PNHP

Minority physicians care for a majority of underserved patients in the U.S.

Minority physicians care for a majority of underserved patients in the U.S.

Minority physicians also play a large role in the care of patients with poorer health, according to a new study in JAMA Internal Medicine

FOR IMMEDIATE RELEASE, December 30, 2013
Contact: Mark Almberg, PNHP communications director; (312) 782-6006; mark@pnhp.org

CAMBRIDGE, Mass. – Black, Hispanic and Asian physicians play an outsized role in the care of disadvantaged patients nationally. Patients who have low incomes, are from racial and ethnic minority backgrounds, have Medicaid insurance, or who do not speak English – groups that historically have difficulty in accessing medical care – are substantially more likely to receive their care from a minority physician, according to a new study appearing online in today’s [Dec. 30] issue of the journal JAMA Internal Medicine. The study found that minority physicians care for 54 percent of minority patients and 70 percent of non-English-speaking patients. Other related findings include: * Asian, Hispanic and Black patients were 19-26 times more likely to be cared for by a minority physician of their same race. * Low-income patients were 1 1/2 to 2 times more likely to be cared for by Black, Hispanic and Asian physicians. * Medicaid patients were 2 times to nearly 4 times more likely to be cared for by Black, Hispanic and Asian physicians. Currently, African-Americans and Hispanics are substantially underrepresented in the physician workforce. Despite making up over 25 percent of the U.S. population, African-Americans and Hispanics make up less than 15 percent of the physicians. “Patients from disadvantaged groups have substantial problems accessing care,” said the lead author, Dr. Lyndonna Marrast, a physician at Cambridge Health Alliance. “The fact that minority physicians are much more likely to care for disadvantaged patients suggests that expanding the racial diversity of the physician workforce in the U.S. could be key to improving access to care.” The study, which analyzed data from a 2010 federal survey of 7,070 patients across the U.S., also showed that minority physicians were substantially more likely to care for patients with worse self-reported health status. For other measures of health, such as obesity, the picture was mixed: Black physicians were more likely, and Hispanic and Asian physicians less likely, to care for obese patients. The Patient Protection and Affordable Care Act, which is being rolled out currently in every state, is expected to expand insurance coverage for low-income, uninsured patients, many of whom will also be minorities. “There is a lot of concern that there will not be enough physicians willing and able to care for them,” said Dr. Danny McCormick, the study’s senior author and associate professor of medicine at Harvard Medical School. “In order to increase the number of Black and Hispanic physicians, medical schools will need to more fully consider the physician workforce needs of the health care system as a whole in admissions decisions.” “Our findings do not argue for strengthening the existing de facto segregation of medical care,” said Dr. Steffie Woolhandler, professor of public health at City University of New York, co-founder of Physicians for a National Health Program, and a study co-author. “But it is clear that doctors’ decisions on where to practice and patients’ decisions on where to go for care combine to create an outsized role for minority physicians in caring for the underserved.” ***** “Minority Physicians’ Role in the Care of Underserved Patients: Diversifying the Physician Workforce May Be Key in Addressing Health Disparities.” Lyndonna Marrast, M.D., Leah Zallman, M.D., M.P.H., Steffie Woolhandler M.D., M.P.H., David Bor, M.D., M.P.H., and Danny McCormick, M.D., M.P.H.  JAMA Internal Medicine, December 30, 2013. ***** Physicians for a National Health Program is a nonprofit research and education organization of more than 18,000 doctors who support single-payer national health insurance. PNHP had no role in funding or otherwise supporting the study described above.

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Mayo Clinic’s Eric Matteson endorses tax-supported universal healthcare

10 Questions: Eric Matteson, MD

By Nancy Walsh
MedPage Today, December 27, 2013 Eric L. Matteson, MD, of the Mayo Clinic, is the chair of rheumatology and professor of medicine.

1. What’s the biggest barrier to your practicing medicine today? Without a doubt, it is lack of access for many patients, especially the un- and underinsured.

2. What is your most vivid memory involving a patient who could not afford to pay for healthcare (or meds, tests, etc.) and how did you respond? I have a young woman with severe erosive RA who has limited mental ability who works 20 hours a week in a rural recycling center at a minimum wage job sorting recyclables. I see her in another state at a small clinic that’s 80 miles away. She has only Medicaid. She is able to afford methotrexate and hydroxychloroquine. We accept losses with the cost of monitoring, and also for the orthopedic surgeries she has required and she cannot afford. I have sought drug and assistance from every company with biologics on the market, some on more than one occasion, and to date have been turned down by all of them. She is not able to even afford gas, or the time off, to come to our center to participate in drug studies.

