PNHP

Townie right on AHCA provisions

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Townie right on AHCA provisions

By Thomas O’Rourke, Ph.D., M.P.H.
The (Champaign, Ill.) News-Gazette, May 23, 2017

Kudos to Ryan Jackson (the Reluctant Townie) for his recent excellent article. “Rodney Davis voted for your death panel” by supporting the American Health Care Act that barely passed the House, 217-213.

Let me add a few other points. Besides taking $880 billion out of Medicaid, it would take another $312 billion out of subsidies that help working families buy private coverage through the Affordable Care Act exchanges. Instead of helping people get care, this money would be diverted to give an $800 billion tax break to people with incomes over $200,000.

Davis’s vote threatens to strip coverage from 57,300 people in our district.

But it doesn’t end there. If the ACA is entirely or partially repealed, 413,700 individuals in the district with employer-sponsored sponsored health insurance are at risk of losing important consumer protections such as coverage of pre-existing conditions and the prohibition on annual and lifetime limits.

Also, 377,200 individuals in our district with health insurance covering preventive services like cancer screenings and flu shots without any copay, coinsurance or deductibles stand to lose their access if the Republican Congress eliminates ACA provisions requiring health insurers to cover important preventive services without cost-sharing.

Undeniably, the ACA is flawed. It left 28 million Americans uninsured and millions more with unaffordable premiums, deductibles and copayments.

But the GOP plan would make things much worse.

Instead of moving backward, we should move forward and go from the ACA to a Medicare for All plan like the one proposed by Rep. John Conyers (H.R. 676).

http://www.news-gazette.com…

U.S. Health Care is Profiteered to Death

Interview with Susan Rogers, M.D.
Black Agenda Report, May 23, 2017

The following is an unofficial, lightly edited transcript of an interview that Dr. Susan Rogers, PNHP national board member, gave to Glen Ford, executive editor of the Black Agenda Report, on May 23. You can listen to the interview above.

Glen Ford: Obamacare remains in a kind of limbo in the U.S. Congress, having been repealed in the House but with no action pending in the Senate. On the single-payer health care front, a majority of House Democrats have finally signed on to Congressman John Conyers’ Medicare for All bill. However, Democratic Party leaders have not gotten behind the measure. And Bernie Sanders has not introduced a single-payer bill in the Senate. In Chicago we spoke with Dr. Susan Rogers, a board member of Physicians for a National Health Program.

Dr. Susan Rogers: I think that it’s just politically difficult for a lot of these congressmen to take a stand for single payer, although, clearly, they cannot support the Republican bill that has been passed in the House. And even the Affordable Care Act: many people know that there are some significant issues with that. There are some positives in the ACA, of course: the fact that people can get coverage for preexisting conditions, that kids can stay on their parents policy till they’re 26. But the Affordable Care Act doesn’t eliminate the whole issue of private-insurance-sponsored health care, which is – that’s the biggest problem. That’s where all the high deductibles are coming from, the copays, the tiered drugs and all of the expenses that are being shifted onto patients. That, the Affordable Care Act does not fix.

GF: I was surprised to see even a Republican seem to admit that single payer’s time has come. That person was defending the Republican bill that would allow states to opt-out or opt-into plans, as this congressman mentioned, “so they could have their single payer or they could have our plan,” which seemed to be an admission that single payer is on the horizon anyway.

SR: That is true. I think a lot of people will say that. However, to have just a small segment of the population in a single-payer system won’t work. That’s been the problem with the public option: the people who would end up being in the public option are people who couldn’t get affordable insurance elsewhere. So here you end up with a pool of people who have a lot of medical issues at high cost. And that’s why that public option or small single-payer systems would not work. I mean, if you look at Medicare, it covers everybody over 65. We all know that’s a very heterogeneous group, in terms of some people who are very, very healthy, and some people who are high utilizers of health care. The pool works because you’ve diluted the risk: you have healthy people and sick people in the same large pool. And that’s the way a single-payer system would work. Everybody has to be in it.

GF: Single payer seems to work in every industrialized country in the world. But folks in the United States, Democrats as well as Republicans, act as if the U.S., the richest country in the world, can’t afford it.

SR: Well, we still have this assumption that health care is a commodity and that the markets dictate how it functions. Buying health care isn’t like buying a car. Everybody needs the same coverage and health care. Everybody doesn’t need the same kind of car. Everybody doesn’t need the same kind of house. So that’s where the market comes in, it’s when people have choices with things. But people talk about choice of health care, which really, when you think about it, makes no sense. Do you know what your health care needs are going to be next week? You have no clue. You assume they’re going to be what they are today, but you don’t know. That’s the whole point of insurance, is to cover you for the unexpected. So to make buying health insurance a matter of choosing what’s best for you – the whole basis of that argument is false. It’s not applicable, because you don’t know what you’re going to need. So you have to be covered for everything. And that’s why people who buy private insurance often end up being exposed to the phenomenal bills, these high deductibles these co-pays, that send them into bankruptcy.

GF: And the net result is that the United States pays more per capita for health care than anybody else in the world – without assuring insurance for everybody

SR: Yes we do. And an interesting part of that number, too, is that the majority of those dollars are already government dollars. So the government is already paying the majority of that per capita expense. Not just Medicaid, not just Medicare, but in terms of the premiums for government employees – all teachers, all policemen, all firemen. All these people get their health premiums paid for in large part with government dollars. And then when you look at the tax write-off by employers for what they spend on employees’ premiums – that’s an additional cost to the government. So the government is already spending more than other countries, and that’s without the additional cost of the costs they’re putting on patients so they have so-called skin in the game. So the government is already paying more than everybody else, so the whole idea that there isn’t money is not true. We would save so much money by eliminating all the administrative costs. It’s ridiculous the amount of time and money that gets spent in administering a system like this that is so complex and so tedious. It’s difficult even for me as a physician who had some medical issues this last year. I found it difficult to navigate the system. So I can’t even imagine how someone who does not understand health care can figure a way through it. It’s impossible.

