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Idaho AFL-CIO endorses H.R. 676, national single-payer health care

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Idaho AFL-CIO endorses H.R. 676, national single-payer health care

By Kay Tillow
Single Payer News, July 1, 2013

Rian Van Leuven, president of the Idaho State AFL-CIO, announced that on June 12, 2013, the delegates to the 55th Annual Idaho State AFL-CIO Convention passed a resolution to publicly endorse and support H.R. 676, single-payer health care.

Further the resolution states, “That the Idaho State AFL-CIO will develop working relationships with community organizations in Idaho which advocate for single-payer health care and Medicaid expansion.”

Louis Schlickman, M.D., an Idaho physician who practices in Meridian and is co-chair of the Physicians for a National Health Program state chapter, showed the movie “Escape Fire” and made a single-payer presentation to the convention prior to the passage of the resolution.

After the resolution for H.R. 676 was passed by the Idaho State AFL-CIO Convention, Dr. Schlickman stated, “Collectively we are all realizing that unions in general can play a huge role in helping others, not just union workers, see the merit in a single-payer financing system of care.”

Dr. Schlickman observed that union members “have seen how one unexpected illness or injury leads to significant catastrophes of health and income status. And most important, they understand the issue of solidarity.”

Idaho is the 43rd state AFL-CIO federation to endorse H.R. 676, which was introduced into the 113th Congress by Representative John Conyers, D-Mich. The bill is subtitled “Expanded and Improved Medicare for All.”

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H.R. 676 would institute a single payer health care system by expanding a greatly improved Medicare to everyone residing in the U. S.

H.R. 676 would cover every person for all necessary medical care including prescription drugs, hospital, surgical, outpatient services, primary and preventive care, emergency services, dental (including oral surgery, periodontics, endodontics), mental health, home health, physical therapy, rehabilitation (including for substance abuse), vision care and correction, hearing services including hearing aids, chiropractic, durable medical equipment, palliative care, podiatric care, and long-term care.

H.R. 676 ends deductibles and co-payments. H.R. 676 would save hundreds of billions annually by eliminating the high overhead and profits of the private health insurance industry and HMOs.

In the current Congress, H.R. 676 has 43 co-sponsors in addition to Rep. Conyers.

H.R. 676 has been endorsed by 604 union organizations including 145 Central Labor Councils/Area Labor Federations and 43 state AFL-CIOs (KY, PA, CT, OH, DE, ND, WA, SC, WY, VT, FL, WI, WV, SD, NC, MO, MN, ME, AR, MD-DC, TX, IA, AZ, TN, OR, GA, OK, KS, CO, IN, AL, CA, AK, MI, MT, NE, NJ, NY, NV, MA, RI, NH, & ID).

For further information, a list of union endorsers, or a sample endorsement resolution, contact:

Kay Tillow, All Unions Committee for Single Payer Health Care—H.R. 676, c/o Nurses Professional Organization (NPO), 1169 Eastern Parkway, Suite 2218, Louisville, KY 40217. Phone: (502) 636-1551, E-mail: nursenpo@aol.com. www.unionsforsinglepayer.org

Administrative costs and profits from crowdfunding

Turning To The Web To Help Pay Medical Bills

By Caroline Mayer
Kaiser Health News, July 2, 2013

Even with Stage IV lung cancer, there are moments when 32-year-old Chip Kennett feels blessed. Over the course of two weeks in April, those moments were many, as 325 friends and family members contributed $56,800 over the Internet to help defray his out-of-pocket medical costs.

The Kennett family of Alexandria is one of thousands turning to the Internet to raise money for medical bills. The sites that host these campaigns operate much like online business fundraising sites such as Kickstarter. It takes only a few keystrokes for a family to set up a Web page, where they tell their story and state a fundraising goal; later, they can spread the word on social media sites such as Facebook. Donations can be made with credit cards or via PayPal.

The contributions, which can be given by name or anonymously, typically range from the very small (as little as $5) to the extremely generous ($1,000 and up). In the Kennetts’ case, donations ranged from $10 to $2,000. Most sites are for-profit and charge a fee, between 3 and 12 percent of the money donated, to cover the processing costs and the expenses of running the Web site.

The Kennetts acknowledge they are lucky to have good health insurance. (Sheila has a federal employee policy through her job at the Senate.) Even so, the Kennetts have paid thousands of dollars in out-of-pocket expenses, including the insurance plan’s co-pay requirements and its $5,000 annual deductible ($7,000 for out-of-network doctors) for both 2012 and 2013.

Medical fundraising sites are growing in number and profitability. In the first 12 months after it launched in 2008, GiveForward raised $225,000 for 359 campaigns; this year, it raised more than $20 million for more than 15,000. Company officials said GiveForward had more than $1.4 million in revenue in 2012 and has raised more than $47 million for families since it began.

When it launched, GiveForward also raised money for other causes — “scholarships, art projects, whatever,” says co-founder Ethan Austin. But the “hugbacks” — calls or messages from users — from medical fundraisers were so appreciative, “we decided, ‘Why do anything else?'”

Austin says he is not surprised at the rapid growth of crowd-funding for medical costs, citing a 2011 National Bureau of Economic Research study that found that half of American adults say they would not be able to come up with $2,000 in the event of a medical emergency. This, taken along with another recent study showing that the average cancer patient incurs as much as $8,500 a year in expenses not covered by insurance, further explains why so many ailing Americans are seeking outside help to pay their expenses, according to Austin.

http://www.kaiserhealthnews.org/Stories/2013/July/02/online-fundraising-to-help-pay-medical-bills-takes-hold.aspx

Comment:

By Don McCanne, M.D.

Crowdfunding: the collective effort of individuals who network and pool their money, usually via the Internet, to support efforts initiated by other people or organizations (Wikipedia).

What a nice gesture – friends, acquaintances and caring strangers joining together to pay medical expenses not covered by a federal employee health policy available through the United States Senate (FEHBP), one of the highest quality private insurance plans available in the United States.

What? Cost sharing has become so prevalent – even amongst the best of our health plans – that people with significant health care needs insured by these plans have to turn to charity to pay their bills? Not even cake sales will do. They need real money. (Isn’t this what insurance is supposed to prevent?)

And who moves in? Entrepreneurs who set up for-profit organizations that provide administrative services for this crowdfunding. Just what we need in a health care system already tremendously overburdened with administrative waste – more administrators who profit from our highly dysfunctional, fragmented health care financing system.

