PNHP

UK Health Minister Lansley on patient accountability for costs

UK Health Minister Lansley on patient accountability for costs

Perspectives on Health Care Reform in the U.K.: A dialogue with UK Secretary of State for Health Andrew Lansley

Brookings, Engelberg Center for Health Care Reform
November 9, 2011

Q&A

Mark McClellan, Director of the Engelberg Center:  Another point (that you mentioned) was the availability of care at a low or at really no cost to patients, to consumers. That is a big difference from the United States, obviously, where not just the more conservative members of our legislatures, but others as well believe that patients should have some accountability, some responsibility for some of the costs, and, conversely, if they make decisions to stay healthier, if they make decisions to use care more effectively, that they should get some of the savings. You put a big emphasis on how these reforms are going to lead to more patient choice in terms of GPs, in terms of hospital care, in terms of specialist teams, and so on. As you said, money following the patient. Is that going to be enough? There are a lot of people here who believe that you really need even more consumer involvement, consumer stake in care to drive real reforms in care.

UK Health Minister Andrew Lansley:  Well, I understand the view that says if people pay directly for something, they value it more. I actually think, in the British context, where health care is concerned, people understand the value of the health care that is provided to them. They don’t need to have it itemized in a bill sent to them and pay for it out of their own pocket to realize that the National Health Service provides them something that they should attach enormous value to. I think, generally speaking, it isn’t the case that people in Britain consume large amounts of health care, that they don’t need to, because it’s free. And in particular, I think through the intermediation process with general practitioners the relationship that is built up between the British public and their general practitioners is instrumental to the process of managing demand in a way that is responsible and effective. Now I think it’s not perfect, and I think that’s one of the central reasons why I think we need to give patients a greater say in decision making. I don’t think, in a free system, as a consequence of that we are going to see irresponsible or excessive demand. I think patients themselves, given good information and opportunities to make choices, on balance, will make decisions that are probably less costly, less invasive, less interventionist because they want to have care that supports them at home and very often they don’t want to be in the hospital. So issues like avoiding admissions to hospitals, I think patients are with us on this. They’re not conflicting with us. See, the one thing I would say is important in terms of access, that we don’t necessarily achieve, where we do need to act is to ensure that patients do have access to the latest and most effective treatments and medicines. And there, particularly, we acted, since the election, in the creation of the Cancer Drug Fund because we knew that, in Britain for example, there was a very low take-up of cancer medicines within five years of their being introduced. And I think that is absolutely an area where the public have an expectation and a right to expect that they should have access to whatever their clinicians regard as the most effective treatment available. Some of it’s cost effective but, you know, on that basis, with clinical judgement, they should be able to get access to it. I have to say, when you look at the cost, literally the transaction cost alone, of moving away from a taxpayer funded service as the NHS is, in the way in which we’re organized, at the moment we have something like five percent of NHS costs consumed in administration. I’m planning to bring that down to about three to three and a half percent over the course of the next four years. That alone will save us about one and one-half billion pounds a year. But that is very modest administration costs relative to the costs of administration of insurance systems in the United States. So on that basis alone I think there is, in a constrained financial bound, there’s no intrinsic merit in moving away from the structure of the system we have.

http://www.brookings.edu/events/2011/1109_uk_health_care.aspx

Comment: 

By Don McCanne, MD

Health Minister Andrew Lansley of the United Kingdom is currently at the center of a storm of controversy over his efforts to further privatize their health care on the theory that expanding market competition for the National Health Service will improve quality and reduce costs. So it is instructive to ask if his views extend to include the U.S. concept of empowering consumers by requiring an even greater financial stake “to drive real reforms in care,” as former CMS Secretary Mark McClellan phrases it.

Although holding very conservative political views, Lansley almost scoffs at the suggestion that British citizens would consume large amounts of care merely because it is free. When you think about it, the suggestion that patients need price sensitivity to prevent over-consumption of health care  is almost an insult. Patients want to consult with their physicians to obtain the most appropriate care for their medical circumstance, in an environment removed from financial considerations. They are not looking for bargain basement deals.

This is about health care, for Pete’s sake. It’s not like deciding whether you are going to purchase a garment at Walmart or at Nordstrom. The assumption in the United Kingdom and in all other wealthier nations, except the United States, is that public stewards will ensure that health care will always be there for you when you need it. It is not a commodity that wise shoppers will follow and then purchase only after it goes on sale.

The advocates of consumer-directed health care are going to have to do a better job of explaining how requiring patients to pay out of their pockets or savings accounts when they access care is an answer to a problem, when that problem doesn’t seem to even exist. As Minister Lansley states, “it isn’t the case that people in Britain consume large amounts of health care… because it’s free.” Further, “the relationship that is built up between the British public and their general practitioners is instrumental to the process of managing demand in a way that is responsible and effective.”

How about that! The traditional physician-patient relationship works!

The per capita health care spending in the United Kingdom is less than half that of the United States. The British did not have to use consumer empowerment through price sensitivity to control their health care spending.

It appears that the only significant impact of increasing the financial stake of the health care consumer has been to erect financial barriers to beneficial health care services. So this detrimental intervention is being offered as a solution to the problem of high health care costs that other nations effectively manage using a responsible relationship between patients and their physicians? Talk about a disconnect between a problem and a solution!

McClellan says, “There are a lot of people here who believe that you really need even more consumer involvement, consumer stake in care to drive real reforms in care.” We could scoff at those people, but they’re in charge now. That’s tragic!

Vouchers for Veterans

By Paul Krugman
The New York Times, Nov. 13, 2011

American health care is remarkably diverse. In terms of how care is paid for and delivered, many of us effectively live in Canada, some live in Switzerland, some live in Britain, and some live in the unregulated market of conservative dreams. One result of this diversity is that we have plenty of home-grown evidence about what works and what doesn’t.

Naturally, then, politicians — Republicans in particular — are determined to scrap what works and promote what doesn’t. And that brings me to Mitt Romney’s latest really bad idea, unveiled on Veterans Day: to partially privatize the Veterans Health Administration (V.H.A.).

What Mr. Romney and everyone else should know is that the V.H.A. is a huge policy success story, which offers important lessons for future health reform.

Many people still have an image of veterans’ health care based on the terrible state of the system two decades ago. Under the Clinton administration, however, the V.H.A. was overhauled, and achieved a remarkable combination of rising quality and successful cost control. Multiple surveys have found the V.H.A. providing better care than most Americans receive, even as the agency has held cost increases well below those facing Medicare and private insurers. Furthermore, the V.H.A. has led the way in cost-saving innovation, especially the use of electronic medical records.

