By Louis Balizet, M.D.
Health Policy Solutions (Denver), Jan. 9, 2014

The Affordable Care Act, while providing some short-term benefits, is, on the whole, unworkable. Quite apart from website failures, its approach to health care is fundamentally flawed. It is exceedingly complex. It perpetuates and entrenches the inefficient insurance model of payment for health care. It does nothing to address the rapacious pricing of pharmaceuticals. It ignores hospitals’ “medical arms race,” in which they expand facilities and services based not on community need, but on potential for profit. It still burdens doctors and hospitals with multiple payers, abstruse coding and insecurity about payment for delivered services. It is subject to state-by-state sabotage. At its most optimistic projection it leaves at least 25 million people uncovered.

Despite three years of preparation, the Affordable Care Act (ACA) is beset by delays, multiple exemptions and computer failures. The Obama Administration celebrates the enrollment of 2.1 million persons in private insurance through the exchanges.

The Centers for Medicare and Medicaid Services, meanwhile, has been cagey about how many of these 2.1 million have actually established a contractual arrangement with an insurance company. This has led to speculation that the number is quite small.

As recently as two months ago, the digital conduit that connects exchanges to insurance companies was described as “under construction.” Repeatedly postponed deadlines have insurance companies scrambling to send bills, register payment and validate coverage. With opening day now behind us, it is likely that hundreds of thousands will find themselves stranded at second base – exchanges negotiated, but insurance not issued.

Many of those who have secured coverage will discover that it is very thin coverage indeed, especially those with bronze plans. These plans approximate “junk insurance”: prohibitively high deductibles and co-pays combined with shrinking provider lists. Insurance companies that have elected to participate in the exchanges may find themselves in actuarial hot water and will raise premiums, further trim provider lists or fold altogether (especially the newly-formed co-ops). This year and especially 2015, may make October through December 2013 look like halcyon days.

The multiple failures of the ACA should come as no surprise to anyone familiar with its sordid political history. Sen. Ted Kennedy’s untimely death deprived the U.S. Senate of a powerful member who was at once its chief expert on health care policy and a decades-long advocate for universal health care. Health care leadership defaulted to Montana Sen. Max Baucus, ill-suited by inclination and background to fashion true reform.

Barack Obama acted less like a president and more like a community organizer as he failed to propose a coherent plan of his own. Into this policy breach stepped special interests, most prominently insurers and Big Pharma; any pretense of universal coverage and bona fide cost controls soon disappeared. What emerged was the euphemistically entitled the Patient Protection and Affordable Care Act, a Rube Goldberg contraption that befuddles experts to this day while richly rewarding those who got in on the ground floor.

What are the alternatives if the ACA craters? This is not a hard question to answer; examples of much better systems abound.

Virtually all other developed nations provide universal health care at two-thirds or less than our cost, with equal or better outcomes. The U.S. spends 17.7 percent of its GDP on health care, and its residents experience a life expectancy of 78.7 years. The corresponding values for France are 11.6 percent and 82.7 years, for Canada 11.2 percent and 81.0 years, and Australia 8.9 percent and 82.0 years.

What these and more than a dozen other countries with similar figures have in common is government-provided or facilitated universal health care, financed by a variety of taxes (income, payroll, sales) without reliance on American-style insurance companies. America should learn from these countries, not ignore or deride them.

The only way out of our currently costly and shameful health care quagmire is single-payer, tax-supported, improved Medicare for all. Medicare is a tax supported single-payer plan that has provided access to health care to tens of millions of Americans over 65 or with disabilities, with 3 percent overhead for close to 50 years. It would need to be altered, however, before universal application. Right now it is partially privatized, with Part B supplements, Part D drug coverage and Medicare Advantage. Involvement of private insurance companies makes it unnecessarily complex and unacceptably expensive. These concessions to private industry have to be eliminated and benefits expanded to include more complete outpatient care and drug coverage.

