PNHP

Using insurance products to penalize unhealthy patients

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Using insurance products to penalize unhealthy patients

Employers Tie Financial Rewards, Penalties To Health Tests, Lifestyle Choices

By Julie Appleby
Kaiser Health News, April 2, 2012

Gone are the days of just signing up for health insurance and hoping you don’t have to use it. Now, more employees are being asked to roll up their sleeves for medical tests — and to exercise, participate in disease management programs and quit smoking to qualify for hundreds, even thousands of dollars’ worth of premium or deductible discounts.

Proponents say such plans offer people a financial incentive to make healthier choices and manage chronic conditions such as obesity, high blood pressure and diabetes, which are driving up healthcare costs in the USA. Even so, studies of the effect of such policies on lifestyle changes are inconclusive. And advocates for people with chronic health conditions, such as heart disease and diabetes, fear that tying premium costs directly to test results could lead to discrimination.

Nonetheless, such plans could be the wave of the future. Faced with crippling healthcare costs, the number of employers embracing such programs shot up from 49 percent in 2010 to 54 percent last year — and more say they expect to do so soon, according to a survey by consultants Aon Hewitt. Big-name participants include insurer UnitedHealthcare, car rental firm Hertz, postage meter maker Pitney Bowes and media owner Gannett, owner of USA TODAY.

And more employers are expected to adopt them starting in 2014, when the health law allows them to offer larger incentives or penalties than they can now.

Starting in 2014, federal law allows employers to raise the value of the perk or penalty from 20 percent of the cost of a worker’s health insurance plan, to 30 percent. Based on the average cost of employer-offered insurance today, that means firms will be able to offer annual discounts or penalties of more than $4,500 a family, or $1,600 for individuals.

Given the available data, it’s hard to parse how much of the reported savings from such programs come from improved health, and how much from the frequent pairing of such programs with high deductible policies, which shift more costs onto workers.

http://www.kaiserhealthnews.org/Stories/2012/April/02/employers-financial-rewards-penalties-health-tests.aspx

Comment:

By Don McCanne, MD

Because we continue to insist that private insurance remains a mainstay of financing health care, we perpetuate the confusion between the health insurance product itself and the actual health care that people need. A well functioning health care financing system should remove financial barriers to health care that people need.

Single payer supporters understand that a universal pool should be financed equitably through progressive taxes, and that full payment for necessary health care should come from this pool – pretty much as they do in Canada. When people need health care, they get it, and the bill goes to the public agency.

In the United States we have inserted these very expensive and wasteful insurer intermediaries that continue to manipulate the patients and the health care providers primarily to meet the requirements of their own insurer business model. To cater to these intermediaries, we are paying them far too much for their administrative excesses while we fail to improve the payment system with the goal of obtaining optimal value in our health care purchasing.

Today’s message demonstrates more of the innovative approaches designed to keep the insurers in business while pretending that these financing innovations improve health, when there is a paucity of evidence for that. Smoking cessation programs are an exception, but they should be separate programs unrelated to health insurance.

Blaming the patient for hypertension, hyperlipidemia, obesity, and diabetes is misdirected since most of these patients have little control over being inflicted with their chronic disorders. Yes, interventions should be instituted where effective, but that does not mean that these people should be financially penalized. Supposed rewards for not having these disorders are really penalties for those that do since the pooled funds are directed away from the patients in need and to the healthy.

This is just another example of attacking the social contract under which we should all receive the care that we need, and transferring the responsibility to individuals who have greater needs. These programs use not only cash penalties and penalties disguised as pseudo-rewards, but also they usually are combined with greater cost sharing, especially higher deductibles. That transfers more of the responsibility to the “consumers” who then have greater control over their own health care – or so the phony argument goes. In reality, these individuals have less control because of the financial barriers being erected between them and their health care – the exact opposite of policies which we should be adopting.

Today Kaiser Health News published a haiku which I wrote in response to Julie Appleby’s article above about penalties being assessed for failing certain health tests. In the haiku, my hyperbole is within the bounds of poetic license since it represents the continuing trends under private insurers:

PAY TO THE TEST

Bad health? Pay up here.
Social contract? That’s passe.
You are on your own.

-Don McCanne, MD

Minnesota: The case for universal care at the state level

By Amy Lange
Star Tribune (Minneapolis), April 2, 2012

Nothing is quite as awe-inspiring as welcoming a newborn into the world. As a nurse and midwife, I’ve been privileged to comfort thousands of laboring women and welcome more than 550 Minnesota babies into my waiting hands. Whether arriving with a robust cry or stunned silence, each is imbued with human dignity and promise. I worked knowing that each mother and baby deserved my full attention and expertise, and I believe that each child, woman and man deserves quality care and secure health coverage. Most Minnesotans, I’m convinced, share this emotional instinct.

Yet in our state and country, the health care we receive is rationed by our ability to afford it rather than provided based on our medical need. Meanwhile, the financial burden for basic care is increasing with the rapid rise of high-deductible plans. And the dominance of employer-based insurance means that a change in jobs yields gaps in coverage, interruptions in care and disruption of the provider-patient relationship.

This sorry state of our health care system is again front-page news, as the Supreme Court weighs arguments it heard last week on the constitutionality of the Affordable Care Act (ACA). Many citizens are wondering what happens next as those necessary reforms hang in the balance.

Against this backdrop, I’m pleased to have collaborated recently with Growth & Justice, a Minnesota public-policy research organization, to produce a report that analyzes the economics of a redesigned health care system for Minnesota (www.growthandjustice.org/beyondaca). Together with the expertise of the Lewin Group, a highly regarded national consulting firm, we analyzed the benefits and costs of a unified and universal health care system for Minnesota, often known as “single-payer.”

Here’s what we found: If Minnesota adopted a unified system with a statewide risk pool, continuous coverage, a common benefit set, and uniform payment rates and reimbursement rules, the annual administrative savings would approach $5 billion. The negotiating clout of a single buyer could save Minnesotans nearly $1 billion on prescription drugs and medical equipment. And with a single claims administrator and the subpoena powers of a state program, we could reduce fraud and realize another $200 million in savings. Paying for the system with a progressive tax structure, rather than increasingly expensive premiums, would reduce average health care costs for all households, except for those in the very highest income brackets.

These combined savings are more than enough to offset both the increased utilization that would result from covering every Minnesotan, and the elimination of deductibles, coinsurance and most copays. In fact, even with a benefit package covering medical, dental, mental health, hospitalization, rehab, vision, hearing and prescription medications, a unified system would save us $4 billion overall in 2014, a 9 percent decrease in health spending. These savings would be achieved despite covering the additional 262,000 Minnesotans who are expected be left uncovered by the ACA.

How much is that in real money, for businesses and families?

The study estimates that, under one financing scenario, employers who currently offer insurance to their employees would save an average of about $1,200 per employee per year. Under the same scenario, an average family would save $1,240 on annual health spending. Those savings would compound over time, because a unified system can establish predictable financing and a global health care budget. With a unified system we could finally bend that cost curve that has been vexing businesses, consumers and governments for decades. The Lewin Group’s projections estimate that the unified system would slow health spending growth, resulting in annual savings of 12 percent or more by 2023.

There are myriad ways to design a health care system, establish benefits and share costs, and there are countless financing alternatives. In fact, we see those variations among all the other wealthy democracies, but the basics are the same in any unified system: birth-to-death coverage, with the democratic government assuring affordability, transparency, equity and access.

Minnesota would not be alone among the states if it forged ahead to provide a universal and unified health system. Governors, legislatures and citizens groups are pushing similar reforms in Vermont, Montana, Oregon and Hawaii. And Minnesota Gov. Mark Dayton favored a universal system for Minnesota in his 2010 campaign.

To be sure, there would be implementation hurdles and political, legal and logistical challenges. Paying for health care with taxes instead of premiums, even if cheaper and fairer overall, will be resisted by antigovernment and antitax ideologues. And yes, sweeping change would create disruption, including the loss of some 42,000 jobs in the current health care bureaucracy. But studies have shown that those losses eventually would be made up by economic growth in other sectors that benefit from greatly reduced health care costs.

Surely few of us are satisfied with the way things are, or are convinced that the Affordable Care Act is the final reform, even if the U.S. Supreme Court upholds it. So let’s hold onto the “unified and universal” option for Minnesota, with the knowledge that we can afford a system in which all newborns can be assured the essential human dignity of access to life-giving care, from the moment they enter the world until they draw their last breath.

Amy Lange, a registered nurse and certified nurse-midwife, is a policy fellow on health care for Growth & Justice, a research organization focused on expanding prosperity.

http://www.startribune.com/opinion/commentaries/145845025.html

GOP attorney general suing over ACA supports single payer

GOP Attorney General Suing Over Obamacare Supports Single-Payer: ‘I Trust The Government More’

By Scott Keyes
Think Progress, March 30, 2012

According to one Republican attorney general in the lawsuit against the health care individual mandate, the problem with Obamacare is that it’s not a government takeover of health care.

