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Low cognitive ability impairs enrollment in Medicare supplemental plans

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Low cognitive ability impairs enrollment in Medicare supplemental plans

Low Cognitive Ability And Poor Skill With Numbers May Prevent Many From Enrolling In Medicare Supplemental Coverage

By Sewin Chan and Brian Elbel
Health Affairs, August 2012

Abstract

Because traditional Medicare leaves substantial gaps in coverage, many people obtain supplemental coverage to limit their exposure to out-of-pocket costs. However, some Medicare beneficiaries may not be well equipped to navigate the complex supplemental coverage landscape successfully because of their lower cognitive ability or numeracy—that is, the ability to work with numbers. We found that people in the lower third of the cognitive ability and numeracy distributions were at least eleven percentage points less likely than those in the upper third to enroll in a supplemental Medicare insurance plan. This result means that many Medicare beneficiaries do not have the financial protections and other benefits that would be available to them if they were enrolled in a supplemental insurance plan. Our findings suggest that policy makers may want to consider alternatives tailored to these high-need groups, such as enhanced education and enrollment programs, simpler sets of plan choices, or even some type of automatic enrollment with an option to decline coverage.

From the Conclusion

Many public policies focus on individual choice as a means of determining exactly how benefits should be distributed or of assuring that a policy has maximal effectiveness. Inherent in all of these policies is the assumption that all or most people have the mental capacity to make the choices that are in their best interest. We have shown that many people do not have this capacity and that this deficiency can affect their choices in adverse ways.

Overall, people in the lower third of the cognitive ability distribution were six to twenty-three percentage points less likely to enroll in a supplemental Medicare insurance plan than those in the upper third of the cognitive ability distribution, even after controlling for a host of other variables. Furthermore, the chance of enrolling in a supplemental Medicare insurance plan was approximately five percentage points lower for those in the lower third of the numeracy distribution than for those in the upper third.

These problems were most pronounced for those with low incomes, low wealth, and multiple chronic illnesses, where the likelihood of enrollment was forty percentage points lower for the least cognitively able, and an additional thirteen percentage points lower for those with weak numeracy skills. People who are chronically ill and those who do not have the financial ability to self-insure against substantial out-of-pocket costs would almost certainly be better off enrolling in supplemental insurance plans.

The magnitude of our findings on cognitive ability and numeracy was sizable, particularly compared to the influence of health on enrollment decisions. By way of comparison, if we add together the estimated effect on enrollment for people who were hospitalized in the past year and those with three or more chronic illnesses, the sum is still considerably less than the negative effect of being in the bottom third of the cognitive ability distribution.

Given the difficulty associated with making good choices, addressing the problem of low cognitive ability and numeracy is important, and not only for Medicare. Health care reform is likely to increase the set of decisions to be made, particularly for the newly insured. Unless there is comprehensive insurance coverage in which all services are covered and the issue of coverage choices is redundant, understanding the role of cognitive ability and numeracy in making these decisions is essential.

http://content.healthaffairs.org/content/31/8/1847.full

Comment: 

By Don McCanne, MD

This study demonstrates that low cognitive ability decreases enrollment in supplemental Medicare insurance plans, preventing these individuals from having the financial protections and other benefits of supplemental coverage. Other studies have shown that this results in impaired outcomes.

Although the authors recommend approaches that would improve enrollment while preserving choice, they end with a statement that begins, “Unless there is comprehensive insurance coverage in which all services are covered and the issue of coverage choices is redundant…”

Of course, an expanded and improved Medicare which, amongst other improvements, would roll into the benefit package the coverage provided by supplemental plans, would obviate the need to make any choices since all reasonable services would be covered. Low cognitive ability and poor skill with numbers would no longer be determinants in whether or not a person had adequate coverage. Everyone would automatically.

It's Time for Single-Payer

By Dr. James Mitchiner
American College of Emergency Physicians (ACEP) News, 08/07/12

“You can always trust the Americans to do the right thing, once they’ve tried everything else.”

Winston Churchill’s iconic remark, reportedly issued at the dawn of America’s entry into World War II, is equally applicable to the present American health care debate and the crisis that spawned it.

Regardless of whether you are elated or disappointed with June’s historic Supreme Court decision upholding the constitutionality of the Affordable Care Act, it is certainly no panacea for the problems facing U.S. health care. Even with the law intact, and despite its best intentions, it will still leave some 25 million uninsured, underinsure millions more, expand the corporatization of health care, and do little to control the escalating costs of care over the long term.

So it’s clear we need to do the right thing: the creation of a national, universal, publicly funded health care system, free of the corrupting power of profit-oriented health insurance, and at the same time capable of passing constitutional muster. In short, the right thing is an expanded and improved Medicare-for-All program, otherwise known as single-payer.

Don’t be so shocked. For the last 30 years, we have tried all the alternatives, and none of them have worked. We have experimented with HMOs, PPOs, high-deductible health plans, health savings accounts, pay-for-performance, capitation, and disease management. These ideas have been promoted in various iterations, often with great fanfare, by public and private payers alike, yet none of them have shown long-term success at bending the cost curve. And the promise of the latest reforms du jour, such as Accountable Care Organizations and Patient-Centered Medical Homes, is speculative at best.

American health care is unique among the world’s democracies in that it was never planned in terms of enabling legislation or explicit constitutional authority. As others have stated, our employer-based insurance system, which now covers about 160 million Americans, was an accident of history. Its lineage can be traced to FDR’s wage and price control policies during World War II, where employers were permitted to offer workers health insurance in lieu of higher wages as a job inducement.

This benefit has evolved piecemeal into the Rube Goldberg complexity that is contemporary employer-sponsored health insurance, with some 1,200 private plans each doing the same things – medical underwriting, coordination of benefits, claims adjudication and denial, marketing, public relations, lobbying, litigating, and paying shareholder dividends and inflated CEO salaries while forcing individuals to pay a higher share of premiums, increased deductibles, expanded copays, or a combination of all three.

Taken as a whole, private insurers’ activities are duplicative, inefficient, wasteful of scarce health care resources, conducive of job lock, and completely misdirected in supporting the 21st-century health care agenda that America needs and deserves.

The objective of the ACA’s individual mandate was to remedy a flaw in the market for health insurance: the expectation by the uninsured that the costs of their inevitable illnesses would be benignly transferred to those fortunate to have coverage. If you believe that guaranteed issue and community-rating requires 100% participation in the health insurance market to sustain financial viability, clearly the most efficient mechanism to achieve this is not through an individual mandate, in which the heavy hand of government coerces people to do what they otherwise would not. If the federal government has a professed welfare interest in controlling health care costs, it can – and should – accomplish that goal through a more economically efficient single-payer mechanism.

Given that the primary business objective of a for-profit insurer is to make a profit, the fundamental question we should be asking is this: What is the marginal value of private health insurance? That is, what advantage vis-à-vis a single-payer model like Medicare does our system of private, profit-oriented health insurance convey to patients, providers, and employers? What exactly do private insurers do, above and beyond what Medicare does, that is deserving of their inflated premiums? To my knowledge, there is no evidence that commercial insurance provides easier access or less hassle-free care, is more cost effective, produces care of higher quality, or has better consumer satisfaction ratings than Medicare (if anyone has evidence to the contrary, from the peer-reviewed health policy literature, please advise). And according to a recent poll, most Americans prefer to keep Medicare as it is, rather than switching to a premium-support financing mechanism as advocated by Rep. Paul Ryan (R-Wis.). Whatever bad things you can say about our government, at least the Feds are not required to make a profit but are required to answer to all taxpayers, rather than private shareholders who are concerned only with the bottom line.

Under a single-payer system, every American would receive a basic package that would include inpatient and outpatient care, primary care and specialty physician services, emergency care, preventive and restorative care, mental health and substance abuse services, dental care, prescription drugs, home health care, and long-term care. Doctors and other providers would be paid based on a fee-for-service schedule, as negotiated with state governments, with funding coming from progressive payroll taxes paid by both individuals and employers. Quality would be monitored and publicly reported, with financial incentives awarded to providers who followed clinical guidelines endorsed by their medical specialty societies. All services provided would be publicly accountable. Medical decision making at the bedside would be left to the physician.