PwC reports that next year 44 percent of employers are considering high-deductible plans as the only option for their employees. The benchmark plans in the Marketplaces (exchanges) are high-deductible plans. The new national standard in health care coverage will leave far too many individuals exposed to financial hardship in spite of having a health care plan.

The logical solution would be to reverse this trend and provide coverage that protects individuals from medical debt. But that’s not the American way. We bring in more administrators and pay them richly, further adding to our almost intolerable national health expenditures.

Hey! Is anybody reading these messages? Single payer. Single payer! SINGLE PAYER!

A doctor who embraces change, personally and politically

By Stacey Butterfield
ACP Internist, July/August 2013

In an era when even small changes to the health care system are highly controversial, leading a campaign for a single-payer system might seem like a daunting task to some. But Andrew D. Coates, MD, FACP, the new president of Physicians for a National Health Program (PNHP), has already tackled unusual challenges in his career.

Dr. Coates didn’t start medical school until he was in his 30s. Prior to attending Columbia University College of Physicians and Surgeons in New York City, he worked in carpentry, factories and a feed mill. “I did hard jobs. … I had a little bit of an adventure in terms of living in different cities and taking manual labor jobs,” he said. “Then I went to graduate school in history.”Dr. Andy Coates

Switching things up again, Dr. Coates turned down opportunities to turn his MA in history into a PhD and instead applied to medical schools. “When I was young I really wanted to be a doctor. I just assumed by the choices I made in college that after that it wasn’t going to happen,” he said. “I hadn’t taken any science classes since 11th grade, so it was a winding road.”

At the end of that road was internal medicine training, and then practice, in upstate New York. But even after settling down there, with children and lifelong connections, and attaining specializations in hospital medicine and palliative care, he grabbed an opportunity to mix things up.

“I took a temporary job at the Northern Navajo Medical Center in Shiprock, New Mexico, and we went as a family … I needed an interpreter, a cultural interpreter as well as a language interpreter, when meeting specific patients,” said Dr. Coates. “The cultural insights were inspiring. Overall I gained a deeper conviction about what medicine has to offer every human being.”

Today, Dr. Coates offers his services as a community hospitalist in Troy, N.Y. “The needs are enormous and we often work over 200 hours a month. We also take turns doing nights, to make sure that one of our group is always available on the floors as well as to do the admissions. I went there because I wanted the experience of practicing the full spectrum of hospital medicine, and I love it,” he said.

Picking up another piece of the medical spectrum, he also serves as a medical director of a local public nursing home, which he describes as having great clinical care (“In recent years, no patient here has gotten a decubitus ulcer,” he said) but crumbling infrastructure (“The roof leaks”).

A recent proposal to privatize the nursing home holds the potential to damage the quality of care, he worries. “We have a great respiratory therapist and superb wound care and rehab nurses, for instance. For-profit nursing homes simply lack the kind of clinical depth that our patients count upon,” he said. “The nursing home experience has raised my consciousness about why public care is superior to private, for-profit care.”

In his newest role, at the helm of the nonprofit PNHP (his two-year term started Jan. 1), he hopes to raise physicians’, patients’ and policymakers’ consciousness about making a clean break with what he characterizes as the “dysfunctional and wasteful” private health insurance model of financing care.

He sees the present costs faced by individuals as hazardous to health: “The evidence shows that co-pays, deductibles and co-insurance schemes cause our patients to avoid necessary care.”

He doubts that reforms currently under way will reorganize how the profession interacts with society.

“If the goal remains to reduce costs and improve quality, I don’t think these things will work. Eventually, we’ve got to deal with the evidence,” he said. “The elements touted to save costs—electronic health records, accountable care organizations—these are not proven to save costs.”

Dr. Coates and his colleagues in the education-oriented, 18,000-member PNHP advocate for a publicly financed, streamlined single-payer model that he says would reduce costs by slashing administrative waste.

“This would free physicians from a mountain of worry about how our patients’ care will be reimbursed, and thus restore the physician-patient relationship,” he said. “There is no question that we could provide best-quality, comprehensive care to all patients. We have all of the necessary resources—especially great health professionals—to do it. It’s just a question of our consciousness.”

Fast facts

Age: 51.

Something I wish I’d learned in medical school: Economics.

Personal hero: Rudolf Virchow, the 19th century pathologist and public health advocate.

Favorite ways to spend free time: Cooking for our family, hiking mountains.

Most recent book read: “Medicine and Public Health at the End of Empire” by Howard Waitzkin, MD, PhD.

Regret: Not showing as much kindness as I feel toward others.

If I weren’t a physician, I would be: Working for a living (That’s a joke, y’all).
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Where ACP stands

ACP published a position paper in the Jan. 1, 2008, Annals of Internal Medicine titled “Achieving a High-Performance Health Care System with Universal Access: What the United States Can Learn from Other Countries.” The position paper offered several policy recommendations, including the following.

Recommendation 1a: Provide universal health insurance coverage to assure that all people within the United States have equitable access to appropriate health care without unreasonable financial barriers. Health insurance coverage and benefits should be continuous and not dependent on place of residence or employment status. The ACP further recommends that the federal and state governments consider adopting one or the other of the following pathways to achieving universal coverage:

1. Single-payer financing models, in which one government entity is the sole third-party payer of health care costs, can achieve universal access to health care without barriers based on ability to pay. Single-payer systems generally have the advantage of being more equitable, with lower administrative costs than systems using private health insurance, lower per capita health care expenditures, high levels of consumer and patient satisfaction, and high performance on measures of quality and access. They may require a higher tax burden to support and maintain such systems, particularly as demographic changes reduce the number of younger workers paying into the system. Such systems typically rely on global budgets and price negotiation to help restrain health care expenditures, which may result in shortages of services and delays in obtaining elective procedures and limit individuals’ freedom to make their own health care choices.

2. Pluralistic systems, which involve government entities as well as multiple for-profit or not-for-profit private organizations, can assure universal access, while allowing individuals the freedom to purchase private supplemental coverage, but are more likely to result in inequities in coverage and higher administrative costs (Australia and New Zealand). Pluralistic financing models must provide 1) a legal guarantee that all individuals have access to coverage and 2) sufficient government subsidies and funded coverage for those who cannot afford to purchase coverage through the private sector.

