PNHP

Comparing the presidential candidates’ views on health reform

Comparing the presidential candidates’ views on health reform

By Reid Fletcher
March 27, 2012

PNHP note: The following synopsis of the health care planks of some of the prominent contenders for the U.S. presidency was prepared and offered to us by Reid Fletcher, a second-year student at Northwestern University’s Feinberg School of Medicine. Note that Mr. Fletcher also sketches a picture of the Massachusetts reform of 2006 as part of his analysis. For a more extensive assessment of the latter, see the Mass-Care and PNHP report of last October.

Mitt Romney, Republican Party

Mitt Romney wants to repeal the Patient Protection and Affordable Care Act (ACA) and replace it with a market-based reform. His primary objective is to increase the number of people insured by the wasteful private insurance companies. Despite abundant evidence to the contrary, Romney claims that increasing reliance on the free market will produce more competition and lower costs. His plan would force more seniors into Medicare Advantage (MA) plans which do not provide any added benefit to seniors, are more expensive, and limit the free choice of seniors due to restrictive private insurance care networks. In fact, MA plans are paid, on average, 14 percent more than traditional Medicare per beneficiary. In addition, MA plans are able to game the risk-adjustment system and thereby overcharge Medicare an additional $30 billion annually, or 8 percent of total Medicare spending.

Romney would also block grant the Medicaid system, which would shift costs to the states and ultimately result in fewer benefits being available to lower income individuals. This is essentially a first step toward unraveling the safety net for the very poor, whom Romney admittedly is “not very concerned about.”

His plan also involves a massive expansion of the availability of health savings accounts (HSAs) combined with high deductible plans (HDPs). Individuals and employers can deposit tax-free dollars into HSAs which can be used to pay for medical expenses. The theory behind these plans is that they will make consumers more “cost-sensitive” to the medical services they acquire. In reality, these plans encourage rationing and discourage preventive care. Furthermore, these plans expose patient to greatly increased risk if the HSA runs out due to unexpected illness and the plans have not been demonstrated to lower overall health care costs.

Romney, of course, is also closely associated with the 2006 Massachusetts reform, a description of which is appended.

Newt Gingrich and Rick Santorum, Republican Party

Both Gingrich and Santorum have expressed health reform plans that are essentially identical to Mitt Romney’s plan. The commonalities include the repeal of the ACA, block granting Medicaid, privatizing Medicare, and expanding the use of HSAs.

Barack Obama, Democratic Party

The Obama administration has touted the ACA as the first step toward universal coverage. Unfortunately this is not true. The ACA will leave at least 25 million people uninsured and tens of millions more underinsured. Low income individual will be forced into an expanded, but still poorly funded, Medicaid system. With increasingly fewer providers excepting Medicaid patients, this will prove to be an inadequate solution. Everyone else will be given subsidies to purchase coverage in the broken private insurance market. Studies have shown that the fragmented private insurance system has contributed to the fact that 31 percent of all health care dollars are spent on administration, nearly twice the amount paid in the single-payer Canadian system.

Jill Stein (Green Party) and Rocky Anderson (Justice Party)

Stein and Anderson are both proponents of a single-payer plan, which would essentially be an improved-Medicare-for-all system. Stein is more consistent on this point than Anderson. Anderson, while he supports a single-payer system, has also said he’s leaving  the door open for a market-based reform.

In a single-payer plan, everyone would be automatically covered by a single public insurer. Everyone would be given the same level of coverage and everyone would have the same freedom to see any provider they choose. This system would reduce administrative waste to the acceptable Canadian levels, which would save nearly $400 billion each year, which is more than enough to cover all of those who are currently uninsured or underinsured.

Furthermore, mechanisms like capital planning, global budgeting, and bulk purchasing would help to control ever-increasing health care costs and improve efficiency within the system.

*****

The Massachusetts reform: an analysis

In 2006 the Massachusetts Legislature, under direction from then-Gov. Mitt Romney, passed a major health reform bill which four years later became the model for the ACA supported by the Obama administration. Given the seeming inevitability of Romney winning the GOP nomination and the highly controversial nature of health care reform, it is highly likely the reform in Massachusetts will come to the forefront of the nation’s attention at some point during the fall elections. The Obama campaign will try to weaken Romney by claiming that the Massachusetts plan is successful and a means to increase insurance coverage; meanwhile the Romney campaign will suggest that the Massachusetts reform was successful, but was not the model for the ACA. In truth, both campaigns will be wrong. The Massachusetts was the model for the ACA and it has been unsuccessful.

What was done in Massachusetts?

Like the ACA, the Massachusetts reform increased coverage by expanding public programs for residents up a certain level of the poverty line while forcing everyone else to buy public insurance or face penalties. The net effect has been to push more people into the private insurance market, so as to lower the total number of uninsured, without modifying the existing private insurance system.

An evaluation

While proponents of the Massachusetts reform will point to the fact that the state now has one of the high rates of health insurance coverage in the country (97.3 percent) as evidence of the success of the legislation, a closer look at the situation quickly shows that the reform effort has not been successful.

We will analyze three areas to demonstrate the failure of the Massachusetts reform: insurance for the poor, cost controls, and rate of underinsurance.

