PNHP

It's now time for significant change in U.S. health care

It's now time for significant change in U.S. health care

By David E. Drake
Des Moines Register, June 3, 2011

As a physician I am regularly faced with patients who have inadequate or no health insurance. A person may call my office to discover that their health “insurance” does not cover mental health or they have such a high deductible they can’t afford to see me. In both cases my office may refer the person to a clinic with a sliding scale, to the same place where I might refer someone who had no insurance at all.

The provision of health care in the U.S. is neither a system nor is it “insurance” of health. What we have is an increasingly broken and costly disconnected patchwork of private insurance plans that are tied to employment or retirement benefits, the latter of which have also been in jeopardy.

Once one loses their job, within a short time health coverage goes with it. Then if the person fails to meet the poverty guidelines for Medicaid, they might qualify for some coverage by Iowa Cares. Iowa Cares can work well for folks living in Polk County or Iowa City, but the many counties distant from those facilities can find persons traveling a day for a routine medical appointment.

The need for a single-payer of health care is more pressing than ever.

Recently, I was overwhelmed to learn what my own health insurance was going to cost. Having switched from providing coverage to my own family and my one employee in a group to an individual plan — as my one employee went on Medicare — I was astounded to learn that the “insurance” carrier had denied me coverage and had listed me as having multiple pre-existing conditions — 90 percent of which were not accurate.

When corrected in a letter by my primary care physician, the “insurance” company accepted me but at a rate of $700 per month for my own plan and another nearly $800 for my wife and two adult kids. The total premium has come to $1,473.15.

What we need in this state and in the U.S. in a true system of health care coverage – not one plagued by hundreds of separate health plans with different deductibles, co-pays, and co-insurances.

While traveling in the United Kingdom and France recently I stopped and talked to people about their health care. And while it’s true that folks will complain about the waiting time to see a specialist not one person wanted to give up their system of health care in exchange for the craziness we find in the United States. In fact several U.K. residents were astounded and disbelieving when I described to them what I face everyday in my office as patients present to me in need of care. Residents of Scotland told me they don’t even carry an insurance card.

Vermont is the first state to have the support of its legislature and governor to begin proceeding to develop our nation’s first universal health care system of payment. As in Canada, physicians and other health care providers, will be able to remain in private practice and will be able to bill one source for their fees. Vermont is expected to have its single-payer system in effect, using Medicare-for-all as its model, by 2017. In the meantime Blue Cross and Blue Shield, Vermont’s main provider of insurance, has not fought the change but sees itself as the possible intermediary between the government and health care providers.

I currently hire a billing service to deal with the complicated challenges of billing and a half-time person in my office who mostly calls insurance companies to verify and clarify benefits. This is a great cost to any medical practice, and I would gladly have staff to only bill one source of payment for my services and to know that everyone who called my office was covered.

We all deserve competent and comprehensive health care – including mental health. Health care should not be tied to employment. I believe it is a right and not a privilege. I know the change will come. I just hope it comes sooner than later.

David E. Drake, D.O., is a physician specializing in family psychiatry. He is in private practice in Des Moines.

http://www.desmoinesregister.com/apps/pbcs.dll/article?AID=2011106050310

The Politics of Doctors

Letter to the Editor
The New York Times, June 2, 2011

To the Editor:

According to your article, “there are no national surveys that track doctors’ political leanings.” There is, however, one statistically valid survey of doctors’ opinion that backs up the idea of a leftward shift.

An article in Annals of Internal Medicine in 2008 showed that support for government establishment of a national health insurance system among doctors nationwide had jumped to 59 percent from 49 percent in 2002.

There was, of course, variation by specialty, with higher support among primary care doctors and less in subspecialties.

STEVEN B. AUERBACH
New York, May 31, 2011

The writer is a pediatrician.

Victory Lap

Editorial
Rutland (Vt.) Herald, May 29, 2011

This is the triumphal phase of the first term of Gov. Peter Shumlin.

Last week his office released a schedule describing the long list of signing ceremonies he will hold throughout the state. Shumlin did not do it alone. Strong Democratic majorities in the House and Senate pushed through an impressive array of legislation on matters great and small. It is a sign of what can happen when voters set a clear direction and elect leaders eager to follow through. The Democratic successes this year also mean that the Democrats will be accountable for the success or failure of their ambitious program.

Shumlin signed the health care reform bill in a ceremony at the Statehouse on Thursday, cheered on by a throng of legislative leaders, advocates and supporters who have been working for years to establish a single-payer system.

One of the principal speakers at the rally was Dr. Deb Richter, who has been a tireless advocate for a single-payer system, meeting with hundreds of groups, publishing books that describe her ideas in comprehensible language and never compromising on her large idea.

Her idea is that health care is a public good that can be provided to everyone, just as we provide education or police protection, and it can be provided more cheaply if we establish a system that reduces the waste of the present haphazard system and the profit-taking of insurers and health care providers.

