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A Medicare lesson for Dick Armey

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A Medicare lesson for Dick Armey

Civil Action No. 08-1715 (RMC)

United States District Court for the District of Columbia

BRIAN HALL, et al. (including Richard Armey), Plaintiffs,
v.
KATHLEEN SEBELIUS, Secretary, Department of Health and Human Services, et al., Defendants.

Plaintiffs are retired Federal employees who have reached age 65 and have applied for, and are receiving, Social Security Retirement benefits. As a result, they are “entitled” to Medicare Part A, coverage. They do not, however, want Medicare coverage. And the only avenue provided to Plaintiffs to un-entitle themselves is to cease receiving Social Security Retirement benefits – and to repay all such benefits already received. Plaintiffs declaim that such a requirement is contrary to the Social Security Act, of which Medicare is a part. The Court concludes that Plaintiffs’ claims are without merit.

FACTS

Plaintiffs Brian Hall, John Kraus, and Richard Armey share the following characteristics:

• They are retired from Federal employment and have attained the age of 65.
• They applied for, and are receiving, Social Security Retirement benefits.
• They are entitled to benefits under Medicare Part A.
• They had previously been enrolled in health plans under the Federal Employees Health Benefit (FEHB) program and wish to continue that coverage in full.
• They do not want to be covered by Medicare Part A and want to disenroll from Medicare Part A.
• They want to continue receiving their monthly Social Security Retirement benefits.

These facts are all undisputed and, for purposes of resolving this dispute, are the only facts that pertain.

ANALYSIS (excerpts)

Every individual who –

(1) has attained age 65, and
(2)(A) is entitled to monthly insurance benefits under section [42 U.S.C. § 402] of this title . . .

shall be entitled to hospital insurance benefits under part A of title XVIII [of this chapter] for each month for which he meets the condition specified in paragraph (2) . . . .

42 U.S.C. § 426(a). What this means is that an individual who has applied for Social Security Retirement benefits and qualifies to receive such benefits, so that he is “entitled” to Social Security Retirement benefits, automatically becomes “entitled” to Medicare Part A upon his 65th birthday. The only way to avoid entitlement to Medicare Part A at age 65 is to forego the source of that entitlement, i.e. Social Security Retirement benefits. There are but two ways to forego Social Security Retirement benefits: (1) fail to apply even though qualified, see 42 U.S.C. § 402(a) (requiring the filing of an application); or (2) withdraw one’s application and repay all retirement benefits already received, see 20 C.F.R. § 404.640.

Social Security regulations provide a means of avoiding entitlement to monthly Social Security Retirement benefits and thereby also provide a means of avoiding entitlement to Medicare Part A benefits. An individual may withdraw an application for Social Security Retirement benefits after it has been filed by submitting a written request and either repaying “[a]ll benefits already paid” or upon the SSA being “satisfied that they will be repaid.” See 20 C.F.R. § 404.640.3 These regulations are of no assistance to Plaintiffs, however, since they want to avoid Medicare Part A and retain their Social Security Retirement benefits.

There is a “dis-enrollment” possibility, albeit very unattractive, that allows a 65 year-old beneficiary to make himself un-entitled for Medicare Part A by foregoing one of the essential requirements to become entitled to Medicare Part A – receipt of Social Security Retirement benefits.

That Medicare entitlement has very specific consequences for a retired Federal employee: If a Federal retiree who has attained age 65 is “not covered” by Medicare Part A, perhaps because he withdrew his application for Social Security Retirement benefits, his FEHB “plan, other than a prepayment plan described in” 5 U.S.C. § 8903(4), “may not provide benefits . . . to pay a charge imposed by any health care provider, for inpatient hospital services which are covered for purposes of benefit payments” by Medicare Part A, “to the extent that such charge exceeds applicable limitations on hospital charges established for Medicare purposes.” 5 U.S.C. § 8904(b)(1)(A). Thus, even if Plaintiffs were to forego and repay all Social Security Retirement benefits, their FEHB-paid benefits would be no more, and no less, than what Medicare Part A would provide.

Plaintiffs argue that “entitled” to Social Security Retirement benefits does not mean “required to accept” so that “entitled” to Medicare Part A benefits does not mean “required to accept.” While the Plaintiffs’ plain-English reading of the word “entitled” has its attractions, in context the Medicare “entitled” does not actually mean “capable of being rejected.” An individual is “entitled” to Social Security Retirement benefits only after he has worked the requisite quarters, attained age 62 (or more), and filed an application. See 42 U.S.C. § 402. There being no affirmative filing of an application necessary for a Medicare Part A entitlement, it is a different type of entitlement because of its automatic nature. The Medicare Part A entitlement is tied exclusively to the fulfilment of two requirements: (1) receiving Social Security Retirement benefits; and (2) being age 65 – the removal of either having the effect of disestablishing that entitlement.

CONCLUSION

Plaintiffs are trapped in a government program intended for their benefit. They disagree and wish to escape. The Court can find no loophole or requirement that the Secretary provide such a pathway. Defendants’ Motion for Summary Judgment [Dkt. # 42], which was previously denied without prejudice, is reconsidered and will be granted and Plaintiffs’ Motion for Summary Judgment [Dkt. # 51] will be denied. A memorializing Order accompanies this Memorandum Opinion.

Date: March 16, 2011

ROSEMARY M. COLLYER
United States District Judge

https://ecf.dcd.uscourts.gov/cgi-bin/show_public_doc?2008cv1715-54

Comment: 

By Don McCanne, MD

Although this looks like another cute trick that Dick Armey tried to pull off, it is much more serious than that. This is a another blatant effort to try to destroy Medicare as a social insurance program to which all people over 65 who are receiving Social Security benefits are entitled.

This was not a broad anti-government stance. Medicare was targeted specifically. In this civil action, the plaintiffs wanted to specify that they had the right to reject Part A of Medicare, but they weren’t rejecting government programs in general because, in the same civil action, they wanted to keep their Social Security benefits, and they wanted to keep their government-sponsored federal employee retirement health benefits program (as their primary coverage and not secondary to Medicare).

