PNHP

Poor Americans in South Less Likely to Get Medical Care: Study

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Poor Americans in South Less Likely to Get Medical Care: Study

Researchers found states in that region imposed strictest eligibility requirements for Medicaid

By Steven Reinberg, HealthDay News
U.S. World and News Report, March 27, 2013

Poor people in the southern part of the United States are more likely to delay getting needed health care, mostly because states in that region impose the strictest eligibility requirements for Medicaid, new research says.

The problem is most pronounced in Texas and Florida, according to the report in the March 28 issue of the New England Journal of Medicine.

“There really is a great deal of variability across the country in access [to Medicaid],” said study author Dr. Cheryl Clark, from the Center for Community Health and Health Equity at Brigham and Women’s Hospital, in Boston.

Counties in states with really restrictive Medicaid policies tend to have the greatest delays, said Clark, the center’s director of health equity research and intervention.

The 2010 Affordable Care Act — derided by critics as “Obamacare” — aims to improve access to Medicaid by expanding the program and offering funding to states that adopt the expansion. Medicaid is a government-run program that offers health coverage to lower-income Americans.

States, however, don’t have to adopt the expanded program and states that have the most restrictive Medicaid policies — including Texas, Florida and Arkansas — have opted out of expanded Medicaid.

“States make different decisions around whether they decide to accept federal support to expand their Medicaid programs,” Clark said. “States are going to look very different in terms of their health care infrastructure and we may see a growing gap in health disparities.”

Another factor causing delays in care is the number of primary care doctors. Delays in care are less likely in places like New England, where there are a lot of primary care doctors, than in areas in the South, where there are fewer such physicians, Clark’s group noted.

Clark said that states that opt out of Medicaid expansion need to come up with another plan to improve access to care for the poor left out of that program.

She said there is a movement across the country to improve access to care for the poor even in places like Texas and Florida that have traditionally been less supportive of medical care for the poor.

Devon Herrick, a senior fellow at the conservative National Center for Policy Analysis, said there are alternatives under the Affordable Care Act to expand Medicaid to cover the poor.

Medicaid won’t improve access to care, he said. One problem, which may only get worse, is fewer doctors will treat Medicaid patients.

“A lot doctors don’t want to treat Medicaid enrollees because reimbursements tend to be half or even lower, compared to private insurance,” he said.

Herrick said he thinks that under the Affordable Care Act, more poor people will be able to get private insurance coverage. “These people would qualify for, really, general subsidies under private coverage,” he said. “The reimbursements to providers are nearly double Medicaid.”

Each state will have to develop its own program, he said. Some will accept Medicaid expansion and others will find a different path. “There is no one-size-fits-all solution,” he said. “There possibly 50 solutions across 50 states, maybe multiple solutions in each state.”

One critic said that private insurance under the Affordable Care Act won’t solve the access problem for many poor Americans.

“Unfortunately, the Affordable Care Act will leave about 30 million Americans uninsured, most of them U.S. citizens. These uninsured will continue to delay care, even for serious problems like heart attacks,” said Dr. Steffie Woolhandler, a professor at CUNY School of Public Health at Hunter College, in New York City.

Some of the newly insured will also delay care because their new coverage is so skimpy that they can’t to afford to use it, said Woolhandler, who is also a co-founder of Physicians for a National Health Program.

“For instance, the least expensive private insurance mandated by ‘Obamacare’ will have deductibles of up to $2,000, meaning that a policyholder who gets sick will need to pay $2,000 out of pocket before their insurance even kicks in,” she said.

“A particularly ominous development is that the Obama administration is now allowing states to force even the poorest families to pay out of pocket before they can get medical care — either by tacking co-payment onto Medicaid or, as in Arkansas, forcing the poor into skimpy private insurance plans. Hence, we can expect medically dangerous delays in care to continue,” Woolhandler said.

http://health.usnews.com/health-news/news/articles/2013/03/27/poor-americans-in-south-less-likely-to-get-medical-care-study

Policy preferences of wealthy Americans

Democracy and the Policy Preferences of Wealthy Americans

By Benjamin I. Page, Larry M. Bartels and Jason Seawright
American Political Science Association, Perspective on Politics, March 2013

