PNHP

NHS reforms will 'betray generations to come'

NHS reforms will 'betray generations to come'

By Dr. Kailash Chand
publicservice.co.uk, May 2, 2012

The NHS will now become ‘just a logo’ – a US style insurance scheme that is divorced from care delivery and dishes out public money to private companies, now that the government’s NHS reforms have passed into law, writes one leading clinician

The NHS bill is now an act. It was a bad bill and now is a bad act. It is a mess. That is my straight forward view of it. I think it is confused and confusing and I think it is unfortunately setting the NHS back.

The implications will betray not only the people who rely on today’s NHS but also generations to come. It will strike at the heart of Britain’s proudest institution. Nobody is opposed to NHS reforms, but the question is what kind of reforms are these and whether it makes our NHS better or worse.

The government has won the parliamentary battle, but no one is quite sure what kind of a victory it has achieved, or at what price. A lot of staff on the ground lack confidence in the bill, or say they don’t like it, at a time when we need massive energy and commitment from the NHS staff. Go to any hospital or GP surgery just now and you will hear the continual opposition from doctors and nurses about this act, their worry about how much harder it will make their jobs. I think they’re right.

Remember, the NHS has to save £20bn by 2015. What it means is managing the NHS with less money and dealing with the consequences on priorities and quality of patient care. The entire NHS workforce could become preoccupied with the changes rather than concentrating on efficiency and innovation the NHS so desperately needs. The reforms would be demoralising, not just for professionals but for patients too, who would begin to see fewer treatments available to fewer people as the NHS cuts start to bite – with wealthier people able to “top up” treatments. The rich really will be able to have much more. It’s not just a postcode lottery, it’s a taxcode lottery.

The NHS is clearly under huge threat, it will be a completely different healthcare system in five-10 years time. A system, which I believe will signal the end of the National Health Service, and a system that will be much worse in terms of access, equity, health outcomes, and cost. The NHS will just be a logo, most cherished institution reduced from being the main provider of heath services in England with one of the biggest workforces in the world, to a US style insurance scheme, divorced from the actual delivery of any care. It will become a bureaucratic governing body dishing out public money to private companies.

My response to the discredited NHS reforms hasn’t just been writing letters and articles about why it is seriously flawed. I also started my own e-petition because I was concerned about the lack of democratic accountability of the coalition government and I wanted the bill to have its ‘day in court’.

The e-petition broadened the debate amongst all sections of society securing around 180,000 signatures. It has inspired other activists and spread knowledge about the reforms. It has stimulated Liberal Democrat factions within the coalition to question their own beliefs and forced the Labour Party to raise its game.

Opposition to the bill has come from a wide spectrum including organisations such as the BMA, most royal colleges, as well as trade unions and patient groups. The e-petition did have its day in court despite attempts by some MPs on the Business Backbench Committee to block it, salvaging a few strands for the democratic rights of those who use e-petitions to force parliamentary debate over an issue that evokes public outrage.

Now that I have been elected to the BMA national council, I’ll do my best to ensure the main priority of BMA is to minimise damage to NHS caused by Health and Social Care Act. I’ll continue my efforts to defend NHS, medical professionalism, and the doctor -patient relationship. And I hope to safeguard patients’ interests in these difficult times.

For me the entire campaign against the Health and Social Care Bill is about saving a service to which I have devoted all my life. I came to this country over 30 years ago to work in what I believe to be the best healthcare system in the world. During those thirty years I have worked in many aspects of the health service and have also campaigned to ensure that the key principles of the NHS, including free universal healthcare for all, are maintained. I work in Tameside which is a deprived borough where the threat of privatisation raises the risks to those who need the NHS the most; elderly people, those with chronic disease, and the mentally ill are the most vulnerable from the coalition reforms under the bill.

The bill may have become law, but those like me who cherish the NHS will continue to fight for the right to universal healthcare as a basic human right regardless of whether they live in flourishing suburbs or inner city deprived areas.

Dr. Kailash Chand OBE is a GP, chairman of Tameside and Glossop NHS and was recently elected to the British Medical Association national council.

NHS reforms will ‘betray generations to come’

By Dr. Kailash Chand
publicservice.co.uk, May 2, 2012

The NHS will now become ‘just a logo’ – a US style insurance scheme that is divorced from care delivery and dishes out public money to private companies, now that the government’s NHS reforms have passed into law, writes one leading clinician

The NHS bill is now an act. It was a bad bill and now is a bad act. It is a mess. That is my straight forward view of it. I think it is confused and confusing and I think it is unfortunately setting the NHS back.

The implications will betray not only the people who rely on today’s NHS but also generations to come. It will strike at the heart of Britain’s proudest institution. Nobody is opposed to NHS reforms, but the question is what kind of reforms are these and whether it makes our NHS better or worse.

The government has won the parliamentary battle, but no one is quite sure what kind of a victory it has achieved, or at what price. A lot of staff on the ground lack confidence in the bill, or say they don’t like it, at a time when we need massive energy and commitment from the NHS staff. Go to any hospital or GP surgery just now and you will hear the continual opposition from doctors and nurses about this act, their worry about how much harder it will make their jobs. I think they’re right.

Remember, the NHS has to save £20bn by 2015. What it means is managing the NHS with less money and dealing with the consequences on priorities and quality of patient care. The entire NHS workforce could become preoccupied with the changes rather than concentrating on efficiency and innovation the NHS so desperately needs. The reforms would be demoralising, not just for professionals but for patients too, who would begin to see fewer treatments available to fewer people as the NHS cuts start to bite – with wealthier people able to “top up” treatments. The rich really will be able to have much more. It’s not just a postcode lottery, it’s a taxcode lottery.