When Medicare was enacted, a decision was mode to be certain that absolutely everyone over 65 on Social Security would be enrolled in Part A – the hospital component. Enrollment would be totally automatic, so much so that an individual could refuse enrollment only by refusing Social Security benefits and refunding to the government any payments already made.

What Dick Armey was trying to do was to establish the principle that individuals could decline Medicare completely and choose a private option (though in this case his private option was a government-sponsored private plan). Thi
s would be another step beyond merely selecting a private Medicare Advantage plan, still subject to Medicare regulations. This would totally divorce private plans from Medicare. The intent of the conservatives all along has been to move Medicare patients into private plans and then destroy Medicare by drastically underfunding it (and “drowning it in a bathtub”).

One of the most fundamental principles of the single payer model is that absolutely everyone is automatically enrolled. Opting out is not an option for anyone. People would still have the freedom to not use the health care system, but they couldn’t opt out of enrollment any more than pacifists like me can opt out of paying for our wars.

The conservatives and libertarians oppose single payer, and they fear that Medicare will be improved and then provided to everyone, as a single payer system. They will not stop in their efforts to shred Medicare into tatters, and walk away with their affluent friends to obtain their boutique health care on their own, leaving the rest of us to fend for ourselves – as if “personal responsibility” could buy a ticket to health care.

Let’s fool them. Let’s fix Medicare and then enroll absolutely everyone – automatically!

Neurology single payer campaign

Dear Colleague and Member of Physicians for a National Health Program,

As neurologist members of the AAN, we were disheartened by the AAN’s recent survey of its membership on legislative issues, which focused on a narrow range of practice-related issues. As supporters of single payer health care, we would like to invite you to join us in signing the letter below to Dr Griggs, the President of the AAN, asking him to undertake a survey of AAN members on their opinions on health care system reform. We suspect that there may be significant support for single payer among neurologists; if this is confirmed, this could be a powerful motivator for the AAN to take a pro-single payer position.

Sincerely,

Dr. Rachel Nardin
Chief, Division of Neurology, Cambridge Health Alliance
Assistant Professor of Neurology, Harvard Medical School

Dr. Laura Boylan
Clinical Associate Professor
Department of Neurology, New York University School of Medicine

Dr. Deborah B. Leiderman
Fellow, AAN
Consulting Neurologist and President, CNS Drug Consulting LLC

Dear Dr Griggs,

We write as concerned neurologists to suggest that the AAN survey its members about their advocacy interests beyond narrowly conceived neurology practice issues. As national health reform efforts continue, we hope that the AAN will advocate for reforms supported by a majority of its members. To do so first requires understanding the views of the membership on health system reform.

In a study published in the Annals of Internal Medicine in 2008, Drs. Caroll and Ackerman surveyed a randomly selected group of 5,000 physicians from the AMA masterfile, asking the following questions: 1) In principle, do you support or oppose government legislation to establish national health insurance? and 2) Do you support achieving universal coverage through more incremental reform?

Overall 59% of doctors in all medical specialties endorsed national health insurance, up from 49% in 2002. This suggests that neurologists’ views might be similar, although neurologists were not specifically surveyed in this study.

We strongly believe that the AAN should carry out a similar survey of its members so as to be able faithfully to represent its members’ voice in the national health reform debate. We ask you to carry out such a survey.

Sincerely,

Why the Vermont student rally for single payer is important to me

I’m a fourth-year student preparing to start residency in Family Medicine. I chose medicine, and primary care in particular, to provide access to health care to the underserved. From all I have read and learned so far, it has become abundantly clear that a single-payer health care plan is the best way to address the horrifying inequities in health care in our country. Being in Massachusetts, I’ve seen firsthand how alternative solutions have fallen short. I’m so inspired by the hope that Vermont can lead the way in showing the country what single payer can do. It gives me hope for the future of health care reform.

— Anjana Sharma
Harvard Medical School 2011

As a University of Vermont College of Medicine student it is incredibly exciting to have students and practitioners come from around the country to support the health reform process that is currently happening in Montpelier. Many of us plan to practice in Vermont after our training is complete, and it is our great hope that every future patient will have the ability to afford quality health coverage for themselves and their families through a single payer system, while still allowing Vermont providers the means to care for their patients in a financially sustainable fashion. We appreciate all of the nationwide support that this rally is highlighting, and we look forward to the time spent together on March 26th!

— Larry Bodden
University of Vermont College of Medicine 2014

I’m a second-year medical student at Albany Medical College in New York and co-president of our PNHP chapter here. Last week I was reminded of why I am a single payer activist. I saw a 62-year-old patient at our downtown screening clinic that had stopped taking his hypertension medication three years ago. His blood pressure was so high we considered sending him to the emergency room. He was a cook in town, but couldn’t afford his medication. He was also a smoker, and his landlord had recently turned off his heat. Needless to say, winter in Albany gets quit frigid. We gave the gentleman a number to a full service free clinic in town, as well as information on free legal aid to pursue his negligent landlord. But I couldn’t help but feeling defeated. This patient needed more. Here was a person whose life would have directly benefited from regular and reliable medical attention and care — his blood pressure would be within a safe range, he would be receiving regular reminders by a physician about the importance of tobacco cessation, he would be connected with resources to improve his dangerous housing condition. It’s not easy to be a student activist, but it’s experiences like these that motivate me. I’m motivated to work for single payer because I know it will improve the lives of my patients and will enhance the effectiveness of, and therefore the pride I have for, our profession.

— Danielle Alexander
Albany (N.Y.) Medical College 2013

Health care should be a right and not based upon the ability to pay. Single payer will allow health care providers to care for all patients who require assistance for healing, regardless of health insurance plan or amount of coverage. Aspiring doctors should be able to practice medicine in an environment that encourages patient-physician relationships and focuses on well-being, rather than on reimbursement rates and profit.

