PNHP

Out-of-pocket medical expenses drive more into poverty

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Out-of-pocket medical expenses drive more into poverty

Census Bureau measures more Americans living in poverty

By Michael A. Fletcher
The Washington Post, November 7, 2011

The Census Bureau on Monday released a new, comprehensive poverty measure that painted a more dismal picture of the nation’s economic landscape than the official measure from September.

The report found that 49.1 million Americans — 16 percent of the population — lived in poverty in 2010, which is higher than the 46.2 million Americans found to live in poverty by the official measure released in September.

The new report marked the culmination of a years-long effort by the Census Bureau to come up with a poverty measure that takes into account the huge amounts of money in social services benefits provided to the needy, as well as their expenses for things such as medical care and payroll taxes.

The increased level of poverty revealed by the supplemental measure is at odds with what some poverty experts expected. The increased level of poverty was fueled by the sharply higher levels of poverty among senior citizens found by the alternative measure.

The poverty rate for those 65 and older was 15.9 percent based on the supplemental measure, much higher than the 9 percent rate for the elderly when using the official poverty yardstick.

http://www.washingtonpost.com/business/economy/census-bureau-report-more-americans-living-in-poverty/2011/11/07/gIQAAHm1wM_story.html

And…

The Research SUPPLEMENTAL POVERTY MEASURE: 2010

Current Population Reports
United States Census Bureau, November 2011

The National Academy of Sciences (NAS) established the Panel on Poverty and Family Assistance, which released its report titled Measuring Poverty: A New Approach in the spring of 1995. Based on its assessment of the weaknesses of the current poverty measure, this NAS panel of experts recommended having a measure that better reflects contemporary social and economic realities and government policy.

SPM (Supplemental Poverty Measure) family resources should be defined as the value of cash income from all sources, plus the value of in-kind benefits that are available to buy the basic bundle of goods (FCSU) minus necessary expenses for critical goods and services not included in the thresholds. In-kind benefits include nutritional assistance, subsidized housing, and home energy assistance. Necessary expenses that must be subtracted include income taxes, social security payroll taxes, childcare and other work-related expenses, child support payments to another household, and contributions toward the cost of medical care and health insurance premiums, or medical out-of-pocket (MOOP) costs.

Resource measure:

Official Poverty Measure:  Gross before-tax cash income

Supplemental Poverty Measure:  Sum of cash income, plus in-kind benefits that families can use to meet their FCSU needs, minus taxes (or plus tax credits), minus work expenses, minus out-of-pocket medical expenses

For children, not accounting for the EITC (Earned Income Tax Credit) would result in a poverty rate of 22.4 percent, rather than 18.2 percent. The inclusion of each of the listed in-kind benefits results in lower poverty rates for children. Not subtracting MOOP (medical out-of-pocket expenses) from the income of families with children would have resulted in a poverty rate of 15.4 percent. Findings are similar for the other two age groups shown. For the 65 years and older group, however, WIC (Women, Infants, and Children program) has no statistically significant effect while SPM (Supplemental Poverty Measure) rates increase by about 7.3 percentage points with the subtraction of MOOP from income. Clearly, the subtraction of MOOP has an important effect on SPM rates for this group.

From the Summary

Results showed a higher proportion of several groups were poor using the SPM. These groups were adults aged 18 to 64 and 65 and over, those in married-couple families or with male householders, Whites, Asians, the foreign born, homeowners with mortgages, and those with private health insurance.

Since in-kind benefits help those in extreme poverty, there were lower percentages of individuals with resources below half the SPM threshold for most groups. The effect of benefits received from each program and expenses on taxes and other non-discretionary expenses on SPM rates were examined. It was shown that medical out-of-pocket expenses had an important effect on SPM rates and on the well-being of those 65 years and older, in particular.

http://www.census.gov/prod/2011pubs/p60-241.pdf

Comment: 

By Don McCanne, MD

Many have believed that our poverty rates would not be so dismal if more factors were considered such as the value of social services benefits, thus the supplemental poverty measure was created. The shocking result is that poverty rates are actually greater, especially because of the additional drain on resources of out-of-pocket medical expenses – a measure even worse for those over 65.

PNHP’s version of single payer would provide first dollar coverage, eliminating out-of-pocket expenses such as deductibles, co-payments, and coinsurance. This would not only reduce financial barriers to health care, it would also reduce U.S. poverty levels. This is partly what we mean by “improved” in “an improved Medicare for all.”

Meet The Architect of Vermont's Single-Payer Plan

Harvard's William Hsiao Zigs as Rest of Health Care Zags

By Hoag Levins
The LDI Health Economist, November 1, 2011

PHILADELPHIA — In the mid-1990s, Harvard health economist William Hsiao abandoned the U.S. health system as an area of study to focus his efforts on the health systems of other countries. The switch was motivated by frustration. “I gave up on the United States,” said the 75-year-old China-born scholar who emigrated to this country as a teenager. “I did not do any more work on the U.S. because Washington politics were so driven by ideology, and money played such an important role in policy making, that I really couldn’t contribute to it any more. The research I did just got pushed aside.”

Hsiao, a professor of economics at the Harvard School of Public Health in Boston, subsequently went on to become one of the world’s leading authorities on national health care systems, providing analysis and consulting services to 30 countries in Europe, Africa, Asia and Australia. He played a major role in reorganizing the health care systems in nine of those nations.

‘Incoherent and incongruent system’

Through it all he retained his dim view of America’s health care system and the lobbyists and partisan politics that control its destiny. In a recent interview in Health Affairs magazine he said the U.S. has “put on so many Band-Aids [on health care] that it has become an incoherent and incongruent system that causes much waste, inefficiencies and poor quality health care.”

