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Americans acknowledge health care disparities but are divided on concerns about fairness

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Americans acknowledge health care disparities but are divided on concerns about fairness

The United States Leads Other Nations In Differences By Income In Perceptions Of Health And Health Care

By Joachim O. Hero, Alan M. Zaslavsky and Robert J. Blendon
Health Affairs, June 2017

Abstract

We examined income gaps in the period 2011–13 in self-assessments of personal health and health care across thirty-two middle- and high-income countries. While high-income respondents were generally more positive about their health and health care in most countries, the gap between them and low-income respondents was much bigger in some than in others. The United States has among the largest income-related differences in each of the measures we studied, which assessed both respondents’ past experiences and their confidence about accessing needed health care in the future. Relatively low levels of moral discomfort over income-based health care disparities despite broad awareness of unmet need indicate more public tolerance for health care inequalities in the United States than elsewhere. Nonetheless, over half of Americans felt that income-based health care inequalities are unfair, and these respondents were significantly more likely than their compatriots to support major health system reform — differences that reflect the country’s political divisions. Given the many provisions in the Affordable Care Act that seek to reduce disparities, any replacement would also require attention to disparities or risk taking a step backward in an area where the United States is in sore need of improvement.

From the Study Results

Views Related To Unmet Need And Fairness In Health Care

Perceptions of unmet health care need and income-based fairness norms varied widely across countries. Perceived unmet health care need in the United States was widespread, with 67 percent of respondents responding that “many” people in the country do not have access to the health care they need. This is over 10 percentage points higher than the level in any other country, and over twice the median country rate of 31 percent. Nonetheless, Americans exhibited less moral concern about income-based differences in the quality of health care that people have access to, compared to respondents in the majority of the other countries in our sample. The proportion of respondents who believed that it is unfair that people with higher incomes can afford better health care than people with lower incomes was 54 percent in the United States, compared to the median country rate of 68 percent.

From the Discussion

The wide disparities in health care in the United States are natural consequences of features of its health care system. High out-of-pocket spending combined with fragmented and incomplete insurance coverage that is poorly targeted to meet economic need exacerbate sociodemographic drivers of disparity. These features expose Americans to catastrophic costs, which disproportionately affect low-income and disadvantaged groups. In spite of high poverty rates, the United States spends a smaller proportion of gross domestic product on social safety nets, compared to other high-income nations, and the constellation of services that can help improve health and access to health care is both less comprehensive and less generous.

Health care disparities are one of several interconnected aspects of US society that drive disparities in health. Poor living conditions and nutrition, unhealthy and stressful work environments, large income inequalities, and other factors have been linked to poor health in the United States, and all of them disproportionally affect low-income populations. In this way, wide disparities in health care are related to broader values systems in the United States that must also be addressed if gaps in health status are to be eliminated.

A current in recent research has addressed the role of norms of fairness in Americans’ attitudes about health care and the part those norms play in the divergence between health care policy in the United States and that of other nations. This research has found widespread concern among Americans about income-related health care disparities. The comparative evidence we presented above, while limited, stands in partial contrast to this work. We found that ethical concerns about the fairness of income-based health care disparities were less common in the United States than in most of the other countries in our sample, and that this norm of fairness reflects varied degrees of support for major health system reform. This is the case even though views that unmet need exists are more prevalent in the United States than in any other country in our sample. In all of the other high-income countries that had similarly low or lower concern about income-based health care inequalities than the United States — such as Australia, Finland, Great Britain, and Taiwan — most respondents believed that basic health care needs are being met.

http://content.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

Ouch! Of 32 middle- and high-income countries studied, more Americans recognize that many people in the country do not have access to the health care they need, but Americans exhibit less moral concern about income-based differences in the quality of health care that people have access to, compared to respondents in the majority of the other countries studied.

The authors state, “We found that ethical concerns about the fairness of income-based health care disparities were less common in the United States than in most of the other countries in our sample, and that this norm of fairness reflects varied degrees of support for major health system reform. This is the case even though views that unmet need exists are more prevalent in the United States than in any other country in our sample.”

This suggests that our greatest barrier to enacting single payer reform is that too many Americans do not have ethical concerns about the lack of fairness of our income-based health care disparities. Yet we do not hear expressions of unfairness with our Medicare program. Do you suppose that, if we had an improved Medicare that covered everyone, most Americans might take pride in the fairness our our health care system? Let’s try it and see. It seems to work in other countries.

If you understand normative economics, you’ll understand single payer

A Tax Cut Might Be Nice. But Remember the Deficit.

By N. Gregory Mankiw
The New York Times, June 2, 2017

In the debate about federal tax policy, one question looms large: Should we have a tax cut that increases the budget deficit?

President Trump says he wants “a massive tax cut 
 maybe the biggest tax cut we’ve ever had.” But the Senate majority leader, Mitch McConnell, who is clearly worried about the growing national debt, says tax reform “will have to be revenue-neutral.” The stage is set for another Republican showdown.

