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Getting less care for more money

The price problem that health-care reform failed to cure

By Alec MacGillis
The Washington Post
October 24, 2010

The health-care law of 2010… sets us on the road to universal health insurance.

But the Democrats’ effort to sell the law to the public may be undermined by what even some ardent supporters consider its biggest shortfall. The overhaul left virtually untouched one big element of our health-care dilemma: the price problem. Simply put, Americans pay much more for each bit of care — tests, procedures, hospital stays, drugs, devices — than people in other rich nations.

Health-care providers in the United States have tremendous power to set prices. There is no government “single payer” on the other side of the table, and consolidation by hospitals and doctors has left insurers and employers in weak negotiating positions.

“We spend fewer per capita days in the hospital compared with other advanced countries, we see the doctor less frequently, and we swallow fewer pills,” said Jon Kingsdale, who oversaw the implementation of Massachusetts’s 2006 health-care law. “We just pay a lot more for each of those units than other countries.”

The 2010 law does little to address this. Its many cost-control provisions are geared toward reducing the amount of care we consume, not the price we pay. The law encourages doctors and hospitals to join “accountable care organizations” that have financial incentives to limit unnecessary care; it beefs up “comparative effectiveness research” to weed out inefficient treatments; and it will eventually tax the most expensive insurance plans to restrain consumers’ superfluous use of health care.

Such measures could reduce redundant tests, emergency room visits and hospital readmissions, which would help control the costs of Medicare, where the government sets rates. But they are less likely to lower prices outside Medicare and stem the growth of private insurance rates.

The main reason for this is politics. Remember how drawn-out the health-care battle was? It started in the spring of 2009 and was waged for a full year. The bill’s proponents in the White House and in Congress had some inkling of how tough the fight with the insurance companies would be. Taking on hospitals, doctors, and drug and device manufacturers as well — the people you’d face in a showdown over prices — might have been fatal.

So there was no price fight. It is one of those fine political ironies: The law derided as socialism may have had an easier time winning favor from a skeptical public if it was, well, a little more socialist.

Politicians wanted to avoid a confrontation over providers’ prices. So a different policy argument took hold: The real reason everything cost so much was the overuse of health care, not the actual prices of treatment.

This argument came primarily from Dartmouth College researchers who had amassed data showing wide disparities in Medicare spending among different regions. Hospitals in the lower-spending areas, mostly in the Upper Midwest and the Northwest, seized on the study to argue that the key to controlling costs was to reward providers like them.

The theory caught fire at the White House. It gave President Obama and his then-budget guru Peter Orszag a way to talk about costs without taking on doctors and hospitals; instead, the White House could simply differentiate between providers that offer “value” and those that don’t.

But the Dartmouth rankings, and the concept they supported, did a “disservice” to the debate, said Robert Berenson of the Urban Institute. For one thing, he and others say, the figures overstate regional differences in Medicare spending, which shrink when socioeconomic factors are taken into account. Second, rates of Medicare spending are not necessarily representative of health-care spending for people under 65. Some of the places that do well in the Dartmouth rankings charge high prices for non-Medicare patients — and were, not surprisingly, among those pushing hardest against a public option.

More broadly, the skeptics argue that merely providing care in smaller quantities will not sufficiently lower costs. They note that Americans already have shorter hospital stays and fewer doctors’ visits than people in other advanced countries. What sets us apart is our high prices for these health-care “units” — a finding trumpeted in a landmark 2003 paper by Princeton’s Uwe Reinhardt and others titled “It’s the Prices, Stupid.” The price problem is only getting worse, researchers and antitrust investigators have found, because of consolidation among providers, and it could be exacerbated by goading them to form even bigger networks.

http://www.washingtonpost.com/wp-dyn/content/article/2010/10/22/AR2010102203394.html

Comment:

By Don McCanne, MD

Many have commented on the fact that the Patient Protection and Affordable Care Act (PPACA) did little to address one of the most important drivers of the reform process – our unique problem of the outrageous costs of health care. We spend far more per capita on health care than any other nation. This article by Alec MacGillis is singled out as recommended reading on this topic, as he is one of the most credible and well-informed journalists who closely observed the reform process.

The important lesson that MacGillis provides us here is that we do not use more health care than other nations, we simply pay much more for it.

Yet reform was based on the principle that we need to cut back on health care excesses that don’t even exist except to a limited extent in some of those regions identified by the Dartmouth researchers as areas of higher utilization. When you consider that we use less care per capita than other nations, it’s clear that efforts to ferret out this marginal waste will have very little impact on our total national health expenditures, though eliminating any waste is certainly beneficial.

The real problem is the amount that we pay for health care, yet very little in PPACA will ameliorate that problem. What could provide relief?

Alec MacGillis provides a strong hint: “Health-care providers in the United States have tremendous power to set prices. There is no government ‘single payer’ on the other side of the table.”

As Margaret Flowers and others have been shouting out all along: “We want a seat at the table!”

The Bredesen-Gruber dispute represents much more than a math problem

ObamaCare's Incentive to Drop Insurance

By Philip Bredesen
The Wall Street Journal
October 21, 2010

Our federal deficit is already at unsustainable levels, and most Americans understand that we can ill afford another entitlement program that adds substantially to it. But our recent health reform has created a situation where there are strong economic incentives for employers to drop health coverage altogether. The consequence will be to drive many more people than projected — and with them, much greater cost — into the reform’s federally subsidized system. This will happen because the subsidies that become available to people purchasing insurance through exchanges are extraordinarily attractive.

The authors of health reform primarily targeted the uninsured and those now buying expensive individual policies. But there’s a very large third group that can also enter and that may have been grossly underestimated: the 170 million Americans who currently have employer-sponsored group insurance. Because of the magnitude of the new subsidies created by Congress, the economics become compelling for many employers to simply drop coverage and help their employees obtain replacement coverage through an exchange.

(Bredesen provides calculations that allegedly demonstrate that the Tennessee government could adjust the compensation of their employees so that they would not lose by purchasing their plans in the exchange, and the cost to the state would be significantly less – a savings to the state of $146 million.)

Our thought experiment shows how the economics of dropping existing coverage is about to become very attractive to many employers, both public and private. By 2014, there will be a mini-industry of consultants knocking on employers’ doors to explain the new opportunity. And in the years after 2014, the economics just keep getting better.

