By Jessica Schorr Saxe, M.D.
The Charlotte (N.C.) Observer, Jan. 17, 2014

Are we a nation of people waiting to have medical insurance so that we can spend our time seeking unnecessary medical care? Really?

The true problem is that many of us don’t get needed care.

Yet the myth of overuse reverberates throughout health care discussions. The myth is applied across socioeconomic classes – though differently. For the poor, it is argued that Medicaid will lead to unnecessary utilization and increased cost. For the privately insured, the myth suggests that people need high deductible health plans (HDHPs) to deter them from using medical care frivolously.

A recent study showed increased emergency department (ED) use for non-urgent conditions in Oregon patients who had recently gotten Medicaid through a lottery. It looked at short-term results of a largely white urban population. Much discussed in the media, it has been used as a warning against Medicaid expansion. It was not suggested that the care was unnecessary – just that much of it could have been provided in an outpatient setting.

Not as publicized was the recent national study of thousands of patients, examining their ED use by health insurance type. It found that Medicaid and privately insured patients used EDs similarly for acute problems, but Medicaid patients were more likely to use the ED for less serious conditions because they lacked other sources of health care. One might infer that the solution is to ensure that Medicaid patients have access to primary care, which is better and more cost-effective for non-urgent conditions.

For the privately insured, it is argued that, with HDHPs, consumers will be more conscious of their expenditures, use less care, and thus save money – largely for employers and insurers. If people have lower premiums and aren’t sick, they may also save money. But those who actually need health care may find themselves with large out-of-pocket expenses. According to the nonpartisan Kaiser Family Foundation, about one third of non-elderly adults had difficulty paying medical bills in 2012. Of people with medical debt, 70 percent are insured, mostly with employer-sponsored insurance – and more likely to have HDHPs.

And what about health, which health insurance is supposed to promote? The nonpartisan Robert Wood Johnson Foundation notes that cost-sharing (deductibles, co-pays and co-insurance) indeed cuts down on use of services, but that patients are as likely to forgo necessary as unnecessary care. Increases in cost-sharing have the worst impact on vulnerable populations, such as the poor, elderly and chronically ill.

Why isn’t anyone talking about the real American epidemic: the underuse of necessary care? A 2012 survey showed that 58 percent of Americans deferred medical care due to cost.

As a family physician, I live with this reality. I think of a patient who had rectal bleeding and one with life-threatening high blood pressure, who avoided the ED because of expense. I see patients who “stretch” their medications to make them last or miss needed visits for lack of co-pays.

Here’s another clue to possible underuse. Though we spend more per person than other countries, we actually use less health care. For example, Americans average 4 doctor visits a year compared to 7 in France and Canada, countries with better health outcomes than ours.

Whether others have health care matters to all of us. We all benefit when our colleagues aren’t working with chronic untreated conditions and our food servers don’t have coughs they can’t afford to have evaluated.

While many of us might have a story about someone who goes to the doctor more than necessary, the evidence asserts that lack of care is a much bigger problem. Even when insured, Americans have better things to do than wait in doctor’s offices when they don’t need to. But many who need health care don’t get it.

We should expand Medicaid, increase availability of primary care, and give access to our disproportionately sick population. Then we should move beyond Obamacare to improved health care for everyone. Other industrialized countries provide access to all, with lower costs and better health outcomes. Like them, we should eliminate insurance companies and for-profit medicine and expand health care to all.

Dr. Jessica Schorr Saxe is a family physician in Charlotte and chair of Health Care Justice – NC.

www.charlotteobserver.com/2014/01/17/4620625/americans-under-use-health-care.html

By Bruce Japsen
Forbes, Jan. 18, 2014

As the Obama administration touts the need for uninsured Americans to sign up for private coverage via exchanges under the Affordable Care Act, the insurance industry sees growth in an expanded Medicaid program for the poor under the health law.

This week, the chief executive of the nation’s largest health insurance company and a new analysis indicate major growth ahead for health plans that have contracts with state Medicaid programs thanks in large part to President Obama’s signature legislative achievement.

