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State opt-outs from Medicaid expansion to result in thousands of deaths

State opt-outs from Medicaid expansion to result in thousands of deaths

Republican state lawmakers’ refusal to expand Medicaid will result in thousands of deaths

Dr. Steffie Woolhandler: 8 million Americans will be excluded from the Affordable Care Act’s Medicaid expansion

By Jessica Desvarieux
The Real News Network, Jan. 31, 2014

PNHP note: The following is a transcript. You can watch the video of this interview here.

JESSICA DESVARIEUX, TRNN PRODUCER: Welcome to The Real News Network. I’m Jessica Desvarieux in Baltimore.

Since the U.S. Supreme Court’s 2012 ruling that states can opt out of Medicaid expansion and the Affordable Care Act, 21 states have done so, and (not surprising) they’re all under Republican control. What is new to this Obamacare saga is a new Harvard University and CUNY study. It found that the lack of Medicaid expansion in these opt-out states will result in about 7,000 to 17,000 deaths a year.

Now joining us to go over the study is coauthor of the report Dr. Steffie Woolhandler. Dr. Woolhandler is the cofounder of Physicians for a National Health Program and professor of public health and medicine at City University of New York.

Thank you for joining us, doctor.

DR. STEFFIE WOOLHANDLER, COFOUNDER, PHYSICIANS FOR A NATIONAL HEALTH PROGRAM: My pleasure.

DESVARIEUX: So, according to your study, nearly 8 million people will not be able to access health insurance because their states opted out. Can you give us a rundown of the health consequences for these 8 million people?

WOOLHANDLER: Yes. Well, we’ll expect between 7,000 and 17,000 of those people to die. We’ll expect about three-quarters of a million, 750,000 people to experience depression that they would have been spared had they had access to health care. We’ll also see that many diabetics will not have access to medications to treat their condition and that women who need pap smears and mammograms will not get the pap smears and mammograms that they need. So we’re going to see a lot of adverse health consequences from what is essentially a political refusal by the red state governors to accept the Medicaid expansion.

DESVARIEUX: And these red state governors, they really have been coming out saying that they cannot afford to expand Medicaid. What’s your response to that?

WOOLHANDLER: Well, that’s completely ridiculous. The first three years of the Medicaid expansion are 100 percent funded by the federal government, and thereafter the expansion is 90 percent funded by the federal government. And, you remember, these billions are going to go into–if they accepted the money, billions would have gone into the state to pay for the hospitals, to pay for hospital workers, doctors, supplies. So it would have been money that would have gone to their states’ economies. So there’s absolutely no economic argument for turning down the Medicaid expansion. The decision by the red state governors to turn down that expansion is purely political.

DESVARIEUX: All right. But they also say, though, that because the federal government is not going to be funding this beyond that three-year mark, they’re concerned that they’ll have to pick up the tab. What do you make of that?

WOOLHANDLER: Well, over the very long run, the federal share is going to fall. But in the next three, four, five years, the federal government’s going to be picking up most of this. And generally when states do their fiscal planning, they only plan for a few years. They don’t usually make fiscal plans 20 or 30 years in advance. So I think these fiscal arguments are really a ruse. I think the real arguments are political.

You know, I want to say Medicaid is not perfect. You know, Medicaid reimburses doctors at such a low rate that often folks with Medicaid find they can’t see a specialist, they can’t get people to take care of them. Nonetheless, Medicaid is really a lot better than being uninsured. And if you have the opportunity to cover uninsured people with Medicaid, you ought to be taking that opportunity.

DESVARIEUX: All right. Dr. Woolhandler, I want to talk also about the 24 million people who would still lack health insurance even if their states expanded Medicaid. Who are these remaining 24 million people? And why are they not covered by the Affordable Care Act?

WOOLHANDLER: Well, the Affordable Care Act, as passed, as signed, was only going to cover about half of America’s uninsured. It was going to leave 23, 24 million people uninsured. Most of those people, as it turns out, will be U.S. citizens. Many of them will earn just a little bit too much to be Medicaid-eligible. They may be eligible for subsidies. But a lot of people find they still can’t afford the health insurance, despite the subsidies. You know, particularly as you get up into the 250 percent of poverty range, still pretty low-income, but not really poor, the subsidies are not very good and people have to take a lot of money out of their pocket to pay their premiums. And then, when they get sick, they find that they have these big deductibles and copayments. So, many folks may look at the insurance that they’re offered under the exchanges and say, I just can’t afford it, this is not worth it, I’m going to remain uninsured.

So what we saw in Massachusetts was, when we did the Massachusetts reform–which, as you know, was the model of the national reform–is only about half of the uninsured ended up getting insurance through the reform. The other half remained uninsured. And, of course, that’s one of the biggest problems with the Obamacare reform: even if it had been implemented as passed, if the Supreme Court had said the whole thing is constitutional, it has to be implemented, we were still going to have 23, 24, 25 million Americans with no health insurance.

DESVARIEUX: All right. Dr. Steffie Woolhandler, thank you so much for joining us.

WOOLHANDLER: My pleasure.

DESVARIEUX: And thank you for joining us on The Real News Network.

Short bio of Dr. Woolhandler:

Dr. Steffie Woolhandler is professor at the CUNY School of Public Health at Hunter College and visiting professor of medicine at Harvard Medical School, where she co-directed the general internal medicine fellowship program and practiced primary care internal medicine at Cambridge Hospital.

Dr. Woolhandler earned her bachelor’s degree from Stanford University,  a medical degree from Louisiana State University, and a master’s degree from the University of California. She worked in 1990-1991 as a Robert Wood Johnson Foundation health policy fellow at the Institute of Medicine and the U.S. Congress.

Dr. Woolhandler is a frequent speaker and has written extensively on health policy, administrative overhead and the uninsured. She has authored more than 50 research articles on health care access and financing. A co-founder and board member of Physicians for a National Health Program, Dr. Woolhandler co-edits PNHP’s newsletter and is a principal author of PNHP articles published in the JAMA and the New England Journal of Medicine in conjunction with Dr. David Himmelstein.

http://therealnews.com/t2/index.php?option=com_content&task=view&id=767&Itemid=74&jumival=11415

Was the ACA ‘politically feasible’?

The group that got health care passed is packing up and going home

By Harold Pollack
The Washington Post, January 5, 2014

Harold Pollack: [S]ingle-payer folks … might ask: “Wouldn’t we have a better system if we had a single payer? Why didn’t HCAN [Health Care for America Now] and its friends push for that?”

Richard Kirsch [chief executive of HCAN]: What’s the expression: “If wishes were horses, beggars would ride?”

Yes — if we could wave a magic wand and design a rational health-care system that would control costs while providing much better access, we wouldn’t design our current one. The ACA was the best that we could get through the American political system. The fact that we failed in every previous instance in the past 100 years reflects the reality that there hadn’t been a reform designed to deal with the realities of American politics….

http://www.washingtonpost.com/blogs/wonkblog/wp/2014/01/05/the-group-tha…

****

Implementing health reform: Four years later

By Timothy Jost
Health Affairs, January 2014

How did things go so wrong [for the Affordable Care Act]? Why is there so much bad news?….

More devastating for the future of the ACA, however, were the 2010 midterm elections. Republicans picked up sixty-three seats in the House, swinging control of the chamber from the Democrats to the Republicans. Before the 2010 elections, Democrats controlled fifty-two state legislative houses and the Republicans thirty-three; after the elections, Republicans controlled fifty-three and the Democrats thirty-two. Before the 2010 election there were twenty-six Democratic and twenty-four Republican governors, and after there were twenty Democrat and twenty-nine Republican. Many saw the election as a referendum on the ACA.

http://content.healthaffairs.org/content/33/1/7.full

By Kip Sullivan, J.D.

Was the Affordable Care Act politically feasible? Was it “the best” America could do in 2009 and 2010? Was single-payer legislation more or less feasible than the ACA? It is still too early to pronounce on the fate of the ACA, but it is not too early to discuss the political feasibility question. We have much to learn from looking back at the muffled debate about that issue among universal coverage advocates prior to the enactment of the ACA.