The Reagan and Bush tax cuts combined the logic of supply-side economics and of Keynesian stimulus. Supply-siders argue that lower marginal tax rates give people more incentive to work and invest. Keynesians argue that leaving more money in people’s pockets, rather than in government coffers, increases spending and that greater demand for goods and services expands employment. When the government enacts deficit-financed tax cuts, the two channels can work simultaneously.

Yet Mr. Trump faces a vastly different set of circumstances. The economy has not experienced a recent recession.

The main macroeconomic problem the nation faces is slow productivity growth, which in turn leads to slow growth in average incomes. Increased budget deficits would only make this problem worse. They would cause the Fed to raise interest rates even faster than otherwise. Higher interest rates would discourage capital investments, further depressing productivity.

In short, Mr. Trump finds himself not in the position of Ronald Reagan in 1981 or George W. Bush in 2001 but rather of Ronald Reagan in 1986. He should follow the Reagan of the later period and aim for revenue neutrality. He should broaden the tax base, lower rates and reform the tax code to promote saving, investment and growth.

A key question is how revenue neutrality is to be judged. Traditional analyses of the effects of tax proposals rely on what is known as static scoring, a method based on the simple but dubious assumption that changes in the tax code do not alter the path of national income. An alternative approach, called dynamic scoring, accounts for the possibility that lower tax rates will promote growth.

Dynamic scoring is potentially more accurate, but it is also more easily abused by those who want to promote their policies with an unhealthy dose of wishful thinking. Tax cuts rarely pay for themselves.

When judging revenue neutrality, policy makers will need to rely on a credible, impartial arbiter, like the Congressional Budget Office. In this era of alternative facts, it would be far too easy to pass irresponsible tax cuts and hand the bill to future generations.

NYT Reader Comment:

By Don McCanne, M.D.

Why do we limit ourselves to Econ 101 type of considerations, such as Mankiw’s Principles of Economics? The greatest economic problem we have faced in recent decades is the transfer of income and wealth to the top, leaving the rest of us struggling to achieve the American Dream.

Piketty, Saez, Zucman and others have provided us with the data that can lead to only one conclusion. We do not need to reduce taxes on income and eliminate the “death tax” to further benefit the wealthy. We need to increase taxes on high incomes, capital gains, financial transactions and on large estates.

The tax revenues could then be used for social programs such as health, education, better retirement benefits through Social Security, and to improve our infrastructure, thus benefiting all of us. And while we’re at it, let’s cut back on spending on our killing machines that are doing so much harm to people of other nations.

Perhaps the Econ 101 professors need to place a greater emphasis on normative economics.

https://www.nytimes.com…

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Normative economics

Normative economics (as opposed to positive economics) is a part of economics that expresses value or normative judgments about economic fairness or what the outcome of the economy or goals of public policy ought to be. – Paul A. Samuelson and William D. Nordhaus (2004). Economics, 18th ed.

https://en.wikipedia.org…

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Must or Should?

Greg Mankiw’s Blog, December 9, 2007

One of the things we teach in introductory economics is the distinction between positive and normative statements. It is useful when reading (or writing) op-eds to keep the distinction in mind.

For example, in today’s NY Times, Cornell economics professor Robert Frank writes:

“Top earners have captured the big share of all income and wealth gains during the last three decades. They’re where the money is. If we’re to pay for public services they and others want, they must carry a disproportionate share of the tax burden.”

The first two sentences are correct statements of fact. The third sentence appears to draw a positive inference from them. Interpreted as such, the sentence is just wrong. Is there any reason to think it is impossible for the government to raise adequate revenue with a proportional tax? Not that I know of, and the article gives no indication of why Frank might think otherwise.

Maybe Frank meant to write “should” rather than “must.” In that case, the sentence would have conveyed a personal political opinion, rather than suggesting (incorrectly) a conclusion of economic science. It would have been more clearly labeled as a normative statement.

http://gregmankiw.blogspot.com…

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Essays in Positive Economics

By Milton Friedman
University of Chicago Press (1953)

Confusion between positive and normative economics is to some extent inevitable. The subject matter of economics is regarded by almost everyone as vitally important to himself and within the range of his own experience and competence; it is the source of continuous and extensive controversy and the occasion for frequent legislation. Self-proclaimed “experts” speak with many voices and can hardly all be regarded as disinterested; in any event, on questions that matter so much, “expert” opinion could hardly be accepted solely on faith even if the “experts” were nearly unanimous and clearly disinterested. The conclusions of positive economics seem to be, and are, immediately relevant to important normative problems, to questions of what ought to be done and how any given goal can be attained. Laymen and experts alike are inevitably tempted to shape positive conclusions to fit strongly held normative preconceptions and to reject positive conclusions if their normative implications – or what are said to be their normative implications – are unpalatable.

Positive economics is in principle independent of any particular ethical position or normative judgments. As Keynes says, it deals with “what is,” not with “what ought to be.”

