PNHP

Health care: Adverse selection

Health care: Adverse selection

By Henry J. Waters III
Columbia (Mo.) Daily Tribune, Jan. 29, 2014

Much is being made by opponents of the Affordable Care Act of adverse selection, the tendency of younger, healthier Americans to avoid buying health insurance, thereby skewing the economics of the plan, which depends on premium income from people needing relatively little care to offset the cost of care for older, sicker patients.

This is a valid point, one of several that demonstrate why Obamacare as currently constituted is not the final answer to health care reform.

As any student of insurance of any kind would know, premium revenue and provider cost must on balance produce a profit. Private insurance companies stay in business by managing these two factors, limiting exposure from policyholders likely to cost too much and limiting costs by negotiating low prices from providers.

This formula works well for companies serving manageable groups of potential patients, such as employer groups, and avoiding coverage for people of predictably high risk, like smokers or those with dangerous illnesses.

Years ago under this system, older people more likely to get sick and poor people who could not pay premium costs were being left behind. Government had to step in with Medicare and Medicaid, programs popular with everyone because they dealt with the parts of the health care system the private sector could not manage, but as time passed it has became clear this selective system will not provide adequate health care for everyone at the lowest price.

The Affordable Care Act is a step forward but can’t succeed fully until all citizens are in the same risk pool with basic care covered in a national insurance system, usually called single-payer.

Single-payer insurance would essentially be an amalgamation and expansion of Medicaid and Medicare to cover people of all ages and means with premiums paid through the tax system. We, the government, would negotiate costs with doctors, hospitals and drug companies and provide guaranteed, efficiently administered payment. Individuals could buy additional coverage out of pocket, but all would be covered with the basic plan.

As we know from experience everywhere in the developed world, this is the only way to provide universal health care at the best price. Everyone would have good basic care, and those who choose could have additional private fee-for-service plans. Health outcomes would be better, and costs would be lower.

Sooner or later, we will end our senseless bickering and get on with it. Sooner is better.

Henry J. Waters III is an editor at the Columbia Daily Tribune.

http://www.columbiatribune.com/opinion/the_tribunes_view/health-care/article_74bf34f0-890b-11e3-a59a-10604b9f7e7c.html

Medicaid patients did improve in the Oregon Health Insurance Experiment

New Medicaid Enrollees In Oregon Report Health Care Successes And Challenges

By Heidi Allen, Bill J. Wright and Katherine Baicker
Health Affairs, February 2014

In 2008 Oregon used a lottery to expand its Medicaid program for low-income adults, Oregon Health Plan Standard (OHP).

For this study we conducted 120 qualitative interviews among Oregon residents who had recently gained Medicaid coverage. Our purpose was to better understand how newly insured patients did—and did not—interact with the health care system

Group 1: Minimal Interactions With Health Care

Forty percent of the newly insured enrollees whom we interviewed did not use their coverage much, if at all.  Low users gave one of the following four main reasons for not using their Medicaid benefits very often.

* Perception Of Good Health

* Confusion About Coverage

* Dissatisfaction With Care

* Access Barriers

Group 2: Regular Or Frequent Interactions With Health Care

The remaining 60 percent of respondents (called regular users) used their insurance more than a time or two but reported varying degrees of success.

* Regular Preventive Care And Minor Needs:

About one-tenth of the regular users took advantage of access to preventive care and also received treatment for occasional illnesses or injuries

* Immediate Health Improvement:

Another tenth of the regular users described an immediate transformation in their health after they received insurance. These people all had serious health problems that could be improved quickly, such as by getting back on a previously effective medication or having an operation that had been postponed because of lack of coverage. The members of this group saw their new insurance coverage as directly related to an improvement in their quality of life.

* Mixed Success:

Forty-four percent of regular users continued to experience challenges. Some interviewees were able to get partial treatment—such as prescriptions for chronic conditions—but had serious needs remaining. Some reported feeling misunderstood by physicians or being unable to build a relationship with a primary care provider. Others struggled with very poor health that continued to deteriorate even with regular treatment.

* Success Over Time:

Finally, 39 percent of regular users reported that their health had improved with insurance, but that it had taken time. They experienced incremental benefits once they found and built a relationship with the right doctor.

Often these users’ problems were addressed in order of severity or impairment. Lifestyle changes, such as modifications to diet and exercise, were not discussed until their acute symptoms had improved. Many of the positive changes that they reported were relatively recent.

http://content.healthaffairs.org/content/33/2/292.abstract

Comment:

By Don McCanne, M.D.

The “Oregon Health Insurance Experiment” made possible the comparison of uninsured patients with Medicaid patients by the natural experiment in which Medicaid patients were selected by lottery from a single population. The initial study reported was not powered to detect changes in health outcomes, but opponents of reform used the lack of demonstrable outcome differences to claim that Medicaid provides no health benefits for the patients enrolled. This new study of these Oregon Medicaid beneficiaries confirms that the claim of no health benefit was an outrageous extrapolation on the part of the opponents of ACA and Medicaid.

The majority of the 60 percent of the Medicaid beneficiaries who were regular users of care significantly benefited from the program. One-tenth experienced immediate health improvement, one-tenth benefited from preventive care and occasional acute care, 39 percent experienced incremental benefits over time, and 44 percent continued to experience challenges though many  of them were able to receive partial treatment.

Some of the reasons given by the 40 percent of the Medicaid beneficiaries who did not use much health care are of concern. Some reasons relate to well-known problems with Medicaid being considered a second-rate welfare program, that is chronically underfunded, and that has access problems due to an insufficient participation by health care professionals.

We can conclude that Medicaid has some definite problems, but we also can refute the opponents of Medicaid and state that it is far better to be insured, even with Medicaid, than not to be insured at all. At the same time, we can also state that mixed results for a portion of the study group should be motive enough for us to advocate emphatically for a higher quality program for everyone – an improved Medicare for all.

Medicaid patients did improve in the Oregon Health Insurance Experiment

New Medicaid Enrollees In Oregon Report Health Care Successes And Challenges

By Heidi Allen, Bill J. Wright and Katherine Baicker
Health Affairs, February 2014

In 2008 Oregon used a lottery to expand its Medicaid program for low-income adults, Oregon Health Plan Standard (OHP).

For this study we conducted 120 qualitative interviews among Oregon residents who had recently gained Medicaid coverage. Our purpose was to better understand how newly insured patients did—and did not—interact with the health care system

Group 1: Minimal Interactions With Health Care

Forty percent of the newly insured enrollees whom we interviewed did not use their coverage much, if at all.  Low users gave one of the following four main reasons for not using their Medicaid benefits very often.

* Perception Of Good Health

* Confusion About Coverage

* Dissatisfaction With Care

* Access Barriers

Group 2: Regular Or Frequent Interactions With Health Care

The remaining 60 percent of respondents (called regular users) used their insurance more than a time or two but reported varying degrees of success.

* Regular Preventive Care And Minor Needs:

About one-tenth of the regular users took advantage of access to preventive care and also received treatment for occasional illnesses or injuries

* Immediate Health Improvement:

Another tenth of the regular users described an immediate transformation in their health after they received insurance. These people all had serious health problems that could be improved quickly, such as by getting back on a previously effective medication or having an operation that had been postponed because of lack of coverage. The members of this group saw their new insurance coverage as directly related to an improvement in their quality of life.

* Mixed Success:

Forty-four percent of regular users continued to experience challenges. Some interviewees were able to get partial treatment—such as prescriptions for chronic conditions—but had serious needs remaining. Some reported feeling misunderstood by physicians or being unable to build a relationship with a primary care provider. Others struggled with very poor health that continued to deteriorate even with regular treatment.

* Success Over Time:

Finally, 39 percent of regular users reported that their health had improved with insurance, but that it had taken time. They experienced incremental benefits once they found and built a relationship with the right doctor.