GF: So it’s not a question of expense which is already exorbitant, but who gets paid and who profits.

SR: That is exactly true. And the ones who are going to get paid are the health insurance companies. There’s no question about that. And if you look at a large hospital, I bet they’ve got more billing clerks than they do nurses per patient. That just tells you where the money is going. It’s not going to health care, it’s going to billing. And if you look at the electronic medical record, which was supposed to be developed to make health care better – so that if you go to a hospital in New York and then see somebody in California, the two doctors should be able to talk, but they often can’t or don’t. The drive for electronic health records, EHRs, was really driven by billing. It was not driven by the need to improve health care or clinical care. It was driven by a way to bill, and that’s the whole concept. So it really isn’t helping health care. It may be a little bit because we can read the notes now of physicians with poor penmanship, but it’s not lowering medical costs. In fact it’s driving costs up.

GF: As a physician, as a person as an activist medical person, what would you like to see happen to get the Congress off the dime on single payer?

SR: I would like to see Congress get educated about this. I have talked with many people who have gone to town hall meetings and had firsthand discussions with representatives across the country. I can speak mostly to people I know who have done so in Illinois. One thing that’s clear. They talk about is just how the congresspeople are so – they don’t know what the system is. They’re actually ignorant about the problems. I hate to use that word because it’s a strong word, but some of the comments that have been made, like “Nobody has died because they didn’t have access.” I mean, where does this person live? What bubble are they living in? And that’s part of the problem – these congressmen are living in bubbles and have no idea of what everyday people go through just to get their health care needs met. And then there is this other assumption too, that the biggest driver of costs in health care are the unhealthy lifestyles of people. That may be true in the sense that some behaviors do lead to more cardiovascular disease, for example, but we have to remember we are all mortal. We are all going to get sick whether we lead a perfectly healthy lifestyle or not. So we all are going to need health care.

GF: That’s right. Almost all of us will die of disease at some point.

SR: Exactly. And even if we die of trauma, there’s still health care in that issue. So the whole idea that staying healthy will prevent you from using health care dollars is a falsehood, because we will all eventually need health care. I know very healthy people who have gotten cancer. I know very healthy people who have gotten heart disease. I know very healthy people who unfortunately lived in an area with bad air and ended up with lung disease. So it’s not just because of poor lifestyles, because obesity is a big problem. Clearly that’s a factor. I’m not denying that. But that’s not what’s necessarily driving up health care costs.

GF: That sounds like the ever-present factor of prejudice in American political thought.

SR: Well, yes, if you look at the health care industry lobby, it’s a huge lobby that has poured billions and billions into congressional races and stuff. And so that’s who people are beholden to. And unfortunately it’s been clearly shown that the congressmen are voting for their donors, not for their constituents.

GF: That was Dr. Susan Rogers of Physicians for a National Health Program.

https://soundcloud.com…

Would California’s proposed single payer system bankrupt businesses?

California Senate Committee on Appropriations: SB 562 (Lara) – The Healthy California Act

By Brendan McCarthy (Consultant)
May 22, 2017

Bill Summary: SB 562 would create a universal, single-payer health care system in California.

Fiscal Impact: The fiscal estimates below are subject to enormous uncertainty. Completely rebuilding the California health care system from a multi-payer system into a single payer, fee-for-service system would be an unprecedented change in a large health care market.

The projected costs and revenue needs for the proposed Program are as follows. For a discussion of the underlying assumptions, see Staff Comments (link below).

* Total annual costs of about $400 billion per year, including all covered health care services and administrative costs, at full enrollment.

* Existing federal, state, and local funding of about $200 billion could be available to offset a portion of the total program cost.

* About $200 billion in additional tax revenues would be needed to pay for the remainder of the total program cost. Assuming this tax was raised through a new payroll tax (with no cap on the wages subject to the tax), the additional payroll tax rate would be about 15% of earned income.

It is important to note that the overall cost of those new tax revenues would be offset to a large degree by reduced spending on health care coverage by employers and employees. Although precise estimates of total spending for employer sponsored health insurance are not available, the best available information indicates that existing spending is between $50 and $100 billion per year. Therefore, total new spending required under the bill would be between $50 and $100 billion per year.

Administrative cost savings would be real, but limited

Under a single payer system, the overall administrative cost of the system would likely be lower than it is in the current multi-payer system. In the United States, the cost of the health insurance industry is about 7% of total costs. In addition, providers, such as hospitals and physicians, incur significant administrative costs to negotiate contracts and comply with health insurer billing requirements. If we assume that the costs on the provider side are equal to the costs of the insurance industry, then current administrative costs are likely to be about 15% of total spending. Administrative costs in the Medi-Cal fee-for-service system and Medicare are about 6% of spending. Assuming that dealing with a single payer system reduced provider administrative costs by half, total administrative costs of the system in the bill would likely be about 9-10% of total spending. This does represent a significant savings in a $400 billion health care system. However, administrative savings are not likely to substantially lower the overall cost of providing health care to the state, compared to costs associated with expanding coverage to the uninsured and increased utilization of services under the bill.

https://ww2.kqed.org…

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Comment:

By Don McCanne, M.D.

With the release of this fiscal analysis of SB 562 – The Healthy California Act – the expected loud protests to the high costs of a single payer system have been forthcoming, especially that the costs would exceed the California state budget and that raising the additional funds required through a 15% payroll tax would bankrupt businesses. The opponents conveniently ignore the opening caution that “the fiscal estimates below are subject to enormous uncertainty.”

In fact, this 8 page analysis is loaded with assumptions and uncertainties based on the lack of detail specified in the proposed legislation, as the author indicates. Health care is almost one-fifth of our gross domestic product, and, by any accounting, that is very expensive. But this does not change fundamental single payer principles. All of the health care funds are moved into a single, publicly-administered system which is administered much more efficiently and which is funded on an equitable basis (which requires progressive taxes because of the decades-long shift of income and wealth to the top).

