PNHP

Do we really have the world’s best cancer care?

Do we really have the world’s best cancer care?

By Samuel Metz, M.D.
KevinMD blog, Dec. 9, 2012

Those who resist health care reform point to America’s great cancer care – instead, we should protect “the best health care system in the world.” After all, if we’re the best, other countries should change, not us.

Do we really have the world’s best cancer care?

A good indication is the American survival rate for breast cancer, the world’s longest. But what are survival rates?

Survival rates reflect time between diagnosis and death from a condition. It is commonly expressed as “Percentage of patients alive five years after diagnosis.” The higher the percentage, the better the treatment appears.

However, treatment is just one of three aspects influencing survival rate.

The first is an earlier diagnosis that does not alter outcome. Although the disease is detected earlier, the patient dies at the same age. Imagine a patient destined to die at age 50 regardless of treatment. Detecting the disease earlier increases survival rate but makes no difference in life expectancy.

Another aspect of survival rate is over-diagnosis. If a tumor grows too slowly to affect life span, then including patients with these tumors in the studied population extends average survival rate independent of treatment. For example, diagnostic scanning for other diseases incidentally may detect slow-growing prostate cancers that, even if untreated, have no effect on life span. If they are included with more malignant cancers, survival rate increases without any treatment improvement.

Survival rates also reflect normal distribution. There are over 200 types of cancers; most are treated similarly among industrialized nations. If we review survival rates from all cancers throughout the industrialized world, different countries lead in different cancers. Survival rates from head and neck cancers are higher in Canada than in the US. Germany has the highest survival rate in esophageal cancer; Austria in stomach cancers; Belgium in pancreatic cancer; etc.

There is the additional question of statistical versus clinical significance. Our five year survival rate for breast cancer is 83.9%, the highest in the world. The survival rate in Canada is 82.5%. Is this difference clinically significant?

Mortality rate, in contrast, reflects the number of people dying of a disease annually. This statistic eliminates the early diagnosis confusion, though over-diagnosis remains.

An intriguing study recently compared mortality rates from all treatable cancers among the US, the UK, France, and Germany. US mortality rates are better compared to our peers. Perhaps Americans do receive better treatment.

Here’s the catch. When mortality rates are restricted only to patients under 65, the US loses its lead – we are right in the middle. Only when we compare mortality rates among patients over 65 do we excel among our peers. Why? Possibly because Medicare gives older Americans the health care access they lacked when younger.

This age breakdown suggests American medicine possibly offers the world’s best cancer care, but only to patients with access to that care. Access for younger Americans depends critically on wealth. Poor Americans without insurance may not receive the excellent care available to wealthier Americans. At least not until their 65th birthday.

The US may offer the world’s best cancer care. However, we cannot boast of leading in cancer outcomes because access is problematic for non-seniors.

Thus, resisters to reform may be right – America does offer the world’s best cancer care. But advocates of reform are also right – too many Americans are denied this excellent care.

America’s poor health statistics do not reflect on our doctors, nurses, and hospitals (who may be the best in the world), but on our inability to get Americans into the clinics and hospitals where these superb providers practice.

We do not need to reform our health care. We need to reform the barriers to accessing that care.

Samuel Metz is an anesthesiologist.

The path to sustaining Medicare

By Jessica Schorr Saxe, M.D.
The Charlotte (N.C.) Observer, Dec. 7, 2012

In January 2009, at the age of 63 1/2, my friend Carol Bentley was laid off her 10-year job without warning. In a one-two punch, her health insurance ended the next day.

She could not afford COBRA.

Desperate about her medical expenses, she was rescued when federal stimulus money temporarily subsidized COBRA for the unemployed. That covered her until she was eligible for Medicare in July 2010.

Even now, tears fill her eyes as she talks about the terror and humiliation of that time. And, without Medicare, she wouldn’t be able to afford necessary care. “I might not even be alive right now,” she said.

Picture those tears as you think of the proposed changes in Medicare.

First, some facts. You have undoubtedly heard the claim that Medicare is moribund. As with Mark Twain, reports of its demise have been highly exaggerated.

The Medicare Part A (hospital coverage) Trust Fund will be solvent until 2024. Even then, using current assumptions, it will cover 87 percent of benefits. And Medicare parts B (outpatient) and D (the drug benefit), funded by premiums and taxes, will continue to be solvent.

Medicare operates relatively efficiently, spending 3 percent or less on administration and overhead compared with 12-14 percent for private insurance.

Elderly Medicare beneficiaries are more satisfied with their insurance and have better access to care and less financial burden from medical bills than non-elderly adults with employer-based insurance.

Does this justify pulling the plug on Medicare as we know it? Hardly.

Some proposed changes are particularly counterproductive. The suggestions to raise the eligibility age to 67 and institute means-testing are high on this list.

Raising the eligibility age would cause physical, mental and financial suffering in seniors who would wait two more years for coverage. It would disproportionately hurt the poor, who are less likely to have other insurance and who have lower life expectancies, giving them fewer years to benefit. It would cost-shift medical expenses from the federal government to others while doing nothing to lower costs. In July 2011, the Kaiser Family Foundation estimated that for the $5.7 billion in federal savings, there would be $3.7 billion additional expenses for affected elderly individuals, $4.5 billion for employers, and billions more for other Medicare beneficiaries and those insured through the exchanges, all of whose premiums would rise.

Means-testing would create one more bureaucracy to implement new criteria, one more set of hurdles for the elderly and disabled to hobble over.