Often these users’ problems were addressed in order of severity or impairment. Lifestyle changes, such as modifications to diet and exercise, were not discussed until their acute symptoms had improved. Many of the positive changes that they reported were relatively recent.

http://content.healthaffairs.org/content/33/2/292.abstract

The “Oregon Health Insurance Experiment” made possible the comparison of uninsured patients with Medicaid patients by the natural experiment in which Medicaid patients were selected by lottery from a single population. The initial study reported was not powered to detect changes in health outcomes, but opponents of reform used the lack of demonstrable outcome differences to claim that Medicaid provides no health benefits for the patients enrolled. This new study of these Oregon Medicaid beneficiaries confirms that the claim of no health benefit was an outrageous extrapolation on the part of the opponents of ACA and Medicaid.

The majority of the 60 percent of the Medicaid beneficiaries who were regular users of care significantly benefited from the program. One-tenth experienced immediate health improvement, one-tenth benefited from preventive care and occasional acute care, 39 percent experienced incremental benefits over time, and 44 percent continued to experience challenges though many  of them were able to receive partial treatment.

Some of the reasons given by the 40 percent of the Medicaid beneficiaries who did not use much health care are of concern. Some reasons relate to well-known problems with Medicaid being considered a second-rate welfare program, that is chronically underfunded, and that has access problems due to an insufficient participation by health care professionals.

We can conclude that Medicaid has some definite problems, but we also can refute the opponents of Medicaid and state that it is far better to be insured, even with Medicaid, than not to be insured at all. At the same time, we can also state that mixed results for a portion of the study group should be motive enough for us to advocate emphatically for a higher quality program for everyone – an improved Medicare for all.

Misleading reports on ACO savings

ACOs saving some money, but Medicare is short on details

By Jenny Gold

Kaiser Health News, January 31, 2014

The Centers for Medicare and Medicaid Services [CMS] announced Thursday that, overall, provider groups involved in Medicare ACO programs saved a total of $380 million in the first year. Sounds like a lot of money, but CMS declined to explain which hospitals were winners and which were losers, how it compared to expectations and how much the participants invested in coordinating care. Also missing is the scale of the savings; CMS did not provide the context of total spending by the ACOs…. It’s also unclear whether the savings figures factored in any losses from some of the ACOs that did not do well. And the agency did not release information about which ACOs saved money and which did not….

http://capsules.kaiserhealthnews.org/index.php/2014/01/acos-saving-some-money-but-medicare-is-short-on-details/

Comment:

By Kip Sullivan, JD

Congress has instructed CMS to conduct several experiments with Medicare ACOs. The first began in 2005, the year before the “accountable care organization” label was invented, and ran through 2010. The participating hospital-clinic chains were called “physician group practices” (PGPs), but within a few years ACO advocates and skeptics alike were asserting that these PGPs were indeed the equivalent of ACOs. The second and third ACO experiments began in 2012. CMS called one program the Pioneer ACO program and the other the Medicare Shared Savings program. 

CMS’s reports on all three ACO experiments have been extremely misleading. Here are the headlines and dates of CMS’s last three reports on its ACO experiments:

July 2011:  Physicians Groups Continue to Improve Quality and Generate Savings 

Under Medicare Physician Pay-for-Performance Demonstration http://www.cms.gov/Medicare/Demonstration-Projects/DemoProjectsEvalRpts/downloads/PGP_Fact_Sheet.pdf,

July 2013: Pioneer Accountable Care Organizations succeed in improving care, lowering costs http://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-Releases/2013-Press-Releases-Items/2013-07-16.html,

January 2014: Medicare’s delivery system reform initiatives achieve significant savings and quality improvements – off to a strong start. http://www.hhs.gov/news/press/2014pres/01/20140130a.html.

Note the pattern: “Costs” are always going down, “quality” is always going up. 

These reports suffer from numerous defects. The worst defects are:

•  CMS fails to report how much it costs the ACOs to participate ;

•  CMS usually fails to give us enough information to determine the relative size of the savings or increased costs; and

•  CMS offers only the vaguest descriptions of what the ACOs are doing and yet, on the basis of a few quality measures, reports that quality is improving for all patients assigned to the ACOs.

Reports in both the general media and the professional literature rarely note these defects (for a typical example, see this article in Businessweek http://www.businessweek.com/articles/2014-01-30/obamacares-medicare-experiment-is-working). The article from Kaiser Health News quoted above (it appeared simultaneously in the Washington Post) is an exception to the rule. KHN reporter Jenny Gold criticizes CMS’s latest report – a press release issued last Thursday on the first-year (2012) results for both the Pioneer and the Shared Savings programs – for the first two defects. She notes CMS reports only on whether Medicare saved money and says not a word about whether the hospital-clinic chains that CMS certified as ACOs saved money after taking their ACO-related costs into account. And she comments on CMS’s failure to put the alleged $380-million first-year savings in context, that is, to help the reader understand whether $380 is a relatively large or small savings.

Gold goes on to quote an expert who did his own back-of-the-envelope calculation and concluded that, if CMS’s reported savings are accurate, CMS’s ACOs are cutting costs for Medicare (not Medicare plus the ACOs) by just $80 per beneficiary per year. (Gold offers a confusing explanation of his methodology, so I can’t vouch for it.) In 2012, Medicare spent $11,325 per beneficiary. Eighty dollars comes to seven-tenths of one percent of $11,325. (You can calculate 2012 per capita Medicare spending for yourself by going to page 6 of the 2013 Medicare trustees report. There you’ll find total spending in 2012 was $574.2 billion and total enrollment was 50.7 million. http://downloads.cms.gov/files/TR2013.pdf)

That estimate of seven-tenths of a percent is close to the half-percent savings (for Medicare only) that CMS reported in its July press release on Pioneer ACOs.

But if you want to know what effect CMS’s ACOs are having on the entire health care system (Medicare plus the ACOs), the only information we have that is remotely useful is the testimony to the Medicare Payment Advisory Commission I quoted here last December 9. https://pnhp.org/blog/2013/12/09/medpac-conflicted-between-fiscal-neutrality-and-paying-private-programs-more/ Katelyn Smalley stated at Medpac’s November 2013 meeting: “CMS reported [ACO Pioneer] program savings of about 0.5 percent…. The ACOs we spoke with confirmed that the cost of running the ACO was about one to two percent….” In other words, ACOs are driving costs up by a percent or two. Until CMS is more forthcoming, Ms. Smalley’s testimony must remain our most reliable estimate of whether ACOs are saving money.

My main quarrel with Gold’s article is that she or, more likely, one of her editors, inserted a misleading phrase in the headline of her article – “Medicare saving some money….” When the Washington Post published Gold’s article on their Wong Blog on January 31, their editor changed the headline to read, “Medicare won’t give a straight answer on Obamacare cost savings” http://www.washingtonpost.com/blogs/wonkblog/wp/2014/01/31/medicare-wont-give-a-straight-answer-on-obamacare-cost-savings/?tid=up_next. Now that’s more like it.

I have a modest request for the entire media: Please don’t insert the word “savings” in any future articles or broadcasts about Medicare ACOs until CMS reports on the cost incurred by the ACOs. There would still be other reasons to suspect there were no savings (the games ACOs play with risk-adjustment being one of them). But if my wish were granted, the media would no longer be an accomplice to the promulgation of CMS’s strange theory that ACO costs are non-existent or so trivial they don’t deserve mention, much less study.

Single Payer Rises Again

By Sarah Jaffe
In These Times, February 3, 2014

As the ACA takes effect, an alternative gains ground at the state level

When Sergio Espana first began talking to people, just over a year ago, about the need for fundamental changes in the U.S. healthcare system, confusion often ensued. Some people didn’t understand why, if the Affordable Care Act (ACA) had passed, people still wanted to reform the system; others thought organizers were trying to sign them up for “Obamacare.”

