PNHP

No, Bernie Sanders is not going to bankrupt America to the tune of $18 trillion

No, Bernie Sanders is not going to bankrupt America to the tune of $18 trillion

By Paul Waldman
The Washington Post, Sept. 15, 2015

The big policy headline today comes from the Wall Street Journal, which delivers this alarming message: “Price Tag of Bernie Sanders’ Proposals: $18 Trillion.”

Holy cow! He must be advocating for some crazy stuff that will bankrupt America! But is that really an accurate picture of what Sanders is proposing? And is this the kind of number we should be frightened of?

The answer isn’t quite so dramatic: while Sanders does want to spend significant amounts of money, almost all of it is on things we’re already paying for; he just wants to change how we pay for them. In some ways it’s by spreading out a cost currently borne by a limited number of people to all taxpayers. His plan for free public college would do this: right now, it’s paid for by students and their families, while under Sanders’ plan we’d all pay for it in the same way we all pay for parks or the military or food safety.

But the bulk of what Sanders wants to do is in the first category: to have us pay through taxes for things we’re already paying for in other ways. Depending on your perspective on government, you may think that’s a bad idea. But we shouldn’t treat his proposals as though they’re going to cost us $18 trillion on top of what we’re already paying.

And there’s another problem with that scary $18 trillion figure, which is what the Journal says is the 10-year cost of Sanders’ ideas: fully $15 trillion of it comes not from an analysis of anything Sanders has proposed, but from the fact that Sanders has said he’d like to see a single-payer health insurance system, and there’s a single-payer plan in Congress that has been estimated to cost $15 trillion. Sanders hasn’t actually released any health care plan, so we have no idea what his might cost.

But health care is nevertheless a good place to examine why these big numbers can be so misleading. At the moment, total health care spending in the United States runs over $3 trillion a year; according to the Centers for Medicare and Medicaid Services, over the next decade (from 2015-2024), America will spend a total of $42 trillion on health care. This is money that you and I and everyone else spends. We spend it in a variety of ways: through our health-insurance premiums, through the reduced salaries we get if our employers pick up part or all of the cost of those premiums, through our co-pays and deductibles, and through our taxes that fund Medicare, Medicaid, ACA subsidies, and the VA health care system. We’re already paying about $10,000 a year per capita for health care.

So let’s say that Bernie Sanders became president and passed a single-payer health care system of some sort. And let’s say that it did indeed cost $15 trillion over 10 years. Would that be $15 trillion in new money we’d be spending? No, it would be money that we’re already spending on health care, but now it would go through government. If I told you I could cut your health insurance premiums by $1,000 and increase your taxes by $1,000, you wouldn’t have lost $1,000. You’d be in the same place you are now.

By the logic of the scary $18 trillion number, you could take a candidate who has proposed nothing on health care, and say, “So-and-so proposes spending $42 trillion on health care!” It would be accurate, but not particularly informative.

There’s something else to keep in mind: every single-payer system in the world, and there are many of them of varying flavors, is cheaper than the American health care system. Every single one. So whatever you might say about Sanders’ advocacy for a single-payer system, you can’t say it represents some kind of profligate, free-spending idea that would cost us all terrible amounts of money.

Since Sanders hasn’t released a health care plan yet, we can’t make any assessment of the true cost of his plan, because there is no plan. Maybe what he wants to do would cost more than $15 trillion, or maybe it would cost less. But given the experience of the rest of the world, there’s a strong likelihood that over the long run, a single-payer plan would save America money. Again, you may think single-payer is a bad idea for any number of reasons, but “It’ll be too expensive!” is probably the least valid objection you could make.

There are some proposals that involve spending new money that we never would have spent otherwise, like starting a war that ends up costing $2 trillion. But in every case, whether we’re doing something new or doing something we’re already doing but in a new way, the question isn’t what the price tag is, the question is whether we think what we’d get for that money makes spending it worthwhile.

For instance, Sanders wants to spend $1 trillion over 10 years on infrastructure. That’s a lot of money, but it’s significantly less than experts say we need to repair all of our crumbling roads, bridges, water systems, and so on. And infrastructure spending creates immediate jobs and has economic benefits that persist over time, which we’d also have to take into account in deciding whether it’s a good idea. But just saying, “$1 trillion is a lot of money!” doesn’t tell you whether or not we should do it.

The conservatives who are acting appalled at the number the Journal came up with are also the same people who never seem to care what a tax cut costs, because they think cutting taxes is a moral and practical good, in the same way that liberals think providing people with health coverage is a moral and practical good. For instance, Jeb Bush recently proposed a tax cut plan whose 10-year cost could be as high as $3.4 trillion. That’s a lot of money that the government wouldn’t be able to spend on the things it’s doing right now, although the campaign argues that we’d get much of that money back in increased revenues because of the spectacular growth the tax cuts would create. If you remember the claims that George W. Bush’s tax cuts would create stunning growth and prosperity for all, you might be just a bit skeptical of the Jeb campaign’s similar assertions. But in any case, we can’t evaluate the value of Jeb’s plan just by saying that $3.4 trillion is a big number. If you knew that the average family in the middle of the income distribution would get less than $1,000 from Jeb’s plan, while the average family in the top one percent would get a tax cut of over $80,000, then you’d have a better sense of whether it’s a good or bad idea.

As a general matter, when you see a headline with an unimaginably large number, chances are it’s going to confuse you more than it will enlighten you. The question when it comes to government should always be not what we’re spending, but what we’re getting for what we spend.

https://www.washingtonpost.com/blogs/plum-line/wp/2015/09/15/no-bernie-sanders-is-not-going-to-bankrupt-america-to-the-tune-of-18-trillion/

Bernie Sanders just slammed a report that claimed his proposals would cost a monstrous $18 trillion

By Brett LoGiurato
Business Insider, Sept. 15, 2015

Sen. Bernie Sanders (I-Vermont) is pushing back on the eye-popping estimated price tag of his progressive wish list of proposals he has offered on the campaign trail.

The Wall Street Journal reported in a front-page story on Tuesday that Sanders’ proposals would total around $18 trillion over 10 years, which the publication said would amount to the “largest peacetime expansion of government in modern American history.”

That would include an estimated $15 trillion over a decade for a revamping of the federal healthcare system to a government-run, “Medicare for all” single-payer approach.

