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UnitedHealth celebrates Trump’s executive order

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UnitedHealth celebrates Trump’s executive order

Top U.S. Health Insurer to Look at Trump Obamacare Alternatives

By Zachary Tracer
Bloomberg, October 16, 2017

UnitedHealth Group Inc., the U.S.’s biggest health insurer, said it’s excited about the the chance to sell health plans President Donald Trump is promoting as alternatives to Obamacare.

Last week, Trump signed an executive order promoting short-term health insurance plans, “association health plans” for business owners who could band together, and tax-advantaged savings accounts that could be used to pay for health services. The order — which Trump has acknowledged as a move to effectively dismantle Obamacare — rattled some health insurance and hospital stocks last week.

“We have a great deal of experience in the areas covered in the order — short-term policies, association plans and expanded use of HRAs,” Chief Executive Officer David Wichmann said on a call with investors. “We will be engaging with policymakers as the regulatory frameworks in these areas are developed.”

UnitedHealth said in a statement Tuesday that its medical-loss ratio, a measure of how much of every premium dollar is spent on care, was 81.4 percent.

The company’s shares rose 4.4 percent to $201.75 at 9:41 a.m. in New York, after earlier rising as much as 5.3 percent for the biggest intraday gain in a year. They’re up about 26 percent so far this year.

https://www.bloomberg.com…

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Comment:

By Don McCanne, M.D.

As President Trump signs an executive order designed to help dismantle Obamacare, look who is celebrating – UnitedHealth Group, Inc., the nation’s largest health insurer. UnitedHealth has already mastered Trump’s tools to increase profits through short-term health insurance plans, association health plans, and health reimbursement arrangements – tools which reduce the amount the insurers have to pay for health care.

Wall Street also wants its piece of the action, as demonstrated by the boost in UnitedHealth’s share prices, now up about 26 percent this year.

UnitedHealth is touting its medical-loss ratio of 81.4 percent, which means that they divert 18.6 percent of their premium revenue to their own purposes, including high executive compensation and shareholder profits. Compare that to Medicare’s spending on health care which is about 98 percent of revenues.

And this afternoon we learn that Sen. Lamar Alexander and Sen. Patty Murray have reached an agreement that would temporarily extend cost-sharing payments in exchange for softening the rules to allow for cheaper, skimpier plans – shifting yet more health care costs away from insurers.

And when we try to offer the single payer solution, our progressive colleagues jump up and say we can’t have a litmus test. We must continue to support those (neoliberals) who have led us down this path to health care purgatory.

What is your next step? A champagne toast with UnitedHealth’s executives? That seems to be all that we are getting out of D.C. Or are we finally going to do something about this? Like demanding an improved Medicare for all. No, really. We have to make that demand and make it in an effective manner. They are not going to volunteer it.

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

Now is time for universal health care

By Rob Stone, M.D.
Bloomington (Ind.) Herald-Times, October 16, 2017

Donald Trump has done for health care what no Democrat was ever able to do: He has made the Affordable Care Act popular. The Senate has tried and failed three times to repeal and replace the ACA. What next?

One thing is certain — it is difficult to predict the future. The most unlikely things have come to pass the last two years: Almost no one predicted that Donald Trump would win the Republican nomination, Bernie Sanders would win the Indiana Democratic primary, and then Trump would win the presidency. Absolutely no one in either party predicted the ACA would still be standing at the end of September 2017.

Is there a way for Republicans to repeal their hated Obamacare and replace it with something that both keeps Trump’s campaign promise to “cover everybody” and that Democrats would get behind? A bipartisan solution?

The answer is hiding in plain sight — repeal Obamacare and replace it with universal Medicare. It will never happen, you say? Stranger things keep happening. Bernie Sanders has introduced such a bill in the Senate, with 16 Senate co-sponsors. The companion bill in the House has 120 co-sponsors.

The great humanitarian-physician Dr. Paul Farmer said, “I can’t show you exactly how health care is a basic human right. But what I can argue is that no one should have to die of a disease that is treatable.”

Especially in the richest nation on earth. I believe everyone deserves health care. You may not believe health care is a “right,” but please tell me whom you believe does not deserve health care.