What’s behind this success? Crucially, the V.H.A. is an integrated system, which provides health care as well as paying for it. So it’s free from the perverse incentives created when doctors and hospitals profit from expensive tests and procedures, whether or not those procedures actually make medical sense. And because V.H.A. patients are in it for the long term, the agency has a stronger incentive to invest in prevention than private insurers, many of whose customers move on after a few years.

And yes, this is “socialized medicine” — although some private systems, like Kaiser Permanente, share many of the V.H.A.’s virtues. But it works — and suggests what it will take to solve the troubles of U.S. health care more broadly.

Yet Mr. Romney believes that giving veterans vouchers to spend on private insurance would somehow yield better results. Why?

Well, Republicans have a thing about vouchers. Earlier this year Representative Paul Ryan famously introduced a plan to convert Medicare into a voucher system; Mr. Romney’s Medicare proposal follows similar lines. The claim, always, is the one Mr. Romney made last week, that “private sector competition” would lower costs.

But we have a lot of evidence about how private-sector competition in health insurance works, and it’s not favorable. The individual insurance market, which comes closest to the conservative ideal of free competition, has huge administrative costs and has no demonstrated ability to reduce other costs. Medicare Advantage, which allows Medicare beneficiaries to buy private insurance instead of having Medicare pay bills directly, has consistently had higher costs than the traditional program.

And the international evidence accords with U.S. experience. The most efficient health care systems are integrated systems like the V.H.A.; next best are single-payer systems like Medicare; the more privatized the system, the worse it performs.

To be fair to Mr. Romney, he takes a somewhat softer line than others in his party, suggesting that the existing V.H.A. system would remain available and that traditional Medicare would remain an option. In practice, however, partial privatization would almost surely undermine the public side of these programs. For example, one problem with the V.H.A. is that its hospitals are spread too thinly across the nation; this problem would become worse if a substantial number of veterans were encouraged to opt out of the system.

So what lies behind the Republican obsession with privatization and voucherization? Ideology, of course. It’s literally a fundamental article of faith in the G.O.P. that the private sector is always better than the government, and no amount of evidence can shake that credo.

In fact, it’s hard to avoid the sense that Republicans are especially eager to dismantle government programs that act as living demonstrations that their ideology is wrong. Bloated military budgets don’t bother them much — Mr. Romney has pledged to reverse President Obama’s defense cuts, despite the fact that no such cuts have actually taken place. But successful programs like veterans’ health, Social Security and Medicare are in the crosshairs.

Which brings me to a final thought: maybe all this amounts to a case for Rick Perry. Any Republican would, if elected president, set out to undermine precisely those government programs that work best. But Mr. Perry might not remember which programs he was supposed to destroy.

http://www.nytimes.com/2011/11/14/opinion/krugman-vouchers-for-veterans-and-other-bad-ideas.html

The One Percent turns class war into generational war

By Dean Baker
Truthout, Nov. 7, 2011

Major news outlets like The Washington Post and National Public Radio constantly bombard us with news pieces on the budget deficit. Invariably these stories focus on the cost of “entitlements,” which most of us know as Medicare, Medicaid and Social Security. The story pounded home in these pieces — often explicitly — is that these programs, that primarily benefit the elderly, are creating the basis for a generational war between the young and the old.

The media focus both contributes to and follows the Washington policy debate. At the moment, we have the Congressional “supercommittee” scheming to produce a deficit reduction plan that will almost certainly involve large cuts to all three programs. There is a commonly repeated view in Washington policy circles, based on no evidence whatsoever, that there will be a disaster if the supercommittee comes up empty handed. This means that members of the committee are feeling great pressure from the 1 percent to produce a package with big cuts to Medicare, Medicaid and Social Security.

It is truly impressive how the Washington elite have managed to make these modest protections for the country’s working population (the 99 percent) into the greatest problem facing the country. The obsession with cutting these programs is occurring at a time when we have more than 25 million people unemployed, underemployed or who have given up looking for work altogether. One might think that Congress would convene a supercommittee to get people back to work rather than figuring out a way to undermine programs that people need, but it’s the 1 percent that pay for elections, not the 25 million workers suffering from their greed and incompetence.

Since almost no one can be immune to the hysteria that the media have created around the cost of these programs, it is worth putting it in some context. Starting with Social Security, the latest projections from the Congressional Budget Office show that the program can pay all benefits through the year 2038 with no changes whatsoever.

Even if we never did anything, the program would be able to pay more than 80 percent of scheduled benefits well into the next century. Since the value of benefits is projected to rise through time, 80 percent of the projected benefit in 2040 is considerably higher than the average benefit received by retirees today. Therefore, the often repeated comment that there will be nothing there for our children or grandchildren is a telltale sign of ignorance or dishonesty.

The cost of making the program fully solvent for its 75- year planning horizon is projected at 0.58 percent of gross domestic product (GDP). By comparison, the increase in annual spending on the military as a result of the wars in Iraq and Afghanistan is 1.7 percent of GDP, almost three times as much. The upward redistribution from the rest of us to the 1 percent over the last three decades was 6 percent of GDP or more than ten times as much as this shortfall. But it is only the shortfall in Social Security that the media want us to see as a crisis.

The health care programs, Medicare and Medicaid, pose more of a problem, but this is because the U.S. health care system is dysfunctional. We pay more than twice as much per person as do people in other wealthy countries with little, if anything, to show in the form of better outcomes. (We rank near the bottom of wealthy countries in life expectancy.)

If we had the same per person health care costs as people in Germany, Canada, or any other wealthy country we would be looking at long-term budget surpluses, not deficits. But controlling costs involves reducing the income and profits of the 1 percent. It means reducing payments to insurers, drug companies, medical equipment manufacturers and highly paid medical specialists.

Rather than control costs, the folks in Washington would rather make people pay even more for health care. This is why we see proposals like raising the age for Medicare eligibility to 67 or turning the program into a voucher system. Both plans are likely to protect the income of health care industry, while making it even more difficult for current or retired workers to cover their health care costs.

The public should realize that “generational warfare” is an agenda that was deliberately designed by the 1 percent to distract the rest of us from the class war that they have been successfully waging over the last three decades. Rather than have a public debate on the policies that have redistributed so much income upward, the 1 percent want to pit children against their parents and grandparents, forcing them to fight over crumbs.

In this context, the only victory that the supercommittee can hand to the 99 percent is a blank sheet of paper. People will have enough things to worry about this Thanksgiving without adding a Congressional plan to slash their Social Security and Medicare.

http://www.truth-out.org/one-percent-turns-class-war-generational-war/1320680738

Why the Occupy Movement is Good for Our Health

By Julie Matthaei and Neil Wollman
CommonDreams.org, Tuesday, November 8, 2011

Recently, the Congressional Budget Office released a report on income inequality which found that the incomes of the top 1% nearly tripled between 1979 and 2007, whereas those of the middle class increased by less than forty percent. In his 2007 study, Jared Bernstein  found that the after-tax income of the top 1% was 21 times higher than that of middle income families in 2005, compared to “only” 8 times higher in 1979. Indeed, inequality has been on the increase.