Hospitals at present maintain staff at particular levels based on anticipated need. Their cardiac departments, for example, estimate a certain number of heart attacks and are prepared to deal with them. Hospitals budget accordingly — for cardiac, oncology, obstetrics, emergency room and other needs. A single-payer system would provide budgets to meet those needs.

The difference is that the individuals who come to the hospitals at a moment of need would not be required to shoulder the load of paying for services. Everyone would pay. That’s because the cardiac and other departments are on stand-by and available for all of us when the need arises. It does not make sense to finance hospitals and other services by bankrupting individuals or feeding profits to insurance companies.

Over the years, Richter has presented this idea convincingly and clearly, sometimes exasperating politicians who felt compelled to water down the idea of a single-payer system. After he signed the single-payer bill on Thursday, Shumlin gave the pen he used to Richter.

Republicans are annoyed because the new law does not specify how the state will pay for the new system and what kind of benefits it will provide. The triumphal talk is premature, Republicans say, because the new system is far from reality.

House Speaker Shap Smith acknowledged that work on the new system is just beginning. “There are definitely people who want to see this fail,” Smith told the crowd on Thursday. “We cannot let that happen. We need to work together to show the way for the entire country.”

The administration has formed “core teams” of officials throughout the government to gather information to be used by the new Green Mountain Care Board, which will oversee establishment of the new system. Everyone, Republican and Democrat, acknowledges that the job of reshaping one-sixth of the state’s economy will not be an easy one.

Shumlin’s victory tour of bill signing ceremonies was curtailed late last week by the flooding in central Vermont that hit many businesses and offices. But the list of bills to be signed remains an impressive one. It includes a jobs bill, a telecommunications bill, a DUI bill and even a bill resolving the contentious issue of Pete the Moose. Pete, it seems, will survive.

There are also bills dealing with human trafficking, transparency in government, hospice and palliative care, registered nurses and marijuana dispensaries.

The marijuana dispensary bill is an example of a law that cuts across the usual conservative-liberal divide to put in place a bill responding to a difficult and complex reality. The bill had the cooperation and support of law enforcement, which will oversee the operations of a limited number of dispensaries that will make available marijuana for those with a compelling medical need.

Vermonters presumably knew what they were doing when they elected a Democratic governor and a strong majority of Democratic lawmakers. That the majority is following through with the promises it made suggests that democracy is working. If the results are less than satisfactory, then the voters will know whom to blame.

What? Increased Medicare spending improves health status?

Medical Spending and the Health of the Elderly

By Jack Hadley, Timothy Waidmann, Stephen Zuckerman, Robert A. Berenson
HSR, May 24, 2011

Abstract

Objective. To estimate the relationship between variations in medical spending and health outcomes of the elderly.

Data Sources. 1992–2002 Medicare Current Beneficiary Surveys.

Study Design. We used instrumental variable (IV) estimation to identify the relationships between alternative measures of elderly Medicare beneficiaries’ medical spending over a 3-year observation period and health status, measured by the Health and Activity Limitation Index (HALex) and survival status at the end of the 3 years. We used the Dartmouth Atlas End-of-Life Expenditure Index defined for hospital referral regions in 1996 as the exogenous identifying variable to construct the IVs for medical spending.

Data Collection/Extraction Methods. The analysis sample includes 17,438 elderly (age >64) beneficiaries who entered the Medicare Current Beneficiary Survey in the fall of each year from 1991 to 1999, were not institutionalized at baseline, stayed in fee-for-service Medicare for the entire observation period, and survived for at least 2 years. Measures of baseline health were constructed from information obtained in the fall of the year the person entered the survey, and changes in health were from subsequent interviews over the entire observation period. Medicare and total medical spending were constructed from Medicare claims and self-reports of other spending over the entire observation period.

Principal Findings. IV estimation results in a positive and statistically significant relationship between medical spending and better health: 10 percent greater medical spending over the prior 3 years (mean=U.S.$2,709) is associated with a 1.9 percent larger HALex value (p=.045; range 1.2–2.2 percent depending on medical spending measure) and a 1.5 percent greater survival probability (p=.039; range 1.2–1.7 percent).

Conclusions. On average, greater medical spending is associated with better health status of Medicare beneficiaries, implying that across-the-board reductions in Medicare spending may result in poorer health for some beneficiaries.

http://onlinelibrary.wiley.com/doi/10.1111/j.1475-6773.2011.01276.x/abstract;jsessionid=14960293163E6619EF2994F69320629A.d03t01

Comment: 

By Don McCanne, MD

Does spending more on Medicare beneficiaries improve health status? This study concludes that, on average, it does. This is an important finding because current innovative efforts to control Medicare spending are based on the Dartmouth studies that conclude that variations in Medicare spending are not correlated with improved health outcomes.