Healthcare is a Human Right Maryland, the group to which Espana belongs, is in pursuit of something else: a truly universal healthcare system that would cover everyone and eliminate insurance companies once and for all. Espana and many others in the growing movement see opportunity in the renewed discussion around healthcare reform as the ACA’s insurance exchanges go into effect.

They believe that the ACA’s continued reliance on (and subsidies of) private insurance simply aren’t good enough. People are still falling through the cracks, employers are trying to dodge the requirement that they provide insurance for their workers, and many states refused federal subsidies to expand their Medicaid programs. What these activists want is a program that would replace existing insurance programs, cover everyone regardless of their employment status, and be funded by the government, with tax dollars. Such a plan had strong support when the national healthcare overhaul was being crafted in 2009—including initial backing by President Obama—but the president and Congress decided it wasn’t politically possible and passed the ACA as a compromise.

Now, the rocky launch of the healthcare exchanges that form the cornerstone of the Affordable Care Act has helped revive interest in single-payer, says Ida Hellander, director of policy and programs for the advocacy group Physicians for a National Health Program. New York State Assemblymember Richard Gottfried, the author of a 20-year-old single-payer bill that is receiving renewed support, points out that single-payer would avoid many of the issues of the ACA’s launch. “When you don’t have means testing and you don’t have to make guesses about who’s going to cover your doctor or your ailment, it’s very simple.”

While Republicans on the national stage have been grandstanding about “repealing and replacing” the ACA, grassroots activists are on the ground in many states organizing their neighbors around the idea of real universal healthcare. A national program remains the end goal, but Nijmie Dzurinko of Put People First! Pennsylvania believes that state efforts could have a domino effect. “Our job is to change what’s politically possible,” says Drew Christopher Joy of the Southern Maine Workers’ Center, which is leading the effort in that state.

According to Hellander, about 25 states already have solid organizing toward single-payer, often accompanied by pending legislation. Some of these efforts predate the ACA: The California Nurses Association led the charge for single-payer in the mid-2000s, twice getting a bill through the California legislature only to have it vetoed by Gov. Arnold Schwarzenegger. Hellander says that the ACA has slowed down some efforts at state reform, as officials turned to setting up exchanges, but the law spurred others in Minnesota, Washington, Hawaii and Oregon. In New York, Gottfried notes that his bill has support from physicians groups, the nurses union and a majority of the lower house of the legislature. And in Massachusetts, considered the laboratory for the ACA, single-payer is now on the table thanks to gubernatorial candidate Don Berwick, the former administrator of the Centers for Medicare and Medicaid Services under Obama.

The biggest legislative victory to date has come in Vermont. Act 48, signed into law by Gov. Peter Shumlin in May of 2011, would begin to create a “universal and unified” healthcare system for the state. The bill, pioneered by the Vermont Workers’ Center (VWC), is at the cutting edge of national healthcare policy. Its passage resulted from years of on-the-ground organizing around the principle that healthcare is a human right—that it must be universal, equitable, participatory, transparent and accountable.

However, Act 48 marks just the beginning of a lengthy process toward healthcare for all residents of the state, regardless of employment or citizenship. The next steps are to figure out how “Green Mountain Care” will fit into federal requirements set by the ACA and to pass a mechanism by which the program will be financed.

The VWC favors a more progressive income tax on individuals and employers, along with a wealth tax. Mary Gerisch, president of the VWC, says, “Even though new taxes or progressive taxation sounds very scary, in reality it’s going to be cheaper for everybody, just like it is in every other country, for them to pay it in taxation rather than to pay out of pocket at the doctor.”

This growing movement has attracted growing opposition, says Gerisch, who notes that a number of TV ads and websites have popped up to oppose Green Mountain Care. And Vermonters for Health Care Freedom, a new 501(c)4 organization founded by longtime Republican political operative Darcie Johnston, has paid for several ads and robocalling campaigns against the plan.

Small business owners, in particular, are susceptible to the fear that new taxes will put them out of business, Gerisch says. She mentions one example of a small business owner who was worried about a 10 percent tax (even though no tax has been decided upon), only to find out that he was already paying 13 percent of his profits to buy insurance for his employees, which would be unnecessary under a state plan.

Healthcare is a Human Right believes the organizing model pioneered in Vermont represents the best chance for passing universal healthcare, and the group is forging ahead with that model in its Maine, Maryland, and Pennsylvania chapters. Among the key elements are base-building and education. To combat corporate scare tactics, activists focus on arming citizens with good information.

In Maryland, according to Espana, more than 90 percent of the 1,200-plus people the organization has surveyed over the last year believe that healthcare is a right, and more than 86 percent support a publicly funded system. “Maryland has been coming off more and more as a progressive state. We’ve been able to get some version of a DREAM Act through, we got marriage equality last year—those are great victories but, economically, they’re not that transformational,” he says.

Joy sees an opportunity to build a strong community-labor alliance around universal care in Maine, where the state AFL-CIOhas gotten on board with the Healthcare is a Human Right campaign, and the Maine State Nurses Association held a free health clinic to provide services and connect people to the campaign.

Dzurinko and Put People First! Pennsylvania have been organizing statewide—not only in Philadelphia and Pittsburgh, but in rural counties where the conventional wisdom has been that progressives can’t win. Dzurinko says that people in those counties frequently suggest, unprompted, that the U.S. should have a national healthcare system “like in Canada.”

“We often limit ourselves tremendously by not talking to people that we fear or that we have been told won’t agree,” Dzurinko says. “We can’t talk about universality unless we really are talking about everyone, and that means organizing in all communities.” Joy agrees: “If you’re not taking the time to really organize from the ground up, we’ll end up with the ACA again.”

For Espana, organizing around single-payer presents an opportunity to begin a broader discussion about economic justice and human rights. “All of these politics of austerity are just lies,” he says. “Through a fight for healthcare reform you can demonstrate that not only is it morally righteous for us to have a universal healthcare system, but it’s actually cheaper.”

http://inthesetimes.com/article/16114/single_payer_rises_again/

Misleading reports on ACO savings

ACOs saving some money, but Medicare is short on details

By Jenny Gold

Kaiser Health News, January 31, 2014

The Centers for Medicare and Medicaid Services [CMS] announced Thursday that, overall, provider groups involved in Medicare ACO programs saved a total of $380 million in the first year. Sounds like a lot of money, but CMS declined to explain which hospitals were winners and which were losers, how it compared to expectations and how much the participants invested in coordinating care. Also missing is the scale of the savings; CMS did not provide the context of total spending by the ACOs…. It’s also unclear whether the savings figures factored in any losses from some of the ACOs that did not do well. And the agency did not release information about which ACOs saved money and which did not….

http://capsules.kaiserhealthnews.org/index.php/2014/01/acos-saving-some-…

Comment:

By Kip Sullivan, JD

Congress has instructed CMS to conduct several experiments with Medicare ACOs. The first began in 2005, the year before the “accountable care organization” label was invented, and ran through 2010. The participating hospital-clinic chains were called “physician group practices” (PGPs), but within a few years ACO advocates and skeptics alike were asserting that these PGPs were indeed the equivalent of ACOs. The second and third ACO experiments began in 2012. CMS called one program the Pioneer ACO program and the other the Medicare Shared Savings program.

CMS’s reports on all three ACO experiments have been extremely misleading. Here are the headlines and dates of CMS’s last three reports on its ACO experiments:

July 2011:  Physicians Groups Continue to Improve Quality and Generate Savings

Under Medicare Physician Pay-for-Performance Demonstrationhttp://www.cms.gov/Medicare/Demonstration-Projects/DemoProjectsEvalRpts/…,

July 2013: Pioneer Accountable Care Organizations succeed in improving care, lowering costs http://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-Releases/2013-Pre…,

January 2014: Medicare’s delivery system reform initiatives achieve significant savings and quality improvements – off to a strong start.http://www.hhs.gov/news/press/2014pres/01/20140130a.html.

