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The $3 trillion elephant in the presidential campaign

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The $3 trillion elephant in the presidential campaign

By Ed Weisbart, M.D.
St. Louis Post-Dispatch, Feb. 16, 2016

Remember the heated discussions about health care in the Republican debates? No, you don’t, because they were arguing about things like fantasy football. In fact, all we heard about health care was, “Repeal Obamacare!”

We get it, being a member of The Repeal Obamacare Club is a prerequisite for running for president on the GOP ticket, as is having no plan with which to replace it.

Jeb Bush promotes tax credits for individuals to purchase “affordable” and “portable” plans. We hope Bush thinks “affordable” means less than 10 percent of annual income, but given that he wants to retain the same insurance industry whose bureaucracy now consumes 30 percent of every health care dollar, it’s unlikely.

Ben Carson supports health savings accounts, a great idea for healthy and wealthy individuals, but a terrible idea for everyone else who would be more deeply trapped in increasingly expensive plans. It’s a particularly bad idea for women, whose annual cost of care typically is $1,000 more than it is for men.

Ted Cruz crows, “Repeal every blasted word of Obamacare.” With what? All the problems Obamacare addressed? Crisis treatment in ERs instead of prudent prevention? Denials for pre-existing conditions? Denials for people with the audacity to get sick and actually use their insurance? Annual and lifetime caps?

Marco Rubio, like Jeb, would give you a refundable tax credit to purchase insurance. How does that control costs? And how is that so different from the premium subsidies provided by Obamacare, which Rubio opposes?

Donald Trump promises: “I am going to take care of everybody. I don’t care if it costs me votes or not. Everybody’s going to be taken care of much better than they’re taken care of now.” So far, Trump offers no details. He either doesn’t have them or doesn’t want us to know them. But when he does, they’ll be “fabulous!”

And what about the Democrats? Hillary Clinton would retain the Affordable Care Act and lower out-of-pocket and prescription costs, but she hasn’t said how. The Affordable Care Act has saved countless lives, but it is essentially an insurance-reform/subsidy program, not the comprehensive solution our nation needs to remedy our chronic bloating of health care costs.

Bernie Sanders supports HR 676, the Expanded and Improved Medicare for All Act, co-sponsored by Rep. William Lacy Clay and 63 other U.S. representatives. It’s a comprehensive plan with robust details. It provides full coverage without premiums, like people enjoy in all other advanced countries, at roughly half of what we spend per person in the United States today.

Any candidate who isn’t forthcoming with these details is ignoring our current dire reality. Our health care system has a literal death grip on this nation. It is the new “giant sucking sound” of money being vacuumed from our entire economy and into health care’s deep, private-profit pockets.

More than another cycle of modest reform, we need to base our solution upon our nation’s most successful health care system, Medicare. We need to divorce our health insurance from our employers, releasing businesses from that burden and giving job mobility back to employees. We need to implement universal access to health care, paid for by progressive taxes, delivered by the world’s best doctors and hospitals. We need to replace our woefully wasteful private insurance system with the efficiency of Medicare.

By eliminating sales, marketing, underwriting and other non-productive administrative functions required of private insurers, Medicare’s overhead is 2 percent; private insurance’s is 18 percent.

We have some of the best health care in the world, but far too many Americans can’t afford to use it, and everyone pays way too much for it. Medicare offers 50 years of proof that our government can administer health care as well or better than anywhere else in the world. Let’s make it available to each and every American, and demand that anyone running for high office explain how they could do better. They won’t because they can’t.

Dr. Ed Weisbart is chairman of Physicians for a National Health Program — Missouri chapter.

http://www.stltoday.com/news/opinion/the-trillion-elephant-in-the-presidential-campaign/article_ae4ef099-5c48-52c2-902d-7c1714f91730.html

PNHP note: Physicians for a National Health Program (PNHP) is a nonpartisan educational organization. It neither supports nor opposes any candidates for public office.

Medicare for all is what U.S. needs

By Jack Bernard
The Citizen (Fayetteville, Ga.), Feb. 16, 2016

I enjoyed reading Dr. Scherz’s (opinion column, 1-10-16), which was well written. As a retired senior level healthcare exec and former GOP elected official, I understand his frustration with the downside of Obamacare (the ACA). I hear much the same from my two sons, who are practicing physicians.

But, I am not in agreement with Scherz’s suggested solution, i.e., going back to the time before we had primary care insurance and having individuals fend for themselves, negotiating direct agreements with each of their doctors. The paperwork, research, skill and time required on both sides would be immense.

And, there it is a certainty that the consumer would pay more due to paucity of easily obtainable comparative data and lack of any leverage when dealing with providers. In other words, Medicare can get better rates than an individual because many providers cannot afford to lose the government’s business, accounting for over half of all U.S. healthcare expenditures.

Along the lines of the Scherz approach, a conservative friend mentioned to me the other day that he agreed with Gov. Mike Huckabee on healthcare. The problem with Americans is that we do not know the cost of healthcare services, so we want everything.

True, there are problems with our insurance system, some of which were identified by Dr. Scherz. Health insurance certainly does insulate the patient from costs. That is what all insurance is supposed to do; should we eliminate all types of insurance? Plus, we are already less insulated than other nations (see study cited below).

One alternative is to have no health insurance for anyone, an impractical suggestion advocated by the then-head of the Georgia Medical Association in response to one of my earlier Atlanta Journal-Constitution editorials. Dr. Scherz seems to suggest something similar for primary physician care, although he does not mention the hospital side where much of the cost, and possibly waste, resides.

Another alternative often suggested by conservatives is to have deductibles so high (one physician I know suggested $10,000) that most patients pay just about everything out of pocket. Does anyone other than the 1 percent really think that is an optimum solution? Unfortunately, due to inaction by Congress, the private insurance system seems headed that way now.