ThinkProgress spoke with Louisiana Attorney General Buddy Caldwell outside the Supreme Court on Wednesday. Caldwell opposes Obamacare and the individual mandate, but for a different reason than most of his fellow litigants: it props up the private health insurance industry. “Insurance companies are the absolute worst people to handle this kind of business,” he declared. “I trust the government more than insurance companies.” Caldwell went on to endorse the idea of a single-payer health care system, saying it’d “be a whole lot better” than Obamacare:

KEYES: You don’t think the subsidies for low-income people are going to be helpful?

CALDWELL: No, no. The worst thing you can do is give it to an insurance company. I want to make my point. All insurance companies are controlled in their particular state. If you have a hurricane come up the east coast, the first one that’s going to leave you when they gotta pay too many claims is an insurance company. Insurance companies are the absolute worst people to handle this kind of business. I trust the government more than insurance companies. If the government wants to put forth a policy where they will pay for everything and you won’t have to go through an insurance policy, that’d be a whole lot better.

http://thinkprogress.org/health/2012/03/30/454261/buddy-caldwell-private-insurance/

Comment:

By Don McCanne, MD

Louisiana Attorney General Buddy Caldwell, a Republican, who has joined the lawsuit against the Affordable Care Act, certainly understands the greatest flaw in the legislation. “The worst thing you can do is give it to an insurance company.” Leading to his conclusion, “If the government wants to put forth a policy where they will pay for everything and you won’t have to go through an insurance policy, that’d be a whole lot better.”

All Parties Ignore the One Way to Reduce Health Care Costs: Single Payer

By David U. Himmelstein, MD, and Steffie Woolhandler MD, MPH
Truthout, March 30, 2012

In a recent full-page newspaper advertisement, IBM touted massive medical savings through computerization. It’s a promise they’ve made before, starting with a report issued in 1961. If only these promises were true.

For 50 years, we’ve been told that computers would give doctors ready access to past tests and diagnoses, eliminating duplicate tests that are unnecessary and costly. But it turns out the reverse is true.

Our study published this month examined 28,741 patient visits to 1,187 physicians. We found that when doctors can view X-ray results online, they actually order 40 percent to 70 percent more X-rays, including costly CT scans and MRIs. And the same holds true for blood tests.

Even the most wired doctors – those with full electronic medical records and those in hospital-owned practices where old test results are most likely to be available electronically – showed no signs of moderating their test ordering.

Sparing doctors the inconvenience of tracking down results seems to lead to more testing, not less.

Computer vendors’ promises of cost savings by eliminating paperwork have also flopped. In a previous study of 3,800 hospitals, we found that computerization actually increased hospitals’ administrative costs.

Make no mistake: we support clinical computing. It’s an essential tool for improving medical care. One of us directed clinical computing at a Harvard hospital for more than a decade. And a handful of hospitals have developed computer systems that have improved care and may even cut costs.

But these successful systems were custom-built by clinicians on the ground and focused on meeting patient care needs. In contrast, business managers are the decisionmakers about computer purchases in most hospitals and large practices, and they’re choosing off-the-shelf software that gives priority to maximizing billings and addressing management’s needs. As our studies show, these management-led systems have increased health costs.

Yet politicians across the political spectrum – from Barack Obama to Newt Gingrich – continue to push computerization as a health care cure-all. Citing consultants’ estimates (in reports mostly funded by computer firms), they promise that the billions invested under the Health Information and Technology for Economic and Clinical Health (HITECH) Act will soon yield hundreds of billions in savings.

It’s not just vendors and consultants who fuel politicians’ delusions. The cost savings promised by computerization may be vaporware, but they’re painless. The realistic alternatives for medical cost control are not.

Someone – insurers, patients, doctors, hospitals or drug firms – will suffer if health care costs are contained. And if computers won’t save us from rising medical costs, we’ll eventually have to look elsewhere for salvation.

Republicans’ proposals would put the onus on patients in the form of higher copayments and deductibles, and by turning Medicare into a voucher program that would cover a shrinking share of seniors’ medical bills. But only extreme – we would say inhumane – financial barriers can keep the very sick patients who account for most costs from seeking care.

Democrats’ plans rely mostly on better care management and coordination, and improved prevention – laudable on other grounds, but unlikely to save much, if anything, according to careful studies and the Congressional Budget Office (CBO).

Both parties studiously avoid the one health-reform solution that – unlike computers – would actually save money while sparing patients: single-payer, nonprofit national health insurance.

Research shows that single-payer reform could save about $380 billion annually that’s currently wasted on insurers’ overhead and the unnecessary paperwork (and screen-work) they inflict on hospitals, doctors and patients. That’s enough money to fully cover the uninsured and eliminate copayments and deductibles for the rest of us.

In the early 1990s, studies by the CBO and the Government Accountability Office (GAO) arrived at similar conclusions. Their basic findings still hold. And, of course, the experience of other developed nations has demonstrated this proposition in practice.

But taking this path would mean taking on the big insurers, drug companies and medical-equipment manufacturers. It’s been much easier for politicians to toss some money to computer vendors and pretend that that will fix health care’s cost problem.

David U. Himmelstein, MD, and Steffie Woolhandler, MD, MPH, are professors of public health at the City University of New York at Hunter College and visiting professors of medicine at Harvard Medical School. They cofounded Physicians for a National Health Program. This article is a Truthout original.

We need universal health care coverage for all

By Hedda Haning, M.D.
Sunday Gazette-Mail (Charleston, W.Va.), April 1, 2012

It was flattering to be quoted in the Gazette editorial March 26 when the Gazette could have used any number of authoritative resources to demonstrate the problems associated with private for-profit health insurance. For example, Physicians for a National Health Program (PNHP), of which I am a member, has produced many studies over the years, published in prestigious journals, showing the negative health effects for the American people of putting profit before care.

Here is their statement in response to the current Supreme Court Hearing on the Affordable Care Act: “Regardless of whether the Supreme Court upholds or overturns the Affordable Care Act in whole or in part, the unfortunate reality is that federal health law of 2010 will not work: (1) it will not achieve universal coverage, as it leaves at least 26 million uninsured, (2) it will not make health care affordable to Americans with insurance, because gaps in their policies will leave them vulnerable to bankruptcy in the event of major illness, and (3) it will not control costs.

“Why? Because the ACA perpetuates a dominant role for the private insurance industry. That industry siphons off hundreds of billions of health care dollars annually for overhead, profit and the paperwork it demands from doctors and hospitals; it denies care to increase insurers’ bottom line; and it obstructs any serious effort to control costs.

“In contrast, a single-payer, improved-Medicare-for-all system would achieve all three goals — truly universal, comprehensive coverage; health security for our patients and their families; and cost control. It would do so by replacing private insurers with a single, nonprofit agency such as Medicare that pays all medical bills, streamlines administration, and reins in costs for medications and other supplies through its bargaining clout.”

Let me emphasize two other points. First, an all-inclusive national health program — call it Medicare for All — would be excellent for the economy. Under such a program Mary Brown from Florida would not have gone bankrupt and she and her husband could have kept their auto shop open. The same dilemma has ruined many small business people. Under Medicare for All, the Browns would pay a national tax appropriate to their income, a payroll tax, and all bills for necessary medical care would have been paid for them.

A major obstacle to changing our way of financing health care is that there are powerful very rich people who don’t want to pay a national tax appropriate to their incomes to support such a program. We certainly know that from past history as the wealthy have always resisted paying fair taxes for Social Security and Medicare. The rest of us do our taxes, but they won’t. Why would anyone think the wealthy should pay their fair share of taxes? What a weird idea (joke).

It was shown years ago in the American automobile industry that the cost of health insurance was more per car than the cost of steel. That has not changed, and it is one thing that has driven our Big 3 to do much of their manufacturing in Canada. So you see corporations capable of moving out are not above taking advantage of another country’s tax supported health care system.

Additionally, West Virginia improvement in health care cost and coverage reported in the editorial comes principally from extending and increasing the coverage under Medicaid. I agree that is a plus — except that whenever we aim a benefit at just one group, it is easy for others to be resentful. It is easy to point a finger at those “poor, fat, lazy, undeserving jerks that are living off our tax support when they really should just get off their butts and find a job.” You have all heard that kind of comment in relation to every program for the less fortunate among us.

That is one reason that I came to the conclusion long ago that we must have the same program for everyone: universal coverage for all, fair for everybody. We must take care of everyone equally if the system is to work and be supported as Social Security and Medicare are — by a wide margin.