Conceptually, single-payer is imbued with many myths and misconceptions.

Myth #1: Single-Payer Is One-Size-Fits-All

The No. 1 myth – the alpha myth – is that single-payer represents a choiceless, one-size-fits-all, government-run health care monopsony. This is a blatant falsehood. Single-payer is simply a more efficient and more equitable way of financing health care – and nothing more. By consolidating the administrative functions of insurance, it eliminates bureaucratic duplication and reduces administrative waste, saving time and money for employers, providers, state governments, and consumers alike. It would remove the profit motive from financing care, but not from delivering it. Single-payer would efficiently provide for all Americans – regardless of age, health condition, income, or employment status – universal health care that is portable, affordable, equitable, nonterminating, publicly accountable, and funded through progressive taxation, which for the average family would imply a small additional payroll tax that is much less than its current outlay for insurance premiums. A single-payer system would not supplant the private practice of medicine; you could go to a primary care doctor, specialist, hospital, pharmacist, and lab of your choice.

Myth #2: Canadian Health Care Would Be Bad for America

Americans love to repeat anecdotes about the supposedly lousy medical care our northern neighbors receive from their single-payer system, by demoralized and overworked doctors who work at ill-equipped hospitals with out-of-date technology. This is rubbish. Do Canadians often wait for weeks to see a specialist? Yes. Do Americans also wait? Yes. There is no evidence that Canadians are dropping dead in the streets while waiting for their emergency bypasses or appendectomies, nor is there any evidence that Canadian physicians are emigrating to the U.S. or other countries en masse. Further, there is no evidence that the quality of care in Cana
da, across the board, is inferior to that practiced in the U.S. Despite comparable rates of smoking and alcoholism, Canadians on average live longer than Americans by more than 2 years, and their infant mortality rate is less than ours. Finally, consider this: Canadians spend much less than we do for health care, both in per-capita dollars and as a percent of GDP, so I have no doubt that if we were to adopt a Canadian-style system and fund it to the tune of $2.6 trillion annually, we would not have 9-month waits for MRIs, even if every one of them was clinically indicated.

Myth #3: Market-Based Medicine Trumps Single-Payer

Some argue that our private, market-based system is fundamentally sound, that it should be freed of government regulation and tweaked to promote greater competition based on price, and thus choice of health insurance plans. Really? Does anyone seriously believe that purchasing health care services is fundamentally no different from buying a new car or a flat-screen TV? (If so, I suggest he or she take a course in health economics.) And would anyone seriously believe that Americans want a choice of health insurance, when what they really desire is a choice of doctors and hospitals? What could be more American, more consumer-friendly, and more constitutional than the ability to choose your health care provider based on whatever criteria you deem important? So why not cut out the middleman and let doctors, hospitals, and other providers compete on such things as quality, service, reputation, convenience, and other personal preferences, rather than having private insurers make these choices for us?

Just consider what “The Market” has done for health care in the last 30 years: a steady increase in the number of uninsured; a decrease in the choice of providers; diversion of resources into more profitable hospitals and services; consolidation of HMOs into health care oligopolies; underfunding of less profitable endeavors, such as public health, trauma centers, and mental health services; unaffordable prescription drugs; dissatisfied patients; frustrated physicians; and of course, an inexorably increasing trajectory of health care costs.

Myth #4: Single-Payer Would Stop Medical Innovation

To my knowledge, there is no correlation between innovation and a country’s method of health care financing. Many technologies and medical advances we now take for granted originated in nations with national health insurance, for example, CT scans and MRIs (Great Britain), laparoscopic cholecystectomy (Canada), percutaneous coronary angioplasty (Germany), and H. pylori treatment (Australia). The largest single source of funding for medical research in the U.S. is a government agency – the National Institutes of Health – which provided almost $31 billion in funding for medical research in fiscal year 2012. And in terms of per-capita drug R&D costs, the U.S. lags behind Britain and Sweden.

Myth #5: Single-Payer Is Impossible to Enact Politically

Perhaps this is true – for now. But if social change depended solely on what was politically pragmatic, women would not have achieved the right to vote in 1920, civil rights legislation would not have been enacted in 1964, and Medicare would have failed in 1965. We should always be careful to distinguish between what’s desirable and what’s doable. The fact that tort reform is certainly desirable, but not politically doable at the present time, has not stopped ACEP from investing significant time and financial resources to advocate for change. Public opinion polls have consistently shown that the level of public support for single-payer is 60% plus. A survey of physicians published 4 years ago showed that single-payer garnered 59% support among the 2,193 physicians polled (support among emergency physicians was even higher, at 69%). Despite this, there is no question that moving to a single-payer system will face enormous obstacles. What is needed, as columnist David Lazarus of the Los Angeles Times pointed out, is a “massive infusion of political courage and the willingness to forsake political purity.”

Myth #6: We Can’t Afford Single-Payer

Given our current system, perhaps the better statement would be “we can’t afford not to have single-payer.” The most recent financial projections portend no overall decrease in the cost trajectory for health care over the next 8 years, even if the ACA remains intact. Under a single-payer model, a modest increase in taxes would be overshadowed by savings from elimination of insurance premiums, offsets from economies of scale, decreased out-of-pocket payments, and the disappearance of cost-shifting. The annual savings from transforming to a single-payer system are estimated to be $400 billion. If you look at the cost curves for U.S. and Canadian health care, they were identical until the mid-1970s, when Canada’s health system was fully implemented. From then on, the curves diverged, with America’s climbing much faster than Canada’s. When Taiwan converted to single-payer in 1995, the costs went up in the first year, as expected, and then leveled off to a reasonable increase of about 3% per year.

What Does This Mean for Emergency Medicine?

Well, consider the ED as a de facto single-payer environment. Patients come to us by choice without needing to first check with their health plan (assuming they have one) to see if their ED visit is covered. We see them without asking them to pay in advance for their ED services, and their care is not predicated on their job, income, or insurance coverage. As emergency physicians, we have more autonomy than our primary care colleagues in terms of making diagnostic and therapeutic decisions without the nonsense of “pre-authorization” or other interference from an insurer who is interested only in the bottom line. While it’s nice to be able to make medical decisions without checking on insurance status, it would be even nicer if we actually got paid for every ED patient treated. Private insurance companies simply have no incentive – in fact, it’s not at all consistent with their business model – to pay for EMTALA-mandated services provided by out-of-network emergency physicians.

Looking again to Medicare as a single-payer model, consider how we emergency physicians interact with Medicare vs. private insurers. In 29 years of practice, I have never had to seek permission from a CMS official to admit a fee-for-service Medicare patient, have never had a consultant refuse a referral for a Medicare beneficiary, and have never had a pharmacist call me to say the prescription for my Medicare patient was not covered by the formulary. This is not true for some of my patients in managed care plans, including those who were sick enough to be admitted but had to be transferred because my hospital (which the patients self-selected) did not participate in their plan.

Single-payer is the only remaining option to simultaneously and synergistically expand access, control costs, preserve choice, and reduce disparities. There is simply no other efficient and constitutionally safe way to do this. Any other proposals are nothing more than tinkering around the edges and based on blind faith that some kind of future financial salvation will somehow save us from the impending health care meltdown. A single-payer, improved Medicare-for-All program would overhaul our dysfunctional health care financing system so that it works best for patients – and for physicians.

Dr. Mitchiner is an emergency physician in Ann Arbor, Mich., a former president of the Washtenaw County (Mich.) Medical Society, and a member of Physicians for a National Health Program. ACEP News is a publication of the American College of Emergency Physicians.

http://www.acepnews.com/index.php?id=495&cHash=071010
&tx_ttnews[tt_news]=1564

It’s Time for Single-Payer

By Dr. James Mitchiner
American College of Emergency Physicians (ACEP) News, 08/07/12

“You can always trust the Americans to do the right thing, once they’ve tried everything else.”

