PNHP

Registered Nurses to the Rescue

Registered Nurses to the Rescue

By Andrew Coates, M.D.
WAMC Northeast Public Radio, March 29, 2013

In a small news article this week in the New York Times, Nina Bernstein reported that a provision of the New York State budget to allow for-profit hospitals was been dropped after opposition from the Assembly leadership, specifically the intervention of Assemblyman Richard Gottfried, chair of the Assembly’s Health Committee.

While hospitals may be run as for-profit businesses in many states, all New York state hospitals are presently either not-for-profit or public institutions. Keeping for-profit hospital care out of New York is good news for people in New York who need hospital care and marks a successful defense of the public interest.

According to the Times’ Stephen Berger, “an investment banker who has long advised the state on health care” was behind the push.

Republican leaders in the New York State Senate proposed to expand the pilot project to allow 10 for-profit hospitals.

The New York State Nurses Association vigorously opposed the measure to allow for-profit hospitals in New York. The nurses organized a grassroots push of over 2,000 phone calls and hundreds of in-person visits to lawmakers, including a last-minute push of busloads of nurses traveling to Albany. Jill Furillo, executive director of the New York State Nurses Association, was quoted in the Times saying: “For-profit health care does not work. People in the Assembly listened to us, and so did Gov. Andrew Cuomo.”

Proponents of for-profit hospitals in New York, like Mr. Berger, point to the need for capital investment in the health care infrastructure.

Berger led a state-appointed committee in 2011 that recommended closing all public hospital beds in the borough. Investment in health care works for the investors, but it doesn’t work for the patients or the caregivers. Public money must ultimately fund the care of the vulnerable and the indigent. Allowing investment companies to take a cut increases costs and robs caregiving.

For-profit hospitals amount to bad public policy. For-profit hospitals have also been shown, in peer-reviewed policy science literature, to provide inferior quality when compared with their nonprofit counterparts. For-profit hospitals also lead to greater health spending than nonprofit ones.

Among the convincing research are studies by Dr. P.J. Devereaux and his team. When it comes to hospitals, Devereaux found that charges at for-profit hospitals were 19 percent greater than at their nonprofit counterparts. In a previous paper, Devereaux and colleagues showed that mortality — death rates — were 2 percent greater at for-profit hospitals.

A cardiologist, Devereaux practices and teaches and performs his research at McMaster University in Ontario, a world-renowned center for evidence-based medicine. Devereaux has also researched the question of for-profit dialysis centers and for-profit nursing homes.

When compared with nonprofit institutions, for-profit dialysis and for-profit nursing homes, like for-profit hospitals, are more expensive and more deadly than nonprofit ones.

Moving a hospital into the private sector shifts its fundamental purpose. A for-profit institution primarily exists to remunerate investors and shareholders. The public service model — or at the very least nonprofit, community-based institutions — still organizes care with a primary responsibility to patients and their caregivers.

During our lifetimes health care has been transformed from its charitable roots into a profit-seeking industry.

For-profits operate over 84 percent of home health care agencies and 85 percent of dialysis clinics. Ninety-six percent of the nation’s outpatient surgery centers are for-profit, a sector that has grown by more than a third since 2004. Hospice care has evolved into a $14 billion business, run mostly for-profit. For-profit hospice!

Over three-fourths of nursing homes are for-profit nursing homes — and the largest owner of for-profit nursing homes are private equity firms run by investment bankers. The exception has been hospitals, where nonprofits and publicly operated facilities had 88 percent of revenues in 2010.

I love our nursing colleagues. Judy Sheridan-Gonzalez, RN at Montefiore Medical Center and elected NYSNA leader, said: “We’ve won this battle, but our fight for New York patients is just beginning. Our opponents can re-introduce these changes as non-budget bills at any time this legislative session. That’s why we’re not letting down our guard.”

For-profit hospitals are bad public policy. But with the trend toward privatization — you might call it the profitization — of health care, the nurses’ public advocacy will remain as indispensable to the patient’s interests as their bedside care.

Dr. Andrew Coates practices internal medicine in upstate New York. He is president of Physicians for a National Health Program.

You can listen to Dr. Coates’ radio broadcast here:
http://www.wamc.org/post/andrew-coates-registered-nurses-rescue

Will ACA raise costs 30%?

Factors Affecting Individual Premium Rates in 2014 for California

By Robert Cosway and Barbara Abbott
Report prepared for Covered California, Milliman, March 28, 2013

Covered California retained Milliman to evaluate the changes in individual health insurance premium rates that might be expected due to the implementation of the Patient Protection and Affordable Care Act (ACA) in 2014.

Summary of Potential Rate Changes for People Currently Insured (includes premium tax credits and cost sharing subsidies)

Premiums
-83.8%  Less than 250% FPL
-46.6%  250% to 400% FPL
+30.1%  Greater than 400% FPL

Cost at time of care (cost sharing)
-61.8%  Less than 250% FPL
-27.3%  250% to 400% FPL
+ 1.2%  Greater than 400% FPL

Total cost of care: Premiums plus cost sharing
-76.2%  Less than 250% FPL
-39.9%  250% to 400% FPL
+20.1%  Greater than 400% FPL

In general, we expect the average currently insured to experience premium increases because they will be part of a new risk pool with a higher average health status. The federal premium tax credits and cost sharing subsidies will more than offset these increases for many low income individuals.

http://www.healthexchange.ca.gov/Documents/Factors%20Affecting%20Individual%20Premiums%20FINAL%203-28-2013.pdf

And…

Cost of the Future Newly Insured under the Affordable Care Act (ACA)

Society of Actuaries, March 2013

Note that the ACA’s affect on premium is not modeled in this research; rather, long-term relative claims cost is modeled.

This analysis will primarily focus on the individual, non-group market.

Finding 3: The non-group cost per member per month will increase 32 percent under ACA, compared to pre-ACA projections.

The post-ACA figures include the impact of a) high risk pool members, b) employers dropping group coverage, and c) increased morbidity from selection by those currently uninsured who now purchase coverage.

http://cdn-files.soa.org/web/research-cost-aca-report.pdf

Comment:

By Don McCanne, M.D.

These two actuarial reports project the potential financial impact of the Affordable Care Act (ACA) on individuals obtaining coverage in the non-group market. The reports are quite complex. Let’s see if we can separate what these reports really say from what the politicians are saying about them.