— Kathleen Mahan
University of Minnesota Medical School 2013

I’m a fourth-year medical student at the Yale School of Medicine, and I entered the field of medicine so that I could help care for anyone who asked. I see that the cost of health insurance is crippling individuals, families, and businesses across the nation. Governor Shumlin of Vermont understands that single payer is the best solution for his state. I’ve been helping to organize the March 26 rally in Montpelier help make single payer a reality. Let’s hope that Vermont can lead the way for all 50 states!

— Carl Berdahl
Yale School of Medicine 2012

As a nurse practitioner working with Boston Health Care for the Homeless Program, I see firsthand the gaps that patient after patient fall through in our current medical system. My patients experience the greatest of life’s hardships every day. The least we can do is give them an equal chance at being healthy to have the strength to pull themselves up again. We need health care reform that is actually comprehensive and completely universal.

— Desiree Otenti
Boston University School of Public Health 2012

As a future physician, I want to participate in a rally that stands for the kind of health care system that I hope to be a practicing part of. As a student at the University of Vermont College of Medicine, I am honored that the state of Vermont is being used as an example of a health care system worth striving for in other states and, hopefully, around the nation. I believe that health care is a fundamental human right and I hope that the rally will spread awareness that physicians in training are hopeful for a system where the patient and physician are focused on one goal, rather than divided between barriers created by insurance companies. It is my hope that setting the example of a single-payer system in Vermont can demonstrate to the nation that comprehensive, quality and affordable care is possible and worth striving for. It is also my hope that policy makers can see that physicians should be involved in decisions about health care and health care policy and should be able to be more involved — since, after all, they are the ones committed to working for the system.

— Mariah H. Stump
University of Vermont College of Medicine 2012

“Miller, this place is killing me!”” That’s Murphy’s Law at P.S. 163, a struggling Bronx, New York, elementary school. Ms. Murphy, another faculty member at the school where I taught in 2006 and 2007, started saying that after we had been teaching there for eight months. Unfortunately, some places really can kill you, or at least contribute to an early death: I know that because I hope to devote my career as a physician to promoting the safety of public institutions like P.S. 163 through environmental epidemiology advocacy and research. There’s no reason why harmful environmental conditions should exist, no place in the America we like to think we know. We need to establish a fair and just American health care system. Vermonters: we’ve we’ve got you covered.

— Maureen Miller
New York University School of Medicine 2013

I feel that the knowledge and experiences that I will gain at the Vermont student rally will translate to a stronger and more robust coordination in Oregon’s fight for single-payer health care. This is the great social movement of my generation, and I want to be there on the front lines to help bring it to fruition in Vermont. I have talked with my wife and she has encouraged me to go. “This is your movement,” she says. I’m going.

— Richard Bruno
Oregon Health and Science University 2013

I am really excited to go to Vermont to show that my generation of doctors is not willing to let the American health care system fail our patients. Currently, the way we provide health care recapitulates and exacerbates the inequalities of our society. It was working at a free clinic at a homeless shelter that made me want to go to medical school. I saw how a doctor-patient interaction had the power to either support or undermine a patient’s sense of self-worth, and unfortunately how often the latter happens. When we continue to construct a health care system based on charity care or a two-tiered model, we send a message that not all Americans are equally deserving of medical care. And this will remain true no matter h
ow much I care for each individual patient unless we have systems-level reform. I’m going the rally in Vermont so that someday soon I won’t have to work in a medical system that keeps patients and our society sick.

— Kirsten Austad
Harvard Medical School 2013

I entered the field of medicine in order to serve those less empowered by circumstance and society, who often experience significant challenges to living healthfully and managing disease. Through my training in medicine and public health thus far, I have seen firsthand how much the current lack of a unified and equitable health care system is a stumbling block in doing the work I care about. This is why action to improve health care, through measures such as implementing a single-payer financing system, is important to me. I strongly believe that our best hope for true systematic health reform in the U.S. lies with individual states that can implement a single-payer financing mechanism along with other reforms to improve health care and control costs. If these leaders are successful, then other states, the broader public, and Washington will find the lure of a well-functioning health care system irresistible. My hope is that some day, everyone in this country will have access to health care and the resources necessary to maximize their health. Lead the way, Vermont!

— Jonathan Takahashi
Harvard Medical School 2012

It doesn’t take long in the hospital to see that the way we arrange health care and health care spending is irrational — it’s not good for patients and it’s not good for health care providers. As a third-year medical student in the Cambridge Integrated Clerkship at Cambridge Health Alliance, I’ve had the chance to see the health system from the patient’s perspective as I follow patients longitudinally through the year. Experiences with these patients have deepened my commitment to single payer. As I help with organizing this rally, I think about a patient I saw in my primary care clinic who came in with uncontrolled diabetes. This man has private insurance through the grocery store where he has worked for a decade — only his plan is full of holes. He reached his spending limit two weeks into his month and was left to pay out-of-pocket for his medications and diabetes supplies — items he simply couldn’t fit into his budget if he wanted to pay for his kid’s clothes or put food on the table. I asked him if he has been checking his sugars and he said, of course not, the strips are too costly. This is just one of many patients’ lives I’ve seen affected by our current system of insurance. These stories make me proud to be part of a movement to right health injustices and to humanize and reorganize our system in a way that makes it possible to get patients the care they need. We need to make single-payer health care a reality.

— Simeon Kimmel
MD/PhD in Anthropology, Harvard Medical School 2016

Lowering mortality by adding more diagnoses (a game)

Geographic Variation in Diagnosis Frequency and Risk of Death Among Medicare Beneficiaries

By H. Gilbert Welch, MD, MPH, Sandra M. Sharp, SM, Dan J. Gottlieb, MS, Jonathan S. Skinner, PhD, John E. Wennberg, MD, MPH
JAMA
March 16, 2011

Context: Because diagnosis is typically thought of as purely a patient attribute, it is considered a critical factor in risk-adjustment policies designed to reward efficient and high-quality care.

Objective: To determine the association between frequency of diagnoses for chronic conditions in geographic areas and case-fatality rate among Medicare beneficiaries.