The opponents have already declared that this legislation is a failure based on the high global costs and the assumption that a payroll tax would replace current private spending. Reading the full report would provide a more objective perspective, in spite of the multitude of uncertainties.

At any rate, those who dismiss this legislation based on spending greater than the California state budget and a 15% payroll tax must be challenged. Our response? This bill would provide each Californian with all essential health care services at a price that each can afford.

Why Won’t More American Corporations Support Single-Payer Health Care?

Warren Buffett is rare among CEOs in publicly recognizing the economic benefits of Medicare for All.

By Helaine Olen
The Nation, May 22, 2017

Talk of single-payer health care in the United States popped up in an unexpected place recently: the most recent Berkshire Hathaway annual meeting. “The whole system is cockamamie,” the company’s vice chair, Charlie Munger, declared. “I think we should have single-payer medicine eventually.” As for partner Warren Buffett, the man known by his fans as the Sage of Omaha, he called health-care costs “the tapeworm of American economic competitiveness” and claimed he “personally” supported a single-payer system.

Those of us who cover individual investing know that the utterings of Buffett and Munger are generally repeated, and repeated again. They turn into aphorisms—how many times have you heard it said of the stock market, “It’s only when the tide goes out that you learn who’s been swimming naked?” But when it comes to health care, it’s something else. There is a day or so of attention, and then it’s nothing but crickets.

What’s going on? You can thank a toxic stew of ideological blindness, fear of controversy, and rampant cost shifting for the silence. The size and power of the industry is a factor too. Healthcare “is the military industrial complex of the 21st century,” says Richard Master, the chief executive officer of MCS Industries, a supplier of picture frames based in Pennsylvania, and the rare C-suiter to publicly support single-payer.

The United States spends more than $3.3 trillion on health care annually. Employer-based insurance covers about half the non-elderly population. The cost is not unsubstantial. Medicare spends less than 2 percent of its budget on administration vs. 18 percent for private insurers. According to the Kaiser Family Foundation, the average premium for a family was $18,142 in 2016. The typical employer picked up about two-thirds of that total. The numbers are adding up, and the politically vaunted small-business sector is yowling. The National Federation of Independent Business’s 2016 Problems and Priorities survey found more than half of those they polled claimed the cost of health insurance was “a critical issue,” they faced.

Healthcare costs also eat away at American business competitiveness. Prior to the Great Recession, General Motors claimed that providing health-care coverage adds another $1,500 onto the sticker price of every new model sold. Starbucks reported around the same time it spent more on health care than on coffee beans. The Affordable Care Act has slowed the overall pace of health-care spending, which nonetheless still exceeds the rate of inflation.

Buffett’s economic point—one he’s made for a number of years—is that corporate honchos obsess about the weight of taxes on their bottom line when they should be pondering the impact of skyrocketing health-care costs instead. For years, he’s pointed out that health-care expenditures were approximately 5 percent of the gross domestic product in the 1960s. Now they are at about 17 percent. Other countries spend significantly less. Healthcare costs make up 11 percent of Canada’s gross domestic product. In Australia—about which Donald Trump recently said, “you have better health care than we do”—it’s approximately 9 percent.

But all this spending isn’t exactly doing wonders. About one in ten American adults still doesn’t have health insurance. Our reputation for world-class care might be a tad exaggerated; our maternal mortality rate has increased substantially since 2000. Never mind the moral argument for health care for a moment. Pay more money for lesser results? Surely, no sane businessman or businesswoman would want to deal with this, not for one blasted moment. In this environment, business and corporate support for single-payer/Medicare For All/whatever you want to call it should be the proverbial no brainer.

But it’s not. Many in the United States business world remain in thrall to a marketplace ideology, mixed with a whiff of self-help. The glory of the market is paramount, and any attempt to enhance the role of government—even when it is in the best interests of the players to do so—is looked on with suspicion. For example, when runaway medical costs caused mass business agita, former Safeway CEO Steve Burd founded a group called the Coalition to Advance Health Care Reform. It endorsed universal coverage but argued it needed to be “market-based” and offer “universal coverage with individual responsibility.” These days, people needing insurance or medical care are routinely referred to as “shoppers” who should compare the price of medical services like they would a can of peas.

The American Sustainable Business Council, a left-leaning business trade group, is now seeking to change things. It recently debuted, in conjunction with a documentary, Big Pharma: Market Failure, an action group called Business Leaders Transforming Healthcare that is making the case for single-payer as a business imperative. More than 150 businesses have signed on to the campaign, including Richard Masters’s MCS Industries, who is also in the film. But it’s going to be a battle. Many of the American Sustainable Business Council’s most recognizable corporate partners have yet to join in.

In an effort to find out why, I contacted Ben & Jerry’s, Eileen Fisher, Patagonia, Seventh Generation, Dansko, Etsy, and The Honest Company—all members of the council who have yet to sign onto the health care campaign. A spokeswoman for Ben & Jerry’s told me, “We all know the US health-care system is broken,” adding, “We believe strongly that everybody should have access to quality care” and that the company could not make a decision on whether or not to sign on to the initiative “until we have formulated our position.”

Jessica Alba’s The Honest Company—a self-described “mission-driven company” dedicated to, among other things, “corporate social responsibility” and “taking selfless actions that benefit others”—wrote back that they work with the American Sustainable Business Council on “issues related to chemical safety and ingredient disclosure” and aren’t “currently engaged” in other initiatives with them.

The others ignored me. I can’t say I am surprised. Corporations are notoriously loath to endorse controversial positions, especially ones that have the potential to put them in the firing line of activists on one side or the other. Then there is the power of the health-care industry, which is responsible for the largest number of jobs added since the last economic downturn. Business leaders stick to the powerful until it’s all but unsupportable.

In lieu of asking for government help, many American corporations are dealing with the health-care expense in a time honored capitalist fashion: they’re sticking it to the workers. A majority of those with employer provided health insurance now have a deductible of at least $1,000, which partly explains why out-of-pocket health-care spending for someone with employer provided health insurance has increased by more than 50 percent since the beginning of the decade. Little wonder recent Congressional Town Halls feature many plaintive pleas for single-payer or a Medicare expansion.