In an appearance on MSNBC Tuesday, Sanders disputed The Journal’s total. He argued that the paper did not take into account the spending reductions that would come with the enactment of a single-payer-type healthcare plan.

“That is not the reality. We will be responding to The Wall Street Journal on that,” Sanders told MSNBC’s Andrea Mitchell of the overall estimate.

“I think most of the expense that they put in there, the expenditures have to do with the single-payer healthcare system,” he continued. “They significantly exaggerated the cost of that, and they forgot to tell the American people in that article that that means eliminating the costs that you incur with private health insurance.”

Sanders, right now the main Democratic challenger to presidential front-runner Hillary Clinton, has not released a detailed healthcare plan as of yet. The Journal relied on an analysis of similar legislation proposed by Rep. John Conyers (D-Michigan) and sponsored by 44 other House Democrats.

The analysis, which was conducted by University of Massachusetts at Amherst economist Gerald Friedman, would “require $15 trillion in federal spending over 10 years, on top of existing federal health spending,” according to The Journal. 

But the analysis has also been cited favorably by progressive advocates of a single-payer healthcare system, who note that Conyers’ bill would purportedly save nearly $600 billion annually by eliminating administrative waste in the private-insurance industry and cutting prices of pharmaceutical medicine.

“In 2014, the savings would be enough to cover all 44 million uninsured and upgrade benefits for everyone else. No other plan can achieve this magnitude of savings on health care,” Friedman wrote in his 2013 analysis.

The Washington Post’s Paul Waldman backed up Sanders on some of his criticism. As Waldman pointed out, the US currently spends about $3 trillion a year — and will spend close to $42 trillion over the next decade — on healthcare. He argued that Sanders’ proposal wouldn’t add on to that total, but rather reallocate the way the US spends money on healthcare.

“By the logic of the scary $18 trillion number, you could take a candidate who has proposed nothing on health care, and say, ‘So-and-so proposes spending $42 trillion on health care!’ It would be accurate, but not particularly informative,” Waldman wrote.

http://www.businessinsider.com/bernie-sanders-wsj-18-trillion

More Americans gain health coverage, but many can’t afford to use it: doctors group

Census Bureau says number of uninsured has dropped to 33 million in wake of Affordable Care Act, but is silent on problems of rising deductibles, copays, coinsurance and narrow networks that deter people from seeking care

FOR IMMEDIATE RELEASE
Sept. 16, 2015

Contact: Mark Almberg, PNHP communications director, 312-782-6006, mark@pnhp.org

“The Census Bureau’s official estimate that 33 million Americans lacked health insurance in 2014 reflects a significant and welcome drop from the 42 million it reported as uninsured in 2013,” said Dr. Robert Zarr, president of Physicians for a National Health Program, today. “But the number of people who remain without coverage is still intolerably high. And the Census Bureau report leaves entirely unmentioned the millions of people who have health insurance but who can’t afford to use it because of high deductibles and copays.”

“Having health insurance is better than not having coverage, as several research studies have shown,” Zarr, a Washington, D.C.-based pediatrician, continued. “For example, the 33 million people the Census Bureau says were uninsured in 2014 means that approximately 33,000 people died needlessly last year because they couldn’t get access to timely and appropriate care.” He cited a landmark study in the American Journal of Public Health showing that for every 1 million persons who are uninsured in a given year, there are about 1,000 deaths linked chiefly to that factor.

“That’s an unnecessary death every 16 minutes,” Zarr said. “That’s completely unacceptable. Moreover, the Congressional Budget Office predicts at least 27 million people will be uninsured every year for the next 10 years – so that’s tens of thousands of preventable deaths, year in and year out.

“And keep in mind that even if all the states had accepted the Medicaid expansion, about 24 million people would still be uninsured under the Affordable Care Act,” he said. “We simply can’t go on like this.”

Zarr pointed out that the problem of underinsurance – i.e. of people having skimpy policies with high deductibles, copays, and other forms of cost sharing that deter them from seeking care and that leave them vulnerable to financial distress and medical bankruptcy in the event of serious illness – is not something the Census Bureau addresses in its annual reports. But it should take this question up, he said, especially in view of how rapidly the problem is worsening.

“A recent study by the Commonwealth Fund shows that about 31 million people who have health insurance – nearly a quarter of all non-elderly adults – are underinsured, nearly double the rate in 2003,” Zarr said. “Of these, 44 percent went without a doctor’s visit, medical test, or prescription due to cost, while 51 percent had problems paying off medical bills or were paying off medical debt over time.

“The average deductible – i.e. before insurance kicks in — for families with popular silver plans in 2015 is estimated to be $6,010, and out-of-pocket costs for copayments and deductibles, after premium payments, for a family of four with an income of about $60,000 per year can be as high as $13,200,” he said. “And of course this applies to ‘in network’ services only. Out-of-network costs can go much, much higher. Such financial barriers are untenable, economically and morally.”

“In short, under the new health law we’re witnessing a dramatic acceleration of the trend of shifting more and more medical costs onto the shoulders of patients and their families, even as medical costs and premiums rise and as private health insurance companies reap record profits.

“How is it possible that in 2015 one of the richest countries in the world still does not guarantee every resident the right to health care?” Zarr continued. “This question would not be necessary if we had a health care system worthy of the name – single-payer national health insurance, or an improved and expanded Medicare for All.”

“A single-payer system would achieve truly universal care, affordability, and effective cost control. It would put the interests of our patients – and our nation’s health – first.”

Zarr continued: “Our patients, our people and our national economy cannot wait any longer for an effective remedy to our health care woes. The stakes are too high. We need to move beyond the administratively wasteful, complex and inadequate ACA to a more fundamental, comprehensive single-payer national health program for all.”

Physicians for a National Health Program (www.pnhp.org) is a nonprofit research and education organization of more than 19,000 doctors who support single-payer national health insurance.

More on CMS’s ill-advised Hospital Readmissions Reduction Program

Patient Characteristics and Differences in Hospital Readmission Rates

By Michael L. Barnett, MD; John Hsu, MD, MBA, MSCE; J. Michael McWilliams, MD, PhD
JAMA Internal Medicine, September 14, 2015

The Medicare Hospital Readmissions Reduction Program (HRRP) financially penalizes hospitals with higher than expected 30-day readmission rates for Medicare patients by reducing annual reimbursements by up to 3%. In 2014, the second year of the program, 2610 hospitals were fined a total of $428 million for excess readmissions. In setting an expected readmission rate for each hospital, the Centers for Medicare and Medicaid Services (CMS) adjusts only for patients’ age, sex, discharge diagnosis, and diagnoses present in claims during the 12 months prior to admission. This limited adjustment has raised concerns that hospitals may be penalized because they disproportionately serve patients with clinical and social characteristics that predispose them to hospitalization or rehospitalization.