The success of Medicare, like other popular programs such as Social Security, lies largely in its broad base of support. Programs targeted to the poor often become poor programs — and thus miss their mark of improving services to the very people they are supposed to help.

Often lost in this disembodied discussion of billions here, billions there, is the question of health. One of the few health indicators on which the U.S. does relatively well is life expectancy at age 65, unquestionably related to Medicare coverage.

To improve Medicare, let’s improve the benefits package, eliminate deductibles, decrease red tape and actually improve well-being while saving money overall.

In the short term, we could eliminate the Medicare Advantage plans (saving $34.1 billion), supply additional appropriations from general tax revenues, allow Medicare to negotiate drug prices, and modify the payroll tax (last adjusted system-wide in 1985) which would sustain the program longer.

Back to Carol’s tears and fears. Multiply those by millions – and think of all the tears we could save in 65- and 66-year-olds by maintaining the current eligibility age. Then think of all the younger uninsured people who try to hold on until the magic age of 65. The Affordable Care Act will insure some but leave millions uncovered.

They will benefit from the long-term solution: to improve Medicare and extend it to all, taking advantage of low administrative costs and high potential for savings and establishing a publicly financed, mainly privately delivered health system.

Only then will we have truly sustainable Medicare – and a truly sustainable health care system for all.

Jessica Schorr Saxe is a Charlotte physician who is chair of the local chapter of Physicians for a National Health Program.

http://www.charlotteobserver.com/2012/12/07/3713065/the-path-to-sustaining-medicare.html

John Goodman says the problem is the anti-capitalist mentality

The Anti-Capitalist Mentality

John Goodman’s Health Policy Blog
By John Goodman
National Center for Policy Analysis, December 10, 2012
(Excerpts)
Have you ever noticed that people who worry about inequality seem to be focused only on certain kinds of inequality? When they obsess about the income and wealth of the top 1%, they seem to be bothered by only some of those at the top, and not others.
For example, have you ever seen Robert Reich or Paul Krugman or any like-minded complainer bemoan the huge salaries of professional athletes?
Even more puzzling, when is the last time you saw any of them assailing worthless heirs?
Something else is odd about the sociology of the anti-inequality crowd. They seem to be unfazed by inequality created by government.
Take the recent Powerball outcome. At $588 million, it was the largest lottery prize in history ― to be shared by two ticketholders.
Then there is the entire structure of elderly entitlements. They mainly take from people who have less and give to people who have more.
Think about that last finding for a moment. Throughout the country, families who are struggling to get by and who cannot afford to buy their own health insurance are paying 15% of their income to fund hip and knee replacements for our true leisure class, so they can get back out on the golf course.
But when Paul Krugman writes about the top 1%, this is not who he has in mind. He is complaining about the incomes of people who run large companies. He wants their tax rate to be 91%!
I think Ayn Rand may have been right. The left is populated by people who are not especially bothered by those who become wealthy by virtue of birth or luck or good fortune. They do not even seem to be bothered by the winner-take-all feature of professional sports that confers millions of dollars on some athletes while those who were almost as good languish in near poverty. No, who they obsess about are the creators, the builders, the entrepreneurs.
They don’t hate the wealthy who don’t deserve their wealth. They hate the wealthy who do deserve it.
(John Goodman understandably wants his comments to be read in full, which you can do at the following link.)
http://healthblog.ncpa.org/the-anti-capitalist-mentality/
Reader Comments:
Don McCanne says:
December 10, 2012 at 12:30 pm
Although everyone already understands this, it is still important to distinguish between equality and equity. Most progressives are not striving for equality of income and wealth, rather the goal is equity – introduce an element of fairness in distribution.
Although sometimes expressed as an anti-corporate bias, the objection is more to policies favoring massive perverse distributions, as from rent seeking for instance. Rent seeking that provides little net benefit to society while the rent seekers scoop up the wealth, to many of us represents an intense sense of unfairness.
The work of Piketty and Saez demonstrates the unfairness that has now become the norm. In the face of a massive transfer to the wealthy, median household incomes are no longer enough to bring average families the American Dream – paying for essential needs while allowing enough for higher education of their children, adequate retirement accounts, medical costs for those with greater needs, and perhaps even a modest improvement in housing and transportation, and even an occasional well-earned vacation. And keep in mind the obvious that half of all households fall below the median.
With equitable public policies in a wealthy nation like the United States, hard working families should be able to realize the American Dream. That’s fair. What isn’t fair is for the rent seekers to establish a plutocracy and use it to break up our unions, clobber our retirement and health programs, ship jobs out of the country, saddle higher education with intolerable debt, all of this and similar abuses on top of filling their coffers with funds they have wrested away from the main source of our productivity – the workers of America.
Inequality will always be with us, but we do need policies that increase fairness by reducing inequity in America.
http://healthblog.ncpa.org/the-anti-capitalist-mentality/comment-page-1/…

This blog on “The Anti-Capitalist Mentality” does pertain to health care reform in that we will never have an equitable health care system for all until we decide that equity – fairness – must be a primary goal of public policy.

Decline in general medicine career choices

General Medicine vs Subspecialty Career Plans Among Internal Medicine Residents

By Colin P. West, MD, PhD and Denise M. Dupras, MD, PhD
JAMA, December 5, 2012

This study of a large national sample of internal medicine residents confirms that general medicine remains a less common career plan overall than subspecialty medicine. Combined with the fact that only a small minority of medical students express interest in general medicine and primary care careers, the small number of internal medicine residents reporting plans for generalist careers means a very limited number of generalists can be expected to enter practice each year.

http://jama.jamanetwork.com/article.aspx?articleid=1475191#RESULTS

Comment:

By Don McCanne, MD

This update confirms that internal medicine residents are selecting the subspecialties in preference to general medicine and primary care. In light of the pressing need for improving our primary care infrastructure, what policies should we support?