Abstract

It is important to know what wealthy Americans seek from politics and how (if at all) their policy preferences differ from those of other citizens. There can be little doubt that the wealthy exert more political influence than the less affluent do. If they tend to get their way in some areas of public policy, and if they have policy preferences that differ significantly from those of most Americans, the results could be troubling for democratic policy making. Recent evidence indicates that “affluent” Americans in the top fifth of the income distribution are socially more liberal but economically more conservative than others. But until now there has been little systematic evidence about the truly wealthy, such as the top 1 percent. We report the results of a pilot study of the political views and activities of the top 1 percent or so of US wealth-holders. We find that they are extremely active politically and that they are much more conservative than the American public as a whole with respect to important policies concerning taxation, economic regulation, and especially social welfare programs. Variation within this wealthy group suggests that the top one-tenth of 1 percent of wealth-holders (people with $40 million or more in net worth) may tend to hold still more conservative views that are even more distinct from those of the general public. We suggest that these distinctive policy preferences may help account for why certain public policies in the United States appear to deviate from what the majority of US citizens wants the government to do. If this is so, it raises serious issues for democratic theory.

Health Care

The public has expressed much more support for tax-financed national health insurance (61 percent in favor) than our wealthy respondents did (just 32 percent). This represents a major gap on a central issue of social welfare policy. Similarly, a solid majority of the public (59 percent), but only a minority of the wealthy (41 percent), said they would be “willing to pay more taxes in order to provide health coverage for everyone.”

Conclusion

Our evidence indicates that the wealthy are much more concerned than other Americans about budget deficits. The wealthy are much more favorable toward cutting social welfare programs, especially Social Security and health care. They are considerably less supportive of several jobs and income programs, including an above-poverty-level minimum wage, a “decent” standard of living for the unemployed, increasing the Earned Income Tax Credit, and having the federal government “see to” —or actually provide—jobs for those who cannot find them in the private sector.

Judging by our evidence, wealthy Americans are much less willing than others to provide broad educational opportunities, by “spend[ing] whatever is necessary to ensure that all children have really good public schools they can go to” or “mak[ing] sure that everyone who wants to go to college can do so.” They are less willing to pay more taxes in order to provide health coverage for everyone, and they are much less supportive of tax-financed national health insurance. The wealthy tend to favor lower estate tax rates and to be less eager to increase income taxes on high-income people. They express concern about economic inequality and favor somewhat more egalitarian wages than they perceive as presently existing, but—to a much greater extent than the general public—the wealthy oppose government action to redistribute income or wealth.

On many important issues the preferences of the wealthy appear to differ markedly from those of the general public. Thus, if policy makers do weigh citizens’ policy preferences differentially based on their income or wealth, the result will not only significantly violate democratic ideals of political equality, but will also affect the substantive contours of American public policy.

http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=8864478

Comment:

By Don McCanne, M.D.

The wealthy have a very strong political voice. They use it to advance their own interests while opposing social programs, including tax-financed national health insurance. This is class warfare, but look at who is waging it.

Strike Debt Kicks Off Second Debt Buy-Up With March for Universal Health Care

By John Knefel
Truthout, March 26, 2013

A coalition of groups associated with Occupy Wall Street took to the streets of midtown Manhattan last Thursday evening calling for the abolition of the for-profit health care system in the United States and the creation of a government-run single-payer system. Around 70 protesters marched to four major health insurance companies to list their grievances with each corporation, often by comparing what they see as the wildly disproportionate salaries of CEOs with health costs for regular patients or the company’s average worker’s salary.

The march was part of a larger project that Strike Debt (which formed from the creative churn of Occupy) is implementing over the week to draw attention to medical debt, which the group sees as a national emergency. Strike Debt also announced that its latest round of a project known as the Rolling Jubilee has bought and abolished over $1 million in medical debt.

Activists handed out fliers on the march with statistics on just how damaging medical debt can be to households: “62% of bankruptcies are linked to medical bills” was featured prominently on the flier, as well as on a banner at the front of the march. Also on the handout was perhaps an even more surprising number: “78% of those who declared medical bankruptcy had insurance at the time they became sick.”

Strike Debt’s mission is to politicize and organize around personal debt, often by arguing that debt is not a moral failing but rather a societal problem that needs to be addressed and resisted collectively. One of the tactics, called Rolling Jubilee, involves buying “debt for pennies on the dollar, but instead of collecting it, abolish[ing] it.” The group buys debt on the open market the same way a collection agency would, but cancels the debt instead of collecting it. Funding comes from donors who contribute to the group through its website.