Design, Setting, and Participants:  Cross-sectional analysis of the mean number of 9 serious chronic conditions (cancer, chronic obstructive pulmonary disease, coronary artery disease, congestive heart failure, peripheral artery disease, severe liver disease, diabetes with end-organ disease, chronic renal failure, and dementia) diagnosed in 306 hospital referral regions (HRRs) in the United States; HRRs were divided into quintiles of diagnosis frequency. Participants were 5 153 877 fee-for-service Medicare beneficiaries in 2007.

Main Outcome Measures:  Age/sex/race–adjusted case-fatality rates.

Results: Diagnosis frequency ranged across HRRs from 0.58 chronic conditions in Grand Junction, Colorado, to 1.23 in Miami, Florida (mean, 0.90 [95% confidence interval {CI}, 0.89-0.91]; median, 0.87 [interquartile range, 0.80-0.96]). The number of conditions diagnosed was related to risk of death: among patients diagnosed with 0, 1, 2, and 3 conditions the case-fatality rate was 16, 45, 93, and 154 per 1000, respectively. As regional diagnosis frequency increased, however, the case fatality associated with a chronic condition became progressively less. Among patients diagnosed with 1 condition, the case-fatality rate decreased in a stepwise fashion across quintiles of diagnosis frequency, from 51 per 1000 in the lowest quintile to 38 per 1000 in the highest quintile (relative rate, 0.74 [95% CI, 0.72-0.76]). For patients diagnosed with 3 conditions, the corresponding case-fatality rates were 168 and 137 per 1000 (relative rate, 0.81 [95% CI, 0.79-0.84]).

Conclusion: Among fee-for-service Medicare beneficiaries, there is an inverse relationship between the regional frequency of diagnoses and the case-fatality rate for chronic conditions.

http://jama.ama-assn.org/content/305/11/1113.abstract

Comment: 

By Don McCanne, MD

This study from the Dartmouth Institute confirms the intuitive observation that the number of diagnoses of serious chronic conditions in Medicare beneficiaries has a positive correlation with case-fatality rates. The greater number of serious problems a person has, the greater the risk of death. But observation of the regional distribution of these serious diagnoses provides troubling results.

In this study, hospital referral regions varied in the average number of diagnoses per patient of these serious chronic conditions. There is an inverse relationship between the regional frequency of diagnoses and the case-fatality rate. As an example, if you had multiple serious diagnoses, your chances of dying are less if your diagnoses were made in a region where more people have a greater number of diagnoses than if the same diagnoses were made in a region where not as many people received multiple diagnoses.

The authors discuss possible explanations, but I’ll go out on a limb, and a very solid one at that, and give my opinion.  Assigning a greater number of serious diagnoses to a patient permits greater remuneration from upcoding, and it provides rewards for favorable quality and outcomes results since the patient is not as ill as the list of diagnoses would otherwise imply.

It is very difficult to differentiate a list of well documented diagnoses from an embellished list that may include some poorly substantiated notations in the record allegedly supporting the diagnoses. It would be very difficult to ferret out the claims that do not warrant additional consideration based on complexity or quality outcomes.

Reform was supposed to bring us higher quality at a lower cost, but it appears that continued gaming of the system will bring us higher costs with spurious results on quality and outcome assessments.

Much more work needs to be done before we could rely on these observations to improve quality and reduce costs. In the meantime, we could certainly tackle the issue of costs head on by the well proven method of enacting a single payer national health program. Quality and efficiency will be a continual work in progress.

Vermonters urge lawmakers to pass single-payer health care

By Anne Galloway
VtDigger.com, March 15, 2011

What happened to Sabra Ewing, could have happened, as she put it, to anyone. She had a high deductible ($20,000) health insurance plan for her family. For years, doctors had told Ewing she was healthy, and she stopped going in for annual checkups to avoid the expense. Then one day she found a dark spot on the side of her heel. It took her three weeks to get an appointment with a dermatologist. By the time Ewing was diagnosed, she had stage three melanoma.

Ewing, of Vershire, said if she had kept up with regular checkups it’s likely the spot would have been detected early and her cancer would have been more readily curable. As it stands now, she said she is receiving treatment from top experts.

“I may not survive,” Ewing said. “I’m not thinking about cost containment. I’m thinking about my 19-month-old grandchild.

Cost containment has become one of Heather Lochlin’s main preoccupations – but not by choice. Lochlin, of Ludlow, who is insured by BlueCross BlueShield of Vermont through Catamount Health, says she has been denied coverage “every step of the way.” Though she has been fully insured throughout her illness, she said there has been “repeated systemic pressure” to limit her care through loopholes in the guidelines and vague information about coverage.

“Denials shouldn’t be based on cost-cutting,” Lochlin said. “The idea that any of us has insurance is a mirage.”

Lochlin and Ewing were two of the more than 70 Vermonters who spoke at a public hearing about H.202, the health care reform bill that would fundamentally alter the existing system, which is now based on a commercial insurance system and fee-for-service reimbursements to doctors and hospitals. Under H.202, the state would be the first in the nation to attempt a conversion to a single payer health care system in which state government would manage the provider payment system and essentially cut commercial insurers out of the loop. All Vermonters, regardless of pre-existing conditions or ability to pay would be covered under the plan.

Advocates for H.202 outnumbered opponents 4-to-1 in the virtual hearing via Vermont Interactive Television at 15 locations around the state. About 70 Vermonters spoke; many more watched the proceedings.

Lawmakers from the Senate and House health care committees attended most of the regional meetings. The hearing was held as a precursor to sure movement on H.202; the bill is slated to be voted out of committee this week.

In two-minute blocks of time, participants shared war stories about run-ins with the insurance industry, opined about the inefficiencies and “inhumanity” of the existing system or expressed reservations about the financial cost of a single payer health care plan.

Battle lines were drawn from the beginning: Advocates and citizens involved with the Vermont Workers’ Center’s Health Care is a Human Right campaign packed the Montpelier VIT site, wearing red T-shirts and the by-now familiar campaign buttons, which feature Rosie the Riveter. About 14 people in the anti-single payer camp spoke up.