Since family medicine residents almost always eventually enter primary care, should training programs de-emphasize general internal medicine and place more emphasis on family medicine, while relegating internal medicine to the subspecialties? That would improve the allocation of residency slots since you would not be losing general medicine residents to the subspecialties after their residencies began. This is not to suggest that subspecialists should skip all training in general medicine. The purpose would be to stem the loss of generalists from the training programs.

Also many agree that the role of nurse practitioners in primary care should be expanded. This would be especially valuable in integrated health systems and medical homes. If so, the expansion should be coordinated with the family medicine programs to achieve an optimal balance of primary care professionals.

Since we aren’t getting the numbers right, shouldn’t we consider an alternative approach? If we had a federally funded national health program, wouldn’t we be striving to improve the use of our resources to be sure that our health care infrastructure is better balanced? Our current dysfunctional, fragmented method of financing our health care system doesn’t seem to be doing the job very well.

Decline in general medicine career choices

General Medicine vs Subspecialty Career Plans Among Internal Medicine Residents

By Colin P. West, MD, PhD and Denise M. Dupras, MD, PhD
JAMA, December 5, 2012
This study of a large national sample of internal medicine residents confirms that general medicine remains a less common career plan overall than subspecialty medicine. Combined with the fact that only a small minority of medical students express interest in general medicine and primary care careers, the small number of internal medicine residents reporting plans for generalist careers means a very limited number of generalists can be expected to enter practice each year.
http://jama.jamanetwork.com/article.aspx?articleid=1475191#RESULTS

This update confirms that internal medicine residents are selecting the subspecialties in preference to general medicine and primary care. In light of the pressing need for improving our primary care infrastructure, what policies should we support?
Since family medicine residents almost always eventually enter primary care, should training programs de-emphasize general internal medicine and place more emphasis on family medicine, while relegating internal medicine to the subspecialties? That would improve the allocation of residency slots since you would not be losing general medicine residents to the subspecialties after their residencies began. This is not to suggest that subspecialists should skip all training in general medicine. The purpose would be to stem the loss of generalists from the training programs.
Also many agree that the role of nurse practitioners in primary care should be expanded. This would be especially valuable in integrated health systems and medical homes. If so, the expansion should be coordinated with the family medicine programs to achieve an optimal balance of primary care professionals.
Since we aren’t getting the numbers right, shouldn’t we consider an alternative approach? If we had a federally funded national health program, wouldn’t we be striving to improve the use of our resources to be sure that our health care infrastructure is better balanced? Our current dysfunctional, fragmented method of financing our health care system doesn’t seem to be doing the job very well.

Medicare for all is the solution for health care costs

By Ewell Scott, M.D.
Lexington Herald-Leader, Letters, Dec. 1, 2012

While agreeing with many of the positive attributes of the Affordable Care Act, as discussed by Richard Cullison recently, the law is not the answer to our health care system catastrophe.

Why? Despite the name of the act, health care will remain unaffordable for most, and 30 million will not be eligible for coverage. The biggest flaw is the act has no provisions to reduce the cost of care or the increase in that cost. We lost Twinkies because of the cost, and our police and firefighters are suing governments to keep up with the outrageous premium increases from private health care insurance companies.

There is a better answer. Medicare for all, from life to death, could save us $400 billion per year. A huge figure, but true. The fiscal cliff could be avoided without needing to cut money for education, security or the military.

We need to stop spending twice as much per capita as other industrialized countries, or we will continue to fall behind.

Dr. Ewell Scott resides in Morehead, Ky.

http://www.kentucky.com/2012/12/01/2427407/dec-1-letters-to-the-editor.html#storylink=misearch

Greg Scandlen explains the irrationality of the individual mandate

The Crown Jewel of ObamaCare Failures

By Greg Scandlen
National Center for Policy Analysis (NCPA), December 5, 2012

Now we get to the biggest failure of them all — the individual mandate. The premise was simple: If people aren’t buying what they should (in this case, health insurance), pass a law telling them they have to, and they will. Presto, Change-o problem solved!

Now, to be fair, Congressional Democrats weren’t quite that simple minded. They threw in lots of subsidies and required that insurers enroll anyone who applied, no questions asked. So, they made it affordable and available, along with being mandated. So, it should work like a charm, right?

Well, maybe in a vacuum. But in reality this rule is being inserted into a very complex and mature system of existing subsidies, responsibilities, and incentives. In this case, one of the primary factors is the role of employers in providing and paying for coverage.

Many people, including this writer, believe that placing that responsibility on employers was a major policy screw-up that created all the wrong dynamics in health care and virtually eliminated market functions because the payer and the consumer were not the same person.

Nevertheless, it is a system we have lived with for two-thirds of a century. Almost everything about health care and employment has been built around that relationship — prospective employees consider a company’s health benefits when deciding to take a new job; employers devote a lot of staff time and resources on choosing benefit programs; laws and regulations are written to ease the problems of interruption of benefits when people change jobs; courts are concerned that employers may not always fulfill their obligations to their workers. Not all employers provide benefits, but all feel an obligation and responsibility to do so, and the ones who don’t offer health benefits often feel conflicted about it.

Unwinding all this, even if desirable, is extremely complex and should take a very long transition period as we all learn new ways of doing things.