4. If you could change or eliminate something about the healthcare system, what would it be? I would have a tax-supported universal healthcare for at least minimum services. http://www.medpagetoday.com/Rheumatology/Arthritis/43597

Comment

By Don McCanne, M.D. Mayo Clinic’s Eric Matteson is yet another prominent physician who supports “tax-supported universal healthcare,” though he qualifies that with “for at least minimum services.” From his example, it seems that he would include most of his field of rheumatology as “minimal services,” though others might say “all essential services.” Nevertheless, there continues to be an increase in those who now are willing to speak out on the need for a publicly-financed health care system that covers everyone. There is a growing consensus that financial barriers to care need to be removed.

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Definitely not singing the praises of Anthem

By James Fieseher, M.D.
Portsmouth (N.H.) Herald, Dec. 26, 2013 Anthem: (n.) a song or hymn of praise or gladness. Anthem is also the name of the premiere health insurer in New Hampshire. There are many people in New Hampshire who believe Anthem is the model of health care. They believe that Anthem, and private health insurance companies like Anthem, rather than the government, should be in charge of your health care. Do they have a point? The Affordable Care Act (ACA) has had an inauspicious roll out, including President Obama’s “lie of the year” stating: “if you like your health insurance, you can keep it.” We have been told that we can’t trust our own government. Indeed, the two parties in Congress trust each other so little that they can’t make even the smallest of compromises. Should we turn the clock back and go back to the days of unrestricted private health care coverage? Do we really want the system that we had just five years ago? During President Bush’s administration in 2008, before the ACA was even a gleam in candidate Obama’s eye, Angela Braly, the CEO of Anthem’s parent company, Wellpoint, voted herself a 51 percent pay raise. Being a responsible businesswoman and knowing how to properly balance a budget, she then promptly raised insurance premiums 39 percent to pay for her raise. What does the CEO of a health insurance company do to merit a 51 percent pay raise — during the biggest recession since the Great Depression of the 1930s? Anthem made health care less affordable and less accessible for individuals and businesses struggling during the recession. Anthem did not improve health care. In fact, Anthem didn’t even provide health care. People who have Anthem health insurance are among the healthiest and wealthiest Americans; after all, you can’t get health insurance if you can’t afford it or have a pre-existing condition. She “merited” a pay raise because Anthem made a profit during the recession by collecting more money from its customers than it paid out in benefits. That represents the successful model of health care touted by the private insurance advocates. Anthem and all health insurance companies do not actually provide or even insure health. They cover medications for hypertension and diabetes, but don’t provide for counseling or the dietary factors that prevent or cure obesity, hypertension and diabetes. Exercise, a clean environment, proper dental care and mental health screening and counseling are all essentials for health management that are not covered by private health insurance companies. They manage disease, not health. Shouldn’t we have a health care system that rewards leaders who actually improve health care? Don’t we want a health care system that prevents high blood pressure, diabetes, strokes, cancer and cardiac disease? We should give raises to the health care insurers who make care more accessible and more affordable. Certainly, we should blame our politicians for focusing on all the wrong aspects of health care. We have a president who states he wants to improve health care and then promises people they can keep their faulty health care plans. We have Republicans who want to repeal the ACA and replace it with smaller, more expensive coverage dominated by businesses like Anthem. We have Democrats who cobbled a weak health care plan together and then weakened it further during implementation. But in truth, the fault lies with us, the voters. We’re fanatic about not raising taxes to pay for improved health care, but say nothing when a business “taxes” us with a 39 percent increase in premiums and then decreases coverage. We dismiss a “government option” where we actually have a say in policy and are silent when a private entity that we can’t control dictates our health care. If government is not the answer, what is? We need a national discussion about health care. Heck, I’ll even take a state or local discussion. We need to look beyond the ACA at what really matters in health care. It’s time to make a list of those qualities that improve health, improve accessibility and lower the cost of care. We need to be honest with ourselves and our neighbors and keep all our options on the table. Then, we need the courage to change the status quo to make it work. Now that deserves an anthem.

