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AMSA & PNHP Essay Contest Winners Announced:

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AMSA & PNHP Essay Contest Winners Announced:

June 26, 2012

The American Medical Student Association and Physicians for a National Health Program are pleased to announce the winners of the first national single payer essay contest for medical students.

The contest was launched at the 2012 AMSA Annual Convention in Houston, where PNHP leaders Dr. Art Chen, Dr. David Ansell, and Dr. Howard Brody addressed medical students about the need for single payer national health insurance, “improved Medicare for all” to heal the US health crisis.

The first prize winner of an iPad is Jan Hallock at Pacific Northwest University in Yakima, Washington. The first runner-up is Victoria Powell at Virginia Commonwealth SOM in Richmond, Virginia, and the second runner-up is Eric LaMotte at UC San Francisco School of Medicine.  Their prizes are $100 and $50 gift cards, respectively.  The winning essays are posted below.

Many thanks to over 40 students who submitted terrific essays and to our judges, Dr. Howard Brody, Dr. David Ansell, Danielle Alexander, Dr. Elizabeth Wiley (AMSA 2012-2013 President), and Kristin Huntoon and Richard Alden Bruno (co-chairs of AMSA’s health care for all task force).

Special thanks to AMSA education and advocacy fellow Colin McCluney, who enthusiastically embraced the project and did a terrific job designing and running the contest.

The contest was advertised through The New Physician magazine (circ. 55,000) and at the AMSA Annual Meeting, as well as through PNHP, raising the profile of single payer among medical students.  We hope the contest will become an Annual Event.  Enjoy!

By Jan Hallock
Pacific Northwest University in Yakima, Washington

“Will this be paid for?”

I sighed silently, hoping the inquirer on the other end of the phone call would accept the only answer I could give.

“Well, Mrs. M, that’s not a question I’m able to answer, but if you look on the back of your insurance card, there should be a phone number for Customer Service. If you call that number, they should be able to help you figure out the cost.”

Mrs. M thanked me and hung up, presumably to spend another twenty minutes on the phone with a series of customer service representatives. I knew there was a good chance she wouldn’t get an answer, because insurance companies are remarkably good at not showing their hand to their customers—they tend to not commit to a certain payment amount, because they generally wait until the procedure is over to decide whether to cover it.

The phone rang again.

“Thank you for calling Dr. K’s office; how can I help you?”

“I have a question about my bill. My insurance said they would cover my annual screening colonoscopy, so why am I getting a $400 bill for it?”

Another sigh. I had chart notes to transcribe, prescription refills to authorize, letters to mail to remind patients to come back for follow-up appointments. Sorting out the fine print of insurance contracts was not how I wanted to spend my time.

“I’m sorry for the confusion, ma’am. Let me get your information, and I’ll contact our billing staff to see what happened.”

I frequently told patients this partial lie: I pretended to not know why they had received a bill for a procedure that their insurance supposedly covered. In reality, I knew that they had received a bill because their insurance had retroactively denied coverage of the procedure. But I still had to spend an average of thirty minutes per patient inquiry learning the details of different insurance policies so I could explain to patients why they ended up with a bill they didn’t expect.
These are obviously anecdotes from my personal experience, not analyses of hard data. But my experience was typical for medical assistants and medical receptionists: at least half the phone calls I received in any given workday had to do with insurance coverage or billing issues, not actual patient care.

This is especially remarkable because I worked for just one doctor, who managed to run her whole practice with just three people: herself, me, and a biller/coder. Think about that: Dr. K could competently manage her patient load and procedures almost by herself, but to work out the insurance payments and patient billing took a full-time trained, certified billing person and one-third to one-half of my time. One and one-half full-time employees, just to deal with insurance companies—is it any wonder that overhead costs are overwhelming doctors in private practice?

One common complaint I’ve heard about a single-payer system is that it would be a bureaucratic nightmare. To be honest, the first time I heard someone argue that, I laughed outright—and then I realized that he was serious. My second reaction was, “Obviously, you’ve never seen how the current system works.” Turns out, he hadn’t: he had insurance through his employer, Microsoft, which offers full coverage for just about everything you can imagine, with no copays. Patients and doctors’ offices alike love Microsoft insurance for its ease of use, its quick payment, and the overall efficiency that comes from their anti-bureaucratic approach to health care coverage. It is the epitome of great health insurance—and the opposite of the insurance coverage most people have.

The gross inefficiency of our current system is, to me, the single biggest problem in our healthcare system, and it is a problem that a single-payer system could easily solve. A single-payer system would streamline all services through one formulary, one billing system, with one set of rules and requirements. Fewer employee hours dedicated to sorting out insurance contract fine print means lower overhead costs, which means lower costs to patients and more physicians being able to stay in private practice. Less time wasted on bureaucratic nonsense means more time devoted to direct patient care, which means longer appointments, better physician availability, and better quality care. This is why I support single-payer health care: better for doctors, better for patients, better for society.

By Victoria Powell
Virginia Commonwealth SOM

In medical school, there is always an upcoming exam, with accompanying late nights and anxiety. Myopia can result from learning about medicine, yet having little exposure to the people that illnesses and injury are happening to. Health policy is a stretch – we’re learning to be doctors, not politicians or administrators. Fortunately, I’ve had a run of experiences that led to my interest in Single Payer, and given these, I feel I have the responsibility to translate my privilege into action.

