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The surge of desktop medicine

Electronic Health Record Logs Indicate That Physicians Split Time Evenly Between Seeing Patients And Desktop Medicine

By Ming Tai-Seale, Cliff W. Olson, Jinnan Li, Albert S. Chan, Criss Morikawa, Meg Durbin, Wei Wang and Harold S. Luft
Health Affairs, April 2017

Abstract

Time spent by physicians is a key resource in health care delivery. This study used data captured by the access time stamp functionality of an electronic health record (EHR) to examine physician work effort. This is a potentially powerful, yet unobtrusive, way to study physicians’ use of time. We used data on physicians’ time allocation patterns captured by over thirty-one million EHR transactions in the period 2011–14 recorded by 471 primary care physicians, who collectively worked on 765,129 patients’ EHRs. Our results suggest that the physicians logged an average of 3.08 hours on office visits and 3.17 hours on desktop medicine each day. Desktop medicine consists of activities such as communicating with patients through a secure patient portal, responding to patients’ online requests for prescription refills or medical advice, ordering tests, sending staff messages, and reviewing test results. Over time, log records from physicians showed a decline in the time allocated to face-to-face visits, accompanied by an increase in time allocated to desktop medicine. Staffing and scheduling in the physician’s office, as well as provider payment models for primary care practice, should account for these desktop medicine efforts.

From the Discussion

Physician burnout with EHR use has been well documented. Some organizations are using medical scribes to reduce documentation burden. Intriguing findings from the recent AMA study on five specialists who had scribes (with their own user identification) suggested that those specialists spent 43.9 percent of their time on face-to-face visits, compared to 23.1 percent among specialists without scribes. Clearly, more studies (preferably with more physicians teamed up with scribes) on the impact of scribes are needed. Our data suggested that 34 percent of logged time (2.10/6.25) was spent on progress notes. Having scribes support this effort could potentially remove one-third of physicians’ work efforts and might reduce burnout.

Twenty-four years after the implementation of the RBRVS-based Medicare Fee Schedule, the Medicare Access and CHIP Reauthorization Act of 2015 established a new framework for Medicare physician payment: the Quality Payment Program. In this program, physicians have two tracks to choose from: the Merit-Based Incentive Payment System and the Advanced Alternative Payment Models. Furthermore, CMS has also launched the Comprehensive Primary Care Plus model. The model has a separate track for practices with relatively more experience in delivering advanced primary care. These practices will receive a hybrid payment of a per beneficiary per month care management fee and fee-for-service payment for claims for evaluation and management services.

CMS has indicated its intention to monitor practices to ensure the delivery of high-quality health care under the Comprehensive Primary Care Plus model. Access logs provide a simple and unobtrusive way for health care delivery systems to examine how their clinicians spend a significant portion of their time.

http://content.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

Health care is, or at least should be, about the patient. This study shows that physicians are splitting their time fairly evenly between direct face-to-face patient care and desktop medicine, especially through the electronic health record. Although desktop medicine does provide some patient benefits we certainly need to ask whether much of that time is wasted for purposes other than patient care.

There is no question but that desktop medicine is contributing to the growing epidemic of physician burnout. Yet desktop medicine is expected to grow further with implementation of the Medicare Access and CHIP Reauthorization Act (MACRA) and the Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (APMs). Far too much effort is being expended on these primarily administrative models rather than being used for what health care is all about: protecting and improving the health of patients.

Let’s get our priorities right.

How New York Could Set A Health Care Example For The Entire Country

By Jean H. Lee
Bustle, April 12 2017

Last month, the GOP raced to convince members of Congress to vote in favor of the American Health Care Act, but Congress ultimately rejected the Republican plan to repeal and replace the Affordable Care Act, getting a bill that would limit essential coverage for a number of social groups off the table. But as many celebrate the continued existence of Obamacare, it might be wise to question whether the it is the best possible option, because while it did remarkable things for a number of Americans, the ACA still left many uninsured or underinsured. Many New York healthcare advocates say there is the hope of a better alternative in the New York Health Act (NYHA).

The NYHA is a single-payer plan that would create a state healthcare system that is, as Assembly Health Committee Chair Richard Gottfried told the Village Voice, “funded entirely by broad-based taxes based on ability to pay.” This means that the NYHA would be funded by taxation on taxable income from employment, capital gains, interest, and dividends.

According to Physicians for a National Health Program, individuals and families would be the ones to choose “the delivery of care,” which means that there will be no network restrictions (like those of private insurers) that keep certain doctors out of reach. This is because when everyone is covered by the same single-payer plan, instead of a number of private insurance programs, everyone has access to the same comprehensive care. So instead of having individuals worry about whether a doctor is in their personal private insurance network and whether they can afford the co-pay, every doctor in New York state would be within reach.

“There is no question that we are in a unique political moment,” says Ursula Rozum, the Campaign for New York Health upstate campaign coordinator. “Now is the time for us to speak up and organize for a healthcare system that guarantees health care for all of us.”

The NYHA would provide any medical service currently required by New York state insurance law, including primary, preventive, specialist, hospital, mental health, reproductive health, vision, dental, and hearing care.

Passing the New York Health Act could also influence federal legislature in the future, considering how past state policies have changed federal ones. The Massachusetts healthcare model has striking similarities to the ACA and demonstrates how impactful state legislation can be. Katie Robbins, the executive director of Physicians for a National Health Program’s NY Metro Chapter (PNHP NY) tells Bustle that the ACA was actually first established in Massachusetts in 2006. “At the time it was known as RomneyCare, and had long been touted by the Heritage Foundation, a conservative think tank,” Robbins says. “Ironically, as soon as President Obama supported it, the Heritage Foundation started to oppose the policy.”

A 2012 article published by the Huffington Post outlined the similarities between the ACA and the Massachusetts model, which proves that a state healthcare model can be a significant influence for federal models. The importance of the New York Health Act — a system funded entirely by broad-based taxes — increases with the knowledge that it could be a model for federal legislation, like the Massachusetts model was.

The New York State Assembly passed a version of the New York Health Act in 2015, and then again in 2016, but it never got a committee hearing in the Republican-run state Senate. In previous years, the healthcare issues that were discussed centered on problems with the ACA. While Obamacare did remarkable things (like banning lifetime limits of healthcare cost) for a large population of Americans, the act still gave control to insurance companies. Many insurance companies demanded high — and quickly rising — insurance premiums and high deductibles that shift costs to the individual.

Robbins says the ACA expanded access to insurance for millions of Americans, but many New Yorkers remained underinsured, which means that many insured people can’t afford to use the insurance they gained access to because of the high deductibles and co-pays.

Economists Milton I. Roemer and John E. Roemer questioned the effectiveness of a healthcare system controlled by private insurance companies in their 1982 article “The Consequences of Free Trade in Health Care: A Public Health Response in Orthodox Economics.” The authors asserted that “only replacement of free trade by systematic social planning could hope to achieve a health care system that allocates resources and distributes services both efficiently and equitably.”

One way to look at how this theory relates to today is to consider that while the ACA covered many more Americans, there are competing private insurance companies with specific provider networks and out-of-network fees. Under the New York Health Act, every healthcare provider can participate in the program and there will be no specified networks. And while healthcare providers are not required to participate, there will be no other insurance coverage to pay a provider who decides not to participate, which incentivizes participation.

Another way to look at it is to consider that private insurance uses money from premiums to fund the needs of people in need of medical services, so insurance companies can set premiums that are quite high. According to the PNHP, the New York Health Act would eliminate these high premiums, deductibles, and co-pays set by insurance companies because, unlike the ACA, the NYHA would not be controlled by private insurance companies.

The NYHA would replace private insurance company coverage for all New York state residents. This is to ensure income equality under the plan by preventing a two-tier system of care, which is when there is a basic system of care and then a secondary option for wealthier people who can afford more, creating a segregated health system like Medicaid. In a two-tier system, people who can pay more often have access to better resources and those who can’t pay more don’t.

The NYHA wants to make sure that all people (wealthy and low-income alike) are equally invested in the healthcare system and have equal access to the same healthcare. To make this possible, there would be no private coverage offered by employers. Instead, every New York resident would have access to New York Health, and employers would pay at least 80 percent of the tax on payroll.

Robbins, the executive director of PHNP’s New York metro chapter, emphasizes that the NYHA would have an equalizing impact. “The New York Health Act guarantees that every resident of New York State will have access to publicly funded health insurance that covers all medically necessary care—no matter what their income, job, health, marital, or immigration status,” Robbins says. She notes that, in this time of immigration uncertainty, that the NYHA would be offered to anyone who could provide proof of residency, not citizenship, in New York State. This allows undocumented New York residents the same right to health care.