The statutory prohibition of system-wide government drug purchasing, embedded in George W. Bush’s Part D legislation, would have to be repealed. Medicare must be empowered to pay hospitals by an annual global budgeting process rather than the complex, costly piecemeal process currently in place. Doctors would have to be fairly compensated and not threatened annually with draconian cuts in income. For all the alterations that would be necessary, Medicare is still a far superior foundation on which to build a universal health care system, compared to the cacophony of hundreds of insurance companies we now contend with.

The flagrant failures of Obamacare, past and yet to come, would seem to argue against trusting the federal government to run a project with the scope of Medicare-based universal health care.

What is indisputable is that neither our government nor any other should attempt to implement a fatally flawed project. The U.S. military provides valuable lessons in this regard. When given an achievable goal and a sound strategy, it produces remarkable results (World Wars I and II). On the other hand, when it is asked to execute a flawed policy, disaster ensues (Vietnam, Iraq, Afghanistan).

No one can discredit the U.S. military on the basis of these failures; rather, blame is rightfully placed on the elected officials who asked the military to attempt the impossible. Likewise, our government should be reasonably expected to achieve what other governments have shown to be achievable – universal health care without breaking the bank. Obamacare’s failings should not blind us to this realization. In fact, there is no option other than improved Medicare for all. It is that, or fiscal and moral Armageddon.

Louis Balizet, M.D., is a recently retired oncologist from Pueblo. He’s a member of the advocacy group, Physicians for a National Health Program, and a leader of Health Care for All Colorado.

http://www.healthpolicysolutions.org/2014/01/09/opinion-the-only-way-out/

By Jessica Schorr Saxe, M.D.
The Charlotte (N.C.) Observer, Jan. 17, 2014

Are we a nation of people waiting to have medical insurance so that we can spend our time seeking unnecessary medical care? Really?

The true problem is that many of us don’t get needed care.

Yet the myth of overuse reverberates throughout health care discussions. The myth is applied across socioeconomic classes – though differently. For the poor, it is argued that Medicaid will lead to unnecessary utilization and increased cost. For the privately insured, the myth suggests that people need high deductible health plans (HDHPs) to deter them from using medical care frivolously.

A recent study showed increased emergency department (ED) use for non-urgent conditions in Oregon patients who had recently gotten Medicaid through a lottery. It looked at short-term results of a largely white urban population. Much discussed in the media, it has been used as a warning against Medicaid expansion. It was not suggested that the care was unnecessary – just that much of it could have been provided in an outpatient setting.

Not as publicized was the recent national study of thousands of patients, examining their ED use by health insurance type. It found that Medicaid and privately insured patients used EDs similarly for acute problems, but Medicaid patients were more likely to use the ED for less serious conditions because they lacked other sources of health care. One might infer that the solution is to ensure that Medicaid patients have access to primary care, which is better and more cost-effective for non-urgent conditions.

For the privately insured, it is argued that, with HDHPs, consumers will be more conscious of their expenditures, use less care, and thus save money – largely for employers and insurers. If people have lower premiums and aren’t sick, they may also save money. But those who actually need health care may find themselves with large out-of-pocket expenses. According to the nonpartisan Kaiser Family Foundation, about one third of non-elderly adults had difficulty paying medical bills in 2012. Of people with medical debt, 70 percent are insured, mostly with employer-sponsored insurance – and more likely to have HDHPs.

And what about health, which health insurance is supposed to promote? The nonpartisan Robert Wood Johnson Foundation notes that cost-sharing (deductibles, co-pays and co-insurance) indeed cuts down on use of services, but that patients are as likely to forgo necessary as unnecessary care. Increases in cost-sharing have the worst impact on vulnerable populations, such as the poor, elderly and chronically ill.

Why isn’t anyone talking about the real American epidemic: the underuse of necessary care? A 2012 survey showed that 58 percent of Americans deferred medical care due to cost.