Enter ObamaCare. This law provides stark incentives for employers to get out of the business immediately. It even assuages any guilt feelings the employer might have by, first requiring that they continue to help pay for it, and next, by offering workers richer subsidies than the employer typically can. An employer will be able to save many thousands of dollars per worker by dropping coverage and sending employees to the Obama Exchange where they will get a choice of benefits plans and substantial subsidies if they make under 400% of the poverty level. Instead of paying, say, $10,000 per worker for coverage, now the employer can pay a simple $2,000 penalty and use the savings to give each worker a raise. Most employers will be able to save even more by reducing their HR departments, and they will be freed of complaints about any problems with the health plan they offer.

In February, 2011 McKinsey & Company did a large (1,329) survey of employers asking about their intentions with the Affordable Care Act and found that 30% said their company would “probably” or “definitely” drop coverage as a result. McKinsey is an extremely credible firm, but that didn’t stop supporters of ObamaCare from lambasting the survey because it was not consistent with other economic analyses. McKinsey had to issue a statement explaining it was not intended to be an economic analysis, it was an opinion survey. I would argue that such a survey is probably far more accurate than an economic analysis that must rely too much on assumptions. Indeed, it likely understated the situation. As employers learn more about the requirements of the new law they are more likely to run away from it.

We can’t know until it happens how many employers will drop coverage, but the 30% estimated by McKinsey may be the minimum. That could mean 50 million or more people who used to get employer coverage no longer will. For those employees this means:

*  No more automatic enrollment going along with the job. People will have to take the initiative to find out about the Exchange.
*  No more pure community rating of the employee share of premiums. The Exchange will vary premiums every year based on a person’s age.
*  No more paycheck deductions of the employee share of premiums. People will have to make some kind of payment arrangement for their share of the premium.
*  No more convenient and friendly HR Department people to answer questions. People will have to seek out an “Exchange navigator” to get their questions answered.

These employees are also likely to find at the Exchange:

*  A clunky web site run by the state or federal government laying out the coverage options.
*  Overpriced insurance options. (Because insurers can no longer ask medical questions, they will have no idea what kind of risks they are enrolling, or the premiums needed to cover those risks. They will err on the side of caution and charge higher premiums.)
*  Confusion about how much they will be charged for their share of the premium. (They will be subsidized, but the amount of the subsidy will vary according to their age, income, geographic location, family size, and choice of plan.)
*  Insurance plans that cover a bunch of stuff they don’t want or need.
*  No reliable source of personalized information. (Ever tried to call the Medicare helpline?)

Finally, they will realize that they don’t need to go through all this. They can delay making a decision until they really need to get health care services:

*  Exchange coverage is guaranteed to accept them at any time with no questions asked.
*  They can save a whole lot of money by not paying premiums and using that money for more pressing needs.
*  There is no meaningful penalty for failing to enroll. What penalty there is applies only to people who make enough money to pay income taxes, and it can be collected only by seizing whatever tax return is due the taxpayer. This can be easily avoided by upping deductions at the start of the year.

Most people have very few medical expenses in the course of a year. According to this chart 50% of the people in the United States consume only 3.9% of all health care expenses each year, while the top 20% consume 78.3%. People in the top 20% will certainly want to be covered but the bottom 50% get no advantage from insurance coverage. They spend far less on services than they would on insurance premiums.

(Scandlen includes here a slide taken from a presentation on “Medicare for All” by Paul Y. Song, MD of Physicians for a National Health Program, graphically demonstrating this distribution of health care consumption.)

Obviously not everyone will make the choice to go uninsured. People who are risk-adverse, or who have ongoing medical needs, or who have small children, will continue to be covered. But every year, every person will have to decide how best to spend their money. A very large number will decide they have better things to do with that money than spend it on insurance coverage they don’t want and never use.

The odds are that after all the trauma and expense of enacting and implementing ObamaCare, we will have fewer people insured than we did before it was enacted.

http://healthblog.ncpa.org/the-crown-jewel-of-obamacare-failures-2/

Comment:

By Don McCanne, MD

Greg Scandlen is a very well informed and respected member of the policy community who has been associated with conservative/libertarian organizations such as the National Center for Policy Analysis, Cato Institute, Galen Institute and Heartland Institute. This article for NCPA is presented in its entirety to demonstrate how much agreement there is with those of us at Physicians for a
National Health Program in defining some of the problems with the highly flawed Affordable Care Act (Obamacare). This article could have been written by one of us at PNHP.

He does not offer any solutions in this particular article, though had he, it would undoubtedly be from his area of expertise and advocacy – consumer-driven health care, including health savings accounts and health reimbursement arrangements. That, of course, is quite a contrast from the single payer solution advanced by PNHP.

When there is so much agreement on what is wrong, why can’t we agree on the solution? Perhaps it’s our respective goals. We at PNHP want everyone to have affordable access to all essential health care services, as a matter of social justice. The advocates of consumer-driven health care seem to place the will of the individual consumer above that of society’s collective will for health care justice. But the divide is not quite that simple.

Supporters of an improved Medicare for all still agree that the patient (health care consumer) should make the ultimate decisions on his or her individual health care, after being informed on the options. The role of the government is to remove the financial barriers to that care.

The consumer-driven advocates would add to the health care consumer (patient) the responsibility of making spending decisions so that they would shop for higher quality and greater value. The role of the government would be to ensure access to basic health care services for those who lack the financial resources to pay for that care.

The problem with the consumer-driven approach is that is what we have now, and it isn’t working. Except for a marginal tax benefit, it doesn’t matter whether the patient’s share of cost comes from a health savings account or from other personal funds. The system perpetuates uninsurance and under-insurance which exposes far too many to financial hardship in the face of medical need.

