PNHP

Senate hearing: Learning from other nations’ health systems

Senate hearing: Learning from other nations’ health systems

Hearing convened by Sen. Bernie Sanders

On March 11, Sen. Bernie Sanders of Vermont chaired a Senate subcommittee hearing on what the health care system in the United States can learn from other countries, particularly Canada, Taiwan, Denmark and France. The following 6-minute video features the testimony of Dr. Danielle Martin, comparing the U.S. and Canadian systems while dispelling myths about health care in Canada.

For a detailed account of the proceedings, including direct links to the full video and to the individual, written statements presented there, see this Quote of the Day post by Dr. Don McCanne, PNHP’s senior health policy fellow.

A four-minute highlight video of the hearing, including all of the panelists from this extraordinary (and to our knowledge, historically unprecedented) session, is available here.

For how the testimony of the Canadian physician, Dr. Danielle Martin, has been received in Canada, click here.

Senate panel examines health systems in Canada, Taiwan, Denmark and France

By Deborah Schumann, M.D.

WASHINGTON – Sen. Bernie Sanders, I-Vt., chairman of the Senate Subcommittee on Primary Health and Aging of the Health, Education, Labor and Pensions Committee, held a hearing Tuesday to gain insight into the health care systems of four other countries, all of which view health care as a human right and have achieved near-universal coverage and access to care for their citizens. 

The senator opened the session with a comparison of the U.S. system with those of other industrialized nations. He noted the U.S. system is characterized by: 

* Double per-capita spending

* Third-world-like access for many in the U.S.

* Financial barriers and bankruptcy consequences related to health care

* 45,000 deaths/year linked to lack of insurance

* Poor efficiency: U.S. ranked 46th out of 48 countries

* Poor outcomes, e.g. of 34 OECD countries, U.S. is 26th in life expectancy

* Drugs are so expensive that many patients forgo treatment

Ranking subcommittee member Sen. Richard Burr, R-N.C., then weighed in, saying that Obamacare is going in the “wrong direction” and that Americans view it unfavorably. He stated that Medicaid is “unsustainable” and is not accepted by 40 percent of physicians. Furthermore, he stated that premiums in the individual market have risen by 41 percent since Obamacare passed. His proposal for improving the system is to increase “individual choice.”

Then the invited witnesses delivered their testimony. 

Tsung-Mei Cheng, L.L.B., M.A., health policy analyst at the Woodrow Wilson School of Public and International Affairs at Princeton University, summarized the features of a single-payer health care system: 

* Single payer does not equal socialized medicine

* Equity of access; access not based on ability to pay

* Equity of payment to providers

* Financing based on ability to pay

* Competition based on quality, not price

* Patients have choice of providers

* No job-lock; not based on employment

* Total spending is easy to control

* Electronic billing leads to substantial savings

* Data capture is facilitated

* Public satisfaction is generally high as demonstrated in other countries

* Medicare (the U.S. single-payer program) is popular

France 

Victor Rodwin, Ph.D., M.P.H., professor of health policy and management at the Robert F. Wagner School of Public Service at New York University, spoke about the French system. It is not a socialized medicine system like Cuba or the U.K., but rather a publicly financed, privately delivered system with supplementary private insurance to cover co-pays. Patients have free choice of providers whether in public or private hospitals. The French people are proud of their system which is based on liberté, égalité and fraternité. There are no gatekeepers or networks and everyone has access to care. The French rate of “avoidable mortality” [e.g. infant and maternal mortality is 55-60 percent that of the U.S., according to The Commonwealth Fund, 2012] France controls its costs through bulk purchasing, price controls and low administration costs. 

Taiwan

Ching-Chuan Yeh, M.D., former Taiwanese minister of health and currently professor at Tzu-Chi University in Taiwan, said that “having a single-payer system is the main reason for our efficient services and also controls prices.” With a national fee schedule, providers compete on the basis of quality. Like France, Taiwan has public financing and private delivery of care which includes both not-for-profit as well as for-profit centers. All payments are made electronically keeping administrative costs down. Dr. Yeh stated that they have achieved 99.6 percent coverage and that there is not much of a problem of waiting lines for services. The country has seen improvements in both longevity and infant mortality since implementing the system in 1995, and they are on the road to a universal, individualized electronic medical record. 

Denmark

Jakob Kjellberg, M.Sc., professor and program director at the KORA-Danish Institute for Local and Regional Government Research in Copenhagen, described the Danish system as “comprehensive and universal.” Danes choose a GP and get referrals from her or him for specialty care. They have full choice of providers including hospitals. If wait-lines are too long, they have the option of going to private hospitals or out of the country. Overall administrative costs are 4.3 percent [i.e. far less than the U.S. system as a whole, which is 15-30 percent by various estimates, but similar to U.S. Medicare’s percentage].

Canada

Danielle Martin, M.D., M.P.P. , vice president for medical affairs and health system solutions at Women’s College Hospital, Toronto, spoke about Canada’s single-payer system. She emphasized that in spite of some shortcomings (wait-times for elective services), the Canadian people are firmly in favor of Canada’s Medicare. There is zero political will in Canada to move to a market-based, for-profit, fragmented system like we have here. She said even conservative politicians don’t oppose Canada’s Medicare, for fear of committing political suicide. The Canadian system is centrally financed but administered by the provinces. It is based on:

* Equity and medical need

* Central oversight for issues e.g. more primary care training

* Low administrative overhead

Canada achieves better outcomes than the U.S. at two-thirds the per capita cost of the U.S. market system. Urgent care is always available.

Speakers for ‘market-based health care’ 

Sally C. Pipes, CEO of the Pacific Research Institute in San Francisco, and David Hogberg, David Hogberg, Ph.D., health care policy analyst at the National Center for Public Policy Research in Washington, had been invited by Sen. Burr to speak in favor of a market-based health care system such as we have in the U.S. Ms. Pipes testified that she had emigrated from Canada to San Francisco. She told the story of her mother who waited several months in a queue, was finally taken care of but died two weeks later. Her opinion was that the Canadian system “would not be suitable for the U.S.” because she thinks that waiting weeks to see a specialist won’t work here. Her punchlines were that 42,000 Canadians come to the U.S. for care every year and that one Canadian top official came to the U.S. for cardiac surgery. Ms. Pipes made clear that waiting too long is bad for your health. 