And so, Hsiao’s history and attitude make it all the more noteworthy that last year, after a 16-year hiatus, he again focused on U.S. health care and became the architect of a new law establishing Vermont as the first state to adopt a “single-payer” health insurance strategy. He recently discussed that experience in a University of Pennsylvania seminar co-sponsored by the Leonard Davis Institute of Health Economics and the Center for Public Health Initiatives.

Vermont and the U.S. face common problems: the uninsured, the underinsured, cost escalation and an uneven quality of care,” he said. “If you’ve read the Commonwealth Fund’s reports, you know the U.S. has some of the best quality care in the world and some of the really not-so-good care. It’s highly uneven. Vermont has the ambition to solve all these problems with a single-payer system.”

Around the world

The single-payer approach is now widely used in other areas of the world including Canada, Great Britain, France, Germany and Switzerland. The model varies widely from country to country but, generally speaking, is a state-run, taxpayer-funded insurance program that standardizes administrative procedures, claims processing and payments across a broad population of patients. That unified system collects all the money, pays all the bills and sets the rates and rules for care.
Called “Green Mountain Care,” the single-payer system outlined in the 203-page Vermont plan that became a 102-page law in May is a public-private hybrid. It envisions a state-organized system of universal coverage for all residents funded by payroll taxes and administered under contract by a large private enterprise, probably an insurance company.

To prepare the plan, Hsiao, who has been a Harvard faculty member for 32 years, led a team that included Jonathan Gruber, an economics professor at the Massachusetts Institute of Technology; Steven Kappel, the head of Vermont’s Policy Integrity organization; and a group of Harvard health policy analysts. Their work was funded by a contract from the Vermont legislature and a grant from the Commonwealth Fund.

When the project began, Hsiao asked the state to define the goals it wanted the plan to achieve. The legislature wrote:

‘Essential health services for all’

“To ensure universal access to and coverage for essential health services for all Vermonters. All Vermonters must have access to comprehensive, quality health care. Systemic barriers must not prevent people from accessing necessary health care. All Vermonters must receive affordable and appropriate health care at the appropriate time in the appropriate setting and health care costs must be contained over time.”

The Harvard professor said Vermont officials also wanted the new plan to establish community-based preventive and primary care centers as the foundation of an overall system that included the state’s 14 hospitals.

Hsiao noted that his international experiences taught him that effective health care policy reform is only possible when there is a certain kind of “opening” in the political fabric. In Vermont, a state where grass-roots community organizations play a larger role in government than in most other states, three things happened to create such an opening.

Growing financial crisis

The first was a rising sense of financial crisis: Vermont currently spends $5 billion annually on health care; those costs now make up 20% of its domestic product and continue to rise. Second, 22% of Vermont’s 625,000 residents are either underinsured or uninsured — a point of great concern in a state known for its politically progressive philosophies. Thirdly, the candidates in the 2010 gubernatorial election harnessed their campaigns to the momentum of the national debate, making Vermont’s health care reform a platform priority second only to jobs.

Hsiao’s team even helped the new governor “sell” the plan to voters and legislators. “You have to frame the issue to capture the public’s imagination and attention so they can resonate with it quickly,” he said. “We used ‘the current system is broken’ because it was a statement that people could all relate to in his or her own way. What we were doing was not economics but rather political economics.”

Using Jonathan Gruber’s microsimulation model, Hsiao’s team analyzed Vermont’s health care economy and identified 16 hurdles that had to be overcome to craft a viable plan. “Then we talked to all the payers; state government, businesses large and small, workers, households,” said Hsiao. “They all told us, ‘I can’t afford another penny for health care. If your proposal requires me to pay more, I’m going to oppose it.’ At the same time, providers were telling us, ‘If you decrease our net income by a penny, we will oppose you.'”

Medicare and Medicaid

Hsiao ultimately recommended a single-payer system because he believed it has the best chance of generating the savings needed to fund the reforms without increasing overall annual health costs. One element was the consolidation of all current Vermont insurance plans, including Medicare and Medicaid, into a single plan. Aside from creating various sorts of efficiencies, this would also eliminate the costs currently paid for the marketing, sales and underwriting expenses of separate insurance companies as well as for the small army of providers’ employees who processed claims.

“In the U.S. today, every insurance plan negotiates separately with providers,” said Hsiao. “On average, a solo practitioner in Vermont has to deal with more than 30 different plans with different rules, rates and payment methods. Physicians on average spend roughly five to eight hours a week dealing with billing and insurance-related work. Their nurse spends half his or her time on this same thing. Close to one administrative clerk has to be hired to do the paperwork. On a larger scale, Massachusetts General Hospital is a major teaching hospital for Harvard Medical School that employs more than 900 clerks to do this work. We ask ‘Is that necessary? Is there a better way that reduces it?'”

Another element of Hsiao’s Vermont plan was to insulate its policy making and management from undue political influence.

‘Divorce politics as much as possible’

“For proponents, the ‘single-payer’ concept usually means the government runs it,” said Hsiao. “We said no. Our p
roposal tried to divorce politics as much as possible by creating an independent board that handles the system’s design, benefit packages, rates and payment methods.”

The plan includes the creation of a “direct negotiations” structure that puts representatives of the payers — businesses, employees and state government — on one side of the table and representatives of the providers — physicians, hospitals, drug companies and consumers — on the other side to work out policies and rates. Hsiao has used this same direct negotiation system in other countries and notes that “even if it’s not implemented that well, it still takes the politics out of the middle, which is particularly important in the U.S. where politics is dominated by powerful and moneyed groups.”