An improved Medicare for all would eliminate financial hardship for individual patients while using public policies to reduce the excessive escalation of our collective health care spending. The latter is a task that our private insurers cannot master, but is ideally suited to a single, national, publicly-administered insurance risk pool.

Greg Scandlen understands this. He understands the inadequacies of his consumer-directed approach. I wish he could explain to us better, in terms devoid of ideology, just what is wrong with our approach – an approach that would provide everyone the care that they need in a progressively-financed system that we can all afford.

Greg Scandlen explains the irrationality of the individual mandate

The Crown Jewel of ObamaCare Failures

By Greg Scandlen
National Center for Policy Analysis (NCPA), December 5, 2012
Now we get to the biggest failure of them all — the individual mandate. The premise was simple: If people aren’t buying what they should (in this case, health insurance), pass a law telling them they have to, and they will. Presto, Change-o problem solved!
Now, to be fair, Congressional Democrats weren’t quite that simple minded. They threw in lots of subsidies and required that insurers enroll anyone who applied, no questions asked. So, they made it affordable and available, along with being mandated. So, it should work like a charm, right?
Well, maybe in a vacuum. But in reality this rule is being inserted into a very complex and mature system of existing subsidies, responsibilities, and incentives. In this case, one of the primary factors is the role of employers in providing and paying for coverage.
Many people, including this writer, believe that placing that responsibility on employers was a major policy screw-up that created all the wrong dynamics in health care and virtually eliminated market functions because the payer and the consumer were not the same person.
Nevertheless, it is a system we have lived with for two-thirds of a century. Almost everything about health care and employment has been built around that relationship — prospective employees consider a company’s health benefits when deciding to take a new job; employers devote a lot of staff time and resources on choosing benefit programs; laws and regulations are written to ease the problems of interruption of benefits when people change jobs; courts are concerned that employers may not always fulfill their obligations to their workers. Not all employers provide benefits, but all feel an obligation and responsibility to do so, and the ones who don’t offer health benefits often feel conflicted about it.
Unwinding all this, even if desirable, is extremely complex and should take a very long transition period as we all learn new ways of doing things.
Enter ObamaCare. This law provides stark incentives for employers to get out of the business immediately. It even assuages any guilt feelings the employer might have by, first requiring that they continue to help pay for it, and next, by offering workers richer subsidies than the employer typically can. An employer will be able to save many thousands of dollars per worker by dropping coverage and sending employees to the Obama Exchange where they will get a choice of benefits plans and substantial subsidies if they make under 400% of the poverty level. Instead of paying, say, $10,000 per worker for coverage, now the employer can pay a simple $2,000 penalty and use the savings to give each worker a raise. Most employers will be able to save even more by reducing their HR departments, and they will be freed of complaints about any problems with the health plan they offer.
In February, 2011 McKinsey & Company did a large (1,329) survey of employers asking about their intentions with the Affordable Care Act and found that 30% said their company would “probably” or “definitely” drop coverage as a result. McKinsey is an extremely credible firm, but that didn’t stop supporters of ObamaCare from lambasting the survey because it was not consistent with other economic analyses. McKinsey had to issue a statement explaining it was not intended to be an economic analysis, it was an opinion survey. I would argue that such a survey is probably far more accurate than an economic analysis that must rely too much on assumptions. Indeed, it likely understated the situation. As employers learn more about the requirements of the new law they are more likely to run away from it.
We can’t know until it happens how many employers will drop coverage, but the 30% estimated by McKinsey may be the minimum. That could mean 50 million or more people who used to get employer coverage no longer will. For those employees this means:
*  No more automatic enrollment going along with the job. People will have to take the initiative to find out about the Exchange.
*  No more pure community rating of the employee share of premiums. The Exchange will vary premiums every year based on a person’s age.
*  No more paycheck deductions of the employee share of premiums. People will have to make some kind of payment arrangement for their share of the premium.
*  No more convenient and friendly HR Department people to answer questions. People will have to seek out an “Exchange navigator” to get their questions answered.
These employees are also likely to find at the Exchange:
*  A clunky web site run by the state or federal government laying out the coverage options.
*  Overpriced insurance options. (Because insurers can no longer ask medical questions, they will have no idea what kind of risks they are enrolling, or the premiums needed to cover those risks. They will err on the side of caution and charge higher premiums.)
*  Confusion about how much they will be charged for their share of the premium. (They will be subsidized, but the amount of the subsidy will vary according to their age, income, geographic location, family size, and choice of plan.)
*  Insurance plans that cover a bunch of stuff they don’t want or need.
*  No reliable source of personalized information. (Ever tried to call the Medicare helpline?)
Finally, they will realize that they don’t need to go through all this. They can delay making a decision until they really need to get health care services:
*  Exchange coverage is guaranteed to accept them at any time with no questions asked.
*  They can save a whole lot of money by not paying premiums and using that money for more pressing needs.
*  There is no meaningful penalty for failing to enroll. What penalty there is applies only to people who make enough money to pay income taxes, and it can be collected only by seizing whatever tax return is due the taxpayer. This can be easily avoided by upping deductions at the start of the year.
Most people have very few medical expenses in the course of a year. According to this chart 50% of the people in the United States consume only 3.9% of all health care expenses each year, while the top 20% consume 78.3%. People in the top 20% will certainly want to be covered but the bottom 50% get no advantage from insurance coverage. They spend far less on services than they would on insurance premiums.
(Scandlen includes here a slide taken from a presentation on “Medicare for All” by Paul Y. Song, MD of Physicians for a National Health Program, graphically demonstrating this distribution of health care consumption.)
Obviously not everyone will make the choice to go uninsured. People who are risk-adverse, or who have ongoing medical needs, or who have small children, will continue to be covered. But every year, every person will have to decide how best to spend their money. A very large number will decide they have better things to do with that money than spend it on insurance coverage they don’t want and never use.
The odds are that after all the trauma and expense of enacting and implementing ObamaCare, we will have fewer people insured than we did before it was enacted.
http://healthblog.ncpa.org/the-crown-jewel-of-obamacare-failures-2/