Since the modern American single-payer movement was formed in the late 1980s, many supporters of universal coverage have claimed that single-payer is not politically feasible. Those who made this argument (Bernstein and Marmor refer to them as “political yes buts” http://healthaffairs.org/blog/2008/08/28/medicare-for-all-why-we-should-…) never explained why multiple-payer “solutions” would be more feasible than single-payer. In the worldview of the “yes buts,” only single-payer proponents had to answer that question. If, on any given day, single-payer proponents could not point to 60 votes in the US senate or majority votes in the US House or in state legislative chambers, the conversation was over: Single-payer was not politically feasible and had to be taken off the table to make room for more “realistic” legislation.

This simple counting-noses definition of “political feasibility” avoided two issues that many observers inside and outside the single-payer movement consider paramount: Any legislation that proposes to achieve universal coverage, or even to cut the uninsured rate substantially, is not politically feasible, or at minimum is no more feasible than single-payer legislation, if

(1) it doesn’t simultaneously reduce health care spending or
(2) is so complex it cannot be implemented within a reasonable period of time.

This definition of feasibility asks not merely whether a given legislative body can be pushed into enacting a given bill. This definition asks as well, once the bill is enacted, is it politically sustainable? By this more realistic definition of political feasibility, a bill might have enough votes to pass a given legislative body, but if the bill can’t contain costs or can’t be implemented within a reasonable period of time, it shouldn’t be assumed to be politically sustainable and therefore should not be assumed to be more politically feasible than other approaches.

Sustainability depends ultimately on how the public perceives legislation after it is enacted. If the public punishes lawmakers who voted for the putative “universal coverage” legislation and rewards legislators who are hostile to government doing anything to help the uninsured and to lower health care costs, the legislation may die on the vine or be repealed.

One would think that this definition of political feasibility would have appealed naturally to the Democrats and their supporters who pushed the ACA because it asks them to take into account the impact of the ACA on voters’ perceptions of Democrats. In other words, it asks Democrats to consult their own self-interest in the course of picking a solution to a problem. It is a noble thing to suffer retribution at the polls for a bill that does good things for people when you know it’s going to work. But it is foolish to suffer retribution for a bill you suspect, or should suspect, will fail, or at minimum, will perform far below the expectations your rhetoric about the bill has created.

When in June 2009, congressional Democrats unveiled the health care “reform” bills that would become the ACA, I and many others were filled with apprehension. Our concern was not that some version of these bills might not pass. To the contrary, our concern was that it might pass (and thereby demonstrate it was “politically feasible” in the narrow sense of the phrase) but not be politically sustainable. In a June 2009 comment on this blog entitled, “Democrats’ hype about health care reform will hurt them,” I said:

“President Obama and Democratic congressional leaders are playing a dangerous game with health care reform. They are raising the public’s expectations sky high before figuring out how to meet those expectations. They are promising to give us the moon – significant cuts in health care costs and universal coverage or something close to it – but even at this late hour they have failed to publish anything resembling a detailed plan to do that. And the hints they have given us about the ‘reforms’ they are likely to endorse indicate they haven’t got a clue how to cut costs.”
https://pnhp.org/blog/2009/06/04/democrats%E2%80%99-hype-about-health-car….

I wanted a real debate about the political feasibility of the Democrats’ multiple-payer solution versus our single-payer proposal, and I thought the most effective way to make my argument was to appeal to Democrats’ self-interest, not just their altruism. Although I doubted the altruism of some members of Congress, I didn’t doubt the altruism of the vast majority of ACA supporters — I knew their desire to minimize the suffering inflicted on this country by our health care system was real. What I questioned was their understanding of how expensive and complex the ACA was going to be. If they didn’t understand that, how could they grasp what a political liability the ACA would be for Democrats? How could they intelligently evaluate the risk that future Congresses might not have enough Democrats in them to protect the ACA from underfunding or outright repeal?

But the debate about political feasibility that I and many others hoped for never came to pass. The single-payer and multiple-payer wings of the American universal coverage movement never discussed whether the ACA would be more feasible — that is, be more likely to pass AND be more sustainable — than a single-payer. We never debated whether the simplicity and efficiency of a single-payer made it more feasible, or at least no less feasible, than the costly and insanely complicated ACA. ACA proponents simply pronounced single-payer “off the table” on the ground that powerful opponents would have made a majority vote in Congress impossible. And that was that.

Four years have now passed since the enactment of the ACA. The sky is clotted with chickens coming home to roost. Evidence that the ACA was never as sustainable as its proponents implied is all around us. This evidence includes evidence of the damage the ACA has inflicted on Democrats. Timothy Jost’s article in the January 2014 Health Affairs contains an excellent summary of the unhappy history of the ACA. One of the most important paragraphs in his paper is the one quoted above in which he notes the damage Democrats suffered during the 2010 elections and that many believe this damage was due in part to the enactment of the ACA in March of 2010. Jost also predicts more bad news for the ACA as a substantial portion of the people insured through exchanges discover their choice of provider has been restricted and their out-of-pocket payments are very high. We are going to see more heartwarming stories about sick people finally getting the medical care they deserve, thanks to the ACA, but it will not be enough to forestall more damage to Democrats (especially if Republicans manage to nominate candidates who can refrain from discussing “legitimate rape” and similar subjects).

None of us have a crystal ball. I don’t claim that if Democrats and groups supporting the ACA had used the opportunity presented to us in 2009-2010 to promote HR 676 instead of the ACA that HR 676 would have passed by March 2010 or even by now. I’m reasonably sure something good would have been enacted — for example, an expansion of traditional Medicare and Medicaid to more people (Bob Kuttner makes a similar argument here http://www.huffingtonpost.com/robert-kuttner/obamacare-republicans_b_429…).

I am, however, absolutely certain about one thing: The universal coverage movement in America would be in a much better position to bring the long fight for universal coverage to a successful conclusion than we are now. There are several reasons why I’m so sure about that.

First, whether we had won big or won some incremental improvements in 2010, the public would have been exposed to a debate about a real solution to the health care crisis as opposed to a debate about make-believe cost containment schemes such as exchanges, “accountable care organizations” and punishing hospitals for “excess” readmissions.

Second, the health insurance industry would be receiving less money from the taxpayer and would be, therefore, less powerful than they are now. The insurance industry has been driving away private-sector customers in droves over the last few decades. If public purchasers — state and federal governments — had long ago stopped throwing money at Aetna et al. with legislation like the ACA, schemes to overpay Medicare Advantage plans, and legislation privatizing state Medicaid programs, the industry would by now be a shadow of its former self and a much less potent opponent of universal coverage.

Third, the political environment for health care reform would be less toxic than it is today, not because conservatives wouldn’t be leveling the same extreme charges they level at all forms of health care reform no matter how innocuous, but because the public would be less vulnerable to extremism and ultimately less cynical about real reform.

ACA proponents may disagree with my assessment of where we might be today if they had joined ranks with the single-payer movement and had fought for HR 676. What they can’t deny is they refused to engage in a real debate about the political feasibility (narrowly defined) AND sustainability of the ACA versus single-payer. They might have learned something if they had.

Med students lobby for New Yorkers’ health

Medical students lobby lawmakers to advance health care proposals

By Claire Hughes
Times Union (Albany, N.Y.), Jan. 28, 2014

ALBANY, N.Y. — Doctors must advocate for their patients’ health — with supervisors who approve procedures, for instance, or insurance companies that pay for services.

On Tuesday, dozens of doctors-to-be tried different advocacy skills — lobbying state lawmakers to advance proposals they believe will improve New Yorkers’ health.

“If we are not going to fight for our patients, who will?” Albany Medical College student Xin Guan asked a few dozen young adults in white coats who had stopped in the basement of the Legislative Office Building for coffee, bagels and a press briefing between their morning and afternoon visits to lawmakers.

It was the first Medical Student Advocacy Day, organized by Guan, originally from California, and two other second-year students from Albany Med, Ajay Major of Indiana and Phyllis Ying of Seattle.

Some 60 to 70 students from around the state joined them. A glance at the coats suggested most were from Albany Med, but some had traveled from several downstate schools, including Albert Einstein College of Medicine, SUNY Downstate Medical Center and Mt. Sinai Medical Center.

Guan, Major and Ying had prepped them with some activist training before the event. Lobbying representatives was a new activity for about half the students, they said.