The NHS is clearly under huge threat, it will be a completely different healthcare system in five-10 years time. A system, which I believe will signal the end of the National Health Service, and a system that will be much worse in terms of access, equity, health outcomes, and cost. The NHS will just be a logo, most cherished institution reduced from being the main provider of heath services in England with one of the biggest workforces in the world, to a US style insurance scheme, divorced from the actual delivery of any care. It will become a bureaucratic governing body dishing out public money to private companies.

My response to the discredited NHS reforms hasn’t just been writing letters and articles about why it is seriously flawed. I also started my own e-petition because I was concerned about the lack of democratic accountability of the coalition government and I wanted the bill to have its ‘day in court’.

The e-petition broadened the debate amongst all sections of society securing around 180,000 signatures. It has inspired other activists and spread knowledge about the reforms. It has stimulated Liberal Democrat factions within the coalition to question their own beliefs and forced the Labour Party to raise its game.

Opposition to the bill has come from a wide spectrum including organisations such as the BMA, most royal colleges, as well as trade unions and patient groups. The e-petition did have its day in court despite attempts by some MPs on the Business Backbench Committee to block it, salvaging a few strands for the democratic rights of those who use e-petitions to force parliamentary debate over an issue that evokes public outrage.

Now that I have been elected to the BMA national council, I’ll do my best to ensure the main priority of BMA is to minimise damage to NHS caused by Health and Social Care Act. I’ll continue my efforts to defend NHS, medical professionalism, and the doctor -patient relationship. And I hope to safeguard patients’ interests in these difficult times.

For me the entire campaign against the Health and Social Care Bill is about saving a service to which I have devoted all my life. I came to this country over 30 years ago to work in what I believe to be the best healthcare system in the world. During those thirty years I have worked in many aspects of the health service and have also campaigned to ensure that the key principles of the NHS, including free universal healthcare for all, are maintained. I work in Tameside which is a deprived borough where the threat of privatisation raises the risks to those who need the NHS the most; elderly people, those with chronic disease, and the mentally ill are the most vulnerable from the coalition reforms under the bill.

The bill may have become law, but those like me who cherish the NHS will continue to fight for the right to universal healthcare as a basic human right regardless of whether they live in flourishing suburbs or inner city deprived areas.

Dr. Kailash Chand OBE is a GP, chairman of Tameside and Glossop NHS and was recently elected to the British Medical Association national council.

Should a single payer system include complementary and alternative therapies?

Studying Complementary and Alternative Therapies

By Paul A. Offit, MD
JAMA, May 2, 2012
In 1992, with an initial budget of $2 million, Congress created the Office of Alternative Medicine (OAM). Based on legislation sponsored by Iowa politicians Tom Harkin and Berkeley Bedell, OAM’s mission was “to explore complementary and alternative healing practices in the context of rigorous science.”
In 1999, OAM became the National Center for Complementary and Alternative Medicine (NCCAM), a center within the National Institutes of Health (NIH). Funding has steadily increased; by 2012, NCCAM’s annual budget had reached $130 million. Since their inception, OAM and NCCAM have spent $1.6 billion. US taxpayers have a right to ask whether money appropriated for NCCAM—like money appropriated for all centers within NIH—has been well spent.
In support of NCCAM’s mission, proponents argue that one century’s folk medicine can be the next century’s mainstream medicine… Indeed, most drugs on today’s hospital formularies were originally derived from plants.
However, unlike studies of drugs derived from plants, many studies funded by NCCAM lack a sound biological underpinning, which should be an important requirement for funding. For example, NCCAM officials have spent $374 000 to find that inhaling lemon and lavender scents does not promote wound healing; $750 000 to find that prayer does not cure AIDS or hasten recovery from breast-reconstruction surgery; $390 000 to find that ancient Indian remedies do not control type 2 diabetes; $700 000 to find that magnets do not treat arthritis, carpal tunnel syndrome, or migraine headaches; and $406 000 to find that coffee enemas do not cure pancreatic cancer. Additionally, NCCAM has funded studies of acupuncture and therapeutic touch. Using rigorously controlled studies, none of these therapies have been shown to work better than placebo. Some complementary and alternative practitioners argue reasonably that although their therapies might not work better than placebos, placebos may still work for some conditions.
Although studies funded by NCCAM have failed to prove that complementary or alternative therapies are anything more than placebos, some proponents—pointing to studies of vaccine safety—argue that negative studies of biologically implausible hypotheses are worthwhile.
Does the same value of rigorously conducted negative studies hold for studies of complementary and alternative therapies? Have negative studies changed behavior? The answer is probably best found in NCCAM-funded studies of dietary supplements and megavitamins. Several studies have shown that garlic does not lower low-density lipoprotein cholesterol, St John’s wort does not treat depression, ginkgo does not improve memory, chondroitin sulfate and glucosamine do not treat arthritis, saw palmetto does not treat prostatic hypertrophy, milk thistle does not treat hepatitis, and echinacea and megavitamins do not treat colds.​ Moreover, some studies have found that megavitamins increase the risk of cancer and heart disease. Because the vitamin and supplement industry is not regulated by the US Food and Drug Administration (FDA), negative studies have not precipitated FDA warnings or FDA-mandated changes on labeling; as a consequence, few consumers are aware that many supplements have not delivered on their claims. In 2010, the vitamin and supplement industry grossed $28 billion, up 4.4% from the year before. “The thing to do with [these studies] is just ride them out,” said Joseph Fortunato, chief executive of GNC Corp. “We see no impact on our business.”
Although evaluating the research portfolio of any institute at the NIH is difficult, social and political pressures may influence area-of-interest funding, and decisions should be based on science. For complementary and alternative medicine, it seems that some people believe what they want to believe, arguing that it does not matter what the data show; they know what works for them. Because negative studies do not appear to change behavior and because studies performed without a sound biological basis have little to no chance of success, it would make sense for NCCAM to either refrain from funding studies of therapies that border on mysticism such as distance healing, purgings, and prayer; redefine its mission to include a better understanding of the physiology of the placebo response; or shift its resources to other NIH institutes.
http://jama.ama-assn.org/content/307/17/1803.full