The full position paper is available online.

http://acpinternist.org/archives/2013/07/profile.htm

We need more than Obamacare

By Neil Shulman, M.D., and Jack Bernard
The Gazette (Cedar Rapids, Iowa), June 30, 2013

The authors of this article have both spent many decades in the health care field. We have seen both the positives and negatives of U.S. health care delivery and financing.

Furthermore, we have thought about how heartless some of us have become over the past few decades. As the most religious developed nation on earth, it is hard to fathom how we as a country can be so callous to our less-privileged citizens.

It is an inconvenient truth that working people in Iowa and around the nation are suffering physically and financially under our current system. Although Obamacare (and Medicaid expansion) is not the option preferred by the authors, as we state below, it is still much better than what we have right now.

In this vein, we were pleased that Iowa’s governor and legislature decided this session to accept Medicaid expansion, via the unique Iowa Health and Wellness Plan. They are to be commended for bucking Tea Party pressures and taking the federal money. If acceptable to the federal government via a “waiver,” the Iowa plan will reduce real suffering for at least some low-income Iowa residents (and improve the financial picture for hard-pressed providers).

Common cases

Many taxpayers are unaware of the suffering, exacerbated by the current health financing system, referred to above. Here are two cases encountered under our existing delivery system; the story is the same in virtually every state:

Case 1 — A 30-year-old small business owner got an object in his eyes. He can’t get it out. So he goes to a large hospital emergency room where he waits to see a doctor so his eye will not become permanently damaged. While waiting, his eye tears up and the object comes out on its own. The doc comes into the examining room, looks in his eye, and miraculously, the object has come out on its own. The patient does not have health insurance, so he is charged more than a patient who is insured: $2,000. The hospital ends up turning over the case to a collection agency.

Case 2 — A 32-year-old woman with an abscess in her liver has the abscess surgically removed. She has insurance under her dad’s policy. However, after the surgery, she loses her coverage and the scar at the site of the surgery is very painful. She cannot get an appointment to see the surgeon without a cash upfront advance payment or insurance. The pain is so bad that she has to get relief in a hospital ER frequently for the next two years — total cost more than $23,000. Now this debt is turned over to a collection agency. And the pain continues.

Many of our state and national legislators continue to be completely disconnected from the underserved segment of the population. They choose to believe that care is readily available and that we have the best health care on earth, regardless of ability to pay. It fits their political philosophy, but, based on the facts, they are 100 percent wrong.

We are the richest and most powerful country on earth. It is up to each of us to step up to the plate. We must tell our elected officials both in Iowa and across the nation that what is morally correct is to have health care as a right of all Americans, not a privilege.

Medicare for all

The best way to achieve that goal will always be Medicare for All.

A bill has been introduced in Congress that promotes single payer. If it is ever adopted, a Medicare For All system would eliminate all the game-playing under our existing system. Medicare has administrative costs that are only 3 percent versus 20 percent to 30 percent for private insurers.

Other nations that have adopted similar single-payer systems have achieved much more effective health care delivery and financing. Morbidity and mortality rates are much better than in our nation, while per capita costs are often half ours. The World Health Organization ranks the U.S. health care system 37th, behind the rest of the developed world.

Medicare For All would simply take our existing national health insurance program, Medicare, and expand it beyond the elderly. It could be funded via payroll taxes, shared by employers and employees.

More on this topic can be viewed at the Physicians For A National Health Program (PNHP) website: www.pnhp.org.

Dr. Neil Shulman, of Decatur, Ga., a practicing physician for a several decades, is an associate professor at Emory Medical School. He is the author of “Doc Hollywood”, which he also produced as a movie. Jack Bernard of Monticello is a retired senior health care executive who has worked extensively with Iowa hospitals, including the Iowa Health System (now UnityPoint Health).

http://thegazette.com/2013/06/30/we-need-more-than-obamacare/

Hardship? No penalty, but no insurance

Guidance on Hardship Exemption Criteria and Special Enrollment Periods

Centers for Medicare and Medicaid Services, June 26, 2013

The Department of Health and Human Services (HHS) finalized provisions concerning how Marketplaces (also known as “Exchanges”) will determine eligibility for and grant certificates of exemption from the individual shared responsibility payment described in section 5000A of the Internal Revenue Code.

This guidance is intended to describe the circumstances that Marketplaces may use in determining what constitutes a hardship if they prevent an individual from obtaining coverage under a QHP.

We clarify that Marketplaces may consider the following circumstances in determining what constitutes a hardship under 45 CFR 155.605(g)(1) if they prevent an individual from obtaining coverage under a QHP, which include an individual who–

* becomes homeless;

* has been evicted in the past six months, or is facing eviction or foreclosure;

* has received a shut-off notice from a utility company;

* recently experienced domestic violence;

* recently experienced the death of a close family member;

* recently experienced a fire, flood, or other natural or human-caused disaster that resulted in substantial damage to the individual’s property;

* filed for bankruptcy in the last 6 months;

* incurred unreimbursed medical expenses in the last 24 months that resulted in substantial debt;

* experienced unexpected increases in essential expenses due to caring for an ill, disabled, or aging family member;

* is a child who has been determined ineligible for Medicaid and CHIP, and for whom a party other than the party who expects to claim him or her as a tax dependent is required by court order to provide medical support. We note that this exemption should only be provided for the months during which the medical support order is in effect; or

* as a result of an eligibility appeals decision, is determined eligible for enrollment in a QHP through the Marketplace, advance payments of the premium tax credit, or cost-sharing reductions for a period of time during which he or she was not enrolled in a QHP through the Marketplace, noting that this exemption should only be provided for the period of time affected by the appeals decision.

http://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/exemptions-guidance-6-26-2013.pdf

Comment:

By Don McCanne, M.D.

The Affordable Care Act (ACA) requires that individuals who fail to enroll in a qualified health plan (QHP) be required to make a shared responsibility payment (a financial penalty for being uninsured). There are several exemptions that allow the penalty to be waived, and one of these is “individuals who experience a hardship.” This guidance defines what constitutes a hardship.

Supposedly a goal of health care reform was to be sure that everyone had health care coverage, but especially those whose personal finances made purchase of insurance prohibitive. That is why the most important provisions of ACA included the expansion of Medicaid for individuals at or near poverty and the establishment of income adjusted subsidies for purchase of private plans within the insurance exchanges (Marketplace).

The shared responsibility payment penalty was established to encourage those who could afford insurance to buy it, with a goal of approaching truly universal coverage.

