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The Canadian health care system I disparaged

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The Canadian health care system I disparaged

Single-payer regime up north represents a better way

By Wendell Potter
The Center for Public Integrity, April 28, 2014

When I returned home after a two-week speaking tour of Canada and began catching up on news about Obamacare, I was angry and upset, and not just at politicians and special interests that benefit from deception-based PR tactics. I was — and still am — mostly angry and upset with myself. And I know I always will be.

Over the course of a two-decade career as a health insurance executive, I spent hours and hours implementing my industry’s ongoing propaganda campaign to mislead people about the Canadian health care system. We spread horror stories about “rationed care” and long waiting times for medically necessary care. Our anecdotes were not at all representative of most Canadians’ experiences, but we spent millions of dollars to persuade Americans that they were.

At every stop between Halifax and Vancouver this month, I explained how the United States had achieved the dubious distinction of having both the most expensive health care system on the planet and also one of the most inequitable. While Canadian lawmakers in the 1960s were implementing a partnership between the federal and provincial governments to create the country’s publicly funded universal health insurance system — known as Medicare — our lawmakers in Washington were establishing America’s own single-payer Medicare program, but only for folks 65 and older and some younger disabled people. Congress also created the federal and state-administered Medicaid program for the nation’s poor.

Ever since, most of the rest of us have had to deal with private insurance companies and pay whatever they felt like charging us for coverage. Canadians are also paying more for coverage these days because of medical inflation and an aging population, but not nearly as much more as we in the U.S. are paying. Just about everybody in every audience I stood before gasped when I told them that health insurance premiums in the U.S. increased 131 percent between 1999 and 2009 — the main reason why 50 million of us were uninsured at the end of the last decade — and that by 2013 the average employer-based family policy cost $16,351.

At one stop in Toronto, I was asked if there was anything about the U.S. system that Canadians should consider adopting. I was stumped. I noted that while we had some of the world’s best doctors and hospitals, they were in many cases off-limits to millions of Americans, many of whom were uninsured because of preexisting conditions that made them “uninsurable” in the eyes of private insurance companies.

Later, on reflection, I realized I should have mentioned some aspects of our Medicare system and our other single-payer program — the Veterans Health Administration — both of which consistently out-perform private insurers in customer satisfaction surveys.

The two aspects of our Medicare system worth emulating are: (1) the fact that it’s a federal arrangement, meaning that benefits and services do not vary from state to state, and (2) the prescription drug benefit (Medicare Part D) that Congress added a few years ago. The Canadian Medicare program is akin to our Medicaid program in that the provinces have broad latitude in administering benefits and services. As a consequence, Albertans’ experience with Medicare can be quite different from that of Newfoundlanders. And the Canadian Medicare program still does not cover medications. Canadians have to buy private insurance for their prescriptions. Consumer advocates there continue to push for the adoption of a nationwide drug benefit.

As for the Veterans Health Administration, which owns and operates its own hospitals, it not only gets higher customer-service scores than private hospitals, it is frequently cited for better health outcomes. For example, the RAND Corporation found in a 2004 study published in the Annals of Internal Medicine that the VHA outperformed all other sectors of the U.S. health care system in 294 measures of quality.

In other words, Canadians should consider making their system even more public than it is, rather than more private.

I usually began my remarks in Canada with an apology — for all the misinformation I helped spread in the U.S. about their system, which, by the way, continues to have overwhelming support. I didn’t encounter a single Canadian who didn’t talk about their Medicare program with pride.

Back in the states, among the distressing pieces I read was a New York Times story last Monday based on interviews with Americans who said they had decided to remain uninsured either because they couldn’t afford to pay the premiums or had just decided to gamble with their health and personal finances.

Those are decisions completely unknown and unnecessary in Canada, where the per capita spending on health care is far lower than it is here and where people live longer.

Former CIGNA executive-turned-whistleblower Wendell Potter writes about the health care industry and the ongoing battle for health reform.

http://www.publicintegrity.org/2014/04/28/14674/canadian-health-care-system-i-disparaged

Ezekiel Emanuel: “Reinventing American Health Care”

Reinventing American Health Care: How the Affordable Care Act Will Improve our Terribly Complex, Blatantly Unjust, Outrageously Expensive, Grossly Inefficient, Error Prone System

By Ezekiel J. Emanuel
PublicAffairs

There are 4 things the average physician can do. One is to begin the process of transformation to more efficient practice, knowing that payment changes that move away from fee for service are inevitably coming.

Second, part of this transformation means that physicians will need to change their business model to increasing efficiency in their delivery of the services.

Third, physicians should engage insurers to try to modify contracts so that they have a financial reward for being more efficient.

Finally, these impending changes confront many physicians with the major existential question of whether to sell their practice to a hospital system or remain independent.

==

Six megatrends

* End of insurance companies as we know them

Insurance companies will either become purveyors of management analytics, and actuarial services, or integrated delivery systems actually employing (or contracting with) hospitals, physicians, and other providers to render patient care.

* VIP care for the chronically and mentally ill

Physicians and hospitals will focus on keeping patients with chronic illnesses healthy and out of the emergency room and hospital, thereby decreasing the frequency of avoidable complications and rate of hospitalization. Then they will begin routinely screening for depression and other mental health problems and develop standardized rapid interventions.

* The emergence of digital medicine and closure of hospitals

Over 1,000 acute-care hospitals will close. We will see a slew of new technologies for remote monitoring, testing, and treating patients in real time outside of the hospital and physicians’ offices.

* End of employer-sponsored health insurance

Fewer than 20% of workers in the private sector will receive traditional employer-sponsored health insurance.

* End of health care inflation

Health care inflation will be GDP+0%.

* Transformation of medical education

Medical education will be transformed in 4 fundamental ways: (1) three-year medical schools and shorter residencies; (2) half of medical school clinical training will be outside of hospitals; (3) integration of nurses, pharmacists, social workers with medical students in multi-professional team training; and (4) formal incorporation of population health and management skills in training.

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Regardless of the short-term political costs, in the longer sweep of history, beginning in 2020 or so, the ACA will increasingly be seen as a world historical achievement, even more important for the United States than Social Security and Medicare had been. And Barack Obama will be viewed more like Harry Truman – judged with increasing respect over time.

http://www.publicaffairsbooks.com/book/hardcover/reinventing-american-health-care/9781610393454

Ezekiel J. Emanuel, speaking about his book, “Reinventing American Health Care: How the Affordable Care Act Will Improve Our Terribly Complex, Blatantly Unjust, Outrageously Expensive, Grossly Inefficient, Error Prone System”

Politics and Prose, April 16, 2014

Q&A

At 39:30

Harvey Fernbach:  I’m a member of Physicians for a National Health Program. We believe in single payer simplicity, Medicare for all. As you know the president was for single payer, he said it, he’s for Medicare for all. Nancy Pelosi has come out for it. Harry Reid has. John Podesta when he signed up for Medicare said, “Hey, I signed up for Medicare in five minutes; how about single payer?” At a recent discussion at the Center for American Progress, Sen Daschle said very vigorously he was for single payer, if it was not for the politics. Do you have any philosophical problems with single payer, aside from the politics?