Insurance for the poor

One of the biggest changes that came with the Romney reform was to the safety net program that provided coverage to low-income residents. Prior to the reform, the “Free Care Pool” completely subsidized medical services for the uninsured and underinsured up to 200 percent of the poverty line, in addition to partially subsidizing care for residents between 200 percent and 400 percent of the poverty line. Health care reform replaced the Free Care Pool with the “Health Safety Net”, which was covers medical services for those unable to purchase insurance on their own. However, major differences exist between these two programs which have serious implications for the level of coverage for the poor. For example, The Health Safety Net only fully subsidizes care for those up to 150 percent of the poverty line and increases cost sharing for residents up to 400 percent of the poverty line. Thus there is a larger burden placed on the poor, which will ultimately result in avoidance of necessary care and poor outcomes

Cost controls

While Massachusetts now boasts one of the highest level of health insurance coverage in the nation, the state also has one of the highest health care costs per capita. Health care reform has done nothing to
slow the quickly rising costs of health care in Massachusetts, and in fact, by some measures the reform legislation has actually exacerbated the problem. This is largely because the reform failed to address the fundamental defects in the system. Instead of directly addressing the dysfunctional and wasteful private insurance market, the reform pumped more people into the system. Overhead and administrative costs related to private insurance are one of the main drivers of increased health care costs, and the Massachusetts reform, like the PPACA, did nothing to address these deficiencies.

Rates of underinsurance

Rates of underinsurance have skyrocketed in Massachusetts since the implementation of reform. The rising costs of private insurance, combined with the individual mandate to purchase that insurance has forced consumers to opt for low cost options like high deductible health plans. In fact from 2010 to 2011, the number of people in high deductible health plans doubled. These plans shift costs to consumers and have been shown to decrease utilization of necessary medical services. These plans de-incentivize cost-saving preventive care and put consumers at high financial risk if they get sick.

Conclusion

The Massachusetts health reform has not been successful. While the state can boast one of the highest rates of insurance coverage in the country, it also has an excessive amount of underinsurance and skyrocketing health care costs. Given that President Obama’s PPACA was largely based on the Massachusetts reform, the prospects for success of the PPACA are minimal. Simply put, forcing a large percentage of the population into the wasteful and inefficient private health insurance system cannot achieve cost savings or quality coverage for all. The only way to achieve this is to reform the health insurance system, and the most effective way to do this is to implement single payer reform.

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

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.

Single-payer system would control health care costs

By Cory D. Carroll, M.D.
The Coloradoan, Letters, March 25, 2012

In medicine, physicians use their training and experience to diagnose and treat patient ills. Over the years, I have witnessed a new condition, not covered in any of my medical school lectures or textbooks, that is at epidemic proportions and worsening. The condition is caused by an out-of-control parasite — the for-profit medical insurance industry.

Decreasing pharmacy benefits, increasing co-pays and out-of-sight deductibles coupled with diminished coverage for care are the symptoms — and there is no foreseeable cure. The for-profit insurance system covers the healthiest Americans and has perfected the art of sucking more and more money from business/patients (higher premiums) and providers (diminished payments) while increasing profits for their executives and shareholders. The governmental programs (Medicare, Veterans Affairs and Medicaid) that are responsible for our elderly, veterans and poor are also cutting back, but these patients are not experiencing the incredibly large increase in out-of-pocket expenses and rarely see a loss of expected services.

The Patent Protection and Affordable Care Act, known by some as “Obamacare,” is a Republican-leaning bill (suggested by Nixon in 1974 and implemented by Romney in 2006) that was an attempt to control costs and protect patients. The two main problems with President Barack Obama’s bill is the legislation is phased in during a four-year period (i.e. it will not be until 2014 until all aspects of the bill will be in place) and it keeps the for-profit insurance industry as a central player (our elderly, veterans and poor still will be covered by the government). The delay in implementing the bill has given the insurance industry ample time to outmaneuver the aspects of the bill that will actually control costs and protect patients. Already, several provisions that should be in effect now have been modified to accommodate the for-profit insurance industry’s whining.

If you support American jobs and desire a stable economy, you need to understand how the lack of medical coverage destabilizes our country. If we had an accessible health care system, for all citizens regardless of employment, businesses would no longer be burdened with escalating health care costs and would be able to generate more jobs — for Americans. Additionally, having affordable access to health care for all citizens would allow entrepreneurs to flourish and allow others to break the corporate chains that keep them from starting private businesses.

If all Americans had guaranteed coverage for necessary medical care, then the medical delivery systems in our communities would be more financially stable and the cost shifting between the “haves” and the “have nots” would cease. Everyone would pay (through a progressive tax system) their fair share. It is insane that the wealthiest nation on the globe allows its citizens to incur personal bankruptcy when they suffer a significant accident or serious illness. Fun fact: The majority of medical bankruptcies occur to individuals/families with insurance.

A single-payer system is not a “government takeover of medicine.” Rather, it is a shift in the financing of health care and would end the inefficiencies and greed of the for-profit insurance industry. It would be the best option to control medical costs and improve health outcomes. A single-payer health care system (not for-profit) is essential if America wants to have a sustainable future.