The burgeoning Occupy Wall Street movement, and its slogan, “We are the 99%,” is drawing critical attention to the grossly unequal distribution of income and wealth in the U.S.  Critiques include the injustice of the high incomes (and lack of incarceration) of Wall Street executives, given that their illegal actions caused the unemployment and homelessness of millions; the corrupting influence on the democratic process of the concentration of wealth in the hands of a few; and the basic indecency of the top 1% having much more than they could ever spend, while millions of Americans lack housing, health care, even food. 

But there any many other serious societal problems associated with inequality which are not so obvious, and which have received little attention from the Occupy movement or the media.  According to researchers Richard Wilkinson and Kate Pickett, more equal societies outperformed less equal ones in fifteen key ways:

– PHYSICAL HEALTH:  People in more equal societies live longer, a smaller proportion of children die in infancy, and self-rated health is better.
– MENTAL HEALTH:  People in more equal societies are far less likely to experience mental illness.
– DRUG ABUSE:  People in more equal societies are less likely to use illegal drugs.
– EDUCATION:  Children do better at school in more equal societies.
– IMPRISONMENT:  Unequal societies are harsher (in that) they imprison a higher proportion of people.
– OBESITY:  Obesity is less common in more equal societies.
– SOCIAL MOBILITY:  There is more social mobility in more equal societies.
– TRUST AND COMMUNITY LIFE:  Communities are more cohesive and people trust each other more in more equal societies.
– VIOLENCE:  Homicide rates are lower and children experience less violence in more equal societies.
– TEENAGE BIRTHS:  Teenage motherhood is less common in more equal societies.
    CHILD WELL-BEING: UNICEF measures of child well-being are better in more equal societies. 

In sum, income inequality is bad for our health, and for our society.  This finding greatly strengthens the case for policies aimed at making our income distribution more equal.

The Occupy Movement’s call for greater income equality also receives support from another finding of Wilkinson and Pickett.  They found that reductions in the level of inequality improve social well-being more than do increases in GDP.  This finding runs counter to a basic tenet of our economic policy – that GDP is the best measure of well-being.  It suggests that pro-growth policies which lead to increased inequality may in fact make people worse off, even if they increase GDP.   Conversely, increasing taxes on the rich would not only increase fairness, but also could increase well-being, even if they were to reduce GDP by discouraging capital investment. 

It is time that we the people, and our representatives in Washington, realize how unhealthy inequality is for us and for our society.  We should all applaud the Occupy Movement for bringing this problem to public attention, and we should join them in demanding that public officials act decisively to reverse this unhealthy trend.  While the top 1% can use their economic advantage and associated power to further enhance their wealth, we encourage them instead to join the 99% in pushing for more equality–as Warren Buffet has–and, perhaps, also improve their health and well-being in the process.  We should all seek the redistribution of income — to “spread the wealth around’ as put by then candidate Barack Obama to Joe the plumber — with more benefits then either likely considered at the time.

Julie Matthaei is a professor of economics at Wellesley College, and a co-founder and board member of the U.S. Solidarity Economy Network; jmatthae@wellesley.edu

Neil Wollman is Senior Fellow, Bentley Alliance for Ethics and Social Responsibility; Bentley University. He is concerned with issues of corporate responsibility; NWollman@bentley.edu

http://www.commondreams.org/view/2011/11/08-2

OWS Receives Flu Shots From Doctors And Nurses

By GLENN WILBURN
MyFoxNY.com, Sunday, 13 Nov 2011

MYFOXNY.COM – Doctors and nurses from Physicians for a National Health Program (PNHP) provided free health care to the Occupy Wall Street protesters at Zuccotti Park on Sunday.

However, a counter protest is being planned against the Occupy Wall Street demonstrators staying in at the park.

The Occupy Wall Street movement is in its third month and many small businesses and residents say it’s time for them to leave.

According to the NYPD, there were two arrests of protesters Saturday night. One of the arrests was for punching an officer.

Police said a fight had started between two men and when they tried to break up it, one of the men stopped and another kept going hitting the officer in the face. The officer wasn’t injured, but both men were taken in.

The Zuccotti Park protesters have been dealing with cold that has been spreading throughout Zuccotti Park.

OWS said within 24 hours of the call for volunteers, close to 70 professionals signed up to provide flu shots.

“We support Occupy Wall Street because economic and social inequalities make our patients sick,” says a statement on PNHP-NY Metro’s blog. “We support OWS because the private health insurance industry exemplifies the central complaint of the OWS movement: unchecked corporate greed threatens human needs.”

The physicians spoke out after providing the flu shot clinic. The health professionals and patients shared their personal stories they feel a national health care system is needed.

http://www.myfoxny.com/dpp/news/ows-receives-aid-from-doctors-and-nurses-20111113

Single-Payer System Would Fix Mandates

By Joseph R. Barrie, M.D.
Letters, The Wall Street Journal, Nov. 14, 2011

Edwin Schindler’s comments (“The Other Side of Insurance Mandates,” Letters, Nov. 10) about autism coverage in New York state are of interest to me because, like Bob and Suzanne Wright (Letters, Nov. 7), I have an autistic grandchild.

I sympathize with Mr. Schindler’s complaint about the cost of coverage but suggest that the balance sheet of his insurer ought to figure in his concerns.

His letter is another reason for this country to consider a single-payer insurance system, and get the for-profit and not-for-profit vultures out of the loop. Pity that our current president lacks the guts to support this concept.

Joseph R.. Barrie, M.D., resides in Harvard, Mass.

http://online.wsj.com/article/SB10001424052970204224604577030540772225510.html

UK Health Minister Lansley on patient accountability for costs

Perspectives on Health Care Reform in the U.K.: A dialogue with UK Secretary of State for Health Andrew Lansley

Brookings, Engelberg Center for Health Care Reform
November 9, 2011

Q&A

Mark McClellan, Director of the Engelberg Center:  Another point (that you mentioned) was the availability of care at a low or at really no cost to patients, to consumers. That is a big difference from the United States, obviously, where not just the more conservative members of our legislatures, but others as well believe that patients should have some accountability, some responsibility for some of the costs, and, conversely, if they make decisions to stay healthier, if they make decisions to use care more effectively, that they should get some of the savings. You put a big emphasis on how these reforms are going to lead to more patient choice in terms of GPs, in terms of hospital care, in terms of specialist teams, and so on. As you said, money following the patient. Is that going to be enough? There are a lot of people here who believe that you really need even more consumer involvement, consumer stake in care to drive real reforms in care.

