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Single payer vs. universal public coverage through managed competition

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Single payer vs. universal public coverage through managed competition

Universal Health Coverage? Why?

By Walter McClure, Alain Enthoven, and Tim McDonald
Health Affairs Blog, July 25, 2017

The Congressional health care debate has become a war between two seemingly irreconcilable extremes, coverage versus budget control. Health care is a right, thunders Bernie Sanders (I-VT). There’s no free lunch, roars back Rand Paul (R-KY). We think both sides miss the boat. Forcing health care into this simplistic left-right straitjacket misleads the nation. It is time to recast the issue properly.

Public Investment

Universal health coverage is better viewed as neither owed to us by government nor a govern­ment give-away; both labels misinform. A more insightful analogy is universal public edu­cation. Does government owe people a public education? Is universal public educa­tion a handout to “takers” who ought to go out and buy it on their own?

When universal public education was first proposed, many of the privileged might have said, what do you want to educate “those” people for, you are just throwing away our tax dollars; if people wish education for their children, let them go out and buy it … ignoring that many could not afford it. Fortunately, we did not listen. We wisely invested in public education for all, and the productivity of our workforce boomed.

In the same way, universal health coverage is a wise public investment. Done right, it will return far more to our national prosperity than it costs in tax dollars.

Perverse Incentives

The crucial caveat is “done right.” Neither Medicare, nor Obamacare, nor the unsound private health insurance market have yet done that kind of broad public investment right. All three lack serious incentives on providers to focus on the long-term, reducing cost while raising quality and keeping people healthy; indeed, the incentives are to raise cost no matter the quality. In particular, all three totally lack either means or incentives for patients to iden­tify and choose providers who are better for less over those who are more costly.

The left’s faith in “single-payer” has proven ill-founded; we have had a public single-payer program for 50 years, Medicare, that absolutely controls the over-65 market. Yet despite the best efforts of the agency its costs still balloon out of control. The right’s faith in the private health care and insurance markets has proven equally ill-founded because both are severely unsound and, as Adam Smith taught us, unsound markets do not self-correct. As a consequence, in the same five decades the private market has done no better than Medicare on cost control. Five decades of efforts by both approaches using bureaucratic controls, micro­manage­ment, and token bonuses to make providers efficient have failed to contain run-away cost.

Looking Beyond The Symptoms

If the object is to broaden and improve the productivity of our workforce, then trying to contain cost by butchering eligibility, benefits, or quality of care and coverage is false economy of the worst order.

The correct approach to true cost containment is to drastically improve the quality and productivity of our bloated medical care system.

It’s not that we don’t know how to practice this kind of medicine, ample research studies show we do. It’s that the present system punishes providers with less revenue if they seriously try, and the most efficient are hurt most of all. It rewards those who run up costs regardless of quality. And because most medical care is a judgment call, there is no way that bureau­crats can second-guess doctors into serious cost contain­ment. But, patients, if properly informed and incented and thereby enabled to freely choose providers for value, would hold them to account by their choices far better than any regulators, public or private, ever could.

In other words, the runaway cost and compromised quality of our present health care system are symptoms of a deeper diagnosis: powerful perverse incentives. Policy keeps missing the diagnosis and treating the symptoms

Moving Beyond ‘Single-Payer Versus Private Market’

We need patients choosing among provider groups and delivery systems, not individual services. Patients generally don’t know what services they need, that’s why one goes to medical school; so a market of individual services makes no sense. Choosing a provider group, on the other hand is something we can expect of informed patients. And once provider groups learn that patients are choosing them based on the value they provide, those groups will begin choosing to deliver the services and referrals that get the best results at least cost, and may, desirably, begin to consolidate into more efficient integrated delivery systems. In short, if we turn the present perverse incentives around—by giving patients (1) objective ratings showing which provider groups are better for less, and (2) rewards consumers to choose them over costly providers (both objectives feasible in practice)—we can, slowly but surely, turn our health care system around into the high-quality, efficient system we seek for our children, our workforce, and our elderly.

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Comments:

By Richard N. Gottfried (Chairman of the New York Assembly Committee on Health):
 
Any set of payment methodologies or delivery system reforms can be done in a way that does good or ill. If we have insurance company payers, they will use their power to serve their interests well, not ours. With a public payer, there is a much better chance that the payer will work for change that is in the public interest. And if the wealthy and powerful are in the same boat as the rest of us, they will make sure they’re in a good boat, and the rest of us will benefit. Yes, a universal coverage system should be “done right.” A single-payer system is how we have the best chance at a system that serves the public, not insurance company stockholders. And a single-payer system enables us to remove financial barriers to care and pay for it fairly, based on ability to pay.

By Don McCanne, M.D.

It’s great that the authors remind us about some of the serious policy defects in our health care system, but there are a few issues here that warrant special comment.

Kenneth Arrow told us why markets do not work well in health care. The efforts to provide patient-consumers with price and quality information have not been very effective, whereas inducing price sensitivity through cost sharing, especially large deductibles, provides an example of an approach that the authors warn us against – “trying to contain cost by butchering eligibility, benefits, or quality of care and coverage.” Unleashing health care shoppers is not the path to value.

