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I’m a Kansas City doctor in Australia. Trump is right about Australian health care

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I’m a Kansas City doctor in Australia. Trump is right about Australian health care

By Marie Shieh
The Kansas City Star, May 27, 2017

President Donald Trump, I heartily agree with you when you told Australian Prime Minister Malcolm Turnbull, “You have better health care than we do.”

You see, I have been both a patient and a doctor in the U.S. and Australia. After working and studying as a family physician in the U.S. for almost 20 years, I landed my dream job working in Australia in 2015. I love working within this excellent health care system where doctors and patients are supported by a program called Medicare. It is similar to American Medicare but covers every Australian of every age for most health care costs.

Patients pay a small out-of-pocket fee, based on income, for things like medications ($7-$30), doctor visits ($0-$30) or X-rays ($0-$40). As their primary care physician, I can decide to charge a copay (children and seniors are always free) or stick with the basic Medicare reimbursement. For example, I might not charge patients I feel might not return for a follow-up visit. The choice is mine. Unlike working in the U.S., I never worry about bringing people back to the office to be sure they are getting the best care.

My Australian patients are not afraid to come see me and get tests done. They can visit physical therapists, dietitians, exercise physiologists, diabetes educators, chiropractors, podiatrists and osteopaths. I do not worry about patients not being able to afford an electrocardiogram, blood tests, radiology tests or medications like I did in the U.S. I can send my Australian patients to the hospital and emergency room, and unlike in the U.S., they are not afraid to go for fear of medical bankruptcy. The hospitals here are of excellent quality.

My Australian patients get care when they need it, not when they can afford it. By contrast, my American patients would routinely avoid care and treatments for fear of cost, leading to complications and extended sickness.

Australian Medicare provides high-quality, compassionate care to the elderly and disabled, which allows my patients to live with dignity at home, not in nursing homes. Take two of my patients, an elderly couple: The husband is 90 years old and the wife 81 years old, with mild dementia. They receive regular home visits from nurses who conduct assessments and dispense medication. They might get a cleaner every two weeks if they cannot get down to scrub floors or bathtubs. And speaking of bathtubs, they get handrails installed for a substantial discount, to keep them safe from falls. These common-sense measures keep patients healthy and cut down dramatically on hospital costs.

My Australian patients with advanced or terminal illness get home visits from me if they are too weak to come to the office. They receive palliative care in their homes, on par with the best treatments I have seen in U.S. hospice care.

Compare this to my experience as a patient in the U.S. I had my first baby in 1992 while in medical school. Even though I carried insurance and enjoyed a normal, unmedicated delivery, we got hit with a bill that was five times our monthly rent. Instead of enjoying our first weeks home with our new son, we spent that time haggling with the insurance company and being threatened by a collection agency. On top of that, our son wasn’t covered for the care he received right after being born, and we received a bill for the newborn check, none of which was covered by our insurance. This would never happen in Australia.

President Trump, you were right. We do have better health care here in Australia. Don’t you think Americans deserve the same?

Marie Shieh, M.D., is an American physician who now works in Australia. She was born in Salt Lake City and raised in Kansas City.

original op-ed:
http://www.kansascity.com…

follow-up interview with Dr. Shieh:
http://www.kansascity.com…

Robert Borosage on paving the way to Medicare for All

Will the Republican Health-Care Debacle Pave the Way for ‘Medicare far All’?

By Robert L. Borosage
The Nation, May 25, 2017

This week, the Congressional Budget Office confirmed what was already apparent: The revised House Republican health-care bill will still deprive millions of Americans — 23 million in the CBO estimate — of health insurance. Senate Republicans are devising their plan in secret, because it too will likely deprive millions of health coverage. In contrast with Republican horrors, Obamacare has grown in popularity, but premiums are rising as insurance companies consolidate monopolies in various states and Trump works to sabotage it. Surely, now is the time for progressives to wage a fierce campaign for Medicare for All.

Americans are more than ready. The popularity of expanding Medicare is surprising, given how little support it has received from the political class.

Will Republican efforts to repeal and replace Obamacare pave the way to Medicare for All? Only if progressives force the debate. Americans are looking for sensible reform. Medicare for All is the right answer. Now is the time for progressives to educate and enlist to take on the entrenched interests that stand in the way.

https://www.thenation.com…

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Comment:

By Don McCanne, M.D.

With the backlash against the Republicans for their ongoing failure to deliver effective health care reform, and with the failure of ACA to provide affordable health care for everyone, the pathway to Medicare for All may now have been paved.

Robert Borosage suggests that it is time for progressives to push the process – force the debate, educate, and enlist. But that should not be limited to progressives in the Democratic party. We should work with Republican progressives, independent progressives, Democratic Socialist progressives, and even, albeit rare, libertarian progressives. By forcing the debate, educating, and enlisting, even conservatives and others who do not usually assign to themselves the “progressive” label, should be ready for a serious consideration of single payer.

Assured health care, at a price we could all afford, who could be against that? Neither ACA nor AHCA would bring us that. Members of Congress will be home on a break this next week. Let them hear from you, though you may not want to announce yourself using the “progressive’ label.

The conservative case for single payer

Efficient. Effective. Practical. Make no mistake, there is a strong conservative case to be made for single payer. This is important because, as our health care crisis deepens, we need to make sure we’re speaking to all Americans. Only then can we can build a broad-based movement that pressures Congress to do the right thing.

