PNHP

Celebrating our nurse colleagues

Celebrating our nurse colleagues

By Andrew D. Coates, M.D., F.A.C.P.
WAMC Northeast Public Radio, June 14, 2013

I practice hospital medicine.

Recently the nurses at our hospital voted to give me an award. They told me about it, discreetly, one by one, ahead of the official notice from the administration. These caregiving colleagues, upon whom our patients in the hospital depend every day, took the time to let me know that they also depend upon me. Wow. A true honor.

We doctors organize and order plans of care, diagnostic tests and specific therapies, adapted to individual needs and immediate circumstances. Physicians, in hospital medicine and in every specialty, have a very challenging role.

To do a good job it often seems that we have be more thorough than smart, for thoroughness combined with insight is what can best protect patients from unexpected events. Being thorough also means counting upon our colleagues in nursing and every allied caregiving discipline.

This intellectual dimension is central to a physician’s life, constantly learning and teaching, ever struggling to confront what it is we don’t know. When we say that physicians embrace lifelong learning we sometimes forget that true learning comes with facing our self-doubts.

Yet shouldering this responsibility is compensated with the privileges of professional autonomy and collaboration in an atmosphere of mutual respect from our colleagues. That is the life of doctors.

Nurses have a different life. Our patients who come to the hospital sick, depend upon nurses in the most crucial, personal ways.

We might paraphrase what the great American writer Zora Neale Hurston once said of woman’s relationship to the world. In comparison to doctors, nurses are “the mule” of the hospital.

Nurses shoulder the burden of caregiving physically, in the moment, when it comes to serious illness. In human life, in sickness like in health, things do not always go as planned. No matter how things go, nurses are there to respond, minute by minute, at the bedside.

In turn, participating in the multidisciplinary effort to help our patients brings its own reward. Our shared efforts, the human relationships among caregivers, adds meaning to our lives as well as those of our patients, for ultimately there is no mind-body duality, but our best human effort, combined. Patients and physicians, for different reasons, depend upon nurses in a profound way, at every step.

The hospital can be such an awful, frightening place, yet when we’re joined in common cause, helping another human being, we find ourselves compelled to be there, loving our role. Seeing hospital care this way helps explain why we need to protect the relationships and efforts of the caregivers in order to protect the patient’s health.

This is an important reason why we need a national health program that will provide for every patient. So many private interests, each with perverse financial incentives, presently invade, warp, thwart, and even poison our caregiving relationships.

But let’s save that for another day.

For today, let’s savor the mutual recognition of caregivers, doing the best we can, together, under the circumstances.

Dr. Andrew Coates practices internal medicine in upstate New York. He is president of Physicians for a National Health Program.

You can listen to Dr. Coates’ radio broadcast here: http://www.wamc.org/post/andrew-coates-celebrating-our-nurse-colleagues

Competition in Medicare programs: Boon or boondoggle?

By Carole Carson
The Union (Nevada City, Calif.), June 11, 2013

Does competition to provide insurance for Medicare recipients reduce costs? Or does competition simply increase the tab picked up by taxpayers?

Dr. Ida Hellander, policy director for Physicians for a National Health Program, a nonprofit research and advocacy group, thought taxpayers should know the answers to these questions.

In her research study published in the International Journal of Health Services, Hellander found that competing insurance programs, called Medicare Advantage plans, did not save money. In fact, since their introduction, the private (mostly for-profit) insurance programs have cost taxpayers an extra $282.6 billion.

Hellander adds, “In 2012 alone, private insurers are being overpaid $34.1 billion.” This money, Hellander believes, should have been used to reduce the federal deficit, shore up Medicare’s trust fund or improve patient care — not to enrich private insurance companies.

In 1985, Medicare contracted with private (mostly for-profit) insurance plans such as UnitedHealth and Humana for coverage of Medicare enrollees in a plan called Medicare Advantage. The idea was that Medicare Advantage plans would compete with the traditional fee-for-service Medicare insurance.