Normative economics and the art of economics, on the other hand, cannot be independent of positive economics. Any policy conclusion necessarily rests on a prediction about the consequences of doing one thing rather than another, a prediction that must be based – implicitly or explicitly – on positive economics. There is not, of course, a one-to-one relation between policy conclusions and the conclusions of positive economics; if there were, there would be no separate normative science. Two individuals may agree on the consequences of a particular piece of legislation. One may regard them as desirable on balance and so favor the legislation; the other, as undesirable and so oppose the legislation.

https://campus.fsu.edu…

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California’s New Single-Payer Proposal Embraces Some Costly Old Ways

By Kaiser Health News
U.S. News & World Report, June 1, 2017

For years, U.S. officials have sought to move Medicare away from paying doctors and hospitals for each task they perform, a costly approach that rewards the quantity of care over quality. State Medicaid programs and private insurers are pursuing similar changes.

Yet the $400 billion single-payer proposal that’s advancing in the California legislature (SB 562) would restore fee-for-service to its once-dominant perch in California.

“Single-payer has its pros and cons, but if it’s built on the foundation of fee-for-service it will be a disaster,” said Stephen Shortell, dean emeritus of the School of Public Health at the University of California-Berkeley. “It would be a huge step backwards in delivering health care.”

Paul Ginsburg, a health economist and professor at the University of Southern California, agreed and said the legislation reads like something out of the 1960s in terms of how it wants to reimburse providers.

“There’s broad consensus we ought to go from volume to value. This bill ignores all the signs pointing to progress and advocates a system that failed,” he said.

https://www.usnews.com…

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Comment:

By Don McCanne, M.D.

Right now Congress is stumbling along in its efforts to reform health care while getting ready to move on to legislating tax cuts – all in the name of increasing freedom of our markets by reducing the role of government.

Perhaps not understanding it, the politicians are practicing what they would believe to be positive economics – that their policy recommendations define the “what must be.” Yet, in reality, they are supporting normative economics – that their policy recommendations define “what ought to be” from their own policy perspective.

Getting bogged down in the positive economics of markets versus the government leads to narrow, stilted thinking. What “must be” masks what “ought to be.”

In taxes, those with money “must” be allowed to feed their funds into the free market to enhance the economy to benefit all of us (or, actually, to benefit those with funds to invest). Thus the government ”must” not be allowed to confiscate those funds through the tax system.

In our arena – health care – consumer preferences “must” play out in the marketplace in order to enhance the services and products offered by the health care delivery system. The role of government in allocating tax funds “must” be diminished to take the shackles off of the marketplace. So economists would say that positive economics always applies – what must be must be – whereas normative economics is always secondary – merely an expression of what some believe ought to be.

Noted health policy experts Paul Ginsburg and Stephen Shortell provide us with an example in telling us that fee-for-service will be a disaster for single payer (Shortell) and that it has been a system that has failed (Ginsburg). These views are presented as if they were positive economics (must be true) whereas they actually represent normative views in that there are other policies inherent in a well designed single payer system that achieve, in a much more patient-friendly manner, the same goals of containing spending. Ginsburg and Shortell are expressing the view that moving from volume to value “must” include elimination of fee-for-service, when, in reality, they are saying it “ought to.”

What really ought to occur is that the system should be designed to place the patient first, as would be the case in a single payer system – a normative approach that does not violate bona fide positive economics (even though the policy and political communities might reclassify these to meet their own ideological preferences).

For the other issue – taxes – we need to apply normative economics as well, as I explain in the Reader Comments in response to Greg Mankiw’s New York Times article (above). The community at large ought to be placed first.

Medicare an ideal model of coverage for everyone

By Edith Kenna, ACSW, LCSW
The (Fort Wayne, Ind.) Journal Gazette, June 5, 2017

Imagine my delight in meeting Dr. William Hsiao, the rock star of health care reform and the man who developed Taiwan’s system in 1995.

In preparation for his work, Dr. Hsiao studied the systems of several high-income countries and settled on the Canadian system as his model. Taiwan’s system is a single-payer, universal system of care. It offers choice of doctors and hospitals, and there is competition between public and private hospitals. Taiwan’s system covers prevention, primary care, hospitalization, mental health, vision, dental, home health and long-term care. There are small copays for service; $4 for outpatient care, 10 percent for hospitalizations of fewer than 30 days, and 20 percent thereafter. There are caps on copays to prevent bankruptcy if someone is seriously ill. Ninety-nine percent of Taiwanese are enrolled, and it took one year to operationalize. Each enrollee has a smart card that he/she provides for care. This card is used for billing and carries with it the patient’s medical history. Reimbursement to providers takes about two weeks.

Our private, for-profit system is expensive. There are no cost controls other than eliminating people or denying care. This is the cost control when making money is the goal. Taiwan’s system operates at about 2.3 percent overhead, while overhead for us is about 15 percent. Warren Buffett favors a Medicare for all system and calls health care costs “the tapeworm running through our economy.” The costs and efficiencies of a private, for-profit system of care are holding back the economy and its citizens, according to Buffett. If you can’t believe this social worker, one might assume Buffett understands how the economy works.

It is possible to have universal coverage and good quality health care for all, but only under a single-payer system, says Dr. Hsiao, a Harvard economist. Medicare for all is way overdue in this country. Medicare covers the sickest and oldest of us with low overhead. Medicare consistently ranks highest in consumer ratings. The AHCA/Trump/Ryancare is an abomination that discourages care, leaves 23 million without access to health care, and puts elimination of coverage for pre-existing conditions back into our system. It does nothing to control your costs for care or medication.

