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Three ways to cut — and improve — Medicare

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Three ways to cut — and improve — Medicare

By Ed Weisbart, M.D.
STAT, Jan. 17, 2018

The Republicans are right. We should cut Medicare. And I know how: Keep Medicare’s funding for actual health care but eliminate bureaucratic waste, profits, and the expensive and preposterous ban on negotiating drug prices. In other words, get rid of Part C and Part D and absorb the extra features into traditional Medicare.

Strong majorities of Americans across the political spectrum agree that Medicare needs to negotiate the price of prescription drugs. Prices here are roughly double what patients in other countries pay for the same drugs. Over the next ten years, Medicare is projected to spend $1.5 trillion on prescription drugs. Clearly, negotiating drug prices would save a lot of money.

Medicare Advantage, formally known as Medicare Part C, was created as a way for the private insurance industry to help control the cost of Medicare. But instead of saving taxpayers money, these for-profit insurers successfully lobbied the federal government to pay them significantly more than would have been paid for comparable patients in “traditional” Medicare.

Although Advantage plans aren’t allowed to overtly exclude costly (read: unprofitable) patients, they have found ways to push high-cost patients back into traditional Medicare by charging high copayments for drugs and services that are mostly used by high-cost patients. For instance, the Advantage plans have raised copayments particularly quickly for ambulance services, home health care, partial hospitalization, and inpatient services. A new analysis shows that the resulting shift of high-cost Advantage patients to the traditional Medicare program saved the for-profit Advantage plans $5.2 billion in 2007-2009.

Advantage plans save additional money by limiting care. Compared to traditional Medicare enrollees, seniors on Advantage plans received 24 percent fewer diagnostic tests, 38 percent fewer flu shots, and 15 percent fewer colon cancer screening tests. That’s just not good medicine.

Because Medicare pays Advantage plans a higher premium for sicker seniors, Advantage plans have learned to cherry-pick healthier seniors and lemon-drop the sicker ones. For example, Medicare pays Advantage plans several thousand dollars extra for patients with heart failure. But insurers know that heart failure ranges from nearly undetectable (and inexpensive to care for) to overwhelming (and very expensive to care for). Insurers have become remarkably effective at attracting the undetectable and shunning the overwhelming. Witness the mobile echocardiogram units that provide free screening for heart failure, a strategy guaranteed to identify trivial — but reimbursable — disease.

And what is the “advantage” of throwing tax dollars at private insurers whose overhead averages 30 percent, compared to a bit over 3 percent for traditional Medicare?

Medicare Advantage insurers have learned how to maximize their payments from the federal government. They have learned to “upcode” — overestimating their members’ disease burden and justifying higher federal reimbursements — to the tune of $2 billion a year. Between upcoding and other schemes, Medicare Advantage plans are paid an average of 105 percent of what comparable patients would cost the traditional Medicare program.

Medicare Advantage is an increasingly popular choice among seniors, and now attracts more than 18 million members. The growth is easy to understand: These plans often come with richer benefit designs and reduced financial exposure for patients. But the trade-off is narrow networks of physicians and hospitals. More than one third of Advantage plans fail to include even a single National Cancer Institute center. None of the Advantage plan networks in the New York City area, for example, include Memorial Sloan Kettering Cancer Center.

Patients with short-term nursing home stays are nearly three times more likely to switch out of an Advantage plan and those with long-term nursing home stays are five times more likely. Twenty-seven percent of those leaving plans with relatively high disenrollment rates do so because of problems getting needed care; 41 percent leave because their preferred provider is not in the plan’s network. The sicker you are, and the more you actually need access to your choice of health care, the less advantage you see to an Advantage plan.

Medicare Advantage plans continue to grow in popularity, now attracting 31 percent of all Medicare beneficiaries. People make this choice because most Advantage plans offer reductions in copays and deductibles, along with enhanced benefits like membership in gym clubs or including a Medicare Part D pharmacy benefit. We could embed these modest features into traditional Medicare and still reap substantial savings for the national budget.

The arithmetic is easy, the benefits are clear, and the money is there. Take the profit motive out of Medicare to save billions. It’s just a matter of political will.

Dr. Ed Weisbart is a family physician and chair of the Missouri chapter of Physicians for a National Health Program.

https://www.statnews.com…

Dr. J. Mark Ryan on ‘Portsmouth This Week’

PNHP Rhode Island President Dr. J. Mark Ryan appeared on “Portsmouth This Week” on YouTube on January 17, 2018. He spoke with host Doug Smith about the advantages of single-payer reform for patients, doctors, taxpayers, and the public at large.

Health-care changes cause inadequate coverage

By F. Douglas Stephenson, L.C.S.W., B.C.D.
The Gainesville (Fla.) Sun, January 17, 2018

In order to further sabotage and undermine quality health care insurance for all, President Donald Trump and the GOP proposed “association health insurance plans” that let small businesses band together and insure themselves or buy insurance as a group.

Association health plans have a bad track record over the past 10 years, with dozens of court cases and enforcement actions by federal and state officials. Many turn into criminal cases involving fraud, embezzlement, diversion of premiums and mismanagement, leaving employers and employees with millions of dollars in unpaid medical bills.

Association health plans are not required to provide essential health benefits like mental health, substance abuse treatment and drug coverage, and claim they are will become exempt from all state insurance laws under Trump’s executive order.

When toxic plans like this are approved, it’s clear that our health-insurance system is broken. Like a cracked pipe, money gushes into our health-care system but steadily leaks out. Money is siphoned into the advertising budgets of private-profit insurance companies and the army of corporate bureaucrats working to deny claims.

Even more dollars are soaked up by the pockets of insurance CEOs who have collectively earned $9.8 billion since the Affordable Care Act was passed in 2010. Nearly a third of all of our health-care dollars go to something other than health care.

Another example is the deceptive appeal of profitable “copper catastrophic” plans. They are stunningly inadequate plans that have very low premiums because their actuarial value is only a pathetic 50 percent, giving the illusion of health insurance coverage.

They cover an average of about half of health-care costs. For 2017, the deductible for these plans is $7,150. These plans will work great if you never get sick or have an accident.

Offering only deteriorating financial protection, especially those with larger deductibles, this downward trend can produce severe adverse consequences for the physical, mental and financial health of the insured. Because of the spartan nature of the newly proposed copper catastrophic plans, the adverse consequences can be anticipated to be even more severe.