From the Results

Our study sample included 33 158 index admissions from 2000 to 2012 for 8767 Medicare beneficiaries in the HRS (Health and Retirement Study) and 8067 index admissions from 2009 to 2012 for 3470 beneficiaries in the HRS. In unadjusted analyses of the 2000-2012 sample, the proportion of admissions followed by readmission significantly differed across categories for 27 of the 29 patient characteristics not included in CMS adjustments (P ≤ .02 for all comparisons). Of these characteristics, 22 remained significantly predictive of readmission after standard CMS adjustments (P ≤ .04).

Of the 22 characteristics significantly predictive of readmission after standard CMS adjustments, 17 were distributed differently between the highest and lowest quintiles (P ≤ .04), with almost all of these differences (16 of 17) indicating that participants admitted to hospitals in the highest quintile of readmission rates were more likely to have characteristics associated with a higher probability of readmission. For example, participants admitted to hospitals in the highest quintile had higher HCC (hierarchical condition category) scores, more chronic conditions, less education, fewer assets, worse self-reported health status, more depressive symptoms, worse cognition, worse physical functioning, and more difficulties with ADLs (activities of daily living) and IADLs (instrumental ADLs) than participants admitted to hospitals in the lowest quintile.

From the Discussion

The higher prevalence of clinical and social predictors of readmission among patients admitted to hospitals with higher readmission rates is likely driven by factors largely outside of a hospital’s influence. Our findings therefore call into question the extent to which variation in hospital readmission rates reflects quality of care and, by extension, the extent to which this variation should serve as the basis for financial penalties. The differences in patient characteristics between hospitals with high vs low readmission rates also suggest that the HRRP imposes substantially greater costs on hospitals disproportionately serving patients more likely to be readmitted. Hospitals serving healthier, more socially advantaged patients may not have to devote any resources to achieving a penalty-free readmission rate, whereas hospitals serving sicker, more socially disadvantaged patients may have to devote considerable resources to avoid a penalty. By selectively increasing costs or lowering revenue for hospitals serving patients at greater risk of readmission, the HRRP therefore threatens to deplete hospital resources available to improve overall quality for populations at high risk of poor outcomes.

Conclusions

Accounting for a comprehensive array of clinical and social characteristics substantially decreased the difference in patients’ probability of readmission between hospitals with higher vs lower readmission rates. This finding suggests that Medicare is penalizing hospitals to a large extent based on the patients they serve.

http://archinte.jamanetwork.com/article.aspx?articleid=2434813

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Comment:

By Don McCanne, MD

This important study adds to the data that show that the Centers for Medicare and Medicaid Services (CMS) is using its Medicare Hospital Readmissions Reduction Program (HRRP) to penalize hospitals that care for a disproportionate share of sicker, more socially disadvantaged patients – penalties that arise from characteristics of the patient population rather than from characteristics of the hospitals serving them.

Obviously this injustice must end. More importantly, CMS needs to stop getting bogged down with poorly designed programs that supposedly would pay for quality rather than volume – more of a wish than a realistic goal. Instead, they need to move ahead with advocacy for policies that most assuredly would improve quality and access while reducing waste – policies that would characterize an Improved Medicare for All. Yes, that would require communicating the need to Congress. But isn’t that the way it works? Congress gives the administration the tools that it needs to ensure that all of us have the health care that we need. At least it works that way in other countries.

Wall Street Journal’s Scary Bernie Sanders Price Tag Ignores Health Savings

By David Dayen
The Intercept, Sept. 15, 2015

The screaming headline on Tuesday’s Wall Street Journal reads “Price Tag of Bernie Sanders’s Proposals: $18 Trillion.” This would comprise “the largest peacetime expansion of government in American history,” the Rupert Murdoch-owned newspaper warns.

The provenance of the figure is in many ways besides the point. Readers are intended to bug their eyes out at such a massive sum, and tsk-tsk at the deeply unserious, budget-busting promises of a democratic socialist. It’s the numerical version of a smear campaign.

But how did the Journal arrive at $18 trillion? They added up the 10-year price tags of seven programs Sanders has endorsed in his candidacy for president. It turns out that $15 trillion of the $18 trillion, or 83 percent of the total, comes from just one of these programs: establishing a single-payer health care system.

The $15 trillion figure is derived from an analysis of a similar single-payer bill, H.R. 676, introduced in 2013 by Rep. John Conyers. Gerald Friedman, a labor economist at the University of Massachusetts at Amherst, conducted the analysis.

What the Wall Street Journal won’t tell you is that $15 trillion in national health spending over 10 years would represent a massive savings for the United States. Right now we spend at twice that rate for health care. According to the Congressional Budget Office, in fiscal year 2013 alone, the U.S. spent $2.8 trillion on total health expenditures, not including the $250 billion tax break employers get for providing health insurance to their workers.

Accounting for cost inflation in health care and extending that out for 10 years, on our current trajectory we would spend more than $30 trillion, compared to the $15 trillion of a single-payer plan, which would totally supplant it.

The entire point of a single-payer health care plan, aside from covering everyone in the country, is to minimize costs, by reducing administrative bureaucracy, the profit motive and middlemen. It costs far less than the current system, which spends more per capita than any developed health system in the world.

That represents a giant savings for the nation, for employers as well as individuals. Friedman’s analysis, which is literally called “How we can afford a national single-payer health plan,” makes this point repeatedly. Assuming that single-payer is paid for through progressive taxation, people would spend far less for their coverage than they do today, if the Wall Street Journal’s explicitly stated numbers are correct.

full: https://theintercept.com/2015/09/15/wall-street-journals-scary-bernie-sanders-price-tag-ignores-health-savings/

Medicare yet to save money through ACOs

Medicare Yet To Save Money Through Heralded Medical Payment Model

By Jordan Rau and Jenny Gold
Kaiser Health News, September 14, 2015

A high-profile Medicare experiment pushing doctors and hospitals to join together to operate more efficiently has yet to save the government money, with nearly half of the groups costing more than the government estimated their patients would normally cost, federal records show.

