PNHP

Expanding Medicare for all would be wise

Expanding Medicare for all would be wise

By Johnathon Ross, M.D.
The Blade (Toledo, Ohio), Letters, March 8, 2015

The U.S. Supreme Court is hearing another case attacking Obamacare (“Bad case against Obamacare,” editorial, March 4). This will not be the last.

The complexity of the Affordable Care Act makes it easy to attack. The 19,000 members of Physicians for a National Health Program, of which I am past president, agree it would be tragic, possibly fatal, for those with Obamacare subsidies to lose coverage.

But these attacks confirm that more durable and effective reform is needed. We would prescribe a constitutional remedy that is known to work — improved and expanded Medicare for all.

That would have many advantages over private insurance marketplaces. Medicare’s financing is fair — all contribute and all benefit, versus a marketplace of private insurance that will ration care by ability to pay. Medicare’s benefits are inclusive and generous, versus private insurance, which seems to be exclusionary, greedy, mean-spirited, and arbitrary.

Medicare for all would allow complete choice of providers, with access to services we prefer, versus private insurance with restricted provider networks and other barriers to care.

Medicare for all would focus on long-term improvements in the health of the nation with public accountability based on professional values, versus private insurance, which must focus on short-term profits, trade secrets, and commercial — and sometimes near-criminal — values. Multiple studies confirm that the simplicity of Medicare for all would save $400 billion a year — enough to cover all the uninsured and improve benefits for the rest of us.

We need to move on quickly from Obamacare. Improved and expanded Medicare for all will save money and save lives. It is the right thing to do.

Dr. Johnathon Ross resides in Ottawa Hills, Ohio.

http://www.toledoblade.com/Opinion/2015/03/08/Expanding-Medicare-for-all-would-be-wise.html

Hawaii Health Authority could reduce health costs, if empowered to do so

By Stephen B. Kemble, M.D.
Honolulu Star-Advertiser, March 8, 2015

In 2009, the Hawaii Legislature passed a bill to create the Hawaii Health Authority, charged with designing a universal health care system covering all residents of Hawaii. 

In 2011, then-Gov. Neil Abercrombie appointed the HHA members, who have submitted two reports outlining a roadmap to a cost-effective, universal health care system, building on models proven in practice elsewhere in the U.S. and from around the world. 

Our Prepaid Health Care Act, passed in 1974, includes an employer mandate, bans pre-existing condition exclusions, and requires a rich benefit package and 80-90 percent actuarial value with no deductible. 

We have had the best coverage package and the broadest risk pooling in the country, along with the least competitive market, and yet until about five years ago, we had among the lowest premiums in the country. Hawaii has also had the lowest per-capita Medicare spending in the country. 

The HHA has sought to expand on the lessons from Prepaid to develop a simplified universal system that would reduce total health care cost through administrative savings, not restrictions on care. 

Based on the experience of other countries and economic analyses of similar proposals, the fully implemented HHA proposal would likely save around 30 percent of our total health care costs. 

Current federal law would prevent full implementation, but by focusing on opportunities for administrative simplification and maximizing risk pooling, substantial savings would still be possible. 

However, the Abercrombie administration chose to ignore the HHA’s recommendations and pursue the reforms promoted by the Affordable Care Act. All the administrative complexity and obstructions to care in our current fragmented health care “system” have been left in place, while adding a new layer of “Accountable Care Organizations” (ACOs) that propose to push insurance risk onto doctors and hospitals via bundled payments and capitation. To counter the resulting incentive to deny and restrict care, another administrative layer of pay-for-performance (P4P) is being added, relying on complex computerized data controlled by insurance companies and government agencies, to supposedly measure and reward “quality.” 

None of this works in practice. ACOs are costing more to administer than they can save by reducing unnecessary care. 

Transferring insurance risk to providers gives them incentives to game documentation and avoid sicker, more complex patients. 

P4P measures have poor validity, don’t improve health outcomes and add administrative costs. 

Administrative burdens and reduced payments are driving smaller and rural hospitals out of business, driving older doctors out of practice prematurely, and deterring younger doctors from entering primary care, psychiatry and other non-procedural specialties. 

We no longer have enough physicians to assure the access to outpatient care required to keep patients out of the ERs and hospitals. 

The result is a dramatic increase in health insurance premiums in the past five to six years, since Hawaii’s health plans began gearing up for the “transformation” envisioned in the ACA. 

My own gross psychiatric practice receipts have been completely flat for the past 10 years, while my health insurance premiums have more than doubled. 

Most of the increase is due to markedly higher administrative costs for hospitals and health insurance plans, plus a recent surge in drug prices by a pharmaceutical industry run amok. 

There is no possibility in Hawaii of finding enough savings from reducing “unnecessary” care to offset the cost of these “reforms.” Abercrombie’s health transformation task force spent federal grants to generate plans that are disconnected from reality. 

The Hawaii Health Authority has not yet been consulted by Gov. David Ige’s administration concerning health policy, but Hawaii could see improving access to care and large health care savings if the HHA were empowered to fulfill its mission, as stated in Hawaii law. 

Stephen B. Kemble, M.D., is a member of the Hawaii Health Authority. 

Copyright (c) Honolulu Star-Advertiser 

http://www.staradvertiser.com/editorialspremium/20150308_Hawaii_Health_Authority_could_reduce_health_costs_if_empowered_to_do_so.html?id=295474101

Let’s do something; let’s innovate!

Innovating Care for Medicare Beneficiaries: Time for Riskier Bets and Embracing Failure

By Ashish K. Jha
JAMA Forum, March 4, 2015

Of all the pressing challenges in the US health care system, lack of innovation in delivery may be the most important.

This lack of innovation in how we do things is a major reason why health care productivity has been so low and high spending has had insufficient benefits for patients.

A major premise of the Affordable Care Act (ACA) was that it would spur new models of care delivery. The architects of the ACA understood that old models of care delivery impeded gains in productivity, made it difficult to improve patient outcomes, and made the health care delivery system inefficient. In response, the ACA established the Center for Medicare and Medicaid Innovation (CMMI), which is responsible for changing how we deliver health care. The ACA provides CMMI with $1 billion per year for 10 years, much larger than the budgets of the Agency for Healthcare Research and Quality and the Patient-Centered Outcomes Research Institute, 2 entities that have gotten far more attention. Will CMMI achieve the meaningful new models of care delivery that our health care system needs? It is unclear, but there is reason for concern.