The authors have long supported competition between truly integrated health care delivery systems – “managed competition.” But assume each system provides comprehensive services. Oversimplifying, yet making a point by using a graphic construct, imagine four competing integrated systems located on four corners of a central intersection in a large city, each with a full complement of services, including specialized services such as cardiac surgery units or neuroscience centers. That duplication of services obviously is wasteful, not to mention that it would still be difficult to shop which integrated system to join for all future care. Since clustering them is not logical, should we spread them out so they serve the four quadrants of the city? Then health care shoppers are more likely to choose based on geographical considerations since bypassing your own center to go to one of the others would impair access because of transportation challenges, not to mention that having coverage under one system would prevent access to noted specialized services in the other centers. And satellite clinics? Do the four systems provide four competing clinics in each suburb or rural community?

It would be far better to have our entire healthcare system integrated. That can best be done though central planning and separate budgeting of capital improvements. That would greatly diminish the waste that we now have because of duplication in competing systems, while ensuring that access to appropriate facilities and services would be more optimal.

In contrasting free market solutions with a publicly financed and administered single payer system, the authors suggest that these are two extremes of political ideology, creating a “simplistic left-right straitjacket.” But when you look at the important issues in health care such as universality, access, affordability, efficiency, equity, and choice of health care providers, it is the public system and not the private market that is designed to ensure that those goals are met. Think of the freedom in the traditional Medicare program and contrast that with the private insurance system (narrow networks, high premiums, high deductibles, instability of coverage, administrative waste, inequity, etc.), and the straitjacket seems to be in the market.

A well designed single payer system – an improved Medicare for all – would provide a framework in which to incentivize quality and value. Integrated systems such as Kaiser Permanente would still provide services within a single payer financing system, but displacing our entire health care delivery system with a cluster of Kaiser Permanente-type entities is not a practical or efficient solution.

(There are also excellent comments by Sarah K. Weinberg and Johnathon Ross available at the link below.)

http://healthaffairs.org…

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Comment:

By Don McCanne, M.D.

The authors support public universal health coverage while rejecting single payer on the left and private insurance markets on the right as “two seemingly irreconcilable extremes, coverage versus budget control,” yet they advocate for competing integrated delivery systems – Alain Enthoven’s dream of “managed competition.”

Dismissing the “simplistic left-right straitjacket” as if it represented two equally ill-advised extremes is in itself a simplistic approach to health policy. The recent Republican effort to get private health insurance right is only the latest example of the deficiency inherent in the fragmented private insurance and public program model of financing health care. We have had over half of a century of experience to prove that it doesn’t work.

In contrast, a well designed single payer model not only resolves most issues with the financing of health care, but it also improves the distribution and efficiency in utilization of resources (see https://www.pnhp.org/nhi).

The authors’ suggestion that the entire health care delivery system be integrated into individual competing delivery systems, like Kaiser Permanente, does not substitute for many of the design features and goals of a single payer system. Plus the concept introduces new logistical challenges such as inefficient duplication of facilities and services, and failure to cover regions that do not support the business plans of the integrated systems.

Patient choice of integrated delivery systems can certainly be included in a single payer system, but such integrated systems alone cannot duplicate all of the important functions of a single payer system that would ensure true universality, access, affordability, efficiency, equity, and choice of health care providers.

Health care professionals and institutions could still compete on perceived quality and service, but we should use central planning to avoid inefficient, wasteful duplication of facilities and services under the theory that we should be promoting price competition in the marketplace. Public administered pricing based on legitimate costs and fair margins is more effective and more efficient.

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After Trumpcare

Republicans wanted to repeal Obamacare and gut Medicaid. Instead they galvanized the push for Medicare for All.

By Adam Gaffney, M.D.
Jacobin, July 30, 2017

The life of Trumpcare was, to repurpose Thomas Hobbes’s words, “nasty, brutish, and short.”

Born in March in the Republican-controlled House, Trumpcare succumbed in the Senate this past week thanks to its fundamentally defective design and pitiable unpopularity, along with the relentless pummeling it received from enraged constituents across the country. After a dramatic vote Thursday night on the final “skinny” version of repeal, it seems safe to say that Trumpcare is now finally where it belongs: six feet under.

The ramifications of this saga will be many and long lasting. One possible effect is a rather paradoxical one: Trumpcare’s architects were intent on undermining the progressive elements of the health care system (for instance, by gradually squeezing Medicaid and degrading protections for the chronically ill), yet they may have wound up bolstering them — most notably, by sparking widespread indignation and resistance.

For though a host of factors helped bring down Trumpcare, we shouldn’t neglect the role of activists — whether it was disability-rights organizations like ADAPT or left groups like Democratic Socialists of America — who never let the bill’s human cost fade from public view.

Vox’s Jeff Stein chronicled many of their actions in recent months: the eighty activists from twenty-one states who were arrested after bursting into the offices of some eighteen Republican lawmakers earlier this month; the disabled Coloradans — several in wheelchairs — who camped out for days in Sen. Cory Gardner’s office in late June; the roughly fifty brave disabled individuals who were hauled away by police for opposing Trumpcare in Sen. Mitch McConnell’s office about a month ago.

