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Can Medicare for All Succeed?

By Steffie Woolhandler, M.D., M.P.H., and David U. Himmelstein, M.D.
The Nation, Letters, August 16, 2017

Joshua Holland’s anti–single payer screed (“Medicare for All Isn’t the Solution for Universal Health Care”) is so riddled with misinformation and outright errors that it makes one wonder whether The Nation has laid off its fact-checkers.

Just one example: In arguing the impossibility of a health-care transformation in a high-spending nation, Holland claims that Switzerland’s health expenditures in 1996 amounted to only 5 percent of GDP. The correct figure is 9.2 percent. [Editor’s Note: This has been corrected in Holland’s article.]

He suggests that cost control under single payer requires halving doctors’ incomes, a serious political problem if it were true. But Canadian doctors make about 80 percent what their US counterparts do, and, taking into account their lower educational debt and post-retirement health expenses (more than $250,000 per couple in the United States), they’re about as well off financially as their US counterparts. Moreover, most US single-payer projections foresee increased spending on physician visits once copayments are abolished, and simplified billing would reduce the bite that office overhead takes out of doctors’ take-home pay.

Holland falsely claims that no one has provided guidance on the transition to single payer. We, and our colleagues in Physicians for a National Program have published in the Journal of the American Medical Association, The American Journal of Public Health, and the New England Journal of Medicine several quite detailed proposals laying out transition plans for acute-care financing, long-term care, and quality monitoring; another, on prescription-drug regulation and financing, is in the works. We’ve analyzed in detail the likely shifts in administrative costs and employment, and the federal single-payer legislative proposals include funding for job retraining and placement and income support to transition the million or so insurance and administrative workers who currently do useless bureaucratic work and whose jobs would be eliminated under single payer. While the transition would be disruptive for some administrative workers, it would be simple for hospitals (they’d stop billing for each patient, Band-Aid, and aspirin tablet and instead be paid lump-sum budgets), and a welcome relief for doctors and nurses, who suffer record high burnout rates in the current medical-industrial complex. That’s why recent polls show that around half of doctors favor single payer (and 21,000 of them have joined Physicians for a National Health Program), and National Nurses United, the leading nurses’ union, is the nation’s strongest single-payer proponent.

Most egregiously, Holland misrepresents the single-payer legislation that’s actually been proposed, citing Medicare’s deficiencies to smear reform proposals. As the title of John Conyers’s bill H.R. 676, the Expanded & Improved Medicare for All Act, makes clear, that legislation would upgrade Medicare coverage, eliminating copayments and deductibles, and fix its other flaws. Holland suggests that, since many Medicare recipients supplement their coverage with private policies, such legislation would boost out-of-pocket costs for millions who currently have employer-paid coverage or Medigap policies. In fact, virtually no one would face increased copayments or deductibles under H.R. 676 (or Bernie Sanders’s forthcoming legislation, or the many state bills), although wealthy Americans’ taxes would rise. And few people would complain about being freed from insurers’ narrow provider networks; not one of the Medicare Advantage plans, without out-of-pocket benefits, covers care at New York’s Memorial Sloan Kettering Cancer Center. Under single payer patients could, as in Canada, choose any hospital or doctor.

Holland’s scare-mongering about the chaos likely to ensue during a transition to single payer echoes The Wall Street Journal’s dire predictions of “patient pileups” and other disasters at the dawn of Medicare in 1965. It didn’t happen then and wouldn’t happen now. Medicare, sans computers, enrolled 18.9 million seniors (displacing private insurance for many of them) within 11 months of its passage.

The real enemies of single payer aren’t the disgruntled patients or doctors whom Holland features but the insurance and pharmaceutical firms that he barely mentions. That powerful opposition is the real problem we have to overcome, not the imagined chaos of the transition or the phony fear that patients would revolt against better coverage.

The authors are primary-care physicians, distinguished professors of public health at the City University of New York at Hunter College, and lecturers in Medicine at Harvard. They founded Physicians for a National Health Program and served as health-policy advisers during Bernie Sanders’s presidential campaign.

https://www.thenation.com…

KHN: Doctors Warm To Single-Payer Health Care

Doctors Warm To Single-Payer Health Care

By Rachel Bluth
Kaiser Health News, August 16, 2017

Single-payer health care is still a controversial idea in the U.S., but a majority of physicians are moving to support it, a new survey finds.

Fifty-six percent of doctors registered either strong support or were somewhat supportive of a single-payer health system, according to the survey by Merritt Hawkins, a physician recruitment firm. In its 2008 survey, opinions ran the opposite way — 58 percent opposed single-payer. What’s changed?

Red tape, doctors tell Merritt Hawkins. Phillip Miller, the firm’s vice president of communications, said that in the thousands of conversations its employees have with doctors each year, physicians often say they are tired of dealing with billing and paperwork, which takes time away from patients.

“Physicians long for the relative clarity and simplicity of single-payer. In their minds, it would create less distractions, taking care of patients — not reimbursement,” Miller said.

In a single-payer system, a public entity, such as the government, would pay all the medical bills for a certain population, rather than insurance companies doing that work.

A long-term trend away from physicians owning their practices may be another reason that single-payer is winning some over. Last year was the first in which fewer than half of practicing physicians owned their practice — 47.1 percent — according to the American Medical Association’s surveys in 2012, 2014 and 2016. Many doctors are today employed by hospitals or health care institutions, rather than working for themselves in traditional solo or small-group private practices. Those doctors might be less invested in who pays the invoices, Miller said.

There’s also a growing sense of inevitability, Miller said, as more doctors assume single-payer is on the horizon.

“I would say there is a sense of frustration, a sense of maybe resignation that we’re moving in that direction, let’s go there and get it over with,” he said.

Merritt Hawkins emailed its survey Aug. 3 and received responses from 1,003 doctors. The margin of sampling error is plus or minus 3.1 percentage points.

The Affordable Care Act established the principle that everyone deserves health coverage, said Shawn Martin, senior vice president for advocacy at the American Academy of Family Physicians. Inside the medical profession, the conversation has changed to how best to provide universal coverage, he said.

“That’s the debate we’re moving into, that’s why you’re seeing a renewed interest in single-payer,” Martin said.

Dr. Steven Schroeder, who chaired a national commission in 2013 that studied how physicians are paid, said the attitude of medical students is also shifting.

Schroeder has taught medicine at the University of California-San Francisco Medical Center since 1971 and has noticed students’ increasing support for a single-payer system, an attitude they likely carry into their professional careers.

“Most of the medical students here don’t understand why the rest of the country doesn’t support it,” said Schroeder.

The Merritt Hawkins’ findings follow two similar surveys this year.

In February, a LinkedIn survey of 500 doctors found that 48 percent supported a “Medicare for all” type of system, and 32 percent opposed the idea.

The second, released by the Chicago Medical Society in June, reported that 56 percent of doctors in that area picked single-payer as the “best care to the greatest number of people.” More than 1,000 doctors were surveyed.

Since June 2016, more than 2,500 doctors have endorsed a proposal published in the American Journal of Public Health calling for a single-payer to replace the Affordable Care Act. The plan was drafted by the Physicians for a National Health Program (PNHP), which says it represents 21,600 doctors, medical students and health professionals who support single-payer.

Clare Fauke, a communications specialist for the organization, said the group added 1,065 members in the past year and membership is now the highest since PNHP began in 1987.

http://khn.org…

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Comment:

By Don McCanne, M.D.

As people learned about single payer and seemed to think it was a good idea, opponents started dragging out the old discredited arguments against the concept. More recently, health reform advocates who claim to be single payer supporters “in an ideal world” have been pushing pablum – incremental measures that fall far short of reform goals. Thus it is refreshing to digest a dose of reality: physicians really are supporting single payer.

And, why? (Borrowing from James Carville) it’s about the patients, stupid!

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

Physicians support single payer, but how strongly?

Survey: 42% of Physicians Strongly Support a Single Payer Healthcare System, 35% are Strongly Opposed

By Phillip Miller
Merritt Hawkins, August 14, 2017

A plurality of physicians strongly support a single payer healthcare system, according to a new survey by Merritt Hawkins.