The single-payer proponents sounded familiar themes: They called for equitable, universal coverage and an end to medical industry profits at the expense of human health.

A young woman named Rebecca from Johnson told the audience that her brother was in a bicycle accident last year in Winooski and injured both legs, knees and arms. He couldn’t move his legs at first, she said, but he refused to go to the hospital because he didn’t have health insurance. A year later, his pain hasn’t dissipated.

“Insurance companies must get out of the way,” Rebecca said. “People don’t need the middle man. If my brother had health insurance, he wouldn’t be feeling pain he’s feeling today. Make health care affordable to everyone so we can all get the health care we need.”

Many of the speakers talked about the rising cost of health care — even for people who have insurance. Several participants said they had gone without coverage at one point or another.

Detractors questioned the quality of a health care system that would be based on a uniform payment system. Several doctors expressed concern about the impact of low Medicaid reimbursements – should the administration of Peter Shumlin succeed in folding the Catamount Health Plan into the Vermont Health Access Plan.

Patricia Leahy Meriam said specialty doctors are afraid they will lose income if they stay in Vermont and they’re looking at “exit strategies.” She warned that special treatment of diseases will be harder to access in the new system because it will place too much emphasis on primary care physicians – at the expense of specialty docs.

Dianna Scholl, a hospital chaplain at Porter Medical Center in Middlebury, said health care workers are put in an immoral and unethical position because of the inequities of the system.

“The problem is the current system doesn’t cover everyone equally at a price we can afford,” Scholl said. “I have seen people with Cadillac insurance get the care they need. The private pay folks and (people with) limited insurance are not able to get care they need. It’s a very basic inequity that is hard to deal with.”

Scholl said she has seen insurance companies override physician’s treatment recommendations. “It was all about the money, it had nothing to do (with whether) we had the right equipment or drugs. It was just about the money. How can we provide compassionate care when we are sending people away or because people don’t have the deductibe or copays.”

http://vtdigger.org/2011/03/15/vermonters-urge-lawmakers-to-pass-single-payer-health-care/

Vermont forum leans toward single-payer health care

By NEAL P. GOSWAMI
Bennington Banner, March 14, 2011

BENNINGTON, Vt. — Dozens of Vermonters offered thoughts on health care reform in Vermont to members of the House and Senate Health Care Committees during a statewide interactive hearing Monday.

The meeting, held at 15 Vermont Interactive Television sites across the state, was largely dominated by supporters of a single-payer health care system that would provide coverage to all Vermonters. Many wore the customary red shirts of the Health Care is a Human Rights Campaign. Many people visible on the television screens held signs that read “Single-Payer NOW.”

In Bennington, Dr. Richard Dundas, a Bennington doctor who founded a free health care clinic, said the current system is broken and asked for a single-payer system.

“I wanted to implore the committee … to change our system because our current one is failing. I’ve been in practice for 30 years. It’s getting worse instead of better. We need universal health care,” Dundas said.

Dundas said a single-payer health care system would help lower costs for medical providers by, in part, eliminating private insurance companies.

“My concept of a single payer is that it has to seriously decrease the overhead that providers and hospitals … have to pay for overhead. This would include burdensome documentation that doctors are required to submit in order to get paid. It also includes severing our ties with the insurance industry,” he said.

Jane Norrie, who also testified in Bennington, said the current system requires tremendous paperwork and overhead. “I heartily agree with Dr. Dundas that we could save a huge amount of money just by not having to make reams of copies,” Norrie said.

Lawmakers are currently considering H.202, a plan submitted by the administration of Democratic Gov. Peter Shumlin. The legislation seeks to lay the groundwork for single-payer health care in Vermont.

It calls for a five-member board to help implement a system in which the state is the only health provider of health care coverage by 2014. Shumlin’s plan does not yet specify a funding mechanism, however. Nor does it provide information about benefits. That is expected to be included in a later phase, according to Shumlin. A payroll tax has been mentioned as a potential primary funding source, however.

Dr. William Hsiao, a Harvard professor and health care expert hired as a consultant by the state, delivered a report to state lawmakers earlier this year detailing where the state would see savings if it implements a single-payer plan. His report is expected to serve as the blueprint for a hybrid single-payer system run by the state but administered by a private insurance company.

With Democrats holding large majorities in both the House and Senate the plan is likely to move forward, despite GOP opposition. Not everyone was in favor of a single-payer system. “In Canada many have died because of their rationing,” said one man in Montpelier.

Others asked for more details on costs and what kind of benefits the plan would provide.

A woman testifying in Burlington decried “left-wing pressure groups” that she said were pushing a single-payer health care system. “These are groups that are loud, they’re outside funding groups using Vermont as a petrie dish,” she said. “Not only is government health care not wanted, there’s no money for it.”

But many of those that testified Monday said they are seeking the universal coverage a single-payer system would provide. Many shared stories of their own struggles with the current system.

A young woman in Brattleboro said her mother was recently laid off, causing a loss of health care covered. As a volunteer receiving a living stipend, the woman said she has only a supplemental plan, which does not cover necessary appointments for a medical condition. “Each appointment would cost me over $600, money I don’t have,” she said. The possibility of a life in pain scares me.”

Another woman in Springfield said she isn’t receiving the care her doctor wants to deliver because of interference from the insurance company. “Currently my care is being influenced by my insurance company. My doctor and I should make those decisions,” the woman said through tears.

The House Health Care Committee is scheduled to focus on H.202 this week and expected to advance it.

http://www.benningtonbanner.com/ci_17614241

Vermont: A Model for Health Care Reform?

By Carl Berdahl
Atrium Magazine, Friday, February 11th, 2011

In the wake of ineffective national health reform, Vermont is poised to try again: Legislators are considering guaranteeing—rather than mandating—health insurance for all Vermonters through a single-payer system.

Lack of health insurance is this era’s major social issue. There are 50 million uninsured Americans by the latest count, and about 45,000 people die each year as a result. Americans love to say that we have the best health care system in the world, but this is statement is false by almost any account. The United States trails other developed countries in most indicators of health: infant mortality, maternal mortality, and life expectancy, for example. We spend more money than any other country on health care, and we really cannot claim to be better off.
 