Dr. Cory D. Carroll lives in Fort Collins.

http://www.coloradoan.com/article/20120326/OPINION04/203260307/Single-payer-system-would-control-health-care-costs

The Medical Golden Rule: Physicians Advocate for Patients

An Expert Interview With David Ansell, MD

By Nancy A. Melville
Medscape Medical News, March 22, 2012

HOUSTON — David Ansell, MD, chief medical officer at Rush University Medical Center in Chicago, Illinois, is the author of “COUNTY: Life, Death and Politics at Chicago’s Public Hospital.” The book details Dr. Ansell’s 17 years of experience working in deplorable conditions at Chicago’s Cook County Hospital, where he and his colleagues would “care for patients in the morning and picket in front of the county building in the afternoon,” as they became activists for health reform.

Dr. Ansell and his colleagues published a study on conditions at the hospital that ultimately led to the passage of the Emergency Medical Treatment and Labor Act, which made it illegal in the United States to dump patients in need of emergency care, regardless of their insurance status.

In his keynote address here at the American Medical Student Association (AMSA) 62nd Annual Convention, Dr. Ansell declared that “healthcare as a human right is the moral issue of our time,” and urged the audience of future physicians to commit themselves to patient advocacy during their careers.

“We are the natural advocates for the poor,” he said. “Because we see the human condition first hand, it is our obligation to speak up on their behalf. You can’t be a doctor and not be touched by the patients and their struggles.”

Dr. Ansell noted that the fact that his mother’s family perished in the Holocaust instilled in him the strong belief in speaking up in the name of human rights.

“The problem I saw wasn’t that governments could do bad things to people, but that neighbors didn’t speak up on behalf of their neighbors.”

A key focus of Dr. Ansell’s ongoing activism is closing inequalities in healthcare, or what he calls the “death gap,” in the United States, which result in Americans dying younger than residents of most other developed countries. “The idea that one should die because they’re poor is obscene,” he said.

Medscape: You noted that the death gap between the richest and poorest communities in the United States is 24 years, whereas in England it is just 7 years. What key elements could realistically be implemented in the United States to reduce this disparity?

Dr. Ansell: Actually, the gap in the United States is 30 years and the gap in Great Britain is now 13 years. Some of the death gap is the result of the design of our healthcare system; much of the death gap is the result of broader social inequalities; some of it has environmental causes. Regardless, the death gap in the United States is unacceptable. We have a healthcare system that is separate and unequal. Where you go, what services are available, are determined by the insurance card you have.

Those with gold-plated insurance policies get access to the best institutions and the best care. Those with lesser insurance, Medicaid, or no insurance have much more difficulty accessing care. Health reform will give more people a card, but will it get them the care they need when they need it?

We know that 45,000 individuals in the United States die each year because of lack of insurance, and 80,000 die because of racial inequalities. It is one thing to have the income and wealth inequalities we have…, but the notion that we allow people in this, the wealthiest nation in the world, to die because they cannot access care is just not right.

Single-payer healthcare for all is the best solution for the United States. It is fair, allows people choice, and it would treat people equally. This would not address all the reasons for the death gap, but it would go a long way to making our health system more equal.

Medscape: The study that you and your colleagues published was pivotal in bringing about the change needed to address the problem of patient “dumping.” What kinds of studies are necessary to address the inequalities in life expectancy between the “haves” and the “have-nots”?

Dr. Ansell: I don’t think we need more studies. We need solutions. Let’s start by agreeing that healthcare is a human right. I believe our failure as a nation to agree that healthcare is a human right, and not a commodity to be bought and sold, is at the root of the problem and is the moral issue of our time.

If we accept that healthcare is a human right, then we would design and operate our health system around the principles of equal access for all and a series of essential healthcare benefits that people would have as a condition of their “citizenship,” not as a condition of their ability to pay. Again, a single-payer system — Medicare for all — is an important first step.

Medscape: The AMSA and other medical groups are working to make the single-payer option a reality in the United States. What changes need to be made in the current healthcare environment for such a system to succeed?

Dr. Ansell: The collective voices of medical students, doctors, and the public will be necessary. The real opposition to a single payer is the health insurance companies, who are profiting mightily from the current set-up. They will not go down without a big fight.

Medical students, doctors, and other healthcare professionals will need to speak up and educate the public about this. The United States has the most expensive healthcare system in the world by 2-fold. We have more than enough money in the system to serve everyone well and turn the focus from sick care to prevention.

A single-payer system will not solve all our ills, but it will provide fair coverage to many more people at a much lower cost. Doctors are the natural advocates for those with less. It is important that those of us who can speak up for fairness and equality — solid American and democratic values — do so. And we will have to elect folks to office who share these beliefs.

Medscape: You mentioned that you were inspired by the commitment of the Suffragettes to change. What person or movement in the present inspires you?

Dr. Ansell: I am inspired by people like Nelson Mandela, who was imprisoned for 26 years because of his opposition to apartheid and then became the president of South Africa. It reminds me that one has to have the long view of these fights for social justice and equality. If we believe that healthcare is a human right and that a single payer is the solution, then we have to look back on previous struggles for inspiration and lessons.

http://www.medscape.com/viewarticle/760728

PNHP statement on the Supreme Court deliberation of the Affordable Care Act

Health law, constitutional or no, fails to remedy ailment: doctors group

Press Release, March 26, 2012

Leaders of Physicians for a National Health Program, an organization of 18,000 doctors who advocate for single-payer national health insurance, released the following statement today:

Regardless of whether the Supreme Court upholds or overturns the Affordable Care Act in whole or in part, the unfortunate reality is that federal health law of 2010 will not work: (1) it will not achieve universal coverage, as it leaves at least 26 million uninsured, (2) it will not make health care affordable to Americans with insurance, because gaps in their policies will leave them vulnerable to bankruptcy in the event of major illness, and (3) it will not control costs.

