CEO C. Dean Germano. So he decided to close the network’s five clinics to new adult Medi-Cal patients, though they continued to serve all of their existing patients and accepted new children.

Q: Were you able to meet the demand for all these new services?

Germano: No, not at all. We quickly became overwhelmed, although there were a couple of things happening all at once. One was certainly the growth in Medicaid coverage, but at the very same time, the state of California expanded Medi-Cal managed care into 28 rural counties. We are one of them. We did not have Medi-Cal managed care prior to this.

We were assigned patients, then assigned more patients. We quickly reached a point where we could not take on more new adult patients to our practice. We had to essentially constrain and at one point close the practice to new adult Medicaid patients.

It was a very big hit [to] the community because adult patients had to go further afield to find services outside of the emergency room. Under managed care, it’s [the health plan’s] responsibility to find a medical home and some of the medical homes were 30 to 40 miles into the mountains.

http://khn.org/news/obamacare-expansion-a-bumpy-ride-for-rural-health-clinics/

***

Medi-Cal Managed Care: An Overview and Key Issues

By Margaret Tatar, Julia Paradise, and Rachel Garfield
Kaiser Family Foundation, March 2, 2016

Access to care

Problem with access to care in Medi-Cal FFS carry over into managed care, challenging Medi-Cal health plans to establish adequate provider networks and improve care. Gaps in access to certain specialists, including psychiatrists and other behavioral health providers, and long-term care services, are the most significant gaps. Providers have cited Medi-Cal’s low payment rates as a barrier to their participation in the program and sued the state on the basis that the fees violate federal Medicaid payment standards. Language and cultural gaps in access to care and gaps in rural access are additional issues.

Major current issues

Two recent developments – CMS’ proposed modernization of the Medicaid managed care regulations and the approval of “Medi-Cal 2020,” the renewal of California’s section 1115 waiver – can be expected to bear on the Medi-Cal managed care program, by increasing plan- and state-level requirements and state oversight responsibilities, and by setting the stage for potential changes in the role and operation of managed care plans in a transforming health care delivery and payment system.

http://kff.org/medicaid/issue-brief/medi-cal-managed-care-an-overview-and-key-issues/

One of the great successes of the Affordable Care Act is the expansion of Medicaid coverage for low-income individuals. But how do you define success? Let’s look at California.

One-third of Californians are on Medi-Cal – California’s Medicaid program. Yes, one-third! Yet California has one of the lowest Medicaid provider payment rates in the nation and frequently does not cover the costs of care provided. California has now transferred about four-fifths of the Medi-Cal patients into managed care. Managed care plans have significant additional administrative costs, yet payment rates were not increased over what was being paid under the fee-for-service program. That means that the actual health care providers have had a further net decrease in payment rates.

So who is going to see these patients? Do you send them to local community health centers? These centers have had problems recruiting enough primary care professionals and thus have had difficulties accepting more Medi-Cal patients. The Shasta Community Health Center even had to temporarily close the practice to new adult Medi-Cal patients. Where do they go?

Taxpayer-supported public hospitals and clinics, including the University of California health systems, seem like a logical place to refer these patients. But they have the same capacity issues. Further, many specialists in the community refuse to accept Medi-Cal patients and thus a greater burden would be placed on the academic center specialists. Most of these specialists are not advocates of noblesse oblige. They particularly do not want to be overworked and underpaid.

Just as emergency departments no longer have the right to refuse patients, some suggest that physicians, hospitals and clinics also be required to accept Medi-Cal patients. Although this was considered, the California legislature decided to take a lesser step. As of 2018, all public hospitals in California will be required to contract with at least one Medi-Cal managed care plan.

This may not seem like that big of a deal, but it does expand the principle beyond emergency departments that the government can mandate that providers be required to see patients while refusing to adequately fund their care. Will it be private hospitals next? Outpatient centers? Private medical practices? Real problem, wrong solution.

What we need instead is an equitable system of financing health care – a single payer national health program. A patient’s access to care should not depend on the payment source, as it does now. Access should be based strictly on health care needs, backed up by an automatic, equitable payment system.