The excerpts above do not refer to employer-sponsored coverage nor do they refer to Medicaid. They refer only to the differences in plans offered in the individual market before ACA and those to be offered after the ACA exchanges are established next January.

The Society of Actuaries reports that cost of claims, not premiums, will increase 32 percent, but, again, only in the individual market. This increase is due to the change in the mix of individuals covered by these plans. The plans will include more costly individuals who have been insured by the state high-risk pools; they will include individuals dropped by employers from their group coverage, and they will include the previously uninsured who have increased morbidity (i.e., poorer health status).

So those politicians who are using this report to claim that “health care costs are going up 30 percent under Obamacare” either do not understand the report, or they are being dishonest. It is only the insurance pools in the individual market that add in unhealthy individuals that are projected to have 30 percent increases in the cost per enrollee, when compared to the cost per enrollee of current plans in the individual market that have been successful in keeping out individuals with greater health care needs.

The Milliman analysis looks at the pre-ACA and post-ACA change in the premiums, not the change in the cost of claims, but they also include the changes in what the individual actually pays when the premium tax credits and cost sharing subsidies are included. Those individuals with incomes below 400 percent of the federal poverty level will pay significantly less than they would in the current individual market.

For individuals who do not receive subsidies or tax credits, the premiums will increase about 30 percent – again because of the change in the mix of the insurance pools which will include enrollees with greater needs. But the total premiums plus cost sharing are expected to increase about 20 percent since there will be almost no change in cost sharing for these higher-income individuals.

So are the costs for the individual market insurance pools going up 20 percent or about 30 percent? Considering the differences in higher-income individuals in one study and the entire individual market in the other study, the separate impact on premiums, cost sharing, and claims, and the variations in actuarial assumptions, these numbers are quite close. Let’s say 25 percent.

But the number doesn’t matter. Whatever it is, it merely represents the fact that insurers offering individual plans must now sell them to anyone who wishes to enroll, no matter how expensive their medical problems may be. By segregating individuals into different insurance pools, the premiums will have to be set based on how healthy or sick that pool is, especially since risk adjustment is only capable of correcting for just a minor portion of the inequities. Administrative complexity and inequities are inevitable under ACA.

The lesson is that it would be much simpler and much more equitable to have a single insurance pool that covers everyone, and fund it through progressive tax policies. Fix Medicare, improve the tax structure, and use it for everyone.

The future of the NHS — irreversible privatisation?

Observations, Health and Social Care Act
BMJ, March 20, 2013

This is the edited transcript of a video interview carried out on 3 March 2013 by Jill Mountford with Dr Lucy Reynolds, research fellow at London School of Hygiene and Tropical Medicine. Dr Reynolds has studied the background of the NHS in detail, and in the interview she shares her view of the consequences of the NHS reforms and possible privatisation of the NHS.

JILL MOUNTFORD: Lucy, can you explain to us what is going on right now? The Health and Social Care Act has been law now for almost a year, and we thought surely that’s all going to go ahead. All of a sudden there is a lot of movement, a lot of anxiety and a lot of agitation around something that’s happening in parliament that’s going to have a big effect on the National Health Service. What is it and why?

LUCY REYNOLDS: The health and social care bill was passed in the form as if it were an aeroplane with no engines. The structure was all there. Its significance was not very plain to many people unfortunately. They looked at it and couldn’t really understand what they were looking at. They couldn’t find the thing in it that was actually going to accomplish the privatisation because really the only marker of it was a little clause explaining that regulations would be issued.

Now those regulations [section 75] are with us, and those regulations provide the jet engines to make that privatisation go ahead. So all of the rest of the plane was put in place last year, and now at the very last minute before this whole thing happens on 1 April 2013 the regulations are coming into place to show that everything has to be put out to competitive markets by CCGs [clinical commissioning groups] and the national commissioning board. That will create rights for private providers to supply which will not only allow them to take quite a lot of the share of the NHS budget for their business right now, it also potentially makes the privatisation irreversible in the future.

JILL MOUNTFORD: For somebody coming to this question fresh who is very concerned, what does this mean? From 1 April what will this mean for them accessing services, and how will it unfold over the next few years?

LUCY REYNOLDS: We’re not going to have a big bang privatisation for the NHS. We’re going to have a very quiet one.

What has happened is that all of the rules that control health financing have been gradually changed since the New Labour times. Overall, we now have the NHS reorganised in such a way that it can be relaunched as a mixed market, so not just the public health sector service, but also a healthcare industry. The rules are structured in such a way that there will be a gradual transition between those two groups. The public sector will shrink away, and the private sector will grow.

But because there will never be an announcement in parliament that the NHS is privatised, and because the private providers will be allowed to use the NHS logo for anything that they are getting NHS funding for, it is very likely that the general public will not be aware that the private sector has in fact come in and taken over whatever bits of the NHS it finds profitable until probably service provision gets fairly bad.

JILL MOUNTFORD: Lucy, you made reference to a mixed market in the National Health Service in the near future. Why is this such a bad thing?

LUCY REYNOLDS: Well, it sounds like a good idea to have diversity and options and these kinds of things, and that would be fine if it weren’t for the fact that the rules of the market are thoroughly stacked. We know for certain that organising [healthcare] as a public sector service is the cheapest and most effective way of providing healthcare. And that is broadly because the market model does not fit healthcare. The market model includes assumptions that both parties are in possession of all information about the subject of the transaction. In markets where the consumer has to rely upon the supplier for guidance, what you get isn’t a market that clears down to a minimum price and is efficient. What you get is soaraway inflation and abuse within that market.

Of course the US health system is the most salutary warning to us, but there are an awful lot of other countries which have had their health services privatised over the last couple of decades.

If you pay doctors only when they do work, then they over-treat people. If you make sure that medical facilities have no way of making any money other than by selling things, then they become salesmen, not advisers and advocates for the public. And actually in the world we have one of the very best public services, and compared to other developed countries it’s also one of the most cost effective. There were several of these in Europe. Sweden’s has been privatised. Spain’s has been privatised. Ours is being privatised. In fact 1 April 2013 is also the day the Spanish government signs over control of its national health service into the competitive market.

JILL MOUNTFORD: So this is an ideological attack on the National Health Service. It’s an attack on the founding principle of free healthcare at point of need.