A Mixed Picture

Four and a half years after launch, CMMI appears to have funded 36 new programs, of which we have evaluations for 9. Nearly all the evaluations are positive, although careful examination of the reports paints a far more mixed picture. Most programs are having minimal effects, on the margins.

For example, the Comprehensive Primary Care Initiative, across 6 states, seems to have a monthly savings of $14 dollars (2% of total Parts A and B spending) per patient, compared with controls, a savings that actually turns negative when the costs of the program are included. The effects on quality are minimal, as well.

Betting on Nontraditional Players

Foremost, CMMI needs to make meaningful bets on nontraditional players—such as startups and small delivery organizations—that are trying to fundamentally upend health care delivery. Next, focusing on organizations that are using technology in radically different ways, employing nontraditional personnel to facilitate care, and targeting new locations for care delivery would also be helpful. Focusing on nonincumbents and taking risks with nontraditional care models would pay much bigger dividends than the marginal savings that current programs are likely to generate.

But they would come at a cost: a high failure rate. Advocates of the current CMMI approach would argue that such failures are unpalatable, given the current political environment. Although that is surely true, the broader health care community must give CMMI the space to fail. Even the talented, highly capable people running CMMI can’t have success rates much higher than those seen in Silicon Valley, where comparably smart investors are using their own money to make bets. But, if they are willing to be risky—and willing to fail—they can have a profound effect on the way health care is delivered. And that will be an investment worth making.

http://newsatjama.jama.com/2015/03/04/jama-forum-innovating-care-for-medicare-beneficiaries-time-for-riskier-bets-and-embracing-failure/

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Market-Based Solutions to Antitrust Threats — The Rejection of the Partners Settlement

By Regina E. Herzlinger, D.B.A., Barak D. Richman, J.D., Ph.D., and Kevin A. Schulman, M.D.
The New England Journal of Medicine, March 4, 2015

Health care consumers won a significant victory when Massachusetts Suffolk County Superior Court Judge Janet Sanders blocked a settlement that would have allowed Partners HealthCare, the system that dominates the Boston area, to acquire three additional health care providers in eastern Massachusetts. Sanders concluded that the acquisitions “would cement Partners’ already strong position in the health care market and give it the ability, because of this market muscle, to exact higher prices from insurers for the services its providers render.”

If this decision is not overturned on appeal, consumers will now be spared those projected price increases. But there is an even bigger reason for New Englanders to celebrate the judge’s ruling. The danger lay not only in Partners’ expanded dominance but also in the degree to which the settlement would have shut out other innovative competitors.

Health care delivery does not rely on fixed assets whose returns should be guaranteed. Rather, it relies on services and interactions between caring clinicians and patients in need. This concept is lost when public policy focuses on regulating returns on invested capital rather than on promoting the provision of high-quality, innovative, efficient clinical services. Innovative, low-cost competitors to most hospital services could abound — for example, telemedicine providers and community-based urgent care centers. Such innovations may represent the public’s best hope for sustainable health care. But the proposed settlement could have squashed opportunities for innovation, since it conceded Partners’ dominance and tried only to contain it.

We need policies that challenge expansions and preserve competition, not those that assist the dominant player. We have our own list: encouraging payment reform that rewards quality and cost-effectiveness; liberalizing scope-of-practice regulations, licensing rules, and other prohibitions to allow more efficient use of human resources; ensuring that professional regulations, state boundaries, and FDA rules do not impede telemedicine and digital products that enable mobile health management; and refining antikickback rules and reimbursement restrictions to enable providers to pursue creative, integrated ventures that could revolutionize the delivery of care. And there is much that attorneys general can do to promote such innovation-oriented policies.

Instead of focusing solely on regulating dominant hospital systems, policymakers should also pursue strategies that can foster real competition and innovation in the price, accessibility, and quality of care.

http://www.nejm.org/doi/full/10.1056/NEJMp1501782?query=TOC

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Comment:

By Don McCanne, MD

Where would this world be without the sage advice of some of the great thinkers of the past and present?

  • “Don’t just stand there. Do something!”
  • “Don’t accept the status quo. Innovate!”
  • “Don’t regulate. Allow markets freedom to compete!”

Thank goodness that these have been our guiding principles in health care for the past century so that now we have the highest quality health care system and the lowest costs, that is except for all of the other nations that have placed a priority on public policies over private innovation.

We still haven’t learned. We are spending billions of taxpayer dollars on just doing something… anything. The CMMI innovations that we have funded have had, at best, only minimal benefits at the margin. In fact, the savings have turned negative when the costs of the programs are included. Worse, the effects on quality have been negligible as well. In these efforts, we’re spending more and buying nothing.

Yet we continue to allow the clarion call for innovation and competition to drown out the message of reform that would finally include absolutely all of us in a high-performance health care delivery system that finally would be truly affordable. Of course, that reform would be a single payer national health program. Our immediate task is to make our clarion call drown out theirs. As it is now, our is hardly a peep. (Think not? Google innovation in health care – 377 million results – and single payer health care – 2 million results.)

Health care law did not end discrimination against those with pre-existing conditions

By Kay Tillow
Firedoglake, MyFDL, March 6, 2015

In 2010 the giant health insurance company WellPoint created an algorithm that searched its database, located breast cancer patients, and targeted them for cancellation of their policies.

A few years earlier Michael Moore’s stunning documentary, “Sicko,” showed an unending list of illnesses that had been used by insurers to refuse to sell people policies, to charge them much more, or to deny payment for “pre-existing conditions.”

The public became acutely aware of these harmful, widespread practices and sharply condemned them. So it was not by chance that this insistent popular support resulted in inclusion of a ban on these practices in the Affordable Care Act (ACA) that was passed in 2010.

The government website explains. “Your insurance company can’t turn you down or charge you more because of your pre-existing health or medical condition like asthma, back pain, diabetes, or cancer. Once you have insurance, they can’t refuse to cover treatment for your pre-existing condition.”

Even some Republicans who are trying to repeal the ACA insist that they stand for keeping a provision against such discrimination. “We would protect people with existing conditions,” sayReps. Paul Ryan, John Kline, and Fred Upton.

Regardless of opinions on mandates or the health reform law in general, the entire nation embraced the part of the legislation that outlawed discrimination on the basis of illness.

So we’ve won, right, at least this much reform? Sadly, no.