Note the pattern: “Costs” are always going down, “quality” is always going up.

These reports suffer from numerous defects. The worst defects are:

•  CMS fails to report how much it costs the ACOs to participate ;

•  CMS usually fails to give us enough information to determine the relative size of the savings or increased costs; and

•  CMS offers only the vaguest descriptions of what the ACOs are doing and yet, on the basis of a few quality measures, reports that quality is improving for all patients assigned to the ACOs.

Reports in both the general media and the professional literature rarely note these defects (for a typical example, see this article in Businessweekhttp://www.businessweek.com/articles/2014-01-30/obamacares-medicare-expe…). The article from Kaiser Health News quoted above (it appeared simultaneously in the Washington Post) is an exception to the rule. KHN reporter Jenny Gold criticizes CMS’s latest report – a press release issued last Thursday on the first-year (2012) results for both the Pioneer and the Shared Savings programs – for the first two defects. She notes CMS reports only on whether Medicare saved money and says not a word about whether the hospital-clinic chains that CMS certified as ACOs saved money after taking their ACO-related costs into account. And she comments on CMS’s failure to put the alleged $380-million first-year savings in context, that is, to help the reader understand whether $380 is a relatively large or small savings.

Gold goes on to quote an expert who did his own back-of-the-envelope calculation and concluded that, if CMS’s reported savings are accurate, CMS’s ACOs are cutting costs for Medicare (not Medicare plus the ACOs) by just $80 per beneficiary per year. (Gold offers a confusing explanation of his methodology, so I can’t vouch for it.) In 2012, Medicare spent $11,325 per beneficiary. Eighty dollars comes to seven-tenths of one percent of $11,325. (You can calculate 2012 per capita Medicare spending for yourself by going to page 6 of the 2013 Medicare trustees report. There you’ll find total spending in 2012 was $574.2 billion and total enrollment was 50.7 million. http://downloads.cms.gov/files/TR2013.pdf)

That estimate of seven-tenths of a percent is close to the half-percent savings (for Medicare only) that CMS reported in its July press release on Pioneer ACOs.

But if you want to know what effect CMS’s ACOs are having on the entire health care system (Medicare plus the ACOs), the only information we have that is remotely useful is the testimony to the Medicare Payment Advisory Commission I quoted here last December 9.https://pnhp.org/blog/2013/12/09/medpac-conflicted-between-fiscal-neutral… Katelyn Smalley stated at Medpac’s November 2013 meeting: “CMS reported [ACO Pioneer] program savings of about 0.5 percent…. The ACOs we spoke with confirmed that the cost of running the ACO was about one to two percent….” In other words, ACOs are driving costs up by a percent or two. Until CMS is more forthcoming, Ms. Smalley’s testimony must remain our most reliable estimate of whether ACOs are saving money.

My main quarrel with Gold’s article is that she or, more likely, one of her editors, inserted a misleading phrase in the headline of her article – “Medicare saving some money….” When the Washington Post published Gold’s article on their Wong Blog on January 31, their editor changed the headline to read, “Medicare won’t give a straight answer on Obamacare cost savings” http://www.washingtonpost.com/blogs/wonkblog/wp/2014/01/31/medicare-wont…. Now that’s more like it.

I have a modest request for the entire media: Please don’t insert the word “savings” in any future articles or broadcasts about Medicare ACOs until CMS reports on the cost incurred by the ACOs. There would still be other reasons to suspect there were no savings (the games ACOs play with risk-adjustment being one of them). But if my wish were granted, the media would no longer be an accomplice to the promulgation of CMS’s strange theory that ACO costs are non-existent or so trivial they don’t deserve mention, much less study.

GOP intransigence accelerates health care crisis

By Andrew D. Coates, M.D., F.A.C.P.
WAMC Northeast Public Radio, Jan. 31, 2014

The Affordable Care Act, President Obama’s health care law, will reduce the number of uninsured through an expansion of both private health insurance and Medicaid. When fully implemented five years from now, it is estimated the law will leave about 30 million people without any form of health insurance, a number that would have been lower had 25 states not “opted out” of Medicaid expansion.

In the meantime Republican lawmakers have continued to call for repeal of the Affordable Care Act.

The Republican majority in the House of Representatives has symbolically voted to repeal the law dozens of times — 14 times over the last year and 35 times during the previous Congress. The irony of voting to repeal a law that was initially a Republican and Heritage Foundation idea — the compulsory purchase of private health insurance —has been highlighted by the fact that Republicans have not seemed to have a counter-proposal, something with which to replace the Affordable Care Act.

This week, evidently in an effort to show they have an alternative, but implicitly acknowledging the ongoing health care crisis, three Republican senators put forward a legislative proposal they call the Patient Choice, Affordability, Responsibility, and Empowerment Act. The Republican senators’ proposal would still use taxpayer money to subsidize the purchase of private health insurance for those can’t afford it, but to a lesser extent than the Affordable Care Act now does.

Oddly, from the party where Grover Norquist’s “no new taxes” pledge is so popular, the Republican senators propose to tax health insurance benefits as income.  The income tax would be levied upon employees, not employers.  This stems from the erroneous theory that health care costs might be reduced if workers are compelled to choose plans with lower premiums, but higher out-of-pocket costs, like co-pays, co-insurance, deductibles.

Under the current law, Medicaid expansion was intended to help millions of people living at or near the poverty level obtain health coverage.  Yet Republican lawmakers in 25 states “opted out” of the expansion of Medicaid that the Affordable Care Act proposed. Had these 25 states implemented the law, nearly 8 million people, presently uninsured, would have gained coverage. The Republican senators would like to see even fewer people covered by Medicaid than their counterparts have allowed state-by-state.

Yesterday, a third-year Harvard medical student, Samuel Dickman, together with senior researchers from Harvard Medical School and the City University of New York, published a study that highlights the human toll of these political decisions.

If all states had “opted in” to the expansion of Medicaid coverage as the law was designed, 7,780,000 more uninsured would have gained coverage. Dickman and colleagues found that if these millions of people gained Medicaid coverage, at least 7,115 and perhaps as many as 17,100 deaths might be prevented.

It is important to state that Medicaid coverage is often inadequate. Medical specialty visits can be impossible to obtain and many states have very restricted access to prescription medications under Medicaid, for two examples. However, having Medicaid remains better than being uninsured.

Dickman also reports because 25 states “opted out” of the Affordable Care Act Medicaid expansion, more than 240,000 people will face catastrophic medical expenses, over 400,000 diabetics will lack access to medications, nearly 200,000 women will forgo mammograms and over 400,000 women will forgo pap smears.

It is not only that Republican intransigence against the Affordable Care Act does nothing to advance the national debate about health care in a direction that would improve quality, increase access or reduce disparities. Nor would Republican proposals offer any means of cost saving, for both out-of-pocket costs and aggregate spending would continue to soar.  It is also important to recognize that the decision to “opt out” of Medicaid expansion has a human toll. As Samuel Dickman said of his research findings, these “political decisions have consequences, some of them lethal.”

Unfortunately, because the Affordable Care Act will not extend coverage to all of the uninsured, is powerless to rein in costs, and keeps profit-seeking in the driver’s seat of the U.S. health system, it too allows an unacceptable situation to persist. Medicaid expansion would lessen preventable death in the United States, for example, yet tens of thousands would still die from lack of health insurance annually, even if all 25 states had “opted in.”

Our nation must move beyond a debate in which neither side will boldly state the obvious goal:  every person in the United States deserves equal access to all necessary health care.

Dr. Andrew Coates practices internal medicine in Upstate New York. He is president of Physicians for a National Health Program.
 
You can find an archive of Dr. Coates’ WAMC radio broadcasts here: http://wamc.org/term/andrew-coates

Was the ACA ‘politically feasible’?

The group that got health care passed is packing up and going home

By Harold Pollack
The Washington Post, January 5, 2014

Harold Pollack: [S]ingle-payer folks … might ask: “Wouldn’t we have a better system if we had a single payer? Why didn’t HCAN [Health Care for America Now] and its friends push for that?”