The Centers for Medicare & Medicaid Services offers the lure of bonuses to health care practitioners who band together as accountable care organizations, or ACOs, to take care of patients. The financial incentives are intended to encourage these doctors, hospitals, nursing homes and other institutions to keep patients healthy rather than primarily treat illnesses, which is what Medicare payments traditionally have rewarded. ACOs that save a substantial amount get to keep a share of the savings as a bonus.

The Obama administration touts ACOs as one of the most promising reforms in the 2010 federal health care law. The administration set a goal that by the end of 2018, half of Medicare spending currently based on the volume of procedures a doctor or hospital performs will instead be linked to quality and frugality. But so far the ACO program generally has been a one-way street, with most doctors and hospitals happy to accept bonuses while declining to be on the hook for a share of any excessive costs run up by their patients.

Last year, Medicare paid $60 billion to 353 ACOs to take care of nearly 6 million Medicare beneficiaries. Some ACOs made significant strides in reducing use of hospitals and other costly resources. But patients at 45 percent of groups cost Medicare more than the government had projected based on their patients’ historic costs, records show. After paying bonuses to the strong performers, the ACO program resulted in a net loss of nearly $3 million to the Medicare trust fund, government records show.

Last year, 196 ACOs saved Medicare money, while 157 ACOs cost more than expected. Medicare ultimately did not realize any savings because it paid out bonuses to 97 ACOs, but only three of the costly ACOs had to repay Medicare for losses their patients incurred.

Jeff Goldsmith, a health industry analyst and professor at the University of Virginia who is a longtime ACO critic, said the ACO model is flawed. Consumers do not actively opt to participate in the ACOs and do not share in any savings, so they lack financial incentives to help keep costs down, he said. ACOs also have limited leverage to control the costs incurred by highly paid specialists such as surgeons and cardiologists. Patients in ACOS can still go to any doctor who accepts Medicare’s regular method of paying, in which they receive a set fee based on the nature of the service without regard to its outcome.

“Faux managed care is actually harder to do than real managed care,” Goldsmith said. The ACO program, he said, “has a bad enough reputation in the provider community that is not going to grow sufficiently to replace regular Medicare.”

http://khn.org/news/medicare-yet-to-save-money-through-heralded-medical-payment-model/

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Comment:

By Don McCanne, MD

Although the Obama administration continues to tout the successes of Medicare accountable care organizations (ACOs), according to this article using government data, the ACO program resulted in a net loss of nearly $3 million to the Medicare trust fund. Thus their headline: “Medicare Yet To Save Money Through Heralded Medical Payment Model”

Compared to what the nation spends on health care, $3 million is not a significant loss. The real tragedy here is that the Centers for Medicare & Medicaid Services (CMS) continues to move forward with this program as the be-all and end-all when it has already been proven to be a miserable failure as a means of significantly reducing health care spending.

Compare the $3 million loss with this program to the approximately $400 billion administrative savings that we could have under a single payer national health program – savings that could be used to actually improve quality and access in our health care system. In more visual numbers, we are comparing an excess spending on the Medicare ACO program of $3,000,000 with a single payer savings on administrative costs of about $400,000,000,000.

We should continue to encourage the ongoing efforts of those dedicated individuals in the health care delivery system who are improving quality and efficiency. But regarding financing, we should quit wasting our time and resources with the flawed Medicare ACO model and move forward with financing reform that really does work – a single payer national health program.

TenOne: Medicare-for-All National Student Day of Action on 10/1/15

By Joan Brunwasser
OpEd News, Sept. 13, 2015

My guest today is Scott Goldberg, a fourth year medical student at the University of Chicago’s Pritzker School of Medicine and a board member of Physicians for a National Health Program. Welcome to OpEdNews, Scott. 

JB: I understand you are helping to coordinate a national day of action, coming up soon. What can you tell us about it?

SG: Thank you for having me, Joan. Yes, I am one of the medical students from Students for a National Health Program (SNaHP) helping to plan the TenOne Medicare-for-All National Student Day of Action. SNaHP is the student section of the national organization, Physicians for a National Health Program, which has around 20,000 doctors and students who advocate for single payer health reform. The idea for TenOne came out of the SNaHP annual summit last February in Chicago. It was our 4th and largest summit thus far, with over 170 students in attendance. We had been inspired by the widespread involvement of students in the White Coats 4 Black Lives die-in that fall and we wanted to do something similar to energize and strengthen the student single payer movement. In short, TenOne is a nationwide action of medical students and allies to raise awareness about the failings of our private health insurance system and what we need to do to fix it — which is to expand and improve Medicare to all. 

JB: Before we get to the nitty gritty of the October action, can you tell us why single payer is so important to you and your fellow medical students? 

SG: Well, for me, I became committed to single payer in 2009 after hearing a talk by Dr. David Himmelstein, one of the co-founders of PNHP. He presented so much evidence that national health insurance, as practiced particularly in Canada, is the most efficient, economical, and just way to provide high-quality, affordable, universal health care access. And that the United States is the only industrialized country in the world, despite our vast wealth, that doesn’t have some form of universal health insurance. But it wasn’t until I began medical school, and started working in the hospital, especially during my third year clinical rotations, that I saw first-hand how devastating our system is on patients’ lives. I remember one Spanish-speaking woman who was unable to receive a lung transplant at our hospital because we weren’t “in-network.” We had to send her to another hospital after developing a trusting relationship with her. I’ve seen patients die because they couldn’t get the care they needed in time. This just does not happen in other first-world countries. So I’m sure my fellow medical students working on this issue feel the same way as I do — that no person, regardless of socioeconomic status, race, ethnicity, or whatever, should be denied something as fundamental to human life as medical care. 

JB: Everything you say makes perfect sense to me, Scott. I covered the medical student die-in when it happened and it was an amazing statement. What kind of participation are you getting for this current action day? 