During his inaugural address, Governor Shumlin of Vermont proposed guaranteeing health insurance to all Vermonters. Current health care costs, he says, “[represent] an enormous hidden tax on families and small businesses across our state. If left untethered, the rising cost of health insurance will cripple us.” Shumlin’s wants to create a single-payer system for Vermont, in which private delivery of healthcare would continue but the government would act as everyone’s health insurer. Such a system, which was systematically barred from the national health reform debate by special interest groups, can be thought of as “Expanded and Improved Medicare-for-all”. By choosing a single-payer system, Vermonters would (1) cleanse themselves of administrative waste that private insurance companies create and (2) unlink health insurance coverage from employment, thereby significantly easing stress that the recession has caused. The people of Vermont would save money, and bureaucracy in the medical system would shrink dramatically.
 
Some people fear that a single-payer system would mean “rationing” of health care resources. The reality is that our current system rations care by ability to pay—and paying is increasingly difficult even for the middle class. A single-payer system, on the other hand, would guarantee Vermonters access to all medically-necessary care.

National health reform under the so-called Affordable Care Act makes half-hearted attempts to control health care costs. It does chip away at the number of uninsured Americans, but it does so by mandating that individuals purchase insurance from a flawed industry, thereby crippling Americans with high copayments and deductibles.

Why waste time bracing a system that is failing?

The nation needs full-fledged health care reform, and Vermont can lead the way. A single-payer universal health care system would save Vermont money and give its people security that the Affordable Care Act simply does not offer. The amount of bureaucracy built into the system would decrease, allowing patients and health professionals to focus one thing—health.
 
But perhaps most importantly, it is time to take care of our friends, family, and neighbors who are uninsured. It is time to put an end to death by uninsurance. It is time to pass guaranteed single-payer universal healthcare. America deserves it, and Vermont will start it.

For more information about single-payer, visit www.pnhp.org. Health professional students and other interested parties will be holding a rally for single-payer in Montpelier, VT on March 26, 2010. Please sign the petition at http://tinyurl.com/studentsforvermont to join the mailing list for this event.

Carl Berdahl, columnist of “Reform”, taking a year off from clinical studies to compare resource utilization and clinical decision-making in American and Canadian emergency departments. He is also working with Physicians for a National Health Program to revitalize the Connecticut chapter through the development of local events and the creation of a statewide speakers’ bureau. Carl has provided care at free clinics in Connecticut, California, and Peru. He welcomes your thoughts and questions via email.

http://www.atrium-magazine.com/2011/02/vermont-a-model-for-health-care-reform/

Vt. Gov. Shumlin Pushes For Single-Payer Health Care

By Anthony Brooks
WBUR Boston Radio, March 10, 2011

As many states, and Republicans in Congress, are looking for ways to roll back President Obama’s signature health care law, Vermont is moving in a different direction.

Most lawmakers there have concerns about the federal overhaul — but not because they oppose reform. Their concern is that the law doesn’t go far enough, and that the cost of health care is crippling the country’s economy.

“It’s killing business, it’s killing job creation and it’s killing working families,” Vt. Gov. Peter Shumlin told Radio Boston’s Anthony Brooks Thursday.

Vermont is moving full-steam ahead with a plan to become the first state in the nation to adopt a European-style single-payer health care plan. Shumlin, a Democrat, campaigned on the issue.

“We want to do three things,” Shumlin said. “The first is to treat health care as a right and not a privilege. The second is to create the first system in the country where health insurance follows the individual and is not a requirement of the employer, which we think is a huge jobs creator. And the third is to contain costs by moving to a system that spends money more wisely.”

Many see the single-payer system as a cost-saving solution, but Shumlin himself admits savings are not something achieved easily.

“No one in health care reform has figured out how to contain costs and our goal in Vermont is to contain costs,” Shumlin said.

Shumlin’s plan is dependent upon changing how health care is paid for.

“We want to be the first state that actually moves from a fee-for-service system to a payment based upon health care outcomes,” Shumlin said. “In other words: reward our providers for keeping people healthy, not the current system where we reward them for the number of procedures that they might do.”

A majority of state lawmakers supports Shumlin’s plan, and this week a key health care committee will vote on a bill that will start moving the state toward single-payer health care. Still, the overhaul of Vermont’s health care system faces hurdles. The state will need a change in Obama’s federal bill to allow Vermont to begin its single-payer push in 2014.

For more, including audio link:
http://radioboston.wbur.org/2011/03/10/vermont-single-payer-2

'Deficit gurus' launch assault on women's health

By Dr. Claudia Chaufan
Santa Cruz (Calif.) Sentinel, March 13, 2011

March is Women’s History Month. But this year, for the vast majority of women in America, there is little to celebrate.

Over the past months, “deficit gurus” in the U.S. House of Representatives have unleashed the most devastating assault on women’s health in our nation’s history. If legislation already passed in the House is approved by the Senate and signed into law by President Obama, women’s rights and health will be set back by decades.

Many critical programs are on the chopping block, such as the Public Health Service Act or Title X, providing basic health services, including Pap smears, family planning services, and cancer screenings to more than 5 million low-income people, mainly women.

Slashing Title X will lead to thousands of unnecessary deaths. Maternal and Child Health Block Grants, chiefly benefitting poor women and children, will be cut by $210 million. The Centers for Disease Control and Prevention will be reduced by some $755 million, undermining many public health efforts such as confronting HIV/AIDS. Community health centers providing essential services to millions of women and families across the country will face a brutal $1.3 billion cut.

This onslaught against women joins that against U.S. working people. Look, for example, at the assault on Medicaid, or the drive to cut wages, benefits and collective bargaining rights. Wisconsin is only the most flagrant example of a nationwide phenomenon.