Richard Kirsch [chief executive of HCAN]: What’s the expression: “If wishes were horses, beggars would ride?”

Yes — if we could wave a magic wand and design a rational health-care system that would control costs while providing much better access, we wouldn’t design our current one. The ACA was the best that we could get through the American political system. The fact that we failed in every previous instance in the past 100 years reflects the reality that there hadn’t been a reform designed to deal with the realities of American politics….

http://www.washingtonpost.com/blogs/wonkblog/wp/2014/01/05/the-group-that-got-health-reform-passed-is-declaring-victory-and-going-home/

****

Implementing health reform: Four years later

By Timothy Jost
Health Affairs, January 2014

How did things go so wrong [for the Affordable Care Act]? Why is there so much bad news?….

More devastating for the future of the ACA, however, were the 2010 midterm elections. Republicans picked up sixty-three seats in the House, swinging control of the chamber from the Democrats to the Republicans. Before the 2010 elections, Democrats controlled fifty-two state legislative houses and the Republicans thirty-three; after the elections, Republicans controlled fifty-three and the Democrats thirty-two. Before the 2010 election there were twenty-six Democratic and twenty-four Republican governors, and after there were twenty Democrat and twenty-nine Republican. Many saw the election as a referendum on the ACA.

http://content.healthaffairs.org/content/33/1/7.full

Comment:

By Kip Sullivan, J.D.

Was the Affordable Care Act politically feasible? Was it “the best” America could do in 2009 and 2010? Was single-payer legislation more or less feasible than the ACA? It is still too early to pronounce on the fate of the ACA, but it is not too early to discuss the political feasibility question. We have much to learn from looking back at the muffled debate about that issue among universal coverage advocates prior to the enactment of the ACA.

Since the modern American single-payer movement was formed in the late 1980s, many supporters of universal coverage have claimed that single-payer is not politically feasible. Those who made this argument (Bernstein and Marmor refer to them as “political yes buts” http://healthaffairs.org/blog/2008/08/28/medicare-for-all-why-we-should-say-yes-not-yes-but) never explained why multiple-payer “solutions” would be more feasible than single-payer. In the worldview of the “yes buts,” only single-payer proponents had to answer that question. If, on any given day, single-payer proponents could not point to 60 votes in the US senate or majority votes in the US House or in state legislative chambers, the conversation was over: Single-payer was not politically feasible and had to be taken off the table to make room for more “realistic” legislation.

This simple counting-noses definition of “political feasibility” avoided two issues that many observers inside and outside the single-payer movement consider paramount: Any legislation that proposes to achieve universal coverage, or even to cut the uninsured rate substantially, is not politically feasible, or at minimum is no more feasible than single-payer legislation, if

(1) it doesn’t simultaneously reduce health care spending or
(2) is so complex it cannot be implemented within a reasonable period of time.

This definition of feasibility asks not merely whether a given legislative body can be pushed into enacting a given bill. This definition asks as well, once the bill is enacted, is it politically sustainable? By this more realistic definition of political feasibility, a bill might have enough votes to pass a given legislative body, but if the bill can’t contain costs or can’t be implemented within a reasonable period of time, it shouldn’t be assumed to be politically sustainable and therefore should not be assumed to be more politically feasible than other approaches.

Sustainability depends ultimately on how the public perceives legislation after it is enacted. If the public punishes lawmakers who voted for the putative “universal coverage” legislation and rewards legislators who are hostile to government doing anything to help the uninsured and to lower health care costs, the legislation may die on the vine or be repealed.

One would think that this definition of political feasibility would have appealed naturally to the Democrats and their supporters who pushed the ACA because it asks them to take into account the impact of the ACA on voters’ perceptions of Democrats. In other words, it asks Democrats to consult their own self-interest in the course of picking a solution to a problem. It is a noble thing to suffer retribution at the polls for a bill that does good things for people when you know it’s going to work. But it is foolish to suffer retribution for a bill you suspect, or should suspect, will fail, or at minimum, will perform far below the expectations your rhetoric about the bill has created.

When in June 2009, congressional Democrats unveiled the health care “reform” bills that would become the ACA, I and many others were filled with apprehension. Our concern was not that some version of these bills might not pass. To the contrary, our concern was that it might pass (and thereby demonstrate it was “politically feasible” in the narrow sense of the phrase) but not be politically sustainable. In a June 2009 comment on this blog entitled, “Democrats’ hype about health care reform will hurt them,” I said:

“President Obama and Democratic congressional leaders are playing a dangerous game with health care reform. They are raising the public’s expectations sky high before figuring out how to meet those expectations. They are promising to give us the moon – significant cuts in health care costs and universal coverage or something close to it – but even at this late hour they have failed to publish anything resembling a detailed plan to do that. And the hints they have given us about the ‘reforms’ they are likely to endorse indicate they haven’t got a clue how to cut costs.”
https://pnhp.org/blog/2009/06/04/democrats%E2%80%99-hype-about-health-care-reform-will-hurt-them/.

I wanted a real debate about the political feasibility of the Democrats’ multiple-payer solution versus our single-payer proposal, and I thought the most effective way to make my argument was to appeal to Democrats’ self-interest, not just their altruism. Although I doubted the altruism of some members of Congress, I didn’t doubt the altruism of the vast majority of ACA supporters — I knew their desire to minimize the suffering inflicted on this country by our health care system was real. What I questioned was their understanding of how expensive and complex the ACA was going to be. If they didn’t understand that, how could they grasp what a political liability the ACA would be for Democrats? How could they intelligently evaluate the risk that future Congresses might not have enough Democrats in them to protect the ACA from underfunding or outright repeal?

But the debate about political feasibility that I and many others hoped for never came to pass. The single-payer and multiple-payer wings of the American universal coverage movement never discussed whether the ACA would be more feasible — that is, be more likely to pass AND be more sustainable — than a single-payer. We never debated whether the simplicity and efficiency of a single-payer made it more feasible, or at least no less feasible, than the costly and insanely complicated ACA. ACA proponents simply pronounced single-payer “off the table” on the ground that powerful opponents would have made a majority vote in Congress impossible. And that was that.

Four years have now passed since the enactment of the ACA. The sky is clotted with chickens coming home to roost. Evidence that the ACA was never as sustainable as its proponents implied is all around us. This evidence includes evidence of the damage the ACA has inflicted on Democrats. Timothy Jost’s article in the January 2014 Health Affairs contains an excellent summary of the unhappy history of the ACA. One of the most important paragraphs in his paper is the one quoted above in which he notes the damage Democrats suffered during the 2010 elections and that many believe this damage was due in part to the enactment of the ACA in March of 2010. Jost also predicts more bad news for the ACA as a substantial portion of the people insured through exchanges discover their choice of provider has been restricted and their out-of-pocket payments are very high. We are going to see more heartwarming stories about sick people finally getting the medical care they deserve, thanks to the ACA, but it will not be enough to forestall more damage to Democrats (especially if Republicans manage to nominate candidates who can refrain from discussing “legitimate rape” and similar subjects).

None of us have a crystal ball. I don’t claim that if Democrats and groups supporting the ACA had used the opportunity presented to us in 2009-2010 to promote HR 676 instead of the ACA that HR 676 would have passed by March 2010 or even by now. I’m reasonably sure something good would have been enacted — for example, an expansion of traditional Medicare and Medicaid to more people (Bob Kuttner makes a similar argument here http://www.huffingtonpost.com/robert-kuttner/obamacare-republicans_b_4293314.html).

I am, however, absolutely certain about one thing: The universal coverage movement in America would be in a much better position to bring the long fight for universal coverage to a successful conclusion than we are now. There are several reasons why I’m so sure about that.

