PNHP

Care crisis: Medicare for all

Care crisis: Medicare for all

By the Editorial Board
The Charleston (W.Va.) Gazette, March 17, 2013

CHARLESTON, W.Va. — Health care should be a human right for all people. Medical insurance should be universal, covering everyone. It should be operated by government, the only sector with enough power to curb runaway trillion-dollar costs. Insurance firms and medical corporations shouldn’t get rich from sickness, their executives pocketing millions per year. U.S. employers shouldn’t be forced to spend more than $7,000 per employee per year for health insurance.

Most modern democracies have nationalized “single-payer” health systems guaranteeing care for all at moderate cost — but America shamefully clings to for-profit medicine, and the U.S. system is a disaster.

The entire March 4 Time magazine is devoted to America’s dilemma, in a cover story titled “Why Medical Bills Are Killing Us.” The 25,000-word study says:

“In the United States, people spend almost 20 percent of the gross domestic product on health care, compared with about half that in most developed countries. Yet in every measurable way, the results our health care system produces are no better and often worse than the outcomes in those countries …. We’re likely to spend $2.8 trillion this year on health care ….”

“Why exactly are the bills so high? What are the reasons, good or bad, that cancer means a half-million or million-dollar tab? Why should a trip to the emergency room for chest pains that turn out to be indigestion bring a bill that can exceed the cost of a semester of college? … Why does simple lab work done during a few days in a hospital cost more than a car?”

The long report describes families who are devastated by colossal medical bills. And it describes sky-high profiteering by medical executives. The CEO of Medtronics electronic device firm was paid $25 million in 2012 — and hospital administrators grab up to $5 million yearly.

It described a blue-collar Oklahoma man who suffered back pain, and a Catholic charity hospital billed him $86,951 for a one-day visit to install an electronic nerve interceptor. The hospital’s administrator is paid $1.9 million per year.

Surprisingly, Time concludes that Medicare, America’s chief “socialized medicine” system, is the best cure for skyrocketing costs, because it clamps tight controls on medical bills. And its bureaucracy is super-frugal. Medicare spends just $3.80 each to process more than 1 billion claims per year — while Aetna insurance spends $30 to process each claim. Commercial insurers waste a lot of money trying to foist bills onto someone else.

For generations, Democrats in Washington have sought to bring low-cost universal health care to America. President Obama’s landmark 2010 reform was a major step. Maybe the wisest course would be to expand Medicare until it covers every American.

http://www.wvgazette.com/Opinion/Editorials/201303170050

Oregon bill backs study of single-payer financing

By Bennett Hall
Corvallis (Ore.) Gazette-Times, March 18, 2013

Oregon health care reformers are hoping a measure working its way through the Legislature will help them prove what they’ve been claiming all along: that a single-payer system is the cheapest way to provide quality care for all.

House Bill 3260 would direct the Oregon Health Authority to conduct a feasibility study on at least four options for financing health care delivery in the state, including a publicly financed single-payer system.

The study also would evaluate the costs of continuing to rely on a mix of public health plans and private insurance; an option that would allow consumers to choose between publicly funded and private plans; and one or more other options designed by the researchers conducting the study.

In addition, HB 3260 sets out a list of criteria that any financing system should meet. Among other things, the system should provide:

• universal access to comprehensive care;
• transparency and accountability;
• integration of physical, dental, vision, mental health and long-term care;
• reduction of administrative costs; and
• sufficient, fair and sustainable financing.

Rep. Michael Dembrow, a chief sponsor of the bill, called it part of a long-term plan to create a single-payer health care system in Oregon.

The Portland Democrat noted that the earliest such a system could be implemented would be 2017, when states can seek waivers under the federal Affordable Care Act. In the meantime, he and others are laying the groundwork.

Earlier this session, Dembrow reintroduced the Health Care for All Oregon Act, which would create the framework for a state single-payer system. While he doesn’t expect that measure, House Bill 2922, to pass this session, Dembrow noted that its already attracted 24 sponsors, more than twice the support he got for HB 3510 in the 2011 Legislature.

“The bill is not fully fleshed out in terms of a funding mechanism,” he said. “What we need to do is get to that level of specificity, and that’s what (HB 3260) does.”

Dr. Mike Huntington of Corvallis, a leader of the statewide reform group Health Care for All Oregon, said a thorough financial analysis could set the stage for serious discussion of single payer.

HB 3260 is similar to a measure passed by lawmakers in Vermont several years ago. The feasibility study it authorized was a key step on that state’s path to adopting a modified single-payer health care system.

“We are convinced that publicly managed financing is critical to any health-care plan,” Huntington said. “But to be persuasive for the public and the Legislature, we want to have a study done specifically for Oregon.”

The study, expected to cost between $250,000 and $500,000, would be financed by grants and private donations. Under terms of HB 3260, the Oregon Health Authority would be expected to complete the job and offer its recommendations on health care funding before the 2015 Legislature opens.

Hearings on the measure have been scheduled for early April before the House Health Care Committee, and Dembrow said he’s expecting a strong show of support.

“I’m feeling very, very optimistic,” he said. “There really seems to be a lot of momentum behind this bill.”

http://www.gazettetimes.com/news/local/bill-backs-study-of-single-payer-financing/article_71ee5e10-8dbf-11e2-a5b9-001a4bcf887a.html

Rhode Island's is 41st state AFL-CIO to endorse H.R. 676

By Single Payer News

On Feb. 25 the Executive Board of the Rhode Island AFL-CIO unanimously endorsed H.R. 676, Expanded and Improved Medicare for All, the national single-payer legislation recently reintroduced into Congress by Rep. John Conyers Jr., D-Mich.

George Nee, president of the Rhode Island AFL-CIO, stated, “Year after year America continues to spend more and get less in return for our broken health care system, something must be done. The Rhode Island AFL-CIO strongly supports single-payer national health care as a way to insure all Americans, cut wasteful spending out of our health care system, and contain costs in a system where prices are spinning out of control. All Americans should have access to high quality affordable health care, that does not jeopardize the financial or physical well-being of themselves, their families, or the companies they work for.”

The vote followed a presentation on single payer health care by J. Mark Ryan, M.D., F.A.C.P., president of the state chapter of Physicians for a National Health Program (PNHP). Dr. Ryan is an internist in Providence where he provides primary care at the University Medicine Foundation. “I was very impressed at how knowledgeable the Executive Board members were about H.R. 676 and the benefits of single-payer national health care,” Dr. Ryan told the All Unions Committee.