So while the ACA did extraordinary things — like making sure preexisting conditions don’t impact health coverage and expanding Medicaid — it’s not perfect, and it might be good to talk about a single-payer plan where the government funds all residents’ health care because this is a path to universal health care where all residents have health coverage. And, New York could soon be an example of universal healthcare for the United States.

https://www.bustle.com…

Watch out! Here comes Stephen Parente

ACA critic Stephen Parente nominated as HHS deputy secretary

By Dave Barkholz
Modern Healthcare, April 10, 2017

Stephen Parente, a healthcare economist, has been nominated to be HHS’ assistant secretary of planning and evaluation.

The University of Minnesota professor would fill a post vacated in June by Harvard economist Richard Frank. In that role, Parente would be a principal advisor to HHS Secretary Dr. Tom Price, consulting on policy, legislative efforts, strategic planning and research.

Parente is familiar with the work of Price. In 2013-2014, he analyzed Price’s ACA replacement proposal in conjunction with the conservative think-tank American Action Forum.

http://www.modernhealthcare.com…

The White House announcement:
https://www.whitehouse.gov…

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Stephen Parente discusses a key option for the Affordable Care Act

By Christopher Snowbeck
StarTribune, December 3, 2016

With Republicans in Washington, D.C., promising to repeal the federal Affordable Care Act, or ACA, the focus is shifting to how the GOP might try to replace it. Stephen Parente of the University of Minnesota is well-positioned to describe what could be coming. In 2013-14, Parente worked with the American Action Forum, a conservative think tank, to evaluate the budget and coverage impact from the Empowering Patients First Act, an ACA replacement plan from U.S. Rep. Tom Price, R-Ga. Last week, President-elect Trump selected Price as his health secretary. More recently, Parente worked with staffers to model the economic impact of “Better Way,” the replacement plan put forward by House Speaker Paul Ryan.

Q: I gather that the dollar value of tax credits under Better Way would be smaller than with the Affordable Care Act, but this reduction fits with lower premiums for coverage, too. Is that right?

A: Correct. One of the biggest changes is the risk-rating piece. The ACA has a 3-to-1 ratio for modified community rating, which means insurers can’t sell coverage to an adult age 64 or older for more than three times what they’d charge a 21-year-old for the same health plan. Better Way proposes a 5-to-1 ratio.

There are fewer caps on deductibles and out-of-pocket spending with Better Way, so that’s another way deregulation brings lower premiums. Finally, fewer health benefits are required to be covered by health plans under Better Way, compared with the ACA.

Q: Minnesota is one of those blue states that has offered generous benefits via Medicaid, plus the MinnesotaCare health insurance program. Will federal funding for the state’s programs decrease?

A: I think many states are probably going to see less Medicaid funding, because it’s going to have to be spread around and there will be some budget constraints. There will definitely be, in that sense, some winners and losers.

http://www.startribune.com…

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Comment:

By Don McCanne, M.D.

Stephen Parente is the policy genius behind Tom Price’s “Empowering Patients First Act” and Paul Ryan’s “Better Way” – two of the cruelest policy proposals of the past decade that shift health care costs from the government to patients in need – all under the guise of “it’s about access” (but not about being able to afford health care).

Parente says that there definitely will be winners and losers, but he didn’t specify that the winners will be wealthy taxpayers and the losers will be patients.

Now Stephen Parente is going to guide policy, legislative efforts, strategic planning and research for the Department of Health and Human Services, under the leadership of HHS Sec. Tom Price. When we desperately need new public policies to help make essential health care more affordable for all of us, the man in charge of policy will begin to tear down and destroy what we do have. He may become the most dangerous individual in government as far as our health care is concerned.

Remember that name – Stephen Parente – and be prepared to use all civil means available to ward off his pending nefarious ventures. Then go out into the streets and march for an improved Medicare for all.

Universal healthcare supporters see their chance: ‘There’s never been more support’

After Republicans’ failed attempt to replace Obamacare, activists across the country rally on behalf of a single-payer system: ‘It’s a right, not a privilege’

By Jessica Glenza
The Guardian, April 11, 2017

It was a cold, misty, gray, early spring day in Albany, New York – the kind of bone-chilling, turn-up-the-heat weather that encourages residents to flee to Florida.

But 500 New Yorkers were still out on the sidewalk lobbying for healthcare reform that has long seemed like a pipe dream: government-provided universal health insurance.

“I wanna make sure my children get healthcare,” said Minerva Solla, a 66-year-old organizer with the New York State Nurses Association. “It’s a right, not a privilege.” Moments earlier she riled the crowd with call-backs: “If they don’t pass it? Vote them out!”

Americans might know the liberal dream as “Medicare for all”. If it ever passed, it could be as comprehensive as the UK’s National Health Service.

Universal healthcare is not a new idea, but one with fresh energy since Republicans’ disastrous attempt to reform the American health system. In Albany, a record number of people turned out to a rally for universal healthcare in New York, several activists and one lawmaker said.

“It’s an uphill battle, and the Republicans are in control of Congress, and there’s no signal they would be willing to let this pass right now,” said Clare Fauke, spokesperson for Physicians for a National Health Program, which advocates for universal healthcare. “But we’ve been thinking in terms of the long game, and there’s never been more support for it than there is right now.”

In a universal healthcare system, New York would pay for every resident not covered by an existing federal health insurance program, like Medicare for the old or Medicaid for the poor. For-profit health insurance companies would be all but eliminated.

That would mean New Yorkers would be freed from “co-pays”, “deductibles”, and “premiums”, all insurance industry jargon for one thing: medical bills.

“We’re unanimous that this is the most logical system going forward,” said Phil DeSalvo, a 29-year-old medical resident from New York City. He and three fellow health workers traveled three hours north on their only day off to protest. Was universal healthcare gaining momentum?

“Absolutely, particularly with the collapse of the plan advanced by the Republicans,” he said. “This is the best solution going forward.”

Despite campaigning for seven years to “repeal and replace” the Affordable Care Act, better known as Obamacare, Republicans’ first attempt at a reform bill sank like a stone.

Trump and the Republican leadership’s concessions to both hardline conservatives and moderate Republicans made the bill a mishmash. Tax credits would have helped Americans buy private insurance, but the gutting of insurance regulations would have made policies practically meaningless. It would have left 52 million people uninsured by the end of the decade, at last estimate.

It had an abysmal 17% public approval rating, and lasted two weeks before it was pulled. It is Trump’s single largest loss to date. In the vacuum of ideas, liberals have conjured hope.

“I think fear of the Republican bill, and fear that it will come back in even worse form, is sparking support,” said Richard Gottfried, a New York City Democrat who has sponsored a universal healthcare bill since 1992.

Advocates of universal healthcare are not missing an opportunity to make a fuss. Physicians for a National Health Program held their first day of national rallies to coincide with the Congressional recess on Saturday. Protests were planned from Florida to New Hampshire, Oregon to North Carolina.

Bernie Sanders plans to introduce a bill in the US Senate to support single-payer healthcare. In the House, there is already a single-payer bill with 93 co-sponsors.

In an issue of the British medical journal the Lancet devoted to the US healthcare system this week, Sanders wrote the opening letter.

“The goal of a healthcare system should be to keep people well, not to make stockholders rich,” wrote Sanders. “The USA has the most expensive, bureaucratic, wasteful, and ineffective healthcare system in the world.”

Sanders called single-payer healthcare “as American as apple pie” – an attempt to throw off single-payer reform’s negative reputation as “socialized medicine”.

Meanwhile, the American healthcare system may be worsening inequalities, the the Lancet found. A widening income gap, paired with insurance companies’ increasing tendency to push health costs on to consumers, has resulted in a “regressive” system in which the richest 1% of Americans can now expect to live up to 15 years longer than the poorest 1%.

Even for those who have insurance, increasing monthly costs have eroded wage gains, the Lancet reported. Medical debt accounts for more than half (52.1%) of all unpaid personal debt.

“I could tell you this – I’ve been on the job for 25 years. When I first started, I paid nothing” for healthcare, said Chris Tague, who works in road construction. He is also a part-time town supervisor in Schoharie County, New York, which voted overwhelmingly for Donald Trump.

Tague’s health insurance costs grew to $20 per week, then to $50 per week, then $75, then to more than $200 per week, he said. Middle class Americans, he said, “work their asses off for nothing”.

The ACA insures more Americans than ever. Nevertheless, 9% of Americans, or 28 million people, remained uninsured in 2015, according to the Kaiser Family Foundation. Those people are predominantly in Republican-led southern states, which rejected an expansion of Medicaid, a federal program for the poor, even though the national government paid for it.

Even conservatives admit that government-run healthcare could save money.

“I mean look, you can save money with a single-payer system, don’t misunderstand me,” said Robert Moffit, a policy analyst at the conservative Heritage Foundation. “But the quality and supply of medical services is going to be determined by government officials.”