SG: SNaHP now has 43 chapters at medical schools across the country. I think this is double the number just four years ago. For TenOne, we have 30 chapters participating as of now. Many of these chapters will be holding actions during the day including teach-ins and rallies. At night, all chapters will be holding a candlelight vigil remembering the approximately 25,000 people that die each year due to uninsurance and the millions more who suffer due to underinsurance. In cities like New York, Philadelphia, Chicago, Los Angeles, and Boston, a number of chapters from different schools will be working together to host one large nighttime action. Also, TenOne is sponsored by a number of other national medical student organizations including American Medical Student Association, Latino Medical Student Association, White Coats 4 Black Lives, Universities Allied for Essential Medicine, and Pre-health Dreamers. I can’t think of another student-led nationwide action for single payer that has been done before. 

JB: I’m curious if any of the medical schools push back against these single payer actions. Are any students fearful that their participation might affect their careers going forward? 

SG: In my three years since starting a student chapter of PNHP, I’ve never had any push back from my medical school. In fact, I think our chapter is the most active on campus and has widespread support from the student body. Many of the faculty and administrators on campus support national health insurance (NHI) and are encouraged by our dedication to the cause. I’ve never heard of any other schools pushing back against single payer actions, but I can’t say definitively if there have been. 

I think some medical students may be anxious about throwing themselves into single payer advocacy for fear that it may affect their careers somehow. But I can say, from my own experience, that it has not affected my career thus far. And there are examples of outspoken faculty members on campus who don’t face repercussions for their beliefs. This idea that speaking out for something as fundamental and urgent as universal health care is threatening to your career is something we need to dismiss. Advocating for single payer is not a Democratic or Republican issue. It is at the core of what it means to be a doctor, which is doing everything in your power to help your patients. 

JB: I’m glad you haven’t experienced or witnessed any push back but I also understand that many students have taken out huge student loans. And that factor can affect everything, including decisions like participating or not in an action like this.  What kind of press coverage have you arranged for TenOne?  I ask because if you don’t get enough coverage, isn’t it like the proverbial tree falling in the forest with no one around to hear? 

SG: It’s true, student loan debt is a major problem. In fact, in countries like Canada, medical education is free. In HR 676, the house bill that would establish national health insurance, there is a provision making medical education free. But the idea that student loan debt affects one’s decision to participate in actions is not something I’ve ever heard from my interactions with other students across the country. As medical students, we are paying a lot of money to schools and so they want to support us in whatever we do. 

As for press coverage for TenOne, we’re talking with national media outlets like OpEdNews! We also have upcoming interviews with other outlets like The Union Edge. We have national and local press coverage lined up for TenOne. And I think the power of this event is not just to generate media attention. No nationwide action like this has ever been done before. We are raising awareness, empowering students, and generating the basis for a broad-based movement for single payer. 

This is not a one-off event just to attract media attention. This is the first in a series of actions to build a movement capable of achieving NHI. 99% of Americans suffer due to expensive, inadequate health care and we are bringing them into the movement. Single payer reform would be the greatest social and economic reform in this country’s history, and so it will take time, energy, and a national movement to achieve. We often overlook that students have been at the forefront of social movements throughout history. The Civil Rights Movement in America was started by college students, specifically the Student Nonviolent Coordinating Committee. 

JB: Again, quite true. Anything you’d like to add before we wrap this up? 

SG: I hope those who read this go to student.pnhp.org to find a TenOne event in their area to attend. This day of action is led by students, but meant for everyone! Also, I’d like to encourage anyone who reads this to start having conversations with their friends, family, colleagues, whomever about the need for single payer health care. Canada passed national health insurance in the 1970s, but activists began having small, informal gatherings in their homes about reform as early as the 1910s. Although we face serious barriers to passing NHI including the enormous wealth of the health insurance and pharmaceutical industries, a majority of Americans currently support government-funded, privately delivered health care. We have the numbers, we just need to unify ourselves. 

JB: Thanks so much for talking with me, Scott. Looking forward to TenOne and its aftermath!

Joan Brunwasser is senior editor at OpEd News.

http://www.opednews.com/articles/TenOne-Medicare-for-All-N-by-Joan-Brunwasser-Action-Alerts_Activists_Awareness_Chicago-150913-440.html

CMS’s low expectations for ACOs, though not admitting it

Medicare’s Vision for Delivery-System Reform — The Role of ACOs

By Hoangmai H. Pham, M.D., M.P.H., John Pilotte, M.H.S., Rahul Rajkumar, M.D., J.D., Elizabeth Richter, M.A., Sean Cavanaugh, M.P.H., and Patrick H. Conway, M.D. (all from the Centers for Medicare and Medicaid Services)
The New England Journal of Medicine, September 10, 2015

Earlier this year, the Department of Health and Human Services announced the goals of tying 30% of Medicare payments to alternative payment models by the end of 2016 and 50% by the end of 2018. That move was reinforced by the Medicare Access and CHIP Reauthorization Act of 2015, which replaced the sustainable growth rate formula for calculating physician payments with a Merit-based Incentive Payment System (MIPS) that consolidates and incorporates key components of the Physician Quality Reporting System, the Physician Value-Based Payment Modifier, and the Medicare Electronic Health Records Incentive program for eligible professionals. The MIPS will adjust payment rates on the basis of physicians’ performance on quality measures, resource use, clinical practice improvement activities, and meaningful use of electronic health records. Eligible professionals participating in eligible alternative payment models could receive a 5% lump-sum incentive payment each year from 2019 through 2024. If they meet program criteria, accountable care organizations (ACOs) could thus be central to Medicare’s strategy for delivery-system reform

Three principles guide CMS as we seek to further improve ACO policies and programs.

First is the importance of maintaining an ongoing test bed of ACO models through the Center for Medicare and Medicaid Innovation.

The second principle is that a concrete strategy for expanding successful models should be based on our testing experience.

The third principle is that ACO initiatives require multiple, distinct “tracks” to engage different types of beneficiaries and providers. Understanding the market’s diversity led to the conclusion that experienced ACOs willing to take financial-performance risks could be allowed to handle more flexible payment structures such as capitation or specific payment waivers but that less-experienced ACOs may take longer than anticipated to establish core capabilities in coordinating care for a population. Those organizations need protection from financial-performance risk during the development phase and, sometimes, direct capital support such as through the ACO Investment Model.