The Rhode Island AFL-CIO is the umbrella organization for more than 250 local unions which represent over 80,000 working men and women across the state. The story on the Rhode Island AFL-CIO website is here.

*****
H.R. 676 would institute a single payer health care system by expanding a greatly improved Medicare to everyone residing in the U. S.

H.R. 676 would cover every person for all necessary medical care including prescription drugs, hospital, surgical, outpatient services, primary and preventive care, emergency services, dental (including oral surgery, periodontics, endodontics), mental health, home health, physical therapy, rehabilitation (including for substance abuse), vision care and correction, hearing services including hearing aids, chiropractic, durable medical equipment, palliative care, podiatric care, and long-term care.

H.R. 676 ends deductibles and co-payments. H.R. 676 would save hundreds of billions annually by eliminating the high overhead and profits of the private health insurance industry and HMOs.

In the current 113th Congress, H.R. 676 has 41 co-sponsors in addition to Conyers.

H.R. 676 has been endorsed by 598 union organizations including 144 Central Labor Councils/Area Labor Federations and 41 state AFL-CIO’s (KY, PA, CT, OH, DE, ND, WA, SC, WY, VT, FL, WI, WV, SD, NC, MO, MN, ME, AR, MD-DC, TX, IA, AZ, TN, OR, GA, OK, KS, CO, IN, AL, CA, AK, MI, MT, NE, NJ, NY, NV, MA, & RI).

For further information, a list of union endorsers, or a sample endorsement resolution, contact Kay Tillow, All Unions Committee for Single Payer Health Care–HR 676, c/o Nurses Professional Organization (NPO), 1169 Eastern Parkway, Suite 2218, Louisville, KY 40217. Phone: (502) 636 1551 E-mail: nursenpo@aol.com, unionsforsinglepayer.org

Single-payer health care: What it is, what it isn't

Step back and look at it with clear eyes. You’ll see that it’s practical.

By Bonnie Blodgett
Star Tribune (Minneapolis), March 16, 2013

Dr. David Dvorak is an emergency room physician. He supports a single-payer system for Minnesota and wants to make one thing clear: “single payer” doesn’t mean socialized medicine.

In Germany, for instance, hospitals and doctors compete for customers, and the market dictates the cost of what they provide. The government pays the bill because health care isn’t viewed as discretionary but as a basic right. Every taxpayer pays in, according to ability and regardless of illness or age. This creates a vast pool, to borrow a term from the insurance industry, and the larger the pool, the smaller the risk that each participant poses to everyone else. Now that’s an insurance plan!

What bothers Dvorak is that in this country health care is such a hodgepodge. About half of us get coverage through our employers. There are nonprofit insurers and for-profit insurers. The latter group spends about twice as much in overhead as their nonprofit peers. If you’re uninsured because you’re self-employed, unemployed or have a preexisting condition and are 19 or older, well, that’s too bad — but not at all surprising. Fifty million Americans are in the same predicament. Health crises are now the No. 1 cause of bankruptcy in the United States.

Veterans Affairs and Medicare take care of the sickest among us yet somehow manage to deliver health care at the lowest cost. Could that be, at least partly, because they’ve eliminated the middleman? The nonpartisan U.S. General Accounting Office concluded that a system like Germany’s would save the United States nearly $400 billion per year, enough to cover all of the uninsured.

Critics believe that single payer would put an end to innovation. It’s a false argument to begin with, but look at the record: Shiny new stents, scanners and specialists don’t automatically deliver improved health. Moreover, gains produced by medical breakthroughs are erased by such mundane realities as this: When people lose their health coverage, they put off going to the doctor until the cost to heal them is through the roof. Who pays? Taxpayers. Fact is, business pays less than 20 percent of our nation’s health bill, while 60 percent is funded by taxes and the rest is out-of-pocket.

We are spending twice as much as other wealthy democracies — yet our health outcomes, including life expectancy and infant mortality, keep heading the wrong way compared with theirs. Meanwhile, insurance companies and their top executives are raking it in. It takes a certain kind of smarts to deliver shareholders the handsome rewards they’ve come to expect from this industry, rewards that also accrue to the benefit of those brainy executives, whose salaries are dwarfed by what they receive in stock options.

In 2009, when the rest of the nation was mired in recession, the New York Times asked the UnitedHealth compensation committee why CEO Stephen J. Hemsley had been awarded $100 million in stock options that year. The committee praised their man for “enhancing the Company’s reputation, ethical culture and tone at the top.” The Times noted that Hemsley’s predecessor, William W. McGuire, “had stepped down in a scandal over his stock options.”

UnitedHealth employs ordinary people, of course. Jobs are important. But do these jobs grow the economy in a meaningful way? Do they create new treatments or diagnose tumors or comfort an ill patient?

Many studies have proven that single-payer systems are vastly more efficient and fair than our own combo platter. The Affordable Care Act reforms a system that needs to be replaced. In 2017, states will be allowed to opt out. Maybe, on this issue, the agendas of left and the right will align. Conservatives who like taking power from the feds and liberals who see health care as a human right might just see eye-to-eye enact the first single-payer system right here in Minnesota.

That’s how it started in Canada. Dvorak likes to point out that when asked in a nationwide poll to pick from a star-studded roster their greatest national hero, Canadians chose Tommy Douglas, who set up a single-payer health care system in Saskatchewan that was so successful the rest of the country wanted in.

Something else Dvorak wants to clarify: He’s not some renegade outlier. Polling shows not only that two-thirds of Americans support single-payer, but that 59 percent of American physicians do, too.

Why didn’t you know that? Spin. Insurance companies spent $1.5 million a day lobbying to ensure that the ACA would pose no significant threat to its presence in health care. That’s what I mean by smart.

Bonnie Blodgett is a St. Paul writer.

http://www.startribune.com/opinion/commentaries/198548261.html

A disaster in the making – defined contribution for employer plans

To Save, Workers Take On Health-Cost Risk

By Anna Wilde Mathews
The Wall Street Journal, March 17, 2013

Last fall, two big employers embarked on a radical new approach to employee health benefits, offering workers a sum of money and allowing them to choose their health plans on an online marketplace. Now, the first results are in: Many workers were willing to choose lower-priced plans that required them to pay more out of their pockets for health care.