For this and other reasons, many argue single-payer reform simply is not viable.

“The history of healthcare reform in the US has dictated that it is politically untenable,” said Richard Boxer, a Los Angeles urologist who studies insurance reform. He pointed out that a public insurance option was proposed when the ACA was first under consideration in 2010. A Democratic Congress rejected the idea.

Grassroots efforts at the state level have also failed.

In Colorado, advocates tried to establish a state-funded universal health program through a ballot initiative last year. State residents would have paid a 10% payroll tax to fund the program.

Though the program would have insured all Coloradans, only 20% of voters favored the effort.

The insurance industry group Coloradans for Coloradans had a seven-to-one fundraising advantage at one point. The group raised more than $4m, its single-largest $1m donation coming from the insurance company Anthem. Comparatively, the pro-universal healthcare group ColoradoCareYES raised $902,000.

“The insurance companies, of course, were worried this would pass,” said Patricia Rice, a spokesperson for ColoradoCareYES. “Because it would signal a tidal wave. Once it passes in one state, I think it would just spread to other states and it would cut into profits.

“They were throwing everything they had at us, and we only had a few spots on television,” said Rice.

The economics of a public option

Most analyses of universal healthcare assume that money taxpayers once spent on private insurance would go to support a government program, and that the elimination of bureaucracy and profit would save money.

A 2015 analysis of single-payer health insurance in New York found the system would save $44.7bn in healthcare costs in the first year, assuming the state could negotiate with drug companies. Studies of single-payer healthcare at the federal level have also found savings. One 1998 study found that a single-payer health system would lead “to sizable savings in the future”.

Not all projections are rosy. The non-partisan Committee for a Responsible Federal Budget analyzed Sanders’ plan for universal health coverage in 2016, and found it would add $19tn to the federal debt.

New York’s latest battle to pass universal healthcare represents a theme in the long fight – so close to passage, but so far from enactment.

Gottfried’s bill is expected to pass the lower New York state assembly, but could run into trouble in the Republican-controlled senate.

The Republican senate majority leader may never let the legislation come to the floor, and it is an open question whether the moderate Democratic governor, Andrew Cuomo, would support the legislation.

If the bill did make it to the senate floor, just one Democrat stands in the way of a majority: Simcha Felder. He represents deeply conservative orthodox Jewish neighborhoods in Brooklyn, and often caucuses with Republicans.

“I do not have a position on the New York health act,” Felder said in an email. “This legislation would be a huge overhaul of the healthcare system in New York, and I would like to hear from experts and other senators on the committee.”

“Everybody’s calling about it,” said a worker in Felder’s office, as she folded a “Healthcare is a human right” sign in half and stuffed it into a wastebin.

Just an hour earlier, Dr Roona Ray was whipping up demonstrators, exclaiming, “We can have healthcare that covers everyone as a right and as a public good,” she said. “There will be no premiums, no co-pays, no co-insurance, no deductibles, no doughnut holes, no bills!”

“The other side has money,” she said, “but we have people.”

https://www.theguardian.com…

America: equity and equality in health

The Lancet devotes special issue to growing U.S. health inequality

Leading British medical journal The Lancet has published a series of papers exploring persistent and growing health inequality in the United States. The series was published in the April 8, 2017 issue of The Lancet, and was curated by PNHP co-founders Drs. David Himmelstein and Steffie Woolhandler, along with Dr. Samuel Dickman.

“America: equity and equality in health” explores the effects of racial segregation, mass incarceration, economic inequality, and a lack of universal health care in the U.S. It comes at an important time in the national health care debate, as policymakers are grappling with the failure of the GOP “repeal and replace” bill, the American Health Care Act, and citizens are demanding a better health care system; one that addresses the gaps that remain after implementation of the Affordable Care Act.

Below, you can access links to the series papers; various interviews and events; national media coverage of the series; and an extensive i nfographic.

To read PNHP’s news release on the series, click here. The full series can be accessed for free (registration required) at thelancet.com/us-health.

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Series Papers

Paper 1: Inequality and the health-care system in the USA
By Samuel L. Dickman, M.D., David U. Himmelstein, M.D., and Steffie Woolhandler, M.D., M.P.H.
http://thelancet.com…

Paper 2: The Affordable Care Act: implication for health-care equity
By Adam Gaffney, M.D. and Danny McCormick, M.D.
http://www.thelancet.com…

Paper 3: Structural racism and health inequities in the USA: evidence and interventions
By Zinzi D. Bailey, Sc.D., Nancy Krieger, Ph.D., Madina Agénor, Sc.D., Jasmine Graves, M.P.H., Natalia Linos, Sc.D., and Mary T. Bassett, M.D.
http://www.thelancet.com…

Paper 4: Mass incarceration, public health, and widening inequality in the USA
By Christopher Wildeman, Ph.D. and Emily A. Wang, M.D.
http://www.thelancet.com…

Paper 5: Population health in an era of rising income inequality in the USA: 1980-2015
By Jacob Bor, Sc.D., Gregory H. Cohen, M.Phil., and Sandro Galea, M.D.
http://www.thelancet.com…

Editorial: America, all things not being equal
By The Lancet
http://www.thelancet.com…

Comment: An agenda to fight inequality
By Sen. Bernie Sanders
http://www.thelancet.com…

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Interviews & Events

Lancet Podcast: America, equity and equality in health
Interview with David Himmelstein, M.D. and Steffie Woolhandler, M.D., M.P.H.
http://www.thelancet.com…

Lancet Podcast: America, equity and equality in health
Interview with Samuel L. Dickman, M.D.
http://usa.thelancet.com…

Symposium: Income Inequality and Health in America
Boston University School of Medicine, April 10, 2017
Panel featuring Zinzi D. Bailey, Sc.D., Jacob Bor, Sc.D., Samuel L. Dickman, M.D., Adam Gaffney, M.D., and Steffie Woolhandler, M.D., M.P.H.
https://livestream.com…

Symposium: Inequality and Health in the U.S.
Harvard Medical School, April 24, 2017
Panel featuring Adam Gaffney, M.D., Samuel L. Dickman, M.D., Jacob Bor, Sc.D., Christopher Wildeman, Ph.D., and Mary T. Bassett, M.D., M.P.H. Panel moderated by Joan Reede, Harvard Medical School. Virtual welcome and remarks by Sen. Elizabeth Warren.
https://hms.mediasite.video.harvard.edu…

Symposium: Equity and Equality in Health
Roosevelt House, Public Policy Institute at Hunter College, May 1, 2017
Program featuring Mary T. Bassett, M.D., M.P.H., Paul Krugman, Ph.D., and David Himmelstein, M.D. Discussion moderated by Lilliam Barrios-Paoli, Ph.D.
http://www.roosevelthouse.hunter.cuny.edu…

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Media Coverage

Inequality is a life and death matter
By Steffie Woolhandler, M.D., M.P.H. and David Himmelstein, M.D.
HuffPost, May 8, 2017
The Republican effort to gut the Affordable Care Act threatens a health care catastrophe. But blocking a backward move isn’t enough. The overall U.S. death rate is rising. The survival gap between rich and poor is widening. Continue reading…

The cost of economic inequality to the nation’s physical health
By Jacob Bor, Sc.D. and Sandro Galea, M.D.
The Boston Globe, April 25, 2017
After its unsuccessful push to reconfigure the U.S. health care system, the Trump administration has signaled that it will turn its attention to tax reform. While the details of the administration’s plan are still unclear, President Trump has indicated in the past a willingness to embrace measures that would greatly favor the wealthy. Continue reading…

Rich Americans live up to 15 years longer than poor peers, studies find
By Jessica Glenza
The Guardian, April 6, 2017
You can’t buy time – except, it seems, in America. Increasing inequality means wealthy Americans can now expect to live up to 15 years longer than their poor counterparts, reports in the British medical journal the Lancet have found. Continue reading…

Rich Americans Live 15 Years Longer Than Poo
r Counterparts: Study
By Anthony Cuthbertson
Newsweek, April 7, 2017
Wealth and health are intrinsically linked in the United States, with rich Americans living between 10 to 15 years longer than their poor counterparts, a study has found. A series of five papers published in the medical journal The Lancet found that a widening income gap, structural racism and mass incarceration are fueling growing health inequalities. Continue reading…

The Richest Americans Live 10 Years Longer than the Poorest
By Alice Park
Time Magazine, April 6, 2017
Money may not buy you happiness, but it may help buy you health, and ultimately a longer life. Researchers analyzing data on income disparities and health outcomes in the U.S. found that health gaps between the rich and poor are widening, and that’s translating to bigger differences in how long people live. Continue reading…

Want to Live Longer? Be Rich
By Jesse Singal
New York Magazine, April 7, 2017
You probably already know that health care in the United States is a bit of a disaster. That’s one of the primary reasons a single piece of bad luck can be ruinous for so many Americans. Continue reading…