First, whether we had won big or won some incremental improvements in 2010, the public would have been exposed to a debate about a real solution to the health care crisis as opposed to a debate about make-believe cost containment schemes such as exchanges, “accountable care organizations” and punishing hospitals for “excess” readmissions.

Second, the health insurance industry would be receiving less money from the taxpayer and would be, therefore, less powerful than they are now. The insurance industry has been driving away private-sector customers in droves over the last few decades. If public purchasers — state and federal governments — had long ago stopped throwing money at Aetna et al. with legislation like the ACA, schemes to overpay Medicare Advantage plans, and legislation privatizing state Medicaid programs, the industry would by now be a shadow of its former self and a much less potent opponent of universal coverage.

Third, the political environment for health care reform would be less toxic than it is today, not because conservatives wouldn’t be leveling the same extreme charges they level at all forms of health care reform no matter how innocuous, but because the public would be less vulnerable to extremism and ultimately less cynical about real reform.

ACA proponents may disagree with my assessment of where we might be today if they had joined ranks with the single-payer movement and had fought for HR 676. What they can’t deny is they refused to engage in a real debate about the political feasibility (narrowly defined) AND sustainability of the ACA versus single-payer. They might have learned something if they had.

Vicco, Ky., stays in spotlight, endorses single payer

By Kentuckians for Single Payer Healthcare

VICCO,  Ky. — This little Appalachian community that made national news a year ago by passing a Fairness Ordinance did it again Monday night. It voted to endorse single-payer health care, H.R. 676, joining 54 other American cities, including Chicago, San Francisco, Seattle, Philadelphia, Detroit and Baltimore.

The struggling coal town of 334 people unanimously endorsed Expanded and Improved Medicare for All, H.R. 676, national single-payer legislation sponsored by Congressman John Conyers Jr. (D-Mich.).

Vicco — established by the Virginia Iron Coal and Coke Company — is now the fourth Kentucky local government to favor single-payer health care.  The others are Metro Louisville, Boyle County, and the city of Morehead. In 2007, the Kentucky House legislators also endorsed the bill.

Vicco was put on the map early last year when The New York Times, USA Today, the Los Angeles Times and other national media covered the passage of the town’s new law prohibiting discrimination based on sexual orientation or gender identity. It was the smallest city in America to pass such a law.

Vicco gained further fame last August when Mayor Johnny Cummings and city commissioners were featured on “The Colbert Report” on cable television. The Colbert segment went viral, with almost three-quarters of a million views.

Since then, Vicco Mayor Johnny Cummings and the city commissioners have won further state and national praise.  At an event that featured Supreme Court Justice Elena Kagan last September, University of Kentucky President Eli Capilouto referred to Vicco when he described Kentucky as a place “deep in values that show up in unexpected ways and in unexpected places.”

Vicco’s newfound reputation as a progressive and humane community led to a presentation Monday night on health care by Dr. Garrett Adams, past president of Physicians for a National Health Program, and three Louisville colleagues, all representing Kentuckians for Single Payer Healthcare (KSPH).

The KSPH members pointed out that every person in Vicco — and everywhere else in the United States — would be covered by a plan similar to but better than the Medicare system that now serves those over 65 years of age.  The H.R. 676 bill would expand Medicare to all ages and would improve it to include dental, vision, mental health — all medically necessary care.  Patients would choose their own doctors and hospitals and there would be no co-pays or deductibles.  H.R. 676 would annually save over $400 billion by ending the profits and waste caused by private insurance companies.  The savings would then be used to expand an improved care to everyone in the country.

Kay Tillow, chair of KSPH, said, “It’s a moral issue. We believe that health care should not depend on ability to pay. We invite other cities to join our grassroots movement.”

The Vicco city commissioners decided to throw the weight of the town government behind this movement. Their resolution appears below.

Text of the Resolution under the seal of the City of Vicco, Kentucky

Whereas:  Barriers to quality medical care infringe on the right to life, liberty and the pursuit of happiness, and access to health care is a fundamental human right, and;

Whereas a bill has been introduced in Congress, H.R. 676, aka The Expanded and Improved Medicare for All Act, that will provide all medically necessary care, including dental and prescription drugs, to everyone in the country from birth to death.  There will be no co-pays nor deductibles so that inability to pay will be removed as an impediment to care.

Whereas with H.R. 676 each person will choose their own physicians, hospitals, and other providers.

Therefore be it resolved that the City of Vicco wholeheartedly endorses H.R. 676, the Expanded and Improved Medicare for All Act; and

Be it further resolved that we call on our representative in Congress, Representative Harold Rogers, to formally co-sponsor H.R. 676 so that the people of our city, our state, and our nation can  move forward toward the excellent health care we deserve.

Signatories:
Mayor Johnny Cummings
Claude Branson, Commissioner
Lula Gibson, Commissioner
Jimmy Slone, Commissioner

An electronic copy of the resolution available upon request from Kay Tillow, nursenpo@aol.com. Kentuckians for Single Payer Healthcare, www.kyhealthcare.org, (502) 636-1551.

A ‘Pause’ to reflect: Chicagoan Quentin Young tells his story

By Rick Kogan
The Chicago Tribune, January 31, 2014

It seems impossible that the life and times and accomplishments of Dr. Quentin Young might be able to fit into fewer than 250 pages, but there it is, colorful and passionate, between the covers of “Everybody In, Nobody Out: Memoirs of a Rebel Without a Pause.”

As Young, in collaboration with Steve Fiffer, writes, “When you get to be my age, there’s no shortage of stories to tell about things you’ve done, people you’ve met, and places you’ve been. Whether those stories are interesting enough to fill a book is for you, the reader, to decide.”

Well, I have read and I have decided, and the answer is a resounding “Yes.”

Young was born in 1923 and raised on the South Side, where he still lives. He enrolled in the University of Chicago at 16, volunteered for the U.S. Army, went to war and served in the medical corps, came back, earned his medical degree at Northwestern University, went to work at Cook County Hospital, where he eventually rose to chairman of the Department of Medicine from 1972 to 1982. He spent more than 60 years in private practice in Hyde Park.

Though on one level this book is about health care and the decades Young has been an articulate and indefatigable advocate for a single-payer national health care system, Young’s passions and interests extend beyond his life’s work. He attended his first protest as a teenager in support of steelworkers’ efforts to unionize. He helped organize the Freedom Summers in Mississippi. Through the decades Young could be found front and center of so many good causes, social justice matters and civil rights issues.

For instance, when Dr. Martin Luther King Jr. brought his fight for open housing and an end to segregation in the public school system to Chicago in 1966, Young was there. After King was hit in the head with a rock during the horrific open-housing march in Marquette Park, Young tended that wound. “We stopped the blood loss and transported him to the hospital,” Young writes. “The event had the capacity to kill him. He was my medical responsibility. In that moment, I was his doctor.”

And he was the doctor for many others, including columnist Mike Royko, the Beatles when the band was making concert visits here, and his lifelong friend and fellow activist Studs Terkel. “I was fortunate to be kind of Zelig to a number of accomplished and well-known Chicagoans and outsiders,” Young writes.

Politicians pepper these pages: the powerful Daleys on the fifth floor of City Hall, neighbor/friend Harold Washington, legendary 5th Ward Alderman Leon Despres, but not Gov. Pat Quinn, who last year nominated Young to the board of the Illinois Sports Facilities Authority. The current occupant of the White House? “I’ll get into my relationship with President Obama and my profound disappointment in Obamacare shortly,” he writes — and he does, very frankly.

This book is the story of a life well and courageously lived. It is an essential for any Chicago book collection. His recall is solid and his style (with Fiffer) compelling.

He is grateful for being able to mine the many newspaper stories that charted his life and career, and the recall of his family members (including his five grown children, two stepchildren and their families) and colleagues, “the thousands I have worked with.” He slyly tips his hat to “(a)nother organization (that) also kept an almost daily diary of my activities during the 1960s and 1970s, the Federal Bureau of Investigation.”