The new online marketplace, operated by consulting firm Aon Hewitt, a unit of Aon PLC, was used by more than 100,000 employees of Sears Holdings Corp. and Darden Restaurants Inc. (Olive Garden and Red Lobster), as well as Aon itself, to pick plans for 2013. The employers gave workers a set contribution to use toward health benefits, and they could opt to pay more each month to get richer plans, or choose cheaper ones that might have bigger out-of-pocket fees, such as higher deductibles.

Such employer-centric marketplaces, known as private exchanges, are separate from the public exchanges created by the federal health overhaul law, which will be set up by state and federal governments. However, the public exchanges, serving individual consumers and small businesses, will operate on a similar principle of allowing people to shop for health coverage in an online marketplace.

Companies offering the exchanges say that a lot of employers are considering the approach. “The interest level is like nothing I’ve ever seen,” said Eric Grossman, a senior partner at Mercer.

Change in workers’ choices:

Consumer-Directed Health Plan (Higher deductible)
2012: 12%
2013: 39%

Health Maintenance Organization (HMO)
2012: 18%
2013: 14%

Preferred Provider Organization (PPO)
2012: 70%
2013: 47%

http://online.wsj.com/article/SB10001424127887323639604578366420251188326.html

Comment:

By Don McCanne, M.D.

Be prepared. Very shortly you will be hearing from the supporters of consumer-directed health plans (CDHPs) of the phenomenal success of these plans wherein you put consumers in charge of the money to be used for their health plan purchases. In the first year of this program, there has been a massive shift from more traditional preferred provider organizations (PPOs) to these CDHPs. But you have to understand why this is really terrible news.

Under the traditional employer-sponsored defined benefit health plans, the employers purchase plans for their employees, with the employees paying a percentage of the premium. If the employer offers options, the employee will often select the plan that requires a lower contribution – typically a PPO, but with enough benefits to provide some health security.

Under this newer model of employer-sponsored defined contribution health plans, the employers give a fixed amount of money to each employee to be used to select plans from these private insurance exchanges. Since the employees become responsible for 100 percent of the premium costs above the employer defined contribution, the employees have a much greater incentive to choose plans with the premiums that are closest to the amount of the employer defined contribution – typically a cheaper CDHP.

The experience in the first year alone, with this Aon-operated exchange, 23 percent of employees dropped PPOs, and 4 percent dropped HMOs, resulting in increased enrollment in CDHPs from 12 percent in 2012 to an astonishing 39 percent in 2013!

While the CDHP advocates spread the word that giving consumers control of their health insurance dollars will lower health care spending by allowing employees to “buy only the insurance that they need,” they will remain silent on what really happened. They shifted risk from the employers and their insurers onto the backs of the employees.

How does this work? First, it is important to understand that the workforce and their young families are the healthiest sector of our society. When selecting a plan, it is understandable that many workers would prefer to take home more money in exchange for the risk of paying more out of pocket in the unlikelihood of a major medical event occurring in the next year. People who live check-to-check welcome trading a higher net income for accepting more risk should a low-odds event happen to them.

Keep in mind that a minority of workers or their family members actually will face major medical events. Should that occur, these individuals, who have quite modest incomes, will be responsible for huge medical bills – bills because of the very high deductibles, high coinsurance, and all costs of out-of-network care in these plans that tend to have more limited networks.

This is a setup for personal bankruptcy. Should these CDHP-enrolled employees lose their bets and end up with major injuries or major medical disorders, a very large percentage of them will face this prospect . This is exactly the opposite of what their health care coverage should be providing. The system should ensure that financial barriers to care are removed so that patients can access the care that they need without having to face severe financial hardship.

So when the CDHP advocates tout the success of empowered health care insurance shoppers, they will be able to claim that it works really well for most workers and their families (only not for those who end up needing health care). We need to keep exposing this con job.

Dr. Steffie Woolhandler: Time to end medical debt, medical bankruptcy

The following is an unofficial, slightly edited set of excerpts from a March 4 telephone interview with Dr. Steffie Woolhandler, professor at the City University of New York School of Public Health at Hunter College, visiting professor of medicine at Harvard Medical School, and co-founder of Physicians for a National Health Program, conducted by Dr. Margaret Flowers and Kevin Zeese on their radio show “Clearing the FOG” on We Act Radio, 1480 AM, in Washington, D.C. It took place in the run-up to Strike Debt/Rolling Jubilee’s week of actions, March 16-23, which will spotlight the problems of medical debt and medical bankruptcy. The full radio show, which includes a spokesperson for Strike Debt, can be listened to here.

Dr. Margaret Flowers: Welcome, Dr. Woolhandler.

Dr. Steffie Woolhandler: Good morning. Thank you for having me.

How to people get into medical debt?

Some people get into medical debt because they have no insurance and they get sick. But the majority of people with serious medical debt have insurance, but their insurance is partial – full of gaps like copayments, deductibles and uncovered services.

So what happens is that people get sick, they try to use their insurance, and find that they’re still left holding literally thousands of dollars in unpaid medical bills.

You’ve done several research studies on health care and bankruptcy. What have those studies found?

We interviewed more than 2,000 people in federal bankruptcy court to figure out why they went into bankruptcy. In about 60 percent of all personal bankruptcies, medical bills and medical illness played a major role. Either people were uninsured and got sick, or they were insured, but found that their insurance really failed them when they had a serious illness.

More than three-quarters of people in medical bankruptcy had health insurance when they first got sick. Now, some of those people got so sick they lost their job, or they had to quit their job to take care of a sick family member. When they lost their job they lost their insurance. But even more commonly, people had insurance, usually private insurance, that they kept throughout their medical illness, but were bankrupted anyway because of gaps in coverage like copayments, deductibles and uncovered services.

What’s the trend regarding copayments, deductibles and uncovered services? Is the situation going to improve when Obamacare takes hold?

No. In fact, the federal health law will make the problem of gaps in coverage much more serious because the required insurance policies under the legislation are extremely skimpy. The so-called bronze policies, which are the cheapest policies that will meet the mandate under Obamacare, will only cover about 60 percent of your medical costs. People who buy those plans will still be responsible for 40 percent of total medical care costs. Typically, for someone with a bronze plan who got sick and tried to use their insurance, they would have at least $6,000 per person in out-of-pocket medical costs every single year they’re sick.