In 2008, I was highly influenced by the presidential campaign of Ralph Nader. Long respected as an advocate for the people, he was having difficulty being taken seriously as a candidate. I was initially annoyed that he was running against the progressive-seeming champion Obama. Only through a friend’s insistence did I listen to his message. I was particularly inspired by his words on Single Payer. He clearly elucidated the reasons why our payment system was broken, corrupt, and wasteful. Through clear data and heart-wrenching stories, he insisted that Single Payer was the only sustainable and compassionate choice, “Everybody in. Nobody out.” Prior to his campaign, I was interested in medicine because I loved the process of scientific innovation and wanted to help translate bench-to-bedside for my patients. After hearing him, I promised myself that if I gained acceptance to medical school, I would use my position to advocate for those who were tossed aside, made to go into bankruptcy, lost homes and jobs, all because they were simply unlucky enough to have an expensive medical condition and poor insurance.

Single Payer did appear the fairest way to allocate limited resources, but mainstream health care debate made it seem equivocal whether it would happen in America. I was convinced, but not compelled enough to become an activist. Arguments during the health care law debates resonated – it was too much effort, and the insurance industry was too strong. I heard older doctors grumbling about low reimbursement for Medicare. Could we work within the current system of multiple private insurers? Was Single Payer worth the fight?

My college friend Jay, 21, was shot in the head by a stray bullet on July 4, 2006. He spent over 100 days in the hospital and contracted almost every hospital-acquired infection imaginable. Due to what I previously thought was solely his strength and his parents’ and health care team’s dedication, he not only survived but has recovered to an extent no one thought possible for such a severe injury. He and his parents spoke to my medical school classmates recently. During the presentation, I learned there was another factor affecting his recovery that I hadn’t yet considered – his father’s excellent health insurance. Being under 22 at the time of injury, he was able to remain on his father’s federal employee plan. He had access to the comprehensive rehabilitation he needed and continues to require. Even so, his parents explained the huge chunks of time they had to spend on the phone with insurance companies, on hold with Mozart playing, while they sought authorization for life-saving surgeries. They admitted that this was nothing compared to what some families on his unit were going through. His parents heard not only about the patients who had no coverage, but also those whose families who were desperate because they had to go back to work to keep their coverage. Who would take care of the patient in recovery while they were at work?

It is not only sad for a young person with a brain injury to not receive necessary rehabilitation during the critical period of recovery because of lack of payment. It is a human rights violation. It could mean the difference between independent living, the ability to earn a living, and a lifelong sentence of disability. Patients continue to require rehab after discharge. The quality and frequency depend on their ability to pay. If a Single Payer system existed in America, resources would be distributed among all patients. Health would not be bound to a job. Our society’s medical discoveries would benefit everyone. No one would go bankrupt from medical expenses. No one would be stuck in the cycle of poverty because of payments for illness and injury. It is for these reasons that I not only support Single Payer, but resolve to use my standing as a future physician to fight for it. I will educate others. It will be difficult, but eventually, we will win. And it will be a victory for all Americans.

By Eric LaMotte
UC San Francisco School of Medicine

As the media focus on the Supreme Court’s coming ruling on the Affordable Care Act, they speculate about the various implications the Court’s decision could have on the individual mandate and many other provisions of the law. However, the contemplation of these scenarios is a distraction.

Instead, we should focus on what we already know, which is that over 15 million Americans will remain uninsured, and tens of millions will be underinsured with barebones plans that won’t prevent financial ruin if illness strikes. We will continue to pay nearly twice what the second most expensive country pays for healthcare, and costs will continue to increase unsustainably.

These facts are not seriously disputed, and yet they describe what many Democrats consider the best-case scenario, which would occur if no aspect of the ACA is struck down.

But we can do better. We should advocate publicly for a single-payer system which establishes comprehensive healthcare as a guaranteed right for all Americans, and which compensates healthcare providers rationally, simply, and fairly from a single insurance fund financed by taxpayers.

This simple system, which would effectively eliminate private health insurance and function like an improved Medicare for everyone, would save enough money by dismantling our Kafkaesque healthcare bureaucracies to cover the tens of millions of Americans who are uninsured now, or who are insured but avoid getting care because it is too expensive.

The Supreme Court’s review of the ACA is not just a distraction, but an opportunity as well. It’s a period when the “Overton Window,” the range of possibilities considered at any given moment to be politically feasible, is in flux.

Many of my fellow medical students support single-payer in theory, but are hesitant to become activists because they see it as politically infeasible in the current political climate. This creates an unfortunate Catch-22, but hints at a broad base of support for single-payer which is waiting to be unleashed when it is perceived to enter the political mainstream.

I often hear people talk about single-payer as politically infeasible because of the strength of the conservatives. Although I agree that single-payer currently seems to have little to no chance of passing the House and Senate, I reject that this is because the idea is unpopular. According to a CBS/NYTimes poll 2009, 59% of Americans said the government should provide national health insurance. 78% of medical students surveyed in 2011 said that PPACA did not go far enough in reforming our healthcare system. Rather than unpopularity, it is the health insurance industry’s powerful influence on our policymakers that keeps single-payer from entering the political mainstream.

Indeed, single-payer has recently received endorsements of preference over the ACA by conservatives such as Fox News contributor Charles Krauthammer and Louisiana A.G. Buddy Caldwell. These endorsements are not such a surprise if you consider that despite being to the left politically, single-payer stands head-and-shoulders above the ACA in terms of its merits as sound public policy.
The media have raised the possibility of the ACA (or its downfall) “paving the way” for a single-payer healthcare system, but such a shift is not going to just magically happen without strong resistance from the insurance industry. Achieving a single payer system will only happen if the population demands it loud enough to be heard over the health insurance lobby, a feat made only more difficult by Citizen’s United.

To become effective advocates for their preferred healthcare system, single-payer advocates will have to leverage a strong understanding of policy, not just politics. For example, cost savings will not just be achieved because the system is “government-run”, thereby eliminating profits. Instead, savings will be achieved by eliminating the bureaucratic complexity we have in our system where patients must navigate a fragmented system of provider networks and unpredictable charges.