The first Rolling Jubilee took place in November of last year and “abolished” more than $100,000 of medical debt. The People’s Bailout, as it was called on Twitter, culminated in a telethon at a New York City music venue and garnered unusually positive press for an Occupy-related action.

The second and latest Rolling Jubilee resulted in an even larger amount of debt abolished: over $1 million, according to a post on the group’s website, for patients in Kentucky and Indiana. “The average debtor owed around $900,” the group wrote, “and we will be abolishing the debt of over 1,000 people.” Strike Debt is in the process of sending out letters to patients whose debt has been bought and abolished, as it did following the first Rolling Jubilee.

One of the most common questions asked of Strike Debt is whether it can buy and cancel specific people’s debt. The answer is no. There are no strings attached for the person whose debt has been bought, though many activists hope that someone on the receiving end of the Rolling Jubilee might throw a few bucks back in the pot – a way of paying it forward, as it were.

Thursday’s action began at Bryant Park around 4 p.m. with activists opening a dozen shredded umbrellas bearing the insignias of insurance companies, such as Cigna and Aetna. The broken umbrellas represented the activists’ beliefs that even those who have private insurance are often not fully protected by it.

In contrast, the marchers also opened a dozen intact umbrellas with the words “Medicare for all” – another phrase for single payer – painted on them.

A physician named David, part of Physicians for a National Health Program (PNHP), addressed the crowd before the march. He railed against the high costs of medical care, lambasting the idea that the solution to the problem is complicated or somehow unknowable. “The answer is single payer,” he said.

The protesters then marched to the offices of United Healthcare Group, Aetna, Blue Cross Blue Shield, and Cigna, chanting “Health care for people, not for profit” and “Bankrupt and broke, insurance is a joke.” The flier that activists handed out on the march claims that “the combined annual compensation for the CEOs” of those four companies “could buy and abolish almost 2 billion dollars of medical debt using the Rolling Jubilee model.”

Katie Robbins, also with PNHP, said the “flimsy insurance [that] people get in case they get sick is a contract that gets broken all the time,” referring to the many people in the U.S .who have insurance but nevertheless are forced to pay huge medical bills. She said that her deductible was so high that virtually any medical procedure would leave her thousands of dollars in debt. She also said that, by her calculations, having a baby could put her as much as $10,000 in debt, adding “that’s not a great place to be.”

John Knefel is the co-host of Radio Dispatch and a freelance writer based in Brooklyn.

http://truth-out.org/news/item/15342-strike-debt-kicks-off-second-debt-buy-up-with-march-for-universal-healthcare

A joint-replacement pavilion limited to prima donna doctors and rich patients

Fremont's Washington Hospital: Joint replacement patients, doctors excluded from new facility

By Ashly McGlone
MercuryNews.com, March 25, 2013

When Robert Cantley needed both knees replaced in August, he was expecting to recover from the surgery at Washington Hospital’s fancy, new $42.7 million Center for Joint Replacement.

According to hospital marketing brochures, the center offered “A Higher Level of Care” in a 20,000-square-foot space featuring 25 private patient rooms, a “breathtaking physical therapy space” and a beautifully landscaped therapy garden.

Instead, Cantley did his physical therapy sessions in a dimly lit hallway on the sixth floor of the main hospital in what he described as “a miserable set of circumstances.”

Cantley’s physician, Dr. John Jaureguito, who has been on the medical staff at Washington for 18 years, said the arrangement means his patients get “second-class” treatment. “Therapy is literally in the hallway,” he said. “I’ve never come across anything like this before.”

What Cantley and many other patients at the public hospital didn’t know was that access to the new center, the only facility of its kind in the Bay Area, is restricted to just two orthopedic surgeons at the hospital — the only ones on the Washington staff who met 24 criteria set by the hospital.

Those two doctors — long the hospital’s primary joint replacement specialists — played a critical role in the creation of the lucrative new center, and one of them acknowledges he helped create the criteria that have excluded many of his fellow surgeons. Some of those surgeons and their patients are crying foul, saying the result is a “two-tier” system of care that favors wealthier patients and chosen doctors.

“It is a community hospital, serving the public,” Cantley, 78, told the publicly elected Washington Township Health Care District board at a meeting last month. “The public in no way, shape or form should be excluded from the new wing.”