As a family physician, I live with this reality. I think of a patient who had rectal bleeding and one with life-threatening high blood pressure, who avoided the ED because of expense. I see patients who “stretch” their medications to make them last or miss needed visits for lack of co-pays.

Here’s another clue to possible underuse. Though we spend more per person than other countries, we actually use less health care. For example, Americans average 4 doctor visits a year compared to 7 in France and Canada, countries with better health outcomes than ours.

Whether others have health care matters to all of us. We all benefit when our colleagues aren’t working with chronic untreated conditions and our food servers don’t have coughs they can’t afford to have evaluated.

While many of us might have a story about someone who goes to the doctor more than necessary, the evidence asserts that lack of care is a much bigger problem. Even when insured, Americans have better things to do than wait in doctor’s offices when they don’t need to. But many who need health care don’t get it.

We should expand Medicaid, increase availability of primary care, and give access to our disproportionately sick population. Then we should move beyond Obamacare to improved health care for everyone. Other industrialized countries provide access to all, with lower costs and better health outcomes. Like them, we should eliminate insurance companies and for-profit medicine and expand health care to all.

Dr. Jessica Schorr Saxe is a family physician in Charlotte and chair of Health Care Justice – NC.

www.charlotteobserver.com/2014/01/17/4620625/americans-under-use-health-care.html

By Bruce Japsen
Forbes, Jan. 18, 2014

As the Obama administration touts the need for uninsured Americans to sign up for private coverage via exchanges under the Affordable Care Act, the insurance industry sees growth in an expanded Medicaid program for the poor under the health law.

This week, the chief executive of the nation’s largest health insurance company and a new analysis indicate major growth ahead for health plans that have contracts with state Medicaid programs thanks in large part to President Obama’s signature legislative achievement.

As state budgets have been hurt by the stagnant economy, lawmakers have turned more patients eligible for Medicaid over to privately-contracted insurance companies. Now, the health law provides a cash infusion of more than $900 billion in federal dollars from 2014 to 2022 to expand Medicaid programs for states interested in the proposition.

“We expect to realize strong growth by serving in several ways: as established Medicaid programs grow through the ACA expansions; as eligible Medicaid prospects are identified through the federal and state exchange markets; and as the inevitable dual eligible …initiatives begin to form and are implemented,” UnitedHealth Group UNH -0.33% (UNH) chief executive officer Stephen J. Hemsley said on the company’s 2013 fourth-quarter and full-year earnings call earlier this week.

Enrollment in health plans that have contracts with Medicaid will rise by 20 percent this year and by nearly 40 percent from last year to 2016, according to a report this week from Avalere Health, a research and advisory services firm on health policy issues tracking the Affordable Care Act.

Other major players in the Medicaid managed care market include Aetna AET -0.1% (AET),  Centene (CNC), Humana HUM +0.43% (HUM), Wellpoint (WLP) and its Americagroup (AMG) as well as a host of Blue Cross and Blue Shield plans.

“The continuing shift toward Medicaid managed care presents a significant growth opportunity for health plans that specialize in managing these low-income populations,” said Avalere executive vice president Matt Eyles said in a statement accompanying the analysis. “Plans that currently operate in Medicaid could see significant membership growth, and those outside of the Medicaid market until now could gain market share by moving into this space.”

This Medicaid funding under the Affordable Care Act is unlike past efforts to expand Medicaid in that the federal government will pick up the full tab for the first three years. The state gradually has to pick up some costs in 2017 but by 2020 the federal government is still picking up 90 percent or more of the Medicaid tab.

It’s a much better funding proposition than the existing Medicaid program that essentially shares the cost between the states and the federal government. The federal government traditionally picks up a little more than half of the cost of Medicaid.