Why? Because the ACA perpetuates a dominant role for the private insurance industry.  That industry siphons off hundreds of billions of  health care dollars annually for overhead, profit and the paperwork it demands from doctors and hospitals; it denies care in order to increase insurers’ bottom line; and it obstructs any serious effort to control costs.

In contrast, a single-payer, improved-Medicare-for-all system would achieve all three goals – truly universal, comprehensive coverage; health security for our patients and their families; and cost control. It would do so by replacing private insurers with a single, nonprofit agency like Medicare that pays all medical bills, streamlines administration, and reins in costs for medications and other supplies through its bargaining clout.

The major provisions of the ACA do not go into effect until 2014. Although we will be counseled to “wait and see” how this reform plays out, we’ve seen how comparable reforms in Massachusetts and other states have worked over the past few decades. They have invariably failed our patients, foundering on the shoals of skyrocketing costs – even as they have profited the big private insurers and Big Pharma.

The Supreme Court’s ruling is not expected until June. Regardless of how it rules, we cannot wait for an effective remedy to our health care woes any longer, nor can our patients. The stakes are too high.

We pledge to continue our work for the only equitable, financially responsible and humane cure for our health care mess: single-payer national health insurance, an expanded and improved Medicare for all.

https://pnhp.org/news/2012/march/health-law-constitutional-or-no-fails-to-remedy-ailment-doctors-group

Comment:

By Don McCanne, MD

The attention to the Supreme Court deliberations on the Affordable Care Act is an unfortunate distraction since, regardless of the outcome, intolerable levels of uninsurance, undersinsurance, and unaffordability will still be with us. We need to replace the Affordable Care Act with single-payer national health insurance, an expanded and improved Medicare for all.

Please share this pivotal message with others, and feel free to use it as a basis for other communications such as letters to the editor, op-eds, reports to community organizations, and any other modality that can educate others on this crucial issue.

Other resources:

PNHP statement on the passage of the Affordable Care Act (March 2010):
https://pnhp.org/news/2010/march/pro-single-payer-doctors-health-bill-leaves-23-million-uninsured

Fact sheet on single payer, improved Medicare for all:
https://pnhp.org/docs/2011/Improved-Medicare-for-All-Fact-Sheet.pdf

Many other resources are available at www.pnhp.org

Health law, constitutional or no, fails to remedy ailment: doctors group

FOR IMMEDIATE RELEASE
March 26, 2012

Contact:
Garrett Adams, M.D., president PNHP
Andrew Coates, M.D., president-elect PNHP
Oliver Fein, M.D.
David Himmelstein, M.D.
Steffie Woolhandler, M.D.
Mark Almberg, PNHP communications director, (312) 782-6006, mark@pnhp.org

Leaders of Physicians for a National Health Program, an organization of 18,000 doctors who advocate for single-payer national health insurance, released the following statement today:

Regardless of whether the Supreme Court upholds or overturns the Affordable Care Act in whole or in part, the unfortunate reality is that federal health law of 2010 will not work: (1) it will not achieve universal coverage, as it leaves at least 26 million uninsured, (2) it will not make health care affordable to Americans with insurance, because gaps in their policies will leave them vulnerable to bankruptcy in the event of major illness, and (3) it will not control costs.

Why? Because the ACA perpetuates a dominant role for the private insurance industry.  That industry siphons off hundreds of billions of  health care dollars annually for overhead, profit and the paperwork it demands from doctors and hospitals; it denies care in order to increase insurers’ bottom line; and it obstructs any serious effort to control costs.

In contrast, a single-payer, improved-Medicare-for-all system would achieve all three goals – truly universal, comprehensive coverage; health security for our patients and their families; and cost control. It would do so by replacing private insurers with a single, nonprofit agency like Medicare that pays all medical bills, streamlines administration, and reins in costs for medications and other supplies through its bargaining clout.

The major provisions of the ACA do not go into effect until 2014. Although we will be counseled to “wait and see” how this reform plays out, we’ve seen how comparable reforms in Massachusetts and other states have worked over the past few decades. They have invariably failed our patients, foundering on the shoals of skyrocketing costs – even as they have profited the big private insurers and Big Pharma.

The Supreme Court’s ruling is not expected until June. Regardless of how it rules, we cannot wait for an effective remedy to our health care woes any longer, nor can our patients. The stakes are too high.

We pledge to continue our work for the only equitable, financially responsible and humane cure for our health care mess: single-payer national health insurance, an expanded and improved Medicare for all.

******

Background

Statement of Physicians for a National Health Program upon the passage of the health law in March 2010. Fact sheet on the crisis in U.S. health care and the case for single-payer health reform. A recent analysis of the Massachusetts health reform.

*******
Physicians for a National Health Program (www.pnhp.org) is an organization of more than 18,000 doctors who support single-payer national health insurance. To speak with a physician/spokesperson in your area, visit www.pnhp.org/stateactions or call (312) 782-6006.