Huckabee, Scherz and others are subtly building on the healthcare establishment’s historical position: “We have the best health care in the world.” The real problem is patients and their reliance on insurance to insulate them from costs. So why change anything on the financing end through government programs like Obamacare (the Affordable Care Act, ACA)?

But, how do other nations view our system? The Journal of the Royal Society of Medicine (the UK’s AMA) did a comparative study in 2011 of 19 countries and found: “In cost-effective terms, i.e., economic input versus clinical output, the USA healthcare system was one of the least cost-effective in reducing mortality rates.”

Our own National Institute of Health (NIH) issued a study (1-9-13) which detailed many problems with our lifestyle, but it also criticized our access problems, stating that 50 million residents had no health insurance. Regarding access, all nations studied did better than the U.S., except Turkey, Chile and Mexico. (Note: Despite its problems, the ACA has made a significant dent in this figure via Medicaid expansion and the healthcare exchanges.)

Specifically, NIH criticized the private-public-provider-payer morass that constitutes American health care delivery and financing, stating that U.S. patients do not receive the care that they need and sometimes receive care that they do not need. It further indicated that “Americans do not experience optimal quality when they do receive health care” due to the “fragmented” nature of our system, creating “inefficiencies and coordination” problems that other nations do not have.

The report also referred to a Commonwealth Fund study which found that Americans were more uncertain than others that their treatments would be adequate if they were seriously ill.

And, NIH found that Americans already had higher deductibles, copayments and out of pocket expenses versus other nations, with 40 percent of those under 65 with insurance reporting access problems due to cost.

As opposed to what many on the right say, the study found that our citizens were more likely than other countries to experience delays when seeing a physician for serious ailments. The study also reported that other studies have shown hospital readmission rates to be higher here, an indicator of lower quality care.

All told, it is a damning indictment of how we get health services in the United States … the result of our excessively expensive but deeply flawed system.

What can we do about the situation? First, stop buying false arguments about the only problem being the patient. We have identifiable access, cost and quality issues.

The website of Physicians for a National Health Program (PNHP) outlines another solution, used by many of the nations who are clearly ahead of us: true national health insurance covering everyone.

With Medicare as the sole payer, not only can costs be controlled and universal access guaranteed, but we can institute national quality measures as well.

Will this grand plan happen tomorrow? No, it will take time. But, if we push our legislators to logically look at facts and science, versus the histrionics of TV entertainers and politician skeptics, that day will come.

Jack Bernard resides in Peachtree City, Ga. His former chairman of a county commission (Jasper County) and chair of the Republican Party there. He is also a a retired healthcare executive and the former director of Health Planning for the state of Georgia. His website is http://universalhealthreform.wordpress.com/.
 
http://thecitizen.com/letters-editor/medicare-all-what-us-needs

Concierge medicine at Mass General

Founded for the Poor, Mass General Looks to the Wealthy

By John Hanc
The New York Times, February 12, 2016

Can a hospital founded more than 200 years ago to treat the poor also adopt a form of medicine some criticize as health care for the rich?

The answer may come in August, when Massachusetts General Hospital, the third-oldest general hospital in the nation, plans to open a concierge medicine practice.

Based in Boston, the hospital, whose $800 million annual research budget is among the nation’s biggest, is affiliated with Harvard Medical School and is perennially ranked No. 1 in many categories of U.S. News & World Report’s listings of the country’s best hospitals.

Despite its reputation, Mass General — as it is known — was established in 1811 to care for the city’s poor and indigent. Patients in concierge medicine are likely to be anything but that.

The idea of wealthy people paying doctors a retainer for exclusive service is not new. With concierge medicine, which was introduced in the 1990s, patients pay physicians a monthly or annual retainer and expect more personalized care and greater access. “A concierge patient who signs up for a practice is not only looking for quality care, they are looking for unfettered access to their provider,” said Dr. Michael R. Jaff, the medical director of Mass General’s Center for Specialized Services and a professor at Harvard Medical School.

There are pros and cons to concierge medicine — or direct primary care, a similar model — which, according to the industry trade magazine Concierge Medicine Today, is embraced by about 6,000 doctors across the country.

“The upside is that it gives more time for patient-physician interaction, and the data shows that generally the more time a patient has with a physician, the better the outcome,” said Dr. Wanda D. Filer, president of the American Academy of Family Physicians. “The downside is that it can be very exclusive and difficult for middle- and low-income patients to afford. So there’s a concern that you’ll have a two-tier system.”

In recent years, concierge medicine and similar types of programs have spread from private practices to hospitals. Mass General’s embrace of it may prove influential.

To critics of concierge medicine, Mass General’s foray into the field is no cause for celebration. “It’s worrisome, unless you’re rich,” said Pauline Rosenau, professor of public health at the University of Texas Health Science Center in Houston. As for the hospital’s historical mission, she added, “I’d say it’s in jeopardy.”

The proximity to the main hospital will give concierge patients easy access to Mass General’s specialists (something not typically offered in private concierge services). “We’ve made the institutional commitment that these patients will get the best of the best at a phone call,” Dr. Jaff said. “So if I call and say I need a general surgeon, they’ll have a world-class general surgeon that day.”

As for benefits of the concierge practice for the rest of the hospital’s patients (Mass General has about 1.5 million outpatient visits a year), Dr. Jaff admitted they were a little less tangible, though still critical. “With dwindling reimbursement,” he said, “there needs to be other sources of revenue to help us support our mission to the community at large.”

What some call “health care for the rich,” the hospital says it believes, can be one such source.

http://www.nytimes.com/2016/02/14/your-money/founded-for-the-poor-mass-general-looks-to-the-wealthy.html?ref=health

***

Comment:

By Don McCanne, M.D.