Medicare already takes care of the sickest and most expensive Americans. Simply expand it to cover everyone. In the process, improve it, remove the co-pays and deductibles and add better hearing and dental coverage. We don’t have to re-invent the wheel.

There is wide agreement that a universal Medicare program is the ideal way to take care of everyone and control costs. The greatest barrier is those who say it can never happen, that it is pie-in-the-sky, that the corporate power against it is too great.

Why have large corporations not championed universal health care? Because it would cause the disintermediation of the private health insurance industry. Disintermediation (a seven syllable mouthful of a word) is what happens when the free market economy figures out how to remove a middleman and let people deal directly with the services they want. Like buying airplane tickets online, or Uber for a taxi, or Airbnb for a hotel room.

We don’t have a true free market for health care. Some say that is because there is too much government regulation, but that turns out not to be the case. Purchasing health care is not like buying a new car. It starts with a doctor and a patient. Patients want choices, but not the choice of which insurance policy to buy. We don’t want insurance companies coming between us and our doctor. We want the freedom to choose our doctor and our hospital. That’s what traditional Medicare does. You can seek care anywhere and not worry about being “in-network.”

The health insurance industry is an expensive middleman that adds no value, but adds huge complexity, cost and inefficiency. Can this unpopular industry be dis-intermediated? Actually, it is inevitable. We can’t afford not to. Private for-profit health insurance is superfluous and obsolete.

Universal health care is where we draw the line; where we make our stand. This is our wedge issue — the people against the powerful and corrupt corporations. I’m betting on the people. Now is the time.

Dr. Rob Stone is director of Hoosiers for a Commonsense Health Plan and Indiana coordinator for Physicians for a National Health Program.

https://www.heraldtimesonline.com…

Medicare for All would offer Americans better health care

By Pamella Gronemeyer, M.D.
St. Louis Post-Dispatch, Letters, October 16, 2017

Now that President Trump has found ways to destroy Obamacare without the need for Congressional approval or our democracy, we must open our eyes and push for the Improved Medicare for All plans supported by Rep. John Conyers, D-Mich., and a majority of congressional Democrats and Sen. Bernie Sanders, I-Vt., and numerous Democratic senators.

A majority of the American people support federal government involvement in the delivery of health care to all Americans. The federal government already pays for about two thirds of health care costs through Medicare, the Veterans Administration and Medicaid. As a physician, I know that Medicare works. It is only at the age of 65 that one sees the curve of health care outcomes improve in relation to other nations because of Medicare.

Medicare for All is publicly funded and privately delivered. The health care bills are paid by one payer, the federal government, not a myriad of insurance companies, personal checks or credit cards. Even more important, there are no people who must turn to Go Fund Me pages to pay their bills or file bankruptcy.

We need to demand that the government represent us and not let edicts of our president control our health and welfare. Call your congressman and senators and ask them to support The House and Senate bills. Learn about Medicare for All through websites at Physicians for a National Health Program or HealthcareNow.

The money that we currently pay for premiums, copay, and deductibles would be reduced by a combination of a progressive tax, employers’ tax and other creative funding. This would be a solution that all Americans can proudly support.

Dr. Gronemeyer resides in Glen Carbon, Ill.

http://www.stltoday.com…

The pecuniary distortion of limited networks

NBER Working Paper 23742: Equilibrium Provider Networks: Bargaining and Exclusion in Health Care Markets

By Kate Ho and Robin S. Lee
National Bureau of Economic Research, August 2017

Abstract

Why do insurers choose to exclude medical providers, and when would this be socially desirable? We examine network design from the perspective of a profit-maximizing insurer and a social planner to evaluate the welfare effects of narrow networks and restrictions on their use. An insurer may engage in exclusion to steer patients to less expensive providers, cream-skim enrollees, and negotiate lower reimbursement rates. Private incentives for exclusion may diverge from social incentives: in addition to the standard quality distortion arising from market power, there is a “pecuniary” distortion introduced when insurers commit to restricted networks in order to negotiate lower rates. We introduce a new bargaining solution concept for bilateral oligopoly, Nash-in-Nash with Threat of Replacement, that captures such bargaining incentives and rationalizes observed levels of exclusion. Pairing our framework with hospital and insurance demand estimates from Ho and Lee (2017), we compare social, consumer, and insurer-optimal hospital networks for the largest non-integrated HMO carrier in California across several geographic markets. We find that both an insurer and consumers prefer narrower networks than the social planner in most markets. The insurer benefits from lower negotiated reimbursement rates (up to 30% in some markets), and consumers benefit when savings are passed along in the form of lower premiums. A social planner may prefer a broader network if it encourages the utilization of more efficient insurers or providers. We predict that, on average, network regulation prohibiting exclusion has no significant effect on social surplus but increases hospital prices and premiums and lowers consumer surplus. However, there are distributional effects, and regulation may prevent harm to consumers living close to excluded hospitals.