James Fieseher, MD, FAAFP, is a Portsmouth resident. http://www.seacoastonline.com/articles/20131226-OPINION-312260368

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Health care costs are the key to deficit reduction

By Thomas Clairmont, M.D.
Portsmouth (N.H.) Herald, Letters, Dec. 27, 2013 Sen. Susan Collins’ editorial, “Bipartisan budget moves economy forward,” (Portsmouth Herald, Dec. 22) states that this accord will save $23 billion over the next decade. She is so impressed by this figure that she mentions it twice. During this period, our government will spend over $45 trillion. This “savings” is the proverbial drop in the bucket. Right now, our national debt is increasing at a whopping $2.64 billion every day, $2 million every second. Her “savings” will be gone in nine days. At the end of this 10-year period, the national debt will be $23.5 trillion. We will be hearing that we shouldn’t be spending money we don’t have, that this debt is unsustainable, and about how the debt we are leaving our children and grandchildren is shameful. Once the election is over, the spending will continue on to infinity. Meanwhile, a serious proposal by economics professor Gerald Friedman of the University of Massachusetts Amherst gets no press at all. He said, “Under the single-payer system created by HR 676, the U.S. could save an estimated $592 billion annually by slashing the administrative waste associated with the private insurance industry ($476 billion) and reducing pharmaceutical prices to European levels ($116 billion). In 2014, the savings would be enough to cover all 44 million uninsured and upgrade benefits for everyone else. No other plan can achieve this magnitude of savings on health care.” This proposal “would cost less for 95 percent of households and reduce the deficit by $154 billion in the first year,” according to Friedman. Republicans have a deficit of ideas on health care reform that actually help people. Here is a thoughtful opportunity for Sen. Collins. Dr. Thomas Clairmont resides in Portsmouth. http://www.seacoastonline.com/articles/20131227-OPINION-312270364

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Some conservatives are coming around to single-payer health coverage

By William R. Davidson Jr., M.D.
The Patriot-News (Mechanicsburg, Pa.), Letters, Dec. 23, 2013 Advocates for single-payer health care reform (also known as “Medicare-for-all”) have persistently requested support from conservatives. After all, freedom to choose doctors and hospitals, as well as enormous economic savings, are consistent with conservative values. Nevertheless, conservatives have largely distanced themselves from single-payer movements. That might be changing. Former Secretary of State Colin Powell recently expressed his desire to see America adopt a single-payer system. Powell’s comments were similar to the sentiments heard only a few days earlier by Dr. Steven Nissen, the head of the department of cardiology at the world renowned Cleveland Clinic. When asked in an interview “What was the biggest barrier to his practice of medicine?”  Dr. Nissen stated quite succinctly: “The lack of a single payer system. We waste enormous amounts of time and energy dealing with insurance companies, whose major goal is figuring out how not to cover patients.” Powell made his comments at a meeting for survivors of prostate cancer. His own experience, as well as that of a close relative and friend, has made him acutely aware of the disparities inherent in our health care system that annually allows 50 million Americans to be uninsured, causes a half million medical bankruptcies, and tolerates spiraling, unsustainable costs. A world traveler, Powell believes all Americans should have a quality, affordable health care system “like those in Europe and Canada.” As a physician, Dr. Nissen has seen how the free market system based on the private insurance paradigm has led to incredible waste, to the point that one out of every three dollars spent on health care goes to administer it. His time and energy which should be spent on patient care and research is wasted wading through a morass of bureaucracy created by the insurance industry. Neither gentleman directly criticizes Obamacare but, by stating they prefer single payer they are pointing out that the Affordable Care Act just won’t get it done. Obamacare enlarges and enhances the influence of the private insurance industry, which has failed us for over 30 years. For many, single payer is the way. Dr. William R. Davidson Jr. resides in Jonestown. http://www.pennlive.com/opinion/index.ssf/2013/12/some_conservatives_are_coming_around_to_single_payer_health_coverage.html

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Americans are paying for health care with more than money