To date, no Republican has co-sponsored H.R. 1384, the Medicare for All Act of 2019, nor did any Republican co-sponsor H.R. 676, the previous single-payer bill in the House. In order for this to happen, members need to hear from their constituents. If you live in a red district, we encourage you to call (202) 224-3121 today. (Click here to find your member of Congress.)

When speaking with a conservative member of Congress – or a conservative colleague, friend, or family member, for that matter – keep the following in mind:

Know your audience

Many single-payer advocates argue that “health care is a human right,” but conservatives may be more persuaded by appealing to the values of loyalty, sanctity, and authority. Dr. Ed Weisbart gave an excellent talk recently, titled Progressive Persuasions: Speaking Beyond the Choir, that explores this topic in detail (see video below).

Dispel common myths

Myth: Single payer is socialized medicine!
Reality: Medicare-for-all applies the principles of the free market to the delivery of health care. Under traditional Medicare, doctors and hospitals compete to attract patients through service, quality, and access – rather than competing to be in the best-reimbursed insurance plans. Medicare-for-all would open up this patient-centered free market to all Americans.

Myth: Single payer would lead to rationing!
Reality: Today’s private health insurance is incredibly restrictive, with narrow provider networks, cost-sharing, and a growing list of treatments that simply aren’t covered. Private insurance comapnies have a financial incentive to deny care, and they often do. Medicare-for-all would make it much easier for patients to access medically necessary care.

Myth: Single payer would stifle innovation!
Reality: Americans are justifiably proud of our nation’s leadership in medical innovation, but may not realize that most of those innovations are paid for using public funds. As pharmaceutical companies engage in trivial research designed to extend patents, our National Institutes of Health funds truly pioneering work. Medicare-for-all would strengthen the alignment of research with our most pressing health needs.

Expose the Canadian boogeyman

Some of the most pervasive myths about single payer relate to Canada’s Medicare program. Many Americans have heard that Canadians suffer long wait times, and flock to the United States to seek medical care. Thankfully, these myths are easily disproven. Consider the following:

‱    The 2002 Health Affairs study Phantoms in the Snow found that an exceedingly small number of Canadians seek care in the U.S.

‱    Waiting lists in Canada can be primarly attributed to lower health spending. Despite this, Canadians do not have to wait to be treated for life-threatening diseases and report fewer unmet health needs overall (see this NBER paper, Table 12).

‱    Former Canadian Medical Association Journal editor-in-chief and one-time market proponent David Woods says single payer is essential to controlling costs.

‱    George Mason University law professor Frank Buckley believes Republicans should embrace single payer, and points to the benefits of Medicare in his native Canada.

‱    Bottom line? Canadian health outcomes are better than American health outcomes, including longer life expectancy and fewer chronic conditions. These gaps have been growing ever since Canada fully implemented its Medicare program in the early 1970s.

Canada Outcomes

Cutting overhead and bureaucracy

Your conservative representative may agree with you that single payer would provide high-quality care, but they may also also argue that the private sector is more efficient than the federal government, and therefore a better steward of our health care dollars.

However, it is our current, market-oriented system that generates the greatest amount of waste and profiteering. Conservatives who hate bureaucracy should be champing at the bit to do away with private insurance company overhead. A February 2017 estimate published in the Annals of Internal Medicine found that single payer would generate $504 billion in administrative savings annually.

Admin Savings

Economists and public health experts have consistently shown that single payer is an efficient and effective use of resources. Here are some prominent examples:

‱    PNHP co-founders, Drs. David Himmelstein and Steffie Woolhandler, argue that single payer would allow for Liberal Benefits, Conservative Spending.

‱    Nobel laureate Angus Deaton favors single payer “because it will get this [health care] monster that we’ve created out of the economy and allow the rest of capitalism to flourish.”

‱    Nobel laureate and noted health care economist Kenneth Arrow lauds the Canadian system (with its private practitioners) and says single payer is “better than any other system.”

Boosting American business

Conservative members of Congress often voice concern over the global competitiveness of American business, and rising health care costs are harmful in that regard. Under single payer, U.S. firms might contribute as much to health care as they do now via a payroll tax, but they would no longer need to shop for group policies. They would also be spared the outrageous annual cost increases that have become commonplace in the large- and small-group markets.

For workers, single payer would allow those who are not a good fit for their jobs to seek more productive employment elsewhere instead of staying put in order to preserve health benefits. And would-be entrepreneurs would no longer fear striking out on their own due to a lack of health insurance.

Ultimately, improved Medicare-for-all would ensure a healthier, more financially-secure workforce. Thankfully, employers are starting to take notice:

‱    The group Business Leaders Transforming Healthcare “strongly supports legislation to transition the United States to a publicly funded health care system.”

‱    MCS Industries founder and owner Richard Master has produced a documentary, FIX IT: Health Care at the Tipping Point, that lays out the business case for single payer.

‱    Berkshire Hathaway vice-chairman (and longstanding Republican) Charlie Munger says single payer is the solution to America’s health care woes.

‱    Marks Group owner and prominent blogger Gene Marks considers himself a “smaller government, fiscally right-of-center guy,” but has concluded that single payer would be best for business.