Mr. Hogberg spoke in favor of “removing the health care system from control of politicians.” He pointed out that the sick are few in number and not political. In his opinion, “patients overuse health care.” He worried about the fact that “France doesn’t pay for pharmaceuticals that are incrementally better.” He reiterated that French co-insurance picks up out-of-pocket expenses for patients while the government controls 77 percent of health care expenditures. His opinion is that the U.S. should look at other countries’ systems in order to discover what policies to avoid and study other competitive markets like auto insurance, food and clothing.

Sen. Sanders asked Mr. Hogberg if we should get rid of Medicare. He did not answer yes or no, but said it is a “moot point.”

Sen. Sanders asked Dr. Rodwin why U.S. health care spending is so high, especially in light of relatively poor outcomes. The answer is that prices are “much higher because we have no price control.” He added, “The free market system doesn’t exist anywhere in health care.”

Sen. Burr asked Dr. Martin why doctors are exiting the public system in Canada. She replied that he had misunderstood her remarks and “that there are no doctors exiting the public system in Canada.” With regard to excessive wait times in Canada, she said that the country has a commission to address the issue and that “the solution is not to move away from our single-payer system toward a multi-payer system.” She said that having a single payer allows the wait-time commission to appropriately address the issue. “Sometimes it is not about the amount of resources, but on how you organize people,” adding, “And this organization should be based on criteria that benefit everyone, not just those who can afford to pay.”

Several other subcommittee members made comments or asked questions.

Sen. Mike Enzi, R-Wy., opined that “the Affordable Care Act was designed to fail so that we would go to single-payer health care.” But he feels that the debacle of the exchanges has convinced Americans that government can’t succeed in universal health care. He didn’t ask any questions.

Sen. Pat Roberts, R-Kan., asked Dr. Martin about how the Canadian system makes changes, e.g. Can the prime minister make changes? She replied that “the public commitment to our single-payer Medicare system is so strong that for a prime minister of any stripe to try and alter that or undermine it in any way would be political suicide.” Sen. Roberts replied, “I got your message.”

Sen. Sanders followed up by saying, “Canadians understand that a system that guarantees health care for all their people in a cost effective way is the way that they want to stay.”

Sen. Chris Murphy, D-Conn., followed up on the wait-time/convenience discussion with the opinion that convenience does not necessarily equal quality. He said that the other two important aspects of quality are outcomes and cost control. 

There was quite a bit of discussion about pharmaceuticals:

* France, Taiwan and Denmark provide drug coverage in their national health care financing systems

* Canada, according to Dr. Martin, has realized that they made a mistake in not including drug coverage in Canadian Medicare. She said that Canada has an estimated 10 percent non-compliance. [the comparable figure in the U.S. is 25 percent]

* Dr. Cheng believes that high drug costs, partially fueled by R&D of new products, is “pricing people out of the system”

* Both Taiwan and Denmark have out-of-pocket limits on drug spending ($1,000/yr. and $600/yr., respectively.

Dr. Cheng concluded the hearing following up on Sen. Murphy’s remarks and responding to a question from Sen. Burr by saying: “Yes, the United States does fund a whole lot of R&D in pharmaceutical and other device innovations. But in so doing we are helping to make the American health care system that much more expensive; in fact so expensive that we are pricing people out of the health care altogether . … In single-payer systems, the government can set aside money for R&D.” He added: “A very serious issue in U.S. health care is overuse. An Institute of Medicine book states that about one-third of U.S. health care is waste. Unnecessary services are about one-third of that waste.”

A video of the hearing and links to statements of all participants can be found here: http://www.help.senate.gov//hearings/hearing/?id=8acab996-5056-a032-522e… 

A 4-minute YouTube video of clips from the hearing can be viewed here: https://www.youtube.com/watch?v=9WdqtPLRc1A 

Dr. Deborah Schumann practiced ophthalmology for 25 years in a variety of clinical settings. Since retiring from practice she has been an active advocate for reform of the U.S. health care system. She is active in Healthcare-NOW of Maryland as well as Physicians for a National Health Program. She resides in Bethesda, Md.

Resolved: The United States should switch to a single payer health care system

The Great Debate – Single Payer or Private Insurance

By Katie Britton

WAMC, March 13, 2014

Students for a National Health Program at Albany Medical College presented The Great Debate at WAMC’s The Linda on the evening of February 21st.  Moderated by Dr. Kimberly Kilby, the debate featured Dr. Paul Song of the Physicians for a National Health Program (PNHP) from California and Dr. Mitchell Heller of the Benjamin Rush Society from New York City as they argued for and against single payer vs. private insurance.

For an audio of the debate (55 minutes): http://wamc.org/post/great-debate-single-payer-or-private-insurance

Comment:

By Don McCanne, M.D.

The debate:

Resolved: The United States should switch to a single payer health care system

Speaking in favor is Paul Song, MD, representing Physicians for a National Health Program – an organization of physicians and others who advocate for “a universal, comprehensive single-payer national health program.”

Speaking in opposition is Mitchell Heller, MD, representing the Benjamin Rush Society – an organization of physicians and others “who believe that the profession of medicine calls its practitioners to serve their patients, rather than the government.”

“We as a society are defined by how we take care of the least amongst us.” – Dr. Song

“It’s hard to understand how command and control models like single payer still gain intellectual traction at all.” – Dr. Heller

Although you should listen to the debate before hearing the results, many of you do not have the extra 55 minutes. So here is the vote:

Before the debate:

66% – For
 5% – Against
29% – Undecided

After the debate:

80% – For
 2% – Against
18% – Undecided

Doctor who schooled U.S. senator ‘thrilled’ by Canadian support

By Carmen Chai
Global News (Canada), March 13, 2014

TORONTO – Dr. Danielle Martin knows Canadians are proud of the country’s universal health care. She is too.

At a U.S. Senate subcommittee earlier this week, the Toronto family doctor laid the smack down on American officials who alleged that doctors and patients were fleeing Canada for greener pastures in the U.S.