Avalere said 38 states and Washington, D.C. contract with private managed care plans “to provide care to some or all of their Medicaid beneficiaries.”

http://www.forbes.com/sites/brucejapsen/2014/01/18/health-insurance-companies-see-obamacare-medicaid-boon/

By George Erickson
Duluth (Minn.) News Tribune, Jan. 17, 2014

U.S. Sen. Paul Wellstone, known as the “conscience of the Senate,” wrote that he spent 85 percent of his time fighting Republican attacks on working families. Were he still alive, Wellstone would be fighting for the thousands who die or are driven into bankruptcy every year because they lack health coverage. He’d be fighting insurance companies that sponsor deceitful ads like the Harry-and-Louise videos of the ’90s that torpedoed President Bill Clinton’s health program. And he’d be thrilled that the Affordable Care Act includes a provision that allows states to create a single-payer system.

Why are so many afraid of a single-payer program that would save them money and provide better care? Why do they cling to a for-profit system that leaves 47 million Americans with no insurance and millions more with substandard coverage that lets insurance companies choose which procedures to allow and which to deny?

Here’s why: Health is a lucrative business. Medicare, a single-payer system that lets you choose your doctor, has low overhead costs of about 3 percent. In comparison, our much-vaunted private system admits to spending an average of 20 percent of your premium dollar on what it chooses to call “operating costs.”

Those who run Medicare receive modest salaries; but in 2002, Norman Payson, the CEO of Oxford Health Plans, took home $76 million; Leonard Schaeffer, the CEO of WellPoint, received $21 million; and D. Mark Weinberg of WellPoint was forced to make do with a mere $14 million. That’s per year!

They don’t seem to care that the U.S. ranks 33rd in health care. They don’t seem to care we have a higher infant mortality rate than single-payer countries like Canada, the United Kingdom, Germany, Japan and Sweden.

In contrast to our for-profit system, where insurance company employees are rewarded for finding loopholes that permit the denial of coverage, single-payer systems exist to deliver health care, not deny it.

Instead we are burdened with a system that works well for members of Congress and those who can afford deluxe coverage. For most of us, such coverage is just a dream, however. Sixty percent of all personal bankruptcy filings involve unaffordable health care costs.

And what about big pharma? In single-payer countries, identical medications cost half as much as here. Could our drug costs be high because there is no competition? Could it be because drug companies spend millions on ads to persuade us to get our doctors to prescribe this drug or that? In just the second quarter of 2009, the medical-services industries spent more than $133 million on lobbying. That’s in just three months, or about $250,000 per legislator.

How can we believe conservative lies about Canadian care after learning that Canadians, when asked to name the greatest Canadian, gave that honor not to Alexander Mackenzie (Canada’s Lewis and Clark) or to one of their national leaders, but to Tommy Douglas, the father of the Canadian health care system?

Why should we trust Republicans who claim to support improving the current system? These are the people who opposed Social Security, minimum wages, unions, women’s rights and bank regulation. Why should we trust the Republicans who tried to kill the Senate health bill with more than 360 amendments?

Finally, why aren’t we rushing to establish a system that has proven efficient, effective and even-handed in countries with single-payer plans that broaden coverage while lowering costs?

Well, now we can — and Vermont is leading the way by using authority granted under the Affordable Care Act to start a single-payer system. As Vermont’s Sen. Bernie Sanders wrote, “The quickest route to a national health care program will be when individual states … demonstrate that universal and nonprofit health care works, and that it is the cost-effective and moral thing to do.”

The rich don’t care, and neither do many of our legislators. Call and email them in support of the Affordable Care Act’s single-payer option. Watch how they vote — and remember it at the next election. That’s what Sen. Wellstone would want you to do.

George Erickson of Eveleth is a member of the Cambridge, Mass.-based Union of Concerned Scientists and of the Thorium Energy Alliance. He’s also a past vice president of the American Humanist Association and the author of four books.

http://www.duluthnewstribune.com/event/article/id/288815/

By Philip Caper, M.D.
Bangor (Maine) Daily News, Jan. 17, 2014

Love it or hate it, even if ObamaCare never fully achieves its intended benefits, it has already had some unintended ones.

First, it has destabilized our deeply dysfunctional health-care system. By doing so, the law has created a real opportunity to fundamentally restructure the way we finance and deliver health care.