Near the end of this fine, fine book, he writes, “As you’ve no doubt noticed in the preceding pages, my views and actions have also propelled me into sharp conflict with institutions and persons who would perpetuate injustice. That was true yesterday; it remains true today. My work is unfinished.”

Ever busy, Young might take a moment to be proud — of his work, his life, this book.

Rick Kogan is a Tribune senior writer and columnist.

“Everybody In, Nobody Out”
By Quentin Young, Copernicus Healthcare, 254 pages, $18.95

http://www.chicagotribune.com/site/chi-everybody-in-nobody-out-quentin-young-20140131,0,7501065.story

State opt-outs from Medicaid expansion to result in thousands of deaths

Republican state lawmakers’ refusal to expand Medicaid will result in thousands of deaths

Dr. Steffie Woolhandler: 8 million Americans will be excluded from the Affordable Care Act’s Medicaid expansion

By Jessica Desvarieux
The Real News Network, Jan. 31, 2014

PNHP note: The following is a transcript. You can watch the video of this interview here.

JESSICA DESVARIEUX, TRNN PRODUCER: Welcome to The Real News Network. I’m Jessica Desvarieux in Baltimore.

Since the U.S. Supreme Court’s 2012 ruling that states can opt out of Medicaid expansion and the Affordable Care Act, 21 states have done so, and (not surprising) they’re all under Republican control. What is new to this Obamacare saga is a new Harvard University and CUNY study. It found that the lack of Medicaid expansion in these opt-out states will result in about 7,000 to 17,000 deaths a year.

Now joining us to go over the study is coauthor of the report Dr. Steffie Woolhandler. Dr. Woolhandler is the cofounder of Physicians for a National Health Program and professor of public health and medicine at City University of New York.

Thank you for joining us, doctor.

DR. STEFFIE WOOLHANDLER, COFOUNDER, PHYSICIANS FOR A NATIONAL HEALTH PROGRAM: My pleasure.

DESVARIEUX: So, according to your study, nearly 8 million people will not be able to access health insurance because their states opted out. Can you give us a rundown of the health consequences for these 8 million people?

WOOLHANDLER: Yes. Well, we’ll expect between 7,000 and 17,000 of those people to die. We’ll expect about three-quarters of a million, 750,000 people to experience depression that they would have been spared had they had access to health care. We’ll also see that many diabetics will not have access to medications to treat their condition and that women who need pap smears and mammograms will not get the pap smears and mammograms that they need. So we’re going to see a lot of adverse health consequences from what is essentially a political refusal by the red state governors to accept the Medicaid expansion.

DESVARIEUX: And these red state governors, they really have been coming out saying that they cannot afford to expand Medicaid. What’s your response to that?

WOOLHANDLER: Well, that’s completely ridiculous. The first three years of the Medicaid expansion are 100 percent funded by the federal government, and thereafter the expansion is 90 percent funded by the federal government. And, you remember, these billions are going to go into–if they accepted the money, billions would have gone into the state to pay for the hospitals, to pay for hospital workers, doctors, supplies. So it would have been money that would have gone to their states’ economies. So there’s absolutely no economic argument for turning down the Medicaid expansion. The decision by the red state governors to turn down that expansion is purely political.

DESVARIEUX: All right. But they also say, though, that because the federal government is not going to be funding this beyond that three-year mark, they’re concerned that they’ll have to pick up the tab. What do you make of that?

WOOLHANDLER: Well, over the very long run, the federal share is going to fall. But in the next three, four, five years, the federal government’s going to be picking up most of this. And generally when states do their fiscal planning, they only plan for a few years. They don’t usually make fiscal plans 20 or 30 years in advance. So I think these fiscal arguments are really a ruse. I think the real arguments are political.

You know, I want to say Medicaid is not perfect. You know, Medicaid reimburses doctors at such a low rate that often folks with Medicaid find they can’t see a specialist, they can’t get people to take care of them. Nonetheless, Medicaid is really a lot better than being uninsured. And if you have the opportunity to cover uninsured people with Medicaid, you ought to be taking that opportunity.

DESVARIEUX: All right. Dr. Woolhandler, I want to talk also about the 24 million people who would still lack health insurance even if their states expanded Medicaid. Who are these remaining 24 million people? And why are they not covered by the Affordable Care Act?

WOOLHANDLER: Well, the Affordable Care Act, as passed, as signed, was only going to cover about half of America’s uninsured. It was going to leave 23, 24 million people uninsured. Most of those people, as it turns out, will be U.S. citizens. Many of them will earn just a little bit too much to be Medicaid-eligible. They may be eligible for subsidies. But a lot of people find they still can’t afford the health insurance, despite the subsidies. You know, particularly as you get up into the 250 percent of poverty range, still pretty low-income, but not really poor, the subsidies are not very good and people have to take a lot of money out of their pocket to pay their premiums. And then, when they get sick, they find that they have these big deductibles and copayments. So, many folks may look at the insurance that they’re offered under the exchanges and say, I just can’t afford it, this is not worth it, I’m going to remain uninsured.

So what we saw in Massachusetts was, when we did the Massachusetts reform–which, as you know, was the model of the national reform–is only about half of the uninsured ended up getting insurance through the reform. The other half remained uninsured. And, of course, that’s one of the biggest problems with the Obamacare reform: even if it had been implemented as passed, if the Supreme Court had said the whole thing is constitutional, it has to be implemented, we were still going to have 23, 24, 25 million Americans with no health insurance.

DESVARIEUX: All right. Dr. Steffie Woolhandler, thank you so much for joining us.

WOOLHANDLER: My pleasure.

DESVARIEUX: And thank you for joining us on The Real News Network.

Short bio of Dr. Woolhandler:

Dr. Steffie Woolhandler is professor at the CUNY School of Public Health at Hunter College and visiting professor of medicine at Harvard Medical School, where she co-directed the general internal medicine fellowship program and practiced primary care internal medicine at Cambridge Hospital.

Dr. Woolhandler earned her bachelor’s degree from Stanford University,  a medical degree from Louisiana State University, and a master’s degree from the University of California. She worked in 1990-1991 as a Robert Wood Johnson Foundation health policy fellow at the Institute of Medicine and the U.S. Congress.

Dr. Woolhandler is a frequent speaker and has written extensively on health policy, administrative overhead and the uninsured. She has authored more than 50 research articles on health care access and financing. A co-founder and board member of Physicians for a National Health Program, Dr. Woolhandler co-edits PNHP’s newsletter and is a principal author of PNHP articles published in the JAMA and the New England Journal of Medicine in conjunction with Dr. David Himmelstein.

http://therealnews.com/t2/index.php?option=com_content&task=view&id=767&Itemid=74&jumival=11415

Was the ACA ‘politically feasible’?

The group that got health care passed is packing up and going home

By Harold Pollack
The Washington Post, January 5, 2014

Harold Pollack: [S]ingle-payer folks … might ask: “Wouldn’t we have a better system if we had a single payer? Why didn’t HCAN [Health Care for America Now] and its friends push for that?”

Richard Kirsch [chief executive of HCAN]: What’s the expression: “If wishes were horses, beggars would ride?”

Yes — if we could wave a magic wand and design a rational health-care system that would control costs while providing much better access, we wouldn’t design our current one. The ACA was the best that we could get through the American political system. The fact that we failed in every previous instance in the past 100 years reflects the reality that there hadn’t been a reform designed to deal with the realities of American politics….

http://www.washingtonpost.com/blogs/wonkblog/wp/2014/01/05/the-group-tha…

****

Implementing health reform: Four years later

By Timothy Jost
Health Affairs, January 2014

How did things go so wrong [for the Affordable Care Act]? Why is there so much bad news?….