Winston Churchill’s iconic remark, reportedly issued at the dawn of America’s entry into World War II, is equally applicable to the present American health care debate and the crisis that spawned it.

Regardless of whether you are elated or disappointed with June’s historic Supreme Court decision upholding the constitutionality of the Affordable Care Act, it is certainly no panacea for the problems facing U.S. health care. Even with the law intact, and despite its best intentions, it will still leave some 25 million uninsured, underinsure millions more, expand the corporatization of health care, and do little to control the escalating costs of care over the long term.

So it’s clear we need to do the right thing: the creation of a national, universal, publicly funded health care system, free of the corrupting power of profit-oriented health insurance, and at the same time capable of passing constitutional muster. In short, the right thing is an expanded and improved Medicare-for-All program, otherwise known as single-payer.

Don’t be so shocked. For the last 30 years, we have tried all the alternatives, and none of them have worked. We have experimented with HMOs, PPOs, high-deductible health plans, health savings accounts, pay-for-performance, capitation, and disease management. These ideas have been promoted in various iterations, often with great fanfare, by public and private payers alike, yet none of them have shown long-term success at bending the cost curve. And the promise of the latest reforms du jour, such as Accountable Care Organizations and Patient-Centered Medical Homes, is speculative at best.

American health care is unique among the world’s democracies in that it was never planned in terms of enabling legislation or explicit constitutional authority. As others have stated, our employer-based insurance system, which now covers about 160 million Americans, was an accident of history. Its lineage can be traced to FDR’s wage and price control policies during World War II, where employers were permitted to offer workers health insurance in lieu of higher wages as a job inducement.

This benefit has evolved piecemeal into the Rube Goldberg complexity that is contemporary employer-sponsored health insurance, with some 1,200 private plans each doing the same things – medical underwriting, coordination of benefits, claims adjudication and denial, marketing, public relations, lobbying, litigating, and paying shareholder dividends and inflated CEO salaries while forcing individuals to pay a higher share of premiums, increased deductibles, expanded copays, or a combination of all three.

Taken as a whole, private insurers’ activities are duplicative, inefficient, wasteful of scarce health care resources, conducive of job lock, and completely misdirected in supporting the 21st-century health care agenda that America needs and deserves.

The objective of the ACA’s individual mandate was to remedy a flaw in the market for health insurance: the expectation by the uninsured that the costs of their inevitable illnesses would be benignly transferred to those fortunate to have coverage. If you believe that guaranteed issue and community-rating requires 100% participation in the health insurance market to sustain financial viability, clearly the most efficient mechanism to achieve this is not through an individual mandate, in which the heavy hand of government coerces people to do what they otherwise would not. If the federal government has a professed welfare interest in controlling health care costs, it can – and should – accomplish that goal through a more economically efficient single-payer mechanism.

Given that the primary business objective of a for-profit insurer is to make a profit, the fundamental question we should be asking is this: What is the marginal value of private health insurance? That is, what advantage vis-à-vis a single-payer model like Medicare does our system of private, profit-oriented health insurance convey to patients, providers, and employers? What exactly do private insurers do, above and beyond what Medicare does, that is deserving of their inflated premiums? To my knowledge, there is no evidence that commercial insurance provides easier access or less hassle-free care, is more cost effective, produces care of higher quality, or has better consumer satisfaction ratings than Medicare (if anyone has evidence to the contrary, from the peer-reviewed health policy literature, please advise). And according to a recent poll, most Americans prefer to keep Medicare as it is, rather than switching to a premium-support financing mechanism as advocated by Rep. Paul Ryan (R-Wis.). Whatever bad things you can say about our government, at least the Feds are not required to make a profit but are required to answer to all taxpayers, rather than private shareholders who are concerned only with the bottom line.

Under a single-payer system, every American would receive a basic package that would include inpatient and outpatient care, primary care and specialty physician services, emergency care, preventive and restorative care, mental health and substance abuse services, dental care, prescription drugs, home health care, and long-term care. Doctors and other providers would be paid based on a fee-for-service schedule, as negotiated with state governments, with funding coming from progressive payroll taxes paid by both individuals and employers. Quality would be monitored and publicly reported, with financial incentives awarded to providers who followed clinical guidelines endorsed by their medical specialty societies. All services provided would be publicly accountable. Medical decision making at the bedside would be left to the physician.

Conceptually, single-payer is imbued with many myths and misconceptions.

Myth #1: Single-Payer Is One-Size-Fits-All

The No. 1 myth – the alpha myth – is that single-payer represents a choiceless, one-size-fits-all, government-run health care monopsony. This is a blatant falsehood. Single-payer is simply a more efficient and more equitable way of financing health care – and nothing more. By consolidating the administrative functions of insurance, it eliminates bureaucratic duplication and reduces administrative waste, saving time and money for employers, providers, state governments, and consumers alike. It would remove the profit motive from financing care, but not from delivering it. Single-payer would efficiently provide for all Americans – regardless of age, health condition, income, or employment status – universal health care that is portable, affordable, equitable, nonterminating, publicly accountable, and funded through progressive taxation, which for the average family would imply a small additional payroll tax that is much less than its current outlay for insurance premiums. A single-payer system would not supplant the private practice of medicine; you could go to a primary care doctor, specialist, hospital, pharmacist, and lab of your choice.

Myth #2: Canadian Health Care Would Be Bad for America

Americans love to repeat anecdotes about the supposedly lousy medical care our northern neighbors receive from their single-payer system, by demoralized and overworked doctors who work at ill-equipped hospitals with out-of-date technology. This is rubbish. Do Canadians often wait for weeks to see a specialist? Yes. Do Americans also wait? Yes. There is no evidence that Canadians are dropping dead in the streets while waiting for their emergency bypasses or appendectomies, nor is there any evidence that Canadian physicians are emigrating to the U.S. or other countries en masse. Further, there is no evidence that the quality of care in Canada, across the board, is inferior to that practiced in the U.S. Despite comparable rates of smoking and alcoholism, Canadians on average live longer than Americans by more than 2 years, and their infant mortality rate is less than ours. Finally, consider this: Canadians spend much less than we do for health care, both in per-capita dollars and as a percent of GDP, so I have no doubt that if we were to adopt a Canadian-style system and fund it to the tune of $2.6 trillion annually, we would not have 9-month waits for MRIs, even if every one of them was clinically indicated.

Myth #3: Market-Based Medicine Trumps Single-Payer

Some argue that our private, market-based system is fundamentally sound, that it should be freed of government regulation and tweaked to promote greater competition based on price, and thus choice of health insurance plans. Really? Does anyone seriously believe that purchasing health care services is fundamentally no different from buying a new car or a flat-screen TV? (If so, I suggest he or she take a course in health economics.) And would anyone seriously believe that Americans want a choice of health insurance, when what they really desire is a choice of doctors and hospitals? What could be more American, more consumer-friendly, and more constitutional than the ability to choose your health care provider based on whatever criteria you deem important? So why not cut out the middleman and let doctors, hospitals, and other providers compete on such things as quality, service, reputation, convenience, and other personal preferences, rather than having private insurers make these choices for us?

Just consider what “The Market” has done for health care in the last 30 years: a steady increase in the number of uninsured; a decrease in the choice of providers; diversion of resources into more profitable hospitals and services; consolidation of HMOs into health care oligopolies; underfunding of less profitable endeavors, such as public health, trauma centers, and mental health services; unaffordable prescription drugs; dissatisfied patients; frustrated physicians; and of course, an inexorably increasing trajectory of health care costs.

Myth #4: Single-Payer Would Stop Medical Innovation

To my knowledge, there is no correlation between innovation and a country’s method of health care financing. Many technologies and medical advances we now take for granted originated in nations with national health insurance, for example, CT scans and MRIs (Great Britain), laparoscopic cholecystectomy (Canada), percutaneous coronary angioplasty (Germany), and H. pylori treatment (Australia). The largest single source of funding for medical research in the U.S. is a government agency – the National Institutes of Health – which provided almost $31 billion in funding for medical research in fiscal year 2012. And in terms of per-capita drug R&D costs, the U.S. lags behind Britain and Sweden.