As state budgets have been hurt by the stagnant economy, lawmakers have turned more patients eligible for Medicaid over to privately-contracted insurance companies. Now, the health law provides a cash infusion of more than $900 billion in federal dollars from 2014 to 2022 to expand Medicaid programs for states interested in the proposition.

“We expect to realize strong growth by serving in several ways: as established Medicaid programs grow through the ACA expansions; as eligible Medicaid prospects are identified through the federal and state exchange markets; and as the inevitable dual eligible …initiatives begin to form and are implemented,” UnitedHealth Group UNH -0.33% (UNH) chief executive officer Stephen J. Hemsley said on the company’s 2013 fourth-quarter and full-year earnings call earlier this week.

Enrollment in health plans that have contracts with Medicaid will rise by 20 percent this year and by nearly 40 percent from last year to 2016, according to a report this week from Avalere Health, a research and advisory services firm on health policy issues tracking the Affordable Care Act.

Other major players in the Medicaid managed care market include Aetna AET -0.1% (AET),  Centene (CNC), Humana HUM +0.43% (HUM), Wellpoint (WLP) and its Americagroup (AMG) as well as a host of Blue Cross and Blue Shield plans.

“The continuing shift toward Medicaid managed care presents a significant growth opportunity for health plans that specialize in managing these low-income populations,” said Avalere executive vice president Matt Eyles said in a statement accompanying the analysis. “Plans that currently operate in Medicaid could see significant membership growth, and those outside of the Medicaid market until now could gain market share by moving into this space.”

This Medicaid funding under the Affordable Care Act is unlike past efforts to expand Medicaid in that the federal government will pick up the full tab for the first three years. The state gradually has to pick up some costs in 2017 but by 2020 the federal government is still picking up 90 percent or more of the Medicaid tab.

It’s a much better funding proposition than the existing Medicaid program that essentially shares the cost between the states and the federal government. The federal government traditionally picks up a little more than half of the cost of Medicaid.

Avalere said 38 states and Washington, D.C. contract with private managed care plans “to provide care to some or all of their Medicaid beneficiaries.”

http://www.forbes.com/sites/brucejapsen/2014/01/18/health-insurance-companies-see-obamacare-medicaid-boon/

By George Erickson
Duluth (Minn.) News Tribune, Jan. 17, 2014

U.S. Sen. Paul Wellstone, known as the “conscience of the Senate,” wrote that he spent 85 percent of his time fighting Republican attacks on working families. Were he still alive, Wellstone would be fighting for the thousands who die or are driven into bankruptcy every year because they lack health coverage. He’d be fighting insurance companies that sponsor deceitful ads like the Harry-and-Louise videos of the ’90s that torpedoed President Bill Clinton’s health program. And he’d be thrilled that the Affordable Care Act includes a provision that allows states to create a single-payer system.

Why are so many afraid of a single-payer program that would save them money and provide better care? Why do they cling to a for-profit system that leaves 47 million Americans with no insurance and millions more with substandard coverage that lets insurance companies choose which procedures to allow and which to deny?

Here’s why: Health is a lucrative business. Medicare, a single-payer system that lets you choose your doctor, has low overhead costs of about 3 percent. In comparison, our much-vaunted private system admits to spending an average of 20 percent of your premium dollar on what it chooses to call “operating costs.”

Those who run Medicare receive modest salaries; but in 2002, Norman Payson, the CEO of Oxford Health Plans, took home $76 million; Leonard Schaeffer, the CEO of WellPoint, received $21 million; and D. Mark Weinberg of WellPoint was forced to make do with a mere $14 million. That’s per year!

They don’t seem to care that the U.S. ranks 33rd in health care. They don’t seem to care we have a higher infant mortality rate than single-payer countries like Canada, the United Kingdom, Germany, Japan and Sweden.

In contrast to our for-profit system, where insurance company employees are rewarded for finding loopholes that permit the denial of coverage, single-payer systems exist to deliver health care, not deny it.

Instead we are burdened with a system that works well for members of Congress and those who can afford deluxe coverage. For most of us, such coverage is just a dream, however. Sixty percent of all personal bankruptcy filings involve unaffordable health care costs.