Martin knew she had to stand her ground. But she didn’t expect the overwhelming response from Canadians who are now applauding how she handled the heated exchange.

So far, she’s been hailed as a national hero for “schooling” the U.S. Senate.

“I think it taps into a really deep pride that Canadians have about single payer health care. I don’t think it’s about me. The basic value that Canadians hold that access to health care should be based on need and not ability to pay is very fundamental to how people view themselves as Canadians,” Martin told Global News on Thursday morning.

“We see our health care system get misrepresented and trashed in the American media as part of their debate quite a lot and that’s a source of real frustration for Canadians,” she said.

The Women’s College Hospital doctor was invited by senators to Washington for a panel on what the U.S. can learn from other countries that function on a single payer health care system. Martin joined a panel of international experts on single payer health care models – doctors from Denmark, France, and Taiwan also shed light on the system.

It was during the question-and-answer period when Martin and Republican Senator Richard Burr began their verbal sparring.

“On average, how many Canadian patients on a waiting list die each year? Do you know?” Burr asked.

“I don’t, sir, but I know that there are 45,000 in American who die waiting because they don’t have insurance at all,” she said.

“What do you say to an elected official who goes to Florida and not the Canadian system to have a heart valve replacement?” Burr asked. He was referring to Newfoundland Premier Danny Williams’ decision to head to Miami for heart surgery in 2010.

“It’s actually interesting because, in fact, the people who are the pioneers of that particular surgery…are in Toronto, at the Peter Munk Cardiac Centre, just down the street from where I work,” Martin quipped back.

Finally, when Burr asked why Canadian doctors are leaving the public system, Martin shot down his claim: “In fact, we see a net influx of physicians from the United States into the Canadian system over the last number of years,” she said.

But Martin wants Canadians to know: as much as it might look like it, the meeting was respectful and the senators graciously welcomed the panelists.

“People have strong opinions about this so it was clear there were clashing views but I certainly didn’t find the tone disrespectful,” Martin told Global News.

She knows a single committee meeting wouldn’t suddenly sway U.S. health officials into considering the Canadian health care model, but Martin said she’s “thrilled” that the exchange has people talking.

“It means this kind of hearing isn’t just political theatre. It serves a social function to get a conversation going and that’s really important,” she said.

So far, she’s received emails and phone calls about her appearance at the Senate meeting. Some people have even written to her to say that they ended up watching the entire 90-minute meeting because they were so enthralled.

Doctor who schooled U.S. senator ‘thrilled’ by Canadian support

PNHP note: For additional Canadian coverage of Dr. Danielle Martin’s testimony, see this story by CBC News:
http://www.cbc.ca/news/world/dr-danielle-martin-gives-washington-a-lesson-on-canadian-health-care-1.2570872

Resolved: The United States should switch to a single payer health care system

The Great Debate – Single Payer or Private Insurance

By Katie Britton

WAMC, March 13, 2014

Students for a National Health Program at Albany Medical College presented The Great Debate at WAMC’s The Linda on the evening of February 21st.  Moderated by Dr. Kimberly Kilby, the debate featured Dr. Paul Song of the Physicians for a National Health Program (PNHP) from California and Dr. Mitchell Heller of the Benjamin Rush Society from New York City as they argued for and against single payer vs. private insurance.

For an audio of the debate (55 minutes): http://wamc.org/post/great-debate-single-payer-or-private-insurance

The debate:

Resolved: The United States should switch to a single payer health care system

Speaking in favor is Paul Song, MD, representing Physicians for a National Health Program – an organization of physicians and others who advocate for “a universal, comprehensive single-payer national health program.”

Speaking in opposition is Mitchell Heller, MD, representing the Benjamin Rush Society – an organization of physicians and others “who believe that the profession of medicine calls its practitioners to serve their patients, rather than the government.”

“We as a society are defined by how we take care of the least amongst us.” – Dr. Song

“It’s hard to understand how command and control models like single payer still gain intellectual traction at all.” – Dr. Heller

Although you should listen to the debate before hearing the results, many of you do not have the extra 55 minutes. So here is the vote:

Before the debate:

66% – For
5% – Against
29% – Undecided

After the debate:

80% – For
2% – Against
18% – Undecided

As ACA deadline looms, Maine doctors show support for single-payer health care

By Jackie Farwell    
Bangor (Maine) Daily News, March 12, 2014

With March 31 fast approaching as the deadline to buy health insurance under the Affordable Care act, the state’s largest physicians group has released new survey results showing Maine doctors favor a very different kind of health reform.

The survey of Maine Medical Association members shows nearly two-thirds of doctors prefer a single-payer health care system.

Conducted in January and completed by more than 450 respondents, the survey asked:

“When considering the topic of health care reform, would you prefer to make improvements to the current public/private system or a single-payer system such as a “Medicare for all” approach?

Nearly 65 percent of doctors preferred the single-payer option, a jump from about 52 percent in a 2008 MMA survey asking the same question.

Single-payer health systems cover everyone under a publicly funded insurance plan run by a single entity, often the government. All hospitals, doctors, and other health providers bill that entity for their services.

Supporters of the “Medicare for all” approach advocate expanding that government program to cover all Americans, not just those over age 65 and people with disabilities.

For the full story, visit:

http://vitalsigns.bangordailynews.com/2014/03/12/affordable-care-act/as-aca-deadline-looms-maine-doctors-show-support-for-single-payer-health-care/

Watch an expert teach a smug U.S. senator about Canadian healthcare

By Michael Hiltzik
The Los Angeles Times, March 12, 2014

A U.S. politician’s I-don’t-need-no-stinkin’-facts approach to health policy ran smack into some of those troublesome facts Tuesday at a Senate hearing on single-payer healthcare, as it’s practiced in Canada and several other countries.

The countries in question have successful and popular government-sponsored single-payer systems, provide universal coverage and match or outdo the United States on numerous measures of medical outcomes — for far less money than the U.S. spends. To explain this, Sen. Bernie Sanders (I-Vt.) asked seven experts to testify before his subcommittee on primary health and aging.