LUCY REYNOLDS: There is certainly an ideology promoted around privatisation, but that is a rationalisation to convince people who otherwise wouldn’t come on board. At the bottom of it it’s about making money.

JILL MOUNTFORD: You made reference to CCGs and how they come into play from 1 April. Can you tell us a little bit about the size of the budget that they’re going to be holding, the power, the massive power shift that’s going to take place and what this means?

LUCY REYNOLDS: The health service is being restructured on to an insurance compatible footing, and the CCGs are technically state-owned insurance schemes. So they are going to be taking on around 80% of the NHS budget and they are going to be parcelling it out to providers. They have been told that they are going to have a lot of autonomy in that and that they will be able to represent the interests of their patients in the matter.

That bit doesn’t appear to be able to be delivered when we have these regulations in place because what the regulations say is that commissioners will put out contracts according to competition law, and they will decide according to competition law. If anybody that didn’t get the contract feels that they don’t like the decision and that it could be faulted on failure to comply with competition law, they are permitted to complain to the sector regulator, Monitor, which is required to enforce competition law. So once everything gets put through the market, the CCGs won’t actually have any autonomy in the matter.

And the reason we have been told about GP empowerment and patient empowerment is firstly to lure the doctors into complying with this. They are belatedly starting to understand that this has been a trick.

The second reason GPs have been told that in CCGs they would have the chance to advance the interests of patients is because it’s very important for our politicians that nobody blames them. The public has been induced to believe that the GPs are taking over and will be in control so in five years when the whole thing is complete chaos and you can’t get decent care, it won’t be the politicians’ fault.

JILL MOUNTFORD: What is the experience of the last 15 years, 13 years under the Labour government though? Is there anything that the Labour government did whilst it was in power to give people the confidence to feel they can rely on Labour to sort out the NHS?

LUCY REYNOLDS: All of the stuff about the purchaser-provider split, the creation of commissioning within the NHS, the first bringing in of these competition regulations direct from Brussels in 2006-2007 by the Labour government, all of this has been absolutely fundamental to
setting the thing up. I think the Labour government has been absolutely critical to the success of NHS privatisation and continues to be so.

JILL MOUNTFORD: On 1 April people are talking about the NHS is now going to be in the thick of being a privatised service. What exactly does that mean?

LUCY REYNOLDS: It’s not suddenly going to turn into a privatised service on 1 April. What happens on 1 April is a bunch of legal and operational changes that affect the way that the NHS functions internally. In general this reform is a health financing reform. So we’re finishing the transition away from the original form of funding of the NHS and moving into a market system which is going to be full-on market.

JILL MOUNTFORD: So full-on market means people are going to be competing for contracts, profits are going to be made, and is profit going to be the driving force as opposed to patient care?

LUCY REYNOLDS: Profit is already the driving force as opposed to patient care, even within traditional NHS hospitals. There won’t be a sudden change, but there will be a new set of legal arrangements which will cause certain things to happen more than others.

And the things that are going to happen include a lot of private providers coming into the health service and a lot of public providers going bust, because every time the public provider of a service does not get the contract to carry on providing that service because a private provider has got it instead, that service will be shut down permanently because there won’t be any more money to pay the staff and keep the lights on.

So gradually this system will kill off all our traditional NHS providers apart from maybe some big names. I’m expecting Great Ormond Street to survive. I’m expecting the Royal Marsden to survive. There are a few other really high profile hospitals around the country where the brand name is so valuable that they might carry on.

It is intended that all NHS hospitals be pushed through the foundation trust pipeline, which is an arrangement organised by competition regulator Monitor to privatise all of our hospitals. So all of our hospitals that aren’t yet foundation trusts are being turned into them, and the foundation trusts are being pushed out into the private sector. So there is an intention that within a few years there simply will not be any public sector health provision, either because it’s been driven out of business by a stacked competition or because it’s just been straight privatised by Monitor.

JILL MOUNTFORD: Rich people have forever used private healthcare and have benefited from it. Now we’re going to have that. What’s the big deal?

LUCY REYNOLDS: Well, actually, you see we don’t really have a proper private health insurance scenario in this country at all because the private health insurance only offers certain kinds of transactions. They like to keep it simple and they like to keep it profitable. So if there is any kind of problem where somebody has got two illnesses at once maybe, or they don’t react to drugs well so you have to find other solutions, or if there is any kind of complication, the private hospitals don’t deal with those people any longer, so they just refer everybody back into the NHS.

People in this country seem to believe you can use private health insurance for everything. But the truth is they are not interested in anybody that’s going to cost them money. So they will certainly make sure that if you are already ill, they charge you a lot, and usually they will exclude ongoing conditions. It is very, very partial and very skewed, and frankly no use whatsoever to anybody that actually needs a lot of medical care. It’s a great way for the insurance companies to make money, but it’s a terrible way to deliver medical care.

JILL MOUNTFORD: You talk of private providers coming in to take over services and public providers losing out in the new commissioning set-up post 1 April. Who are these private providers? Are they health experts?

LUCY REYNOLDS: Well, under the rules of competition law it’s not permitted to really restrict your providers. But a lot of them are general outsourcing companies that can just see a useful income stream. They’re not people who have any kind of commitment to public health or the individual welfare of patients.

And you know the government has been very careful to muddy the water and make out that a public healthcare provider is pretty equivalent to a private healthcare provider, but actually their goals are completely different. In the public sector doctors attempt to arrange to have enough money to treat the medical needs of the people that come to them for help. The purpose is treatment, and the money is a means to an end.

Once you move into the private sector, company law forces company staff to prioritise making money for the shareholders above everything else. The whole system is about making money. What we need to do is move back to a public service model in which things are arranged so doctors can help people who are ill. At the moment this reform is taking us in quite the opposite direction.

JILL MOUNTFORD: So once the rules have locked in from 1 April, is there anything that can be done to prevent the private market or the market from governing our health service from there on?

LUCY REYNOLDS: Those rules could be taken away again. The problem comes when the contracts are awarded to the private sector. So at the moment an awful lot of things are being done by traditional NHS providers. But we will now have a regime where everything has to go out to tender and the private contractors are considerably advantaged in winning those tenders.

JILL MOUNTFORD: Why are they advantaged?

LUCY REYNOLDS: They designed the rules, and the tendering process [is] quite highly technical—legally, financially and operationally. Just having medical knowledge is not enough. You need people who are good on legal and financial stuff and are experts in bid preparation. Private companies have a dedicated bid team who do nothing but search for bids to apply for, prepare the bids, and pull in the external consultants to get exactly the right technical expertise in.