Do not let Congress and the president get away with the charade that Obamacare is the root of the problems in U.S. health care. Prior to the passage of Obamacare, 45 million people were uninsured, and pre-existing conditions were never covered until eligible for Medicare or Medicaid. The intent of Obamacare was to keep private, for-profit insurers in the mix. Big health care and big pharma still made billions under Obamacare, but not enough for them, President Donald Trump and Congress. If the marketplace and free enterprise were going to work, it would have done so by now. It doesn’t work, and it can’t work because health care is not a commodity. There is no market when the consumer has no idea what he/she is buying; there is no way to compare value vs. cost. It’s plain dumb to assume health care can be sold and compared like a car, cell phone or toilet paper.

Medicare for all is way overdue in this country. The Expanded and Improved Medicare for All Act, again introduced in Congress, now has 112 co-sponsors, the most ever in its history since first introduced in 2003. Sen. Bernie Sanders, I-Vermont, is expected to introduce similar legislation in the Senate. We can no longer be the only western democracy without some form of national health insurance.

We the people deserve better, no matter what politicians think. Call your senators and your representative today at the free congressional switchboard. Voice prompts will direct you. Call now, call often and say no to the AHCA. Say yes to Medicare for all, and your own health care.

http://www.journalgazette.net…

Americans support including long-term care under Medicare

Long-Term Care in America: Views on Who Should Bear the Responsibility and Costs of Care

The Associated Press-NORC Center for Public Affairs Research, May 2017

Results from the 2017 Long-Term Care trends poll find that two-thirds of Americans age 40 and older feel the country is not prepared for the rapid growth of the older adult population. The Associated Press-NORC Center for Public Affairs Research survey also finds that at the local level, less than half of older Americans say their community is doing a good job of meeting older adults’ needs for nursing homes, assisted living facilities, and home health care aides to provide long-term care. Additionally, a majority of older adults say they would like the federal government to devote a lot or a great deal of effort this year to helping people with the costs of ongoing living assistance.

To help policymakers, health care systems, and families address this issue, research conducted by The AP-NORC Center examines awareness of older Americans’ understanding of the long-term care system, their perceptions and misperceptions regarding the likelihood of needing long-term care services and the cost of those services, and their attitudes and behaviors regarding planning for long-term care.

Overall, about a quarter of adults age 40 and older are able to correctly estimate the national average monthly cost of living in a nursing home, living in an assisted living facility, and hiring a part-time home health care aide.

While already underestimating the costs of most care, only 15 percent of Americans age 40 and older are very or extremely confident that they will have the financial resources to pay for long-term care.

Overall, older Americans have not done much planning for their future or current needs for ongoing assistance. Two-thirds (67 percent) say they have done only a little or no planning at all for their own needs. About a quarter (23 percent) say they have done a moderate amount of planning, and just 1 in 10 say they have done a great deal or quite a bit of planning.

Americans are confused about how they might pay for any needed care. The source that most Americans age 40 and older expect to rely heavily on to pay for ongoing living assistance is Medicare, which 57 percent say they will rely on quite a bit or completely. However, Medicare does not cover many expenses associated with long-term care, including most care in nursing homes, assisted living facilities, or from home health care aides.

Today, 70 percent of older Americans support a government-administered long-term care insurance program, similar to Medicare, a significant jump from the 53 percent who said the same last year.

Though support for a government-administered program for long-term care insurance similar to Medicare is lowest among Republicans, it still receives majority support. Eighty-three percent of Democrats favor such a program compared to 69 percent of independents and 54 percent of Republicans.

http://www.longtermcarepoll.org…

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Comment:

By Don McCanne, M.D.

Americans fear the prospects of long-term care, especially how they would pay for it should it become necessary. This survey reveals that a majority of Democrats, independents and Republicans – 70 percent overall – support a program similar to Medicare as the payment source for long term care.

The nation is ill-prepared for anticipated future needs for long-term care. Currently the most important program to cover these costs is Medicaid, but that requires the indignity of becoming destitute in order to qualify for the program.

Americans are very supportive of our Medicare program and a clear majority supports such a program for covering long-term care. The solution seems obvious; include long-term care under the Medicare program.

Single payer supporters understand that an improved Medicare for all would automatically do this. We should no longer demand destitution for those of modest means as a ticket to long term care.

We can do better with single-payer

By Harvey Fernbach, M.D., M.P.H.
Yale Medicine, Spring 2017 

Cathy Shufro’s review of EMBRACE, by Gilead Lancaster, M.D. [Yale Medicine, Winter 2017], encouraged me to read it. Although well-intended, the author made two significant errors in his approach to universal health coverage. He strongly believes that for-profit insurers still have a role, even after years of bad experience by patients, hospitals, and physicians. For-profit insurers are known for cherry-picking customers, steering patients away from specialists, and denying and rationing care for profit. Second, he favorably compares his approach to the Canadian single-payer program and leaves out H.R. 676, Expanded and Improved Medicare for All Act, which has 79 co-sponsors in the U.S. Congress. With input from Physicians for a National Health Program (PNHP.org), H.R. 676 offers comprehensive care for all, is not linked to employment, and would establish a universal single-payer health care system. This means medical, surgical, mental health, dental, prescriptions, hospitals, and long-term care, with no out-of-pocket costs. Numerous studies have demonstrated that this could be done with the same amount currently spent on health care. In 2013, United Health axed their contract with the 1,200-physician Yale Medicine practice, causing harm to many. We can do better with single-payer simplicity.