Three Insights About Inequality in American Health Care
By Jesse Singal
New York Magazine, April 11, 2017
Lately, it has felt like the debate over Obamacare has masked some of the bigger questions swirling around the U.S. health system. Obamacare is important, yes, but America’s issues on this front run much, much deeper than the presence or absence of that one law. Continue reading…

What we know about the 30 million Americans who are still uninsured
By Julia Belluz
Vox, April 7, 2017
The size of the uninsured group is well-known, but less clear is what this group looks like. A new series in the Lancet on health inequality paints a pretty good picture. People who go without insurance in America are not refusing coverage for ideological reasons: They simply can’t afford to pay. Continue reading…

Lancet series puts spotlight on health inequity in the U.S.
By Paige Minemyer
Fierce Healthcare, April 7, 2017
Societal issues in the U.S., including systemic racism, poverty and mass incarceration, contribute to health inequity, a new series of studies has found. The Lancet released a five-part look at health inequity in the U.S., titled the “United States of Health.” Continue reading…

You Can Thank Racism, Mass Incarceration, and Our Health System for the Survival Gap Between the Rich and Poor
By Nick Keppler
Vice News, April 11, 2017
The United States’ for-profit healthcare system not only fails miserably to offer the same life-extending treatments to the poor as it does the rich, but it also reinforces racial and socioeconomic disparities, according to a wide-ranging five-part series published in the medical journal The Lancet. Continue reading…

The Prison-Health Paradox
By Olga Khazan
The Atlantic, April 7, 2017
A recent review of the impacts of incarceration on health published Thursday in The Lancet hints at a surprising upshot: Getting out of jail can be miserable, but going to jail can temporarily protect health—at least for some men. Continue reading…

When a man goes to prison, his children’s health suffers, too, study finds
By Max Blau
STAT, April 6, 2017
Researchers found that children of incarcerated men have higher rates of asthma, obesity, substance misuse, and behavioral and mental health problems. And the impact can linger for years, even into their adulthood. Continue reading…

Children Of Incarcerated Fathers Often Suffer Health Issues That Can Last Through Adulthood
By Cameron Norsworthy
Romper, April 6, 2017
Incarceration affects families emotionally and socially, and new research shows that there are long-lasting physical complications as well. According to a recent study, the children of incarcerated fathers often suffer health issues to intense degrees, and these health issues are often chronic conditions that can last all the way through adulthood. Continue reading…

Rich black people have worse health than rich white people
By Jessica Hamzelou
New Scientist, April 6, 2017
America’s health is in poor shape. The health gap between the rich and poor is now far bigger than the difference in income – that’s one of the messages from a series of papers published in The Lancet today. But wealth is only part of the problem. Continue reading…

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Infographic

Conservative roadmap for improving AHCA

CBO Provides A Roadmap For Improving AHCA

By Joseph Antos and James Capretta, American Enterprise Institute (AEI)
Health Affairs Blog, April 4, 2017

The future of the American Health Care Act (AHCA), the GOP-drafted plan to repeal and replace the Affordable Care Act (ACA), is unclear after the bill was pulled before the House of Representatives could vote on it. But the debate over the ACA and proposals to replace several of its key provisions is unlikely to remain off the national agenda permanently.

The best place to start is with the cost estimate of (AHCA) produced by the Congressional Budget Office (CBO).

Trump administration officials, some members of Congress, and assorted commentators have criticized CBO for this estimate, arguing that it is a fundamentally inaccurate assessment of what would occur if AHCA passed. This criticism is misplaced. While some of CBO’s assumptions are indeed questionable, there is little doubt that the agency’s bottom line assessment is basically correct: The bill, as currently structured, would trigger a rise in premiums in the short-run, a sharp increase in the number of people without insurance over the next two years, and then also a steady increase in the number of uninsured Americans over the following eight years.

Instead of trying to discredit this finding, the authors of the legislation would be better off fixing the bill. CBO’s estimate provides a roadmap for what needs to be done to improve the chances the bill will produce the results its authors intend.

Changing the ACA’s insurance rules in a coherent and systematic manner in AHCA was difficult because the proposal’s sponsors were trying to pass the measure using the budget reconciliation process.

AHCA is thus an awkward proposal. It effectively eliminates the individual mandate while leaving in place the ACA’s rules prohibiting the use of health status in setting premiums or determining what is covered by insurance. The authors of the measure propose “continuous coverage protection” as a substitute for the individual mandate. Under that provision, insurers would charge a one-year, 30 percent surcharge on premiums to anyone who has experienced more than a two-month break in their insurance coverage.

This penalty is far too weak to work. A young, healthy consumer experiencing a break in coverage has a strong incentive to stay uninsured as long as possible. Once he decides to purchase health insurance, the consumer will be required to pay a 30 percent surcharge on his premium for one year. After that, the consumer will once again pay without penalty the same community rate as everyone else of the same age and gender.

AHCA also substitutes less generous age-based credits for the income-adjusted subsidies of the ACA for lower-income households, and repeals enhanced funding to the states for the Medicaid expansion population. As a result, younger and healthier consumers would have less of an incentive to buy coverage.

That is a recipe for even more adverse selection, driving up premiums for those who remain insured through the individual market.

Needed Adjustments

* Higher Financial Penalties For Failure To Maintain Coverage

The AHCA approach is an attempt to replace governmental force with personal responsibility. Under AHCA, no one is required to have insurance, but there are financial consequences for choosing to remain uninsured. However, rather than an arbitrary fixed surcharge, the penalty should be commensurate with the added costs imposed on the health system when such people decide not to buy insurance. For example, the penalty could include a premium surcharge that increases with time out of the market, and a waiting period could be imposed before benefits are paid. Such an approach would eliminate the perverse incentive of a fixed penalty that encourages individuals to remain uninsured, avoiding premium payments, for as long as possible.

* The ‘No-Premium’ Health Insurance Option And Automatic Enrollment

Another factor reducing CBO’s estimate of the AHCA’s take-up of insurance is some people’s unwillingness to pay a premium that is larger than the value of their credit. A comprehensive revision of AHCA could broaden the types of plans offered by insurers to include at least one plan available with a premium exactly equal to the credit. Such a plan would provide protection against catastrophic losses without requiring first-dollar coverage for routine expenses. To further improve insurance take-up, AHCA should allow states to automatically enroll uninsured individuals into “no-premium” plans, with an option to change plans or opt out entirely.

* A Compromise On Medicaid Eligibility Within A Reformed Program

A new uniform national income standard could be set at a level that would free up resources to provide stronger federal support for all state Medicaid programs. Non-expansion states would not be required to expand their Medicaid eligibility to the new standard, but they would receive additional funding through a block grant. Expansion states would likely phase down their programs to the new income standard. In addition, states would be given more control over the program, allowing them to operate Medicaid in ways that promote individual responsibility and ease the transition to private health coverage.

* Additional Support For Low-Income Households Above Medicaid Eligibility

Subsidies ranging from $2,000 to $4,000 per person are not sufficient to make non-group insurance affordable for many with low incomes. AHCA should be revised to provide additional support for these families.

Looking Forward

Instead of condemning or ignoring CBO, congressional leaders would be well-advised to take full advantage of the agency’s analytic expertise to make the needed adjustments to the AHCA plan. That will ensure all sides are better prepared for serious debate when health policy again moves back onto center stage.

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Published Comment:

By Don McCanne, M.D.

Trying to tweak the lousy AHCA model to make it work better is not a rational approach when more fundamental policy defects are ignored.

Worrying about keeping down spending through the federal budget doesn’t make much sense when it is total spending on health care, public and private, that is important. Federal health care spending is more efficient than spending through private insurers. In fact, eliminating private insurers reduces the profound administrative waste of both the private insurers and the burden they place on health care providers. Thus increasing the federal health care budget in this manner would produce an even greater offset in private spending. That savings could then be used to pay for the uninsured and for the excess cost sharing of the underinsured.

Inducing “personal responsibility” in health care spending is code language of conservatives for erecting financial barriers to health care – a terrible policy choice. The financing system should encourage, not discourage, access to beneficial health care services. The administrators can make better decisions than an uninformed public on what care is detrimental and should not be covered.

We already know what happens when Medicaid decisions are turned over to the states, and often it is not good for patients in need. Besides, Medicaid has a welfare stigma and would continue to be underfunded. It would be far better to cover everyone under the same comprehensive program that ensures access for everyone to all essential health care services.

Even continuing with ACA is a mistake because no matter how many tweaks are applied, we will continue to perpetuate the uninsured, underinsured, narrow networks, and excessive cost sharing (to slow premium increases to protect the private insurers instead of patients). These policies are detrimental to patients.