Greg Scandlen is a very well informed and respected member of the policy community who has been associated with conservative/libertarian organizations such as the National Center for Policy Analysis, Cato Institute, Galen Institute and Heartland Institute. This article for NCPA is presented in its entirety to demonstrate how much agreement there is with those of us at Physicians for a National Health Program in defining some of the problems with the highly flawed Affordable Care Act (Obamacare). This article could have been written by one of us at PNHP.
He does not offer any solutions in this particular article, though had he, it would undoubtedly be from his area of expertise and advocacy – consumer-driven health care, including health savings accounts and health reimbursement arrangements. That, of course, is quite a contrast from the single payer solution advanced by PNHP.
When there is so much agreement on what is wrong, why can’t we agree on the solution? Perhaps it’s our respective goals. We at PNHP want everyone to have affordable access to all essential health care services, as a matter of social justice. The advocates of consumer-driven health care seem to place the will of the individual consumer above that of society’s collective will for health care justice. But the divide is not quite that simple.
Supporters of an improved Medicare for all still agree that the patient (health care consumer) should make the ultimate decisions on his or her individual health care, after being informed on the options. The role of the government is to remove the financial barriers to that care.
The consumer-driven advocates would add to the health care consumer (patient) the responsibility of making spending decisions so that they would shop for higher quality and greater value. The role of the government would be to ensure access to basic health care services for those who lack the financial resources to pay for that care.
The problem with the consumer-driven approach is that is what we have now, and it isn’t working. Except for a marginal tax benefit, it doesn’t matter whether the patient’s share of cost comes from a health savings account or from other personal funds. The system perpetuates uninsurance and under-insurance which exposes far too many to financial hardship in the face of medical need.
An improved Medicare for all would eliminate financial hardship for individual patients while using public policies to reduce the excessive escalation of our collective health care spending. The latter is a task that our private insurers cannot master, but is ideally suited to a single, national, publicly-administered insurance risk pool.
Greg Scandlen understands this. He understands the inadequacies of his consumer-directed approach. I wish he could explain to us better, in terms devoid of ideology, just what is wrong with our approach – an approach that would provide everyone the care that they need in a progressively-financed system that we can all afford.

Will Liz Fowler determine the drugs you can have?

Analysis finds big state-by-state swings in prescription coverage

By Sam Baker
The Hill, December 4, 2012

President Obama’s signature healthcare law requires insurance plans to cover a range of prescription drugs, but the number of drugs covered will vary widely from state to state, according to a new analysis from Avalere Health.

Based on its analysis of state benchmark plans, Avalere said some states cover as little as 45 percent of available drugs, while others cover more than 99 percent.

“This means that … linking drug coverage to the benchmark formulary will result in drastically different coverage requirements state-to-state,” Avalere said.

http://thehill.com/blogs/healthwatch/health-reform-implementation/270829-analysis-finds-big-state-by-state-swings-in-rx-coverage

Map of state variations in number of drugs covered:
http://www.avalerehealth.net/news/spotlight/Avalere_Benchmark_Formulary_Breadth.pdf

And…

Obamacare architect leaves White House for pharmaceutical industry job

By Glenn Greenwald
The Guardian, December 5, 2012

When the legislation that became known as “Obamacare” was first drafted, the key legislator was the Democratic Chairman of the Senate Finance Committee, Max Baucus, whose committee took the lead in drafting the legislation. As Baucus himself repeatedly boasted, the architect of that legislation was Elizabeth Folwer, his chief health policy counsel; indeed, as Marcy Wheeler discovered, it was Fowler who actually drafted it.

What was most amazing about all of that was that, before joining Baucus’ office as the point person for the health care bill, Fowler was the Vice President for Public Policy and External Affairs (i.e. informal lobbying) at WellPoint, the nation’s largest health insurance provider (before going to WellPoint, as well as after, Folwer had worked as Baucus’ top health care aide).

More amazingly still, when the Obama White House needed someone to oversee implementation of Obamacare after the bill passed, it chose … Liz Fowler.

Now, as Politico’s “Influence” column briefly noted on Tuesday, Fowler is once again passing through the deeply corrupting revolving door as she leaves the Obama administration to return to the loving and lucrative arms of the private health care industry: “Elizabeth Fowler is leaving the White House for a senior-level position leading ‘global health policy’ at (pharmaceutical giant) Johnson & Johnson’s government affairs and policy group.”

It’s difficult to find someone who embodies the sleazy, anti-democratic, corporatist revolving door that greases Washington as shamelessly and purely as Liz Fowler.

http://www.guardian.co.uk/commentisfree/2012/dec/05/obamacare-fowler-lobbyist-industry1

Comment:

By Don McCanne, MD

A well designed, national, single payer financing system would ensure that everyone would receive whatever appropriate drugs they might need. Instead, we have an inefficient, fragmented, costly financing system that imposes regulatory and financial barriers in the way of many needed medications, in a manner inconsistent from state to state.