While the group shared a concern for health issues, they spoke with legislators about proposals that interested them as individuals. Small groups organized around a few popular issues, including bills to provide universal health coverage for all New Yorkers, allow marijuana for medical use, and prohibit doctors from participating in the torture and improper treatment of prisoners.

Anti-hunger advocate Mark Dunlea gave the students a pep talk before they headed back out to meet their afternoon slate of legislators. Dunlea’s group, Hunger Action Network of New York State, works with a coalition of organizations that provide aid to low-income people who struggle with the costs of health care.

He told the students that their future profession would carry some weight with legislators. And he reminded them that legislators are public servants.

“Remember, these guys work for you,” he said. 

http://www.timesunion.com/local/article/Med-students-lobby-for-New-Yorkers-health-5183446.php

Canadian Health Care: Separating Opinion From Fact

By Trudy Lieberman
The Huffington Post Canada, Jan. 29, 2014

One thing Americans and Canadians can agree on is that we don’t want each other’s health care systems. In truth, most Americans don’t know how Canada’s system works and Canadians don’t know much about the U.S. system.

What Americans know has come mainly from the negative talking points of politicians and others who have argued for years against national health insurance. Two decades ago, The New York Times reported that Canadian women had to wait for Pap smears, a point vigorously refuted by the Canadian ambassador who shot back in a letter to the Times editor: “You, and Americans generally, are free to decide whatever health care system to choose, avoid or adapt, but the choice is not assisted by opinions unrelated to fact.”

Yes, there are waiting lists for some services — but, no, Canadians are not coming across the border in droves to get American care.

There’s misinformation among Canadians, too. Wherever I went, Canadians told me they thought, mostly based on what they said they heard on CNN and Fox, that Obamacare meant America was getting universal health coverage like their country has.

When I explained the law was simply another patch on a patchwork quilt of coverage, and the Congressional Budget Office had estimated last year there would still be some 30 million people without insurance, the reaction was “the news media didn’t tell us that.” A former deputy health minister in New Brunswick said to me, “After all that, you will still have 30 million people without coverage!”

Separating fact from opinion as the Canadian ambassador long ago urged was something I tried to do as I made my way across Canada while visiting there recently. In some ways, the Canadian system is very different from U.S. health care. In other ways, it’s very much the same and faces similar challenges in the years ahead.

What we don’t share

Although the Affordable Care Act in the U.S. calls for more people to have health insurance by offering subsidies and mandating all Americans have it or face penalties, the concept of universality is still a far distant goal. The Canada Health Act, on the other hand, calls for universality — all residents must be covered by the public insurance plan run by their province on uniform terms and conditions. They have coverage wherever they are treated in their home province, and there’s none of this stuff about limiting the doctors and hospitals that patients can use as a condition of getting full benefits. In Canada, there are no financial barriers to care at the point of service as there are and will continue to be in the U.S.

Canadians don’t pay coinsurance of 30 percent or 50 percent if they have an outpatient procedure or go to an urgent care clinic, charges that are becoming increasingly common here. They don’t worry about paying a gigantic bill if they happen to use an out-of-network doctor or hospital. The publicly-funded system north of the border bases patients’ access to medical services on need, not on the ability to pay. To use the word “ration,” Canadians ration by need; Americans ration by price and will continue to do so as the ACA is implemented.

Because it’s publicly funded, Canadian health care is more equitable. There’s no such thing as buying a platinum plan and getting first-rate coverage or a cheapo bronze policy and paying 60 per cent of the bill yourself. The tiered policies available in the state exchanges further bake inequality into the U.S. system. People have wildly varying benefits depending on where they live, how old they are, where they work, and how much they can afford to spend on health insurance.

That’s not the case in Canada, except when it comes to prescription drug coverage. Drug benefits are quite unequal in Canada, and the lack of them is a pretty big hole for about 10 percent of the population. There is no universal drug benefit, although two provinces have mandatory drug insurance — you can get it from an employer or buy it from a public plan. About 40 per cent of the population gets coverage from their employers. If you can’t afford the premium, there are subsidies. In that sense, Canadian drug coverage in those provinces resembles Obamacare. Still, having drug benefits does not necessarily mean adequate coverage, says Globe and Mail health columnist, André Picard: “The big difference from the rest of Canada’s system is there is very little first-dollar coverage of prescription drugs.”

On this trip I heard much more about the social determinants of health than I hear in the U.S. Almost everyone I interviewed mentioned the dismal health stats for aboriginal populations and the need to improve access and quality of care. I tried to remember the last time I heard anyone discuss the medical problems of Native Americans or quality of care provided by the Indian Health Service.

I asked Michael Decter, a health policy expert and a former deputy health minister in Ontario, what was his wish list for Canadian health care. Topping his list was not more money for the health system; it was more for education aimed at improving the lives of aboriginal peoples. Better education correlates with better health. The second was drug coverage. Canada’s infamous waiting times were not high on his list of priorities. In fact, he didn’t even mention them as a problem.

Trudy Lieberman, a former president of Association of Health Care Journalists, is a contributing editor to the Columbia Journalism Review. She is a fellow at the Center for Advancing Health where she blogs about paying for health care. This article is published with permission of the AHCJ. 

http://www.huffingtonpost.ca/trudy-lieberman/canadian-health-care_b_4683089.html

Oncologists Call for Single-Payer System

By Charles Bankhead
MedPage Today, Jan. 29, 2014

Oncologists have a “moral and ethical obligation” to their patients to advocate for a single-payer universal health insurance program, according to two oncologists who stated their case in an editorial.

A single-payer system would simplify healthcare delivery for patients and providers without sacrificing quality of care, said Ray Drasga, MD, and Lawrence Einhorn, MD, in an editorial published online in the Journal of Oncology Practice, a journal of the American Society of Clinical Oncology.

The switch to such a national system would face huge and innumerable challenges, but gradual implementation, perhaps even on a state-by-state basis, would reduce the administrative burdens, they wrote.

“Because the [Affordable Care Act or ACA] will fail to remedy the problems of the uninsured, the underinsured, rising costs, and growing corporate control over care giving, we cannot in good conscience stand by and remain silent,” said Drasga, a retired oncologist in Chicago, and Einhorn, of Indiana University in Indianapolis.

“Life is short, especially for some patients with cancer; they need help now.”

Making Their Case

Drasga and Einhorn state their case for a single-payer system by delineating problems that such a system could address:

  • Reduced administrative costs, which currently account for almost a third of healthcare expenditures
  • Eliminating many bankruptcies attributable to healthcare costs, which accounted for more than 60% of family bankruptcies identified in a 2009 report
  • Improved health, as indicated by evidence that being uninsured increases the mortality hazard by 40%
  • Building on an existing structure, noting that about 60% of all healthcare in the U.S. is publicly funded
  • Implementation of proven cost-containment strategies, which are absent from the ACA
  • Improving quality of care and outcomes by increasing access to care
  • Reverse the trend toward for-profit, investor-owned healthcare plans
  • Preserve physician’s income potential, as judged by experience with the Canadian healthcare system

The authors devoted special attention to the cost of drugs and devices. They cited a study showing that pharmaceutical companies charge 50% more in the U.S. than in Europe for the same drugs. Much of the difference can be traced to large outlays for marketing and for a 20% profit margin, they said. By comparison, research and development (R&D) accounts for about 13% of drug costs.

The Department of Veterans Affairs gets a 40% discount on medication by buying in bulk. Medicare is legally forbidden to negotiate drug prices.

“Lower drug prices would not jeopardize drug innovation,” Drasga and Einhorn stated. “Most true innovations in therapeutics (as opposed to me-too drugs that are slightly different versions of existing drugs) stem from publicly financed research.”

The issue of drug pricing is especially relevant to oncology, they added, where the median cost of a new drug has risen to $10,000 a month since 2010.

The authors called on ASCO to lead the way in advocating for a single-payer system, which would orient healthcare “toward care giving, not toward maximizing investors’ profits.”

ASCO has taken no position on a single-payer or other type of healthcare system, said ASCO chief executive officer Allen Lichter, MD.