I want a single-payer system because as a future physician, I want to spend my time treating patients, not dealing with billing personnel over the phone haggling to get treatments approved. As a taxpayer, insurance subscriber, and future patient, I want to spend less money, in a more predictable manner, and be guaranteed that I will get the care that I need.

I believe that we can enact a single-payer system, but I assure you that the road to it will not be paved for us by the successes or failures of the ACA. Although sound public policy is on our side, this means little if we continue to let the health insurance industry dictate which ideas are allowed into the discussion.

Private Medicare Advantage plans being paid for phantom care of VA patients

Duplicate Federal Payments for Dual Enrollees in Medicare Advantage Plans and the Veterans Affairs Health Care System

By Amal N. Trivedi, MD, MPH; Regina C. Grebla, MGA, MPH, PhD; Lan Jiang, MS; Jean Yoon, PhD; Jent Mor, PhD; Kenneth W. Kizer, MD, MPH
JAMA, June 26, 2012

Abstract

Context: Some veterans are eligible to enroll simultaneously in a Medicare Advantage (MA) plan and the Veterans Affairs health care system (VA). This scenario produces the potential for redundant federal spending because MA plans would receive payments to insure veterans who receive care from the VA, another taxpayer-funded health plan.

Objective: To quantify the prevalence of dual enrollment in VA and MA, the concurrent use of health services in each setting, and the estimated costs of VA care provided to MA enrollees.

Design: Retrospective analysis of 1 245 657 veterans simultaneously enrolled in the VA and an MA plan between 2004-2009.

Main Outcome Measures: Use of health services and inflation-adjusted estimated VA health care costs.

Results: Among individuals who were eligible to enroll in the VA and in an MA plan, the number of persons dually enrolled increased from 485 651 in 2004 to 924 792 in 2009. In 2009, 8.3% of the MA population was enrolled in the VA and 5.0% of MA beneficiaries were VA users. The estimated VA health care costs for MA enrollees totaled $13.0 billion over 6 years, increasing from $1.3 billion in 2004 to $3.2 billion in 2009. Among dual enrollees, 10% exclusively used the VA for outpatient and acute inpatient services, 35% exclusively used the MA plan, 50% used both the VA and MA, and 4% received no services during the calendar year. The VA financed 44% of all outpatient visits (n = 21 353 841), 15% of all acute medical and surgical admissions (n = 177 663), and 18% of all acute medical and surgical inpatient days (n = 1 106 284) for this dually enrolled population. In 2009, the VA billed private insurers $52.3 million to reimburse care provided to MA enrollees and collected $9.4 million (18% of the billed amount; 0.3% of the total cost of care).

Conclusions: The federal government spends a substantial and increasing amount of potentially duplicative funds in 2 separate managed care programs for the care of same individuals.

http://jama.jamanetwork.com/article.aspx?articleid=1197014#AuthorInformation

Comment: 

By Don McCanne, MD

Most veterans who are eligible for enrollment in the Veterans Administration health care system are also eligible for enrollment in Medicare when they turn 65. Many of these veterans elect to enroll in the publicly-financed but private Medicare Advantage plans. This study shows that these private plans benefit greatly by receiving full capitation payments for all care in spite of the fact that they avoid the costs of the care that is actually delivered in our publicly-financed VA system. Thus taxpayers are paying twice for the same care – real care in the VA system and phantom care under the Medicare Advantage plans.

The authors suggest that rules could be changed to rectify this. Either the VA could be authorized to bill the private Medicare Advantage plans for care delivered by the VA (currently prohibited by federal law – a law dating back to before private Medicare plans were available), or the capitation payments to the Medicare Advantage plans could be adjusted downward to reflect the use of VA facilities.

There is a far better choice. The traditional Medicare program could be improved by expanding benefits and eliminating out-of-pocket cost sharing. Then we could get rid of the private Medicare Advantage plans with their profound administrative waste and the restrictions in health care choices that they inflict upon their patients. The VA-eligible patient would be able to choose either Medicare or the VA system, but regardless, we would be paying for the care only once, instead of twice like we are now.

In fact, the improved Medicare system would be so effective that we should all be able to have it as participants in a single payer national health program. Providing veterans with the choice of the VA system would not be much different from providing the rest of us with the choice of an integrated health care delivery system such as Kaiser Permanente. It would be just another health care delivery option under an improved Medicare for all.

Medicare for All takes show on the road in Calif.

By Mari Edlin
California Healthline, June 26, 2012

Neither the Affordable Care Act nor the challenges it faces in the Supreme Court has stopped the wheels from turning for the California Nurses Association, Physicians for a National Health Program and Campaign for a Healthy California.

The three organizations took to the road last week on a three-week, statewide bus tour to rally for single-payer, national health system — “Medicare for All.”

Akin to the Canadian system, which sprouted in Saskatchewan in the 1940s and quickly spread to other provinces, Medicare for All would replace private insurance with a single public agency paying medical claims – not much different than how Medicare operates today for senior adults.

Short of being a federal initiative, Medicare for All is holding out for buy-in from individual states.

Each stop along the route of the California tour will provide basic medical screenings followed by a public town hall meeting, raising awareness for Medicare and a single-payer system and enabling Californians to express their opinions.

“Our tour will showcase the fact that there is a single payer solution to the health care crisis, while also getting word out to districts to urge legislators to vote,” said Bill Skeen, executive director of the California Chapter of Physicians for a National Health Program in Oakland.

“Right now, we look at Medicare as a program for when we turn 65, but it has proven to work for the Veterans’ Administration, the chronically disabled and for legislators, who get lifetime health insurance despite how long they serve in office,” said Deborah Burger, president of the California Nurses Association.