Ezekiel Emanuel:  Well, first of all, I think someone once said, “It’s not going to happen so I’m not wasting any time on it.” I think that was Jonathan Gruber, economist at MIT. It isn’t going to happen, so let’s just get clear. It ain’t gonna happen! We barely got the Affordable Care Act through. Single payer, zero chance! Okay, so let’s just be clear on that.

Dr. Fernbach:  No, I don’t think that’s clear. You can go twenty-five years back, and I’m not saying we’d do in six months, or by the end of this talk, but to say that sixty percent of the American people who are for it can’t have what they want…

Dr. Emanuel:  Let me repeat myself.

Dr. Fernbach:  Please.

Dr. Emanuel:  Certainly in my lifetime, not happening. Okay, so I’m not wasting any of my time on it. Okay? Let me just say philosophically I also do have some disagreements with it. Okay? It depends what you mean by “single payer.” You need.. you don’t want to have one system determining payments like Medicare does for 310 million people. I don’t think that’s an efficient system. There are many things Medicare does that aren’t efficient, that they can’t do, and they have to do slowly because they’re affecting so much of medical practice and so many people. Second, you do get a lot of political gridlock; a lot of what Medicare does is a response to political pressures rather than to top quality policy pressures or policy ideas. Second, you do want to have a lot of experimentation. We don’t know the best way to care for someone who’s got chronic conditions or mental illness. We just don’t. We need to experiment a lot, and I think if you have single payer it gets hard to experiment on those things. So, for those reasons, I’m not a wildly big advocate of it because I think it would slow down the ability to make changes. Having said that, you know, I also don’t think it’s politically gonna happen, so.. We couldn’t even, look, we couldn’t even get the public option. Okay? I mean… and we barely got this bill through! It has failed a hundred years worth! Okay?

http://www.politics-prose.com/video/reinventing-american-health-care

Comment:

By Don McCanne, MD

Ezekiel Emanuel’s “Reinventing American Health Care” is largely a history of reform efforts and a description of the enactment and early implementation of the Affordable Care Act. The last section is his view of the future of American health care – the source of the excerpts above.

Some of his suggestions are mere platitudes. Others are “it-sounds-like-a-good-idea” abstractions, but have little solid policy support as to how they would be accomplished. Other recommendations are basic functions physicians already provide. Several of his ideas have already been suggested by others and hold little promise of benefit, and still other ideas are simply sort of weird.

One example is he says that we should replace fee-for-service with bundled payments. Yet Medicare representatives objected for three reasons. There was too much uncertainty without extended testing; the computer infrastructure would have to be very complex to pay based on bundles; and the delivery system is not organized to handle bundles. Although Medicare was adamantly opposed, they were able to slip into ACA ten demonstration projects with the proviso that the administration could then mandate bundled payments throughout Medicare without the need to return to Congress.

In several interviews while promoting his book he has been asked if he sees the changes he predicts as steps toward single payer. He is quite emphatic in rejecting any such possibility. His response to Harvey Fernbach, transcribed above, is typical.

His opposition to single payer dates back to his previous efforts to sell the concept of vouchers for private insurance, paid for by a value-added tax, as the ideal model for reform – a proposal he shared with Victor Fuchs. Although he did not get that, tax credits for the purchase of individual “marketplace” plans seem to be close enough for him.

In his previous book, “Healthcare, Guaranteed,” he devotes an entire chapter to single payer. He concludes, “In their zeal, single-payer advocates seem to forget how American institutions and governmental agencies actually operate. They envision superbly efficient, incorruptible bureaucracies capable of rational policy choices. Unfortunately, American governmental agencies do not spontaneously operate this way.” Thus he dismisses single payer with the trite “incompetent government” meme.

The good news is that you do not have to put “Reinventing American Health Care” on your “must read” list, though some may find it of value as escape literature. But be forewarned that it is not humorous.

Single-payer advocate makes pitch to doctor executives

By Andis Robeznieks
Modern Healthcare, Vital Signs blog, April 28, 2014

CHICAGO — The American College of Physician Executives annual meeting drew a record 830 attendees, including one doctor whose presentation on the merits of a national single-payer system may have been something of a surprise.

Dr. Ed Weisbart described himself as a long-time ACPE member who is also a member of Physicians for a National Health Program and now serves as chairman of the single-payer advocacy group’s Missouri chapter.

Weisbart, a family physician, had a table full of PNHP literature and a poster indicating that salaries for Canadian physicians are comparable or better than those earned by U.S. doctors. The poster also said that Canadian physicians pay lower malpractice insurance premiums.

His intent, Weisbart said, was to build bridges between the two organizations, and he left with “several pages” of new names to add to the PNHP mailing list. “I think it was time well-spent.”

One visitor to his table questioned whether the government could be trusted to run the nation’s healthcare system. Weisbart replied that he agrees. PNHP’s goal, he said, is to have a publicly funded, privately operated system.

“I think many people wouldn’t want to see a government-delivered healthcare system with physicians employed by the federal government,” he said.

http://www.modernhealthcare.com/article/20140428/BLOG/304289995

Important AAP policy statement on high-deductible health plans

Policy Statement: High-Deductible Health Plans

American Academy of Pediatrics
PEDIATRICS, April 28, 2014

Abstract

High-deductible health plans (HDHPs) are insurance policies with higher deductibles than conventional plans. The Medicare Prescription Drug Improvement and Modernization Act of 2003 linked many HDHPs with tax-advantaged spending accounts. The 2010 Patient Protection and Affordable Care Act continues to provide for HDHPs in its lower-level plans on the health insurance marketplace and provides for them in employer-offered plans. HDHPs decrease the premium cost of insurance policies for purchasers and shift the risk of further payments to the individual subscriber. HDHPs reduce utilization and total medical costs, at least in the short term. Because HDHPs require out-of-pocket payment in the initial stages of care, primary care and other outpatient services as well as elective procedures are the services most affected, whereas higher-cost services in the health care system, incurred after the deductible is met, are unaffected. HDHPs promote adverse selection because healthier and wealthier patients tend to opt out of conventional plans in favor of HDHPs. Because the ill pay more than the healthy under HDHPs, families with children with special health care needs bear an increased cost burden in this model. HDHPs discourage use of nonpreventive primary care and thus are at odds with most recommendations for improving the organization of health care, which focus on strengthening primary care.

This policy statement provides background information on HDHPs, discusses the implications for families and pediatric care providers, and suggests courses of action.

http://pediatrics.aappublications.org/content/early/2014/04/22/peds.2014-0555.full.pdf

Comment:

By Don McCanne, MD

Although this policy statement from the American Academy of Pediatrics is on High-Deductible Health Plans, its reach is well beyond that. It describes some of the consequences of the way that we pay for health care today, not only for children but for everyone.

The abstract above touches on some of these fundamental flaws, but the full statement should be read in its entirety. The last two pages of the text provide a list of recommendations that greatly increase administrative complexity while falling far short of what needs to be done to correct these injustices in health care financing. Single payer advocates will immediately recognize that the financing system needs to be replaced with a single payer system that provides first dollar coverage.

This important policy statement should be downloaded to share with others as we continue with our efforts to provide health care justice for all.