Say it isn’t true. Mass General? Concierge hospital? Two-tier medicine? Selling the front of the queue to the wealthy?

Is the payment of a bribe to gain better health care access access ethical just because Mass General has given its stamp of approval? They say the money will help support their mission to the community at large, but how does pushing the entire queue back by giving the wealthy a ticket to butt in in front of everyone else help those with low or moderate incomes?

It gives a new meaning to triage. As we organize the delivery of care based on need and urgency, we now have a new paramount guideline, “Let the money in first!”

Under a more egalitarian single payer system, at least the bribes would not be so flagrant.

The flip-flop behind the flawed attacks on Sanders’s single-payer plan

By David U. Himmelstein and Steffie Woolhandler
The Washington Post, Letters, Feb. 12, 2016

The Jan. 29 editorial “The real problem with Mr. Sanders” alleged that Sen. Bernie Sanders’s (I-Vt.) health-care plan “rests on unbelievable assumptions about how much he could slash health-care costs.” That dismissive claim was based on a deeply flawed analysis by Kenneth Thorpe, an Emory University professor and former Clinton administration official who, like Democratic presidential candidate Hillary Clinton, has done a recent flip-flop on the facts about single-payer.

So what has changed? In 2003, Thorpe calculated that single-payer would achieve huge administrative savings — more than 10 percent of total health spending, equivalent to $350 billion this year alone. Now he has cut that estimate by more than half, even though the costs of bureaucracy in the United States have continually climbed, while they’ve remained low in single-payer nations.

Thorpe previously predicted that single-payer would cause a modest uptick in the utilization of care. Now — despite the fact that fewer are uninsured — he has decided there would be a huge increase.

Finally, Thorpe says nothing about savings on drug prices, despite the fact that every nation with a national health-insurance program gets discounts of about 50 percent.

The old Kenneth Thorpe — like the old Hillary Clinton — acknowledged the facts about single-payer. The new one ignores them. The editorial board should know better.

David U. Himmelstein and Steffie Woolhandler are professors of health policy and management at the City University of New York School of Public Health and lecturers in medicine at Harvard Medical School. They reside in New York.

https://www.washingtonpost.com/opinions/the-flip-flop-behind-the-flawed-attacks-on-sanderss-single-payer-plan/2016/02/12/32e82bd0-c9d8-11e5-b9ab-26591104bb19_story.html

PNHP note: Physicians for a National Health Program (PNHP) is a nonpartisan educational organization. It neither supports nor opposes any candidates for public office. For a more detailed critique of Kenneth Thorpe’s flawed analysis, see this article by Drs. David Himmelstein and Steffie Woolhandler in The Huffington Post.

In Fact, Argue Experts, Sanders’ Medicare-for-All Numbers ‘Do Add Up’

“It’s indisputable that single-payer systems in other countries cover everyone for virtually everything, and at much lower cost than our health care system,” PNHP co-founder says

By Nadia Prupis
Common Dreams, Feb. 12, 2016

During Thursday night’s Democratic presidential debate, Hillary Clinton criticized Bernie Sanders’ proposal for a “Medicare for All” healthcare program, stating, “the numbers just don’t add up.”

“A respected health economist said that these plans would cost a trillion dollars more a year,” Clinton said, likely referring to a recent analysis by Emory University professor Kenneth Thorpe, who helped craft a single-payer healthcare system in Sanders’ home state of Vermont, which said Sanders’ proposal was off by an extra $1.1 trillion annually.

“So if you’re having Medicare for all, single-payer, you need to level with people about what they will have at the end of the process you are proposing,” Clinton said. “And based on every analysis that I can find by people who are sympathetic to the goal, the numbers don’t add up, and many people will actually be worse off than they are right now.”

But according to other healthcare experts, both Clinton and Thorpe are working with false calculations.

Dr. Steffie Woolhandler, a professor in public health at City University of New York at Hunter College and co-founder of the advocacy group Physicians for a National Health Program, said Friday that the “numbers on single-payer do, in fact, add up.”

“It’s indisputable that single-payer systems in other countries cover everyone for virtually everything, and at much lower cost than our health care system,” Woolhandler said. “Experience in countries with single-payer systems, such as Canada, Scotland, and Taiwan, proves that we can have more, better and cheaper care.”

For example, “if the U.S. moved to a single-payer system as efficient as Canada’s, we’d save $430 billion on useless paperwork and insurance companies’ outrageous profits, more than enough to cover the 31 million Americans who remain uninsured, and to eliminate co-payments and deductibles for everyone,” she said.

In January, Woolhandler and her colleague Dr. David Himmelstein authored a response to Thorpe’s analysis that found it to be based on “several incorrect, and occasionally outlandish, assumptions,” including “administrative savings of only 4.7 percent of expenditures” and “huge increases in the utilization of care, increases far beyond those that were seen when national health insurance was implemented in Canada, and much larger than is possible given the supply of doctors and hospital beds.”

“Moreover, it is at odds with analyses of the costs of single-payer programs that he produced in the past, which projected large savings from such reform,” the professors wrote.

Woolhandler said Friday, “A single-payer system could save even more money by bargaining with drug companies for discounts on drugs. Other countries get discounts of about 50 percent, and as the biggest customer we could have the bargaining power to get similar savings…Finally, single-payer systems have been better at controlling costs over the long-haul.”

“Our medical arms race—with hospitals competing to offer expensive high tech care, even when they don’t do enough to be good at it—has driven up costs and compromised the quality of care. In contrast, single-payer nations have used thoughtful health planning, to invest in expensive high tech care where it’s needed, not just where it’s redundant but profitable,” she said.

During Thursday’s debate, Sanders rejected the argument that his plan was “unachievable.”

“Every major country on earth, whether it’s the UK, whether it’s France, whether it’s Canada, has managed to provide healthcare to all people as a right and they are spending significantly less per capita on healthcare than we are,” he said. “So I do not accept the belief that the United States of America can’t do that.”