The pressure simply did not let up, especially during the final stretch. As Senate Republicans moved into the eleventh hour of their repeal effort this week, protestors hounded them from the chamber’s gallery, chanting: “Don’t kill us, kill the bill!”

Trumpcare ultimately fractured the Right. But it powerfully united grassroots progressives and leftists.

A related factor in Trumpcare’s death was progressives’ swift victory in framing the debate in the moral language of life and death. Scoring from the Congressional Budget Office — which estimated that Trumpcare would leave 20 million more people uninsured — was widely cast as damning, and various observers proceeded to quantify the bloodshed that could be expected to flow from such a reckless withdrawal of health care access.

Republicans couldn’t own any of this. Instead they were forced to respond with a hopelessly ineffective combination of obfuscation and deceit. Earlier this month on Fox, for instance, Secretary of Health and Human Services Tom Price made the comical claim that “we’re going to be able to cover more individuals on this bill than are currently covered.”

Yet Price’s lie can also be seen as almost encouraging: it was essentially a concession that universal coverage should be our common moral ambition.

Similarly, consider the emotional debate over “pre-existing conditions.” The idea that people should be punished for their illnesses received widespread condemnation throughout the Trumpcare debacle (witness Jimmy Kimmel’s viral monologue about his sick newborn son), but for the most part, the House and Senate bills included provisions that would have effectively worsened protections for the sick. Again, Republicans had to respond to criticism with duplicity, as when President Trump tweeted that Republicans would surely be “taking care of pre-existing conditions!”

Even before they lost the repeal battle, in other words, Republicans had already lost the moral war. As a result, the Obamacare repeal effort — or more precisely, the response it provoked — may have inadvertently strengthened the conceptualization of health care as a basic social right.

Conservative commentator Charles Krauthammer conceded as much back in March, noting that Medicare for All could be the next logical demand in the coming years.

After all, the case has now been made that uninsurance is a species of violence. So if it is morally abhorrent to leave nearly 50 million uninsured (as Trumpcare would have done), why is it acceptable to leave 28 million uncovered (as the status quo law will do)?

And if it is beyond the pale to punish people with pre-existing conditions by charging them higher premiums, how is it appropriate to force them to pay handsomely at the point of health care use (through deductibles) simply because they have more medical needs?

It’s worth restating again: there is now a broad consensus that being sick should not mean paying more for health care through premiums. This exact same logic, however, would seem to preclude forcing the sick to pay more for health care through cost sharing. There simply is not much daylight between risk-adjusted premiums and deductibles: both function as types of taxes on the sick.

The activists resisting Trumpcare decried uninsurance and underinsurance as gravely immoral, framing that helped slay the venomous bill. But these ideas — and these passions — will not now suddenly melt away in the summer heat.

Trumpcare’s authors were hoping to deliver the coup de grâce to health care universalism. Instead they seem to have galvanized it.

The health care journey, then, is far from over. This time, however, it will be progressives and leftists at the helm, with Medicare for All the increasingly discernible destination on the horizon.

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

https://jacobinmag.com…

Single-payer is simpler and fairer

By Susan Miller, M.D.
Richmond (Va.) Times-Dispatch, July 30, 2017

Regarding the Commentary column, “Single-payer ‘dream’ would be a nightmare for Americans,” by Chris Renkar: On the contrary, the Improved Medicare for All Act, HR676, would be a godsend for Americans. The only loser in the fight to expand Medicare is the insurance industry. Under HR676 all Americans are automatically enrolled. All medically necessary care, drugs, equipment, hospitalizations, hospice, dental and eye care are included.

What the promoters of the insurance market fail to admit is that the market for health care is unlike the market for other consumer goods. The ability to make an informed choice about health care services is highly constrained by unequal information between the patient and the physician and the need for services right now.

The ACA exchanges are narrowing and prices are rising because of the failure of the for-profit insurance markets. The reasons for increasing delays in the U.K. are due to the Conservative government trying to privatize the National Health System. In most universal systems, the government collects money to pay the independent physicians, pharmacists, and hospitals for the care of citizens. There will always be a decision about whether taxes go to education, roads or the military versus health care. In the U.S. we ration based on one’s ability to pay. We pay more than twice the per-capita cost of the universal systems and have worse health statistics in nearly all important metrics.

Two things stand in the way of a simpler, less expensive and more fair health care system: political will and the health insurance industry.

This fight is essentially a moral one. Do we believe health care is a commodity or a human right; a social good like education that benefits our entire society by ensuring a competitive workforce and a level playing field for businesses, or just another way to make money from the illnesses of others?

http://www.richmond.com…

It’s Time for the Adults in This Nation To Talk Seriously About Medicare for All

Today, we breathe a quick sigh a relief. But we cannot celebrate a return to the failed status quo.

By Carol Paris, M.D.
Common Dreams, July 28, 2017

Hundreds of people slept overnight in cars, or camped for days in a field. They told stories of yanking out their own teeth with pliers, of reusing insulin syringes until they broke in their arm, of chronic pain so debilitating they could hardly care for their own children. At daybreak, they lined up for several more hours outside a white tent, waiting for their chance to visit a doctor. For many, this was the first health care provider they’ve seen in years.