This latest absurd plan shows once again the fallacy that we can take beneficial policies and detrimental policies and combine them into a reasonable compromise. Good policy for big insurance companies means bad policies for hapless patients and families.

Bad policies cannot be neutralized by political accommodations. Under a well-designed Medicare for all national insurance program, catastrophic plans like these would not exist. The sooner we get to single-payer health insurance, the better it will be for all of us — meanwhile, buyer beware!

https://www.gainesville.com…

3.2 million Americans entered the ranks of the uninsured in 2017

U.S. Uninsured Rate Steady at 12.2% in Fourth Quarter of 2017

By Zac Auter
Gallup, January 16, 2018

The percentage of U.S. adults without health insurance was essentially unchanged in the fourth quarter of 2017, at 12.2%, but it is up 1.3 percentage points from the record low of 10.9% found in the last quarter of 2016. The 1.3-point increase in the uninsured rate during 2017 is the largest single-year increase Gallup and Sharecare have measured since beginning to track the rate in 2008, including the period before the Affordable Care Act (ACA) went into effect. That 1.3 point increase represents an estimated 3.2 million Americans who entered the ranks of the uninsured in 2017.

Several factors likely contributed to the increase in the uninsured rate in 2017. Some insurance companies stopped offering insurance through the exchanges, and the resulting lack of competition drove up the cost of plans for consumers. This may have caused some Americans, especially those who failed to qualify for federal subsidies, to forgo insurance.

Further, media coverage of the policies to repeal and replace the healthcare law may have caused some consumers to question whether the government would enforce the penalty for not having insurance. Congressional Republicans made several attempts to repeal or replace the healthcare law during 2017, ultimately passing a tax bill in December that repealed the individual mandate.

The uninsured rate rose for all demographic groups in 2017, with the exception of those aged 65 and older, all of whom qualify for Medicare coverage. It increased most among young adults, blacks, Hispanics and low-income Americans.

By far, the biggest change in 2017 was the decline in the percentage of Americans purchasing their own plans, likely through ACA healthcare exchanges.

Having passed their tax bill, congressional Republicans’ 2018 legislative goals include reforming funding mechanisms for Medicaid and Medicare — programs that subsidize healthcare coverage for low-income, disabled and elderly Americans. With less federal assistance from these programs to help offset the rising cost of health insurance, fewer Americans may be able to afford health insurance.

http://news.gallup.com…

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Comment:

By Don McCanne, M.D.

According to this Gallup/Sharecare survey, in the past year the number of uninsured Americans increased from 10.9% to 12.2%, an increase of 3.2 million individuals.

Although supporters of the Affordable Care Act can cite reasons for this reversal of the prior increase in the numbers who are insured, doesn’t that merely confirm that our current system is not working if we agree that truly universal coverage – absolutely everyone – is an essential goal of reform? Yet supposedly progressive reform advocates are coming out of the woodwork to dismiss the single payer concept as they propose mere additions to our highly dysfunctional financing system, leaving all of the flaws in place.

What we can say is that the current system is falling miserably short. Too many remain uninsured; many more remain underinsured; administrative excesses continue to ramp up; lack of affordability and financial hardship have been perpetuated; choice in health care professionals and institutions is diminishing, and burnout is rampant. A well designed single payer system would fix these problems. This decline in the numbers who are insured proves that the current system, even with tweaks, is not up to it.

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Why does it cost $32,093 just to give birth in America?

The US is the most expensive nation in the world in which to have a baby – and it may factor into thousands of bankruptcies each year.

By Jessica Glenza
The Guardian, Jan. 16, 2018

Stella Apo Osae-Twum and her husband did everything by the book. They went to a hospital covered by insurance, saw an obstetrician in their plan, but when her three sons – triplets – were born prematurely, bills started rolling in.

The hospital charged her family $877,000 in total.

“When the bills started coming, to be very honest, I was an emotional wreck,” said Apo Osae-Twum. “And this is in the midst of trying to take care of three babies who were premature.”

America is the most expensive nation in the world to give birth. When things go wrong – from pre-eclampsia to premature birth – costs can quickly spiral into the hundreds of thousands of dollars. While the data is limited, experts in medical debt say the costs of childbirth factor into thousands of family bankruptcies in America each year.

It’s nearly impossible to put a price tag on giving birth in America, since costs vary dramatically by state and hospital. But one 2013 study by the the advocacy group Childbirth Connection found that, on average, hospitals charged $32,093 for an uncomplicated vaginal birth and newborn care, and $51,125 for a standard caesarean section and newborn care. Insurance typically covers a large chunk of those costs, but families are still often on the hook for thousands of dollars.

Another estimate from the International Federation of Health Plans put the average amount insurers paid for a vaginal birth in the US at $10,808 in 2015. That is quintuple the IFHP estimate for another industrialized nation, Spain, where it costs $1,950 to deliver a child. The amount insurers pay for births in America is lower than the amount billed by hospitals because insurers negotiate lower prices.

Even the luxurious accommodations provided to the Duchess of Cambridge for the birth of the royal family’s daughter Princess Charlotte – believed to have cost up to $18,000 – were cheaper than many births in America.

Despite these high costs, the US consistently ranks poorly in health outcomes for mothers and infants. The US rate of infant mortality is 6.1 for every 1,000 live births, higher than Slovakia and Hungary, and nearly three times the rate of Japan and Finland. The US also has the worst rate of maternal mortality in the developed world. That means America is simultaneously the most expensive and one of the riskiest industrialized nations in which to have children.

American families rarely shoulder the full costs of childbirth on their own – but still pay far more than in other industrialized nations. Nearly half of American mothers are covered by Medicaid, a program available to low income households that covers nearly all birth costs. But people with private insurance still regularly pay thousands of dollars in co-pays, deductibles and partially reimbursed services when they give birth. Childbirth Connection put the average out of pocket childbirth costs for mothers with insurance at $3,400 in 2013.

In Apo Osae-Twum’s case, private insurance covered most of the $877,000 bill, but her family was responsible for $51,000.

Apo Osae-Twum was the victim of what is called “surprise billing.” In these cases, patients have no way of knowing whether an ambulance company, emergency room physician, anesthesiologist – or, in her case, a half-dozen neonatologists – are members of the patient’s insurance plan.

Even though Apo Osae-Twum went to a hospital covered by her insurance, none of the neonatologists who attended to her sons were “in-network.” Therefore the insurance reimbursed far less of their bills.