The campaign is heartened by the California State Legislature’s passage of a statewide, single-payer bill in 2006 and 2008; both were vetoed by Republican Gov. Arnold Schwarzenegger.  SB 810, The California Universal Healthcare Act resurrected in 2010, failed to pass the Senate floor by two votes earlier this year.

The California Nurses Association and the Physicians for a National Health Program agree the Supreme Court ACA rulings will not affect their initiative no matter what direction it takes. But that’s not to say they don’t support some of the law’s provisions, such as guarantee issue and health care coverage of young adults – 26 or younger — under their parents’ plans, Burger said.

“If the law is overthrown, we plan to move forward anyway,” she said. “As a nurse, I see the devastating effect of self-rationed health care, where patients either end up in the emergency room, hospital or in the morgue. Medicare for All will help cut costs and ensure affordability and accessibility.”

Skeen said the Affordable Care Act is built on a shaky foundation and will not change the current underlying private insurance model. “To get health care for all, you have to eliminate private insurance and expand public insurance to everyone,” he said. “If the law is struck down, we’ll just be back to status quo.”

 Another concern, expressed by Don McCanne, senior health policy fellow for Physicians for a National Health Program, is failure of the state’s health insurance exchange to fully cover the uninsured.

Despite the upward pressure on Medicare spending, per capita expenditures for Medicare beneficiaries are expected to increase more slowly than in the private sector, according to the Kaiser Family Foundation. Burger is confident that Medicare for All would provide more savings than accrued through private insurance. Among private insurers, about 30 cents of every dollar goes to administration, lobbying and profit, while the overhead for Medicare is just 3%, Medicare for All proponents point out.

“The industry has a vested interest in the individual mandate, which will require people to buy insurance coverage,” Burger said. “But that’s not the same as Medicare’s goal of getting more people treated and providing better health care.”

Most Medicare for All proponents believe there’s enough money being spent now to provide coverage for everybody — a combination of contributions to Medicare through taxes and redirecting current premiums to Medicare.

We don’t need to spend more money; we just have to spend it differently by eliminating overhead and spending more on patient care, Skeen said.

Skeen, who estimates single payer could save $8 billion, is in favor of making health care into a social service. “Health care should be a given right and not cause people to go bankrupt in order to pay for it,” he said.

He hopes California will follow in the footsteps of Vermont, which last year  passed a single payer health care law.

http://www.californiahealthline.org/capitol-desk/2012/6/medicare-for-all-takes-show-on-the-road.aspx#ixzz1yupVJ5kA

For-profit managed-care Medicaid the wrong path

By Rita Valenti, R.N.
Atlanta Journal Constitution, Letters, June 24, 2012

Re “Goal: Coverage that won’t soak taxpayers” (Opinion, June 17): As a registered nurse with 30 years of patient-care experience, I was appalled by the misinformation in this piece. What does “soak” taxpayers is the unbridled extraction of public funds to private, for-profit, managed-care corporations that use people’s health care needs to make profits — while adding nothing to patient care or healthy outcomes. Adding another layer of private for-profit unaccountable bureaucracy is the problem — not the solution. Health care should not be a commodity, but a right. Public funds need to be used for the public good, not to enrich private companies. An improved federal Medicare for all of us is the first step toward a just and comprehensive health care system.

Rita Valenti, R.N., is a former state assemblywoman. She resides in Clarkston.

http://www.ajc.com/opinion/readers-write-6-24-1462955.html

What about the insurance subsidies?

Health Reform Subsidy Calculator

Kaiser Family Foundation

Based on the Patient Protection and Affordable Care Act (including subsequent amendments in the Health Care and Education Reconciliation Act of 2010), as signed by the President.

The premiums are illustrative examples in 2014 dollars derived from estimates of average premiums for 2016 from the Congressional Budget Office.

Premium subsidies are based on a silver plan (with an actuarial value of 70%), so all premiums shown are for silver coverage. People may be able to pay a lower premium for less comprehensive coverage (i.e., a bronze plan, with an actuarial value of 60%). The tables showing results by age and income also reflect premiums for silver coverage, though the minimum insurance that people would be required to obtain would be bronze coverage.

The actual premium calculated is adjusted for family type, and for age (within the three to one limit specified in the proposal). Subsidized people can enroll in more expensive plans, but must pay the full difference in the premium.

Health Reform Subsidy Calculator:
http://healthreform.kff.org/SubsidyCalculator.aspx#incomeAgeTables

Comment: 

By Don McCanne, MD

On June 28, the Supreme Court will release its ruling on the constitutionality of the Affordable Care Act. If the full Act is repealed, individuals who would have purchased plans in the state insurance exchanges will receive neither their premium subsidies nor their tax credits for out-of-pocket expenses. What precisely would they be losing?

Let’s use the Health Reform Subsidy Calculator to check a few examples. In each example, we will assume that the policyholder is 45, has a family of four, and does not have employer coverage available. For this family living in a region with a medium cost factor, the predicted premium for the silver plan (70% actuarial value) is $14,245. In the examples, we will change only the income level.

Income:  $31,155 (133% of poverty)
Premium payment:  None – covered by Medicaid
Maximum out-of-pocket costs:  None – covered by Medicaid

Income:  $31,156 (133% of poverty plus $1)
Premium payment:  $935
Maximum out-of-pocket costs:  $4,167

Note that at this level, one additional dollar of income results in the family losing the more comprehensive benefits of the Medicaid program, and mandates that they pay a premium of $935 plus potential out-of-pocket expenses of $4,167, for a total exposure of $5,202. That’s a staggering amount at this income level. Compliance surely would be a problem, not by lack of will but simply by inability to pay.