The overall daily administration of the new system would be put out for bid to private contractors. “When Vermont Blue Cross-Blue Shield understood that, their board of directors actually changed its policy to say that it would work with Vermont’s single-payer system,” Hsiao said.

Payment system leverage

Perhaps the most important mechanism for achieving savings and controlling quality across the new system will be its unified reimbursement capabilities. “We’ve learned from experience around the world that if you want to reduce waste and improve quality, the leverage you use is the payment system,” said Hsiao. “And the way to do that is to create the right incentive structures. Think of it like putting a magnet in the right place so that iron particles will automatically be drawn there.”

He notes that when the system is implemented in the next several years there will be winners and losers. “Some — like the uninsured and underinsured — will gain. We recommend that primary physicians also gain in income,” he said. “But there’s no free lunch. Somebody has to pay and some will lose. Private insurance companies, for instance — particularly those outside Vermont. Another group to lose will be employers who do not offer health insurance or offer very shallow insurance. Their costs will go up.” Couples who both have high-income jobs will also pay more, and specialist physicians will see a decline in income.

Hsiao readily admits that no health care model — including single payer — has totally succeeded. “I don’t think any country has solved the problem of controlling health care costs. All the advanced economies as well as middle income countries are trying to find a way to do that. The one that has been able to do that best so far is England, but its centralized system does that in fits and starts. France is also doing a very good job but is decentralized through different states and cities, so they don’t have as tight control as Great Britain.”

Does he think that Vermont’s gambit could ultimately influence other states or even the federal government to explore single-payer systems?

He said the biggest challenge to that would be “opposition from insurance industry, pharmaceutical industry and major medical centers. I believe the [U.S. health care] crisis will continue to deepen, and I will make a prediction that within ten years the American people will be willing to make a big change, like going toward a single-payer system. The question is whether the physicians will agree. If the public, the physicians and hospitals do agree to it, I think the opposition from the insurance industry can be overcome.”

Oregon's Mad as Hell Doctors win national award

By Bill Graves
The Oregonian, Nov. 7, 2011

A group of Oregon physicians who call themselves the Mad as Hell Doctors failed to put a single-payer option on the table in Congress’ debate on health reform two years ago, but they did win a national award recently for trying.

Physicians for a National Health Program awarded the doctors the Dr. Quentin Young Health Activist Award nine days ago during the organization’s national conference in Washington, D.C. The Mad as Hell Doctors won the award for “passionate work and play” in efforts to bring public awareness to problems in the health care system.

The doctors took their name from the 1976 movie “Network,” in which a character rallied the public with the line: “I’m mad as hell, and I’m not going to take it anymore.”

Six Mad as Hell Doctors embarked from Portland two years ago in a motor home on a cross-country campaign for a single-payer  solution to the nation’s health care system, an option that had been dismissed in the unfolding congressional health care debate. A single-payer plan would create one organization, a nonprofit or, more likely, the federal government, to run one health insurance program for the nation, something like Medicare for everyone.

The doctor activists, promoted by Adam Klugman, a Tigard political activist, took their message to about 30 cities before reaching Washington, D.C. They continue to tour, speak and advocate for health care reform.

Doctors involved in the cross-country campaign included: Dr. Eugene Uphoff and Dr. Samuel Metz of Portland; Dr. Paul Hochfeld of Corvallis, Dr. Michael Huntington of Corvallis, Dr. Joseph Eusterman of Wilsonville and Dr. Bob Seward of Forest Grove.

More than 600,000 people in Oregon, most adults, lack health insurance. The state hopes to enlist most of them by 2014 in an Oregon Health Exchange, an insurance marketplace, still under design, where they can shop for government-subsidized coverage.              

http://mobile.oregonlive.com/advorg/db_/contentdetail.htm?contentguid=eh2R3WK2&full=true#display

South Carolina Information

Sign our petition urging Biden and S.C. legislators to support Medicare for All

PNHP South Carolina is urging the entire S.C. Congressional delegation as well as the Biden administration to support the passage and implementation of the single-payer [improved] Medicare for All bills when they are re-introduced in the U.S. House and Senate in 2021.

Sign the Petition!

Contact Information

PNHP Chapter: Health Care for All – South Carolina

Website: www.pnhpsc.org

Media Contacts

David Keely, M.D.
(803) 417-2770
dfkeely3@gmail.com

Dr. David Keely is president of Health Care for All-South Carolina. He is semi-retired as a public health policy educator and physician epidemiologist with Primary Care Medicine and Public Health Synergy, his part-time consulting business. He grew up in Philadelphia and obtained his bachelor’s degree from Swarthmore College and his medical degree from Wake Forest University. He did his family medicine residency at the Medical University of South Carolina (MUSC) and later he did the MPH program at UNC-Chapel Hill School of Public Health. He has practiced family medicine for more than 30 years in multiple settings: in private practice, at a community health center, and as part of a health department. David was the full-time, three-county, public health district director for South Carolina’s Department of Health and Environmental Control for eight years. He also served in the National Health Service Corps for two years along the way.

The Fight to Save Britain’s NHS

By Jacqueline Davis, M.D.

[Note: The following remarks were delivered to the Annual Meeting of Physicians for a National Health Program in Washington, D.C., on Oct. 29.]

My American husband said – talk slowly otherwise they won’t understand your accent. Added to that handicap I have rather lost my voice so I’m really hoping you can understand me today.

First I want to thank you for inviting me here. I bring greetings from the land of socialized medicine and death panels, to the land of “islands of excellence in a sea of misery.”

I’ve never been to this city before and when I told family and friends about my invitation to Washington they assumed I was off to meet the president. I told them it was much more important than that. But just in case he’s listening – I could be free for tea tomorrow ….

