PNHP

Another P4P dud

Another P4P dud

The Long-Term Effect of Premier Pay for Performance on Patient Outcomes

By Ashish K. Jha, M.D., M.P.H., Karen E. Joynt, M.D., M.P.H., E. John Orav, Ph.D., and Arnold M. Epstein, M.D.
The New England Journal of Medicine, March 28, 2012
Tying financial incentives to performance, often referred to as pay for performance, has gained broad acceptance as an approach to improving the quality of health care. The Centers for Medicare and Medicaid Services (CMS) recently completed a 6-year demonstration of pay for performance for hospitals through the Premier Hospital Quality Incentive Demonstration (HQID), and the Affordable Care Act calls for CMS to expand this program to nearly all U.S. hospitals in 2012. The policy of tying financial incentives to the quality of performance has strong face validity — that is, paying for better care should promote improvements in quality and, ideally, lead to better patient outcomes. Whether pay for performance will lead to better patient outcomes, however, is unclear.
Although there is evidence from the Premier HQID that pay for performance is associated with modest improvements in the processes of care, much less is known about its effect on patient outcomes.
We found little evidence that participation in the Premier HQID program was associated with declines in mortality above and beyond those reported for hospitals that participated in public reporting alone, even when we examined care over a period of 6 years after the program’s inception. Furthermore, we found no differences in trends in mortality between conditions for which outcomes were explicitly linked to incentives and conditions for which outcomes were not linked to incentives.
Prior studies of the Premier HQID showed that the early gains in process quality had mostly dissipated after 5 years under the program. Werner et al. found that the modest benefits in adherence to process measures were most perceptible for hospitals that were eligible for larger bonuses, that were well financed, or that operated in less competitive markets. We failed to find that these factors were associated with a significantly greater effect on outcomes.
In summary, we found little evidence that participation in the Premier HQID program led to lower 30-day mortality rates, suggesting that we still have not identified the right mix of incentives and targets to ensure that pay for performance will drive improvements in patient outcomes. Even though Congress has required that the CMS adopt pay for performance for hospitals, expectations with regard to programs modeled after Premier HQID should remain modest.
http://www.nejm.org/doi/full/10.1056/NEJMsa1112351?query=TOC#t=abstract

Pay for performance (P4P) is one of the measures in the Affordable Care Act (Sec. 3001) that supposedly is designed to improve quality and reduce costs. The recommendation was based on data such as this Medicare Hospital Quality Incentive Demonstration (HQID) which had shown that providing financial bonuses and penalties improves processes of care. But does it improve outcomes?
This large study of hospital performance had already shown early but non-sustained improvement in processes, but it turns out that paying for this performance did not improve patient outcomes. P4P did not improve 30 day nor 6 year mortality for the conditions studied – three medical conditions (acute myocardial infarction, congestive heart failure, and pneumonia) and two surgical procedures (coronary-artery bypass grafting [CABG] and total knee or total hip replacement). Yet the Affordable Care Act requires that all hospitals participate in the value-based purchasing (VBP) program, which provides financial incentives for both high achievement and improvement in performance – an approach closely modeled after the Medicare HQID.
This “teach to the test” P4P experiment did, in fact, result in rewards and penalties for hospitals based solely on process measures, though having no impact on outcomes. Such programs seem to promote gamesmanship much more than they promote actual improvements in quality – appealing to hospitals that were “eligible for larger bonuses, that were well financed, or that operated in less competitive markets.” It is yet another example of the multitude of unproven or minimally effective quality and cost measures in the Affordable Care Act.
The tragedy is that Congress and the President rejected the proven model of reform that would have achieved these goals – a single payer national health program. One benefit of the Supreme Court hearings this week is that there has been a resounding response that single payer is the answer. If only we could convert that perception into action. If only…

Marcia Angell: Happy birthday, ObamaCare

By Marcia Angell, M.D.
USA Today, March 27, 2012

The Patient Protection and Affordable Care Act, otherwise known as ObamaCare, turned 2 years old Friday, just in time for this week’s Supreme Court hearings on its constitutionality. The major provisions of the law, meant to increase the number of insured Americans while controlling costs, will be implemented in 2014, but a few are already in effect. What are its prospects, and will it survive intact to its next birthday? The outlook, I’m afraid, is not good.

For starters, the law was greatly weakened before it was even enacted. To win the support of the powerful health insurance industry, President Obama included the unpopular mandate requiring uninsured Americans to buy private insurance. Not only did this set off a legal battle, it preserved and expanded the central role of the insurance companies, whose abuses caused many of health care’s problems in the first place. They will get millions of new customers, many with government subsidies. In addition, the idea of a “public option” — government-sponsored insurance to compete with private insurers — was scuttled, wasting critical opportunities to try to control costs.

Let’s look briefly at the major provisions: First, the law encourages employers to provide health benefits by fining large companies that don’t and subsidizing small ones that do. Second, Medicaid, the federal/state program for the poor, will be expanded to cover an additional 16 million people. And third, everyone else without Medicare or employer-sponsored insurance, estimated as another 16 million people, will have to buy private insurance or be fined. States will create (or have created for them by the feds) shopping exchanges to pool risks and offer a menu of approved insurance plans for individuals and small businesses, with subsidies for people earning less than 400% of the federal poverty level. (Note that of the roughly 50 million uninsured people when the law was enacted, 18 million would be left uncovered.)

Insurance abuses addressed

The law addresses the worst abuses of insurance companies by prohibiting them from excluding people with pre-existing conditions, dropping policy holders who develop expensive illnesses, or using more than 20% of premiums for overhead, marketing and profits. But companies can still set their own prices, and they’ll be allowed to charge older customers up to three times more than young people.

To finance the law, the payroll tax that supports Medicare will be increased for high earners, who will also pay a small additional tax on unearned income. In addition, support for private Medicare Advantage plans will be reduced, and there will be unspecified cuts in Medicare payments to hospitals and other medical facilities, and a variety of fees levied on health companies.

Runaway costs

That’s the theory. What’s the likely reality? At the time of enactment, the non-partisan Congressional Budget Office estimated that over 10 years, the new funding would more than cover the cost to the federal budget. But costs to the private sector — businesses and individuals — were not addressed in the CBO analysis, nor was cost inflation. Given the influx of new customers and government money, health costs will likely rise rapidly and quickly outstrip funding. There will, of course, be revisions to the CBO analysis as the law is implemented and conditions change, but none can be more than crude estimates.

Monday’s Supreme Court hearing was just the beginning of a torrent of legal challenges to various provisions of the law. For example, many states, particularly Republican ones, have indicated that they will not establish state insurance exchanges or cooperate with the federal government in doing so, and that will be litigated, too.

Regulating the law will be a bureaucratic nightmare. Even in friendly states, establishing insurance exchanges will be a complicated job involving multiple state agencies. Monitoring insurance companies will be even harder. The prohibitions against abuses can almost certainly be skirted, and insurers have a strong incentive to do so.

So I fear that this 2-year-old law will unravel before it is fully implemented. As state exchanges falter, individuals and businesses could be faced with prohibitively high premiums or punishing fines. The most vulnerable Americans will be those in their 50s and early 60s, who will have to pay the highest premiums and are most likely to have chronic illnesses.

Of course, if there is a Republican sweep in November, ObamaCare will be systematically dismantled.

When Obama was an Illinois state senator, he favored a single-payer health system — such as Medicare — for all. Even as president, he admitted in the summer of 2009 that a single-payer system was the only way to provide universal care. He was right then.

Medicare outperforms private insurance on every measure. It insures nearly everyone older than 65 for the entire package of benefits, no one can be excluded or dropped from coverage, and its overhead is very low. When ObamaCare inevitably fades away, it will be time to revisit the single-payer option.