Excess emergency department charges for uninsured and out-of-network care

Variation in Emergency Department vs Internal Medicine Excess Charges in the United States

By Tim Xu, MD, MPP; Angela Park; Ge Bai, PhD, CPA; et al
JAMA Internal Medicine, May 30, 2017

From the Introduction

Patients presenting to different emergency departments (ED) can face widely varying charges for similar care. Hospitals use chargemasters (list of services and their charges) to compile each patient’s bill, but the actual payment depends on the patient’s insurance type and network status. In-network patients and their insurers usually pay discounted amounts, whereas uninsured and out-of-network patients may be liable for the full hospital charges. In 2012, the 50 hospitals in the United States with the highest markups charged patients at least 9.2 times what the Medicare program would pay for care.

In this study, we used physician payment data from the Centers for Medicare & Medicaid Services to study the variation in markups on ED professional services and in relation to markups in internal medicine. We also examined the association between the level of markup and the characteristics of the hospitals and their patient populations.

From the Results

Nationwide, services provided by emergency medicine physicians to Medicare Part B fee-for-service beneficiaries totaled $4 billion in charges and $898 million in Medicare-allowable amounts, representing an overall markup ratio of 4.4 (340% excess charges). By contrast, the overall markup ratio for all services provided by internal medicine physicians was 2.1 (110% excess charges). Markup ratios for common ED services varied widely by procedure code and hospital.

By hospital, the aggregated markup ratio for all ED services ranged from 1.0 to 12.6; the aggregated markup ratio for all internal medicine services ranged from 1.0 to 14.1. Greater ED markup ratios by hospital were associated with for-profit status, greater uninsured population, African American and Hispanic patient populations, and location in the southeastern United States. These associations between markups and hospital characteristics were not present for internal medicine services.

From the Discussion

In this national study of hospital pricing practices in 2013, we found wide variation in excess charges for ED services relative to what Medicare would have paid. Moreover, ED services were generally priced higher than those in the internal medicine department for the same services within a given hospital. Emergency departments with the greatest markups were more likely to be for-profit and serve larger uninsured populations. These findings reinforce the recent interest among states in protecting patients from excess medical charges.

In addition to uninsured patients, insured but out-of-network patients can become subject to chargemaster prices. In the course of negotiations between insurers and physicians over payment rates, patients of physicians who remain out of network may receive a balance bill for the difference between the chargemaster price and the amount paid by the insurer. Out-of-network care can also result from hospitals outsourcing ED and other physician services to private contractors who are not part of the hospital’s insurer network.

Conclusions

Using national Medicare payment data, our study demonstrates the wide variation in the prices EDs charge patients for medical services, which can vary between 1.0 and 12.6 times the Medicare-allowable amount by hospital. Moreover, we found that hospitals typically charge patients more for similar services when performed by an ED physician compared with an internal medicine physician. In this context, the ongoing trends of uninsurance, hospital consolidation, and narrowing insurance networks since implementation of the Affordable Care Act are poised to increase the potential for patient financial harm in the years to come. Now, more than ever, protecting uninsured and out-of-network patients from highly variable hospital pricing should be a policy priority.

http://jamanetwork.com…

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Comment:

By Don McCanne, M.D.

We have long recognized the injustices of emergency department patients being charged higher rates if they are uninsured or if the physicians providing the care are not in the networks of the patients’ insurance plans. This study adds to our understanding by quantifying the extra costs faced by the patients. These charges typically are 4 times  Medicare-allowable rates for the emergency physician and as much as 12 times for the hospital.

These unjust excessive charges would not exist in a well designed single payer system – an improved Medicare for all. Patients would benefit by the elimination of cost sharing, and the professionals and institutions would be paid based on legitimate costs and fair margins. Everyone would benefit except insurers and providers who currently gouge.

California’s single payer bill would reduce costs for most businesses and households

Economic Analysis of the Healthy California Single-Payer Health Care Proposal (SB-562)

By Robert Pollin, James Heintz, Peter Arno, and Jeannette Wicks-Lim
Political Economy Research Institute (PERI), University of Massachusetts – Amherst, May 2017

The State of California is considering a bill to create a statewide single-payer health care system. This study provides an economic analysis of the proposed measure, The Healthy California Act (SB-562). The study includes four major sections: 1) Cost Estimate of Universal Health Care Coverage in California; 2) Cost Saving Potential under Healthy California; 3) Financing Healthy California; and 4) Impact on Individual California Families and Businesses.