I’ve been asked to speak today about our fight to save the National Health Service. Who are we and why are we having to fight? We are the campaigning organizations I work with, in particular Keep our NHS Public, which we started about seven years ago in response to the Labour government’s marketization policies for the NHS – the NHS which Tony Blair had promised would be safe in his hands.

Why is the NHS worth defending? The NHS was a great act of social solidarity when it was founded in 1948 in the aftermath of the Second World War. It’s ironic that we are told we can no longer afford it but it was created in a period when the UK had huge debts, but importantly when people believed in acting together for a common purpose, and that the state could intervene for the benefit of society.

The intention was that people should be freed from the fear of the financial consequences of illness and that good health care should be available to all regardless of wealth, the three core principles being

* Meets the needs of everyone

* Free at the point of delivery

* Based on clinical need not ability to pay

And by and large it has managed to maintain those principles.

Of course the NHS faces the challenges that all health systems do, i.e. changing demographics, increased range and cost of treatments, rising patient expectation and the global financial crisis. But in the face of all these the NHS still manages to be one of the most cost-efficient and equitable health services in the world. And the public love it. At the end of the Labour government’s 13 years in power it had the highest satisfaction ratings ever, and it still is the most popular institution in the UK bar none, and that includes the royal family.

So if it’s so good, why are we having to fight for it? Because there’s another big challenge which all public services face and that is the neoliberal agenda which still has the upper hand despite its current manifest failures on a global scale.

A successful public service is an affront to the free marketeers. They simply won’t let the facts get in their way. Despite all evidence to the contrary they continue to insist anything the public sector can do the private sector can do better and more cheaply, and no evidence to the contrary will persuade them otherwise.

So the politicians for ideological reasons, and the private sector for financial reasons, have had the NHS – traditionally publicly funded, publicly delivered and publicly accountable – in their sights for some time. They have acted together, beneath the radar, to turn the NHS from a cost-effective integrated public service into a kite mark attached to a ragbag of competing private providers.

For those who are interested in how this happened I recommend an excellent book, “The Plot against the NHS.” It’s enough now to say that since 2000 governments have pursued a policy towards the NHS that the electorate hasn’t voted for and doesn’t want, a profoundly anti-democratic state of affairs.

The process actually began under Margaret Thatcher with the internal market and was continued under New Labour with the Private Finance Initiative and policies which increased marketization. It has now come to crisis point with Andrew Lansley’s Health and Social Care Bill. After Prime Minister Cameron’s specific pre-election promise of no more top-down reorganizations, secretary of state for health Andrew Lansley produced a bill the size of a telephone directory, and everyone knew it was going to be very bad news.

And so it has proved. In brief the proposed changes are as follows:

* The current system of commissioning care will change completely, with 80 percent of the budget going to family doctors (GPs). And they will be responsible for commissioning services, NHS services, rather than publicly provided by NHS organizations, will be provided by any willing provider, i.e. anyone with a mop and a bucket. They will be coyly called the “NHS family.”

* Competition will be paramount and (according to politicians) drive improvements. Anti-competitive behavior will not be tolerated. This will be enforced by an organization called Monitor, chaired by an ex-employee of McKinsey, the management consultants.

* Hospitals will all have to become Foundation Trusts which are in effect autonomous competing businesses. Their only remit is to make a profit and they don’t have to offer services on which they can’t make a profit.

* There will no longer be a cap on income that hospitals can make from private patients. This is likely to lead to private patients filling NHS hospital beds, with NHS patients going to the back of the queue and a two-tier service.

* Personal health budgets are being rolled out.

This has all been driven with the usual spin of “patient choice” and “power in the hands of doctors,” but even so the vast majority of health professionals and the public don’t want anything to do with this bill.

What are our fears?

Most GPs don’t have the time, expertise or interest to get involved in commissioning health care. It will be done – is already being done in some places – by private companies such as UnitedHealth which has just signed a big contract in London. If the private sector is commissioning care and at the same time delivering it is tantamount to putting the thieves in charge of the jewelers shop.

Serious fears for the doctor/patient relationship especially in primary care. UK GPs are very effective gatekeepers to secondary care, one of the reason why the NHS is so cost-effective, but it’s very important that patients trust their judgment and decisions.

Up till now you trusted your GP to give advice on clinical grounds. But now – if your GP says no to treatment and/or referral is it because they want to pocket the money that is saved – which the bill allows them to do? Or if they refer you to Hips R Us down the road, is it because their wife has a financial interest in it? 25 percent of GPs already have a direct interest in the private sector. This suspicion will be very corrupting, and most GPs are worried about it.

We fear GPs will be unwilling or financially unable to refer patients to hospitals and “care in the community” is already becoming weasel speak for hospital closures.

Hospitals will see their incomes reduced and will turn to private patients to make them up. Until now there has been a cap on private patient (PP) income but that has been removed. If NHS beds fill with PPs, then NHS patients will have to wait and we will see a two-tier service develop.

With services being provided by competing organizations we know there will be fragmentation of the care provided to patients and disruption of the patient pathway.

We fear that unprofitable services and patients will be quietly dropped.

We fear the loss of public accountability with the private sector hiding behind commercial confidentiality (as they did
with Independent Sector Treatment Centres, free-standing surgical clinics).

We fear NHS services being reduced to a core of poor services for poor people, with those who can afford it topping up their personal health budgets with insurance or out-of-pocket payments and those who can’t afford it going without.

And we really fear the arrival of the private companies, many of them from the U.S., whose behavior leaves much to be desired. They want to “cherry pick,” leaving the NHS to pick up the complex expensive patients as well as providing the expensive emergency care and the training that is not attractive to the private sector. We fear they will behave in a fraudulent way as they do already in the USA.