There are few studies that estimate the number of families who go bankrupt from this type of unexpected expense. One of the best estimates is now outdated – conducted 10 years ago. But one of the authors of that research, Dr Steffie Woolhandler, estimates as many as 56,000 families each year still go bankrupt from adding a new family member through birth or adoption.

“Why any society should let anyone be bankrupted by medical bills is beyond me, frankly,” said Woolhandler. “It just doesn’t happen in other western democracies.”

Since Woolhandler conducted that research in 2007, 20 million Americans gained health insurance through the Affordable Care Act health reform law, and consumer protections were added for pregnant women. But Republicans and the Trump administration have pledged to repeal these consumer protections.

“People face a double whammy when they’re faced with a medical condition,” said Woolhandler. Bankruptcy is often “the combined effect of medical bills and the need to take time off work.”

There is no nationwide law that provides paid family leave in the US, meaning most families forgo income to have a child.

And although childbirth is one of the most common hospital procedures in the nation, prices are completely opaque. That means Americans don’t know how much a birth will cost in advance.

Dr Renee Hsia, an emergency department physician at the University of California San Francisco and a health policy expert likened the experience to buying a car, but not knowing whether the dealership sells Fords or Lamborghinis. “You don’t know, are you going to have a complication that is a lot more expensive? And is it going to be financially ruinous?”

According to Hsia’s 2013 study, a “California woman could be charged as little as $3,296 or as much as $37,227 for a vaginal delivery, and $8,312 to $70,908 for a caesarean section, depending on which hospital she was admitted to.”

Apo Osae-Twum and her family only found relief after a professional medical billing advocate agreed to take their case. Medical Cost Advocate in New Jersey, where Derek Fitteron is CEO, negotiated with doctors to lower the charges to $1,300.

“This is why people are scared to go to the doctor, why they go bankrupt, and why they forgo other things to get care from their kids,” said Hsia. “I find it heartbreaking when patients say … ‘How much does this cost?’”

https://www.theguardian.com…

Claudia Fegan’s message in the spirit of Martin Luther King Jr.

Beyond the flawed Obama health care reform. ‘The time is always right to do what’s right’: Dr. King

By Claudia Fegan, M.D.
January 15, 2011

It is indeed an honor and a privilege for me to stand here today celebrating the life and work of Dr. Martin Luther King Jr.

We learned much from Dr. King, even though he was taken from us too soon. He taught us that “the time is always right to do what’s right.”

As we stand here today, there are 50 million Americans who are uninsured. African Americans are represented disproportionately among the uninsured. We represent only 12 percent of the population, yet we are 20 percent of the uninsured. This is our issue.

As a result of not having insurance, we have decreased access to the preventive services that would allow us to live longer, healthier, richer lives. We pay a tremendous price for this.

Our infant mortality rate is about 2.5 times that of whites, our rates of death from heart disease and cancer are 1.5 times that of whites, our rate of death from diabetes is almost 2.5 times that of whites and our rate of death from HIV is 5 times that of whites. African American patients on dialysis are less likely to be referred for evaluation for kidney transplant and therefore, not surprisingly, we are far less likely to get a kidney transplant. This is our issue.

The Institute of Medicine in its 2004 study on “The Consequences of Uninsurance” estimated over 18,000 people a year die as a result of not having access to health insurance. Uninsured adults receive fewer and less timely preventive and screening services; uninsured cancer patients die sooner due to delayed diagnosis; the uninsured receive less chronic illness care, poorer hospital care and are more likely to die in the hospital; and the risk of premature death among uninsured Americans is 25 percent higher than among Americans with health insurance.

This is our reality, the reality of health care for African Americans in this country. We will never get more until we demand more. This is our issue.

The fierce urgency of now

Since 1986, Physicians for a National Health Program has been trying to convince physicians, patients and politicians that if we tossed out the private insurance industry and made the government the single payer for health care in this country, we could provide coverage for everyone with same money we are using now to cover only two-thirds of the country poorly.

I have a patient who is 63 years old. Ms. Lenoir has worked all her life, she is active in her church, she cares for her elderly mother and together she and her husband have raised their children to be self-sufficient members of society. Ms. Lenoir does not have health insurance because her employer has never provided that benefit.

The problem is Ms. Lenoir needs a new hip. After more than 20 years of arthritis in her hip, the joint is destroyed. She has bone grinding on bone. No amount of anti-inflammatory medication will relieve her pain.

I sent Ms. Lenoir to a pain specialist who injected the joint to provide her with temporary relief and who then called me and said, “this woman needs a new hip.” I told her, I know that, but have you got one you can give her? No one will pay for a hip for her until she turns 65 and Medicare will provide her with coverage.

I wish you could look into this woman’s eyes each time she comes to see me and feel her pain. Will the legislation passed last year provide her with a new hip before she turns 65 in 2013? No, probably not. This is our issue.

In the book “The Heart of Power,” David Blumenthal chronicles the efforts of presidents from Franklin Roosevelt through George W. Bush to achieve access to health care for the American public. “Major health reform is virtually impossible: difficult to understand, swarming with interests, powered by money, and resonating with popular anxiety,” he writes.

The congressional veteran and co-chair of the 9/11 Commission, Lee Hamilton, said, “Health care is so difficult because Congress is an incremental body and health care is a non-incremental issue.”

What Barack Obama did with the passage of the Patient Protection and Affordable Care Act (ACA) was nothing short of miraculous, but it was not enough and it will not solve our problems.

Going forward there will not be a fair, open or honest discourse about this legislation. It is a fact that ACA will do nothing to control costs. That is the major flaw of the legislation. Why are we still talking about single payer? Because single payer will address the issues of cost, access and quality.

Being right is not enough

Dr. King taught us being right is not enough. We have to win the hearts of the American public. We didn’t lose the war to gain access to health care for all Americans. We got battered in an ugly skirmish, but we’re not done.

It is time to change our tactics. The opportunity for change is still ahead of us. More recent studies have taught us that actually 45,000 people die each year as a result of not having health insurance, which means 180,000 more people will die before the full implementation the ACA. If everything goes exactly as planned, there will still be at least 23 million uninsured once all the changes have taken effect. This is our issue.

Camille Rucks was a security guard for a small company on the South Side of Chicago. In the spring of 2008 she developed breast cancer. She received outstanding care at the University of Chicago and did well. However, in November 2008, which we now know was the beginning of the recession, when her company began to struggle, she was laid off. She thought she was targeted because she had been out sick so much when she was receiving chemo, but it doesn’t matter.