Myth #5: Single-Payer Is Impossible to Enact Politically

Perhaps this is true – for now. But if social change depended solely on what was politically pragmatic, women would not have achieved the right to vote in 1920, civil rights legislation would not have been enacted in 1964, and Medicare would have failed in 1965. We should always be careful to distinguish between what’s desirable and what’s doable. The fact that tort reform is certainly desirable, but not politically doable at the present time, has not stopped ACEP from investing significant time and financial resources to advocate for change. Public opinion polls have consistently shown that the level of public support for single-payer is 60% plus. A survey of physicians published 4 years ago showed that single-payer garnered 59% support among the 2,193 physicians polled (support among emergency physicians was even higher, at 69%). Despite this, there is no question that moving to a single-payer system will face enormous obstacles. What is needed, as columnist David Lazarus of the Los Angeles Times pointed out, is a “massive infusion of political courage and the willingness to forsake political purity.”

Myth #6: We Can’t Afford Single-Payer

Given our current system, perhaps the better statement would be “we can’t afford not to have single-payer.” The most recent financial projections portend no overall decrease in the cost trajectory for health care over the next 8 years, even if the ACA remains intact. Under a single-payer model, a modest increase in taxes would be overshadowed by savings from elimination of insurance premiums, offsets from economies of scale, decreased out-of-pocket payments, and the disappearance of cost-shifting. The annual savings from transforming to a single-payer system are estimated to be $400 billion. If you look at the cost curves for U.S. and Canadian health care, they were identical until the mid-1970s, when Canada’s health system was fully implemented. From then on, the curves diverged, with America’s climbing much faster than Canada’s. When Taiwan converted to single-payer in 1995, the costs went up in the first year, as expected, and then leveled off to a reasonable increase of about 3% per year.

What Does This Mean for Emergency Medicine?

Well, consider the ED as a de facto single-payer environment. Patients come to us by choice without needing to first check with their health plan (assuming they have one) to see if their ED visit is covered. We see them without asking them to pay in advance for their ED services, and their care is not predicated on their job, income, or insurance coverage. As emergency physicians, we have more autonomy than our primary care colleagues in terms of making diagnostic and therapeutic decisions without the nonsense of “pre-authorization” or other interference from an insurer who is interested only in the bottom line. While it’s nice to be able to make medical decisions without checking on insurance status, it would be even nicer if we actually got paid for every ED patient treated. Private insurance companies simply have no incentive – in fact, it’s not at all consistent with their business model – to pay for EMTALA-mandated services provided by out-of-network emergency physicians.

Looking again to Medicare as a single-payer model, consider how we emergency physicians interact with Medicare vs. private insurers. In 29 years of practice, I have never had to seek permission from a CMS official to admit a fee-for-service Medicare patient, have never had a consultant refuse a referral for a Medicare beneficiary, and have never had a pharmacist call me to say the prescription for my Medicare patient was not covered by the formulary. This is not true for some of my patients in managed care plans, including those who were sick enough to be admitted but had to be transferred because my hospital (which the patients self-selected) did not participate in their plan.

Single-payer is the only remaining option to simultaneously and synergistically expand access, control costs, preserve choice, and reduce disparities. There is simply no other efficient and constitutionally safe way to do this. Any other proposals are nothing more than tinkering around the edges and based on blind faith that some kind of future financial salvation will somehow save us from the impending health care meltdown. A single-payer, improved Medicare-for-All program would overhaul our dysfunctional health care financing system so that it works best for patients – and for physicians.

Dr. Mitchiner is an emergency physician in Ann Arbor, Mich., a former president of the Washtenaw County (Mich.) Medical Society, and a member of Physicians for a National Health Program. ACEP News is a publication of the American College of Emergency Physicians.

http://www.acepnews.com/index.php?id=495&cHash=071010&tx_ttnews[tt_news]=1564

Every person deserves access to health care

By Julie Pease, M.D., et al.
Bangor Daily News, Aug. 5, 2012

On the occasion of Medicare’s 47th birthday, we urge the immediate expansion of Medicare to everyone in the United States. We need a health care system that provides access to every one of us, no matter how sick, poor, old or unemployed we may be. We need reduced costs. We need improved health outcomes.

The Affordable Care Act is not the solution. At its best, the ACA will leave 75,000 Maine people without health coverage. Another 110,000 or more will be underinsured and at risk for financial catastrophe or death when they get sick.

The ACA will not slow the soaring costs of health care. Maine’s health care costs, currently $8,500 per capita per year, will remain among the highest in the country. With no restriction on prices charged by insurance companies, many people will find even the lowest-tier policies unaffordable. Others will be unable to afford deductibles and necessary care. Still more will be bankrupted by out-of-pocket expenses when they get sick. Patients will be compelled to defer health care until they are desperately ill, further eroding public health in Maine and the rest of the nation.

The ACA entrenches the worst aspects of our health care system:

* Private health insurance companies remain the dominant portal through which most patients can access health care. Because of our current system of more than a thousand insurance plans, associated administrative waste consumes 31 percent of total health care spending. If this administrative loss were invested in health care, we could provide comprehensive care to every person with no additional funding.

* The ACA reduces Medicare costs by paying providers less, a tactic which encourages providers to avoid Medicare patients.

* The Supreme Court decision on the ACA struck down the provision which penalized states that refused to expand their Medicaid programs. In Maine, Gov. LePage proposes not only to refuse to expand MaineCare, but to curtail existing enrollment and services without penalty. If allowed by the federal government, this would further increase Maine’s numbers of uninsured residents.

* The ACA encourages cost-shifting to patients in the form of compulsory purchase of expensive policies, higher deductibles and higher co-pays.

No other nation uses our unique private insurance system, which penalizes the sick by charging them more, by reducing their benefits or by denying care altogether. None allow private insurance companies to place profit over coverage. Yet, all of them provide better care to more people for less money than we do.

Instead of further privatization of our health care system, we implore Congress to immediately extend Medicare to every person in the United States and then to work to improve it. Making Medicare universal would:

* Insure health care access to every American regardless of health, wealth, age or employment.

* Allow patients to choose their physicians, rather than having insurance companies choose for them.

* Reduce fraud by using a single set of consistent rules, regulations and forms throughout Maine and the rest of the country.

* Reduce costs of health care by eliminating administrative waste generated by the private health insurance industry. Harvard economist Dr. William Hsiao estimates that under a single system such as improved Medicare for all, Mainers would save 10 percent of total health care spending, or $1 billion in the first year alone. This is not speculation, but is based on the demonstrated performance in many other countries around the world.

Improving Medicare would:

* Include everyone, giving each person equal access and benefits.

* Cover all necessary medical, dental, vision, mental health and long-term care with little or no patient cost-sharing.

* Negotiate fair prices for pharmaceuticals, medical devices and health services.

* Determine benefits and payments based on need and evidence, not on politics.

* Assure guaranteed access to health care for all communities by defining global operating budgets for health facilities with separate capital budgets to facilitate better health planning.

We can no longer tolerate having the highest health care costs with the worst outcomes in the industrialized world. We cannot rely on our private insurance industry or on the ACA to remedy our crisis. We implore our congressional leaders to immediately protect, improve and expand Medicare. Every person in the Maine and in the United States needs and deserves access to health care.

Doctors Julie Pease and Edward Pontius are physicians who practice psychiatry in Brunswick. Dr. Philip Caper is a retired internist who lives in Brooklin. All three are members of Physicians for a National Health Program, a nonprofit research and education organization of 18,000 physicians, medical students and health professionals who support single-payer national health insurance.

http://bangordailynews.com/2012/08/05/opinion/every-person-deserves-access-to-health-care/

Everyone should be entitled to Medicare

By Bill Moyers
Moyers & Company, Aug. 4, 2012

PNHP note: The 7-minute video corresponding to the transcript below is available here.