How about lowering the Medicare age gradually, one decade at a time, beginning with age 55?

Marcia Angell, M.D., is senior lecturer in social medicine at Harvard Medical School and former editor in chief of the New England Journal of Medicine.

http://www.usatoday.com/news/opinion/forum/story/2012-03-22/obama-health-reform-court/53732820/1

Matthews asks Gruber about starting over with single payer

Hardball with Chris Matthews

MSNBC, March 27, 2012

Chris Matthews:  Professor Gruber, I’ve got a curve ball for you, from the left field, all right? I’m mixing my metaphors here. If the Supreme Court strikes down the individual mandate today, which is the most conservative way to have national health for everybody, requiring people to take responsibility as individuals. If that fails, and the progressive left of the Democratic Party says, no, now’s our chance to go for single payer, or what’s called the public option – I guess they’ll wind up being the same thing because there won’t be another option really. Is that a better economic proposition? That the government simply provides health insurance for the country? Single payer. Is that a better economic deal with no profit motive?

Jonathan Gruber:  I think that single payer, if you could start over, I think that single payer has a lot to recommend it, but we can’t, and I think the bottom line is…

Chris Matthews:  But we might have to start over after tonight.

Jonathan Gruber:  No. I agree, but if we start over, the problem with failing, if this ruling goes against… this law fails, we’ll see the same pattern we’ve seen for the past century, which when we start over again which will on average be about seventeen years from now, because it’s about every seventeen years we start over, it’s going to be further to the right of where we are.  Every seventeen years… Remember Richard Nixon proposed something to the left of the Affordable Care Act. Every seventeen years we move to the right. If this fails, the next round is not going to be single payer. It’s going to be even more conservative than what we have now.

http://www.msnbc.msn.com/id/3036697/#46873470

Comment:

By Don McCanne, MD

What is the basis for this conversation about starting over if the Affordable Care Act (ACA) is struck down by the Supreme Court? Implicit is the concept that the Affordable Care Act actually accomplished the reform that we need. Of course, it didn’t. So, regardless of the decision, we wouldn’t be starting over since no iteration of ACA would hardly even begin to complete the process of reform.

For those who believe that ACA is the most feasible path to reform, there are some issues in this debate that would have the appearance of a make-or-break outcome (even though ACA itself isn’t a make-or-break model).

Based on the first two days of deliberation before the Supreme Court, it appears that the individual mandate to purchase private insurance may well be struck down. If it is, then both sides (plus an amicus from America’s Health Insurance Plans) agree that guaranteed issue and community rating should be declared inseverable and struck along with the individual mandate.

Though an intact ACA falls intolerably short on reducing uninsurance, underinsurance, and unaffordability, a decision eliminating guaranteed issue (eliminates pre-existing condition exclusions) and community rating (prevents insurers from gouging those with greater health care needs) would leave yet many more uninsured, especially those with greater health care needs plus the healthy invincibles whose funds are needed for the insurance risk pools. That should be enough to cause ACA supporters to take another look at single payer, though the mess we have with an intact ACA should make them reconsider anyway. ACA did not turn out to be the affordable-care-for-everyone model that supporters had hoped for at the beginning.

So we wouldn’t be starting over again since ACA was merely a misfire that gained us very little. A misfire is not enough to restart the seventeen year clock, not to mention that the clock is only an illusion anyway.

And Gruber’s contention that our next reform efforts will move further to the right because that’s the way history has led us? Really? Was Social Security a move to the right? Was Medicare a move to the right? Was the Civil Rights Act a move to the right?

Does health care really fall at some point along a linear, bipolar, one-dimensional span between right and left? Of course not, though we should tell the ideologues in Congress who believe this that such in-the-box thinking is why we are replacing them in the forthcoming election. We want not just the elderly but everyone in America to be able to say, “Leave my Medicare alone!”

Matthews asks Gruber about starting over with single payer

Hardball with Chris Matthews

MSNBC, March 27, 2012
Chris Matthews: Professor Gruber, I’ve got a curve ball for you, from the left field, all right? I’m mixing my metaphors here. If the Supreme Court strikes down the individual mandate today, which is the most conservative way to have national health for everybody, requiring people to take responsibility as individuals. If that fails, and the progressive left of the Democratic Party says, no, now’s our chance to go for single payer, or what’s called the public option – I guess they’ll wind up being the same thing because there won’t be another option really. Is that a better economic proposition? That the government simply provides health insurance for the country? Single payer. Is that a better economic deal with no profit motive?
Jonathan Gruber: I think that single payer, if you could start over, I think that single payer has a lot to recommend it, but we can’t, and I think the bottom line is…
Chris Matthews: But we might have to start over after tonight.
Jonathan Gruber: No. I agree, but if we start over, the problem with failing, if this ruling goes against… this law fails, we’ll see the same pattern we’ve seen for the past century, which when we start over again which will on average be about seventeen years from now, because it’s about every seventeen years we start over, it’s going to be further to the right of where we are. Every seventeen years… Remember Richard Nixon proposed something to the left of the Affordable Care Act. Every seventeen years we move to the right. If this fails, the next round is not going to be single payer. It’s going to be even more conservative than what we have now.
http://www.msnbc.msn.com/id/3036697/#46873470

What is the basis for this conversation about starting over if the Affordable Care Act (ACA) is struck down by the Supreme Court? Implicit is the concept that the Affordable Care Act actually accomplished the reform that we need. Of course, it didn’t. So, regardless of the decision, we wouldn’t be starting over since no iteration of ACA would hardly even begin to complete the process of reform.
For those who believe that ACA is the most feasible path to reform, there are some issues in this debate that would have the appearance of a make-or-break outcome (even though ACA itself isn’t a make-or-break model).
Based on the first two days of deliberation before the Supreme Court, it appears that the individual mandate to purchase private insurance may well be struck down. If it is, then both sides (plus an amicus from America’s Health Insurance Plans) agree that guaranteed issue and community rating should be declared inseverable and struck along with the individual mandate.
Though an intact ACA falls intolerably short on reducing uninsurance, underinsurance, and unaffordability, a decision eliminating guaranteed issue (eliminates pre-existing condition exclusions) and community rating (prevents insurers from gouging those with greater health care needs) would leave yet many more uninsured, especially those with greater health care needs plus the healthy invincibles whose funds are needed for the insurance risk pools. That should be enough to cause ACA supporters to take another look at single payer, though the mess we have with an intact ACA should make them reconsider anyway. ACA did not turn out to be the affordable-care-for-everyone model that supporters had hoped for at the beginning.
So we wouldn’t be starting over again since ACA was merely a misfire that gained us very little. A misfire is not enough to restart the seventeen year clock, not to mention that the clock is only an illusion anyway.
And Gruber’s contention that our next reform efforts will move further to the right because that’s the way history has led us? Really? Was Social Security a move to the right? Was Medicare a move to the right? Was the Civil Rights Act a move to the right?
Does health care really fall at some point along a linear, bipolar, one-dimensional span between right and left? Of course not, though we should tell the ideologues in Congress who believe this that such in-the-box thinking is why we are replacing them in the forthcoming election. We want not just the elderly but everyone in America to be able to say, “Leave my Medicare alone!”

As Supreme Court Hears Case, Does Law Do Enough to Fix Health Crisis?