As the authors of this new study indicate, arbitrary across-the-board reductions could result in poorer health for some beneficiaries. Even arbitrarily reducing spending in high cost areas could have detrimental effects if that higher spending were appropriate for the health status of the local population.

Medicare funds belong to all of us, so there is a responsibility for our stewards to spend those funds wisely and properly. They should pay for beneficial care but not pay for detrimental care nor for outrageously expensive care that is of no benefit. That means that we need more information about the benefits and risks of health care. We need comparative effectiveness studies and, yes, cost effectiveness studies. We need the type of information that is being collected, organized and disseminated by the British National Institute for Health and Clinical Excellence (NICE). We need scientific input free of commercial interests such as that provided by our National Institutes of Health.

It is not only Medicare that needs this input.  All care provided by our entire health care delivery system should benefit from this input. Obviously a single payer monopsony would have the ability and power to move funds from detrimental care to beneficial care.

What is Washington doing about this? The Republicans want to give up on government control of Medicare spending and instead shift more of that responsibility to individual Medicare beneficiaries through a defined contribution scheme (premium support). Medicare beneficiaries of limited means and with limited medical sophistication do not make good health care shoppers. The Democrats want to show the Republicans that they can be tough on deficit reduction by including Medicare in the negotiations for budgetary spending cuts – trying to find cuts that inflict the least pain, though painful nevertheless.

Come on. Put away the guillotines, machetes, axes and cleavers. Let’s start spending the right way. Let’s direct our resources to quality care that benefits us all.

About NICE
http://www.nice.org.uk/aboutnice/

About NIH
http://www.nih.gov/about/

About Single Payer
https://pnhp.org/facts/single-payer-resources

What? Increased Medicare spending improves health status?

Medical Spending and the Health of the Elderly

By Jack Hadley, Timothy Waidmann, Stephen Zuckerman, Robert A. Berenson
HSR, May 24, 2011

Abstract

Objective. To estimate the relationship between variations in medical spending and health outcomes of the elderly.

Data Sources. 1992–2002 Medicare Current Beneficiary Surveys.

Study Design. We used instrumental variable (IV) estimation to identify the relationships between alternative measures of elderly Medicare beneficiaries’ medical spending over a 3-year observation period and health status, measured by the Health and Activity Limitation Index (HALex) and survival status at the end of the 3 years. We used the Dartmouth Atlas End-of-Life Expenditure Index defined for hospital referral regions in 1996 as the exogenous identifying variable to construct the IVs for medical spending.

Data Collection/Extraction Methods. The analysis sample includes 17,438 elderly (age >64) beneficiaries who entered the Medicare Current Beneficiary Survey in the fall of each year from 1991 to 1999, were not institutionalized at baseline, stayed in fee-for-service Medicare for the entire observation period, and survived for at least 2 years. Measures of baseline health were constructed from information obtained in the fall of the year the person entered the survey, and changes in health were from subsequent interviews over the entire observation period. Medicare and total medical spending were constructed from Medicare claims and self-reports of other spending over the entire observation period.

Principal Findings. IV estimation results in a positive and statistically significant relationship between medical spending and better health: 10 percent greater medical spending over the prior 3 years (mean=U.S.$2,709) is associated with a 1.9 percent larger HALex value (p=.045; range 1.2–2.2 percent depending on medical spending measure) and a 1.5 percent greater survival probability (p=.039; range 1.2–1.7 percent).

Conclusions. On average, greater medical spending is associated with better health status of Medicare beneficiaries, implying that across-the-board reductions in Medicare spending may result in poorer health for some beneficiaries.

http://onlinelibrary.wiley.com/doi/10.1111/j.1475-6773.2011.01276.x/abstract;jsessionid=14960293163E6619EF2994F69320629A.d03t01

Does spending more on Medicare beneficiaries improve health status? This study concludes that, on average, it does. This is an important finding because current innovative efforts to control Medicare spending are based on the Dartmouth studies that conclude that variations in Medicare spending are not correlated with improved health outcomes.

As the authors of this new study indicate, arbitrary across-the-board reductions could result in poorer health for some beneficiaries. Even arbitrarily reducing spending in high cost areas could have detrimental effects if that higher spending were appropriate for the health status of the local population.

Medicare funds belong to all of us, so there is a responsibility for our stewards to spend those funds wisely and properly. They should pay for beneficial care but not pay for detrimental care nor for outrageously expensive care that is of no benefit. That means that we need more information about the benefits and risks of health care. We need comparative effectiveness studies and, yes, cost effectiveness studies. We need the type of information that is being collected, organized and disseminated by the British National Institute for Health and Clinical Excellence (NICE). We need scientific input free of commercial interests such as that provided by our National Institutes of Health.

It is not only Medicare that needs this input.  All care provided by our entire health care delivery system should benefit from this input. Obviously a single payer monopsony would have the ability and power to move funds from detrimental care to beneficial care.