(Mr. Bredesen, a Democrat, is the governor of Tennessee.)

http://online.wsj.com/article/SB10001424052702304510704575562643804015252.html

And…

A Health Reform Critic Flunks Math

By Jonathan Gruber
The New Republic
October 21, 2010

Tennessee Governor Phil Bredesen takes to the Wall Street Journal editorial page on Thursday to attack health care reform.

The gist of Bredesen’s argument is pretty simple: Some firms will find it more attractive to stop offering insurance and let employees get coverage through the new insurance exchanges, where generous subsidies will be available. But the Affordable Care Act, which I’ve long supported, imposes strong penalties on firms that do not offer insurance, as well as sizeable tax credits for smaller firms that encourage them to offer. And in most firms, the majority of employees will make too much money to be eligible for large subsidies anyway. It is for this reason that the Congressional Budget Office estimated that PPACA will reduce employer sponsored insurance in the U.S. by only about 2.5 percent by 2019. In other words, the effect on employer sponsored coverage will likely be small.

First of all, Tennessee state employees generally make too much money to get big subsidies through the exchanges. Forty percent have incomes higher than 400 percent of the poverty lines, which means they’d be eligible for no tax credits at all; even for those with incomes below that level, the average tax credit would offset just a third of their premium cost. Second, if these individuals lost their public employee insurance and went into the exchanges, they would want to receive the same very generous benefits they get now – coverage comparable to the platinum plans offered in the exchange. Working from CBO’s estimate of the cost of less generous plans in the exchange in 2016, those plans would cost about $6650 for an individual and $17,400 for a family in 2014.

Using the Governor’s estimates of 40,000 state employees, and accounting for the low subsidization and high cost of the very generous benefits they would need to get in the exchange, I estimate that it would cost state employees about $425 million out of their own pockets to replicate in the exchange what they get today from the state.

(Gruber provides calculations that allegedly refute Bredesen’s contention that the state could save money by shifting employees to the exchange – rather the cost to the state would increase by about $230 million.)

Bredesen ignores one other important point: Employer-sponsored insurance in the U.S. is already eroding, on its own. The share of individuals with employer-sponsored coverage has declined by almost 15 percent over the past decade. These individuals have to turn to a broken and dysfunctional non-group market, resulting in higher premiums, growing rates of uninsurance, and increased medical bankruptcy. These are exactly the individuals who will be assisted by the market reforms and tax credits put in place by Affordable Care Act.

(Jonathan Gruber is a professor of economics at MIT and member of the Massachusetts Health Connector Authority Board. He has served as a paid technical consultant to the Department of Health and Human Services and continues to advise policymakers about health care reform.)

http://www.tnr.com/blog/jonathan-cohn/78583/health-reform-critic-flunks-math

And…

Employers looking at health insurance options

By Ricardo Alonso-Zaldivar
The Washington Post
October 24, 2010

The new health care law wasn’t supposed to undercut employer plans that have provided most people in the U.S. with coverage for generations.

“I don’t think you are going to hear anybody publicly say ‘We’ve made a decision to drop insurance,’ ” said Paul Keckley, executive director of the Deloitte Center for Health Solutions. “What we are hearing in our meetings is, ‘We don’t want to be the first one to drop benefits, but we would be the fast second.’ We are hearing that a lot.” Deloitte is a major accounting and consulting firm.

Two provisions in the new law are leading companies to look at their plans in a different light.

One is a hefty tax on high-cost health insurance aimed at the most generous coverage. Although the “Cadillac tax” doesn’t hit until 2018, companies may have to disclose their exposure to investors well before that. Karen Forte, a Boeing spokeswoman, said concerns about the tax were partly behind a 50 percent increase in insurance deductibles the company just announced.

Bigger questions loom over the new insurance markets that will be set up under the law.

They’re called exchanges, and every state will have one in a few years. Consumers will be able to shop for coverage among a range of plans in the exchange. To help make premiums affordable, the law provides tax credits for households making up to four times the federal poverty level, about $88,000 for a family of four.

(Tennessee Gov. Philip) Bredesen said last week that employers could save big money by dropping their health plans and sending workers to buy coverage in the exchange. They’d face a fine of $2,000 per worker, but that’s still way less than the cost of providing health insurance. Employers could even afford to give workers a raise and still come out ahead, Bredesen wrote in a Wall Street Journal opinion piece.

Employers are actively looking at that. “I don’t know if the intent was to find an exit strategy for providing benefits, but the bill as written provides the mechanism,” said Deloitte’s Keckley, the consultant.

Another wrinkle: the health insurance tax credits available through the law are keyed to relatively Spartan insurance plans, not as generous as most big employers provi
de. Send your workers into the insurance exchange, and valuable employees might jump to a competitor that still offers health care.

MIT economist Jon Gruber says it’s impossible to create new government benefits without some unintended consequences, but he doesn’t see a big drop in employer coverage.

http://www.washingtonpost.com/wp-dyn/content/article/2010/10/24/AR2010102400495.html

Comment:

By Don McCanne, MD

The disputed math of the incentives for employers to either continue offering their employees health plans or to drop the plans in favor of employees purchasing their own plans in the exchanges is an important question because it determines whether employers will continue to contribute to the premiums or if the taxpayers will assume that burden through subsidies for the exchange plans. What is not so obvious is that, in the background, there are two much more important policy considerations.

What will happen if employees continue to receive employer-sponsored coverage? Or what will happen if employees end up receiving their plans through the state exchanges?

We already know what is happening with employer-sponsored coverage. Jonathan Gruber points out that this coverage has already declined by 15 percent in the past decade. Industry surveys indicate that employers want out. As Paul Keckley of Deloitte says, many employers want to be a “fast second” to drop their coverage after one major employer leads the way.

In the meantime, employers are shifting more of the costs for care to their employees in order to slow the rate of increase in the employers’ component of the premium paid. As Karen Forte of Boeing said, they also increased their deductibles partly to postpone the imposition of the hefty “Cadillac tax” on plans based on the premium paid. With health care costs continuing to escalate, this tax soon will be assessed on average plans, providing further motivation for employers to dump their programs.