And…

THINGS GET HOTTER FOR HOXSEY

U.S. Food and Drug Administration posts warning against man who makes millions from cancer victims

LIFE, April 16, 1956
Caption of a photograph of Harry Hoxsey:
HARRY HOXSEY holds the book he wrote which touts his cancer treatment. Beside him on a plaque is his motto: “The world is made up of two kinds of people – dem that takes and dem that gets took.”
http://books.google.com/books?id=Pk8EAAAAMBAJ&pg=PA125&dq=Harry+Hoxsey&hl=en#v=onepage&q=Harry%20Hoxsey&f=false

Complementary and alternative medicine (CAM) is a topic frequently brought up in discussions, forums, and in the medical and lay literature. When confronted on this topic, I usually respond by saying that anyone should be able to spend their own funds as they desire, but when the rest of us are paying the bills, whether through premiums for private insurance or through taxpayer-financed public programs such as Medicare, there is a responsibility for the administrator of the funds to prevent wasteful cost overruns by limiting spending to health care that is compliant to well accepted standards of mainstream medicine, which includes promising new diagnostic and therapeutic options that adhere to the rigors of science.
The application of science to medicine is a dynamic. Many older approaches prove to be ineffective or even harmful. As we gain new evidence, those approaches should be denied payment from our collective health funds, whether private or government. Beneficial new approaches should be added. These decisions should continue to be based on science.
What is different about the scientific evaluation of existing and innovative medical interventions and the evaluation of CAM? Why is CAM segregated, as, for example, in the National Center for Complementary and Alternative Medicine (NCCAM)? Quite simply, complementary and alternative therapies do not arise from inductive scientific reasoning. They are based on faith exclusively and have no basis in the scientific disciplines. If new discoveries suggest that there could be a scientific basis warranting further evaluation of a complementary or alternative therapy – an exceedingly rare event – then it is no longer classified as CAM but is moved into the arena of bone fide scientific research.
Should the government have any role in oversight of CAM? Yes, for two reasons. Most important, some CAM therapy is harmful, and the government has an legitimate role in protecting us from harm by removing from the market truly dangerous products with no redeeming value. The other role of government is to ensure that the producers and sellers of these ineffective products are providing honest disclosure to the consumers. Such disclosure is not required today. If the product is crap, the producers should be required to tell us that it is crap.
What the government should not be doing is wasting our tax dollars on this phony research strictly for the purpose of pleasing the eccentrics who have political influence.
My concerns go back to my teenage years when I had several discussions with my father – a physician – over these topics now classified as CAM though more appropriately referred to then as quackery. I remember very clearly reading a LIFE magazine article on the cancer quack Harry Hoxsey. I have repeated to myself over an over again throughout the years Hoxsey’s motto that appeared in the photograph of him in that article (which I was amazed that I could find today with a Google search – link above):
“The world is made up of two kinds of people – dem that takes and dem that gets took.”
Until now, I have been reserved in my comments on CAM, partly because so many sincere, dedicated individuals in our single payer coalitions are supportive of CAM – including some members of PNHP who should know better. But dammit! Quackery is quackery! The smug CAM producers who retreat to their mansions are “dem that takes,” and the uninformed patient/victims lacking an adequate scientific background are “dem that gets took.”
When I was a teenager, I wanted to become a physician like my father and help clean house of these unscrupulous thieves. Alas, they are still with us, and now they have been joined by their brethren in the insurance industry who don’t have a tangible product to sell us but rather simply expropriate our money directly out of our collective health funds in exchange for taking away our choices in health care. That’s worse than quackery!
(This is not a PNHP policy statement, but is a cathartic release of pent up emotions of the author.)

Where they take care of their sick — and ours

By Greg Dobbs
The Denver Post, April 23, 2012

BELFAST, NORTHERN IRELAND — When I’m sick, I want the world’s best health care as much as anybody.

That’s why I’m happy to report that 36 hours after launching on a fantastic journey through the length and depths of my digestive tract — after I collapsed and almost died more than a week ago from massive internal bleeding — an expensive and innovative tool called the PillCam, collecting almost 60,000 diagnostic images inside me to pinpoint the problem, has just completed its mission.

The thing is, this wasn’t at the internationally famous Mayo Clinic, or the vaunted Cedars-Sinai in Los Angeles, or our own world-class University of Colorado Medical Center.

It was at the big, battle-tested, National Health Service trauma center in Belfast, Northern Ireland, called Royal Victoria Hospital — known to locals as well as reporters like me who covered the warfare here in the 1970s and ’80s as the Royal Vic.