UK Health Minister Andrew Lansley:  Well, I understand the view that says if people pay directly for something, they value it more. I actually think, in the British context, where health care is concerned, people understand the value of the health care that is provided to them. They don’t need to have it itemized in a bill sent to them and pay for it out of their own pocket to realize that the National Health Service provides them something that they should attach enormous value to. I think, generally speaking, it isn’t the case that people in Britain consume large amounts of health care, that they don’t need to, because it’s free. And in particular, I think through the intermediation process with general practitioners the relationship that is built up between the British public and their general practitioners is instrumental to the process of managing demand in a way that is responsible and effective. Now I think it’s not perfect, and I think that’s one of the central reasons why I think we need to give patients a greater say in decision making. I don’t think, in a free system, as a consequence of that we are going to see irresponsible or excessive demand. I think patients themselves, given good information and opportunities to make choices, on balance, will make decisions that are probably less costly, less invasive, less interventionist because they want to have care that supports them at home and very often they don’t want to be in the hospital. So issues like avoiding admissions to hospitals, I think patients are with us on this. They’re not conflicting with us. See, the one thing I would say is important in terms of access, that we don’t necessarily achieve, where we do need to act is to ensure that patients do have access to the latest and most effective treatments and medicines. And there, particularly, we acted, since the election, in the creation of the Cancer Drug Fund because we knew that, in Britain for example, there was a very low take-up of cancer medicines within five years of their being introduced. And I think that is absolutely an area where the public have an expectation and a right to expect that they should have access to whatever their clinicians regard as the most effective treatment available. Some of it’s cost effective but, you know, on that basis, with clinical judgement, they should be able to get access to it. I have to say, when you look at the cost, literally the transaction cost alone, of moving away from a taxpayer funded service as the NHS is, in the way in which we’re organized, at the moment we have something like five percent of NHS costs consumed in administration. I’m planning to bring that down to about three to three and a half percent over the course of the next four years. That alone will save us about one and one-half billion pounds a year. But that is very modest administration costs relative to the costs of administration of insurance systems in the United States. So on that basis alone I think there is, in a constrained financial bound, there’s no intrinsic merit in moving away from the structure of the system we have.

http://www.brookings.edu/events/2011/1109_uk_health_care.aspx

Health Minister Andrew Lansley of the United Kingdom is currently at the center of a storm of controversy over his efforts to further privatize their health care on the theory that expanding market competition for the National Health Service will improve quality and reduce costs. So it is instructive to ask if his views extend to include the U.S. concept of empowering consumers by requiring an even greater financial stake “to drive real reforms in care,” as former CMS Secretary Mark McClellan phrases it.

Although holding very conservative political views, Lansley almost scoffs at the suggestion that British citizens would consume large amounts of care merely because it is free. When you think about it, the suggestion that patients need price sensitivity to prevent over-consumption of health care  is almost an insult. Patients want to consult with their physicians to obtain the most appropriate care for their medical circumstance, in an environment removed from financial considerations. They are not looking for bargain basement deals.

This is about health care, for Pete’s sake. It’s not like deciding whether you are going to purchase a garment at Walmart or at Nordstrom. The assumption in the United Kingdom and in all other wealthier nations, except the United States, is that public stewards will ensure that health care will always be there for you when you need it. It is not a commodity that wise shoppers will follow and then purchase only after it goes on sale.

The advocates of consumer-directed health care are going to have to do a better job of explaining how requiring patients to pay out of their pockets or savings accounts when they access care is an answer to a problem, when that problem doesn’t seem to even exist. As Minister Lansley states, “it isn’t the case that people in Britain consume large amounts of health care… because it’s free.” Further, “the relationship that is built up between the British public and their general practitioners is instrumental to the process of managing demand in a way that is responsible and effective.”

How about that! The traditional physician-patient relationship works!

The per capita health care spending in the United Kingdom is less than half that of the United States. The British did not have to use consumer empowerment through price sensitivity to control their health care spending.

It appears that the only significant impact of increasing the financial stake of the health care consumer has been to erect financial barriers to beneficial health care services. So this detrimental intervention is being offered as a solution to the problem of high health care costs that other nations effectively manage using a responsible relationship between patients and their physicians? Talk about a disconnect between a problem and a solution!

McClellan says, “There are a lot of people here who believe that you really need even more consumer involvement, consumer stake in care to drive real reforms in care.” We could scoff at those people, but they’re in charge now. That’s tragic!

Dr. Jacqueline Davis on the fight to save Britain’s NHS

The Fight to Save Britain’s NHS: Luncheon address by Jacqueline Davis, M.D.

Physicians for a National Health Program
National Meeting, Washington, D.C., October 29, 2011

(Excerpts)

First I want to thank you for inviting me here. I bring greetings from the land of socialized medicine and death panels, to the land of “islands of excellence in a sea of misery.”

I’ve never been to this city before and when I told family and friends about my invitation to Washington they assumed I was off to meet the president. I told them it was much more important than that. But just in case he’s listening – I could be free for tea tomorrow….

****

Of course the NHS faces the challenges that all health systems do, i.e. changing demographics, increased range and cost of treatments, rising patient expectation and the global financial crisis. But in the face of all these the NHS still manages to be one of the most cost-efficient and equitable health services in the world. And the public love it. At the end of the Labour government’s 13 years in power it had the highest satisfaction ratings ever, and it still is the most popular institution in the UK bar none, and that includes the royal family.

So if it’s so good, why are we having to fight for it? Because there’s another big challenge which all public services face and that is the neoliberal agenda which still has the upper hand despite its current manifest failures on a global scale.

****

A successful public service is an affront to the free marketeers. They simply won’t let the facts get in their way. Despite all evidence to the contrary they continue to insist anything the public sector can do the private sector can do better and more cheaply, and no evidence to the contrary will persuade them otherwise.

So the politicians for ideological reasons, and the private sector for financial reasons, have had the NHS – traditionally publicly funded, publicly delivered and publicly accountable – in their sights for some time. They have acted together, beneath the radar, to turn the NHS from a cost-effective integrated public service into a kite mark attached to a ragbag of competing private providers.

****

Up till now you trusted your GP to give advice on clinical grounds. But now – if your GP says no to treatment and/or referral is it because they want to pocket the money that is saved – which the bill allows them to do? Or if they refer you to Hips R Us down the road, is it because their wife has a financial interest in it? 25 percent of GPs already have a direct interest in the private sector. This suspicion will be very corrupting, and most GPs are worried about it.

****

We fear NHS services being reduced to a core of poor services for poor people, with those who can afford it topping up their personal health budgets with insurance or out-of-pocket payments and those who can’t afford it going without.

And we really fear the arrival of the private companies, many of them from the U.S., whose behavior leaves much to be desired. They want to “cherry pick.” leaving the NHS to pick up the complex expensive patients as well as providing the expensive emergency care and the training that is not attractive to the private sector. We fear they will behave in a fraudulent way as they do already in the USA.