Conservative voters are embracing single payer

Now that Congressional Republicans have unveiled the American Health Care Act, a growing number of their supporters are recognizing the empty promise of “repeal and replace.” They are demanding real reform, as evidenced by an April 2017 Economist/YouGov poll that found 46% of Republicans and 40% of Trump voters favor “Expanding Medicare to provide health insurance to every American.”

Economist Poll

Single-payer reform is vitally important, and progressives can’t go it alone. Talk to your conservative friends, colleagues, family members, and elected officials. Listen to their concerns. Let them know that a humane, efficient, high-quality health care system is possible, but only if we work together.

Health Care Financing: It’s a tape worm

By Ewell Scott, M.D., F.A.C.P.
The Morehead (Ky.) News, May 26, 2017

When Warren Buffett talks, everybody who is anybody sits right up and listens.

Mr. Buffett, living in Oklahoma in a modest ranch house situated in a middle class neighborhood, demands the attention of Wall Street Tycoons and Hedge Fund Managers as he has the uncanny ability of predicting the future in economic terms. He picks out the winners. His reputation for honesty, plain speaking and accuracy are legendary.

Well, just last week he described our current health care financing system a “tape worm.” WOW. I do not want to have a tape worm. Since childhood the image of a silent grisly creature eating away, living in my gut, was scary.

But I am afraid the shoe fits, as our private health insurance based system is literally wasting huge amounts of money.

We in the USA spend twice as much as any other civilized country but get less. Our military, the best and largest, consumes 5 percent of our gross domestic product while total health care spending is responsible for 18 percent. We needlessly spend ours on an inefficient, fragmented, confusing system.

Mr. Buffett’s co-executive at Berkshire Hathaway, Charlie Munger has recently called for adopting a single payer health care system with progressive financing to get rid of this unwanted situation. Medicare for All, new and improved, would do it.

Let’s tell our politicians we want a truly universal, affordable and comprehensive health care financing system.

http://www.themoreheadnews.com…

Take action to rein in pharmaceuticals

By Robert Blake, M.D.
The Missourian, May 26, 2017

Pharmaceutical companies are among the most profitable companies in the world, and their executives are among the highest paid. In recent years, drug prices have markedly increased, rendering more and more Americans unable to afford essential medications.

Companies incur legitimate expenses for research and development of new drugs; however, their combined expenditures for lobbying, contributions to political campaigns, direct advertisements to consumers and promotional efforts, including free gifts, targeting physicians far exceed what they devote to research and development. Furthermore, the National Institutes of Health and other federal sources provide significant funding for research of many drugs that become highly profitable for companies. Taxpayers subsidize the development of drugs that they later must pay high prices to obtain or cannot afford to buy.

The film, “Big Pharma – Market Failure,” recently shown at the Columbia Public Library, documents the failure of the market to supply many medications at a reasonable price. The film emphasizes the devastating effects of escalating drug prices on small businesses that provide health insurance for employees.

We can take actions to address this serious problem.

‱ The federal law that prohibits Medicare from negotiating drug prices with pharmaceutical companies must be repealed. By negotiating prices, the Veterans Affairs  provides essential drugs to veterans at lower prices; Medicare should be allowed to do this.

‱ American consumers should be legally able to purchase medications from legitimate foreign sources. Prices of the same drugs are much lower in countries like Canada. The ensuing competition will reduce prices in the U.S.

‱ The public should have input into the pricing of drugs that were developed with taxpayer assistance.

‱ We need effective limitations on lobbying and campaign contributions from wealthy corporations, which unduly influence lawmakers to the benefit of the companies and the detriment of the public.

‱ Patent laws should be reformed to prevent companies from perpetuating monopolies on drugs by making trivial changes that confer no therapeutic advantage.

We should no longer passively submit to harmful practices of drug companies.

Dr. Robert Blake is a Columbia resident.

http://www.columbiamissourian.com…

HHS Secretary Price on the CBO Report

H.R. 1628, American Health Care Act of 2017

Congressional Budget Office, May 24, 2017

CBO and JCT estimate that enacting the American Health Care Act would reduce federal deficits by $119 billion over the coming decade and increase the number of people who are uninsured by 23 million in 2026 relative to current law.

CBO Summary:
https://www.cbo.gov…

CBO Full Report (41 pages):
https://www.cbo.gov…

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HHS Secretary Price Statement on CBO Report

U.S. Department of Health and Human Services, May 24, 2017

Following the release of the Congressional Budget Office (CBO) report analyzing the American Health Care Act, Health and Human Services (HHS) Secretary Tom Price, M.D. released the following statement:

“The CBO was wrong when they analyzed Obamacare’s effect on cost and coverage, and they are wrong again. In reality, Americans are paying more for fewer healthcare choices because of Obamacare, and that’s why the Trump Administration is committed to reforming healthcare. In a new analysis released just last night, HHS reported that premiums in the individual market have more than doubled since many of Obamacare’s regulations and mandates were implemented.”

HHS released a new analysis yesterday that shows premiums have doubled for individual health insurance plans since 2013, the year before many of Obamacare’s regulations and mandates took effect.

https://www.hhs.gov…

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Comment:

By Don McCanne, M.D.

Even though we spend far more on health care than other nations, the market has not been effective in allocating our funds in a manner that would ensure adequate health care for all. This is a time and circumstance wherein we clearly need government leadership.