Income:  $93,700 (400% of poverty)
Premium payment:  $8,901
Maximum out-of-pocket costs:  $8,333

Income:  $93,701 (400% of poverty plus $1)
Premium payment:  $14,245
Maximum out-of-pocket costs:  $12,500

So at an income of $93,700, the premium would be $8,901 and the potential out-of-pocket costs would be $8,333, for a total exposure of $17,234. That is quite a dent for a family that is trying to save for two college educations, a retirement fund, and maybe for replacement of the broken-down family automobile. But add just one more dollar of income and the premium shoots up to $14,245 and potential out-of-pocket expenses to $12,500, for a total of $26,745. Then what are you going to cut out of the family budget? And isn’t the $9,511 increase quite a “tax” to pay on that one dollar of additional income?

Just the premium increase alone might cause this family to downgrade their coverage from silver (70% actuarial value) to bronze (60%) in order to save on the premium. If so, this family literally would be placing a bet that none of them would develop a serious medical problem, and it would lose the bet if any of them did so. Should we really be forcing a family to gamble on its health care coverage?

If the Affordable Care Act is repealed, all of this goes away, and many more would remain with no coverage at all. That would be tragic. But even if the Act is upheld, this coverage is still far from satisfactory, and should be unacceptable as a standard for our nation. Regardless of the Supreme Court decision, we should replace the Affordable Care Act with a program that really does work: a single payer, improved Medicare for all.

Affordable Care Act: We can do better

By Laurence S. Jacobs, M.D.
The Democrat and Chronicle (Rochester, N.Y.), June 18, 2012

The country now awaits the upcoming Supreme Court decision regarding the Affordable Care Act (ACA). No matter what decision is made, however, it is important to recognize the inadequacies of the ACA, and to understand the optimal solution to our health insurance crisis.

It should be recognized that the ACA has a number of commendable features. These include the expansion of Medicaid, enhanced funding for community health centers, restrictions on rescission of policies and on denials of coverage based on pre-existing conditions, and the provision for coverage of children up to age 26 on their parents’ policies. However, these could have all been enacted on a stand-alone basis.

However, the ACA entails many problems, of access, cost, and equity. When fully implemented by 2019, the ACA will cover less than half of our currently uninsured, leaving approximately 26 million people without health insurance. Such uninsurance is presently instrumental in the deaths of about 50,000 people per year, nearly one every minute. Many people forgo needed care because of costs; in 2010, 75 million working age adults went without necessary care due to costs!

Health insurance premiums have more than doubled since 2000; many middle-income families are faced with policies that consume up to 10 percent of income, yet provide poor coverage which offers little protection against financial ruin in case of major illness. Employer programs now cost over $15,000 annually for family coverage, and many covered people will increasingly have to deal with a limited provider network and minimal coverage, as employers reduce options and shift rising costs to employees. Skimpy insurance, with high deductibles, copays and other out-of-pocket expenses, comprise the new norm of unaffordable underinsurance.

While the personal bankruptcy rate due to medical bills in the rest of the industrialized world is zero, more than 60 percent of such bankruptcies in the United States are related to medical bills; almost 80 percent of those being bankrupted had health insurance prior to illness. The rate has not declined in Massachusetts since passage of that state’s health reform bill, as much of the new coverage there is bare bones high deductible policies. Since the ACA contains no effective cost-control measures, the situation summarized above can be expected to worsen if the ACA survives in any form following the Supreme Court decision.

We are alone in the industrialized world in employing a profit-driven private insurance system for funding our health care. The result is a fragmented patchwork of coverage, and chronic conflict between generation of returns for shareholders versus taking care of patients. The fragmentation results in extraordinary inefficiencies, with 31 cents of every health care dollar (totaling $400 billion per year) diverted to overhead, marketing, profit, executive compensation and the imposition of excessive paperwork on providers. In contrast, Medicare runs on an overhead of under 3 percent. Rather than continuing to funnel our health insurance coverage and processes through these private, profit-driven companies, we should follow the example of much of the developed world and institute a single-payer, simplified mechanism for funding our national health care.

Such a scheme would be primarily a payment mechanism. Patients would have free choice of physician, hospital and other health care facilities. Moreover, only a single-payer system offers effective methods for cost control, such as global hospital budgeting, capital planning, negotiated fees and bulk purchasing. It is easy to understand why the health insurance industry and the pharmaceutical industry, stakeholders who benefit from the status quo, have fought against a single-payer plan with every means available to them.

No matter what the Supreme Court decides, we have the opportunity as a country to embrace a solution to this problem, if we have the political will to do so. Two-thirds of the population and 59 percent of physicians support the establishment of a national health insurance program. It is the right thing to do and, increasingly, it is imperative that we do so.

Dr. Laurence S. Jacobs is Professor of Medicine Emeritus at the University of Rochester and Vice-Chair of the Finger Lakes Chapter of Physicians for a National Health Program.

http://www.democratandchronicle.com/article/20120619/OPINION02/120618010/Affordable-Care-Act-We-can-do-better?nclick_check=1

Single payer, not free market, is the answer

By Patricia Downs Berger, M.D.
Letters, Boston Globe, June 16, 2012

In the June 13 op-ed “A free market brings down health costs” Jeff Jacoby asked, “What is the best way to make sure that Americans with chronic medical conditions … can afford the insurance they need?” Jacoby’s answer is the free market, a business model based on “supply and demand, competition, and flexible prices.” He seems to forget that medical care is not a commodity that we buy and sell, but a basic human necessity.

Universal access to affordable, high-quality medical care is what we all want for ourselves and our families, but it can only happen if we have a single-payer system that embodies this goal. Such a system means that there would be a single government entity that would pay health care bills instead of myriad private companies and government plans.