“Please do not tell me that in this country, if—and here’s the if—we have the courage to take on the drug companies, and have the courage to take on the insurance companies, and the medical equipment suppliers, if we do that, yes, we can guarantee health care to all people in a much more cost effective way,” he said.

The charge that the numbers for a sweeping healthcare reform plan “don’t add up” is one that Clinton herself has been hit with in the past, regarding the Health Security Act—dubbed ‘Hillarycare’—introduced in 1993 under President Bill Clinton’s administration.

This work is licensed under a Creative Commons Attribution-Share Alike 3.0 License
 
http://www.commondreams.org/news/2016/02/12/fact-argue-experts-sanders-medicare-all-numbers-do-add

PNHP note: Physicians for a National Health Program (PNHP) is a nonpartisan educational organization. It neither supports nor opposes any candidates for public office.

Single-payer would cut costs, improve care

By John Benziger, M.D.
Kennebec (Maine) Journal, Letters, Feb. 11, 2016

Just as the tobacco and fossil-fuel industries sponsored “experts” to perpetuate the idea that their industries were harmless, the for-profit American heath care industry is now engaging in misinformation claiming Bernie Sander’s single-payer system would “break the bank.”

The truth is that an “Improved Medicare For All” single-payer system would cut costs drastically and provide coverage for everybody. Virtually every other developed country has an affordable universal system that proves the point.

At issue is that single-payer threatens the multimillion-dollar paychecks of insurance companies and their CEOs, and the outrageous profits of drug and medical device companies and medical entrepreneurs. Under single-payer, private health insurance companies are gone and the system can negotiate for lower drug and medical device costs.

People are waking up to see that corporate greed is hurting Americans. We have a broken for-profit health care system. Quality is mediocre, and more than 25 million Americans are still uninsured. Medicare, Medicaid and hospitals are under threat of new cuts. Meanwhile the nation’s for-profit health industry nets billions in profits, and CEOs take home tens of millions in pay.

A single-payer “Improved Medicare For All” would cut costs dramatically by streamlining health care paperwork and making health care affordable. Savings would be enough to provide coverage for everyone, without ANY additional spending! The concept is popular with the American people and enjoys the support of most doctors.

Consult Physicians for a National Health Program (pnhp.org) and learn how you can help bring about a real universal health care system. Add your voice to the growing chorus, and tell our leaders to stand up for the health of the American people rather than the wealth of our richest firms.

Dr. John Benziger resides in South China, Maine.

https://www.centralmaine.com/2016/02/11/single-payer-would-cut-costs-improve-care/

PNHP note: Physicians for a National Health Program (PNHP) is a nonpartisan educational organization. It neither supports nor opposes any candidates for public office.

Choose a high ranked hospital and lose your choice of plans

Most Regionally Ranked Hospitals Stay In-Network with Marketplace Plans, But Participation Declines

By Katherine Hempstead, PhD, MA
Robert Wood Johnson Foundation,  February 6, 2016

Looking at network participation by state, nearly all highly ranked regional hospitals were in-network with at least one marketplace plan in both 2015 and 2016.

Key Findings

*  Network participation decreases significantly, however, as more than half of hospitals reduce the number of networks in which they participate between 2015 and 2016.

*  The percent of hospitals in-network with only one marketplace plan increased from 7 percent in 2015 to 20 percent in 2016.

*  Network participation declined more in metro areas.

*  Customers loyal to a particular hospital can in most cases still find a marketplace plan that includes it, but choices are narrowed in 2016 relative to 2015; plans with these hospitals may be more expensive.

Conclusion

Many consumers returning to the marketplace in 2016 may find that their choices have changed in ways that limit their access to certain providers. Yet it is still the case that almost all of these highly rated hospitals are in-network with at least one marketplace plan.

http://www.rwjf.org/en/library/research/2016/02/most-regionally-ranked-hospitals-stay-in-network-with-marketplac.html

Brief (15 pages, mostly tables):
http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2016/rwjf426368

***

Comment:

By Don McCanne, M.D.

A well-functioning health care system should be designed such that patients who would specifically benefit from the services of a highly ranked regional hospital should be assured of access to that hospital. Instead, we have a health care system that ignores the primacy of the patient, and, in this instance, places the highest priority on the business relationship between the hospital and the insurer. As a result, far too many insured patients do not have coverage for highly ranked regional hospitals.

In many communities, only one insurer includes the highly ranked hospital. Thus the patient must make a choice between buying that plan, which is usually more expensive, or buying a competing plan which otherwise may be more suitable because of the many other variables between plans. This is getting worse since participation of highly ranked hospitals in multiple plan networks is declining.

A far better system would provide the patient with a choice of primary care services wherein guidance can be provided to ensure access to the most appropriate facilities and specialized services in the community. To inject into the consideration private insurer restrictions on what services and facilities can be used is the epitome of poor health planning. Yet this is the system that many politicians and policy wonks insist that we must protect, limiting changes to incremental tweaks.

What incremental change would fix this? Should we require all insurers to cover all health care professionals and all facilities? If so, then how would an insurer have any power to negotiate lower rates with a provider that must be included? Instead of negotiating individually with providers should we set standard rates, as Medicare does? If so, then why would we continue to use a wasteful, fragmented market of private plans and public programs when one public entity could administer the system much more efficiently?

These are not examples of incremental steps that preserve our multi-payer system. This is one step that replaces our dysfunctional financing system with a single payer national health program. Our financing system is beyond repair, and incremental additions won’t change that. It’s the fundamentally flawed financing infrastructure that needs to be replaced.

What incremental changes would ensure coverage for seasonal farm workers?