Cross-border checkup: Dr. Danielle Martin defends Canada’s single-payer system

Health-care advocate alumna takes fight to Washington

By Adela Talbot
Western (University) News, London, Ont., April 24, 2014

Danielle Martin sure can stand her ground.

Last month, the 2003 Schulich School of Medicine & Dentistry graduate spoke as part of an international panel presenting to the U.S. Senate’s Subcommittee on Primary Health and Aging. Invited alongside health-care professionals from Taiwan, France and Denmark to present a defense of a single-payer health-care system, Martin did just that.

And when conversation veered toward an attack of Canada’s health-care system, and its long wait times for certain procedures, Martin delivered a defense that has garnered much applause from fellow Canadians and national media.

“On average, how many Canadian patients on a waiting list die each year? Do you know?” asked U.S. Sen. Richard Burr, R-N.C., in Washington, D.C., last month.

“I don’t, sir, but I know there are 45,000 in America who die waiting because they don’t have insurance at all,” replied Martin, a family physician and vice-president of medical affairs and health systems solutions at Women’s College Hospital in Toronto.

And that’s just one snippet of her Senate exchange with the anti-Obamacare Republican.

After completing her undergraduate degree at McGill University, Martin first worked in health-care policy and politics. She applied to Schulich for medical school and arrived at Western in 1999. Having done her residency in family medicine in Toronto, she stayed put. She took on a Master’s of Public Policy at the University of Toronto and has since enjoyed a professional life as a doctor who gets things done – with and without her white coat.

“My area of interest has always been health-care systems and how can we construct health-care systems to best serve the needs of the population; that’s what drew me to medical school in the first place,” Martin said.

In 2006, along with colleagues across the country, she helped establish Canadian Doctors for Medicare, a national physician organization that does advocacy work around evidence relating to equity and access to health-care services.

“Unlike many other medical leaders who sort of start from a clinical interest and move into policy issues later in their careers, I started out with a policy interest and then developed a love of family medicine during my medical training at Western,” Martin continued.

“But my interest has really been in health-care systems, and my primary concern, until recently, has been around the preservation and enhancement of publically funded health care in Canada – trying to make sure that we construct an insurance model that makes sure that access to health care is based on need, rather than ability to pay.”

The Senate hearing had more elements of political theatre than a substantive policy discussion.

Martin was invited to testify by the committee chairman, U.S. Sen. Bernie Sanders, an independent Vermont senator and self-described socialist who has advocated for the United States to adopt a single-payer system like in Canada.

Burr, however, is no fan of the single-payer system.

According to the Center for Responsive Politics, health professionals, insurance companies and pharmaceuticals/health products companies ranked second, third and fifth, respectively, among his top donors. Combined, these industries, which led the fight against Obamacare, have given the senator more than a million dollars toward his campaign. Elected in 2004, and then again in 2010, Burr ranked second among 100 senators in receiving donations from health insurers and topped the list of those receiving money from pharmaceuticals/health products companies.

But in response to Burr, and other critics of single-payer health-care systems, Martin has a message: There is no evidence to support a claim that the structure of the system is to blame for lengthy wait times.

“On the international panel that day, there was a representative from Taiwan, which is a true single-payer system that has no wait times at all. The U.K. model, which is a two-tier health-care model, has struggled a lot with wait times. There’s no causality there,” she explained.

At the same time, Canada can be better, Martin continued. But saying that is not a critique of the Canadian Medicare system.

“The Canadian system’s not perfect, but what we need to be doing is protecting the public insurance plan and doing everything we can to fix the delivery system so that it will meet people’s needs better into the future. We call that ‘better Medicare’ – building a better version of the public health-care system that we have,” she explained.

“Supporting Medicare doesn’t mean making excuses for areas in which the system is underperforming. Supporting it means remaining committed to the values and principles that underpin it, and working very hard, every day, to do all we can to make it better for patients.”

Addressing long patient wait times – which largely affect non-urgent cases, Martin noted – includes considering options like a central intake assessment in which there is a single common queue that would ensure patients are seen by the next available specialist or surgeon. Another option is primary-care reform that would connect patients with a hub of health-care specialists that includes doctors, nurse practitioners and pharmacists working together, ensuring patients have same day or next-day access to primary care.

“Obviously, nobody wants to see patients waiting too long for care. The question is, how do you go about fixing the problem? Those of us who are working in the system are looking at trying to make better utilization of the resources that we have. There’s lots of good work being done in the country,” she explained, noting she was thrilled to see so much support of her defense in the U.S. Senate.

“An explicit articulation of our values is important. The reaction I’ve had has been overwhelming and I think that speaks to the profound values of Medicare Canadians hold, and that’s terrific and heartening,” Martin said.

Pharmacare is the next big challenge she sees coming for Canada’s health-care system.

“It really is an accident of history that we’ve ended up with publicly funded health-care system that provides us insurance for doctor and hospital care not for their medially essential medications,” she said.

“We really need to do everything we can to advocate as physicians for our patients to get access to the medically necessary pharmaceuticals they require. They are not optional; in many cases, they are life saving medications and it ends up costing the system more when we have people being admitted and readmitted to the hospital because their chronic illnesses aren’t controlled because they can’t afford their medicine.”

While she has encountered some political courtship as a result of her advocacy, it’s a career Martin won’t be pursuing.

“I feel really lucky to be able to be in a job where I have this opportunity to both do patient care and think about these big picture issues. I can’t really imagine anything better at this stage of my career,” she said.

http://communications.uwo.ca/western_news/stories/2014/April/crossborder_checkup_healthcare_advocate_alumna_takes_fight_to_washington.html

Single payer in the next presidential term?

Fox News Poll, April 13-15, 2014

14. I’m going to read a list of potential candidates for the 2016 Democratic nomination. Please tell me which one you would like to see as the Democratic presidential nominee.

69%  Hillary Clinton

14%  Joe Biden

 6%  Elizabeth Warren

 2%  Andrew Cuomo

 1%  Martin O’Malley

 –   (Other)

 4%  (None of the above)

 3%  (Don’t know)

15. I’m going to read a list of potential candidates for the 2016 Republican nomination. Please tell me which one you would like to see as the Republican presidential nominee.

15%  Chris Christie

14%  Jeb Bush

14%  Rand Paul

 9%  Paul Ryan

 8%  Marco Rubio

 7%  Ted Cruz

 5%  Scott Walker

 5%  Rick Santorum

 5%  Rick Perry

 2%  Bobby Jindal

 1%  (Other)

 6%  (None of the above)

 9%  (Don’t know)

http://www.foxnews.com/politics/interactive/2014/04/21/fox-news-poll-independents-more-likely-to-back-anti-obamacare-candidates/

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Clinton urges move away from fee-for-service payment model; says current system is not serving physicians, or patients, well

California Medical Association, April 21, 2014

Former Secretary of State Hillary Rodham Clinton addressed 700 physicians, practice managers, medical students and others at the Western Health Care Leadership Academy in San Diego. Delivering the keynote address live via satellite, Secretary Clinton urged the California Medical Association to work with other like-minded organizations to help advance meaningful health care delivery and payment reform, instead of continuing to “rejigger” a broken system.

“At some point, we have to move away from fee for service payment for medical care,” said Secretary Clinton. “It is not serving physicians well, or any other health care providers, and I don’t believe it’s serving patients well.”