Last July, over 300 patient advocacy groups wrote to Sylvia Burwell, Secretary of Health and Human Services, to express their concerns. “(W)e are increasingly aware of evidence that new enrollees, especially those with chronic health conditions, are still facing barriers to care,” the letter said.

The groups that signed the letter are well known. They include the American Lung Association, Epilepsy Foundation, The Leukemia and Lymphoma Society, National Alliance on Mental Illness, The Parkinson’s Association, Easter Seals, and the AIDS Institute. They praised the ACA for helping many of their members to finally get coverage. All of these groups supported the ACA prior to its passage and still do.

The letter urges action against discriminatory benefit designs that limit access for patients that were subjected to pre-existing conditions restrictions prior to the ACA. They spell it out. Some plans do not include all the drugs prescribed for enrollees. Some plans don’t cover critical medications including combination therapies. Plans can remove medications during the plan year. Some plans are restricting access to drugs by requiring prior authorization, step therapy, and quantity limits. The network of physicians and hospitals in some plans is so narrow as to deny patients the specialty care needed. Much of the information needed for patients to choose the most appropriate plan is not available.

The letter details the damage. High cost sharing means patients don’t get the drugs they need.  Some plans sold on the exchanges require patients to pay 30, 40 or 50% for drugs that go for several thousand dollars a month. HIV drugs, certain cancer medications, and multiple sclerosis drugs are among them.

The Leukemia & Lymphoma Society found exchange plans in several states that charged patients with blood cancer as much as 50% co-insurance rates.

Charis Hill, a biking enthusiast from Sacramento, California, counted on the medication Enbrel to keep her moving despite her diagnosis of ankylosing spondylitis.  But then the cost went up to $2,000, far more than she could afford. “Insurance companies are basically singling out certain conditions by placing some medications on high-cost tiers,” Ms. Hill said. She called it “pretty blatant discrimination.”

Julie Davis, a young wife and mother of two from Louisville, Kentucky, is struggling with the consequences of this failure to end the discrimination. Her epilepsy medication, Keppra, that had kept her stable and seizure free suddenly skyrocketed from $60 per month co-pay to $1,200.  The high price forced her to change medications in spite of the professional judgment of her physician. The seizures returned. With the problem not yet solved, Ms. Davis has written an Op Ed and testified before the Kentucky Senate Health and Welfare Committee. She and her organization, the Epilepsy Foundation of Kentuckiana, are publicizing the injustice and working to pass state legislation to cap drug co-pays in Kentucky.

HIV/AIDS patients have had to struggle to obtain the drugs crucial to their survival. Carl Schmid, deputy executive director of the AIDS Institute, asserted that “limited benefit coverage, cost-sharing for medications that can reach as high as 50%, and lack of transparency … mean many patients … are not receiving the care and medications they need.”

Even the insurance commissioner of the state of Washington, Mike Kreidler, said “there is no question” that “discrimination is creeping back.”

After spelling out the many ways in which patients with chronic conditions are denied access to medications and specialists, the letter concludes: “We believe these practices are highly discriminatory against patients with chronic health conditions and may, in fact, violate the ACA non-discrimination provisions.”

On October 27, 2014, Secretary Burwell responded to the letter. She said they would take a look at all of the issues and work to make it better for the future.

The dialog between Burwell and the patient advocacy groups continues. The advocacy groups urge a crackdown on the companies that continue to discriminate.

As of February 2015, a study by Avalere Health found that some exchange plans place all drugs used to treat complex diseases – such as HIV, cancer, and multiple sclerosis – on the highest cost-sharing tier. In 2015 an even higher number of the plans in the exchanges have placed drugs necessary for special conditions on tiers out of reach for patients. “In spite of the pushback, it’s getting worse, not better,” said Don McCanne, MD, Physicians for a National Health Program policy expert.

When patients can see that their medication is not covered or is far too expensive, they will avoid those plans. That will allow those insurers to “lemon drop,” to keep those who have expensive chronic conditions out of their plans. The impact is the same as underwriting and rescission. Good for profits, bad for patients.

Insurance companies have more tricks than wily coyote. Their power at the center of our profit-based health care system leaves them in position to defy the law and call the shots. With most of the enforcement left to understaffed state regulators and violations ubiquitous, we can expect the insurance companies to continue to avoid the sick, to price care beyond their reach, and to find ways to refuse payment.

No other nation in the industrialized world allows insurance companies to run their health care system. Discrimination is inherent in for-profit health care. The United States has tried every solution that the insurance companies and their paid experts can devise. It’s now time to admit that to end the discrimination we must move to single payer public financing that frees our health care from the control of the insurance and drug industries.

Kay Tillow is a leader of Kentuckians for Single Payer Health Care and the All Unions Committee for Single Payer Health Care–HR 676. She resides in Louisville, Ky.

http://my.firedoglake.com/blog/2015/03/06/health-care-law-did-not-end-discrimination-against-those-with-pre-existing-conditions/

Deterioration in employer-sponsored health plans

The Great Cost Shift: Why Middle-Class Workers Do Not Feel the Health Care Spending Slowdown

By Topher Spiro, Maura Calsyn, Meghan O’Toole
Center for American Progress, March 3, 2015

In recent years, the growth in overall health care costs has slowed dramatically. But for millions of Americans with employer-sponsored insurance, or ESI, this slowdown is illusory. From 2008 through 2013, the average annual growth rate of employees’ monthly premium contributions and out-of-pocket expenses, adjusted for inflation, was more than double that of average annual growth in real per-capita national health care spending, which was less than 2 percent per year. This growth has also outpaced employers’ costs of offering these benefits by more than 40 percent.

Employees experiencing higher health care costs tend to blame the Affordable Care Act, or ACA, even though the law largely leaves the employer-based system alone. In fact, many employers report that the ACA has had only a negligible influence on their health care costs.

The actual reason why employee and employer costs are increasing at different rates is because employers have, over time, shifted greater responsibility for health care expenses to their employees through higher deductibles, higher copayments, and higher coinsurance — a practice that began long before the passage of the ACA. Other employers pay smaller shares of their employees’ health care premiums.