By Amy Goodman
Democracy Now, March 27, 2012

As the Supreme Court weighs whether the Affordable Care Act goes too far, we host a debate on whether the law goes far enough. The case is reviving the heated tensions that surrounded the health care reform law in the debate leading up to its passage two years ago. Although support for the measure is often equated with backing the expansion of health coverage for all Americans, there are some who maintain it didn’t go far enough in helping the uninsured. We speak to Dr. Stephanie Woolhandler, co-founder of Physicians for a National Health Program, and Dr. John McDonough, who played a key role in shaping Mitt Romney’s health care reform law in Massachusetts as well as the Affordable Care Act. The new health care law is “going to leave tens of millions of Americans woefully underinsured, with gaps in their coverage like copayments and deductibles, so they’ll still be bankrupted by illness. And it’s not going to control cost,” Woolhandler argues. “So we still need single-payer national health insurance regardless of what happens at the Supreme Court.” But McDonough notes that “the moment when there would be sufficient political will for the Congress and the president to come together and pass meaningful, near-comprehensive reform, that might take another 20 years.” [Includes rush transcript below. PNHP note: Dr. Woolhandler’s comments begin at the 13 minute, 40 seconds mark of the program; the segment can be directly accessed at the following link; the interview lasts 25 minutes.]

http://www.democracynow.org/2012/3/27/healthcare_debate_as_supreme_court_hears

Guests:

Dr. Steffie Woolhandler, professor of public health at CUNY-Hunter College and a primary care physician. She is a visiting professor at Harvard Medical School and the co-founder of Physicians for a National Health Program.

John McDonough, professor at the Harvard School of Public Health and director of the New Center for Public Leadership. Between 2008 and 2010, he served as a senior adviser on national health reform to the U.S. Senate Committee on Health, Education, Labor and Pensions. And between 2003 and 2008, he served as executive director of Health Care for All in Massachusetts, playing a key role in passage of the 2006 Massachusetts health reform law. His new book is called Inside National Health Reform.

Rush Transcript

AMY GOODMAN: The Supreme Court is convening a historic session on the constitutionality of the Affordable Care Act, the landmark health care reform bill signed by President Obama two years ago. Oral arguments began Monday with a debate over whether the law can be contested in light of a statute that protects taxes from challenge before they take effect. Today, justices will hear arguments over an issue at the heart of so-called “Obamacare,” the individual mandate that requires most people buy health insurance by 2014 or pay a tax penalty. A third and final day of arguments will be held on Wednesday.

The Supreme Court case is expected to have huge implications for the nation and the 2012 elections and is being followed closely by all sides of the health care debate. On Monday, supporters and opponents of the health care law gathered outside the Supreme Court to make their voices heard.

WILLIAM YOUNG: It’s not about politics. It’s not about being partisan or, you know, linking up to some kind of—linking up to some kind of position that you need to tie yourself to. This is about people taking care of other people. And it’s about the idea that we’re putting profit over people. And big health insurance companies don’t need any help; they’re making a lot of money. And I think that regular people need to advocate for themselves, because the insurance companies are not going to advocate for you. But Obama will, and that’s what this bill does.

ROD RHOADES: We support health care reform from our hearts. We are sad when children go to the hospital, and they don’t have insurance. That breaks our hearts. That cannot be here in America. But this bill is unconstitutional. It was—it’s illegal. It was done on bribes and kickbacks to Obama’s campaign supporters. We’re completely against it. We want real reform, where the money goes to the people in the hospitals that need it. That’s what we want.

AMY GOODMAN: Also appearing outside the Supreme Court was Republican presidential hopeful Rick Santorum, who touted his steadfast opposition to the health care law.

RICK SANTORUM: This bill has far-reaching consequences for the economic health of this country and for basic liberty in our society. And that’s why this decision and the debate that is going on right now is fundamental. And there’s one candidate in this race who can actually make the contrast that is necessary between the Republican position, the conservative position, and one that is an overwhelmingly supported by the American public, and one that Barack Obama believes in. And that’s Rick Santorum.

AMY GOODMAN: The argument of the Supreme Court case is reviving the heated tensions that surrounded the health care law in the debate leading up to its passage two years ago. But although support for the health care law is often equated with backing the expansion of health care coverage for all Americans, there are some who maintain the bill did not go far enough in helping the uninsured. In an amicus brief filed with the Supreme Court last month, a group of physicians argued against the health care mandate altogether, saying Congress should instead legislate a single-payer system to provide universal care for all.

I’m joined now by two guests on opposite sides of this overlooked part of the health care debate. Dr. Steffie Woolhandler is co-founder of Physicians for a National Health Program, whose members signed on to the amicus brief arguing against the individual mandate and for single payer. She is a primary care physician who teaches in public health at CUNY-Hunter College and at Harvard Medical School.

And joining me from Boston is John McDonough, professor at the Harvard School of Public Health, director of the New Center for Public Leadership. Between 2008 and 2010, he served as a senior adviser on national health reform to the U.S. Senate Committee on Health, Education, Labor and Pensions. And between 2003 and 2008, he served as executive director of Health Care for All in Massachusetts, playing a key role in the passage of the 2006 Massachusetts health reform law, known as Romneycare, regarded by many as the model for the current health care law. He has a new book out; it’s called Inside National Health Reform.

We welcome you both to Democracy Now! And we’re going to begin with Professor McDonough. The importance, the significance, of this Supreme Court hearing over these three days?

DR. JOHN McDONOUGH: Well, it could be very consequential in terms of some of the key features of the law: the Medicaid expansion for 16 million low-income Americans, as well as the success of the private health insurance expansion through the individual mandate. I think, ultimately, far less important than the decision of any—the Supreme Court will be the decision of voters in November, on November 6th. Really, the future of this law will be decided by who controls the White House and who controls Congress next year, and the Supreme Court is really secondary.

AMY GOODMAN: Steffie Woolhandler?

DR. STEFFIE WOOLHANDLER: Well, I want to say, our organization, Physicians for a National Health Program, did not take a position on the Suprem
e Court deliberations. Some of the members opposed the mandate and did weigh in in the amicus brief. Some were more ambivalent and felt that there was some good in the bill. What we all agree on, however, is that the bill is not a solution. It will leave 27 million Americans uninsured when it’s fully implemented. It’s going to leave tens of millions of Americans woefully underinsured, with gaps in their coverage like copayments and deductibles, so they’ll still be bankrupted by illness. And it’s not going to control cost. So we still need single-payer national health insurance regardless of what happens at the Supreme Court.

AMY GOODMAN: Do you care if the Supreme Court were to reject it, say the individual mandate is not constitutional?

DR. STEFFIE WOOLHANDLER: Well, the individual mandate is a very, very bad idea. The good parts of the bill are things like a Medicaid expansion, which does not require an individual mandate, some regulations on the insurance industry, which does not require a mandate. All of those could have been done without the mandate. The problem with the mandate is it’s telling people that they have to turn over their money to the private health insurance industry. There’s also $447 billion in taxpayer money that is going to be turned over to the private health insurance industry. So the bill is strengthening the position of the private health insurance industry, the very industry that’s responsible for $380 billion in wasted health care dollars on bureaucracy and paperwork.

AMY GOODMAN: Professor McDonough?

DR. JOHN McDONOUGH: I don’t disagree with the assertions of my friend, Dr. Woolhandler. And I would agree with her that I think a single-payer plan could be far preferable. The reality was that there was no possibility in 2009, 2010, of achieving passage of anything close to a single payer. And I think, really, the question is, does the Affordable Care Act move the system forward by eliminating pre-existing conditions, by creating the Medicaid expansions, by undertaking so many other important improvements to the health care system, tripling the size of the National Health Service Corps, providing important new funding for community health centers, just many, many important provisions? The question is, is, does the Affordable Care Act move the system forward, and was it worth doing? And I guess that’s probably where we disagree. I think that, short of a single-payer system, that the Affordable Care Act was the best that we could get done and that it really will provide significant, meaningful, important improvements for the lives and the health and the well-being of many, many millions of Americans and really does move the system forward in very important ways in terms of trying to address some serious deficiencies in the quality and efficiency of medical care delivery in the United States.