That is the American way we all learned about in school, justice and equality for all.

Hedda Haning is a Charleston physician.

http://wvgazette.com/Opinion/OpEdCommentaries/201204010042

Dr. Claudia Fegan on "Up with Chris Hayes," MSNBC, March 31, 2012


Dr. Claudia Fegan, past president of Physicians for a National Health Program and currently chief medical officer at John H. Stroger Jr. (Cook County) Hospital, appeared on the “Up with Chris Hayes” show on MSNBC on March 31 to discuss the Supreme Court and the Affordable Care Act. Also on the panel were Yale University law professor Akhil Amar, former President Obama adviser Neera Tanden and the Washington Examiner’s Tim Carney. The clips of Dr. Fegan above are excerpts from a much longer segment of the show which is available from MSNBC here.

In her closing remarks, when asked what her takeaway from the discussion was, Dr. Fegan said, “I didn’t realize that the complexity of the Affordable Care Act would make single payer seem like the most logical way to provide our patients with what every patient wants: to be treated with dignity and respect and have access to the health care that I believe they deserve. How can we be the most powerful nation in the world and not guarantee access to health care, which has such an impact on people’s quality of life and is so important to the health of the nation?”


http://upwithchrishayes.msnbc.msn.com/_news/2012/03/31/10957961-now-we-know-where-supreme-court-justices-get-their-news?lite

Dr. Claudia Fegan on “Up with Chris Hayes,” MSNBC, March 31, 2012


Dr. Claudia Fegan, past president of Physicians for a National Health Program and currently chief medical officer at John H. Stroger Jr. (Cook County) Hospital, appeared on the “Up with Chris Hayes” show on MSNBC on March 31 to discuss the Supreme Court and the Affordable Care Act. Also on the panel were Yale University law professor Akhil Amar, former President Obama adviser Neera Tanden and the Washington Examiner’s Tim Carney. The clips of Dr. Fegan above are excerpts from a much longer segment of the show which is available from MSNBC here.

In her closing remarks, when asked what her takeaway from the discussion was, Dr. Fegan said, “I didn’t realize that the complexity of the Affordable Care Act would make single payer seem like the most logical way to provide our patients with what every patient wants: to be treated with dignity and respect and have access to the health care that I believe they deserve. How can we be the most powerful nation in the world and not guarantee access to health care, which has such an impact on people’s quality of life and is so important to the health of the nation?”


http://upwithchrishayes.msnbc.msn.com/_news/2012/03/31/10957961-now-we-know-where-supreme-court-justices-get-their-news?lite

Profusion of single payer responses to Supreme Court deliberations

NOTE: Wait! Don’t go away! You are not expected to read today’s message in its entirety. This is merely a sampling of the plethora of new articles that suggest that single payer may be the answer to the constitutionally-challenged Affordable Care Act. They represent the views of enthusiastic liberals, reluctant conservatives, and everyone in between. If you read only one entry, I would suggest the very last one, which is my response to today’s New York Times Economix blog by Uwe Reinhardt. Although at times it seems like we single payer activists are hollering in the wind, the profusion of responses demonstrates that single payer is now widely recognized as a model that would work for all of us. Keep hollering!

On The Individual Mandate: Towards A Single-Payer System Or Public Option?

By Renée Landers
Health Affairs Blog, March 29, 2012

Early in the arguments, in an exchange with the Solicitor General, Justice Kennedy raised the idea that one alternative available to Congress may be to “use the tax power to raise revenue and to just have a national health service, single payer.”

Toward the end of the day’s arguments, Justice Sotomayor pressed Mr. Carvin on the same point:  “I want to understand the choices you’re saying Congress has.  Congress can tax everybody and set up a public health care system.”

These discussions leave the Court, conservatives, and the public with a curious dilemma.  Through the Affordable Care Act, Congress has tried to regulate private insurance markets to solve the market problem of making health insurance affordable for the uninsured, whatever their individual health status.  If that market-based approach does not survive a Commerce Clause challenge, what alternatives are left to Congress?  One alternative is to do nothing, which does not seem to be economically responsible given accelerating health care costs and certainly leaves tens of millions of Americans in a precarious and untenable situation.

The other option would be for the government, as the last resort, to create the “public option” that was so controversial during the debates over the Affordable Care Act, or to move entirely to a single-payer system, eschewing markets.

http://healthaffairs.org/blog/2012/03/29/renee-landers-on-the-individual-mandate-towards-a-single-payer-system-or-public-option/

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A stronger prescription for what ails health care

By Eugene Robinson
The Washington Post, March 29, 2012

Our only choice is to try to hold the costs down. President Obama tried to make a start with a modest approach that works through the current system. If this doesn’t pass constitutional muster, the obvious alternative is to emulate other industrialized nations that deliver equal or better health care outcomes for half the cost.

I’m talking about a single-payer health care system. If the Supreme Court strikes down ObamaCare, a single-payer system will go from being politically impossible to being, in the long run, fiscally inevitable.

http://news.investors.com/article/606069/201203291839/single-payer-next-if-obamacare-struck-down.htm

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Judicial activists in the Supreme Court

By E.J. Dionne Jr.
The Washington Post, March 28, 2012

The irony is that if the court’s conservatives overthrow the mandate, they will hasten the arrival of a more government-heavy system. Justice Anthony Kennedy even hinted that it might be more “honest” if government simply used “the tax power to raise revenue and to just have a national health service, single-payer.” Remember those words.

http://www.washingtonpost.com/opinions/activist-judges-on-trial/2012/03/28/gIQAKdE2gS_story.html

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My Mom, the Supreme Court, and the Affordable Care Act

By Emil Guillermo
San Francisco Chronicle, March 28, 2012

My mom died before the Clintons attempted their push for reform, and before Obama came up with his intricate compromise. Before then, Mom’s old fashioned Medicare plan worked just fine.
 
So I know this crazy Supreme Court debate to overturn the Affordable Care Act would have surely given her chest pains.
 
She’d ask, “Why can’t the government just extend Medicare to all?” (Seniors have a way of getting to the point. Unlike lawyers.) Medicare is a single payer system that doesn’t have people crying “Socialism!” It doesn’t get conservatives’ dander up about individual liberty and the broad powers of the federal government.
 
And it works. Everyone gets the care they need.
 
Done.
 
If only mom were alive and in charge.

http://blog.sfgate.com/eguillermo/2012/03/28/my-mom-the-supreme-court-and-the-affordable-care-act/

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If Obamacare is overturned, will that lead to single payer? And would that be a good thing?

By Ezra Klein
The Washington Post, March 29, 2012

Eventually, we end up with something close to a single-payer system, as a majority of Americans — and particularly a majority of Americans who have significant health risks — are covered by the government.

http://www.washingtonpost.com/blogs/ezra-klein/post/if-obamacare-is-overturned-will-that-lead-to-single-payer-and-would-that-be-a-good-thing/2012/03/29/gIQAQwypiS_blog.html

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Single-Payer or Bust

By Steve Erickson
The American Prospect, March 30, 2012

Striking down the individual mandate leaves only one of two options: adopt a system in which government pays for health care, or do nothing.

http://prospect.org/article/single-payer-or-bust

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RedBlueAmerica: Will ‘Obamacare’ survive?

Scripps Howard News Service, March 29, 2012

Joel Mathis:  The insurance mandate was a half-step toward that goal. Let’s take the full step: Single-payer health insurance, run and administered by the government, with no private-sector middlemen to add costs and reap profits from taxpayers.

Ben Boychuk:  The problem with the single-payer fantasy is it makes promises the government cannot keep. The health-care budget is not unlimited. Government would make choices about your health care based not on what you need, but how much a procedure costs. In truth, that’s becoming the case more and more under our existing system, which is why reform remains essential.

http://www.scrippsnews.com/node/68356

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What if Supreme Court strikes down Obama healthcare act?

By Mark Mardell
BBC News, March 29, 2012

(A Democrat strategist I’ve spoken to) adds that defeat might make Democrats more radical and argue that what is called here a “single payer system” – a tax-funded national health system as we have in the UK – is the only real answer, rather than President Obama’s market-sensitive half-way house.

http
://www.bbc.co.uk/news/world-us-canada-17540685

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Obamacare health-insurance exchanges are set up to fail

By Paul Mulshine
The Star Ledger, March 25, 2012

The real threat is not that Obamacare will take over Medicare. It’s the other way around, says Mike Cannon, a health-care expert with the free-market Cato Institute in Washington.

“These exchanges are built to fail,” said Cannon. “They’ll drive private insurance companies out of the market. When they do, the whole thing will collapse.”