To some degree, this long-term cost shifting has contributed to the overall health care slowdown. Increased cost sharing discourages the use of health care — individuals tend to spend less on their health care when they are subjected to higher fees or deductibles — which has lowered overall health care spending. Employees with higher cost sharing are more likely to avoid or delay even beneficial and cost-effective care. Employers, insurers, and public health care programs benefit from these savings, while individual employees with significant health care needs face greater out-of-pocket costs. Employees have increasingly reported that their health care costs are unaffordable. In other words, almost everyone in the health care system is realizing savings, but employees’ costs are rising.

Unlike changes to wages, which are straightforward and transparent, these types of changes to employees’ health benefits can be hard to understand, making cost-shifting efforts difficult for employees to detect.

The Great Cost Shift (full 31 page report can be downloaded at this page): https://www.americanprogress.org/issues/healthcare/report/2015/03/03/105777/the-great-cost-shift/

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Comment:

By Don McCanne, MD

One of the most important goals of the Affordable Care Act was to preserve the part of our health care financing system that supposedly was working quite well: employer-sponsored insurance. However, in a process that had already begun and has further intensified since the beginning of ACA implementation, the coverage for employees has deteriorated, with costs being shifted from the employer to the employee without a commensurate increase in wages, leaving employees considerably worse off – especially those employees with greater health care needs.

This report from the Center for American Progress provides an excellent explanation of the mechanisms of this shift in spending from the employer to the employee. Unfortunately, their neoliberal recommendations for correcting this problem are grossly inadequate. Not only would they leave in place the otherwise highly flawed model of financing health care through a multitude of private health plans, they would merely increase transparency of this shift that has been taking place, while increasing administrative complexity by requiring employers to return half of the savings to the employee, and, yes, they would throw in three free primary care visits per year – big deal!

This problem is serious and requires truly transformative change. Instead of allowing employers to continue to implement their current agenda of introducing further relatively opaque changes that will compound the deterioration of the effectiveness of their health plans, we should terminate these plans and replace them with a far more efficient, equitable, and effective single payer national health program.

A single payer system would end employers’ concerns about excessive increases in health care costs, not to mention relieving them altogether from the need to maintain a health benefit program. Much more importantly, it would ensure truly affordable, reasonably comprehensive health care benefits not only for all of their employees, but for everyone else in the nation as well.

Tsung-Mei Cheng on the success of Taiwan’s single payer system

Reflections On The 20th Anniversary Of Taiwan’s Single-Payer National Health Insurance System

By Tsung-Mei Cheng
Health Affairs, March 2015

Abstract

On its twentieth anniversary, Taiwan’s National Health Insurance (NHI) stands out as a high-performing single-payer national health insurance system that provides universal health coverage to Taiwan’s 23.4 million residents based on egalitarian ethical principles. The system has encountered myriad challenges over the years, including serious financial deficits. Taiwan’s government managed those crises through successive policy adjustments and reforms. Taiwan’s NHI continues to enjoy high public satisfaction and delivers affordable modern health care to all Taiwanese without the waiting times in single-payer systems such as those in England and Canada. It faces challenges, including balancing the system’s budget, improving the quality of health care, and achieving greater cost-effectiveness. However, Taiwan’s experience with the NHI shows that a single-payer approach can work and control health care costs effectively. There are lessons for the United States in how to expand coverage rapidly, manage incremental adjustments to the health system, and achieve freedom of choice.

Lessons Learned

The most important lesson of Taiwan’s experience is that the single-payer approach can offer all citizens timely and affordable access to needed health care on equal terms, regardless of the patient’s social, economic, and health status; sex; age; place of residence; and employment status.

A second lesson is that a single-payer model such as Taiwan’s can control costs effectively. It is administratively simple and inexpensive and is the ideal platform for a powerful health IT system. It also facilitates global budgeting, if that is the only way to keep health spending in line with the growth of GDP.

A third lesson is the importance of investing heavily, up front, in a modern IT infrastructure. A modern IT system such as Taiwan’s allows the government to have information about health utilization and spending in almost real time.

Fourth, Taiwan’s case illustrates that health policy makers should not miss windows of opportunity for major health reform. Enabling factors include rapid economic growth, which makes it easier to redistribute resources; strong popular demand for reform; strong political leadership; a broad social and political consensus on the ethical principles that guide the health system; and the availability of a cadre of competent civil servants motivated and able to implement reform.

Lessons For The United States

Taiwan’s experience demonstrates that with competence and goodwill, the challenge of adding a large influx of newly insured citizens can be met. Health systems appear to be adaptive, and the case of Taiwan illustrates that incremental improvements on reform are possible.

Taiwan’s experience also might induce Americans to think more deeply about the term freedom of choice. In health care, freedom of choice could mean choice among health insurance carriers and health insurance contracts, choice among health care providers, or both. For Taiwan’s citizens, freedom of choice among providers of health care trumped freedom of choice among insurance carriers and contracts. These citizens’ high satisfaction with their health system suggests that they still endorse that choice. By contrast, in the United States freedom of choice among insurance carriers and products ranks above freedom of choice among health care providers, which often is limited to narrow networks of providers.

A growing body of literature has shown that by international standards, enormous human resources are used in the United States to facilitate choice among insurers and insurance products, process claims, and annually negotiate a payment system that results in rampant and bewildering price discrimination. Relative to the less complex health systems elsewhere in the industrialized world, the US system is a poor platform for the effective use of modern health IT.

According to a recent report by the Institute of Medicine, the US system has excessive administrative costs that in 2009 amounted to $190 billion. That is more than it would cost to attain true universal health care in the United States.

It is not this author’s role to prescribe what Americans should or should not do in regard to freedom of choice. But it is appropriate to invite readers to think more deeply about the relative benefits and costs of their choices. It is remarkable that in cross-national surveys, Americans have consistently given their health care delivery system relatively high marks, but their health system relatively poor ones.

Tsung-Mei Cheng is a health policy research analyst at the Woodrow Wilson School of Public and International Affairs, Princeton University, in Princeton, New Jersey.

http://content.healthaffairs.org/content/34/3/502.abstract

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Comment:

By Don McCanne, MD

The people of the United States have continued to watch our health care spending increase far beyond that of all other nations. We have watched the quality of our insurance coverage deteriorate as insurers take away our choices of physicians and hospitals and shift more costs to those with health care needs, often causing the very financial hardships that health insurance should be preventing. And we have continued to tolerate leaving tens of millions uninsured.