What coverage can we anticipate in the exchanges? Gruber says that employees will want the platinum plans in the exchanges that are comparable to the more traditional employer-sponsored plans, but is that what they would get? Because the extra cost of the platinum plans would be paid in full by the employee, it is much more likely that they would select the relatively Spartan bronze and silver insurance plans for which the subsidies are targeted. These are UNDER-insurance plans with inadequate subsidies which inevitably will cause financial hardship for those actually in need of health care.

Though the question of whether financing will be through employer-provided benefits or through taxpayer subsidies for the exchanges is an important question, it dodges the real issue: Will the workforce continue to forgo wage increases to receive plans from their employers – plans with diminishing actuarial value (under-insurance), or will employers finally jettison their plans, turning their employees over to exchanges to purchase low actuarial value bronze or silver plans (since only the wealthy will be able to afford the gold or platinum plans).

Whether we should use employer-provided benefit funds or taxpayer funds is an easy question. It is far more equitable and efficient to use the tax system to finance health care. For employers, it would be much better for them to pay their equitable share in taxes than to continue struggling with the management and expenses of their health benefit programs.

Whether we should adopt policies that favor employer-sponsored plans versus exchange plans isn’t a question that we should be asking at all. In either instance we would perpetuate the wasteful, inefficient, and grossly inadequate financing system with which we are now burdened. Mandating under-insurance for everyone, except the wealthy, is a terribly flawed policy.

What we need instead is first-dollar coverage of all necessary health care for everyone – a single payer national health program – an improved Medicare for all. Now that we can all afford.

Dr. Margaret Flowers to visit Madison, Wisc. November 17-20

There are many opportunities to see or talk to Dr. Flowers this week – please see the list below!

Wednesday, November 17
Grand Rounds ~ 7:30 – 8:30 AM
St. Mary’s Hospital Primary Care Conference
700 South Park St., Madison

Wednesday, November 17
Live Call-In Radio Interview, 5:00 – 6:00 PM
Wisconsin Public Radio, The Ben Merens Show

Wednesday, November 17
Public Presentation ~ 7:00 – 8:30 PM
”US Healthcare Reform: Where We Go from Here”
The Labor Temple
1602 South Park St., Madison

Thursday, November 18
Grand Rounds ~ 7:30 to 8:30 AM
UW Department of Pediatrics
Health Sciences Learning Center,
Room 1345
750 Highland Ave., Madison

Friday, November 19
Grand Rounds ~ 7:00 – 8:00 AM
Meriter Hospital
202 South Park St., Madison

Friday, November 19
Luncheon with Staff, Faculty and Students
12:00 Noon – 1:30 PM
UW School of Medicine and Public Health
Health Sciences Learning Center, Room 1345
750 Highland Ave., Madison
— RSVP to wisconsinpnhp@gmail.com

Friday, November 19
PNHP Wisconsin “Gala” Fundraiser
With special guests Wisconsin Senator Mark Miller and Representative Chuck Benedict
6:00 – 9:00 PM
EVP Coffee House
3809 Mineral Point Road, Madison

Questions? Contact us at email address: wisconsinpnhp@gmail.com

Healthcare reform model polls poorly with Massachusetts doctors

By Julian Pecquet
The Hill, Oct. 22, 2010

Doctors in Massachusetts think the state’s healthcare overhaul — the model for Democrats’ national reform law — was a poor choice, according to a new poll.

The Massachusetts Medical Society surveyed 1,000 practicing doctors in its annual Physician Workforce Survey and found only 14 percent recommended Massachusetts’s 2006 overhaul as a model for the nation. The Massachusetts reform effort, signed into law by then-Gov. Mitt Romney, created a “Health Connector” and required people to buy subsidized, government-regulated insurance — much like the federal law enacted in March.

A plurality of respondents — 34 percent — preferred a single-payer system, while 32 percent favored a public-private mix with a public option. And 17 percent opted for the status quo before reform, when low-premium, high-deductible health plans were allowed.

Single-payer advocates immediately embraced the results.

“Massachusetts physicians realize that the state’s health reform has failed to make health care affordable and accessible, and won’t work for the nation,” said Rachel Nardin, chair of neurology at Cambridge Hospital and president of the Massachusetts chapter of Physicians for a National Health Program. “These findings show the high support for single-payer Medicare for all by physicians on the front lines of reform.”

http://thehill.com/blogs/healthwatch/health-reform-implementation/125451-massachusetts-doctors-dis-health-reform-model

Possibilities for Medicare For All?

By Saul Friedman
Time Goes By blog, Oct. 23, 2010

Who would have guessed that one of the most right-wing Republicans in the Senate would predict that the American people, sooner rather than later, will see the passage of single-payer, universal health care such as Medicare for All?

I hasten to add that this prediction from Senator Tom Coburn of Oklahoma, would not be to his liking; indeed he’d probably fight to his last breath to prevent such a proposal from becoming law.

Coburn, a physician, is known as “Dr. No” because of all the nominations and legislation he has obstructed with his lone objection, the latest being the emergency aid to the earthquake victims in Haiti. He’s also the M.D. who suggested we pray that the late Senator Robert Byrd (D, WV), would be too ill to cast a crucial vote on health reform, which Coburn opposed. (Byrd voted and the health reforms passed.)

Now that the Affordable Care Act is law, Coburn predicted in a speech earlier this month to the Republican Women’s Club of Tulsa, “There will be no insurance industry left in three years. That is by design. You’re going to make insurance unaffordable for everyone — which is what they want. Because if there’s no private insurance left, what’s left? Government-centered, government-run. Single-payer health care.”

The reforms, he said, will mean “the beginning of the end of America” unless they are killed by repeal, or the courts.

He didn’t explain who is the “they” who want insurance to be unaffordable. The Obama administration has criticized companies that have sharply raised premiums and asked them to desist. And the law’s requirement that individuals must buy insurance (the so-called individual mandate), subsidized by the government, is expected to add millions of new customers to the insurers’ rolls.

As far as I know, no one in the Obama White House is plotting to extend the health reforms into Medicare for All, which is too bad. But Coburn may be right without knowing why; the greed and stupidity of the insurance and drug industries could kill the reforms and bring on true universal health care if they continue their rapacious conduct.

That’s a strong possibility, according to a more rational and traditional conservative, Professor Paul J. Feldstein, of the University of California and an expert in Health Care Management in the school of business who has written text books on health economics. He was interviewed for the journal, Nursing Economics, by Peter I. Buerhaus, on the faculty of Vanderbilt University.