From the Introduction

Since the passage of the Affordable Care Act (2010) there has been growing concern among policymakers about “narrow network” health insurance plans that exclude particular medical providers. Selective contracting by insurers — in which only particular providers are accessible — is not a new phenomenon. Dating back to the 1980s, managed care insurers have used exclusion to steer patients towards more cost effective or higher quality hospitals and physicians, and to negotiate lower reimbursement rates. While networks broadened somewhat with the “managed care backlash” of the 1990s (Glied, 2000), recent high profile exclusions from state exchange plans have reinvigorated the debate over the desirability of such practices. Amid concerns that restrictive insurer networks may adversely affect consumers by preventing access to high-quality hospitals (Ho, 2006), or may be used to “cream skim” healthier patients, regulators at the state and federal levels are considering formal network adequacy standards for both commercial plans and plans offered on state insurance exchanges.

In this paper, we examine the private and social incentives for exclusion of hospitals from insurer networks, and consider the potential effects of network adequacy regulations in the U.S. commercial (employer-sponsored) health insurance market. We begin with a simple framework that isolates the fundamental economic trade-offs when deciding whether or not to exclude a hospital, and identifies the empirical objects required to measure the costs and benefits from exclusion. We then extend the model of the U.S. commercial health care market developed and estimated in Ho and Lee (2017) — which incorporates insurer-employer bargaining over premiums and consumer demand for hospitals and health insurers — to capture exclusionary incentives on the part of insurers. Extensions include incorporating a stage of strategic network formation by an insurer and allowing for endogenous outside options in bargaining. Finally, we use our model to predict equilibrium market outcomes under hospital networks that would be chosen by an agent maximizing social or consumer welfare, or by a profit-maximizing insurer. By comparing outcomes across networks either maximizing different objectives or required to cover all hospitals in a market, we uncover circumstances when private incentives diverge from social or consumer preferences, and evaluate the effects of certain forms of network regulation.

Conclusion

Narrow provider networks have grown more prevalent in both exchange and employer-sponsored health care markets in recent years. Their presence raises important questions. Are these plans effective at reducing spending, and if so, through what means? And is regulation warranted — are the networks that are introduced too narrow from either a social or consumer welfare perspective?

Our paper addresses these and related questions. We extend the model of the commercial U.S. health care market developed in Ho and Lee (2017) by endogenizing an insurer’s hospital network and incorporating a new bargaining concept that explicitly captures an insurer’s incentives to exclude. In the employer-sponsored setting that we examine, we find that selective contracting and informed network design can have substantial effects on overall health care spending. Narrow hospital networks are preferred by a profit-maximizing insurer primarily due to their ability to substantially reduce negotiated rates — and not necessarily due to cream-skimming healthier enrollees or steering patients towards lower-cost hospitals. A private insurer tends to engage in exclusion more than is socially optimal, but typically does so to a lesser extent than the average consumer would prefer because consumers often benefit from substantial premium reductions.

These results support the argument that allowing insurers to exclude providers can substantially reduce hospital payments and premiums without significantly affecting social surplus. This tends to benefit consumers (and hence employers) on average, implying that employers and insurers may wish to work together to control spending through exclusion. Our framework may be useful for these and other interested parties to inform network design. It also can be used to address potential distributional consequences of exclusion by identifying affected populations and quantifying the transfers needed to offset harm from reduced access.

http://www.nber.org…

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Comment:

By Don McCanne, M.D.

This paper looks at the motivation of insurers in establishing narrower hospital networks (profit-maximization, of course) and the perspective of the consumer (i.e., patient) and the social planner.

For the insurer, it’s simple. Contract with the hospital(s) that will agree to the lowest negotiated rates. Quality, cream-skimming or steering patients to lower-cost hospitals has little to do with it as long as the insurers save on negotiated rates.