The survey of 1,033 physicians indicates that 42 percent strongly support a single payer health care system while 14 percent are somewhat supportive. Over one-third (35 percent) strongly oppose a single payer system while six percent are somewhat against it. The remaining three percent neither support nor oppose single payer.

The results contrast with a national survey of physicians Merritt Hawkins conducted in 2008, which indicated that 58 percent of physicians opposed single payer at that time while 42 percent supported it.

In Merritt Hawkins’ experience, there are four reasons why a growing number of physicians are in favor of single payer. First, they are seeking clarity and stability. The fits and starts of health reform and the growing complexity of our current hybrid system are a daily strain on most doctors. Many of them believe that a single payer healthcare system will reduce the distractions and allow them to focus on what they have paid a high price to do: care for patients.

Second, it’s a generational issue. The various surveys that Merritt Hawkins has conducted for The Physicians Foundation in the past show that younger doctors are more accepting of Obamacare, ACOs, EHR, and change in general than are older physicians As the new generation of physicians comes up, there is less resistance among doctors to single payer.

Third, there is a feeling of resignation rather than enthusiasm among some physicians about single payer. These physicians believe we are drifting toward single payer and would just as soon get it over with. The 14% of physicians surveyed who said they “somewhat” support single payer are probably in this group.

Fourth, there is a philosophical change among physicians that I think the public and political leaders on both sides of the aisle now share, which is that we should make an effort to cover as many people as possible.

However, while single payer has gained acceptance among some physicians, it remains strongly opposed by over one third and strongly or somewhat opposed by over 40 percent. It is still a polarizing issue among physicians and is likely to remain so for the foreseeable future.

Phillip Miller is Vice President of Corporate Communications for Merritt Hawkins.

https://www.merritthawkins.com…

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Kaiser Health Tracking Poll – August 2017: The Politics of ACA Repeal and Replace Efforts

Kaiser Family Foundation

READ TO ALL: As you may know, the 2010 Affordable Care Act created health insurance exchanges or marketplaces where people who don’t get coverage through their employers can shop for insurance and compare prices and benefits.

Q12. Thinking about President Trump and Republicans’ next steps on health care, which of the following do you think is more important for them to work on now? Should they work on (READ LIST)? (rotate response options 1-2/2-1)

69% – Fixing the remaining problems with the Affordable Care Act in order to help the marketplaces work better

29% – Continuing plans to repeal and replace the Affordable Care Act

2% – Something else (VOL.)

1% – Don’t know/Refused

http://files.kff.org…

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Comment:

By Don McCanne, M.D.

This Merritt Hawkins survey adds to the accumulated data that shows that a majority of physicians support a single payer system – 56 percent in this survey, with a 42 percent plurality strongly so. This demonstrates a significant increase in support compared to their last physician poll a decade ago.

Phillip Miller, Vice President of Corporate Communications for Merritt Hawkins, expresses the view that “there is a feeling of resignation rather than enthusiasm among some physicians about single payer.”

The current Kaiser Foundation Tracking Poll showed that, given a choice, 69 percent of the general public would prefer to fix “the remaining problems with the Affordable Care Act in order to help the marketplaces work better,” whereas 29 percent would prefer to continue plans “to repeal and replace the Affordable Care Act.” Only 2 percent volunteered “something else,” presumably including single payer. It appears that the current surge in support of single payer is not strong enough for those polled to voluntarily cite single payer as a preference to the options of either fixing ACA or repealing and replacing it.

Our physician colleagues and the public at large need to continue to hear our three messages until they become steadfast believers and activists for the cause: 1) In spite of the improvements, patching the Affordable Care Act will still leave us far short of an efficient, equitable, affordable health care system that is truly universal, 2) current repeal and replace proposals would make health care even less accessible and less affordable, and 3) single payer – an improved Medicare for all – would finally bring affordable care to absolutely everyone.

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

Single-payer health system is the way to go

By Marc H. Lavietes, M.D.
Asbury Park (N.J.) Press, August 14, 2017

I agree with recent letter writers: health care decisions should be between doctor and patient only. However, given the high cost of our pharmacopoeia and modern medical technology, the day of the altruistic physician accepting token payment from less affluent patients is gone. Bandaids such as those mentioned in the letters will not work. Yes, tort reform will help (a little). Purchasing insurance across state lines courts disaster; inadequate but inexpensive plans will siphon off young healthy persons from the general pool, making insurance more expensive for others.

By contrast, a single payer system administered by a non – profit entity will preserve the sanctity of the doctor – patient relationship. In such systems the administrator serves only as the bank. Single payer reimburses treatment, i.e., heart failure, asthma, etc., rather than fee – for – service, i.e., CAT scan, catheterization. Thus, the economics of single payer encourages medical decisions based upon patients’ need rather than physicians’ income. Yes, physicians will at times negotiate with the payer regarding complex, costly medical decisions as well as their own salaries. But the non – profit payer, unlike the private insurance company, will have no profit motive. Unlike the corporate CEO or shareholders, the government administrator will not earn millions of dollars yearly.

What works well in France and Canada will work for us! Our experience with the ACA tells us that lesser incremental change, i.e., bandaids, will not.

http://www.app.com…

Subsidizing health insurance cannot ever get us to universal coverage

NBER Working Paper 23668: Subsidizing Health Insurance for Low-Income Adults: Evidence from Massachusetts

By Amy Finkelstein, Nathaniel Hendren, and Mark Shepard
National Bureau of Economic Research, August 2017

Abstract

How much are low-income individuals willing to pay for health insurance, and what are the implications for insurance markets? Using administrative data from Massachusetts’ subsidized insurance exchange, we exploit discontinuities in the subsidy schedule to estimate willingness to pay and costs of insurance among low-income adults. As subsidies decline, insurance take-up falls rapidly, dropping about 25% for each $40 increase in monthly enrollee premiums. Marginal enrollees tend to be lower-cost, consistent with adverse selection into insurance. But across the entire distribution we can observe – approximately the bottom 70% of the willingness to pay distribution – enrollee willingness to pay is always less than half of own expected costs. As a result, we estimate that take-up will be highly incomplete even with generous subsidies: if enrollee premiums were 25% of insurers’ average costs, at most half of potential enrollees would buy insurance; even premiums subsidized to 10% of average costs would still leave at least 20% uninsured. We suggest an important role for uncompensated care for the uninsured in explaining these findings and explore normative implications.

From the Introduction

Governments spend an enormous amount of money on health insurance for low-income individuals. For instance, the U.S. Medicaid program (at $550 billion in 2015) dwarfs the size of the next largest means-tested programs – food stamps and the EITC ($70 billion each). Perhaps because of these high and rising costs, public programs increasingly offer partial subsidies for health insurance, requiring enrollees to pay premiums to help cover costs. Partial subsidies are a key feature of market-based programs such as Medicare Part D and the Affordable Care Act (ACA) exchanges, and even traditional low-income programs like Medicaid and the Children’s Health Insurance Program (CHIP) increasingly require premiums for some enrollees. Partial subsidies are also a textbook policy response to adverse selection if a full coverage mandate may not be efficient.

In this paper, we estimate low-income individuals’ willingness to pay (WTP) for health insurance, assess how it compares to the cost they impose on the insurer, and discuss the positive and normative implications for subsidized health insurance programs. We do so in the context of Massachusetts’ pioneer health insurance exchange for low-income individuals, known as “Commonwealth Care” or “CommCare.” Established in the state’s 2006 health care reform, CommCare offered heavily-subsidized private plans to non-elderly adults below 300% of poverty who did not have access to insurance through an employer or another public program.

We first document two main descriptive patterns. First, enrollee demand is highly sensitive to premiums. With each discrete increase in enrollee premiums, enrollment in CommCare falls by about 25%, or a 20-24 percentage point fall in the take-up rate. Second, we find that despite the presence of a coverage mandate, the market is characterized by adverse selection: as enrollee premiums rise, lower-cost enrollees disproportionately drop out, raising the average cost of the remaining insured population.