At that point, some sort of single-payer system would be needed to cover the people the private insurers don’t want. Those who’ve been arguing Medicare should be extended to everyone would probably win at the polls.

http://blog.nj.com/njv_paul_mulshine/2012/03/obamacare_health-insurance_exc.html

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If Health Law Is Overturned, What Will Liberals Do?

By Michael D. Shear
The New York Times, March 28, 2012

If Democrats make little progress on alternatives, some purists might decide it’s best to just renew the case for a single-payer system in which all Americans receive health care paid for by the government.

Sidney M. Wolfe, the director of the Health Research Group at Public Citizen, an advocacy group, has been pushing for government-run health care for decades.

http://thecaucus.blogs.nytimes.com/2012/03/28/if-health-law-is-overturned-what-will-liberals-do/?hp

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Overturning health care law could lead to a single-payer system

By Peter Morici
SunSentinel, March 26, 2012

Conservatives, by persuading a majority of Justices to overturn the individual mandate, could reverse Washington’s relentless push to over regulate individual and business behavior, but they could ultimately instigate their worst nightmare — a single payer system akin to the British system.

http://articles.sun-sentinel.com/2012-03-26/news/fl-morici-single-payer-health-0326-20120326_1_individual-mandate-health-insurance-affordable-care-act-requirement

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After the Ruling

By Maggie Fox
National Journal, March 29, 2012

There is one easy solution to the issue—a single-payer health system that strictly controls costs and administrative fees, using evidence-based science to determine which interventions, drugs, and diagnostic tests are worth the money and effort.

http://www.nationaljournal.com/daily/after-the-ruling-20120328?mrefid=freehplead_3

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ACA Alternatives Waiting in the Wings

By Emily P. Walker
MedPage Today, March 29, 2012

While Republicans are crafting limited-government alternatives to the Affordable Care Act (ACA), some on the other side of the political spectrum are trumpeting a single-payer, government-run system as the preferred alternative to the ACA.

The irony is that while the public option wasn’t popular enough to pass, no one disputes the Supreme Court wouldn’t be considering the case if a single-payer plan had passed, because expanding Medicare and taxing everyone more would have been well within the powers of Congress.

http://www.medpagetoday.com/Washington-Watch/Reform/31930

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Experts: Medicaid Expansion Will Stand; Mandate’s Fate Unclear

By George Lauer
California Healthline, March 29, 2012

Some see the potential for a quicker move toward single payer solutions if all or part of the ACA is ruled unconstitutional.

While he didn’t go so far as to call for provisions of the ACA to be struck down, Bill Skeen, executive director of the California chapter of Physicians for a National Health Program, did see potential for progress in such a scenario.

“If the ACA is dismantled, I don’t predict there will be an easy road for single payer, but there is the sort of last-man-standing feeling that — OK, the plan Congress put together isn’t holding up. Single payer is the last best option.”

http://www.californiahealthline.org/features/2012/experts-medicaid-expansion-will-stand-mandates-fate-unclear.aspx

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Chris Matthews, Ezra Klein Identify Strategy To Impose ‘De Facto Single Payer System’

by Noah Rothman
Mediaite, March 29, 2012

On Wednesday, Hardball host Chris Matthews and Washington Post columnist Ezra Klein discussed the potential for all or part of President Obama’s health care reform law to be ruled unconstitutional in the Supreme Court and the ways in which progressives could move forward with health care reform in a post-Affordable Care Act world. Klein confirmed conservative’s latest fear: striking down the health care law could pave the way for a single payer system that could be implemented over time through the budget reconciliation process in the Senate.

http://www.mediaite.com/tv/chris-matthews-ezra-klein-identify-strategy-to-impose-de-facto-single-payer-system/

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Growth & Justice lays out its case for Minnesota single-payer health care

By Beth Hawkins
MinnPost, March 29, 2012

What if single-payer were feasible?

On Wednesday, the St. Paul-based progressive-leaning think tank Growth & Justice made its case, releasing a first-of-its-kind analysis showing that a unified system of health care could provide all Minnesotans with guaranteed cradle-to-grave care at a projected savings of about $190 billion over 10 years. By 2023, overall savings could be 12 percent to 33 percent per year, it said.

During his gubernatorial campaign, Mark Dayton supported a single-payer system for Minnesota, Smith added. The advent of ACA presents a good opening to put the topic back in the public discourse.

“This option needs to stay on the table,” he said. “It is an attempt to change the conversation. … This is one of the last big hurdles for a fair and just society. You can’t just check out of the social contract.”

http://www.minnpost.com/health/2012/03/growth-justice-lays-out-its-case-minnesota-single-payer-health-care

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The Wall Street Journal: Unwitting Advocates of Single-Payer

By David Frum
The Daily Beast, March 29, 2012

The crazy thing about the litigation over the Affordable Care Act is this… nobody disputes that Congress has full authority to set in motion a national healthcare program. Congress could tax all American at any rate — or any schedule of rates, no matter how confiscatory for those at the top — and then use the money to fund a British-style National Health Service.

http://www.thedailybeast.com/articles/2012/03/29/wall-street-journal-single-payer.html

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If Health Care Refor
m Falls, Look in the Mirror

By Karen Dolan
The Huffington Post, March 29, 2012

Candidate Barack Obama campaigned on universal coverage. He told would-be supporters that, if he were “starting from scratch,” single-payer would be ideal. Indeed, he even understood that the only true reform, that would sufficiently control costs and actually achieve universal coverage, was a single payer, government-sponsored health care system. The evidence is overwhelming that only such a system can achieve those goals.

Isn’t it time to fight for Medicare for all?

http://www.huffingtonpost.com/karen-dolan/health-care-reform_b_1388082.html

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How Obamacare’s Rejection Would Lead to Single Payer

By Josh Barro
Forbes, March 28, 2012

Strike down Obamacare, and single payer instantly becomes the number one organizing cause for liberals in America. This Congress won’t pass a single payer insurance law, but you can bet Democrats would the next time they control both the legislative and executive branches.

http://www.forbes.com/sites/joshbarro/2012/03/28/how-obamacares-rejection-would-lead-to-single-payer/

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Single-Payer Briar Patch

By Timothy Noah
The New Republic, March 28, 2012

The professional Obama-hater Dick Morris said today on Fox News that if President Obama is elected to a second term after the Supreme Court strikes down Obamacare (as is looking more likely) then “he’ll move to a single payer system.”

http://www.tnr.com/blog/timothy-noah/102125/single-payer-briar-patch

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Take It From Me: Defending Obamacare is Super-Hard

By Reid Cherlin
GQ, March 27, 2012

It would have been easy for Verrilli—or any of us—to explain single-payer health care. “Look,” we could have said, “the government is paying for everyone to have coverage.” End of story. But single-payer is not what our brilliant, world-leading political system gave us.

http://www.gq.com/news-politics/blogs/death-race/2012/03/take-it-from-me-defending-obamacare-is-super-hard.html

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Lawmakers Propose Single-Payer System For Mass.

By Meghna Chakrabarti
WBUR, March 28, 2012

A major national story is playing out in the halls of Beacon Hill: this week’s Supreme Court hearings on the national Affordable Health Care Act.

Some lawmakers want the state to push health care reform to the next level. They’ve introduced a bill that would bring a “single-payer” system to the Bay State.

http://radioboston.wbur.org/2012/03/28/single-payer-proposal

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What’s really wrong with Obamacare

By Cathy Young
Newsday, March 29, 2012

If the Affordable Care Act is struck down, the eventual outcome may be better health care reform — or it may be a more socialistic road, such as a single-payer system.

Libertarian and conservative voices are essential to the health care debate. But they should be careful not to lapse into a defense of freeloading or unconstrained spending on expensive (and not always beneficial) medical procedures. Freedom is a key conservative and libertarian principle; so is responsibility.

http://www.newsday.com/opinion/oped/young-what-s-really-wrong-with-obamacare-1.3632152

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If the Mandate Fails, Single Payer Awaits

By George Zornick
The Nation, March 27, 2012

One obvious option, besides just doing nothing and allowing health care costs to continue their exponential growth while more people lose coverage, is a single-payer health insurance plan. There is no doubt about the constitutionality here — the government is clearly allowed to levy taxes to fund public benefits.