The government was very clever with the bill, which is about the deeply unacceptable break-up and sell-off of the NHS. They knew they would never get away with that so they sugarcoated the bitter pill with GP commissioning.

And GPs fell for it initially – many were excited by the prospect of holding the budget. Then they woke up to the fact that they would be doing this against the background of $30 billion to be saved over four years, and they would be made the scapegoats for cuts, closures and rationing. They would also have the private sector doing the commissioning, telling them what to do and probably ultimately employing them.

Less than 20 percent of GPs now approve of the bill and very few think it will benefit patients. But because the government have started to implement the changes before the bill is law they have had to engage or see others do so on their behalf.

So, you see why we have to fight this. Because of the complexity of the bill, people, and in particular doctors, were either too busy to look at it or couldn’t understand it when they did. One of the problems we have had is engaging the profession because they didn’t notice what was going on, or trusted too much to our union to take on the problem or felt powerless given the lack of any visible sign of opposition. There is also a minority of “doctorpreneurs” who see financial opportunities and never mind the long-term consequences.

Because the language used was about patient and doctor empowerment patients felt reassured by the thought of money and power in the hands of their local friendly family doctors and it has been hard work to expose the spin.

Another problem was identifying and co-coordinating all the bodies who were opposed to the proposed legislation, in particular working with the health unions who tend to be suspicious of other organizations.

Our organization was vociferous from day one, saying that the bill spelled the end of the NHS, and of course we were accused of shroud waving and gross exaggeration. But we stuck in there and joined together with other campaigning organizations and the pressure has built up over the last year. How did we do it?

We produced analyses and simple 10-point critiques of the bill in our regular campaign newspaper as well as special pamphlets and postcards. We wrote doggedly – all of us would take it in turns – to national and local papers and had a lot of articles and letters published.

We offered to do public talks, to our own groups and also to anyone from medical students to pensioners, and in fact those two groups turned into some of our most outspoken supporters. We helped organize online petitions. We put a lot of energy into lobbying politicians.

We have helped exposed the scandals of the revolving door between government and the private sector and the infiltration of government by corporate interests. We have questioned the neutrality of so called think tanks and helped expose the strength of the health lobbying industry in Westminster.

We marched, we used social media to spread our message and some of us even got elected to the Council of the British Medical Association so that we could begin to change our union from within.

As the bill passed from the House of Commons to the House of Lords the profession finally woke up and there has been a flurry of open letters, both to our union, the BMA, asking it to oppose the bill (published in the BMJ), to politicians in both houses and to newspapers.

We, the NHS Consultants’ Association, wrote to the Academy of Royal Colleges, the umbrella body for specialist professional bodies, asking them to get involved. They are traditionally very conservative and excuse inaction by saying they are apolitical, but we pointed out that their remit is quality, training and standards, all of which are threatened by the legislation. They have since published a letter to the government stating their concerns.

Despite what amounts to a public outcry in the last couple of months, the bill is now going through the House of Lords with the prospect that it may emerge with little changed.

The problem we have come to realize is that we aren’t just fighting the Tory government; we are fighting the global medical industrial complex with all its power, influence and money. And its cozy relationship with today’s politicians.

It’s easy to lose hope but we mustn’t. We have to take on this cozy configuration of politicians and giant corporations which have come to a “comfortable accommodation” at our expense. We must change the tone of the debate with these people who know the price of everything and the value of nothing.

We must say that the market should serve society rather than society serving the market, that there are public goods and goals for which the market is not suited and that what matters is not how affluent a country is but how unequal it is. We must collect evidence and use it to criticize and expose. We must create the strong voice of civil society and we doctors have a particular duty to be that voice and we must organize and use it.

Firstly because – and we must never lose sight of the fact – we are right. Secondly, we are the patients’ true advocates and our patients are depending on us. And finally Aneurin Bevan, the great founder of the NHS, said, “The NHS will last as long as there are folk left with the faith to fight for it.”

We must be those folk because, personally, I am not prepared to let him down.

Dr. Jacqueline Davis is a consultant radiologist working in a hospital in London. She is co-chair of the NHS Consultants’ Association, a nationwide group of distinguished physicians representing all specialties, and a member of the Keep Our NHS Public campaign.

Massachusetts physicians prefer single payer over the Affordable Care Act

Temperatures Rise Over Costs Of Care: Polls Find Public, Doctors Favor More Government Involvement

By Livia Gershon
Worcester Business Journal, November 7, 2011

Presumably, doctors are more familiar than the general public with the pressures driving up health care costs, and an overwhelming majority of them also say there needs to be some government involvement in the health care system. A survey by the Massachusetts Medical Society this fall found that 41 percent of doctors thought the best option for health care reform in the U.S. would be to adopt a single-payer system like Canada’s. That number was up from 34 percent in 2010.

(Another survey by the Blue Cross Blue Shield of Massachusetts Foundation) found that 88 percent of Massachusetts residents think it’s important for the state government to take major action on health care costs.

http://www.wbjournal.com/news50169.html

And…

Physician Workforce Study

Massachusetts Medical Society
September 28, 2011

6.1.  Practicing Physicians Opinions on U.S. Health Care System Reform

A question was added to the Practicing Physician Survey in 2010 to document how physicians view upcoming system changes in national health care reform. The following question was asked again this year of each of the respondents: 
 
Which of the following would you choose as the best option for the U.S. health care system?
 