There are some other reasons why it’s stacked, Tory MP Sarah Wollaston started asking questions [at the Health Select Committee] about cherry-picking to the economists in charge of Monitor, And they explained that in order to resolve the cherry-picking problem, which is that the private providers only take the bits they can make the most money out of and ignore everything else, a special mechanism has been put in place which uses what is called a local tariff facility, which is in the Health and Social Care Act.

The arrangement is that where a provider has been cherry-picking, the CCG [will] be able to say well, since you don’t offer the full service, and the full standard tariff is set up to reflect a provider which does offer the full service, you need to drop your prices. If Monitor approves that, then the CCG and the private provider can make a deal to have a special lower tariff, allowing competition on price which the government said would be impossible. And that means that the private providers can systematically undercut all of the public providers on price.

And every time one of those contracts is lost for the first time into the private sector, it means that that the public sector capacity to deliver that service disappears because there is nobody to pay the ongoing salaries. So this is a very important mechanism, and it goes directly against the assurances that our politicians gave us.

JILL MOUNTFORD: I assume that it will be bigger organisations that are running bigger chunks of healthcare. Is that not likely to be a model or not?

LUCY REYNOLDS: The healthcare won’t be run in the same way as presently. They’ll do it all in the way that makes them the most money so it will look d
ifferent. I mean I’m sure the actual physical infrastructure won’t change very much to start with, and certainly the logo will be the same. But the entire ethos and way of doing things and likely outcomes and transparency—all of that’s going to be different.

JILL MOUNTFORD: What does this mean—we’ve got lots of fragmented care, some privatised, the cherry-picked stuff privatised, the profit-making stuff privatised, the less profitable, the more nitty-gritty, the more needed stuff perhaps, more long-term stuff will be there in the public sector.

LUCY REYNOLDS: But with not enough budget to actually do it any longer. What is plain is that this has been a long-term plan with things set up in a predictable way such that the outcome is likely to be privatisation of the NHS.

Footnotes
Jill Mountford is an activist for the Alliance for Workers’ Liberty. The full interview can be viewed at www.youtube.com/watch?gl=CO&hl=es-419&v=OkTnCtg_Omk.
Provenance and peer review: Not commissioned; not externally peer reviewed

Cite this as: BMJ 2013;346:f1848

CORRECTION: In this Observations article (an edited transcript of a video interview by Jill Mountford with Dr Lucy Reynolds on 3 March 2013), Jill Mountford wishes us to clarify that it was as a member of the steering committee on the “Save Lewisham Hospital” campaign that she conducted the interview (BMJ 2013;346:f1848, doi:10.1136/bmj.f1848).
Cite this as: BMJ 2013;346:f2047

http://www.bmj.com/content/346/bmj.f1848?utm_medium=email&utm_campaign=7362&utm_content=BMJ%20-%20What%27s%20New%20Online&utm_term=The%20future%20of%20the%20NHS%E2%80%94irreversible%20privatisation%3F&utm_source=Adestra_BMJ

Digital archive of Health/PAC Bulletin now available

By the Health/PAC Archives Workgroup
Press release, March 25, 2013

Before there was an Internet, with blogs, listservs and web pages to turn to, there was the Health/PAC (Policy Advisory Center) Bulletin, a hard-hitting and muckraking U.S. journal of health activism and health care system analyses and critiques.

A new website, www.healthpacbulletin.org, contains a complete and searchable digital collection of Health/PAC’s influential articles, which were published from 1968 through 1993. The site is easily accessible and free.

During the bulletin’s quarter-century existence, Health/PAC staffers and authors in New York City (and, for a brief time, in a West Coast office in San Francisco) wrote and spoke to health activists across the country on every issue from free clinics to women’s health struggles to health worker organizing to environmental justice.

Health/PAC both reported on what was going on and reflected back on a wide variety of strategies and tactics to build a more just health care system – a conversation that continues today.

Health/PAC coined the terms “medical empire” and “medical-industrial complex” to capture the ways the profit motive distorted priorities in the American health care system. It critiqued big Pharma and rising health care costs, explored the differing forms of health activism, and made it clear that a seemingly disorganized health care system was in fact quite organized to serve ends other than health care.

Its first book, “The American Health Empire” (1970), published by Random House, brought its analysis to national attention. Other edited collections of the Bulletins followed: “Prognosis Negative” (1976) and “Beyond Crisis” (1994).

Many of today’s leading health activists, reformers and policy scholars got their start at Health/PAC.

The new website adds immeasurably to the resources documenting the history of mid- to late-20th-century American health policy and politics. Activists, scholars, journalists, practitioners, professors, and students will all find these bulletins a source of useful analysis and information. This is not only a way to learn about the late 20th-century history, but to consider why certain issues continue to plague our health system.

The site is a work in progress and its editors welcome feedback and suggestions. It was a real labor to get these collected and available and we hope readers will find the site a useful resource.

For more information, please contact the archives workgroup at contact@healthpacbulletin.org.

Merlin Chowkwanyun, Feygele Jacobs, Ronda Kotelchuck and Susan M. Reverby for the former HEALTH/PAC staff and board.

The Health/PAC Archives Workgroup: Merlin Chowkwanyun, Feygele Jacobs, Susan Reverby, Ronda Kotelchuck, David Rosner, Oliver Fein and Robb Burlage.

HMOs score poorly on access

HMO Quality Ratings Summary - 2013

Office of the Patient Advocate
State of California

“Health Care Quality is getting the right care at the right time.”

*     poor
**    fair
***   good
****  excellent

First rating is for “HMO provides recommended care,”
and the second rating is for “Getting care easily”:

***  *   Aetna Health of California, Inc.
***  *   Anthem Blue Cross – HMO
***  **  Blue Shield of California – HMO
***  *   CIGNA HMO
***  *   Health Net of California, Inc.
**** **  Kaiser Permanente – Northern California
**** *   Kaiser Permanente – Southern California
***  *   Sharp Health Plan
***  *   UnitedHealthcare of California
***  **  Western Health Advantage

http://reportcard.opa.ca.gov/rc2013/hmorating.aspx

Comment:

By Don McCanne, M.D.