By Philip Caper, M.D.
Bangor (Maine) Daily News, Dec. 19, 2013 Americans now spend close to $3 trillion a year for health care, around 18 percent of our GDP. That works out to almost $9,000 per person in Maine, almost twice as much per person as the average for other wealthy nations that provide health care for all their people. Not only do we pay more, but we pay in far more ways than any other country. Some are obvious. They include health insurance premiums, “out of pocket” co-pays and deductibles, and payments for health care products and services that are not covered by insurance. Out-of-pocket payments are increasing every year as insurers shift more of the rising costs to their customers and employers to their employees. We also pay in ways that are not so obvious. We all pay federal, state and local taxes to support programs such as Medicare and Medicaid, health care for federal, state and local employees, military personnel, the Veterans Affairs and many others. Since employment-related health insurance is tax exempt, we also pay around $250 billion a year in the form of lost tax revenues, that is then made up by higher taxes on all of us. Other ways we pay are almost invisible, but we feel them anyway. Workers no longer bargain for increased wages or better working conditions. In a weak economy, any small gains they have made in total compensation have been more than consumed by increases in health care costs. As a result, real wages are declining. At a recent national health care conference I attended, there was a panel discussion about the effects health care costs on a small central Maine town. Employee health care costs have risen dramatically over recent years. Benefits for the town’s 11 employees now total $18,000 each for a total of almost $200,000. This has forced severe cutbacks in other services such as road maintenance, public safety, libraries, education, and (ironically) emergency medical services. Diminished public services and a deteriorating quality of life is one more way we pay for our health care. This should come as no surprise. During the past sixty years or so Americans have generously poured money into our health care system through thousands of channels that are individually difficult and collectively impossible to control. Since Americans view health care as a business, we’ve allowed our health care system to become populated by thousands of profit seeking companies (some nominally nonprofit), each trying to maximize profits and competing for a larger share of an ever-growing pie. Many of these private businesses are heavily subsidized by tax-supported health care programs and tax breaks. So far, we have been unwilling to put any effective restraints around the growth of this huge pot of gold. This is not a failure of capitalism or corporations. They are simply doing what they are supposed to do — create wealth for their owners. It’s a massive failure of public policy. It’s the fault of all of us, including our political leaders, for failing to put any meaningful constraints around our health care system to keep it affordable for everybody. The result has been the creation of a gargantuan medical-industrial complex that has become the pac-man of public and private budgets. It is riddled with inefficiency and waste including unjustifiably high prices and excessive use of lucrative services and products, many of them without demonstrated value or downright harmful. The Affordable Care Act begins to make some timid efforts at addressing this problem. Nobody I know thinks they will be sufficient. After seven years of “RomneyCare” (after which the Affordable Care Act was patterned), Massachusetts now has almost everybody insured, but it has the highest health care costs of any state in the country. Some public figures there are beginning to suggest moving toward a statewide single-payer system. As I’ve written before, the market forces the ACA is trying to harness have not, will not and cannot solve this problem. As most other wealthy countries have done, we need to channel the many existing health care revenue streams together into a single funnel with a publicly managed flow-control valve, and then muster the political will to use it. That is what our neighbors in Vermont are now in the process of trying to do. As one Canadian conference participant put it, “It breaks my heart to see Americans destroying your schools, libraries and public safety to pay for health care.” It breaks my heart, too. We can do a lot better. 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/2013/12/19/health/americans-are-paying-for-health-care-with-more-than-money/

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'Sticker shock' over Obamacare bolsters single-payer argument

New reporting by AP underscores systemic problems with healthcare system based on for-profit insurance model

By Jon Queally
Common Dreams, Dec. 23, 2013 As the political uproar surrounding the Affordable Care Act has played out over recent months, one single fact remains: the private insurance model—on which the law widely known as Obamacare is based—is more complicated, more expensive, and provides less coverage than a simple, “everybody in/nobody out,” single-payer model that almost every other advanced country in the world enjoys. And even within the debate about whether or not Obamacare is a “step forward” or a “step back” for healthcare delivery in the U.S., what’s become increasingly clear—as was predicted by progressive critics of the Obamacare model—is that though portions of the law undoubtedly improve the kinds of coverage that some people receive, others are still excluded from the system entirely and among those who are now purchasing insurance for the first time in their lives many will face “sticker shock” at the high premiums or out-sized deductibles. As new reporting by The Associated Press highlights: “As a key enrollment deadline hits Monday, many people without health insurance have been sizing up policies on the new government health care marketplace and making what seems like a logical choice: They’re picking the cheapest one. “Increasingly, experts in health insurance are becoming concerned that many of these first-time buyers will be in for a shock when they get medical care next year and discover they’re on the hook for most of the initial cost. “The prospect of sticker shock after Jan. 1, when those who sign up for policies now can begin getting coverage, is seen as a looming problem for a new national system that has been plagued by trouble since the new marketplaces went online in the states in October.” What the AP goes on to describe is how the economic hardships that most middle- and low-income Americans experience on a daily basis compel them to choose insurance policies with the lowest monthly premium, but don’t realize that the huge deductibles attached to those plans mean that they may have huge medical bills to pay before their coverage kicks in. In addition, because the state-level exchanges from which participants in Obamacare must purchase their plans are so complicated, many consumers—especially those with little experience navigating the private insurance marketplace—won’t possess the technical or financial savvy to calculate the best plan for themselves or their family. “I am so deeply clueless about all of this,” said 29-year-old Adrienne Matzen, an actor in Chicago, told the AP. She’s been  mostly without insurance since she turned 21, but must now figure out how to receive coverage she can afford while living with two chronic illnesses and earning less than $20,000 a year. Someone like Matzen—who ultimately may or may not be individually better off under the ACA—exemplifies why the overall system is still so far from the ideal that progressive critics of Obamacare say is possible.  The choices available to her  depend on the state she lives in, her ability to navigate the choices, and a host of other complex factors. As the AP reports: “The complexities of insurance are eye-glazing even for those who have it. Only 14 percent of American adults with insurance understand deductibles, according to one recent study.” On the other hand, a single-payer or Medicare-For-All approach, according to its proponents, would cut out both the complexity and an enormous part of the expense that has historically plagued private insurance industry and will remain under Obamacare. This summer, Gerald Friedman, a professor of economics at the UMass Amherst, released a study showing that a single-payer system like the one described in Rep. John Conyers’ HR 676 could save as much as $592 billion a year in U.S. healthcare costs. According to his fiscal assessment, those savings would be more than enough to cover all 44 million people the government estimates will be uninsured in the coming year while also improving the existing coverage for everyone else. “Paradoxically, by expanding Medicare to everyone we’d end up saving billions of dollars annually,” Friedman said of his findings. “We’d be safeguarding Medicare’s fiscal integrity while enhancing the nation’s health for the long term.” And as Dr. Steffie Woolhandler, a spokeswoman for Physicians for a National Health Program, recently explained on Democracy Now!: “[Single payer/Medicare for all] means you would get a card the day you’re born, and you’d keep it your entire life. It would entitle you to medical care, all needed medical care, without co-payments, without deductibles. And because it’s such a simple system, like Social Security, there would be very low administrative expenses. We would save about $400 billion, which would allow us to afford the system. I mean, I just want to remind you that when Medicare was rolled out in 1966, it was rolled out in six months using index cards. So if you have a simple system, you do not have to have all this expense and all this complexity and work.” Jon Quealy is a staff writer at Common Dreams. http://www.commondreams.org/headline/2013/12/23-3