Secretary Clinton told attendees that she shares physicians’ frustration with Congress’s inability to make any progress on fixing the current broken payment system. She said she would like to see more systemic reform so that physicians are fully reimbursed for everything that goes into the care of patients. “It is deeply bothersome to me that it is still not accepted that a lot of what constitutes wellness—things that a physician can be promoting with his or her patients—should be reimbursed by Medicare,” Clinton said. “When a physician sits down with a patient and says ‘I’m going to give you a nutrition regimen. I’m going to have my nurse or my PA check in on you to make sure that you’re walking every day.’ These are all things that would keep that patient out of the operating room for a bypass or a stent or some other expensive intervention.”

“We’re never going to resolve the injustice, the unpredictability, the unfairness that unfortunately permeates the current system,” she said. “We need to move away from this very narrow approach to reimbursing physicians.”

“At some point, I hope we’re going to be able to take a look at the broad base of funding streams, both public and private, that go into funding health care–particularly physicians’ pay—and look more at who the patient is and what the doctor is providing that patient, instead of what the program is and how we can keep trying to put square pegs in a round hole.”

Secretary Clinton also held up California’s implementation of the Affordable Care Act as a model for the nation. “We’re going to be watching closely what happens in California. Seeing what works, and what doesn’t. States like California, intent on covering more citizens and fostering bold experimentation to improve outcomes and reduce costs, will not only lead the way, but help everyone else find the way.”

Secretary Clinton also urged all stakeholders to work together to keep pushing for improvements to the health care system. “The transparency called for under the Affordable Care act is going to reveal a lot of information. Some of it may be surprising. And some of it may even be quite troubling,” said Clinton. “But for the first time, we’re going to see information. And everyone will be able to look at the same information. We can then try and figure out ‘Is there a problem that needs to be fixed?’”

The data collected under the Affordable Care act will, according to Clinton, will allow us to ask questions that will give us much better insight into how we can move towards a more efficient, quality driven health care system.

“I think this is a great opportunity, if we do it with that kind of open attitude of ‘let’s learn what works, let’s make this better.’ Let’s hear from physicians and nurses and pharmacists, you name it. Everyone come to the table. What do you think needs to be changed?” 

http://www.cmanet.org/cma-alert/archives/april-21-2014/#11

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Position Statement on the Affordable Care Act (ACA)

PNHP California, April 9, 2014

Excerpt:

Recognizing that we share core principles with those who worked hard to implement the ACA, including the desire for a healthcare system that is truly universal, affordable and provides comprehensive benefits with one standard of high quality care, we resolve to:

• Build bridges to ACA supporters to forge strong alliances for continued reform.

• Work with our partners towards the successful implementation of ACA and to find solutions for the 3-4 million Californians who are still left out of the system, including the undocumented.

• Support efforts to provide healthcare as a basic human right rather than a commodity available only to those who can afford it.

http://pnhpcalifornia.org/2014/04/news-article-pnhp-california-aca-position-paper/

Comment:

By Don McCanne, MD

Considering the difficulty that President Obama has experienced in passing and then implementing the Affordable Care Act (ACA), it is clear that he is in no position to advocate for single payer reform before he leaves office. Thus it seems reasonable to consider the prospects of enacting single payer reform during the term of our next president. What are the prospects?

As people gain more experience with the ACA reforms, it is likely that many will be disappointed. The marketplace (exchange) plans that most people are selecting have relatively low actuarial values with high deductibles, thus many will experience financial hardship should they have significant health care needs. Also many will be disappointed with the narrow provider networks which will often prevent patients from having their choice of physicians and hospitals. Since employers are now adopting some of these same insurance innovations, many who previously were satisfied with their employer-sponsored coverage may also become much less content with their coverage.

It is thought that, by 2017, enough people will have become dissatisfied with our high-cost, administratively inefficient, dysfunctional system that many of them will be ready for an improved Medicare for all. That happens to be the year that our next president will take office. Will we have a president who is willing to support a vastly superior alternative – a single payer national health program?

Obviously we cannot predict the results of a presidential election this far in advance, but we can take a look at the political climate – a climate which is unlikely to change dramatically in the next few years.

Looking at the Fox poll and other recent polls, the clear front runner is Hillary Clinton. Although it is possible that the Republican Party could rally around a candidate that would be a serious challenge to Clinton, currently she outpolls each of the Republicans under consideration.

Suppose Hillary Clinton were elected president, what could single payer advocates expect? The report on her speech to physicians in California is reproduced above in its entirety, mainly to show what was left out of her message. There is certainly no mention of single payer nor expanding Medicare. She does mention moving away from fee-for-service payments, and expanding payments for “wellness-things,” while holding up California’s implementation of ACA as a “model for the nation.” She also touted information transparency. In her last run for the presidential nomination she had displaced her previous failed proposal with the current ACA model. Based on her comments, it is highly likely that her efforts at reform would be limited refinement of the ACA model, if she can get past the crippling partisan divide in Congress.

Should a Republican be elected, it is likely that efforts would be directed to replacing some elements of ACA with policies supporting less regulation of insurance products, limitation of mandates, and ability of individuals to purchase insurance products in less regulated states. No serious potential Republican candidate supports single payer.

So, no single payer will be coming from the top. Then what can we do? We should intensify our efforts to educate the public at large – so they understand why ACA does not seem to be working well for them, while showing them how single payer is precisely the model we need. We need to create a critical threshold of support coming from the general public. If the demand is intense enough, the politicians will follow.

But a caveat. The single payer message must be loud and clear. People must understand that the ACA model is fundamentally flawed and must be superseded by a single payer system. Many single payer supporters abandoned the cause and chose to support the “progressive” alternative – Obamacare. They continue to be involved in the implementation of this highly flawed model (better than nothing but still highly flawed). Fortunately, there are still organizations, such as PNHP, that are not willing to compromise and dilute the single payer message. Doing so would merely continue us down the incremental path of reform, when there are no incremental steps that bridge the gap between a fragmented system of private and public payers and a single payer system.

PNHP California has adopted a position statement calling for “work(ing) with our partners towards the successful implementation of ACA.” Most of the progressive community is already engaged in supporting ACA, and they really do not need more help. Muddling the message of the single payer purists that remain can only perpetuate inertia in the single payer movement. Some sincerely believe that helping the ACA supporters will result in reciprocal support for our efforts on single payer. Really? They are going to help us disassemble a system that they worked so hard on to build?

Let’s not adulterate our single payer message.

Reaping rewards for medical product innovation

Gilead Profit Triples, Hepatitis C Drug Revenue Reaches $2.3B

Fox Business, April 22, 2013

Gilead Sciences Inc (GILD), which ignited a fierce debate over prescription drug prices, said its new $1,000 hepatitis C pill generated quarterly sales of $2.27 billion, helping the company’s quarterly net profit nearly triple.

http://www.foxbusiness.com/industries/2014/04/22/gilead-profit-triples-hepatitis-c-drug-revenue-reaches-23b/

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MIA In The War On Cancer: Where Are The Low-Cost Treatments?