And what about big pharma? In single-payer countries, identical medications cost half as much as here. Could our drug costs be high because there is no competition? Could it be because drug companies spend millions on ads to persuade us to get our doctors to prescribe this drug or that? In just the second quarter of 2009, the medical-services industries spent more than $133 million on lobbying. That’s in just three months, or about $250,000 per legislator.

How can we believe conservative lies about Canadian care after learning that Canadians, when asked to name the greatest Canadian, gave that honor not to Alexander Mackenzie (Canada’s Lewis and Clark) or to one of their national leaders, but to Tommy Douglas, the father of the Canadian health care system?

Why should we trust Republicans who claim to support improving the current system? These are the people who opposed Social Security, minimum wages, unions, women’s rights and bank regulation. Why should we trust the Republicans who tried to kill the Senate health bill with more than 360 amendments?

Finally, why aren’t we rushing to establish a system that has proven efficient, effective and even-handed in countries with single-payer plans that broaden coverage while lowering costs?

Well, now we can — and Vermont is leading the way by using authority granted under the Affordable Care Act to start a single-payer system. As Vermont’s Sen. Bernie Sanders wrote, “The quickest route to a national health care program will be when individual states … demonstrate that universal and nonprofit health care works, and that it is the cost-effective and moral thing to do.”

The rich don’t care, and neither do many of our legislators. Call and email them in support of the Affordable Care Act’s single-payer option. Watch how they vote — and remember it at the next election. That’s what Sen. Wellstone would want you to do.

George Erickson of Eveleth is a member of the Cambridge, Mass.-based Union of Concerned Scientists and of the Thorium Energy Alliance. He’s also a past vice president of the American Humanist Association and the author of four books.

http://www.duluthnewstribune.com/event/article/id/288815/

By Philip Caper, M.D.
Bangor (Maine) Daily News, Jan. 17, 2014

Love it or hate it, even if ObamaCare never fully achieves its intended benefits, it has already had some unintended ones.

First, it has destabilized our deeply dysfunctional health-care system. By doing so, the law has created a real opportunity to fundamentally restructure the way we finance and deliver health care.

Second, the troubled rollout of the Affordable Care Act has shined a spotlight on how unnecessarily complicated our fragmented health insurance system is, and how great is the need to fundamentally reform it. That in turn has reignited public interest in further reform, and strengthened a growing popular movement.

For example, this past October well over 100 people turned out in Portland on the second night of the World Series to view a movie and discussion about health care reform. Here in the heart of Red Sox Nation, that is notable.

Last week, Maine’s legislature held a hearing on LD 1345, a bill that would create a path to a state-level single-payer system for Maine. Such proposals have been around for years, met with tepid interest from the public and vigorous opposition from insurance companies and other corporate interests.

This time it was different. The hearing room was packed to overflowing with enthusiastic supporters. Forty-five members of the public took the day off and traveled to Augusta to testify in person. Another 15 to 20 submitted written testimony. Of those, 57 testified in favor of the proposed legislation, two against and one undecided. Only representatives of the health insurance industry openly opposed the bill.

The media frenzy surrounding the troubled rollout of the ACA since early October has provided commentators (including myself) many opportunities to point out publicly that although the functionality of the ACA’s websites fell short in many states, the underlying problem is not bad software. It is the expensive complexity baked into the law. That level of complexity can only be justified by politics — the perceived need to preserve a central role for private health insurance companies, despite their widespread unpopularity, as a means of financing health care.

A simple expansion of Medicare, at the federal or state level, would eliminate 95 percent of that complexity, and with it much of the public confusion and distrust surrounding health-care reform. Largely because of its requirement that people, including large employers, buy private health insurance, the ACA has forced large numbers of people who, to date, have had little reason to care about health-care reform to pay attention.

The level of public apathy in Maine about the pathology in our health care system has been significantly reduced. That has created new opportunities for public education.

For example, one of the health insurance lobbyists testifying at last week’s hearing complained that the proposed legislation would provide “free health care” to lawyer-lobbyists, such as himself. He thought that was unfair. I agree: I’d be the last one in the state to want to give free health care to health insurance lawyer-lobbyists. He’d have to pay taxes into the same fund as all the rest of us to assure that everyone gets the same high-quality standard of care.