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Simple solution — single payer

By Rochelle Dworet, M.D.
Health Policy Solutions (Denver, Colo.), Dec. 23, 2013 So the Affordable Care Act is finally being implemented, even online.  Our state has its own exchange, which seems to run better than the national model.  The people in the states that implemented their own exchanges are all busy heaping accolades on each other. However, the real question is, “Where is the single-payer solution that would save hundreds of millions of dollars and lives?” Our fiscally prudent cohorts should want a system of private care or whatever the provider fancies with a low overhead to administer, and one that covers everyone — namely single payer.  After all, let’s remember that Medicare was implemented within six months of passage using one’s Social Security number and all the relevant information documented on index cards.  No fancy computer system was required with exorbitant expenditures to make it work. Now seniors love their Medicare, as witnessed by the signs, “Government, hands off my Medicare.” Unfortunately, the big PR firms, lobbyists and corporate giants that control the medical empire make way too much in salaries and bonuses to care about what is good for people. We recently mourned the loss of one of the greatest civil and human rights activists ever, Nelson Mandela.  Yet, we forget that the United Nations decreed that health care is a human right.  We, as a civil society, have an obligation to all our brothers and sisters to afford them health care regardless of financial means. But no, as Steven Brill pointed out in “The Bitter Pill,” his Time Magazine article last March,  hospitals and clinics charge as much as they can get away with based on some medical fiction called the “Chargemaster,” a system more suited to a Star Wars movie than to humanity.  Is it any wonder that we are the only developed nation with a 62 percent bankruptcy rate due to medical debt, and two-thirds of those people had insurance! As a physician, I know that medicine does not fit a business model.  Each time a patient enters into a discussion and examination for care, she breaks the mold of another algorithm and diagnostic code.  Providers need to use their skills to fullest capacity and be compensated fairly whether they are in primary care or a narrower specialty.  It is a team approach that creates success at wellness. Our current system of grabbing for dollars perpetuates greed and discontent among healers. The answer to the problems with Obamacare is exactly what Mark Shields said on Inside Washington on Oct. 27, “Two words: single payer.” Dr. Rochelle “Shelley” Dworet is president of Health Care for All Colorado, a group advocating for a public universal health care system in Colorado. http://www.healthpolicysolutions.org/2013/12/23/opinion-simple-solution-single-payer/

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Incrementalism predicted for 2014

With Health Law Cemented, G.O.P. Debates Next Move

By Jonathan Weisman
The New York Times, December 26, 2013 Senator Kelly Ayotte, Republican of New Hampshire, said she was teaming up with Democrats on a host of incremental changes to the law, such as expanding health savings accounts and repealing a tax on medical devices. And other Republicans are wondering aloud how long they can keep up the single-minded tactic of highlighting what is wrong with the law without saying what they would do about the problems it was supposed to address. http://www.nytimes.com/2013/12/27/us/politics/as-health-law-cements-its-place-gop-ponders-how-to-attack.html?ref=politics&pagewanted=all

Comment

By Don McCanne, M.D. Democrats want to repair some of the defects in the Affordable Care Act. Republicans want to include some of their favorite proposals such as expansions of health savings accounts and catastrophic plans, and loosening restrictions on sale of insurance products across state lines. Members of both parties wish to curry the favor of the voters before the November elections. This is a setup for mediocre incrementalism when what we really need is… well, the most popular NYT reader response (out of 475 at moment) says it well: Atikin – North Carolina
The only logical solution: single-payer.