In January 2009, when she had some blood-streaked sputum, her primary care physician (PCP) ordered a chest X-ray that showed a spot that raised the question of maybe her cancer had returned. Her oncologist told her she couldn’t see her because she was no longer insured. Her surgeon never returned her phone calls.

Her PCP called me because she was not able to get the necessary tests done for Camille because she was no longer insured. I told her PCP to have Camille come see me the next day.

I said, sure, of course, this is what we do; we’re the County Hospital. In less than a week she had a CT of her chest, and within two weeks she had been seen by pulmonary and oncology. She did have metastatic cancer and we took care of her.

I wish I could tell you this story had a happy ending, but it doesn’t. Camille died last year, but she told me she had no regrets. We treated her with dignity and respect.

My question is this: Who doesn’t deserve dignity and respect? Why should you have to pass a wallet biopsy before a health care provider determines she can talk to you, order a test, figure out what is wrong or decide how to treat you? This is our issue.

Affordable Care Act will not work

The Affordable Care Act has not made health care a right. Access to care is a profit center controlled by the insurance industry. We pay them to limit access to care. We spend more per capita on health care than any country in the world — more than $8,000 per person — and yet we are ranked only 36th in the world by the World Health Organization for the care we provide.

Under the ACA, everyone will be required to carry or purchase private insurance. For those who can’t afford it, we’re requiring states to either cover them under Medicaid or to provide supplements so they can purchase private insurance. This is an industry that has a history of profiteering by retroactively denying coverage to people with illnesses. So now we’re requiring everyone to buy coverage, and yes, we have told the insurance companies they can’t deny coverage to those with illnesses.

My question is why can’t we just pay for the care without having to go through the insurance industry? They are not to be trusted. Ask the state of Massachusetts how it has worked out for them with mandating insurance coverage and paying for those who can’t afford it. The cost of premiums has gone up so high so fast in the first year the governor met with the major companies to request they hold off on their premium increases because the costs had exceeded three times the original projections. The state now teeters on insolvency. This is our issue.

We spend enough money on health care in this country. We just let too many people who aren’t involved in providing care take profit from it.

This is about justice. Health care should be a right to which everyone is entitled. Remember we live in the wealthiest country in the world. We spend more on health care than any other country. It is time we got our money’s worth. It is time we got the health care we deserve, not the care the insurance industry is willing to let us have. It is time we made health care a right and not a privilege.

We have to speak up. We have to speak loudly. We have to make our voices heard.

The Affordable Care Act is an opportunity: It is not going to work!

A simpler and just solution

We have to remind the people — there is still a simpler, easier solution. People want to know, they have questions. They will ask, is this the answer? Will this work? Will this solve the problem?

Multinational Big Pharma charges the American public the highest pharmaceutical prices in the world, while it sells the very same drugs all over the world at prices one-half, one-third or even one-tenth of the price they charge in the United States. They do this because in the rest of the industrialized world, there is legislation that limits profits for medications, while the U.S. allows these companies to charge whatever the market will bear. The Affordable Care Act does not address this issue. This is our issue.

Dr. King said, “When people get caught up with that which is right and they are willing to sacrifice for it, there is no stopping point short of victory.” The Affordable Care Act was not victory. We now have a House of Representatives that thinks the American public will be appeased by political theater instead of substance.

What the American public wants is not so different from what African Americans want and deserve. We want guaranteed access to care, freedom of choice of provider, quality health care and two words you don’t hear in association with health care very much anymore: trust and respect.

We know it can be done because every other industrialized country in the world has figured how to do this. Most of them spend less than half what we do and they have better outcomes with more satisfaction.

It is not so complicated what we want: we want a health care system that takes everybody in and leaves nobody out. It is only the phony solutions they are attempting to confuse us with, that are complicated, just so we don’t notice they fail to expand coverage to those who need it and deserve it. That’s why this will be the civil rights struggle of the 21st century, and this is our issue.

I understand people are reluctant to criticize the ACA because our president is under assault from the right and he needs our support. I think Dr. King would tell us it is important to tell the truth: “The time is always right to do what’s right.”

When I think about this struggle I think about a poem my father taught me as a child. It was written by Langston Hughes and is called “Mother to Son.”

Well, son, I’ll tell you: Life for me ain’t been no crystal stair.
It’s had tacks in it, And splinters, And boards torn up,
And places with no carpet on the floor — Bare.
But all the time I’se been a-climbin’ on, And reachin’ landin’s,
And turnin’ corners, And sometimes goin’ in the dark
Where there ain’t been no light.
So, boy, don’t you turn back. Don’t you set down on the steps.
’Cause you finds it’s kinder hard. Don’t you fall now —
For I’se still goin’, honey, I’se still climbin’,
And life for me ain’t been no crystal stair.

The issue of guaranteeing access to care for everyone is an issue of social justice. Battles for social justice are never over, because there will always be reactionary forces waiting in the wings to turn back the clock. There are no easy solutions. We have to be willing to fight for what we believe in and keep fighting.

The night before he was assassinated Martin Luther King said: “Let us stand with greater determination. And let us move in these powerful days, these days of challenge to make America what it ought to be. We have an opportunity to make America a better nation.”

I hope you will join me in saying what we expect from any health care program any politician will offer us: Everybody in, Nobody out! Everybody in, Nobody out!

Thank you.

Claudia Fegan, M.D., is chief medical officer at the Cook County Health and Hospitals System and past president of Physicians for a National Health Program.

https://pnhp.org…

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Comment:

By Don McCanne, M.D.

Seven years ago today, on the birthday of Martin Luther King Jr., Dr. Claudia Fegan delivered the following remarks to the Louisville (Ky.) Urban League. This was after President Obama signed the Affordable Care Act but before most of it was implemented. Today we still see blatant racism, voter suppression, intolerable inequities in income and wealth, and many other social injustices including the denial of affordable health care for far too many of our people. Thus it is appropriate that we take another timely look at Martin Luther King’s message delivered through Claudia Fegan’s heartfelt remarks.

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Health care is now the largest employment sector

Health Care Just Became the U.S.'s Largest Employer

By Derek Thompson
The Atlantic, January 9, 2018

In the last quarter, for the first time in history, health care has surpassed manufacturing and retail, the most significant job engines of the 20th century, to become the largest source of jobs in the U.S.