BILL MOYERS: I read a news story this week that sent me on a nostalgic trip down memory lane. This past Monday, July 30th was the 47th anniversary of Medicare, and to celebrate it, the “Raging Grannies,” as they’re known, gathered outside the county office building in Rochester, New York to protest rumored cuts to their Medicare coverage.

RAGING GRANNIES: This old grey granny now needs a test or two –

BILL MOYERS: They praised Medicare in song as “the best deal we have in the country,” and even called for expanding it Medicare into universal health care for everyone.

It seems the Republican Speaker of the House, John Boehner, was coming up from Washington to raise funds for Republican congressional candidate Maggie Brooks. The “Raging Grannies” wanted to make certain Ms. Brooks didn’t sign on to the GOP budget which includes cuts to Medicare.

For myself, the “Raging Grannies” channeled a familiar voice, the Texas twang of my boss back in 1965, Lyndon Baines Johnson. I was a White House assistant at the time and had been working with the President and others on the team trying to get Medicare through Congress. Even with overwhelming Democratic majorities in the House and Senate, it was one tough fight. Others had tried before us.

In his 1948 State of the Union message, President Harry Truman said:

HARRY TRUMAN: This great Nation cannot afford to allow its citizens to suffer needlessly from the lack of proper medical care. Our ultimate aim must be a comprehensive insurance system to protect all our people equally against insecurity and ill health.

BILL MOYERS: But every time Harry Truman proposed legislation to do just that, Congress refused to budge. In the 1960s, John F. Kennedy took up the cause:

JOHN F. KENNEDY: Our working men and women, instead of being forced to ask for help from public charity, once they are old and ill, should start contributing now to their own retirement health program through the Social Security System…

BILL MOYERS: But his proposal failed in the Senate by just two votes.

On the other side, actor Ronald Reagan, still in private life, had signed on as the American Medical Association’s hired spokesman in their campaign against Medicare. Doctors’ wives organized thousands of small meetings in homes around the country, where guests listened to a phonograph record of Reagan deploring the evils of “socialized medicine”:

RONALD REAGAN: Behind it will come other Federal programs that will invade every area of freedom as we have known it in this country […] until one day, as Norman Thomas said […] you and I are going to spend our sunset years telling our children and our children’s children what it once was like in America when men were free.

BILL MOYERS: But now, it was Lyndon Johnson’s turn. Tragically thrust into the White House by Kennedy’s assassination, LBJ, the son of Franklin Roosevelt’s New Deal and Harry Truman’s Fair Deal, vowed to finish what they had started. He pushed us relentlessly to get it done. Here he is talking to his Vice President, Hubert Humphrey, in early March of 1965:

LYNDON JOHNSON: They are bogged down. The House had nothing this week, all damn week. Now that’s where you and Moyers and Larry O’Brien have got to find something for them. And the Senate had nothing […] so we just wasted three weeks […] Now we are here in the first week in March, and we have just got to get these things passed […] I want that program carried. And I’ll put every Cabinet officer behind you. I’ll put every banker behind you. I’ll put every organization we got behind you […] I’ll put the labor unions behind you.”

BILL MOYERS: About all he had left was the White House kitchen sink, and pretty soon he threw that behind us, too.

Later that March he called me to talk about a retroactive increase in Social Security payments that we were supporting. I had argued for it as a stimulus to the economy. LBJ said okay, but reminded me that social security and Medicare were about a lot more than economics:

LYNDON JOHNSON: My inclination would be […] that it ought to be retroactive as far back as you can get it […] because none of them ever get enough. That they are entitled to it. That that’s an obligation of ours. It’s just like your mother writing you and saying she wants $20, and I’d always sent mine a $100 when she did. I never did it because I thought it was going to be good for the economy of Austin. I always did it because I thought she was entitled to it. And I think that’s a much better reason and a much better cause and I think it can be defended on a hell of a lot better basis […] We do know that it affects the economy […] But that’s not the basis to go to the Hill, or the justification. We’ve just got to say that by God you can’t treat grandma this way. She’s entitled to it and we promised it to her.

BILL MOYERS: LBJ kept that promise. He pushed and drove and cajoled and traded, until Congress finally said yes. And so it was that 47 years ago, we traveled to Independence, Missouri, the hometown of Harry Truman, and there with the former president at his side, LBJ signed Medicare into law. Turning to Truman, whom he called “the real daddy of Medicare, ” Johnson signed him up as its first beneficiary. Harry Truman was 81.

All this was high drama, touched with history, sentimentality, politics, and compromise. A whole lot of compromise. The bill wasn’t all LBJ wanted. It was, in fact, deeply flawed. There were too few cost controls, as some principled conservatives warned, who were then rudely ignored. Co-pays and deductibles remain a problem. And we didn’t anticipate the impact of new technology, or the impact of a burgeoning population.

In fact, even as he signed the bill we still weren’t sure what all was in it. As LBJ himself once told me, never watch hogs slaughtered before breakfast and never, never, never show young children how legislation gets enacted.

But Lyndon Johnson had warned: “We will face a new challenge and that will be what to do within our economy to adjust ourselves to a life span and a work span for the average man or woman of 100 years.”

That longevity, and the cost, are what we must now reckon with. As the historian Robert Dallek has written, Medicare and Medicaid, the similar program for the very poor, “…did not solve the problem of care at reasonable cost for all Americans,” but “the benefits to the elderly and the indigent…are indisputable.” And there’s no going back, current efforts notwithstanding. A new study in the journal Health Affairs finds that Medicare beneficiaries age 65 and older are more satisfied with their health insurance, have better access to care, and are less likely to have problems paying medical bills than working-age adults who get insurance through employers or purchase coverage on their own.

So sing on, Raging Grannies, sing on. The surest way to save so popular and efficient a health care system is to make it available to everyone.

RAGING GRANNIES: Everybody in and nobody out, single-payer Medicare for all.

At least one man thinks the answer is Medicare for everyone

By Tom Eblen
Lexington (Ky.) Herald-Leader, Aug. 6, 2012

Medicare turned 47 years old last Monday. Bill Mahan celebrated by setting up a booth on Main Street to try to convince passersby that America’s health insurance crisis could be eased considerably if everyone had Medicare.

The Lexington retiree collected about 125 signatures for his petition. It asks members of Congress to support proposed legislation that would strengthen Medicare, which now covers more than 47 million seniors and disabled people, and make it the vehicle for providing basic universal health insurance coverage.

But Mahan spent much of his seven hours on Main Street listening to people tell him their horror stories: lack of insurance, inadequate coverage, baffling paperwork, treatment they can’t afford to get and medical bills they can’t afford to pay.

“I’ve heard so many stories, it’s just unbelievable,” said Mahan, 68, who went on Medicare three years ago. “I don’t know what to tell these people.”

What Mahan mostly tells them is that these problems are likely to continue until the United States has a single-payer health insurance system.

Under proposed single-payer systems, private doctors and hospitals would provide health care services, but the government would pay the cost from tax revenue. It is the system used in Canada and most European countries, which the World Heath Organization says offers better care for less cost than the United States does.

President Harry S. Truman proposed a single- payer system after World War II, but business interests fought it. President Lyndon Johnson was able to muster enough political support to create Medicare for seniors, which he signed into law July 30, 1965.

When President Barack Obama and a Democratic-controlled Congress pushed through health care reform legislation in 2010, a single-payer system wasn’t even considered. That was because of opposition from insurance companies, which wouldn’t even allow a “public option” choice.

Instead, we ended up with reform legislation that will cover more people and outlaw the worst insurance industry abuses but still will leave an estimated 23 million people uninsured and do too little to curb rising costs.

Republicans have vowed to repeal “Obamacare” but have proposed no adequate alternatives. Senate Republican Leader Mitch McConnell of Kentucky complains that Obama’s health care law is “Europeanizing” America, but he fails to mention that those European systems provide high-quality, universal care with much less administrative cost and hassle.