When it was realized that there were many legitimate situations in which individuals would not qualify for either Medicaid or the subsidies for the exchange plans and yet could not afford to purchase plans, it was thought that it would be unfair to penalize these individuals for being uninsured, as if that were not enough of a penalty. Thus the exemptions from the penalty were established.

Of the exemptions, hardship is perhaps the most compelling. But think about that. These are individuals who have the greatest need to have the security of health care coverage, yet, instead of establishing measures that would bring them under the insurance umbrella, they are being left bare – exposed to greater financial hardship and greater barriers to health care access.

Is this the best that we can do for these people – waive a financial penalty for the sin of being uninsured – a penalty that they couldn’t pay anyway?

Absolutely everyone should be covered – automatically. How many times do we have to say it? Single payer.

Everything you ever wanted to know about Canadian health care in one post

By Sarah Kliff
Washington Post, July 1, 2013

We spend a decent amount of time talking about the Canadian health care system in our health care debate. Today being Canada Day (yes, really), it feels like a good time to brush up on how our northern neighbors actually deliver health care and how well it works. Without further ado, a completely painless guide to the Canadian health care system.

So, how exactly does the Canadian health care system work?

The Canadian health care system was built around the principle that all citizens will receive all “medically necessary and hospital physician services.” To that end, each of Canada’s 10 provinces and three territories finance and run a statewide health insurance program. There is no cost-sharing for the health care services guaranteed under federal law.

While Canadians are guaranteed access to hospital and physician services, it is up to each province to decide whether to cover “supplementary” benefits, like dental care and drug coverage. About two-thirds of Canadians take out private, supplemental insurance policies (or have an employer-sponsored plan) to cover these services.

While Canada is traditionally thought of as a publicly financed system, spending on these supplemental benefits means that 30 percent of health spending comes from private sources. One 2011 study found that nearly all Canadian spending on dental care came from non-government dollars, 60 percent covered by employer-sponsored plans and 35 percent paid out of pocket. Some Canadian legislators have made pushes to increase the scope of Canada’s public health plan, to cover more services, but have so far proved unsuccessful.

While Canada’s health care system is publicly financed, many providers are not government employees. Instead, doctors are usually reimbursed by the government at a negotiated fee-for-service rate. The average primary care doctor in Canada earns $125,000 (in the United States, that number stands at $186,000).

How much does it cost? 

In 2009, Canada spent 11.4 percent of its Gross Domestic Product on health care, which puts it on the slightly higher end of OECD countries:

This probably has a lot to do with the lower unit cost of health care in Canada. An MRI that costs, on average, $1,200 in the United States comes in at $824 north of the border. It also has to do with lower administrative costs: A 2010 Health Affairs studyfound that doctors in Ontario, a Canadian province, spent $22,205 each year dealing with the single-payer agency, compared to the $82,975 American doctors spend dealing with private insurance companies, Medicare and Medicaid.

How well does the Canadian health care system work?

The OECD tends to give the Canadian health care system high marks on outcomes in its regular look at international health care systems. “Canada’s survival rates for breast and colorectal cancer are among the highest in the OECD,” the international organization noted in its 2011 report. “Canada also does well in primary care, preventing costly hospital admissions from chronic conditions such as asthma and uncontrolled diabetes.”

Where Canada does not do well is on wait times, which tend to be longer than in other countries, especially to see specialists or obtain an elective surgery. A Commonwealth Fund survey in 2010 found that 59 percent of respondents reported waiting more than four weeks for an appointment with a specialist, more than double the number in the United States:

Canada has recently started taking steps to address this: In 2005, it had each province set evidence-based benchmarks for wait times for various procedures. “Provinces have made considerable progress with efforts to manage and reduce wait times, and many now meet wait-time benchmarks for at least 75 percent of patients,” the Commonwealth Fund found in 2010 report. “Generally, when available, trend data show waits for care are decreasing in the areas of joint replacement, sight restoration, cardiac surgery, and diagnostic imaging scans.”

Do Canadians like their health care system?

Canadians certainly view their health care system as crucial to national identity: 85 percent say that eliminating the public plan would “result in a fundamental change to the nature of Canada.”

That does not, however, mean there isn’t gripping about its shortcomings. A 2007 pollconducted by Queens University in Kingston, Ont. found that, while public opinion had ticked up slightly, “a large majority of Canadians still believe that the system is unsustainable and urgently in need of substantive change.” Most of the concerns had to do with long wait times and difficulty accessing care. The survey also found widespread support for increasing health care spending.

Put into an international perspective, however, Canada’s system looks to be relatively well liked. A 2011 Gallup Poll found that 57 percent of Canadians felt “satisfied” or “very satisfied” with their access to health care services (in the United States, that number stood at just 25 percent).

We need much more than Medicaid expansion

By Andrew D. Coates, M.D., F.A.C.P.
WAMC Northeast Public Radio, June 28, 2013

It is common for people to assume that President Obama’s Affordable Care Act will lead to universal coverage; after all, that was its stated aim.

Coverage under the plan, which will not be fully implemented for seven more years, would be driven by a law making private health insurance compulsory, with an individual mandate to purchase health insurance or else pay a fine, for all but the poor, much like the reform led by Gov. Romney in Massachusetts. For the poor, the goal was to expanding Medicaid eligibility to everyone with an income below 138 percent of the federal poverty level.

But the Supreme Court, when it upheld the law as constitutional overall, also ruled that states could opt out of the Medicaid expansion.

We now know that a significant number state governments will opt out, in the end perhaps more than twenty in all. Texas, Florida, Kansas, Alabama, Louisiana, Mississippi, Georgia and Wisconsin are among the states that have decided not to expand Medicaid to all of the poor.

Some commentators and journalists have laid the blame at the feet the Supreme Court for the fact that the president’s “health care overhaul” will fall far short of universal health coverage for our nation. They cite projections that the reform was designed to enroll 16 million of today’s 50 million uninsured people in Medicaid programs. The point is that that many millions will not become eligible as long as their state governments opt out of expanding Medicaid.

But being eligible for Medicaid is different from enrolling.

In a study published this month on the Health Affairs blog, researchers Rachel Nardin, Leah Zallman and others estimated the impact of Medicaid expansion on the uninsured. They took into account the fact that people have to enroll in Medicaid by basing their estimates upon published take-up rates for public programs, prior publications, and Congressional Budget Office estimates regarding implementation of the president’s health care plan.