It hasn’t been a perfect experience. I’ve felt lost in the chaos of the emergency room. I’ve had bloodlines spring leaks where they’re inserted in my arms. I’ve heard fellow patients screaming all night. And I’ve been presented with a couple of plates of food I wouldn’t pay for at a restaurant. But you know what? It’s a hospital! As a veteran of life-threatening traumas, I’ve suffered the same at institutions in the United States.

More important, just as I have in American hospitals, I’ve had the high-tech procedures I needed when I needed them. Two angiograms, two endoscopies, CT scans, X-rays, a colonoscopy, and that tiny alien capsule that I swallowed, the PillCam.

Some argue that in a universal health care system like this one, you’ll get urgent care only if you have urgent needs.

Well, about 10 years ago when my back collapsed and I was reduced to crawling around with screaming pain until I could have some vertebrae fused, I’d say the need was pretty urgent. But it took a week and a half to get me into surgery. That was in suburban Denver.

The bottom line is, maybe it’s socialized medicine, but the doctors and nurses and procedures and protocols here are first-rate; they saved my life.

By the way, I have pre-existing conditions, which disqualify me for most insurance at home. Except for personal medical history to help treat me, no one here even asked. In fact, the bureaucracy is so minimal and the priorities so different, no one has even asked to see an identification card to prove who I am, let alone a credit card to prove my ability to pay.

And the cost? The “emergency” parts — the ambulance, the ER, the transfusions — came with no charge. The rest? Oh, since I only came to Belfast to shoot a television news segment and don’t pay taxes and thus am not insured, I’ll pay all right, but since the model for hospital revenue isn’t based on market-driven, sometimes-price-gouging profit centers, I won’t pay through the nose.

If you think it’s no different in the U.S., you’re not paying attention.

But here’s the biggest difference between the two health care systems: This one is open for everybody. Residents don’t have to assess and agonize over the cost because they don’t have insurance. If they need medical care at any level, they just go. As I did. And get fixed. As I am.

And guess what: Anyone here who doesn’t like their universal health care system and wants something more can have it, through private insurance, if they’re willing and able to pay for it. Gee. That’s just like us.

Greg Dobbs is a Denver-based correspondent for “World Report” on HDNet television.

http://www.denverpost.com/opinion/ci_20446181/where-they-take-care-their-sick-mdash-and#ixzz1tjnIRKgW

Khati Hendry on Canada's solution to insurance job lock

Email

From: Khati Hendry
To: Don McCanne
Date: Tue, May 1, 2012 at 10:56 PM
Subject: Re: qotd: Lack of retiree plans can cause job lock

Hi Don,

This article reinforces one of the things that really impressed me when I first moved from the US to practice in Canada 7 years ago–I started seeing all these patients who were retiring way before age 65.  What was up?  They didn’t all seem independently wealthy.  Some were taking up other avocations, running B&Bs, but others were, well, just retired.  Of course the big difference is that they don’t have to take into account health insurance.  They are covered working, retired, laid-off, in transition, in school, married, single, rich, poor–you understand completely.  What a difference it makes to a life when you don’t have the angst of health financial disaster looming, and you can make your decisions on all the other things important to you.

Cheers,
Khati

MiniProfile: Khati Hendry
http://futurehealth.ucsf.edu/Public/Leadership-Programs/MiniProfile.aspx?asuid=4863

qotd May 1, 2012: “Lack of retiree plans can cause job lock”
https://pnhp.org/news/2012/may/lack-of-retiree-plans-can-cause-job-lock

Comment: 

By Don McCanne, MD

If you read Khati Hendry’s MiniProfile (link above) you will see that she is indeed an expert, but her credibility stems not just from what she has done in her career. Much more, it is her dedication to making the health care system work for her patients and for all patients that most qualifies her when she speaks out on health care justice.

For more on her views, this link provides access to a transcript of a radio broadcast featuring Dr. Hendry on “Demystifying the Canadian Health System”

Khati Hendry on Canada’s solution to insurance job lock

Email

From: Khati Hendry
To: Don McCanne
Date: Tue, May 1, 2012 at 10:56 PM
Subject: Re: qotd: Lack of retiree plans can cause job lock

Hi Don,

This article reinforces one of the things that really impressed me when I first moved from the US to practice in Canada 7 years ago–I started seeing all these patients who were retiring way before age 65.  What was up?  They didn’t all seem independently wealthy.  Some were taking up other avocations, running B&Bs, but others were, well, just retired.  Of course the big difference is that they don’t have to take into account health insurance.  They are covered working, retired, laid-off, in transition, in school, married, single, rich, poor–you understand completely.  What a difference it makes to a life when you don’t have the angst of health financial disaster looming, and you can make your decisions on all the other things important to you.

Cheers,
Khati

MiniProfile: Khati Hendry
http://futurehealth.ucsf.edu/Public/Leadership-Programs/MiniProfile.aspx?asuid=4863

qotd May 1, 2012: “Lack of retiree plans can cause job lock”
https://www.pnhp.org/news/2012/may/lack-of-retiree-plans-can-cause-job-lock

Comment: 

By Don McCanne, MD

If you read Khati Hendry’s MiniProfile (link above) you will see that she is indeed an expert, but her credibility stems not just from what she has done in her career. Much more, it is her dedication to making the health care system work for her patients and for all patients that most qualifies her when she speaks out on health care justice.