Physician Philip Caper of Brooklin is a founding board member of Maine AllCare, a nonpartisan, nonprofit group committed to making health care in Maine universal, accessible and affordable for all. He can be reached at pcpcaper21@gmail.com.

http://bangordailynews.com/2014/01/16/health/love-it-or-hate-it-obamacares-spurring-interest-in-the-pathology-of-health-care/print/

By Deanna Pogorelc
MedCity News (Cleveland, Ohio), Jan. 17, 2014

The latest outcry for a single-payer healthcare system comes from a duo of prominent cancer doctors who call on their fellow oncologists to support what they call “an improved Medicare for all” resembling Canada’s healthcare system.

In an article scheduled to be published today in the Journal of Oncology Practice, Drs. Ray Drasga and Lawrence Einhorn remark that, as cancer doctors, they’re challenged by trying to advise the best treatments that a patient can afford. Because underinsurance is becoming the “new normal,” they say, cancer treatment may need to be compromised. And because every insurance plan is different, it’s hard for providers to know whether certain treatments will be covered.

Einhorn is a professor of medicine at Indiana University School of Medicine, a past president of the American Society of Clinical Oncology and the doctor who led treatment of Lance Armstrong. Drasga spearheaded efforts to start a free clinic in Crown Point, Ind.

They proposition that a single-payer system would remove some of the financial barriers to cancer care, make reimbursement simpler and cut down on the burdensome administrative overhead of private insurance companies.

They lay out their case:

    “(The single-payer system) would provide universal, comprehensive coverage with free choice of providers. All medical care would be covered, including provider visits, hospital care, prescription drugs and rehabilitation. Copayments, deductibles, insurance premiums and out-of-pocket expenses would be eliminated.”

A public agency would manage a single insurance plan for each region of the country that would be financed by payroll and income taxes.

    “The public agency would manage the plan and the health care budget in a transparent way. The allocation of available health resources (ie, rationing) would be guided by medical considerations, not on the basis of meeting corporate requirements for a return on investment or on the basis of a patient’s ability to pay.”

Doesn’t that all sound too good to be true? “We think not,” they write. “Because a single-payer system is a sensible and realistic solution, we believe its achievement is possible with sufficient understanding among the public and their elected representatives.”

It would be a challenging transition, they admit. But state-by-state implementation would lessen the administrative burdens, and ultimately such a plan could save up to $380 billion annually, they write.

Lance Armstrong’s doctor calls for single-payer system

By Froma Harrop
The Spokesman-Review (Spokane, Wash.), Jan. 18, 2014

In the beginning, Massachusetts opened the gates to same-sex marriage and universal health coverage. California started to liberalize drug laws by legalizing medical marijuana. The sky didn’t fall on any of these efforts, initially regarded as dangerous social experiments by many conservatives.

Now red states such as Kentucky are launching state-run health insurance exchanges. Federal judges in conservative Utah and Oklahoma are calling bans on gay marriage unconstitutional. And purple Colorado has legalized recreational marijuana use.

Most of us have a vision of the way things ought to be. It is human nature to want others to see the same light we do.

Conservative foes of abortion hold deep convictions that ending a pregnancy is a moral travesty. Liberals make similar arguments against a health care system that lets thousands of Americans die for lack of medical attention, which happens when market forces run the show.

Social activists who live and breathe their cause often seek to impose their views on a diverse nation. They don’t realize that they can more easily get what they want in states whose culture shares their views. Showing that a state has enacted their ideas with good effect is the most expedient way of spreading their ideas coast to coast.

But putting such power in state hands doesn’t always sit well. Liberals, especially, point to slavery and Jim Crow laws as great evils that flew under the banner of states’ rights. These were moral outrages that the federal government had to stop, and did.

True, but many less momentous struggles can be more peaceably and efficiently won through example. As the late U.S. Supreme Court Justice Louis Brandeis famously said, states can serve as the “laboratories of democracy.”