California’s Office of the Patient Advocate defines health care quality as getting “the right care at the right time.” So how well are the HMOs doing?

To assess whether or not the right care is being provided, the HMOs report their compliance with standard Health Plan Employer Data and Information Set (HEDIS) measurements. The HMOs make certain that their health care professionals are aware of the 37 HEDIS measurements that will be made, and that they know that it is important to be certain that compliance is documented.

All ten of the California HMOs were able to document that they were either “good” or “excellent” at providing the right care for these 37 measured clinical recommendations. No measurement was made of the hundreds of thousands of other clinical decision processes that take place. It remains debatable as to whether 37 HEDIS measurements are adequate to determine if the HMO is always good or excellent at providing the right care, but there are those of us who have our doubts (pardon the cautious, restrained language).

So regardless of whether or not it was the right care, was it provided at the right time? Patients were surveyed about “experiences in getting appointments with doctors and other providers when needed and getting tests, treatments and other care without delay.” No HMO was rated excellent; no HMO was rated good. Three were rated fair, and seven were rated poor. At least from the patients’ perspective, care was not being provided at the right time.

Under a single payer system, patients have free choice of their health care professionals and institutions. HMOs take away that choice, subjecting patients to severe financial penalties should they obtain care outside of the HMO. The results of this survey suggest that, once HMOs have captive patients, they limit access by limiting system capacity and by establishing queues that are beyond the tolerance of their patients.

The delegated model of HMOs has no place in a single payer system since they function more as intrusive private insurers rather than as truly integrated health care delivery systems.

HMOs that are fully integrated health care delivery systems, such as Kaiser Permanente, do have a place in a single payer system. Right now, Kaiser is heavily dependent on workers enrolling in Kaiser’s plans through their employment, often choosing Kaiser as their least-worst option.

Once we have a single payer system with patients choosing their health care based on perceived quality, to compete successfully with the rest of the health care delivery system, Kaiser will have to show that they can deliver the right care at the right time. After all, that’s what single payer is all about.

Poor Americans in South Less Likely to Get Medical Care: Study

Researchers found states in that region imposed strictest eligibility requirements for Medicaid

By Steven Reinberg, HealthDay News
U.S. World and News Report, March 27, 2013

Poor people in the southern part of the United States are more likely to delay getting needed health care, mostly because states in that region impose the strictest eligibility requirements for Medicaid, new research says.

The problem is most pronounced in Texas and Florida, according to the report in the March 28 issue of the New England Journal of Medicine.

“There really is a great deal of variability across the country in access [to Medicaid],” said study author Dr. Cheryl Clark, from the Center for Community Health and Health Equity at Brigham and Women’s Hospital, in Boston.

Counties in states with really restrictive Medicaid policies tend to have the greatest delays, said Clark, the center’s director of health equity research and intervention.

The 2010 Affordable Care Act — derided by critics as “Obamacare” — aims to improve access to Medicaid by expanding the program and offering funding to states that adopt the expansion. Medicaid is a government-run program that offers health coverage to lower-income Americans.

States, however, don’t have to adopt the expanded program and states that have the most restrictive Medicaid policies — including Texas, Florida and Arkansas — have opted out of expanded Medicaid.

“States make different decisions around whether they decide to accept federal support to expand their Medicaid programs,” Clark said. “States are going to look very different in terms of their health care infrastructure and we may see a growing gap in health disparities.”

Another factor causing delays in care is the number of primary care doctors. Delays in care are less likely in places like New England, where there are a lot of primary care doctors, than in areas in the South, where there are fewer such physicians, Clark’s group noted.

Clark said that states that opt out of Medicaid expansion need to come up with another plan to improve access to care for the poor left out of that program.

She said there is a movement across the country to improve access to care for the poor even in places like Texas and Florida that have traditionally been less supportive of medical care for the poor.

Devon Herrick, a senior fellow at the conservative National Center for Policy Analysis, said there are alternatives under the Affordable Care Act to expand Medicaid to cover the poor.

Medicaid won’t improve access to care, he said. One problem, which may only get worse, is fewer doctors will treat Medicaid patients.

“A lot doctors don’t want to treat Medicaid enrollees because reimbursements tend to be half or even lower, compared to private insurance,” he said.

Herrick said he thinks that under the Affordable Care Act, more poor people will be able to get private insurance coverage. “These people would qualify for, really, general subsidies under private coverage,” he said. “The reimbursements to providers are nearly double Medicaid.”

Each state will have to develop its own program, he said. Some will accept Medicaid expansion and others will find a different path. “There is no one-size-fits-all solution,” he said. “There possibly 50 solutions across 50 states, maybe multiple solutions in each state.”

One critic said that private insurance under the Affordable Care Act won’t solve the access problem for many poor Americans.

“Unfortunately, the Affordable Care Act will leave about 30 million Americans uninsured, most of them U.S. citizens. These uninsured will continue to delay care, even for serious problems like heart attacks,” said Dr. Steffie Woolhandler, a professor at CUNY School of Public Health at Hunter College, in New York City.

Some of the newly insured will also delay care because their new coverage is so skimpy that they can’t to afford to use it, said Woolhandler, who is also a co-founder of Physicians for a National Health Program.

“For instance, the least expensive private insurance mandated by ‘Obamacare’ will have deductibles of up to $2,000, meaning that a policyholder who gets sick will need to pay $2,000 out of pocket before their insurance even kicks in,” she said.

“A particularly ominous development is that the Obama administration is now allowing states to force even the poorest families to pay out of pocket before they can get medical care — either by tacking co-payment onto Medicaid or, as in Arkansas, forcing the poor into skimpy private insurance plans. Hence, we can expect medically dangerous delays in care to continue,” Woolhandler said.

http://health.usnews.com/health-news/news/articles/2013/03/27/poor-americans-in-south-less-likely-to-get-medical-care-study

Policy preferences of wealthy Americans

Democracy and the Policy Preferences of Wealthy Americans

By Benjamin I. Page, Larry M. Bartels and Jason Seawright
American Political Science Association, Perspective on Politics, March 2013

Abstract

It is important to know what wealthy Americans seek from politics and how (if at all) their policy preferences differ from those of other citizens. There can be little doubt that the wealthy exert more political influence than the less affluent do. If they tend to get their way in some areas of public policy, and if they have policy preferences that differ significantly from those of most Americans, the results could be troubling for democratic policy making. Recent evidence indicates that “affluent” Americans in the top fifth of the income distribution are socially more liberal but economically more conservative than others. But until now there has been little systematic evidence about the truly wealthy, such as the top 1 percent. We report the results of a pilot study of the political views and activities of the top 1 percent or so of US wealth-holders. We find that they are extremely active politically and that they are much more conservative than the American public as a whole with respect to important policies concerning taxation, economic regulation, and especially social welfare programs. Variation within this wealthy group suggests that the top one-tenth of 1 percent of wealth-holders (people with $40 million or more in net worth) may tend to hold still more conservative views that are even more distinct from those of the general public. We suggest that these distinctive policy preferences may help account for why certain public policies in the United States appear to deviate from what the majority of US citizens wants the government to do. If this is so, it raises serious issues for democratic theory.