We use a simple model to analyze the implications of these descriptive patterns.

The model allows us to translate the descriptive patterns into two main results about willingness to pay and costs for these plans. First, even large insurance subsidies are insufficient to generate near-complete take-up of insurance by low-income adults.

These findings suggest that even modest enrollee premiums can be a major deterrent to universal coverage among low-income people. This deterrent is likely to be even larger in the ACA exchanges, in which income-specific premiums are significantly higher than in CommCare.

Second, although adverse selection exists, it is not the primary driver of low take-up. The cost of marginal consumers who enroll when premiums decline is less than the average costs of those already enrolled, implying that plans are adversely selected. But across the in-sample distribution – which spans the 6th to the 70th percentile of the willingness to pay distribution – the willingness to pay of marginal enrollees still lies far below their own expected costs imposed on insurers for either the H or L plans. For example, for the median willingness to pay individual, the gap between the costs of the marginal enrollee and average costs of enrollees explains only one-third of the $300 gap between willingness to pay and average costs. This suggests individuals would not enroll even if prices were subsidized to reflect the expected cost of marginal enrollees. Enrollment is low not simply because of adverse selection, but because people are not willing to pay their own cost imposed on the insurer.

In the final section of the paper, we briefly explore potential explanations for our findings and analyze their normative implications. Back-of-the-envelope calculations using estimates from the prior literature suggest that moral hazard effects of health insurance cannot explain much of the gap between willingness to pay and costs. However, an estimate of the uncompensated care available to the uninsured suggests that this can account for nearly all of our estimated gap between willingness to pay and costs of insurance.

If we interpret our willingness to pay estimates normatively as individuals’ value of insurance, they suggest that most low-income enrollees would prefer being uninsured to having to pay the cost they impose on the insurer. This suggests that subsidies in this market cannot be justified simply as a response to adverse selection. Our results suggest two potential such justifications for subsidies: as an offset to the externalities resulting from uncompensated care (i.e., the Samaritan’s dilemma (Buchanan, 1975; Coate, 1995)), or as a means of redistribution to low-income households.

5.1 Why Is WTP so Low?

We estimate that willingness to pay is less than one-third of average costs. This cannot be fully explained by adverse selection driving a wedge between average costs and costs for marginal enrollees. We estimate that willingness to pay is also always less than half of marginal enrollees’ own expected costs. This stylized fact runs counter to a standard assumption in textbook models of insurance demand – that willingness to pay for insurance equals expected costs plus a value of risk protection.

In principle, moral hazard offers a potential explanation. If the provision of health insurance leads individuals to consume care they wouldn’t have consumed when uninsured (“moral hazard”), their willingness to pay for this additional care will be less than the cost they would have had to pay for it when uninsured. In practice, however, moral hazard is unlikely to be large enough to explain the results. Insurance would have to increase costs by a factor of at least 200% to explain the estimated gap between willingness to pay (Wj) and own costs (Cj). This seems well outside the plausible range of estimates.

By contrast, uncompensated care for the low-income uninsured is large enough to rationalize their low willingness to pay for CommCare. Uncompensated care for the uninsured reduces willingness to pay relative to the gross cost of this insurance, since some share of those costs pays for care that, if uninsured, would have been paid for by third parties. Estimates suggest that the uninsured pay only about 20% to 35% of their cost of care, which is remarkably similar to our estimated ratio of WTP to own costs for the H plan. Not surprisingly therefore, a simple back-of-the-envelope calculation suggests that the magnitude of uncompensated care for the low-income uninsured could close most of the gap between willingness to pay (WH) and own expected cost (CH).

A large role for uncompensated care also can potentially explain differential take-up findings for low- vs. high-income populations. The low willingness to pay we find for the low-income population in Massachusetts contrasts with the findings for higher-income individuals in Massachusetts: Hackmann, Kolstad, and Kowalski (2015) estimate that individuals above 300% of the federal poverty line in Massachusetts are willing to pay the (gross) cost they impose on the insurer. One parsimonious way to rationalize these findings is that only low-income individuals are able to obtain substantial uncompensated care, and this uncompensated care when uninsured reduces the willingness to pay for formal insurance.

From the Conclusion

This paper estimates willingness to pay and costs for health insurance among low-income adults using data from Massachusetts’ pioneer subsidized insurance exchange. For at least 70% of the low-income eligible population, we find that willingness to pay for insurance is far below insurers’ average costs. Adverse selection exists, despite the presence of the coverage mandate, but is not the driving force behind low take up. We estimate that willingness to pay is less than half of enrollees’ own expected costs; thus, even if insurers could set prices conditional on an individual’s willingness to pay, at least 70% of the market would be uninsured.

From a positive economics perspective, our results point to substantial challenges in getting to universal coverage via partially subsidized insurance programs like the ACA’s exchanges. For example, we estimate that even subsidizing premiums down to 10% of insurer costs would generate only 80% coverage. This reality may underlie the incomplete take-up of insurance under the ACA, despite a coverage mandate and generous subsidies. We provide suggestive evidence of an important role for uncompensated care in explaining why willingness to pay is substantially below (gross) insurance costs. This in turn suggests a potential economic rationale for subsidies as a response to the “Samaritan’s dilemma” to offset the implicit tax that uncompensated care imposes on formal insurance (Coate, 1995).

http://www.nber.org…

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Altruism, the Samaritan’s Dilemma, and Government Transfer Policy

By Stephen Coate
American Economic Review, 1995, vol. 85, issue 1, 46-57

Abstract

This paper shows that altruism provides an efficiency rationale for public provision of insurance to the poor. The framework is one in which there are rich altruists and risk-averse poor who face some possibility of loss. The government represents the rich and makes transfers on their behalf. With unconditional transfers, the poor may forgo insurance and rely on private charity to bail them out in the event of loss. This reliance on private charity has adverse efficiency effects. These may be avoided if the government makes in-kind transfers of insurance.

http://econpapers.repec.org…

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Distribution of the Nonelderly Uninsured by Federal Poverty Level (FPL) in 2015

Kaiser Family Foundation

26% – Under 100%

27% – 100%-199%

28% – 200%-399%

19% – 400%+

http://www.kff.org…

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Comment:

By Don McCanne, M.D.

Wading through this technical 56 page paper, the following understated observation may be the most important: “our results point to substantial challenges in getting to universal coverage via partially subsidized insurance programs like the ACA’s exchanges.” That is, using income related premium tax credits for plans in the ACA exchanges, even with an individual mandate, is a grave design defect because it can never get us to universal coverage.

This study looked at low-income individuals and showed that, not only did adverse selection result in individuals remaining uninsured, but a much greater factor was that the willingness to pay for a percentage of the premium is far below the insurers’ average costs. Even with 90% of the premium subsidized, 20% of the individuals would remain uninsured, and the percent insured dropped off rapidly as the individuals’ share increased.

The authors cite a reference that indicates that higher-income individuals are willing to pay the cost they impose on insurers. But lest we think that avoiding the purchase of insurance due to cost is limited to lower income individuals, that is refuted by the Kaiser Foundation report that shows that the uninsured are distributed throughout all income levels – 19% of them having incomes over 400% of the federal poverty level. Any proposed policy correction should not be limited to lower-income individuals.

The authors suggest that “only low-income individuals are able to obtain substantial uncompensated care, and this uncompensated care when uninsured reduces the willingness to pay for formal insurance.” The authors cite Coate in regard to the “Samaritan’s dilemma” as a rationale for subsidies, but Coate states, “The government represents the rich and makes transfers on their behalf. With unconditional transfers, the poor may forgo insurance and rely on private charity to bail them out in the event of loss. This reliance on private charity has adverse efficiency effects. These may be avoided if the government makes in-kind transfers of insurance.”