For more on her views, this link provides access to a transcript of a radio broadcast featuring Dr. Hendry on “Demystifying the Canadian Health System”

Missouri House Committee to Hear 'Missouri Universal Health Assurance Act'

The Lincoln County (Troy, Mo.) Journal
May 1, 2012

On Wednesday, May 2, a Missouri House committee will hear state Rep. Michael Brown’s HB 1405 — the Missouri Universal Health Assurance Act — which seeks to establish a publicly administered universal health care system for the state of Missouri. Under the proposed law all Missouri citizens regardless of income would have immediate access to the newly created government insurance program. Brown, D-Kansas City, said HB 1405 would have an immediate positive impact on the state.

“The Missouri Universal Health Assurance Act would give all Missourians regardless of the amount of money they make access to quality and affordable health insurance,” said Brown, “The cost of health care is increasing, incomes are being reduced, and unemployment remains high. Now more than ever, people need a health program like the one being proposed in HB 1405.”

The Missouri Universal Health Assurance Act has garnered the support of various organizations across the state including Missourians for Single-Payer Health Care and Physicians for a National Health Program.

“HB 1405 would provide every Missouri resident with comprehensive medical, mental, and dental insurance,” said Ed Weisbart, MD, chair for the St. Louis chapter of Physicians for a National Health Program. “Missouri has the opportunity to become a model-state for a nationwide universal health care system. Under a universal system, Missouri citizens and companies will see immediate cost savings.”

In his statement, Dr. Weisbart cited a study conducted by the Missouri Foundation for Health in 2003 that claimed Missouri would save anywhere from $1.3 billion to $1.7 billion dollars in reduced health care spending.

Under HB 1405, the program would be paid for by a newly created progressive income “tax-premium” in addition to federal health grants and waivers.

“There are those who will say that providing universal health coverage to every Missourian will bankrupt our state. That is simply not true,” said Brown. “Under HB 1405, middle-class families will pay 2 percent of their income into a transparent, public health fund. The new income tax acts as a health care premium would and replaces it. Citizens across our state will see immediate savings in premium costs alone.”

According to a study by the Kaiser Family Foundation, a Missouri family of four paid an average of $12,680 in health care premiums in 2008. As proposed by the Missouri Universal Health Assurance Act, a household with a combined annual income of $75,000 would pay just $1,500 in additional taxes each year. Likewise, a household making $250,000 would pay an additional $7,500. Both of these amounts are significantly lower than current premium costs.

HB 1405 will be heard tomorrow at noon in the Missouri House Health Care Policy committee. The bill is expected to face heavy opposition from majority Republicans who have an 8-4 majority on the committee.

http://www.lincolncountyjournal.com/?p=4462

Missouri House Committee to Hear ‘Missouri Universal Health Assurance Act’

The Lincoln County (Troy, Mo.) Journal
May 1, 2012

On Wednesday, May 2, a Missouri House committee will hear state Rep. Michael Brown’s HB 1405 — the Missouri Universal Health Assurance Act — which seeks to establish a publicly administered universal health care system for the state of Missouri. Under the proposed law all Missouri citizens regardless of income would have immediate access to the newly created government insurance program. Brown, D-Kansas City, said HB 1405 would have an immediate positive impact on the state.

“The Missouri Universal Health Assurance Act would give all Missourians regardless of the amount of money they make access to quality and affordable health insurance,” said Brown, “The cost of health care is increasing, incomes are being reduced, and unemployment remains high. Now more than ever, people need a health program like the one being proposed in HB 1405.”

The Missouri Universal Health Assurance Act has garnered the support of various organizations across the state including Missourians for Single-Payer Health Care and Physicians for a National Health Program.

“HB 1405 would provide every Missouri resident with comprehensive medical, mental, and dental insurance,” said Ed Weisbart, MD, chair for the St. Louis chapter of Physicians for a National Health Program. “Missouri has the opportunity to become a model-state for a nationwide universal health care system. Under a universal system, Missouri citizens and companies will see immediate cost savings.”

In his statement, Dr. Weisbart cited a study conducted by the Missouri Foundation for Health in 2003 that claimed Missouri would save anywhere from $1.3 billion to $1.7 billion dollars in reduced health care spending.

Under HB 1405, the program would be paid for by a newly created progressive income “tax-premium” in addition to federal health grants and waivers.

“There are those who will say that providing universal health coverage to every Missourian will bankrupt our state. That is simply not true,” said Brown. “Under HB 1405, middle-class families will pay 2 percent of their income into a transparent, public health fund. The new income tax acts as a health care premium would and replaces it. Citizens across our state will see immediate savings in premium costs alone.”

According to a study by the Kaiser Family Foundation, a Missouri family of four paid an average of $12,680 in health care premiums in 2008. As proposed by the Missouri Universal Health Assurance Act, a household with a combined annual income of $75,000 would pay just $1,500 in additional taxes each year. Likewise, a household making $250,000 would pay an additional $7,500. Both of these amounts are significantly lower than current premium costs.