These economists join others in concluding that consumers prefer narrower-network insurance plans. But it needs to be emphasized, once again, that patients are not choosing narrower-network plans simply because they prefer not to be burdened by having to make decisions regarding having a broader choice in their health care options. They choose narrower-network plans solely for one reason – lower insurance premiums. It would be incorrect to conclude that patients do not mind giving up provider choice as long as they can save some money. Rather it is that insurance premiums have become so expensive that they find paying them often creates a financial hardship. They do not want to give up their choice of health care providers, but many often feel that they have no other option since they have little or no disposable income.

From the standpoint of the social planner, health care resources should be made available based on need. Arbitrarily removing options for care based on pecuniary benefit to the insurer conflicts with optimal social planning. These and other economists tend to be somewhat, but not completely, dismissive of the social planner. They do concede that it could be beneficial to address “potential distributional consequences of exclusion by identifying affected populations and quantifying the transfers needed to offset harm from reduced access.” Or, “there are distributional effects, and regulation may prevent harm to consumers living close to excluded hospitals.”

It shouldn’t be just about money – about insurers’ profits and about patients’ spending as consumers. Social planning is crucial in providing optimal access to health care services. It doesn’t take much thought to conclude which model emphasizes social planning – the for-profit, private insurance model, or the patient service model of a well designed, single payer national health program – an improved Medicare for all. If you need a reminder, the traditional Medicare program does not use provider networks. Costs are contained in much more patient-friendly ways.

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

Dr. Farzon Nahvi on ‘NowThis’

New York-based emergency physician Dr. Farzon Nahvi recorded a video op-ed that was posted to the “NowThis Politics” Facebook page on October 16, 2017. He said single-payer reform was needed to protect two distinct groups of patients: those without private health insurance and those with private health insurance.

A single payer system could mean more coordinated care

By Paula L. Stillman, M.D., M.B.A.
Philadelphia Inquirer, October 16, 2017

I do not want to have to switch my health care coverage.

For the past 15 years, I have had multiple spinal epidural injections to relieve my sciatic nerve pain. The injection lasts for 4-6 months and I am pain free during that interval. All of my records and images are at a major hospital in Delaware where I worked for 8 years.  When I left that position I went on Medicare. My injections continued without a copay. I now work at a major health system in Philadelphia and receive health coverage through that health care system.

Recently, I went down to Delaware for my epidural injection before a major out of town trip. The injection worked and I was pain free. Imagine my surprise when I received a bill for a copay for the hospital facility fee for over $1200. I did not realize that the hospital in Delaware was a tier 3 provider. I was never told this before the procedure or the amount of my copay. In fact, I received the bill almost 3 months after the procedure. I appealed this case to Blue Cross and am waiting their decision. I told them that I was never told about the co pay before the procedure and it was bad medicine for me to change providers. I am awaiting their decision.

I should be able to go to whatever health care system I choose and to stay with the hospital that has all of my records and has past experience with my problem. I do not want to switch. For years, I have been very satisfied with the care that I received in Delaware. I have been essentially pain free and able to travel, exercise and enjoy life. Just because my insurance coverage has changed, I should not have to switch my providers. This is bad medicine.

A single payer plan could solve this problem, and Bernie Sanders’ proposal would be a good first step. No one should have their care disrupted because they were forced to change insurance.

Dr. Stillman is Director of Community Engagement of The Institute of Emerging Health Professions at Jefferson University.

http://www.philly.com…

All Americans deserve good health care

By Rian Podein, M.D.
Wisconsin State Journal (Madison, Wisc.), October 16, 2017

Medicare for all is patriotic.

Our nation proudly acts patriotic when we support our military troops. This patriotism naturally extends to supporting our neighbors too. Our brave military men and women are often placed in harms way sacrificing, life and limb.

The same is true of our courageous countrymen and women who may also find themselves in harm’s way, whether by natural disaster, national tragedy, mass shootings, terrorism or illness.

Rightfully, we have guaranteed our military personnel access to high quality and affordable health care via the Veteran’s Administration. We owe the same patriotic commitment to our neighbors.