The percent of practicing physicians choosing each response is outlined below:
 
1.  Both public and private plans with a public buy-in option (allow businesses and individuals to enroll in a public Medicare-like health insurance plan that would compete with private plans) — 23% 
 
2.  Keep the existing mix of public and private plans, but allow insurers to sell plans with limited benefits and high deductibles to keep premiums low. State subsidies would help low-income individuals buy insurance. Individuals could choose to buy a less expensive catastrophic plan, more expensive comprehensive coverage, or no insurance at all — 15% 
 
3.  The recent national plan (Patient Protection and Affordable Care Act) passed by Congress in 2010 (modeled after the Massachusetts health reform law of 2006). This plan includes an individual mandate, expansion of public programs, American Health Benefit Exchanges, changes to private insurance including prohibiting the denial of coverage for preexisting conditions, and employer requirements —- 17% 
 
4.  Single-payer national health care system offering universal health care to all U.S. residents — 41%
 
5.  Other (please specify) — 4%
 
While more physicians prefer single payer as the best option for U.S. heath care reform compared to last year’s survey results (41% in 2011 and 34% in 2010), the majority of physicians prefer other options (59% in 2011 and 66% in 2010).

http://www.massmed.org/AM/Template.cfm?Section=Research_Reports_and_Studies2&TEMPLATE=/CM/ContentDisplay.cfm&CONTENTID=61512

Comment: 

By Don McCanne, MD

Of five options for the U.S. health care system presented to Massachusetts physicians, far more – 41 percent – preferred single payer to any other option. That was almost twice as many as those who preferred the second choice option. The single payer choice jumped from 34 percent last year, likely representing further dissatisfaction with their current system based on a design very similar to that of the Affordable Care Act.

The leadership of the Massachusetts Medical Society is not very supportive of single payer, pointing out in this report that 59 percent of Massachusetts physicians prefer other options to single payer. But if they were more objective, they would have pointed out that when offered a choice of “The recent national plan (Patient Protection and Affordable Care Act) passed by Congress in 2010 (modeled after the Massachusetts health reform law of 2006),” 83 percent of physicians prefer other options.

Presenting the remaining data in the same manner, 85 percent of physicians prefer other options to high deductible plans, 77 percent prefer other options to a “public option,” and 96 percent prefer one of the listed options (including single payer) to any other undefined option that they might otherwise prefer.

From this we can conclude that a clear plurality of Massachusetts physicians, who have direct experience with the Affordable Care Act model, would prefer single payer, and that support is increasing. By a large majority, they reject any other option, including their current system based on the model of the Affordable Care Act.

Psychiatrists Should Prescribe Good Jobs!

By H. Steven Moffic, MD
Psychiatric Times, November 3, 2011,

“Love and work are the cornerstones of our civilization.” This quote, rightly or wrongly attributed to Freud, simply and succinctly indicates the importance of the “Occupy Wall Street” movement.

Maslow, in his prioritization of our basic mental health needs, put security, safety, and adequate nourishment right at the top. Since it is clear that good work opportunities are diminishing in the USA and even more so in other parts of the world, our cornerstones are crumbling.

While it must be true that many occupiers around the world are there for other psychological and social reasons, and the tactics debatable at times, the crumbling of the mental health of our citizens and the mental healthcare that we can provide seems unmistakable. To wit:

• Loss of jobs is correlated with an increase in anxiety, depression, substance abuse, and suicide risk.

• Loss of good jobs or unsatisfying jobs often contributes to problems in relationships with loved ones.

• Obtaining jobs has traditionally been more difficult for the mentally ill.

• Obtaining jobs has even been more difficult for those large numbers of mentally ill being released from jails and prisons.

• Without such jobs, committing more crimes is more likely.

• Large numbers of returning veterans from the “war on terrorism”, and so many with health and mental health problems, will also be seeking jobs.

• The economic conditions influencing job loss has also resulted in Medicaid cuts and funding reductions in some of our “safety net” state mental healthcare programs

• There has been some job loss in some of our public community mental health systems in terms of clinicians and staff.

• Many private practices are not thriving.

• Where the so-called “millionaire’s tax” has been put in place in California, more outpatient services for the severely mentally ill resulted in less arrests and incarceration.

• There are ethical principles that support us advocating for jobs, including Sections 3 and 7 of the Principles of Medical Ethics of the American Medical and Psychiatric Associations (“A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient” and “A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health”, respectively).

• Although we can provide medication and psychotherapy to address some of the psychiatric effects of insufficient and inadequate jobs, correcting the core problem will be more effective.

Of course, psychiatrists can’t really prescribe a job, and other than the Clubhouse movement, obtaining jobs is not part of any treatment guidelines that I know of.

Nevertheless, for all the above reasons and more, we can advocate that more and better jobs will help the mental health of our citizens.

We can do that as citizens, as psychiatric professionals, or as part of a professional organization that is willing to speak out on this need.

Please join me in doing so in any way that you see fit. Thank you.

Increasing Medicare Age Could Lead To Higher Costs

By Julie Rovner
NPR, Nov. 7, 2011

Congress’ so-called deficit reduction “supercommittee” is down to the final weeks of deliberations in its efforts to come up with $1.2 trillion in budget savings. And one proposal that keeps cropping up is the idea of raising the eligibility age for Medicare.

GOP presidential candidate Mitt Romney became just the latest to propose it in his speech to the Americans for Prosperity Foundation on Friday.

“As with Social Security, the eligibility age should slowly increase to keep pace with increases in longevity,” Romney said. Social Security’s “normal” retirement age is gradually rising from 65 to 67 thanks to a change instituted in 1983.

Many health care providers, including major hospital groups, have also been urging members of the supercommittee — formally the Joint Select Committee on Deficit Reduction — to consider raising Medicare’s eligibility age rather than cutting their payments.