Many liberals are enthusing over a bill introduced last month by Sen. Bernie Sanders, a liberal Vermont independent, and Rep. Jim McDermott, a Washington state Democrat, which would create a national single-payer health care system.

I happen to think the Sanders-McDermott proposal – actually a modified single-payer plan allowing private supplemental coverage – is splendid. But it also has zero chance of passage. Recall how even the modest “public option” – a government plan to compete with the private insurers – couldn’t get past Congress, including some Democratic members.

The best hope for national single-payer is to let Vermont show that its homegrown version will work. If Vermont can cut its health care spending by over 30 percent under single-payer, as is projected, other states will copy it, with no pressure needed from Washington.

Gay activists regard laws banning same-sex marriage as a great injustice, and with reason. But simply waiting for a Supreme Court decision making same-sex marriage legal nationwide, no certainty, would have been a massive waste of time. Marriage is a state responsibility, so what better place to change the laws than in states open to it?

New Mexico’s Supreme Court just ruled that the ban on gay marriage was unconstitutional. In Virginia, another purple state, the Democratic leaders are going full speed ahead. They are bolstered by polls showing that 56 percent of Virginians are in favor of same-sex marriage, a reversal from the 57 percent supporting a ban in 2006. This tide of change would not have rolled in had liberal states not demonstrated what happens to the broader society when gay couples marry: very little.

Some states will do things noxious to liberals, for example, on gun control and public financing for education. Conservatives will dislike decisions made in liberal places. Fine. Let’s all make a pact to stop trying to make everyone else over in our own image.

Nothing convinces like successful examples. Liberals, above all, should have more confidence in their own.

Froma Harrop is a columnist for Creators Syndicate.

http://www.spokesman.com/stories/2014/jan/18/froma-harrop-states-are-still-good-laboratories/

By K.W. Hillis
The Lawton (Okla.) Constitution, Jan. 19, 2014

LAWTON, Okla. — Affordable Care Act reforms address some problems with health care in the U.S., but it doesn’t solve core issues, said Dr. Ed Weisbart, chair of the Physicians for a National Health Program (PNHP) — Missouri Chapter.

An advocate of a single-payer national health insurance system similar to Canada’s or Great Britain’s health care systems, Weisbart met with The Lawton Constitution editorial board last week to talk about those core issues and a new bill before Congress.

“We have a crisis in health care in the United States. It undermines our ability to compete globally. It places huge burdens on businesses and on families. It is the biggest driver of bankruptcy in the country. It makes people vulnerable to having real estate bankruptcies,” he said. “That is going on in the context of our wasting approximately a third of what we pay on health care on the administration of it compared to other countries, where they spend around 2-5 percent on health care (administration) … (we pay) 31 percent.”

The waste of that money “that doesn’t, in fact, impact health outcomes, drives me crazy,” said Weisbart, a self-described fiscal conservative who practiced as a family physician in Chicago for 20 years and then was the chief medical officer for Express Scripts in St. Louis, Mo., before retiring three years ago.

Fixing those problems and core issues will take a lot more than the ACA, which will still leave some people at risk for bankruptcy due to medical bills not covered by insurance, many not insured and more underinsured than before, he said.

The answer for him and members of the PNHP is a single-payer national health insurance program that is an “improved Medicare for everyone.”

 “Medicare’s overhead is roughly 2 percent … (and up to 5 percent according to some people). But it is nothing like we are spending today. So I look at that and I look at the fact that most seniors like their Medicare program and most seniors have to buy supplements to their Medicare because Medicare is imperfect. What I think makes the most sense is we somewhat fix those problems with Medicare, those gaps, embed those supplements into the core program and then get rid of the 65-year-old age limit and give it to everybody.”

The cost of covering everyone from birth would be covered by going from a 31 percent overhead to a 2-5 percent overhead, he said.

“It more than pays for delivering care to everyone and that makes us able to compete globally … it is a simple concept, really.”

This concept is laid out in a 30-page bill — H.R. 676, Expanded & Improved Medicare for All Act — which Rep. John Conyers, D-Mich., introduced to the House of Representatives in February 2013. The bill is now in committee and can be read in summary or in full at http://congress.gov.