Everyone would have a government-issued medical card to use for medical care that would replace the for-profit health insurance industry coverage, and there would be no more premiums, deductibles, or co-insurance that act as barriers to seeking care.

Single payer would be publicly funded through the tax system and federal and state funds already committed to health care through programs such as Medicare, Medicaid, and the Children’s Health Insurance Program. Single payer is not a pie-in-the-sky theory. Variations have been working well in industrialized nations where health costs are half of what we spend in the United States and health outcomes are better.

Dr. Patricia Downs Berger co-chairs Mass-Care, a campaign for a single payer health care system for Massachusetts. She resides in Brookline.

http://articles.boston.com/2012-06-16/letters/32247699_1_single-payer-health-care-health-costs

Innovation leader – Medicare or private insurance?

How Medicare Solves Private Plans’ Problems and Vice Versa

By Austin Frakt, PhD
JAMA Forum, June 21, 2012

In a new article in the Annual Review of Economics, Katherine Baicker, Amitabh Chandra, and Jon Skinner point out some of the ways Medicare has helped solve a coordination problem among private plans:
 
“It is natural to ask why private providers have not adopted ACOs [Accountable Care Organizations, groups that give coordinated health care and for whom payment is tied to achieving health care quality outcomes and goals that can lead to cost savings] or more bundled payments on their own. This remains a puzzle. One explanation is that it is a coordination problem—all insurers may want to adopt larger bundled payments, but no single insurer can make the transition. This is certainly consistent with the historical record on the adoption of prospective payment for hospital care. Once it was introduced in Medicare, private plans were quick to adopt it. Similarly, private hospitals were quick to use the federal government’s efforts to measure quality of care even though nothing stopped them from forming consortiums to measure quality before these federal efforts.”

Their points are generally valid in that it’s common for private plans to adopt certain types of payment reforms and quality monitoring after these measures are introduced in Medicare but not before. Nevertheless, there are some examples of ACO-like contracts made by private plans ahead of the Medicare counterparts. And that doesn’t count the failed attempts at capitation (establishing a dollar amount to cover the cost of health care services provided for an individual during a specified length of time) by private insurers and provider groups in the 1990s. I don’t think this invalidates the general point the authors make. It seems Medicare has solved a coordination problem among private insurers.
 
Indeed, some of the things Medicare will do are properly viewed as public goods. All but a handful of large, dominant health plans cannot convince large hospital systems to accept a new form of payment system. But Medicare can. What health plan will do its own comparative effectiveness analysis to determine which interventions work best for managing a condition? Medicare will or could. The results of both of these types of innovations, and others, will be public information and can benefit all plans and all consumers.
 
History shows that Medicare has done some things private plans seem unable to do, and then private plans voluntarily copy Medicare. But it goes the other way too.
 
For example, private plans have innovated in ways that traditional Medicare has not. Managed care, consumer-directed health plans, prescription drug benefits, and catastrophic coverage all exist or existed in the commercial market before adoption by Medicare (if ever). In some cases, the Medicare program, though not the traditional fee-for-service arm of Medicare itself, followed private plans’ lead, adding managed care plans (Medicare Advantage) and a prescription drug benefit (Part D), for example.

There does seem to be a coordination problem among private plans that Medicare solves. Likewise, the private sector sometimes does a better job of designing health plan options. That both plan types, private and government, play a worthwhile role needn’t be shocking or blasphemous. The fact that they both play worthwhile roles ought to be widely acknowledged. Naturally, it often isn’t—least of all, it seems, in our politically charged health policy debates.

http://newsatjama.jama.com/2012/06/21/jama-forum-how-medicare-solves-private-plans-problems-and-vice-versa/

Comment: 

By Don McCanne, MD

Austin Frakt makes the point that both Medicare and the private health insurers have each independently introduced innovations that then can help the other when these innovations are shared. But when you look at the respective innovations, it becomes obvious which innovator it is that truly serves the interests of patients.

Medicare attempts to create greater value when using taxpayer and premium dollars for the payment of health care services. Thus you see innovations such as the adoption of prospective payment for hospital care. We benefit both as taxpayers and as patients.

Look at the innovations of private insurers that Frakt mentions: managed care, consumer-directed health plans, and prescription drug benefit plans. These designs take away choice of health care professionals and institutions, choice of drug benefits, and also erect financial barriers between the patient and health care. Here the process of innovation is not used to benefit patients, but rather is designed to enhance the business model of the intermediary intruder – the private insurance plans.

Frakt points out that these private innovations are being used by Medicare in the private Medicare Advantage plans and in the private Part D Medicare drug benefit. True, but these are terrible innovations to introduce into Medicare because they waste funds and reduce choice while increasing administrative complexity. Medicare’s adoption of private innovations has been a bad thing, not a good thing.

Coordinated care is certainly beneficial and should be expected regardless of whether Medicare or private insurers are paying the bills. There may be instances where bundling of payment would be appropriate, just as capitation has been appropriate in selected circumstances. If it benefits both taxpayers and patients, it would be appropriate. The risk is that the business mind of the private insurers will most likely morph accountable care organizations into intermediary intruders designed to benefit third party payers, likely at a cost to patients. That is not a desirable innovation.

Frakt does make the important point that Medicare does not provide catastrophic coverage, whereas some private plans do. Medicare certainly should as well. But that’s not really a private plan innovation; it’s merely a benefit that should have been included in Medicare in the first place. That is one more reason why we advocate for an improved Medicare for all, rather than merely for a universal expansion of the existing Medicare program.

Government can do it. In fact, it is leading on the catastrophic coverage benefit by making it a requirement through the Affordable Care Act. Innovation in the private sector benefits the private sector. Innovation in the government serves the public interest. Trading public and private innovation is not in our interest when we come out the losers.