As Buerhaus wrote, he conducted the interview (may need free registration) because, while the health reforms “did not include language to transition toward a single-payer system, this does not preclude that over time, and depending on how the legislation is implemented, a single-payer system might eventually be adopted as many people and advocacy groups desire.”

The description “single-payer” can be confusing, and Feldstein defined it: “When a government is the only payer of health services. It does not mean that the government owns the health provider, like the U.S. owns VA hospitals. An example is Canada, where the government is the only payer for all the basic medical services provided to its citizens.”

Feldstein is not necessarily a fan of such systems; he’s a believer in the market, but he favors some regulation and restraints. When he was asked if the health reforms could lead to the adoption of a single-payer system, Feldstein said:

“I can see a scenario where there is very little cost containment and little pressure to keep insurance premiums from rising substantially. And if there is a weak mandate for individuals to purchase health insurance, then the resulting adverse selection [enrolling too many sick people] is likely to cause insurers to increase their premiums. People will become dissatisfied…and may become more supportive of a government funded public insurance option…

“Eventually, if many individuals purchase public insurance we could end up with a single-payer system or something close to one. We already pay the health care for tens of millions of people with the Medicaid and Medicare programs, and you can just pretty much put a public insurance option together with these programs into one system.”

He acknowledged that a single-payer system would cover more Americans, spend less money per patient and save on the vast administrative costs now spent on the fragmented private health insurance establishment. But Feldstein said a single-payer system would include budget restraints that could retard advances in technology and lead to rationing, inefficiencies and a reduction in preventive care because of the greater demands for acute and urgent care.

Dr. Don McCanne, of Physicians for a National Health Program (PNHP), praised Feldstein for “a more intellectual” and “sincere” discourse on the singe-payer issue. But “it is distorted by exaggerated potential adverse consequences of single-payers,” he said, “by his failure to include certain inescapable benefits.”

Dr. Quentin Young, Barack Obama’s physician in Chicago before he became president [PNHP note: Obama was actually the patient of Dr. Young’s colleague, Dr. David Scheiner, at their clinic], agrees that the new health reforms could lead to a single-payer system, if it is undermined by its critics, challenges in the courts and “destabilizing pressures” from the insurance industry. Indeed, he adds, “the law may unravel sooner than many suspect.”

Young, a founding member of PHNP, warned that if the Affordable Care Act collapses, “Single-payer Medicare for all needs to be ready to fill the gap.”

And in the meantime, he hoped Obama would reject cuts in Medicare that may be suggested by his deficit commission. “Medicare should be strengthened by improving it and extending it to everyone,” he said.

There are two bills calling for Medicare for All, one (HR 676) that has been introduced by Representative John Conyers (D. Mich), the second longest serving member of the House. Information on his bill may be found at the healthcarenow website.

The second bill, introduced by Senator Bernie Sanders, (I, Vt.), is the American Health Act, S. 703, which calls for state based single-payer systems that combine all current programs such as Medicare and Medicaid. You can study this proposal at govtrack.

When Young was Obama’s doctor, Obama favored Medicare For All, as do many Democratic lawmakers who have co-sponsored the Conyers and Sanders bills. Obama now says he would favor Medicare for All, “if we were starting from scratch.”

Well, why not start? Maybe in the second term, if there is one.

Pulitzer Prize-winning journalist Saul Friedman writes the weekly Gray Matters column which appears here each Saturday.

http://www.timegoesby.net/weblog/2010/10/gray-matters-possibilities-for-medicare-for-all.html

Why Republicans Are Always Worried That Their Pet Corporations Might Face Real Free Market Competition

Whenever corporate executives begin talking about how they support "free markets" and "competition," check to see if you still have your wallet.

By Michael Moore
Alternet, October 21, 2010

I have a rule of thumb that’s served me well my whole life: whenever corporate executives begin talking about how they support “free markets” and “competition,” check to see if you still have your wallet.

That’s because no one — not Karl Marx, not Fidel Castro, not your niece who owns the only lemonade stand on the block — hates competition more than corporations. The whole goal of a corporation is to crush all the competition. When corporate executives start pushing for “free market policies,” what they mean is a government that lets them become a monopoly.

Don’t believe me? Well, count how many corporate CEOs (and Republican politicians) stand up and cheer for the Obama administration this week:

The Justice Department sued Blue Cross Blue Shield of Michigan on Monday, asserting that the company, the state’s dominant health insurer, had violated antitrust laws and secured a huge competitive advantage by forcing hospitals to charge higher prices to Blue Cross’s rivals.

The civil case appears to have broad implications because many local insurance markets, like those in Michigan, are highly concentrated, and Blue Cross and Blue Shield plans often have the largest shares of those markets. […]

Blue Cross and Blue Shield, like most insurers, contracts with hospitals, doctors, labs and other providers for services. The lawsuit took direct aim at contract clauses stipulating that no insurance companies could obtain better rates from the providers than Blue Cross. Some of these contract provisions, known as “most favored nation” clauses, require hospitals to charge other insurers a specified percentage more than they charge Blue Cross — in some cases, 30 to 40 percent more, the lawsuit said.

As the New York Times reports, Blue Cross Blue Shield insures 60% of Michiganders — including me and everyone in my office. They have nine times more customers than the state’s next largest insurer.

And they’re just doing what businesses do, even non-profits like Blue Shield: use all their power to eliminate the competition. In fact, if Daniel J. Loepp, Blue Cross’s CEO, didn’t do that, he’d be kicked out and someone who did would replace him. (I’d hate to see that happen — he always seems like a real gentlemen when he writes every year to tell us they’re hiking our premiums 27%.)

So this is the future we face with health care in the U.S., even with Obama’s new bill: endless battles between the federal government and health insurance corporations as the companies use all their ingenuity to give us fewer choices and higher prices…at least until we get President Palin, who’ll stop fighting the biggest insurance companies and start helping them kill their competition. Which she’ll do while giving tons of speeches about the need for competition and free markets.

Is there any solution for Michigan? Yes, and it’s just across the river in Canada: they have single-payer health insurance. Of course, at this point we pretty much do too. The difference is that our single-payer is run by a corporation. Theirs is run by the government — or to put it another way, democratically.