Is this a place torn by war, famine or natural disaster? No, this charity medical clinic was last weekend in southwest Virginia, in the wealthiest country in the world, where we spend nearly three times as much money on health care as other similar countries.

And what do we get for our money? The very definition of health care rationing: 28 million Americans without insurance, and millions more insured, but avoiding treatment because of sky-high deductibles and co-pays. Compared to ten other wealthy countries, the U.S. ranks dead last for life expectancy, and access to care. We even have the lowest number of hospital beds per capita, a way that health experts measure the capacity of a nation’s health system. It’s as if our system was designed to deny care.

America does hit the top of the list in some areas. Compared to other nations, American doctors and patients waste the most hours on billing and insurance claims. We have the highest rate of infant mortality, and the highest percentage of avoidable deaths—patients who die from complications or conditions that could have been avoided with timely care.

Clearly, this system is broken. Like a cracked pipe, money gushes into our health care system but steadily leaks out. Money is siphoned into the advertising budgets of insurance companies and the army of corporate bureaucrats working to deny claims. Even more dollars are soaked up by the pockets of insurance CEOs who have collectively earned $9.8 billion since the Affordable Care Act was passed in 2010. Nearly a third of our health care dollars go to something other than health care.

President Trump recognized voters’ frustration and campaigned on a promise of more coverage, better benefits, and lower costs. We couldn’t agree more with these goals. However, instead of trying to fix our broken system, GOP leaders are acting more like toddlers, mid-tantrum, smashing our health system into smaller and smaller pieces, threatening to push even more Americans—the most vulnerable among us—through the cracks. Last night, a few Senate Republicans stood up and acted like adults, putting an end to this dangerous game.

Today, we breathe a quick sigh of relief. But we cannot celebrate a return to the status quo, a system that rations health care based on income and allows 18,000 Americans to die each year unnecessarily.

Where do we go from here?

Republicans had eight years to come up with a plan that achieves more coverage, better benefits and lower costs. Have our elected leaders simply run out of ideas?

The good news is that we already have a proven model for health financing that is popular among both patients and physicians. It provides medically-necessary care to the oldest and sickest Americans with a fraction of the overhead of private insurance. It’s called Medicare, and I can tell you as a physician that it has worked pretty darn well for more than 50 years.

Not only do we have a model, we have a bill that would expand Medicare to cover everyone and improve it to include prescriptions, dental, vision, and long-term care. It’s called H.R. 676, the Expanded and Improved Medicare for All Act, a single-payer plan that would provide comprehensive care to everyone living in the U.S. The bill would yield about $500 billion annually in administrative savings while covering the 28 million currently uninsured. Medicare for all is gaining steam with a record 115 co-sponsors, a majority of House Democrats.

Now that Republican senators have finally worn themselves out, Sen. Bernie Sanders plans to file his own single-payer Medicare for all bill. Senators from both parties will be asked to choose a side: Do you support the current system of health care rationing, medical bankruptcies and unnecessary deaths; or a program proven to work both here and in every other developed country?

A majority of Americans now believe that health care is a human right, and that it is our government’s responsibility to achieve universal coverage. We’ve tried everything else except Medicare for all. What are we waiting for?

Dr. Carol Paris is a psychiatrist and president of Physicians for a National Health Program (PNHP).

https://www.commondreams.org…

The obvious Obamacare replacement, but when?

The obvious Obamacare replacement has been here all along

By John Garamendi
The Sacramento Bee, July 27, 2017

The ongoing uncertainty in Congress surrounding health care legislation, and the intentional sabotage of the Affordable Care Act, is destabilizing the insurance marketplace, driving up costs, discouraging new enrollments, and making Americans worried about the future of their health care.

In the short term, Congress should shore up the Affordable Care Act with bipartisan, commonsense improvements, such as a reinsurance program to stabilize the market for high-risk policyholders, legislation to make cost-sharing reductions permanent, and government permission to negotiate for lower prescription drug prices. But in the longer term, the time is right to think about ways to make access to health care truly universal and cover those who are still left behind. By far the simplest solution is Medicare For All.

Opponents may point to the difficulties California has had in trying to implement its own state-based universal health care system. A stand-alone plan in California would somehow have to incorporate existing federal health insurance programs – an impossible task given the political realities of the Trump Administration.

But a federal Medicare for All program would face no such obstacles: It would simply use the existing Medicare infrastructure and expand it to cover everyone.

Seniors know the peace of mind that comes from having the guarantee of health insurance. Imagine if all Americans could say the same.

John Garamendi represents the 3rd congressional district in California.

http://www.sacbee.com…

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Comment:

By Don McCanne, M.D.

As soon as John McCain joined Susan Collins and Lisa Murkowski and cast the vote that defeated the Republican effort to repeal and replace Obamacare, Senate minority leader Chuck Schumer repeated McCain’s earlier plea to return to regular order and reform health care on a bipartisan basis through the usual committee process. That inevitably leads to incremental change, if any change at all, which would have only a negligible impact compared to the need that exists.

Americans previously understood the deficiencies of the Affordable Care Act, and now they have been shown that reducing a government role in oversight of the private insurance industry would never fulfill the promise by the politicians of better care at a lower cost. Americans are ready for a national health program, and that is reflected in the response of the 115 members of Congress who are cosponsoring John Conyers’ HR 676, the Expanded & Improved Medicare for All Act.