Update on deaths from being uninsured

Dying for Coverage: The Deadly Consequences of Being Uninsured

Families USA
June 2012

Key Findings

* Across the nation, 26,100 people between the ages of 25 and 64 died prematurely due to a lack of health coverage in 2010.

* Between 2005 and 2010, the number of people who died prematurely each year due to a lack of health coverage rose from 20,350 to 26,100.

* Between 2005 and 2010, the total number of people who died prematurely due to a lack of health coverage was 134,120.

Why Insurance Matters

* The uninsured are less likely to have a usual source of care outside of the emergency room.

* The uninsured often go without screenings and preventive care.

* The uninsured often delay or forgo needed medical care.

* Uninsured Americans are sicker and die earlier than those who have insurance.

* The uninsured pay more for medical care.

http://familiesusa2.org/assets/pdfs/Dying-for-Coverage.pdf

Comment: 

By Don McCanne, MD

In 2010, about 26,000 of the nearly 50 million people without health insurance died due to the lack of that insurance. At best, about 26 million people will remain uninsured if the Affordable Care act is upheld by the Supreme Court. That means that we will continue to accept about 13,000 deaths per year as a consequence of our failure to enact a single payer national health program.

It is one thing to accept inordinate financial waste in our system in order to cater to the private insurance industry, but it is quite another to accept so much suffering and death. The former reflects on our illogical willingness to accept social injustices in order to cater to the moneyed class, but to knowingly accept the latter reflects on the most basic moral fiber of our society.

Is it that people don’t understand? Or are we really that animalistic?

Addendum:

Today’s Quote of the Day used updated numbers from Families USA on the number of deaths that result from being uninsured. Their numbers were based on the 2002 methodology of the Institute of Medicine.
However, under “Methodology,” the Families USA report states, “A study published by Harvard Medical School researchers late in 2009 that used more recent data found that the lack of health insurance now raises mortality rates by 40 percent. If we had applied the latter estimate of the impact of uninsurance on mortality, rather than the 25 percent figure used by the IOM, our mortality estimates would have increased substantially.”
The numbers are worse than those reported earlier today. Rather than zeroing in on sterile recalculations, let’s think about the real people whose lives are lost and what we need to do to prevent that in the future.
The Harvard study, authored by co-founders of PNHP and their colleagues:

NHIS report on insurance coverage

Health Insurance Coverage: Early Release of Estimates From the National Health Interview Survey, 2011

By Robin A. Cohen, Ph.D., and Michael E. Martinez, M.P.H., M.H.S.A.
CDC, Division of Health Interview Statistics, National Center for Health Statistics
June 2012

The Centers for Disease Control and Prevention’s (CDC) National Center for Health Statistics (NCHS) is releasing selected estimates of health insurance coverage for the civilian noninstitutionalized U.S. population based on data from the 2011 National Health Interview Survey (NHIS).

* In 2011, 46.3 million persons of all ages (15.1%) were uninsured at the time of interview, 58.7 million (19.2%) had been uninsured for at least part of the year prior to interview, and 34.2 million (11.2%) had been uninsured for more than a year at the time of interview.

* In 2011, the percentage of children under age 18 years who were uninsured at the time of interview was 7.0%.

* Among adults aged 19–25, the percentage uninsured at the time of interview decreased from 33.9% (10 million persons) in 2010 to 27.9% (8.4 million) in 2011.

* Among adults aged 19–25, 56.2% were covered by a private plan in 2011, an increase from 2010 (51.0%).

Estimates of enrollment in HDHPs and CDHPs
 
Based on data from the 2011 NHIS, 29.0% of persons under age 65 with private health insurance were enrolled in an HDHP (high-deductible health plan), including 9.2% who were enrolled in a CDHP (consumer-directed health plan) and 19.9% who were enrolled in an HDHP without a health savings account (HSA). Enrollment in HDHPs increased from 25.3% in 2010 to 29.0% in 2011. There was a significant increase in enrollment in HDHPs without HSAs, and in CDHPs, between 2007 (when NHIS started collecting this information) and 2011.

Based on data from 2011, among persons under age 65 with private health insurance, 26.9% with employment-based coverage were enrolled in an HDHP, compared with 52.4% of those with a private plan that was directly purchased or obtained through means other than employment. The percentage of persons covered by employment-based private plans who were enrolled in HDHPs increased from 15.6% in 2007 to 26.9% in 2011. The percentage of persons covered by directly purchased private health plans who were enrolled in HDHPs increased from 39.2% in 2007 to 52.4% in 2011. 

Insurance coverage by poverty status

The percentage of poor children who were uninsured at the time of interview decreased from 1997 through 2011. During the same period, the percentage of poor adults who were uninsured remained relatively stable.

Among children, all poverty status groups experienced an increase in public coverage between 1997 and 2011. However, the largest increase was seen among near poor children, for whom coverage by a public plan increased by 36.5 percentage points during the same period.

The rate of private coverage among near poor children was 25.1 percentage points lower in 2011 than in 1997. Among near poor children the percentage without health insurance and the percentage with private health insurance coverage have declined since 1997, while public coverage has increased. Private coverage generally decreased among near poor adults aged 18–64, from 52.6% in 1997 to 35.4% in 2011, so that the uninsured rate is now higher than the private coverage rate for this population. Private coverage among not poor adults aged 18–64 generally decreased from 1997 through 2011.

http://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201206.pdf

Comment: 

By Don McCanne, MD

The good news is that the percentage of individuals uninsured at the time of the National Health Interview Survey declined from 16.0% in 2010 to 15.1% in 2011. The improvements were primarily due to an increase in enrollment of children in public programs, and an increase in enrollment of young adults in their parents’ private insurance plans.