Or consider the chorus that, both from the right and from sectors of the “liberal” left, is calling for “saving” Social Security by reducing benefits, increasing eligibility age or privatizing the program. Yet Social Security is financially sound for at least another 27 years. Whatever problems it may have could be easily fixed by simply raising the cap on the taxable income of the very wealthy. And Medicare and other publicly financed health care programs, favorite targets of the budget cutters, pose a problem only because the U.S. health care system, pre- and post- the federal health law, is built upon a rotten foundation: for-profit health insurance.

Despite subtle differences, both sides of the political aisle convey the same message: “We” must pay for “our excesses” that caused “the deficit” by giving up on our “generous benefits.”

Notably, Wall Street excesses figure nowhere in these arguments, even if its benefits are clear. As President Obama noted candidly in his State of the Union address, “the stock market has come roaring back and corporate profits are up.”

Meanwhile, our “benefits” don’t even include guaranteed access to basic health care, as is the norm in every other wealthy nation. The new federal law has “reformed” the system essentially by mandating us to purchase for-profit insurance increasingly under-insurance under penalty of a fine, and expanding coverage, not necessarily care, through an underfunded Medicaid program. Finally, it leaves at least 23 million people uninsured annually a decade from now.

If this scenario is allowed to stand, women will suffer disproportionately. But in the spirit of International Women’s Day, women’s groups and others are fighting back, and championing the most just and cost-effective solution to our health care woes — single-payer national health insurance, an improved Medicare for All.

As we commemorate those 15,000 brave women who back in 1908 marched through New York City demanding shorter hours, better pay and voting rights, American women and working Americans generally must demand no less.

Claudia Chaufan, M.D., is an assistant professor at the Institute for Health and Aging at UC San Francisco. She is also vice president of Physicians for a National Health Program — California http://pnhpcalifornia.org/.

http://www.santacruzsentinel.com/ci_17604643

Employer-sponsored health plans under the Affordable Care Act

Health Policy Brief: Employers and Health Care Reform

Health Affairs/Robert Wood Johnson Foundation
March 9, 2011

To expand access and strengthen the employment-based health system, the Affordable Care Act of 2010 will require midsize and large companies to make payments to the federal government if they do not offer health insurance to their employees and dependents starting in 2014.

What’s in the law?

Under the Affordable Care Act, beginning in 2014 employers with at least 50 full-time employees (or equivalent full- and part-time workers) will have to provide “qualified” health insurance coverage to their full-time employees and their dependents. Qualified coverage means that plans are comprehensive (pay at least 60 percent of health care expenses) and affordable (cost less than 9.5 percent of employees’ household incomes).

If employers don’t offer qualified coverage, and if their employees purchase coverage instead through a new state insurance exchange with the assistance of federal subsidies, companies will have to make an “assessable payment” of up to $2,000 for every full-time employee beyond the first 30 employees. The amount of the assessment will be adjusted annually to reflect the growth in national insurance premium costs.

If employers do offer coverage, but the coverage does not meet certain parameters, they may still have to pay assessments. First, employers will be assessed if a plan is judged not to be comprehensive. This means the coverage must have an “actuarial value” of at least 60 percent. In other words, the employer pays on average at least 60 percent of health care expenses and the employee pays on average 40 percent of these expenses through deductibles and copayments.

Second, employers will be assessed if the employees’ premiums are considered unaffordable relative to their household incomes. Specifically, the employee’s share of the premium must not exceed 9.5 percent of his or her annual household income.

Starting in 2014, if either of these two conditions is not met, the employer must pay a $3,000 annual assessment for each employee who declines his or her employment-based insurance and obtains government-subsidized coverage through an exchange.

Small businesses with fewer than 50 full-time employees (or equivalent full- and part-time workers) don’t have to meet the requirement and are exempt from having to offer health insurance.

Many companies face payments:

A study by the Mercer consulting firm found that 38 percent of US employers may face paying assessments starting in 2014, because their coverage might not be considered affordable for at least some of their employees.

“Free-choice vouchers”:

Employees who earn less than four times the federal poverty level (in 2011, $43,560 for an individual and $89,400 for a family of four) and whose share of the premium is between 8 percent and 9.5 percent of his or her household income, can choose to enroll in an exchange instead of the employer plan. The employer must issue the employee a “free-choice voucher” equal to the amount the employer would have paid under the employer’s plan.

Tax on high-value health plans:

Beginning in 2018, “Cadillac” or high-value health plans will be subject to a 40 percent excise tax on premium amounts exceeding $10,200 for single coverage and $27,500 for families.

What’s the likely impact?

The Congressional Budget Office (CBO) and the Joint Committee on Taxation estimated that provisions of the Affordable Care Act, including the employer requirement, will result in 3 million fewer people having employer-provided coverage in 2019. This would be the net result of a series of big changes.

First, the CBO estimates that 6–7 million people would acquire employer coverage for the first time because the requirement would increase workers’ demand for coverage through their jobs. Second, another 1–2 million who currently have employment-based coverage would instead move to the exchanges because the coverage would be more affordable. Third, about 8–9 million others covered under an employer plan under current law would lose employer coverage because firms would choose to no longer offer coverage. These firms are likely to be smaller companies employing lower-wage workers who would be eligible for exchange subsidies.

In addition, according to the CBO, employers will pay about $52 billion in additional assessments between 2014 and 2019. Under the law, that money will be put toward the new subsidies for millions of workers and their families to defray the cost of purchasing health coverage through the exchanges.

“Pay and walk away”:

Among companies of all sizes currently offering benefits, 76 percent reported they would continue to do so in January 2014. Of the rest, 15 percent reported they would offer coverage to at least some full-time employees, and 9 percent said they would stop offering coverage altogether. Among firms with 200 or more full- and part-time equivalent employees, 7 percent planned to drop coverage. “For some large firms, in particular, there is a desire to pay and walk away,” said Susan McIntyre, senior vice president of Market Strategies International’s health care division, in a statement.

Tempted to drop coverage:

The math could make the idea to drop coverage tempting. In 2010, the average annual premium cost for employer-based coverage was $5,049 for a single person and $13,770 for a family, although employers generally do not pay the entire cost. Many employers might consider paying $2,000 or $3,000 in assessments to be more cost-effective. On the other hand, many large employers say they view offering health coverage to be an important part of their overall compensation strategy, and necessary to attract the best workers.