It’s also important to understand what factors do not drive the CMS approach to ACO policies. Our programs are not premised on the expectation that ACOs should evolve into Medicare Advantage health plans. Medicare beneficiaries are the ones who decide to enroll in Medicare Advantage or remain in traditional Medicare. Some now also proactively select an ACO as part of traditional Medicare. We believe that all beneficiaries deserve access to high-quality, coordinated care regardless of which program they choose and that provider organizations should decide which lines of business are most appropriate for them. Some may choose to serve patients as both an ACO and a health plan; others may choose one path or the other or take advantage of other alternative payment models such as bundled payments. We are therefore striving to maintain comparable business cases for ACO initiatives and Medicare Advantage, but some disparities in program requirements will persist because of statutory provisions and other factors inherent in the programs (for example, actuarial approaches must acknowledge that a health plan can choose the counties where it offers a Medicare Advantage product, but an ACO is constrained by the bricks and mortar of its available providers and facilities and cannot easily change location).

CMS policies are also not premised on the expectation that for an ACO program to be successful, all ACOs in it must succeed financially. Design elements certainly shape the potential for ACOs to earn shared savings, but ACOs also vary widely in their capabilities and decisions regarding staffing, infrastructure, and specific interventions. We judge the performance of initiatives on the basis of whether our policies appropriately reward good quality of care and savings to Medicare — results that might be achieved only by the most prepared subset of ACOs. We believe it’s important that with experience, ACOs be able to settle into the payment arrangements that best match their readiness and appetite for risk.

Finally, although CMS has implemented policies to promote improvement in ACO performance, we don’t believe that all ACOs can consistently improve on their spending performance over the long run or that it would be ideal for beneficiaries if spending continually declined. There are challenges, however, in setting national policies given large geographic disparities in practice patterns, Medicare spending, and beneficiary needs. We’re therefore emphasizing rewarding improvement in spending performance in these early years of ACO initiatives and aim to exercise sound judgment regarding the appropriate pace and approach to setting spending benchmarks over the long term. Ideally, our strategy would gradually shift from rewarding only spending reductions to also rewarding absolute spending levels, as in the Next Generation ACO Model, while considering the level of ACO penetration in Medicare and the degree of spending improvement — and do so without imparting sudden shocks to health care markets or exacerbating inequities.

We look forward to finding more strategies to help ACOs succeed faster, spur participation in more communities, combine multiple payment approaches for providers, and strengthen the business case for ACOs. Providers should compare ACO earnings not with what they could earn in today’s fee-for-service payment environment but with what they could expect to earn in the future if they didn’t participate in such alternative payment models. Although the challenges are protean, so are the opportunities, and we look forward to continued partnership with patients and providers.

http://www.nejm.org/doi/full/10.1056/NEJMp1507319

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Comment:

By Don McCanne, MD

We are moving full steam ahead with delivery reform through alternative payment models in which accountable care organizations (ACOs) are anticipated to play a major role. That is why it is important to read and understand the vision that our CMS bureaucrats have for the future of Medicare.

A quick read indicates that we are well on our way to pretending that we are paying for value rather than volume through ACOs. But a careful read of the full, unedited article suggests that CMS has really low expectations for ACOs, even though their rhetoric does not suggest that.

We are headed in the wrong direction. We need a single payer national health program if we expect to increase efficiency and value in our delivery of heath care.

The way our CMS bureaucrats are clogging up our Medicare program should make us consider using all caps for “improved,” as in “IMPROVED Medicare for All.” Or just simply call it “single payer” – that’s a more precise label anyway.

Prescription Drug Affordability Act of 2015

The Prescription Drug Affordability Act of 2015

Statement by Sen. Bernard Sanders
September 10, 2015

Thank you all for coming. And let me say a special thanks to Congressman Elijah Cummings.

No one in Congress has done more to lower the outrageously high price of prescription drugs than Congressman Cummings and I thank him for his leadership not only on this issue, but so many others in the House.

We are here today to talk about a huge issue of consequence to the American people. And, that is the fact that the American people pay, by far, the highest prices for prescription drugs in the entire world.

In the richest country in the history of the world, Americans should not have to live in fear that they will die because they cannot afford to take the life-saving medication they need.

The American people should not have to go without the medication they need because Congress does not have the courage to stand up to the prescription drug industry.

The time has come to say very loudly and very clearly that enough is enough. The greed of the pharmaceutical industry is killing Americans. It has got to stop.

It is time for the United States to join the rest of the industrialized world by implementing prescription drug policies that work for everybody, not just the CEOs of the pharmaceutical industry.

That’s exactly what the legislation that Congressman Cummings and I will be introducing today begins to do.

Specifically:

1. This bill requires Medicare to use its bargaining power to negotiate with the prescription drug companies for better prices – a practice that was banned by law. Not only would this substantially reduce the prices seniors pay for drugs, it could save Medicare over half a trillion dollars over the next decade.

2. This bill would allow individuals, pharmacists, and wholesalers to import prescription drugs from licensed Canadian pharmacies where drug prices are 40 percent lower per person than they are in the U.S.

3. This bill would hold the pharmaceutical industry accountable when they defraud the American people. Today, nearly every major pharmaceutical company has been convicted of either civil or criminal fraud. And even though the Justice Department has won suits requiring them to pay billions in fines, the prescription drug companies simply treat these fines as the cost of doing business. Our bill would say that if a drug company is convicted of fraud, they will lose their market exclusivity on the drugs they sell.

4. This bill would end “pay for delay” – a practice in which brand name prescription drug companies pay other companies not to manufacture cheaper generic drugs. The FTC has estimated that pay for delay is costing consumers and taxpayers about $3.5 billion a year in higher drug prices. That is unacceptable.

5. This bill would demand more transparency from drug companies, who have been concealing the true cost of their research and development.

Let me just conclude my remarks by saying this. I know how hard it will be to pass this legislation. I know how hard it will be to defeat the prescription drug industry. In fact, to my knowledge the prescription drug industry has never lost a battle on Capitol Hill.

But at a time when a huge majority of the American people want us to take action, when 74 percent of Republicans and 93 percent of Democrats, want the federal government to negotiate with the drug companies to lower prices, the time has come to say enough is enough. We cannot let the drug companies continue to rip-off Americans who are suffering any longer.

http://www.sanders.senate.gov/download/prepared-remarks-on-the-prescription-drug-affordability-act-of-2015

Prescription Drug Affordability Act of 2015 (Bill number pending): http://www.sanders.senate.gov/download/text-of-prescription-drug-affordability-act-of-2015

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Comment:

By Don McCanne, MD

When we enact an improved Medicare for all, it would be important for Medicare to have the power to negotiate better drug prices with the prescription drug companies. The Prescription Drug Affordability Act of 2015 would establish that principle, clearing one more hurdle on our way to health care justice for all.