The only two surgeons who qualified, Dr. John Dearborn and Dr. Alexander Sah, received a five-year contract from the hospital to staff the center through May 2017 while maintaining their status as independent contractors, not employees, according to the contract.

The average single joint-replacement surgery performed at Washington Hospital in 2011 cost nearly $160,000, more than twice the California average, state data show.

According to one of Dearborn’s secretaries, neither he nor Sah accepts Medi-Cal or Alameda Alliance, which serve low-income residents, but typically carry lower reimbursement rates for doctors and hospitals than does Medicare.

http://www.mercurynews.com/bay-area-news/ci_22853885/fremonts-washington-hospital-patients-doctors-excluded-from-new

Comment:

By Don McCanne, M.D.

There are ten orthopedists on the staff of Washington Hospital in Fremont, California who perform joint-replacement surgery, but only two are allowed to use the hospital’s state-of-the-art Center for Joint Replacement. The Center charges more than twice the average for California, while the two approved surgeons apparently have a policy of discouraging low-income residents, including Medi-Cal patients.

Perhaps the most appalling consequence is that the patients of the other eight orthopedists receive their post-op physical therapy in the hallway of the main hospital rather than in the new “breathtaking physical therapy space.”

As a community hospital, serving the public, and with pressure from the state Department of Public Health and the Washington Township Health Care District, it is likely that this arrangement will be modified.

So what does this have to do with health care reform? We can ask ourselves if a single payer system that separately budgets capital improvements would have ever allocated funds for a state-of-the-art center serving only two prima donna surgeons and their affluent patients exclusively. Of course not. Attention surely would have been directed to a decision on whether or not it was even appropriate to establish a separate joint replacement pavilion. Likely the funds would have been better spent on improving or replacing existing surgical and physical therapy facilities.

Achieving the goal of health care justice for all will be made that much more difficult if our health care professionals and administrators fall below the ethical plane that we envision for the healing arts.

Single-payer health care is the only viable solution

By William Davidson, M.D.
The Patriot-News (Mechanicsburg, Pa.), March 24, 2013

A recent Sunday Opinion section of the Patriot-News presented two differing views of the Affordable Care Act (ACA), better known as Obamacare. Don Kusler defended the legislation while Grace-Marie Turner felt it should be repealed. Mr. Kusler noted that the law will reduce the number of uninsured by expanding Medicaid and having the government help the working poor buy health insurance policies.

Including college-age children on their parent’s policies as well as rules to prevent insurance denials because of previous conditions were other reasons to defend the ACA, according to Mr. Kusler. Ms. Turner, on the other hand, feels the legislation will be too costly, destroy jobs, and inhibit the medical industry’s creativity. She feels a new law promoting market competition would expand access to care, drive down costs while stimulating the economy.

Both points of view seem superficially defendable. But both are misleading the readers by what they don’t say. Ms. Turner seems to suffer from a very short memory. Long before President Obama came to office America’s small businesses had been experiencing double-digit increases in healthcare premiums such that many businesses no longer offer health insurance to their employees.

A competitive health care market place has been in place in America for well over 30 years. The result is we have the most expensive, dysfunctional system in the entire industrial world that leaves 1 of 6 Americans uninsured, a million medical bankruptcies, and 45,000 premature deaths yearly because of limited access to care. The countries with the less competitive markets have none of these disadvantages and spend half as much.

Mr. Kusler fails to mention that legislation that prevents denials for “previous conditions” doesn’t help much if the premiums are unaffordable. Obamacare does not prevent the insurance industry from raising premiums as was pointed out in Ms. Turner’s editorial. Even with expansion of Medicaid and government subsidies to buy insurance, ACA will leave more than 20 million Americans uninsured, a fact Mr. Kusler does not include. More importantly, the American “non-system” of health care requires 1 in 3 health care dollars to be spent on administration.

Such an incredible bureaucratic waste will become even greater as the government attempts to track employment and financial status of its citizens in order to determine their eligibility for subsidies. Finally, and the most glaring oversight by Mr. Kusler, is the reality that the medical insurance products that Americans will purchase will come with high deductibles, co-pays, and limited protection against serious illness. By preserving the private insurance industry’s stranglehold on health care, Obamacare makes health care subject to corporate profitability — not a public good.