In response to a Congressional Budget Office report showing that the current proposed health reform legislation – American Health Care Act of 2017 – would likely cause another 23 million people to lose their health insurance, besides its other deleterious effects, HHS Secretary Tom Price fails to acknowledge the severe deficiencies of the legislation and instead condemns the report as being “wrong.” This is not a casual comment; he distributes this through an official HHS release of the U.S. government.

Of course, the report isn’t wrong; it’s a prediction, based on the best available information.

What is wrong is that we have in place a public servant who would destroy whatever he can of the important public health role served by the Department of Health and Human Services. He is driven by his nutty anti-government ideology and would sacrifice the health services of tens of millions of Americans simply for the expediency of implementing his destructive agenda.

Although there are some checks and balances, nevertheless he is in a position to do considerable harm to America’s health care. He should not be left in office for four to eight years while we wait for the next president to replace him. Citizen action is required – now.

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

The US healthcare system is at a dramatic fork in the road

By Adam Gaffney, M.D.
The Guardian, May 25, 2017

The US healthcare system – and with it the health and welfare of millions – is poised on the edge of a knife. Though the fetid dysfunction and entanglements of the Trump presidency dominate the airwaves, this is an issue that will have life and death consequences for countless Americans.

The Congressional Budget Office’s (CBO) dismal “scoring” of the revised American Health Care Act (AHCA) on Wednesday made clear just how dire America’s healthcare prospects are under Trump’s administration. But while the healthcare debate is often framed as a choice between Obamacare and the new Republican plan, there are actually three healthcare visions in competition today. These can be labelled healthcare past, healthcare present, and healthcare future.

Let us begin with healthcare past, for the dark past is precisely where Republicans are striving to take us with the AHCA. The bill – narrowly passed by the House on 4 May – is less a piece of healthcare “reform” than a dump truck sent barreling at high speed into the foundation of the healthcare safety net.

Wednesday’s CBO score reflects the modifications made to the AHCA to pacify the hard-right Freedom Caucus, changes that allowed states to obtain waivers that would relieve health insurers of the requirement that they cover the full spectrum of “essential healthcare benefits”, or permit them to charge higher premiums to those guilty of the misdemeanor of sickness, all purportedly for the goal of lowering premiums.

In fairness, the CBO report did find that these waivers would bring down premiums for non-group plans. This, however, was not the result of some mysterious market magic, but simply because, as the CBO noted, covered benefits would be skimpier, while sicker and older people would be pushed out of the market.

In some states that obtained waivers, “over time, less healthy individuals 
 would be unable to purchase comprehensive coverage with premiums close to those under current law and might not be able to purchase coverage at all”. Moreover, out-of-pocket costs would rise for many, for instance whenever people needed to use services that were no longer covered – say mental health or maternity care.

Much else, however, stayed the same from the previous reports. Like the last AHCA, this one would cut more than $800bn in Medicaid spending over a decade, dollars it would pass into the bank accounts of the rich in the form of tax cuts, booting about 14 million individuals out of the program in the process. And overall, the new AHCA would eventually strip insurance from 23 million people, as compared to the previous estimate of 24 million.

It’s worth noting here that Trump’s budget – released Tuesday – proposed additional Medicaid cuts in addition of those of the AHCA, which amounted to a gargantuan $1.3tn over a decade, according to the Center on Budget and Policy Priorities.

The tax plan and budget – best characterized as a battle plan for no-holds-barred top-down class warfare drawn up by apparently innumerate xenophobes – would in effect transform the healthcare and food aid of the poor into bricks for a US-Mexico border wall, guns for an already swollen military, and – more than anything – a big fat payout to Trump’s bloated billionaire and millionaire cronies.

What becomes of this violent agenda now depends on Congress – and on the grassroots pressure that can be brought to bear upon its members.

But assuming the AHCA dies a much-deserved death – quite possible given the headwinds it faces in the Senate – we will still have to contend with healthcare present.

Last week, the Centers for Disease Control released 2016 results from the National Health Interview Survey, giving us a fresh glimpse of where things stand today. And on the one hand, the news seemed good: the number of uninsured people fell from 48.6 to 28.6 million between 2010 and 2016.

On the other hand, it revealed utter stagnation: an identical number were uninsured in 2016 as compared with 2015, with about a quarter of those with low incomes uninsured last year (among non-elderly adults). It also suggested that the value of insurance is declining, with “high-deductible health plans” rapidly becoming the rule and not the exception: for the privately insured under age 65, 39.4% had a high-deductible in 2016, up from 25.3% in 2010.

Healthcare present, therefore, is an unstable status quo: an improvement from healthcare past, no doubt, but millions remain uninsured and out-of-pocket health costs continue to squeeze the insured.

Which takes us to the third vision, that of healthcare future. As it happens, another recent development provided a brief glimmer of hope for that vision. As the Hill reported, the Democratic congressman John Conyers held a press conference yesterday (Physicians for a National Health Program, in which I am active, participated) to announce that his universal healthcare bill – the “Expanded & Improved Medicare For All Act” – had achieved 111 co-sponsors, amounting to a majority of the House Democratic Caucus and the most in the bill’s history.

This bill – like other single-payer proposals – is the precise antithesis of Paul Ryan’s AHCA. Rather than extract coverage from millions to provide tax breaks for the rich, it would use progressive taxation to provide first-dollar health coverage to all.