Those interested in how the U.S. matches up should watch the whole 90-minute session. (The official subcommittee hearing record is available.)

By far the high point of the morning was an exchange between Sen. Richard Burr (R-N.C.) and Danielle Martin, a physician and health policy professor from Toronto. The exchange, in which Martin bats down the myths and misunderstandings about the Canadian system that Burr throws at her, starts at about the 1:08:15 mark.

(The reference to “Premier Williams” is to Newfoundland Premier Danny Williams, whose decision to have a heart valve procedure in Miami, near where he owns a condo, rather than Canada, is widely viewed in Canada as a rich man’s failure to investigate the care available to him closer to home.)

Here’s a lightly edited transcript of the key moments, which start with Burr asking Martin about the observation in her written testimony that wait times for elective surgery in single-payer systems will lengthen as doctors move out of the public system:

BURR: Why are doctors exiting the public system in Canada?

MARTIN: Thank you for your question, Senator. If I didn’t express myself in a way to make myself understood, I apologize. There are no doctors exiting the public system in Canada, and in fact we see a net influx of physicians from the United States into the Canadian system over the last number of years.

What I did say was that the solution to the wait time challenge that we have in Canada — we do have a difficult time with waits for elective medical procedures — does not lie in moving away from our single-payer system toward a multipayer system. And that’s borne out by the experience of Australia. So Australia used to have a single-tier system and did in the 1990s move toward a multiple-payer system where private insurance was permitted. And a very well-known study by Duckett, et al., tracked what took place in terms of wait times in Australia as the multipayer system was put in place.

And what they found was in those areas of Australia where private insurance was being taken up and utilized, waits in the public system became longer. 

BURR: What do you say to an elected official who goes to Florida and not the Canadian system to have a heart valve replacement?

MARTIN: It’s actually interesting, because in fact the people who are the pioneers of that particular surgery, which Premier Williams had, and have the best health outcomes in the world for that surgery, are in Toronto, at the Peter Munk Cardiac Center, just down the street from where I work.

So what I say is that sometimes people have a perception, and I believe that actually this is fueled in part by media discourse, that going to where you pay more for something, that that necessarily makes it better, but it’s not actually borne out by the evidence on outcomes from that cardiac surgery or any other.

(The ultimate zinger came at the end of the exchange, when Burr thought he had Martin down for the count about wait times in Canada, and she neatly put the difference between the Canadian and U.S. systems in perspective.)

BURR: On average, how many Canadian patients on a waiting list die each year? Do you know?

MARTIN: I don’t, sir, but I know that there are 45,000 in America who die waiting because they don’t have insurance at all.

http://www.latimes.com/business/hiltzik/la-fi-mh-watch-a-canadian-20140312,0,2995139.story#ixzz2vmQDiy2b

Tickets written to ‘Truthful Tuesday’ protesters calling for Medicaid expansion

By Jamie Self
The State (Columbia, S.C.), March 11, 2014

COLUMBIA, S.C. — Protesters calling on lawmakers to expand Medicaid under the federal Affordable Care Act — and to stop trying to impede the law in South Carolina — blocked a driveway into the State House parking garage for the second week in a row.

This time, the 11 protesters standing in the street were asked to step aside and await tickets — a different outcome than last week, when Columbia Police hauled protesters off in patrol cars. Another protester today was written a ticket after attempting to block traffic with his vehicle.

Lexington resident Daniel Deweese, 26, only got a verbal warning last Tuesday when he blocked the entrance to the State House parking garage, long enough to allow a group of protesters to block traffic. Today, Deweese was among the protesters ticketed for standing in the road.

Their message today was the same as last week.

Deweese cited a study that says 1,000 people in South Carolina will die without access to Medicaid.

“This is not ethical, and there are people who will not stand for this and will risk arrest” to make the point, he said.

“I’m about as law-abiding a citizen as they come,” said David Ball, who represents a group called Healthcare for All South Carolina, the state chapter of Physicians for a National Health Program.

A nurse for 25 years and U.S. Air Force reservist, Ball said he was willing to participate in civil disobedience, even with risk of arrest or a ticket, to raise awareness about the broken healthcare system.

Ball, who says Medicare should be available for everyone from “cradle to grave,” also said the United States is one of the richest countries, but spends a lot more than other countries on healthcare — a problem he attributed to powerful healthcare and pharmaceutical lobbyists.

Steve Compton, a social worker from Greenville who also received a ticket, said he’s seen the impact of poverty on healthcare and came out to protest as a way of increasing “the attention that we can bring to the problem. Not enough information has been given to citizens” about the Affordable Care Act or what the state’s rejecting of expanding Medicaid would do.

The protest was one of several that activists, organized under the umbrella of Truthful Tuesday, have planned at the State House.

The protesters all have the same March 28 court date as those arrested last week, Columbia Police officials said Tuesday.

http://www.thestate.com/2014/03/11/3318943/buzz-12-more-tickets-written-to.html#storylink=cpy

Senate committee on single payer lessons for the U.S.

Subcommittee Hearing – Access and Cost: What the US Health Care System Can Learn from Other Countries

Committee on Health, Education, Labor and Pensions (HELP) , Subcommittee on Primary Health and Aging
United States Senate, March 11, 2014

Statement by:
Tsung-Mei Cheng, LL.B., M.A.
Health Policy Research Analyst
Woodrow Wilson School of Public and International Affairs, Princeton University

Today’s hearing is focused on “international single payer health system models that provide universal coverage of health care.” I will tailor my remarks according to the three sub-themes the Committee wishes to explore, namely:

*  Primary care access in single payer systems

*  Health care costs in single payer systems, and

*  Cross-country comparisons of health outcomes

Before proceeding with the Committee’s agenda in more detail, however, I would like to provide the Committee with a summary of my main points:

1. If equity and social solidarity in access to health care and financing health care were fundamental goals of a health care system, the single payer system provides an ideal platform for achieving these goals.

2. Single-payer systems typically are financed by general- or payroll taxes in a way that tailors the individual’s or family’s contribution to health-care financing to their ability to pay, rather than to their health status, which until this year has long been the practice in the individual health insurance market in the U.S.