HB 1405 will be heard tomorrow at noon in the Missouri House Health Care Policy committee. The bill is expected to face heavy opposition from majority Republicans who have an 8-4 majority on the committee.

http://www.lincolncountyjournal.com/?p=4462

Khati Hendry on Canada's solution to insurance job lock

Email
From: Khati Hendry
To: Don McCanne
Date: Tue, May 1, 2012 at 10:56 PM
Subject: Re: qotd: Lack of retiree plans can cause job lock
Hi Don,
This article reinforces one of the things that really impressed me when I first moved from the US to practice in Canada 7 years ago–I started seeing all these patients who were retiring way before age 65.  What was up?  They didn’t all seem independently wealthy.  Some were taking up other avocations, running B&Bs, but others were, well, just retired.  Of course the big difference is that they don’t have to take into account health insurance.  They are covered working, retired, laid-off, in transition, in school, married, single, rich, poor–you understand completely.  What a difference it makes to a life when you don’t have the angst of health financial disaster looming, and you can make your decisions on all the other things important to you.
Cheers,
Khati
MiniProfile: Khati Hendry
http://futurehealth.ucsf.edu/Public/Leadership-Programs/MiniProfile.aspx?asuid=4863
qotd May 1, 2012: “Lack of retiree plans can cause job lock”
https://pnhp.org/news/2012/may/lack-of-retiree-plans-can-cause-job-lock

If you read Khati Hendry’s MiniProfile (link above) you will see that she is indeed an expert, but her credibility stems not just from what she has done in her career. Much more, it is her dedication to making the health care system work for her patients and for all patients that most qualifies her when she speaks out on health care justice.
For more on her views, this link provides access to a transcript of a radio broadcast featuring Dr. Hendry on “Demystifying the Canadian Health System”

Lack of retiree plans can cause job lock

Providing Retiree Health Insurance Encourages Early Retirement

By Claire Brunel
National Bureau of Economic Research (NBER), Digest, May 2012

Employees under the age of 65 have substantially higher turnover rates at firms that offer subsidized retiree health coverage than at firms that do not.

The strong link between health insurance and employment in the United States may cause workers to delay retirement until they become eligible for Medicare at age 65. However, some employers extend health insurance benefits to their retirees, and individuals who are eligible for such benefits need not wait until age 65 to retire with group health coverage.

In Does Retiree Health Insurance Encourage Early Retirement (NBER Working Paper No. 17703), authors Steven Nyce, Sylvester Schieber, John Shoven, Sita Slavov, and David Wise use employee-level data from 64 diverse firms that are clients of TowersWatson, a leading benefits consulting firm, to investigate the impact of retiree health insurance on early retirement. After controlling for individual characteristics and pension incentives, they find that employees under the age of 65 have substantially higher turnover rates at firms that offer subsidized retiree health coverage than at firms that do not. Subsidized retiree health coverage has its strongest effects at ages 62 and 63, resulting in a 21 percent increase in the probability of turnover at age 62 and a 32 percent increase in the probability of turnover at age 63.

Moreover, higher subsidy rates are associated with greater turnover than lower subsidy rates. For example, an employer contribution of 50 percent or more of the cost of health insurance raises turnover by nearly 34 percent at age 62, and by nearly 44 percent at age 63. The authors estimate that a subsidy of 50 percent or more lowers the expected retirement age by 9 months overall, and by more than a year for workers with 15 or more years of experience.

http://www.nber.org/digest/may12/w17703.html

NBER Working Paper – “Does Retiree Health Insurance Encourage Early Retirement?”:
http://papers.nber.org/papers/w17703

And…

Implementation of the Early Retiree Reinsurance Program

GAO (U.S. Government Accountability Office)
September 30, 2011

During the last decade the number of large employers offering health benefits to retirees – including early retirees not eligible for Medicare – has declined. Among all large firms that offered health benefits to active employees from 2001 to 2010, the percentage that offered health benefits to retirees decreased from 39 percent in 2001 to 28 percent in 2010. According to the Agency for Healthcare Research and Quality, individuals age 55 to 64 who lack health insurance are vulnerable to high health care costs associated with serious and chronic illnesses. The Early Retiree Reinsurance Program (ERRP) was established pursuant to the Patient Protection and Affordable Care Act (PPACA) to provide reimbursement to participating employment-based health plans. The reimbursements provided by the program are intended to cover a portion of the cost of providing health benefits to early retirees – individuals age 55 and older who are not eligible for Medicare.

The largest share – about 46 percent – of the $2.7 billion in ERRP reimbursements approved as of June 30, 2011, went to government entities. In general, this distribution of reimbursements is consistent with the provision of retiree health benefits in the marketplace. In particular, government entities are more likely than other types of employers to provide health benefits to their retirees. HHS projects that the $5 billion appropriated for ERRP will be expended by the end of fiscal year 2012 – before the January 1, 2014, end date for the program.

http://www.gao.gov/products/GAO-11-875R

Comment: 

By Don McCanne, MD

Job lock is one of the problems with using a system of financing health care that is heavily dependent on employer-sponsored coverage. Individuals who might otherwise consider other options to their current employment are locked into their jobs under the threat of losing their coverage if they leave. Amongst the forgone options, those who could and would want to retire early may have to wait until eligible for Medicare at age 65 if they have to give up their employer-sponsored plan.

There continues to be an erosion in retiree health benefits offered by employers, and this NBER study shows that it makes a difference. The data show that close to 10 percent of individuals at ages 56 to 64 will exit their jobs only if they receive a retiree health plan with an employer contribution of 50 percent or more.

The framers of the Affordable Care Act recognized this problem. Although there are numerous technical complexities, theoretically the state insurance exchanges would provide individuals not qualified for other programs with private insurance plans that were intended to be affordable based on generous pensions or based on income-indexed subsidies. Congress even authorized a transitional program – the Early Retiree Reinsurance Program – which would provide subsidies to encourage employers to continue coverage until the exchanges were up and running. Unfortunately this program will run out of funds by the end of this year.

Should we want people to retire early? With our high rates of unemployment, it would be great to open up employment opportunities for individuals desperate for work. Even if we return to a vibrant economy, many economists recommend that we still need policies to keep unemployment high enough to ensure a competitive labor market, lest the employers would have to pay higher wages or salaries for their employees. So we should establish policies that discourage early retirement? Nonsense.