When President Obama arrived on the scene, America’s health care system was in need of repair just like our economy was in need of help. Unfortunately, in both instances, the Obama administration in collaboration with both parties called upon corporate America to fix the problems that they (corporate America) had largely created. Not unexpectedly, their solutions served corporate America’s interests rather than that of most Americans and at the end of the day we will find that our health care system problems will remain unsolved.

Both Mr. Kusler and Ms. Turner reflect the views of our present political power structure and both leave out the only viable solution which is a publicly financed, privately delivered single-payer system.

Dr. William Davidson is a retired cardiologist and now works part-time at the Veterans Administration Hospital in Lebanon. He is also a member of HealthCare4AllPa which advocates for Single Payer state bill SB400 (The Family and Business Health Care Security Act).

http://www.pennlive.com/opinion/index.ssf/2013/03/single_payer_health_care_solution.html

Single-payer health care is still right way to go

By Dave Zweifel
The Capital Times (Madison, Wis.), March 23, 2013

For the 11th straight year, Michigan Democratic Rep. John Conyers has introduced what he calls the Expanded and Improved Medicare for All Act to establish a universal, single-payer health care system in the United States similar to what exists in most developed countries throughout the world.

Conyers’ plan is the real health care reform that the United States, if its politicians weren’t so beholden to special interests, would have adopted decades ago.

Instead, we are struggling with more jury-rigged reform that allows governors like Wisconsin’s Scott Walker to play cynical political games to make it as complicated as possible.

Obamacare is surely better than anything we’ve had up until now and once it is fully implemented will remove millions of Americans from the rolls of the uninsured.

But a single-payer plan is still the way the nation ought to go. Everyone in the country would have health care from the day they’re born to the day they die. Conyers would essentially expand the single-payer Medicare program for senior citizens to include everyone in the country.

It would cover primary care, inpatient and outpatient care, emergency care, prescription drugs, durable medical equipment, long-term and palliative care, mental health services, dental services, vision and hearing.

Conyers, who was joined by 37 other House members, would provide that private hospitals, physicians and other health providers could continue to operate as private nonprofit entities, but they would no longer be investor-owned. Hospitals, health centers and other health care organizations would be paid a monthly lump sum within a global budget to cover all operating expenses while physicians would be paid fee-for-service payments or offered regular salaries.

Under the Michigan congressman’s plan, a trust fund would be established to fund the Medicare for All program. The fund would include existing sources of federal government spending for health care, increase personal income taxes on the top 5 percent of income earners and institute modest payroll tax increases. That total is expected to be less than the premiums and health care expenses currently borne by companies and individuals.

Conyers’ plan has little chance of going anywhere, but one of these days perhaps the country will wake up to finally making health care a right of U.S. citizenship.

Dave Zweifel is editor emeritus of The Capital Times.

http://host.madison.com/news/opinion/column/dave_zweifel/plain-talk-single-payer-health-care-is-still-right-way/article_b190882c-9251-11e2-9aff-001a4bcf887a.html#ixzz2OZA6gf4z

That's what you get when you kick the can down the road

By Andrew Coates, M.D.
WAMC Northeast Public Radio, March 22, 2013

“Kicking the can down the road” is an idiom that means to defer something crucial in hopes that the problem will become someone else’s responsibility. The other day it occurred to me that “kicking the can down the road” has become a trademark of contemporary governments worldwide — from the European debt crisis, to the so-called sequester, to the decision to defer changing the tax on New York’s wealthy until a non-election year.

In many ways President Obama’s “health care overhaul,” the Affordable Care Act, is another example of kicking the can down the road. Here at the third anniversary of the reform, the bulk of the law will not begin to take effect until next year — and its full process will continue through 2019, all the way to the Presidential election after the next Presidential election.

Perhaps then it is small wonder that the Kaiser Family Foundation Health Tracking Poll found this week that a solid majority of Americans, fifty-seven percent, have no idea what the impact of the Affordable Care Act will be. Three years after “health care overhaul” was signed into law we’re still Waiting for Godot.

The Kaiser Foundation pollsters had the good sense to ask about things that were part of the debate four years ago but not part of the law. They found that a majority of people mistakenly believe that the reform will implement a so-called “public option” insurance plan.  Four of ten people think that there are government “death panels” empowered to decide whether Medicare beneficiaries live or die, although this too has no basis in reality.