So if health care reform goes down, the next logical step may well be just extending Medicare to everyone.

http://www.thenation.com/blog/167071/if-mandate-fails-single-payer-awaits

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Kucinich: Single-payer healthcare on its way regardless of how Supreme Court rules

By Julian Pecquet
The Hill, March 26, 2012

The Supreme Court’s review of President Obama’s healthcare reform law is just another step on the inevitable path toward a single-payer medical system, Rep. Dennis Kucinich (D-Ohio) said Monday.

http://thehill.com/blogs/healthwatch/legal-challenges/218185-kucinich-single-payer-healthcare-on-its-way-regardless-of-how-supreme-court-rules

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Health Care Jujitsu

By Robert Reich
The Huffington Post, March 26, 2012

But with a bit of political jujitsu, the president could turn any such defeat into a victory for a single-payer healthcare system — Medicare for all.

http://www.huffingtonpost.com/robert-reich/single-payer-health-care_b_1381382.html

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Individual Mandate Is Ryan Tax Credit by Other Name

By Ezra Klein
Bloomberg, March 28, 2012

The real fight is over whether the Affordable Care Act should exist at all. Republicans lost that battle in Congress, where they lacked a majority in 2010. Now they hope to win it in the Supreme Court, where they hold a one-vote advantage. The argument against the individual mandate is a pretext to overturn Obamacare. But it’s a pretext that could set a very peculiar precedent.

If the mandate falls, future politicians, who will still need to fix the health-care system and address the free-rider problem, will be left with the option to move toward a single payer system or offer incredibly large, expensive tax credits in order to persuade people to do things they don’t otherwise want to do. That is to say, in the name of liberty, Republicans and their allies on the Supreme Court will have guaranteed a future with much more government intrusion in the health-care marketplace.

http://www.bloomberg.com/news/2012-03-28/individual-mandate-is-ryan-tax-credit-by-other-name.html

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The Supreme Court and the National Conversation on Health Care Reform

By Uwe E. Reinhardt
The New York Times, Economix, March 30, 2012

Once again America is having one of its “national conversations” on health care reform. This time the buzz is over arguments before the Supreme Court on the constitutionality of certain provisions in the Affordable Care Act. The justices’ rulings will be landmark decisions, because they will indirectly go much beyond the act itself to our entire system of governance.

The two major substantive decisions the Supreme Court has to make are:

1. Whether Congress has the constitutional authority to mandate every legal residen
t in the United States to have insurance coverage for a specified package of health benefits (hereafter the “mandate”) or whether that is an issue for the states to decide.

2. Whether Congress has the constitutional authority to expand eligibility for Medicaid benefits from the highly varied income thresholds that currently define eligibility to anyone under 133 percent of the federal poverty level.

Reader Comment:

By Don McCanne
San Juan Capistrano, CA

The intense attention being given to the constitutionality of the individual mandate and the severability of guaranteed issue and community rating and to the constitutionality of the Medicaid expansion superficially seems to have detracted from the fundamental issue of whether or not the Affordable Care Act itself should serve as a durable model for health care reform.

With the best possible outcome of the Supreme Court deliberations, we’ll still be faced with uninsurance (at least 26 million uninsured), underinsurance (low actuarial value plans with spartan essential benefits) and unaffordability (lack of effective systemic cost containment).

Right now we are seeing a surge in commentaries declaring that we will end up with single payer (Medicare for all) if the mandate and guaranteed issue and community rating are struck down by the Supreme Court, simply because that’s the only rational financing option left for us.

We will, in fact, end up with single payer, but not because of the pending Supreme Court decision. We will adopt a single payer system simply because we will not be able to continue to tolerate uninsurance, underinsurance and unaffordability.

http://economix.blogs.nytimes.com/2012/03/30/the-supreme-court-and-the-national-conversation-on-health-care-reform/

Another P4P dud

The Long-Term Effect of Premier Pay for Performance on Patient Outcomes

By Ashish K. Jha, M.D., M.P.H., Karen E. Joynt, M.D., M.P.H., E. John Orav, Ph.D., and Arnold M. Epstein, M.D.
The New England Journal of Medicine, March 28, 2012

Tying financial incentives to performance, often referred to as pay for performance, has gained broad acceptance as an approach to improving the quality of health care. The Centers for Medicare and Medicaid Services (CMS) recently completed a 6-year demonstration of pay for performance for hospitals through the Premier Hospital Quality Incentive Demonstration (HQID), and the Affordable Care Act calls for CMS to expand this program to nearly all U.S. hospitals in 2012. The policy of tying financial incentives to the quality of performance has strong face validity — that is, paying for better care should promote improvements in quality and, ideally, lead to better patient outcomes. Whether pay for performance will lead to better patient outcomes, however, is unclear.

Although there is evidence from the Premier HQID that pay for performance is associated with modest improvements in the processes of care, much less is known about its effect on patient outcomes.

We found little evidence that participation in the Premier HQID program was associated with declines in mortality above and beyond those reported for hospitals that participated in public reporting alone, even when we examined care over a period of 6 years after the program’s inception. Furthermore, we found no differences in trends in mortality between conditions for which outcomes were explicitly linked to incentives and conditions for which outcomes were not linked to incentives.

Prior studies of the Premier HQID showed that the early gains in process quality had mostly dissipated after 5 years under the program. Werner et al. found that the modest benefits in adherence to process measures were most perceptible for hospitals that were eligible for larger bonuses, that were well financed, or that operated in less competitive markets. We failed to find that these factors were associated with a significantly greater effect on outcomes.

In summary, we found little evidence that participation in the Premier HQID program led to lower 30-day mortality rates, suggesting that we still have not identified the right mix of incentives and targets to ensure that pay for performance will drive improvements in patient outcomes. Even though Congress has required that the CMS adopt pay for performance for hospitals, expectations with regard to programs modeled after Premier HQID should remain modest.

http://www.nejm.org/doi/full/10.1056/NEJMsa1112351?query=TOC#t=abstract

Comment:

By Don McCanne, MD

Pay for performance (P4P) is one of the measures in the Affordable Care Act (Sec. 3001) that supposedly is designed to improve quality and reduce costs. The recommendation was based on data such as this Medicare Hospital Quality Incentive Demonstration (HQID) which had shown that providing financial bonuses and penalties improves processes of care. But does it improve outcomes?

This large study of hospital performance had already shown early but non-sustained improvement in processes, but it turns out that paying for this performance did not improve patient outcomes. P4P did not improve 30 day nor 6 year mortality for the conditions studied – three medical conditions (acute myocardial infarction, congestive heart failure, and pneumonia) and two surgical procedures (coronary-artery bypass grafting [CABG] and total knee or total hip replacement). Yet the Affordable Care Act requires that all hospitals participate in the value-based purchasing (VBP) program, which provides financial incentives for both high achievement and improvement in performance – an approach closely modeled after the Medicare HQID.

This “teach to the test” P4P experiment did, in fact, result in rewards and penalties for hospitals based solely on process measures, though having no impact on outcomes. Such programs seem to promote gamesmanship much more than they promote actual improvements in quality – appealing to hospitals that were “eligible for larger bonuses, that were well financed, or that operated in less competitive markets.” It is yet another example of the multitude of unproven or minimally effective quality and cost measures in the Affordable Care Act.

The tragedy is that Congress and the President rejected the proven model of reform that would have achieved these goals – a single payer national health program. One benefit of the Supreme Court hearings this week is that there has been a resounding response that single payer is the answer. If only we could convert that perception into action. If only…

Marcia Angell: Happy birthday, ObamaCare

By Marcia Angell, M.D.
USA Today, March 27, 2012

The Patient Protection and Affordable Care Act, otherwise known as ObamaCare, turned 2 years old Friday, just in time for this week’s Supreme Court hearings on its constitutionality. The major provisions of the law, meant to increase the number of insured Americans while controlling costs, will be implemented in 2014, but a few are already in effect. What are its prospects, and will it survive intact to its next birthday? The outlook, I’m afraid, is not good.

For starters, the law was greatly weakened before it was even enacted. To win the support of the powerful health insurance industry, President Obama included the unpopular mandate requiring uninsured Americans to buy private insurance. Not only did this set off a legal battle, it preserved and expanded the central role of the insurance companies, whose abuses caused many of health care’s problems in the first place. They will get millions of new customers, many with government subsidies. In addition, the idea of a “public option” — government-sponsored insurance to compete with private insurers — was scuttled, wasting critical opportunities to try to control costs.

Let’s look briefly at the major provisions: First, the law encourages employers to provide health benefits by fining large companies that don’t and subsidizing small ones that do. Second, Medicaid, the federal/state program for the poor, will be expanded to cover an additional 16 million people. And third, everyone else without Medicare or employer-sponsored insurance, estimated as another 16 million people, will have to buy private insurance or be fined. States will create (or have created for them by the feds) shopping exchanges to pool risks and offer a menu of approved insurance plans for individuals and small businesses, with subsidies for people earning less than 400% of the federal poverty level. (Note that of the roughly 50 million uninsured people when the law was enacted, 18 million would be left uncovered.)

Insurance abuses addressed

The law addresses the worst abuses of insurance companies by prohibiting them from excluding people with pre-existing conditions, dropping policy holders who develop expensive illnesses, or using more than 20% of premiums for overhead, marketing and profits. But companies can still set their own prices, and they’ll be allowed to charge older customers up to three times more than young people.