Which of these three visions will win out is uncertain, but the outcome of the contest will have a lasting impact on the country. We can only hope that the thuggish, rapacious vision championed by Trump and his administration does not prevail.

https://www.theguardian.com…

Single Payer Benefits

By Jack Mayer, M.D., M.P.H.
Vermont Public Radio, May 25, 2017

Winston Churchill once quipped that, You can always count on Americans to do the right thing – after they’ve tried everything else.

I like that quote because it allows me to be cautiously optimistic that in the end, the current chaotic health care debate may actually result in a Medicare-for-All, single payer system.

We already have a limited form of this in Medicare and Medicaid. Both work very well and provide excellent care for all who are eligible.

I’ve been a Vermont pediatrician for decades and I’ve been advocating for a single payer system since medical school. Obamacare – also known as the Affordable Care Act or the ACA – was a modest step towards universal coverage, but its repeal and the Republican bill to replace it will be dangerous for my patients, because there are multiple problems with the American Health Care Act – or what I prefer to think of as Trumpcare.

According to the Congressional Budget Office, if the proposed Trump/Republican health care plan passes, 23 million will lose insurance, premiums will rise, pre-existing condition protections will be at risk, Medicaid will be slashed, costs will be shifted to hospitals, clinics and states, and huge tax-breaks will accrue to people with incomes over $200,000, as well as big insurance and drug companies – while the rest of us get virtually no tax relief.

Almost every medical organization and AARP opposes this Republican plan.

But any insurance-based system will be dependent on the obsolete medical insurance industry, as it acts as an intermediary between providers and patients, without providing even one iota of care. And this places enormous administrative burdens on providers, while producing dubious outcomes. No other country pays as high a proportion of GDP towards health care and gets less quality and access than the United States.

A single payer plan would simplify the delivery of health care – and would do so with greater equity and fairness. Every other industrialized country provides a system of inexpensive, universal access to health care in recognition that health care is a human right, not a free-market commodity.

Without affordable access, children born into struggling families lose health insurance, and families go into debt or bankruptcy. Untreated children and adults suffer, thousands die.

Perhaps after trying everything else, Americans will finally see the wisdom in a system that would be equitable, simpler, less expensive, and provide excellent care for everyone.

audio here:
http://digital.vpr.net…

Ethics of equitable versus equal in health care

Health Insurance Benefits Should Be Equitable, Not Necessarily Equal

By Betsy Q. Cliff, Michael Rozier, and A. Mark Fendrick
Health Affairs Blog, May 22, 2017

As policy makers grapple with potentially undoing or modifying the largest expansion of health insurance in a generation, the cost and generosity of benefits hold center stage. Traditional underpinnings of insurance plans — premiums, deductibles, copayments, and coinsurance — frequently create barriers to the optimal use of these plans by consumers. They also can exacerbate inequities in health care, by inhibiting the use of services known to benefit health. Novel approaches to insurance plan design to produce a more equitable and efficient distribution of health care expenditures are warranted.

Following the principle of equality, insurance benefit designs traditionally have offered the same benefit structure to all enrollees. Consumer cost sharing at the point of service is typically uniform regardless of need or potential clinical benefit — often it’s based on the acquisition cost. This one-size-fits-all mentality seems like a great idea on the surface but can create deeply unfair outcomes.

Instead, we should be designing insurance coverage in a way that provides access to care for people who need it, when they need it. That requires a subtle but important shift from equal access to equitable access. The first approach treats all people, regardless of clinical need, the same. The second recognizes that clinical need is an essential factor in determining where to direct resources and does not apologize for treating people with different needs differently.

A feasible and effective approach to better aligning expenditures with patient-centered outcomes is value-based insurance design (VBID). VBID structures consumer cost sharing around the idea of clinical nuance, which recognizes that the value of medical services depends on who receives it, who provides it, and where it is provided. This nuanced strategy supports the goals of equity by reducing financial barriers to specific services for targeted populations who need them most. This approach can also be used to deter the use of services when there is low or no expected clinical benefit to the patient.

Equity Versus Equality

The concept of equity is most often applied to health outcomes, in terms of addressing the burden of disease borne by one group compared to another. The solution to these inequities often involves assessing the distribution of health determinants and allocating resources accordingly.

Equity is also embedded in the financing of our health system. For example, Medicaid Disproportionate Share Hospital payments follow the principle of equity rather than equality: Health care organizations that bear the greatest share of uninsured or underinsured patients receive the largest share of funds from this program.

In most situations, a fair health care system ought to concern itself more with equity than equality. If people responded identically to, and had equal need for, clinical services, then access to those services should be equal. Since this is clearly not the case, it makes sense to discriminate based on the likelihood of clinical benefit. In other words, we should not let the potential negative effects of “bad” discrimination (for instance, failing to prescribe a drug based on a person’s racial or sexual identity) obscure the potential advantages of “good” discrimination, which would make it easier for some groups to obtain a service based on clinical need. Equity is premised on the idea that some types of discrimination — treating unequals unequally — is not only good but also necessary.

In particular, tailoring insurance benefits in this way allows individuals to access the best care for their clinical situation. To help ameliorate disparities, patients who are in the most need and services shown to have the most benefit should be supported by their insurance coverage at the most generous levels.