What is Washington doing about this? The Republicans want to give up on government control of Medicare spending and instead shift more of that responsibility to individual Medicare beneficiaries through a defined contribution scheme (premium support). Medicare beneficiaries of limited means and with limited medical sophistication do not make good health care shoppers. The Democrats want to show the Republicans that they can be tough on deficit reduction by including Medicare in the negotiations for budgetary spending cuts – trying to find cuts that inflict the least pain, though painful nevertheless.

Come on. Put away the guillotines, machetes, axes and cleavers. Let’s start spending the right way. Let’s direct our resources to quality care that benefits us all.

About NICE
http://www.nice.org.uk/aboutnice/

About NIH
http://www.nih.gov/about/

About Single Payer
https://pnhp.org/facts/single-payer-resources

Means testing Medicare

Ryan Says Rich Should Pay More as Sanders Defends Entitlements for Wealthy

By Brian Faler
Bloomberg, May 30, 2011

Bernie Sanders, the U.S. Senate’s only avowed socialist, may be the chamber’s fiercest advocate of taxing the rich to cut the federal deficit. That doesn’t mean he wants to reduce their Social Security and Medicare benefits.

Representative Paul Ryan, the Republican chairman of the House Budget Committee, wants to give the wealthy big tax breaks to encourage them to invest and create jobs. He also wants to take away many of their retirement benefits.

Democrats say Social Security and Medicare have endured because they offer benefits to people of all incomes, and accuse Republicans of trying to kill the programs by stripping away their beneficiaries, beginning with the rich. Republicans say the fairest way to curb the deficit is to scale back the programs for those who need them least.

With polls showing the public supports limiting benefits to the wealthy, and some Democratic leaders signaling a willingness to consider the idea, the rich may face cuts as lawmakers debate how to curb the national debt.

Sanders, 69, said the debate isn’t just about numbers.

“The strength of Social Security and Medicare is that everybody is in,” the Vermont independent said in an interview. “Once you start breaking that universality and you say that if you’re above a certain income, two years later that income goes down and 10 years later it becomes a welfare program.”

Republicans say the waves of retiring baby boomers, as well as increasing health-care costs, are the real threats to the programs because the benefits are unsustainable.

“The thing that tears the social contract is insolvency,” said Ryan, 41, a Wisconsin Republican. “Means-testing is an obvious solution to our fiscal problems,” he said. “The alternative is everybody gets cut, so why don’t we put the money where it should go — to the people who need it.”

Representative James McDermott, a Washington Democrat, said providing benefits to those who don’t need them is a small price to pay to ensure the programs are available to everyone else.

“I don’t worry about paying a few benefits to Warren Buffett or Bill Gates,” he said. “As long as we make absolutely sure we got public support” for the programs.

http://www.bloomberg.com/news/2011-05-31/ryan-says-rich-should-pay-more-as-sanders-defends-entitlements-for-wealthy.html

Comment: 

By Don McCanne, MD

Paying for health care and receiving health care are two different issues.

Under an ideal system, everyone should receive all essential health care services that they need without having to face financial barriers that might prevent them from accessing that care.

Since health care now has become so expensive that many cannot afford it, an ideal system would also finance that care based on the ability to pay. Those with greater means would pay more. Also, since the need for health care is very unevenly distributed, an insurance function of pooling the costs is absolutely essential.

Assuming that everyone gets the care that they need, there are two fundamental ways of paying for it. You can fund the entire costs in advance through a single risk pool. That is the simplest administratively and certainly would be the most equitable if each person contributed a given amount based on their means – most easily accomplished through progressive taxes.

The other way would be to establish a catastrophic risk pool through taxes or premiums that only partially fund care, and then assess cost-sharing payments (deductibles, co-payments, coinisurance) based on services received, at the time they are received. Since ability to pay remains an issue, to ensure access each individual would have to be means tested to determine what subsidies would be required (as in the Affordable Care Act). This greatly increases the administrative complexity and costs of financing care. The health care provider, the payer, and the patient each must account for each and every service and the allocation of responsibility for payment.

Although insurance premiums are normally thought of as a method of financing the risk pool, they have taken on a new twist in Medicare Part B (physician services) and Part D (drug benefit). Although these programs are partially funded through the tax system, the additional Part B and Part D premiums assigned to the individual beneficiaries are now means tested. In a sense, they are now accounted for as a means tested but negative benefit. The greater one’s means, the less the benefit. This is an important strategy  of the opponents of Medicare because it weakens the support of the more affluent members of our society and risks converting Medicare into a welfare program.

If all health care has already been prepaid by taxes paid into into a common risk pool, then none of this is necessary. The patient simply receives needed care, and that’s it.