P.S. Blue Cross Blue Shield is fantastic at making secret agreements with hospitals, but not so great at actually getting people health care: the U.S. is now ranked 49th worldwide in life expectancy. Look out, French Polynesia, we’re coming for you next!

Massachusetts doctors snub state’s health reform as model for country, pick single-payer system instead

FOR IMMEDIATE RELEASE
Oct. 22, 2010

Contact:
Rachel Nardin, M.D., chair of neurology, Cambridge Hospital; president, Massachusetts Physicians for a National Health Program

Patricia Downs Berger, M.D., retired internist; co-chair, Mass-Care: The Massachusetts Campaign for Single Payer Health Care

Benjamin Day, executive director, Mass-Care: The Massachusetts Campaign for Single Payer Health Care

BOSTON – For the first time the Massachusetts Medical Society has asked doctors what they think about health reform in its annual “Physician Workforce Survey” of 1,000 practicing physicians in the state, and the results may strike some as surprising.

A plurality of the physician respondents, 34 percent, picked single-payer health reform as their preferred model of reform, followed by 32 percent who favored a private-public insurance mix with a public option buy-in. Seventeen percent voted for the pre-reform status quo, including the permissibility of insurers offering low-premium, high-deductible health plans.

Remarkably, only 14 percent of Massachusetts doctors would recommend their own state’s model as a model for the nation. A small number of respondents, 3 percent, chose an unspecified “other.”

In other words, the doctors with the most on-the-ground experience with the Massachusetts plan, after which the Obama administration’s new health law is patterned, regard it as one of the least desirable alternatives for financing care.

The findings contrast with an earlier survey of Massachusetts physicians’ opinions on health reform funded by the Blue Cross Blue Shield of Massachusetts Foundation and the Robert Wood Johnson Foundation. That survey, published in the New England Journal of Medicine in October 2009, found that three-fourths of doctors in the state support the Massachusetts reform law. However, the survey did not allow respondents to express their preference for alternative models of health reform.

Dr. Rachel Nardin, chair of neurology at Cambridge Hospital and president of the Massachusetts chapter of Physicians for a National Health Program, said: “Massachusetts physicians realize that the state’s health reform has failed to make health care affordable and accessible, and won’t work for the nation. These findings show the high support for single-payer Medicare for all by physicians on the front lines of reform.”

While many in the country look to Massachusetts as a role model for the country, Dr. Patricia Downs Berger, co-chair of Mass-Care, the single-payer advocacy coalition in Massachusetts, and a member of the Massachusetts Medical Society, notes, “Physicians in Massachusetts, particularly after health reform, know from experience that the current health care system is not sustainable and is not addressing the deep inequalities and high costs faced by patients, and they are calling for a more fundamental change.”

A survey published in the Annals of Internal Medicine in April 2008 showed that 59 percent of U.S. physicians support government action to establish national health insurance, an increase of 10 percentage points over similar findings five years before.

Link to the 2010 Physician Workforce Survey (relevant pages: 86-90):
http://www.massmed.org/AM/Template.cfm?Section=Research_Reports_and_Studies2&TEMPLATE=/CM/HTMLDisplay.cfm&ContentID=36167

Link to 2009 Blue Cross Blue Shield survey of Massachusetts physicians:
http://healthpolicyandreform.nejm.org/?p=2133&query=home

http://www.hsph.harvard.edu/news/press-releases/2009-releases/three-fourths-of-mass-physicians-health-reform-law.html

Link to April 2008 survey in the Annals of Internal Medicine:
https://pnhp.org/docsurvey/annals_physician_support.pdf

The National Health Program Reader

Edited by Ida Hellander, M.D. and Matthew Petty

Edition 3.3, Updated on October 21, 2011

Section I: PNHP’s Proposal for Single-Payer National Health Insurance

Physicians’ Proposal for Single-Payer National Health Insurance (JAMA, 2003)
Frequently Asked Questions

Section II: The Evidence-Based Case for Single Payer National Health Insurance

Topic A: Patients need single payer

Talking Point 1: Nearly two-thirds of all bankruptcies are caused by medical bills; three-quarters of those bankrupted had health insurance at the time they got sick or injured.
Himmelstein, D.U., Thorne, D., Warren, E., Woolhandler, S. (2009). “Medical Bankruptcy in the United States, 2007: Results of a National Study.” Am J Med, 122, 741-746.
Himmelstein, D.U., Thorne, D., Warren, E., Woolhandler, S. (2009). “Medical Bankruptcy Q&A.”
Talking Point 2: The uninsured do not receive all the medical care they need: 45,000 die annually. One-third of uninsured adults have a chronic illness and don’t receive needed care.
Wilper, A., et. al. (2009). “Health Insurance and Mortality in U.S. Adults.” Am J Public Health, 99, 2289-2295.
Press Release for Wilper, A., et. al. (2008). “A National Study of Chronic Disease Prevalence and Access to Care in Uninsured U.S. Adults.” Arch Intern Med, 149, 170-176.

Topic B: We can afford single payer

Talking Point 3: Administrative costs consume 31 percent of health spending, most of it unnecessary. The U.S. could save enough on administrative costs (almost $400 billion in 2009) with a single-payer system to cover the uninsured.
Woolhandler, S., Campbell, T., & Himmelstein, D.U. (2003). “Costs of Health Care Administration in the U.S. and Canada.” N Engl J Med, 349, 768-775.
Talking Point 4: Taxes already pay for more than 60 percent of US health spending, and business pays less than 20 percent. Americans pay the highest health care taxes in the world; we pay for national health insurance, but we don’t get it.
Woolhandler, S. & Himmelstein, D.U. (2002). “Paying for National Health Insurance – And Not Getting It.” Health Affairs 21(4), 88-98.
Talking Point 5: The U.S. spends more per capita on health care than other nations.
OECD Health Data 2011 (excerpted charts)