It is possible that employers will watch closely to see how their peer companies respond. In a July 2010 survey by Fidelity Investments, 65 percent of large employers said they were not seriously considering eliminating health care benefits because of the new law. But when asked what they would do if others dropped coverage, 36 percent said they too would consider eliminating coverage. Another 36 percent said they would not drop coverage and the remaining employers were unsure.

http://www.healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_42.pdf

Comment: 

By Don McCanne, MD

What will happen to employer-sponsored coverage under the Affordable Care Act? Perhaps one of the most alarming provisions of the Act is that plans with a 60 percent actuarial value (patients pay an average of 40 percent of their health care bills) qualify to fulfill the employers’ obligations to provide coverage or pay an assessment. Thus the Act is establishing under-insurance as the new standard.

Premiums on more generous plans are approaching a level that will trigger a a 40 percent excise tax. One way to avoid that tax would be to reduce the actuarial value of the plans to the minimum requirement. With employers’ aversion to taxes, many will surely consider that.

With these low actuarial value plans, employees will surely complain about the high out-of-pocket costs they will face when they need health care. Since employers won’t want to make their employees unhappy, they will be motivated to drop their plans altogether and pay t
he much lower assessments required by the Act. We already know that most employers may not want to lead on this, but a great many will certainly follow once a few do it, and they have said so.

It is frequently stated that employers will want to continue to offer plans in order to attract more qualified employees, but this argument seems rather disingenuous. Employers now have an out.

When employers drop their health plans, there is no assessment on the first 30 employees, and then only $2000 for each beyond the 30. Employers can use some of the savings for pay raises, and then the employees, most of whom will be eligible for government subsidies, can select their own plans in the exchanges. Why would employers use health plans as an enticement – plans that are otherwise readily available in the exchanges – when they can use higher wages to compete in the labor markets?

Our experience shows that plans with low actuarial values – usually high-deductible plans – still frequently have premiums that are unaffordable for many. Combining unaffordable premiums with low actuarial values, it won’t be long before middle-income Americans realize that the private insurers have foisted off on us a highly defective product: UNAFFORDABLE UNDER-INSURANCE. You go broke if you buy it, and you go broke if you need to use it!

Single payer, anyone?

Single-Payer Supporters Stand Strong in Salem

A rally and emotional hearing for House Bill 3510 put spotlight on single-payer system

By Rebecca Robinson
The Lund Report (Portland, Ore.), March 11, 2011

SALEM, Ore. — Supporters of single-payer healthcare legislation had their day in Salem Friday, with a well-attended hearing on the Capitol steps and an emotional hearing for the single-payer bill, House Bill 3510, before the House Health Care Committee.

“This is not all about the bill,” Rep. Mike Dembrow (D-Portland), the sponsor of House Bill 3510, told supporters at Friday’s noontime rally. “Single-payer is a movement.”
 
Dembrow and other supporters of a single-payer system point to existing programs such as Medicare, Medicaid and the Veterans Administration, as current examples of single-payer healthcare in America: government-run systems with no copays, deductibles or cost-sharing that allow patients to choose their healthcare provider.
 
Dembrow’s sentiment was echoed by all in attendance, including his fellow Representative, Jules Bailey (D-Portland), and Dr. Paul Gorman, a physician at Oregon Health and Science University.
 
“All of us are one illness away from bankruptcy in the current system,” said Gorman, who likened the U.S. insurance industry to Big Tobacco.
 
“They [the insurance industry] are selling us a product that’s harmful to all of us, for a profit,” Gorman said.
 
Legislators heard more about House Bill 3510, also known as the Affordable Health Care for All Oregon Act, from both supporters and opponents at a hearing Friday afternoon. Dembrow and Gorman reiterated their endorsement of the bill, and many more came forward to testify in support of a single-payer system.
 
“Payment with a single-payer system will be simpler for everyone to understand, and much less expensive to negotiate,” said Dr. Doug Bigelow, a professor emeritus of psychiatry at OHSU. He spoke of his eight years practicing in British Columbia, Canada, in a single-payer system with universal coverage, no deductibles and free choice of doctors for patients.
 
“I can say that this system works very well, it’s comparatively inexpensive, and very popular,” said Bigelow. “What stymies us here is the deep structural transformation” required to change the current system – work, he argued, that is both necessary and would lead to long-term savings.
 
An independent insurance agent Paco Maribona, said that even though a single-payer system could cost him and other agents their jobs, he still supported the bill, because “the advantage of all Oregonians getting coverage is worth it.”
 
“I asked my [Portland Community College] students if they didn’t have insurance, and two-thirds of them raised their hands,” said Terri Mills, a longtime nurse educator. “It’s so ironic; they don’t have access to the care they themselves will someday be providing.” She called for “evidence-based policy” that would stem the “growing crisis that continues to erode our living standards.”
 
Opponents of the bill pulled no punches.
 
“We shouldn’t rely on top-down solutions” like House Bill 3510, said Steve Buckstein of the Cascade Policy Institute, “but instead bottom-up liberations.” To reduce costs and improve access, Buckstein argued, use the profit motive.
 
“Walmart started offering $4 generic prescription drugs, and Fred [Meyer] matched those prices,” said Buckstein. “Prices dropped quickly, and [the companies] did it for profit.”
 
Eric Fruits, an economist for the state, likened the single-payer system to an “All-you-can-eat health care buffet” with no cost controls.
 
“It’s impossible to simultaneously provide universal insurance coverage, control costs, and maintain provider participation,” Fruits asserted.
 
Individual consumers also expressed their concerns about government-mandated healthcare.
 
“I’m standing today on my fundamental, constitutional right to choose,” said Kate Jaudes of Salem. “I don’t want the government to force me to go to an MD or punish me if I don’t.”
 
No matter the outcome, both sides will continue to work on either side of the issue to, in Rep. Bailey’s words, “get this done.”

http://www.thelundreport.org/resource/single_payer_supporters_stand_strong_in_salem