3. These systems protect individual households from financial ruin due to medical bills.

4. Single-payer health systems typically afford patients free choice of health-care provider, albeit at the expense of not having a freedom of choice among different health insurers. Remarkably, in the U.S. households have some freedom of choice of health insurers – to the extent their employer offers them choice – but most Americans are confined to networks of providers for their insurance policy. In other words, Americans appear to have traded freedom of choice among providers for the sake of choice among insurers.

5. In single-payer systems “money follows the patient.” Therefore providers of health care must and do compete for patients on the basis of quality and patient satisfaction, but not price.

6. In a single payer health insurance system, health insurance is fully portable from job to job and into unemployment status and retirement. The “job-lock” phenomenon prevalent in the US is unknown in those systems, contributing to labor-market efficiency.

7. Because all funds to providers of health care in a single-payer system flow from one payer, it is relatively easy to control total health spending in such systems. Indeed, total national health spending as a percent of GDP in countries with single-payer systems is lower than it tends to be in non-single-payer health systems. This does not mean providers are left without a voice. Provider inputs are part of the formal negotiations over health-care budgets.

8. For the most part, single-payer systems achieve their cost control by virtue of the monopsonistic market power they enjoy vis a vis providers of health care. It is a countervailing power that the highly fragmented U.S. health-insurance system lacks vis a vis providers.

9. As part of their effort to control total health spending, however, and to avoid the waste of excess capacity that easily develops in health care, some single-payer systems (the UK and Canada) put constraints on the physical capacity of their health system (number of inpatients beds, MRI scanners, etc). That approach can lead to rationing by the queue. The alternative to rationing by such administrative devices, of course, is rationing by price and ability to pay, an approach used by design or by default in the United States. Rationing by price or by non-price mechanism are just alternative forms of rationing.

10. A single-payer system is an ideal platform for a uniform electronic health information system of the sort, for example, used by our Veterans Administration health system (a single-payer system in its own right). There is a common nomenclature which enables 100% electronic billing and claims processing, thus yielding significant savings in administrative costs.

11. Because they conveniently capture information on all health-care transactions, single-payer systems provide a data base that can be used for quality measurement, monitoring and improvement, and also for more basic research on what drives health spending and what clinical treatments works and does not work in health care. It enables evidence based medicine and the tracking of efficacy and safety of new drugs and devices once they are introduced after approval by government based on results of clinical trials.

Statement of Tsung-Mei Cheng (28 pages): http://www.help.senate.gov/imo/media/doc/Cheng.pdf

Video of the hearing and links to statements of all participants: http://www.help.senate.gov//hearings/hearing/?id=8acab996-5056-a032-522e-e39ca45fcfbe

Comment:

By Don McCanne, M.D.

Sen. Bernie Sanders chaired a Senate committee hearing on what the health care system in the United States can learn from other countries. Tsung-Mei Cheng provided an excellent overview of single payer and of the sharp contrasts between the United States and other nations. Her 28 page statement is well worth downloading to use as an information resource in educating others about single payer.

Other informative presentations included those of Victor Rodwin on France, Ching-Chuan Yeh on Taiwan, Danielle Martin on Canada, and Jakob Kjellberg on Denmark. Even the presentations from the other side by Sally Pipes and David Hogberg were helpful in that they showed how silly (sadly) their views were when contrasted with a group of experts who understand well how systems based on solidarity work. If you can find the time, viewing the entire video (1 hour & 46 minutes) and reading the statements would be well worth the effort (link above).

If you don’t have the time, at least view this 4 minute YouTube video of clips from the hearing: https://www.youtube.com/watch?v=9WdqtPLRc1A

Senate committee on single payer lessons for the U.S.

Subcommittee Hearing – Access and Cost: What the US Health Care System Can Learn from Other Countries

Committee on Health, Education, Labor and Pensions (HELP) , Subcommittee on Primary Health and Aging
United States Senate, March 11, 2014

Statement by:
Tsung-Mei Cheng, LL.B., M.A.
Health Policy Research Analyst
Woodrow Wilson School of Public and International Affairs, Princeton University

Today’s hearing is focused on “international single payer health system models that provide universal coverage of health care.” I will tailor my remarks according to the three sub-themes the Committee wishes to explore, namely:

*  Primary care access in single payer systems

*  Health care costs in single payer systems, and

*  Cross-country comparisons of health outcomes

Before proceeding with the Committee’s agenda in more detail, however, I would like to provide the Committee with a summary of my main points:

1. If equity and social solidarity in access to health care and financing health care were fundamental goals of a health care system, the single payer system provides an ideal platform for achieving these goals.

2. Single-payer systems typically are financed by general- or payroll taxes in a way that tailors the individual’s or family’s contribution to health-care financing to their ability to pay, rather than to their health status, which until this year has long been the practice in the individual health insurance market in the U.S.

3. These systems protect individual households from financial ruin due to medical bills.

4. Single-payer health systems typically afford patients free choice of health-care provider, albeit at the expense of not having a freedom of choice among different health insurers. Remarkably, in the U.S. households have some freedom of choice of health insurers – to the extent their employer offers them choice – but most Americans are confined to networks of providers for their insurance policy. In other words, Americans appear to have traded freedom of choice among providers for the sake of choice among insurers.

5. In single-payer systems “money follows the patient.” Therefore providers of health care must and do compete for patients on the basis of quality and patient satisfaction, but not price.

6. In a single payer health insurance system, health insurance is fully portable from job to job and into unemployment status and retirement. The “job-lock” phenomenon prevalent in the US is unknown in those systems, contributing to labor-market efficiency.

7. Because all funds to providers of health care in a single-payer system flow from one payer, it is relatively easy to control total health spending in such systems. Indeed, total national health spending as a percent of GDP in countries with single-payer systems is lower than it tends to be in non-single-payer health systems. This does not mean providers are left without a voice. Provider inputs are part of the formal negotiations over health-care budgets.

8. For the most part, single-payer systems achieve their cost control by virtue of the monopsonistic market power they enjoy vis a vis providers of health care. It is a countervailing power that the highly fragmented U.S. health-insurance system lacks vis a vis providers.