By Jake Bernstein
ProPublica, April 23, 2014

Increasingly, Big Pharma is betting on new blockbuster cancer drugs that cost billions to develop and can be sold for thousands of dollars a dose. In 2010, each of the top 10 cancer drugs topped more than $1 billion in sales, according to Campbell Alliance, a health-care consulting firm. A decade earlier, only two of them did. Left behind are low-cost alternatives, including generics, that have shown some merit but don’t have enough profit potential for drug companies to invest in researching them.

The predominant focus of cancer drug development today is on “targeted therapies” that are both innovative and lucrative. These drugs block the growth and spread of cancer by interfering with specific molecules involved in tumor growth. Fashioning these targeted therapies involves costly molecular and genetic experimentation, but once patented the investment can translate into enormous drug company profits.

http://www.propublica.org/article/where-are-the-low-cost-cancer-treatments

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Healing Medical Product Innovation

By Steven Garber, Susan M. Gates, Emmett B. Keeler, Mary E. Vaiana, Andrew W. Mulcahy, Christopher Lau, Arthur L. Kellermann
RAND Corporation, April 22, 2014

Previous studies aimed at reining in spending on technology have focused on changing how existing medical technologies are used. But what about also encouraging the creation of technologies that could improve health and reduce spending, or that provide large-enough health benefits to warrant any extra spending? A recent RAND study focused on policies that could help change which medical products—drugs, devices, and health information technologies—get invented in the first place.

To spur inventors to create medical products that lower health care spending and promote health, policymakers need to address the perverse financial incentives that lead inventors and investors in the opposite direction. Currently, large profits are most often available from creating increasingly expensive products that boost spending, whether or not they also substantially improve health. In contrast, inventors face relatively weak incentives to create products that would help decrease spending.

The RAND research team developed ten high-priority policy options that could change the costs, rewards, and risks that inventors and investors face. We synthesized information from scientific, trade, and popular literature; conducted interviews with more than 50 national experts from a variety of fields; sought input from a panel of accomplished technical advisors; and developed illustrative case studies of eight medical products.

Ten Policy Options for Healing Medical Product Innovation

1.  Enable More Creativity in Funding Basic Science

2.  Offer Prizes for Inventions

3.  Buy Out Patents

4.  Establish a Public-Interest Investment Fund

5.  Expedite FDA Reviews and Approvals for Technologies That Decrease Spending

6.  Reform Medicare Payment Policies

7.  Reform Medicare Coverage Policies

8.  Coordinate FDA and CMS Processes

9.  Increase Demand for Technologies That Decrease Spending

10. Produce More and More Timely Technology Assessments

Because the stakes in reining in health care spending are so high, and the need to get more health benefits from the money we spend is so great, we believe all of these options should be considered—the sooner the better.

RAND Research Brief: http://www.rand.org/pubs/research_briefs/RB9767.html

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Comment:

By Don McCanne, MD

New technology and drug development is being driven by profits in the private sector – massive profits. Even those of us fortunate enough to not have to use the new technology are still paying for it through taxes to support government health programs and through higher premiums for private insurance plans.

As the nation with the highest health care spending it has become an imperative that we do something about this. The drive to obtain lower prices in health care will not come from the private sector since its first priority is massive profits. Change will have to come from our government.

RAND has published a Research Brief listing ten policy options for “healing medical product innovation.” The list includes some reasonable concepts and some ideas that perhaps are not so hot. What is important is that policy wonks are thinking about the problem and pushing us to do something about it. Especially important is the concept that innovation should be targeted to reducing costs when possible, not to deliberately designing products to be more expensive.

RAND’s suggestions do include a major role for the private sector, but give them too much control, in my opinion. More control should lie with government entities such as the NIH. The private sector wants better products at higher prices whereas the government should incentivize better products at lower prices. As long as the private sector would be willing to provide us with greater value, they should receive legitimate costs plus fair margins.

The benefits of medical product innovation should accrue primarily to the people, both as improvements in health technology, and as reductions in costs. It is the consumers who ultimately pay for the development costs who should be reaping most of the benefits – not Wall Street, Madison Avenue, passive investors, nor the superabundance of administrators that permeate our health care system. 

The point is that we can do something about this misdirection of our funds. We need to place a priority on the ethics of health care spending – the same type of priority that would also lead to a single payer financing system – thereby creating much greater value in health care for all of us.

Patients paying more upfront for care

Providers say delays in collection threaten viability of hospitals

By David Markiewicz
Atlanta Journal-Constitution, April 15, 2014

Doctors and hospitals increasingly are asking insured patients to pay more of their bills for elective procedures at the time of the service, rather than collecting a small fee upfront and waiting until later to get the rest of what’s owed. 

A fundamental shift in coverage is prompting the change: the rise of high-deductible insurance plans. 

Earlier collection helps avoid payment delays and bad debt, experts say, but also raises concerns. 

“I think the new aggression on the part of providers to collect payments reflects the growing cost of health care and their need to stay financially viable,” said Sara Collins, vice president at the Commonwealth Fund, an independent foundation that supports research on improving the U.S. health care system. “From a consumer standpoint,” she added, “I think it’s a very ominous development for patients. The trends in employer-based coverage, and most people have that, is towards ever-increasing levels of out-of-pocket exposure.” 

Hospitals and physician practices say they are under greater financial pressure to get payment for the services they provide, and can’t easily do what they have historically done: collect a token copay upfront, perform the procedure, then sit back and wait for insurers to run the numbers and for patients to pay their share. 

Insurance is covering less, and if patients don’t pick up the rest, providers are stuck holding the debt. 

With unpaid medical debt in the tens of billions of dollars and rising, and with the number of high deductible plans increasing, the issue is stressing everyone, and potentially affecting care. 

“Even people with six-figure salaries can have trouble paying a $5,000 deductible,” said Dr. Douglas Lundy, the co-president for Resurgens Orthopaedics. “People are choosing not to do tests or surgery. The high deductibles are hurting things.” 

The growth in high-deductible plans and increasing bad debt are closely related, said Michael Mascolo, North Region Employee Benefits Practice Leader for Wells Fargo Insurance. Providers used to have very few people in these plans, but that has changed. More employers are offering high-deductible plans, and workers are signing up for them because they offer lower premiums. The high-deductible plans save employers money and can mean lower premiums for employees. 

The number of workers with high-deductible plans that included a health savings account option jumped to 20 percent of all covered workers last year, from 5 percent in 2007, according to the Kaiser Family Foundation. 

‘Explosion’ of bad debt 

Kaiser said one in three Americans has had problems paying medical bills in the last year, is paying old bills over time, or has bills that can’t be paid at all. 

As a result, Mascolo said, there is “an explosion of bad debt.” 

American hospitals provided $41 billion in uncompensated care in 2011, according to the American Hospital Association. That includes “bad debt” for services that hospitals expected to be paid for but were not, and charity care. 

“We’re being flooded with patients with little or no ability to pay their portion of the bill,” Greg Hurst, chief operating officer for Piedmont Healthcare said. Approximately 50 percent of its patients are on a high-deductible plan with some form of co-insurance, he said. 

“For elective procedures, we’re going to have to be disciplined about collecting the patient’s financial obligation at time of service,” Hurst said. 

At Piedmont, bad debt and charity care combined increased from $207 million in fiscal year 2011 to $324 million in fiscal year 2013. It’s expected to rise to $414 million this year. Bad debt makes up about 75 percent of the increase. 