This is really the first time that the government has put its stamp of approval on such extremely skimpy policies. In the past, some states were trying to get consumer protections or were trying to regulate the insurance market to make the policies more generous, but Obamacare really reversed that trend with the federal government stepping in and saying we’re going to have these bronze policies that only pay 60 percent of your costs. The federal government is saying, “That’s fine with us, we think that’s OK.”

So the new federal health law has in some ways made the problem of underinsurance worse. It does improve the problem of being completely uninsured, we all know that. Approximately half of all currently uninsured people will receive coverage under Obamacare, and the other half – around 30 million people – will remain uninsured. But when we get to the problem of underinsurance, people with only partial coverage, Obamacare actually makes the situation worse.

The subsidies only kick in with the silver plan or higher. Is that true?

For whatever reason, the subsidies are only available if you purchase at the silver level, and the subsidies phase out at about 250 percent of the federal poverty level, so the subsidies disappear at a relatively low income level.

Can you speak about the impact of financial barriers to care on our health?

There’s a tremendous body of research saying that when people have no insurance, they don’t get preventive care, they don’t get primary care, and when they have a serious illness and go to the hospital they have much worse outcomes – they’re more likely to die.

There’s a growing body of evidence showing that people who have insurance, but have these skimpy policies, so-called underinsurance policies, also face really bad health consequences. When people have skimpy policies they delay getting primary care, they delay going to the hospital, and they also have worse outcomes than people who have full coverage.

We need a system where everybody has coverage for all medically necessary care, because that’s really the only way to assure people get the care they need, and it’s the only way to protect the budget of American families from the very high costs when a serious illness hits.

Do other countries have this problem of underinsurance?

Many countries have systems that cover virtually 100 percent of all medical care. In Canada, traditionally, people have 100 percent coverage of hospital costs, 100 percent coverage of doctors. Certainly in Great Britain there’s a tradition of 100 percent coverage for many people.

Some of the European countries do have copayments; however, in those countries they have much more equal income distribution so they don’t have the huge group of very poor people that we have here, or even low-income people like we have here, who just don’t have the cash in their pocket to pay a copayment.

We have a bad situation in the United States with a lot of income inequality, lots of people who are just barely getting by on their paychecks, and then health care costs, which even if you have insurance, can run into thousands and thousands of dollars out-of-pocket expenses every year.

How will Obamacare affect the middle class?

The underinsurance is actually a very big hit on working families. People are living paycheck to paycheck but are getting by, they’re making it work, and then something like appendicitis or a bad car accident will sink the family and push them into bankruptcy. So one of the things that would really improve the financial security of working families would be if insurance really covered everything.

You’ve also lived and worked in Massachusetts. How is their health law working out?

The Massachusetts health law was the model for the national plan. In Massachusetts, the new law cut the number of uninsured by approximately half, which is what is expected to happen nationally, but you still have about half of the uninsured around, lacking insurance.

The problem is that after enactment of the law, a lot of the services that were available free for the uninsured have been cut. Safety-net funding was reduced by the law. And again that’s going to happen with Obamacare. There’s about $36 billion in cuts to safety-net hospital payments under the federal
health law. There will still be uninsured people – 30 million of them after Obamacare is fully implemented – but the safety-net institutions that care for them will be starved of funds. So, while some people may be better off under Obamacare, certainly, some folks who are uninsured will be significantly worse off under the new legislation.

So basically what’s happening is that cuts are being made to public programs so as to subsidize private insurance?

Yes, that’s what’s going on. And it’s important to remember that the safety-net institutions are not just there for uninsured people – that’s very important, of course – but safety-net institutions also take care of patients with insurance who can’t get care in the private sector. Some who have mental illness problems, or substance abuse problems, may not be welcome in the private sector, regardless of their insurance. Those folks may have to seek care in the safety net, and those institutions have seen their funds taken away and given to private insurance under the Massachusetts law and also the Obamacare legislation.

Has the Massachusetts reform controlled costs?

Health care costs have absolutely not been controlled in Massachusetts despite the fact that then-Gov. Romney claimed that the 2006 reform would control them. Massachusetts’ health care costs are the highest in the nation and continue to rise very rapidly. In fact, it’s pretty certain that they’re the highest health care costs anywhere in the world.

How about medical bankruptcies in Massachusetts? You’ve also done research on that, correct?

Medical bankruptcy in Massachusetts still accounts for about half of all bankruptcies. That was true before the 2006 legislation went into effect and that was true after 2009, after the legislation had been around for a couple of years.

It’s pretty clear that what was done in Massachusetts didn’t impact the problem of medical bankruptcy in any significant way. And if you look at what the insurance is like in Massachusetts, it’s pretty similar to what will occur under Obamacare, that is, very high copayments and deductibles.

If you go on the Massachusetts exchange website, it’s actually called The Connector, you’ll see the cost of a policy of someone in their fifties. For someone in their fifties, the premium would be about $5,000 per year, but then that policy would come with a $2,000 deductible – so figure $7,000 out-of-pocket before the insurance pays a single penny. And then, thereafter, for the next $15,000 in spending, you, the patient, are responsible for 20 percent of the costs, year after year.

Keep in mind that the plans in Massachusetts are a little better than what we can expect under Obamacare.

You’ve been working on these problems for many years. What do you think is the solution?

A single-payer solution, sometimes called an expanded and improved Medicare for all. Everyone would be covered in a program like Medicare, only the single payer would eliminate all of the copayments and deductibles that exist in Medicare.

It’s sometimes called a single-payer system. It’s the type of system that they have in Canada and in several western European countries. You pay for the system out of taxes. Patients have complete free choice of doctor and hospital. There’s no copayments, no deductibles for covered services.

Nations with single-payer systems actually have lower health care costs than in the United States, largely because the administrative costs in a single-payer system are so much lower. If you just have one agency, something like Medicare or Social Security, paying all the doctor bills, giving budgets to hospitals, and so on, you save several hundred billion dollars a year on health care paperwork and administration and that makes the entire health care system substantially more affordable, not just for individuals, but for the government and society.

How can listeners to this program get involved?

I mostly want to echo what’s been said by some of the Strike Debt/Rolling Jubilee people. People are in debt and it’s not your fault if you’re in debt and it’s particularly not your fault if you’re in debt because of a medical problem. This is unfair. No other developed nation forces people to go into debt because they get sick. We need to be thinking of moving toward a fair, efficient, single-payer system so that no one ever has to go into debt because they have the misfortune of being sick.

Americans need Medicare for All

By Hedda Haning, M.D.
Daily Mail (Charleston, W.Va.), March 12, 2013

What’s the matter with our health care?