The policies we need are an efficient, publicly-administered universal risk pool, equitable funding based on ability to pay, removal of financial barriers to care, and free selection of health care providers. These policies benefit patients, and the models that have been constructed and are in use in some other nations would provide much better value for our health care spending.

Besides, a majority of the population now understands the superiority of single payer, including many Trump supporters. The nation is now ready for a single payer, improved Medicare for all.

http://healthaffairs.org…

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Comment:

By Don McCanne, M.D.

Although the ACA was an improvement, it still has fundamental structural defects that prevent us from achieving the goals of true universality, affordability, equity, efficiency and access, no matter how much it is tweaked. The Republican AHCA proposal was merely another set of tweaks that went in the wrong direction, and we would have fallen further behind in the goals of reform.

Joseph Antos and James Capretta understand policy well, but they have saddled themselves with the conservative ideology professing that much of the responsibility for containing health care costs should be placed in the hands of the patient-consumer. Models to do that do reduce government spending on health care, but at today’s very high costs they impair access to beneficial health care services because of the lack of affordability of the patient’s out-of-pocket component of the spending.

Some conservatives recognize that low-income individuals need greater government support, as do Antos and Capretta, but their consumer-directed models also place too much of a financial burden on America’s workforce and their families. Also their insistence on using private insurance plans in the marketplace perpetuates the profound administrative waste that uniquely characterizes the American health care financing system, and perpetuates the deleterious tools of the private insurance industry such as sky-high deductibles and ultra-narrow provider networks.

Look specifically at the policies that Antos and Capretta consider to be beneficial. They would assess a large, progressive premium penalty after an interval of being uninsured once that individual decides to purchase insurance – a clear disincentive to bringing the uninsured into the market when policies should be designed instead to be certain everyone is always covered, not to mention that the additional penalty would make the premium unaffordable for most individuals. They would create optional plans with premiums equivalent to the government credit – an approach only made possible by further increasing deductibles and other cost sharing to truly unaffordable levels, not only perpetuating but expanding the flawed policy of offering almost worthless coverage in order to make premiums affordable. They would reduce the federal support of and privatize the Medicaid program while increasing “individual responsibility” through out-of-pocket payments that Medicaid beneficiaries simply do not have (except for the insulting token payments promoted by Pence and Verma simply to satisfy their own conservative ideological preferences).

Antos and Capretta do not reject the principle of government spending since they recommend it for low- and middle-income individuals and families. But they are quite willing to sacrifice the efficiencies and equity of a single payer system simply to include conservative ideology that places individual responsibility over social solidarity. Other nations have shown that publicly administered single payer tools are capable of slowing the increase in health care spending in a patient-friendly manner. Requiring excess cost sharing and taking away provider choice certainly are not patient-friendly.

Forget trying to tweak AHCA by placing conservative principles above patient service. Also forget trying to tweak ACA by placing the concepts of incrementalism and supposed political feasibility above patient service. Let’s go for the model that places patient service first – a well designed, single payer national health program – an improved Medicare for all.

Health care forum educates residents about single-payer system

By Ashley Stewart
Owatonna (Minn.) People’s Press, April 10, 2017

Imagine a health insurance system without premiums, deductibles and co-pays.

That’s a system, commonly referred to as a single-payer health care, that Dr. David Dvorak, an emergency room physician at the Minneapolis VA Health Care System, and Gary Eagen, a retired teacher and member of Health Care for All Minnesotans, spoke about — and advocated for — Saturday afternoon during a health care forum sponsored by Steele County Indivisible at the Owatonna Public Library.

“I’m a member of Physicians for a National Health program, an organization of about 30,000 physicians nationally who support single-payer as the most efficient and equitable way to get to universal health care,” Dvorak said. “We believe that the most wealthy nation on the planet should figure out how to provide quality health care to all its citizens, and again, we believe single-payer is the best way forward.”

Dvorak, who spoke first, outlined the issues with the country’s current health care system, which he said primarily, benefits multibillion-dollar health insurance and pharmaceutical companies, before explaining what single-payer health care is.

Some of the issues he referenced with news articles, studies and graphs were the increase in out-of-pocket medical expenses and growth in high-deductible insurance plans as well as the rising cost of health insurance and the reduced benefits within each plan — a trend, Dvorak showed, that started before the Affordable Care Act.

“Obamacare kind of became the whipping boy for everything wrong with the health care system,” he said. “This is a problem that is baked into our system. This isn’t Obamacare. This is our system.”

Dvorak said even individuals with health insurance don’t seek care when they need it because they can’t afford it, which can in many cases worsens the diagnosis.

“We hear people say we need to have skin in the game. You know, you can’t give people too good of insurance because then they’ll just run to the doctor for every sore throat and every sniffle,” he said. “I think the problem is not only do we have skin in the game, but now we have our hearts and lungs and brains in the game because this is what’s at risk when we don’t get care when we need it. That’s the consequence of underinsurance.”

Dvorak said the increased cost in health care is attributed to the administrative expenses of the insurance companies, like marketing and advertising and executive salaries.

But according to Dvorak and Eagen, there’s a solution.

Under the Affordable Care Act, states can apply for a state innovation waiver to pursue “innovative strategies for providing their residents with access to high quality, affordable health insurance while retain the basic protections” of the law starting Jan. 1, 2017.

“That’s exciting news for single-payer supporters,” Dvorak said.

Single-payer health care is a “unified system” that covers all citizens and is funded publicly, while the serves are delivered privately.

“Just like we pay for our police protection, our fire protection, our military, you could say health care is another kind of protection, and we all pay into it based on our ability to pay,” Dvorak said, adding the strengths are the coverage, unified risk pool and it’s a simple and efficient system that can be paid for by slashing administrative costs and other expenses resulting from health insurance companies.

For patients, he said, it wouldn’t require them to have a job in order to have insurance, it would allow them to choose their provider and remove financial barriers to care.

Eagen said Minnesota Sen. John Marty co-authored a bill in February that received bipartisan support from more than 30 legislators regarding the Minnesota Health Plan, which is a state version of single-payer health care that covers all medical-related expenditures, like dental, medical, prescription and mental illness. He also spoke about Marty’s book, “Healing Health Care.”

A study from The Lewin Group, a health care policy research and management consulting firm, showed Minnesota could save $4 billion by switching to single-payer health care while covering all residents, Dvorak presented.

Dvorak said the “big downside” about single-payer health care is the job loss of “many, many good people who work for insurance companies,” but they could be retrained in the new system and there’d still be a savings.

“Some won’t have a job for a bit, but they’ll have health insurance,” Eagen said.

Some of the 20 people who attended the event and expressed vocal support for the system, asked what’s holding up action to switch to single-payer health care, like other developed nations.

Dvorak said it’s the “losers in the single-payer system,” which are the multibillion insurance and pharmaceutical industries who put money into the political system.

Paul Swenson of Owatonna, who’s been in the insurance industry for nearly 40 years, said, “I’m with you guys,” before expanding on his frustrations with the health insurance industry and explain what needs to be done to move it forward, like getting more people educated on the topic without sensationalizing and misinforming them to garner support.

“We have to stop the divisiveness. We do,” he said.

After Dvorak and Eagen’s presentation, the film, “Fix It Health Care at the Tipping Point.”

Steele County Indivisible is a local group committed to the progressive movement started by the nationwide Women’s March in January and it encourages grassroots activism at the local, regional and national levels.

“Everyone is welcome. We speak in many voices and we follow the principles of the Women’s March Minnesota in pursuit of truth, equity and justice,” said Dr. Beth Gilthvedt, a local optometrist and member of Steele County Indivisible.

The group, she said, plans on participating in the March for Science on April 22 at the state capitol.

http://www.southernminn.com…

Single-payer system rises on horizon

By The Editorial Board
The Concord Monitor, April 9, 2017

The president has predicted that Obamacare will explode this year. If it does, as conservative columnist Charles Krauthammer recently noted, its replacement may well be a single-payer national health insurance system. To that we would say, “It’s about time.”

Germany created its national health care system in 1883, Great Britain in 1911. The following year former president Teddy Roosevelt, running on the Bull Moose ticket, proposed a similar system, albeit for low-wage workers.

It scarcely seems possible that a stupendously dysfunctional, hyper-partisan Congress and a petulant president could do something as monumental as enacting Medicare for all, which is what bills filed in the House and Senate would do. But if Obamacare collapses, tens of millions of Americans would become uninsured. They will be angry.

Look at the list of the states with the highest percentage of uninsured, the ones that would benefit most by Medicare for all. Texas tops the list at 16 percent, followed by Georgia, Alabama, Arizona, Florida, Mississippi and Oklahoma. Trump carried all of them. He also carried states that took advantage of the Affordable Care Act’s option to expand Medicaid. Voters there would be even angrier.