9. As part of their effort to control total health spending, however, and to avoid the waste of excess capacity that easily develops in health care, some single-payer systems (the UK and Canada) put constraints on the physical capacity of their health system (number of inpatients beds, MRI scanners, etc). That approach can lead to rationing by the queue. The alternative to rationing by such administrative devices, of course, is rationing by price and ability to pay, an approach used by design or by default in the United States. Rationing by price or by non-price mechanism are just alternative forms of rationing.

10. A single-payer system is an ideal platform for a uniform electronic health information system of the sort, for example, used by our Veterans Administration health system (a single-payer system in its own right). There is a common nomenclature which enables 100% electronic billing and claims processing, thus yielding significant savings in administrative costs.

11. Because they conveniently capture information on all health-care transactions, single-payer systems provide a data base that can be used for quality measurement, monitoring and improvement, and also for more basic research on what drives health spending and what clinical treatments works and does not work in health care. It enables evidence based medicine and the tracking of efficacy and safety of new drugs and devices once they are introduced after approval by government based on results of clinical trials.

Statement of Tsung-Mei Cheng (28 pages):http://www.help.senate.gov/imo/media/doc/Cheng.pdf

Video of the hearing and links to statements of all participants:http://www.help.senate.gov//hearings/hearing/?id=8acab996-5056-a032-522e…

Sen. Bernie Sanders chaired a Senate committee hearing on what the health care system in the United States can learn from other countries. Tsung-Mei Cheng provided an excellent overview of single payer and of the sharp contrasts between the United States and other nations. Her 28 page statement is well worth downloading to use as an information resource in educating others about single payer.

Other informative presentations included those of Victor Rodwin on France, Ching-Chuan Yeh on Taiwan, Danielle Martin on Canada, and Jakob Kjellberg on Denmark. Even the presentations from the other side by Sally Pipes and David Hogberg were helpful in that they showed how silly (sadly) their views were when contrasted with a group of experts who understand well how systems based on solidarity work. If you can find the time, viewing the entire video (1 hour & 46 minutes) and reading the statements would be well worth the effort (link above).

If you don’t have the time, at least view this 4 minute YouTube video of clips from the hearing: https://www.youtube.com/watch?v=9WdqtPLRc1A

International experts tell senators that single-payer improves national health at less cost

By Mark Karlin
Truthout/Buzzflash, March 11, 2014

Here are two basic facts to remember about the health care system in the United States. First, there is the high cost, as noted in a 2012 report on PBS:

How much is good health care worth to you? $8,233 per year? That’s how much the U.S. spends per person.

Worth it?

That figure is more than two-and-a-half times more than most developed nations in the world, including relatively rich European countries like France, Sweden and the United Kingdom. On a more global scale, it means U.S. health care costs now eat up 17.6 percent of GDP….

Whether measured relative to its population or its economy, the United States spends by far the most in the world on health care.

The U.S. spent $8,233 on health per person in 2010. Norway, the Netherlands and Switzerland are the next highest spenders, but in the same year, they all spent at least $3,000 less per person. The average spending on health care among the other 33 developed OECD countries was $3,268 per person.

That statistic brings up the much-beloved free market criteria of return on investment (ROI), at which the US performs abysmally according to many studies when it comes to health. 

An NPR article in 2013 is entitled, “US Ranks Below 16 Other Rich Countries In Health Report”:

It’s no news that the U.S. has lower life expectancy and higher infant mortality than most high-income countries. But a … new report says Americans are actually less healthy across their entire life spans than citizens of 16 other wealthy nations.

And the gap is steadily widening.

“What struck us — and it was quite sobering — was the recurring trend in which the U.S. seems to be slipping behind other high-income countries,” the lead author of the report, Dr. Steven Woolf, tells Shots.

He says Americans of all ages up to 75 have shorter lives and more illness and injury.

It should be noted that in this report, the United States is being compared to other “developed” nations.  A recent United Nations Population Divison report ranked the US 40th in life expectancy among all nations in 2010.

In short, the US spends the most on medical care with poor life expectancy results, even including many nations that are not considered wealthy.

The Affordable Care Act (ACA) may have made insurance coverage more inclusive, but it keeps the insurance companies in charge of calling the shots (for those without Medicare, Veterans Care or Medicaid) and adding to the cost of health care through administrative costs and profit.

According to the advocacy organization Public Citizen, a number of experts from single-payer nations recently testified at a Senate sub-committee hearing chaired by Sen. Bernie Sanders (I-VT), a leading supporter of Medicare for all. The spokespersons from Canada and Denmark offered compelling reasons why the US should move from a private-insurance system to a government administered program (such as, well, Medicare):

For example, the Canadian witness, Dr. Danielle Martin, vice president of medical affairs and health system solutions at Women’s College Hospital, compared access to care, quality of care and costs in the U.S. and Canadian systems, and found all were superior in Canada. Martin compared the American average for administrative costs of 31 percent to the 1.3 percent administrative costs paid by Canada (not counting costs for private supplemental plans available to Canadians.) Professor Jakob Kjellberg from the Danish Institute for Local and Regional Government Research, who served as the Danish expert witness, said his country’s administrative costs are only 4.3 percent of total health care spending. 

In short, as has been argued before, private health insurance (which we still obviously have under the ACA) increases the cost of medical care, with nearly a third of that cost eaten up by private insurance non-health related revenue.  To repeat the testimony cited above: 31 percent of US health insurance costs goes to insurers, while in Canada only 1.3 percent of medical costs are administrative.

As far as access to care, to the contrary of what Sarah Palin infamously asserted — that government care would lead to death panels — it is private insurance companies who employ staff to decide whether medical care — sometimes a matter of life or death with chronic illnesses and rare diseases — should be provided.  Medicare does not employ “profit-increasers” to deny care.

Indeed, a spokesperson for Public Citizen pointedly summarized the hearing:

Today’s panel was a good first step that will hopefully inspire a real discussion about the benefits of single-payer health care in the United States, said Susan Harley, deputy director of Public Citizen’s Congress Watch division. A single-payer, or Medicare-for-all, system would eliminate health insurance companies from the equation, ensuring that only patients and their doctors make decisions about care options.