For the past generation we also have been observing the natural experiment in single payer healthcare financing taking place in Taiwan – Taiwan serving as the experimental subject and the United States as the control. As Tsung-Mei Cheng explains in this Health Affairs article, it has been a spectacular success for Taiwan. Had we adopted a similar program twenty years ago, today everyone would be covered, no one would face financial hardship because of medical bills, we would have freedom of choice of our physicians and hospitals, we would have eliminated much of our profound administrative waste, and our total national health expenditures would have followed a lower trajectory and thus would be much less than they are today.

What is it about American exceptionalism? In our stubbornness, we are going to continue our feeble search for policy solutions to our intolerable deficiencies and inequities in health care, when we have before us one of the nearest to perfect natural experiments ever completed – in precisely the reform that we need. By the definition, “much better than average,” exceptional we are not. Or by the definition, “deviating from the norm,” we should have no pride in either our health care system or in our obstinate refusal to apply proven health policies that would inject much needed remedies into our sick system.

At our PNHP meetings and in the health policy literature, Tsung-Mei Cheng has provided us with an abundance of observations and data that should illuminate for us a clear path forward for reform. We just have to make good use of her contributions. We can begin by sharing this Health Affairs article with others who care about the future of our health care system.

Medical Students Step into Advocacy Roles

By Kim Krisberg
AAMC Reporter, February 2015

In early December, hundreds of medical students at schools nationwide donned their white coats and came together in protest after grand juries in Ferguson, Mo., and New York decided not to indict police officers in the deaths of unarmed black men. From Howard University College of Medicine in Washington, D.C., to the University of California, San Francisco, School of Medicine, medical students organized white coat “die-ins,” lying on the sidewalks and floors of their campuses en masse with signs that read “White Coats for Black Lives.”

“We believe health care is a human right and see health as fundamental in the exercise of all other rights,” said James Besante, a fourth-year student at the University of New Mexico School of Medicine. “When we say black lives matter, we mean that our fellow medical students and patients and families matter. These are our classmates; these are our patients.”

Besante is a student representative on the Board of Directors of Physicians for a National Health Program, whose student members and chapters took a leading role in organizing and promoting the white coat die-ins. In addition to protesting the jury decisions, Besante said the protests were designed to jumpstart conversations about institutional racism and bias. In a news release, the organization said, “We as medical students feel that this is an important time for medical institutions to respond to the violence and race-related trauma that affect our communities and the patients we serve.”

December’s protests are the most recent example of medical students stepping into the advocacy roles. For some time, medical students have used their budding expertise to head to the offices of elected officials to discuss issues like access to care, student debt, or climate change. And while being a public advocate certainly is not a requirement for physicians, “you’re a leader whether you know it or not or want it or not,” said Doug Skrzyniarz, MHSA, associate vice president of government affairs and an adjunct professor at Wayne State University School of Medicine in Detroit.

“When our students go to Lansing or Washington, and have their white coats on, they have a voice with legislators that other professionals, quite frankly, just don’t have,” Skrzyniarz said. “You’ll be treating thousands of people in your community, and in that role, people will look to you. Legislators know that.”

Skrzyniarz directs and teaches the school’s Medicine and Political Action in the Community elective, which provides information on health policy, advocacy, and leadership development to first- and second-year medical students. When the course began in 2009, there were 20 students enrolled; now there are 120. Skryzniarz said one of the course’s most popular activities is its lobby day during which students travel to Lansing and advocate directly to state legislators.

“Medical students have an extremely busy schedule, and so I try to avoid competing with the main part of their curriculum,” he said. “At the end of the day, I want them to develop the confidence to continue being advocates in the future.”

From an advocacy perspective, the authenticity of the medical student experience can be particularly compelling for policymakers, explained Atul Grover, M.D., Ph.D., AAMC chief public policy officer. “Students can help explain to members of Congress and their staff what [key issues] mean for their future patients,” he said. “It’s really about trying to break through some of the noise.”

Grover noted that while the AAMC typically has organized more grasstops advocacy by engaging deans and CEOs, the association recently launched a new grassroots effort to mobilize student voices in support of robust funding for graduate medical education (GME). Students who visit the new website, www.aamcaction.org, can sign up to receive issue updates and learn about opportunities to engage in direct advocacy with lawmakers. While the initial focus is GME funding, the AAMC hopes to bring the campaign’s voice to other topics, such as medical research funding.

At the American Medical Student Association (AMSA), advocacy comes with the territory, whether in support of medical education or nontraditional medical issues such as climate change, which scientists predict will have serious human health impacts. The association has about 38,000 members and more than 250 affiliated chapters at medical schools nationwide. Britani Kessler, D.O., the association’s national president, remembers her first AMSA convention in 2006 when she joined hundreds of medical students as they rallied on Capitol Hill for the reauthorization of the Children’s Health Insurance Program. The experience inspired her to continue speaking out when she began her medical education at Nova Southeastern University in Ft. Lauderdale, Fla., where she served as president of the AMSA chapter.

Kessler noted that effective advocacy is not confined to legislative offices. For example, her AMSA chapter helped organize a local health fair for the area’s large community of migrant farm workers, who face substantial barriers to care. “Bringing health care to your community—that’s a form of advocacy,” said Kessler, who will begin a pediatrics residency this summer.

Social determinants of health, such as access to regular care, are a common theme in medical student advocacy. In Health and Human Rights, an elective course at Tulane University School of Medicine, the goal is to remind students that biology is only one factor that influences a patient’s health, said Daniel Bausch, M.D., who developed and teaches the course. The curriculum requires student teams to present on a relevant topic. The only requirement is that teams also suggest policy solutions to the problem, noted Bausch, an associate professor in the Department of Tropical Medicine. Presentations have covered topics like human trafficking in India and prison conditions in Louisiana. Bausch expects police-community relations to be a popular topic in the coming year.

“It’s not about what’s right or wrong,” he said. “It’s about getting students to look inward and find what’s important to them and giving them some tools and inspiration to act externally.”

External action is central for medical students involved with Physicians for a National Health Program and its 35 student chapters. At the national level, the organization’s annual summit educates attendees on a single-payer health care system, offering workshops on topics such as advocacy, public speaking, and letter writing. According to Besante, students want to know more about policy and how to influence the process. “Students want to take an active role in the health justice movement,” he said. “The medical profession has lost a lot of ground in protecting the physician-patient relationship. We are the future of medicine, and we want to make it work not only for our patients, but also for ourselves.”