Are Medicare Pay-for-Performance Benefits Worth the Risk?

By Jacqueline DiChiara
RevCycle Intelligence, Sept. 10, 2015

Medicare pay-for-performance (P4P) incentives are inadvertently diverting money away from those financially aching hospitals primarily serving minorities and the economically disadvantaged to instead inflate the revenues of those hospitals serving a more financially prosperous population of patients. Such is confirmed by recent research from David U. Himmelstein, MD, FACP, Lecturer in Medicine at Harvard Medical School and Professor at the City University of New York School of Public Health at Hunter College, and Steffie Woolhandler, MD, MPH, FACP, Lecturer in Medicine at Harvard Medical School, Professor in the CUNY School of Public Health at Hunter College, and Adjunct Clinical Professor at Albert Einstein College of Medicine.

“Medicare’s [P4P] program, which does not adjust for patients’ socioeconomic status, assumes that bonuses and penalties will prod substandard providers to improve or see their patients migrate to higher-quality options,” state Himmelstein and Woolhandler. “However, when quality problems are due to a hospital’s financial distress and patients cannot go elsewhere, penalizing low scorers may well punish patients and exacerbate quality disparities. Prescribing a starvation diet for safety-net hospitals that are strapped for cash and are quality challenged makes no sense unless the goal is to close them.”

Medicare pay-for-performance incentives

Ask Himmelstein and Woolhandler, “Are P4P’s benefits worth the risk? The evidence is surprisingly slim. A few small, randomized, controlled trials in outpatient settings have shown improvement on surrogate measures, but most have found no improvement, and none have demonstrated reductions in death or disability rates.”

Hospital administrators “game” P4P arrangements by coercing physicians to embellish diagnoses to beef up their medical outcomes, confirm Himmelstein and Woolhandler. As RevCycleIntelligence.com recently reported, Himmelstein and Woolhandler additionally confirm hospitals are steadily reclassifying Medicare patient readmissions as “observation stays” or delivering care for recurring Medicare patients in the Emergency Room (ER) to thwart Medicare’s financial penalties. 

“Researchers who used external data to audit Medicare Advantage plans’ ‘safe prescribing’ quality reports discovered that 95% of plans overstate their scores, pushing down the rankings of the 5% who told the truth,” confirm the authors. “At a hospital where we worked, the administration responded to poor scores for risk-adjusted mortality rates by hiring coding consultants, even as it was laying off clinical staff. Within 6 months, risk adjusted mortality rates improved to better than expected and Medicare reimbursement climbed $3 million. Soon after, administrators made physician attendance at coding-coaching sessions mandatory,” they explain.

The recent sustainable growth rate (SGR) fix, they add, will associate 18 percent of Medicare physician fees to cost and quality performance metrics. P4P pressures will “intensify,” they say, as confusion escalates with paperwork befuddlement involving clarity of costs and quality deficits.

Indeed, as Himmelstein confirmed to RevCycleIntelligence.com in a personal interview, paperwork issues are a substantial concern requiring active addressing within the healthcare space: one-third of the total healthcare dollar goes toward paperwork and bureaucracy, he explained. “We are wasting an enormous amount of money that ought to go to healthcare on paperwork … [which is] an extraordinarily inefficient way of deploying resources,” Himmelstein said.

In addition to the notion of possible paperwork chaos, maintaining the integrity of physicians’ work is perhaps now in question, the authors add. “Tethering physicians’ rewards to box checking and redundant documentation risks both substituting insurers’ priorities for patients’ goals and demoralizing physicians. Pay for performance can crowd out intrinsic motivation that keeps us doing good work even when no one is looking,” the authors state. “A growing body of behavioral economics research indicates that when preexisting motivation is high, monetary incentives often undermine performance on complex cognitive tasks – particularly when incentives are contingent on specific task performance or associated with surveillance, deadlines, or threats,” they add.

The concept of paying for quality is an attractive option, they confirm. However, the modification of policies “that have been proven nowhere” merely means millions are in severe danger of risk, they maintain.

http://revcycleintelligence.com/news/are-medicare-pay-for-performance-benefits-worth-the-risk

Nothing Can be Gained in a Broken System

Courage Campaign’s Paul Y. Song shares his journey to pursue justice in the U.S. health care system

By Paul Y. Song, M.D.
Inheritance, September 2015

In 1991 then United States Surgeon General C. Everett Koop asked me and my fellow graduating medical students to raise our right hands and repeat the Hippocratic Oath.

“I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous.”

In the nearly 25 years since then, and despite all of the amazing medical advances, I have found our medical system to be far too deleterious and mischievous for my patients. I have witnessed too many patients of mine go bankrupt from medical bills while cancer ravaged their bodies. I have seen too many of my patients patients being denied necessary tests and treatment by insurance companies. And I have seen too many uninsured or Medicaid patients with advanced incurable cancer simply because they did not have timely access to a doctor.

In his 1966 speech to the Medical Committee of Human Rights, Martin Luther King, Jr. said, “Of all the forms of inequality, injustice in health is the most shocking and inhuman.” Sadly this inequality is worse now than it was back then.

Even with the positive strides achieved by the Affordable Care Act, we still have a health care system in which 45,000 people die each year in the U.S., simply because they are uninsured. We still have a country where 70 percent of all uninsured come from communities of color. Despite the fact that we spend twice as much per person on health care than any other industrialized nation, we still have a system where nearly 1.2 million people with insurance go bankrupt each year due to a major medical illness. 

We still have a health care system that does not cover our undocumented brothers and sisters. And we still have a system where too many doctors perform unnecessary medical procedures, too many hospitals charge obscene fees for goods and services, and too many pharmaceutical companies gouge patients for their lifesaving drugs.

In the meantime, the biggest for-profit health insurers continue to unfairly raise premiums, make record profits, and watch their stocks hit all-time highs, all the while maintaining a perverse system that only makes money by denying care.

I found myself spending more and more time on the phone with insurance companies on behalf of my patients, fighting for the care they deserved and needed. I saw the emotional and economic toll that cancer took on my patients. I witnessed far too many of my patients sacrificing their lifesavings, selling their longtime homes, and making painful decisions about what to give up in order to pay for their rapidly escalating premiums, co-pays, medications, and deductibles.