Providing highly technical studies such as this one from NBER advances the science on which we base our policy decisions, but it does not take an MIT economist to come to the conclusion that when a policy is not working, you need to change it. Even generous premium tax credits for ACA exchange plans can never get us to universal coverage, yet government making in-kind transfers of insurance will, providing we include all income levels and fund the program with income transfers through progressive taxation.

Again, subsidizing health insurance cannot ever get us to universal coverage. Single payer will.

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

Radiation oncologist Fumiko Chino gives us a lesson on medical debt

Out-of-Pocket Costs, Financial Distress, and Underinsurance in Cancer Care

By Fumiko Chino, MD; Jeffrey M. Peppercorn, MD, MPH; Christel Rushing, MS; S. Yousuf Zafar, MD, MHS; et al
JAMA Oncology, August 10, 2017

The financial burden of cancer treatment is a well-established concern. Owing to cost sharing, even insured patients face financial burden and are at risk for worsened quality of life and increased mortality. Underinsured patients (those spending more than 10% of their income on health care costs) are a growing population, and are at risk given the looming heath policy and coverage changes on the horizon.

From the Discussion

More than one-third of insured cancer patients receiving anticancer therapy faced out-of-pocket costs that were greater than expected, and patients with the most distress were underinsured, paying almost one-third of their income in health care-related costs. Patients at risk for unexpected costs had less household income and faced higher out-of-pocket costs.

http://jamanetwork.com…

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Widowed Early, A Cancer Doctor Writes About The Harm Of Medical Debt

By Alison Kodjak
NPR, August 10, 2017

Ten years ago, Fumiko Chino was the art director at a television production company in Houston, engaged to be married to a young Ph.D. candidate.

Today, she’s a radiation oncologist at Duke University, studying the effects of financial strain on cancer patients. And she’s a widow.

“I think of him every day,” Chino says of her late husband, Andrew Ladd. “It drives me to do the type of research that I do — that’s looking at the financial toxicity of cancer care.”

Chino is co-author of a research letter, published Thursday in JAMA Oncology, that shows that some cancer patients, even with insurance, spend about a third of their household income on out-of-pocket health care costs outside of insurance premiums.

In 2005, before they were married, Chino and Ladd were living together in Houston. She was working in entertainment, and he was on the verge of earning his doctorate in robotics at Rice University. Each had medical insurance – she through her job, he through the school.

Then he started to vomit and lose weight.

He was diagnosed with neuroendocrine carcinoma, an aggressive cancer of endocrine cells that can strike in a variety of places in the body and can be hard to treat.

It was a huge blow for the young couple, still in their 20s, with promising careers ahead of them. Still, they looked to the future and decided to go ahead with their wedding.

But as Ladd’s treatment moved forward, a harsh reality hit. His student insurance didn’t cover much.

Soon, his medical costs surpassed his insurance policy’s $500,000 lifetime limit (before ACA). But the bills kept coming.

Even as insurance coverage has expanded (under ACA), deductibles and copays on many policies have risen, leaving patients to shoulder more of the financial burden for their health care.

“The stress and overwhelming crushing defeat of these bills that would come in every week — it had an effect on our quality of life,” Chino says.

Despite his illness, Ladd landed a job as a professor at the University of Michigan. It came with health insurance, and he continued treatment there.

But he never moved into his office. Three months into his time at Michigan, he died.

Chino was left with an ocean of debt. She estimates it’s in the hundreds of thousands of dollars.

That’s when she found a new mission in life. She enrolled in Duke’s medical school and teamed up with Dr. Yousuf Zafar, who has made a specialty out of studying and writing about “financial toxicity,” which he describes as the toxic effects of financial strain from health care costs. He’s lead author on the JAMA Oncology study that Chino worked on.

“Patients are frustrated,” Zafar says. “They believe they’ve got insurance. They believe they paid for insurance and that insurance should fully cover their cancer care.”

“We need to do a better job explaining to our patients how much benefit they can get from treatment,” he says. “But also how much harm they can face, whether that harm is physical toxicity or financial toxicity.”

Ten years after Ladd’s death, Chino is still dealing with the aftereffects.

“I still owe the debt,” she says. “I stopped answering phone calls from debt collectors.”

http://www.npr.org…

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Comment:

By Don McCanne, M.D.

Health care professionals who are health reform activists can certainly identify with the plight of radiation oncologist Fumiko Chino. Not only did she face the almost unbearable tragedy of her husband’s lethal cancer, she has been left with overwhelming medical debt in spite of insurance coverage.

Helping all of us to better understand the financial impact of cancer, Dr. Chino has co-authored an article in JAMA Oncology, “Out-of-Pocket Costs, Financial Distress, and Underinsurance in Cancer Care.” Her lead co-author, Dr. Yousuf Zafar, acknowledges what a problem “financial toxicity” is and suggests that we need to do a better job of explaining to patients not only the physical toxicity of cancer therapy but also the financial toxicity. (Pause…)

We certainly admire Dr. Zafar for his efforts to educate us on financial toxicity, but we really do need to move beyond just talking about it. Our health care financing system needs to be redesigned to remove financial barriers to care, and, further, when an individual is already suffering from impaired health, the last thing we need to do is to add financial hardship through medical debt.

It is no secret that a well designed single payer program would remove financial barriers to care and prevent medical debt. People would just get health care when they need it and not have to worry about how they would pay for it.

It will be a breakthrough when medical journal editors who publish articles on the problems of financing health care begin to request that the authors include a remedy for financial toxicity – one that has been proven beyond any doubt to be fully effective – a single payer national health program.

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

Medi-Cal violates civil rights

California talks big on health, but so few docs take Medi-Cal that it violates civil rights

By Bill Lann Lee
The Sacramento Bee, August 9, 2017

California draws praise for leading the country in many ways, but our state is faltering badly in an area that is vital to millions: healthcare for our most vulnerable residents.

Fully one-third of our population, including seniors, people with disabilities and children, depend on Medi-Cal, the Medicaid health insurance program for low-income Californians. While there is wide coverage, Medi-Cal recipients have worse access to healthcare than Medicaid recipients in almost every other state, judged by the percentage of physicians who accept Medicaid patients.

This means suffering for people who have health coverage but, in fact, can’t get care. Too often, Medi-Cal patients are told no doctors will treat them, must endure long delays in scheduling appointments, and are forced to travel long distances for care. Poor, disproportionately Latino Medi-Cal patients often are unable to access care they would receive if covered by other health insurance.

Our state’s payments are so low that they deter many providers from treating more than a few, if any, Medi-Cal patients, with physicians saying that Medi-Cal payments are far below their costs of providing care, whether in fee-for-service or managed care.

This not only endangers the health of millions of Californians, but as our state officials should know, it violates health and civil rights laws.

Why?

Today, Latinos are more than half of all Medi-Cal enrollees statewide. As Latino enrollment in the program surged, Medi-Cal’s relative reimbursement rates plummeted.

In 2000, Medi-Cal rates were about two-thirds of Medicare’s, but they have fallen to about half what Medicare pays. Meanwhile, the number of Latinos in Medi-Cal climbed from 2.3 million in 2000 to 7.2 million in 2016. California’s politicians cannot blame financial shortfall; this alarming trend of disinvestment continued whether the state budget was tight or flush.

Civil rights and healthcare laws require that Medi-Cal recipients have access to healthcare equal to people with other insurance, such as Medicare and employer-sponsored insurance. Our state health officials have been so resistant to improving this situation that my organization, the Civil Rights Education and Enforcement Center, joined the Mexican American Legal Defense and Educational Fund to challenge this inequality.

Making sure that Medi-Cal provides the access to health care for those it covers is simple justice.

Bill Lann Lee, former Assistant Attorney General for Civil Rights with the U.S. Department of Justice, is senior counsel at the Civil Rights Education and Enforcement Center.

http://www.sacbee.com…

Los Angeles Times editorial: Does state funding for Medi-Cal discriminate against the Latinos it serves?
http://www.latimes.com…

***

Comment:

By Don McCanne, M.D.

Many proclaim that the greatest success of the Affordable Care Act was the 30 percent increase in Medicaid enrollment – now 74 million individuals. But Medicaid is a chronically underfunded welfare program, critically so in states like California.