Proliferation of for-profit, freestanding emergency departments

Where Do Freestanding Emergency Departments Choose to Locate? A National Inventory and Geographic Analysis in Three States

By Jeremiah D. Schuur, Olesya Baker, Jaclyn Freshman, Michael Wilson, David M. Cutler
Annals of Emergency Medicine, July 12, 2016 (online)

Study objective

We determine the number and location of freestanding emergency departments (EDs) across the United States and determine the population characteristics of areas where freestanding EDs are located.

Methods

We conducted a systematic inventory of US freestanding EDs. For the 3 states with the highest number of freestanding EDs, we linked demographic, insurance, and health services data, using the 5-digit ZIP code corresponding to the freestanding ED’s location. To create a comparison nonfreestanding ED group, we matched 187 freestanding EDs to 1,048 nonfreestanding ED ZIP codes on land and population within state. We compared differences in demographic, insurance, and health services factors between matched ZIP codes with and without freestanding EDs, using univariate regressions with weights.

Results

We identified 360 freestanding EDs located in 30 states; 54.2% of freestanding EDs were hospital satellites, 36.6% were independent, and 9.2% were not classifiable. The 3 states with the highest number of freestanding EDs accounted for 66% of all freestanding EDs: Texas (181), Ohio (34), and Colorado (24). Across all 3 states, freestanding EDs were located in ZIP codes that had higher incomes and a lower proportion of the population with Medicaid. In Texas and Ohio, freestanding EDs were located in ZIP codes with a higher proportion of the population with private insurance. In Texas, freestanding EDs were located in ZIP codes that had fewer Hispanics, had a greater number of hospital-based EDs and physician offices, and had more physician visits and medical spending per year than ZIP codes without a freestanding ED. In Ohio, freestanding EDs were located in ZIP codes with fewer hospital-based EDs.

Conclusion

In Texas, Ohio, and Colorado, freestanding EDs were located in areas with a better payer mix. The location of freestanding EDs in relation to other health care facilities and use and spending on health care varied between states.

http://www.annemergmed.com/article/S0196-0644(16)30199-8/fulltext

***

Are free-standing emergency rooms helping only the wealthy?

By Sabriya Rice
The Dallas Morning News, August 3, 2016

Business is booming in Texas for free-standing emergency departments. The centers are emerging in wealthier neighborhoods, where patients are privately insured and are less likely to have Medicaid or Medicare, finds a study published in July in the Annals of Emergency Medicine.

That’s concerning for some health policy researchers. Emergency services in the U.S. have historically been provided by hospitals, and therefore must adhere to federal regulations that protect patients from being denied care if they cannot afford it.

“It’s the one part of health care where there is some expectation that everyone can have access,” said Dr. Jeremiah Schuur, lead author of the study. “That might not be the case in a parallel emergency system, one that is not regulated by the same standard that has prevented hospitals from dumping patients.”

They are also worried that the proliferation is not helping improve access to emergency care, for which Texas got an “F” in a 2014 report card from the American College of Emergency Physicians.

In 2009, Texas became the first state to make it legal for emergency services to be provided by private for-profit companies, not just hospitals. The number of stand-alone emergency departments jumped from 19 in 2010 to just over 200 to date, according to Texas Department of State Health Services data.

http://www.dallasnews.com/business/health-care/20160802-are-free-standing-emergency-rooms-helping-only-the-wealthy.ece

***

Comment:

By Don McCanne, M.D.

Texas is leading the nation in establishing for-profit, freestanding emergency departments. And what has that brought them? An “F” from the American College of Emergency Physicians.

Physicians for a National Health Program not only supports coverage of all essential health benefits for everyone, but we also support regional planning and separate budgeting of capital improvements within a non-profit health care delivery system. Texas shows us why.

Texas entrepreneurs are placing their new, for-profit emergency departments in locations that provide the greatest income potential – areas with higher incomes, greater prevalence of insurance, fewer patients with Medicaid, and lower concentration of Hispanics, even though these areas were already better served by existing hospitals and emergency departments. They go for the buck, but ignore the need.

The longer we wait to enact an equitable, efficient, and more effective health care financing system, the greater will be the cumulative losses from greed and inefficiency, and the greater will be the cumulative suffering and deaths due to our inaction.