They found that the president’s plan, overall, “will minimally alter the demographic composition of the uninsured, regardless of whether undecided states opt-in or out. While Blacks and Hispanics will continue to be overrepresented among the uninsured, the majority will be non-Hispanic, white, low-income, working-age adults, many of them employed. The majority (around 80 percent) of the uninsured will be U.S. citizens, irrespective of states’ acceptance of Medicaid expansion. More than 4.3 million children and nearly 1.0 million veterans will remain uninsured under either scenario.”

The study also looked at the state governments presently undecided about whether to opt in or out of Medicaid expansion. The researchers found “if all currently undecided states opt-in, 29.8 million people will remain uninsured, whereas if all opt-out, the number of uninsured will total 31.0 million, 1.2 million above the opt-in scenario.”

Recently in the hospital I met a patient, a woman with limited intellectual ability and serious chronic health issues who had moved from another state so that her sister could help her each day. Applying for Medicaid seemed beyond the abilities of our patient, even with her sister’s help. Yet by enrolling in Medicaid our patient could gain access to medications that would help keep her out of the hospital.

Medicaid expansion will help our nation’s poor and blocking it seems an unnecessary cruelty on the part of state governments. Because the president’s reform also will reduce funding to safety-net hospitals, financial devastation will continue to plague poor Americans who become seriously ill, more so in those states that opt out.

On the other hand, Medicaid remains a poor program for poor people, with poor reimbursement for specialty care and hospital care. State-by-state privatization schemes and funding cutbacks continue undermine access to care for those who have Medicaid. Even if all of the poor were automatically enrolled in Medicaid our health system would still remain indefensible, for it would codify an unjust two-tier system, burdened with deep racial disparities.

The Affordable Care Act will fall well short of providing affordable health coverage to all Americans. Tens of millions of people will remain uninsured. We still need a program that will make sure that everyone receives care, not coverage.

If access to comprehensive care is the goal, as it should be in a great modern democracy, then nothing short of a system of national health insurance – everyone in, nobody out – will work.

Dr. Andrew Coates practices internal medicine in upstate New York. He is president of Physicians for a National Health Program.

You can listen to Dr. Coates’ radio broadcast here: http://www.wamc.org/post/andrew-coates-we-need-much-more-medicaid-expansion

Why are health insurance premiums higher for public employers?

Why are Health Insurance Premiums So Much Higher for Public Employers Compared to Private Employers?

Co-author: Tom Buchmueller
Presenter: Alice Zawacki, Ph.D., Senior Economist, Center for Economic Studies, Bureau of the Census
AcademyHealth, 2013 Annual Research Meeting, June 23-25, 2013

Research Objective:

The Great Recession of 2007-2009, which took a major toll on the U.S. economy, was especially hard on state and local governments. The fiscal crises have led to increased scrutiny of public sector compensation practices and renewed debate about how the compensation of public sector employees compares to that of private sector workers. Employer-sponsored health insurance represents a substantial share of non-wage compensation and rising health care costs are a pressing concern for both public and private employers. According to data from the Medical Expenditure Panel Survey-Insurance Component (MEPS-IC), average health insurance premiums in the late 1990s until 2000 were similar for public and private employers. In subsequent years, public sector premiums grew more than private sector premiums. In 2000, premiums for large public sector plans were $705 or 22% higher than premiums for large private sector plans. By 2009, this difference grew to $1580 or 35%. This paper examines changes in employee demographics, plan type and plan benefit design with the goal of explaining why premiums in the private and public sectors have diverged over the past decade.

Study Design:

To study the premium differences between sectors, we conduct regression analyses on plan-level data from the 1996-2009 MEPS-IC augmented with additional worker demographic characteristics we impute from the 2000 Decennial Census and the 2009 American Community Survey. Population Studied: Health insurance plans offered by state and local governments and private sector employers with at least 100 employees.

Principal Findings:

Early work shows that over 40 percent of the premium difference for all plans in 2009 is attributable to demographic factors: public workers are older, more likely to be female and are more educated than workers in the private sector. Some of the gap is also explained by the fact that cost sharing increased more in the private than the public sector.

Conclusions:

These findings are consistent with the idea that private employers were more aggressive in increasing cost sharing in the health plans offered to employees. Increases in cost sharing can lead to lower utilization of services for which benefit is low relative to the cost, implying an increase in economic welfare. Alternatively, if utilization is not significantly affected, increases in deductibles, co-payments and co-insurance will merely shift costs from low risk employees who use relatively little care (but pay premiums in the form of reduced wages) to higher risk employees who use more care.

Implications for Policy, Delivery or Practice:

While the growing gap in health benefits spending in the public and private sector does not necessarily imply that public sector benefits are excessive, it is natural for policy makers to look to health insurance costs as a potential area for reform and savings. It is important that efforts in this area be guided by a clear and detailed understanding of the health benefits that are provided to public sector employees and how those benefits compare to those in the private sector.

http://www.academyhealth.org/files/ARM/2013/All%20Podium%20Presentations.pdf

Comment:

By Don McCanne, M.D.

In the past decade, health insurance premiums for state and local government employers have grown more than premiums for employers in the private sector. Although some of this is due to demographic characteristics, a significant portion has been due to an increase in the use of cost sharing in the private sector. Plans for public employers have maintained the same level of benefits, whereas the coverage in plans for private sector employers has deteriorated.

The policy implications of this should have us concerned. As explained in a message earlier this week, the trend in the private sector has been to expand the use of cost sharing, especially high-deductible plans, with a detrimental impact on employees. It is highly unlikely that private employers would support a reversal of this trend.

State and local governments have faced difficult budget decisions, so it is logical that they would look at the high costs of their employee health benefit programs as a source for reducing budget deficits. Many have already tapped into their programs for retirees. Although unions for public employees have been more effective in protecting benefits, there will be considerable pressure to follow the lead of the private sector and expand the use of cost sharing.

There is a far better option other than simply trying to adjust the differences in plans for public and private employees. Instead of thinking about traditional private insurance design options, especially those that emphasize catastrophic coverage, we should consider changing everyone to a prepaid health care system in which financial barriers to care are removed – a single payer system.

Not only is single payer coverage much better, it also provides the greatest value in health care. If we adopted a single payer system, both public and private employers would no longer be placed in the role of trying to control their budgets by hacking away at employees’ well earned health benefit programs.