One-third of Californians are enrolled in Medi-Cal (California’s Medicaid), and over half – 7.2 million – are Latinos. Access is impaired because of a lack of willing providers due to payments that are well below the costs of providing health care. Unequal access to care violates the civil rights of the Latinos enrolled in this program. More broadly, it establishes the principle that lower income individuals on Medicaid are not entitled to the same level of access to care as those with higher incomes covered by more traditional health insurance.

A single payer system would be much more egalitarian, ensuring as much as possible that care would be there for anyone who needs it.

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Medicare for All Should Be a Litmus Test

Don’t believe the critics. Medicare for All is the most realistic way to win universal, equitable health care.

By Adam Gaffney, M.D.
Jacobin, August 10, 2017

Fresh off a victory against Trumpcare, health care activists are now looking hopefully towards the future. Already there has been significant progress: within the Democratic Party “Medicare for All” has now achieved a level of support and enthusiasm unprecedented in recent memory.

Yet even as a broad spectrum of progressives coalesces around the cause, others are warning that we should be pressing on the brakes, not the throttle. Joshua Holland penned a piece in the Nation making this case just last week, and Paul Krugman made many similar points in his New York Times column on Monday.

Both argue that single payer should not be a “litmus test” for progressive candidates. They’re sorely mistaken.

Let’s begin with Holland’s arguments as to why Medicare for All may not be the best solution to our health care woes. Holland opens by asserting that while advocates want to use Medicare as the model for single payer universal health care, “Medicare isn’t a single-payer system in the sense that people usually think of it.” After all, he correctly notes, Medicare is partially privatized (via Medicare Advantage plans run by private insurers, as well as in the privatized design of its drug benefit). In addition, because Medicare imposes out-of-pocket expenses on enrollees (for example, co-payments and deductibles) and fails to cover some services, many enrollees purchase supplementary coverage (“Medigap” plans).

“The array of options,” Holland writes, “can be bewildering — it’s a far cry from the simplicity that single-payer systems promise.”

Indeed it is! Which is precisely why prominent single-payer proposals discard these flawed elements. Medicare Advantage primarily functions as a siphon from the public purse to insurance company coffers, and Medicare’s out-of-pocket payments squeeze many seniors. Both are unnecessary. Both should be nixed.

There seems to be some confusion here between what we might call “Currently Existing Medicare for All,” which basically nobody is proposing, and what advocates mean when they speak of “Medicare for All.” But there shouldn’t be: you don’t have to read Conyers’s bill to know that its title is not the “Medicare-for-All Act,” but rather the “Expanded and Improved Medicare-for-All Act.” Holland clearly understands this (he mentions later in his piece that Conyers’s legislation lacks cost-sharing and includes comprehensive benefits), but for the most part he fails to incorporate it into his analysis, leading him to erroneous conclusions.

Consider, for instance, a second point that Holland and Krugman raise: the disruptive impact that single payer could have for those who are already insured through their employer. Krugman believes that problems might arise when the “156 million people who currently get insurance through their employers, and are largely satisfied with their coverage,” switch to single payer. Holland is even more fretful about the political impact of such “loss aversion,” arguing that the portion of the population that enjoys decent employer-sponsored plans may not be thrilled at the idea of being shepherded into Medicare.

“Many employer-provided policies cover more than Medicare does,” he notes, “so a lot of people would objectively lose out in the deal.”

But would they? Again: all major single-payer proposals go beyond Medicare, eliminating cost-sharing and covering a more comprehensive array of health care benefits.

What differentiates the small-bore approaches that Holland and Krugman support from the deeper reform that single-payer advocates propose is that the latter is designed to improve health care for everybody, not just to make sure the uninsured get some form of coverage. After all, despite the talk about people wanting to keep their good employer-sponsored plans, in 2016 29 percent of covered workers had a high-deductible health plan (up from 4 percent in 2006), while the dollar value of workers’ deductibles has shot up by 300 percent since 2006.

Workers also often face copayments and coinsurance (a percent of the cost of the health care service paid out of pocket) for doctors’ visits, hospitalizations, tests, and drugs. And such payments are generally much higher under the non-group private plans purchased on or off the Obamacare exchanges. Many also have to deal with shifting — and often narrow — networks of doctors and hospitals, to the great detriment of doctor-patient relationships and continuity of care, not to mention choice and equal access.

In short, Holland’s point about “loss aversion” misses the mark by a mile: who would resent exchanging a limited network, high-deductible private insurance plan for a public plan that provided first-dollar comprehensive coverage without networks, and which could never be taken away?

Holland doubles down on this point, however, and brings up a related concern. He suggests that because some doctors might not take part in the national health program, “we couldn’t even promise that if you like your physician you can keep seeing him or her.” Yet a single-payer system would be the only game in town: while a tiny percentage of physicians might cater to the rich with boutique concierge practices, we can safely predict that the vast majority of physicians would participate in the national health program.

Why? Well, consider that even today (when there are alternative forms of insurance), some 93 percent of primary care doctors who see adults accept Medicare — essentially the same percent as those who accept private insurance. This rate would presumably be even higher under Medicare for All. Canadian physicians, after all, do quite well under the country’s single-payer system. And to ensure the same held true in the US, we could subsidize the educational costs of health care workers who participate in the national health program, as the latest proposal from Physicians for a National Health Program recommends.

Holland is on firmer ground when he moves to the issue of overall health care spending. While single payer would produce administrative savings, he’s right to note that we can’t reverse history: implementing Medicare for All wouldn’t suddenly bring US health care expenditures in line with those of single-payer countries. But so what? It doesn’t need to.

International examples strongly indicate that, at the very least, single payer should be no more expensive (in terms of overall national health spending) than what we have today. And what single-payer advocates are really arguing is not that we will soon be spending the same percentage of GDP on health care as Canada, but rather that by eliminating the enormous waste of the extractive and useless private health insurance apparatus and slashing drug prices (among other efficiencies), we will generate the savings we need to create the system we want: one in which everybody has first dollar coverage and equitable health care access.

But might there be a third, less disruptive, alternative to the status quo and single payer?

On the one hand, many other systems don’t actually do the sorts of things that single-payer advocates are calling for in the US (this is Holland’s point); on the other, single payer is not the only international example worth considering (a point that both Holland and Krugman stress).

Holland, for instance, notes that US single-payer proposals go beyond Canadian Medicare, which doesn’t cover prescription drugs or dental and eye care, causing many to buy supplementary insurance plans. This is true, yet it only reinforces the argument for a better single-payer system here. Canadian Medicare should cover those things; the fact that it doesn’t is one flaw of that overall superior system. One study, for instance, found that among eleven high-income nations, Canada was surpassed only by the US in the proportion of residents aged fifty-five and over who didn’t take medications because of cost. Not surprisingly, progressives in Canada are pushing for universal drug coverage.

Pointing out other single-payer systems’ shortcomings, then, is hardly a knock against a proposal for a more comprehensive single-payer system here.

In other respects, however, it’s not clear that single-payer advocates are asking for much more. Holland asserts, for instance, that “no other health care system offers such expansive benefits” as Conyers’s Medicare-for-All bill, which eliminates out-of-pocket costs for all health care services. While it is true that most systems have some form of (rather limited) cost-sharing, this is both unnecessary, and not universally the case, as Holland seems to suggest. There are no co-payments (much less deductibles) for doctor visits or hospitalizations in Canada or the United Kingdom. And in Northern Ireland, Scotland, and Wales, prescription drugs are free for all.

The second and larger point that Krugman and Holland stress is that some European nations have more of a mixed private-public model, and thus that single payer is not the only option. “There are lots of ways to skin this cat,” Holland writes. But while it is true that every health system is something of a snowflake, the best European examples share some key similarities. What we call single payer is basically national health insurance, which despite some (mostly unnecessary) organizational heterogeneity and complexities is what basically exists in countries like Australia, Canada, and (for the most part) France. The United Kingdom also has a single-payer system, albeit coupled with a more socialized delivery system: nationalized hospitals.