Masters told me he thinks the comments at the Berkshire Hathaway meeting are a game changer. “It’s a remarkable green light for business leaders to start thinking about single-payer.” Maybe he’s on to something: The week that began with Munger endorsing single-payer ended with Aetna Healthcare’s chief executive officer Mark Bertolini saying the United States needed to “debate” single-payer but stopping short of endorsing it. “If the government wants to pay all the bills, and employers want to stop offering coverage, and we can be there in a public-private partnership,” he told a group of Aetna employees in a private conversation subsequently leaked to Vox, “then let’s have that conversation.”

https://www.thenation.com…

What do leaders of the medical-industrial complex think about reform?

Healthcare Strategy in the Year of Uncertainty; Even amid significant legislative ambiguity, reform remains a market-driven issue.

By Aamer Mumtaz, Alan London, MD, and David Fairchild, MD
Healthcare Financial Management Association, May 2017

Among the dozen C-suite leaders from leading health systems and AMCs in nine states who we interviewed over the past two months, most believe that the healthcare market has many of the same characteristics and challenges as it did in 2011: Cost growth is an issue, quality and value are ongoing concerns, and breaking even on government programs is a challenge. With some critical caveats, the appropriate short-term provider response thus will not be fundamentally different from the past seven years:

• The search for value will continue, with clinical integration, care coordination, and high-quality care still the paths to get there.

• Scale will become even more important as systems look for ways to reduce the per unit cost of care.

• Commercial insurance will remain the main engine of growth for providers, with Medicare Advantage the most attractive government program financially.

• Medicaid and the ACA marketplaces are wild cards. What happens in those spaces will be felt disproportionately by systems serving high numbers of underprivileged patients, including systems operating in rural areas.

• The move toward quality will continue despite the potential waning of government support for innovation.

• Speed to market for new initiatives in the pipeline will be important.

• Cost reduction and asset redeployment will be essential in an increasingly cash-strapped environment.

“No regret” moves

Providers are focused on moves that transcend the ongoing legislative and regulatory uncertainty and instead address more fundamental economic forces. Such moves include:

• Achieving scale through partnerships and alliances

• Commercial market growth (e.g., through targeted ambulatory expansion)

• Continued focus on Medicare Advantage

• Aggressive cost control

• Partnerships with health plans to share more risk

• Building the clinical network

• Slowdown or halt on long-term investments

Economics overshadows politics

Our preliminary discussions with leaders from major health systems around the country have cofirmed that healthcare reform remains driven primarily by market forces as opposed to legislative initiatives. As one West Coast executive told us, “The challenges facing health care are more economic than political.”

Just as in 2011, imperatives to reduce costs and to achieve profitable growth through the delivery of value remain key. In fact, cutting costs, improving clinical integration, and addressing quality and customer service needs — all while focusing on profitable markets for growth — arguably will be even more important strategies in 2017 and going forward than they were in 2011.

http://www.bdcadvisors.com…

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Comment:

By Don McCanne, M.D.

So who really determines the nature and scope of the health care delivery system? Is it the doctors and nurses? They are busy trying to make the system we have work for their patients, and they are having difficulties with that. Is it the politicians? They continue to feed the largest share of money into the system (taxes – often opaque – to pay for health care) while turning much of it over to the medical-industrial complex.

The medical-industrial complex is composed of interwoven, overlapping organizations and their executives that make spending decisions through various financing vehicles such as commercial insurance, managed care organizations, accountable care organizations, health plan administrators for public and private programs, and the like. According to this survey of C-suite leaders, they want more of it – more integration (anti-competitive consolidation), more care coordination (care management prioritizing executive business decisions), shifting care to where the money is (outpatient services now epitomized by the most expensive of all – free-standing emergency departments), more programs to promote “quality” (think MACRA and MIPS), more government financing of private insurance (prominent examples being Medicare Advantage and Medicaid managed care), while achieving scale in all of this (more and more of it), and they want it right now (before the social movement for health care as a right – single payer – can gain traction).

Many of the measures are touted as methods of controlling costs when the real cost containment efforts are directed to reducing volume and price as a method of ratcheting down the growth of spending on the actual health care delivery system. Although excessive prices and over-utilization are problems, so are under-utilization and inadequate pricing. Establishing barriers to care and not compensating the delivery system adequately do a disservice to patients and their health care professionals, especially when there are far more patient-friendly methods of containing spending, which also reduce the abuses.

Our current bearing will leave these people in charge, with more of the same. So what should we do? What should be our strategy and tactics? Is sticking placards in the faces of politicians and shouting “single payer” enough? Can we truly organize and coordinate with the greater social justice movement? Can we convince the medical-industrial complex that they need to be active participants and even leaders in a sincere movement for health care justice for all? They are going to be there whether or not we want them involved, though we should be able to cull those who really care for patients from those who are simply after acquisition of substantial personal wealth.

Regardless, take another look at what these C-suite executives have in store for us. It is terrible for health care professionals who really do care and even worse for patients. We can do far better with the $3.2 trillion we are already spending on health care (it’s our money!) than to turn it over to the medical-industrial complex and let them do with it what they will. As these authors state, “reform remains a market-driven issue” when we know that markets are anathema to health care justice.

No more feeble organizing. Let’s have the real thing.

A majority of physicians favor a single-payer health system

By Elizabeth Hakas, M.D.
Pittsburgh Post Gazette, May 21, 2017

As a person with 30 years of experience working in health care (first, as a medical assistant during college, and later, as a physician), I am very concerned about the GOP’s American Health Care Act. It will remove $880 billion in funding from Medicaid and remove the subsidies that help millions of Americans buy private health insurance. I must admit that I was not a huge fan of the Affordable Care Act (Obamacare), but the AHCA is much worse — a disaster in the making.