In 2000, there were 7 million more workers in manufacturing than in health care. At the beginning of the Great Recession, there were 2.4 million more workers in retail than health care. In 2017, health care surpassed both.

The U.S. spends hundreds of billions of dollars each year on Medicare, Medicaid, and health-care benefits for government employees and veterans. More subtly, the U.S. subsidizes private insurance in several ways, including through a tax break for employers that sponsor health care. This public support makes health-care employment practically invincible, even during the worst downturns. Incredibly, health-care employment increased every month during the Great Recession.

Recently, the growth in health-care employment is stemming more from administrative jobs than physician jobs. The number of non-doctor workers in the health industry has exploded in the last two decades. The majority of these jobs aren’t clinical roles, like registered nurses. They are mostly administrative and management jobs, including receptionists and office clerks. It’s not always clear that these workers improve health outcomes for patients.

This isn’t the end of health care’s run. It’s just the beginning. Of the 10 jobs that the Bureau of Labor Statistics projects will see the fastest percent growth in the next decade, five are in health care and elderly assistance. The entire health-care sector is projected to account for a third of all new employment.

The work that seemed to define the 20th century in the American imagination included union jobs held by white men who made things. But manufacturing employment peaked in the late 1970s. Forty years later, the fastest-growing occupations—like personal care and home-health aides—are quite the opposite: poorly paid, lacking a strong union, often female, and disproportionately filled by immigrants (who account for one-third of the in-home health care workforce). Services are the new steel.

https://www.theatlantic.com…

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Comment:

By Don McCanne, M.D.

So now the U.S. health care system has passed manufacturing and retail as the largest employment sector. And the majority of the newer jobs are administrative and management, according to Derek Thompson (senior editor at The Atlantic).

When we have the most expensive health care system in the world and we have so many deficiencies that result in mediocrity, is this really the best way we could be spending these additional health care dollars, especially since we already have an egregious excess of administrative services? It seems like we should be restructuring our system to make it more efficient, like maybe establishing a single payer, improved Medicare for all. Cut the waste and improve the health care product to make it work well for all of us. It will still be an important part of the job sector, but under single payer the services will provide greater health care value.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

Using Medicaid Section 1115 waivers to take away health care

State 1115 Proposals to Reduce Medicaid Eligibility: Assessing Their Scope and Projected Impact

By Sara Rosenbaum, Vikki Wachino, Rachel Gunsalus, Maria Velasquez and Shyloe Jones
The Commonwealth Fund, January 11, 2018

In a marked contrast to the Clinton, Bush, and Obama administrations, which encouraged states to use Section 1115 demonstrations to expand Medicaid coverage for low-income adults, the Trump administration has signaled its desire to move in the opposite direction by using 1115 — which allows the U.S. Department of Health and Human Services (HHS) and states to test innovations in Medicaid and other public welfare programs without formal legislative action — to shrink eligibility and enrollment, in expansion and nonexpansion states alike. Guidance released today by the Centers for Medicare and Medicaid Services could speed up the approval of such demonstrations.

The administration likely will integrate 1115 Medicaid eligibility reduction demonstrations as part of its anticipated initiative to reduce the scope of means-tested public assistance.

Ten States with Pending Medicaid Section 1115 Waiver Applications

Arizona: Work requirement; additional eligibility redeterminations; five-year lifetime limit on coverage

Arkansas: Work requirement; elimination of retroactive eligibility

Indiana: Six-month lockout for failure to provide necessary information at reenrollment; work requirement; increased premiums

Kansas: Work requirement; three-year lifetime time limit on coverage

Kentucky: Enforceable premiums accompanied by lockout; elimination of retroactive eligibility; and a work requirement

Maine: Work requirement; reintroduction of an asset test; elimination of retroactive eligibility; and elimination of hospital presumptive eligibility (that is, temporary eligibility while a full application is being considered)

Mississippi: Work requirement

New Hampshire:  Work requirement

Utah: Work requirement; enrollment caps; five-year lifetime limit on coverage; removing presumptive eligibility

Wisconsin:  Denying eligibility for premium nonpayment; a 48-month time limit (with the ability to gain additional coverage time by working); and behavioral modification requirements

These proposals raise significant questions, such as whether a proposal that lacks impact estimates or that claims to have no impact satisfies 1115 requirements. Federal regulations governing 1115 demonstrations would seem to say no. Another, perhaps deeper, question is whether proposals that purport to impose criteria that will result either in the loss of health insurance or the future denial of benefits even fall within the scope of authority 1115 confers on the HHS Secretary. The purpose of 1115 is to enable the Secretary to undertake demonstrations that promote the objectives of programs that are the subject of the demonstration. In the case of Medicaid, its objective, as stated in law, is to furnish medical assistance to people who need it. In any demonstration, it is likely that potential gains are weighed against risks. In these pending demonstrations, however, the scale appears lopsided, with only downsides for the poor. How, exactly, do proposals to deny or end health insurance advance Medicaid’s basic program objective? While achieving greater efficiencies are laudable and necessary aims of any program, especially one as large as Medicaid, simply culling the rolls of needy residents should not be confused with efficiency; indeed, such a result runs counter to the program’s most basic purpose of providing care to those who need it.

http://www.commonwealthfund.org…

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You’re Sick. Whose Fault Is That?

By Dhruv Khullar
The New York Times, January 10, 2018

The idea that Americans should take personal responsibility for their health has recently received renewed attention. Vice President Mike Pence has argued for “bringing freedom and individual responsibility back to American health care.”

Mick Mulvaney, director of the Office of Management and Budget, expressed a more punitive view, saying, “That doesn’t mean we should take care of the person who sits at home, eats poorly, and gets diabetes.”

What does it actually mean to take personal responsibility for health?

The basic idea is that if we adopt healthful lifestyles, are compliant patients and save money for our own medical care, we’ll feel better, spend less and reduce our burden on others.

Medicaid reform is the policy context in which personal responsibility is most frequently discussed.

Seema Verma, administrator of the Centers for Medicare and Medicaid Services, previously helped shape Indiana’s Medicaid expansion. To get full benefits in Indiana, patients must contribute monthly to a “personal wellness and responsibility account.” If they fail to pay, they may have benefits cut or lose coverage entirely for six months.

Personal responsibility is not always demanded equally of people at every income level. Many lawmakers want more “skin in the game” for Medicaid recipients, but not as many clamor for higher deductibles for wealthy Americans — even though they’re more likely to have enough “skin” to meaningfully play “the game.”