High-cost Medicare patients are wrong target for savings

Contribution of Preventable Acute Care Spending to Total Spending for High-Cost Medicare Patients

By Karen E. Joynt, MD, MPH; Atul A. Gawande, MD, MPH; E. John Orav, PhD; Ashish K. Jha, MD, MPH
JAMA, June 24, 2013

Objective

To quantify preventable acute care services among high-cost Medicare patients.

Discussion

We found that more than 70% of the roughly $91.7 billion in acute care costs in the Medicare population in 2010 were for the 10% of patients that comprise the high-cost cohort. Approximately 10% of these costs were for what were deemed potentially preventable causes as calculated using standard algorithms; the percentage was slightly higher for the persistently high-cost cohort. Hospital referral regions with a higher primary care or specialist physician supply had higher annual preventable costs per capita.

The biggest drivers of inpatient spending for high-cost patients were catastrophic events such as sepsis, stroke, and myocardial infarction, as well as cancer and expensive orthopedic procedures such as spine surgery and hip replacement. These findings suggest that strategies focused on enhanced outpatient management of chronic disease, while critically important, may not be focused on the biggest and most expensive problems plaguing Medicare’s high-cost patients. Indeed, while a proportion of these very expensive inpatient episodes may be potentially preventable (such as acute myocardial infarction or degenerative joint disease leading to orthopedic procedures), their prevention would likely require a long time horizon and substantial investments in population wellness. Such investments are critically important for ensuring the health of the population, but the time frame needed to see cost savings is likely years, not weeks or months.

These findings may shed light on why many recent efforts to control costs for these very medically complex, high-utilizing patients, including the Medicare Coordinated Care Demonstration programs, have failed to do so, even in cases in which there was a small decrease in hospital admissions. The majority of these programs have focused on providing enhanced outpatient services, such as frequent telephone and in-person contact, patient education, enhanced medication management services, and assistance with transitional care following a hospitalization. These types of services are targeted toward reducing ambulatory care–sensitive hospitalizations, and investing further in disease management programs may lead to reductions in avoidable ED visits and hospitalizations. Although these visits are still very expensive in aggregate, our findings suggest that they make up a small proportion of the total acute care spending among the costliest of patients. As a result, while disease management may yield cost savings, even a substantial reduction in these preventable hospitalizations is unlikely to have a large effect on overall spending levels within this cohort.

Conclusions and Relevance

Among a sample of patients in the top decile of Medicare spending in 2010, only a small percentage of costs appeared to be related to preventable ED visits and hospitalizations. The ability to lower costs for these patients through better outpatient care may be limited.

http://jama.jamanetwork.com/article.aspx?articleid=1699911

Comment:

By Don McCanne, M.D.

The experts keep talking about the 30 percent of spending that is wasted on clinical services, and they keep proposing and implementing solutions to squeeze that waste out of our system. Yet when we look closer at the waste and at the methods being used to reduce it, we find that most efforts are relatively ineffective, and, further, that much of that suspect care may not be wasteful after all. This study adds to the data showing how elusive the goal of eliminating clinical waste has been.

Yet the savings that they are looking for are potentially recoverable, but not in the clinical services. They are to be found primarily in the financing infrastructure. The non-clinical administrative waste is profound in our current financing system. It could be dramatically reduced by adopting a single payer system (eliminating the administrative excesses of the private insurers and the administrative burden they place on the delivery system, placing hospitals on global budgets, negotiating rates with health care professionals, bulk purchasing of pharmaceuticals, and separate planning and budgeting of capital improvements).

We should continue to make efforts to improve clinical services. But we should not look upon these improvements as a source of savings that would allow us to continue to unjustly enrich the superfluous vested interests who are diverting our finite funds from health care. Why would we want to continue to reward them anyway? Let’s fix what we do know is wrong with the system… especially since we know how to do that.

Large employers moving en masse to high deductibles

Medical Cost Trend: Behind the Numbers 2014

PwC Health Research Institute, June 2013

Each year, HRI issues its projection for the following year’s medical cost trend based on activity in the market that serves employer-based insurance.

Consumer-driven health plans – insurance coverage with a high-deductible – are set to go mainstream in 2014. According to the 2013 PwC Touchstone Survey of major US companies, 44% of employers are considering offering high-deductible health plans as the only benefit option to their employees in 2014. Already, 17% of employers offer high-deductible plans as their only option in 2013, a 31% increase over 2012.

High-deductible health plans, which place greater responsibility on consumers, are designed to promote cost-conscious decisions. A recent study reported families that switched from a traditional health plan to a high-deductible plan spent an average of 21% less on healthcare in the first year.

The ACA, with its new insurance marketplaces, accelerates the move to consumer-driven plans. Many of the newly insured say they are willing to accept plan features such as higher deductibles in return for lower monthly premiums – as found in the new bronze and silver plans.

2013 – Average deductibles

$1,230 – In-network
$2,110 – Out-of-network

http://www.pwc.com/en_US/us/health-industries/behind-the-numbers/assets/medical-cost-trend-behind-the-numbers-2014.pdf

Comment:

By Don McCanne, M.D.

The forces supporting consumer-driven health care (CDHC) have incessantly asserted emphatically that the answer to our health care spending problem is to place the consumer (i.e., patient) in charge of health care spending. Although some of us have been trying to explain the horrible consequences of this approach, the mainstream media disseminated the message of the CDHC advocates so effectively that it has now become a meme. The CDHC camp has won the policy battle.

How can we say this? CDHC has now become virtually synonymous with high-deductible health plans (HDHP). Whether or not the deductible passes through a health savings account or is paid directly really doesn’t make much difference since the designated cash account is simply a matter of tax policy rather than health policy. Let’s look at a very brief history of HDHPs to see if we can understand why we lost.

Large employer-sponsored group plans have been the mainstay of health coverage in the United States for decades. They have provided comprehensive coverage through high actuarial value plans which required only modest cost sharing by the patient. As health care costs increased, large employers depended more on controlling spending by creating networks of providers with contracted rates. In contrast, individuals, and to a certain extent smaller employers, were unable to afford the premiums for high actuarial value plans and so the insurers heavily marketed high-deductible plans that had much more competitive premiums; so that’s what people bought.

When the Affordable Care Act was written, it was recognized that high actuarial value plans would be unaffordable unless the government subsidies were much larger than members of Congress were willing to budget. Thus the decision was made to make the benchmark plan for the insurance exchanges a low actuarial value plan (silver), made possible only by using high deductibles.