“We have long advocated that every American deserves to have insurance coverage,” Lichter told MedPage Today. “We have advocated that those patients who receive a new cancer diagnosis and don’t have insurance should be placed into Medicare because facing a cancer diagnosis without insurance lowers your risk of survival, as Dr. Drasga and Dr. Einhorn pointed out in their paper.”

Payment Reform

Coinciding with the Drasga-Einhorn editorial, ASCO and the Community Oncology Alliance (COA) jointly issued principles for achieving payment reform in oncology.

The six principles focus on:

  • Oncologists taking a leadership role in payment reform
  • The inadequacy of current reimbursement models
  • The need for new models for delivering oncology services to ensure high quality and value
  • Retaining choices in payment models at the local level
  • Improved measurement of quality
  • The inadequacy and inequity of reimbursement for oncology drugs under Medicare Part B

The editorial provides “a good look at Nirvana,” but most community-based oncologists would find it difficult to embrace, said Mark Thompson, MD, president of the COA, which represents community oncology practices and centers.

“You can’t dispute a lot of the facts that they lay out in the article,” said Thompson, who practices at the Mark H. Zangmeister Center in Columbus, Ohio. “We do spend a huge amount of money in administering healthcare in the U.S.

“The difficulty that most of us who have spent any time in Washington — and I’ve spent a lot of time there — is the idea of making this public, which to me translates into government. I don’t think we have a government or a Medicare program that can handle all of the wonderful suggestions that they talk about.”

To the arguments against government-run programs, Drasga and Einhorn countered that “years of private-sector solutions have failed. There needs to be a major paradigm shift in our approach to funding healthcare in the U.S.”

Strong opposition to a single-payer system is to be expected because a lot of money is at stake, Drasga told MedPage Today. Several academic oncologists turned down Drasga’s offer of co-authorship before Einhorn accepted.

“I think they were afraid that it might hurt their relationship with pharma,” he said. “A lot of research is funded by the pharmaceutical industry. There are a lot of powerful forces that do not want to see something like socialized insurance come along.”

Nirvana or not, the single-payer approach is coming, Drasga continued. Vermont has set the process in motion by starting implementation of a state-run single-payer system. Total implementation is anticipated by 2017.

“Once one or two states get programs in place and see that they can save millions and millions of dollars, plus insure everybody, I think we could see a snowball effect,” he said.

The Vermont program is envisioned as “kind of a Medicare for all, but at the state level,” said Deb Richter, MD, a primary care physician from Montpelier who also is on the board of directors of Green Mountain Healthcare, the organization coordinating implementation of the state’s single-payer plan.

Program leaders still have to jump through a lot of legislative and bureaucratic hoops (including waivers from the ACA and Medicare), but they remain optimistic the plan will be fully operational by 2017. The waivers could provide a portion of the funding for system, but the state still has to come up with extra revenue, currently estimated at $1.6 to $2 billion.

The Green Mountain board will submit revenue options to the state legislature in March.

When fully implemented, the plan will leave little business for private insurers, Richter said. The state plans to accept bids for administration of the system, but the market for private insurers will be limited to Vermonters who opt out of the state-run plan.

Whether support for a single-payer system catches fire remains to be seen, but reaction to the Drasga-Einhorn editorial has been limited thus far in the week-plus since the online article appeared, said journal editor John Cox, DO, of Texas Oncology in Dallas.

“The intention was to stir the pot the little, and I suspect we will because this is an issue that has a lot of strong feelings on both sides,” Cox told MedPage Today.

Charles Bankhead is a staff writer at MedPage Today.

http://www.medpagetoday.com/HematologyOncology/OtherCancers/44034

OncoBlog: Single-Payer, the Authors Respond

By Charles Bankhead
MedPage Today, February 6, 2014

When two oncologists wrote an editorial to make a case for a single-payer healthcare system, the response was immediate, abundant, and passionate — on both sides of the issue. One reader, Gary Jones, AA-C, of Case Western Reserve in Cleveland, wrote apoint-by-point rebuttal of the editorial, which set off another round of verbal jousting among MedPage Today readers. In response to the rebuttal by Jones, the two oncologists, Ray E. Drasga, MD, of Chicago, and Lawrence Einhorn, MD, of Indiana University in Indianapolis, submitted their own point-by-point response, published here as a guest blog.

“We read the rebuttal by Mr. Jones and appreciate his time and effort to comment upon our article in Journal of Oncology Practice (JOP). Medical oncologists are particularly data-driven and make clinical decisions based upon evidence-based medicine. Initially, data becomes information which can then lead to a change in standard practice. However, sometimes data simply permits us to form opinions and write commentaries.

“We did not expect complete congruence among the readers of the JOP paper. We realized the conclusions we reached would be contentious with a certain segment of the intended audience. H.L. Mencken once opined, ‘For every complex problem there is an answer that is clear, simple, and wrong.’ However, that does not mean we should avoid solutions for difficult issues, nor accept that the current status quo in healthcare is immutable. With these points in mind, we would like to respond to the points [in boldface below] that were raised by Mr. Jones.”

1. Overhead costs for Medicare and Medicaid are higher than those in the private sector. Calculating the overhead costs based on the Medicare trustees’ report rather than using Zycher’s methodology dramatically changes per-capita spending. For example in 2005, Medicare’s per-capita spending was $144 compared with $680 in the private sector. Medicare’s overhead of 1.4% includes all types of nonmedical spending by the Centers for Medicare and Medicaid Services, as well as other federal agencies, such as the IRS, and is based on data contained in the latest report of the Medicare trustees. Alternative estimates aren’t credible and have been refuted elsewhere. Under the Affordable Care Act, insurers are allowed overhead and profits of 15% of premiums, or 10-fold Medicare’s.

2. Data on bankruptcies related to healthcare costs are inaccurate or misleading. The high proportion (three-fourths) of people with coverage at the onset of illness or injury demonstrates how widespread the problem of under-insurance is. This is particularly the case for cancer patients, who face high deductibles, copays, and high medication costs even with coverage. When you add the under-insured to the uninsured, about 80 million Americans would be financially devastated by a serious illness. In a recent study from the CDC, one-fourth of Americans reported having problems paying medical bills. We have a national problem and need a national solution. Medical bankruptcies in Canada are unheard of.

3. Outcomes with Medicare and Medicaid should be compared with those of private-sector payers, not with the underinsured or uninsured. Medicare is better than private insurance at controlling costs, and beneficiaries are more satisfied with their coverage. Furthermore, studies show that the private Medicare Advantage plans that participate in the Medicare program raise Medicare’s costs by 14% per beneficiary — over $34 billion annually.

4. Using the existing publicly funded system as the foundation for a single-payer system makes little sense. Instead of building on the existing system run by private insurers, who consider every dollar spent on healthcare to be a “loss,” we propose the U.S. adopt a nonprofit national health insurance program, like an improved Medicare for all. We propose to stop using public funds to enrich the drug and insurance companies. We are already paying for comprehensive coverage for everyone, but we aren’t getting it.

5. Government-mandated cost-containment strategies will not work. Effective cost-containment strategies are well known and include implementing global budgets for hospitals, negotiated fees with providers, and bulk-purchasing of drugs and medical supplies. Although it’s better at controlling costs than private insurers, if the U.S. Medicare program was as good at controlling costs as Canada’s is for care of the elderly, the U.S. would have saved over $2 trillion since 1980, when our health systems diverged.

6. Increased access to care does not assure improved quality of care or outcomes. The U.S. ranks 19th out of 19 high-income countries in preventing deaths amenable to medical care, and while we are improving slightly, other countries are improving faster, so we are falling further behind.

7. Reverse the trend toward government-funded healthcare and empower patients by increasing choices. People don’t want to be free to choose between two or three or 300 overpriced, defective insurance products. They want to choose their doctors and know they will receive medically necessary healthcare if they become ill or injured. Private insurance with its “skinny” networks means that people have a limited choice of oncologists and may have to change doctors annually.

8. Physician income will decrease as government-funded healthcare increases. Once you factor in lower malpractice costs in Canada and their much lower overhead to run a practice, the difference in earnings isn’t that great. Besides, with our much greater level of health spending (twice Canada’s) we can afford to continue to pay physicians well.

OncoBlog is a blog by the MedPage Today staff for readers with an interest in oncology. This post comes from guest bloggers Ray Drasga, MD, and Lawrence Einhorn, MD.