AMY GOODMAN: Dr. Woolhandler, what about that, that Obama got done what he could?

DR. STEFFIE WOOLHANDLER: Well, I practiced primary care for decades in Massachusetts, and I still teach there, and I’m at a public hospital. And I saw what happened in Massachusetts, which—with the Romneycare that was a model for Obamacare. Some people got helped a little bit; some people got hurt a little bit. But for most of the doctors and patients, nothing changed. That is, people still could not afford care and had to seek care in the public sector because they were unable to afford the care that they needed.

AMY GOODMAN: We’re going to break and then come back to this discussion. Dr. Steffie Wooldhandler, co-founder of Physicians for a National Health Program, and Dr. John McDonough of the Harvard School of Public Health, where Dr. Steffie Woolhandler just came from. His new book is called Inside National Health Reform. This is Democracy Now! Back in 45 seconds.

[break]

AMY GOODMAN: Our guest, Dr. Steffie Woolhandler, co-founder of Physicians for a National Health Program, came from the Harvard School—from Harvard Medical School to New York, and she is teaching now at CUNY, City University of New York. Professor John McDonough is still at the Harvard School of Public Health. His new book is called Inside National Health Reform.

I want to play an excerpt of attorney Robert Long speaking to the high court justices about the Anti-Injunction Act, the federal law that purports to require someone to actually be taxed before they can challenge that tax.

ROBERT LONG: Our initial submission is, you don’t have to determine that this is a tax in order to find that the Anti-Injunction Act applies, because Congress very specifically said that it shall be assessed and collected in the same manner as a tax, even if it’s a tax penalty and not a tax.

AMY GOODMAN: John McDonough, what exactly is attorney Robert Long opposing about the Affordable Care Act?

DR. JOHN McDONOUGH: Well, he’s not opposing or supporting it. He’s saying that there is an 1867 law, the Anti-Injunction Act, and a key part of it says you can’t sue to prevent the collection of a tax until the tax has actually gone into effect and people are paying it. I happen to think, based upon my reading—and I’m not an attorney—that there’s a very strong case that the Anti-Injunction Act prevails. I think, though, that the justices on both sides of the ideological spectrum want to decide this, and that was clear from their questioning yesterday. And so, I think the Anti-Injunction Act kind of is going to be moved to the back of the room or kind of in a closet. And if the justices end up in some kind of a significant deadlock, then they might at the end, if they can’t resolve it, pull the Anti-Injunction Act out of the closet and use it. Otherwise, I think they’re going to do everything they can to try to make some more definitive ruling by June.

AMY GOODMAN: Professor McDonough, you occupy an interesting position. You were key in both Romneycare, the health care act in Massachusetts that has become really the basis of what many call Obamacare, or the Affordable Care Act—you were involved with both. Now you have these two presidential candidates most likely going up against each other, and you have Romney saying that he completely opposes what President Obama has managed to have passed into law. What is your response to that?

DR. JOHN McDONOUGH: Mitt Romney found himself in a quite peculiar position. The individual mandate emerged from conservative Republican circles in the late ’80s and early ’90s and gained prominence as an alternative to the Clinton health reform vision in ’93, ’94. And Republicans kept beating that drum for years. Mitt Romney mistakenly thought they meant it and were serious, and so he took their idea, and he actually worked to and helped to actualize it in Massachusetts as part of the Massachusetts health reform law. And then, when they attempted to do it on a national basis through the Democrats’ health care initiative, all the Republicans who said they were for this deserted the ship, jumped off the ship. But Romney couldn’t do it, because he was pictured holding the steering wheel with Ted Kennedy when they made it happen. So, he finds himself in an ironic situation in terms of supporting something that was very much Republican orthodoxy and then watched all the Republicans abandon it.

You know, the truth is that Romney had a very minimalist vision of what Massachusetts health reform would be. It was one that—I was in the advocacy community at the time—that we did not support at all. But the Democrats had overwhelmingly control in the House and the Senate. And we were able to work with them to make what is now referred to as Romneycare much more robust and full. And right now in Massachusetts, more than 98 percent of all res
idents have health insurance. About 99.8 percent of children have health insurance. It’s not perfect. For every flaw that Dr. Woolhandler names, I could probably name two or three. It is a significant step forward, in terms of doing a better job in terms of providing coverage and some financial protection. And overwhelmingly in Massachusetts, people support it and think it has worked and it’s been a good thing.

AMY GOODMAN: Dr. Steffie Woolhandler?

DR. STEFFIE WOOLHANDLER: Let me tell you that it is not true that 98 percent of people have health insurance in Massachusetts. The Census Bureau says 94 percent. And let me tell you the kind of health insurance that people have. If you go on the exchange website in Massachusetts and try to buy health insurance for someone my age, you’re going to be taking $5,600 out of your pocket to pay the premiums. Then, if you got sick, you would have a $2,000 deductible. So you’re $7,600 out of pocket before the insurance pays a penny. And you’re mandated to buy that coverage; you don’t have a choice. So, things are not—are not at all solved in Massachusetts. Some people were helped; some were hurt. But many people still can’t afford care.

You know, one of the things that happened in Massachusetts, and is going to happen nationally, is money was taken out of safety-net hospitals to pay for the bill. Nationally, $36 billion is going to be removed from safety-net hospitals to pay for Obamacare. And that means that the remaining uninsured—and there will be 27 million uninsured—the tens of millions who are underinsured, may have no place to go when they get sick, because the safety net has been cut. So there’s some very negative consequences to these bills in Massachusetts and nationally, as well as the positive consequences that John is talking about.

AMY GOODMAN: If this Affordable Care Act is ruled unconstitutional by the Supreme Court, it’s possible nothing will change in some 20 years. What do you—do you think that is true?

DR. STEFFIE WOOLHANDLER: Absolutely not. The health care system is in a complete state of crisis. And that’s what’s going to reopen the health care debate. You know, history is not just made by legislators. It’s also made by small people like us, doctors, nurses, patients, people who write letters to the editor—

AMY GOODMAN: States.

DR. STEFFIE WOOLHANDLER: —who go to meetings. You can do state-level reform.

AMY GOODMAN: Well, aren’t a number of states, one by one—for example, Vermont—aren’t they now just adopting a very different—they’re coming up with their own kind of single-payer system.

DR. STEFFIE WOOLHANDLER: Yes. Well, certainly there’s state-level efforts in Vermont and in Hawaii that are talking about single payer. But this debate is not going to shut down for 20 years, because the American people cannot get health care. You know, when we talk about 27 million people remaining uninsured under Obamacare, we’re talking about one in 1,000 of them dying every year because they lack health insurance, approximately 27,000 deaths annually from lack of health insurance. And that’s unacceptable to me as a physician, and I think it’s unacceptable to the American people. And the health reform debate will continue regardless of what happens in the Supreme Court this week.

AMY GOODMAN: Professor McDonough, the individual mandate, if it is deemed unconstitutional by the high court, by the Supreme Court, because in the legislation it was made unseverable, would it throw out the whole plan?

DR. JOHN McDONOUGH: No, absolutely not. I think that the most that the court would throw out with the individual mandate, if they did that—and I don’t think they will, but if they did—they would throw out the guaranteed issue, meaning the protection against pre-existing conditions and medical underwriting, and they might throw out the community rating, as well, which we would—I would think would be very unfortunate and would create a less functional insurance market, for sure.