The most radical GOP plan, proposed by Rep. Paul Ryan of Wisconsin and endorsed by many Republican leaders, essentially would privatize Medicare. But an independent analysis by the non-partisan Congressional Budget Office found that Ryan’s plan, rather than reducing costs, would increase them dramatically, including almost doubling seniors’ out-of-pocket expenses.

Ironically, Obama’s reform law was based on market concepts developed by the conservative Heritage Foundation. Republican presidential candidate Mitt Romney created a similar — and rather successful — health insurance system for Massachusetts when he was governor.

Single-payer advocates say “Obamacare” is better than what we had, but it just further subsidizes private insurance companies. It reinforces our current system’s fatal flaw: the inherent conflict between businesses trying to make as much money as possible and society’s need to provide basic health care to everyone at an affordable cost.

“Insurance companies don’t improve health care,” Mahan said. “They only add cost and complexity.”

Improving and expanding Medicare would require tax increases, but single-payer advocates think that, on balance, they would amount to far less than we now pay for private insurance that costs more and covers less with each passing year. That has been the experience in countries with single-payer systems.

House Resolution 676, introduced by Rep. John Conyers, D-Mich., to create a single-payer system, has been endorsed by dozens of consumer groups, church denominations and organizations representing thousands of physicians and other health professionals. Advocacy groups include Kentuckians for Single Payer Healthcare (Kyhealthcare.org), Improved Medicare for All (Medicareforall.org) and Physicians for a National Health Program (Pnhp.org).

But without public pressure, the legislation is unlikely to get a fair hearing in the Republican-controlled House of Representatives or the Democratic-controlled Senate. The health insurance industry is just too powerful.

During Romney’s recent overseas campaign trip, the Republican presidential candidate praised Israel for having a healthy population while spending only 8 percent of gross domestic product on health care, compared to 18 percent in the United States.

How does Israel do it? Since 1995, the Jewish state has had a non-profit insurance system heavily controlled by the government that provides basic health care for everyone. Imagine that.

Tom Eblen is a Herald-Leader columnist.

http://www.kentucky.com/2012/08/06/2286868/tom-eblen-at-least-one-man-thinks.html

Oregon single-payer advocates hold house parties for their cause

By Bennett Hall
Gazette-Times (Corvallis, Ore.), Aug. 5, 2012

On a recent Wednesday night in Corvallis, a dozen people sit around Nadine Grzeskowiak’s living room sipping organic lemonade and munching gluten-free pie while video images flickered on a screen.

But they’re not watching the London Olympics. They’re viewing a Power Point presentation on America’s health care crisis.

After a series of statistics detailing soaring insurance premiums, worsening health problems and widespread medical bankruptcies, up pops a slide on the benefits of single-payer health care.

It’s not a government takeover of private medical care, Grzeskowiak tells the intimate gathering of friends and neighbors. It’s simply a rational response to a national emergency.

“People in this country don’t want anybody to take their freedoms away,” she says. “The thing is, we actually lost our freedom in this country a long time ago when it comes to health care.”

Statewide push

House parties like this one are being organized all over Oregon by reform advocates like Grzeskowiak, a registered nurse whose struggles with undiagnosed celiac disease soured her on a system she believes puts profits before patients.

“Why should I look for celiac disease,” she said one doctor asked her, “when there’s no treatment I can bill for?”

Grzeskowiak is the vice chair of Mid-Valley Health Care Advocates, one of several regional organizations working under the umbrella of Health Care for All Oregon in a statewide push to declare health care a human right.

The grassroots campaign is modeled after a successful effort in Vermont and is seen as a stepping stone on the road to establishing universal, taxpayer-funded health insurance for all Oregonians — a single-payer system.

Mid-Valley Health Care Advocates has held more than a dozen house parties to date, said Bud Laurent, the organization’s chair. Each one usually attracts 12 to 15 people, and they seem to create a self-sustaining momentum.

“We’re averaging about three a month,” Laurent said. “Often what happens is that a house party will spawn a house party.”

It’s a bottom-up strategy calculated to win a few supporters at a time. Attendees are encouraged to get involved in various ways, from distributing promotional materials and writing letters to the editor to recording video testimonials and posing for a photo holding a “Health Care Is a Human Right” placard.

The idea is to gradually build a groundswell of support for single-payer health care in this state, then push for legislative action.

New momentum?

Previous efforts to promote the idea in the Legislature have fallen short, and voters roundly rejected a Health Care for All Oregon ballot measure in 2002. Oregon reformers want to make sure they have public opinion firmly on their side before going back to the political well again.

“In my mind, we need to work at least a year, maybe two,” Laurent said, before introducing another single-payer bill or launching another initiative petition.

Not everyone at Grzeskowiak’s party was ready to jump on the single-payer bandwagon, with some of the guests asking pointed questions about the advisability of scrapping private insurance and replacing it with a government-run system financed by tax money.

That was a cue for some of the other reform advocates at the gathering to jump into the fray.

Private insurance is wasteful, argued Paul Hochfeld, an emergency room physician who co-founded a single-payer advocacy group called the Mad As Hell Doctors.

The mishmash of health plans we have now takes money away from patient care and diverts it to overhead, while the payment system creates perverse incentives to do costly and unnecessary procedures, Hochfeld said.

Meanwhile, those who can’t afford insurance put off treatment until they get desperately ill and show up in the ER, driving up the amount of uncompensated care hospitals must provide and pushing up costs for everyone else.

“What we have to do is get people to understand that we are all paying for everybody anyway,” he said.

“We just have to find a way to get value for our money.”

Eventually the conversation becomes more general, with many of the guests sharing personal horror stories of rejected insurance claims, crushing medical bills and illness left untreated for lack of coverage.

There’s also a lively exchange of ideas on different ways to improve the system.

Hochfeld said he doesn’t expect to change anyone’s mind about health reform at a house party. Most people, he believes, stake out their positions based on political ideology or personal values. But some are receptive, and those are the ones he’s hoping to reach.

“It’s not about converting people,” he said. “It’s about talking to the people who haven’t made up their minds yet one way or the other.”

Cheryl Lohman came to Grzeskowiak’s house willing to be persuaded. A small business owner with no health insurance, she recently helped her mother through a health crisis and worries about what would happen if she got sick herself.

“I’m kind of scared,” she told the group. “And I wonder what the United States would look like if we didn’t have to worry about health care.”

By the end of the meeting, Lohman is aflame with enthusiasm for single-payer health care. She grabs a stack of promotional literature, picks up some “Health Care Is a Human Right” buttons featuring a Rosie the Riveter look-alike in a nurse’s uniform, and gets her picture taken for the photo petition.

Before she leaves, Lohman tells Grzeskowiak she’s determined to do something to help promote the cause.

“It’s bubbling up inside,” she says. “I know I want to make a difference.”

http://www.gazettetimes.com/news/local/reform-party/article_aa7ac65e-ddd1-11e1-aa60-001a4bcf887a.html

Vermont Wields New Power Over Hospital Budgets

By Bob Kinzel
Vermont Public Radio, August 2nd, 2012

Vermont’s Green Mountain Care Board, established by state law in May 2011 and given new powers last spring, is taking over responsibility for virtually every aspect of health care in the state. This month’s project for the new regulatory board: How much hospital budgets should go up on an annual basis.

The board has established a cap on spending increases of no more than 3.75 percent annually. But as a group, Vermont’s 14 hospitals are seeking increases of roughly 7 percent for the coming 12 month period.

“We know there are some legitimate reasons that hospitals might need to grow higher than the 3.75 percent, most of those having to do with circumstances beyond their control,” said Anya Rader Wallack, the chairwoman of the Green Mountain Care Board.

The board may allow some increases above 3.75 percent, if the hospitals can prove that they are using the money to make investments that will lower costs in the long run.

But Wallack says the bottom line is that hospital spending needs to be kept under control: “We have a responsibility to hold down costs. So we’ll be looking at all of these requests with an eye toward how we can stay within that target, because we don’t think Vermonters can afford more than that.”

She says reviewing hospital budgets is a critical piece of the board’s efforts to help control health care costs in the state.