Ensuring Access Through Equitable Benefits

Allowing benefit programs to adapt to those who are most likely to benefit from care could allow physicians to better tailor treatment to each patient and allow patients to better respond to evidence-based recommendations. Using VBID promotes this goal in three distinct ways.

First, VBID reduces cost sharing for specific services that are shown to have the highest clinical benefit.

Second, VBID enhances benefits for specific patient populations.

Third, whereas traditional benefit designs can keep people from accessing innovative medications due to higher cost, VBID can help tailor cost sharing to the specific clinical circumstance.

Coverage arrangements in most insurance plans are designed under principles of equality rather than equity. To fully realize the benefits of medical advances, ensure access for those who could benefit most, and enhance the efficiency of our health care expenditures, we need to change this paradigm. Equitable benefit design recognizes that many chronic conditions often require tailored therapies for achieving results and allows for discrimination based on clinical need. Better health outcomes, especially for those most in need, require us to apply principles of equity in all aspects of our health care system, including benefit design.

http://healthaffairs.org…

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Comment:

By Don McCanne, M.D.

The concepts of equitable and equal, as applied to health care, are certainly crucial. It is imperative that health care and the financing of it be equitable – fair – but it does not necessarily have to be equal. This article discusses these concepts in regard to value-based insurance design (VBID), appropriately reflecting the biases of a University of Michigan health management and policy professor (and a partner in V-BID Health), A. Mark Fendrick, and two of his graduate students.

It is clear that our fragmented, multi-payer health care system is neither equitable nor equal. Because of the great variety of health care financing systems in the United States, or lack thereof, people certainly do not have equal access to health care services and products. Nor is the system equitable since some are served very well when in need, and others are served poorly, if at all. There is an inherent unfairness in having impaired access to the most expensive health care system in the world.

The authors recognize that insurance design contributes to these inequities. They suggest that they could be diminished by redesigning benefits so that they are value-based. But they limit their considerations by adhering to the ideology of consumer-directed health care in which patients share in the costs of health care services as they are accessed (deductibles, copayments, coinsurance, tiering of benefits, penalties for out-of-network care, etc.). Thus their emphasis is on insurance design rather than on more direct financing of essential health care services.

This approach perpetuates and adds to the complexity and waste of our uniquely American health care financing system that is weighted down by profound administrative excesses. Tweaking benefits within an individual plan certainly does not make the benefits equal to those in a multitude of other private and public plans. Even if value-based tweaks were adopted by many other plans and programs, the overall impact on health care would be almost infinitesimal compared to the great needs we have in health care reform.

Much more important than not creating equality, VBID also would have too small of an impact on health care equity. Jiggering benefits would not begin to address the deficiencies that the uninsured and underinsured face, perpetuating our profound unfairness in health care access and affordability.

So let’s set private insurance plans aside and look at these concepts in the single payer model of health care financing. How do you make the system equitable – fair? You make it accessible and affordable for everyone. Central planning and budgeting of capital improvements ensures that health care facilities and professionals are as available as the logistics and resources would allow.

Affordability? Considering the profound inequality in income and wealth and the very high costs of health care, payment into the common risk pool must be based on ability to pay if financing of the system is to be equitable. This is accomplished through progressive tax policies. There could not be a more ethical example on why our health care system must be equitable, but not necessarily equal. An equitable system would be designed to make sure that essential health care benefits are available to all, and thus equal (though benefits that should not be funded by a public system would not be equal), but the financing, to be equitable, must not be equal.

We can forget about the value-based benefit tweaks for private consumer-directed health plans. We need real fixes in our health care system that are universally equitable.

Dr. Phil Verhoef speaks at Medicare-for-all press conference

Transcription by Kay Tillow
Daily Kos, May 24, 2017

A few hours before the CBO announced that 23 million Americans would lose their health insurance under the Republican health care bill passed by the House, Congressman John Conyers, seven co-sponsors of HR 676, and representatives of physicians and nurses groups gathered near the Capitol to announce the amazing growth of both public and Congressional support for single payer.

The following remarks were made by PNHP board adviser Dr. Phil Verhoef:

So I’m an ICU physician at the University of Chicago and as an ICU physician I depend on research and evidence to help inform me about how to practice medicine, how to take care of critically ill kids and adults in the ICU.

But I look at our current health care system, and when I look at the evidence and when I look at the research, I’m pretty sure that our health care system is also critically ill. Why do I say that? Well, look, based on research published last week we ranked 80th out of 195 countries and that is by far the worst of the developed countries in this world.

But more importantly we have 30 million uninsured patients in this country. What that means based on research and evidence is that we will have no less than 20,000 deaths this year because of that lack of insurance. That is unacceptable.

On top of that costs are out of control.

We spend the most per person out of pocket on health care. We spend the most per person per GDP. We spend the most on every possible measure that you can think of.

And so we are failing on every front…this is a critically ill health system. So I say, as a critical care physician, What’s the solution?

Well, one solution has been proposed in Trumpcare and I can tell you that I’m pretty sure, even without CBO’s report which we expect later today, that this is actually going to make our critically ill system even worse.

It’s a little bit like giving grandma a heart attack when she is already in the ICU for pneumonia And so ultimately why would that happen? So look, if 24 million people lose health insurance, that’s another 20,000 deaths that we can lay at the feet of the architects of this awful bill.