The primary goal of Healthy California is to provide high-quality health care to all California residents, including those who are presently either uninsured or underinsured. The study finds that the providing full universal coverage would increase overall system costs by about 10 percent, but that the single payer system could produce savings of about 18 percent. The study thus finds that the proposed single-payer system could provide decent health care for all California residents while still reducing net overall costs by about 8 percent relative to the existing system.

We propose two new taxes to generate the revenue required to offset the loss of private insurance spending: a gross receipts tax of 2.3 percent and a sales tax of 2.3 percent, along with exemptions and tax credits for small business owners and low-income families to promote tax-burden equity.

Within this proposed tax framework, Healthy California can achieve both lower costs and greater equity in the provision of health care in California for both families and businesses of all sizes. Thus, net health care spending for middle-income families will fall by between 2.6 – 9.1 percent of income.

Small firms that have been providing private health care coverage for their workers will experience a 22 percent decline in their health-care costs as a share of payroll. The small firms that have not provided coverage will still make zero payments for health care under Healthy California through their gross receipts tax exemption. Medium-sized firms will see their health care costs fall by between 6.8 and 13.4 percent as a share of payroll relative to the existing system. Firms with up to 500 employees will experience a 5.7 percent fall, and the largest firms, with over 500 employees, will experience a 0.6 percent fall as a share of payroll relative to the existing system.

In sum, the establishment of the Healthy California single-payer system will generate financial benefits for both families and businesses throughout the California economy. For families at most income levels and for businesses of most sizes, these financial benefits will be substantial. These benefits are in addition to those that the residents of California will achieve through having universal access to decent health care.

http://www.healthycaliforniaact.org…

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Comment:

By Don McCanne, M.D.

This meticulous economic study of the the Healthy California single-payer health care proposal (SB-562) reveals that it would provide health care for all Californians while reducing net costs for almost all households and businesses. This study is much more credible than the staff committee report released last week, primarily because of the detail in this study and the application of well established health policy science to the analysis.

A multitude of articles based on the cursory staff study have been published stating that total costs and a hypothetical high payroll tax would be outrageous and totally unaffordable. This study lays those claims to rest and should be used to refute the rhetoric of the opponents of single payer reform in California.

In fact, California cannot afford to pass up this opportunity to bring health care to everyone while finally controlling our spending on it.

If you wish to see how a single payer system really could provide health care for everyone while reducing costs for businesses and households alike, you should download the full analysis and study it (link above).

Dr. Mark Ryan underscores the importance of single payer health care in Rhode Island

Interview by Dan Yorke
State of Mind, May 31, 2017

Dr. Ryan, chairman of the Rhode Island chapter of PNHP, and Rep. Aaron Regunberg (D-Distrcit 14), discuss proposed single-payer legislation at the state level. Dr. Ryan presented several slides to make the case for fundamental reform (full slide sets available here). His portion of the panel discussion begins at the 10:40 mark.

original link:
http://foxprovidence.com…

Blumenauer: US Could Have Single Payer Care Within A Decade

Portland-based Democratic Congressman spoke Tuesday to a supportive crowd about the role Oregon could play in changing the national healthcare debate.

By Courtney Sherwood
The Lund Report, May 31, 2017

U.S. Congressman Earl Blumenauer touted single-payer healthcare as a solution to the nation’s tangled and expensive system of care on Tuesday, in a speech before a politically supportive audience at First Unitarian Church of Portland.

Speaking to packed pews, the Democrat was joined on stage by author and single-payer activist T.R. Reid, state Senator Michael Dembrow, D-Portland, state Rep. Alissa Keny-Guyer, D-Portland, and activist physicians Samuel Metz and Paul Gorman.

Blumenauer described the Affordable Care Act as a slightly left of center compromise bill that must be protected or improved during the current era of Republican dominance in Congress. But he also argued that now is the time to discuss a more left-leaning alternative, even if it may take years to enact actual change.

“Because of the near-meltdown of the economy, the fierce turmoil of the Tea Party, the chaos of the past 10 months, I think we’re in a position today to put together a solution,” Blumenauer said.

“I think transformational change is possible far quicker than people recognize,” the congressman continued. “There’s something happening around the country. Twenty years from now there will be a single payer system of some variation. I think it could be 10 years. Things may happen sooner, depending on what we all do.”

As to that question of what to do, Blumenauer turned the microphone over to Reid, who reiterated arguments put forth in his best-selling book, “The Healing of America: A Global Quest for Better, Cheaper and Fairer Health Care.”

Through his work, Reid looked at roughly 35 developed democracies to see how each approached healthcare, the author said.

“All the other countries like us, all the other developed democracies on the planet, have decided to provide healthcare for everybody,” Reid said. “There’s only one industrialized democracy that does not provide healthcare for everybody, and that’s the world’s richest country, the United States of America. To me this is a national disgrace.”

Reid noted that there’s no universal approach to universal coverage. Some countries offer single-payer care, others like Japan and Germany host multiple insurance plans that collectively cover everyone. Some provide totally free care with never a bill to pay, others require co-pays or other investments in the system.

Regardless of specifics, these countries consistently spend less per capita on medical treatment, and get better results at the same time.