Topic C: Single payer ensures high quality health care

Talking Point 6: Single-payer national health insurance is the best way to ensure high-quality health care.
Schiff, G.D., Bindman, A.B., & Brennan, T.A. (1994). “A Better Quality Alternative: Single-Payer National Health System Reform.” J Am Med Assoc, 272, 803-808.
Talking Point 7: Other countries have high quality care with lower levels of amenable mortality.
Nolte, E. & McKee, M. (2011). “Variations in Amenable Mortality – Trends in 16 High-Income Nations.” Health Policy.
Talking Point 8: Competition among investor-owned, for-profit entities – including hospitals, HMOs, hospice care, and nursing homes – increases costs and degrades quality.
Woolhandler, S. & Himmelstein, D.U. (2007). “Competition in a publicly funded healthcare system.” Brit Med J, 335, 1126-1129.
Himmelstein, D. & Woolhandler, S. (2004). “The high costs of for-profit care.” Can Med Assoc J, 170, 1814-1815.
Devereaux, P.J., et. al. (2004). “Payments for care at private for-profit and private not-for-profit hospitals: a systematic review and meta-analysis.” Can Med Assoc J, 170, 1817-1824.
Devereaux, P.J., et. al. (2002). “A systematic review and meta-analysis of studies comparing mortality rates of private for-profit and private not-for-profit hospitals.” Can Med Assoc J, 166, 1399-1406.
Himmelstein, D.U., Woolhandler, S., Hellander, I., & Wolfe, S.M. (1999). “Quality of Care in Investor-Owned vs. Not-for-Profit HMOs.” J Am Med Assoc, 282, 159-163.
Perry, J.E. & Stone, R.C. (2011). “In the Business of Dying: Questioning the Commercialization of Hospice.” J Law Med Ethics, Summer, 224-234.
Comondore, V.R., et. al. (2009). “Quality of care in for-profit and not-for-profit nursing homes: systematic review and meta-analysis.” Brit Med J, 339.

Topic D: Single payer is good for physicians

Talking Point 9: Single payer removes corporate barriers to physicians’ ability to practice medicine.
Grumbach, K. & Bodenheimer, T. (1990). “Reins or Fences? A Physicians’ View of Cost Containment.” Health Affairs, Winter, 120-126.
Hayes, G.J., Hayes, S.C., & Dystra, T. (1993). “Physicians Who Have Practiced in Both the United States and Canada Compare the Systems.” Am J Public Health, 83, 1544-1548.
Talking Point 10: Medical malpractice systems can be harnessed to ensure better quality in single-payer systems. The cost and quantity of medical malpractice suits are decreasing.
Schiff, G. (2003). “Medical Malpractice. Health Care Quality and Health Care Reform,” Forum Report #4. PNHP NY Metro.
Canadian Health Services Research Foundation. (2006). “Mythbusters: Medical malpractice suits plague Canada.”
Adelman, S.H. & Westerlund, L. (2004). “The Swedish Patient Compensation System: A viable alternative to the U.S. tort system?” Bull Am Coll Surg 89(1), 25-30.
Talking Point 11: It is a myth that doctors practicing under national health insurance are compensated significantly worse than their American colleagues.
How does national health insurance affect physicians’ income?” PNHP document.
Duffin, J. “The Impact of Single-Payer Health Care on Physician Income in Canada, 1850-2005.” Am J Public Health, 101(7), 1198-1208.

Topic E: How other countries do it: international health systems

Talking Point 12: Every other industrialized, capitalist country has some form of non-profit national health care.
Hellander, I. “International Health Systems for Single Payer Advocates.” PNHP Documents.
Reid, T.R. (2008). “PBS Frontline Interview with T.R. Reid, Fall 2008.”
Case Study: Canada
Lasser, K., Himmelstein, D.U., & Woolhandler, S. (2006). “Access to Care, Health Status, and Health Disparities in the United States and Canada: Results of a Cross-National Population-Based Survey.” Am J Public Health, 96, 1300-1307.
Guyatt G.H., et al. (2007). “A systematic review of studies comparing health outcomes in Canada and the United States.” Open Medicine, 1, E27-36.
Katz, S.J., Cardiff, K., Pascall, M., Barer, M.L., & Evans, R.G. (2002). “Phantoms in the Snow: Canadians’ Use of Health Care Services in the United States.” Health Affairs, 21(3), 19-31.
Case Study: Taiwan
Underwood, A. (2009). “Health Care Abroad: Taiwan.” The New York Times Prescriptions Blog, Nov. 3.
Cheng, T.M. (2009). “Lessons from Taiwan’s Universal National Health Insurance: A Conversation With Taiwan’s Health Minister Ching-Chuan Yeh.” Health Affairs, 28(4), 1035-1044.

Topic F: Alternative reform proposals

Talking Point 13: Alternative proposals for “universal coverage” do not work. State health reforms over the past two decades have failed to reduce the number of uninsured.
Himmelstein, D.U. & Woolhandler, S. (2010). “Obama’s Reform: Not Cure for What Ails Us.” Brit Med J, 340, c1778.
Angell, M. (2008). “Health Reform You Shouldn’t Believe In.” The American Prospect, April 21.
Woolhandler, S., Day, B., & Himmelstein, D.U. (2008). “State Health Reform Flatlines.” Int J Health Serv, 38, 585-592.
Himmelstein, D.U., Thorne, D., & Woolhandler, S. (2011). “Medical Bankruptcy in Massachusetts: Has Health Reform Made a Difference?” Am J Med, 124, 224-228.

Topic G: Controlling health care costs

Talking Point 14: Computerized medical records and chronic disease management do not save money.
Himmelstein, D.U., Wright, A., & Woolhandler, S. (2010). “Hospital Computing and the Costs and Quality of Care: A National Study.” Am J Med, 123(1), 40-46.
Geyman, J. (2007). “Disease Management: Panacea, Another False Hope, or Something in Between?” Ann Fam Med, 5, 257-260.
Talking Point 15: Immigrants and emergency department visits by the uninsured are not the cause of high and rising health care costs.
Mohanty, S., et. al. (2005). “Health Care Expenditures of Immigrants in the United States: A Nationally Representative Analysis.” Am J Public Health, 95, 1431-1438.
Tyrance, P.H., Himmelstein, D.U., & Woolhandler, S. (1996). “US Emergency Department Costs: No Emergency.” Am J Public Health, 95, 1527-1531.
Talking Point 16: Co-pays and deductibles are not necessary to control costs and reduce unnecessary care.
Goodell, S. & Swartz, K. (2010). “Cost-sharing: Effects on spending and outcomes.” Robert Wood Johnson Foundation. The Synthesis Project, Policy Brief No. 20.
Talking Point 17: Drug companies spend more on marketing (31 percent) and profits (20 percent) than on R & D (13 percent). Lower drug prices would not jeopardize drug innovation, much of which is, in fact, publicly-funded.
Light, D.W. & Warburton, R.N. (2005). “Extraordinary Claims Require Extraordinary Evidence.” J Health Econ, 24, 1030-1033.
Light, D.W. & Lexchin, J. (2005). “Foreign Free Riders and the High Price of U.S. Medicines.” Brit Med J, 331, 958-60.