Congress and the President could have consulted with those fine folks at Physicians for a National Health Program, and then we would have a system that serves the needs of patients. Instead, they consulted a “sleazy, anti-democratic, corporatist,” Liz Fowler, who orchestrated a program that instead primarily serves the needs of the insurance and pharmaceutical industries. She had previously played a key role in the 2003 Medicare Prescription Drug Act (MMA), a program that prohibits government contracting for drugs under Part D of Medicare. She entered the revolving door as a pawn of the insurance industry and departs as a pawn of the pharmaceutical industry – the very industries for which she wrote the legislation.

Shame.

We can change it.

Will Liz Fowler determine the drugs you can have?

Analysis finds big state-by-state swings in prescription coverage

By Sam Baker
The Hill, December 4, 2012
President Obama’s signature healthcare law requires insurance plans to cover a range of prescription drugs, but the number of drugs covered will vary widely from state to state, according to a new analysis from Avalere Health.
Based on its analysis of state benchmark plans, Avalere said some states cover as little as 45 percent of available drugs, while others cover more than 99 percent.
“This means that … linking drug coverage to the benchmark formulary will result in drastically different coverage requirements state-to-state,” Avalere said.
http://thehill.com/blogs/healthwatch/health-reform-implementation/270829…
Map of state variations in number of drugs covered:
http://www.avalerehealth.net/news/spotlight/Avalere_Benchmark_Formulary_…
And…

Obamacare architect leaves White House for pharmaceutical industry job

By Glenn Greenwald
The Guardian, December 5, 2012
When the legislation that became known as “Obamacare” was first drafted, the key legislator was the Democratic Chairman of the Senate Finance Committee, Max Baucus, whose committee took the lead in drafting the legislation. As Baucus himself repeatedly boasted, the architect of that legislation was Elizabeth Folwer, his chief health policy counsel; indeed, as Marcy Wheeler discovered, it was Fowler who actually drafted it.
What was most amazing about all of that was that, before joining Baucus’ office as the point person for the health care bill, Fowler was the Vice President for Public Policy and External Affairs (i.e. informal lobbying) at WellPoint, the nation’s largest health insurance provider (before going to WellPoint, as well as after, Folwer had worked as Baucus’ top health care aide).
More amazingly still, when the Obama White House needed someone to oversee implementation of Obamacare after the bill passed, it chose … Liz Fowler.
Now, as Politico’s “Influence” column briefly noted on Tuesday, Fowler is once again passing through the deeply corrupting revolving door as she leaves the Obama administration to return to the loving and lucrative arms of the private health care industry: “Elizabeth Fowler is leaving the White House for a senior-level position leading ‘global health policy’ at (pharmaceutical giant) Johnson & Johnson’s government affairs and policy group.”
It’s difficult to find someone who embodies the sleazy, anti-democratic, corporatist revolving door that greases Washington as shamelessly and purely as Liz Fowler.
http://www.guardian.co.uk/commentisfree/2012/dec/05/obamacare-fowler-lob…

A well designed, national, single payer financing system would ensure that everyone would receive whatever appropriate drugs they might need. Instead, we have an inefficient, fragmented, costly financing system that imposes regulatory and financial barriers in the way of many needed medications, in a manner inconsistent from state to state.
Congress and the President could have consulted with those fine folks at Physicians for a National Health Program, and then we would have a system that serves the needs of patients. Instead, they consulted a “sleazy, anti-democratic, corporatist,” Liz Fowler, who orchestrated a program that instead primarily serves the needs of the insurance and pharmaceutical industries. She had previously played a key role in the 2003 Medicare Prescription Drug Act (MMA), a program that prohibits government contracting for drugs under Part D of Medicare. She entered the revolving door as a pawn of the insurance industry and departs as a pawn of the pharmaceutical industry – the very industries for which she wrote the legislation.
Shame.
We can change it.

It’s not profit that is destroying our health; it’s the private insurance business model

By Samuel Metz, M.D.
Firedoglake, Dec. 3, 2012

Many Europeans use private health insurance companies, a few of them for-profit. These Europeans enjoy better care for more people at lower cost than we do. But the European business model differs radically from that in the U.S. In fact, American insurance companies find the European model not only alien, but intolerable. Imagine American insurance companies playing by these European rules:

* You can set any price on your policy, but you must sell it at the same price to everyone, regardless of health.

* You must sell a policy to anyone who applies, no exceptions.

* No policy can be cancelled for any reason, not even failure to pay (the government will step in). Patients, however, can change companies without notice.

* Every policy must cover all treatable diseases. No matter what policy they purchase, patients will never risk destitution (or death) if they suffer a treatable condition.

* Your company must pay every claim from every licensed provider within 30 days. You can protest the payment, but only after you pay the bill.

* Every provider receives the same payment for the same service, regardless of patient or their insurance.

* Your records are an open book. Every dollar (or Euro) that passes through your hands is open to the public. There are no proprietary secrets.

* If you still manage to cherry pick healthier patients, the government will impose a premium to subsidize other companies with sicker patients.

With this model, European companies compete with lower prices, extra benefits, and better customer service. Isn’t that a refreshing change?

The American business model has no such rules. How do American insurance companies compete?

* They avoid sick patients. Highly paid underwriters detect potentially expensive patients before policies are offered. And the best way to avoid sick patients is with high policy prices.

* They slash benefits. Reduced benefits both discourage sick patients from buying a policy and reduce provider payments if they do.