Aaron Fox, M.D., M.S., an assistant professor at Albert Einstein College of Medicine, said that as medical training focuses more on specialization, “we’re losing the idea that you can have a broader impact on health and wellness.” Fox directs the Research-Based Health Activism course and co-directs another course, Health Disparities: From Awareness to Action. During the research-based elective about policy and advocacy, students must develop a research project and a plan to disseminate the project’s findings to community stakeholders. In a 2006 Journal of General Internal Medicine article about the course, authors found the curriculum “represents a multidisciplinary model for developing physician activists.”

While Fox said he does not believe a majority of medical students are interested in advocacy work, “there is a small majority who do want these skills and they can have a large impact.” He added that students and physicians can be effective advocates without being health policy experts.

“I think what matters most are the stories,” Fox said. “If [students] can articulate how the social determinants of health, like poverty or racism, impact the health of individuals, they can be very effective.”

Kim Krisberg has written this article as a special to the Reporter.

https://www.aamc.org/newsroom/reporter/february2015/426086/advocacy.html

Vermont Workers’ Center says single payer possible by 2017

By Erin Mansfield
VTDigger.org, March 2, 2015

The Vermont Workers’ Center and the National Economic and Social Rights Initiative say single payer health care could still be on the table.

Building off the financing plan that Gov. Peter Shumlin used in deciding not to proceed with single payer, the study, published in February, says the state can use progressive tax structures to provide a universal program by 2017.

The plan would give medical, dental and vision coverage for all Vermont residents, but would exclude those who work in Vermont but commute from other states.

The plan assumes the same 6 percent out-of-pocket costs as Shumlin’s report from Dec. 30, but proposes progressive income taxes, a progressive payroll tax on employers, taxing capital gains as income, and liquefying the assets of Blue Cross Blue Shield of Vermont into a reserve fund.

Ellen Schwartz, president of the Vermont Workers’ Center, said her organization began developing the alternative plan in December, immediately after Shumlin released the details that led him to put single payer on the back burner earlier that month.

Schwartz said the two organizations’ plan is “more equitable” than the governor’s because the organizations recommend a graduated payroll tax — starting at 4.1 percent for small companies and maxing out around 20 percent for the government and employers with 1,000 or more workers.

“One of the reasons the governor said (single payer) wouldn’t work for small businesses is he had an 11.5 percent flat payroll tax on all businesses,” Schwartz said, adding that her organization “wanted something that wouldn’t harm small businesses.”

Anja Rudiger, program director for the National Economic and Social Rights Initiative, said her organization considered the governor’s plan inequitable.

“We focus on equity in this report because that’s what we saw was the biggest shortfall in the governor’s report,” Rudiger said. “When we took a look at his proposal, we were actually not surprised.”

Similar to the governor’s plan, the organizations recommend a sliding scale tax on earned income of up to 9.5 percent. However, the groups call the governor’s plan to cap the income tax when a household reaches $27,500 in payments “regressive.” They recommend that all income above 523 percent of the federal poverty level be subject to the 9.5 percent tax.

The study recommends implementing a wage ratio aimed at eliminating the incentive for companies to lower wages as a way to lower payroll tax obligations, and includes a Medicare wrap-around to bring Medicare patients’ coverage up to the same level as Green Mountain Care.

Additionally, the study proposes repealing the law that allows high-income Vermonters to pay a lower percentage in taxes on capital gains than on earned income.

The study says repealing the capital gains tax exclusion would have generated $17.3 million in revenue in fiscal year 2013 and estimates that the state lost $7.8 million in 2012 from high-income households that benefit from the capital gains tax exclusion.

Jim Harrison, president of the Vermont Retail Association, said his group “appreciates” a graduated approach to the payroll tax that takes small businesses into account. However, the group does not have a position on the study in general.

“We would be concerned for what the impact would be on the economy at the higher levels,” Harrison said of the nearly 20 percent payroll tax on employers with more than 1,000 workers. “There could very well be some impacts.”

Harrison estimated that the employer’s share of federal payroll taxes for Social Security and Medicare is around 7.7 percent; he said payroll taxes could cost around 9.5 percent for Vermont employers when you include what businesses spend on workers’ compensation and unemployment insurance.

“Payroll cost is often times the biggest single cost of every business,” Harrison said. “It would be very concerning if (large businesses) chose not to stay in the state.”

Betsy Bishop, president of the Vermont Chamber of Commerce, said the profit margins on her members are too thin to pass any more payroll taxes in the Legislature.

“We have a real concern about raising a payroll tax, using that as a funding source for any long-term state need,” Bishop said. “In our view, taxing payroll is in essence suppressing wages, and there’s no other place for it to come out than on that line item.”

To address the employer cost of workers’ compensation insurance, the organizations recommend phasing the costs into Green Mountain Care, but do not outline a period of time or method for doing so.

The study recommends integrating workers’ compensation into Green Mountain Care through a tax, saying that it would “streamline healthcare access for workers and would also reduce redundant administration.”

The organizations also recommend dissolving Blue Cross Blue Shield of Vermont and turning the Green Mountain Care Board into a public corporation. The state would then keep Blue Cross Blue Shield’s estimated $132 million in surplus, based on figures from 2013, to fund a reserve fund for Green Mountain Care.

The study says the $132 million figure is almost as much as the state needs for a reserve fund, and says the governor over budgeted when he planned a $200 million reserve fund in his Dec. 30 financing plan.

According to the study, Vermont should still work to obtain a federal Medicare and TRICARE waiver, negotiate prices with pharmaceutical companies, set rates for hospitals, include long-term care, and work toward a program with no out-of-pocket costs.

The groups say the plan can be implemented with a $362 million surplus by 2017. Schwartz said the Vermont Workers’ Center wants the Legislature to pass the plan this year.

Vermont Workers’ Center says single payer possible by 2017

The Obamacare Challenge We Need? Improved, Expanded Medicare for All

How is it possible that in 2015 one of the richest countries in the world still does not guarantee every resident the right to health care?

By Robert Zarr, M.D.
Common Dreams, March 4, 2015

As a primary care pediatrician who sees children of low-income families in Washington, D.C., I am reminded every day of the vulnerability of our children’s health to the ill-informed whims of our lawmakers and courts.

Those children will be on my mind as I gather with others outside the Supreme Court today.

Just yesterday, I saw my 16-year-old patient Mary, who suffers from Down’s syndrome and congenital heart disease, both conditions with lifelong disabilities. I have known Mary for the last 13 years.