PNHP statement on the Supreme Court deliberation of the Affordable Care Act

Health law, constitutional or no, fails to remedy ailment: doctors group

Press Release, March 26, 2012
Leaders of Physicians for a National Health Program, an organization of 18,000 doctors who advocate for single-payer national health insurance, released the following statement today:
Regardless of whether the Supreme Court upholds or overturns the Affordable Care Act in whole or in part, the unfortunate reality is that federal health law of 2010 will not work: (1) it will not achieve universal coverage, as it leaves at least 26 million uninsured, (2) it will not make health care affordable to Americans with insurance, because gaps in their policies will leave them vulnerable to bankruptcy in the event of major illness, and (3) it will not control costs.
Why? Because the ACA perpetuates a dominant role for the private insurance industry. That industry siphons off hundreds of billions of health care dollars annually for overhead, profit and the paperwork it demands from doctors and hospitals; it denies care in order to increase insurers’ bottom line; and it obstructs any serious effort to control costs.
In contrast, a single-payer, improved-Medicare-for-all system would achieve all three goals – truly universal, comprehensive coverage; health security for our patients and their families; and cost control. It would do so by replacing private insurers with a single, nonprofit agency like Medicare that pays all medical bills, streamlines administration, and reins in costs for medications and other supplies through its bargaining clout.
The major provisions of the ACA do not go into effect until 2014. Although we will be counseled to “wait and see” how this reform plays out, we’ve seen how comparable reforms in Massachusetts and other states have worked over the past few decades. They have invariably failed our patients, foundering on the shoals of skyrocketing costs – even as they have profited the big private insurers and Big Pharma.
The Supreme Court’s ruling is not expected until June. Regardless of how it rules, we cannot wait for an effective remedy to our health care woes any longer, nor can our patients. The stakes are too high.
We pledge to continue our work for the only equitable, financially responsible and humane cure for our health care mess: single-payer national health insurance, an expanded and improved Medicare for all.
https://pnhp.org/news/2012/march/health-law-constitutional-or-no-fails-to-remedy-ailment-doctors-group

The attention to the Supreme Court deliberations on the Affordable Care Act is an unfortunate distraction since, regardless of the outcome, intolerable levels of uninsurance, undersinsurance, and unaffordability will still be with us. We need to replace the Affordable Care Act with single-payer national health insurance, an expanded and improved Medicare for all.
Please share this pivotal message with others, and feel free to use it as a basis for other communications such as letters to the editor, op-eds, reports to community organizations, and any other modality that can educate others on this crucial issue.
Other resources:
PNHP statement on the passage of the Affordable Care Act (March 2010):
https://pnhp.org/news/2010/march/pro-single-payer-doctors-health-bill-leaves-23-million-uninsured
Fact sheet on single payer, improved Medicare for all:
https://pnhp.org/system/assets/drupal/docs/2011/Improved-Medicare-for-All-Fact-Sheet.pdf
Many other resources are available at www.pnhp.org

Single Payer and the Supreme Court

Surprisingly, several groups seek to challenge the Affordable Care Act from the left

By Robert Kuttner
The American Prospect, March 23, 2012

When the Supreme Court begins its extraordinary three days of hearings on the constitutionality of the Affordable Care Act, one of the oddities will be an amicus brief challenging the act’s individual mandate from 50 doctors who support national health insurance. They point out the inconvenient truth that, contrary to the administration’s representations, the government did not need to require citizens to purchase insurance from private companies in order to meet its goals of serving the health-care needs of the populace. Congress could have enacted a single-payer law.

Since the Constitution unambiguously gives Congress the power to tax, there has never been a serious constitutional challenge to our tax-supported systems of health insurance, Medicare, and the services of the Veterans Health Administration system. In the words of the brief:

“Amici thus submit this brief for the purpose of disputing the primary tenet of the Government’s position, that Congress cannot regulate the national healthcare market effectively unless it has power to require that citizens purchase insurance from private insurance companies. On the contrary, as set forth herein, Congress has already demonstrated that it can regulate healthcare markets effectively by implementing a single payer system such as Medicare or the VHA.”

Much of the brief is devoted to demonstrating the superior efficiencies of single-payer systems, but it is also offers a formidable summary of the constitutional argument against the government’s view of what the Commerce Clause permits.

“Government contends that the provision is not only ‘reasonable’ but also ‘necessary’ to its broader regulation of the national healthcare market. Brief for Petitioners. In particular, the Government contends that the individual mandate is ‘key to the viability of the Act’s guaranteed-issue and community-rating provisions.’ But while it might be true that these provisions will adversely impact private insurers’ profits, and that the individual mandate offsets this adverse impact by guaranteeing the private insurers a large stream of new customers who are required by law to purchase insurance, that is not sufficient to render the individual mandate constitutional. If it were, Congress could ‘reform’ any private industry – whether it be automobiles, coal, pharmaceuticals or any other – by enacting legislation requiring every that American purchase the industry’s goods or services in exchange for some perceived public good the industry provides. Yet Congress has never before enacted such a mandate.”

Ouch.

The brief further contends that none of the cases cited by the government “support the conclusion that the commerce power permits Congress to enact any regulation it finds necessary to the viability of a larger scheme regulating interstate commerce.”