If the Affordable Care Act is upheld, we can anticipate a further increase in enrollment in Medicaid. If not, at least public coverage for low-income children should be maintained.

The more alarming news in this report is the increase in high-deductible health plans, both those acquired through employment and especially those purchased in the individual market. The increase in private coverage made possible through the establishment of state insurance exchanges will be in lower-actuarial value plans – primarily high-deductible plans. Also employers are expected to shift more of their plans to high-deductible coverage.

High-deductible plans equate with underinsurance. These plans leave people with health care needs vulnerable to financial barriers to care. With this report, once again we see that underinsurance is becoming the new standard in America. That wouldn’t occur if we were to adopt an improved Medicare for all.

What SCOTUS ruling might mean to Vermont's single-payer plan

By Mike Miliard, Contributing Editor
Government Health IT, June 18, 2012

“The Affordable Care Act doesn’t do a whole heck of a lot for Vermont,” says Deb Richter, MD, president of Vermont Healthcare For All. “Most of the provisions in it, we’ve already done. It’s kind of a shame, in a way. We would have momentum, and probably could’ve gotten further with single-payer, if the ACA had not happened.”

Vermont comes by its reputation for progressive politics honestly. And one of its signal achievements on that front is a piece of legislation known as Act 48, signed into law by Democratic Governor Peter Shumlin in June 2011, which lays the initial groundwork for the Green Mountain State to make the pioneering move to a single-payer system.

“Because of the growth of our healthcare expenditures every year, we had to do something,” says Peg Franzen, president of the Vermont Workers’ Center, which labored for years to build momentum behind the bill. “Insurance companies are doing what they’re supposed to do; they’re making profits for their shareholders. But that’s not the way we should have a health system set up. Healthcare shouldn’t be a commodity.”

But there’s a long road ahead before so-called Green Mountain Care – tagged by opponents with the predictable epithet of “ShumlinCare” – becomes a reality in Vermont. Political pitfalls on the state and national level mean a single-payer future is far from certain. But since Act 48’s passage a year ago, work on the policy front has been ongoing, aimed at improving the state’s healthcare system, regardless of the outcome.

Seeking to offer near-universal coverage for Vermont’s 626,000 citizens, the state-funded insurance pool is still years away from coming to fruition, and has many questions still to be answered.

One not-inconsequential detail: how it will be funded. A variety of new taxes are under consideration, but won’t be voted on in the near future.

Act 48 also contained provisions to launch a health insurance exchange as required by the ACA, set up pilots to explore medical home and bundled-payment reforms and established the Green Mountain Care Board – a panel of policy experts to set rates, design benefits packages and suggest funding strategies.

Those are just first steps. As noted above, one stumbling block along the way could be the federal Affordable Care Act – which itself is up in the air, of course – with the Supreme Court ruling due by June’s end.

Vermont hopes to use money disbursed by the ACA to help build those insurance exchanges. The federal law says every state must have one by 2014, but it also allows states to petition for a waiver from the national rules if they can prove they’re providing equal or better coverage of their own.

“One major advantage it could (provide) is help bring in federal dollars when people buy health insurance on the exchange,” Richter says. “And then that sum of money is what we would expect to get as a subsidy when we finally do single payer.”

But waivers won’t be available until 2017. In today’s political climate, five years is an eternity. Whether that necessary bit of dispensation ever comes depends “on the administration in Washington,” Richter adds.

If it could happen today, there would be “a good chance” of success, she adds. “Obama has said if he could do it over, then single payer would be the way he would go. He’s also said he believes in states’ rights to innovate and do some models on their own.” If it’s the Romney administration? “I don’t think so.”

The next few years will be pivotal – on policy, politics and public opinion fronts.

“There’s a lot of misinformation out there,” Franzen says. “There’s been a real attempt to spread a lot of fear. Which we knew would happen. When we got into this, we all knew it was going to be a five year or more battle.”

In the meantime, work toward a better healthcare system has been moving forward in earnest. In the year since Act 48 was passed, the Green Mountain Care board has been hard at work on projects around cost containment, says its chair, Anya Rader Wallack.

“Right now we’re very focused on trying to implement payment reform models in the state, moving away from fee-for-service,” she says. “And we’re working with providers around the state to develop some models for doing that.”

Other responsibilities include “a whole realm of benefit design, for both our health benefit exchange and the single-payer financing plan that the governor’s office will be bringing back to the legislature next year,” Wallack says. “For both of those purposes we have to sign off on a benefit package that would form the floor, essentially, for everyone in Vermont. We are waiting for recommendations on those and will have to delve into whether to approve them.”

In terms of the single-payer law, “there’s still a lot of work to be done,” she says. But, “as for our work, we’re sort of off and running. We have those responsibilities, regardless of what happens in the future with the single-payer plan.”

Nationally, whether the ACA stands or falls “doesn’t really affect our work at all,” she adds, referring to the Green Mountain Care board. “It affects the single-payer plan, and it affects our implementation of the health benefit exchange, because if the [individual] mandate is removed, it means the state will have to determine whether to pass a mandate at the state level to assure everybody’s covered.”

Single-payer may have far to go before it’s a reality. But even if it ends up a vanishing pipe dream, Vermont is in much better shape, when it comes to keeping its citizens covered, than most other states.

By the same token, even if the Affordable Care Act is upheld and goes into full effect, “at best, it will bring the rest of the country to where Vermont already is,” Richter says. “Act 48 was intended to go beyond that.”

“Regardless of what happens with [single-payer], or with ObamaCare,” Wallack adds, “if we do our job right, we’ll have a more sustainable, higher-quality healthcare system, I think, than anywhere else in the country.”

http://www.govhealthit.com/news/what-scotus-ruling-might-mean-vermonts-single-payer-plan?page=0,1