No more “let’s wait and see how the Affordable Care Act is working.” The establishment of these freestanding departments coincided with implementation of the Affordable Care Act. Our health policies are designed to benefit the health care industry, and patients have been included only because they are the necessary coal to stoke their ovens. We need to change that. Now!

Proliferation of for-profit, freestanding emergency departments

Where Do Freestanding Emergency Departments Choose to Locate? A National Inventory and Geographic Analysis in Three States

By Jeremiah D. Schuur, Olesya Baker, Jaclyn Freshman, Michael Wilson, David M. Cutler
Annals of Emergency Medicine, July 12, 2016 (online)

Study objective

We determine the number and location of freestanding emergency departments (EDs) across the United States and determine the population characteristics of areas where freestanding EDs are located.

Methods

We conducted a systematic inventory of US freestanding EDs. For the 3 states with the highest number of freestanding EDs, we linked demographic, insurance, and health services data, using the 5-digit ZIP code corresponding to the freestanding ED’s location. To create a comparison nonfreestanding ED group, we matched 187 freestanding EDs to 1,048 nonfreestanding ED ZIP codes on land and population within state. We compared differences in demographic, insurance, and health services factors between matched ZIP codes with and without freestanding EDs, using univariate regressions with weights.

Results

We identified 360 freestanding EDs located in 30 states; 54.2% of freestanding EDs were hospital satellites, 36.6% were independent, and 9.2% were not classifiable. The 3 states with the highest number of freestanding EDs accounted for 66% of all freestanding EDs: Texas (181), Ohio (34), and Colorado (24). Across all 3 states, freestanding EDs were located in ZIP codes that had higher incomes and a lower proportion of the population with Medicaid. In Texas and Ohio, freestanding EDs were located in ZIP codes with a higher proportion of the population with private insurance. In Texas, freestanding EDs were located in ZIP codes that had fewer Hispanics, had a greater number of hospital-based EDs and physician offices, and had more physician visits and medical spending per year than ZIP codes without a freestanding ED. In Ohio, freestanding EDs were located in ZIP codes with fewer hospital-based EDs.

Conclusion

In Texas, Ohio, and Colorado, freestanding EDs were located in areas with a better payer mix. The location of freestanding EDs in relation to other health care facilities and use and spending on health care varied between states.

http://www.annemergmed.com/article/S0196-0644(16)30199-8/fulltext

***

Are free-standing emergency rooms helping only the wealthy?

By Sabriya Rice
The Dallas Morning News, August 3, 2016

Business is booming in Texas for free-standing emergency departments. The centers are emerging in wealthier neighborhoods, where patients are privately insured and are less likely to have Medicaid or Medicare, finds a study published in July in the Annals of Emergency Medicine.

That’s concerning for some health policy researchers. Emergency services in the U.S. have historically been provided by hospitals, and therefore must adhere to federal regulations that protect patients from being denied care if they cannot afford it.

“It’s the one part of health care where there is some expectation that everyone can have access,” said Dr. Jeremiah Schuur, lead author of the study. “That might not be the case in a parallel emergency system, one that is not regulated by the same standard that has prevented hospitals from dumping patients.”

They are also worried that the proliferation is not helping improve access to emergency care, for which Texas got an “F” in a 2014 report card from the American College of Emergency Physicians.

In 2009, Texas became the first state to make it legal for emergency services to be provided by private for-profit companies, not just hospitals. The number of stand-alone emergency departments jumped from 19 in 2010 to just over 200 to date, according to Texas Department of State Health Services data.

http://www.dallasnews.com/business/health-care/20160802-are-free-standing-emergency-rooms-helping-only-the-wealthy.ece

Texas is leading the nation in establishing for-profit, freestanding emergency departments. And what has that brought them? An “F” from the American College of Emergency Physicians.

Physicians for a National Health Program not only supports coverage of all essential health benefits for everyone, but we also support regional planning and separate budgeting of capital improvements within a non-profit health care delivery system. Texas shows us why.

Texas entrepreneurs are placing their new, for-profit emergency departments in locations that provide the greatest income potential – areas with higher incomes, greater prevalence of insurance, fewer patients with Medicaid, and lower concentration of Hispanics, even though these areas were already better served by existing hospitals and emergency departments. They go for the buck, but ignore the need.