Congressman John Garamendi of California represents the enthusiasm for a federal Medicare for All as he explains in his op-ed. But he joins other members of Congress in qualifying his support by saying, “In the short term, Congress should shore up the Affordable Care Act with bipartisan, commonsense improvements.” “But in the longer term, the time is right to think about ways to make access to health care truly universal and cover those who are still left behind.” Now is not that time?

“Single payer but not now” has become the byword of the incrementalists. If we move forward with an emasculated public option or an unaffordable Medicare buy-in, the process will come to halt, likely for decades, while we “see how this works.” We do not need more policy experimentation. We know what works. Single payer, Medicare for all, or whatever you want to call it, but let’s do it now!

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Senate defeats single payer amendment

By Don McCanne, M.D.
United States Senate, July 27, 2017

In the Senate an amendment to the Republican repeal and replace legislation was introduced by Sen. Steve Daines (R-MT) that would establish a single payer system in the United States – an expanded and improved Medicare for all – using the exact same language as in HR 676 introduced in the House by Rep. John Conyers.

The vote:
0 – Yes
57 – No
43 – Present

All Republicans, including Sen. Daines, voted against it. Democratic Senators Donnelley, Manchin, Tester, and Heitkamp, along with Independent Senator King, voted against it. All other Democrats voted Present.

Sen. Bernie Sanders had said before the vote that failure of Sen. Daines and other Republicans to vote for their amendment would demonstrate that this was a sham to be used to campaign against moderate Senators in the next election. When no Republican voted for it, most Democrats plus Independent Sen. Sanders voted Present.

It is a sad commentary that the most important health policy legislation ever introduced in Congress – legislation that would have brought health care justice to all – was used by the Republicans as a tool for political chicanery.

Do they think this was some kind of a joke? They just rejected legislation that would have prevented hundreds of thousands of people over the years from facing physical suffering due to lack of medical care, financial hardship, and even death. Death!

We could forgive them for a bad joke, but this?

Mobilize the forces. This is war! Not the guns and bombs type of war but a war against man’s inhumanity to man.

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Man was made to mourn: A Dirge

Many and sharp the num’rous ills
Inwoven with our frame!
More pointed still we make ourselves
Regret, remorse, and shame!
And man, whose heav’n-erected face
The smiles of love adorn, –
Man’s inhumanity to man
Makes countless thousands mourn!

–  Robert Burns, 1784

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Jimmy Carter on board for single payer

Jimmy Carter Believes U.S. Will Eventually Go to Single-Payer Health System

By Louise Radnofsky
The Wall Street Journal, July 23, 2017

Former President Jimmy Carter said he believed the U.S. would in time adopt a fully government-run health insurance system, or “Medicare for all,” in remarks ahead of his Sunday school class here. “I think eventually we’ll have a single-payer system,” said the former U.S. leader.

https://blogs.wsj.com…

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Comment:

By Don McCanne, M.D.

President Carter, welcome aboard.

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Should PNHP postpone single payer and advocate for incremental reform?

Single payer can’t happen in California. At least, not right away

By Steve Tarzynski
Los Angeles Times, July 25, 2017

Given the dismal state of healthcare reform in Washington, liberal Californians have rallied around the idea that the state should establish a single-payer program. Although in the future such a system would be workable and desirable, the reality is that at the moment a single-payer bill cannot pass. Fighting for one in the immediate term is a waste of time.

But by 2020, California might just be ready for single payer — if advocates achieve a string of smaller but important legislative victories to build power.

Such steps might include: a state individual mandate; a state employer mandate that also covers part-time workers and their dependents; continued guaranteed coverage for children in the country illegally; giving the state insurance commissioner the power to regulate insurance premiums; setting a process to negotiate drug and medical device pricing; administrative reforms to streamline Medi-Cal so that there is less waste and better coordination and continuity of care; engaging the state’s tech sector to assist with such streamlining; advancing nonprofit delivery systems and moving away from fee-for-service practice; and opening up Medi-Cal to everyone, which would effectively create a state public option robust enough to compete on a level playing field against private insurers.

We do not need yet another devastating loss. Time, treasure and effort would be better spent winning the series of smaller victories that create the pathway to single payer. And in four years, a substantially stronger single-payer movement could successfully lobby a new Congress and president for federal waivers.

More than a century ago, Theodore Roosevelt called for a system of national health insurance. Single-payer advocates have been working for decades. They’ll have to work a few years more.

Steve Tarzynski is a physician and president of California Physicians Alliance.

(For a fair representation of Steve Tarzynski’s views, be sure to read the full article available at the link below.)

http://www.latimes.com…

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Comment:

By Don McCanne, M.D.

How much incremental reform do we need before we are ready to enact a single payer system, whether at the state or federal level? Or are we ready now?

The California chapter of Physicians for a National Health Program (PNHP) struggled with these questions without resolve, and it was decided to split the chapter into two organizations – PNHP California and California Physicians Alliance (CaPA), CaPA having been a predecessor organization in California. PNHP is a single issue organization advocating for single payer reform whereas CaPA advocates for incremental reforms with an ultimate goal of single payer.