Other nations admittedly have more complex systems. Making sense of the basic nature of Germany’s system, for instance, has been called something of a “puzzle,” yet its not-for-profit system of highly regulated statutory sickness funds — jointly run by labor and employers — barely resembles the Obamacare system, and might better be seen as a decentralized form of national health insurance.

Then there is the Dutch example, often cited by those who find the incremental road appealing. However, though it is true that in 2006 the Dutch transitioned toward a somewhat more market-oriented, Switzerland-like, “managed competition” model, its system remains tightly regulated well beyond the Obamacare system; more importantly, evidence suggests that the managed competition makeover wasn’t particularly helpful, and indeed may have had a dubious impact in terms of equity and efficiency. As Kieke Okma, Theodore Marmor, and Jonathan Oberlander concluded in the New England Journal of Medicine in 2011:

The Dutch experience provides a cautionary tale about the place of private insurance competition…The idea that the Dutch reforms provide a successful model for US Medicare to emulate is bizarre. The Dutch case in fact underscores the pitfalls of the casual use (and misuse) of international experience in US health care reform debates.

Two final, key points: first, it is not clear that transitioning to a more complicated public-private model that turns insurers into nonprofit, highly regulated funds will be more politically feasible in the US than going all the way to national health insurance. The industry will fight both to the death. And second, hybrid models — like those in the Netherlands and Switzerland — are less efficient than fully public ones. If first-dollar comprehensive universal health care under single-payer produces some new costs (and it will), achieving such a system would only be that much more expensive, and perhaps truly unaffordable, when implemented within the framework — and subordinated to the interests of — the bloated private insurance industry.

In reality, neither Holland nor Krugman are recommending we adopt the Dutch model. What is it, then, that the Medicare-for-All naysayers are actually promoting in place of single payer?

Krugman mentions that the public option should be strongly considered, but that otherwise progressives should basically abandon health care reform and move on to other things. Holland, for his part, more explicitly discusses an ambitious public-option-like program drawn from political scientist Jacob Hacker, which he calls “Medicare-for-All-Who-Need-It.” But here’s the thing about both: they would not, if achieved, deliver the benefits that Medicare-for-All proponents are fighting for.

This is not simply about different ways to skin a given cat, as Holland writes, but about which particular cat we intend to skin (with due apologies to cat lovers). Single-payer advocates’ aims are admittedly ambitious, yet also quite clear: we want to eliminate uninsurance and underinsurance, and create a right to equitable, comprehensive, first-dollar health care for everyone in the country, as soon as possible. And our proposals (e.g., the Conyers bill) would achieve those goals if implemented.

The more incremental reform proposals wouldn’t. As I’ve written recently, adding a public option to the Affordable Care Act’s marketplaces would — according to the Congressional Budget Office — fail to even reduce the number of uninsured. And the admittedly far more robust Medicare for Some that Holland seems to favor would — even if it nearly eliminated uninsurance (hardly a certainty) — fail to remedy the US health care system’s other fundamental flaws.

What would it do for the growing ranks of the underinsured, including workers with employer plans who are being squeezed by rising deductibles and soaring drug costs? What would it do for those insured under Medicare, who lack access to important services like dental care, or who face cost-sharing that takes a sledgehammer to their finances? What would it do for drug prices on the national level? And how would it create the system-wide savings needed to achieve the comprehensive, first-dollar system single-payer proponents are struggling for?

Critiques like Holland and Krugman’s therefore crumble at the most basic level. With Improved and Expanded Medicare for All, we are aiming to improve health care for all — which is precisely what makes our project so politically potent, and hence possible: it is a universal program that, by giving something to nearly everybody, is designed to bring together the admittedly enormous coalition required to win it.

Those with Medicaid would retain their (often) broad benefits, but would enjoy equity of access. They’d be able to go to the same doctors and hospitals as everybody else, and perhaps more importantly, not worry about losing coverage as soon as they receive a tiny raise. Those insured by their employers (or via the Obamacare exchanges) would see their deductibles melt away, their networks expand, and the fear of losing coverage disappear forever. Those with Medicare could stop using scant household funds to buy supplementary “Medigap” plans, and would have their teeth cared for. And none of us would need to worry about getting dropped from our health coverage — or facing a medical bill, much less a medical bankruptcy — until the end of our days.

Sound good? It would be. Seem bold? Absolutely, but other nations show that it’s possible. Should Medicare for All be a litmus test? Damn right.

Adam Gaffney is a physician whose work has appeared in Salon, Dissent, and In These Times. He blogs at theprogressivephysician.org.

https://jacobinmag.com…

Dr. Adam Gaffney on ‘The Take’

PNHP national board member Dr. Adam Gaffney appeared on “The Take With Sue O’Connell” on New England Cable News on August 10, 2017, to present the case for improved Medicare for all. He addressed common concerns about logistics and financing, and added that the effort to repeal and replace the ACA had galvanized the movement for single payer.

Staff burnout in federally qualified health centers

Federally Qualified Health Center Clinicians And Staff Increasingly Dissatisfied With Workplace Conditions

By Mark W. Friedberg, Rachel O. Reid, Justin W. Timbie, Claude Setodji, Aaron Kofner, Beverly Weidmer and Katherine Kahn (all from RAND)
Health Affairs, August 2017

Abstract

Better working conditions for clinicians and staff could help primary care practices implement delivery system innovations and help sustain the US primary care workforce. Using longitudinal surveys, we assessed the experience of clinicians and staff in 296 clinical sites that participated in the Centers for Medicare and Medicaid Services (CMS) Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration. Participating FQHCs were expected to achieve, within three years, patient-centered medical home recognition at level 3—the highest level possible. During 2013–14, clinicians and staff in these FQHCs reported statistically significant declines in multiple measures of professional satisfaction, work environment, and practice culture. There were no significant improvements on any surveyed measure. These findings suggest that working conditions in FQHCs have deteriorated recently. Whether findings would be similar in other primary care practices is unknown. Although we did not identify the causes of these declines, possible stressors include the adoption of health information technology, practice transformation, and increased demand for services.

From the Discussion

Our findings are consistent with reports of increasing burnout and declining professional satisfaction among physicians across the United States, not just in safety-net clinics. However, they differ with the only assessment of longitudinal changes in provider experience during a medical home initiative published to our knowledge, in which transformation within a single Group Health Cooperative site was associated with improvements in provider burnout between 2006 and 2008. This discrepancy might be explained by differences in time frame, type of clinic (FQHC versus integrated system), and intervention design (the Group Health pilot was motivated by and designed to mitigate provider burnout). Moreover, some FQHCs have high staff turnover, and most serve patients with complex medical, behavioral, and social needs—which can make practice transformation more difficult. The finding that top-of-license scores did not improve suggests that many FQHCs in our sample may have transformed only to a modest extent. Applying for and receiving medical home recognition could have been a higher priority than transformation. In addition, when safety-net clinics have insufficient staffing levels, this can increase the risk of burnout associated with quality improvement efforts.

Conclusion

Clinicians and other staff members working in a national sample of federally qualified health center sites reported declines over time in multiple measures of professional satisfaction, work environment, and practice culture. Our analysis could not identify the factors contributing to these declines. However, as additional health system changes accumulate under the Medicare Access and CHIP Reauthorization Act of 2016 and new legislative and regulatory activity, policy makers should consider further study of how these forces could affect primary care working conditions—especially in FQHCs and other safety-net clinics.

http://content.healthaffairs.org…

***

Comment:

By Don McCanne, M.D.

Imagine the satisfaction it must bring to health care professionals to practice in an environment wherein you know that you are providing health care access to less fortunate individuals who might otherwise go without care. Furthermore, these Federally Qualified Health Centers were engaged in improving the delivery system in a manner that should increase satisfaction through attaining the highest status level of patient centered medical homes. Yet measures of professional satisfaction, work environment, and practice culture all declined in this study, resulting in provider burnout. What went wrong?