****

Our organization was vociferous from day one, saying that the bill spelled the end of the NHS, and of course we were accused of shroud waving and gross exaggeration. But we stuck in there and joined together with other campaigning organizations and the pressure has built up over the last year. How did we do it?

We produced analyses and simple 10-point critiques of the bill in our regular campaign newspaper as well as special pamphlets and postcards. We wrote doggedly – all of us would take it in turns – to national and local papers and had a lot of articles and letters published.

We offered to do public talks, to our own groups and also to anyone from medical students to pensioners, and in fact those two groups turned into some of our most outspoken supporters. We helped organize online petitions. We put a lot of energy into lobbying politicians.

We have helped expose the scandals of the revolving door between government and the private sector and the infiltration of government by corporate interests. We have questioned the neutrality of so called think tanks and helped expose the strength of the health lobbying industry in Westminster.

We marched, we used social media to spread our message and some of us even got elected to the Council of the British Medical Association so that we could begin to change our union from within.

****

The problem we have come to realize is that we aren’t just fighting the Tory government; we are fighting the global medical industrial complex with all its power, influence and money. And its cozy relationship with today’s politicians.

It’s easy to lose hope but we mustn’t. We have to take on this cozy configuration of politicians and giant corporations which have come to a “comfortable accommodation” at our expense. We must change the tone of the debate with these people who know the price of everything and the value of nothing.

We must say that the market should serve society rather than society serving the market, that there are public goods and goals for which the market is not suited and that what matters is not how affluent a country is but how unequal it is. We must collect evidence and use it to criticize and expose. We must create the strong voice of civil society and we doctors have a particular duty to be that voice and we must organize and use it.

Firstly because – and we must never lose sight of the fact – we are right. Secondly, we are the patients’ true advocates and our patients are depending on us. And finally Aneurin Bevan, the great founder of the NHS, said, “The NHS will last as long as there are folk left with the faith to fight for it.”

We must be those folk because, personally, I am not prepared to let him down.

(Dr. Jacqueline Davis is a consultant radiologist working in a hospital in London. She is co-chair of the NHS Consultants’ Association, a nationwide group of distinguished physicians representing all specialties, and a member of the Keep Our NHS Public campaign.)

(You may have to cut and paste this link for it to work.)
https://pnhp.org/news/2011/november/the-fight-to-save-britain’s-nhs

Comment: 

By Don McCanne, MD

We share with the British concerns about the neoliberal attack on our health care services. In their case it is an attack on their public National Health Service, whereas in our case it is an attack on Medicare and other public programs and, even greater, a virtual blockade – a dysfunctional private financing construct that often uses public money – that prevents us from bringing comprehensive health care services to all of our people.

This luncheon address by Dr. Jacqueline Davis was a highlight of PNHP’s recent annual meeting in Washington, DC. You may want to take a moment this weekend to read the entire address, available at the link above, and then savor it. You’ll then understand clearly why we gave her a standing ovation, not to mention that it will reinforce your dedication to the cause of health care justice for all.

Dr. Jacqueline Davis on the fight to save Britain’s NHS

The Fight to Save Britain’s NHS: Luncheon address by Jacqueline Davis, M.D.

Physicians for a National Health Program
National Meeting, Washington, D.C., October 29, 2011

(Excerpts)

First I want to thank you for inviting me here. I bring greetings from the land of socialized medicine and death panels, to the land of “islands of excellence in a sea of misery.”

I’ve never been to this city before and when I told family and friends about my invitation to Washington they assumed I was off to meet the president. I told them it was much more important than that. But just in case he’s listening – I could be free for tea tomorrow….

****

Of course the NHS faces the challenges that all health systems do, i.e. changing demographics, increased range and cost of treatments, rising patient expectation and the global financial crisis. But in the face of all these the NHS still manages to be one of the most cost-efficient and equitable health services in the world. And the public love it. At the end of the Labour government’s 13 years in power it had the highest satisfaction ratings ever, and it still is the most popular institution in the UK bar none, and that includes the royal family.

So if it’s so good, why are we having to fight for it? Because there’s another big challenge which all public services face and that is the neoliberal agenda which still has the upper hand despite its current manifest failures on a global scale.

****

A successful public service is an affront to the free marketeers. They simply won’t let the facts get in their way. Despite all evidence to the contrary they continue to insist anything the public sector can do the private sector can do better and more cheaply, and no evidence to the contrary will persuade them otherwise.

So the politicians for ideological reasons, and the private sector for financial reasons, have had the NHS – traditionally publicly funded, publicly delivered and publicly accountable – in their sights for some time. They have acted together, beneath the radar, to turn the NHS from a cost-effective integrated public service into a kite mark attached to a ragbag of competing private providers.

****

Up till now you trusted your GP to give advice on clinical grounds. But now – if your GP says no to treatment and/or referral is it because they want to pocket the money that is saved – which the bill allows them to do? Or if they refer you to Hips R Us down the road, is it because their wife has a financial interest in it? 25 percent of GPs already have a direct interest in the private sector. This suspicion will be very corrupting, and most GPs are worried about it.

****

We fear NHS services being reduced to a core of poor services for poor people, with those who can afford it topping up their personal health budgets with insurance or out-of-pocket payments and those who can’t afford it going without.

And we really fear the arrival of the private companies, many of them from the U.S., whose behavior leaves much to be desired. They want to “cherry pick.” leaving the NHS to pick up the complex expensive patients as well as providing the expensive emergency care and the training that is not attractive to the private sector. We fear they will behave in a fraudulent way as they do already in the USA.

****

Our organization was vociferous from day one, saying that the bill spelled the end of the NHS, and of course we were accused of shroud waving and gross exaggeration. But we stuck in there and joined together with other campaigning organizations and the pressure has built up over the last year. How did we do it?

We produced analyses and simple 10-point critiques of the bill in our regular campaign newspaper as well as special pamphlets and postcards. We wrote doggedly – all of us would take it in turns – to national and local papers and had a lot of articles and letters published.

We offered to do public talks, to our own groups and also to anyone from medical students to pensioners, and in fact those two groups turned into some of our most outspoken supporters. We helped organize online petitions. We put a lot of energy into lobbying politicians.

We have helped expose the scandals of the revolving door between government and the private sector and the infiltration of government by corporate interests. We have questioned the neutrality of so called think tanks and helped expose the strength of the health lobbying industry in Westminster.

We marched, we used social media to spread our message and some of us even got elected to the Council of the British Medical Association so that we could begin to change our union from within.

****

The problem we have come to realize is that we aren’t just fighting the Tory government; we are fighting the global medical industrial complex with all its power, influence and money. And its cozy relationship with today’s politicians.