It’s a proposal that makes sense, says Joseph Antos of the American Enterprise Institute, a conservative Washington, D.C., think tank. “People are just healthier when they hit 65 than they were 40 years ago,” shortly after Medicare began.

“In 1965, there were a lot more jobs that required real physical effort,” Antos says. “Whereas these days, for a lot of people turning 65, the physical effort is getting out of their desk chair at 5 o’clock.”

Another reason raising Medicare’s eligibility age has gotten more politically palatable is the passage of last year’s health law. Right now, it’s almost impossible for older people to buy their own health insurance due to pre-existing health conditions. And even if they can find coverage, it’s usually unaffordably expensive.

But starting in 2014, assuming all goes as scheduled, all that will change.

“No matter what age you are,” says Antos, “you can apply for insurance, and no matter what your physical condition is, you will be eligible” for insurance coverage.

Shifting Costs Around

So, problem solved, right?

Well, not so fast, says Tricia Neuman of the Kaiser Family Foundation. She and some colleagues did an analysis of what the change would mean earlier this year.

Neuman says if raising the eligibility age is looked at purely as a mechanism to reduce the federal deficit, then it’s definitely a winner.

“This proposal will save money for the federal government and save money for Medicare,” Neuman says. And the downside? “It would do so by shifting costs to other payers.”

Specifically, some costs would shift to employers because they’d have to continue to cover many of those people who’d continue to work. Some costs would also shift to those 65- and 66-year-olds themselves, if they’re no longer working. They’d have to pay for their own insurance.

And states might have to pay more, too. If those people have low incomes, they might end up on Medicaid, rather than Medicare.

But it’s not even a dollar-for-dollar shift. It turns out that moving 65- and 66-year-olds out of Medicare would actually raise costs for the health system as a whole, according to the Kaiser analysis.

“So even though this proposal would save money for Medicare, costs overall will increase,” Neuman says.

That’s because taking the youngest, healthiest people out of Medicare would leave behind the sicker, older people and thus raise Medicare premiums for everyone left behind.

Meanwhile, those same people who are young by Medicare standards are old compared to the working population, so those 65- and 66-year-olds would cause overall premiums to rise by staying in that insurance pool, too.

In the end, while the federal government would save a net of about $6 billion in 2014 from such a switch, overall health spending would grow by nearly $8 billion, illustrating, yet again, that nothing in health care is ever as simple as it appears.

http://www.npr.org/2011/11/07/142023367/raising-medicare-age-could-lead-to-higher-costs

Health care legislation botched

By Bill Roy
The Topeka Capital-Journal, Nov. 6. 2011

The New York Times on Oct. 30 published the first of a promised series of articles by Ezekiel J. Emanuel, an oncologist, who is now professor of medical ethics and health policy at the University of Pennsylvania.

The Times bills Emanuel as a former White House adviser, which indeed he was during the writing of the Patient Protection and Affordable Care Act in 2009 and 2010. He probably had privileged access, because he is the brother of Rahm Emanuel, now mayor of Chicago, who was President Barack Obama’s White House Chief of Staff during that period.

Emanuel, who has the finest education in two disciplines, medicine and political philosophy, that America and Britain (Oxford) can offer, writes extensively. His writings were widely published during that critical period when a Democratic president and Congress were considering the most critical domestic legislation that can come before any U.S. Congress.

Emanuel and others ignored the fact that the health care systems of every other member of the Organization of Economic Cooperation and Development is, in one way or another, a single-payer health care system that covers everyone at a much lower cost than we are spending to insure only 5/6ths of our population.

The president, Congress and their advisers forfeited any chance of writing satisfactory health insurance legislation when they refused to let a single-payer system be considered. The Democrats followed the advice of the Ezekiel and Rahm Emanuels of the party, and wrote a crummy law that does not cover everyone, and will not control costs.

By their actions, they sacrificed the political careers of many of their members, a congressional majority and possibly a two-term Obama presidency. But most of all, they forfeited the health and money of the American people, who intend to make them pay dearly.

Surely, they had good reasons. Not so, read this statement by Ezekiel Immanuel and co-author Victor Fuchs, a celebrated senior Stanford economist.

“The biggest problem with single-payer is its failure to cohere with core American values. Single-payer puts everyone into the same system with the same coverage and makes it virtually impossible to add amenities and services through the private market.”

There it is, the smoking gun, the origin of the legislative mess now known to most Americans by the pejorative “Obamacare,” which will likely to be found unconstitutional by the Supreme Court or repealed by the next Congress.

As a recognized medical ethicist, Emanuel surely would like to avoid the 20,000 to 50,000 premature deaths a year resulting from the uninsured’s failure to seek and receive timely medical care.

But the deaths, anguish and suffering will continue, in part due to the hubris of two brilliant men who stepped out of their fields of expertise and decided “American core values” will not accept a basic system of health care for all.

The insurance companies won. They kept their current business and will receive more, compliments of the new law. They can still pay their executives $1 billion a year, as United HealthCare Group paid CEO William McGuire in 2006, and, assisted by AARP, rip off as much of the health care dollar as their greed and bookkeeping dictates.

While we cannot rely on Emanuel’s political judgment, we can probably depend on his facts, to wit.

Based on 2009 figures, health care cost us $7,960 each. Canadians paid $4,363 each; British paid $3,487 each; and Norwegians, with the second most expensive system, paid $5,352 each.

If each Kansan in a given year paid $6,000 per year for health care instead of $8,000,we could save $2,000 times our population of 2,723,507. Our savings would be $5,447,014,000. And, we would still be paying more per person for health care than any other nation.

The potential savings for Kansans of $5.44 billion is consistent with Montana Gov. Brian Schweitzer’s observation that his state spent $8 billion on health care in 2010, while just to his north, Canadian Province Saskatchewan with a nearly identical population was spending $4.2 billion.