“I think this is significant in two senses,” Wallack said. “One is that hospital expenditures are a very significant portion of the total health care spending in Vermont.  The other is that this is the first time that the responsibility for hospital budgets and the responsibility for insurer rates has been in the same place.”

The board will hold a public hearing on the hospital requests in the middle of August. It will issue its ruling about the proposed spending increases in September.

Vermont is in the process of becoming the first state to have a single-payer health system. Gov. Peter Shumlin, a Democrat, said he would like to see the single-payer system implemented as early as 2016, a year earlier than previous estimates.

This story is part of a collaboration that includes Vermont Public Radio, NPR and Kaiser Health News.

Another Lesson From Colorado

By Dr. Marvin Malek
The Rutland Herald, Aug 5, 2012

Three hospitals in Colorado have announced that they will forgive the medical bills of the victims of the Aurora, Colo., mass shooting. A kind gesture. These individuals suffered serious gunshot wounds, and many will be left with lifelong disabilities. It seemed like this was enough suffering for these individuals and their families to endure.

These hospitals may forgive the bills of the victims of the shootings, but the care these patients received is anything but free. Teams of critical care nurses, trauma surgeons, physical therapists, and many others were there, and are always ready to handle victims of falls, crashes—and even mass shootings. The readiness of this team is a key part of the health care infrastructure.

It is safe to assume that the same day the shootings occurred, dozens of other people also utilized the services these three hospitals provide. Chances are that some have cancer, others heart disease, some may have neurologic disorders robbing them of the ability to think, to walk, to talk. These people did as much to cause their suffering as the victims of the shooting. But these individuals will not see their bills forgiven. Instead, innumerable bills will head their way. The worrisome letters from the insurance companies will arrive, possibly denying payment for all or part of their care. Some of these families will be taking out loans to pay the bills, a few will go bankrupt, others sell or foreclose on their homes. Hard not to think of this as kicking people when they’re down: If such patients become too ill to continue working, they may then lose their health care coverage at the very time they need it most, and their family members may become uninsured as well if they are included in the policy.

In every other developed country, major financial burdens are never imposed on individuals who take ill, and there is no country where loss of employment will lead anyone to end up without health insurance. Instead, the health care infrastructure is viewed as an essential resource.

This is what single payer health care is about. We all pay in when we’re well to support the health care infrastructure that will be there to care for us when we’re sick. To many Americans, this sounds utopian. But this pretty much describes the structure of health care financing in nearly every other developed country. And this is why their single payer health care systems are viewed as an essential benefit of civilized society. Not only is every citizen cared for when they’re sick, but these systems are far less costly compared to the complicated morass of a health care system we are forced to put up with here in the United States.

We’ve heard scare tactics against single payer health care for so long, that it must have come as a surprise to many Americans when one of the main highlights of the Opening Ceremony at the Olympic Games in London was a tribute to the British National Health Service. The idea of an American Olympics holding a tribute to our health insurance system would be viewed by any American as laughable.

So let’s have Vermont lead the way on single payer health care. Maybe the effort here in Vermont will be the first step toward America joining the rest of the developed world in creating a single payer health care system. Perhaps the way the shooting victims were treated in Colorado will be an inspiration. Caring for our neighbors. It’s a matter of basic decency.

Marvin Malek is an internist practicing at Central Vermont Medical Center in Berlin.

http://www.rutlandherald.com/article/20120805/OPINION06/708059911/1018/OPINION

Fireworks! Orchestras! and dancing doctors!

Fireworks! Orchestras! and dancing doctors!

Health Care – A Counter-Ceremony Honoring America’s Health Care System

By Kevin Horrigan
St. Louis Post-Dispatch, August 5, 2012

“Perhaps not surprisingly in a country where health care reform is so controversial, it was the high-profile presence of the NHS that stunned many American writers…. Certainly the U.S. equivalent, which would be dancing health insurance corporate executives, was hard to imagine.”

— Paul Harris, in The Guardian, June 28

Hah, hah, hah. Very funny. It’s not hard at all to imagine what the “U.S. equivalent” to your Olympic Opening Ceremony’s salute to Britain’s National Health Service would look like. I’m already working on it.

Sure, “dancing health insurance corporate executives” will be part of it. If you’d made that much money last year, you’d want to dance, too.

“Executives in the top spots at the country’s seven largest publicly traded health plans were paid a collective $87 million for their services in 2011,” American Medical News reported in May.

Picture this: It’s night in Florida. We’re in a darkened Raymond James Stadium in Tampa, jammed with 66,000 delegates to the Republican National Convention and their guests. A spotlight illuminates the stage. The seven top health care CEOs, carrying canes and dressed in white top hats and tails, prance on stage as the Mormon Tabernacle Choir sings “Puttin’ on the Ritz.”

Pretty nice, huh? And that’s just the start.

The spotlight widens to show 94 primary care doctors, in multi-colored scrub suits, forming a ring around David Cordani, the CEO of Cigna Health Care, bowing and scraping to honor the fact that at $19.1 million, Cordani made more in 2011 than all 94 of them combined.

The orchestra breaks into Gershwin’s “It Ain’t Necessarily So” as the stadium floor is lighted, revealing 400 actual health insurance bureaucrats wearing telephone headsets and sitting at small desks. They shake their heads back and forth in our “Salute to Rescission.”

The crowd erupts, because fans know that if Republicans repeal the Affordable Care Act, God will be in his heaven, all will be right with the world and insurance companies once again will be allowed to retroactively cancel coverage when someone needs it.

But now! What’s that? Lights around the stadium’s upper tier are forming a large donut, signifying the “Medicare donut hole” that will return once “Obamacare” is eliminated, thus insuring that drugs for anything between basic coverage and catastrophe are not covered. The orchestra swings into “Live and Let Die.”

Cannons in the end zones fire clouds of pills into the sky. As they fall to the floor, out of the stadium tunnels limp thousands of senior citizens who are allowed to scrounge for the pills. But only for three minutes, because it’s time for our….

Tribute to the ER! Giant video boards flash the image of former President George W. Bush uttering these immortal words in 2007: “I mean, people have access to health care in America. After all, you just go to an emergency room.”

The theme from the TV show “ER” comes up as sirens wail, ambulances and EMS trucks tear around the stadium floor, disgorging patients into the busy “emergency department” on center stage, already jammed with insured adults and children who have no primary care doctors.

Our ER “treats” them and send them on their way with big weights (symbolizing hospital bills) strapped to their backs, which they then pass to the people in the crowd — who are delighted to get them!

On guy-wires stretched across the top of the stadium a huge number “17.6” sparkles in gold and silver lights. It represents the percentage of the gross domestic product devoted to health care — 8 percent higher than the Brits. The music swells into Creed’s “Can You Take Me Higher?”

The crowd sings along, waving 66,000 foam “We’re Number 1” fingers, signaling America’s status as the nation with the most expensive health care in the world — 2.4 times more expensive than the silly Brits.

KA-BOOM! go the fireworks. We crane our heads skyward to see a giant figure “37,” symbolizing the World Health Organization’s ranking of the American health care system.

The big finale: With the crowd’s attention diverted skyward, volunteers — all of them from health insurance companies — have erected cardboard cutouts of men, women, children and babies around the floor of the stadium. There are so many of them — 45,000 — that they loop around the field in a squiggly line almost a mile long.

They represent the 45,000 Americans whose lack of health insurance contributes to their premature death each year, according to a 2009 study by the Harvard Medical School. Now riding into the stadium atop Rafalca, his wife’s Olympic dressage horse, is Mitt Romney, who will be nominated for president on the following night.

He guides the mare’s nose to the first cardboard figure. A simple nudge and, like dominoes, they topple over in spectacular sequence. The crowd goes wild.

http://www.stltoday.com/news/opinion/columns/kevin-horrigan/horrigan-fireworks-orchestras-and-dancing-doctors/article_3416f532-c574-5985-8ea6-802428691c1d.html

Comment: 

By Don McCanne, MD

Of course, depending on what happens in November, we could see an alternative “big finale.”