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Don’t forget New York

Single Payer for New York

The New York Times, December 23, 2013 To the Editor: Re “Under Health Law, Independent Practitioners in City Face Canceled Policies” (news article, Dec. 14): The Affordable Care Act makes important repairs to our broken health care system. The problem is that it leaves insurance companies in charge — with high premiums, high deductibles and co-pays; too much control over which doctors or hospitals we can go to and what care they can provide; and high administrative costs. The exchanges are complicated because the system requires means-testing to see who is eligible for Medicaid or subsidies, and then requires people to select from multiple plans. We could cover everyone, provide better coverage and save billions through publicly sponsored, single-payer health coverage, like an improved version of Medicare for everyone — and no insurance companies. Washington might not be ready to act, but individual states have long been the “laboratories of democracy.” New York can do better.

Richard N. Gottfried
New York, Dec. 14, 2013 (The writer, chairman of the New York State Assembly Health Committee, is the author of a bill in the New York Legislature to establish a state single-payer health plan.) http://www.nytimes.com/2013/12/24/opinion/single-payer-for-new-york.html?ref=opinion&_r=0 A.5389/S.2078, New York Health – an act to establish a single payer health program: http://assembly.state.ny.us/leg/?sh=printbill&bn=A05389&term=2013

Comment

By Don McCanne, M.D. As the Affordable Care Act unfolds it becomes all too obvious that the repairs in our system of financing health care are falling far too short of the goals of universality, affordability, administrative simplicity, and accessibility with free choice of hospitals and health care professionals. Clearly we need a single payer system that would easily achieve these goals. New York, with the leadership of Assemblyman Richard Gottfried, has joined other states in attempting to enact a state-based single payer system. What we desperately need is a federal government that partners with states – all states – in enacting legislation that will bring single payer to all of us. With the surge in a renewed interest in single payer, we need grassroots and coalition efforts to be sure that people understand the single payer approach and then will demand it when they go to vote. Let’s pull out all stops between now and next November.

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Commodification harms not only our health care

Do bigger governments lead to happier people?

An interview by Dylan Matthews
The Washington Post, December 23, 2013 Benjamin Radcliff is a professor of political science at the University of Notre Dame. His current research focuses on how public policy affects human happiness. Dylan Matthews:  You argue that social democratic or left-leaning policies are more conducive to happiness. What sorts of things are you talking about? Government spending? Regulations? Both?

Benjamin Radcliff:  I have organized my research around two dimensions of policy. The first is the size of government, i.e. of what it is government does, from the tax burden to the generosity of the welfare state to the total impact of the government in terms of its overall consumption on GDP. The second involve institutions that protect people in labor markets, which means labor unions and economic regulations (the minimum wage, mandated vacation time, etc.), which provide a degree of sovereignty and power for workers in their employment relationships. Two sides of the coin: the general scope of what government does to make life more secure for people and the stuff that works specifically in terms of peoples’ work conditions. Both types of policies contribute to what social theorists call “decommodification,” meaning limiting the degree to which in a capitalist economy people have to act as commodities in order to survive. You have to sell your labor power on the market. Decommodification measures how much people can opt out of the labor market, whatever the reason, and provides a way of judging to what extent have we made them free of market commodification. More decommodification makes people happier, and it does so for rich and poor people, men and women, and controlling for just about any other thing. Similar empirical results obtain when considering total social spending on education, health care, total government consumption, the tax burden, a well-known OECD measure of employee protection legislation, even indices on the size of government and labor market regulation from the conservative Fraser Institute. The smaller the government, the less happy people are. Another variable I find of interest is labor union membership and density, i.e. do you belong, and the percentage of all workers who belong the unions. People who belong to unions are happier, and, more importantly, union density is strongly related to levels of happiness for union members and non-members.