One observation might give us a clue. A similar prior effort to transform a Group Health Cooperative site into a medical home resulted in a decline in provider burnout. The authors report that “the Group Health pilot was motivated by and designed to mitigate provider burnout.” In contrast the various innovations taking place today are designed by bureaucrats and policy wonks largely based on widespread application of health policy theory flavored by ideology. They don’t get it.

Could single payer improve the situation? It could if the stewards were always keeping in mind what is best for the patient, and that includes ensuring the contentment of the health care workforce. A single payer system should automatically establish the presumption that this is all about improving the health of the patients and the community at large. It is not about providing a favorable business environment for the stakeholders even though that means perpetuating health care injustices such as lack of insurance, impaired access, financial hardship, health care inequity, and poorer health outcomes.

So one of the more important gifts of converting to a single payer system would be an improvement in attitude. We really need it.

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America’s Health Care System Kills People—But It Doesn’t Have to Be This Way

In Australia, vital services like cancer treatments are free; in the US, countless people struggle to even get screened. We spoke to cancer patients in both countries about the drastic difference single-payer health insurance can make.

By Gabby Bess
Broadly, August 9 2017

Linda Kimber is a 65-year-old retiree in Australia. When discussing how she was diagnosed with breast cancer last November, through a thick Australian accent, over the phone, Kimber is straightforward and direct. Frankly, she makes cancer sound like it’s not a big deal.

At least one part of her treatment definitely wasn’t: She didn’t have to worry about the cost of the surgery, rounds of radiotherapy, and subsequent follow-ups. Unlike in the US, where the stress of financial panic often compounds a health emergency, Australia’s universal Medicare system, which provides free health insurance for every citizen through a general tax and an additional levy on high-income earners, covered the bill.

Kimber says the care she received was stress-free as well. After she was diagnosed, she was given a list of doctors to choose from for her surgery, and it was scheduled for three weeks later at a public hospital. “Then they just told me a day for the operation and I came in on that day,” she said. “That was basically it. From there, it was all in their hands. I’ve had radiotherapy. I saw a medical oncologist, and the follow-up has been absolutely fantastic. They bent over backwards.”

Following her surgery, a nurse came to her house every day to check in on her draining tube. In addition, she says, the hospital gave her a large pink tote bag to carry around the instruments related to her drain tube care—and books to read while recovering. “It was wonderful,” she said.

Australia’s health care system is consistently ranked one of the best in the world and the best for positive health outcomes. Every Australian is covered by public insurance and the option also exists for people to buy additional private insurance. For regular doctor’s visits in the public system, Australians either pay nothing or a small copay over what Medicare reimburses. (It’s up to physicians to decide whether or not they charge a copay, and low-income citizens, citizens over 65, parents with a child under the age of six, and children under the age of 16 never pay a copay. Many doctors choose to waive the copay, or bulk bill, to attract patients and to make sure that money isn’t a barrier to access.) And after that, if your doctor refers you to a specialist or recommends surgery to manage a condition, all visits and treatments are free.

Australia also has free, national preventative programs, since it’s in everyone’s best interest to detect diseases early on, when they’re less expensive to treat. In Kimber’s case, BreastScreen Australia, which calls in women between the ages of 50 and 74 for a free mammogram every two years, was able to detect the tumor in her breast while it was small and before it could spread to other parts of her body and cause additional, more serious complications. “Her prognosis is good,” her general practitioner, Dr. Marie Shieh, told Broadly. In two weeks, Kimber has an appointment with her oncologist and an ultrasound, where she will find out if she is in remission.

When I asked Kimber if she would have wanted to go through cancer treatment in America, her answer was a resounding no. Who could blame her? In comparison, health care in the US is a gamble, and if you have cancer you might not also have health insurance.

Some people receive insurance through their employers, which might be comprehensive or skimpy, expensive or not. Others get it through the byzantine system of the Affordable Care Act exchanges, in which private insurers receive subsidies from the government in order to be able to eliminate preexisting conditions and keep costs down. People who fall below the poverty line and the elderly are insured through Medicaid and Medicare, respectively.

This patchwork of insurance schemes leaves holes everywhere. Without guaranteed, universal coverage, many Americans have to make dangerous calculations when they’re sick. Instead of being automatically provided with the care that they need, they have to ask: Should I see a doctor or save the money?

Those who argue that the US government should directly pay hospitals and doctors for everyone’s care are always met with the same rebuke: It’s simply impossible to move the country to such a system. But it’s really our current system, not single-payer health care, that should evoke incredulous reactions. Health care in the United States consistently ranks last among wealthy countries, despite being the most expensive by far.

Kimber says she doesn’t know how Americans get by without the health security she has. “I think [health care in the US] is horrendous, to be honest. I think it’s absolutely disgusting,” she said. “If it’s the middle of the night and you’ve got chest pain and something could be wrong with your heart, you wouldn’t want to be lying there thinking that you can’t afford to go to the hospital. How terrible is that?”

Dr. Shieh, now a general practitioner in Australia, used to be a family doctor in the US. Practicing medicine stateside, she saw firsthand how cruel our health care system is—and when she moved to Australia, she saw how much better it could be.

“When I was in the US, I knew there was a problem, but I didn’t know what the solution could be. I worked in places where patients couldn’t afford the medicines I had prescribed, where I would try to refer them to specialists and their insurance wouldn’t cover those referrals, where they wouldn’t come back to see me because it was too expensive,” she said. “Once I couldn’t order an electrocardiogram because it was too expensive for the patient. I just felt bad for people. I realized a lot of people just couldn’t afford health care.”

Ryan Wanninger, now 40, didn’t have insurance when he was diagnosed with cancer two years ago. As a self-employed IT technician and freelance music instructor in Boston, he made enough money to disqualify him from the state’s Medicaid program—MassHealth—and he didn’t receive employer-sponsored insurance. Some years his IT business would do better than others, so on the good years he signed up for a health insurance policy, and when money was tight he dropped his policy and went without it.

Then the 2008 financial crisis hit. “When the economy crashed I lost half of my clientele in one week. They all called me and canceled contracts, dropped services, maintenance, everything,” he said over the phone. “I had a couple big jobs that I had bid on—all of those were canceled. Every business was panicking when the economy tanked. That was horrendous.” For the next few years he steadily forwent insurance because he no longer had the money to spare as he was trying to build his client list back up.

In early 2014, a few months after the ACA exchanges were up and running in Massachusetts, Wanninger finally attempted to get insurance again now that he had the money. But the state’s ACA-compliant website was a complete failure. “Despite trying several times to use the website I was unsuccessful,” he said. “I spoke with personnel over the phone about this because the national deadline was quickly approaching. I was first told that all applicants were having similar problems and that nobody was successfully signing up for any plans.”

Wanninger says was told that because of the site’s technical issues, he would be able to sign up after the national deadline. But when he tried again to get insurance through the exchange he was denied. Two months later, while Wanninger was finishing up a job, he started to feel horribly sick.

“I got in my car and I looked in the rearview mirror, and I saw my eyes were yellow and my skin was yellow. I was jaundiced,” he explained. “I wasn’t even sure I could drive home that day because I felt like I was going to pass out. I had to call a friend to talk to me just to keep me awake, and I drove right down to the hospital.”

In the hospital parking lot, he called one of his guitar lesson clients, who happened to be a doctor there, for help because he had no health insurance or regular doctor. The doctor did blood work tests on Wanninger over several days and found large numbers of cancer antigen in his bloodstream. To find out exactly where the cancer was in his body, Wanninger needed a CT scan, but his lack of insurance became a problem.

“The CT scan was tricky,” he said. “The hospital didn’t want to allow me to have a CT scan—it was very expensive, a few thousand dollars, and I didn’t have insurance to cover it.”

Panicking and ill, he went to the counselor at the hospital to see what his financial aid options were. By some miracle, he says, he happened to be in luck: As Massachusetts’s state health care system struggled with the transition to comply with the ACA, the state government allowed anyone to sign up for Medicaid, even if they didn’t meet the income requirements.