Health Care

The public has expressed much more support for tax-financed national health insurance (61 percent in favor) than our wealthy respondents did (just 32 percent). This represents a major gap on a central issue of social welfare policy. Similarly, a solid majority of the public (59 percent), but only a minority of the wealthy (41 percent), said they would be “willing to pay more taxes in order to provide health coverage for everyone.”

Conclusion

Our evidence indicates that the wealthy are much more concerned than other Americans about budget deficits. The wealthy are much more favorable toward cutting social welfare programs, especially Social Security and health care. They are considerably less supportive of several jobs and income programs, including an above-poverty-level minimum wage, a “decent” standard of living for the unemployed, increasing the Earned Income Tax Credit, and having the federal government “see to” —or actually provide—jobs for those who cannot find them in the private sector.

Judging by our evidence, wealthy Americans are much less willing than others to provide broad educational opportunities, by “spend[ing] whatever is necessary to ensure that all children have really good public schools they can go to” or “mak[ing] sure that everyone who wants to go to college can do so.” They are less willing to pay more taxes in order to provide health coverage for everyone, and they are much less supportive of tax-financed national health insurance. The wealthy tend to favor lower estate tax rates and to be less eager to increase income taxes on high-income people. They express concern about economic inequality and favor somewhat more egalitarian wages than they perceive as presently existing, but—to a much greater extent than the general public—the wealthy oppose government action to redistribute income or wealth.

On many important issues the preferences of the wealthy appear to differ markedly from those of the general public. Thus, if policy makers do weigh citizens’ policy preferences differentially based on their income or wealth, the result will not only significantly violate democratic ideals of political equality, but will also affect the substantive contours of American public policy.

http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=8864478

Comment:

By Don McCanne, M.D.

The wealthy have a very strong political voice. They use it to advance their own interests while opposing social programs, including tax-financed national health insurance. This is class warfare, but look at who is waging it.

Strike Debt Kicks Off Second Debt Buy-Up With March for Universal Health Care

By John Knefel
Truthout, March 26, 2013

A coalition of groups associated with Occupy Wall Street took to the streets of midtown Manhattan last Thursday evening calling for the abolition of the for-profit health care system in the United States and the creation of a government-run single-payer system. Around 70 protesters marched to four major health insurance companies to list their grievances with each corporation, often by comparing what they see as the wildly disproportionate salaries of CEOs with health costs for regular patients or the company’s average worker’s salary.

The march was part of a larger project that Strike Debt (which formed from the creative churn of Occupy) is implementing over the week to draw attention to medical debt, which the group sees as a national emergency. Strike Debt also announced that its latest round of a project known as the Rolling Jubilee has bought and abolished over $1 million in medical debt.

Activists handed out fliers on the march with statistics on just how damaging medical debt can be to households: “62% of bankruptcies are linked to medical bills” was featured prominently on the flier, as well as on a banner at the front of the march. Also on the handout was perhaps an even more surprising number: “78% of those who declared medical bankruptcy had insurance at the time they became sick.”

Strike Debt’s mission is to politicize and organize around personal debt, often by arguing that debt is not a moral failing but rather a societal problem that needs to be addressed and resisted collectively. One of the tactics, called Rolling Jubilee, involves buying “debt for pennies on the dollar, but instead of collecting it, abolish[ing] it.” The group buys debt on the open market the same way a collection agency would, but cancels the debt instead of collecting it. Funding comes from donors who contribute to the group through its website.

The first Rolling Jubilee took place in November of last year and “abolished” more than $100,000 of medical debt. The People’s Bailout, as it was called on Twitter, culminated in a telethon at a New York City music venue and garnered unusually positive press for an Occupy-related action.

The second and latest Rolling Jubilee resulted in an even larger amount of debt abolished: over $1 million, according to a post on the group’s website, for patients in Kentucky and Indiana. “The average debtor owed around $900,” the group wrote, “and we will be abolishing the debt of over 1,000 people.” Strike Debt is in the process of sending out letters to patients whose debt has been bought and abolished, as it did following the first Rolling Jubilee.

One of the most common questions asked of Strike Debt is whether it can buy and cancel specific people’s debt. The answer is no. There are no strings attached for the person whose debt has been bought, though many activists hope that someone on the receiving end of the Rolling Jubilee might throw a few bucks back in the pot – a way of paying it forward, as it were.

Thursday’s action began at Bryant Park around 4 p.m. with activists opening a dozen shredded umbrellas bearing the insignias of insurance companies, such as Cigna and Aetna. The broken umbrellas represented the activists’ beliefs that even those who have private insurance are often not fully protected by it.

In contrast, the marchers also opened a dozen intact umbrellas with the words “Medicare for all” – another phrase for single payer – painted on them.

A physician named David, part of Physicians for a National Health Program (PNHP), addressed the crowd before the march. He railed against the high costs of medical care, lambasting the idea that the solution to the problem is complicated or somehow unknowable. “The answer is single payer,” he said.

The protesters then marched to the offices of United Healthcare Group, Aetna, Blue Cross Blue Shield, and Cigna, chanting “Health care for people, not for profit” and “Bankrupt and broke, insurance is a joke.” The flier that activists handed out on the march claims that “the combined annual compensation for the CEOs” of those four companies “could buy and abolish almost 2 billion dollars of medical debt using the Rolling Jubilee model.”

Katie Robbins, also with PNHP, said the “flimsy insurance [that] people get in case they get sick is a contract that gets broken all the time,” referring to the many people in the U.S .who have insurance but nevertheless are forced to pay huge medical bills. She said that her deductible was so high that virtually any medical procedure would leave her thousands of dollars in debt. She also said that, by her calculations, having a baby could put her as much as $10,000 in debt, adding “that’s not a great place to be.”