Some of these economists have suggested that we should not ever allow unemployment rates to drop below 4 percent, in order to prevent labor costs from increasing. Yet these are often the same economists – and politicians – who helped to “end welfare as we know it,” and even now are recommending further reductions in unemployment compensation and in the supplemental nutrition assistance program (food stamps). These market ideologues are supporting an agenda of keeping them unemployed so we can get cheap labor, but starve the individuals we don’t need. Heartless.

If you read the excerpts from the GAO report above, you will see that the government has been more responsible than the private sector. The government is more likely to provide health benefits to their retirees, and more likely to use the Early Retiree Reinsurance Program to benefit them.

But we really don’t all need to become government employees to increase the likelihood of having health coverage should we retire early. We need only to establish an improved Medicare for everyone, then employment and retirement decisions would never have to be based on the availability of health benefits. Everyone would have health care – forever.

Lack of retiree plans can cause job lock

Providing Retiree Health Insurance Encourages Early Retirement

By Claire Brunel
National Bureau of Economic Research (NBER), Digest, May 2012
Employees under the age of 65 have substantially higher turnover rates at firms that offer subsidized retiree health coverage than at firms that do not.
The strong link between health insurance and employment in the United States may cause workers to delay retirement until they become eligible for Medicare at age 65. However, some employers extend health insurance benefits to their retirees, and individuals who are eligible for such benefits need not wait until age 65 to retire with group health coverage.
In Does Retiree Health Insurance Encourage Early Retirement (NBER Working Paper No. 17703), authors Steven Nyce, Sylvester Schieber, John Shoven, Sita Slavov, and David Wise use employee-level data from 64 diverse firms that are clients of TowersWatson, a leading benefits consulting firm, to investigate the impact of retiree health insurance on early retirement. After controlling for individual characteristics and pension incentives, they find that employees under the age of 65 have substantially higher turnover rates at firms that offer subsidized retiree health coverage than at firms that do not. Subsidized retiree health coverage has its strongest effects at ages 62 and 63, resulting in a 21 percent increase in the probability of turnover at age 62 and a 32 percent increase in the probability of turnover at age 63.
Moreover, higher subsidy rates are associated with greater turnover than lower subsidy rates. For example, an employer contribution of 50 percent or more of the cost of health insurance raises turnover by nearly 34 percent at age 62, and by nearly 44 percent at age 63. The authors estimate that a subsidy of 50 percent or more lowers the expected retirement age by 9 months overall, and by more than a year for workers with 15 or more years of experience.
http://www.nber.org/digest/may12/w17703.html
NBER Working Paper – “Does Retiree Health Insurance Encourage Early Retirement?”:
http://papers.nber.org/papers/w17703

And…

Implementation of the Early Retiree Reinsurance Program

GAO (U.S. Government Accountability Office)
September 30, 2011
During the last decade the number of large employers offering health benefits to retirees – including early retirees not eligible for Medicare – has declined. Among all large firms that offered health benefits to active employees from 2001 to 2010, the percentage that offered health benefits to retirees decreased from 39 percent in 2001 to 28 percent in 2010. According to the Agency for Healthcare Research and Quality, individuals age 55 to 64 who lack health insurance are vulnerable to high health care costs associated with serious and chronic illnesses. The Early Retiree Reinsurance Program (ERRP) was established pursuant to the Patient Protection and Affordable Care Act (PPACA) to provide reimbursement to participating employment-based health plans. The reimbursements provided by the program are intended to cover a portion of the cost of providing health benefits to early retirees – individuals age 55 and older who are not eligible for Medicare.
The largest share – about 46 percent – of the $2.7 billion in ERRP reimbursements approved as of June 30, 2011, went to government entities. In general, this distribution of reimbursements is consistent with the provision of retiree health benefits in the marketplace. In particular, government entities are more likely than other types of employers to provide health benefits to their retirees. HHS projects that the $5 billion appropriated for ERRP will be expended by the end of fiscal year 2012 – before the January 1, 2014, end date for the program.
http://www.gao.gov/products/GAO-11-875R

Job lock is one of the problems with using a system of financing health care that is heavily dependent on employer-sponsored coverage. Individuals who might otherwise consider other options to their current employment are locked into their jobs under the threat of losing their coverage if they leave. Amongst the forgone options, those who could and would want to retire early may have to wait until eligible for Medicare at age 65 if they have to give up their employer-sponsored plan.
There continues to be an erosion in retiree health benefits offered by employers, and this NBER study shows that it makes a difference. The data show that close to 10 percent of individuals at ages 56 to 64 will exit their jobs only if they receive a retiree health plan with an employer contribution of 50 percent or more.
The framers of the Affordable Care Act recognized this problem. Although there are numerous technical complexities, theoretically the state insurance exchanges would provide individuals not qualified for other programs with private insurance plans that were intended to be affordable based on generous pensions or based on income-indexed subsidies. Congress even authorized a transitional program – the Early Retiree Reinsurance Program – which would provide subsidies to encourage employers to continue coverage until the exchanges were up and running. Unfortunately this program will run out of funds by the end of this year.
Should we want people to retire early? With our high rates of unemployment, it would be great to open up employment opportunities for individuals desperate for work. Even if we return to a vibrant economy, many economists recommend that we still need policies to keep unemployment high enough to ensure a competitive labor market, lest the employers would have to pay higher wages or salaries for their employees. So we should establish policies that discourage early retirement? Nonsense.
Some of these economists have suggested that we should not ever allow unemployment rates to drop below 4 percent, in order to prevent labor costs from increasing. Yet these are often the same economists – and politicians – who helped to “end welfare as we know it,” and even now are recommending further reductions in unemployment compensation and in the supplemental nutrition assistance program (food stamps). These market ideologues are supporting an agenda of keeping them unemployed so we can get cheap labor, but starve the individuals we don’t need. Heartless.
If you read the excerpts from the GAO report above, you will see that the government has been more responsible than the private sector. The government is more likely to provide health benefits to their retirees, and more likely to use the Early Retiree Reinsurance Program to benefit them.
But we really don’t all need to become government employees to increase the likelihood of having health coverage should we retire early. We need only to establish an improved Medicare for everyone, then employment and retirement decisions would never have to be based on the availability of health benefits. Everyone would have health care – forever.