Current legislation that can fulfill this patriotic commitment includes bills introduced in the U.S. House of Representatives by Rep. John Conyers, D-Mich., and more recently in the Senate by Sen. Bernie Sanders, I-Vt.

The time has come to support our troops and our neighbors with the right to health care.

http://host.madison.com…

Dr. Thomas Clairmont on ‘The Senior View’

Dr. Thomas Clairmont appeared on “The Senior View” on Portsmouth (N.H.) Public Media on October 14, 2017. He was joined by Dr. David Rutstein and other guests to discuss “health care in America.” The panel lamented the outrageous (and rising) cost of care and Dr. Clairmont pushed for single-payer reform to address this problem.

Trump’s abrupt termination of cost-sharing reductions

Trump Administration Takes Action to Abide by the Law and Constitution, Discontinue CSR Payments

U.S. Department of Health & Human Services, October 12, 2017

U.S. Health and Human Services Acting Secretary Eric Hargan and Centers for Medicare & Medicaid Services Administrator Seema Verma released the following statement announcing that cost-sharing reductions payments will be discontinued immediately based on a legal opinion from the Attorney General:

“It has been clear for many years that Obamacare is bad policy.  It is also bad law. The Obama Administration unfortunately went ahead and made CSR payments to insurance companies after requesting – but never ultimately receiving – an appropriation from Congress as required by law.  In 2014, the House of Representatives was forced to sue the previous Administration to stop this unconstitutional executive action. In 2016, a federal court ruled that the Administration had circumvented the appropriations process, and was unlawfully using unappropriated money to fund reimbursements due to insurers.  After a thorough legal review by HHS, Treasury, OMB, and an opinion from the Attorney General, we believe that the last Administration overstepped the legal boundaries drawn by our Constitution.  Congress has not appropriated money for CSRs, and we will discontinue these payments immediately.”

https://www.hhs.gov…

HHS Memo with opinion of Attorney General Jefferson B. Sessions III:
https://www.hhs.gov…

CBO: The Effects of Terminating Payments for Cost-Sharing Reductions:
https://www.cbo.gov…

NYT: 12 ways Trump is scaling back Obamacare:
https://www.nytimes.com…

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Executive Order: Promoting Healthcare Choice and Competition Across the United States

The White House, October 12, 2017

Among the myriad areas where current regulations limit choice and competition, my Administration will prioritize three areas for improvement in the near term: association health plans (AHPs), short-term, limited-duration insurance (STLDI), and health reimbursement arrangements (HRAs).

https://www.whitehouse.gov…

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Comment:

By Don McCanne, M.D.

In order to make health care more affordable for lower-income individuals, the Affordable Care Act required that credits (cost-sharing reductions or CSR) be paid to the insurers to cover a portion of the cost sharing. Republicans chose to block these payments by refusing to appropriate the funds required, forcing the Obama administration to use an alternative source of funds – a move which is now under legal challenge (use link above to see Attorney General Sessions’ opinion).

The Trump administration has now ordered the immediate termination of the CSR payments.

The Congressional Budget Office has previously provided an analysis of the consequences of terminating the CSR payments (see link above). There are too many variables to predict with certainty what will happen, but the action at least is likely to be disruptive to the silver plans offered in the exchanges (the silver plans being the ones that quality for the CSR payments).

Also yesterday President Trump issued an Executive Order instructing agencies to modify regulations for association health plans (AHPs), short-term, limited-duration insurance (STLDI), and health reimbursement arrangements (HRAs). Again, because of variables in implementation of this executive order, the impact is uncertain, but it is likely to be quite negative.

The New York Times has listed other ways in which Trump’s administration is scaling back the Affordable Care Act (see link above). All of these measures together will certainly increase the number of uninsured, reduce health care benefits covered by the innovative plans, while increasing exposure to financial risk. Too many patients will end up sicker and poorer.

At a time when there is a surge of interest in single payer reform – an improved Medicare for all – the pushback against the Trump chicanery could expedite the political processes required to advance health care justice to all. We should be sure that the nation understands that there is a much better way out, but also that they will have to demand that change.

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

The time for universal health care and single-payer is near

We should not have to wait another 17 years to see a change that is so critically needed now.