John Knefel is the co-host of Radio Dispatch and a freelance writer based in Brooklyn.

http://truth-out.org/news/item/15342-strike-debt-kicks-off-second-debt-buy-up-with-march-for-universal-healthcare

A joint-replacement pavilion limited to prima donna doctors and rich patients

Fremont's Washington Hospital: Joint replacement patients, doctors excluded from new facility

By Ashly McGlone
MercuryNews.com, March 25, 2013

When Robert Cantley needed both knees replaced in August, he was expecting to recover from the surgery at Washington Hospital’s fancy, new $42.7 million Center for Joint Replacement.

According to hospital marketing brochures, the center offered “A Higher Level of Care” in a 20,000-square-foot space featuring 25 private patient rooms, a “breathtaking physical therapy space” and a beautifully landscaped therapy garden.

Instead, Cantley did his physical therapy sessions in a dimly lit hallway on the sixth floor of the main hospital in what he described as “a miserable set of circumstances.”

Cantley’s physician, Dr. John Jaureguito, who has been on the medical staff at Washington for 18 years, said the arrangement means his patients get “second-class” treatment. “Therapy is literally in the hallway,” he said. “I’ve never come across anything like this before.”

What Cantley and many other patients at the public hospital didn’t know was that access to the new center, the only facility of its kind in the Bay Area, is restricted to just two orthopedic surgeons at the hospital — the only ones on the Washington staff who met 24 criteria set by the hospital.

Those two doctors — long the hospital’s primary joint replacement specialists — played a critical role in the creation of the lucrative new center, and one of them acknowledges he helped create the criteria that have excluded many of his fellow surgeons. Some of those surgeons and their patients are crying foul, saying the result is a “two-tier” system of care that favors wealthier patients and chosen doctors.

“It is a community hospital, serving the public,” Cantley, 78, told the publicly elected Washington Township Health Care District board at a meeting last month. “The public in no way, shape or form should be excluded from the new wing.”

The only two surgeons who qualified, Dr. John Dearborn and Dr. Alexander Sah, received a five-year contract from the hospital to staff the center through May 2017 while maintaining their status as independent contractors, not employees, according to the contract.

The average single joint-replacement surgery performed at Washington Hospital in 2011 cost nearly $160,000, more than twice the California average, state data show.

According to one of Dearborn’s secretaries, neither he nor Sah accepts Medi-Cal or Alameda Alliance, which serve low-income residents, but typically carry lower reimbursement rates for doctors and hospitals than does Medicare.

http://www.mercurynews.com/bay-area-news/ci_22853885/fremonts-washington-hospital-patients-doctors-excluded-from-new

Comment:

By Don McCanne, M.D.

There are ten orthopedists on the staff of Washington Hospital in Fremont, California who perform joint-replacement surgery, but only two are allowed to use the hospital’s state-of-the-art Center for Joint Replacement. The Center charges more than twice the average for California, while the two approved surgeons apparently have a policy of discouraging low-income residents, including Medi-Cal patients.

Perhaps the most appalling consequence is that the patients of the other eight orthopedists receive their post-op physical therapy in the hallway of the main hospital rather than in the new “breathtaking physical therapy space.”

As a community hospital, serving the public, and with pressure from the state Department of Public Health and the Washington Township Health Care District, it is likely that this arrangement will be modified.

So what does this have to do with health care reform? We can ask ourselves if a single payer system that separately budgets capital improvements would have ever allocated funds for a state-of-the-art center serving only two prima donna surgeons and their affluent patients exclusively. Of course not. Attention surely would have been directed to a decision on whether or not it was even appropriate to establish a separate joint replacement pavilion. Likely the funds would have been better spent on improving or replacing existing surgical and physical therapy facilities.

Achieving the goal of health care justice for all will be made that much more difficult if our health care professionals and administrators fall below the ethical plane that we envision for the healing arts.

Single-payer health care is the only viable solution

By William Davidson, M.D.
The Patriot-News (Mechanicsburg, Pa.), March 24, 2013

A recent Sunday Opinion section of the Patriot-News presented two differing views of the Affordable Care Act (ACA), better known as Obamacare. Don Kusler defended the legislation while Grace-Marie Turner felt it should be repealed. Mr. Kusler noted that the law will reduce the number of uninsured by expanding Medicaid and having the government help the working poor buy health insurance policies.

Including college-age children on their parent’s policies as well as rules to prevent insurance denials because of previous conditions were other reasons to defend the ACA, according to Mr. Kusler. Ms. Turner, on the other hand, feels the legislation will be too costly, destroy jobs, and inhibit the medical industry’s creativity. She feels a new law promoting market competition would expand access to care, drive down costs while stimulating the economy.

Both points of view seem superficially defendable. But both are misleading the readers by what they don’t say. Ms. Turner seems to suffer from a very short memory. Long before President Obama came to office America’s small businesses had been experiencing double-digit increases in healthcare premiums such that many businesses no longer offer health insurance to their employees.

A competitive health care market place has been in place in America for well over 30 years. The result is we have the most expensive, dysfunctional system in the entire industrial world that leaves 1 of 6 Americans uninsured, a million medical bankruptcies, and 45,000 premature deaths yearly because of limited access to care. The countries with the less competitive markets have none of these disadvantages and spend half as much.

Mr. Kusler fails to mention that legislation that prevents denials for “previous conditions” doesn’t help much if the premiums are unaffordable. Obamacare does not prevent the insurance industry from raising premiums as was pointed out in Ms. Turner’s editorial. Even with expansion of Medicaid and government subsidies to buy insurance, ACA will leave more than 20 million Americans uninsured, a fact Mr. Kusler does not include. More importantly, the American “non-system” of health care requires 1 in 3 health care dollars to be spent on administration.

Such an incredible bureaucratic waste will become even greater as the government attempts to track employment and financial status of its citizens in order to determine their eligibility for subsidies. Finally, and the most glaring oversight by Mr. Kusler, is the reality that the medical insurance products that Americans will purchase will come with high deductibles, co-pays, and limited protection against serious illness. By preserving the private insurance industry’s stranglehold on health care, Obamacare makes health care subject to corporate profitability — not a public good.