I will tell you my bias upfront: I am in favor of a single-payer system for our country, in which the government acts as “insurer” or “payer” and the care is provided through various means (private practices, community clinics, academic and community hospitals, etc. — just like now!) such as is the case in Canada. It would reduce administrative costs, and we could use the saved money to pay for care, rather than to line the pockets of insurance company executives. Such a system should be unconnected to one’s employment status and funded by taxes.

If we took all of the money that employers and workers pay toward their health “insurance” now, and instead called that “taxes,” it would be more than enough to provide excellent coverage for every single American. It just makes sense.

When I discuss this issue with my physician friends and colleagues, I am amazed at how many of them agree with this. I have yet to talk to a single physician who favors the AHCA over the ACA, and I have talked to many who favor single payer. This is in line with multiple national polls of physicians, which indicate that a national single-payer system (such as the Expanded & Improved Medicare for All Act, HR 676) is the most favored option among a majority of practicing physicians in this country. It is fair and morally correct that everyone in the U.S. have access to decent health care and that it be available consistently despite the changes that occur occasionally in most people’s lives: periods of unemployment, financial challenges, pre-existing conditions, etc.

I hope to see a single-payer health care system instituted in this country in my lifetime. In the meantime, we should all be vigorously rejecting the AHCA, which is a terrible step backward.

http://www.post-gazette.com…

America’s ranking on amenable mortality is an embarrassment

First-ever global study finds massive health care inequity

By the Institute for Health Metrics and Evaluation (IHME)
EurekAlert, May 18, 2017

A first-ever global study finds massive inequity of access to and quality of health care among and within countries, and concludes people are dying from causes with well-known treatments.

“What we have found about health care access and quality is disturbing,” said Dr. Christopher Murray, senior author of the study and Director of the Institute for Health Metrics and Evaluation (IHME) at the University of Washington. “Having a strong economy does not guarantee good health care. Having great medical technology doesn’t either. We know this because people are not getting the care that should be expected for diseases with established treatments.”

Professor Martin McKee, from the London School of Hygiene & Tropical Medicine, who participated in the study, commented: “Using deaths that could be avoided as a measure of the quality of a health system is not new but what makes this study so important is its scope, drawing on the vast data resources assembled by the Global Burden of Disease team to go beyond earlier work in rich countries to cover the entire world in great detail, as well as the development of a means to assess what a country should be able to achieve, recognizing that not all are at the same level of development. As the world’s governments move ahead to implement the goal of universal health coverage, to which they committed in the Sustainable Development Goals, these data will provide a necessary baseline from which they can track progress.”

The United States had an overall score of 81, tied with Estonia and Montenegro. As with many other nations, the US scored 100 in treating common vaccine-preventable diseases, such as diphtheria, tetanus, and measles. But the US had nine treatment categories in which it scored in the 60s: lower respiratory infections (60), neonatal disorders (69), non-melanoma skin cancer (68), Hodgkin’s lymphoma (67), ischemic heart disease (62), hypertensive heart disease (64), diabetes (67), chronic kidney disease (62), and the adverse effects of medical treatment itself (68).

“America’s ranking is an embarrassment, especially considering the US spends more than $9,000 per person on health care annually, more than any other country,” Dr. Murray said. “Anyone with a stake in the current health care debate, including elected officials at the federal, state, and local levels, should take a look at where the US is falling short.”

The study was published today in the international medical journal The Lancet, and represents the first effort to assess access and quality of services in 195 countries from 1990 to 2015. Researchers used a Healthcare Access and Quality (HAQ) Index, based on death rates from 32 causes that could be avoided by timely and effective medical care, known as “amenable mortality.”

https://www.eurekalert.org…

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Healthcare Access and Quality Index based on mortality from causes amenable to personal health care in 195 countries and territories, 1990–2015: a novel analysis from the Global Burden of Disease Study 2015

The Lancet, May 18, 2017

Drawing from GBD 2015 (Global Burden of Diseases, Injuries, and Risk Factors Study), we constructed a novel measure of personal health-care access and quality — the HAQ Index (Healthcare Quality and Access Index) — by using highly standardised estimates of 32 different causes that are amenable to personal health care. Compared with previous efforts, the HAQ Index provides a clearer signal on personal health-care access and quality over time and place because GBD provides enhanced comparability of cause of death data, helps to account for variation due to behavioural and environmental risk factors, and includes 195 countries and territories over time. Our analysis showed large differences in personal health-care access and quality, spanning from a low of 23·1 in Ethiopia in 1990 to higher than 90 in Andorra, Iceland, Switzerland, Norway, and Sweden in 2015. The global HAQ Index improved from 40·7 in 1990 to 53·7 in 2015, and 167 of 195 countries and territories significantly increased their HAQ Index during this time. Although the HAQ Index and SDI (Socio-demographic Index) were highly correlated, we noted substantial heterogeneity for geographies at similar SDI.

The Healthcare Access and Quality Index (HAQ Index) for the highest quartile of the Socio-demographic Index (SDI):

95  Andorra
94  Iceland
92  Switzerland
90  Sweden
90  Norway
90  Australia
90  Finland
90  Spain
90  Netherlands
89  Luxembourg
89  Japan
89  Italy
88  Ireland
88  Austria
88  France
88  Belgium
88  Canada
87  Slovenia
87  Greece
86  Germany
86  Singapore
86  New Zealand
86  South Korea
86  Denmark
86  Israel
85  Cyprus
85  Qatar
85  Malta
85  Czech Republic
85  United Kingdom
85  Portugal
82  Kuwait
82  Croatia
81  Estonia
81  United States
81  Montenegro
80  Lebanon
80  Hungary
80  Poland
79  Saudi Arabia
79  Bermuda
79  Bahrain
79  Slovakia
78  Latvia
78  Taiwan
77  Puerto Rico
77  Lithuania
76  Macedonia
76  Chile
75  Serbia
74  Romania
74  Belarus
74  Cuba
73  Ukraine
72  United Arab Emirates
72  North Mariana Islands
72  Russia
71  Bulgaria
71  Greenland
70  Virgin Islands
70  Brunei
68  Argentina
68  Armenia
67  Barbados
67  Antigua and Barbuda
67  Malaysia
66  Seychelles
64  Azerbaijan
64  The Bahamas
63  Guam
62  Georgia
62  Trinidad and Tobago
61  Kazakhstan
58  Grenada
58  Turkmenistan

The full PDF of this Lancet article (36 pages) can be downloaded for free at this link:
http://www.thelancet.com…

***

Comment:

By Don McCanne, M.D.