I reached out to pharmaceutical companies to see if my patients could get samples or greatly discounted drugs, and I worked closely with social workers to find suitable support when patients reached their economic limits.

But I realized that for every one patient that I could help, there were thousands elsewhere that were falling through the cracks.

While my medical practice afforded me a very comfortable life, I felt a lot like Solomon when he wrote Ecclesiastes.

“Yet when I surveyed all that my hands had done and what I had toiled to achieve, everything was meaningless, a chasing after the wind; nothing was gained under the sun” (Eccl. 2:11 NIV).

All my own financial and professional success could not mask the overall brokenness I saw daily in our health care system.

I was becoming more and more depressed, seeing the daily toll that this broken system was taking on my patients and the countless others who could not even see a doctor. I came across this story:

“On a street corner I saw a cold shivering girl in a thin dress, with no hope of a decent meal. I got angry and said to God: ‘Why did you permit this? Why don’t you do something about it?’ God replied, “I certainly did something about it. I made you.”

It was then that I realized I could no longer silently participate in this broken system without trying to make a real difference. For the first time, I felt a real calling to fight for a better health care system for all. In the years since, I have dedicated my life to doing just that.

Like someone trying to find a cure for cancer, I learned as much as I possibly could about health care in the U.S. and health care in all the other major industrialized countries. I began this study with no preconceived notions, but simply immersed myself in copious amounts of published data and studies and sought out opinions from numerous leading health care leaders.

After this extensive education, I felt very comfortable speaking throughout the U.S. about what was wrong with our health care system and how we could improve it. I immediately found myself at odds with most in the medical community, who were quick to defend the status quo, including Dr. Ron Paul, who I debated on Larry King Live in the run-up to the Affordable Care Act. 

Many do not want any change that will threaten their way of life, even if it will improve the lives of countless others; this is unfortunate.

“Learn to do right; seek justice. Defend the oppressed” (Isaiah 1:17 NIV).

I believe that our current health care system oppresses far too many for us not to do anything. I also think that Acts 2:44-45 shows that we as a society are all in this together:

“All the believers were together and had everything in common. They sold property and possessions to give to anyone who had need” (NIV).

In the years since I answered this call, I have spoken at countless health care conferences, to numerous community groups, and have emerged as a voice to counter those who not only think nothing is wrong, but also that we have the best health care system in the world. I was fortunate to serve as a visiting fellow on health care policy in the California Department of Insurance and was a leading voice in trying to achieve insurance rate regulation in California.

I have always believed that we are defined as a society by how we care for the least among us as Matthew 25 describes.

That is why I continue to fight for those without a voice, especially when it comes to health care.

Two years ago, I took over as the leader of the Courage Campaign, an online organization with over 1 million members who advocate and fight for a more progressive California and nation. I serve on a purely voluntary basis, which has forced me to cut back on my hours as a physician. And while I now make less as a doctor than I did at any point of my career, I feel that I am also helping more people than ever before, and for this I feel extremely blessed to do what I do.

I will not hesitate to call out those who hijack facts to defend their ideology and especially those who distort what I believe God calls us to do.

I pray that more and more brothers and sisters will feel a similar calling. There is still far too much health care injustice to remain silent.

Paul Y. Song, M.D., is a physician, healthcare activist, and biotechnology executive. He is on the faculty at the Samuel Oschin Cancer Center at Cedars Sinai Medical Center and is the Chief Medical Officer of ATGen Global. He is also the executive chairman of the Courage Campaign, a progressive online organization, and the co-chair for a Campaign for a Healthy California.

PNHP note: Dr. Paul Song is a member of the national board of Physicians for a National Health Program.

http://www.inheritancemag.com/issues/35/nothing-can-be-gained-in-a-broken-system

The truth on the distribution of HSAs

Health Savings Accounts: Growth Concentrated Among High-Income Households And Large Employers

By Lorens A. Helmchen, David W. Brown, Ithai Z. Lurie and Anthony T. Lo Sasso
Health Affairs, September 2015

Between 2005 and 2012, the share of employers whose employees had health savings accounts (HSAs) and the share of employees working at these employers grew more than tenfold. High-income and older tax filers both established HSAs and fully funded their HSAs at least four times as often as did low-income and younger filers.

Although suggestive, the evidence to date on the take-up of HSAs has been limited to surveys, which rely on modest samples of several thousand individuals or employers that have chosen to participate. In this study we examined US tax records to offer a definitive depiction of the growth and ownership patterns of HSAs.

http://content.healthaffairs.org/content/34/9/1594.abstract

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Comment:

By Don McCanne, MD

Although there are innumerable surveys available on health savings accounts (HSAs), this is the definitive word since it used actual US tax records of filings on these tax-advantaged accounts. We can now say with absolute certainty that four times as many high-income and older tax filers both established and fully funded their HSAs as did low-income and younger filers.

This is what was predicted by many of us since the tax expenditures associated with these accounts (taxes not paid since the contributions are deducted from taxable income) are regressive tax policies benefiting higher income individuals with little or no benefit for those with low incomes. It is patently unfair to use our tax funds to subsidize the rich but not the poor.

But there is another consequence of HSAs that has a much greater negative impact. That is that an HSA must be combined with a high-deductible health plan. Many studies have confirmed that these high-deductible plans have left many middle- and low-income individuals and families underinsured. They face financial hardship should they need health care, because of the high out-of-pocket expenses associated with these insurance plans that shift health care costs from the insurers to patients in need.

Although HSAs are designed to pay for care received before reaching the deductible, this study confirms that the HSA accounts of lower-income individuals contain few if any funds at all. An empty HSA account doesn’t open doors to health care.

Another annoying feature is that these accounts can be used for retirement expenses once reaching age 65. What is fair about supporting these accounts for wealthier individuals with our tax expenditures that lower income individuals do not receive, even if they do have some funds in their accounts? Because of these regressive tax policies, the charge that they work for the wealthy and healthy but not the sick and poor really is true.

Many conservatives recognize that we need public policies to help support those with lower incomes. It is difficult to reconcile that view with their current push to expand the use of HSAs that are designed primarily to benefit the rich.

This issue would go away if we enacted an improved Medicare for all.