More than 7,100 deaths likely from states’ rejection of Medicaid expansion: Health Affairs Blog

Harvard and CUNY researchers say death toll from 25-state ‘opt-out’ may be as high as 17,100 annually; hundreds of thousands more will be harmed by depression, untreated diabetes, and skipping mammograms and pap smears

FOR IMMEDIATE RELEASE, January 30, 2014
Contact: Mark Almberg, communications director, PNHP, (312) 782-6006,  mark@pnhp.org

The decision by 25 states to reject the expansion of Medicaid coverage under the Affordable Care Act will result in between 7,115 and 17,104 more deaths than had all states opted in, according to researchers at Harvard Medical School and the City University of New York.

The study, the first detailed estimate of the health impact of the states’ decision to reject the Medicaid expansion (with state-by-state data as well), is being published today at the Health Affairs Blog.

The researchers found that because of the states’ “opting out” of the Medicaid expansion, 7.78 million people who would have gained coverage will remain uninsured. In addition to the thousands of excess deaths associated with that lack of coverage, the rejection of the Medicaid expansion will have the following likely impacts:

* 712,037 more persons diagnosed with depression
* 240,700 more persons suffering catastrophic medical expenses
* 422,533 fewer diabetics receiving medication
* 195,492 fewer women receiving mammograms and
* 443,677 fewer women receiving pap smears

“We calculated the number and characteristics of people who will remain uninsured as a result of their state’s opting out of the Medicaid expansion, and applied these figures to the known effects of insurance expansion from prior studies,” said Samuel Dickman, a third-year medical student at Harvard Medical School and the study’s lead author. “The results were sobering. Political decisions have consequences, some of them lethal.”

Dickman and his colleagues, longtime health researchers at Harvard Medical School and the City University of New York, drew on demographic data from the Census Bureau’s 2013 Current Population Survey and estimates on Medicaid take-up rates from the Congressional Budget Office and elsewhere to characterize those who would remain uninsured in states opting out of Medicaid expansion.

They developed estimates of the health effects of remaining uninsured based on previous studies that used state-level data on Medicaid expansions and death rates, the National Health and Nutrition Examination Survey Mortality Follow-up, and the Oregon Health Insurance Experiment.

In addition to arriving at national estimates, the researchers were able to break the findings down by state.

For example, in Texas, the largest state opting out of the Medicaid expansion, approximately 2 million people who would otherwise have been insured will remain uninsured as a result of the state’s action.

“Texas’ refusal to accept federal money to expand Medicaid will result in 184,192 more people experiencing depression, 62,610 more people suffering catastrophic medical expenses, and as many as 3,035 avoidable deaths,” said Dr. Steffie Woolhandler, a professor of public health at the City University of New York who is also on the faculty at Harvard Medical School.

The study includes a table showing expected excess deaths and other harms from opting out of the Medicaid expansion on a state-by-state basis.

“Medicaid is far from perfect,” said Dr. David Himmelstein, who also teaches at CUNY and Harvard. “In many parts of the country Medicaid pays so little that patients have trouble finding a doctor who will accept it. A single-payer program like Canada’s that covers all Americans is a far better solution for both the poor and the middle class. But until we get to single payer, Medicaid is the only safety net for many low-income Americans.”

Woolhandler and Himmelstein are also co-founders of Physicians for a National Health Program, a nonprofit research and education organization of more than 18,000 doctors who support single-payer national health insurance. PNHP had no role in funding or otherwise supporting the study.

A link to the study at the Health Affairs Blog is available here.

*****

“Health and Financial Harms of 25 States’ Decision to Opt Out of Medicaid Expansion.” Samuel L. Dickman, A.B.; David U. Himmelstein, M.D.; Danny McCormick, M.D., M.P.H.; Steffie Woolhandler, M.D., M.P.H. Health Affairs Blog, January 30, 2014.

State Medicaid opt-out will cost over 7,000 lives, maybe 17,000

Opting Out Of Medicaid Expansion: The Health And Financial Impacts

By Sam Dickman, David Himmelstein, Danny McCormick, and Steffie Woolhandler
Health Affairs Blog, January 30, 2014

The Affordable Care Act (ACA) was designed to increase access to health insurance by: 1) requiring states to expand Medicaid eligibility to people with incomes less than 138 percent of the Federal Poverty Level (FPL) ($19,530 for a family of three in 2013), with the cost of expanded eligibility mostly paid by the federal government; 2) establishing online insurance “exchanges” with regulated benefit structures where people can comparison shop for insurance plans; and 3) requiring most uninsured people with incomes above 138 percent FPL to purchase insurance or face financial penalties, while providing premium subsidies for those up to 400 percent of FPL.

Recent studies suggest that Medicaid expansion will result in health and financial gains.  Older studies also found salutary health effects of expanded or improved insurance coverage, particularly for lower income adults.

The Supreme Court ruled in June 2012 that states may opt out of Medicaid expansion, and as of November 2013, 25 states have done so.

The Consequences of Opting Out

The Supreme Court’s decision to allow states to opt out of Medicaid expansion will have adverse health and financial consequences. Based on recent data from the Oregon Health Insurance Experiment, we predict that many low-income women will forego recommended breast and cervical cancer screening; diabetics will forego medications, and all low-income adults will face a greater likelihood of depression, catastrophic medical expenses, and death.

The ACA’s tax subsidy for insurance purchase on the Exchanges is only available to persons with incomes above 100 percent of FPL.  People below this threshold in opt-out states (the so-called low-income “coverage gap”) will see no benefit as the law goes into effect.  They may even see harm because the ACA cuts disproportionate share (DSH) funding to safety net hospitals, reducing the resources available to care for the remaining uninsured.

Examining the numbers

Nationwide, 47,950,687 people were uninsured in 2012; the number of uninsured is expected to decrease by about 16 million after implementation of the ACA, leaving 32,202,633 uninsured.  Nearly 8 million of these remaining uninsured would have gotten coverage had their state opted in.  States opting in to Medicaid expansion will experience a decrease of 48.9 percent in their uninsured population versus an 18.1 percent decrease in opt-out states.

We estimate the number of deaths attributable to the lack of Medicaid expansion in opt-out states at between 7,115 and 17,104.  Medicaid expansion in opt-out states would have resulted in 712,037 fewer persons screening positive for depression and 240,700 fewer individuals suffering catastrophic medical expenditures. Medicaid expansion in these states would have resulted in 422,553 more diabetics receiving medication for their illness, 195,492 more mammograms among women age 50-64 years and 443,677 more pap smears among women age 21-64. Expansion would have resulted in an additional 658,888 women in need of mammograms gaining insurance, as well as 3.1 million women who should receive regular pap smears.

http://healthaffairs.org/blog/2014/01/30/opting-out-of-medicaid-expansion-the-health-and-financial-impacts/

Comment:

By Don McCanne, M.D.

Apparently for no other purpose than to make a political statement, politicians in about half of our states are willing to expose about 8 million poor people to further financial hardship and greater impairment in health care access. More than 7,000 of those people will die as a result. That’s not simply politics; that’s a crime!

In a PNHP press release, Dr. David Himmelstein, co-author of the study and co-founder of PNHP said it well: “Medicaid is far from perfect. In many parts of the country Medicaid pays so little that patients have trouble finding a doctor who will accept it. A single-payer program like Canada’s that covers all Americans is a far better solution for both the poor and the middle class. But until we get to single payer, Medicaid is the only safety net for many low-income Americans.”

PNHP press release: https://www.pnhp.org/news/2014/january/more-than-7100-deaths-likely-from-states-rejection-of-medicaid-expansion-%C2%A0health-a

State Medicaid opt-out will cost over 7,000 lives, maybe 17,000

Opting Out Of Medicaid Expansion: The Health And Financial Impacts

By Sam Dickman, David Himmelstein, Danny McCormick, and Steffie Woolhandler
Health Affairs Blog, January 30, 2014

The Affordable Care Act (ACA) was designed to increase access to health insurance by: 1) requiring states to expand Medicaid eligibility to people with incomes less than 138 percent of the Federal Poverty Level (FPL) ($19,530 for a family of three in 2013), with the cost of expanded eligibility mostly paid by the federal government; 2) establishing online insurance “exchanges” with regulated benefit structures where people can comparison shop for insurance plans; and 3) requiring most uninsured people with incomes above 138 percent FPL to purchase insurance or face financial penalties, while providing premium subsidies for those up to 400 percent of FPL.