Topic H: The public supports single payer, “Medicare for all”

Talking Point 18: A majority of physicians (59 percent), and an even higher proportion of Americans (two-thirds), support national health insurance or “Medicare for all.”
Carroll, A.E. & Ackerman, R.T. (2008). “Support for National Health Insurance among U.S. Physicians: 5 Years Later.” Ann Intern Med, 148, 566.
PNHP. (2007). “PNHP Backgrounder: Recent Public Polls on Single Payer.”
Single payer endorsers (HR 676, unions, etc.)

Section III: Tools for Activists

Finding your niche in activism
Building the movement with public speaking
PNHP PowerPoints
Media tips
Congressional visit “how to” kit
Handouts for talks
Key Features of Single-Payer National Health Insurance
Frequently Asked Questions
The case for an Improved Medicare for All
PNHP Research
Background Fact Sheet
Financing single-payer national health insurance: Myths and facts

Find more resources for activists at www.pnhp.org/action/activism

Health food for thought

By Evan Tuchinsky
Paradise (Calif.) Post, Oct. 19, 2010

Last week I took an assignment from another newspaper to cover the Mad As Hell Doctors’ appearance in Chico. The advocates for a single-payer system were completing a tour of California, and the capacity crowd at Harlan Adams Theater was the biggest they drew. They found a very receptive audience.

The panel – four physicians from the Pacific Northwest, joined by a local doctor and two local nurses – raised some thought-provoking points about healthcare reform. If you’re unhappy about the Patient Protection and Affordable Care Act, you’re in good company, and you have something in common with these crusading physicians who find reasons for displeasure on both sides of the debate.

They’re mad about disinformation like “death panels” and “socialized medicine,” which clouds the discussion. They’re also mad that the single-payer option wasn’t even considered by the White House and Congress, leaving us with a compromise bill with fundamental flaws.

They see single-payer insurance as critical.

“Single payer” tends to get lumped in with “nationalized medicine” even though there is a key distinction: Insurance would come from the public sector, but care would come from the private sector. Despite the oft-heard crises of “keep your government out of my healthcare,” MAHD speakers argue that the majority of healthcare money flows from the government right now. Three of the five groups covered by insurance are seniors (Medicare), children from low-income families (Medicaid/Medi-Cal) and military veterans (VA).

The imbalance in economics comes when private, for-profit insurers can cherry-pick plum customers. If all insured Americans – young and old, healthy and sick – were part of the same “risk pool,” instead of segregated, premiums from the former would cover expenses of the latter.

The so-called “government option” would have been a disaster, one Mad As Hell Doctor explained, because “the private insurers would game the system and throw all the sick people to the public option, and when the public option failed, the private insurers would say, ‘See, the government can’t do healthcare!'”

The idea of a government-run insurance monopoly raises understandable fears, even among those who see benefits in a single system – benefits such as less paperwork, fewer sets of rules and, correspondingly, a greater share of each healthcare dollar going to actual healthcare.

Before getting alarmed, though, it’s important to look at the status quo and assess fears accordingly. Take the notions of lines and rationing, for instance. There already are lines. Emergency rooms are backed up. It’s hard to get a doctor’s appointment if you don’t already see a primary-care physician. And, as one MAHD speaker asked, how long have you waited on the phone line when calling an insurer?

As for rationing, insurers do this now when they deny treatment or require lengthy authorization processes for procedures, medicines and equipment they cover. The Mad As Hell Doctors gave me a lot to think about, and I know I’m not alone.

http://www.paradisepost.com/opinion/ci_16371041

Expert: Single-Payer Health System Could Save Maine $1 Billion a Year

With health care costs high and rising, state lawmakers are trying to come up with new alternatives incorporating recent federal reform laws. Today in Augusta, a committee heard from a health care expert who says a single-payer system could save a billion dollars in Maine each year.

» Click here to listen to the story

Maine Public Broadcasting Network
Oct 19, 2010

In the early 1990s, when Taiwan wanted to tackle rising health care costs, it hired economist William Hsiao to come up with a solution. And it was a tall order, Hsiao told the Legislature’s Joint Select Committee on Health Care Reform Opportunites and Implementation.

“Taiwan decided that everyone should have access to basic health care. However, health care costs money, and regardless of how you pay for it — either out of your own pocket or though premiums paid partly by your employer or out of your own pocket — it’s going to be paid by somebody, through some avenue.”

With the goal of affordable universal coverage that is sustainable over time, Taiwan developed a single-payer system, adminstered by the government. Hsiao, a professor at Harvard, says the cost is much lower than in the United States health care system, and it is paid for by employers, employees and the federal government.

And, he says, nearly everybody is covered. “They even sent people under the bridges to find the homeless to enroll them. And the Taiwanese that live overseas fly back to Taiwan for their health care, because it is literally free, and high quality.”

Hsiao spoke to a committee room crowded with health care lobbyists. The committee was formed following the passage of the federal Affordable Care Act last spring, to prepare Maine for the law’s implementation.

One committee member wondered if there is another way to develop mandatory, standardized health care coverage while still using private insurers, in a system more like that seen in Holland and Germany.

“I wouldn’t call it single-payer, but then I’m a Republican,” says Rep. Les Fossel, a Republican from Alna. He points out that the state requires car insurance, and it is provided through private insurers. Though he is not sold on single-payer, he says something needs to change.

“The thing is, we simply can’t sustain the system as it is going forward now,” Fossel says. “The Affordable Health Care Act did a whole lot to define coverage, but Truman had it wrong when he said ‘the buck stops here.’ The buck keeps being shoved down to the guy at the lowest level. And we have to figure out a way to pay for it. And this is going to be an extraordinarily difficult thing, and yet if we don’t, we are going to kill people.”