Professor Leonard Rodberg, from Queens College/CUNY, has described this concept in these insightful comments (personal communication):

“The central feature of the Canadian health care system is not that it is a single payer system; it is that financial considerations do not enter into the patient’s decision to seek medical care, nor in the doctor’s decision on what treatment to recommend for the patient. It is not only that there is no exchange of money between patient and doctor; the patient has to pay no money for the visit at any time. There is no fighting with the insurance company to get a claim paid, and no complicated bookkeeping on the part of either the patient or the doctor.”

“We in PNHP have often observed that the term ‘single payer’ is not helpful in explaining what we mean by a national health program. I learned in Canada that it also doesn’t describe the essence of what we are seeking. We tend to treat the absence of cost-sharing as simply a feature of the single payer plan we want. I am now convinced that, instead, we should view the removal of financial barriers to care as the core of what we advocate: no billing of patients, no cash exchange between patient and provider, no checking with insurance companies, etc.

“Too often, we speak as if our goal is a single payer system. I believe that is a mistake. Our goal should be the removal of all financial barriers to care; a single payer system is simply a means, and not the only means, to that goal. What makes the Canadian system, and others, work so well is not its single payer character, but the fact that funding of the system is completely separated from the delivery of care. That should be what we seek through a national health program.”

Eliminate Unneeded Overhead

By David Himmelstein and Steffie Woolhandler
Room for Debate Blog
New York Times, June 1, 2011

David Himmelstein and Steffie Woolhandler are internists and professors of public health at the City University of New York. They are co-founders of Physicians for a National Health Program.

Eliminating unneeded overhead would save Medicare nearly $100 billion annually. A thicket of insurance and hospital bureaucrats and profiteers distort medical priorities and drain money from care. The most obvious are private insurers who run Medicare Advantage plans that extract overhead, averaging 15 percent, or $1,000 per senior more than overhead in traditional Medicare.

Hospitals also devote a quarter of their revenue to overhead, nearly twice what’s needed. Vast marketing departments and whole buildings that house highly paid financial schemers are the norm in our medical centers. Their goals: attract patients for profitable high tech procedures (whether needed or not); avoid the unprofitably ill (e.g. most psychiatric patients); and jack up billings by exaggerating patients’ illnesses and gaming reimbursement rules.

Rev up your scanner and you’ll find many impressive-sounding (but unimportant) diagnoses that can add thousands to a Medicare bill. Would hospitals do such a thing? Research demonstrates that such overdiagnosis is epidemic. An M.R.I. will find nasty looking knee and spine abnormalities in many Medicare-aged patients who don’t (and won’t) suffer from serious knee or back pain. Most men over 80 have a few abnormal prostate cells that will never make them sick (and won’t be helped by treatment) but can be profitably labeled “cancer.” Such overdiagnosis will bring big bonuses under Medicare’s proposed new payment rules; the risk adjustment formula will reward hospitals that label patients with more diagnoses.

Uprooting the bureaucrats will require taking the profit out of health care and simplifying our payment system. Let’s pay hospitals as we currently pay fire departments: one check each month to cover their entire operating budget, with no profit taken out and hence little reason for financial scheming. Of course, this would require a single payer reform that eliminates the need to keep track of who got each aspirin. That kind of reform has allowed Canada’s Medicare program to simultaneously cover everyone and hold down costs.

http://www.nytimes.com/roomfordebate/2011/06/01/what-medicare-services-to-cut-starting-today/eliminate-unneeded-overhead

National single-payer advocate at the Capitol

By Casey Seiler
Albany Times Unions, June 1, 2011

Dr. Garrett Adams, president of Physicians for a National Health Program, is swinging through the Capital Region meeting with fellow advocates for a single-payer health care system, and doing interviews with Susan Arbetter of “The Capitol Pressroom” (listen to the podcast of this morning’s show here) and WAMC’s “Vox Pop” (coming later this week).

In the interest of full disclosure, I should note that Adams and my sainted mother, notorious Twitter enthusiast and letter-writer Harriette Seiler, have worked on this issue together for several years in my hometown of Louisville, Ky.

Although the overall results of the 2010 elections could be read as a fairly strong rejection of the push for a single-payer system — popularly known by the shorthand of “Medicare for all” — Adams says the cause is “alive and well.” He’s heartened by more recent developments such as Vermont Gov. Peter Shumlin’s decision last week to sign into law legislation that would create a single-payer program for the Green Mountain State, which could become operational by 2014 if Vermont receives necessary waivers from the feds.

“For the first time, a U.S. governmental entity has said that health care is a fundamental right for everyone in the state,” said Adams, who noted that he was seeing “a lot of energy” on other state plans, as well.

Even so, he called the Vermont plan a “work in progress,” and said he remained disappointed that the bill allows for the continued involvement of private insurers.

Adams, a pediatrician who began his day joining in grand rounds at Albany Medical Center, made it clear that it isn’t just critics of what’s been described as a government takeover of health care who remain disappointed in the federal Affordable Care Act. Those advocating for a government takeover of health care see it as a half-a-loaf measure that will ultimately evolve or fail.