Recent studies suggest that Medicaid expansion will result in health and financial gains.  Older studies also found salutary health effects of expanded or improved insurance coverage, particularly for lower income adults.

The Supreme Court ruled in June 2012 that states may opt out of Medicaid expansion, and as of November 2013, 25 states have done so.

The Consequences of Opting Out

The Supreme Court’s decision to allow states to opt out of Medicaid expansion will have adverse health and financial consequences. Based on recent data from the Oregon Health Insurance Experiment, we predict that many low-income women will forego recommended breast and cervical cancer screening; diabetics will forego medications, and all low-income adults will face a greater likelihood of depression, catastrophic medical expenses, and death.

The ACA’s tax subsidy for insurance purchase on the Exchanges is only available to persons with incomes above 100 percent of FPL.  People below this threshold in opt-out states (the so-called low-income “coverage gap”) will see no benefit as the law goes into effect.  They may even see harm because the ACA cuts disproportionate share (DSH) funding to safety net hospitals, reducing the resources available to care for the remaining uninsured.

Examining the numbers

Nationwide, 47,950,687 people were uninsured in 2012; the number of uninsured is expected to decrease by about 16 million after implementation of the ACA, leaving 32,202,633 uninsured.  Nearly 8 million of these remaining uninsured would have gotten coverage had their state opted in.  States opting in to Medicaid expansion will experience a decrease of 48.9 percent in their uninsured population versus an 18.1 percent decrease in opt-out states.

We estimate the number of deaths attributable to the lack of Medicaid expansion in opt-out states at between 7,115 and 17,104.  Medicaid expansion in opt-out states would have resulted in 712,037 fewer persons screening positive for depression and 240,700 fewer individuals suffering catastrophic medical expenditures. Medicaid expansion in these states would have resulted in 422,553 more diabetics receiving medication for their illness, 195,492 more mammograms among women age 50-64 years and 443,677 more pap smears among women age 21-64. Expansion would have resulted in an additional 658,888 women in need of mammograms gaining insurance, as well as 3.1 million women who should receive regular pap smears.

http://healthaffairs.org/blog/2014/01/30/opting-out-of-medicaid-expansio…

Apparently for no other purpose than to make a political statement, politicians in about half of our states are willing to expose about 8 million poor people to further financial hardship and greater impairment in health care access. More than 7,000 of those people will die as a result. That’s not simply politics; that’s a crime!

In a PNHP press release, Dr. David Himmelstein, co-author of the study and co-founder of PNHP said it well: “Medicaid is far from perfect. In many parts of the country Medicaid pays so little that patients have trouble finding a doctor who will accept it. A single-payer program like Canada’s that covers all Americans is a far better solution for both the poor and the middle class. But until we get to single payer, Medicaid is the only safety net for many low-income Americans.”

PNHP press release: https://pnhp.org/news/2014/january/more-than-7100-deaths-likely-from-…

Western N.Y. physicians call for single-payer health system

By Henry Davis
The Buffalo News, Jan. 28, 2014

If Buffalo is any indication, the campaign for single-payer health insurance didn’t die with the Affordable Care Act.

Advocates in Western New York remain undaunted despite a discouraging history of defeat in the United States in the quest for a Medicare-for-all type health system.

They and others nationwide have seized on the shortfalls and technical problems during the roll out of President Obama’s health care law to refocus attention on a single-payer system similar to Canada’s.

“The same forces that created the disparity and injustice in our health system shaped Obamacare,” said Dr. Kathleen Grimm, a pediatrician and internal medicine specialist who heads a local chapter of Physicians for a National Health Program.

The fledgling chapter is small – about 12 core people – but it represents the most organized effort here in recent memory to pursue single payer.

The group is sponsoring a public talk by Dr. Andy Coates, president of Physicians for a National Health Program, from 5:30 to 7:30 p.m. Thursday in D’Youville College’s Madonna Lounge.

Coates also will visit the University at Buffalo on Friday to encourage more medical students to get involved.

“We have to take sentiment and turn it into action,” said Dr. Robert Milch, a co-founder and the former medical director of Hospice Buffalo, at a recent meeting of the local chapter.

Members like Milch point with optimism to Vermont, which is moving ahead with plans for a statewide single-payer system that could begin in 2017 if officials can agree on a way to finance it.

Vermont is taking advantage of a provision in the Affordable Care Act that allows states to try other ideas for health reform as long as they meet certain standards for cost and coverage.

“Vermont has the best chance to become the single-payer laboratory for the rest of the country,” said Dr. Deb Richter, a former Buffalo physician who heads Vermont Health Care for All, the leading advocacy group in Vermont for a single-payer system.

Single-payer health care is not socialized medicine, in which doctors and hospitals work for the government. It’s a system in which the government is the primary payer of care. Medicare, the federal health plan for those 65 and older, exemplifies a single-payer system.

The case Grimm and others make against the existing health system begins with the fact that the U.S. spends almost twice as much as other developed nations on care. However, the measurable results are at best the same, and problems persist with patient safety, poor access and coordination of care as patients move from one setting to another.

They argue that administrative waste consumes an enormous share of health spending and creates bureaucratic hassles, a problem studies have documented.

The existence of multiple private insurers, for instance, means hospitals and doctors must administer many different contracts with different coverage and policies.

To single-payer advocates, the Affordable Care Act maintains an inefficient, complicated and dysfunctional health system in which policy is influenced by powerful lobbies and medical decisions too often are dictated by financial issues.

“It is very simple in medicine today: If there is a profit motive, you are going to do more,”said Dr. Roberto Diaz Del Carpio, an internal medicine specialist.

“Health care has become a commodity,” he said. “That works if we we’re talking about something like iPhones, and my product is better than someone else’s. But everyone should have good insurance.”

Advocates also criticize the health law for failing to cover millions of Americans while keeping an increasingly costly insurance system tied to employment.

“I see so many people who want to go back to work but fear losing their Medicaid coverage. Health insurance oppresses them,” said Jessica Bauer Walker, executive director of the Community Health Worker Network of Buffalo.

Henry Davis is News Medical Reporter.

http://www.buffalonews.com/city-region/medical/western-new-york-physicians-call-for-single-payer-health-system-20140128

Single-payer medical care system would improve Americans’ health

By Jessica Bauer Walker
The Buffalo News, Jan. 28, 2014

By Jessica Bauer Walker

The U.S. health care system is sick. We spend twice as much as any other country on medical care and have the best technological advances in the world. Yet our health outcomes are the worst of any industrialized nation, consistently ranking 30th or worse on the World Health Organization index.

Many factors influence health. Research has shown that public health is supported in large part by investment in preventative care as well as the “social determinants of health” such as access to a good education, nutritious food and jobs that pay a living wage.

The Affordable Care Act, or Obamacare, makes some good efforts at improving our health care system. Prohibition of denial of coverage to individuals with pre-existing conditions, expansion of Medicaid, raising the age limit for coverage for young adults on their parents’ plans, and investments in community-based health centers and Community Health Workers in under-served neighborhoods will all improve quality and access in health care.

But we need to go further. An estimated 23 million will still be uninsured by 2019. Many more will be left with inadequate coverage to meet their needs, vulnerable to the epidemic of medical debt, which is the number one cause of bankruptcy in the United States.

In America, we believe citizens have certain rights. We mandate children’s education through public schools, and provide legal representation to those accused of a crime who cannot afford to hire their own. How is it that we do not believe health to be a human right, but instead treat it as a commodity? Health care is bought and sold, controlled by private interests such as insurance and pharmaceutical companies, and increasingly by for-profit hospitals and health care providers.

There is a cheaper, better, more humane way. Single-payer health insurance would create one public agency to organize health financing. Delivery of care would remain largely private but, like Medicare, would cover individuals for all medically necessary services.