Farm Contractors Balk At Obamacare Requirements

By April Dembosky
Kaiser Health News, February 11, 2016

Obamacare is putting the agricultural industry in a tizzy.

Many contractors who provide farm labor and must now offer workers health insurance are complaining loudly about the cost in their already low-margin business.

Some are also concerned that the forms they must file with the federal government under the Affordable Care Act will bring immigration problems to the fore. About half of the farm labor workforce in the U.S. is undocumented.

Last year, employers with 100 or more full-time employees had to offer health insurance to their workers or pay a stiff penalty. This year, employers with 50 to 99 full-time employees must comply.

“There’s definitely going to be some repercussions to it,” said Jesse Sandoval, a farm labor contractor based in Stockton, California.

Sandoval has about 100 workers on his payroll. When farmers need a crew to pick cherries, pumpkins or asparagus, they call him to send the workers. He has to offer them insurance this year, and he’s smarting over the price tag. At $300 a month per employee, he’s looking at a $30,000 monthly bill.

Sandoval said he can’t absorb the hit. “The numbers aren’t there,” he said. “My margin is 10 percent, and I have to increase expenses 10 percent? Well, that doesn’t work.”

So, like a lot of contractors, he’s passing the bill on to the farmers, who in turn are passing the bill on to the farm workers. Under the Affordable Care Act, employees can be asked to contribute 9.5 percent of their income toward health premiums.

But for farm workers who pick oranges or peaches for $10 an hour, that’s still too much. Agostin Garcia of Fresno, California, said the two contractors he works for near Fresno offered him insurance directly. But when he saw the price tag, he turned them both down.

“For me, I’m the only one in my house who works,” he said. “There’s five of us in the family. It just wouldn’t work. Either I pay for health insurance, or I pay the rent and utilities.”

Garcia said only a fraction of his co-workers have signed up for coverage. He said when farm labor contractors hand out packets explaining the coverage, the page where workers reject it is right on top.

“I think they do it intentionally,” Garcia said. “They comply with the laws by saying, ‘I offered.’ But they know that nobody’s going to accept it, they know that nobody’s going to pay those amounts.”

The cost isn’t the only thing about Obamacare stressing people out in the ag industry. Some are worried about immigration problems. Employers have to file new health care forms with the IRS for all their workers, whether or not they accept the insurance.

Farm labor contractors say they’re stuck in a Catch-22. Technically, immigrants who are in the U.S. illegally aren’t eligible for Obamacare benefits. But employers can’t admit that any of their employees may be working illegally, so they have to offer the insurance or face stiff fines from the IRS, maybe even a discrimination claim.

http://khn.org/news/farm-contractors-balk-at-obamacare-requirements-2/

***

Comment:

By Don McCanne, M.D.

Seasonal agricultural workers do not fit into a neat slot in the dysfunctional, fragmented financing system that President Obama and Congress have selected for us.

Following is a paragraph from my Quote of the Day of June 1, 2010 on this topic:

“Just briefly touching on some of the policies inherent in PPACA: employers with over 50 full-time equivalent employees will have to purchase coverage for their seasonal employees or pay a $2000 penalty per employee, even though that may be a staggering bill because of a temporary ten-fold increase in the number of employees; since most seasonal employees are uninsured, moving in and out of coverage during the harvest season results in instability of coverage; many seasonal workers are undocumented and thus ineligible for purchase of plans in the exchanges, defeating the purpose of the individual mandate; seasonal workers might be able to obtain care through community health centers, though that depends on having clinics accessible and may mean that important specialized services may not be provided, and the mere existence of such clinics may not fulfill the mandate requirements anyway; though the workers and their families might be eligible for Medicaid on an income basis, that may conflict with the employer mandate; etc.”

At that time, I wrote, “What would fix this would be a single payer national health program with automatic enrollment for everyone, financed separately though equitable tax policies.”

Yet our politicians rejected single payer, and instead insisted on improving the Affordable Care Act incrementally. Now that the topic of single payer has become one of the leading issues in the presidential campaign, there has been a surge of politicians, policy wonks, and columnists who are telling us that only incremental reform can work. They say we have to build on the current system.

So what incremental steps have been taken on improving coverage of seasonal agricultural workers since I wrote the above critique over five years ago? None. Now give some thought to incremental changes that we might introduce now that would ensure seasonal agricultural workers affordable access to health care throughout the year. (Pause.) Still thinking? We’ll give it some more time. Okay. Ready to describe the incremental changes to ACA that would ensure year-round affordable coverage for these workers? Thought not.

Regular readers understand that incremental reforms cannot do much more than tweak the current system. The reason is that the health financing infrastructure perpetuated by ACA is so highly flawed that it cannot be repaired. It proves the lie that “we have to build on the system we have.” We need a new, effective infrastructure.

The next time that someone says that single payer is too hard politically, demand that she tell you the precise incremental changes that will ensure health insurance coverage for the seasonal workers who help put food on our tables. As she stammers, or maybe repeats a non-responsive 15 second canned sound bite, emphatically point out that single payer would do it.


Physicians for a National Health Program (PNHP) is a nonpartisan educational organization. It neither supports nor opposes any candidates for public office.

Single-Payer ‘Medicare for All’ Gets Boost From New Study

By Ken Terry
Medscape Medical News, Feb. 9, 2016

Presidential candidate Bernie Sanders’ proposal to create a single-payer “Medicare for all” system has drawn criticism because, opponents say, it would lead to a big increase in taxes. But a new study estimates that the federal, state, and local governments paid for 64.3% of US health spending, or $1.877 trillion, in 2013 and that it would not take much higher taxes to finance a single-payer system.

According to David U. Himmelstein, MD, and Steffie Woolhandler, MD, MPH, from the City University of New York School of Public Health at Hunter College, who wrote the article, the government share of national health expenditures will rise to 67.1% by 2024. At that point, they argue, there will be only a 4-point spread between what the US government pays for in our public/private healthcare system and the 71% of Canadian health spending that that country’s government spends on its single-payer system.