Large employers have been looking for relief from the very high costs of their employee health benefit programs. It looks like they’ve found it, now that HDHPs are becoming the new standard set by our government for the plans in the exchanges. This report from PwC shows that 12 percent of employers used HDHPs as their only option in 2012, and that may increase to 44 percent next year! That is a phenomenal shift in such a short period, and is the basis for saying that the CDHC (HDHP) camp has won the policy battle.

Not only are patients assessed a significant financial penalty for seeking health care (an average $1,230 deductible), that penalty is almost doubled if the patient obtains care out of network ($2,110 deductible) – a greater likelihood as narrower networks become more prevalent.

HDHPs have become popular for one reason only, and that is not because they make patients better shoppers. It is only because the premium to purchase the health plans is more affordable (or for self-insured employers the amount paid out in benefits is less).

There are two important trade-offs for the lower premiums. One is that people will decline to obtain appropriate health care since they will have to pay full fees until the deductible is met. A properly designed financing system should make it easier for people to obtain the care they need, not more difficult. The other is that far too many people have little or no discretionary income, and high deductibles create a financial hardship for them. The health care financing system should reduce or eliminate financial hardship, not create it.

And the out-of-network penalties? A financing system should increase health care choices for patients, not reduce them.

This boat is not going to turn around. Within two or three years, HDHPs will be the standard for employer-sponsored coverage. More people will suffer. The media knew that this change had to come, but only because they didn’t listen to us. They simply dismissed single payer because of another meme – “it isn’t feasible.”

I’m not a violent person, but the next time I hear, “skin in the …,” watch out!

Swiss support single payer

Swiss voters back single-payer health insurance

Swiss Broadcasting Corporation
swissinfo.ch, June 24, 2013

The proposal of creating a single fund for health insurance would be accepted by voters if the ballot for the initiative were held today, according to a poll commissioned by the pharmaceutical lobby group Interpharma.

About 65 per cent of the population would approve the proposal and 28 per cent would reject it, according to the first poll conducted on the issue. The result is still not very conclusive, as only about 31 per cent of people surveyed said they would actually participate in the vote.
 
In 2014 or 2015, the initiative for public health insurance will be put to a nationwide vote, which if accepted will see current providers of basic cover replaced by a single public fund. Under Swiss law, health insurance is compulsory, and residents currently may choose between offerings of about 60 companies which provide coverage.

The initiative – supported by the centre-left Social Democrats and by the Greens as well as by patient and consumer organisations – would leave only supplemental insurance in the hands of private companies.
 
The survey was conducted as part of the 2013 Health Monitor by GfS Bern research and polling institute.  The Health Monitor also showed that three out of four people in Switzerland view the health system in Switzerland positively, the highest share ever.

http://www.swissinfo.ch/eng/swiss_news/Swiss_voters_back_single-payer_health_insurance.html?cid=36250986

swissinfo.ch, April 19, 2013

According to the 2012 Health Monitor of the GfS Bern research and polling institute, 40 per cent of those questioned were in favour of a change, while 45 per cent preferred to stick with the current system.

http://www.swissinfo.ch/eng/swiss_news/Seeking_a_political_cure_for_rising_health_costs.html?cid=35544180

Comment:

By Don McCanne, M.D.

Whereas last year 40 percent of Swiss voters supported change in the health insurance system, the same poll this year shows that 65 percent support a single fund for health insurance – single payer. It is difficult to know if this support is malleable, and whether it would hold up under the political rhetoric of campaigns. A similar measure in 2007 was rejected by 70 percent of their voters.

Nevertheless, it should make us challenge those who keep telling us that we need a system just like the Swiss have – a mandate to purchase plans from a market in which about 60 insurers participate. Clearly, though they view their system positively, there is very strong support for a single public health insurance program.

CMS’s new website (https://www.healthcare.gov/) promotes the “Health Insurance Marketplace.” Sounds sort of like the Swiss system. If we’re going copy the Swiss, why don’t we skip their mistakes and go directly to single payer?

The good news on reference pricing isn't all good

CalPERS Members Had Similar to Better Outcomes at Facilities Charging Less for Hip and Knee Replacements

WellPoint
Press Release, June 23, 2013

A pilot program for the California Public Employees’ Retirement System lowered the price of members’ hip and knee replacement surgeries by 19 percent in one year while also demonstrating similar to better outcomes at lower-cost hospitals.

The analysis, conducted by HealthCore, WellPoint’s outcomes research company, will be presented at the AcademyHealth Annual Research Meeting today in Baltimore. The study is based on findings for the referenced-based purchasing design program for CalPERS members developed by CalPERS and WellPoint’s affiliated health plan in California.

As part of the CalPERS intervention program, members of the California Public Employees’ Retirement System were given a list of designated facilities that charged less than $30,000 for in-patient costs associated with each knee and hip replacement surgery.

To qualify for the list, hospitals had to have already contracted with the network of WellPoint’s California affiliated health plan, which manages a robust credentialing process.

Members were able to either choose from 46 facilities on the list that would result in them paying little to no out-of-pocket costs beyond deductible or co-insurance or pay the difference if they used another facility that charged more than $30,000.

The result was that CalPERS health plan costs dropped significantly – by 19 percent from $35,408 to $28,695, per surgical-related admission.

http://ir.wellpoint.com/phoenix.zhtml?c=130104&p=irol-newsArticle&ID=1832119&highlight=

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Hospitals cut some surgery prices after CalPERS caps reimbursements

By Chad Terhune
Los Angeles Times, June 13, 2013

When the California Public Employees’ Retirement System told its Anthem Blue Cross members it would pay only up to $30,000 for a knee or hip replacement surgery, some patients shopped around for a cheaper hospital.

What may be more surprising is that about 40 higher-priced hospitals in the state cut their surgery prices significantly to avoid losing patients. That response accounted for about 85% of the $5.5 million CalPERS saved over two years, researchers at UC Berkeley found, with the rest of the savings coming from patients opting for lower-cost hospitals.