By Richard C. Dillihunt, M.D.
Portland (Maine) Press Herald, October 13, 2017

Seventeen years ago, I wrote an op-ed for the Maine Sunday Telegram headlined “Universal Medicare: The time is coming” (Nov. 19, 2000). Apparently I jumped the gun, as it has not taken place yet.

Now I feel like a cicada, an insect that looks like a huge fly, emerging after 17 years of hibernation under the bark of a tree and emitting unique and characteristic shrill buzzing sounds to attract attention to itself. Now the sounds come from independent Vermont Sen. Bernie Sanders. The concern of our nation regarding health care for all is reaching a crescendo, and we need to address this. The resounding will of the people should be recognized and acted upon.

The recent and astounding conversion of now-retired Sen. Max Baucus, D-Mont., into a supporter of a system of single-payer care like that of Canada leaves one breathless. Baucus owed this to every American, having blocked single-payer eight years ago as an architect of the Affordable Care Act.

Today I repeat the message after all these years. The time for universal health care and single-payer is near, and the politicians of all parties have an obligation to awaken and do what hundreds of millions of Americans crave. Poll after poll expresses this desire.

Current efforts otherwise in Washington are dying day by day, and the gasping last breaths of politicians to repair, replace, revise, renew or whatever are just roadblocks and flimsy efforts to make an easy job impossible.

President Trump, Senate Majority Leader Mitch McConnell, House Speaker Paul Ryan and so many others should be ashamed they have not pushed the easy button bringing superior health care to every last citizen of America. Repeated tweaking of and failures to change the system with little study and no experience only expose amazing incompetence, lack of education and profound political positioning. Trying to solve these issues with political threats and outright lies rather than facts would be laughable if it were not such a serious matter, easily the most important domestic issue of our time.

We owe it to one another to bring about this change and elevate our position to the top. In a recently released, reliable comprehensive study of health care worldwide, our only top position is cost. We blow away every other nation as we spend $9,000 per capita yearly on care – about 17 percent of our gross domestic product.

However, we are far down the list, tied with Estonia and Montenegro, in quality of and access to health care. On a scale of 0 to 100, our overall grade point average is 81. That, to me, is a cruel joke. Top score went to Andorra, a little country in the Alps – boasting a score of 95. Big countries like Norway and Australia beat us with ease. Yes, this is hard to believe. Just check the article, published May 18 in The Lancet – the accurate, highly regarded journal from the U.K. It is all there.

Money is not the problem. How can we wear Gucci shoes while preemies die? How can we let our horn of plenty stop on Wall Street while addicts lives’ end as they wait in vain down the street for rehabilitation services? How can we spend $4 billion on another destroyer scraping its sides on the Panama Canal while health care-related bankruptcies humiliate Middle America?

Should we be sending billions to Egypt to buy tanks that shoot at each other? Or a billion to Ukraine for forgotten reasons?

I again submit: The time has come for Americans to take care of ourselves. Look over our northern border and we will see how it works – at huge savings. Note that the per capita cost of health care here has more than doubled since the publication of my 2000 Telegram op-ed – even though Canada has enjoyed both liberal and conservative governments during this time, with no change in the love for single-payer there.

The per capita cost of health care in Canada is a little less than half of what we pay in the U.S. Politics should not lead the way on how to fix your mother’s hip – or how to pay for it. We need more civilized ways to face these responsibilities. Virtually all polls agree with this position.

Personally, I have more at stake here. I do not want to wait another 17 years to see a change that is so critically needed now. I am sick of living under the bark of a tree. Please study the issues on switching to universal health care and single-payer. Then join Bernie Sanders and a huge majority of our fellow Americans in supporting single-payer care.

http://www.pressherald.com…

Guns

Death by Gun Violence — A Public Health Crisis

By Howard Bauchner, MD (1); Frederick P. Rivara, MD, MPH (2); Robert O. Bonow, MD, MS (3); Neil M. Bressler, MD (4); Mary L. (Nora) Disis, MD (5); Stephan Heckers, MD (6); S. Andrew Josephson, MD (7); Melina R. Kibbe, MD (8); Jay F. Piccirillo, MD (9); Rita F. Redberg, MD, MSc (10); John S. Rhee, MD, MPH (11); June K. Robinson, MD (12)
JAMA (Published simultaneously in JAMA and the 11 JAMA Network Journals), October 9, 2017

Author Affiliations:

1) Editor in Chief, JAMA and The JAMA Network
2) Editor, JAMA Pediatrics and JAMA Network Open
3) Editor, JAMA Cardiology
4) Editor, JAMA Ophthalmology
5) Editor, JAMA Oncology
6) Editor, JAMA Psychiatry
7) Editor, JAMA Neurology
8) Editor, JAMA Surgery
9) Editor, JAMA Otolaryngology–Head & Neck Surgery
10) Editor, JAMA Internal Medicine
11) Editor, JAMA Facial Plastic Surgery
12) Editor, JAMA Dermatology

The shooting in Las Vegas, Nevada, that left 59 people dead, 10 times that number wounded, and thousands of people with the psychological distress from being present at the scene during and after the massacre has once again raised the issue of what we as a nation can and should do about guns. The solution lies in not just focusing on Las Vegas and the hundreds of other mass shootings that have occurred in the United States in the last 14 months, but rather to underscore that on average almost 100 people die each day in the United States from gun violence. The 36,252 deaths from firearms in the United States in 2015 exceeded the number of deaths from motor vehicle traffic crashes that year (36,161). That same year, the US Centers for Disease Control and Prevention reported that 5 people died from terrorism. Since 1968, more individuals in the United States have died from gun violence than in battle during all the wars the country has fought since its inception.

Guns do not make individuals, their families, or homes safer and they result in far more deaths to loved ones than to an intruder intending to cause harm. Often forgotten is that 60.7% of the gun deaths in 2015 in the United States were suicides. Means used to attempt suicide matter; guns will result in suicidal deaths well over 90% of the time, whereas ingestion of pills or wrist cutting will be unsuccessful more than 90% of the time. The majority of people who try to commit suicide but survive the attempt will not go on to die from suicide; if the attempt is with a gun, there will be no second chance at life.

The journals of the JAMA Network are dedicated to improving the health of people across the globe. We do so by addressing the most important public health problems harming people and publishing the best science that can be done. The journals have published important work on gun violence; in the past year this has included studies on differences in gun use during terrorist attacks in the United States compared with other countries, the effect of exposure to gun violence in the media on children’s interest in real guns, the relationship between firearm laws and firearm homicides and suicides, and the association of “stand your ground” laws with homicide and suicide. Research on gun violence is important, although Congress over the last 2 decades has placed limits on that science from being conducted. This attempt to suppress research into gun violence resulted in a 64% decline in the number of firearm studies per million citations in SCOPUS between 1998 and 2012.

Physicians and other health care professionals can do more. The US Court of Appeals for the 11th Circuit has ruled that attempts to prevent physicians from asking and counseling patients about guns violate the First Amendment. As with any epidemic, prevention is important. Physicians and others should ask about guns in the home, especially for high-risk patients, and advise about removal and safe storage. Good evidence has shown that safe storage of firearms is effective in reducing misuse. Physicians can conduct appropriate screening and early intervention for suicide, the most common cause of gun deaths.

We, as editors of the journals in the JAMA Network, are committed to providing policy makers, as well as the medical community and the US public, with accurate, timely information to guide interventions that will reduce injuries and deaths from guns. Numerous polls have shown that the majority of citizens want action that will make a difference. Other countries have acted: when a mass shooting happened in Australia 2 decades ago, the federal government responded with legislation within 2 weeks of the event banning semiautomatic rifles. Since 1996, there has not been a mass shooting on that continent.

Guns kill people. More background checks; more hotel, school, and venue security; more restrictions on the number and types of guns that individuals can own; and development of “smart guns” may help decrease firearm violence. But the key to reducing firearm deaths in the United States is to understand and reduce exposure to the cause, just like in any epidemic, and in this case that is guns.

https://jamanetwork.com…

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Comment:

By Don McCanne, M.D.

Suppose we identified a public health hazard that caused 36 deaths. There would certainly be considerable interest in the nature of the problem and what could be done about it. Suppose that were 360 deaths instead. That would be national news that would be followed up with Congressional hearings. Suppose it were 3,600 deaths. Whoa. Yet, in 2015, there were 36,252 deaths from firearms in the U.S.