Second, the troubled rollout of the Affordable Care Act has shined a spotlight on how unnecessarily complicated our fragmented health insurance system is, and how great is the need to fundamentally reform it. That in turn has reignited public interest in further reform, and strengthened a growing popular movement.

For example, this past October well over 100 people turned out in Portland on the second night of the World Series to view a movie and discussion about health care reform. Here in the heart of Red Sox Nation, that is notable.

Last week, Maine’s legislature held a hearing on LD 1345, a bill that would create a path to a state-level single-payer system for Maine. Such proposals have been around for years, met with tepid interest from the public and vigorous opposition from insurance companies and other corporate interests.

This time it was different. The hearing room was packed to overflowing with enthusiastic supporters. Forty-five members of the public took the day off and traveled to Augusta to testify in person. Another 15 to 20 submitted written testimony. Of those, 57 testified in favor of the proposed legislation, two against and one undecided. Only representatives of the health insurance industry openly opposed the bill.

The media frenzy surrounding the troubled rollout of the ACA since early October has provided commentators (including myself) many opportunities to point out publicly that although the functionality of the ACA’s websites fell short in many states, the underlying problem is not bad software. It is the expensive complexity baked into the law. That level of complexity can only be justified by politics — the perceived need to preserve a central role for private health insurance companies, despite their widespread unpopularity, as a means of financing health care.

A simple expansion of Medicare, at the federal or state level, would eliminate 95 percent of that complexity, and with it much of the public confusion and distrust surrounding health-care reform. Largely because of its requirement that people, including large employers, buy private health insurance, the ACA has forced large numbers of people who, to date, have had little reason to care about health-care reform to pay attention.

The level of public apathy in Maine about the pathology in our health care system has been significantly reduced. That has created new opportunities for public education.

For example, one of the health insurance lobbyists testifying at last week’s hearing complained that the proposed legislation would provide “free health care” to lawyer-lobbyists, such as himself. He thought that was unfair. I agree: I’d be the last one in the state to want to give free health care to health insurance lawyer-lobbyists. He’d have to pay taxes into the same fund as all the rest of us to assure that everyone gets the same high-quality standard of care.

Physician Philip Caper of Brooklin is a founding board member of Maine AllCare, a nonpartisan, nonprofit group committed to making health care in Maine universal, accessible and affordable for all. He can be reached at pcpcaper21@gmail.com.

http://bangordailynews.com/2014/01/16/health/love-it-or-hate-it-obamacares-spurring-interest-in-the-pathology-of-health-care/print/

By Deanna Pogorelc
MedCity News (Cleveland, Ohio), Jan. 17, 2014

The latest outcry for a single-payer healthcare system comes from a duo of prominent cancer doctors who call on their fellow oncologists to support what they call “an improved Medicare for all” resembling Canada’s healthcare system.

In an article scheduled to be published today in the Journal of Oncology Practice, Drs. Ray Drasga and Lawrence Einhorn remark that, as cancer doctors, they’re challenged by trying to advise the best treatments that a patient can afford. Because underinsurance is becoming the “new normal,” they say, cancer treatment may need to be compromised. And because every insurance plan is different, it’s hard for providers to know whether certain treatments will be covered.

Einhorn is a professor of medicine at Indiana University School of Medicine, a past president of the American Society of Clinical Oncology and the doctor who led treatment of Lance Armstrong. Drasga spearheaded efforts to start a free clinic in Crown Point, Ind.

They proposition that a single-payer system would remove some of the financial barriers to cancer care, make reimbursement simpler and cut down on the burdensome administrative overhead of private insurance companies.

They lay out their case:

    “(The single-payer system) would provide universal, comprehensive coverage with free choice of providers. All medical care would be covered, including provider visits, hospital care, prescription drugs and rehabilitation. Copayments, deductibles, insurance premiums and out-of-pocket expenses would be eliminated.”