The real facts are not encouraging. Inadequate access to care, uninsurance, underinsurance, medical bankruptcy and state-by-state rationing of care for the poor remain the order of the day. The real experience for those in need of medical care has not improved. Indeed in many communities it has worsened.

Still, the Affordable Care Act promises private insurance for the uninsured — starting next year. The plans offered through the state exchanges will be benchmarked to cover a minimum of 60 percent of the anticipated health care costs.

That means that a family plan purchased on the on the New York exchange will cost about $21,000 in a year in premium payments, plus an anticipated $12,500 in out of pocket expenses. Of course you can pay more if you want better coverage. In other words, starting this fall the uninsured will be able to sign up for unaffordable — yet insufficient — health coverage.

Families earning less that $92,000 will be given tax subsidies for insurance premiums, — but each family eligible will face a significant, personalized, calculus problem about whether or not to purchase insurance.

The Kaiser Family Foundation’s polling found that most people have no idea about this. I think this reveals popular wisdom. Some things we might rather not know! Cynicism and distrust of the anti-establishment that amounts to a healthy impulse.

The mainstream media consistently fails to lead with the facts. He-said, she-said reporting, with no grounding in facts, dominates. Casual attention to NPR and the daily papers invited the conclusions that both death panels and socialism were debated on Capitol Hill.

The real problem is that the Affordable Care Act kicked the can down the road, rather than taking responsibility for the health care crisis that the United States has right now. Small wonder that people don’t know how the law will change the status quo — when the ACA never aimed to to change the status quo in the first place. Unaffordable underinsurance will remain the best we can do.

That’s what you get when you kick that can down the road — until the day when the cans in the road block the way forward. Soon now we will all need to face the fact that nothing short of a public, national single-payer health program will be able to control costs, guarantee access to all, improve the quality of care — and raise us all up.

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’ commentary here:
http://www.wamc.org/post/andrew-coates-thats-what-you-get-when-you-kick-can-down-road

U.S health care is ill

By W. Dillaway, M.D.
Star-Ledger (Newark, N.J.), Letters, March 22, 2013

I do not envy Kathleen Sebelius, our secretary of Health and Human Services. Her job compels her to defend our health care system.

Her March 20 op-ed was headlined, “Health care is on the mend across the U.S.” Unfortunately, the U.S. health care system is far from being on the mend. To the contrary; the U.S. health care system fails irrefutably and unacceptably with both its economics and its ethics.

Fortunately, a single-payer, universal health care, also known as Improved and Expanded Medicare for All (H.R. 676 in Congress), offers a singular and simple solution for both the economics and ethics of our failed system.

Dr. W. Dillaway is New Jersey chapter president, Physicians for a National Health Program.

Can we recover waste by identifying geographic variations in health care?

Interim Report of the Committee on Geographic Variation in Health Care Spending and Promotion of High-Value Health Care: Preliminary Committee Observations (2013)

Institute of Medicine
The National Academies

A geographic value index would adjust payment to all providers within a defined area based on aggregate measures of spending and quality. The committee sought to determine empirically whether providers within a defined area behave similarly (e.g., exhibit similar patterns of service use across sub-regions, clinical conditions and quality measures). Consistent with a body of literature, analyses commissioned by the committee observed variation in health care spending at every geographic level (Hospital Referral Regions, Hospital Service Areas, Metropolitan Statistical Areas) studied, and additional research found variation among hospitals within Hospital Referral Regions, among physicians in the same group practice, and even within individual providers when treating different conditions. Further, Hospital Referral Regions do not consistently rank high or low across quality measures, nor is there a consistent relationship between utilization and various quality measures. These preliminary observations suggest that a geographic value index would reward low-value providers in high-value regions and punish high-value providers in low-value regions.

Health policy leaders suggest that, to improve value, payment reforms need to create incentives to encourage behavioral change in the locus of care (provider and patient), and thus payment should target decision-making units, whether they be at the level of the individual providers, hospitals, health care systems, or stakeholder collaboratives. Payment reforms contained in the ACA (e.g., value-based purchasing, accountable care organizations, bundled payments) and being tested in the commercial market and Medicaid, do target decision makers rather than geographic areas. Because these reforms are relatively new, there is little evidence to date about their effects on the value of care. Nevertheless, the results of the subcontractors’ work for this study suggest that tying a decision-making unit’s payment to its actions, as these reforms do, is preferable to induce desired changes in care. Further, because post-acute care, particularly home health and skilled nursing, is a major source of unexplained variation in Medicare spending, reforms that address incentives to overuse post-acute care, including fraud in that use, could have a large impact on health care efficiency.

http://www.iom.edu/Reports/2013/Geographic-Variation-in-Health-Care-Spending-and-Promotion-of-High-Care-Value-Interim-Report.aspx

Comment:

By Don McCanne, M.D.