In addition to collecting more upfront, hospitals are trying to offset the problem of unpaid debt by being more efficient, Hurst said. The debt squeeze also is leading to more individual negotiations in which the provider tries to work out a payment plan. 

Another option for providers is to tap a patient’s health savings account — funds set aside by an employee that can be used to cover medical expenses — if the employee has an HSA. They are becoming popular complements to high-deductible insurance plans. 

Upfront estimates 

Providers say they are further addressing the problem by giving patients a better idea before the service of what their cost will be, and by structuring payment plans they can manage. 

Emory Healthcare President and CEO John Fox said the health system has financial counselors at the front desk. They talk with patients who carry high deductibles to help determine the amount of their responsibility and how to meet it. 

“We try to sort it out right there,” he said. 

Emory also works with a bank to offer credit to patients who might not be able to get it elsewhere. Fox said this means added risk for the health system, which carries some risk/ guarantee for the debt, but the alternative is worse. 

Not every situation works out. 

Michael Manning had successful cancer surgery two years ago at one local hospital, but the 29-year-old from Norcross chafed when told he had to pay thousands of dollars out of pocket at the time of his service because he hadn’t met his deductible. 

He couldn’t work out a payment plan, and the bill ended up with collectors, leaving him frustrated. 

“I said, ‘Y’all will get paid when you get paid,’” he recalled. 

While providers are willing to work with patients who struggle with their bills, they inevitably must collect. 

Said Lundy, “We try to be compassionate to peoples’ position, but at the end of the day we have to pay staff.” 

http://www.ajc.com/news/business/patients-paying-more-up-front-for-care/nfZ6m/

Health spending expected to accelerate again

Acceleration Is Forecast for Spending on Health

By Eduardo Porter
The New York Times, April 22, 2014

The Affordable Care Act may well be on track to meeting its primary goal of providing coverage for most uninsured Americans and protecting everyone against the risk of losing their insurance. But for all its innovative proposals to flush waste out of the system, reining in health care spending still appears well beyond the grasp of Obamacare.

“We have been consistently bending the cost curve over the last 20 years, but the kinds of things that we do don’t tend to be permanent,” said Charles Roehrig, who runs the Center for Sustainable Health Spending at the Altarum Institute, a nonprofit based in Washington. “It will take a lot of work just to stay on the same curve we have been on for a while.”

The evolution of the American medical-industrial complex has been driven by two critical dynamics. The first is the development of new technologies. The second is our willingness to pay for them.

Most health care economists agree that the Affordable Care Act, along with other forces, will help reduce waste, pushing the industry to drop the “fee for service” model that encourages doctors and hospitals to spend more whether it is useful or not.

Last November, President Obama’s Council of Economic Advisers issued a hopeful analysis, which posited that structural changes flowing from the act were helping push the growth in health care spending to its slowest on record.

David Cutler of Harvard points to studies that suggest that straightforward changes, such as improving the dismal management of American hospitals, could cut health care costs by 25 to 50 percent. “Getting better is not rocket science,” he said.

But that optimism might be premature. Mr. Roehrig argues that the decade-long slowdown in spending growth reflects a response to the two recessions that provided the economic bookends to the first decade of the new century; not a fundamental shift in the way the system operates.

During that period, employers pushed workers to take insurance with higher out-of-pocket payments, which discouraged use. Medicaid in financially troubled states has cut provider fees and limited access to high-cost services. And, of course, many unemployed workers who lost their company health insurance cut back on visits to the doctor.

These effects, Mr. Roehrig noted, have by now mostly petered out. As the economy recovers, spending growth will resume its climb, reinforced even more by the understandable demands from the eight million newly insured Americans under the health law for services they couldn’t afford previously. He forecasts that health spending will grow substantially faster than G.D.P. in the near future, but expects the gap to shrink gradually to below one percentage point over time. In the long run, he projects that health care spending could consume 30 percent of G.D.P.

Mark McClellan, a former administrator for the Centers on Medicare and Medicaid Services under George W. Bush, and Alice Rivlin, a former vice chairwoman of the Federal Reserve, point out that innovations that improve health or reduce the cost of medical services may also increase demand.

“It would be a mistake to assume that slow growth in health care spending will continue,” they wrote, “or that spending reflects high-value care and therefore, health care delivery reform is no longer an urgent priority.”

Over the last 40 years or so, health care spending has been growing 2.4 percentage points faster than the economy, on average.

But that slowdown still isn’t good enough. By 2032, health care will consume almost a quarter of the nation’s economic production, taking an even bigger bite from workers’ wages and either forcing taxes up to pay the government’s share, adding more to the national debt, or squeezing other important public services.

So, if Americans really want to win the health care spending war, it may take more than reform. It may still take a revolution.

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Comment:

By Don McCanne, MD

There has been much speculation about the causes of the recent slowdown in health care spending, but, more importantly, about whether the more recent uptick indicates a return to greater health care inflation and, even more importantly, whether new innovations – especially those in the Affordable Care Act (ACA) will be capable of slowing the increases in spending.

Nobody can reliably predict the future. But the policy community can take a careful look at the facts we do have on hand and make decisions that would improve the odds of achieving a goal of more efficient spending in health care.

Almost every article supportive of the cost containment measures in ACA mentions vague concepts such as no longer paying for volume in health care services but paying for quality instead. If they make an attempt to explain how we might do that, they often invoke accountable care organizations, which, at best, seem to be more loosely designed managed care organizations that so far have failed the tests of greater efficiency and higher quality, other than a few reports of positive but negligible impacts that could never “bend the cost curve” nor truly improve quality.

What we do know is that our administrative waste is profound and that the excesses are readily recoverable – a crucial point that was omitted from this and most other current articles on the causes of our high health care costs. A single payer system would have a major impact on reducing waste in health care spending. We also know that health care prices in the United States are outrageous, and public administration through a single payer system would bring prices down to a level that pays legitimate costs plus fair margins.

We do know that there are excesses in high tech medicine. Again, a single payer system could use objective data, such as comparative effectiveness studies, to make decisions on eliminating payment for useless or harmful services. Also, capital planning can reduce excess capacity which would ameliorate its supply side-driven overutilization. The savings may be offset by improving access to beneficial services for underserved populations, but that spending would increase the overall quality of care provided by the health care delivery system – quality meaning getting the right care to the right people at the right time.

So, as far as predicting health care cost containment in the future we know that a single payer system would have a dramatic effect. But we can also predict quite reliably that dinking around with the meager wish-list policies of ACA will only distract us from moving forward with single payer policies that would really work.

Eduardo Porter writes that it may take a revolution to win the health care spending war. The battle would be between the American people and the economic elite that drive policy (Gilens and Page) and concentrate wealth (Piketty). Obviously non-violent civil action through the democratic process would be vastly preferable to a violent coup, but people are going to have to get off their duffs and initiate citizen action.