It’s easy to lose hope but we mustn’t. We have to take on this cozy configuration of politicians and giant corporations which have come to a “comfortable accommodation” at our expense. We must change the tone of the debate with these people who know the price of everything and the value of nothing.

We must say that the market should serve society rather than society serving the market, that there are public goods and goals for which the market is not suited and that what matters is not how affluent a country is but how unequal it is. We must collect evidence and use it to criticize and expose. We must create the strong voice of civil society and we doctors have a particular duty to be that voice and we must organize and use it.

Firstly because – and we must never lose sight of the fact – we are right. Secondly, we are the patients’ true advocates and our patients are depending on us. And finally Aneurin Bevan, the great founder of the NHS, said, “The NHS will last as long as there are folk left with the faith to fight for it.”

We must be those folk because, personally, I am not prepared to let him down.

(Dr. Jacqueline Davis is a consultant radiologist working in a hospital in London. She is co-chair of the NHS Consultants’ Association, a nationwide group of distinguished physicians representing all specialties, and a member of the Keep Our NHS Public campaign.)

(You may have to cut and paste this link for it to work.)
https://pnhp.org/news/2011/november/the-fight-to-save-britain’s-nhs

We share with the British concerns about the neoliberal attack on our health care services. In their case it is an attack on their public National Health Service, whereas in our case it is an attack on Medicare and other public programs and, even greater, a virtual blockade – a dysfunctional private financing construct that often uses public money – that prevents us from bringing comprehensive health care services to all of our people.

This luncheon address by Dr. Jacqueline Davis was a highlight of PNHP’s recent annual meeting in Washington, DC. You may want to take a moment this weekend to read the entire address, available at the link above, and then savor it. You’ll then understand clearly why we gave her a standing ovation, not to mention that it will reinforce your dedication to the cause of health care justice for all.

Occupy actions, PNHP Annual Meeting report, Healthcare Reform 2.0

Nov. 10, 2011

Dear PNHP colleague,

Today’s message contains six points:

1. Update on the Occupy movement and single payer
2. ‘Healthcare Reform 2.0’ by Woolhandler and Himmelstein
3. PNHP’s Annual Meeting draws large crowd
4. Update on protest of IOM’s skimpy benefits model
5. More rumblings from Super Committee on cuts to Medicare, Medicaid and Social Security
6. Keep PNHP in mind for end-of-year giving

1. Update on the Occupy movement and single payer


Photo by Thomas Good / NLN

If you’ve watched or participated in the Occupy Wall Street movement that’s been sweeping the nation, giving voice to the demand of “the 99 percent” to put human needs before corporate greed, you’ve probably noted the appearance of signs and chants such as “Health care is a human right,” “Get Wall Street out of our health care,” and “Medicare for All.”

PNHP members and other single-payer advocates have definitely been part of the mix.

You may have seen, for example, Drs. Kenneth Weinberg and Steven Auerbach of PNHP’s N.Y. Metro chapter talking about why physicians support OWS on “Countdown with Keith Olbermann” recently. (You’ll spot many other PNHP members in the 6-minute video footage too.)

The N.Y. Metro chapter played a central role in the formation of a “Health care for the 99 percent working group” within the OWS movement and helped spark an Oct. 26 “March against the insurance industry” that drew more than 1,000 people who protested outside the corporate offices of WellPoint and the for-profit WellCare Health Plans, and protested the closing of St. Vincent’s Hospital in Greenwich Village.


Photo by Thomas Good / NLN

The march drew national media attention. This gallery of photos shows the spectrum of the marchers’ demands, including a call for “Single payer now.” You’ll find more on the march and the chapter’s statement of why PNHP supports the OWS (among them: “We support OWS because economic and social inequalities make our patients sick”) at the N.Y. Metro chapter’s blog.

Many doctors, nurses and other health professionals have provided medical help to the occupiers in Manhattan’s Zuccotti Park, too.

And this is only New York City! Ongoing actions are taking place in more than 100 U.S. cities, according to OccupyTogether.org, not to mention actions under way around the world.


Photo by Thomas Good / NLN

As the OWS workshop at PNHP’s Annual Meeting revealed, our members are involved all across the country, in cities large and small. (By the way, there was a march and protest led by Dr. Margaret Flowers and the October2011.org Freedom Plaza occupiers outside the offices of America’s Health Insurance Plans, the trade group, in Washington, around the time of our Annual Meeting. Quite a few PNHP members marched and spoke there, calling for a single-payer health system. Many Annual Meeting attendees visited the Occupy DC site too.)

Some PNHP activists are giving teach-ins on single payer to the general assemblies. Others are providing other forms of support. If you’d like to become more involved but don’t know how to do so, drop us a note at admin@pnhp.org and we’ll be happy to help.

2. ‘Healthcare Reform 2.0’ by Woolhandler and Himmelstein

This week a new article titled “Healthcare Reform 2.0” by Drs. Steffie Woolhandler and David Himmelstein was published by Social Research, an international quarterly. Dr. Don McCanne, senior health policy fellow at PNHP, observes: “This brief primer (9 short pages plus references) on Healthcare Reform 2.0 will provide little new information for those who have followed the research and educational efforts of the leadership of PNHP. Nevertheless, it should be downloaded to be used as an advocacy piece to explain to others why Healthcare Reform 1.0 (Affordable Care Act) will remain a failure, and why we have to move on to Healthcare Reform 2.0 (expanded and improved Medicare for All). By distributing this, electronically or in hard copy, you can become a part of the popular movement to counter corporate power [echoing a theme in the article].” Download the article here.

3. PNHP’s Annual Meeting draws large crowd


Photos by Mark Almberg / PNHP

Nearly 300 people from 28 states and the District of Columbia packed the ballroom of the Kellogg Conference Hotel at Gallaudet University in Washington on Oct. 29 for PNHP’s Annual Meeting. It was one of our largest meetings ever, and the mood was decidedly upbeat and forward-looking.

The participants listened to PNHP leaders such as Drs. David Himmelstein and Steffie Woolhandler along with Canada’s Robert Evans, the U.K.’s Dr. Jacqueline Davis, authors Phillip Longman and Dr. David Ansell, and activists like Drs. Mardge Cohen, Claudia Fegan, Garrett Adams and Quentin Young. Several of the plenary presentations and workshop slideshows can be found here, and more will be forthcoming.

The workshops covered everything from state single-payer efforts to the Occupy movement to how to build a PNHP chapter, to mention just a few. Participants joined in roundtable discussions and informal exchanges in the hallways and, in the case of the 40 or so medical students who were in attendance, also danced to the music of “the Cornel West theory” late into the night.

You’ll find some photos of the Annual Meeting here.