The article was published online January 21 in the American Journal of Public Health.

Physicians for a National Health Program (PNHP), a group that has long advocated for a single-payer system, seized on the study’s findings to argue that now is the time to switch to single payer, which is not a surprise, as the study’s authors are cofounders of the organization.

“We pay the world’s highest health care taxes. But patients are still saddled with unaffordable premiums and deductibles,” said Dr Woolhandler in a news release. “Meanwhile, billions are squandered on paperwork, and insurers and drug companies pocket huge profits at taxpayer expense.”

Moreover, PNHP and Sen. Sanders argue, higher taxes for single-payer healthcare would be more than offset by the elimination of private insurance premiums and reduced administrative costs.

According to the Centers for Medicare & Medicaid Services, all levels of government together accounted for 43% of US health spending in 2013. The main reason for the difference between that figure and the higher number arrived at by Dr Himmelstein and Dr Woolhandler is that the latter includes the loss to the US Treasury caused by the tax exclusion for private health insurance.

In addition, the coauthors note, much of the insurance costs of public employees are accounted for as “private coverage” because the insurance claims are paid by private companies that administer the insurance for the government. But in actuality, the money is coming from the public purse in the form of benefits to the employees.

Hidden Costs

This is not the first time Dr Himmelstein and Dr Woolhandler have shown the gulf between the official estimate and what they regard as the real percentage of health costs paid by the government. In a 2002 paper published in Health Affairs, they calculated that in 1999, the government paid 59.8% of health costs compared with the Centers for Medicare & Medicaid Services estimate of 45.3%.

Mark V. Pauly, PhD, a professor of healthcare management at the Wharton School of the University of Pennsylvania, told Medscape Medical News that Dr Himmelstein’s and Dr Woolhandler’s methods are sound. As the coauthors point out in their article, most health economists, as well as the US Office of Management and Budget, regard the tax exclusion for private insurance as a form of healthcare spending. People who receive employer-sponsored health insurance do not have to pay taxes on the part of the insurance premium their company pays on their behalf. As a result, the government has to increase other taxes, Dr Woolhandler explained in an interview with Medscape Medical News.

She and Dr Himmelstein calculated that tax subsidies for private health spending totaled $295.9 billion in 2013. Federal income and payroll tax subsidies accounted for about 80% of that, they said.

Government employers made 28% of all employer payments for private health insurance in 2013; by 2014, the study projected, that will increase to 31%. More than 80% of those payments were made by state and local governments, which employ far more people than the federal government.

Overall, US tax-funded healthcare spending accounts for a larger share of GDP (11.2% in 2013) than does total health spending in any other country, the coauthors said, and they project that that figure will rise to 13.2% of GDP in 2024.

Meanwhile, private employers’ spending for health insurance premiums as a share of national spending fell from a high of 18.5% in 2000 to 2001 to 16.7% in 2013 and is expected to drop to 14.5% in 2024, the study shows.

Dr Woolhandler attributed most of the decline in employer-sponsored insurance to two factors. First, fewer employers offered insurance and/or fewer people accepted it because of the expense. Second, Medicaid expansions before and after the passage of the Affordable Care Act led to more low-wage and part-time workers being covered by Medicaid. Dr Pauly also pointed to the shrinkage in the number of people employed by large firms, which are more likely to offer insurance than small ones.

Much Higher Taxes?

Dr Pauly was skeptical, however, of the claim that a relatively small tax hike would be sufficient to move the United States to a single-payer system. Most economists believe that the government pays for about half of healthcare spending, including costs for the National Institutes of Health and capital expenditures, which are not included in the Centers for Medicare & Medicaid Services estimate, he said. With the United States currently spending $3.3 trillion on healthcare, “Medicare for all” would require roughly $1.65 trillion in new taxes, he noted.

Even assuming that government pays for two thirds of healthcare spending, that does not mean that a single-payer system in which the government pays for everything would require only slightly higher taxes, he said. For one thing, the Canadian government does not pay for all healthcare services: it does not cover drugs, for example, although it does restrict their prices.

Also, he observed, the US government controls or influences more healthcare costs than it pays for. If an employee excludes $15,000 a year from taxable income as the value of private health insurance for his or her family, for example, the government is losing about a third of that amount. But the government influences the cost of that insurance, because its subsidy encourages that employee to buy more expensive coverage. “So the estimate of how much of healthcare is taxpayer funded is only a lower boundary estimate of how much control the government really exerts,” he said.

Am J Public Health. Published online January 21, 2016. Abstract

http://www.medscape.com/viewarticle/858550

PNHP note: Physicians for a National Health Program (PNHP) is a nonpartisan educational organization. It neither supports nor opposes any candidates for public office.

Changing provider networks when enrollment periods are closed

InHealth customers mad about late notice dropping OhioHealth

By Ben Sutherly
The Columbus Dispatch, February 10, 2016

Some central Ohio consumers say a Westerville-based health insurer intended to keep quiet about its plan to drop OhioHealth hospitals and doctors from its provider network until it was too late for many of its enrollees to change their health plan.

In those complaints, the consumers, who mostly live in Franklin or Delaware counties, expressed frustration over InHealth Mutual’s last-minute notice to consumers about its plan to drop most OhioHealth providers as of March 1.

Many consumers said they were not notified of InHealth’s plan to narrow its provider network until last week, though some received robocalls on Jan. 30, the day before the deadline to sign up for health insurance through the federally run health-insurance marketplace.

During the first half of January, InHealth’s leaders decided to drop OhioHealth from the provider network. An official with the Ohio Department of Insurance said that InHealth contacted the department late on Jan. 15, triggering a required 15-day review period during which department officials review documents to ensure that insurance companies clearly explain provider-network changes to consumers.