Obama could enter the stadium on his trusty steed “Single Payer,” and immediately run into the obscure maze of “Machinery Politics,” knocking Obama off of “Single Payer” who is immediately diverted to the glue factory as Obama remounts on “Pragmatic Incrementalist” who saunters over and nudges the first of 30,000 cardboard cutouts. The crowd goes wild (though only those sitting in the far left saw what really happened).

We’re going to have to do something about that crowd!

(They say that practical jokes have to be executed absolutely perfectly or you shouldn’t even try them. There is something about the domino cascade of 30,000 to 45,000 cutouts of American men, women, children and babies that just doesn’t sit well. Can we ever get the crowd to understand?)

Where ‘Socialized Medicine’ Has a U.S. Foothold

By UWE E. REINHARDT
Economix Blog, The New York Times, August 3, 2012

Last Friday’s exuberant celebration of Britain’s National Health Service during the opening ceremony for the 2012 Olympics, directed by the Oscar-winning filmmaker Danny Boyle, got me thinking about American attitudes about socialized medicine.

As might be expected, the event elicited a few tut-tuts from Conservative members of Parliament, and more stern rebukes from the commentariat in the United States, most vehemently by Rush Limbaugh.

Bashing the N.H.S. has become a favorite ritual during any debate on health care reform on this side of the Atlantic. As the disgraceful treatment of Dr. Donald Berwick, former administrator of the Centers for Medicare and Medicare Services, illustrates, any American remarking positively on the N.H.S. runs the risk of being declared unfit to serve in government and vehemently attacked in the blogosphere.

The most humorous illustration of American N.H.S.-bashing was supplied during the heated health reform discussions in 2009 by Investor’s Business Daily. In an editorial, the paper asserted, “People such as scientist Stephen Hawking wouldn’t have a chance in the U.K., where the National Health Service would say the quality of life of this brilliant man, because of his physical handicaps, is essentially worthless.”

Dr. Hawking, who has lived and worked in Britain all of his life, responded: “I wouldn’t be here today if it were not for the N.H.S. I have received a large amount of high-quality treatment without which I would not have survived.”

Eventually, Prof. Ara Darzi, a former minister of health, head of surgery at Imperial College in London and Britain’s ambassador for health and life sciences, and Tom Kibasi of McKinsey & Company, an honorary lecturer at Imperial College, gently lectured American readers on this amusing episode and on the actual modus operandi of the N.H.S. The episode also opened a lively and sometimes bemused blog traffic in Britain.

Although I personally have never advocated adopting an N.H.S.-style approach to health reform in the United States, I have been puzzled for decades by the almost instinctive habit among many Americans of incessantly running down every other country’s approach to health care and health insurance.

Is this habit born of the deep-seated insecurity that might naturally arise from the cognitive dissonance of boasting “ours is the best health system in the world,” all the while beholding daily the travails and hand-wringing over the sometimes glaring shortcomings of the American health care system?

I have found that one effective way I can stop N.H.S.-bashing dead in its track is to ask bashers this simple question: “Why don’t you like my son?” I posed that question to a congressman who had berated “socialized medicine” during a hearing on health insurance reform at which I testified.

In response to the stunned look this question invariably elicits, I go on: ”You see, our son is a retired captain of the U.S. Marine Corps. He is an American veteran. Remarkably, Americans of all political stripes have long reserved for our veterans the purest form of socialized medicine, the vast health system operated by the U.S. Department of Veterans Affairs (generally known as the V.A. health system). If socialized medicine is as bad as so many on this side of the Atlantic claim, why have both political parties ruling this land deemed socialized medicine the best health system for military veterans? Or do they just not care about them?”

I must note that there is a widespread confusion in this country over the terms “social health insurance” and “socialized medicine.”

Among policy wonks, “social health insurance” is understood to be health insurance to which the individual makes contributions on the basis of ability to pay, rather than on the basis of health status. Such a system can be coupled, and often is, with purely private health care delivery systems, including for-profit enterprises. Canada, Taiwan, Japan, South Korea, Germany, the Netherlands and Switzerland come to mind.

Socialized medicine refers to systems that couple social health insurance with government-owned and operated health care facilities, such as Britain’s N.H.S. or the Hong Kong Hospital Authority, a still-appreciated legacy of British colonialism. Socialized medicine also typified the health systems operated by the former socialist countries in the Soviet orbit. Evidently, the V.A. health system perfectly fits the definition of socialized medicine.

Occasionally one does come across an American politician who mutters something about privatizing the V.A. health system. I doubt this idea would have much political traction, either as part of a party’s platform or in the presidential candidates’ campaign repertoire.

In fact, I would dare presidential candidates professing a distaste for socialized medicine to call openly for abolition of the V.A. health system in favor of a purely privatized system – e.g., a defined contribution system such as that advocated for Medicare by Representative Paul D. Ryan, Republican of Wisconsin and chairman of the House Budget Committee.

So far I have not received a satisfactory answer from detractors of “socialized medicine” to my question of why we have the V.A. health system when socialized medicine putatively is so evil. Perhaps some commentators on this blog will enlighten me.

Before responding, however, readers might consider these readings, which can be found in an Internet search on “V.A. Health Care and Quality”: a book by Phillip Longman, “The Best Care Anywhere: Why V.A. Health Care Is Better Than Yours”; an article on V.A. health care in the American Medical Association’s amednews.com, and, finally, from the Rand Corporation’s nationally recognized team of experts on the quality of health care in the United States this eye-opening report.

http://economix.blogs.nytimes.com/2012/08/03/where-socialized-medicine-has-a-u-s-foothold/

Single payer slips into CAP forum

Cutting Health Care Costs: Leading Experts Propose Bold Solutions

Center for American Progress
August 2, 2012

The Center for American Progress convened leading health policy experts—including current and former federal and state officials, executives of health insurers and hospital systems, physicians, and economists—to develop bold and innovative solutions. These solutions are designed to reduce overall health care spending for both public and private payers.

Please join us as we release alternative strategies that would protect Americans’ access to necessary care. Several of the experts will be on hand to present the solutions, lead a discussion of the issues, and answer your questions.

From the Q&A discussion:

Harvey Fernbach, MD, a practicing physician with Physicians for a National Health Program: Wouldn’t you think that many of the bold solutions would do better if we simply expanded and improved Medicare, and take the insurance companies which are profit oriented and the businesses out of the equation because they wouldn’t have to play a major role.  That’s why President Obama was for it. I believe… we believe that… (inaudible) …a related metaphor… single payer is the gold medal for health care. I’d like to get your opinion on it.

Tom Daschle: Let me start with that because that’s as much of a political question as it is a medical one, or a health related question. I personally believe that a Medicare for all approach would be terrific. I’d be very enthusiastic about it. The problem is the current political lay of the land prevents it. So we have to deal with what’s possible, and in dealing with what’s possible, it seems to me that taking the concepts that we know could work, redesigning them and improving what we’ve got may the the next step. The ACA is the next step. It creates a new infrastructure that allows for a lot of the things we know work well, to work better across the entire country. But one day, perhaps, we’ll be in a position to alter that political landscape to accommodate something a little bit more aggressive.

Harvey Fernbach: (inaudible) … ACA eventually to single payer.

Tom Daschle: I think ACA puts us on the thirty yard line in terms of what it is we have to do with seventy yards to go. (Audience laughter.) But we’ve got a good start.

Video of CAP forum:
http://www.americanprogress.org/events/2012/08/cuttingcosts.html

Comment:

By Don McCanne, MD

This is a followup to yesterday’s Quote of the Day message on a forum on recommendations to contain health care spending, sponsored by the Center for American Progress. It was noted that single payer advocates were once again excluded from the process. Well, not quite. PNHP’s Harvey Fernback was in the audience and asked a question that prompted Tom Daschle to proclaim that “a Medicare for all approach would be terrific” and he would be “very enthusiastic about it.”

Thanks, Harvey, for being there. It’s a lesson for all of us in our reform advocacy activities. Be there and do it!

Daschle says that we still have seventy yards to go, so let’s get with it.