Such a system, utilized by many countries healthier than ours, gives patients more choice over their provider and services, and doctors more autonomy to focus on care. Streamlining payment through one nonprofit payer would free up one-third of every health care dollar currently spent on advertising and paperwork, saving more than $400 billion per year – enough to provide comprehensive, high-quality coverage for all Americans.

Buffalo is undergoing revitalization, and part of it needs to be policy changes necessary to create the healthy people who will be the backbone of any robust society and economy. With an eye to the future, let us ask our local, state and national leaders to ensure health and health care as a human right.

Jessica Bauer Walker is executive director of the Community Health Worker Network of Buffalo.

http://www.buffalonews.com/opinion/another-voice/another-voice-single-payer-medical-care-system-would-improve-americans-health-20140128

Vermont tests single payer and the country is watching

By Darshak Sanghavi, M.D., and Sarah Bleiberg
KevinMD blog, Jan. 28, 2014

While the Affordable Care Act, or Obamacare, has been criticized by its opposition as “socialized medicine,” it relies heavily on private health insurance. On the other end of the political spectrum is the idea that a government-run single payer system, similar to Canada’s, is the best way to deliver health care. (This is sometimes shorthanded in the U.S. as “Medicare for All.”) However, this system has been believed politically impossible here—until now. In May 2011, Governor Pete Shumlin of Vermont signed into law “An Act Relating To A Universal And Unified Health System,” House Bill 202 (HB 202), establishing a single payer health care system beginning in 2017. In passing this legislation, Vermont has become a closely watched laboratory for health reform.

What are the pros and cons of a “single payer” system?

In general, single payer health care means that all medical bills are paid out of a single government-run pool of money. Under this system, all providers are paid at the same rate, and citizens receive the same health benefits, regardless of their ability to pay.

There are a number of proposed benefits to a single payer system. Currently, providers must follow different procedures with each of many insurance companies to get paid, creating an enormous amount of administrative work. Under a single payer system, providers might reap significant savings from reduced administrative expenses, and be able to focus more on delivering care. As with Medicare, a single payer system may also give the state stronger leverage to negotiate lower rates for drugs, medical devices, payments to providers and other expenses, resulting in lower overall costs. Additionally, a single payer system provides universal access to health insurance, which eliminates the problem of the uninsured.

However, Vermont’s innovative proposal still leaves room for further improvement. Specifically, a single payer system alone does not address “fee-for-service” reimbursement for providers, which may encourage overuse and does not recognize quality and value. Other concerns also exist. Generally, private insurance rates have been substantially higher than Medicare rates, and providers worry that universal rate setting may lead to overall lower revenues. Others have worried that Vermont does not have enough doctors, and an influx of newly insured citizens may result in longer wait times and inability to access health care when necessary.

What does Vermont’s law actually do?

HB 202 established Green Mountain Care (GMC) and sets Vermont on track to have a single payer health care system beginning in 2017.

Here’s how it will work: All Vermont residents will automatically be eligible for GMC. Private insurance companies will no longer sell insurance in the state, but federal employees as well as employees of self-insured companies, will continue to receive their employer sponsored plans. In these cases, their health insurance will be supplemented by GMC. When a patient with GMC goes to the doctor, hospital or other caregiver, all of their expenses will be billed to GMC. Someone with GMC as their secondary coverage will have this option available to them if their primary insurance is not as comprehensive as GMC.

On the back end, GMC will combine the money Vermont currently receives from Medicaid, other federal funding available through the Affordable Care Act, and a yet-to-be-determined new tax on individuals and employers. For now, Medicare funding will remain separate. However, Vermont may choose to fold this funding into GMC as well, in the future.

The Green Mountain Care Board (GMCB) will control GMC. They will oversee the development and implementation of new payment models, provide a recommendation to the legislature on the benefit package and budget for GMC, and set rates for provider reimbursement. Parts of GMC will also be contracted out to private companies including claims administration and provider relations.

For now, Vermont is still required to set up a health insurance exchange available to all residents, in accordance with the Affordable Care Act. But when GMC rolls out in 2017, the exchange will either be eliminated or may still be available in some form if GMC ends up offering multiple benefit plan options.

What obstacles remain?

To begin with, HB 202 requires the GMCB to certify that Vermont’s plan meets a number of conditions before it can be implemented: GMC will not negatively impact the economy, GMC will reduce the rate of growth of Vermont’s health care costs, the financing plan for GMC will be sustainable, administrative costs will be reduced, all Vermonters will have health insurance that covers at least 80% of their health care costs, and providers will be reimbursed at a reasonable rate. Additionally, Vermont will need to apply for waivers from the federal government, as well as the Medicare and Medicaid programs in order to combine all of the funding it receives from these programs into GMC. These requirements pose a serious challenge to the implementation of GMC. While the state has begun working towards these goals, several uncertainties remain.

First, the state needs to figure out how much the plan will cost. A report from the University of Massachusetts Medical School estimated that the total cost of the healthcare system in 2017 will be $5.9 billion. This number is based on the assumption that GMC would pay providers at 105% of what Medicare currently pays them, which is more than they receive from Medicaid but less than what they currently receive from private payers. Using this estimate, the state would need to raise $1.6 billion to supplement the funding it will receive from the federal government, Medicare and Medicaid. An opposing group, including providers, payers, and the business community commissioned its own report which assumed the rates would be between 115% and 125% of Medicare, raising the cost estimate to between $1.9 and $2.2 billion. The differing estimates in these reports mostly demonstrate the increasing concern from various healthcare stakeholders regarding the Shumlin administration’s plan. However, they also make the point that much is still unknown about how much GMC will cost in 2017.

Second, the state hasn’t decided how to raise this money. The report they released stated that there were a number of possible revenue sources that require further study before a final decision is made. However, Governor Shumlin has indicated that that a payroll tax (similar to the one funding Medicare now) would likely play a large part in the final financing plan. Based on an estimate from the UMass report that a 1% payroll tax could raise $119 million, a financing plan would have to include a fairly large payroll tax or a combination of taxes to cover the $1.6 billion that is estimated to be necessary. (Any tax would be in place of the current premiums and other health insurance costs that individuals and employers pay.) Governor Shumlin has said that he will announce his financing plan in a year, but some believe this is too long to wait. Senator Peter Galbraith, a Democrat, introduced a bill proposing an 11% payroll tax on employers and a 2% payroll tax on individuals, combined with a tax on other earnings such as capital gains, to fund GMC.

Third, planning and execution must proceed in an orderly manner. As the recent Obamacare exchange roll-out demonstrated, this can be a difficult process. Still, such planning has begun. In addition to the looming issues of how much it will cost and where the money will come from, the legislature is beginning to look at when to begin collecting funds, how much providers will be paid, malpractice reform, a benefits package, and many other pertinent issues.

Vermont has committed to an innovative path, even though much is still up in the air as to what Green Mountain Care will actually look like in 2017. One thing is clear, the rest of the country will be watching Vermont’s success or failure closely.

Darshak Sanghavi is a pediatric cardiologist and fellow and managing director, Engelberg Center for Health Care Reform at the Brookings Institution.  Sarah Bleiberg is a research assistant, Engelberg Center for Health Care Reform.  They can be reached on Twitter @BrookingsMed.

http://www.kevinmd.com/blog/2014/01/vermont-tests-single-payer-country-watching.html

Medical school students lobby Albany for single payer health plans

By Kyle Hughes
The Oneida (N.Y.) Daily Dispatch, Jan. 28, 2014

ALBANY, N.Y. — A group of 70 medical school students held their first-ever Capitol lobbying day Tuesday, calling for universal health care, medical marijuana and reining in insurers that now account for a third of the cost of healthcare here.

One of the organizers of Medical Student Advocacy Day, Albany Medical College student Ajay Major, said he was inspired by the problems he said first-hand among backstretch workers at Saratoga Race Course.

“When I was in college I volunteered as a public health worker and an interpreter at the race track up in Saratoga,” Major said. “These workers, most of whom were shipped up with the horses, (who are) from Central America, live in small concrete cubes with minimal pay, long hours and a dangerous job. They have no formal healthcare in this country for their acute or their chronic conditions.”

“Local physicians, public health workers and social workers created a two bed clinic run out of an old double-wide trailer,” the Indiana resident added. “The clinic, supported by donations from local hospitals, was entirely free of charge to its patients. The clinic provided the entire spectrum of care … I’m here today because I was inspired by my colleagues at the race track who understood that it was their duty as healers to provide for their patients.”