Although the ACA is to be praised for providing many uninsured people an opportunity to sleep with some peace of mind, it is still a rickety system constructed to ensure the political support of medical insurance companies.

US politicians, including President Obama, regularly boast about the US being the leader of the world in progress and a model for other nations.

Having the most expensive healthcare system, with the worst general outcome ranking for developed nations, looks like the US is a wobbly caboose not a powerful engine.

Medicare for all could solve that problem when it comes to cost-effectively fostering a healthy national population.

Afternote: The Daily Show, as usual, brought home the reality of the dysfunctional national US health care system in this recent segment. Click here.

Mark Karlin is editor of Buzzflash at Truthout.

http://www.truth-out.org/buzzflash/commentary/international-experts-tell-senators-that-single-payer-improves-national-health-at-less-cost

What the U.S. can learn about health care from other countries

PNHP note: The following press release was issued by the staff of Sen. Bernie Sanders of Vermont on March 11.

Other major countries offer better health care at less cost than the United States, according to witnesses who testified on Tuesday at a Senate hearing chaired by Sen. Bernie Sanders. “What this hearing is really about is two fundamental issues. First, the U.S., the wealthiest country on the planet, is the only major industrialized country in the world that does not guarantee health care as a right to its citizens. Should we consider joining the rest of the world? I’d argue we should,” Sanders said. “Second, the U.S. spends twice as much as other countries that have much better health outcomes. What can we learn from these countries?” asked Sanders, chairman of the Senate Subcommittee on Primary Health and Aging.

Citing World Health Organization data, Sanders said the U.S. spends as much as three times more on health care than other industrialized countries. Health care outlays in the U.S. account for about 18 percent of our Gross Domestic Product, significantly more than in France, Germany, Denmark, Canada, Great Britain, Australia, Norway, Taiwan and Israel.

In Denmark, “all citizens have access to care; no one may be denied services on the basis of income, age, health or employment status,” according to Jakob Kjellberg, an economist from Copenhagen. Victor Rodwin, an expert on the French health care system, said “the French have easy access to primary health care, as well as specialty services, at half the per capita costs of what we spend in the U.S.

Other witnesses said the money Americans sink into their expensive health care system does not buy better care. “Canada achieved health outcomes that are at least equal to those in the U.S. at two-thirds the cost,” according to one witness at the hearing, Dr. Danielle Martin of Women’s College Hospital in Toronto.

The United States ranks 26th in life expectancy compared to other countries ranked by the Paris-based Organization for Economic Cooperation and Development. People who live in Italy, Spain, France, Australia, Israel, Norway and other countries live 2 to 3 years longer than Americans.

The Affordable Care Act has improved access to insurance, but millions of Americans still lack insurance or have plans with such high deductibles and copayments that they cannot afford the care they need. As a result, some 45,000 uninsured Americans die each year because they didn’t go to a doctor in time.

A major factor driving up health care costs in the U.S. is the high cost of prescription drugs. Hospital stays also cost more. While hospitals in Germany and France charge $3,000 for an appendectomy, for example, the average price for the same procedure in American hospitals is $13,000. Some U.S. hospitals charge $28,000.

“It is time for the U.S. to join the rest of the industrialized world and guarantee access to health care as a right of all people, not just a privilege for those who can afford it,” Sanders said.

http://www.sanders.senate.gov/newsroom/recent-business/us-can-learn-other-countries-health-care

Testimony by international experts underscores benefits of single-payer health care systems

At congressional hearing, experts provide further evidence the U.S. should implement ‘Medicare for All’

By Public Citizen National Journal, March 11, 2014

WASHINGTON — Testimony given today by experts from Canada, Denmark, Taiwan and other countries underscores that single-payer health care systems remove the kind of hindrances to quality care that still plague the U.S., Public Citizen said today.

The witnesses provided compelling evidence to the members of the U.S. Senate Health, Education, Labor, and Pensions (HELP) Committee’s Subcommittee on Primary Health and Aging regarding the benefits of efficient, single-payer health care systems in their respective nations.

Citing cost savings and improved access to health care, expert witnesses explained to subcommittee members what’s been clear to Public Citizen for years: A Medicare-for-all, single-payer system would remove one of the main hurdles the U.S. faces in the quest to provide quality health care for everyone: high overall administrative charges from insurance companies.

For example, the Canadian witness, Dr. Danielle Martin, vice president of medical affairs and health system solutions at Women’s College Hospital, compared access to care, quality of care and costs in the U.S. and Canadian systems, and found all were superior in Canada. Martin compared the American average for administrative costs of 31 percent to the 1.3 percent administrative costs paid by Canada (not counting costs for private supplemental plans available to Canadians.) Professor Jakob Kjellberg from the Danish Institute for Local and Regional Government Research, who served as the Danish expert witness, said his country’s administrative costs are only 4.3 percent of total health care spending.

U.S. Sen. Bernie Sanders (I-Vt.), who chairs the subcommittee, is a longtime champion of single-payer health systems and introduced legislation late in 2013, the American Health Security Act of 2013 (S. 1782), to move the United States to a unified system of health care delivery. In addition, U.S. Rep. John Conyers (D-Mich.) has introduced single-payer legislation, the Expanded and Improved Medicare-For-All Act (H.R. 676).

Several witnesses discussed their countries’ goals of equity and how universal access to care was well-regarded by citizens. Dr. Ching-chuan Yeh of Taiwan, former health minister of Taiwan and professor at the School of Public Health, College of Medicine at Tzu Chi University, explained how the nation has achieved 99.6 percent coverage for the population and subsequently has seen increases in life expectancy and a drop in the infant mortality rate.

“Today’s panel was a good first step that will hopefully inspire a real discussion about the benefits of single-payer health care in the United States,” said Susan Harley, deputy director of Public Citizen’s Congress Watch division. “A single-payer, or Medicare-for-all, system would eliminate health insurance companies from the equation, ensuring that only patients and their doctors make decisions about care options.”