Dylan Matthews:  How does that compare to the effects on happiness of non-policy things like, say, the effect of being married or unemployed? Benjamin Radcliff:  The literature would tell you that being married has a huge positive impact on wellbeing, while unemployment has an equally powerful negative effect. They thus make nice benchmarks for comparing the effect of other variables. My results suggest that the effect of the political variables is much larger by orders of magnitude. Dylan Matthews:  Can you talk a bit more about what you mean by “decommodification”? Do you mean not being reliant on work to live — not being a commodity yourself — or the carving out of certain things (human organs, say) that just aren’t commodities you can buy and sell? Benjamin Radcliff:  A society is decommodified to the degree to which people are not entirely dependent on labor market participation in order to survive — principally because they are aged, because they are ill, or simply because jobs are scarce, but also, potentially, so that they can take time to care for a new child or an ailing family member, etc. My research suggests people lead better lives in those societies that are the most decommodified. The reasons are easy enough to understand: There’s a famous quotation observing that a capitalist economy, whatever its many positive aspects, creates a situation in which people have to behave as commodities in order to survive. It doesn’t take great insight to realize that people do not enjoy being reduced to commodities, so a society that limits that necessity is likely to be a better one in which to live. Now, to be sure, the market economy absolutely contributes to human well-being in other ways — no one can deny that — but we have a macro- vs. micro-problem. At the macro level, capitalism works well. I would agree that the market society is one of humanity’s greatest achievements. But at the micro level it depends at the very core of its logic, as even Adam Smith was at pains to point out, on the idea of using other people (employees) as a means to making profits for oneself. The people we hire to do work are just mere commodities in the profit-loss calculations, no more worthy of special concern than barrels of oil or bushels of grain. The last chapter of my book (“The Political Economy of Human Happiness”) discusses these moral tensions that capitalism creates. My conclusion is that the social safety net, labor market regulations and labor unions all limit the degree to which people become mere commodities, and thus are more likely to lead fulfilling lives. http://www.washingtonpost.com/blogs/wonkblog/wp/2013/12/23/do-bigger-governments-lead-to-happier-people/

Comment

By Don McCanne, M.D. On a positive note just in time for the Holiday Season, we can be assured that we have it within our power to increase happiness throughout the nation by joining together, as a government, in decommodifying ourselves within our own society, but that means that we cannot leave power in the hands of those who would commodify us. Peace.

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Uwe Reindardt on the U.S. path to three-tiered health care

The Economics of Being Kinder and Gentler in Health Care

By Uwe E. Reinhardt
The New York Times, December 20, 2013 In the late 1980s, about 35 million respondents to large nationwide surveys declared that they lacked health insurance of any kind. The comparable number now is close to 50 million. Then, as now, the endless “national conversation” went on and on, pondering ways to achieve truly universal health insurance coverage, a feat most other developed nations accomplished long ago. Then, as now, news organizations and the health services research community reported on the financial and physical hardship that many low-income, uninsured Americans face when they fall ill. And then, as now, the prices for identical health care goods and services were more than twice as high in the United States as they were – and still are – in the member nations of the Organization for Economic Cooperation and Development. For all the wonderful things the United States health system has done for the American people, then, as now, it has also helped price some degree of kindness out of our souls, a side effect of their treatments that the leaders of American health care at some point must begin to contemplate. My interpretation is that opposition to the Affordable Care Act largely reflects the age-old reluctance among many of the nation’s haves and the healthy to help purchase for America’s lower-income families and the chronically ill the super-expensive health care that the haves enjoy themselves. That attitude is all the more striking because of the generous federal indirect subsidies enjoyed by many of the haves, especially high-income Americans. (I am thinking specifically of the generous tax preference accorded employment-based health insurance, the largest tax expenditure in the federal budget.) Some people on both the extreme left and right seem to believe that the current travails of implementing the Affordable Care Act and the possibility of a so-called “death spiral” in the market for individual health insurance may usher in single-payer health insurance in the United States – say, Medicare for all. I do not find that a likely prospect. Rather than embracing a single-payer system, the United States is more likely to stumble, in fits and starts, toward something resembling officially sanctioned tiering of the American health care experience by income class, as follows: FOR MEDICAID BENEFICIARIES AND THE UNINSURED, a budget-constrained system of public hospitals and public clinics. It would allow politicians to ration health care (through tight budgets) without ever having to acknowledge that they were doing so. In other words, it would reduce the price of being kind. FOR THE EMPLOYED MIDDLE CLASS, a mixed system with defined contributions by employers, private health insurance exchanges and reference pricing by insurers. Under a restructured Medicare program also based on a defined contribution model, reference pricing would be likely to apply to Medicare beneficiaries as well. Depending on how it is operated – e.g., if it were solely based on cost, in abstraction of quality – reference pricing also permits tiering of the health care experience by income class, without anyone having to say so openly. FOR THE UPPER-INCOME GROUPS, boutique medicine, which is already growing in the United States. Here the sky will be the limit. And what do readers think? http://economix.blogs.nytimes.com/2013/12/20/the-economics-of-being-kinder-and-gentler-in-health-care/