Let me just agree and disagree with my friend Steffie, who I really respect. She’s terrific and does wonderful work. First of all, I totally agree the debate would not end if the law were thrown out. However, the moment when there would be sufficient political will for the Congress and the president to come together and pass meaningful, near-comprehensive reform, that might take another 20 years. The debate certainly would not end. But these moments that occur in the early ’90s, in 2009, 2010, in 1965, in 1935, these are not moments that come every session, every decade. These are every generation or every other generation before these chances happen. And that’s why it’s important, I think, to build on it. The original Social Security Act that Franklin Roosevelt signed in 1935 excluded two-thirds of working African Americans, excluded more than half of working women, but it was the foundation and the structure that was built on over time to create the Social Security system we have and we know and recognize today. And I think it’s similar with Medicare and Medicaid, and it’s similar with the Affordable Care Act.

AMY GOODMAN: Steffie Woolhandler?

DR. STEFFIE WOOLHANDLER: Well, this is a little like saying that we’re going to start Social Security by handing over money to the private pension funds. What’s going on here in Obamacare is we’re saying we’re going to get to universal health care by turning over hundreds of billions of dollars to the private health insurance industry, the group that’s been blocking reform and blocking change for decades. So, we’re starting off in the wrong direction here, if we’re trying to start going toward universal health care.

AMY GOODMAN: The Supreme Court decision is being closely followed by many who say they could benefit from the law. Robyn Martin is a mother of a seven-month-old son who suffers from a serious heart condition.

ROBYN MARTIN: We need the Supreme Court to uphold the Affordable Care Act, because we need this little boy to continue to have health care without having to worry about hitting a limit, without having to add up each one of our visits to see how close we’re going to get to an arbitrary limit that a health insurance company sets for us.

AMY GOODMAN: Dr. Woolhandler, what do you say to people like Robyn Martin?

DR. STEFFIE WOOLHANDLER: Well, we definitely need the universal health care. ’Til we get there, we need guaranteed issue, we need community rating. But all of those things could be done without the mandate. There was community rating in this country for decades when I was growing up, which means that everybody pays the same insurance premium and—under Blue Cross, when I was growing up. So we do not need the individual mandate in order to have these things, and we did not need to hand over hundreds of billions of dollars to the private health insurance industry to get those helpful parts of the legislation.

AMY GOODMAN: How did we get to where we are? How did the Affordable Care Act end up, as you say, captured by the insurance industry?

DR. STEFFIE WOOLHANDLER: Well, the insurance industry wrote the framework for Romneycare in the form of Blue Cross Blue Shield Foundation in Massachusetts that wrote the original framework. When it came time for Obamacare, the Senate framework, which became the backbone of the law, was written by none other than Elizabeth Fowler, whose previous job had been vice president of WellPoint, the nation’s largest private insurance company. The insurance industry spent hundreds of millions of dollars lobbying on this bill. They gave hu
ndreds of millions to the Democrats and hundreds of millions to the Republicans, both supporting and opposing the bill, but assuring that voices from the left who supported real universal health care, real single payer, were shut out.

The only way those voices ultimately got heard was because people showed up in front of the White House in white coats and demonstrated. Doctors and nurses got arrested in Senate hearings. We forced the issue of single payer back onto the agenda against the wishes of the private health insurance industry. And that’s what needs to happen if we’re ever going to get to a real universal system that’s affordable, that gets rid of the private health insurance industry, and recaptures that $380 billion in excess paperwork costs and uses it to cover everyone.

AMY GOODMAN: Professor John McDonough, is Governor Romney lying when he says he doesn’t support an individual mandate? Was that your experience in Massachusetts?

DR. JOHN McDONOUGH: Oh, no, he robustly supported it. He did. And I think he would—I don’t think he’s backed away from saying he supports it. I think the way he has parsed it is he said, “Well, I support it on the state level, but not as a federal requirement.”

AMY GOODMAN: Yes, that is what he says.

DR. JOHN McDONOUGH: And so, you can judge that for what you think. But there are many, many statements in 2007, ’08 and ’09 where he indicated support for a national mandate. So, either he’s lying, or he’s changed his views on the utility of doing it on a national basis.

AMY GOODMAN: Not to mention he and his wife’s support of Planned Parenthood as part of that program.

DR. JOHN McDONOUGH: Well, we have a long list of those kinds of situations we can look at.

AMY GOODMAN: Well, I want to thank you both for being with us. John McDonough is with the Harvard School of Public Health. His new book is called Inside National Health Reform. And Dr. Steffie Woolhandler is co-founder of Physicians for a National Health Program. She was working at Harvard Medical School and has moved to New York, working within the CUNY system, the City University of New York.

This is Democracy Now!, democracynow.org, The War and Peace Report.

http://www.democracynow.org/2012/3/27/healthcare_debate_as_supreme_court_hears

Santorum right about 'Better Health, More Freedom'

By Daniel D. Bennett, M.D.
The Capital Times (Madison, Wis.), March 30, 2012

As a freedom-loving American, I am pleasantly surprised to find that presidential candidate Rick Santorum and I agree on an issue. While the Supreme Court considers the merits of the Affordable Care Act (aka “Obamacare”), Santorum is campaigning in front of a banner proclaiming “Better Health, More Freedom.” So far, so good. We agree.

On better health, I assume that Santorum desires better health for ALL Americans. One critical element in achieving “better health” is universal access to necessary health services. Emergency rooms cannot and do not provide adequate health care for the vast majority of illnesses but, for many Americans, emergency rooms are their only venue for obtaining medical care. Our medical “safety net” is weak and porous. Millions of Americans have no access to health care, and millions more are limited by their inability to pay high deductibles and co-pays. Unaffordable medical care is no longer just a problem for the poor and uninsured. Fortunately, it appears that Santorum and I agree on our dire need to improve access to care.

On more freedom, absolutely. I want the freedom to see the physician of my choosing rather than the physician on contract with my insurance company. A parent with a chronically ill child deserves the freedom to know that her child will have health care without regard to “lifetime limits” and “pre-existing conditions.” Imagine the freedom to start a small business or create a new product without worrying that you and your family are left at risk of bankruptcy (or worse) due to a serious illness or injury. How many budding entrepreneurs are trapped in large companies because they need health insurance? Patients would find it freeing to make medical decisions based on outcomes data rather than out-of-pocket cost. As a physician, I want freedom from the expanding administrative complexity of our profit-driven health insurance industry. Fundamentally, we cannot be truly free while shareholder interests take priority over the needs of the sick.

There is only one rational solution and this, I suspect, is where Rick Santorum and I disagree. A national tax-supported single-payer health insurance system will provide better health care AND more freedom. The Affordable Care Act makes the critical mistake of perpetuating and expanding the for-profit health care model. I bristle at the idea of using taxes to subsidize and force citizens to purchase a terrible product. As things stand, health insurance coverage does not guarantee health care access. This is the time for real health care reform. This is our moon landing, our interstate highway system and, considering the casualties, our civil war. With the money we are already spending, we can design and implement a universal health care system that will be the envy of the world. If Rick Santorum will agree to that, even I might vote for him.

Dr. Daniel D. Bennett is a member of the steering committee of Wisconsin Physicians for a National Health Program.

http://host.madison.com/ct/news/opinion/column/dr-daniel-d-bennett-santorum-right-about-better-health-more/article_d3876198-79e4-11e1-9e73-0019bb2963f4.html?sourcetrack=moreArticle

Santorum right about ‘Better Health, More Freedom’

By Daniel D. Bennett, M.D.
The Capital Times (Madison, Wis.), March 30, 2012

As a freedom-loving American, I am pleasantly surprised to find that presidential candidate Rick Santorum and I agree on an issue. While the Supreme Court considers the merits of the Affordable Care Act (aka “Obamacare”), Santorum is campaigning in front of a banner proclaiming “Better Health, More Freedom.” So far, so good. We agree.