And kill jobs, he might have added. Jim Miller, general manager of Wooden Boat Publications, which employs 33 people in Brooklin, says small businesses are struggling with fast-rising health care costs.

“We had a renewal in May and we experienced a 17 percent increase in premiums, which is an increase of $48,000. That’s a one-year increase,” Miller says. “Unfortunately, there is nothing we can do to offset this cost, nor is there any way to understand why this happened.”?

Miller spoke at a press conference held by Maine AllCare, which used Hsiao’s visit to beat the drum for health care reform. He says Wooden Boat is self-insuring part of its employees’ deductibles this year, basically gambling on the health of its employees. And Miller says the lack of affordable health care puts the business at a competitive disadvantage.

“We are also faced with competition from international magazines located in countries that offer national health insurance,” he says. “They are at a cost advantage, as are the U.S. magazines we compete against who have chosen to drop coverage for their staff.”

William Hsiao is now working as a consultant to the state of Vermont, as it tries to develop an affordable health care plan. And he says that if Taiwan is any example, the United States could save a lot of money by moving toward a single-payer system.

“Taiwan right now, 2009, is spending 6.1 percent of its GDP for health care. The United States last year was spending 16.7 percent of its GDP for health care,” he says.?

In Taiwan, Hsiao says, the system saw 10 percent cost savings just by rooting out the health care providers who were fraudulently or excessively billing for services. Similar savings in Maine, he says, would equal a billion dollars a year.

http://www.mpbn.net/Home/tabid/36/ctl/ViewItem/mid/3478/ItemId/13906/Default.aspx

Poor healthcare may shorten American lives – study

By Maggie Fox, Health and Science Editor
Reuters, Oct. 7, 2010

WASHINGTON — Americans die sooner than citizens of a dozen other developed nations and the usual suspects — obesity, traffic accidents and a high murder rate — are not to blame, researchers reported on Thursday.

Instead, poor healthcare may be to blame, the team at Columbia University in New York reported.

They found that 15-year survival rates for men and women aged 45 to 65 have fallen in the United States relative to the other 12 countries over the past 30 years.

Such figures are frequently cited by supporters of healthcare reform, and critics often point out that the United States also has higher rates of obesity, more traffic fatalities and more murders than these countries.

Columbia’s Peter Muennig, who led the study published in the journal Health Affairs, said his team accounted for these factors this time.

“But what really surprised us was that all of the usual suspects — smoking, obesity, traffic accidents, and homicides — are not the culprits,” Meunnig said in a statement.

“The U.S. doesn’t stand out as doing any worse in these areas than any of the other countries we studied, leading us to believe that failings in the U.S. health care system, such as costly specialized and fragmented care, are likely playing a large role in this relatively poor performance on improvements in life expectancy.”

In June, the Commonwealth Fund, which advocates on and does research focusing on healthcare reform, reported that Americans spend twice as much on healthcare as residents of other developed countries — $7,290 per person — but get lower quality and less efficiency.

Muennig and Sherry Glied compared the United States to Australia, Austria, Belgium, Britain, Canada, France, Germany, Italy, Japan, the Netherlands, Sweden and Switzerland.

All these countries provide universal health insurance, in contrast to the United States, where 15 percent of the population lacks health insurance, although healthcare reform passed in March is designed to lower that disparity.

Republicans have promised to derail the legislation if they gain power in Congress in next month’s elections.

COSTS GO UP

Between 1975 and 2005, medical costs went up in all the countries, as did life expectancy. But costs went up far more in the United States and life expectancy increased to a far lower degree.

Glied and Meunnig do not believe obesity accounts for the differences. While more Americans are obese, overall the populations in all the nations have been getting fatter, they said.

“For obesity to explain the decline in U.S. life expectancy or the increase in health spending relative to the 12 comparison countries, Americans would have to be becoming obese at a faster rate than people in the comparison nations over time,” they wrote. But this has not been happening.

Americans are less likely to smoke, and while Americans are more likely to die in car crashes or be murdered, again these rates do not explain the lower life expectancy, the Columbia team said.

“The findings undercut critics who might argue that the U.S. health care system is not in need of major changes,” they wrote.

They noted that the United States has been dropping in life expectancy tables for decades.

“In 1950, the United States was fifth among the leading industrialized nations with respect to female life expectancy at birth, surpassed only by Sweden, Norway, Australia, and the Netherlands,” they wrote. At last count, the United States was 46th in female life expectancy; 49th for both sexes. (Editing by Eric Walsh)

http://www.reuters.com/article/idUSN0622294120101007

Low-Cost Lessons from Grand Junction, Colorado

By Thomas Bodenheimer, M.D., M.P.H., and David West, M.D.
The New England Journal of Medicine
October 7, 2010

According to the Dartmouth Atlas of Health Care, average per capita Medicare spending in Grand Junction was $6,599 in 2007 – 24% lower than the national average and 60% below high-cost Miami.

Moreover, Grand Junction scored above the national average on a number of measurements of preventive care, diabetes, asthma, and other quality metrics.

We believe that seven interrelated features of the health care system that may explain the relatively low health care costs could be adopted elsewhere. These are leadership by the primary care community; a payment system involving risk sharing by physicians; equalization of physician payment for the care of Medicare, Medicaid, and privately insured patients; regionalization of services into an orderly system of primary, secondary, and tertiary care; limits on the supply of expensive resources, including specialists, beds, and equipment; payment of primary care physicians for hospital visits; and robust end-of-life care. These features could be replicated in other markets – though generally not without political battles.

http://www.nejm.org/doi/pdf/10.1056/NEJMp1008450

Comment:

By Don McCanne, MD

Although I am taking a break this week and won’t provide a comment here, an excellent commentary on the Bodenheimer and West article has been posted by Joshua Freeman, Professor and Chair of the Department of Family Medicine for the University of Kansas School of Medicine. He states, “Grand Junction, Colorado may not have all the answers to our health care system, any more than Canada or Britain or Switzerland do. But it is doing a lot of things right, it is saving money, and it is improving the health of the community, and that’s a lot more than most areas in the US are doing.”

For Josh Freeman’s full commentary:
http://medicinesocialjustice.blogspot.com/2010/10/lower-costs-in-grand-junction-primary.html

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A Health Reform Critic Flunks Math

Employers looking at health insurance options

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