ACO patients receive two-thirds of their specialized care outside of their assigned ACO

Outpatient Care Patterns and Organizational Accountability in Medicare

By J. Michael McWilliams, MD, PhD; Michael E. Chernew, PhD; Jesse B. Dalton, MA; Bruce E. Landon, MD, MBA, MSS
JAMA Internal Medicine, April 21, 2014

In this study of 145 organizations participating in the Medicare ACO programs, over one-third of beneficiaries attributed to an ACO in 2010 or 2011 was not assigned to the same ACO in both years. Thus, in any given year, a substantial share of patients for whom an ACO is held accountable may be newly or transiently assigned. Although healthy beneficiaries using little primary care contributed to this instability, unstably assigned beneficiaries were more likely than stably assigned beneficiaries to be in several high-cost groups that may be targeted for care management, including the top decile of total spending.

Much of the outpatient specialty care for patients assigned to ACOs, particularly higher-cost patients with more office visits and chronic conditions, was provided by specialists outside of patients’ assigned organizations, even among more specialty-oriented ACOs. In contrast, leakage of office visits with PCPs for ACO-assigned patients was minimal. In addition, less than 40% of outpatient Medicare spending billed by ACO physicians was for care provided to beneficiaries assigned to the billing ACO. This percentage was much lower for specialty-oriented than for primary care–oriented organizations, suggesting that ACOs currently provide substantial amounts of specialty care to patients receiving primary care elsewhere. Thus, at least initially, incentives in traditional Medicare for organizations participating in ACO programs may continue to be largely fee-for-service in nature, particularly for outpatient specialty care.

https://archinte.jamanetwork.com/article.aspx?articleid=1861039

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Comment:

By Don McCanne, MD

In this study of Medicare Accountable Care Organizations (ACO), 66.7% of office visits with specialists were provided outside of the assigned ACO, especially for higher-cost patients with more office visits and chronic conditions. That hardly represents a model designed to control costs.

Some suggest that tighter relationships need to be established between Medicare patients and ACOs, but that already exists in the Medicare Advantage plans – a model proven to increase costs. It is clear that the nebulous ACO concept has only been a wish on the part of policymakers that physicians and hospitals could somehow organize themselves to provide better, cheaper care. But we now have enough evidence to state that ACOs also are a failure.

The vested interests have indicated that they are going to continue to try to improve the model when it really needs to be replaced. The direction that they are headed is towards more managed care. What we need instead is a financing model that is already proven to reduce waste and improve quality – a single payer national health program. The ACO advocates need a strong dose of disruption, or they will continue leading us down the wrong path.

Gilens and Page: Average citizens have little impact on public policy

Testing Theories of American Politics: Elites, Interest Groups, and Average Citizens

By Martin Gilens and Benjamin I. Page
Perspectives on Politics, April 9, 2014, forthcoming Fall 2014

Abstract

Each of four theoretical traditions in the study of American politics – which can be characterized as theories of Majoritarian Electoral Democracy, Economic Elite Domination, and two types of interest group pluralism, Majoritarian Pluralism and Biased Pluralism – offers different predictions about which sets of actors have how much influence over public policy: average citizens; economic elites; and organized interest groups, mass-based or business-oriented.

A great deal of empirical research speaks to the policy influence of one or another set of actors, but until recently it has not been possible to test these contrasting theoretical predictions against each other within a single statistical model. This paper reports on an effort to do so, using a unique data set that includes measures of the key variables for 1,779 policy issues.

Multivariate analysis indicates that economic elites and organized groups representing business interests have substantial independent impacts on U.S. government policy, while average citizens and mass-based interest groups have little or no independent influence. The results provide substantial support for theories of Economic Elite Domination and for theories of Biased Pluralism, but not for theories of Majoritarian Electoral Democracy or Majoritarian Pluralism.

American Democracy?

Each of our four theoretical traditions (Majoritarian Electoral Democracy, Economic Elite Domination, Majoritarian Interest Group Pluralism, and Biased Pluralism) emphasizes different sets of actors as critical in determining U.S. policy outcomes, and each tradition has engendered a large empirical literature that seems to show a particular set of actors to be highly influential. Yet nearly all the empirical evidence has been essentially bivariate. Until very recently it has not been possible to test these theories against each other in a systematic, quantitative fashion.

By directly pitting the predictions of ideal-type theories against each other within a single statistical model (using a unique data set that includes imperfect but useful measures of the key independent variables for nearly two thousand policy issues), we have been able to produce some striking findings. One is the nearly total failure of “median voter” and other Majoritarian Electoral Democracy theories. When the preferences of economic elites and the stands of organized interest groups are controlled for, the preferences of the average American appear to have only a minuscule, near-zero, statistically non-significant impact upon public policy.

Interest groups do have substantial independent impacts on policy, and a few groups (particularly labor unions) represent average citizens’ views reasonably well. But the interest group system as a whole does not. Over-all, net interest group alignments are not significantly related to the preferences of average citizens. The net alignments of the most influential, business oriented groups are negatively related to the average citizen’s wishes. So existing interest groups do not serve effectively as transmission belts for the wishes of the populace as a whole.

Furthermore, the preferences of economic elites (as measured by our proxy, the preferences of “affluent” citizens) have far more independent impact upon policy change than the preferences of average citizens do. To be sure, this does not mean that ordinary citizens always lose out; they fairly often get the policies they favor, but only because those policies happen also to be preferred by the economically elite citizens who wield the actual influence.

What do our findings say about democracy in America? They certainly constitute troubling news for advocates of “populistic” democracy, who want governments to respond primarily or exclusively to the policy preferences of their citizens. In the United States, our findings indicate, the majority does not rule — at least not in the causal sense of actually determining policy outcomes. When a majority of citizens disagrees with economic elites and/or with organized interests, they generally lose. Moreover, because of the strong status quo bias built into the U.S. political system, even when fairly large majorities of Americans favor policy change, they generally do not get it.

A possible objection to populistic democracy is that average citizens are inattentive to politics and ignorant about public policy; why should we worry if their poorly informed preferences do not influence policy making? Perhaps economic elites and interest group leaders enjoy greater policy expertise than the average citizen does. Perhaps they know better which policies will benefit everyone, and perhaps they seek the common good, rather than selfish ends, when deciding which policies to support.

But we tend to doubt it. We believe instead that – collectively – ordinary citizens generally know their own values and interests pretty well, and that their expressed policy preferences are worthy of respect. Moreover, we are not so sure about the informational advantages of elites. Yes, detailed policy knowledge tends to rise with income and status. Surely wealthy Americans and corporate executives tend to know a lot about tax and regulatory policies that directly affect them. But how much do they know about the human impact of Social Security, Medicare, Food Stamps, or unemployment insurance, none of which is likely to be crucial to their own well-being? Most important, we see no reason to think that informational expertise is always accompanied by an inclination to transcend one’s own interests or a determination to work for the common good.

Despite the seemingly strong empirical support in previous studies for theories of majoritarian democracy, our analyses suggest that majorities of the American public actually have little influence over the policies our government adopts. Americans do enjoy many features central to democratic governance, such as regular elections, freedom of speech and association, and a widespread (if still contested) franchise. But we believe that if policymaking is dominated by powerful business organizations and a small number of affluent Americans, then America’s claims to being a democratic society are seriously threatened.

http://www.princeton.edu/~mgilens/Gilens%20homepage%20materials/Gilens%20and%20Page/Gilens%20and%20Page%202014-Testing%20Theories%203-7-14.pdf

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Comment:

By Don McCanne, MD

Martin Gilens and Benjamin Page present historical data that show that average Americans, even when represented by majoritarian interest groups, have negligible influence in shaping public policy. In sharp contrast, the economic elites and their business-oriented interest groups wield tremendous influence in public policy.