The bill “establishes the Medicare for All Program to provide all individuals residing in the United States and U.S. territories with free health care that includes all medically necessary care, such as primary care and prevention, dietary and nutritional therapies, prescription drugs, emergency care, long-term care, mental health services, dental services, and vision care,” according to the bill’s summary at congress.gov.

Other key features of the bill, listed by PNHP, are: “Universal, comprehensive coverage; no out-of-pocket payments; a single insurance plan in each region, administered by a public or quasi-public agency; global operating budgets for hospitals, nursing homes, allowed group and staff model HMOs and other providers with separate allocation of capital funds; free choice of providers; public accountability … ; ban on investor-owned, for-profit health care providers; and protections of the rights of health care and insurance workers.”

The basic problem with the U.S. health care system, even with ACA, is that for other than high-tech health care — the U.S. leads in longest survival rates for those diagnosed with any cancer — the U.S. rates are surprisingly low in other areas, he said. Those areas include the numbers of maternal and infant deaths and that the U.S. ranks No. 51 in life expectancy. Before universal health care was introduced in Canada, Canadians had the same life expectancy as those in the U.S. “Now it is 2½ years longer than ours … The point is we don’t have a business model for the things that actually improve life-expectancy for most Americans.”

Even with the advent of ACA, many people who are under 100 percent of the poverty level will still lack any health coverage at all because half of the states did not expand Medicaid to cover those people. Getting insurance via the ACA marketplace “is better than being uninsured, but it is mediocre insurance,” he said, explaining that most insurance requires individuals to pay 10 to 30 percent of the costs, “so underinsurance is the new norm in this country.” ACA also won’t change the 31 percent administrative overhead or personal bankruptcies due to medical costs.

Horror stories about long waits for care and other problems in universal health care systems are often cited. Weisbart suggested that actual data from those countries and the context of that data paints a different picture.

One study examined the wait time for elective surgery in various countries, using waiting more than four months as the metric.

“In the the United States, less than 10 percent of people wait that long. In Canada, which is the worst in their study, 25 percent of people wait more than four months for elective surgery. That is not the image we have of 80 percent of people waiting months … the thing to think about is that Canadians and (other single-payer countries) spend only a small portion of what we spend on health care.”

Despite the wait, there is an upside, according to Canadians surveyed.

“Every one of them will say ‘that is awful.’ … they will all complain, but in the next breath they will say ‘but I know that when I get cancer, when I get this or that, I will be seen immediately, I will be seen for free … and if I have to make a tradeoff, I’d rather wait a few months for my elective surgery for the security of knowing that when I have a major problem I’ll be taken care of,’” he said.

Other stories about Canadians flocking to the U.S. for health care and physicians moving to the U.S. are also not supported by data, Weisbart said, explaining that valid data from health care systems worldwide can be accessed on the Organization for Economic Co-operation and Development’s website, www.oecd.org.

Weisbart said there are safeguards built into HR 676 for those who are worried about big government deciding what type of health care Americans get.

The safeguards include the premise that everyone in the country is covered under the plan so the people making the decisions of where monies go are invested in the results. Another safeguard is regional boards made up of patients, physicians and others.

The result of everyone getting the same access to care determined by the boards would allow the U.S. population to get what it wants most — “to see the doctor of their choice and go to the hospital of their choice,” he said.

With this plan, “the ones that lose are the insurance industry and the drug and (medical) device industry,” he said. Despite the reduced compensation and incentives to drug and medical device companies that help with medical breakthroughs, “the vast majority of medical breakthroughs in this country is funded by the National Institutes of Health … it is government funded.”

The ones that win “would be everybody else.” There would be a rise in taxes, but “without premiums or copays, 95 percent of the people would pay less, not more.”

He doesn’t expect the U.S. to really have a serious discussion about the proposed single-payer system until 2015, when those who didn’t get insurance under ACA will have to pay a tax penalty.

“Then I’m hopeful that … the country will be ready again to engage in a serious debate of a fundamental health care reform. (But) as we wait, more and more people die and more businesses can’t compete globally,” he said.

K.W. Hillis is a staff writer. Photo by Steve Miller.