4. Update on PNHP’s protest of IOM’s skimpy benefits model

More than 2,000 physicians, including some of the most distinguished figures in U.S. medicine, have signed a letter to the Institute of Medicine protesting the IOM’s recommendation that cost rather than medical need be the basis for defining the “essential benefits” that insurance policies must cover when the federal health reform law takes effect in 2014.

The protest letter and the names of its signers have been submitted to a journal for publication, and in due time the letter will be submitted to Secretary Kathleen Sebelius of the Department of Health and Human Services as part of the formal comment process on the IOM committee’s recommendations. If you’d like to sign the letter, it’s not too late to do so.

5. More rumblings from the Super Committee on cuts to Medicare, Medicaid and Social Security

Since our last message about the secret discussions of the congressional Super Committee, the 12-member bipartisan panel appointed by President Obama charged with finding at least $1.2 trillion in cuts to federal spending, word has leaked out that Democrats on the committee (and the Democratic leadership) may approve a “deficit deal” with Republicans that involves cuts to Social Security, Medicare and Medicaid benefits in exchange for small revenue increases.

This has resulted in a storm of opposition from a wide spectrum of groups, including the AFL-CIO and the National Organization for Women.

For several years now, PNHP, Healthcare-Now and other single-payer advocates have consistently opposed any proposals to weaken to our nation’s social insurance programs and have instead argued that to save lives and money we should adopt a single-payer health system.

Please continue to send that message to your elected representatives. The Super Committee is scheduled to make its recommendations by Nov. 23. The Congressional Switchboard phone number is (202) 224-3121.

6. Keep PNHP in mind for end-of-year giving

It’s not too early to begin thinking about making a tax-deductible donation to PNHP before the end of the calendar year. As you know, we receive no financial support from large foundations — not to mention the insurance industry and Big Pharma! We instead rely on our membership base to fund all of our organizing and educational activities.

Please give generously to PNHP’s work to advance the cause of single payer in the year ahead.

Cordially,

Garrett Adams, M.D., M.P.H.
President

Why are we here?

By Claudia Fegan, M.D.

[Note: The following remarks were delivered to the participants in this year’s PNHP Leadership Training Institute in Washington, D.C., on Oct. 28.]

Why are we here?

We are here because every patient deserves to be treated with dignity and respect.

I had a patient who worked as a laborer, not a high-paying job, but a job that allowed him to buy a home and support his family. I met him 10 years ago. I was challenged to control his blood pressure. It was very difficult. I tried numerous combinations of medications.

Over the course of 2-3 years he had frequent visits, allowing me to adjust his meds. We talked a lot. I got to know this man very well. He always came alone. He talked about his children, his wife, his disappointments, his accomplishments and life.

Eventually we got that blood pressure under control and we saw each other less frequently. Five years later he had a massive myocardial infarction, a heart attack. His wife brought him to County Hospital and we admitted him. He was a good candidate for bypass surgery, so he had the procedure, did well and went home weakened, but hopeful.

I remember he told how fortunate he felt because his brother, with poorly controlled diabetes, doesn’t live near County and is unable to get regular care.

Six months after his bypass surgery my patient had a massive gastrointestinal bleed and again his wife brought him to County where he eventually had to have a hemicolectomy. After that his wife brought him to all his appointments with all of his medications. It was clear he was having trouble with his memory and he needed help to manage his complicated regimen.

There were good times and bad, sometimes everything was working and sometimes not.

He developed claustrophobia and could not stand being sent to the Emergency Department at County where there was usually a 12-24 hour wait on a gurney before he got admitted to the floor. Sometimes he yelled and complained and his wife cried, sometimes the three of us had a good laugh about something silly. Life carried on.

Last month in the middle of the night he became short of breath and stopped breathing before the paramedics arrived. Although he was revived it was clear by the time he arrived at the hospital we had lost the man we all knew.

I had that conversation with his wife – that he would not want to be preserved on a ventilator this way indefinitely. She told me she believed that, but wanted to know how I knew.

I told her we had had that conversation early on in our relationship and, although he never returned the advance directives form, despite being given it numerous times, he was clear on his wishes. I don’t think he could read the form and he didn’t want to discuss it with his wife.

Once his brothers and sisters arrived from out of town, life support was discontinued and he died.

His wife called me a week later to thank me for all I had done. I told her it was my job.

Two weeks later his sister called to ask if I would be her doctor.

Why are we here? Because there is no patient in need who doesn’t deserve what my patient got: he was treated with dignity and respect.

Why are we here? This month Wal-Mart, the largest private employer in the United States, decided all future part-time workers who work less than 24 hours a week would no longer be eligible for insurance benefits; new workers who work 24-33 hours a week would no longer able to cover their spouses on their policies; employees with HMO coverage would now have a $5,000 deductible; and all employees would have to pay a larger share of their premium costs, causing more employees to opt out of accepting the company’s health insurance benefit.

We are here because access to health care should be a right and not a privilege based on your ability to pay for it.

Why are we here? We are here because this month the esteemed Institute of Medicine decided the “essential health benefits” under the new health law should be defined as a package that will fall under a pre-defined cost target instead of building a package of essential benefits based on appropriate data and then figuring out what that would cost.

We are here because someone has to say this is wrong.

Why are we here? We are here because a Consumer Reports analysis of National Committee for Quality Assurance rankings noted the five largest national insurers, Aetna, Cigna, Humana, Kaiser Permanente and United Healthcare, plus the mostly state-based Blue Cross Blue Shield plans, account for about 75 percent of the 390 ranked private plans, but only 36 percent of the top 50 in terms of quality.

United Healthcare is the nation’s largest health insurance company, but none of its private plans rank among the top 100, and most occupy the bottom half.

We are here because we know there is a better way to guarantee the public access to quality health care. A single-payer health care system would actually allow us to get a better handle on the quality of care delivered.

Why are we here? We are here because undocumented immigrants represent 1 in 7 of the uninsured. These undocumented immigrants will not be eligible for public insurance or any type of the private coverage obtained through the exchanges created under the Affordable Care Act.

If we had a real single-payer national health program, the financing of the system and the delivery of care would be separated from each other. Everyone would contribute funds to the system based on their ability to pay.

In such a system, everyone, including undocumented immigrants, would receive care. We are here because in a just society we would guarantee access to care to everyone, regardless of their ability to pay or their immigration status.

Archbishop Oscar Romero from El Salvador said, “Do not give in charity what is due in justice.” Archbishop Romero was assassinated one day after a sermon where he called on Salvadoran soldiers, as Christians to obey God’s higher order and to stop carrying out the government’s repression and violations of basic human rights.

I mention Archbishop Romero not because I am a religious person, but because he spoke to a responsibility of people in positions of authority.

As physicians we have a responsibility to those in need, particularly to our nation.

Why are we here? We are here because people are suffering, people are dying and we know the answer. We are here to arm ourselves with the information we need to heal our nation, to save our patients.