The next morning he was able to meet with an oncologist, where he found out his prognosis was dire. He had a tumor on his colon, the original site of the cancer; a tumor on his liver, which had caused the jaundice; and tumors on his lungs. He was 24 hours from going into septic shock, his doctors informed him. If he hadn’t been able to get a CT scan when he did and go in for surgery, he would have died.

“I’m lucky in some respects, but health care shouldn’t rely on luck,” Wanninger said. He was able to stay on the state’s Medicaid program for seven months before the state finished the conversion to meet all the mandates of the ACA and they were able to review the cases of the applicants who had been covered by MassHealth during the transition period.

In other respects, however, he’s not so lucky. By the time the seven-month period ended, Wanninger’s condition worsened to the point where he had to stop working, so he qualified for Medicaid outright. When his cancer was detected it was already advanced; as of three months ago, the last treatment available to him stopped working.

Wanninger says the US health care system is to blame for his now-terminal status. “In retrospect, it was pretty clear that I had been neglecting myself and had been neglected by doctors, back when I had one, and the health system,” Wanninger said in a video he made about his health care struggles in support of single-payer health care. “My father died of the same colon cancer at the age of 37 back in 1986. No one told me that because of this I should have been having regular colonoscopy screenings every three to five years, starting in my twenties.” And in any case, he added in our interview, he didn’t have health insurance to cover a colonoscopy.

“Health care should be a right. People should be able to have basic scans, testing, and things that can catch major diseases before they become a problem,” Wanninger said. “My life will most likely be shortened because of this, and that’s not fair to me. This could have most likely been prevented. A colonoscopy would have found a small tumor and it could have been removed safely.”

Wanninger’s treatments have all been covered through Medicaid, but, as he puts it, he’s “lucky.” As he works through his bucket list items—a trip to Spain funded by money his friends pooled together, a solo guitar concert that he will be putting on, which his doctors will attend—and looks to experimental trials for a possible cure, he at least does not have to file for bankruptcy. He says that within the first month of his diagnosis, he racked up $60,000 worth of bills, which he would not have been able to pay. In total, he says he treatments have cost more than $1 million.

“It’s pretty obvious that the way our system is now doesn’t work. We have to do something better,” he said.

Despite the passage of the Affordable Care Act in 2010, 27 million people are still uninsured. Many people, like Wanninger, have been left out by the complicated scheme devised to make private insurance market tenable. People who are insured by the ACA have found that costs have been rising out of the realm of affordability because, as it turns out, giving sick people health care coverage isn’t profitable for insurance firms. Even more are underinsured, meaning they have insurance that doesn’t actually cover their health care costs.

Universal, single-payer insurance would entirely eliminate this dysfunction. And with the amount we spend on our piecemeal health care system—through premiums, Medicaid, Medicare, the ACA, and the VA—universal health care is not fiscally out of reach. Currently, the cost of managing chronic diseases accounts for 75 percent of the nation’s health spending, according to the CDC; giving everyone access to free, preventative services would cause this to go down.

Cutting out the middleman—insurance companies—would also drive down costs. “What single-payer proposes is actually very simple,” Dr. Carol Paris, the president of the advocacy group Physicians for a National Health Program, which has written a policy paper on what single-payer could look like in the US, told Broadly. “Take all of the money we’re currently spending in a very fragmented way on the financing of health care and create one risk pool. That’s the single payer. It’s really just a way of eliminating the administrative waste, and the profit of the health insurance industry that contributes nothing to the health of the American people.”

By doing this, Paris says, we would save about $500 billion a year. “That’s just by eliminating the bureaucratic waste and profit of the health insurance industry,” Paris adds. “Then if we also negotiated drug prices, which we would be in a much better position to do, as a single negotiator for every person in the country, we could save another hundred billion dollars a year.”

Paris says a single-payer system is “the only sensible way to manage the financing of health care.” There are certainly flaws with Australia’s health care system, as well as with the universal coverage schemes in other countries, “but it’s absolutely better than what we do in the United States,” she said. Ironically, a major problem with health care in New Zealand, where Paris has worked, and in Australia is that private insurers are allowed to exist alongside the public system. “But they don’t ration care based on your ability to pay for it. No one is turned away because they can’t afford care,” Paris explained.

Now that the Republican’s draconian efforts to repeal the ACA have been stalled, it’s time for the Democratic party to stand up for something more ambitious; the proposed “bipartisan reforms” to the Affordable Care Act are not enough. For most people who live with the burden of the US health care system, the need for single-payer is clear. There’s been growing support for single-payer over the last year, but Paris says we still have a long way to go to bring politicians on board with the idea.

“We are going to have to have a movement of movements. The American people are going to have to make it toxic for our members of Congress not to get on board with this,” she warned. “When they actually feel like their ability to get elected is weighing in the balance, they’re suddenly going to become outspoken advocates for a national health program, but they’re not going to do it until then.”

Wanninger says that if his story can help build that movement by changing even one person’s mind about single-payer, that would check off another item on his bucket list.

https://broadly.vice.com…

Single-payer health system can be had with U.S. ingenuity

By Carol A. Paris, M.D.
Alaska Dispatch News (Anchorage), August 9, 2017

In his column regarding a single payer health care system (ADN, Aug. 2), Charles Wohlforth rightly points out Americans currently spend more per person for health care than any other developed country. What do we get for our yearly $3.2 trillion? Compared to other industrialized nations, we rank 25th in preventable deaths, we leave 28 million uninsured, and our businesses are losing their competitive edge due to the cost of employee health insurance.

Attempts at incremental, market-based reforms have failed to return our nation to its position as a global leader in health care. But it is not beyond our grasp. A single-payer solution would save $500 billion annually by eliminating the “middle men,” the private insurance companies and their third-party administrator subsidiaries that siphon profits out of the system, but contribute nothing toward patient care.

Wohlforth notes investor-owned health care entities such as for-profit hospitals, surgery centers and nursing homes would be required to reorganize as nonprofit entities under a single-payer plan. But he is wrong to equate removal of the profit motive with “massive nationalization of private assets and individuals’ careers.” To be clear, the delivery of care would remain as it has always been: a mix of public (VA and IHS) and private care. Hospitals and doctors’ offices would be privately run. We simply need to eliminate the profit motive and conflicts of interest that drive up health care costs for everyone.

The Senate’s failure to repeal the Affordable Care Act has opened up a new national dialogue on the future of health care. While some may argue for more market-based tweaks to our health system, Wohlforth correctly points out in a previous column that “increased competition” can never work in rural states like Alaska because of its small population and isolation from larger markets.

We can either act boldly to achieve universal, high-quality health care at lower costs, or we can bow to Wohlforth’s assessment that it can’t be done. As for me, I’ll put my faith in American ingenuity and determination any day.

Dr. Carol Paris is a psychiatrist and president of Physicians for a National Health Program. She resides in Nashville.

https://www.adn.com…

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Doctors Warm To Single-Payer Health Care

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Survey: 42% of Physicians Strongly Support a Single Payer Healthcare System, 35% are Strongly Opposed

Kaiser Health Tracking Poll – August 2017: The Politics of ACA Repeal and Replace Efforts

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NBER Working Paper 23668: Subsidizing Health Insurance for Low-Income Adults: Evidence from Massachusetts

Altruism, the Samaritan’s Dilemma, and Government Transfer Policy

Distribution of the Nonelderly Uninsured by Federal Poverty Level (FPL) in 2015

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Out-of-Pocket Costs, Financial Distress, and Underinsurance in Cancer Care

Widowed Early, A Cancer Doctor Writes About The Harm Of Medical Debt

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California talks big on health, but so few docs take Medi-Cal that it violates civil rights

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Don’t believe the critics. Medicare for All is the most realistic way to win universal, equitable health care.

Federally Qualified Health Center Clinicians And Staff Increasingly Dissatisfied With Workplace Conditions

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In Australia, vital services like cancer treatments are free; in the US, countless people struggle to even get screened. We spoke to cancer patients in both countries about the drastic difference single-payer health insurance can make.

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