For the vast majority of docs, their primary concern is to take good care of their patients. But the fact is they also have to pay their expenses and earn a living.

The way things stand now, providers carry much uncompensated care on their books. Their administrative overhead — for pre-approving procedures, re-submitting denied requests, appealing, billing and collecting payments — is huge.

Let me explain about usual and customary fees.

That is the fee the doctor “usually” charges for a given procedure. Insurance companies say they want to pay the doctor’s “usual and customary fees,” but doctors have learned from experience that private insurance companies will pay about half of what the doctor bills.

Doctors solve the problem by billing double what they know will really cover their costs so as to overcome the insurance company scam. This is an old game.

The big problem is that patients suffer, because uninsured patients are responsible for the entire “usual and customary” fee, proving it is usual and customary. They aren’t allowed to scam the billing numbers as the insurance companies do.

Uninsured patients always pay more if they can afford to pay anything.

Also, in the United States, private insurance overhead is at least 30 percent, a cost passed onto the payer. To clarify: the 30 percent does not pay for care.

In the private setting, overhead pays for administration (including repeatedly denying care), advertising and profit.

Medicare has a 3 percent overhead. It’s not Medicare that will bankrupt us; it is private insurance.

Around the world, advanced countries, all having some variation of a Medicare-like system, pay half of what we do and get better care. 

Some suggest that employment will suffer in the United States if numbers of administrative personnel and costs drop because we switch to Medicare for All.

Actually we need more nurses taking care of patients in offices, hospitals, nursing homes, and helping students in school. We just have to prioritize and pay for their employment.

We need more primary care physicians. We need more mental health professionals, including school counselors. Employment will not be seriously at risk.

And just FYI, most medical providers in national health programs overseas have approximately the same income as docs do here. That is true even though we spend twice as much on health care in this country than any other developed country does.

Money wouldn’t seem to be a major issue for doctors, and most of them, particularly in primary care, want out of the “free” market.

Again, what most doctors want is to take good care of their patients; therefore, most doctors want single-payer health care or Medicare for All, as do most Americans when polled.

That means a system in which tests and treatments are not profit-driven, but rather depend on studies that show the best way to care for patients, and then provide the needed care for everyone.

I emphasize: While I am talking about public payment, the care is private. You would choose your own provider, doc or hospital.

Many folks don’t realize that the cost of drugs are tightly regulated elsewhere.  Pharmaceuticals in all other advanced countries are as good as ours, but cost a fraction of those on our market.

Somehow the pharmaceutical companies manage to make a really healthy profit even overseas. They don’t have to bankrupt Americans to make money.

By the way, our Veterans Administration system, in recent years considered the model health care provider in our country according to outcomes and patient satisfaction, bargains drug costs way down.

Can the rest of us learn something here?

Did you know that employer-sponsored health care began during World War II to make up for the wartime wage freeze? That approach was useful then, but doesn’t work for us now.

More than 46 million people are uninsured or under-insured in our country even though most of them are currently employed.

Nearly 50 percent of personal bankruptcies are related to medical expenses even though more than 50 percent of the bankrupt had medical insurance at the time the illness began.

Unfortunately, we have even heard – including in West Virginia – of corporations declaring bankruptcy primarily so they can dump employee benefits, including health care.

Contrary to all rumors, according to rankings on every health care outcome from infant mortality to life expectancy to availability of high-tech equipment, our medical care is mediocre at best. We spend much more per capita than any other developed country and our costs are rising faster.

Let me repeat: Our health care is not the best in any way!

So our current health care system is not the best for patients or doctors, and it is not good for the economy either. Health costs weigh on employers.

Few small businesses can afford to pay for health insurance for their employees these days. Even large corporations feel the sting.

A few years back, it cost at least $1,500 per car for GM to cover health care for employees.  It has to be higher now. Is it any wonder that more cars are currently made in Canada than in Michigan or the entire United States? 

And from the workers’ point of view, if they do have health insurance, they feel unable to risk it by changing jobs. They can’t take that chance either to climb the skills or wage ladder.

Our national medical bill is well over a trillion dollars and climbing.

Health care the way we do it now, private and profit driven, is what threatens our future financial stability.

And that is in spite of the fact that millions of Americans don’t have any health insurance at all.

We can simultaneously make our health care system and our economy better by changing from private health administration to Medicare for All. We have to stop being gullible, and we have to stand for care before profit.

Learn more, and help us work for change. Please join us at 7 p.m. April 25 at the University of Charleston for an open public forum on Single Payer Health Care (and a comparison with the Affordable Care Act).

Haning, a retired physician, lives in Charleston.

http://www.dailymail.com/Opinion/Commentary/201303110146

Selling Expensive Health Care Lemons

By Philip Caper, M.D.
Bangor Daily News, March 14, 2013

In 1970, a University of California economist named George Akerlof wrote a paper titled “Selling Lemons.” In it he explained that a market characterized by a large asymmetry of information between seller and buyer would also soon become characterized by a decrease in the quality of goods and dominated by crooked sellers and gullible buyers. In 2001 he won the Nobel Prize for his work.

Sad to say, I can think of no market that better fits these criteria than health care. In a March 4 Time Magazine cover story titled “The Bitter Pill: Why Medical Bills Are Killing Us,” reporter Steven Brill dissects a number of hospital bills and traces the detailed charges back to their origins. He concludes, “everyone along the supply chain – from hospital administrators (who enjoy multimillion-dollar salaries) to the salesmen, executives and shareholders of drug and equipment makers – was reaping a bonanza. The only exceptions, I found, were those actually treating the patients – the nurses and doctors.”

When you need medical care there is absolutely no way you can accurately determine ahead of time what that care will cost you. Don’t hope to get anything approaching a rational explanation for what you are charged after the fact either. The best you can hope for is that whatever insurance you have will cover most of the costs. If not, you are at the mercy of the hospital and, if you can’t pay, its collection agency.

So you can’t know much about the prices of health care. How about the appropriateness or quality of that care? Again, unless you are a doctor you have very few ways to independently judge the safety or benefits of tests, procedures or prescriptions.

And sometimes not even then. Even among well-trained and conscientious doctors, a great deal of uncertainty exists about the risks and benefits of tests and procedures they order and perform.