However, an official with the Ohio Department of Insurance said nothing stops insurers from starting the notification process during the 15-day review period.

Ohioans who buy coverage through healthcare.gov typically cannot sign up for a different plan after the open-enrollment period ends. There are some exceptions that allow for a special enrollment period; among them, the loss of a job, a move or the birth of a child. But an eleventh-hour change in an insurance company’s provider network isn’t one of them.

The federal government will not create a special enrollment period for people affected by InHealth’s decision, said Andy Slavitt, acting administrator for the Centers for Medicare & Medicaid Services, in a conference call last week.

http://www.dispatch.com/content/stories/local/2016/02/09/Consumers-upset-about-insurer-dropping-hospitals.html

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Comment:

By Don McCanne, M.D.

One of the more important considerations in selecting plans offered through the healthcare.gov insurance exchanges is whether or not an individual’s physicians and hospitals are included in the provider networks selected by the insurer. Although this is supposed to place more control into the hands of the health care consumer, in fact, the insurer is free to change the provider network at any time, yet the patient is prohibited from changing insurers outside of the open enrollment period. Patients lose their providers and can’t do anything about it until open enrollment for the next year.

The Affordable Care Act does allow special enrollment periods for unavoidable circumstances wherein a person loses their coverage, but CMS is reducing these special enrollments to prevent patients from supposedly gaming the system. Apparently it is acceptable for insurers to game the system through bait and switch of their provider networks, but Andy Slavitt, the acting CMS administrator, stated that he will not open up enrollment for these victims of bait and switch.

Really, is cracking down on special enrollment periods to the detriment of the patient the type of incremental change we can expect going forward? Great for the insurers, terrible for the patients.

What is wrong here? It is that the model of health care financing that has been foisted on us is one that is designed to take good care of the insurers while treating patients as a necessary nuisance since insurers otherwise would not have a business without them.

Yesterday the citizens of New Hampshire had something to say about a government that takes good care of the wealthy but makes middle- and low-income individuals second class citizens. We have a crying need for a single payer national health program, so it has to be up to us to select politicians who will bring it to us. Most of those currently in office are not going to do it.

Physicians for a National Health Program (PNHP) is a nonpartisan educational organization. It neither supports nor opposes any candidates for public office.

Healthcare.gov wants to become an active purchaser?

Will Healthcare.gov Get A California Makeover?

By Pauline Bartolone
Kaiser Health News, February 9, 2016

Experts say the California exchange uses more of its powers as an “active purchaser” than the vast majority of other states. That means it can decide which insurers can join the exchange, what plans and benefits are available and at what price.

The federal government — in pending proposed rules for 2017 — has signaled it too wants to have more of a hand in crafting plans. Healthcare.gov would be forging ahead on a path California already paved, swapping variety for simplicity in plan design.

“Not letting [health] plans define what’s right for consumers, but defining it on behalf of consumers 
 is a better model for the market,” said Peter Lee, executive director of Covered California.

“We want to make sure every consumer has good choice but not infinite choice,” said Lee.

Most other states, including those in the federal exchange, haven’t subscribed to that idea so far. They have a clearinghouse model, in which all health insurers and plan designs are accepted as long they comply with the Affordable Care Act. That can mean the same insurer offers multiple plans with slightly different premiums, deductibles and copays. Even within one metal tier, say silver, the same insurer might offer half a dozen slightly different plans.

Now, the federal government proposes to create standard cost-sharing designs in various metal tiers and make them easily accessible on healthcare.gov. And it’s considering how to improve “value” by being more selective about plans.

Covered California holds insurers to a higher bar than what’s required under the Affordable Care Act.

Covered California says it’s the only exchange in the country that requires all plans to be standardized (not just some, which the federal government is proposing).

But one of two health insurance regulators in California, the state Department of Insurance, said Covered California’s strict guidelines may not benefit consumers.

It has created a situation in which the exchange “has fewer carriers than would otherwise be the case,” said Janice Rocco, deputy commissioner of the California Department of Insurance.

Health insurers on a national level are “strongly” opposed to an active purchaser model for states served by healthcare.gov, including standardized benefits.

“It could discourage many from enrolling if they can’t find a policy that works best for them,” said Clare Krusing from America’s Health Insurance Plans.

“Where there is competition and choice is where consumers benefit and where health plans benefit,” said Krusing.

http://khn.org/news/will-healthcare-gov-get-a-california-makeover/

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Comment:

By Don McCanne, M.D.

Covered California – one of the more successful state-operated ACA insurance exchanges – has two features that are currently being considered for the federally-operated ACA exchanges: standardized cost-sharing designs and active purchasing of plans.

By creating standards for deductibles and other cost sharing, it makes it easier for plan shoppers to compare plans since the out-of-pocket expenses theoretically would be the same. After checking provider lists to see if their physicians are in-network, and checking formularies to see if their drugs are covered, shoppers can then select their plans based on the premiums.

Of course there are still some uncertainties. It is not uncommon to obtain care out of network, so another plan’s network may have turned out to be preferable. Also medical conditions change which might require drugs that are not in the plan’s formulary but may be covered by other plans.

In contracting with plans for the exchanges, Covered California decided to use active purchasing. In a non-transparent process, Covered California negotiates with the plans in an attempt to gain the best value for the plan beneficiaries. Under this process, not all plans are accepted, thus the insurers are motivated to offer better value than they might otherwise.

Active purchasing introduces more instability into the process. Plans moving into or out of the exchanges may face unprecedented changes in their administrative requirements which can be very disruptive to their business model. Changes required by the instability of contracts increase administrative expenses which are ultimately borne by the plan beneficiaries, adding to costs when the intent was to decrease costs. These disruptions apply not only to the private insurers but also to the physicians and hospitals who are included in the networks. Since active purchasing reduces the number of plans available, any change in plans covered would have a greater impact on the contracted providers thereby threatening insolvency.