There is legitimacy for both organizations.

CaPA leadership believes that advocating for incremental reforms would establish a better working relationship with other organizations supporting health care justice. Joint advocacy efforts supposedly should reduce the resistance to the more comprehensive reform that a single payer system would bring us. More importantly, incremental reforms can be beneficial during the interim before transition to a single payer system clears the political hurdles.

PNHP leadership believes that we should do all that we can to expedite the transition to a bona fide single payer system. We have a long history of incrementalism and each step has resulted in postponement of a serious consideration of single payer. Right now the battle in Congress is between supporting the incremental policies in the Affordable Care Act or replacing them with measures that would set us back even further. Yet the concept that the government should play a greater role has gained traction amongst Americans, and we should be moving forward with a process that will accomplish that instead.

There are many individuals and organizations who support the various incremental proposals. They do not want for lack of a voice. On the other hand, there is a need for a loud, clear and unwavering voice for single payer reform, lest the message be lost in the incremental mishmash. PNHP will remain a major contributor to the clarion call. CaPA should as well though Steve Tarzynski in his op-ed says that fighting for single payer in the immediate term is a waste of time. But if we expect results by 2020, there is much work to be done now.

For full disclosure, I should say that I am a member of the transitional steering committee for PNHP California as we revitalize our chapter, and I am also a member of the advisory board for CaPA. I believe that both organizations play important but somewhat different roles in the California health care reform movement.

As a former national president of PNHP, I do have a bias. Both organizations support single payer as the ultimate goal, and I am going for that. I do support beneficial measures that may provide transitional relief, but devoting time, resources, and effort to single payer is not a waste of time; it is an absolute moral imperative. We need to go all out, now!

PNHP California
www.pnhpcalifornia.org

CaPA
http://caphysiciansalliance.org

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What does the health policy literature tell us about consumer shopping?

From The Archives: Prices And Consumer Shopping

By Rachel Dolan
Health Affairs Blog, July 19, 2017

The American Health Care Act and the proposed Better Care Reconciliation Act would both result in higher premiums and deductibles for many individuals in the private nongroup market according to the Congressional Budget Office. While the path forward for health reform is now somewhat unclear, the trend of higher consumer cost sharing will likely continue. Higher deductibles and cost sharing are often touted as ways for individuals to have “skin in the game” in health care costs and to help consumers be better shoppers. But what does the research say about the ability to truly shop for health care services? Is it possible? Does it save money? And do consumers even want to do it? Here’s what we know based on research published in the pages of Health Affairs.

Health Care Prices Vary A Lot – And Not Because Of Quality

Shopping For Health Care Has Serious Limitations

Consumers Don’t Really Use Price Tools

The trend of increased consumer cost sharing along with increased expectations that those consumers should engage in price shopping is not going away. But it’s naïve to believe that just increasing the cost burden on consumers and providing them with online tools to compare doctors is going to fix the serious cost problem we have in the US health care system.

http://healthaffairs.org…

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Comment:

By Don McCanne, M.D.

The politicians would have us believe that the health care battle is between those who would protect the policies of the Affordable Care Act and those who would replace Obamacare with a system that places a greater duty on the health care consumer to be a responsible purchaser. In fact, supporters of both approaches tout consumer price sensitivity.

The Affordable Care Act was designed specifically using lower actuarial value plans which require greater cost sharing, especially higher deductibles, supposedly driving the patient to be a more prudent health care shopper. The replacement proposals would merely magnify that – increasing cost sharing in order to reduce insurance premiums. In fact, the supporters of replacement would go so far as to require 100 percent cost sharing for the 22 million who would become uninsured – the nadir (zenith to some) of consumer-directed health care.

This article by Rachel Dolan, the Special Assistant to the Editor-in-Chief at Health Affairs, summarizes some of the studies from the Health Affairs archives, while providing links to those studies, concluding, “it’s naïve to believe that just increasing the cost burden on consumers and providing them with online tools to compare doctors is going to fix the serious cost problem we have in the US health care system.”

The intensity of the obsession with this ideology is demonstrated by the efforts of the Trump administration to introduce cost sharing into Medicaid – a program designed for low-income individuals with no discretionary income. How do they shop with money they do not have at hand?

Americans are not demanding a health care financing system in which they have to look into their own pockets to see what health care they can afford. They want a system that removes financial barriers to care so they can receive the care they actually need. Many Americans were relatively unhappy with the inadequacies of the Affordable Care Act, creating support for repeal and replacement. But when they learned that the proposed replacement would be even worse, they realized more than ever that government programs that have been successful in other nations may be just what we need.

Instead of price shopping it would be much better to have government oversight to make sure that our health care spending is fair, and to leave to the patient-consumers choices in the selection of their health care professionals and institutions, just as we now have with our traditional Medicare program. Tell the politicians to forget consumer price shopping; it doesn’t belong in health care. We can do far better with an equitable, publicly financed program.

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Charlie Gard’s case is tragic. But it’s not a warning about public health care.

Conservatives are using a sick baby’s story for their own political purposes.