As the number of doctors who have become employees of profit or non-profit corporations has increased (now about 80 percent of Maine doctors and rising), they have come under pressure to increase the number of “units of service” they provide – visits, tests, procedures and prescriptions – in order to maximize the revenues and profits of the institutions that employ them.

Lately, the need for many commonly performed procedures has come under question by both government and private health care organizations. The U.S. Preventive Services Task Force has recently warned against the routine performance of some. They include mammograms for young women, hormone replacement therapy for older women, prostate cancer tests for older men and drug treatment to prevent osteoporosis. Many are now thought to do more harm than good. There are many more such examples.

Similarly, the American Board of Internal Medicine, one of the medical profession’s most important credentialing bodies, has recently launched a program called “Choosing Wisely.” Its purpose is to identify tests and procedures that are overused and to persuade doctors and patients to use fewer of them. More than 35 medical specialty societies have joined this campaign, each selecting five or more tests or procedures that they believe are significantly overused. Among these are imaging procedures such a CT scans and MRI, the use of which has exploded in frequency and cost in recent years. It is almost impossible for patients to accurately assess the need for and quality of care.

I still believe that most health care workers want to do the right thing by our patients. But our corporatized and business-oriented health care system is making it increasingly difficult.

Businesses try to optimize prices and sales in order to maximize revenues. When “consumers” (patients) have little or no information about what they’re buying, Akerlof’s prediction that maximization of profits rather than value will dominate decision-making comes true. In other words, the asymmetry of information between patients (who possess little) and health care providers and administrators (who possess a lot) makes anything like a rational market in health care services impossible.

That hasn’t stopped free market ideologues from peddling their flawed and self-serving ideas to anyone who will listen, including some uninformed and perhaps naive lawmakers. One result is legislation like Maine’s new health insurance reform law, passed two years ago.

In his Time article, Brill documents that Medicare is much more efficient and does a much better job of controlling costs than private insurance.  It seems to me that he makes a compelling case for expanding Medicare to everybody. But, in the end, he backs off of actually recommending it because, as he explained in an interview, he fears the power of a health care industry that generates huge profits and spends four times as much on lobbying as does the defense industry.

I’m not so sure he’s right about that. I believe people power can overcome corporate power, especially in states such as Maine.

The next time you hear somebody saying “let the market work in health care,” the most reasonable response would be to pat them on the head, and have a good laugh.

But our profit-driven health care system is bankrupting individuals, putting enormous stress on businesses and state and federal governments and destroying the therapeutic doctor-patient bond of trust. So I guess it’s no laughing matter.

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/2013/03/14/opinion/selling-expensive-health-care-lemons/

Steven Brill on using single payer to "clean up the system"

Experts debate all-payer setups vs. Medicare for all

By Brett Norman
Politico, March 14, 2013

Health care prices are too damn high.

That’s the punch line to the provocative Time magazine piece “Bitter Pill” by Steven Brill, who laid out his diagnosis of the problem Wednesday at a Center for American Progress panel.

He cited sky-high hospital executive salaries and operating margins, monopolistic and opaque pricing by providers and a fearsome lobbying force — many times larger than those of the oil and gas or defense industries — that has beaten policymakers into submission.

“The lap-doggery to the health care industry is bipartisan,” he said. The article has sent hospitals and other stakeholders to the wall in defense of the system, and it’s fueling debates in policy circles.

But while many policy experts agree with much of Brill’s diagnosis of factors that are driving up costs, there’s far less consensus on what to do about it.

Brill said the voluminous feedback he’s received since publishing the article breaks down along two lines. Conservatives believe consumers need to have more “skin in the game” — to pay more of health costs so they become more conscientious shoppers and put pressure on providers to more efficiently compete for their business. And liberals see the solution in Medicare-for-all, a single-payer system, amplifying the negotiating might the federal health care program already leverages to keep costs down.

Brill rejected the single-payer possibility as impractical in his article but now says that he is increasingly siding with that camp. “It’s sort of the cleanest way to clean up the system,” he said.

Brill believes that the federal health care law in general does little to control costs and will most likely drive up the cost of insurance because of new requirements for more robust coverage.

He gave little credence to the Beltway policy wonk goal of transforming the health care system away from paying for quantity of services provided to paying for health outcomes and the quality of care. He said similar efforts to move the legal profession away from billing by the hour and toward meeting performance benchmarks have either failed or proved more expensive.

http://www.politico.com/story/2013/03/experts-debate-all-payer-setups-vs-medicare-for-all-88835.html

Comment:

By Don McCanne, M.D.

Steven Brill provided such a convincing argument for using Medicare as a universal program to control health care spending that he now seems to be convincing himself that we should look beyond the current approach of dismissing single payer as impractical. As he says, single payer is “sort of the cleanest way to clean up the system.”

Experts debate all-payer setups vs. Medicare for all

By Brett Norman
Politico, March 14, 2013

Health care prices are too damn high.

That’s the punch line to the provocative Time magazine piece “Bitter Pill” by Steven Brill, who laid out his diagnosis of the problem Wednesday at a Center for American Progress panel.

He cited sky-high hospital executive salaries and operating margins, monopolistic and opaque pricing by providers and a fearsome lobbying force — many times larger than those of the oil and gas or defense industries — that has beaten policymakers into submission.

“The lap-doggery to the health care industry is bipartisan,” he said. The article has sent hospitals and other stakeholders to the wall in defense of the system, and it’s fueling debates in policy circles.

But while many policy experts agree with much of Brill’s diagnosis of factors that are driving up costs, there’s far less consensus on what to do about it.

Brill said the voluminous feedback he’s received since publishing the article breaks down along two lines. Conservatives believe consumers need to have more “skin in the game” — to pay more of health costs so they become more conscientious shoppers and put pressure on providers to more efficiently compete for their business. And liberals see the solution in Medicare-for-all, a single-payer system, amplifying the negotiating might the federal health care program already leverages to keep costs down.

Brill rejected the single-payer possibility as impractical in his article but now says that he is increasingly siding with that camp. “It’s sort of the cleanest way to clean up the system,” he said.

But two panel members, Ezekiel Emanuel, a senior fellow at CAP who advised the Obama administration on its health care law, and Giovanni Colella, CEO of Castlight Health, offered more market-oriented, all-payer alternatives.

Colella, whose company is dedicated to making health care costs and quality of different providers transparent and comparable, argued that better information will go a long way toward transforming the health care sector into a free market.