When President Obama arrived on the scene, America’s health care system was in need of repair just like our economy was in need of help. Unfortunately, in both instances, the Obama administration in collaboration with both parties called upon corporate America to fix the problems that they (corporate America) had largely created. Not unexpectedly, their solutions served corporate America’s interests rather than that of most Americans and at the end of the day we will find that our health care system problems will remain unsolved.

Both Mr. Kusler and Ms. Turner reflect the views of our present political power structure and both leave out the only viable solution which is a publicly financed, privately delivered single-payer system.

Dr. William Davidson is a retired cardiologist and now works part-time at the Veterans Administration Hospital in Lebanon. He is also a member of HealthCare4AllPa which advocates for Single Payer state bill SB400 (The Family and Business Health Care Security Act).

http://www.pennlive.com/opinion/index.ssf/2013/03/single_payer_health_care_solution.html

Single-payer health care is still right way to go

By Dave Zweifel
The Capital Times (Madison, Wis.), March 23, 2013

For the 11th straight year, Michigan Democratic Rep. John Conyers has introduced what he calls the Expanded and Improved Medicare for All Act to establish a universal, single-payer health care system in the United States similar to what exists in most developed countries throughout the world.

Conyers’ plan is the real health care reform that the United States, if its politicians weren’t so beholden to special interests, would have adopted decades ago.

Instead, we are struggling with more jury-rigged reform that allows governors like Wisconsin’s Scott Walker to play cynical political games to make it as complicated as possible.

Obamacare is surely better than anything we’ve had up until now and once it is fully implemented will remove millions of Americans from the rolls of the uninsured.

But a single-payer plan is still the way the nation ought to go. Everyone in the country would have health care from the day they’re born to the day they die. Conyers would essentially expand the single-payer Medicare program for senior citizens to include everyone in the country.

It would cover primary care, inpatient and outpatient care, emergency care, prescription drugs, durable medical equipment, long-term and palliative care, mental health services, dental services, vision and hearing.

Conyers, who was joined by 37 other House members, would provide that private hospitals, physicians and other health providers could continue to operate as private nonprofit entities, but they would no longer be investor-owned. Hospitals, health centers and other health care organizations would be paid a monthly lump sum within a global budget to cover all operating expenses while physicians would be paid fee-for-service payments or offered regular salaries.

Under the Michigan congressman’s plan, a trust fund would be established to fund the Medicare for All program. The fund would include existing sources of federal government spending for health care, increase personal income taxes on the top 5 percent of income earners and institute modest payroll tax increases. That total is expected to be less than the premiums and health care expenses currently borne by companies and individuals.

Conyers’ plan has little chance of going anywhere, but one of these days perhaps the country will wake up to finally making health care a right of U.S. citizenship.

Dave Zweifel is editor emeritus of The Capital Times.

http://host.madison.com/news/opinion/column/dave_zweifel/plain-talk-single-payer-health-care-is-still-right-way/article_b190882c-9251-11e2-9aff-001a4bcf887a.html#ixzz2OZA6gf4z

That's what you get when you kick the can down the road

By Andrew Coates, M.D.
WAMC Northeast Public Radio, March 22, 2013

“Kicking the can down the road” is an idiom that means to defer something crucial in hopes that the problem will become someone else’s responsibility. The other day it occurred to me that “kicking the can down the road” has become a trademark of contemporary governments worldwide — from the European debt crisis, to the so-called sequester, to the decision to defer changing the tax on New York’s wealthy until a non-election year.

In many ways President Obama’s “health care overhaul,” the Affordable Care Act, is another example of kicking the can down the road. Here at the third anniversary of the reform, the bulk of the law will not begin to take effect until next year — and its full process will continue through 2019, all the way to the Presidential election after the next Presidential election.

Perhaps then it is small wonder that the Kaiser Family Foundation Health Tracking Poll found this week that a solid majority of Americans, fifty-seven percent, have no idea what the impact of the Affordable Care Act will be. Three years after “health care overhaul” was signed into law we’re still Waiting for Godot.

The Kaiser Foundation pollsters had the good sense to ask about things that were part of the debate four years ago but not part of the law. They found that a majority of people mistakenly believe that the reform will implement a so-called “public option” insurance plan.  Four of ten people think that there are government “death panels” empowered to decide whether Medicare beneficiaries live or die, although this too has no basis in reality.

The real facts are not encouraging. Inadequate access to care, uninsurance, underinsurance, medical bankruptcy and state-by-state rationing of care for the poor remain the order of the day. The real experience for those in need of medical care has not improved. Indeed in many communities it has worsened.

Still, the Affordable Care Act promises private insurance for the uninsured — starting next year. The plans offered through the state exchanges will be benchmarked to cover a minimum of 60 percent of the anticipated health care costs.

That means that a family plan purchased on the on the New York exchange will cost about $21,000 in a year in premium payments, plus an anticipated $12,500 in out of pocket expenses. Of course you can pay more if you want better coverage. In other words, starting this fall the uninsured will be able to sign up for unaffordable — yet insufficient — health coverage.

Families earning less that $92,000 will be given tax subsidies for insurance premiums, — but each family eligible will face a significant, personalized, calculus problem about whether or not to purchase insurance.

The Kaiser Family Foundation’s polling found that most people have no idea about this. I think this reveals popular wisdom. Some things we might rather not know! Cynicism and distrust of the anti-establishment that amounts to a healthy impulse.

The mainstream media consistently fails to lead with the facts. He-said, she-said reporting, with no grounding in facts, dominates. Casual attention to NPR and the daily papers invited the conclusions that both death panels and socialism were debated on Capitol Hill.

The real problem is that the Affordable Care Act kicked the can down the road, rather than taking responsibility for the health care crisis that the United States has right now. Small wonder that people don’t know how the law will change the status quo — when the ACA never aimed to to change the status quo in the first place. Unaffordable underinsurance will remain the best we can do.

That’s what you get when you kick that can down the road — until the day when the cans in the road block the way forward. Soon now we will all need to face the fact that nothing short of a public, national single-payer health program will be able to control costs, guarantee access to all, improve the quality of care — and raise us all up.

Dr. Andrew Coates practices internal medicine in upstate New York. He is president of Physicians for a National Health Program.

You can listen to Dr. Coates’ commentary here:
http://www.wamc.org/post/andrew-coates-thats-what-you-get-when-you-kick-can-down-road