By Adam Gaffney, M.D.
The Washington Post, July 24, 2017

The saga of Charlie Gard — the critically ill 11-month-old boy with a spectacularly rare genetic disorder, who is on life support in a London hospital — seems to be coming to a close. Charlie has been at the center of a highly politicized imbroglio with international reach as a result of a disagreement between his parents and physicians over his fate. On Monday, however, that appears to have ended, after his parents learned of the results of an MRI performed last week and decided it was “too late” for an experimental therapy that had been offered in the United States.

This is, more than anything, an utterly heart-rending situation for Charlie’s family. Looking back at the controversy over his medical care from an American prospective, however, one is also struck by how Charlie was used politically in this nation: Right-wing politicians and commentators have wielded his tragic case as a crude cudgel against the public provision of health care, essentially accusing the British National Health Service of sentencing him to die.

“I stand with Charlie Gard and his parents,” House Speaker Paul D. Ryan (R-Wis.) posted on Facebook on July 13. “Health care should be between patients and doctors. Government has no place in the life or death business.” President Trump, meanwhile, offered to “help” the child via Twitter. On Rush Limbaugh’s show, Vice President Pence opined, “We hope and pray that little Charlie Gard gets every chance, but the American people oughta reflect on the fact that for all the talk on the left about single-payer, that’s where it takes us.” Just last week, the House Appropriations Committee moved unanimously on an amendment that would grant Charlie residency status in the United States to facilitate his transfer here to receive experimental treatment, as his parents were hoping (until Monday), but his doctors opposed. The latter felt that the evidence was scant that the therapy would do him any good and that continuing life support would just prolong his suffering.

There’s a serious hypocrisy in the conservative rhetoric, as others have pointed out. After all, Republicans are simultaneously attempting to dismantle the health-care safety net, which helps ensure that people don’t die simply because they are poor. Perhaps Ryan’s talk about the “death business” was actually a form of projection. Regardless, Ryan didn’t frame the debate quite right in his Facebook post. Health care should be between physicians and patients, he said — but it was Charlie’s own doctors who were pushing for a palliative care-only approach. Ultimately, it wasn’t Ryan’s government bureaucrats, but rather Charlie’s health-care providers who decided that his condition was beyond treatment. (British courts agreed with them.)

Charlie had the terrible misfortune of inheriting a pair of genetic mutations that deplete his body of mitochondria, the minute structures that produce energy molecules that cells need to live. As a result, he has for months suffered — according to the hospital — “catastrophic and irreversible brain damage.” He cannot breathe, he essentially cannot move, and he cannot hear. He has been kept alive because of the miracle — and sometimes the curse — of life support.

To be clear, there would have been no debate — and no controversy — whatsoever if Charlie’s physicians and parents had been in agreement: The physicians would have already proceeded to withdraw life support some time ago, and we would never have heard of the case. This happens in ICUs in the United States and Britain every day. In other words, this case was never about what many people thought it was about. It was not about “euthanasia.” It was not about “death panels.” It was not about the “value of life.” And although the case captivated “conservative groups from the United States led by Catholics and evangelicals,” it was not really about religion. In Catholic doctrine, for instance, it is permissible to cease life support when an individual is overcome with disease. “We may reject life-prolonging procedures that are insufficiently beneficial or excessively burdensome,” as medical directives from the United States Conference of Catholic Bishops note.

Finally, it was never about “socialized medicine.” The means by which a health-care system is funded neither creates nor resolves these difficult situations: They are instead the inevitable consequence of the mid-20th–century invention of the ICU and of life-support tools like ventilators. I would wager that most, if not nearly all, critical-care clinicians have found themselves in scenarios where they felt they were doing a true disservice to another human being — performing invasive procedures, maintaining life support, prolonging suffering — because they were compelled to push ahead by a sick patient’s family. I most certainly have.

And therein lies the crux of the Charlie case: There was no consensus between family and physicians. His physicians have firmly and consistently held that his condition makes discontinuing life support — and instead providing only palliative care so he was as comfortable as he could be — the appropriate medical decision, and they have been supported in this by multiple court decisions. Charlie’s parents wanted life support continued to take him to the United States, where Columbia University neurologist Michio Hirano had initially offered to provide an experimental treatment (“nucleoside bypass therapy”) that had never been tried, as STAT notes, on someone with his particular genetic mutation. Though it’s now a moot point, the question lingers: Had Charlie’s doctors been wrong to prevent his transfer, and withhold the treatment, earlier?

One cannot know from the sidelines, but it is worth noting that the April High Court judgment refers to Hirano, at least at that time, as “the only expert in this case who has been suggesting that there is any potential benefit in nucleoside therapy” and notes that the physician himself once said, “I can understand the opinion that he is so severely affected by encephalopathy [brain dysfunction] that any attempt at therapy would be futile. I agree that it is very unlikely that he will improve with that therapy.” More recently, Hirano testified with what sounded like odd precision that there might be an “11 percent to 56 percent chance of clinically meaningful improvement” in the strength of Charlie’s muscles. With claims about new evidence, the case went back to court, and the controversy became only more heated.

The Great Ormond Street Hospital, where Charlie is being cared for, did, in fact, consider this therapy but ultimately determined “that the experimental treatment, which is not designed to be curative, would not improve Charlie’s quality of life” and could not “reverse the brain damage that has already occurred.”