Health care spending tends to fall under a Bell curve. Most of it falls in the middle, but some falls under the low end (low-cost) and some falls under the high end (high-cost). The Dartmouth studies have confirmed the geographical nature of this distribution. Thus much attention has been directed to devising methods of recovering the allegedly excessive spending in the high-cost regions. This report casts doubt that such an effort would be productive.

To begin with, the Bell curve or Gaussian distribution (normal distribution) is to be expected even when resources are being used properly. Further, this variation is found not only between geographic regions, but also between hospitals within the same regions, between physicians within the same group practices, and even by the same physicians managing different conditions. Thus measures designed to reduce spending only in geographical regions at the high end will be too blunt because they would reduce not only high-cost care of lower value, but they also would reduce legitimately high-cost care that is providing full value.

The authors of this Institute of Medicine report suggest that payment reforms instead should target decision makers rather than geographical areas. The decision makers include individual providers, hospitals, health care systems, and stakeholder collaboratives. Health payment reforms of the Affordable Care Act are designed to do just that. These include measures such as accountable care organizations, value-based purchasing, and bundled payments. Of course, adjusting payments based on these and similar reforms are much more complex administratively than merely adjusting payments based on regional spending levels.

It is questionable as to whether or not such payment systems could ever be effective in significantly improving value in the entire health care system since most impacts of the payment models are effective only at the margin, if even there. Further, Gaussian distributions would apply to these new models as well, making it likely that payment adjustments would be inappropriate for some, even if appropriate for others.

Think of the Bell curve again, but for decision makers rather than geographical regions. Many have suggested that 30 percent of health care represents wasteful spending. What if you lop off the upper 30 percent of care under the Bell curve? First you have to believe that you can identify low-value care in advance – a highly unlikely scenario. Then you have to assume that all care in the lower 70 percent provides value whereas that in the upper 30 percent does not – a preposterous assumption.

What about the lower 30 percent of the curve. Does it really represent high-value, low-cost care? Or does it represent care that is not being delivered (and therefore not measured), even if it should be. Shouldn’t we be directing more efforts to be sure that we are meeting patient needs, even if it could increase health care spending?

We are looking for ways to slow down the outrageous increases in spending for what is often mediocre care. These feeble measures that are designed to tweak decision makers are complex and likely will cost as much to administer as any meager savings that they could realize. Some of the ideas may be worth pursuing, such as value-based purchasing, but we should not deceive ourselves that these are the grand solutions for our excessive spending.

All other wealthy nations provide care for everyone at much lower costs, and they have done it without playing these pseudo-wonk policy games. We can’t rely on silly, little tweaks. We need fundamental reform of our health care financing system. We need a single payer national health program.

Single-payer health care model would save even more money than cooperative

By Ann Molison
The Coloradoan, Letters, March 21, 2013

During this month there have been two editorials, one written by the Coloradoan’s editorial board, and one by a spokesperson for a relatively new organization, Colorado Health Care Cooperative. Both writers are in support of a proposed cooperative health plan. The plan, which has yet to go before the state Senate, would result in savings and be run by a private board of directors.

This is a complex plan, so much so that the members of the state Legislature have not provided a bill number as they sort out the legalities and other issues it raises.

Another plan, first developed for the “208 Commission” will save a good deal more money than the cooperative would. It is being revised and has the support of Health Care for All Colorado. This simple and common-sense plan would move everyone living in Colorado to a public, nonprofit, single-payer model. It would have one payer and wouldn’t compete with private insurance plans. It would be similar to Medicare for all residents and its duration would be for life.

Currently over 25 states have proposed a plan similar to one which Health Care for All Colorado is refining.

From 7 to 8:30 p.m. April 3 in the Harmony Library, Donna Smith will discuss the road she has taken over the past 10 years to bring real universal health care reform in the form of a public, nonprofit, health care for all. We are pleased this outstanding national leader has joined Health Care for All Colorado as our executive director. You can learn more about our plan and Donna Smith by going to our website at www.healthcareforallcolorado.org.