Personal responsibility is an attractive goal with deep roots in American culture. But if it’s too aggressively pursued, it may conflict with another worthy ideal: In a nation as wealthy as the United States, sick humans deserve health care — even if they can’t pay, and even if they’ve made some bad choices.

https://www.nytimes.com…

***

Comment:

By Don McCanne, M.D.

Medicaid is a program designed to help low-income individuals obtain the health care that they need. Section 1115 waivers are a process established to allow states to facilitate the goal of furnishing medical assistance to people who need it (the purpose as stated in law). Yet the current administration is encouraging the use of the waivers to shrink eligibility and enrollment – taking health care away from those in need – the exact opposite of the intent and letter of the law.

Representatives of the administration cloak this in terms of encouraging personal responsibility for one’s own health. Taking away an individual’s health benefits is not a policy that improves health; it impairs it.

Nobody is going to argue that an individual should not be expected to take care of his own health. But the role of society should be to encourage good health through educational efforts and appropriate social programs. One of the most important programs is the provision of health care which should be rendered regardless of ability to pay, even for those individuals who may have made some bad choices (as have we all).

If a person does not complete his lessons in a school class does that mean that he should be deprived of any further education? If a person receives a speeding ticket, does that mean that she should be denied access to our nation’s highways? If person has a grease fire flare up on her stove does that mean that fire protection services should be denied in the future? If a person was unable to contribute to an IRA, does that mean that future Social Security benefits should be denied? If a person ran over their municipal water allotment does that mean that their water services should be cut off permanently? If a person under 65 is unable to find a job does that mean that she should she be denied health care? Of course not to all of these.

Where personal responsibility does lie is with our public stewards and their obligation to make our public programs work for the people. Now there we can be justly critical of their failure to fulfill their own personal responsibility while serving in their stewardship. Should we take way their health care? (No, just fire them.)

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Mandating employment for Medicaid eligibility

Understanding the Intersection of Medicaid and Work

By Rachel Garfield, Robin Rudowitz, and Anthony Damico   
Kaiser Family Foundation, January 5, 2018

As of December 2017, 32 states have implemented the ACA Medicaid expansion.1 By design, the expansion extended coverage to the working poor (both parents and childless adults), most of whom do not otherwise have access to affordable coverage. While many have gained coverage under the expansion, the majority of Medicaid enrollees are still the “traditional” populations of children, people with disabilities, and the elderly.

Some states and the Trump administration have stated that the ACA Medicaid expansion targets “able-bodied” adults and seek to make Medicaid eligibility contingent on work. Under current law, states cannot impose a work requirement as a condition of Medicaid eligibility, but some states are seeking waiver authority to do so.

This issue brief provides data on the work status of the nearly 25 million non-elderly adults without SSI enrolled in Medicaid (referred to as “Medicaid adults” throughout this brief) to understand the potential implications of work requirement proposals in Medicaid. 

Data Findings

* Among nonelderly adults with Medicaid coverage—the group of enrollees most likely to be in the workforce—nearly 8 in 10 live in working families, and a majority are working themselves.

* Most Medicaid enrollees who work are working full-time for the full year, but their annual incomes are still low enough to qualify for Medicaid.

* Many Medicaid enrollees working part-time face impediments to finding full-time work.

* Nearly half of working adult Medicaid enrollees are employed by small firms, and many work in industries with low employer-sponsored coverage offer rates.

* Among the adult Medicaid enrollees who were not working, most report major impediments to their ability to work.

Policy Implications

* Under current law, states cannot impose a work requirement as a condition of Medicaid eligibility.

* Some states have proposed tying Medicaid eligibility to work requirements using waiver authority that may be approved by the Trump Administration.

* Research shows that Medicaid expansion has not negatively affected labor market participation, and some research indicates that Medicaid coverage supports work.

* Implementing work requirements can create administrative complexity and put coverage at risk for eligible enrollees who are working or who may be exempt.

https://www.kff.org…

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Verma Outlines Vision for Medicaid, Announces Historic Steps Taken to Improve the Program

CMS.gov, November 7, 2017

In a significant shift from prior policies, in speaking about the new approach to Section 1115 demonstrations, Seema Verma emphasized the agency’s commitment to considering proposals that would give states more flexibility to engage with their working-age, able-bodied citizens on Medicaid through demonstrations that will help them rise out of poverty. engagement and work activities.

“We will not just accept the hollow victory of numbers covered [in the program], but will dig deeper and demand more of ourselves and of you,” said Verma. “For those unable to care for themselves, we will create sustainable programs that will always be there to provide the care you need, to provide choices and allow you to live as independently as possible. For those that just need a hand up, we will provide you the opportunity to take charge of your health care and assist and empower you to rise out of poverty and government dependence to create a better life for yourselves and your family.”

https://www.cms.gov…

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Daugaard: S.D. seeking to impose Medicaid work requirement

By James Nord
Sioux City Journal, January 9, 2018

South Dakota is asking the Trump administration to allow the state to require some Medicaid recipients to work to qualify for the government-funded health coverage for the poor, Gov. Dennis Daugaard said Tuesday in his State of the State address.

“Work is an important part of personal fulfillment,” Daugaard said. “By making this adjustment to our Medicaid program, we can continue to help those who need it the most and start to connect those who can work with jobs that give them that sense of self-worth and accomplishment.”

The governor has made workforce development a key policy focus. He said South Dakota doesn’t have enough workers in many skilled fields, which is a barrier to economic growth. In metro Sioux City, which includes Union County, unemployment below 3 percent has made it more difficult for new and expanding workers to find qualified applicants.

http://siouxcityjournal.com…

***

Comment:

By Don McCanne, M.D.

With encouragement oƒ CMS Administrator Seema Verma, many states are now applying for Medicaid Section 1115 waivers that would allow them to establish work requirements as a condition for enrollment in the Medicaid program. There are two policy issues here – health care and jobs.

Public policies should be established to ensure that everyone has access to affordable health care and that jobs are available for those who need employment. Since Medicaid was designed to help low-income individuals and families, then  everyone who is qualified on an income basis should automatically be covered. Also the government should support jobs programs to minimize the scourge of unemployment.