It works essentially as a reverse deductible for employees and their families. Their employer will pay up to a certain amount for a surgery, colonoscopy or lab test and anything above that amount comes out of the patient’s pocket.

http://www.latimes.com/business/money/la-fi-mo-calpers-hospital-surgery-prices-20130623,0,6571991.story

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Effects of a Reference-Based Purchasing Design Program on Healthcare Utilization and Outcomes of Knee and Hip Replacement Surgeries

Co-authors: Sze-jung Wu, HealthCore, Inc.; Michael Belman, Anthem Blue Cross; Andrea DeVries, HealthCore, Inc.
Presenter: Chia-hsuan Li, M.S., Senior Research Analyst, Health Plan Research, HealthCore, Inc.
AcademyHealth, 2013 Annual Research Meeting, June 23-25, 2013

Research Objective:

Controlling healthcare expenditure while ensuring the delivery of high-quality care is a priority for payers. Recognizing the wide discrepancies in cost for joint replacement procedures, a large employer group in California implemented a RBPD program (Reference-Based Purchasing Design program) beginning in 2011 for total knee replacement (TKR) and total hip replacement (THR) based on a threshold facility payment of $30,000. Members were given a list of designated facilities meeting the threshold and were told that they would be responsible for cost differences above the threshold if they chose non-designated facilities. This study is aimed at evaluating the impact of the RBPD program on utilization and patients’ health outcomes, relative to a comparison population.

Study Design:

A retrospective observational study was conducted using administrative claims. We compared TKR and THR rates at RBPD-designated facilities in the intervention group to a comparison group without the RBPD program at baseline year (2010) and intervention year (2011). The change in average cost per procedure was measured. We also compared postsurgery infection, complication, and hospital readmission rates between two cohorts. The difference in utilization and health outcomes between groups were examined by ANOVA and chi-square tests. Multinomial logistic models were fitted to examine the likelihood of unfavorable health outcomes between groups adjusted for age, gender, and comorbid conditions.

Population Studied:

Adults under age 65 diagnosed with osteoarthritis and receiving a unilateral TKR or THR. The intervention cohort consisted of members of the employer group where the RBPD program was implemented (N=799), whereas the comparison cohort contained individuals not covered by the employer health plan but living in the same geographic area (N= 5,279). Each patient was followed for 30 and 90 days following the surgery or until their health plan eligibility ended.

Principal Findings:

Use of RBPD-designated facilities rose 21% among the intervention group (from 45.7% in 2010 to 55.5% in 2011, p<.01) while decreasing 24% among the comparison group (46.5% & 35.4%, p<.01). Average allowed cost (sum of plan paid and patient out-of-pocket) decreased 20.6% for TKR (p<.01) and 13% for THR (p=.01) for the entire intervention group. Patients in the intervention group using RBPD-designated facilities experienced reductions in allowed cost, so did those using non-designated facilities. The reductions were greater for non-designated facilities users (p<.01 both procedures). Out-of-pocket cost remained unchanged (p>.5 both). RBPD-designated facilities were associated with lower adjusted likelihood of 30-day general infection and complication (OR: 0.47, 95% C.I.: 0.24 – 0.94 infection; 0.68, (0.47, 0.98) complication), and a statistical insignificant adjusted rate of 90-day hospital readmission (1, (0.58,1.77) ).

Conclusion:

The RBPD program increased the use of designated facilities by 21% for the entire intervention group, achieving allowed cost reductions of 18% per procedure while out-of-pocket cost to members remained relatively flat. The quality was unaffected. Implications for Policy, Delivery or Practice: Traditional cost-sharing strategies have shown little effect on member’s choice in providers, most likely because members are insensitive to procedure costs and unaware of cost variation. RBPD addresses these barriers. This study suggests that a RBPD program can engage members to choose high-value services with lower cost but unaffected quality.

Funding Source(s): WellPoint, Inc.

AcademyHealth Podium Presentation Abstracts (page 33 for this report): http://www.academyhealth.org/files/ARM/2013/All%20Podium%20Presentations.pdf

Comment:

By Don McCanne, M.D.

Reference pricing controls spending by setting a price near the low end of market prices for a given health care service or bundled service, and then requiring the patient to pay any amount over the reference price. It is a reversal of charging the patient a deductible, in that the patient pays any excess at the top, rather than a set amount at the bottom. It is a form of defined contribution, and as such could expose the patient to potentially much higher costs above the reference price.

California Public Employees’ Retirement System (CalPERS) and WellPoint’s Anthem Blue Cross joined together in this pilot program on reference pricing. Prices for the services covered wer
e reduced – 13% for total hip replacement and and 21 percent for total knee replacement – and out-of-pocket costs did not change for patients. It worked. Facilities reduced their prices to reference levels, and patients used facilities that adhered to reference prices, and therefore they were not penalized financially.

The primary trade off appeared to be that 21 percent of patients switched to facilities that were not their initial choices. This has a potential of disrupting established, integrated care patterns, though this was not evaluated in the study. An example might be of a reference price for diagnostic imaging that is available only in an institution not associated with your usual sources of care, leading you to either disrupt your care or suffer higher out-of-pocket spending.

There also can be a problem establishing a reference price. The insurer may set a price available only in distant urban regions – a price that is not available in your community. You could have a $50,000 procedure that might cost you $1,000 under a high-deductible PPO, but have a price of $30,000 under reference pricing, leaving you stuck with a bill of $20,000 if you find that a reference-based institution is not readily accessible. Reference pricing is not a perfect solution.

There is a much more fundamental problem with reference pricing that is not so obvious. In a September 2012 Health Affairs article on reference pricing (in centers of excellence), James Robinson and Kimberly MacPherson write, “Both reference pricing and centers-of-excellence contracting can be used by Medicare Advantage health plans because they have the ability to impose differential cost-sharing requirements and exclude providers altogether from their contractual networks. However, the new benefit designs will be applicable to traditional Medicare only if the program becomes willing and able to use consumer cost sharing to channel patients to particular providers based on quality and efficiency.”

From this comment, it is obvious that reference pricing is a creation of those who believe that the consumer (patient) should be in charge of making purchasing decisions based on price. It is the obsession of the policy community with this market concept of health care purchasing that has led to the highly dysfunctional, egregiously expensive, and poorly allocated health care system that we have today.

Think about it. The traditional Medicare program has been far more effective than the private insurers at getting health care priced appropriately, and yet they say that we should abandon that approach and “use consumer cost sharing to channel patients.” That is, we should shift risk to the patients – exposing them to financial penalties should they not make perfect decisions in their health care purchasing, even as the private insurers create yet more barriers to perfectly priced health care!

Forget reference pricing. Let’s let our public administrators obtain the best value for us through global budgeting of our hospitals and negotiated rates for professional services and products, as we would have with a single payer system. A “reference price” wouldn’t make any sense in such a logical system. There would be only one price, paid by our public administrator, based on legitimate costs and fair margins.