Ironically, part of the argument for introducing the Advantage plans was that the competition would lower Medicare costs. Indeed, since their inception, the Advantage plans have become increasingly popular because they offer enrollees additional benefits at reduced premiums. But because of the added benefits, the lower premiums and the need to make a profit, the Advantage programs cost Medicare about 25 percent more than the traditional Medicare program.

Medicare currently pays these privately run plans a set premium per enrollee (about $10,123). This amount is $2,526 more than the premium paid for enrollees covered under the standard Medicare plan.

About 27 percent of Medicare beneficiaries are currently covered under Medicare Advantage plans. Given how profitable the Advantage plans are for private insurers and how attractive the expanded benefits and lower premiums are for enrollees, this number is expected to grow at a fast clip.

Just how profitable are these programs for the private insurers?

UnitedHealth Group could afford to bump the annual compensation of its chief executive officer, Stephen J. Hemsley, to $13.9 million from $13.4 million in the prior year. The increase was based in part on his leadership in solidifying the company’s position as “the biggest provider of the privately run, subsidized versions of the government’s Medicare program for the elderly and disabled people.”

Guess who’s subsidizing Mr. Hemsley’s salary? Look around. It’s you, me and other taxpayers.

Dr. Steffie Woolhandler, coauthor of the study, concludes, “It’s clear that having Medicare Advantage programs compete with Medicare doesn’t save us money. In fact, the opposite is the case. The private plans only add waste, and the aggregate waste is staggering — enough to be a significant drag on the economy.”

Can taxpayers afford the extra cost to help private insurers make a profit from Medicare? Given the intent of Medicare to provide basic healthcare coverage to all enrollees, should all enrollees receive the same benefits? Or are some recipients entitled to expanded benefits at reduced premiums? If so, should taxpayers cover the cost of paying for these extra benefits and lowered premiums?

Or does a single-payer, not-for-profit model with universal benefits and premiums make more financial sense?

What do you think?

Carole Carson lives in Nevada City.

PNHP note: The study referred to above can be found here.

http://www.theunion.com/opinion/columns/6891332-113/medicare-advantage-plans-benefits

Why does Kaiser have the highest premiums in the California exchange?

Kaiser's Obamacare rates surprise analysts

By Chad Terhune
Los Angeles Times, June 12, 2013

In California’s new state-run health insurance market, Kaiser Permanente will cost you.

The healthcare giant has the highest rates in Southern California and some other areas of the state, surpassing rivals such as Anthem Blue Cross and other smaller competitors. The relatively high premiums from such a strong supporter of the federal healthcare law surprised industry analysts, and it has sparked considerable debate about the company’s motives.

Some experts say Kaiser intentionally bid high to avoid drawing too many customers next year who are sick or who have been uninsured for years and may be costlier to treat. Others suspect Kaiser was worried that lower premiums would bring an influx of newly insured patients that could overwhelm its in-house roster of doctors and hospitals.

“Kaiser is not as low cost as many people think,” said Glenn Melnick, a USC health policy professor. “They appear to be protecting themselves because the people signing up in the first year are likely to be the sickest ones.”

Overall, Kaiser is the state’s biggest health insurer with a 40% share of the market.

(Marian) Mulkey of the California HealthCare Foundation said Kaiser has regretted being the low-cost option at times in the past and being overrun by too many members at one time. Other insurers may have more flexibility to add doctors and hospitals to their network as enrollment builds.

Kaiser, on the other hand, could face the costly decision to contract with outside hospitals to absorb some of its overflow.

“We are focused on sustainable prices for the long haul,” (Bill Wehrle, Kaiser’s vice president of health insurance exchanges) said. “If you make a large mistake in this environment, it can be hard to recover.”

http://www.latimes.com/business/la-fi-kaiser-health-rates-20130613,0,7939146.story

Comment:

By Don McCanne, M.D.