Her family has been through some very rough times. I still distinctly remember listening to Mary’s mother tell me that her family was homeless, just a few years ago. Mary’s mother was in tears. They had no place to live, two children to feed, and both parents were unemployed.

To the best of my ability, I reassured Mary’s mother that despite hard times for her and her family, she would still have me as her child’s pediatrician, and Medicaid for her child’s health insurance.

At that moment I reminded myself that it takes a societal commitment to public institutions like Medicaid and community health centers to provide care to millions of Americans like Mary who would otherwise go without.

Yet when Mary turns 21, she might not qualify for Medicaid. Depending on what state Mary and her family live in, she may or may not have access to the doctors she will need for the rest of her life.

Children and their families need stability in their lives, and yet health insurance in our country remains prone to great instability and harsh surprises. Mary’s case is by no means unique.

How is it possible that in 2015 one of the richest countries in the world still does not guarantee every resident the right to health care? This question would not be necessary if we had a health care system worthy of the name – single-payer national health insurance, or an improved and expanded Medicare for All.

Today, at the Supreme Court, the latest assault on the highly convoluted, corporate-friendly Affordable Care Act is unfolding. The justices will be hearing oral arguments in the case of King v. Burwell. The case is a legal challenge to a small piece of the ACA that, if upheld, would have potentially big consequences.

At issue is whether the ACA’s language allows the federal government to provide subsidies to people who buy health insurance in states that didn’t set up their own “marketplaces,” i.e. in states that rely on the federally run marketplace, HealthCare.gov, in whole or in part, to serve their populations.

Only 13 states (plus the District of Columbia) set up their own state-managed marketplaces. Thirty-four states declined to do so; three others turned to the federal marketplace when their own IT systems failed.

King and his fellow plaintiffs argue that a subsection of the ACA that says subsidies should flow to people “through an exchange established by the state” should be interpreted to mean that only people who live in those 13 states with state-managed marketplaces should be entitled to subsidies. They say people who buy through the federally run marketplaces should not get subsidies.

If the Supreme Court upholds the King challenge, the health and financial harms to our nation’s patients will be substantial.

For example, the Urban Institute estimates 9.3 million people in 34 states would lose their subsidies within the year, making their premiums largely unaffordable. An estimated 8.2 million would consequently join the ranks of the uninsured.

We know that lack of insurance means a much higher risk of death. One landmark study suggests that if an additional 8 million people lose health insurance coverage, we’ll witness an estimated 8,000 “excess deaths” annually.

So here is the picture: nine very well-insured Supreme Court justices are literally holding the lives of many thousands in their hands. Their ruling is expected in June.

But that’s not the half of it. Keep in mind that, by the same calculus, under the Affordable Care Act, some 30,000 preventable deaths are occurring each year due to the law’s lack of coverage of 30 million people. And about 24 million of those would still be uninsured even if all the states had accepted the Medicaid expansion.

Regardless of how the court rules, the sad reality is that the ACA won’t be able to achieve universal coverage. It won’t make care affordable or protect people from medical bankruptcy. Nor will it be able to control costs.

The ACA is fundamentally flawed in these respects because, by design, it perpetuates the central role of the private insurance industry and other corporate and for-profit interests (e.g. Big Pharma) in U.S. health care.

In contrast, a single-payer system – an improved Medicare for All – would achieve all three goals mentioned above: truly universal/comprehensive/lifelong care, affordability, and effective cost control.

It would be legally robust and simple to administer, saving approximately $400 billion annually by slashing the administrative bloat in our private-insurance-based system. That money would be redirected to clinical care, allowing us to eliminate all copays and deductibles.

But single-payer national health insurance is not just about financing health care. It goes much deeper than that. It is the first most important step we can take in this country to level the playing field between the rich and poor, the sick and healthy, the young and the aged, and among all colors of the human race.

Single payer would restore a sense of ownership in both those receiving and providing health care, by democratizing our health care system, rather than leaving it in the hands of politicians and vested interests who hold their purse strings.

It is time that we take back our health care system, and run it in a fair, rational way to provide quality comprehensive lifelong health care to every American. Our children and their families have no time to lose.

Robert Zarr, M.D., M.P.H., is president of Physicians for a National Health Program.

This work is licensed under a Creative Commons Attribution-Share Alike 3.0 License

http://commondreams.org/views/2015/03/04/obamacare-challenge-we-need-improved-expanded-medicare-all

PNHP release on King v. Burwell

Health law’s complexity invites attack, even as it fails to cure ailment: doctors group

Physicians for a National Health Program (PNHP), March 3, 2015

King v. Burwell shows how Affordable Care Act’s corporate-inspired, convoluted structure makes it an easy target for opponents

Latest legal challenge threatens to add more than 8 million people to the ranks of the tens of millions who are currently uninsured, leading to an additional 8,000 ‘excess deaths’ annually linked to lack of insurance

‘This case is yet another reason to swiftly move beyond the failing ACA to a simpler, publicly financed, improved-Medicare-for-All system that would cover everyone, make care affordable, and control costs,’ says president of single-payer physicians’ group

FOR IMMEDIATE RELEASE
March 3, 2015

Contact:
Mark Almberg, PNHP communications director, (312) 782-6006, mark@pnhp.org

The following statement was released today by leaders of Physicians for a National Health Program, a research and educational organization of 19,000 doctors who support single-payer national health insurance, or “an improved Medicare for all.”

This week’s arguments before the Supreme Court in the case of King v. Burwell demonstrate once again how the Affordable Care Act’s administrative complexity and flaws – largely reflecting its accommodation to the private health insurance industry and other corporate, profit-oriented interests in U.S. health care – make it vulnerable to legal attacks by its opponents.

The ACA clearly lacks the simplicity and legal robustness that a single-payer plan would have. Single payer would be simple: everyone in the U.S. would be covered for all medically necessary care in a single program financed by equitable taxes.

If the court upholds King and his fellow plaintiffs’ challenge to premium subsidies in over 30 states, the health and financial harms to our patients will be considerable. By some estimates, more than 8 million people will quickly lose insurance coverage, increasing the intolerable suffering we already see today.

One consequence of this loss of coverage would be an additional 8,000 “excess deaths” each year – deaths linked to lack of insurance. That figure is over and above the estimated 30,000 annual preventable deaths that are currently occurring under the ACA due to its having left 30 million people uninsured. This is completely unacceptable.