Ann Molison is president of the Health Care for All Colorado Foundation.

http://www.coloradoan.com/article/20130321/OPINION03/303210061/Single-payer-health-care-model-would-save-even-more-money-than-cooperative?nclick_check=1

Selling private health insurance will not strengthen democracy

By Andrew D. Coates, M.D.
Portside news service, March 22, 2013

Nelson Lichtenstein (“Obamacare’s other benefit,” L.A. Times, March 19) is correct to hint at the potential for human liberation that universal, free access to necessary health care would bring to the United States, especially in view of the declining standard of living for the great majority of our population.

But his effort to spin the Affordable Care Act (ACA) and the corporate-backed enrollment of millions of people in private insurance plans as a liberating blow for democracy is an impossible stretch.

In this new, post-ACA era, inadequate access to care, uninsurance, underinsurance, medical bankruptcy and state-by-state rationing of care for the poor will remain the order of the day.

Enrollment in Medicaid and/or a costly, insufficient private insurance policy will not prove liberating for the American people, let alone for those who gain such inadequate “coverage.”

The present acceleration of hideous inequalities, long a hallmark of our unjust health system, will further erode, not restore, democracy in the United States.

Health system planning in the U.S. is increasingly based upon maximizing corporate profits, consolidating financial control, and otherwise enhancing corporate interests. It is based less and less upon individual and community health needs.

Despite its modest benefits, the ACA does not resolve these problems. In many ways it exacerbates them.

Yet Lichtenstein waxes enthusiastic about the potential for the ACA’s state health insurance exchanges, the instruments through which the government aims to compel the uninsured to purchase private health insurance, to contribute to a new flowering of civic involvement and democracy.

He does this even as he acknowledges that the “stakeholders” in the drive to expand private insurance and Medicaid are the big insurers, private hospitals and Big Pharma.

On top of this Lichtenstein invokes the great progressive reform movements of the last 100 years – the battle for women’s suffrage, the fight for jobs and justice during the Great Depression, the struggle for Civil Rights, and the movement to save the environment – as the inspiration for … enlisting people in exchanges where they can buy what will certainly be shoddy private health insurance.

“Because signing up for Obamacare will be complicated,” he envisions a campaign modeled on an army of H&R Block tax preparers! This notion of “Obamacare civic activism” is not only wrongheaded as historical analogy — it is shockingly disrespectful of the creative self-action and self-sacrifice of so many, including those who gave their lives for the causes he cites.

When it comes to health care needs in the United States, we must keep our eye on the prize. The fact remains that nothing short of a public, national single-payer health program will be able to control costs, guarantee access to all, improve the quality of care and protect the vulnerable.

Yes, the movement that wins health care for all will need to draw lessons from the great social movements of the past. Yes, real health reform will give new impetus to our nation’s democracy. Peddling private health insurance policies to the working poor will not get us there.

Dr. Andrew D. Coates is president of Physicians for a National Health Program (pnhp.org).

Health care for all

By Garrett Adams, M.D.
Courier-Journal (Louisville, Ky.), Letters, March 21, 2013

Humana’s sponsorship of Actors Theatre’s Festival of New Plays is unsettling to me. Why? Health insurance companies make profit for their shareholders in the following ways: by tightening administrative expenses, by restricting benefits, by refusing to insure bad risks, by steadily raising premiums, co-pays and deductibles and by denying claims.

A personal example: My friend Cheryl was a healthy young bicyclist with a successful legal career. She got leukemia. With treatment she went into remission. But, while waiting for insurance company approval to pay for a curative bone marrow transplant at MD Anderson Hospital in Texas (more about MD Anderson in Time magazine, March 4), her leukemia relapsed, and she died.

Health care in this country is now a commercial enterprise, a way to get rich from the suffering of others. Personal tragedies lie especially at the feet of health insurance companies. Knowing the deep suffering caused by this broken system, we can understand that health insurance company underwriting of arts and civic projects, even though well-intended, is problematic. Some day, like other developed countries, we will have publicly funded national health insurance. Everyone will have high quality, affordable health care and no moral dilemmas about financing the arts.

Garrett Adams, M.D., M.P.H., resides in Louisville.

http://www.courier-journal.com/article/20130321/OPINION02/303210012/Letters-Kennedy-Helm-health-care-liberals-guns