“That law will have to be replaced,” Adams said. “It was a large step forward in many ways, but it falls short.”

http://blog.timesunion.com/capitol/archives/69118/national-single-payer-advocate-at-the-capitol/

Means testing Medicare

Ryan Says Rich Should Pay More as Sanders Defends Entitlements for Wealthy

By Brian Faler
Bloomberg, May 30, 2011

Bernie Sanders, the U.S. Senate’s only avowed socialist, may be the chamber’s fiercest advocate of taxing the rich to cut the federal deficit. That doesn’t mean he wants to reduce their Social Security and Medicare benefits.

Representative Paul Ryan, the Republican chairman of the House Budget Committee, wants to give the wealthy big tax breaks to encourage them to invest and create jobs. He also wants to take away many of their retirement benefits.

Democrats say Social Security and Medicare have endured because they offer benefits to people of all incomes, and accuse Republicans of trying to kill the programs by stripping away their beneficiaries, beginning with the rich. Republicans say the fairest way to curb the deficit is to scale back the programs for those who need them least.

With polls showing the public supports limiting benefits to the wealthy, and some Democratic leaders signaling a willingness to consider the idea, the rich may face cuts as lawmakers debate how to curb the national debt.

Sanders, 69, said the debate isn’t just about numbers.

“The strength of Social Security and Medicare is that everybody is in,” the Vermont independent said in an interview. “Once you start breaking that universality and you say that if you’re above a certain income, two years later that income goes down and 10 years later it becomes a welfare program.”

Republicans say the waves of retiring baby boomers, as well as increasing health-care costs, are the real threats to the programs because the benefits are unsustainable.

“The thing that tears the social contract is insolvency,” said Ryan, 41, a Wisconsin Republican. “Means-testing is an obvious solution to our fiscal problems,” he said. “The alternative is everybody gets cut, so why don’t we put the money where it should go — to the people who need it.”

Representative James McDermott, a Washington Democrat, said providing benefits to those who don’t need them is a small price to pay to ensure the programs are available to everyone else.

“I don’t worry about paying a few benefits to Warren Buffett or Bill Gates,” he said. “As long as we make absolutely sure we got public support” for the programs.

http://www.bloomberg.com/news/2011-05-31/ryan-says-rich-should-pay-more-as-sanders-defends-entitlements-for-wealthy.html

Paying for health care and receiving health care are two different issues.

Under an ideal system, everyone should receive all essential health care services that they need without having to face financial barriers that might prevent them from accessing that care.

Since health care now has become so expensive that many cannot afford it, an ideal system would also finance that care based on the ability to pay. Those with greater means would pay more. Also, since the need for health care is very unevenly distributed, an insurance function of pooling the costs is absolutely essential.

Assuming that everyone gets the care that they need, there are two fundamental ways of paying for it. You can fund the entire costs in advance through a single risk pool. That is the simplest administratively and certainly would be the most equitable if each person contributed a given amount based on their means – most easily accomplished through progressive taxes.

The other way would be to establish a catastrophic risk pool through taxes or premiums that only partially fund care, and then assess cost-sharing payments (deductibles, co-payments, coinisurance) based on services received, at the time they are received. Since ability to pay remains an issue, to ensure access each individual would have to be means tested to determine what subsidies would be required (as in the Affordable Care Act). This greatly increases the administrative complexity and costs of financing care. The health care provider, the payer, and the patient each must account for each and every service and the allocation of responsibility for payment.

Although insurance premiums are normally thought of as a method of financing the risk pool, they have taken on a new twist in Medicare Part B (physician services) and Part D (drug benefit). Although these programs are partially funded through the tax system, the additional Part B and Part D premiums assigned to the individual beneficiaries are now means tested. In a sense, they are now accounted for as a means tested but negative benefit. The greater one’s means, the less the benefit. This is an important strategy  of the opponents of Medicare because it weakens the support of the more affluent members of our society and risks converting Medicare into a welfare program.

If all health care has already been prepaid by taxes paid into into a common risk pool, then none of this is necessary. The patient simply receives needed care, and that’s it.

Professor Leonard Rodberg, from Queens College/CUNY, has described this concept in these insightful comments (personal communication):

“The central feature of the Canadian health care system is not that it is a single payer system; it is that financial considerations do not enter into the patient’s decision to seek medical care, nor in the doctor’s decision on what treatment to recommend for the patient. It is not only that there is no exchange of money between patient and doctor; the patient has to pay no money for the visit at any time. There is no fighting with the insurance company to get a claim paid, and no complicated bookkeeping on the part of either the patient or the doctor.”