It would be more than a little ironic if a majority of the Court struck down the Affordable Care Act by relying on these arguments. These points have been made by others, of course. But what’s nervy is that some single-payer advocates are tactically allying themselves with the political right in a momentous Supreme Court battle.

The brief is filed in the name of two groups, Single Payer Action and It’s Our Economy, and was written by attorney Oliver Hall. It explicitly asks the Court to uphold the ruling of the Court of Appeals for the Eleventh Circuit finding the individual mandate unconstitutional.

This tactic must have given some single-payer advocates pause, since the most prominent single-payer group, Physicians for a National Health Program (PNHP) and such noted proponents of national health insurance as Drs. David Himmelstein and Steffie Woolhandler of Physicians for a National Health Program are not on the brief.

If the Affordable Care Act were to be struck down, it would be a political blow to the Obama administration, as well as another case of overreach by the Roberts Court.

But the Court could well uphold the act. Some observers have suggested that the conservatives on the Court are having second thoughts about the unintended consequences of the Citizens United decision on unlimited political giving. Justices Scalia and Kennedy, moreover, have gone both ways on prior cases involving the reach of the commerce clause and may decide that this is not the time to further risk the Court as an institution, which severely impaired its credibility in Bush v. Gore.

On the other hand, if the Court struck down only the individual mandate, the rest of the act would live on. And the administration and Congress would have to find other ways to prevent uninsured people from free-riding on the system. As my colleague Paul Starr has proposed, a Court finding that the mandate was illegal would not necessarily kill the whole law. Other incentives and disincentives could be created so that most people would find it attractive to purchase insurance.

The amici have a point. A single-payer program would be more efficient and unambiguously constitutional, and even the Affordable Care Act need not be such a gravy train for the insurance industry. This brief, though risky, could turn out to be constructive mischief.

http://prospect.org/article/single-payer-and-supreme-court

Insurers promoting phony "self-insured" plans for small employers

California seeks limits on small-business self-insurance trend

By Chad Terhune
Los Angeles Times, March 23, 2012

Self-insurance, in which employers pay medical providers for their workers’ care, has traditionally been used only by large employers that have the financial resources to pay for expensive medical claims.

Now some insurers are chasing after much smaller customers with new plans designed to limit employer payouts for big claims using what’s called stop-loss policies. This guarantees that businesses won’t be responsible for anything over a certain amount per employee, perhaps as low as $10,000 or $20,000, with the rest paid by an insurer. Regulators and health-policy experts say this arrangement undercuts the notion of self-insurance since employers aren’t bearing much of the risk, and it allows companies to circumvent some state insurance rules.

“This is not real self-insurance. This is clearly a sham,” said Mark Hall, a professor of law and public health at Wake Forest University who has studied the small-business insurance market.

Critics said insurers such as Cigna Corp. are using these new plans to game the system and cherry-pick companies with healthier workers. They said this could undermine a key goal of the federal Affordable Care Act to lower premiums by pooling together more healthy and sick Americans into insurance exchanges. Premiums could continue to escalate without a diverse pool of consumers.

Insurance officials say that they are responding to employer demands for more affordable coverage and that regulators shouldn’t interfere in the market.

Self-insurance is attractive for many reasons, particularly the prospect of lower costs. It’s exempt from state insurance regulations such as mandated benefits, granting employers the flexibility to design their own benefit package and the opportunity to reap some of the savings from employee wellness programs. A federal law, the Employee Retirement Income Security Act, or ERISA, governs self-funded plans. Some aspects of the Affordable Care Act do apply to self-insurance, such as the elimination of caps on lifetime benefits and some preventive care at no cost.

Anthem Blue Cross, California’s largest for-profit insurer and a unit of WellPoint Inc., began selling these self-insured plans to employers with as few as 35 workers March 1, down from its previous minimum of 250 employees. Assurant Inc., a New York-based insurer, is selling plans to companies in California and other states with as few as 10 workers.

Marc Neely, vice president for Cigna’s self-insured business in 14 Western states, said his sales to small businesses with as few as 25 people are growing at a double-digit rate because employers are fed up with annual rate hikes of 10% to 15% on their traditional plans. Neely said Cigna offers stop-loss coverage as low as $20,000 per employee. “We’re excited about California as a growth market for us,” Neely said.

http://www.latimes.com/business/la-fi-small-business-insure-20120323,0,4149546.story

Comment:

By Don McCanne, MD

Now that the Affordable Care Act (ACA) is law, we can be assured the the private insurers will be team players in helping to craft regulated insurance markets that will serve the interests of patients first. Right? Wrong! Just read this article about how they are dumping much of the risk onto employers through these phony “self-insured” plans, while using ERISA to escape some of the regulatory provisions of ACA.

These crooks will never change. It is in their corporate DNA. No matter how much they are regulated, they will always find a way around to cheat the payers and avoid paying for the sick. This is what insurance market innovation is all about – screw the patients and take the money and run.

(For more, this topic was covered in a previous message: https://pnhp.org/news/2011/november/exemptions-for-self-insured-plans-place-employees-at-risk)

Insurers promoting phony “self-insured” plans for small employers

California seeks limits on small-business self-insurance trend

By Chad Terhune
Los Angeles Times, March 23, 2012

Self-insurance, in which employers pay medical providers for their workers’ care, has traditionally been used only by large employers that have the financial resources to pay for expensive medical claims.