“Obamacare may turn out to be unworkable, indeed doomed, but it is having a profound effect on the zeitgeist: It is universalizing the idea of universal coverage,” Krauthammer wrote. “Acceptance of its major premise – that no one be denied health care – is more widespread than ever.”

Indeed it is. Last year a Gallup poll found 58 percent support for a single-payer system, and that was before Republicans failed to repeal and replace Obamacare. “The arc of the moral universe is long,” Dr. King said, “but it bends towards justice.”

Health care spending consumes nearly 18 percent of the economy but much of that spending – estimates are in the 30 percent range – does nothing to improve the health of the American people, whose life expectancy actually fell in 2015, according to the Center for Health Statistics. The death rate for white, working-class voters – Trump voters – rose the most dramatically. Meanwhile, the system wastes money that could be spent to combat substance abuse, obesity and other preventable killers.

Hospitals and other providers spend billions to “code” bills to inflate them and maximize revenue. Insurance companies, lawyers and federal employees do the same to dispute those bills. None of it does anything to improve health.

A single-payer system, one that negotiates with providers and drug companies to get the best deal, would eliminate that waste and save a fortune. But it would do much more. It would stimulate entrepreneurship by ending job lock – people who remain in jobs only because they need insurance. It would free employers from the burden of providing health insurance, lift the threat of bankruptcy by medical bill and eliminate an enormous source of stress imposed on all players, employers, doctors, patients and family members.

The most ideologically conservative Republicans are implacably opposed to government paying for health care, which is what every other developed nation does. Others, especially those representing states that have benefited greatly from expanded Medicaid, may not be so intractable. Trump, during one presidential debate, indirectly supported a single-payer system, saying “it works in Canada. It works incredibly well in Scotland.”

It took Nixon to go to China. It may take Trump, to establish universal health insurance. Krauthammer thinks it could happen. “A broad national consensus is developing that health care is indeed a right. This is historically new. … It suggests that we may be heading inexorably to a government-run, single-payer system.”

We hope he’s right.

http://www.concordmonitor.com…

The Lancet Series on ‘America: Equity and Equality in Health’

Editorial: America, all things not being equal

The Lancet, April 8, 2017

In an effort to better understand the conditions and mechanisms driving health disparities in the USA, this week, The Lancet breaks ground once again by publishing, America: Equity and Equality in Health — a stark and dire update to the first Series — focused on appraising where the greatest discrepancies lie. Comprising five papers, the Series looks in depth at the current inequalities in the health-care system and chronicles the beneficial influence of the ACA on health-care equity as well as the continued barriers and shortcomings in providing coverage.

http://www.thelancet.com…

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Inequality and the health-care system in the USA

By Samuel L Dickman, David U Himmelstein, Steffie Woolhandler

Widening economic inequality in the USA has been accompanied by increasing disparities in health outcomes. The life expectancy of the wealthiest Americans now exceeds that of the poorest by 10–15 years. This report, part of a Series on health and inequality in the USA, focuses on how the health-care system, which could reduce income-based disparities in health, instead often exacerbates them. Other articles in this Series address population health inequalities, and the health effects of racism, mass incarceration, and the Affordable Care Act (ACA). Poor Americans have worse access to care than do wealthy Americans, partly because many remain uninsured despite coverage expansions since 2010 due to the ACA. For individuals with private insurance, rising premiums and cost sharing have undermined wage gains and driven many households into debt and even bankruptcy. Meanwhile, the share of health-care resources devoted to care of the wealthy has risen. Additional reforms that move forward, rather than backward, from the ACA are sorely needed to mitigate health and health-care inequalities and reduce the financial burdens of medical care borne by non-wealthy Americans.

http://www.thelancet.com…

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The Affordable Care Act: implications for health-care equity

By Adam Gaffney, Danny McCormick

Although the ACA improved coverage and access—particularly for poorer Americans, women, and minorities — its overall impact was modest in comparison with the gaps present before the law’s implementation. We discuss proposals for change from opposite sides of the political spectrum, together with their potential impact on health equity.

http://www.thelancet.com…

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Structural racism and health inequities in the USA: evidence and interventions

By Zinzi D Bailey, Nancy Krieger, Madina Agénor, Jasmine Graves, Natalia Linos, Mary T Bassett

In this conceptual report, the third in a Series on equity and equality in health in the USA, we use a contemporary and historical perspective to discuss research and interventions that grapple with the implications of what is known as structural racism on population health and health inequities. Structural racism refers to the totality of ways in which societies foster racial discrimination through mutually reinforcing systems of housing, education, employment, earnings, benefits, credit, media, health care, and criminal justice. We argue that a focus on structural racism offers a concrete, feasible, and promising approach towards advancing health equity and improving population health.

http://www.thelancet.com…

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Mass incarceration, public health, and widening inequality in the USA

By Christopher Wildeman, Emily A Wang

The USA is the world leader in incarceration, which disproportionately affects black populations. Nearly one in three black men will ever be imprisoned, and nearly half of black women currently have a family member or extended family member who is in prison. The emerging literature on the family and community effects of mass incarceration points to negative health impacts on the female partners and children of incarcerated men, and raises concerns that excessive incarceration could harm entire communities and thus might partly underlie health disparities both in the USA and between the USA and other developed countries.

http://www.thelancet.com…

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Population health in an era of rising income inequality: USA, 1980–2015

By Jacob Bor, Gregory H Cohen, Sandro Galea

Although the increase in income inequality since 1980 has been driven largely by soaring top incomes, the widening of survival inequalities has occurred lower in the distribution — ie, between the poor and upper-middle class. Growing survival gaps across income percentiles since 2001 reflect falling real incomes among poor Americans as well as an increasingly strong association between low income and poor health. Changes in individual risk factors such as smoking, obesity, and substance abuse play a part but do not fully explain the steeper gradient. Distal factors correlated with rising inequality including unequal access to technological innovations, increased geographical segregation by income, reduced economic mobility, mass incarceration, and increased exposure to the costs of medical care might have reduced access to salutary determinants of health among low-income Americans.

http://www.thelancet.com…

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Comment: An agenda to fight inequality

By Bernie Sanders

The USA is one of the richest countries in the world, but that reality means very little for most people because so much of that wealth is controlled by a tiny sliver of Americans. During the past 35 years, there has been a massive transfer of wealth away from the middle class and the poor to the top 0·1% of the US population.

Such inequality continues to be one of the greatest moral and economic issues of our time. It is also a huge health issue.

The USA’s dysfunctional health-care system is a major contributor to the nation’s health inequalities. Today, the US health-care system too often serves to enrich wealthy investors and executives, while impoverishing, and even bankrupting, many working families.

Health care is not a commodity. It is a human right. The goal of a health-care system should be to keep people well, not to make stockholders rich. The USA has the most expensive, bureaucratic, wasteful, and ineffective health-care system in the world.16 Medicare- for-all would change that by eliminating private health insurers’ profits and overhead costs, and much of the paperwork they inflict on hospitals and doctors, saving hundreds of billions of dollars in medical costs.

Making sure that every citizen has the right to child care, health care, a college education, and a secure retirement is not a radical idea. It is as American as apple pie. It will allow us to realise the ideals of the USA: that all of us are created equal — that we all have the right to life, liberty, and the pursuit of happiness.

http://www.thelancet.com…

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Profile: David Himmelstein and Steffe Woolhandler: advocates for an equitable US health system

By Richard Lane

With President Donald Trump’s failure to get the American Health Care Act (AHCA) as far as a vote in Congress, are they optimistic for the future? “The AHCA’s defeat has certainly buoyed our spirits. Obamacare expanded coverage, but its adherence to a market-based approach hobbled the reform, leaving it open to Trump’s attacks”, says Woolhandler. “The surging opposition that triggered the collapse of the Republican plan signals the broad support for a non-market alternative that can create a new opening for single payer, so yes, we have some grounds for optimism,” Himmelstein says.

http://www.thelancet.com…

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Comment:

By Don McCanne, M.D.

For those looking for something to read this weekend, you couldn’t do better than this Lancet series on the lack of equity and equality in America and its impact on health care. If you don’t have time, at least you can get the gist of the theme by reading these relatively short excerpts. Also, the articles are well worth saving as a reference source to use in our advocacy for expanding health care justice throughout America.

Medicare for all

By William R. Davidson, M.D.
The Lebanon (Penn.) Daily News, April 7, 2017

The American people were right to reject the Republican Party’s recent attempt (Trumpcare) to “repeal and replace” Obmacare because a 300-billion-dollar tax break for the richest 2% while increasing the number of uninsured would have been a giant step backward. Still, Obamacare leaves a lot to be desired and this is the time to move forward, not backward, and bring all citizens under the umbrella of an improved Medicare-for-All.