On better health, I assume that Santorum desires better health for ALL Americans. One critical element in achieving “better health” is universal access to necessary health services. Emergency rooms cannot and do not provide adequate health care for the vast majority of illnesses but, for many Americans, emergency rooms are their only venue for obtaining medical care. Our medical “safety net” is weak and porous. Millions of Americans have no access to health care, and millions more are limited by their inability to pay high deductibles and co-pays. Unaffordable medical care is no longer just a problem for the poor and uninsured. Fortunately, it appears that Santorum and I agree on our dire need to improve access to care.

On more freedom, absolutely. I want the freedom to see the physician of my choosing rather than the physician on contract with my insurance company. A parent with a chronically ill child deserves the freedom to know that her child will have health care without regard to “lifetime limits” and “pre-existing conditions.” Imagine the freedom to start a small business or create a new product without worrying that you and your family are left at risk of bankruptcy (or worse) due to a serious illness or injury. How many budding entrepreneurs are trapped in large companies because they need health insurance? Patients would find it freeing to make medical decisions based on outcomes data rather than out-of-pocket cost. As a physician, I want freedom from the expanding administrative complexity of our profit-driven health insurance industry. Fundamentally, we cannot be truly free while shareholder interests take priority over the needs of the sick.

There is only one rational solution and this, I suspect, is where Rick Santorum and I disagree. A national tax-supported single-payer health insurance system will provide better health care AND more freedom. The Affordable Care Act makes the critical mistake of perpetuating and expanding the for-profit health care model. I bristle at the idea of using taxes to subsidize and force citizens to purchase a terrible product. As things stand, health insurance coverage does not guarantee health care access. This is the time for real health care reform. This is our moon landing, our interstate highway system and, considering the casualties, our civil war. With the money we are already spending, we can design and implement a universal health care system that will be the envy of the world. If Rick Santorum will agree to that, even I might vote for him.

Dr. Daniel D. Bennett is a member of the steering committee of Wisconsin Physicians for a National Health Program.

http://host.madison.com/ct/news/opinion/column/dr-daniel-d-bennett-santorum-right-about-better-health-more/article_d3876198-79e4-11e1-9e73-0019bb2963f4.html?sourcetrack=moreArticle

Health information technology is a tower of Babel, by intent

By Marvin Malek, M.D.
Vtdigger.org, March 29, 2012

On Feb. 12, 2002, Fred Hernden, a retired Vietnam veteran, developed weakness and abdominal pain. He had recently moved to New Mexico from Woodstock, Vt. It was not by accident that the small home he bought was located near the Albuquerque Veterans Affairs Hospital. Within seconds of sitting down with Fred in the examining room at the VA, Dr. Steve Searles, Fred’s new doctor, pulled up Fred’s entire record from the White River VA on his computer, including detailed information about the treatment Fred had received for colon cancer, and the exact dimension of the aortic aneurysm that had been identified six months earlier at the White River VA. Based on his exam that day and review of these previous records, Dr. Searles could develop a diagnostic plan on the day of that first visit.

Even a full decade later, Fred’s experience can only happen at a Veterans Affairs hospital. If Fred were being treated in any private sector hospital, receipt of medical information from other practitioners will require days, sometimes weeks, nearly always be incomplete, tests will be needlessly repeated, treatment may be delayed.

During the 1990s, the VA system was converted from a medical backwater to the forefront of high quality medical care. Ten years earlier, doctors and programmers within the VA system began the pioneering work of developing a software program to be used as a medical record. Ultimately named “Vista,” this well-liked software is now used by every clinical worker in the VA system. This linkage of every VA facility in the country with the same, user-friendly software program was the centerpiece of the effort to improve quality of care throughout the VA system.

This effort paid off. In the largest such study yet performed, VA hospitals outranked a large group of private sector hospitals in every area measured, including preventive care, chronic care, patient satisfaction, and treatment of heart disease, while spending 35 percent less than the private sector hospitals.

In 2001, the Institute of Medicine released an influential series of reports documenting the large number of serious medical errors occurring on a daily basis in hospitals and medical practices across the U.S., and they recommended adoption of electronic health records as a key solution. In early 2004, President George Bush set out a landmark federal policy whose goal was to have every Americans’ health record be in electronic form by 2014.

Bush era policy — and the consequences

But the Institute of Medicine — as well as subsequent federal policy — did not specifically recommend the VA system’s route toward computerization: To use a single, popular software language to connect every hospital and doctor’s office. Instead, under Bush era policy — which has been continued through the Obama years, new agencies and programs were created to promote wider electronic health records adoption. Also, through the federal Medicare program, the federal government adopted strong financial incentives to providers to use any “certified” software program — initially bonus payments, then later financial penalties for failing to do so. The government also provided funding across the country for state-based organizations to encourage hospitals and medical practices in each state to make use of electronic health records, and to provide technical assistance. In Vermont, that organization is called Vermont Information Technology Leaders (VITL).

In response to this policy, over 100 private sector software companies rushed to take advantage of this huge market niche. The rush occurred because it would be key to these companies’ financial success to quickly get an attractive product on the market so that hospitals would opt for their product first. This was important both because hospitals’ decisions would likely influence the decisions of doctors in the hospitals’ service areas, but especially because the costs of transitioning from one software system to another would likely be as great or greater than the cost of initially adopting an electronic health record.

Unsurprisingly, given the rush to quickly gain market share, these software products have been a huge disappointment to providers: They are falling far short of their potential to improve quality of care, and it will require years of use — and substantial upgrades of the software — to even think about the possibility that electronic health records adoption will ever actually reduce health care costs.

If the late Steve Jobs were forced to use any of these products, he would be appalled at the primitive functionality doctors and nurses are contending with.

Babel, by intent

And in addition to being “user-unfriendly,” another disadvantage of the government’s strategy of leaving medical software to the private sector was that none of these programs “speak” with any of the other competing software products.

The 11th chapter of Genesis tells the story of humanity disobeying a commandment of God by building a very tall tower as a symbol of their earthly power. To punish mankind for this disobedience, God “confused the languages of humanity so that they could no longer communicate with each other.” As a consequence, the tower at Babel could not be completed.

In health care, we have created our own “Babel” of incompatible medical software products. And this time, we can’t blame God.

Federal policy not only failed to encourage all providers to adopt a single software system, but the Office of the National Coordinator of Health IT actually requires VITL and all the state-based agencies to highlight a minimum of two software programs as a condition of receiving federal grant funding.

But it’s not exclusively the government’s fault: There is plenty of blame to go around: None of the major hospital or professional organizations pushed for having all hospitals use the same software — in spite of the enormous success the VA and other countries have achieved doing just that.

Recognizing that this laissez-faire approach has primarily benefited the software developers rather than patients, the government has been funding VITL and the other relevant state grantees to work on “inter-operability” — meaning taking all these incompatible languages, and trying to extract key data elements and making them available to those using other programs. Needless to say, even after years of this effort, this interoperability retrofit remains a distant second place to the seamless communication VA providers have with each other through the VISTA system.

So we remain in the non-communicative chaos of Babel. And it is safe to say that our goal — the “towering” need for improved quality and lower cost — will not be achieved until we create a unified information system.