To finance the law, the payroll tax that supports Medicare will be increased for high earners, who will also pay a small additional tax on unearned income. In addition, support for private Medicare Advantage plans will be reduced, and there will be unspecified cuts in Medicare payments to hospitals and other medical facilities, and a variety of fees levied on health companies.

Runaway costs

That’s the theory. What’s the likely reality? At the time of enactment, the non-partisan Congressional Budget Office estimated that over 10 years, the new funding would more than cover the cost to the federal budget. But costs to the private sector — businesses and individuals — were not addressed in the CBO analysis, nor was cost inflation. Given the influx of new customers and government money, health costs will likely rise rapidly and quickly outstrip funding. There will, of course, be revisions to the CBO analysis as the law is implemented and conditions change, but none can be more than crude estimates.

Monday’s Supreme Court hearing was just the beginning of a torrent of legal challenges to various provisions of the law. For example, many states, particularly Republican ones, have indicated that they will not establish state insurance exchanges or cooperate with the federal government in doing so, and that will be litigated, too.

Regulating the law will be a bureaucratic nightmare. Even in friendly states, establishing insurance exchanges will be a complicated job involving multiple state agencies. Monitoring insurance companies will be even harder. The prohibitions against abuses can almost certainly be skirted, and insurers have a strong incentive to do so.

So I fear that this 2-year-old law will unravel before it is fully implemented. As state exchanges falter, individuals and businesses could be faced with prohibitively high premiums or punishing fines. The most vulnerable Americans will be those in their 50s and early 60s, who will have to pay the highest premiums and are most likely to have chronic illnesses.

Of course, if there is a Republican sweep in November, ObamaCare will be systematically dismantled.

When Obama was an Illinois state senator, he favored a single-payer health system — such as Medicare — for all. Even as president, he admitted in the summer of 2009 that a single-payer system was the only way to provide universal care. He was right then.

Medicare outperforms private insurance on every measure. It insures nearly everyone older than 65 for the entire package of benefits, no one can be excluded or dropped from coverage, and its overhead is very low. When ObamaCare inevitably fades away, it will be time to revisit the single-payer option.

How about lowering the Medicare age gradually, one decade at a time, beginning with age 55?

Marcia Angell, M.D., is senior lecturer in social medicine at Harvard Medical School and former editor in chief of the New England Journal of Medicine.

http://www.usatoday.com/news/opinion/forum/story/2012-03-22/obama-health-reform-court/53732820/1

Matthews asks Gruber about starting over with single payer

Hardball with Chris Matthews

MSNBC, March 27, 2012

Chris Matthews:  Professor Gruber, I’ve got a curve ball for you, from the left field, all right? I’m mixing my metaphors here. If the Supreme Court strikes down the individual mandate today, which is the most conservative way to have national health for everybody, requiring people to take responsibility as individuals. If that fails, and the progressive left of the Democratic Party says, no, now’s our chance to go for single payer, or what’s called the public option – I guess they’ll wind up being the same thing because there won’t be another option really. Is that a better economic proposition? That the government simply provides health insurance for the country? Single payer. Is that a better economic deal with no profit motive?

Jonathan Gruber:  I think that single payer, if you could start over, I think that single payer has a lot to recommend it, but we can’t, and I think the bottom line is…

Chris Matthews:  But we might have to start over after tonight.

Jonathan Gruber:  No. I agree, but if we start over, the problem with failing, if this ruling goes against… this law fails, we’ll see the same pattern we’ve seen for the past century, which when we start over again which will on average be about seventeen years from now, because it’s about every seventeen years we start over, it’s going to be further to the right of where we are.  Every seventeen years… Remember Richard Nixon proposed something to the left of the Affordable Care Act. Every seventeen years we move to the right. If this fails, the next round is not going to be single payer. It’s going to be even more conservative than what we have now.

http://www.msnbc.msn.com/id/3036697/#46873470

Comment:

By Don McCanne, MD

What is the basis for this conversation about starting over if the Affordable Care Act (ACA) is struck down by the Supreme Court? Implicit is the concept that the Affordable Care Act actually accomplished the reform that we need. Of course, it didn’t. So, regardless of the decision, we wouldn’t be starting over since no iteration of ACA would hardly even begin to complete the process of reform.

For those who believe that ACA is the most feasible path to reform, there are some issues in this debate that would have the appearance of a make-or-break outcome (even though ACA itself isn’t a make-or-break model).

Based on the first two days of deliberation before the Supreme Court, it appears that the individual mandate to purchase private insurance may well be struck down. If it is, then both sides (plus an amicus from America’s Health Insurance Plans) agree that guaranteed issue and community rating should be declared inseverable and struck along with the individual mandate.

Though an intact ACA falls intolerably short on reducing uninsurance, underinsurance, and unaffordability, a decision eliminating guaranteed issue (eliminates pre-existing condition exclusions) and community rating (prevents insurers from gouging those with greater health care needs) would leave yet many more uninsured, especially those with greater health care needs plus the healthy invincibles whose funds are needed for the insurance risk pools. That should be enough to cause ACA supporters to take another look at single payer, though the mess we have with an intact ACA should make them reconsider anyway. ACA did not turn out to be the affordable-care-for-everyone model that supporters had hoped for at the beginning.

So we wouldn’t be starting over again since ACA was merely a misfire that gained us very little. A misfire is not enough to restart the seventeen year clock, not to mention that the clock is only an illusion anyway.

And Gruber’s contention that our next reform efforts will move further to the right because that’s the way history has led us? Really? Was Social Security a move to the right? Was Medicare a move to the right? Was the Civil Rights Act a move to the right?

Does health care really fall at some point along a linear, bipolar, one-dimensional span between right and left? Of course not, though we should tell the ideologues in Congress who believe this that such in-the-box thinking is why we are replacing them in the forthcoming election. We want not just the elderly but everyone in America to be able to say, “Leave my Medicare alone!”

As Supreme Court Hears Case, Does Law Do Enough to Fix Health Crisis?

By Amy Goodman
Democracy Now, March 27, 2012

As the Supreme Court weighs whether the Affordable Care Act goes too far, we host a debate on whether the law goes far enough. The case is reviving the heated tensions that surrounded the health care reform law in the debate leading up to its passage two years ago. Although support for the measure is often equated with backing the expansion of health coverage for all Americans, there are some who maintain it didn’t go far enough in helping the uninsured. We speak to Dr. Stephanie Woolhandler, co-founder of Physicians for a National Health Program, and Dr. John McDonough, who played a key role in shaping Mitt Romney’s health care reform law in Massachusetts as well as the Affordable Care Act. The new health care law is “going to leave tens of millions of Americans woefully underinsured, with gaps in their coverage like copayments and deductibles, so they’ll still be bankrupted by illness. And it’s not going to control cost,” Woolhandler argues. “So we still need single-payer national health insurance regardless of what happens at the Supreme Court.” But McDonough notes that “the moment when there would be sufficient political will for the Congress and the president to come together and pass meaningful, near-comprehensive reform, that might take another 20 years.” [Includes rush transcript below. PNHP note: Dr. Woolhandler’s comments begin at the 13 minute, 40 seconds mark of the program; the segment can be directly accessed at the following link; the interview lasts 25 minutes.]

http://www.democracynow.org/2012/3/27/healthcare_debate_as_supreme_court_hears

Guests:

Dr. Steffie Woolhandler, professor of public health at CUNY-Hunter College and a primary care physician. She is a visiting professor at Harvard Medical School and the co-founder of Physicians for a National Health Program.

John McDonough, professor at the Harvard School of Public Health and director of the New Center for Public Leadership. Between 2008 and 2010, he served as a senior adviser on national health reform to the U.S. Senate Committee on Health, Education, Labor and Pensions. And between 2003 and 2008, he served as executive director of Health Care for All in Massachusetts, playing a key role in passage of the 2006 Massachusetts health reform law. His new book is called Inside National Health Reform.

Rush Transcript

AMY GOODMAN: The Supreme Court is convening a historic session on the constitutionality of the Affordable Care Act, the landmark health care reform bill signed by President Obama two years ago. Oral arguments began Monday with a debate over whether the law can be contested in light of a statute that protects taxes from challenge before they take effect. Today, justices will hear arguments over an issue at the heart of so-called “Obamacare,” the individual mandate that requires most people buy health insurance by 2014 or pay a tax penalty. A third and final day of arguments will be held on Wednesday.

The Supreme Court case is expected to have huge implications for the nation and the 2012 elections and is being followed closely by all sides of the health care debate. On Monday, supporters and opponents of the health care law gathered outside the Supreme Court to make their voices heard.