Fifty years ago Medicare was enacted over the protests of Southern bigots, most physicians (AMA), popular Conservatives (Ronald Reagan), and, of course, the insurance and pharmaceutical industries. Unfortunately, those negative voices were strong enough that only the elderly and seriously disabled were included. Thus, for the past half century we have been left with a system that yearly causes a half million medical bankruptcies, unaffordable premiums and deductibles, as well as thousands of preventable deaths amongst our non-elderly population.

Why Medicare has not been expanded to include everyone is largely explained by the lobbying efforts of the pharmaceutical and insurance industries which have literally bought most of our legislators (both Democrat and Republican). In addition, there has been a massive disinformation program that has perpetuated the myth that Medicare for All would lead to limitations in choice of doctors and hospitals, unsustainable costs, as well as an expansive, out of control bureaucracy. These are lies which better describe our present system based on the private insurance paradigm. Private insurers, not traditional Medicare, tell us which doctors we can and cannot see. Our present healthcare system costs twice as much as Single Payer systems in Europe and Canada mainly because our dysfunctional bureaucracy is many times larger.

Having practiced Medicine for over 40 years, I have never met a person over 65 who has turned in his Medicare card because he (or she) refuses to be associated with a “corrupt”, “one size fits all”, choice limiting, “government run”, bureaucratic, Socialistic system that includes people “I don’t like”. Over the years, Medicare has saved millions of lives. Many more lives will be saved if Medicare is expanded to include all Americans.

http://www.ldnews.com…

Time for universal coverage/single-payer system

By David M. Pratt
The Buffalo News, April 7, 2017

Contrary to what many U.S. citizens believe, research on health care outcomes shows that the United States has one of the worst health care systems in the developed world.

The 2000 World Health Organization (WHO) study on health care outcomes found that the U.S. ranked 31st out of 191 countries studied despite spending a greater percentage of its gross domestic product on health care than any other country. Per the WHO study, the U.S. ranked 39th in infant mortality and 36th in life expectancy.

In a 2014 study conducted by the Commonwealth Fund, the U.S. ranked dead last in overall health care outcomes in comparison with 11 industrialized countries. According to the Commonwealth Fund study, the U.S. ranked last in access, efficiency, equity and healthy lives.

The most pressing question is: Why do we get such poor outcomes despite spending so much? The answer to this question is related to the extraordinary sums we spend on administrative costs in the U.S. compared to other industrialized countries.

According to the Commonwealth Fund, administrative costs account for 25 percent of the health care dollar in the U.S. compared with an average of 12 percent in other developed countries. Lower administrative costs in these countries have been achieved through the use of a single-payer system, which is considerably more efficient than our multipayer system.

According to Gerald Friedman, Ph.D., professor of economics at the University of Massachusetts (2013), we would save $476 billion per year in administrative costs alone in a single-payer system.

In addition, nearly all other developed nations provide universal coverage, which has also been shown to be instrumental in reducing cost.

Universal coverage encourages preventive care, routine care and early intervention. In our system, the uninsured (or underinsured) delay care until there is a dire need, which is substantially more costly to treat. In addition, universal coverage provides negotiating leverage for various medical expenditures, most notably pharmaceuticals.

According to Friedman’s calculations, total annual administrative and pharmaceutical savings in a single-payer/universal coverage system would be $592 billion per year, enough to fund expanded coverage, improved benefits and enhanced reimbursements to providers.

We have recently experienced a tumultuous political debate on health care in the U.S. and still the recently proposed House bill pleased very few.

The best research we have indicates that the universal coverage/single-payer option is by far the most economical and clinically effective system. It’s time to be rational about health care in this country. It’s time to “make Americans healthy again.” We owe ourselves good health care. Cost can be manageable if we are willing to reconstruct our largely employer-funded, private insurance system. It’s time to reconsider adopting a universal coverage/single-payer system.

David M. Pratt, Ph.D., is a New York State licensed psychologist in private practice at Western New York Psychotherapy Services.

http://buffalonews.com…

Leading British medical journal spotlights ‘inequality and health’ in U.S.

New studies in The Lancet examine effects of racial segregation, mass incarceration, economic inequality and a lack of universal health care as factors in declining U.S. health outcomes, and point to a growing ‘survival gap’ between rich and poor

FOR IMMEDIATE RELEASE, April 6, 2017, at 6:30pm EST
Contact: Clare Fauke, communications specialist, PNHP, 312-782-6006, clare@pnhp.org

The life expectancy of the wealthiest Americans, which now exceeds that of the poorest Americans by 10 to 15 years, continues to grow, according to a series of papers published today in The Lancet, one of the world’s oldest and most respected medical journals. This “survival gap” is a result of America’s fractured, for-profit health system, as well as its rapidly growing economic inequality, racial segregation and mass incarceration, which is unique among industrialized nations, researchers say.

These topics and several others are discussed in a five-paper series in The Lancet called “America: Equity and Equality in Health,” featuring new data and analysis by prominent U.S. health researchers, as well as a special commentary by Senator Bernie Sanders, I-Vt., in which he calls for a “Medicare for All” single-payer system.

Dr. David Himmelstein, the lead author of the series, says: “Today, 43 million Americans are poor, and although the Affordable Care Act has nearly halved the number of people without insurance, 29 million Americans, many of them poor or near-poor, remain uninsured. Health inequalities are more entrenched than ever, and rather than address them, the U.S. health care system often exacerbates them. In order to tackle health inequalities in the U.S., it is essential that we move towards a non-market financing system that treats health care as a human right.” Himmelstein is an internist, professor of public health at the City University of New York (CUNY) at Hunter College, lecturer in medicine at Harvard Medical School and co-founder of Physicians for a National Health Program.

In his commentary, Sen. Sanders emphasizes the links between economic inequality and health outcomes, stressing the urgent need for a universal health program covering all Americans. He writes: “Such inequality continues to be one of the greatest moral and economic issues of our time. It’s also a huge health issue. … The USA has the most expensive, bureaucratic, wasteful, and ineffective health care system in the world. Medicare-for-all would change that by eliminating private health insurers’ profits and overhead costs, and much of the paperwork they inflict on hospitals and doctors, saving hundreds of billions in medical costs.”

The researchers of the five studies are chiefly physicians and public health researchers holding prominent positions at the CUNY, Harvard Medical School, Harvard’s School of Public Health, Boston University School of Public Health, Cornell University, Yale School of Medicine, and several other institutions, including the New York City Department of Health and Mental Hygiene.

Selected highlights of the five studies appear below, followed by “Key Facts” on health inequalities in the U.S. All articles contain extensive data, tables, graphs, and key takeaways from the The Lancet’s editors. For more information, visit www.lancet.com/us-health.

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America: Equity and Equality in Health – a new Series from The Lancet

Study 1. “Inequality and the health-care system in the USA,” by Samuel L. Dickman, M.D., David U. Himmelstein, M.D., and Steffie Woolhandler, M.D., M.P.H.

Since 1986, the top 0.1 percent of American households has accumulated nearly half of all new wealth, and now controls as much wealth as the bottom 90 percent, whose share has fallen steadily. As top incomes have risen, so has extreme poverty. More than 1.6 million households in the U.S, including 3.5 million children, survive on incomes of less than $2 per person per day – the World Health Organization’s definition of extreme poverty; this number has more than doubled since the 1990s.

As economic inequality has deepened, so too has inequality in health. Almost every chronic condition, from stroke to heart disease and arthritis, follows a predictable pattern of rising prevalence with declining income. The life expectancy gap between rich and poor Americans has been widening since the 1970s, with the difference between the richest and poorest 1 percent now standing at 10.1 years for women and 14.6 years for men.

Instead of reducing income-based disparities in health, the market-based American health care system often exacerbates them by its very design. Low-income Americans have worse access to care than do wealthy Americans, partly because so many remain uninsured despite coverage expansions of the ACA. For individuals with private insurance, rising premiums and cost sharing have undermined wage gains and driven many households into debt and even bankruptcy. Meanwhile, the share of health care resources devoted to care of the wealthy has risen.

The uninsured (who are disproportionately poor) pay for much of their care out of pocket and, because they do not have insurers’ negotiating leverage, are charged the highest prices. One in four adults under the age of 65 reported problems paying medical bills; 34 percent of insured Americans with difficulty paying medical bills were unable to pay for food, heat, or housing, 15 percent took out high-interest payday loans, and 42 percent took on extra jobs or worked additional hours to pay medical bills.

Study 2: “The Affordable Care Act: implication for health-care equity,” by Adam Gaffney, M.D., and Danny McCormick, M.D., M.P.H.

Despite the reforms promised by the Affordable Care Act (ACA), financial barriers to care persist and might be worsening. While the ACA has nearly halved the number of Americans without health insurance, the high cost of co-payments, deductibles and co-insurance still drive many insured households into debt, even bankruptcy. The ACA’s Medicaid expansion targeted the poorest Americans, but 19 states – mostly southern states with large minority populations and poor records of health care access – chose to opt out. Even if the ACA were not altered or repealed, 28 million people would remain uninsured in 2024.