Emanuel argued that the public is unlikely to ever have good enough information to become selective health care consumers or, at least, is unlikely to act on that information. He pointed instead to payment reforms such as pilot projects included in the Affordable Care Act that pressure providers themselves to profit from becoming more efficient. And he said that he expects the growth of health care costs, which historically have far outpaced inflation, to level off with the growth in the rest of the economy by the end of the decade.

Brill believes that the federal health care law in general does little to control costs and will most likely drive up the cost of insurance because of new requirements for more robust coverage.

He gave little credence to the Beltway policy wonk goal of transforming the health care system away from paying for quantity of services provided to paying for health outcomes and the quality of care. He said similar efforts to move the legal profession away from billing by the hour and toward meeting performance benchmarks have either failed or proved more expensive.

“If I have to read another [former Office of Management and Budget Director Peter] Orszag article on fee-for-service, I will hang myself,” Brill said.

http://www.politico.com/story/2013/03/experts-debate-all-payer-setups-vs-medicare-for-all-88835.html#ixzz2NWPKFElV

Don't look for workplace wellness programs to produce significant cost savings

A Hospital System’s Wellness Program Linked To Health Plan Enrollment Cut Hospitalizations But Not Overall Costs

By Gautam Gowrisankaran, Karen Norberg, Steven Kymes, Michael E. Chernew, Dustin Stwalley, Leah Kemper and William Peck
Health Affairs, March 2013

This study examined the effectiveness of a program put in place by BJC HealthCare, a hospital system based in St. Louis, Missouri, that tied employees’ eligibility to participate in the system’s most generous health plan with participation in a wellness program. We found reductions in inpatient costs but similar increases in non-inpatient costs. Therefore, we conclude that although the program did cut some hospitalizations, it did not save money for the employer in the short term. This finding underscores that wellness program incentives under the Affordable Care Act are unlikely to greatly reduce health care spending over the short run.

http://content.healthaffairs.org/content/32/3/477.abstract#aff-7

And…

Wellness Incentives In The Workplace: Cost Savings Through Cost Shifting To Unhealthy Workers

By Jill R. Horwitz, Brenna D. Kelly and John E. DiNardo
Health Affairs, March 2013

The Affordable Care Act encourages workplace wellness programs, chiefly by promoting programs that reward employees for changing health-related behavior or improving measurable health outcomes. Although there may be other valid reasons, beyond lowering costs, to institute workplace wellness programs, we found little evidence that such programs can easily save costs through health improvement without being discriminatory. Our evidence suggests that savings to employers may come from cost shifting, with the most vulnerable employees — those from lower socioeconomic strata with the most health risks — probably bearing greater costs that in effect subsidize their healthier colleagues.

Despite the proliferation of wellness programs, drawing reliable conclusions about their financial returns on investment is difficult. Safeway credits its program with holding per capita health care costs flat from 2005 to 2009. However, employers’ reports are largely anecdotal. Some of them may attribute savings to wellness programs that could have resulted from unrelated causes, such as concurrent benefit restructuring or selection via restrictions on participation in the programs to certain job categories. A review of employer wellness studies concludes that they commonly suffer from insufficient controls, selection, and inadequate data.

http://content.healthaffairs.org/content/32/3/468.abstract

Comment:

By Don McCanne, M.D.

Workplace wellness programs were included in the Affordable Care Act partly as a means of promoting better health, but also as a means of reducing future health care spending though prevention of disease. The problem is that there is little empirical evidence that there is a potential for large cost savings from these programs. The two articles cited tend to confirm that wellness programs should not be relied upon to control future spending.

In no way does this mean that workplace wellness programs should be abandoned. Promoting health is a beneficial endeavor and should be encouraged. Rather, there are two other take-home lessons from these articles.

If financial incentives are included in wellness programs, they should be very carefully designed. The article by Jill Horwitz and her colleagues shows that savings to employers may result in the shifting of costs to employees who are more vulnerable due to their lower socioeconomic status which is associated with greater health risks. Using wellness funds for the already healthy while penalizing the more vulnerable is not wise policy.

The other lesson is that we should not pretend that wellness programs, along with the other tweaks in the Affordable Care Act, are going to bring us enough cost savings such that we can abandon efforts to enact the fundamental reforms that we need to ensure that absolutely everyone receives essential health care services under a program that we can afford.

Enacting a single payer national health program – an improved Medicare for all – is perhaps the most important step that we can take to promote wellness for all of us. Of course, there are many other public health measures that we should support, including addressing our serious socioeconomic inequities and injustices. But enacting single payer would be a great first step.

PNHP members react to Time's ‘Bitter Pill’

PNHP note: In addition to longer commentaries by Dr. James Kahn and Dr. Don McCanne on Steven Brill’s special report in Time magazine titled “Bitter Pill: Why Medical Bills are Killing Us,” many members and supporters of Physicians for a National Health Program sent in letters to the editor of the magazine. We reprint here a selection of those letters, none of which have been among the 21 letters published to date.Bitter Pill

Accurate data, flawed conclusions

In “Bitter Pill,” a well-researched and in many ways thoughtful essay, Steven Brill gets all the data right, but then draws conclusions that are surprisingly off the mark.

After providing nearly 20 pages of damning evidence — against both the excesses and inefficiencies of the private health insurance industry, and the runaway profiteering of hospitals, pharmaceutical and device manufacturers — he arrives, or appears to arrive, at the obvious point: that is, “the best way both to lower the deficit and to help save money for people” is “the single payer approach favored by liberals and used by most developed nations.” Here he is right on the mark. But then abruptly, having just provided an argument that clearly supports it, he dismisses this conclusion. He provides two reasons for backing away from single payer: first, “no doctor could hope for anything approaching the income he or she deserves (and that will encourage future doctors to want to practice).” Second, “this kind of systemic overhaul … seems unrealistic” given the extraordinary political power and influence of the health care industry.

The first assertion is factually incorrect. In fact, most doctors would earn the same under a single-payer system as they do now. The main difference in the professional life of myself and of tens of thousands of physicians like me would be freedom from the unimaginably exhausting and time-consuming demands of private insurance company rules and regulations. For those doctors whose high incomes ($1 million or more annually) result from billing for individual procedures like cardiac catheterization and joint replacements, incomes would likely suffer somewhat, but would certainly remain in the mid- to high-six figures. It’s hard to believe that as a nation, we would reject such urgently needed reforms simply to protect these multimillion-dollar salaries.