WILLIAM YOUNG: It’s not about politics. It’s not about being partisan or, you know, linking up to some kind of—linking up to some kind of position that you need to tie yourself to. This is about people taking care of other people. And it’s about the idea that we’re putting profit over people. And big health insurance companies don’t need any help; they’re making a lot of money. And I think that regular people need to advocate for themselves, because the insurance companies are not going to advocate for you. But Obama will, and that’s what this bill does.

ROD RHOADES: We support health care reform from our hearts. We are sad when children go to the hospital, and they don’t have insurance. That breaks our hearts. That cannot be here in America. But this bill is unconstitutional. It was—it’s illegal. It was done on bribes and kickbacks to Obama’s campaign supporters. We’re completely against it. We want real reform, where the money goes to the people in the hospitals that need it. That’s what we want.

AMY GOODMAN: Also appearing outside the Supreme Court was Republican presidential hopeful Rick Santorum, who touted his steadfast opposition to the health care law.

RICK SANTORUM: This bill has far-reaching consequences for the economic health of this country and for basic liberty in our society. And that’s why this decision and the debate that is going on right now is fundamental. And there’s one candidate in this race who can actually make the contrast that is necessary between the Republican position, the conservative position, and one that is an overwhelmingly supported by the American public, and one that Barack Obama believes in. And that’s Rick Santorum.

AMY GOODMAN: The argument of the Supreme Court case is reviving the heated tensions that surrounded the health care law in the debate leading up to its passage two years ago. But although support for the health care law is often equated with backing the expansion of health care coverage for all Americans, there are some who maintain the bill did not go far enough in helping the uninsured. In an amicus brief filed with the Supreme Court last month, a group of physicians argued against the health care mandate altogether, saying Congress should instead legislate a single-payer system to provide universal care for all.

I’m joined now by two guests on opposite sides of this overlooked part of the health care debate. Dr. Steffie Woolhandler is co-founder of Physicians for a National Health Program, whose members signed on to the amicus brief arguing against the individual mandate and for single payer. She is a primary care physician who teaches in public health at CUNY-Hunter College and at Harvard Medical School.

And joining me from Boston is John McDonough, professor at the Harvard School of Public Health, director of the New Center for Public Leadership. Between 2008 and 2010, he served as a senior adviser on national health reform to the U.S. Senate Committee on Health, Education, Labor and Pensions. And between 2003 and 2008, he served as executive director of Health Care for All in Massachusetts, playing a key role in the passage of the 2006 Massachusetts health reform law, known as Romneycare, regarded by many as the model for the current health care law. He has a new book out; it’s called Inside National Health Reform.

We welcome you both to Democracy Now! And we’re going to begin with Professor McDonough. The importance, the significance, of this Supreme Court hearing over these three days?

DR. JOHN McDONOUGH: Well, it could be very consequential in terms of some of the key features of the law: the Medicaid expansion for 16 million low-income Americans, as well as the success of the private health insurance expansion through the individual mandate. I think, ultimately, far less important than the decision of any—the Supreme Court will be the decision of voters in November, on November 6th. Really, the future of this law will be decided by who controls the White House and who controls Congress next year, and the Supreme Court is really secondary.

AMY GOODMAN: Steffie Woolhandler?

DR. STEFFIE WOOLHANDLER: Well, I want to say, our organization, Physicians for a National Health Program, did not take a position on the Suprem
e Court deliberations. Some of the members opposed the mandate and did weigh in in the amicus brief. Some were more ambivalent and felt that there was some good in the bill. What we all agree on, however, is that the bill is not a solution. It will leave 27 million Americans uninsured when it’s fully implemented. It’s going to leave tens of millions of Americans woefully underinsured, with gaps in their coverage like copayments and deductibles, so they’ll still be bankrupted by illness. And it’s not going to control cost. So we still need single-payer national health insurance regardless of what happens at the Supreme Court.

AMY GOODMAN: Do you care if the Supreme Court were to reject it, say the individual mandate is not constitutional?

DR. STEFFIE WOOLHANDLER: Well, the individual mandate is a very, very bad idea. The good parts of the bill are things like a Medicaid expansion, which does not require an individual mandate, some regulations on the insurance industry, which does not require a mandate. All of those could have been done without the mandate. The problem with the mandate is it’s telling people that they have to turn over their money to the private health insurance industry. There’s also $447 billion in taxpayer money that is going to be turned over to the private health insurance industry. So the bill is strengthening the position of the private health insurance industry, the very industry that’s responsible for $380 billion in wasted health care dollars on bureaucracy and paperwork.

AMY GOODMAN: Professor McDonough?

DR. JOHN McDONOUGH: I don’t disagree with the assertions of my friend, Dr. Woolhandler. And I would agree with her that I think a single-payer plan could be far preferable. The reality was that there was no possibility in 2009, 2010, of achieving passage of anything close to a single payer. And I think, really, the question is, does the Affordable Care Act move the system forward by eliminating pre-existing conditions, by creating the Medicaid expansions, by undertaking so many other important improvements to the health care system, tripling the size of the National Health Service Corps, providing important new funding for community health centers, just many, many important provisions? The question is, is, does the Affordable Care Act move the system forward, and was it worth doing? And I guess that’s probably where we disagree. I think that, short of a single-payer system, that the Affordable Care Act was the best that we could get done and that it really will provide significant, meaningful, important improvements for the lives and the health and the well-being of many, many millions of Americans and really does move the system forward in very important ways in terms of trying to address some serious deficiencies in the quality and efficiency of medical care delivery in the United States.

AMY GOODMAN: Dr. Woolhandler, what about that, that Obama got done what he could?

DR. STEFFIE WOOLHANDLER: Well, I practiced primary care for decades in Massachusetts, and I still teach there, and I’m at a public hospital. And I saw what happened in Massachusetts, which—with the Romneycare that was a model for Obamacare. Some people got helped a little bit; some people got hurt a little bit. But for most of the doctors and patients, nothing changed. That is, people still could not afford care and had to seek care in the public sector because they were unable to afford the care that they needed.

AMY GOODMAN: We’re going to break and then come back to this discussion. Dr. Steffie Wooldhandler, co-founder of Physicians for a National Health Program, and Dr. John McDonough of the Harvard School of Public Health, where Dr. Steffie Woolhandler just came from. His new book is called Inside National Health Reform. This is Democracy Now! Back in 45 seconds.

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AMY GOODMAN: Our guest, Dr. Steffie Woolhandler, co-founder of Physicians for a National Health Program, came from the Harvard School—from Harvard Medical School to New York, and she is teaching now at CUNY, City University of New York. Professor John McDonough is still at the Harvard School of Public Health. His new book is called Inside National Health Reform.

I want to play an excerpt of attorney Robert Long speaking to the high court justices about the Anti-Injunction Act, the federal law that purports to require someone to actually be taxed before they can challenge that tax.

ROBERT LONG: Our initial submission is, you don’t have to determine that this is a tax in order to find that the Anti-Injunction Act applies, because Congress very specifically said that it shall be assessed and collected in the same manner as a tax, even if it’s a tax penalty and not a tax.

AMY GOODMAN: John McDonough, what exactly is attorney Robert Long opposing about the Affordable Care Act?

DR. JOHN McDONOUGH: Well, he’s not opposing or supporting it. He’s saying that there is an 1867 law, the Anti-Injunction Act, and a key part of it says you can’t sue to prevent the collection of a tax until the tax has actually gone into effect and people are paying it. I happen to think, based upon my reading—and I’m not an attorney—that there’s a very strong case that the Anti-Injunction Act prevails. I think, though, that the justices on both sides of the ideological spectrum want to decide this, and that was clear from their questioning yesterday. And so, I think the Anti-Injunction Act kind of is going to be moved to the back of the room or kind of in a closet. And if the justices end up in some kind of a significant deadlock, then they might at the end, if they can’t resolve it, pull the Anti-Injunction Act out of the closet and use it. Otherwise, I think they’re going to do everything they can to try to make some more definitive ruling by June.

AMY GOODMAN: Professor McDonough, you occupy an interesting position. You were key in both Romneycare, the health care act in Massachusetts that has become really the basis of what many call Obamacare, or the Affordable Care Act—you were involved with both. Now you have these two presidential candidates most likely going up against each other, and you have Romney saying that he completely opposes what President Obama has managed to have passed into law. What is your response to that?

DR. JOHN McDONOUGH: Mitt Romney found himself in a quite peculiar position. The individual mandate emerged from conservative Republican circles in the late ’80s and early ’90s and gained prominence as an alternative to the Clinton health reform vision in ’93, ’94. And Republicans kept beating that drum for years. Mitt Romney mistakenly thought they meant it and were serious, and so he took their idea, and he actually worked to and helped to actualize it in Massachusetts as part of the Massachusetts health reform law. And then, when they attempted to do it on a national basis through the Democrats’ health care initiative, all the Republicans who said they were for this deserted the ship, jumped off the ship. But Romney couldn’t do it, because he was pictured holding the steering wheel with Ted Kennedy when they made it happen. So, he finds himself in an ironic situation in terms of supporting something that was very much Republican orthodoxy and then watched all the Republicans abandon it.