More devastating for the future of the ACA, however, were the 2010 midterm elections. Republicans picked up sixty-three seats in the House, swinging control of the chamber from the Democrats to the Republicans. Before the 2010 elections, Democrats controlled fifty-two state legislative houses and the Republicans thirty-three; after the elections, Republicans controlled fifty-three and the Democrats thirty-two. Before the 2010 election there were twenty-six Democratic and twenty-four Republican governors, and after there were twenty Democrat and twenty-nine Republican. Many saw the election as a referendum on the ACA.

http://content.healthaffairs.org/content/33/1/7.full

By Kip Sullivan, J.D.

Was the Affordable Care Act politically feasible? Was it “the best” America could do in 2009 and 2010? Was single-payer legislation more or less feasible than the ACA? It is still too early to pronounce on the fate of the ACA, but it is not too early to discuss the political feasibility question. We have much to learn from looking back at the muffled debate about that issue among universal coverage advocates prior to the enactment of the ACA.

Since the modern American single-payer movement was formed in the late 1980s, many supporters of universal coverage have claimed that single-payer is not politically feasible. Those who made this argument (Bernstein and Marmor refer to them as “political yes buts” http://healthaffairs.org/blog/2008/08/28/medicare-for-all-why-we-should-…) never explained why multiple-payer “solutions” would be more feasible than single-payer. In the worldview of the “yes buts,” only single-payer proponents had to answer that question. If, on any given day, single-payer proponents could not point to 60 votes in the US senate or majority votes in the US House or in state legislative chambers, the conversation was over: Single-payer was not politically feasible and had to be taken off the table to make room for more “realistic” legislation.

This simple counting-noses definition of “political feasibility” avoided two issues that many observers inside and outside the single-payer movement consider paramount: Any legislation that proposes to achieve universal coverage, or even to cut the uninsured rate substantially, is not politically feasible, or at minimum is no more feasible than single-payer legislation, if

(1) it doesn’t simultaneously reduce health care spending or
(2) is so complex it cannot be implemented within a reasonable period of time.

This definition of feasibility asks not merely whether a given legislative body can be pushed into enacting a given bill. This definition asks as well, once the bill is enacted, is it politically sustainable? By this more realistic definition of political feasibility, a bill might have enough votes to pass a given legislative body, but if the bill can’t contain costs or can’t be implemented within a reasonable period of time, it shouldn’t be assumed to be politically sustainable and therefore should not be assumed to be more politically feasible than other approaches.

Sustainability depends ultimately on how the public perceives legislation after it is enacted. If the public punishes lawmakers who voted for the putative “universal coverage” legislation and rewards legislators who are hostile to government doing anything to help the uninsured and to lower health care costs, the legislation may die on the vine or be repealed.

One would think that this definition of political feasibility would have appealed naturally to the Democrats and their supporters who pushed the ACA because it asks them to take into account the impact of the ACA on voters’ perceptions of Democrats. In other words, it asks Democrats to consult their own self-interest in the course of picking a solution to a problem. It is a noble thing to suffer retribution at the polls for a bill that does good things for people when you know it’s going to work. But it is foolish to suffer retribution for a bill you suspect, or should suspect, will fail, or at minimum, will perform far below the expectations your rhetoric about the bill has created.

When in June 2009, congressional Democrats unveiled the health care “reform” bills that would become the ACA, I and many others were filled with apprehension. Our concern was not that some version of these bills might not pass. To the contrary, our concern was that it might pass (and thereby demonstrate it was “politically feasible” in the narrow sense of the phrase) but not be politically sustainable. In a June 2009 comment on this blog entitled, “Democrats’ hype about health care reform will hurt them,” I said:

“President Obama and Democratic congressional leaders are playing a dangerous game with health care reform. They are raising the public’s expectations sky high before figuring out how to meet those expectations. They are promising to give us the moon – significant cuts in health care costs and universal coverage or something close to it – but even at this late hour they have failed to publish anything resembling a detailed plan to do that. And the hints they have given us about the ‘reforms’ they are likely to endorse indicate they haven’t got a clue how to cut costs.”
https://pnhp.org/blog/2009/06/04/democrats%E2%80%99-hype-about-health-car….

I wanted a real debate about the political feasibility of the Democrats’ multiple-payer solution versus our single-payer proposal, and I thought the most effective way to make my argument was to appeal to Democrats’ self-interest, not just their altruism. Although I doubted the altruism of some members of Congress, I didn’t doubt the altruism of the vast majority of ACA supporters — I knew their desire to minimize the suffering inflicted on this country by our health care system was real. What I questioned was their understanding of how expensive and complex the ACA was going to be. If they didn’t understand that, how could they grasp what a political liability the ACA would be for Democrats? How could they intelligently evaluate the risk that future Congresses might not have enough Democrats in them to protect the ACA from underfunding or outright repeal?

But the debate about political feasibility that I and many others hoped for never came to pass. The single-payer and multiple-payer wings of the American universal coverage movement never discussed whether the ACA would be more feasible — that is, be more likely to pass AND be more sustainable — than a single-payer. We never debated whether the simplicity and efficiency of a single-payer made it more feasible, or at least no less feasible, than the costly and insanely complicated ACA. ACA proponents simply pronounced single-payer “off the table” on the ground that powerful opponents would have made a majority vote in Congress impossible. And that was that.

Four years have now passed since the enactment of the ACA. The sky is clotted with chickens coming home to roost. Evidence that the ACA was never as sustainable as its proponents implied is all around us. This evidence includes evidence of the damage the ACA has inflicted on Democrats. Timothy Jost’s article in the January 2014 Health Affairs contains an excellent summary of the unhappy history of the ACA. One of the most important paragraphs in his paper is the one quoted above in which he notes the damage Democrats suffered during the 2010 elections and that many believe this damage was due in part to the enactment of the ACA in March of 2010. Jost also predicts more bad news for the ACA as a substantial portion of the people insured through exchanges discover their choice of provider has been restricted and their out-of-pocket payments are very high. We are going to see more heartwarming stories about sick people finally getting the medical care they deserve, thanks to the ACA, but it will not be enough to forestall more damage to Democrats (especially if Republicans manage to nominate candidates who can refrain from discussing “legitimate rape” and similar subjects).

None of us have a crystal ball. I don’t claim that if Democrats and groups supporting the ACA had used the opportunity presented to us in 2009-2010 to promote HR 676 instead of the ACA that HR 676 would have passed by March 2010 or even by now. I’m reasonably sure something good would have been enacted — for example, an expansion of traditional Medicare and Medicaid to more people (Bob Kuttner makes a similar argument here http://www.huffingtonpost.com/robert-kuttner/obamacare-republicans_b_429…).

I am, however, absolutely certain about one thing: The universal coverage movement in America would be in a much better position to bring the long fight for universal coverage to a successful conclusion than we are now. There are several reasons why I’m so sure about that.

First, whether we had won big or won some incremental improvements in 2010, the public would have been exposed to a debate about a real solution to the health care crisis as opposed to a debate about make-believe cost containment schemes such as exchanges, “accountable care organizations” and punishing hospitals for “excess” readmissions.

Second, the health insurance industry would be receiving less money from the taxpayer and would be, therefore, less powerful than they are now. The insurance industry has been driving away private-sector customers in droves over the last few decades. If public purchasers — state and federal governments — had long ago stopped throwing money at Aetna et al. with legislation like the ACA, schemes to overpay Medicare Advantage plans, and legislation privatizing state Medicaid programs, the industry would by now be a shadow of its former self and a much less potent opponent of universal coverage.

Third, the political environment for health care reform would be less toxic than it is today, not because conservatives wouldn’t be leveling the same extreme charges they level at all forms of health care reform no matter how innocuous, but because the public would be less vulnerable to extremism and ultimately less cynical about real reform.

ACA proponents may disagree with my assessment of where we might be today if they had joined ranks with the single-payer movement and had fought for HR 676. What they can’t deny is they refused to engage in a real debate about the political feasibility (narrowly defined) AND sustainability of the ACA versus single-payer. They might have learned something if they had.