So where is Congress on this? The latest gun tragedy in Las Vegas included the use of bump stocks – devices that allow semi-automatic weapons to fire in rapid succession just like machine guns. So bipartisan legislation was introduced to ban these devices. Speaker Paul Ryan responded by saying that this was a matter for the regulators, so no legislation will be introduced on the House floor. The National Rifle Association – NRA – still owns Congress.

Unfortunately, the well meaning editorial by the 12 JAMA Network editors is all too typical of the responses to these tragedies. Gun violence is tragic, and we should do something about it. Pause. (Time to get back to work.)

Since 1968, more U.S. residents have died from gun violence than have have died in battle during all the wars the country has fought since its inception.

It’s time to get serious about gun violence. Let’s sit down at the negotiating tables with an opening position that all guns throughout the nation be collected and melted down – no compromises – though we would listen to counter proposals.

What does this have to do with single payer? Eliminating gun violence would reduce our national health expenditures in a beneficial way – one of the prime goals of an improved Medicare for all.

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

Only ‘Medicare for All’ can fix our broken health-care system

By Greg Silver, M.D.
Orlando Sentinel, October 12, 2017

The patient looked terrified when she showed me her broken arm that wouldn’t straighten out. “What am I supposed to do?” she asked.

She was a waitress, about 25 years old, working to support her family. She had broken her right arm near the elbow several weeks prior and was seen in a local emergency room. Since she had no insurance, she couldn’t afford the follow-up visits. So the arm healed crooked, and it was now difficult and painful for her to hold a tray.

She was scared of losing her job. I wished I could tell her everything would be OK, but that wasn’t true. What should have been a straightforward treatment process was cut short due to cost, and now she would need surgery to fix it. Without insurance, she couldn’t possibly afford surgery, but she also couldn’t afford to lose her job. I didn’t have an answer.

I’ve been a primary-care physician for 30 years, and these conversations have become heartbreakingly routine. Consider the 45-year-old hairdresser with severe hip arthritis, in constant pain, barely able to stand and work. He badly needs a hip replacement but, without insurance, what is he supposed to do? Or the 63-year-old paralyzed on his left side from a stroke, but who can’t afford to see his doctor or buy his medicine. He knows that he is at high risk for another stroke, or worse. Feeling hopeless he told me, “I hope the next one just kills me.”

Sadly, these stories are uniquely American. Only in America do we force millions of fellow citizens to beg for charity care, suffer the economic cost of huge medical bills or file bankruptcy. Not surprisingly, we live shorter lives with worse health outcomes — life expectancy and infant mortality, for example — than most other industrialized nations. According to the Annals of Internal Medicine, 18,000 Americans die each year from a lack of insurance.

It doesn’t have to be like this.

In the richest nation on Earth, we already spend more than twice as much as other nations that actually provide universal health care. Even with the Affordable Care Act, we leave 28 million people without any coverage. Those with workplace insurance plans face skyrocketing costs: The average family of four pays $11,685 in premiums and out-of-pocket costs per year, and from 2005 to 2015, average deductibles rose 229 percent. Sixty percent of those filing medical bankruptcy actually had insurance coverage when they got sick.

The root cause of our system failure is the private insurance industry and its wasteful bureaucratic complexity, fragmentation and profit motive. We desperately need a streamlined single-payer program that would provide universal coverage for all Americans, such as Rep. John Conyers’ House Resolution 676 and Sen. Bernie Sanders’ Senate Bill 1804. This type of “Medicare for all” system works like today’s Medicare, when all medical bills are paid for by a single government fund, and patients can visit the hospital or doctor of their choice for all medically necessary care.

Can the U.S. afford this? We currently spend more than $3 trillion per year on health care; nearly two-thirds of that is already paid for by your tax dollars. By cutting out the private insurance middlemen and negotiating drug prices, we could easily save $500 billion per year, enough to expand coverage to everyone.

As noted Princeton Professor Uwe Reinhardt once said, “The issue of universal coverage is not a matter of economics. Little more than 1 percent of gross domestic product assigned to health could cover all. It is a matter of soul.”

Medicare for All is efficient, it has been proved, and it’s simply the right thing to do. One day I hope that when a patient looks me in the eye and asks, “What am I supposed to do?” I’ll have a real answer for them.

Dr. Greg Silver practices urgent care in Pinellas and Pasco counties. He is a Florida-based member of Physicians for a National Health Program.

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