Why are we here? We are here because Dr. Quentin Young turned 88 years old this year. He has worked tirelessly in this effort his entire professional career. We owe it to Quentin to carry on this fight and to win it in his lifetime.

Although Quentin’s parents Abe and Sarah each lived to be 98, we should not assume we have 10 more years to win this fight. We know what needs to be done and we know how to frame the discussion.

It is so simple, we need a plan that takes everybody in and leaves nobody out. Come one say it with me, we will feel better for it:

Everybody in, Nobody out!
Everybody in, Nobody out!
Everybody in, Nobody out!

Now let’s go out and change this country for the better.

Claudia Fegan, M.D., F.A.C.P, C.H.C.Q.M., is interim chief medical officer at the Cook County Health and Hospitals System and past president of Physicians for a National Health Program. She is co-author of the book “Universal Health Care: What the United States Can Learn from Canada” and a contributor to another book, “10 Excellent Reasons for National Health Care.”

Reinhardt: Placing "All-Payer" in the reform dialogue

The Many Different Prices Paid To Providers And The Flawed Theory Of Cost Shifting: Is It Time For A More Rational All-Payer System?

By Uwe E. Reinhardt
Health Affairs, November 2011

Abstract

In developed nations that rely on multiple, competing health insurers — for example, Switzerland and Germany — the prices for health care services and products are subject to uniform price schedules that are either set by government or negotiated on a regional basis between associations of health insurers and associations of providers of health care. In the United States, some states — notably Maryland — have used such all-payer systems for hospitals only. Elsewhere in the United States, prices are negotiated between individual payers and providers. This situation has resulted in an opaque system in which payers with market power force weaker payers to cover disproportionate shares of providers’ fixed costs — a phenomenon sometimes termed cost shifting — or providers simply succeed in charging higher prices when they can. In this article I propose that this price-discriminatory system be replaced over time by an all-payer system as a means to better control costs and ensure equitable payment.

http://content.healthaffairs.org/content/30/11/2125.abstract

Comment: 

By Don McCanne, MD

This is an important contribution to the health policy literature. It is intended to be a seminal paper designed to displace the useless discussion of cost shifting between public programs and private insurers with a discussion of reducing price discrimination (charging individuals, private insurers or government programs different prices for the same services) by shifting to an all-payer system that would better control costs and ensure equitable payment.

An all-payer system simply establishes “uniform price schedules that are either set by government or negotiated on a regional basis between associations of health insurers and associations of providers of health care.”(1) Why is this important?

Although there is considerable variation in prices throughout the health care system, high prices, on average, have been a major contributor to our very high per capita spending on health care.(2) As Uwe Reinhardt explains, much of this excessive pricing has resulted from private insurers, with a weak market presence, negotiating with health care providers, especially hospitals, that dominate their respective markets. The health care provider consolidation that is taking place can only compound the impact of this market distortion.

Although private insurers also are consolidating, competing plans are still not in a position to extract major price concessions from dominant health care providers. All-payer price setting through government or association negotiation is designed to displace the ineffectual private insurers as price negotiators while establishing both better cost control and more equitable payments for health care.

(In some areas, private insurers have been able to hold prices down at Medicare rates for physicians where the physicians have a very weak negotiating clout. This is less true of hospitals that have a weaker clout.)

Price discrimination – charging different prices for the same services – hits especially hard those who have the weakest bargaining power: individual patients who are now bearing more of the costs of health care. Contrary to widely held ideological beliefs, here it is price discrimination in the private insurance market and not the government that has created the perversity of rationing based on the ability to pay.

In his article, Reinhardt explains, “It should be recognized that the higher the fraction of health care spending that individuals and families must bear out of their own resources, the more heavily the model relies on rationing health care by price and the patient’s ability to pay — that is, rationing by income level. It may surprise some readers that anyone would associate markets with rationing. But as economists tell their students, free markets represent just one of many styles of rationing. Relying on price and ability to pay is precisely how markets in general manage to ration scarce resources among unlimited ends.”(1)

One of the reasons that this article on all-payer systems is so important is that we are at a crossroads in the reform process. He writes, “At this time, the US health system appears to stand at a clearly delineated crossroads. On one road, Americans would seek better control over national health spending through an all-payer system, such as the one operated by Maryland for the hospital sector. On the other road, Americans would seek better control of health care prices and national health spending through greater reliance on market forces for most of the health system. Depending on how that road is traveled, it could entail more pronounced rationing of health care by income class, meaning less health care for those who cannot afford it. The battle over US health policy in the coming decades is likely to be over which road to take.”(1)

Since an all-payer system would correct only a portion of the flaws in our health care financing, why shouldn’t we go full bore and enact a single payer system? Reinhardt brings up the political feasibility argument, as follows, “In any event, an all-payer system with multiple private insurers would be likely to be more broadly politically feasible than a government-run single-payer system, such as Canada’s provincial, government-run single-payer insurance systems. A single-payer system, of course, would be another alternative that would eliminate price discrimination and any cost shifting.”

Reinhardt discusses the effectiveness of all-payer for hospitals in the state of Maryland. In a previous response to the Maryland all-payer system, I stated, “If we can succeed in reestablishing a public service role for government, then wouldn’t it be reasonable to simply enact an all-payer system for hospitals? The problem is that it only makes one change in our fragmented, dysfunctional system of financing care, and not a complete change at that. Under all-payer, only the rates are controlled, but each service still must be accounted for and paid for independently, and the hospitals would still have multiple public and private payers with which they would have to interact.”(3)

So what about Switzerland? Reinhardt mentions it as having successfully applied an all-payer system. In another previous message on the OECD/WHO report on Switzerland, I stated, “It is not clear why so many in the U.S. are enamored of the Swiss health insurance system when this OECD/WHO report confirms that it is highly inefficient and fragmented, with profound administrative waste, inequitably funded, with regressive financing and with wide variations in premiums, has the highest out-of-pocket costs, has an increasing prevalence of managed care intrusions, and is controlled by a private insurance industry that has learned how to game risk selection at significant cost to those on the losing end.”(4)

Uwe Reinhardt is to be highly commended for moving us in the right direction, but…

We’ve said it before and we’ll say it again. If political feasibility is the barrier to enacting a single payer system, let’s not simply jettison single payer; let’s change the political feasibility instead! All-payer might be a modest incremental improvement (modest when compared to what needs to be done), but why settle for that when we can have it all through an improved and expanded Medicare for all?

(1) http://content.healthaffairs.org/content/30/11/2125.full

(2) https://pnhp.org/docs/Its-The-Prices-Stupid.pdf

(3) https://pnhp.org/news/2011/september/hospitals-all-payer-or-global-budgets

(4) https://pnhp.org/news/2011/october/oecdwho-report-on-the-swiss-health-system