A public agency would manage a single insurance plan for each region of the country that would be financed by payroll and income taxes.

    “The public agency would manage the plan and the health care budget in a transparent way. The allocation of available health resources (ie, rationing) would be guided by medical considerations, not on the basis of meeting corporate requirements for a return on investment or on the basis of a patient’s ability to pay.”

Doesn’t that all sound too good to be true? “We think not,” they write. “Because a single-payer system is a sensible and realistic solution, we believe its achievement is possible with sufficient understanding among the public and their elected representatives.”

It would be a challenging transition, they admit. But state-by-state implementation would lessen the administrative burdens, and ultimately such a plan could save up to $380 billion annually, they write.

Lance Armstrong’s doctor calls for single-payer system

By Froma Harrop
The Spokesman-Review (Spokane, Wash.), Jan. 18, 2014

In the beginning, Massachusetts opened the gates to same-sex marriage and universal health coverage. California started to liberalize drug laws by legalizing medical marijuana. The sky didn’t fall on any of these efforts, initially regarded as dangerous social experiments by many conservatives.

Now red states such as Kentucky are launching state-run health insurance exchanges. Federal judges in conservative Utah and Oklahoma are calling bans on gay marriage unconstitutional. And purple Colorado has legalized recreational marijuana use.

Most of us have a vision of the way things ought to be. It is human nature to want others to see the same light we do.

Conservative foes of abortion hold deep convictions that ending a pregnancy is a moral travesty. Liberals make similar arguments against a health care system that lets thousands of Americans die for lack of medical attention, which happens when market forces run the show.

Social activists who live and breathe their cause often seek to impose their views on a diverse nation. They don’t realize that they can more easily get what they want in states whose culture shares their views. Showing that a state has enacted their ideas with good effect is the most expedient way of spreading their ideas coast to coast.

But putting such power in state hands doesn’t always sit well. Liberals, especially, point to slavery and Jim Crow laws as great evils that flew under the banner of states’ rights. These were moral outrages that the federal government had to stop, and did.

True, but many less momentous struggles can be more peaceably and efficiently won through example. As the late U.S. Supreme Court Justice Louis Brandeis famously said, states can serve as the “laboratories of democracy.”

Many liberals are enthusing over a bill introduced last month by Sen. Bernie Sanders, a liberal Vermont independent, and Rep. Jim McDermott, a Washington state Democrat, which would create a national single-payer health care system.

I happen to think the Sanders-McDermott proposal – actually a modified single-payer plan allowing private supplemental coverage – is splendid. But it also has zero chance of passage. Recall how even the modest “public option” – a government plan to compete with the private insurers – couldn’t get past Congress, including some Democratic members.

The best hope for national single-payer is to let Vermont show that its homegrown version will work. If Vermont can cut its health care spending by over 30 percent under single-payer, as is projected, other states will copy it, with no pressure needed from Washington.

Gay activists regard laws banning same-sex marriage as a great injustice, and with reason. But simply waiting for a Supreme Court decision making same-sex marriage legal nationwide, no certainty, would have been a massive waste of time. Marriage is a state responsibility, so what better place to change the laws than in states open to it?

New Mexico’s Supreme Court just ruled that the ban on gay marriage was unconstitutional. In Virginia, another purple state, the Democratic leaders are going full speed ahead. They are bolstered by polls showing that 56 percent of Virginians are in favor of same-sex marriage, a reversal from the 57 percent supporting a ban in 2006. This tide of change would not have rolled in had liberal states not demonstrated what happens to the broader society when gay couples marry: very little.

Some states will do things noxious to liberals, for example, on gun control and public financing for education. Conservatives will dislike decisions made in liberal places. Fine. Let’s all make a pact to stop trying to make everyone else over in our own image.

Nothing convinces like successful examples. Liberals, above all, should have more confidence in their own.

Froma Harrop is a columnist for Creators Syndicate.

http://www.spokesman.com/stories/2014/jan/18/froma-harrop-states-are-still-good-laboratories/