Second, this bill (Trumpcare) achieves financial responsibility by providing a humongous tax cut to actually destabilize Medicare at same time that it guts Medicaid. So what that really means is that we are balancing the books on the backs of senior citizens, children, people with disabilities and the poor.

And this just doesn’t make any sense to me.

But we have a solution, we have a therapy for this critically ill patient, our health care system, and that is HR 676, improved and expanded Medicare for All.

Again I turn to research and evidence based on studies from other countries around the world that use similar systems, it saves lives, it saves money, it improves health outcomes.

The thing that burns me up is that we have a solution on the books and there is not political will to move forward with it except for Congressman Conyers and the 111 cosponsors that have been supportive.

As an ICU physician, I know what the solution to our critically ill system is and that’s HR 676 Improved and Expanded Medicare for All and I hope to see political will to stop the deaths of people for lack of health insurance.

full press conference transcription:
http://www.dailykos.com…

full press conference video:

Single Payer In California? Can We Afford It? Can We Afford Not To?

By Paul Y. Song, M.D.
HuffPost, May 24, 2017

This week, the California State Senate Appropriations Committee released their fiscal analysis of SB562 sponsored by Senators Lara and Atkins. Opponents immediately screamed that #SB562 would cost $400 billion per year, more than three times California’s $124 billion general fund budget for next year.

It is very important to understand that the author indicates that this analysis was done while much of the specific details of the proposed legislation are still not finalized, and therefore the assumptions are quite general and conservative. Still, the summary reports that annual government spending on health care is roughly $200 billion, while employers spend $100 to $150 billion towards covering their employees. Without any mention of what individuals currently pay for premiums, co-pays, deductibles, and prescription drugs, the additional required “total new spending” would therefore be $50 to $100 billion per year. So under this worse case scenario, this would be between $106 and $212 per month per Californian in additional taxes.

Now before everyone gets scared away by this daunting price tag, it is important to look at these two graphics to put this into a much needed perspective.

Fig. 1
Fig. 1

Over the past 16 years, workers have had to contribute 221 percent more toward their employer-sponsored premiums (Fig. 1), while premiums have increased 203 percent and wages and inflation have lagged far behind.

Fig. 2
Fig. 2

At the same time, in addition to contributing more towards their premiums, workers have also had to pay more (Fig. 2) in co-pays and deductibles (67 percent more over the last 5 years). Thus in reality, workers are getting squeezed on both ends while having less take home pay. Many would argue that they are already paying upwards of $106 – $212 a month towards medications, co-pays, deductibles with no end in sight. This all goes away under #SB562!!

Plus, if everyone has improved coverage, powerful hospitals can no longer gouge us upwards of 331 percent (Fig. 3) with exorbitant prices for aspirin, hospital stays, OR use, etc. (Fig. 4) under the guise that it is needed to pay for uncompensated care which many not-for-profits fail to provide inadequate amounts of (Fig. 5).

Fig. 3
Fig. 3

Fig. 4
Fig. 4

Fig. 5
Fig. 5

And when Kaiser and United Healthcare use their massive market share to negotiate steep drug discounts, it is considered good free market business sense. So why is it bad if our single payer negotiates similar discounts for all of us?!

Please do not let the sticker price scare you. Healthcare is indeed expensive and our current system is unsustainable not to mention immoral and broken. Left as is, it is estimated to consume 20 percent of our GDP by 2025 while tens of millions remain uninsured nationally unless we really do something about it. With a GOP congress which places trickle down ideology above compassion, the health of nearly 1 out of 3 Californians who are on Medicaid remains under constant threat, not to mention the millions with pre-existing conditions, women, and our older folks. SB562 is truly the only way to proactively protect our health security by fixing our badly broken system while providing every Californian with true healthcare peace of mind. And at a price which is more than reasonable in the context of no more outrageous premiums, co-pays, or deductibles.

Some say we cannot afford it. It is clear that we can no longer afford not to.

Dr. Paul Y. Song is a national board member of Physicians for a National Health Program and co-chair of the Campaign for a Healthy California.

http://www.huffingtonpost.com…

House Democrats See ‘Medicare For All’ As The Answer To Trumpcare

Rep. John Conyers’ single-payer bill has never been this popular.

By Daniel Marans
HuffPost, May 24, 2017

House Democrats on Wednesday touted unprecedented majority support for a bill that would expand Medicare to the entire U.S. population, reflecting a growing liberal consensus behind single-payer health insurance.

Rep. John Conyers (D-Mich.), who has been introducing single-payer legislation since 2003, said at a press conference that Democrats must counter the Republican bill to repeal the Affordable Care Act with support for “Medicare for all.”

“Obviously we’re all united in opposition to Trumpcare. That’s easy,” he said. “People know what we’re against, but we want to promote more what we are for.”

The press conference was scheduled to take place hours before the nonpartisan Congressional Budget Office released its assessment of the updated version of the Obamacare repeal bill that the House of Representatives passed earlier this month.

Conyers was joined by Democratic Reps. Bonnie Watson Coleman (N.J.), Steve Cohen (Tenn.), Ro Khanna (Calif.), Jamie Raskin (Md.), Keith Ellison (Minn.) and Mark Pocan (Wis.), the newly elected co-chair of the Congressional Progressive Caucus.

Like many progressives, Conyers has long said that the problems bedeviling the American health care system are rooted in its reliance on private insurance.