Comment

By Don McCanne, M.D. Uwe Reinhardt, an astute observer of the U.S. health care system, does not see single payer in our future, but rather sees an “officially sanctioned tiering of the American health care experience by income class.” We already have the three tiers that he describes, but the middle tier is rapidly evolving in a way that may provoke a renewed and more intense interest in single payer. The lowest tier – Medicaid beneficiaries and the uninsured – have never had much of a political voice. Nevertheless, even the most heartless of politicians recognize that we must provide care for indigent pregnant women and children. Thus we have the chronically underfunded Medicaid program plus safety net hospitals and community health centers. Some states also have included other low-income adults, though they still make up the largest percentage of the uninsured. Except for the most basic of primary care services and care for events that threaten life or limb, access to health care for this sector is limited, especially for specialized services. As Professor Reinhardt indicates, politicians are able to ration health care for Medicaid beneficiaries and the uninsured without admitting that they are doing it, merely by placing restraints on the budget. Since it is unAmerican to ration health care, they would never do that, but rather they merely refuse to budget spending that we can’t afford. (Of course, inadequate funding of health care is rationing, and we actually can afford to pay for health care for all, though we do need more efficiency in our financing system.) The highest tier – the upper-income groups – have never had problems with gaining access to the best care available. That is true now, and will be true no matter what health care financing system we will have. Some have expressed concerns that in a truly egalitarian system, such as a single payer system, the wealthy would have to give up some of the finer amenities of health care and stand in line with the rest of us, but that will never happen. The wealthy are not hampered by noblesse oblige when it comes to moving to the front of the line for health care. Besides, a well designed system should not have an excessive queue anyway. The middle tier – the employed middle class – will see greater changes in health care access and affordability, changes that have already begun. Although the plans to be offered in the state exchanges will include many of these changes, employers are already following by modifying their plans to reduce their own exposure to costs. Higher deductibles and other forms of cost sharing are shifting more costs to the pockets of those who need health care. Although ten categories of benefits will be required under the plans, the insurers have considerable flexibility in the composition of benefits within each category and will leave out selected benefits that some individuals will need, especially some of the more expensive benefits. Insurers are reducing their networks of physicians and hospitals, further limiting patient choice of their health care providers, unlike the traditional Medicare program, which allows free choice. Patents may still face catastrophic losses since the maximum out-of-pocket expenditures apply only to covered benefits provided within the networks. Care unavoidably obtained out of network and health care services not included as a plan benefit can result in costs that threaten personal bankruptcy. Even the allowed maximums would create a hardship for many. Employers are beginning to switch to defined benefit contributions to health plans that would be selected from private (not state) health exchanges. This voucher approach allows employers to shift the future increases in health care costs disproportionately to the employees. Reference pricing is the process of setting a low price for given health care services and requiring the patient to pay the full difference in prices if the patient selects a more expensive provider. This is another method of shifting more costs to the patient, not to mention that it further limits choice of providers since these extra costs may be truly unaffordable. A shift in control of Congress and the White House to conservatives may well result in premium support of Medicare (vouchers – a defined contribution), thereby allowi ng Medicare to adopt some of these same policies that shift more costs to patients in need. The obvious point is that the exchange plans and now even employer-sponsored plans will cause the employed middle class to become quite dissatisfied with our health care financing system. Once they or their families and friends have enough negative experiences with our health care financing, and once they understand single payer – an improved Medicare for all – it will be the middle class workers that will be the loudest in demanding change. In the meantime, under our present three-tiered system, we will be able to obtain a basic level of care for Tiny Tim, just not the specialized services that he really needs. And Ebenezer Scrooge will be able to access his boutique providers, with the sky as the limit. But what about the people of the village? Once Scrooge gains control of the insurance industry, will he further advance the current agenda of making health care more expensive to increase profits, and less accessible to reduce costs? Will another visit from the Ghost Of Christmas Yet To Come be adequate? Or will he be hardened enough to carry on, as Reinhardt writes, “the age-old reluctance among many of the nation’s haves and the healthy to help purchase for America’s lower-income families and the chronically ill the super-expensive health care that the haves enjoy themselves.” Though should we really expect a different outcome? We now have a society that when Bob Cratchit pulls himself up by his bootstraps and runs for mayor, we elect Ebenezer Scrooge instead.

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