Regardless of how the court rules, the unfortunate reality is that the ACA won’t be able achieve universal coverage. It won’t make care affordable or protect people from medical bankruptcy. Nor will it be able to control costs.

The ACA is fundamentally flawed in these respects because, by design, it perpetuates the central role of the private insurance industry and other corporate and for-profit interests (e.g. Big Pharma) in U.S. health care.

In contrast, a single-payer system – an improved Medicare for All – would achieve truly universal care, affordability, and effective cost control. It would be simple to administer, saving approximately $400 billion annually by slashing the administrative bloat in our private-insurance-based system. That money would be redirected to clinical care. Copays and deductibles would be eliminated.

A growing section of the insured population is already facing very high copays, deductibles and coinsurance, deterring them from seeking needed care. This trend is toxic and unsustainable.

Physicians can’t wait for an effective remedy any longer, nor can our patients. The stakes are too high.

Dr. Robert Zarr, a Washington, D.C.-based pediatrician who will be in front of the Supreme Court building on Wednesday at 10 a.m. Eastern, is president of Physicians for a National Health Program.

Zarr said today: “The King v. Burwell case is yet another reason to swiftly move beyond the failing ACA to a simpler, publicly financed, improved-Medicare-for-All system. Such a system would cover everyone, make care affordable, and control costs. Based on our experience with the Medicare program and the experience of other nations, we know it will work. It’s the only moral and fiscally responsible thing to do.”

https://www.pnhp.org/news/2015/march/health-law’s-complexity-invites-attack-even-as-it-fails-to-cure-ailment-doctors-grou

****

Comment:

By Don McCanne, MD

The Supreme Court case of King v. Burwell is appropriately receiving extensive coverage in the media since the decision of the Court has the potential to cause perhaps 8 million individuals to lose their health insurance, plus it would adversely impact health insurance markets through spiraling premiums due to adverse selection.

Even though a decision prohibiting subsidies in federally-administered state exchanges would be disastrous, the hype over this case obscures the much more intolerable disaster of perpetuating the inequities and injustices of our current health care financing system. The consequences of continued inaction on single payer reform constitutes proportionately a much greater disaster, regardless of the outcome of King v. Burwell. Over 30 million will still remain uninsured, tens of millions will experience financial hardship in the face of medical need, perhaps even personal bankruptcy, while private insurers will continue to take away our choices of physicians and other health care professionals, take away our choices of hospitals, and take away our choices of pharmaceuticals that our physicians say we should have.

Merriam-Webster includes as two of the definitions of “state”: “a politically organized body of people usually occupying a definite territory; especially one that is sovereign,” and “the operations or concerns of the government of a country.” It would be tragic if the court ruled that this silly argument on the meaning of “state” had enough substance to allow a few ideologically-driven Supreme Court justices to deprive 8 million people of insurance coverage. But it would be a much greater tragedy if we allow this to divert us from accomplishing the imperative: establishing a single payer national health program – an improved Medicare for all.

Health law’s complexity invites attack, even as it fails to cure ailment: doctors group

King v. Burwell shows how Affordable Care Act’s corporate-inspired, convoluted structure makes it an easy target for opponents

Latest legal challenge threatens to add more than 8 million people to the ranks of the tens of millions who are currently uninsured, leading to an additional 8,000 ‘excess deaths’ annually linked to lack of insurance

‘This case is yet another reason to swiftly move beyond the failing ACA to a simpler, publicly financed, improved-Medicare-for-All system that would cover everyone, make care affordable, and control costs,’ says president of single-payer physicians’ group

FOR IMMEDIATE RELEASE
March 3, 2015

Contact:
Mark Almberg, PNHP communications director, (312) 782-6006, mark@pnhp.org

The following statement was released today by leaders of Physicians for a National Health Program, a research and educational organization of 19,000 doctors who support single-payer national health insurance, or “an improved Medicare for all.”

This week’s arguments before the Supreme Court in the case of King v. Burwell demonstrate once again how the Affordable Care Act’s administrative complexity and flaws – largely reflecting its accommodation to the private health insurance industry and other corporate, profit-oriented interests in U.S. health care – make it vulnerable to legal attacks by its opponents.

The ACA clearly lacks the simplicity and legal robustness that a single-payer plan would have. Single payer would be simple: everyone in the U.S. would be covered for all medically necessary care in a single program financed by equitable taxes.

If the court upholds King and his fellow plaintiffs’ challenge to premium subsidies in over 30 states, the health and financial harms to our patients will be considerable. By some estimates, more than 8 million people will quickly lose insurance coverage, increasing the intolerable suffering we already see today.

One consequence of this loss of coverage would be an additional 8,000 “excess deaths” each year – deaths linked to lack of insurance. That figure is over and above the estimated 30,000 annual preventable deaths that are currently occurring under the ACA due to its having left 30 million people uninsured. This is completely unacceptable.

Regardless of how the court rules, the unfortunate reality is that the ACA won’t be able achieve universal coverage. It won’t make care affordable or protect people from medical bankruptcy. Nor will it be able to control costs.

The ACA is fundamentally flawed in these respects because, by design, it perpetuates the central role of the private insurance industry and other corporate and for-profit interests (e.g. Big Pharma) in U.S. health care.

In contrast, a single-payer system – an improved Medicare for All – would achieve truly universal care, affordability, and effective cost control. It would be simple to administer, saving approximately $400 billion annually by slashing the administrative bloat in our private-insurance-based system. That money would be redirected to clinical care. Copays and deductibles would be eliminated.

A growing section of the insured population is already facing very high copays, deductibles and coinsurance, deterring them from seeking needed care. This trend is toxic and unsustainable.

Physicians can’t wait for an effective remedy any longer, nor can our patients. The stakes are too high.

Dr. Robert Zarr, a Washington, D.C.-based pediatrician who will be in front of the Supreme Court building on Wednesday at 10 a.m. Eastern, is president of Physicians for a National Health Program.

Zarr said today: “The King v. Burwell case is yet another reason to swiftly move beyond the failing ACA to a simpler, publicly financed, improved-Medicare-for-All system. Such a system would cover everyone, make care affordable, and control costs. Based on our experience with the Medicare program and the experience of other nations, we know it will work. It’s the only moral and fiscally responsible thing to do.”