This study establishes a new landmark in health policy research. It provides a basis of determining how all nations are doing in reducing premature deaths by providing timely and effective health care, that is, in improving their “amenable mortality” rates.

To no surprise for those who follow health policy, the Healthcare Access and Quality Index (HAQ Index) for the United States falls about in the middle of nations in the highest quartile of the Socio-demographic Index (SDI). Although our per capita spending on health care is about twice the average of these nations, our access and quality are only average. We do not have the best health care system in the world, in spite of what reform opponents say.

As Christopher Murray, a senior author of this study, states, “America’s ranking is an embarrassment.” Look at the countries that rank above us. If, like them, we used our public resources more effectively we would no longer have to be ashamed of our performance. Just through the tax system alone we are already spending more per capita than almost all of the other nations do in both public and private spending combined.

It’s not that we need to make a decision to finance health care through our taxes; we already largely do that. Instead we need to improve the allocation of our tax funds plus our private spending. We can do that best by enacting and implementing a well-designed single payer national health program – an improved Medicare for all. With all that we are spending, we should be at the top of the list.

Yoho’s ACA vote

By F. Douglas Stephenson, LCSW
Ocala Star Banner, May 18, 2017

I’m a retired clinical social work psychotherapist and have seen many patients worried about the future of health/mental health care. Congressman Ted Yoho’s recent vote for the GOP’s American Healthcare Act (AHCA) that repeals much of the Affordable Care Act (the ACA or Obamacare) gravely threatens the health of thousands of his District 3 constituents.

The GOP bill would take $880 billion out of Medicaid, and another $312 billion out of subsidies that help working families buy private coverage through the ACA exchanges. Instead of helping people get care, this money would be diverted to give an $800 billion tax-break windfall to people with incomes over $200,000, as well as big insurance and drug companies. The rest of us would get virtually no tax relief.

If Rep. Yoho had supported expansion of Medicaid, many could now afford new coverage through the exchange. All told, his vote threatens to strip coverage from thousands of people in our district, would weaken protections for people with pre-existing conditions, boost premiums for people over 40, and take tens of millions of dollars from our hospitals and clinics.

The ACA is deeply flawed. It left 28 million Americans uninsured and millions more with unaffordable premiums, deductibles and copayments. But the GOP plan would make things much worse. Instead of moving backward, we should move forward from the ACA to a “Medicare for All” plan like the one proposed Rep. John Conyers (H.R. 676).

http://www.ocala.com…

2017 Milliman Medical Index: $27,000

By Chris Girod, Sue Hart, Scott Waltz
May 2017

In 2017, the cost of healthcare for a typical American family of four covered by an average employer-sponsored preferred provider organization (PPO) plan is $26,944, according to the Milliman Medical Index (MMI).

Key findings of the 2017 MMI include:

1. The MMI’s annual rate of increase is 4.3%. This is the lowest rate since we began tracking the MMI in 2001. Yet the total dollar amount is still bracingly high. Of the $26,944 spent by the MMI’s family of four, $11,685 is paid by the employee, through a combination of $7,151 in payroll deductions for premium, and $4,534 in out-of-pocket costs incurred at time of care.

2. Prescription drug trends are lower, but still high. For the first time since 2013 and 2014, the family of four’s prescription drug trends have decreased in two consecutive years. Still, the 2017 prescription drug cost increase of 8% is more than double the medical increase of 3.6%.

3. Employees pay a bigger piece of the healthcare cost pie. Through their payroll deductions and through out-of-pocket expenses incurred when care is received, employees now pay for about 43% of expenses and employers pay the other 57%. The difference between these two shares has gradually narrowed since 2001, when employees contributed 39% and employers contributed 61%. High growth in per-employee healthcare expenditures have pushed employers to limit their contribution increases to amounts below the rate of healthcare inflation.

Some stakeholders have held out hope that federal healthcare reform efforts would help control healthcare cost growth. So far, those efforts have had relatively little direct impact on the MMI, because the MMI represents healthcare costs in an employer-sponsored health plan, while the primary focus of healthcare reform has been on the individual insurance marketplace and Medicaid. The employer market tends to be one of the most stable markets for health insurance companies, and one of the most financially important for healthcare providers such as hospitals and physicians. As discussed in a later section of this report, providers receive higher payment for patients in employer-sponsored plans, for the exact same basket of services, than they do for other insured patients. Employers and employees have been subsidizing other markets for many years.

Footnote 1: The Milliman Medical Index is an actuarial analysis of the projected total cost of healthcare for a hypothetical family of four covered by an employer-sponsored preferred provider organization (PPO) plan. Unlike many other healthcare cost reports, the MMI measures the total cost of healthcare benefits, not just the employer’s share of the costs, and not just premiums. The MMI only includes healthcare costs. It does not include health plan administrative expenses or insurance company profit loads.

http://us.milliman.com…

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Comment:

By Don McCanne, M.D.

Much attention is paid to premiums and deductibles of insurance plans in the United States. A much more important number is what we are actually paying for health care. The Milliman Medical Index (MMI) represents the total average cost of actual health care for a hypothetical family of four with an employer-sponsored PPO. For 2017, that cost is $26,944 ($27,000 rounded – the number to remember).

Although not comparing identical population sectors, nevertheless the burden of health care costs can be approximated by contrasting the MMI with the median household income, which is $56,516 for 2015 – thus health care costs for a typical family of four are close to one-half of the median household income.