Now some insurers are chasing after much smaller customers with new plans designed to limit employer payouts for big claims using what’s called stop-loss policies. This guarantees that businesses won’t be responsible for anything over a certain amount per employee, perhaps as low as $10,000 or $20,000, with the rest paid by an insurer. Regulators and health-policy experts say this arrangement undercuts the notion of self-insurance since employers aren’t bearing much of the risk, and it allows companies to circumvent some state insurance rules.

“This is not real self-insurance. This is clearly a sham,” said Mark Hall, a professor of law and public health at Wake Forest University who has studied the small-business insurance market.

Critics said insurers such as Cigna Corp. are using these new plans to game the system and cherry-pick companies with healthier workers. They said this could undermine a key goal of the federal Affordable Care Act to lower premiums by pooling together more healthy and sick Americans into insurance exchanges. Premiums could continue to escalate without a diverse pool of consumers.

Insurance officials say that they are responding to employer demands for more affordable coverage and that regulators shouldn’t interfere in the market.

Self-insurance is attractive for many reasons, particularly the prospect of lower costs. It’s exempt from state insurance regulations such as mandated benefits, granting employers the flexibility to design their own benefit package and the opportunity to reap some of the savings from employee wellness programs. A federal law, the Employee Retirement Income Security Act, or ERISA, governs self-funded plans. Some aspects of the Affordable Care Act do apply to self-insurance, such as the elimination of caps on lifetime benefits and some preventive care at no cost.

Anthem Blue Cross, California’s largest for-profit insurer and a unit of WellPoint Inc., began selling these self-insured plans to employers with as few as 35 workers March 1, down from its previous minimum of 250 employees. Assurant Inc., a New York-based insurer, is selling plans to companies in California and other states with as few as 10 workers.

Marc Neely, vice president for Cigna’s self-insured business in 14 Western states, said his sales to small businesses with as few as 25 people are growing at a double-digit rate because employers are fed up with annual rate hikes of 10% to 15% on their traditional plans. Neely said Cigna offers stop-loss coverage as low as $20,000 per employee. “We’re excited about California as a growth market for us,” Neely said.

http://www.latimes.com/business/la-fi-small-business-insure-20120323,0,4149546.story

Comment:

By Don McCanne, MD

Now that the Affordable Care Act (ACA) is law, we can be assured the the private insurers will be team players in helping to craft regulated insurance markets that will serve the interests of patients first. Right? Wrong! Just read this article about how they are dumping much of the risk onto employers through these phony “self-insured” plans, while using ERISA to escape some of the regulatory provisions of ACA.

These crooks will never change. It is in their corporate DNA. No matter how much they are regulated, they will always find a way around to cheat the payers and avoid paying for the sick. This is what insurance market innovation is all about – screw the patients and take the money and run.

(For more, this topic was covered in a previous message: https://www.pnhp.org/news/2011/november/exemptions-for-self-insured-plans-place-employees-at-risk)

Georgia cost-control bill means well, but is naive

By Jack Bernard
Atlanta Journal-Constitution, March 22, 2012

Co-sponsored by Rep. Paul Broun of Athens, the bill is a well-meaning but naive and misguided attempt to control state and federal expenditures.

It is similar to Rep. Paul Ryan’s plan for radical Medicare reform through vouchers, legislation passed by the House last year and soundly rejected by the Senate.

Controlling Medicaid expenses is clearly needed for national deficit reduction, and to lessen the fiscal burden on states like ours. From 2006 to 2009, Georgia Medicaid expenditures rose from $3.9 billion to $5.6 billion. However, balancing the budget on the backs of 2 million of Georgia’s poorest residents by cutting the care they receive (which is what will happen) is not the way to go.

A much better, more comprehensive solution is to do away with both Medicaid and the Affordable Care Act (i.e., Obamacare) by expanding Medicare to cover all ages and people, including national elected officials. With Universal Medicare all costs can be controlled and complete access assured. Medicare has overhead expenses of about 3 percent, one-tenth of the overhead costs of private insurers. Further, one part of the ACA that should be kept is the Medicare Independent Payment Advisory Board, set up to make sure that costs do not escalate.

Under Universal Medicare, the savings can be spent reimbursing doctors and other providers for direct care, taking care of sick people, versus buying second homes and yachts for insurance company CEOs who are making millions of dollars each year in bonuses, stock options and ridiculous salaries.

Medicare is one of the few programs that taxpayers enthusiastically support, even many of the tea party’s gray panthers. It is hard for anyone to attack a program almost everyone understands and generally likes. In other words, if Medicare is good enough for granny, then it’s good enough for me and my congressman. Now, that is a political slogan that Joe Sixpack can get behind.

Medicare must be responsive to the voters because it is a publicly funded program authorized by our elected representatives. Who elects the CEOs of health insurance companies? What real power does the individual policy holder have when denied a claim (otherwise known as rationing)? Almost none.

The benefits of Medicare for all, as well as costs relative to existing private programs, have been established by a national group, Physicians for a National Health Program. (Their website — www.pnhp.org — contains information on single payer systems.)

Unfortunately, PNHP and other progressive groups were virtually shut out of the political process when reform was discussed in Washington in 2009. The insurance lobby was, and still is, one of the strongest in our capital.