The second assertion — that it “seems unrealistic” for Medicare to be improved and expanded to include comprehensive coverage for all Americans — is logically flawed. Brill himself admits that the halfway measures he goes on to propose are similarly “unlikely to happen” given the current political power structure. Beyond this, if our society had followed his logic in 1917 or 1954, today we’d be living in a country where women were forbidden to vote and where schools were separated by race.

The injustice of our current health care system is a civil rights issue as urgent as women’s suffrage and desegregation. Now the oppressed are not only women or minorities, but all of us who find ourselves outside the 1 percent of wealth and influence. An improved and expanded Medicare for All would change this. Virtually all other developed countries know this. When will we wake up to this?

Jim Recht, M.D.
Cambridge, Mass.
The writer, a psychiatrist, is co-chair of Massachusetts PNHP.

Brill missed the elephant in the room

Mr. Brill focuses on eight hospital billing statements yet dismisses the American private insurance industry as “ho-hum.” He missed the biggest elephant in the room. The largest single expense in American medicine is the administrative costs of private insurance that would be recovered with a single payer financing plan – that’s $350 billion annually and rising. That $350 billion represents 40 percent of our premium dollars. Half are insurance industry administrative costs; the other half are physician and hospital costs to collect from insurance companies. Remember this industry denies 30 percent of all first claims, requiring physicians to spend $82,000 each to pay clerks to persist in second and third claims.

That $350 billion is more than the combined income of all American physicians; more than the nation spends on all medications; more than we spend on obesity and tobacco-related diseases – combined; and more than we need to expand care to provide complete coverage of everyone in the country.

Every other industrialized nation provides better care to more people for less money than we do, and none use a private insurance industry like ours. Replacing it with a national single payer financing agency, even with no change in hospital billing, will provide everyone in the U.S. with health care for less than spend now. Mr. Brill found the bitter pill but missed the elephant.

Samuel Metz, M.D.
Portland, Ore.
The writer, an anesthesiologist, is a member of the Oregon chapter of Physicians for a National Health Program.

Cure for ailing health system falls short

Mr. Brill’s excellent article does a wonderful job of showing just how expensive, chaotic, dysfunctional and inequitable our health care “non-system” is. However, his prescription for the cure for this “lethal” system leaves much to be desired.

As a physician for 40 years, a Medicare recipient, a patient and an advisor for Medicare Rights helping seniors navigate the complicated terrain of today’s Medicare, I have come to a see that there is a better way to reform. I believe that a single-payer, publicly funded, privately delivered, Medicare for All is the best solution to our health care problem. Treating health care as a social need and not as a commodity from which to make a profit is the only moral path to health justice. It is also the most fiscally conservative solution. All other industrialized nations have already figured this out.

We need to learn from them.

Elizabeth Rosenthal, M.D.
Larchmont, N.Y.
The writer, a dermatologist, is a board member of the N.Y. Metro Chapter of PNHP.

Medicare for All would drive down costs

As someone who has worked on all side
s of the health care field (regulator, nonprofit, for-profit) for 30 years, I was intrigued by the Brill piece “Why Medical Bills Are Killing Us.” On the analysis of the problem, Brill was mainly on target, but he missed the mark on most of his proposed solutions. For example, hospital competition is not the answer to getting lower prices and never has been. Hospital coordination of services within a region via regulation is a far more cost effective way to minimize duplicative purchases of expensive technology, for instance. Furthermore, group purchasing of supplies, pharmaceuticals and capital equipment by large, strong hospital systems has been shown time and again to drive down vendor prices by up to 20 percent versus pricing given to small independent hospitals with no clout. I know: I supervised hundreds of these studies in every area of the country and with many providers, including Sloan-Kettering. He glosses over the real solution: a single-payer system which forces hospitals to be more efficient. Medicare for All, incorporating quality measures, would eliminate all the “chargemaster” game playing Brill decries. The inefficient providers would be paid the same as the effective ones. With higher costs, they would be driven out. Likewise for the ones with poor quality. Plus, the 20-plus percent administrative/marketing costs currently charged by private insurance companies, versus just 3 percent with Medicare, could be put back into direct care where it belongs.

Jack Bernard
Monticello, Ga.

Mere tweaks won’t solve the problem

Steven Brill, in his well-researched special report, “Bitter Pill,” built a definitive case for further improving Medicare and then providing it for everyone as a single-payer national health program. Citing the power of special interests, he then rejects that concept and leaves us with a recommendation for a few tired ideas that would only tweak our dysfunctional health care system. It is time for us to accept the fact that the only special interest that really matters is the patient.

Don McCanne, M.D.
San Juan Capistrano, Calif.
The writer is senior health policy fellow, Physicians for a National Health Program.

Medicare model points the way

Steven Brill rightly identifies the heart of our health care cost problem as wildly inflated charges as well as wasteful diversion of health care dollars to corporate profits enforced by governmental protections for corporate interests. He also rightly notes that LOWERING the age of eligibility for Medicare (making Medicare available to more people) would improve/reduce our health care costs. But then he waffles and says that he isn’t going to come right out and support “single payer,” when, of course, he has just made a case for the single-payer system we have right now that is working so well: Medicare. I’m not sure why he does this, but let me underscore again his observation that Medicare is functioning well, that it does not pay the wildly inflated charges, and that we should make the Medicare option available much more widely — ideally available to all — if we are to bring health care costs under control without simply requiring all patients to pay for everything out of pocket (as increased co-pays or as payment for coverage denied by corporate insurance plans).

Judy Bertelsen, M.D.
Berkeley, Calif.
The writer practices geriatric medicine and is a member of PNHP California.

Why not turn to ‘most logical’ solution?

Steven Brill’s “Bitter Pill: Why Medical Bills are Killing Us” describes the irrationality of the health care market and underscores its gross unfairness toward our nation’s patients, be they insured, underinsured or uninsured. However, Mr. Brill’s remedies for this mess (“tax hospital profits at 75 percent and have a tax surcharge on all non-doctor hospital salaries that exceed, say, $750,000” and “outlaw the chargemaster”) seem more contorted and less workable than what Sloan-Kettering’s chief operating officer, John Gunn, called the “most logical solution” — a single-payer system, an expanded and improved Medicare for all. The Medicare model is a much simpler, economical way of paying for care, and from the look of the shiny new hospitals in retiree-laden Florida, it’s clearly viable.

Roy Korn, M.D.
Middleburgh, N.Y.
The writer is an internist who specializes in geriatric medicine.