“Republican proposals focus on market-based reforms that would slash federal funding for Medicaid, replace the ACA’s subsidies with regressive tax credits, and further privatize Medicare,” says Dr. Adam Gaffney, a pulmonary specialist at Cambridge Health Alliance and Harvard Medical School. “Rather than improve the health inequalities that remain a grave problem even in the era of the ACA, this approach would only make things worse. Real reform is now needed to take us towards a universal single-payer system.”

Study 3: “Structural racism and health inequities in the USA: evidence and interventions,” by Zinzi D. Bailey, Sc.D., Nancy Krieger, Ph.D., Madina Agénor, Sc.D., Jasmine Graves, M.P.H., Natalia Linos, Sc.D., and Mary T. Bassett, M.D.

Health and health equity are substantially influenced by the places where people live, work, play, and pray. In the U.S., high levels of racialized economic segregation and structural racism are key determinants of public health. The ongoing residential segregation of African Americans is associated with adverse birth outcomes, such as an infant mortality rate that is twice as high for African Americans than it is for whites. Marginalized groups also face an increased exposure to air pollutants, decreased longevity, increased risk of chronic disease, and increased rates of homicide and other crime. Residential segregation also affects health care access, utilization, and quality at the neighborhood, health care system, provider and individual levels.

“Racial and ethnic health disparities in the United States are well documented, but structural racism is rarely discussed as a root cause,” says Dr. Mary T. Bassett, commissioner of the New York City Department of Health and Mental Hygiene. “Structural racism refers to all the ways in which systems foster inequitable outcomes, whether in housing, education, employment, media, health care or the criminal justice system. All have profound effects on health. If we don’t address structural racism, health inequities will persist.”

The authors point to several potential solutions to improve health equity by targeting structural racism, including community programs to address housing and access to health care; policy reform to reduce sentencing laws and imprisonment; and training the next generation of health professionals.

Study 4: “Mass incarceration, public health, and widening inequality in the USA,” by Christopher Wildeman, M.D., and Emily A. Wang, M.D.

On any given day, the U.S. incarcerates more of its citizens (2.2 million) and at a higher percentage (7 percent of the population) than any other country in the world. Mass incarceration shapes inequality in American health, disproportionately affecting African American communities where one in three black men will be imprisoned in their lifetime, nearly six times the rate of white men. An African American child born in 1990 had a 25.1 percent chance of having a father sent to prison; for those whose fathers did not finish high school, the risk was roughly double that, at 50.5 percent. Nearly half of black women currently have a family member or extended family member who is in prison.
Incarcerated individuals have increased prevalence of infectious disease (including sexually transmitted diseases, HIV, and hepatitis C), chronic medical conditions (such as hypertension, diabetes, and asthma), substance abuse and mental health disorders. Upon release, they earn 30 percent less than similar individuals who have never been imprisoned, further compounding the health-poverty trap.

Interestingly, correctional facilities provide many incarcerated adults with their first access to preventive and chronic medical care, since prisons and jails are some of the only places in the U.S. where health care is guaranteed by law. An estimated 40 percent of individuals with chronic medical conditions are diagnosed with a chronic condition while incarcerated, and 80 percent report seeing a medical provider while incarcerated. These gains are short-lived, however, since recently-released inmates are less likely to have a primary care physician and are at a disproportionately high risk of mental health problems.

“Overcrowding, high costs and aggressive policing have led to increasing recognition that mass incarceration has failed,” says Dr. Christopher Wildeman of Cornell University. “But, sweeping reforms are needed to reduce incarceration of technical parole violators, expand community corrections for low-level property and drug crimes, and medical paroles for elderly or sick inmates, in addition to expanded access to health care for individuals affected by the criminal justice system.”

Because the U.S imprisons many more of its citizens than do other developed democracies, mass incarceration might have contributed to the country’s lagging performance on health indicators such as life expectancy. One study suggests that U.S. life expectancy would have increased 51.1 percent more and infant mortality would have fallen 39.6 percent more from 1983 to 2005 if incarceration had remained at the mid-1980s level.

Study 5: “Population health in an era of rising income inequality in the USA: 1980-2015,” by Jacob Bor, Sc.D, S.M.; Gregory Cohen; and Sandro Galea, M.D., Ph.D.

Incomes for poor and middle-income Americans have barely changed since the 1970s and, adjusted for inflation, have actually declined since 2000. Poverty has emerged as an increasingly important risk factor for mortality in American adults, and the expanding “survival gaps” between rich and poor cannot be explained away by individual risk factors such as smoking, obesity and substance abuse.

The survival gap widened in the 2000s, as life expectancy between 35 and 75 years of age increased for wealthy men and women, but did not change for poor men and actually declined for poor women, as measured by both income and level of education. Life expectancy for white Americans without a high school diploma dropped by 5.3 years for women and 3.4 years for men. The increase in deaths from poisonings, suicide, and liver disease together accounted for half of the total increase in mortality in this group.

The life-expectancy gap between college-educated Americans and those with less than a high school education increased by 0.8 years for men and 2.6 years for women from 1990 to 2008. However, the gains in survival enjoyed by white Americans with at least a high school education were not experienced by African Americans, suggesting that the health benefits of education might be cancelled out by factors associated with race and ethnicity such as structural racism.

The authors provided several reasons for the drop in health outcomes for low-income and lesser-educated Americans: (1) less access to technological innovations in medicine and information about complex health risks and preventive behaviors; (2) increasing geographical segregation that creates inequalities in access to health care; (3) reduced economic mobility and increased persistence of poverty; (4) rapidly increasing incarceration rates; and (5) the erosion of public subsidies for health insurance and other health inputs, and increasing exposure to market prices.

The American health care system exacerbates these problems. Even for those with health insurance, rising deductibles and co-payments are shifting more of the costs of care onto users. Since the early 2000s, health spending for wealthier Americans has soared, whereas expenditures have risen modestly for the middle class and actually fallen for those with low incomes, a health-poverty trap driven by medical cost.

Without immediate interventions to reduce inequality, U.S. may see the emergence of a 21st century “health-poverty trap” as economic insecurity can lead to poor health, and poor health can further limit economic productivity, bankrupt households and impoverish families.

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KEY FACTS: Health inequalities in the U.S.

The U.S. is one of the most unequal countries in the OECD – only Chile, Turkey and Mexico are more unequal.
The life expectancy gap between rich and poor is among the highest in developed countries. The richest 1 percent of Americans live 10-15 years longer than the poorest 1 percent.
The life expectancy gap has increased in recent decades, with poverty an increasingly strong risk factor for early death.
Many people forgo medical care altogether: 39 percent of low income Americans reported not seeing a doctor because of costs, compared to 7 percent in Canada and 1 percent in the U.K.
The U.S. health care system is the most expensive of any other country, yet people with serious illness commonly face financial hardship – 1 in 10 families with medical bill problems have declared bankruptcy.
The poorest fifth of American spend 6 percent of their income on private insurance – nearly twice what the wealthiest fifth pay at 3.2 percent.
The ACA significantly reduced the number of people who are uninsured – from 48.6 million in 2010, to 28.6 million in 2015, mostly through Medicaid expansions which Congress recently threatened to roll back.
Before the 2014 implementation of the ACA, in 2012 43 percent of adults avoided needed care and 41 percent had medical bill difficulties, down to 36 percent and 35 percent in 2014.
In 2015, inequalities remain: 25.2 percent of poor Americans are uninsured, compared to 7.6 percent of non-poor Americans; 27.7 percent for Hispanics, 14.4 percent for non-Hispanic blacks and 8.7 percent for non-Hispanic whites.
U.S. life expectancy would have increased 51.1 percent more and infant mortality would have fallen 39.6 percent more from 1983 to 2005 if incarceration had remained at its mid-1980s level.

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Physicians for a National Health Program (www.pnhp.org) is a nonprofit research and educational organization of more than 21,000 doctors who support a single-payer national health program. PNHP had no role in funding or otherwise supporting the studies or commentary described above.

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Published Comment:

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Editorial: America, all things not being equal

Inequality and the health-care system in the USA

The Affordable Care Act: implications for health-care equity

Structural racism and health inequities in the USA: evidence and interventions

Mass incarceration, public health, and widening inequality in the USA

Population health in an era of rising income inequality: USA, 1980–2015

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Profile: David Himmelstein and Steffe Woolhandler: advocates for an equitable US health system

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New studies in The Lancet examine effects of racial segregation, mass incarceration, economic inequality and a lack of universal health care as factors in declining U.S. health outcomes, and point to a growing ‘survival gap’ between rich and poor

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