Block grants — effectively cutting health care to poor people — are not the answer to our problems. Neither is going backward, dumping the ACA and relying on the “free market” to cure our ills. A recent Gallup survey shows that the insurance problem is getting much worse in our state and the nation. In Georgia, the number of uninsured is increasing rapidly, from 19 percent in 2008 to 22 percent in 2011. That rate is even faster than the U.S. rise from 15 percent to 17 percent. In fact, only five states have a higher rate of uninsured than Georgia. .

A single payer program covering all Americans should have been passed in 2009 — and it will be, in future years when the true financial and human costs of misguided reforms like the ACA, Medicaid block grants and Medicare vouchers are clear.

Jack Bernard, a senior health care executive for 25 years, serves on the Jasper County Board of Commissioners.

http://www.ajc.com/opinion/bill-means-well-but-1395148.html

Occupy Health Care? Will 'Medicare for all' catch fire?

Maybe ‘Medicare for All’ can catch fire as a populist slogan

By James Hill and Samuel Levey
Iowa City Press-Citizen, March 22, 2012

Even as voices from the Occupy Wall Street movement have faded in recent months, the conversations they started continue. Wall Street greed, corporate recklessness and growing economic inequality are still in the news and still being talked about — along with other grievances caught up in the movement’s wide net.

Problems in the health care sector are among them; many can be found posted on websites along with demands for change, often under a banner of “Occupy Health Care.”

No doubt the U.S. health care system is a worthy offender and deserves such attention. Consider the massive out-of-control spending ($2.6 trillion in 2010, more than 16 percent of GDP), the glaring inefficiencies, the stubbornly high number of medical errors and the persistent waste, fraud and abuse.

Of these, the offense that ought to merit a storm of protest is the ever-climbing cost of health care. In 2011, the national bill for health care increased by 4.5 percent, health insurance premiums rose by 9 percent, and the average cost of employer-provided coverage for a family exceeded $15,000. Today costs continue on an upward spiral of national spending.

Some supporters of President Obama’s Affordable Care Act of 2010 believe the legislation will be able to “bend the curve” of spending when fully implemented, as it is intended to do, by reducing costs over the long term.

And it’s true that restructuring the delivery of health care could have a notable effect on cost. As economist David Cutler notes, “The potential savings from delivery system reform are enormous. … (Given enough time,) 30 percent of annual medical spending — nearly $2,300 per person — could be eliminated without any adverse health consequence.”

But much skepticism remains. Many strong supporters of health care reform who rallied behind Obama’s early efforts now doubt the ACA will halt the inexorable rise in health care cost.

Former New England Journal of Medicine editor Arnold Relman asks, “If neither party is proposing effective solutions to the cost crisis and political deadlock in Washington is preventing the consideration of new ideas, are we doomed to witness a slowly collapsing health care system that eventually will provide adequate care only to those who can afford to pay?”

Other critics take a similarly dim view of the Affordable Care Act’s prospects for cost control. For physicians Steffie Woolhandler and David Himmelstein, the blame is not in political gridlock but the enormous influence of corporations, from health insurers to pharmaceutical companies, in the making of American health care policy.

As long as health care is run as a bottom-line business with financial incentives driving it, they argue, the overtreatment of patients and rising administrative overhead will continue, pushing up overall costs.

While Relman finds encouraging possibilities for cost-control in the trend toward multispecialty group practices and salaried physicians, he remains a firm believer in the superior virtues of the program Congress once again failed to pass: comprehensive national health insurance.

Like Woolhandler and Himmelstein, Relman favors universal coverage under a single-payer, taxpayer-supported public system. Under this system, advocates argue, the bedeviling problems of patient overtreatment and excessive administrative costs can be brought under control via prepaid comprehensive care while health care insurance is extended to all Americans — features not possible under the act.

The response of such single-payer stalwarts to the achievement of Affordable Care Act is tepid support at best. And in the minds of many liberal reform advocates, the act is inadequate health care legislation, not something to celebrate and feel good about.

Perhaps that dissatisfaction is now working its way into a new health care rhetoric that appears to align itself somewhat with the rhetoric of the Occupy movement. Starr, himself an admitted “strong reformer,” describes the ideological/class lines on which health care in American has been fought over its history, then wonders if the “special interests were arrayed on one side and the suffering masses on the other, the conflict would fit easily into a familiar populist picture of the world.”

A populist picture is perhaps what Woolhandler and Himmelstein have in mind. America is now divided on the issue of health care financing, they argue, and “while the American people want an expanded and improved Medicare for All — that is a single-payer system — corporations dead set against single-payer reform have come to dictate the agendas of both political parties. Hence, the only way to win national health insurance is to build a popular movement to counter corporate power.”

If “Medicare for All” can catch fire as a populist slogan, just as “Occupy Wall Street” did in 2011, under the force of widening economic and political divisions, perhaps a full-blown Occupy Health Care movement will emerge.

For that to happen, however — for reformers to have more than a scattering of websites to show for their efforts — the movement will need something more to move it forward: a visible groundswell of discontent.

Jim Hill is a writer who lives in Coralville. Samuel Levey is a professor in the Department of Health Management and Policy in the University of Iowa College of Public Health.

http://www.press-citizen.com/article/20120322/OPINION02/303220043/Occupy-Health-Care-?odyssey=nav|head