“There are different routes to that destination, but they all agree on what we ought to do,” said Reid, who lamented his home state of Colorado’s failed effort to enact its own statewide system of coverage.

That initiative effort failed when voters balked at the $25 billion pricetag, and as insurance industry opponents outspent supporters by $8 million-to-$800,000, Reid said.

But Oregon could be more successful at winning that ballot box battle, he argued.

“Here in Oregon, you’ve got a bunch of trouble makers, rabble rousers, apple cart upsetters, doctors, patients, members of Congress” – not to mention, state legislators, he noted.

Among those legislators are Democrats Sen. Dembrow and Rep. Alissa Keny-Guyer, who each argued in favor of radical action within the state.

Keny-Guyer noted that already this legislative session, small reforms are advancing through the process – including a bill that would limit out-of-pocket pharmaceutical costs to insured patients, and would force drug makers to offer rebates to insurance companies if they charge significantly more in Oregon than in other major countries around the world.

And Dembrow spoke of growing support among Democrats in the state for a single-payer bill – unlikely to pass this legislative session, especially without any Republican backing, but a possibility for a future ballot referendum.

“California is making support for single payer a marker for Democrats down there,” and that leadership could help Oregon activists gain momentum, he said.

“What we have to think about doing, as we are preparing for our election here in Oregon, to put single payer on the ballot – which right now is looking like the year 2020 – is how can we partner with Washington so they get it on their ballot in 2020? How do we partner with Colorado so they get it on their ballot in 2020?” Dembrow asked.

He argued that coordinating efforts across multiple states would help activists resist the flow of big business lobbying funds. “All those insurance dollars are going to get spread out. Because otherwise they are going to pick us off state by state. And let me say, if California can do it, it’s going to make it so much easier for the rest of us. As many of us know, you put California together with Oregon and Washington, you’ve got the world’s sixth largest economy.”

https://www.thelundreport.org…

Provide improved Medicare for all

By Emilio V. Perez-Jorge, M.D.
The (Columbia, SC) State, May 31, 2017

I encounter patients daily who are worried about the future of health care. One of the greatest threats to the health of our nation and our state is the revised American Health Care Act, currently being considered by the U.S. Senate.

The bill would take money out of Medicaid, and cancel subsidies that help working families buy private coverage through the Affordable Care Act’s health-insurance exchanges.

The Affordable Care Act, also known as Obamacare, has helped citizens afford health-care coverage, but it has some flaws as well. That is why we should move forward to a single-payer “improved Medicare for all” plan.

Ask your state legislators to introduce the Palmetto Comprehensive Health Care Act, which Rep. David Mack and Sen. Brad Hutto proposed in 2015. At the federal level, ask your U.S. representatives to support the “Expanded and Improved Medicare for All Act” (H.R. 676), and ask Sens. Lindsey Graham and Tim Scott to oppose the revised American Health Care Act.

Dr. Emilio V. Perez-Jorge resides in Lexington.

http://www.thestate.com…

U.S. patients would benefit from single-payer plan

By Andrew Quint, M.D.
Columbia (MO) Daily Tribune, May 30, 2017

I would like to respond to Luke Davis’ recent commentary in the Tribune. Having worked as a primary care physician at Family Health Center, a federally qualified community health center, serving medically underserved patients in Columbia since 1997, I have experienced firsthand the inequality, inefficiency and warped incentives of our healthcare system.

Davis writes that treatment in a single-payer system “tends to be lower in overall quality.” For example, he cited a recent study of the Canadian health care system that found the average wait time for medically necessary treatment after seeing a specialist was 9.8 weeks. Davis’s citation of this study leaves out a critically important caveat: It was a survey of wait times for elective treatment — by definition not medically urgent care. While a longer wait time for this type of treatment is frustrating, it does not mean the Canadian system produces meaningfully lower quality care. Moreover, my uninsured patients often don’t ever get to see a specialist. One patient had a kidney stone that wouldn’t pass; he experienced pain and blood in his urine for three months. Only when he got insurance through the Affordable Care Act could I get him in to see a specialist to have the stone removed. Uninsured patients are not counted in these statistics on wait times because they often don’t even get referred to specialists.

Davis says that in the United States, “government programs and regulations also guarantee that a certain baseline level of care is provided to all residents.” This is not true unless one believes that access to an emergency room constitutes a “baseline level of care”. If you are bleeding or having a heart attack, you can go to an emergency room and be treated even if you don’t have health insurance. But emergency rooms do not provide preventative care or treat chronic diseases such as diabetes and do not provide the vast bulk of medical care that people need to avoid ending up in an emergency room with a heart attack or stroke.

The infant mortality rate in the United States is 6 per 1,000 live births; in Canada it is 4.8. Life expectancy in the United States at birth in 2012 was 81.2 years for females, 76.4 for males. In Canada it was 83.6 for females and 79.4 for males. We have higher rates of premature death for all leading causes of death than comparable countries on average. Our rates of all-cause mortality, premature death, death amenable to healthcare, and disease burden are not improving as quickly as in other comparable countries during the past 10 years. We have better short-term outcomes after treatment for certain conditions, such as 30-day mortality post-heart attack and ischemic stroke. Five-year survival rates for specific cancers (like breast and colon cancer) are higher here. But we lag behind comparable countries in prevention and other measures of quality. We have relatively higher hospital admission rates for many preventable conditions, including congestive heart failure, asthma and diabetes complications. And we have higher rates of medical errors than comparable countries.