The longer we wait to enact an equitable, efficient, and more effective health care financing system, the greater will be the cumulative losses from greed and inefficiency, and the greater will be the cumulative suffering and deaths due to our inaction.

No more “let’s wait and see how the Affordable Care Act is working.” The establishment of these freestanding departments coincided with implementation of the Affordable Care Act. Our health policies are designed to benefit the health care industry, and patients have been included only because they are the necessary coal to stoke their ovens. We need to change that. Now!

Democratic delegate works for Sanders and single-payer healthcare

By Jeff Bendix
Medical Economics, July 29, 2016

For Eve Shapiro, MD, MPH, being a delegate at this year’s Democratic National Convention is just the latest expression of her dedication to progressive causes.

Shapiro, a Tucson, Arizona pediatrician, voted for Vermont Senator Bernie Sanders in her state’s Democratic primary because of his support for a single-payer health plan, as well as other liberal causes.  She became a member of Arizona’s delegation as a result of her work with the state chapter of Progressive Democrats of America, an outgrowth of Vermont Governor Howard Dean’s unsuccessful campaign for the 2004 Democratic presidential nomination. In 2000, she campaigned vigorously on behalf of a successful initiative to expand Medicaid access in Arizona.

“I’ve been involved in politics since I was in high school, when I worked on the Eugene McCarthy campaign,” she said in a telephone interview with Medical Economics. “I kind of grew up with an emphasis on social justice. Now I try to get involved with progressive candidates on all different levels from governor to congressional races to local races.”

In addition to her local activity, Shapiro is a long-time member of Physicians for a National Health Plan. “As a physician, I could see the inequalities of our health system, and the only possible way to cover everyone at an affordable cost is a single-payer system,” she said.

To continue reading, please visit the “Medical Economics” website:

http://medicaleconomics.modernmedicine.com/medical-economics/news/democratic-delegate-works-sanders-and-single-payer-healthcare

PNHP note: Physicians for a National Health Program (PNHP) is a nonpartisan educational and research organization. It neither supports nor opposes any candidate for public office or any political party.

Single-payer health care plan is best solution

By Jack Bernard
The Florida Times-Union (jacksonville.com), Aug. 2, 2016

Single payer really does a much better job than an inefficient multi-payer system like ours.

And, before his candidacy, the Donald knew that fact. Per Trump’s own words (his 2000 book, “The America We Deserve”): “The Canadian Plan also helps Canadians live longer and healthier than Americans. We need, as a nation, to reexamine the single-payer plan.”

Even with Obamacare fully implemented, 9 percent of Americans are still uninsured (16 percent in my home state of Georgia, one of the highest uninsured states, along with Florida).

The uninsured depend on expensive, inefficient private medical insurance. The key exceptions are the very poor (covered by Medicaid), plus seniors and the disabled, who are getting Medicare.

The leaders of my party, the GOP, want to “privatize” traditional government-offered Medicare to “save” it, thus virtually destroying it.

Many continue to view Medicare as socialism, despite the fact that almost all providers do not currently work for our federal government and would remain private under “Medicare for All.”

As a former Republican elected official, I believe that many aspects of government are inefficient. For example, due to Congress, we have a staffed Post Office in every small town, rather than having an automated facility. And many times an unneeded local military base was going to close, only to be kept open via raw politics.

But that does not mean that all government programs are no good or that government employees are to blame for shortcomings. Most waste is caused by politicians skirting their responsibilities due to interest groups and political pressures, a Trump talking point.

I believe in eliminating governmental waste and in utilizing the private sector when it is shown to be more effective, But Medicare, with only 3 percent administrative costs, has been shown to be more efficient than private insurers, with up to 20 percent administrative and marketing overhead.

It is time to depoliticize this fight and look at the experience of other nations with single payer. Their health outcomes are better and they spend much less per capita on health care, per every reputable study. What we lack is political will in the leadership of both parties.

During this campaign, Donald Trump has stated multiple times that our current health care system is broken. Unfortunately, during the primary, he caved in to the GOP right wing and earlier this year released a bland rehash of the same old Republican ideas — pushing private Health Savings Accounts, having insurance sold across state lines and creating block grants for Medicaid.