* They pass costs to patients with increased deductibles and co-pays. Healthy patients (the ones companies want to keep) won’t notice because they don’t need health care. At least until they get sick.

* They delay or deny provider payments. If the payment process is frustrating enough, many providers simply give up trying to collect. That’s money they keep.

Profit? No difference. To succeed, both for-profit and not-for-profit companies follow the same rules. If not, your company is toast.

It is not profits but the business model that places the financial interests of our health insurance industry in opposition to the medical interests of its clients. Neither removing profits, nor enhancing competition, nor deregulation will increase health care quality or make health care more accessible.

Our American insurance business model is the source, not the solution, of our health care problems. We must run – not walk – away from letting private insurance companies determine our health care.

Samuel Metz is a Portland anesthesiologist active in health care reform. He is also a member of two organizations advocating publicly funded universal health care: Mad As Hell Doctors and Physicians for a National Health Program. He is the local chapter representative of Health Care for All Oregon, an umbrella organization of over 50 groups working for better health care in Oregon.

http://my.firedoglake.com/healthcareforall/2012/12/03/its-not-profit-that-is-destroying-our-health-its-the-private-insurance-business-model/

Obamacare architect leaves White House for pharmaceutical industry job

Few people embody the corporatist revolving door greasing Washington as purely as Elizabeth Fowler

By Glenn Greenwald
The Guardian (U.K.), Dec. 5, 2012
      
When the legislation that became known as “Obamacare” was first drafted, the key legislator was the Democratic Chairman of the Senate Finance Committee, Max Baucus, whose committee took the lead in drafting the legislation. As Baucus himself repeatedly boasted, the architect of that legislation was Elizabeth Fowler, his chief health policy counsel; indeed, as Marcy Wheeler discovered, it was Fowler who actually drafted it. As Politico put it at the time: “If you drew an organizational chart of major players in the Senate health care negotiations, Fowler would be the chief operating officer.”

What was most amazing about all of that was that, before joining Baucus’ office as the point person for the health care bill, Fowler was the Vice President for Public Policy and External Affairs (i.e. informal lobbying) at WellPoint, the nation’s largest health insurance provider (before going to WellPoint, as well as after, Fowler had worked as Baucus’ top health care aide). And when that health care bill was drafted, the person whom Fowler replaced as chief health counsel in Baucus’ office, Michelle Easton, was lobbying for WellPoint as a principal at Tarplin, Downs, and Young.

Whatever one’s views on Obamacare were and are: the bill’s mandate that everyone purchase the products of the private health insurance industry, unaccompanied by any public alternative, was a huge gift to that industry; as Wheeler wrote at the time: “to the extent that Liz Fowler is the author of this document, we might as well consider WellPoint its author as well.” Watch the five-minute Bill Moyers report from 2009, embedded here, on the key role played in all of this by Liz Fowler and the “revolving door” between the health insurance/lobbying industry and government officials at the time this bill was written and passed.

More amazingly still, when the Obama White House needed someone to oversee implementation of Obamacare after the bill passed, it chose . . . Liz Fowler. That the White House would put a former health insurance industry executive in charge of implementation of its new massive health care law was roundly condemned by good government groups as at least a violation of the “spirit” of governing ethics rules and even “gross,” but those objections were, of course, brushed aside by the White House. She then became Special Assistant to the President for Healthcare and Economic Policy at the National Economic Council.

Now, as Politico’s “Influence” column briefly noted on Tuesday, Fowler is once again passing through the deeply corrupting revolving door as she leaves the Obama administration to return to the loving and lucrative arms of the private health care industry: “Elizabeth Fowler is leaving the White House for a senior-level position leading ‘global health policy’ at Johnson & Johnson’s government affairs and policy group.”

The pharmaceutical giant that just hired Fowler actively supported the passage of Obamacare through its membership in the Pharmaceutical Researchers and Manufacturers of America (PhRMA) lobby. Indeed, PhRMA was one of the most aggressive supporters — and most lavish beneficiaries — of the health care bill drafted by Fowler. Mother Jones’ James Ridgeway proclaimed “Big Pharma” the “big winner” in the health care bill. And now, Fowler will receive ample rewards from that same industry as she peddles her influence in government and exploits her experience with its inner workings to work on that industry’s behalf, all of which has been made perfectly legal by the same insular, Versailles-like Washington culture that so lavishly benefits from all of this.

It’s difficult to find someone who embodies the sleazy, anti-democratic, corporatist revolving door that greases Washington as shamelessly and purely as Liz Fowler. One of the few competitors I can think of is Adm. Michael McConnell, who parlayed his military and intelligence career into a lucrative gig at Booz Allen, one of the nation’s largest private intelligence contractors; then became George W. Bush’s Director of National Intelligence (where he spearheaded a huge gift to the telecom industry — retroactive immunity shielding it from all accountability for its participation in the illegal Bush NSA eavesdropping program — as well as continued his Booz Allen work of privatizing intelligence and surveillance functions); then returned to the loving arms of Booz Allen, where he now exploits his national security credentials on behalf of industry interests (by, for instance, spearheading the fear-mongering campaign about cyber-warfare in order to advocate for security programs that would amply enrich Booz Allen’s clients).

This is precisely the behavior which, quite rationally, makes the citizenry so jaded about Washington. It’s what ensures that the interests of the same permanent power factions are served regardless of election outcomes. It’s what makes a complete mockery out claims of democracy. And it’s what demonstrates that corporatism and oligarchy are the dominant forms of government in the US.

http://www.guardian.co.uk/commentisfree/2012/dec/05/obamacare-fowler-lobbyist-industry1