You know, the truth is that Romney had a very minimalist vision of what Massachusetts health reform would be. It was one that—I was in the advocacy community at the time—that we did not support at all. But the Democrats had overwhelmingly control in the House and the Senate. And we were able to work with them to make what is now referred to as Romneycare much more robust and full. And right now in Massachusetts, more than 98 percent of all res
idents have health insurance. About 99.8 percent of children have health insurance. It’s not perfect. For every flaw that Dr. Woolhandler names, I could probably name two or three. It is a significant step forward, in terms of doing a better job in terms of providing coverage and some financial protection. And overwhelmingly in Massachusetts, people support it and think it has worked and it’s been a good thing.

AMY GOODMAN: Dr. Steffie Woolhandler?

DR. STEFFIE WOOLHANDLER: Let me tell you that it is not true that 98 percent of people have health insurance in Massachusetts. The Census Bureau says 94 percent. And let me tell you the kind of health insurance that people have. If you go on the exchange website in Massachusetts and try to buy health insurance for someone my age, you’re going to be taking $5,600 out of your pocket to pay the premiums. Then, if you got sick, you would have a $2,000 deductible. So you’re $7,600 out of pocket before the insurance pays a penny. And you’re mandated to buy that coverage; you don’t have a choice. So, things are not—are not at all solved in Massachusetts. Some people were helped; some were hurt. But many people still can’t afford care.

You know, one of the things that happened in Massachusetts, and is going to happen nationally, is money was taken out of safety-net hospitals to pay for the bill. Nationally, $36 billion is going to be removed from safety-net hospitals to pay for Obamacare. And that means that the remaining uninsured—and there will be 27 million uninsured—the tens of millions who are underinsured, may have no place to go when they get sick, because the safety net has been cut. So there’s some very negative consequences to these bills in Massachusetts and nationally, as well as the positive consequences that John is talking about.

AMY GOODMAN: If this Affordable Care Act is ruled unconstitutional by the Supreme Court, it’s possible nothing will change in some 20 years. What do you—do you think that is true?

DR. STEFFIE WOOLHANDLER: Absolutely not. The health care system is in a complete state of crisis. And that’s what’s going to reopen the health care debate. You know, history is not just made by legislators. It’s also made by small people like us, doctors, nurses, patients, people who write letters to the editor—

AMY GOODMAN: States.

DR. STEFFIE WOOLHANDLER: —who go to meetings. You can do state-level reform.

AMY GOODMAN: Well, aren’t a number of states, one by one—for example, Vermont—aren’t they now just adopting a very different—they’re coming up with their own kind of single-payer system.

DR. STEFFIE WOOLHANDLER: Yes. Well, certainly there’s state-level efforts in Vermont and in Hawaii that are talking about single payer. But this debate is not going to shut down for 20 years, because the American people cannot get health care. You know, when we talk about 27 million people remaining uninsured under Obamacare, we’re talking about one in 1,000 of them dying every year because they lack health insurance, approximately 27,000 deaths annually from lack of health insurance. And that’s unacceptable to me as a physician, and I think it’s unacceptable to the American people. And the health reform debate will continue regardless of what happens in the Supreme Court this week.

AMY GOODMAN: Professor McDonough, the individual mandate, if it is deemed unconstitutional by the high court, by the Supreme Court, because in the legislation it was made unseverable, would it throw out the whole plan?

DR. JOHN McDONOUGH: No, absolutely not. I think that the most that the court would throw out with the individual mandate, if they did that—and I don’t think they will, but if they did—they would throw out the guaranteed issue, meaning the protection against pre-existing conditions and medical underwriting, and they might throw out the community rating, as well, which we would—I would think would be very unfortunate and would create a less functional insurance market, for sure.

Let me just agree and disagree with my friend Steffie, who I really respect. She’s terrific and does wonderful work. First of all, I totally agree the debate would not end if the law were thrown out. However, the moment when there would be sufficient political will for the Congress and the president to come together and pass meaningful, near-comprehensive reform, that might take another 20 years. The debate certainly would not end. But these moments that occur in the early ’90s, in 2009, 2010, in 1965, in 1935, these are not moments that come every session, every decade. These are every generation or every other generation before these chances happen. And that’s why it’s important, I think, to build on it. The original Social Security Act that Franklin Roosevelt signed in 1935 excluded two-thirds of working African Americans, excluded more than half of working women, but it was the foundation and the structure that was built on over time to create the Social Security system we have and we know and recognize today. And I think it’s similar with Medicare and Medicaid, and it’s similar with the Affordable Care Act.

AMY GOODMAN: Steffie Woolhandler?

DR. STEFFIE WOOLHANDLER: Well, this is a little like saying that we’re going to start Social Security by handing over money to the private pension funds. What’s going on here in Obamacare is we’re saying we’re going to get to universal health care by turning over hundreds of billions of dollars to the private health insurance industry, the group that’s been blocking reform and blocking change for decades. So, we’re starting off in the wrong direction here, if we’re trying to start going toward universal health care.

AMY GOODMAN: The Supreme Court decision is being closely followed by many who say they could benefit from the law. Robyn Martin is a mother of a seven-month-old son who suffers from a serious heart condition.

ROBYN MARTIN: We need the Supreme Court to uphold the Affordable Care Act, because we need this little boy to continue to have health care without having to worry about hitting a limit, without having to add up each one of our visits to see how close we’re going to get to an arbitrary limit that a health insurance company sets for us.

AMY GOODMAN: Dr. Woolhandler, what do you say to people like Robyn Martin?

DR. STEFFIE WOOLHANDLER: Well, we definitely need the universal health care. ’Til we get there, we need guaranteed issue, we need community rating. But all of those things could be done without the mandate. There was community rating in this country for decades when I was growing up, which means that everybody pays the same insurance premium and—under Blue Cross, when I was growing up. So we do not need the individual mandate in order to have these things, and we did not need to hand over hundreds of billions of dollars to the private health insurance industry to get those helpful parts of the legislation.

AMY GOODMAN: How did we get to where we are? How did the Affordable Care Act end up, as you say, captured by the insurance industry?

DR. STEFFIE WOOLHANDLER: Well, the insurance industry wrote the framework for Romneycare in the form of Blue Cross Blue Shield Foundation in Massachusetts that wrote the original framework. When it came time for Obamacare, the Senate framework, which became the backbone of the law, was written by none other than Elizabeth Fowler, whose previous job had been vice president of WellPoint, the nation’s largest private insurance company. The insurance industry spent hundreds of millions of dollars lobbying on this bill. They gave hu
ndreds of millions to the Democrats and hundreds of millions to the Republicans, both supporting and opposing the bill, but assuring that voices from the left who supported real universal health care, real single payer, were shut out.

The only way those voices ultimately got heard was because people showed up in front of the White House in white coats and demonstrated. Doctors and nurses got arrested in Senate hearings. We forced the issue of single payer back onto the agenda against the wishes of the private health insurance industry. And that’s what needs to happen if we’re ever going to get to a real universal system that’s affordable, that gets rid of the private health insurance industry, and recaptures that $380 billion in excess paperwork costs and uses it to cover everyone.

AMY GOODMAN: Professor John McDonough, is Governor Romney lying when he says he doesn’t support an individual mandate? Was that your experience in Massachusetts?

DR. JOHN McDONOUGH: Oh, no, he robustly supported it. He did. And I think he would—I don’t think he’s backed away from saying he supports it. I think the way he has parsed it is he said, “Well, I support it on the state level, but not as a federal requirement.”

AMY GOODMAN: Yes, that is what he says.

DR. JOHN McDONOUGH: And so, you can judge that for what you think. But there are many, many statements in 2007, ’08 and ’09 where he indicated support for a national mandate. So, either he’s lying, or he’s changed his views on the utility of doing it on a national basis.

AMY GOODMAN: Not to mention he and his wife’s support of Planned Parenthood as part of that program.

DR. JOHN McDONOUGH: Well, we have a long list of those kinds of situations we can look at.

AMY GOODMAN: Well, I want to thank you both for being with us. John McDonough is with the Harvard School of Public Health. His new book is called Inside National Health Reform. And Dr. Steffie Woolhandler is co-founder of Physicians for a National Health Program. She was working at Harvard Medical School and has moved to New York, working within the CUNY system, the City University of New York.

This is Democracy Now!, democracynow.org, The War and Peace Report.

http://www.democracynow.org/2012/3/27/healthcare_debate_as_supreme_court_hears