“We in PNHP have often observed that the term ‘single payer’ is not helpful in explaining what we mean by a national health program. I learned in Canada that it also doesn’t describe the essence of what we are seeking. We tend to treat the absence of cost-sharing as simply a feature of the single payer plan we want. I am now convinced that, instead, we should view the removal of financial barriers to care as the core of what we advocate: no billing of patients, no cash exchange between patient and provider, no checking with insurance companies, etc.

“Too often, we speak as if our goal is a single payer system. I believe that is a mistake. Our goal should be the removal of all financial barriers to care; a single payer system is simply a means, and not the only means, to that goal. What makes the Canadian system, and others, work so well is not its single payer character, but the fact that funding of the system is completely separated from the delivery of care. That should be what we seek through a national health program.”

Support rises for Medicare as anniversary nears

June 2, 2011

Dear PNHP colleagues and friends,

The nation is rallying in support of Medicare and advocacy for single payer is on the rise. Please join us in protecting Medicare from privatization and celebrating the work of our activists in Vermont.

The popular Medicare program will turn 46 this July. We encourage you to write letters to the editor and opinion articles to your local paper in anticipation of Medicare’s anniversary next month. Now is the time to expand and improve – not cut – Medicare. For tips on how to write letters to the editor and opinion articles, please visit the Get Active section of our website. I recommend Dr. Quentin Young’s wonderful article from last year on the history and impact of Medicare to give you an idea of how this public program changed the lives of millions overnight. If you would like assistance on editing or pitching an article, please write organizer@pnhp.org. We’re happy to help!

Last week Dr. Quentin Young wrote a scathing “thank you” note to Rep. Paul Ryan (R-Wisc.). As you know, Rep. Ryan put forth a proposal to destroy Medicare as we know it, effectively rallying the public. PNHP Past President Dr. Oliver Fein calls the plan “Medicare for no one.” We say, “Expand and Improve Medicare for All.” Here’s an excerpt from Dr. Young’s letter-

“Since you succeeded in securing virtual unanimous support from the Republican majority in the House of Representatives for your voucher program, the rejection of your plan has been demonstrated nationwide. The spectacular defeat of Ms. Corwin in the 26th district of New York on May 24, 2011, is clearly the earliest expression of the vital importance our nation attaches to a single-payer comprehensive health plan for the elderly, Medicare.” Read more here.

In other news, I’ve just returned from a visit to our PNHP Upstate New York Chapter where I met with local activists and the media, and presented Grand Rounds. It was a fantastic visit and I want to thank all of the activists who worked to make it possible. We at PNHP are redoubling our outreach through our Grand Rounds program. If you’re a scheduler of Grand Rounds at your hospital and interested in hosting a PNHP speaker, please click here.

Wendell Potter recently wrote a great article, “Health Insurers Have Had Their Chance,” showing the support for single payer from California to Ohio to Vermont. As Vermont moves forward with its recently-passed health reform bill, activists on the ground are working hard to ensure that a single-payer system is implemented. There is great news that PNHP Past President Dr. Deb Richter, was recently appointed to the Vermont nominating committee for the Green Mountain Care board!

We’re heartened to see so much activism around the country and the growing physician voice calling for single-payer health insurance.

Cordially,

Garrett Adams, MD, MPH
President

PS- PNHP is proud to announce a new series of special conference calls dedicated to dilating on a particular aspect of health policy. Stay tuned for dates and more information.

Vermont Passes Single-Payer Health Care, World Doesn't End

Advocates celebrate, but critics warn: A few details—like, er, funding—have yet to be worked out.

By David Goodman
Mother Jones, May 30, 2011

As Gov. Peter Shumlin took his spot on the granite steps of the Vermont State House, a row of people fanned out behind him wearing bright red t-shirts proclaiming, “Health care is a human right.” The slogan sounded noble, and wildly unrealistic. Until the governor spoke.

“We gather here today to launch the first single-payer health care system in America,” began Shumlin, a Democrat who has been governor barely four months. “To do in Vermont what has taken too long: have a health care system, the best in the world, that treats health care as a right, and not a privilege.”

Moments later, the governor made history, signing a law that sets Vermont on a course to provide health care for all of its 620,000 citizens through a European-style single payer system called Green Mountain Care. Key components include containing costs by setting reimbursement rates for health care providers and streamlining administration into a single, state-managed system. The federal health care reform law would not allow Vermont to enact single payer until 2017; Vermont is asking the administration to grant it a waiver so that it can get there even faster, by 2014.

The push for single payer system in Vermont was built slowly and methodically over the last decade, but has moved with remarkable speed since Shumlin took office in January. A few weeks after the new governor’s inauguration, the Democratic-controlled legislature convened a rare joint session to hear from Dr. William Hsiao, a Harvard economist who has been involved in designing health care systems in seven countries. Last year, the legislature commissioned Hsiao to analyze the costs and benefits of various health care options, ranging from single payer to a fully privately managed system. The soft-spoken economist told a packed state House that a single payer plan would be about 25 percent cheaper for consumers, businesses, and the government than the current system of private health insurance, saving about $500 million in just the first year.