“We will never get universal care built on a foundation of private, for-profit insurers,” he said. “The only way we will get there is the way every other advanced country on the planet has, through a universal system like expanded Medicare.”

Critics like Conyers argue that Obamacare is flawed because of too little, not too much, government intervention.

The reform law enlarged private insurance rolls by requiring anyone in the individual market above a certain income level to seek coverage in government-regulated private insurance exchanges ― and providing them subsidies to do so. Now the number of insurance options in these markets has begun to dwindle because for-profit companies find it too costly to cover new enrollees, who tend to be sicker than the general population.

There are a number of ways that the federal government could entice insurers to stay in the exchanges, such as reimbursing them for their highest-cost cases and improving how they enforce the individual insurance mandate. But if private insurers were not part of the equation, these triage measures would be unnecessary.

Progressive single-payer advocates say that these challenges, along with the unprecedented political threat to Obamacare from President Donald Trump and congressional Republicans, have created the right political moment to push their ideal into the party’s mainstream.

Sen. Bernie Sanders (I-Vt.), who turned “Medicare for all” into a progressive rallying cry with his insurgent presidential campaign, plans to introduce companion legislation to Conyers’ bill in the Senate this summer. His single-payer bills have not attracted any co-sponsors in the past.

The growing level of support for Conyers’ bill suggests this time might be different. The legislation, known as the Expanded and Improved Medicare for All Act, has 111 co-sponsors ― including Dels. Eleanor Holmes Norton of D.C. and Gregorio Sablan of the Northern Mariana Islands, who can’t vote on legislation on the House floor. Still, it is a solid majority of the 193-member House Democratic Caucus and the most support such legislation has ever received. The bill has even attracted support from some fiscally conservative members like Rep. Jim Cooper (D-Tenn.).

The previous high-water mark for Conyers’ bill was in 2008, when 93 of his colleagues got behind it. The Democratic caucus was much larger at the time, however, so the bill’s supporters constituted a smaller proportion. Last Congress, the bill attracted just 63 co-sponsors.

House Assistant Minority Leader James Clyburn (D-S.C.) and Democratic Caucus Chair Joseph Crowley (D-N.Y.), both members of leadership, have co-sponsored the bill.

Yet single-payer legislation would undoubtedly face a steep climb, even if Democrats took back the House in 2018. Currently, Medicare requires co-payments from seniors and people with disabilities above a certain income level.

House Minority Leader Nancy Pelosi (D-Calif.) said earlier this month that “the comfort level with a broader base of the American people is not there yet,” and encouraged activists to try to enact single-payer plans at the state level first.

In addition to extending Medicare coverage to the whole population, Conyers’ bill would improve on Medicare’s coverage levels by having the government pick up the entire tab for everything from preventive care visits to dental care.

To pay for this expansion, the law would increase personal income taxes by 5 percent for higher earners, institute a new tax on worker payroll, and levy new taxes on investment income and financial transactions.

But Conyers’ bill is also deliberately vague on some of the details. Aside from the income tax hike, the legislation does not specify the levels of all the new taxes, or the earnings thresholds where they would take effect. But a 2013 analysis of the bill by Gerald Friedman, an economist at the University of Massachusetts, Amherst, assumed that the new high-income surtax would increase taxes on households earning $225,000 or more by 6 percent, and the payroll tax would levy new 3 percent or 6 percent taxes on employers of all workers.

Ultimately, the taxes on workers and employers would be a net financial win for the country, saving Americans nearly $600 billion a year in lower health care costs, according to Friedman.

But when the reality of those upfront tax increases sets in for members of Congress, it could be a tough sell.

What’s more, several efforts to wring savings from private health care providers during the crafting of Obamacare collapsed as Democrats succumbed to industry pressure en masse. Since Conyers’ bill envisions that the government will use its bargaining power to bring costs into line with those of other countries, it could face similar resistance from providers.

State-level experiments with single-payer health insurance face similar if not greater challenges due to the size of their risk pool. Vermont tried to adopt a single-payer health insurance plan in lieu of Obamacare, but gave up when the costs of transitioning to the the new system proved too great.

Some progressive groups, including the National Nurses United, are now throwing their weight behind a serious effort to create a single-payer health insurance system in California. The plan could cost as much as $400 billion a year, according to a legislative analysis released Monday and conducted at the request of state lawmakers promoting the policy. Half of that amount would have to be raised through new taxes.

Challenges notwithstanding, progressive activists and Democratic lawmakers are tired of asking for less than what they really want and encountering unified Republican opposition anyway.

Even if it stands no chance of approval in the short-term, they say that a push to expand the popular Medicare program is a political winner that can help Democrats take back Congress.

At Wednesday’s press conference, Pocan observed that town hall discussions about implementing “Medicare for all” draw a more enthusiastic response than any other issue. He said the issue was widely praised at a town hall he recently held in in Kenosha, Wisconsin, which is in Republican House Speaker Paul Ryan’s district.

Indeed, 60 percent of Americans favor extending Medicare to the entire population, according to an Economist/YouGov poll from April.

Ellison, who is deputy chair of the Democratic National Committee, emphasized that no one in the DNC would tell lawmakers and candidates what position to take on a given issue ― but the power of suggestion is fair game.

“I recommend that you win your election, and I think a good way to do it is to support the Conyers bill,” he said.

http://www.huffingtonpost.com…