What should be done now: federal policy

How could we have done better? By the year 2000 or so, when the VA’s accomplishment was already crystal clear, the federal Department of Health and Human Services should have acted promptly to have the VISTA system adopted at hospitals throughout the country. To their credit, they did open up VISTA as public access, downloadable software available for free to all potential users. But this was not enough: For adoption outside the VA system, VISTA would have required technical support staff widely available to train new users, to troubleshoot problems and glitches that crop up, especially for hospitals that are just starting to adopt the system.

The VA is in the midst of a major upgrade of their electronic health records. A new Web-based software system (currently referred to as “Aviva”) is being designed with superior data-sharing capacity with the major private sector commercial electronic health records s
ystems.

But a single upgrade is not enough. With all the computer-related talent in the U.S., it’s not hard to imagine teams of programmers working with physicians in all specialties and other health workers as well to continually upgrade and improve the software.

Federal policy should also begin to incorporate a comprehensive cost control strategy into their HIT policy. Neglecting the cost issue has led electronic health records adoption in the U.S. to have taken the most expensive possible route. So long as the electronic health records policy remains balkanized in the private sector, electronic health records costs will remain extremely high.

What should Vermont do?

The state of Vermont has thus far conformed to the U.S. model of HIT policy, promoting the least effective and most costly avenue toward the adoption of electronic health records. Even within our small state, dozens of incompatible software systems are being used by providers of care, and are generally disgruntled with the quality of the software they are using.

Policy recommendation #1: Conduct a survey of all institutions and a random sampling of Vermont health-care workers to determine the number of electronic health records software programs currently in use in Vermont, and also user satisfaction with these software applications (comparing user friendliness to software used for other functions, such as spreadsheet, word processing, etc).

The intent of the recently enacted Act 48 health reform legislation is to create a “universal, unified” health care system that provides affordable care to all residents of our state. Those who crafted the legislation envisioned a single reimbursement system, and this is clearly an integral element of reform. But failing to unify the medical information systems providers are using is ludicrous. If the various providers who are involved in the care of a patient are all using incompatible software languages, the essential goal of providing seamless, coordinated care will not be realized.

Policy recommendation #2: Vermont’s health policy leaders — both in government (e.g. Green Mountain Care Board) and in the private sector — should promote the adoption of a single, user-friendly software system. Appropriate incentives should be put in place for its adoption. A task force should be convened which would include all major providers in the state — including representatives from the Veterans Administration and both university centers — whose goal would be to realize this vision. If appropriate technical support can be obtained to support the transition, having every provider in the state of Vermont adopt the VA’s software system would be preferable, since it is well-liked by users and available free of charge in the public domain. Since this effort will likely take at least two to three years, it seems reasonable to try to transition to the VA’s upgraded “Aviva” system. The state-of-the-art data sharing capacity being built into the new system will facilitate this transition.

Vermonters seeking care in other states in the U.S. will not benefit from this proposal. Regrettably, it is not realistic to expect that the rest of the U.S. will attempt to create this obvious underpinning for the transformation to an efficient, unified system of care. Fortunately, even if this transition is limited to Vermont providers, a big step forward will still be accomplished for Vermont.

Until now, policy makers in Vermont have not regarded the cost of electronic health records adoption as one of the areas we could look to in the effort to achieve control over our health care costs. Remarkably, when the state of Vermont released an annual report on health cost inflation last year, they even went so far as to completely exclude HIT costs from their analysis of hospital cost inflation. There is no justification for walling off HIT costs into an untouchable, sacrosanct category.

Policy recommendation #3: HIT costs should be on the table. The huge expenditures made to private sector software companies each year, the needlessly high training costs and lost productivity associated with the use of user-unfriendly software, and the cost of scrambling to receive linguistically incompatible records from other providers are all highly relevant to Vermont’s health cost control effort.

The task force I am proposing should take into consideration both short- and long-term HIT costs. The hospitals in Vermont are paying extremely high charges to software vendors annually, and will be doing so for years to come. While transitioning to a different software system will be costly for these hospitals, this initial cost would be paid off over time if the cost to hospitals of the new system were significantly lower.

Numerous national foundations are interested in improving the poor performance of the U.S. health care system both in the domains of cost and quality. The health information system is the linchpin of the effort to improve quality and control cost. It therefore seems likely that Vermont could receive grant support from one or more national foundations for this effort.

As is the case with most of the other key aspects of Vermont’s reform process, resistance to change and to subsuming parochial interests to the greater interest of the state as a whole will form a major obstacle to its implementation. But if policymakers and leaders in Vermont’s health care community set out the goal of creating a unified, cost-effective HIT system for the state of Vermont, this goal can be achieved.

Marvin Malek, M.D., is a physician who practices internal medicine at Central Vermont Hospital.

http://vtdigger.org/2012/03/29/malek-health-information-technology-is-a-tower-of-babel-by-intent/

Don’t lose any sleep over supply of doctors

By Jason Kelley, M.D.
The Stowe Reporter, March 22, 2012

I have to take issue with the assertions in Mr. Steve Chambers’ letter (Stowe Reporter, March 15) regarding the health-care legislation passed last year by the Vermont Legislature.

He makes it clear that he doesn’t like the legislation, describing it as “reckless,” a “train wreck” and even “Marxist.”

His comments were based on a recent symposium at the public safety building which brought to Stowe three staunch opponents of the legislation.

There’s not room enough to rebut all the assertions made by Mr. Chambers, but as a physician I have to take issue with one point. Among the scare tactics he musters about Vermont’s novel legislation is the claim that untold numbers of doctors will “flee” Vermont when it is implemented.

There are simply no data to support this assertion.

To the contrary, plenty of physicians are attracted to the quality of life that Vermont is so proud of. Indeed, the record shows that the pool of licensed physicians in Vermont has more than kept pace with the growth of the population. As a result, Vermont now boasts the sixth-highest proportion of physicians per capita of any state. That translates into nearly 600 more doctors per capita than the national average.

And if any ideologue physicians left the state, they would quickly be replaced by newly recruited physicians. At a rally at Montpelier last year, 250 medical students and doctors in training from as far afield as Oregon and California made it clear they would be particularly attracted to practicing in our state when universal health care coverage is implemented.

Vermont’s supply of doctors is not something we have to lose any sleep over.

Dr. Jason Kelley lives in Hartford, Vt.

http://www.stowetoday.com/stowe_reporter/opinion/letters_to_the_editor/article_76c24cda-7443-11e1-98f3-0019bb2963f4.html

Healthcare Debate: As Supreme Court Hears Landmark Case, Does Law Do Enough to Fix Health Crisis?


Democracy Now!
March 27, 2012

As the Supreme Court weighs whether the Affordable Care Act goes too far, we host a debate on whether the law goes far enough. The case is reviving the heated tensions that surrounded the healthcare reform law in the debate leading up to its passage two years ago. Although support for the measure is often equated with backing the expansion of health coverage for all Americans, there are some who maintain it didn’t go far enough in helping the uninsured. We speak to Dr. Stephanie Woolhandler, co-founder of Physicians for a National Health Program, and Dr. John McDonough, who played a key role in shaping Mitt Romney’s healthcare reform law in Massachusetts as well as the Affordable Care Act. The new healthcare law is “going to leave tens of millions of Americans woefully underinsured, with gaps in their coverage like copayments and deductibles, so they’ll still be bankrupted by illness. And it’s not going to control cost,” Woolhandler argues. “So we still need single-payer national health insurance regardless of what happens at the Supreme Court.” But McDonough notes that “the moment when there would be sufficient political will for the Congress and the president to come together and pass meaningful, near-comprehensive reform, that might take another 20 years.”