The data emboldened Shumlin, the legislature, and the single-payer advocates who had organized throughout the past decade, even as Shumlin’s Republican predecessor dismissed their ideas. Last fall, Shumlin had campaigned on twin themes of job creation and health care reform, and he often cited his experience as the owner of a successful travel business. (“I know firsthand that the biggest obstacle to job growth is the 10, 20, 30 percent increases in insurance premiums.”) He slammed the current “unsustainable system that will…bankrupt us.”

Single payer advocates have been a constant and visible presence around the state. The independent Vermont Workers’ Center launched its “health care is a human right” campaign in 2008—inspired, said health care organizer James Haslam, by the desperate calls the Center was receiving on its workers’ hotline. “It was becoming more of a health care hotline,” he said. The group’s members went door to door, conducted numerous forums for legislators and organized health care rallies that drew thousands.

Health care providers also spoke up. Dr. Deb Richter, a family physician, moved to Vermont in 1999 from upstate New York, where she despaired at seeing her patients getting sicker and even dying as a result of problems with health insurance. As chair of Vermont Health Care for All, she gave 500 talks around the state, and helped bring along many reluctant health care providers. Richter was beaming when I saw her in the State House lobby last week. “I feel ecstatic,” she told me. “It’s like giving birth.”

Shumlin, a wiry, hyper-energetic lawmaker who often insists on shaking every hand in the crowd, staked his gubernatorial candidacy on single payer. It was a bold and risky move. The former president of the Vermont Senate, he was narrowly elected governor last fall after winning a five-way Democratic primary by some 200 votes, and defeating a popular Republican Lieutenant Governor by just 2 percent. Shumlin pointedly ignored the national Democratic strategy of tacking to the center, and instead championed progressive issues, from abortion rights to closing the state’s lone nuclear plant, to health care reform. I asked him why he’d hitched his star to single payer.

“It’s first of all a huge jobs creator, secondly we can’t sustain the current system—we are spending money faster than we are able to earn it,” he told me before heading outside to sign the bill. “So we think it’s an economic development issue as well as a human right.” But when I asked whether Vermont might a national model, the governor sounded a humble note. Major questions—such as how the program will be funded—have yet to be worked out. “You know, we are launching an ambitious effort here,” he said. “We want it in place by 2014. But I don’t think we should ask anyone to follow us until we figure it out. And that’s what we’re trying to do.”

Opponents have focused on the unknowns in the reform effort. Not a single Republican in the House, and only one Republican in the Senate, supported the bill. Republican Rep. Patti Komline, assistant state House minority leader, told me, “When people ask questions like how much is it going to cost and who’s gonna pay for it—they say, ‘Well this bill is more fact finding and information gathering.’ Which doesn’t make it very historic.”

Physicians for a National Health Program has also been ambivalent about the bill, saying Vermont’s law “is much more modest in its actual reach than a single-payer plan would be.” Richter, a past president of the organization, responded, “You have to think positive and continue to take action to try to get to next level and the next step. Some of the criticisms are over details that haven’t yet been worked out.”

Organized opposition to Vermont’s health reform was relatively muted in the last few months, and was mainly led by insurance agents. But advocates are bracing for an influx of national money and media. “There are definitely people who want to see this fail. We cannot let that happen,” said House Speaker Shap Smith. “We need to work together to show the way for the entire country.”

Shumlin’s early success on health care has caught the attention of Washington. In April, Congressional Democrats asked Shumlin to appear opposite Wisconsin Gov. Scott Walker before a Congressional committee. In a rebuke to Walker, Shumlin talked about his approach to Vermont’s fiscal challenges. “I don’t start with collective bargaining, and I don’t start with my public pensions. I start with the true costs. In Vermont—and this is true of most of the states of the country—health care is my biggest rising cost.”

On this muggy late-May day, Shumlin reveled in the success of his signature effort. He walked over to shake hands with a group of University of Vermont medical students, conspicuous in their white lab coats. Therese Ray, a first year medical student from Denver, told me that as a result of single payer, “I will absolutely stay in Vermont.” Another med student, Larry Bodden from New Orleans, said he grew up in an uninsured household. “My family had a deep seated fear of having to go to the doctor because we didn’t have insurance. I look forward to Vermonters not having that fear.”

Gov. Shumlin suddenly called for the several hundred people who had gathered to come closer as he signed the bill. “Everybody in,” he shouted.

“Nobody out!” came the reflexive reply, a call and response version of a slogan of the grassroots single-payer campaign. Shumlin chuckled, then made the single-payer bill the law of the Green Mountain State.

David Goodman is a contributing writer for M
other Jones and coauthor of Static: Government Liars, Media Cheerleaders and the People Who Fight Back.

http://motherjones.com/politics/2011/05/vermont-single-payer-health-care