There is simply nothing to suggest that the hospital was motivated at any point by anything other than what it saw as Charlie’s best interest. This was never about cost-cutting or rationing; Charlie is simply not, as the headline of Washington Examiner put it, “a baby … condemned to death by socialized medicine.” He is a baby tragically condemned to death by a fatal illness, which would be true in any country.

Admittedly, the landscape of who gets to make the critical decisions about stopping life support is different in the United States compared with Britain. As bioethicist Michael Dauber wrote in STAT, in the United States, when doctors and “surrogate” decision-makers disagree on continuing life support, the wishes of the surrogates — in a case like Charlie’s, where the patient is both too young and too ill to make medical decisions, his parents — take precedence. In Britain, the matter can be resolved in courts (and a guardian is appointed to represent children). Charlie’s case essentially revolved around the proper balance of power between surrogates and physicians over medical decision-making.

The British approach may strike many here as problematic: The core principle around which so many of our bioethics debates revolve is autonomy, which is to say the sovereignty of the individual over his or her own body, the right to be at the center of all medical decisions. Paradoxically, however, the principle of autonomy is often of limited applicability in critical care, as during a moment of an overwhelming illness, many people are unable to engage in the complex, necessary discussions (in Charlie’s case, he is obviously also too young).

There is simply no ideal solution, contrary to Ross Douthat’s assertion in the New York Times that the situation is an “easy question, whose answer makes the case a moral travesty.” Some may be horrified at the notion of physicians making decisions “over” family members, but this happens frequently. For instance, if parents insist that their child not receive a lifesaving treatment for religious reasons, they can — and should — be ignored. Obviously, the Charlie case is different: There is nothing to suggest improper motivations on the behalf of his parents, and they were trying to provide, and not deprive him of, care, albeit of questionable utility.

But look at it from the perspective of Charlie’s physicians, who have been receiving a torrent of death threats and abuse. Continuing life support — and sustaining his potential suffering — so that he could cross the Atlantic to obtain experimental therapy that they believed has no chance of curing him and little chance of significantly palliating him would have constituted a form of real harm.

However we answer it, the question of how decisions about the cessation of life support are made is an issue that is separate from how we structure and fund our health-care system. Attempts to link universal health care with one particular approach to end-of-life decision-making are disingenuous and dangerous. Chalie’s doctors have wanted to withdraw life support from him for months because they believe that is the best way they can help him. Those who denounced them are today fighting fervently to withdraw health coverage from millions to make way for tax cuts for the rich.

Which one is the real moral travesty?

Adam Gaffney is an Instructor in medicine at Harvard Medical School and a pulmonary and critical care physician at the Cambridge Health Alliance and serves on the board of directors of Physicians for a National Health Program.

https://www.washingtonpost.com…

A More Progressive Economic Agenda

Interview With Dr. Steffie Woolhandler

Ralph Nader Radio Hour, July 22, 2017

As the U.S. Senate contemplated detrimental changes to health care, PNHP co-founder Dr. Steffie Woolhandler spoke with Ralph Nader about what a different approach – a single-payer national health program – would mean for patients and doctors.

“Medicare for All would mean that everybody on the day they were born would get an insurance card that would pay for all medically needed care at the doctor or hospital of their choice,” she said.

“For doctors it would mean that everybody came with the same coverage; and we no longer had to worry about would the patient come back to see us for follow-up or would they decide that’s just too expensive.

“That’s not pie in the sky. That is the way that the single–payer systems work in countries like Canada or Scotland.”

Dr. Woolhandler’s interview begins at approximately the 40:10 mark, above.

https://ralphnaderradiohour.com…

Americans say that health care coverage is the responsibility of the federal government

Views on Replacing the ACA

The Associated Press-NORC Center for Public Affairs Research, July 13-17, 2017

Q44. Is it the responsibility of the federal government to make sure that all Americans have health care coverage, or not?

March 2017
52% – Yes, a federal government responsibility
47% – No, not a federal government responsibility

July 2017
62% – Yes, a federal government responsibility
37% – No, not a federal government responsibility

http://apnorc.org…

***

Comment:

By Don McCanne, M.D.

In only four months support of the view that it is the responsibility of the federal government to make sure that all Americans have health care coverage has gone from a 5 percentage point spread to a 25 point spread. The Republicans want to take credit for health care reform, and they actually may be able to take credit for this shift in opinion, even though it is in the opposite direction of their passionate support for further privatization of health care financing.

The years of unrelenting criticism of Obamacare by the Republicans along with the recognition that too many people are facing problems with affordability and access led to the concerns about the adequacy of the Affordable Care Act. In calling for repeal, the Republicans promised that they would replace Obamacare with a much better program, presumably bringing improved access at lower costs.

But then what happened this year now that Republicans have control of the House, Senate and the White house and can act on their promises? They tried to hide their actual policy positions behind closed doors shielded with false rhetoric. They were exposed when it became clear to all that their bucket of promises was empty.

It took only four months for Americans to realize that Bernie Sanders and all of the other Medicare-for-all advocates were right. The private sector can’t deliver, and the Republicans proved it. We need the federal government to take the responsibility of seeing that all Americans have health care.

It is our job to make sure that this American epiphany does not fade.

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