And, of course, Saskatchewan covered everyone, while Montana had more than 150,000 uninsured.

The Times and Emanuel will bring us interesting information. Maybe they will come up with the right answer this time. But they wasted our last, best chance.

Bill Roy is a retired physician and former member of Congress. He has a law degree and lives in Topeka. He may be reached at wirroy@aol.com.

http://cjonline.com/opinion/2011-11-06/bill-roy-health-care-legislation-botched#.Trfy03KwVbE

Exemptions for self-insured plans place employees at risk

Healthwatch

By Julian Pecquet and Sam Baker
The Hill, November 3, 2011

Consumer advocate and law Professor Tim Jost on Thursday urged the National Association of Insurance Commissioners to take a “leadership role” in pressing states to address potential gaps in the healthcare law’s applicability. The law’s consumer protections don’t apply to all types of plans, and Jost said those gaps pose problems for both consumers and insurers.

Self-insured plans are exempt from most of the law’s regulations, and policies offered by large employers also don’t have to meet certain requirements. Jost said small businesses are shifting toward self-insurance, so employees will be stuck without benefits Congress intended to provide. There’s also a risk to insurers, he said, because small businesses could drop their self-insured policies and move into the exchanges as soon as one of their workers gets sick.

http://thehill.com/blogs/healthwatch/other/191759-overnight-health-health-budgets-back-in-spotlight

And…

Self-Insurance and the Potential Effects of Health Reform on the Small-Group Market

By Kathryn Linehan
National Health Policy Forum, December 21, 2010

Self-insured employer plans are explicitly exempted from some requirements, though “self-insured” is a term not defined in PPACA (or elsewhere). The exemptions are described below.

• Self-insured plans are not required to provide coverage with minimum essential benefits.
• Individual and small-group plans are required to participate in a risk-adjustment system, but self-insured plans are exempt.
• Self-insured plans are not subject to provisions (specifically, medical loss ratio requirements and review of premium increases) that are intended to limit insurer earnings.
• Starting in 2014, health insurers are required to pay an annual fee to be calculated by the Secretary, but self-insured plans do not have to pay this fee.

In a September 2010 paper, Timothy Stoltzfus Jost described the “threat” of self-insuring to exchanges:

If small businesses with healthy employees can remain “self-insured” until the health of their pool deteriorates and then join the exchange, premiums within the exchange will increase and the exchange will become less viable. If a state opens its exchange to groups above 100, the threat is even greater, as legitimate self-insured plans will seek to insure their employees through the exchange when their experience deteriorates. Moreover, the self-insured plans that have proven most adept at providing high-quality benefits to their employees at low cost (which exist at many large firms) are likely to remain independent of the exchange, while less successful self-insured plans turn to the exchange for coverage.

https://www.nhpf.org/uploads/announcements/IB840_PPACASmallGroup_12-21-10.pdf

Comment: 

By Don McCanne, MD

Well over half of all employees who obtain their health insurance through their work are enrolled in self-insured plans – plans in which health care bills are paid by the employer rather than by a private insurer (except for stop-loss insurance). By self-insuring, employers escape state insurance regulation, and they are exempt from many of the provisions of the Affordable Care Act.

These exemptions may benefit the employers, but they expose the employees and their families to greater risks, potentially impairing health care access and increasing the cost sharing burden, including costs for care that the plan is not required to cover.

Some say that employers will not compromise their self-insured plans since they would be used to attract better qualified employees, but we are already seeing a shift of risk from employers to employees through greater cost sharing and other plan innovations. As mentioned in a message earlier this week, there has been an increase in the sale of deceptive “self-insured packages” which are merely stop-loss plans that look like health insurance, but that are exempt from the regulatory oversight of private health plans. As health care costs continue to rise, employers surely will continue to leverage lax self-insured rules to accrue to their own benefit, at a cost to their employees.

For those employers who end up facing higher costs in their self-insured plans resulting from deterioration in the average health status of their employee pools, they have the out of transferring their employees to the new state insurance exchanges. Of course, subjecting the exchanges to adverse selection (enrolling more costly patients) will drive up premiums for everyone else enrolled in the exchange plans.

As we have said many times before, the fundamental flaw in the reform process was that Congress elected to build on our highly dysfunctional, fragmented system of financing health care. It wasn’t working before, and the tweaks in the Affordable Care Act are not near enough to make it work now.

We need to start over with an improved Medicare that covers everyone.

"Narrow networks" take away choice

Health Net set to offer discounted insurance

By Ken Alltucker
The Arizona Republic, November 3, 2011

Health Net of Arizona is teaming with Banner Health to offer a new health-maintenance-organization insurance plan that allows businesses and their workers access to discounted care if they agree to limit their network of health providers.

The Health Net ExcelCare HMO plan offers customers a network exclusively made up of Banner Health Network medical providers and Banner Health hospitals.

Although it’s Health Net’s initial foray into “narrow networks” in Arizona, the health insurer said that it has had success enticing both large and small employers in California to choose similar plans with slimmed-down networks.

Health Net has been among the most aggressive in promoting HMO plans with narrow networks, but other insurance companies such as Aetna and UnitedHealth Group have also offered such plans.

http://www.azcentral.com/business/articles/2011/11/01/20111101health-net-offer-discounted-insurance.html

Comment: 

By Don McCanne, MD

“Narrow networks” – sharply limiting the network of physicians and hospitals that the insurer will cover – is yet another example of private insurer innovation in their marketed products. Only in the private sector can taking away patients’ choices in their health care professionals and institutions be considered an improvement in product design. A public single payer system would be designed to enhance access, not restrict it.