Instead, our current government administration is driven by ideology that would achieve the opposite results. They would place the burden of obtaining employment on the individuals, even when there are essentially no jobs available. Then to penalize them for their failure, they would deprive them of their Medicaid coverage. Seema Verma refers to this as empowering them “to rise out of poverty and government dependence to create a better life for yourselves and your family.” No job, no health insurance does not make for a better life. South Dakota Gov. Dennis Daugaard is about to show us the perversities of these policies. Besides, the Kaiser Foundation paper shows us that they are attempting to address a problem that hardly even exists.

What policies do we have that would deprive Medicare beneficiaries of their coverage? Of course, we do not have any such policies. Medicare is a social insurance program that is a right for those qualified. We don’t use the threat of cancellation as a stick to shape people up. We simply give them medical care when they need it.

Medicare does need some major revisions to make it a better program. Then it can be used to provide automatic health care coverage for absolutely everyone. Then we can go to work to be sure that every individual has a right to employment within the limits of their capabilities. When the private sector doesn’t come through, there are plenty of potential public projects that can make this a better nation for all of us.

But first we have to select government stewards who have their policy priorities aligned with the people. Democracy anyone?

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Physicians for Single Payer

By Corinne Frugoni, M.D. and Wendy Ring, M.D.
North Coast Journal (Humboldt County, Calif.), January 10, 2018

Our current profit-driven health care system is closing physician practices and burning out doctors. The average American physician spends nearly nine hours a week wrangling with insurance companies and the average medical practice spends $72,000 per doctor per year just dealing with insurers. That’s why a majority of Humboldt physicians support a single payer health program. In a recent guest opinion (“Setting the Record Straight,” Dec. 28, 2017), North Coast state Assemblymember Jim Wood explained his rationale for stalling Senate Bill 562, The Healthy California Act. Looks like Wood is going against medical advice.

The Healthy California Act is the first step toward solving Humboldt’s health care ills. It would eliminate our crazy quilt of public programs and private for-profit insurance in favor of a single public agency funding health care for all Californians. Under this plan, hospitals and medical offices would remain as they are. All that would change is who pays the bills.

Wood says he supports universal coverage but “we just need to take the time to find the right path.” These days, when the average patient with private insurance pays a $4,000 deductible before insurance pays anything, having coverage is no guarantee for health care. California State Insurance Commissioner Dave Jones thinks single payer is the right path. We don’t need to waste more time looking for another.

Wood claims that a transition to a single payer plan would be too complicated. In reality eliminating multiple payers and profit would simplify the system. Under S.B. 562, doctors would no longer be micromanaged by private insurance or burdened by costly paperwork. Patients would be free to choose any doctor or hospital without worrying about who is in or out of network because there would be no networks. We could change jobs or locations, get married or divorced without worrying about health coverage. We’d simply present a health ID card and get health care. Medical bills, premiums, deductibles, co-pays and collection agencies would all become obsolete. Deferring medical treatment because of cost would become a thing of the past. No one would have to gamble on affordability or benefit packages because everyone would be equally covered with comprehensive, high quality benefits. The Healthy California Act is radical in its simplicity. It would return the wasted health care dollars and talents of skilled professionals to their original intended purpose: patient care, public health and medical research.

Let’s look to history. In July of 1965, President Lyndon Johnson signed Medicare, a government funded insurance program into law. By 1966, Medicare coverage for all Americans 65 and older took effect. Was it all that complicated?

Wood says we can’t afford a single payer system. A single payer program dedicated to the public’s health instead of corporate profits would cost us less and give us more. A streamlined payment system would dramatically lower administrative costs. The layers of insurance bureaucracy and reams of insurance bills would be eliminated. A single buyer, negotiating on behalf of all of us, would have tremendous bargaining power to lower the price of drugs and medical equipment. Seventy percent of the California health budget is already being paid for with our taxes. A recent analysis by the nonpartisan Political Research Institute found that a California single payer system could be a funded by eliminating premiums and substituting an additional modest sales tax on non-essential items plus gross receipts taxes for businesses making over $2 million. This would create savings for households, businesses and the state.

Wood says that single payer advocates are a small vocal group implying that their views aren’t shared by most of his constituents. Surveys show that the majority of Californians support single payer health care. S.B. 562 has been endorsed by the cities of Eureka, Arcata, Manila, Albany, Berkeley, El Cerrito, Emeryville, West Hollywood, Los Angeles, Oakland, San Francisco and Richmond, and by the counties of Marin, Santa Clara and San Francisco. It is supported by the California Nurses Association, the California Teachers Association and many other health, education and labor organizations.

A single payer system won’t solve all our problems. But it is far better than the patchwork system we have now with private health insurance companies that look at health care as a commodity geared toward making a profit for shareholders. With single payer, all California residents and politicians, from people who are unemployed, to working families and all the way up to the governor would have the same health coverage and interest in maintaining a high quality, well-functioning health system.

S.B. 562 has been endorsed by the California Democratic Party but powerful interests want the bill kept off the floor of the Legislature until it shrivels and dies. Wood and the Assembly Speaker Anthony Rendon say the bill lacks details. Solutions can’t be worked out as long as the bill is held hostage in the Rules Committee while the select committee that Wood chairs obfuscates. Meanwhile our health system here in Humboldt is crumbling, premiums are up 33 percent and the new tax bill will lead to large cuts in Medi-Cal and Medicare, on which many local residents depend. As our representative, Jim Wood should be responding to the needs of his constituents by championing the Healthy California Act, S.B. 562. We need actions, not more studies. We don’t have any time to lose.

https://www.northcoastjournal.com…

For Big Pharma, profits come first, not patients

By John Perryman, M.D.
Chicago Tribune, Letters, January 10, 2018

In an editorial celebrating “the genius that drives the development of…powerhouse drugs,” the Tribune Editorial Board continues to propagate the fallacy that high drug prices, driven by “market forces,” are a necessary cost to help fund further research. The drug in question this time is Luxturna, a treatment for a rare form of vision loss that comes at the whopping price of $850,000 per patient.

A few points need to be clarified.

First, most large drug companies spend more on sales and marketing than on research and development.

Second, since 1980 and the Bayh-Dole Act, drug companies can feed off research funded by the National Institutes of Health, which they acquire at late stages of development. As pointed out by former New England Journal of Medicine editor Dr. Marcia Angell, the big companies can either license the drugs or buy out small biotech companies carrying out NIH-funded research. In short, much of the research going into these products is funded by taxpayers, not pharmaceutical revenues.