He said those kinds of selfless acts of providing healthcare is viewed as extraordinary when it should be the norm.

“Not only is the U.S. the only developed country without universal healthcare, we’re also paying twice as much per capita on healthcare as other industrialized nations,” said student Xin Guan, who came to study at Albany Med from California. “Does this mean we provide better care? No, in fact we are falling behind in all measures of morbidity and mortality.”

She said medical bills are the reason behind 62 percent of all personal bankruptcies, and noted that even with Obamacare, about 30 million people in the U.S. will lack health insurance. “Thirty-one percent of every healthcare dollar goes into private insurance bureaucracy,” she said.

Another student, Phyllis Ying of Seattle, said when she volunteered at farmers markets, doctors organized to bring healthy food to poor residents of Albany’s South End. “For our patients, being their advocate is essential,” she said. “As one of the South End parents said to me, ‘we need this.’ “

The bills the group lobbied in favor of Tuesday included:

• A4440/S2397: Prohibits participation in torture and improper treatment of prisoners by health care professionals, a measure that has been introduced in part as a response to post 9/11 actions by the U.S. government. The bill memo says “There is very strong evidence that U.S. health professionals have been directly engaged in or complicit in torture and other cruel, inhuman or degrading treatment of prisoners and detainees. The situation does not appear to be that of a few errant individuals, but a more systemic problem, facilitated by official policy.”

• A5389/S2078: Establishes the New York Health program, a comprehensive system of access to health insurance for New York state residents. The bill “would create a universal single payer health plan — New York Health — to provide comprehensive health coverage for all New Yorkers.” It would replace private insurance and be financed by a combination of state funds and payroll taxes. “Every New York resident would be eligible to enroll, regardless of age, income, wealth, employment, or other status. There would be no premium, deductibles, or co-pays. Coverage would be publicly funded.”

• A2889/S2717: Directs the commissioner of health to promulgate rules and regulations for the labeling of prescription drugs in languages other than English.

• A7648/S4283: Requires gluten contamination safeguards in food establishments owned, operated or leased by any department or agency of the state or SUNY. The bill mandates cross contamination safeguards to provide food safety for those with allergies or celiac disease.

• S1682: Provides for medical use of marijuana. The bill sets up a legal medical marijuana system for certified patients.

Kyle Hughes writes for NYSNYS News, a news service about government and politics based in the New York State Capitol, Albany.

http://www.oneidadispatch.com/general-news/20140128/medical-school-students-lobby-albany-for-single-payer-health-plans-medical-marijuana

Oncologists Call for a Single-Payer Healthcare System in US

By Roxanne Nelson
Medscape Medical News, Jan. 28, 2014

The Patient Protection and Affordable Care Act (ACA), known as Obamacare, will not solve the healthcare crisis that cancer patients face. The only real solution, according to 2 oncologists, is a single-payer system of national healthcare insurance.

The crisis in healthcare is felt “more acutely” by cancer patients because the cost of cancer care, particularly new cancer drugs, has soared in recent years, say Ray Drasga, MD, a community-based oncologist in Crown Point, Indiana, and Lawrence Einhorn, MD, professor of medicine at Indiana University Hospital in Indianapolis.

In a report published in the January issue of the Journal of Oncology Practice, Drs. Drasga and Einhorn call on their fellow oncologists and American Society of Clinical Oncology (ASCO) to advocate for a single-payer national health insurance program.

The medical system needs to be oriented toward caregiving, not toward maximizing investors’ profits, they say.

“We cannot in good conscience stand by and remain silent,” they write. “Life is short, especially for some patients with cancer; they need help now.”

“All of our patients deserve dignity,” they conclude. “It is our moral and ethical obligation as physicians to advocate for universal access to healthcare. Oncologists, working in conjunction with ASCO, are well positioned to educate legislators about single-payer national health insurance. The time to start is now.”

A single-payer system is one in which a public or quasipublic agency handles all healthcare financing. Depending on the particular system, healthcare delivery can remain in public or private hands. The system endorsed by the authors is basically “improved Medicare for all” and, in a number of ways, would resemble the current arrangement in Canada.

There would be universal, comprehensive coverage with free choice of providers, and all medical care would be covered, including provider visits, hospital care, prescription drugs, and rehabilitation, they explain. Copayments, deductibles, insurance premiums, and out-of-pocket expenses would be eliminated.

Cancer Care in Crisis Mode

Oncologists are finding it more difficult to care for patients because of the rising cost of treatment and the high prevalence of patients who are uninsured or underinsured, the authors note. Increasingly, oncologists are having to compromise on therapies so that patients can afford the treatment regimen.

“With the costs of cancer care skyrocketing out of control, most people with cancer are burdened not only physically, but also financially,” said Dr. Drasga in a statement. “They delay or do not receive care due to their inability to pay.”

Cancer patients feel the crisis in healthcare more acutely because of the high cost of drugs, tests, and procedures, he added. “For example, the cost of a new cancer drug has increased to a median price of $10,000 per month since 2010, and some drugs cost much more.”

The cost of care has been a continuing challenge for patients and their physicians. As previously reported by Medscape Medical News, oncologists often do not discuss the cost of drug therapy with their patients. Many are also unaware of how much medication actually costs their patients.

In 2011, Richard Sullivan, MD, from King’s Health Partners Integrated Cancer Centre in London, United Kingdom, and colleagues concluded that the cost of cancer care in high-income countries is becoming “unsustainable” ( Lancet Oncol. 2011;12:933-980). They noted that cancer care is rapidly becoming beyond the reach of all but the most affluent and the well-insured Americans, and that a drastic shift in cancer policy is needed to rein in current costs.

Dr. Drasga agrees. “The situation is worsening,” he said. “We need a fundamental shift in our approach to funding healthcare in the United States.”

In the United States, the healthcare system, including cancer care, has major problems. Millions are either uninsured or underinsured, the cost of medications is higher than in any other developed country, and the healthcare delivery system has transformed into an investor-owned business, Drs. Drasga and Einhorn point out.

Situation Will Worsen Under ACA

The ACA is not going to solve these issues, they note. It will not “remedy the problems of the uninsured, the underinsured, rising costs, [or] growing corporate control over caregiving.”

The authors note that 48.6 million people were uninsured in 2011. Although the ACA is expected to lower that number, the Congressional Budget Office estimates that 31 million Americans will still be uninsured in 2023.

Similarly, the issue of underinsurance or insufficient coverage is likely to persist, if not worsen. “Insurance plans with limited networks of providers, along with high deductibles, copays, and out-of-pocket costs, are making underinsurance the new normal,” they say. “The most affordable plans on the state health exchanges, the bronze and silver plans, leave 30% or 40% of healthcare costs, respectively, to be paid by policyholders.”

In the ACA, the private insurance industry remains at the center of the health system. Drs. Drasga and Einhorn believe that the current trend toward high-deductible health plans, underinsurance, and cost shifting to patients will almost certainly get worse.

With the initiation of a single-payer plan, administrative overhead, which places an enormous economic burden on both physicians and facilities, would be dramatically reduced, the authors point out. Currently, 31% of every healthcare dollar in the United States is used for administrative overhead, which is double the rate in Canada. Although Canada has a separate insurance plan in each province, the situation in the United States is even more complex.

Each of the hundreds of insurance companies and thousands of different private plans has departments for marketing, eligibility determination, claims processing, and use review, not to mention profits to fund.

“As a result, private insurance overhead averages 14.0% of premiums, compared with the traditional overhead of Medicare of just 1.4%,” they note.

“Overhead accounts for more than one quarter of all hospital spending in the United States because of the need to generate itemized per-patient bills for a plethora of plans and haggle over how much insurers will pay,” they add.

The ACA has failed to address many of the problems in the American healthcare system, and years of solutions emanating from the private sector have failed. Therefore, there needs to be a “major paradigm shift” in the approach to funding healthcare, Dr. Drasga and Dr. Einhorn conclude.

The authors have disclosed no relevant financial relationships.

J Oncol Pract. 2014;10:7-11. Abstract

http://www.medscape.com/viewarticle/819839