Of interest is the fact that the MMI does not include plan administrative expenses nor insurance company profits – just health care costs (the portion of the premium nominally paid by the employer, the portion of the premium paid by the employee through payroll deductions, and the out-of-pocket medical expenses paid by the employee). Also the percentage that families nominally pay has been increasing – now 43 percent – though they also actually pay for the employers’ contributions as well through forgone wage increases. Also, though the increase in the MMI from last year was only 4.3 percent, in dollars it is an $1118 increase – an amount that would add an additional significant burden to most household budgets.

Although current negotiations for replacement health care legislation are taking place behind closed doors, numerous sources have indicated that the most important goal stated by the negotiators is to reduce the premiums paid for insurance. Very little attention is being paid to actual health care costs (except for rhetoric about markets and competition, which has very little application to health care spending).

Why this emphasis on premiums? Frankly, when people need to buy health insurance, they want to know what it is going to cost them. For the 80 percent of people who remain relatively healthy, that means that they want to know what the premium, or their share of the premium, will be. Studies have shown that the healthy will accept higher deductibles and narrower networks in order to get lower premiums.

So how do you keep premiums low? You shift the costs from the insurer to the patient, and there are several methods of doing that, all of which are currently under consideration.  As mentioned, the most obvious is to increase the deductibles, and that is why we are now seeing deductibles in the thousands of dollars. Other cost sharing such as copayments and coinsurance also shift costs to the patients. The negotiators are also considering reducing the essential health benefits that the plans are required to cover so that individuals can “buy only the insurance that they need.” Not only does this defeat the purpose of pooling risk, but nobody can predict their own health care requirements for the following year, so benefits omitted again would have to be covered out-of-pocket by the patient. Also insurers can reduce spending by establishing narrow networks and contracting with the cheapest providers, but sometimes care must be obtained out-of-network, and, again, that shifts costs to the patients. Tiering of benefits is used to place more expensive benefits in a higher tier level for which the patient must bear a much greater out-of-pocket cost (not to mention that it discourages individuals who will need the expensive services or products from purchasing those plans, saving the insurer money, thus lowering premiums). In essence, you lower the price of insurance premiums by destroying the insurance function of sharing risk equitably. Is this really what Americans want?

Making health care less affordable for patients has two adverse consequences: it creates financial hardships for patients who cannot avoid expensive health care, and it causes patients to forgo beneficial health care services that they really should have, thus impairing health outcomes.

A well designed single payer national health program avoids both of these consequences while using policies that are even more effective in slowing the increases in actual health care spending (substantial reduction in administrative waste, global budgeting of national health expenditures, separate, more effective budgeting of capital improvements and system capacity, negotiated and administered budgets for hospitals and other institutions, and negotiated rates for health care professionals, pharmaceuticals, and medical supplies).

When they talk about premiums and say it’s about “access” (but remain silent on paying for health care), challenge them. It’s about health care reform that works for all of us – an improved Medicare for all.

Canadian vs. U.S. health care

Our health care system is neither rational nor moral, and it will almost certainly get worse under the present administration.

By Kenneth Krell, M.D.
Idaho Post-Register, May 17, 2017

Despite the U.S. spending twice as much per capita on healthcare compared to Canada, our northern neighbors have longer life expectancy (80.3 years vs. 78.6 years), lower infant mortality rates, lower rates of chronic cardiovascular disease and diabetes, and generally seem to get along quite well, thank you, despite spending 10 percent of GDP on healthcare as opposed to the U.S.’s 15 percent.

Some of that Canadian advantage has likely come from healthier living up north—obesity rates of 14 percent vs. the U.S.’s 30.6 percent, along with lower smoking rates and a generally healthier lifestyle.

It’s been unclear if their universal healthcare system — as opposed to our disjointed, hodgepodge of healthcare financing and delivery in the U.S. — is at least partially responsible for the differences in health outcomes.

Until now.

A study in the April 18 “Annals of Internal Medicine” compares survival of patients with cystic fibrosis in the U.S. and Canada, with shocking results.

Median survival in both countries increased between 1990 and 2013; however, survival in Canada increased far more, with a median age of survival 10 years greater in Canada than the U.S. (50.9 years vs. 40.6 years).

Much of the difference could only be explained by the lack of healthcare coverage in U.S. patients. Canadians had a somewhat lower risk of death compared to U.S. patients with continuous or intermittent Medicare or Medicaid, but they had a whopping 77 percent lower risk compared with U.S. patients who had no health insurance. And—perhaps most damning—there was no advantage in survival for Canadians when compared with U.S. patients who had private insurance.

The differences in survival were attributable to the health insurance status of U.S. patients. If you had private insurance you survive at the same rate as Canadians — if you don’t, your life is at stake — with a median 10 year less survival.

As the authors state, “no statistically significant difference in risk of death was seen between Canadian patients and U.S. patients with other insurance (primarily private coverage)… The fact that the risk for death in the United States varied depending on the type of health insurance coverage raises the possibility that differences in the health care systems may explain part of the survival gap documented.”

An accompanying editorial states, “Now we are faced with the more difficult task of trying to identify and implement solutions to bridge this survival gap., which seem to be based on fundamental differences in the two nations’ health care systems.”

In Idaho, since the Affordable Care Act, the percentage of citizens without health coverage has fallen from 22 percent in 2011 to 14 percent in 2015. That’s still 237,372 people without health insurance, including 78,000 who fall through the Medicaid gap. Over 237,000 Idahoans at risk for the kind of adverse health outcomes this study demonstrates, all of whom, for health care, would be better off in any other civilized country.

What is clear is that, as Americans, our health care system is neither rational, ethical nor moral, and will almost certainly get worse under the present administration. As a result more people will die. And, as Americans, we must live with that obscene fact until we decide the deaths will stop by moving to a sensible, equitable universal healthcare delivery system that insures coverage—equally—for all Americans.

Dr. Krell is an intensivist at Eastern Idaho Regional Medical Center in Idaho Falls.

http://www.postregister.com…

Medicare is the solution to our health care woes

By Ed Weisbart, M.D.
The Kansas City Star, May 17, 2017

I applaud The Kansas City Star for addressing complex health policy issues through many recent columns, including one on May 10 by U.S. Rep. Kevin Yoder among others. Unfortunately, these authors are misinformed in critical ways.