In addition to the national movement to adopt a single-payer health care system, state-based proposals have been put forward in several states (Vermont, New York, California, Pennsylvania, Minnesota, Hawaii and Colorado) that would require a single government payer for health care services instead of a patchwork of private and public health insurers. As explained by the subcommittee witnesses, such systems have a record of providing comprehensive, universal care at a significantly lower cost than we pay for the U.S.’s fragmented system, which leaves millions of people with no coverage.

“Public Citizen supports states moving toward single-payer systems and has outlined a road map for states to achieve the important goal of maximum coverage with minimum cost,” Harley said. “However, we need a national system that truly provides health care for all. We are encouraged by today’s hearing and look forward to a robust discussion about replicating the best of international models of single-payer here in the U.S.

http://www.nationaljournal.com/library/123291

UNITE HERE report on ACA and worsening inequality

The Irony of ObamaCare: Making Inequality Worse

UNITE HERE, March 7, 2014

The promise of Obamacare was the right one and the hope for extending healthcare coverage to the un- and under-insured a step in the right direction. Yet the unintended consequences will hit the average, hard-working American where it hurts: in the wallet. Currently a national dialogue is emerging by all political parties on the issue of income inequality. That is a debate worth having. The White House and Congressional Democrats are “resetting” the domestic agenda following the negative fallout from the rollout of the ACA. They plan to shift focus from health care to bread and butter issues of income inequality that have eroded the American paycheck for decades.

Ironically, the Administration’s own signature healthcare victory poses one of the most immediate challenges to redressing inequality. Yes, the Affordable Care Act will help many more Americans gain some health insurance coverage, a significant step forward for equality. At the same time, without smart fixes, the ACA threatens the middle class with higher premiums, loss of hours, and a shift to part-time work and less comprehensive coverage.

*  Transferring A Trillion Dollars in Wealth: Most of the ACA’s $965 billion in subsidies will go directly to commercial insurance companies, one of the largest transfers of public wealth to private hands ever. Since the ACA passed, the average stock price of the big for-profit health insurers doubled, their top executives were paid more than a half billion dollars in cash and stock options, and in the past 2 years, the top 10 insurers have spent $25 billion on mergers and acquisitions.

*  Strangling Fair Competition: Before reform, different types of health plans were regulated under different bodies of law. The Obama Administration has blocked many non-profit health funds from competing for the law’s proposed trillion dollars in subsidies by refusing to set fair regulations for different types of plans. The unbalanced playing field will give employers of people covered by these plans powerful incentives to drop coverage.

*  Moving to Part Time Work: The Administration’s experts say employers won’t follow the incentives and drop coverage. But they also told the nation that employers would not cut workers’ hours to get below the 30-hour per week threshold for “full time” work, even as 388 employers announced hours cuts since early 2012.

*  Cutting People’s Pay: If employers follow the incentives in the law, they will push families onto the exchanges to buy coverage. This will force low-wage service industry employees to spend $2.00, $3.00 or even $5.00 an hour of their pay to buy similar coverage.

Conclusion

For two years, labor unions and employer partners have patiently explained to the Obama Administration and Congress the potential damage that the ACA poses to these unique, successful non-profit health plans.

Having already made efforts to accommodate businesses, churches and congressional staff, it is ironic that the Administration is now highlighting issues of economic inequality without acting to preserve health plans that have been achieving the goals of the ACA for decades. Without a smart fix, the ACA will heighten the inequality that the Administration seeks to reduce.

We take seriously the promise that “if you like your health plan, you can keep it. Period.” UNITE HERE members like their health plans. UNITE HERE’s plans are ready to compete with the corporate giants of the health insurance industry if Washington will simply create a level playing field.

http://cdn.ralstonreports.com/sites/default/files/ObamaCaretoAFL_FINAL.pdf

Comment:

By Don McCanne

UNITE HERE is a union of service workers in hotels and other industries. Many of their members are insured through non-profit Taft-Hartley plans with joint union-management governance structures. This report shows how the Affordable Care Act can have a negative impact on the health care coverage and hours of employment of union members, in effect making inequality worse.

Some of their legitimate complaints:

*  Employers are not required to make available health insurance to employees who work less than 30 hours per week. Although the Obama administration denies that this will cause employers to reduce the hours that many of their employees work, it is already happening. Obviously that reduces the employees’ net incomes and may disqualify them from receiving insurance coverage.

*  Employers do not have to provide any health coverage at all if they do not have more than 50 employees. Many employers are taking measures to stay below the 50 full-time employee threshold.

*  Employer penalties for not providing coverage are far smaller than the employer costs of their health benefit programs. It is likely that many employers will elect to pay the penalties rather than support a health plan. Yet it is unlikely that employers will increase wages enough to compensate for the lack of an employee health benefit program.

*  Most UNITE HERE union members have wages low enough to qualify for subsidies to help pay for plans obtained through the state or federal insurance exchanges. Yet those subsidies cannot be used for employees in the UNITE HERE Taft-Hartley plans. (They do indirectly receive the tax benefit of deductibility for employer-sponsored plans, but at their income levels, this benefit may be negligible.)

*  More expensive plans will be subject to a 40 percent excise tax. The UNITE HERE Taft-Hartley plans may be subject to this tax, not because the benefits are too generous, but rather because health care costs are so high and because many of the employees in the service industry union are older with greater health care costs. This excise tax is borne by the employee through higher premiums and forgone wage increases.

*  All plans, including Taft-Hartley plans, pay taxes that are used to ease the financial transition of private plans offered on the exchanges. Though the union members ultimately pay these taxes, they receive none of the benefits since Taft-Hartley plans do not qualify for transitional financial support.

*  Self-funded plans, such as these Taft-Hartley plans, are prohibited from being offered to the public and thus cannot benefit from market competition as the exchange plans can.

*  ACA generously subsidizes private health plans with some of those funds going to overpaid executives and wealthy shareholders, thereby contributing to worsening inequality.

Although UNITE HERE calls for Congress and the president to level the playing field through legislation and rule making, a far better solution would be to establish a single payer national health program.

Under an improved Medicare for all, UNITE HERE union members would receive more generous benefits, with first dollar coverage, and with a net cost to them in taxes that would be significantly less than what they are currently paying in premiums and forgone wages. A single payer system would be more effective in reducing inequality than would tweaking the Taft-Hartley plans.