Third, the pharmaceutical industry has a massive lobbying presence, consistently spending over $200 million a year, according to the Center for Responsive Politics. It has more than two lobbyists for every member of Congress and spends tens of thousands of dollars per election cycle. That type of investment is only undertaken when there is a significant return expected. For example, Congress placed a provision in the 2003 Medicare Prescription Drug Benefit that prohibits Medicare from negotiating with drug companies on pricing. Now that’s a return on lobbying costs!

I fully agree that there are many talented and dedicated people working at these companies. However, before we succumb to misty-eyed tributes to the role free markets play in providing miracle drugs, let’s be clear as to exactly what is going on. These companies profit from taxpayer-funded research. Also, as publicly traded for-profit entities, their primary goal is maximizing the wealth of their shareholders.

Those are the facts we need to remember when hearing about high drug prices.

http://www.chicagotribune.com…

Update on California single payer bill

Assembly Speaker Says Single-Payer Remains Shelved

By Ben Bradford
Capital Public Radio, January 8, 2018

“Absolutely nothing has happened with the bill,” Assembly Speaker Anthony Rendon, a Los Angeles-area Democrat, says of the high-profile Senate measure to establish single-payer health care.

Rendon shelved the bill last year, after it passed the Senate, calling it “woefully incomplete,” because it does not specify how the state would would seek federal approval, bypass constitutional spending limits and cover as much as a $400 billion cost.

Six months later, the speaker says the status of Senate Bill 562 remains the same.

“The sponsors of the bill have sat on their hands and done nothing for the past six months,” Rendon says. “None of the authors have made any significant amendments.”

Those pointed words about the sponsor refer to the California Nurses Association, the liberal union known for flashy and no-holds-barred advocacy of its causes.

The speaker says he’s more interested in developing a universal health care proposal, which could mix government and private coverage options, rather than focusing solely on a single-payer system.

An Assembly Committee is meeting again next week to discuss universal coverage legislation.

http://www.capradio.org…

***

Nurses Catch Assembly Speaker in Lie About Healthy California Bill

RNs to Rendon: “No Excuses. We’ve Done Our Job; You Do Yours.”

California Nurses Association/National Nurses United, January 4, 2018

The nearly 100,000 registered nurses of the California Nurses Association (CNA)—co-sponsors of SB 562, the Healthy California Act, which would guarantee healthcare to all Californians—strongly condemn California Assembly Speaker Anthony Rendon’s statement this week that SB 562 sponsors have “sat on their hands and done nothing the past six months.”

“Perhaps Speaker Rendon is confusing his own inaction, after undemocratically parking SB 562, with the clear, loud stand thousands of Californians have taken for months, demanding Rendon unfreeze this lifesaving bill so it can move forward,” said CNA Associate Executive Director, Bonnie Castillo, RN. “Nurses have watched our patients suffer and die for far too long, and that’s why we are unrelenting in our demand for guaranteed healthcare. We expect our elected officials to work on the bill, not breach the public’s trust by halting the normal legislative process or waste time.”

The Healthy California Act, SB 562 passed the full Senate in June and was set for consideration in the Assembly when Speaker Rendon abruptly refused to let it out of the Rules Committee. In response, RNs and other backers of the bill have rallied, canvassed and organized in support of SB 562, in a grassroots movement across the state.

SB 562 sponsor and advocate actions in the past six months include:

* Published study by expert economists at UMass Amherst, setting forth a mechanism on how to pay for SB 562
* 17 amendments proposed
* 200 canvassing events held statewide, covering all 80 Assembly districts
* 15,000 supporters gathered at in-person events across California
* 6,000 doors knocked
* 1,500 new volunteers added to canvassing efforts
* 35 district office visits conducted
* Thousands of phone calls made
* 21 more canvasses are scheduled for January, 2018 alone

“SB 562 supporters don’t have time to sit on our hands, because our hands have been too busy knocking on doors, picking up phones, opening legislative office doors, and holding up ‘Medicare for All’ signs all over California,” said CNA co-president Deborah Burger, RN. “It’s beyond insulting that Speaker Rendon would tell working people, including the nurses who have spent countless hours standing up for our patients’ right to life saving care, that WE haven’t done enough. Allowing this bill to move forward is Rendon’s job, and he needs to stop shifting blame and get to work.”

“Every day that the Assembly members keep talking about it, people get sick and die. They’re inside [the state capitol] with their suits and ties and good health care, and every day people are dying,” said RN Cathy Kennedy. “We’ve done the research, and we know that in California there is money to provide health care for all. It’s time they stop talking about it and do something about it!”

A recent survey showed that a full 70 percent of Californians favor establishing a public, Medicare for all type system providing universal single-payer health coverage. CNA also sponsored the aforementioned study by expert economists at University of Massachusetts Amherst on how to pay for SB 562—revealing that enacting the bill would save Californians $37 billion off our current cost for healthcare.

With widespread public support and a funding mechanism, nurses say Rendon’s recent comments only reveal that elected officials need to stop standing in the way of what their constituents want: guaranteed healthcare.

http://www.nationalnursesunited.org…

***

California State Assembly

Select Committee on Health Care Delivery Systems and Universal Coverage: Arambula, Wood, Chairs

Informational Hearing: Achieving Better Access and Greater Value in California’s Health Care System
Wednesday, January 17, 2018
1 p.m. to 5 p.m.
State Capitol, Room 4202

http://healthcare.assembly.ca.gov…

***

SB-562: The Healthy California Act:
https://leginfo.legislature.ca.gov…

***

Comment:

By Don McCanne, M.D.

The nature of the dispute between California Assembly Speaker Anthony Rendon and the California Nurses Association on the status of SB-562, The Healthy California Act, a single payer bill for California, can be gleaned from the reports above.

Probably the most significant statement is the following: “The speaker says he’s more interested in developing a universal health care proposal, which could mix government and private coverage options, rather than focusing solely on a single-payer system.”

A series of informational hearings on health care reform in general is taking place now, but the Select Committee will not be able to take any legislative action. It is difficult to see how these hearings could result in any meaningful legislation for this session of the state legislature. The hearings seem to be merely a diversionary tactic on the part of Rendon.

Why this update? If any state could enact a semblance of single payer legislation, it would be California. This demonstrates the barriers we have even with supposedly optimal political alignment.

The lesson? We need a large-scale social movement in support of greater Democracy. Read Page and Gilens, “Democracy in America?” and then act on it:

https://pnhp.org…

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