To no surprise, the private insurers are not enthusiastic about either standardization of the plans or active purchasing. With standardization, the plans are less able to hide their innovations that improve the profits and competitiveness of the plans (i.e., the plans can be more competitive when the consumers do not know what they are buying). Active purchasing drives plan revenues down and exposes them to greater risk since the contract may not be renewed.

Clare Krusing of the insurance lobby organization, AHIP, says, “Where there is competition and choice is where consumers benefit and where health plans benefit.” Instead of plans competing for contracts with the ACA exchanges, they want to compete for individual patients. But the patients lose because there is less plan oversight when there is no active purchasing, and there is less transparency when the plans do not have to comply with standardized cost-sharing.

Cost-sharing standardization and active purchasing are the types of incremental reforms we can expect from those who say that we must build on what we have. These will do almost nothing for the problems that face us such as the 29 million uninsured, the tens of millions underinsured, the loss of choice of health care providers, and the interminable increase in health care spending.

We do have a better choice. Join the forces who are advocating for a single payer national health program. With single payer, we would no longer have to direct our health policies to maintaining a lucrative private health insurance infrastructure. Instead we could direct our health policies to taking care of patients, and that, of course, is what reform should be all about.

Deloitte update of ACA Section 1332 state innovation waivers

State health coverage innovation and Section 1332 waivers: Implications for states

By Anne Phelps
Deloitte Health Policy Brief

Executive summary

Although states and the federal government have implemented most Affordable Care Act (ACA) provisions, a few are scheduled to go into effect in the coming years. One such provision is Section 1332 State Innovation Waivers, (1332) which allows states to pursue alternative and innovative strategies for ensuring that residents have access to high-quality, affordable health insurance as long as they meet certain requirements. Within the constraints of Section 1332, states have numerous options for revamping their current approaches to providing health coverage to individuals and families. If approved, the waivers can go into effect beginning January 1, 2017. To implement reforms next year and take advantage of realizing innovative alternatives for health care coverage, states should consider acting now.

New guidance from the US Departments of Health and Human Services (HHS) and Treasury released at the end of 2015 indicates that waiver proposals from states using the federally facilitated health insurance exchange might not be considered feasible at this time because “the Federal platform cannot accommodate different rules for different states.” Instead, these states may want to consider establishing their own exchange platform and then apply for a 1332 waiver.

This health policy brief presents a number of potential waiver-associated coverage alternatives, including those being discussed by some states. While some options are mutually exclusive, states may include multiple innovative concepts in their applications. It is important to note that, even with the new HHS and Treasury guidance, the analysis required to support a 1332 waiver application may require states to leverage actuarial, policy, technology, and data expertise.

A final consideration

As the United States moves closer to the next presidential election, the health care landscape will continue to shift and evolve. Beginning in 2017, an Administration other than the Obama Administration will have stewardship over the ACA and its various provisions, including Section 1332 State Innovation Waivers, for the first time. States should be aware that – depending on where they are in the application process at the start of 2017 – approvals may depend on the goals of the new Administration.

http://www2.deloitte.com/us/state-innovation-and-waivers

PDF of report (8 pages):
http://www2.deloitte.com/content/dam/Deloitte/us/Documents/life-sciences-health-care/us-dchs-state-health-innovation.pdf

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Comment:

By Don McCanne, M.D.

Section 1332 of the Affordable Care Act allows states to pursue waivers allowing alternative approaches to implementation of the Act as long as they comply with certain minimal requirements. In December, HHS released an advisory which gives guidance to what sort of innovations might be approved. This Deloitte health policy brief includes this guidance in updating the description of Section 1332 waivers and how the states may use them.

A few points:

*  Section 1332 does allow innovations that can improve access and equity and thus should be considered by state activists who wish to improve their health care systems, though the innovations are quite limited.

*  Section 1332 does allow innovations that might rely more heavily on market dynamics and thus could threaten the social insurance gains of ACA, though those innovations are also quite limited, but state activists should be on guard to help protect what gains have been made.

*  States with federally facilitated health insurance exchanges will not be able to receive waivers because of the administrative complexity: “the Federal platform cannot accommodate different rules for different states.”

*  States that have not accepted federal funds to expand their Medicaid programs may find that the political climate may inhibit any efforts to improve their systems through waivers.

*  The December 2015 advisory indicates that HHS will be quite rigid in the interpretation of what innovations would be allowed. This will protect states from efforts to dismantle the gains of ACA, but it will also prevent states from using Section 1332 to establish a state-based single payer system. Nevertheless, improvements such as all-payer systems may be allowed, although the administrative requirements may be overwhelming.

*  The Deloitte report emphasizes the importance of politics: “Beginning in 2017, an Administration other than the Obama Administration will have stewardship over the ACA and its various provisions, including Section 1332 State Innovation Waivers, for the first time. States should be aware that – depending on where they are in the application process at the start of 2017 – approvals may depend on the goals of the new Administration.”

So this report does further confirm the fact that states can improve their health systems through Section 1332 waivers. Until we can enact a single payer national health program, state efforts should be pursued.

This report also confirms that state efforts alone are grossly inadequate and that federal legislation for a national health program is an imperative.

This year, single payer is back in the political arena. Although state reform efforts are encouraged, we cannot allow these efforts to displace or even dilute the drive for national single payer. Even if it is difficult to see the political path to immediate enactment, at a minimum, through education, grassroots and coalition efforts we can move much closer to the political threshold required to make single payer inevitable.

Read the Deloitte policy brief, give thought as to how far short Section 1332 waivers will leave us, and then join the national political movement that will finally bring health care justice to all.