These are simply Band-Aids on a gaping wound, not resolving the basic cost escalation problem in our current system. Furthermore, access to care will clearly be impeded under the current Trump plan which would wipe out the incontrovertible access gains of Obamacare. Only a single-payer system can eliminate the expensive bureaucratic maze of billing created by multiple payers and have the clout with drug companies and providers in order to accomplish the goal of universal access and cost containment.

It is my hope that, for the general election, Trump will decide that it is better politics to return to his earlier idea of a Canadian-style “Medicare For All” system. I truly believe that he knows this is the correct course for the nation and will get him votes in that a 2016 Gallup survey shows that the majority of the nation now “wants a federally funded health care system that provides insurance for all Americans.”

Even if he does not take this position before November, I also suspect that if he is elected, flip-flopping Donald will eventually go back to single payer.

But only time will tell.

Jack Bernard of Peachtree City, Ga., was the first director of Health Planning for the state of Georgia. He also served as a senior level executive with several national health care firms.

http://jacksonville.com/business/columnists/2016-08-02/story/guest-column-single-payer-health-care-plan-best-solution#

PNHP note: Physicians for a National Health Program (PNHP) is a nonpartisan educational and research organization. It neither supports nor opposes any candidate for public office or any political party.

Insurer exclusions put women at risk

Women’s Health Coverage Since the ACA: Improvements for Most, But Insurer Exclusions Put Many at Risk

By Dania Palanker (National Women’s Law Center) and Karen Davenport
The Commonwealth Fund, August 2, 2016

Issue: Since enactment of the Affordable Care Act (ACA), many more women have health insurance than before the law, in part because it prohibits insurer practices that discriminate against women. However, gaps in women’s health coverage persist. Insurers often exclude health services that women are likely to need, leaving women vulnerable to higher costs and denied claims that threaten their economic security and physical health.

Goal: To uncover the types and incidence of insurer exclusions that may disproportionately affect women’s coverage.

Method: The authors examined qualified health plans from 109 insurers across 16 states for 2014, 2015, or both years.

Key findings and conclusions: Six types of services are frequently excluded from insurance coverage: treatment of conditions resulting from noncovered services, maintenance therapy, genetic testing, fetal reduction surgery, treatment of self-inflicted conditions, and preventive services not covered by law. Policy change recommendations include prohibiting variations within states’ “essential health benefits” benchmark plans and requiring transparency and simplified language in plan documents.

Problems from lack of transparency

There is little transparency in plan documents regarding health insurance exclusions. As a result, women may unwittingly enroll in plans containing exclusions that impact their coverage, and remain unaware of the exclusions until they seek services or have a claim denied. The short overview of coverage provided for each plan on the marketplace—called the “Summary of Benefits and Coverage”—includes space for information on exclusions. However, only 13 exclusions are required to be listed, and none of the exclusions described in this brief are in that group. Identifying all exclusions requires reading the underlying plan document, such as the evidence of coverage; yet some plan documents are over 100 pages long and exclusions appear in various sections. Terminology also varies among insurers; for example, some plans exclude “maintenance therapy” and others exclude “maintenance care.” In addition, some exclusions appear among only a small number of insurers, so women cannot know all the exclusions to look for in their plans. For example, six insurers exclude services resulting from an enrollee’s failure to comply with or accept recommended treatment, which is problematic for women who are less likely than men to adhere to prescription protocols. These factors make it difficult for women to identify and compare exclusions across plans.

http://www.commonwealthfund.org/publications/issue-briefs/2016/aug/womens-health-coverage-since-aca

***

Comment:

By Don McCanne, M.D.

The Affordable Care Act included provisions to prohibit discrimination against women in health insurance plans. However it is in the DNA of private insurers to work around regulations in order to serve their own interests, and this is what they have done regarding discriminatory policies against women, as this study shows.

We put our health care financing in charge of individuals who are running a private business. It would be unrealistic for us to expect them to do anything other than to optimize the business opportunity for themselves.

Had we established our own public program – a single payer national health program – our public employees would have been dedicated to service – trying to make the program work in getting us the health care that we need. Further, they would have done it without all of the expense and administrative complexity that characterizes our dysfunctional multi-payer system.

Better service for less money? We can still do it.