Our per capita spending on health care is double that of other developed countries. In 2016 the United States spent $9,024 per capita on health care; Canada spent $4,506. Despite our high cost, with a few exceptions, our outcomes are generally worse than in those countries. We excel at high technology high cost care. We do not perform nearly as well on lower cost preventative care. The economic incentives in our system favor high cost medications and procedures rather than low cost educational interventions and prevention.

A colleague of mine attended a lecture on research to develop a drug to promote the growth of new blood vessels around arterial blockages. Instead of heart surgery, a patient could take this drug to grow a bypass. When it was pointed out to the speaker that exercise promotes the growth of new blood vessels around blockages, he replied “Yes, but we don’t get paid for that.”

Single-payer systems in other countries are cheaper, provide better access to care, and allow those countries to improve the financial incentives that make their health care systems more rational, with more focus on prevention of diseases and their complications.

Andrew Quint is medical director at the Family Health Center in Columbia.

http://www.columbiatribune.com…

CMS Administrator Verma is further privatizing enrollment in insurance exchanges

Consumer Advocates Wary Of New Marketplace Rules For Brokers

By Michelle Andrews
Kaiser Health News, May 30, 2017

Signing up for coverage on the health insurance marketplace should be easier for some people this fall because new federal rules will allow brokers and insurers to handle the entire enrollment process online, from soup to nuts. Some consumer advocates are concerned, though, that customers going this route won’t get the comprehensive, impartial plan information they need to make the best decision due to the financial self-interest of insurers and brokers.

“Facilitating the participation of brokers and getting web brokers involved is a good thing for the market,” said Timothy Jost, emeritus professor at Washington and Lee University School of Law in Virginia and an expert on health reform. But there are risks for consumers. “If you’re enrolling with a web broker, you could see ‘best deals’ that often aren’t the best deal for you but are the best deal for the people who are marketing them.”

The staff at online health insurance broker eHealth is thrilled with the change.

“It’s a big deal,” said Nate Purpura, vice president of consumer affairs at eHealth. “Many people, including our CEO, have been to Washington, D.C., multiple times to explain the benefits of being able to help in this way.”

Its website, which works with 180 insurance carriers nationwide, offers about 75 percent of the plans that are available on healthcare.gov, Purpura said.

That’s a problem, say some policy analysts. Federal rules require web brokers to display basic information about all the plans that are available on the federal marketplace, whether or not they actually sell them. It includes the name of the plan and insurer that offers it, the type of plan — HMO, PPO, EPO — and metal level (bronze, silver, gold or platinum). Web brokers must also publish a disclaimer that says the website information about all the available marketplace plans might not be complete and provide a link to healthcare.gov.

But the information web brokers present about plans they sell and get a commission for may be much more comprehensive than the information provided about plans they don’t handle.

But some analysts remain concerned that details about how consumers’ privacy and security will be protected under the new system are still too vague.

“This is really sensitive information, people’s tax information, which needs to be highly protected,” said Jost. “There are a lot of concerns with confidentiality and privacy. I have some concerns about fraud.”

http://khn.org…

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The Centers for Medicare and Medicaid Services (CMS) announces streamlined direct enrollment process for consumers seeking Exchange coverage

CMS.gov, May 17, 2017

“This is another important step to help create stability in the health insurance market,” said CMS Administrator Seema Verma. “It is common sense to make it as simple and easy as possible for consumers to shop for and access health coverage. It is time to get the federal government out of the way and give patients the best tools to make their own healthcare decisions.”

https://www.cms.gov…

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Comment:

By Don McCanne, M.D.

CMS Administrator Seema Verma is expanding the role of private insurance brokers, such as eHealth, in enrolling individuals in plans offered by the government ACA health insurance exchanges. Not only do the private brokers promote only selected plans on the exchanges, they obviously are motivated to push the plans for which they receive a generous commission, whether or not the plans selected are in the best interests of the enrollees. This does not serve the applicants well.

In her CMS release, Verma states, “It is time to get the federal government out of the way.” Her pro-privatization, anti-government ideology is so intense that she says that it is “common sense” to add additional, wasteful private administrative services with these outside brokers, paying them fees with our tax money, and yet depriving enrollees of the full informational services that our current government-operated exchanges are providing.

Worse services, piling on of administrative excesses, and diverting public money to private vendors are a terrible price to pay simply to please the anti-government bureaucrats that are filling the positions of public trust in this administration.

In a recent Quote of the Day, it was recommended that her boss, HHS Secretary Tom Price, be replaced based on the potential havoc created by his adhering to his nutty anti-government ideology. She should be replaced for the same reason as well – ASAP.

This comment is the opinion of the author and is not an official view of Physicians for a National Health Program.