Why are premiums going up and insurers withdrawing from markets? As imperfect as the Affordable Care Act may be, extreme partisans have blocked the pieces of the ACA that would have prevented these problems. They cut all the funds for the portions of the ACA that were intended to limit the losses of insurers, and cut all the funds for educational components that would have attracted lower risk uninsured enrollees.

Too many states have used their legislative authority, created by the ACA, to block these unjustified increases in premiums. Those states that did so have had far lower increases in premiums and more stable marketplaces. It is appalling to hear these politicians declaring the failure of the ACA after they themselves voted to destroy the very features that would have prevented these problems.

There is a simpler and more robust solution hiding in plain sight: HR 676, the Expanded & Improved Medicare for All Act. First introduced in 2003, it has now reached a record high of 108 co-sponsors. The bill very simply calls for improving the known problems with Medicare and providing it to all Americans.

Medicare is a remarkably successful public health program, with American seniors having nearly the longest life expectancy of any industrialized nation. (American life expectancy ranks near the bottom until we reach the age of Medicare eligibility.)

Medicare is also remarkably efficient. Traditional Medicare reports an overhead of 1.4 percent, increased to 6 percent when including the increased overhead of Parts C (“Medicare Advantage”) and D (the Medicare drug benefit), which are delivered by the private insurance industry. By comparison, Aetna, Anthem and United each report overheads greater than 18 percent.

Critics say our nation cannot afford to do this, but they’re wrong. There are at least 25 studies at both state and federal levels demonstrating that the savings of a Medicare-for-all strategy would match or outweigh any additional costs. Economists estimate that anyone earning less than $500,000 per year would save more by eliminating health care premiums, co-pays and deductibles than any small increase in the taxes needed to fund this.

Critics also say the free market will solve our health care crisis, but the health care market is unlike most other products. Despite market solutions, our health care costs are roughly double those in any other industrialized nation. About 750,000 of us travel overseas every year for health care because our “free market” has phenomenally higher prices than their universal programs.

More than 1 million Americans currently have GoFundMe accounts to pay for their surgery, chemotherapy and other medical expenses. Health care is the most common driver of American bankruptcy.

Why has our free market failed so miserably? Perhaps because health care cannot and will not be solved by the free market. The largest health care expenses happen when we are ill, desperate and vulnerable. At those moments, we are the least able to shop around. That’s not how a free market works.

The country would win, most individuals would win, but sadly, the health insurance industry and pharmaceutical manufacturers would not.

I consider myself a fiscal conservative and a proud American patriot. For both reasons, I find it disturbing when I hear people say the United States is unable to develop a health care system that performs as well as the rest of the modern world. We have already built that solution: Medicare. Improve it, and give it to us all.

We are Americans. We pride ourselves on our innovations and know-how. We are just allowing ourselves to be misled by those who gain from our neglect.

Ed Weisbart, M.D., is chair of Physicians for a National Health Program — Missouri chapter.

http://www.kansascity.com…

Health care legislation being shaped in secrecy

Secret Republican Senate Talks Are Shaping Health Care Legislation

By Susan Davis
NPR, May 15, 2017

The Senate is negotiating its own legislation to repeal and replace much of the Affordable Care Act in secret talks with senators hand-picked by party leaders and with no plans for committee hearings to publicly vet the bill.

Most Republicans see no political advantage to attempting to craft bipartisan legislation that could aid vulnerable Red State Senate Democrats heading in to the midterm elections. In other words, there is mutual disinterest in bipartisanship when it comes to the fundamentals of Obamacare.

The GOP health care talks are expected to roll through the summer months in the Senate. The long-term strategy — according to senior GOP aides in both the House and Senate — is to pass a Senate bill and send it back to the House for an up-or-down vote.

http://www.npr.org…

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Hope You Don’t Expect The Senate GOP To Be Transparent About Obamacare Repeal

By Jonathan Cohn
HuffPost, May 13, 2017

House leaders wrote legislation privately and then pushed it through the two committees of jurisdiction with markup sessions that lasted just one day each. Leaders had to pull the bill from the House floor at the last minute, because it lacked enough support to pass, but their response was to return to private negotiations, hash out the additional amendments, and then proceed quickly with the final vote.

Of course that was precisely what House Speaker Paul Ryan (R-Wis.) and his allies were trying to accomplish ― to avoid public scrutiny, to get legislation through the House before either the media or the public could recognize and seize on its shortcomings. Now it looks like Senate Republicans are intent upon doing the same thing.

Democrats are furious, in part because most of them were around in 2009 and 2010 when they spent more than a year writing and debating what eventually became the Affordable Care Act. For all of the discussion that took place behind closed doors back then, quite a lot took place in public ― over the course of more than 130 hearings, spanning five committees, according to a Democratic tally that didn’t even include administration events like the daylong, bipartisan session at Blair House that President Barack Obama presided over personally.

The deciding factor could be public reaction, but the public can’t react to a bill unless it gets a good look at it. It appears Republican leaders are trying not to let that happen.

http://www.huffingtonpost.com…

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Comment:

By Don McCanne, M.D.

Health policy is difficult enough for the public to understand without our politicians going behind closed doors to hash it out. As Jonathan Cohn states, “The deciding factor could be public reaction, but the public can’t react to a bill unless it gets a good look at it.”

Polls do show that the public is reacting favorably to the policy features of single payer. They understand that an improved Medicare for all would bring each of them essential health care that is affordable and that allows free choice of health care professionals and hospitals. Many even believe that health care should be a right, but they don’t have to believe that as long as they themselves can be assured of life-long affordable access to essential health care services.

Maybe someone should slip under the Senators’ door the Physicians’ Proposal, so that they can take a good look at it in privacy.

A Physicians’ Proposal for Single-Payer Health Care Reform:
https://www.pnhp.org/nhi