Thomas Piketty and Emmanuel Saez have shown that the flow of income to the top has resulted in a concentration of wealth that is not only self-sustaining but likely to perpetuate the transfer of more wealth to the wealthiest, at a cost to everyone else.

This combination – a concentration of wealth at the top with the domination of policymaking by the economic elite, does not bode well for new policies that would be established for the common good.

In health care reform, the common good would have been served by improving coverage through the removal of financial barriers to care and by expanding coverage to everyone. Instead, the interests of the economic elite were served by increasing the market for private insurance products that, for the majority, increased financial barriers to care and reduced choice of providers, while leaving tens of millions of the most vulnerable without any coverage. More wealth moves to the passive investors at the top, while the deterioration in coverage requires average Americans to spend more out-of-pocket through higher deductibles.

We desperately need a well-designed single payer system if we want everyone to have the health care that they should have. At this point it appears that the economic elites are not going to allow single payer, and we will have no say.

Even though our Constitution laid the plans for a democracy, by fiat we now have a plutarchy (plutocratic oligarchy). Although Gilens and Page have shown that our Majoritarian Electoral Democracy has “only a minuscule, near-zero, statistically non-significant impact upon public policy,” perhaps the people can still change that. Although recent history demonstrates citizen inertia, that does not necessarily lock in the future. Think of Social Security, Medicare, and the Civil Rights Act.

A decade ago, in a book review for the NEJM on “Universal Coverage: The Elusive Quest for National Health Insurance” by Rick Mayes, I wrote the following: “Mayes does give us hope. Although he acknowledges that critical junctures are rare, he notes that they do occur, especially in response to unmet social needs. Perhaps the deterioration in insurance coverage that has taken place may have brought us much closer to our next critical juncture than most of us realize.” (https://www.pnhp.org/news/2005/july/rick-mayes-on-the-elusive-quest-for-national-health-insurance)

So what can we do to reverse the process under which “policymaking is dominated by powerful business organizations and a small number of affluent Americans”? Will citizen action through education, coalitions and grassroots efforts be adequate? In spite of such ongoing efforts, we have certainly fallen short so far.

History has taken us to a point wherein the economic elite rules. Can the people revitalize democracy, or is the wealthy ruling class too powerful? If the elite are not responsive to our needs, will our nation be ripe for civil unrest? At the moment, citizen inertia continues to empower the economic elite.

Why Canada may be heading down the ‘slippery slope’ toward American-style health care

By Wendell Potter
The Huffington Post, April 14, 2014

VANCOUVER, British Columbia — During the year leading up to the 2008 presidential primaries, my insurance industry colleagues and I were working hard to influence the debate on health care reform.

Our number one objective: make Americans so afraid of “heading down the slippery slope toward socialism” that no candidate would even consider supporting a Canadian-style, single-payer health care system.

Leading the scare campaign behind the scenes was the trade association, America’s Health Insurance Plans. With help from a right-wing Canadian outfit called the Fraser Institute, which has received funding from the Koch brothers and other American donors, AHIP put together a three-ring binder of talking points for insurance company executives to use in speeches and media interviews.

The contribution from the Fraser Institute, a long-time advocate of privatizing the Canadian system, was a handful of selective statistics and anecdotes designed to create a negative perception of single-payer health care.

At the time, I had done no research of my own about the Canadian system. I hate to admit it, but I had outsourced my thinking to the Fraser Institute. I also hate to admit that I was willing to do that out of self-interest. If the U.S. adopted a single-payer system, I would be out of a job.

With that as background, it’s hard for even me to believe that, nearly seven years later, I’m on a cross-country tour of Canada warning our neighbors to the north about the dangers of “heading down the slippery slope” toward American-style health care.

The reality is that Canadians spend far less per capita on health care then we do in the U.S., yet they have better health outcomes overall. And they have achieved universal coverage.

By contrast, while Obamacare is making it possible for many people to enroll in affordable health care plans for the first time, it will still leave several million of us in the ranks of the uninsured.

What I’m doing on this tour, organized by the Canadian Health Coalition, is disabusing folks of the notion that more private involvement in their health care system will necessarily lead to better quality of care and lower prices. That, essentially, is the promise being held out by the country’s conservative Prime Minister, Stephen Harper.

Harper has frustrated supporters of the current system by refusing to renew a 10-year compact between the federal government in Ottawa and the 13 provincial governments, which are largely responsible for administering their own health care programs.

In that sense, the Canadian system is more like our Medicaid program, which gives the states broad latitude to determine benefits and eligibility, than our traditional Medicare program, which is entirely federally funded and operated.

One of the key provisions of that compact — known as the Health Accord — was a commitment that the federal government would increase its financial support to the provinces by 6 percent per year. The Health Accord also stipulates that the federal dollars be allocated based on both population and need.

In other words, over the past decade, the poorer provinces have been getting a proportionally larger check from Ottawa than the richer provinces.

What Harper is proposing as an alternative is a scheme in which starting in 2017 the growth in the annual federal payment to the provinces would be pegged to the growth in the country’s gross domestic product, usually considerably less than 6 percent, but no less than 3 percent.

Harper further proposes to allocate the federal money only on the basis of population and population growth. Under this scenario, fast-growing provinces like oil-rich Alberta would fare much better than the relatively small, slow-growing Atlantic provinces of Nova Scotia, Newfoundland, New Brunswick and Prince Edward Island.

Andre Picard, a columnist for The Globe and Mail, Canada’s national newspaper, last week did the math in a way the Harper government hadn’t, and it clearly showed just how starkly the change would affect the fortunes of the provinces.

Alberta would be the big winner, getting more than 27 percent more than it does today. Newfoundland, on the other hand, would get zip.

Patient advocates, who want the Accord not only renewed but expanded to include pharmacy and long-term care benefits, fear that Harper’s proposal would quickly lead to a much more inequitable system because the smaller provinces would likely have no alternative but to cut their health care budgets. Both access to timely care and the quality of care provided would be affected.

And like their counterparts in the U.S. and elsewhere, Canadian conservatives believe as an article of faith that the “free market” and “choice and competition” can lead to cost-saving efficiencies.

I tell audiences that while this sounds good, it actually hasn’t worked out that way south of their border.

I’ve described how the endless quest to satisfy shareholders’ profit expectations created a situation in which insurance companies refused to sell coverage to people who’ve been sick in the past. And I’ve told them about how the cost of a stay in a U.S. hospital has increased far faster than even medical inflation because every hospital in town wants to have the latest bells and whistles to attract paying customers.

Like every country with an aging population, Canada will have to implement some changes to make sure care continues to be accessible and affordable, but the U.S. model is not the example Ottawa and the provinces should follow.

Wendell Potter, a contributing writer to the Huffington Post, is also an author, public speaker and president of Wendell Potter Consulting.

http://www.huffingtonpost.com/wendell-potter/why-canada-may-be-heading_b_5146865.html?utm_source=Alert-blogger&utm_medium=email&utm_campaign=Email%2BNotifications