Health Care Jujitsu

By Robert Reich
The Huffington Post, March 26, 2012

Not surprisingly, today’s debut Supreme Court argument over the so-called “individual mandate” requiring everyone to buy health insurance revolved around epistemological niceties such as the meaning of a “tax,” and the question of whether the issue is ripe for review.

Behind this judicial foreplay is the brute political fact that if the Court decides the individual mandate is an unconstitutional extension of federal authority, the entire law starts unraveling.

But with a bit of political jujitsu, the President could turn any such defeat into a victory for a single-payer health care system – Medicare for all.

Here’s how.

The dilemma at the heart of the new law is that it continues to depend on private health insurers, who have to make a profit or at least pay all their costs including marketing and advertising. Yet the only way private insurers can afford to cover everyone with pre-existing health problems, as the new law requires, is to have every American buy health insurance – including young and healthier people who are unlikely to rack up large health care costs.

This dilemma is the product of political compromise. You’ll remember the Administration couldn’t get the votes for a single-payer system such as Medicare for all. It hardly tried. Not a single Republican would even agree to a bill giving Americans the option of buying into it. But don’t expect the Supreme Court to address this dilemma. It lies buried under an avalanche of constitutional argument.

Those who are defending the law in Court say the federal government has authority to compel Americans to buy health insurance under the Commerce Clause of the Constitution, which gives Washington the power to regulate interstate commerce. They argue our sprawling health insurance system surely extends beyond an individual state.

Those who are opposing the law say a requirement that individuals contract with private insurance companies isn’t regulation of interstate commerce. It’s coercion of individuals.

Unhappily for Obama and the Democrats, most Americans don’t seem to like the individual mandate very much anyway. Many on the political right believe it a threat to individual liberty. Many on the left object to being required to buy something from a private company.

The President and the Democrats could have avoided this dilemma in the first place if they’d insisted on Medicare for all, or at least a public option.

After all, Social Security and Medicare require every working American to “buy” them. The purchase happens automatically in the form of a deduction from everyone’s paychecks. But because Social Security and Medicare are government programs financed by payroll taxes they don’t feel like mandatory purchases.

Americans don’t mind mandates in the form of payroll taxes for Social Security or Medicare. In fact, both programs are so popular even conservative Republicans were heard to shout “don’t take away my Medicare!” at rallies opposed to the new health care law.

There’s no question payroll taxes are constitutional, because there’s no doubt that the federal government can tax people in order to finance particular public benefits. But requiring citizens to buy something from a private company is different because private companies aren’t directly accountable to the public. They’re accountable to their owners and their purpose is to maximize profits. What if they monopolize the market and charge humongous premiums? (Some already seem to be doing this.)

Even if private health insurers are organized as not-for-profits, there’s still a problem of public accountability. What’s to prevent top executives from being paid small fortunes? (In more than a few cases this is already happening.)

Moreover, compared to private insurance, Medicare is a great deal. Its administrative costs are only around 3 percent, while the administrative costs of private insurers eat up 30 to 40 percent of premiums. Medicare’s costs are even below the 5 percent to 10 percent administrative costs borne by large companies that self-insure, and under the 11 percent costs of private plans under Medicare Advantage, the current private-insurance option under Medicare.

So why not Medicare for all?

Because Republicans have mastered the art of political jujitsu. Their strategy has been to demonize government and seek to privatize everything that might otherwise be a public program financed by tax dollars (see Paul Ryan’s plan for turning Medicare into vouchers). Then they go to court and argue that any mandatory purchase is unconstitutional because it exceeds the government’s authority.

Obama and the Democrats should do the reverse. If the Supreme Court strikes down the individual mandate in the new health law, private insurers will swarm Capitol Hill demanding that the law be amended to remove the requirement that they cover people with pre-existing conditions.

When this happens, Obama and the Democrats should say they’re willing to remove that requirement – but only if Medicare is available to all, financed by payroll taxes. If they did this the public will be behind them — as will the Supreme Court.

Robert Reich, Ph.D., is professor of public policy at the University of California, Berkeley. This post originally appeared at RobertReich.org.

http://www.huffingtonpost.com/robert-reich/single-payer-health-care_b_1381382.html

NHS dismantling law passes, while risks kept secret

NHS reforms finally become law

By Andrew Woodcock, Tim Schulthorpe
The Independent, March 27, 2012

The Government’s controversial reforms to the NHS became law today after a tortuous 14-month passage through Parliament, when the Queen granted Royal Assent to the Health and Social Care Bill.

The new rules mean the Government can create GP commissioning groups to buy health care for patients and scrap Primary Care Trusts (PCTs).

Labour has bitterly opposed the passage of the new law, insisting it threatens the foundation of the NHS and paves the way for private services to get too involved.

A draft risk register leaked today showed that ministers were warned 18 months ago of the risk that the reforms could lead to a loss of financial control, reduced productivity and emergencies being less well managed.

The Department of Health, which refused to comment on today’s leak, has resisted a ruling from the Information Commissioner that it should release the final version of the risk register in response to a freedom of information request from Labour.

Shadow health secretary Andy Burnham said today’s document showed that ministers were warned before they launched the Bill that it was “likely to cause major damage to the NHS”.

Identifying 43 separate areas of potential risk, the draft register rates each on a scale of one to five, where a rating of one means little likelihood and very low impact and five means almost certain to occur and very high impact.

The likelihood and impact figures are multiplied together to give an overall risk rating, with a maximum score of 25.

Among 13 areas given a risk rating of 16 – with likelihood and impact each assessed at four out of five – were:

* Parliamentary amendments creating “unforeseen consequences for the system”;

* Costs being driven up by GP consortia using private sector organisations and staff;

* Implementation beginning before adequate planning has been done;

* Loss of financial control;

* “Unhelpful conflict” between the NHS commissioning board and regulator Monitor;

* GP consortia going bust or having to cut services for financial reasons;

* GP leaders being drawn into managerial processes which end up driving clinical behaviour.

Other dangers, considered to have a lower rating of 12, included the risk that “NHS role in emergency preparedness/responsiveness is more difficult to manage through a more devolved organisation, and so emergencies are less well managed/mitigated”.

Staff concerns and union action over the reforms could lead to “deterioration in relations, lower productivity in the Department of Health/NHS and delays in programme”, the document said.

And there was a warning that strategic health authorities and primary care trusts might lose “good people” who then have to be re-employed to run the new system.

Mr Burnham told the Guardian: “Now we know why David Cameron refused to publish the risk register before the Bill was through Parliament – it’s because civil servants were telling him his reorganisation was likely to cause major damage to the NHS.

“David Cameron will never be forgiven for knowingly taking these risks with the country’s best-loved institution.”

http://www.independent.co.uk/news/uk/politics/nhs-reforms-finally-become-law-7592991.html

Comment:

By Don McCanne, MD

David Cameron’s conservative government has succeeded in dismantling the National Health Service, turning it over to “GP consortia using private sector organisations and staff,” with “GP leaders being drawn into managerial processes which end up driving clinical behaviour.” The process became final today when the Queen granted Royal Assent.

As a sign of the nefarious process involved, the Cameron government refused an order to release the “risk register” that described the dangers inherent in this legislation that were “likely to cause major damage to the NHS.” Only on the day that the Queen granted her Royal Assent was a draft of the risk register leaked.

The lesson for the United States? Without greater citizen involvement, nominal democracies are, in fact, plutocracies. We bear the consequences of our inaction.

What greater example could there be than the fact that the most watched Supreme Court decision in decades evolves around a consideration as to how large the private insurance industry’s market will be, rather than the consideration that should be under review: whether the people have the right to join together as a nation to ensure health care justice for all.