More on small businesses and self-insured plans

Implementing Health Reform: Amidst Turbulence, Federal Work Goes On

By Timothy Jost
Health Affairs Blog, April 27, 2012

Stop-Loss Coverage And Self-Insured Plans

On April 27, 2012, HHS, Treasury, and Labor published a Request for Information Regarding Stop Loss Insurance. The concern that drives this is the potential of stop loss-insured self-insured employer plans destabilizing the small group insurance market post-2014.

Employers have always had reasons to self-insure. Plans that are self-insured escape state regulation, including state mandates, and can be less expensive than commercial insurance for low-risk groups. The Affordable Care Act (ACA), however, increases these incentives dramatically. Insurers understand this, and are actively marketing “self-insured” products to small groups. These products offer administrative services and “stop-loss” coverage that shields small employers from the risk that would otherwise make self-insured status unattractive. They often have very low “attachment points,” which define when the employer ceases to bear risk and the stop-loss insurer takes over. Some stop loss plans are almost indistinguishable from high deductible health plans, except that the risk remains nominally with the employer rather than the employee.

Self-insured plans become more attractive to small groups under the ACA for two reasons. First, they are subject to fewer regulatory requirements than are insured plans. Whether in or out of the exchange, small group plans must offer the essential benefits package, include their members in a single risk pool, participate in the risk adjustment program, offer the same premiums without regard to health status, and offer the precious metal tiers. Self-insured plans are not, however, subject to these requirements.   Moreover, neither self-insured plans nor the stop-loss coverage that makes self-insurance possible for small groups are subject to the ACA’s minimum medical loss ratio requirements. Self-insured plans are also exempt from a fee imposed on insurers under ACA section 9010 and stop-loss plans do not need to justify unreasonable rate increases.

Second, once the ACA establishes guaranteed issue and bans health status underwriting and pre-existing condition exclusions for small groups in 2014, the risk to small employers of self-insuring will be dramatically reduced. Under current law in most states, a self-insured small employer faces the prospect of significantly increased stop-loss rates or lack of affordable access to conventional insurance if the group’s risk profile deteriorates (e.g. an employee or dependent gets cancer or needs an organ transplant). But, beginning in 2014, insurers (in or out of the exchange) will not be able to refuse to insure higher-risk small groups or exclude preexisting conditions, and will have to insure them at standard rates. SHOP (small employer) exchanges cannot have open enrollment periods for employers but must admit small employers whenever they apply for coverage. The threat of adverse selection to the exchanges could be substantial. Healthy small groups will be able to self-insure with stop-loss coverage and then leave that coverage and enter the exchange at standard rates the moment an employee or dependent suffers a serious illness or accident.

Without stop loss insurance, however, self-insured small group plans become much less viable. Few small groups can fully take on the risk of self-insuring without stop-loss. As of this point, stop loss insurance for small groups is not regulated at the federal level and largely unregulated at the state level. The term “self-insured” is not defined in the ACA, and the agencies clearly have the authority to define when a plan with stop-loss coverage is in fact so fully-insured that it ceases to be self-insured. In the request for information, the agencies are seeking to determine how common stop-loss coverage is, how it operates, how insurers decide which employers to insure and how much they charge, and how stop loss insurance is regulated. Presumably regulations will follow.

http://healthaffairs.org/blog/2012/04/27/implementing-health-reform-amidst-turbulence-federal-work-goes-on/

Comment: 

By Don McCanne, MD

The Affordable Care Act offers Mack-truck-size loopholes for small businesses that decide to self-insure – loopholes that defeat many of the noble intentions of health care reform. Timothy Jost describes these loopholes above.

In his full article available at the link above, Professor Jost also describes 1) several technical considerations for the medical loss ratio, 2) some of the complexities in determining whether individuals have access to employer-sponsored plans, which in turn can affect eligibility for exchange plans, and 3) technicalities that determine whether or not employer-sponsored plans meet minimum value requirements.

A quick read of the full article will reinforce two points that we already know: 1) the Affordable Care Act significantly increases the administrative complexity of health care financing when our system is already weighted down with expensive administrative excesses, and 2) the Act opens up further the opportunity for gaming the system thereby perpetuating and expanding the inequities and injustices of our uniquely American system that already uses gaming that drives up costs and diverts our finite funds away from health care.

As Professor Jost says, more regulations should follow. Great. Each loophole patch seems to create multiple additional loophole opportunities.

It is astounding that we continue to make such an intense effort to try to get this turkey to fly when we could have a health care system that would soar like an eagle. (If only metaphors could send us off in the right direction, but alas… )