Kaiser Permanente was the prototype health maintenance organization (HMO) that sparked the managed care revolution, seeking lower costs supposedly without compromising quality. So why should a low cost leader come in with the highest premiums for Covered California – California’s new exchange that is being established under the Affordable Care Act (ACA)?

The strategies and negotiations were secret, so we don’t really know. But there are a couple of possible explanations. Initial enrollment may include more people with health problems who need insurance, whereas healthier individuals may opt out since initial non-participation penalties are very small, and they can always join later. By Kaiser setting premiums higher, this initial influx of less healthy but more expensive patients would be diverted to competing plans because of the attraction of their lower premiums.

Another possible reason is that the current Kaiser patient population is relatively stable at about 40 percent of the California insurance market. When patients change their PPO or HMO plans that use provider networks, they do not have as much disruption as they do when they move into or out of Kaiser Permanente. Such a move always entails a complete change of their physicians and hospitals. Since Kaiser realizes that they have not only dominant market share but also a stable group of satisfied patients who do not want any disruption in their care, they know that they can charge a little bit more for their plans since patients are willing to pay the modest differences to avoid such disruptions.

There is another reason that is perhaps the most important of all. Kaiser Permanente is a truly integrated health care delivery system with its own hospitals, clinics, health care professionals and other components of the health care delivery system. They can provide virtually all services to every one of their plan members. Carefully planning and executing system capacity is absolutely essential in the Kaiser model.

Large, abrupt changes in enrollment can be catastrophic from a business perspective. If they lose too many patients all at once they are sitting there with expensive excess capacity that is not generating revenues. On the other hand, if they have a sudden large influx of patients, especially patients who would require greater amounts of health care, they would strain their capacity, with overloads in their primary care clinics, with patients destined for admission waiting in the hallways because the hospital’s beds are full, and with intolerably excessive queues for patients waiting for high-tech and specialized services. Obviously, they would have very unhappy patients.

Instead of making large, abrupt changes in their system capacity to match large fluctuations in patient enrollment, Kaiser controls their patient enrollment, keeping patients out if there are too many, or increasing aggressive marketing if there are too few. Under our fragmented, dysfunctional system of financing health care, it is only natural that Kaiser would adjust its patient enrollment to fit its business model rather than adjust its business model to better accommodate patients.

This issue of capacity is important. The United States needs to improve central planning since we have amongst the worse maldistribution of capacity. We have too many regions with excess capacity, which causes wasteful over-utilization, and other regions with deficient capacity, which impairs access to needed care. As a major player, allowing Kaiser to have autonomy in its planning takes good care of Kaiser but at a cost of fragmenting the systemic planning that we need.

Most proposed single payer models include integrated health systems such as Kaiser Permanente. Presumably Kaiser, like other players in the system, would negotiate global budgets, fees and capitation rates, and negotiate separate budgets for capital improvements.

But what about patient choice? The new accountable care organizations (ACOs) would still ensure patient choice, especially since, under the ACA rules, patients may not even know that they have been assigned to a particular ACO. Should Kaiser, which, in essence, is a transparent mega-ACO, be allowed to lock their patients into their own system when other ACOs cannot?

Suppose their patients had the freedom to come and go as they please. Would  the patient choices be that be much different from choosing another primary care entity that has well established referral patterns for high-tech and specialized services, and established practice relationships with other hospitals? Isn’t the goal of expanded information technology to provide a similar level of interconnectedness between all providers that Kaiser has within its own system?

Instead of being a closed system, shouldn’t Kaiser just be another choice for patients within the health care delivery system? Under a single payer system, that choice would not be based on price since single payer eliminates the need to shop prices. Rather choice would be based on perceived quality. Wouldn’t it be better if the various elements of the health care delivery system were knocking themselves out to be sure that they have very contented, healthier patients?

(Changing the Kaiser Permanente model is controversial. Today’s comment should not be considered a specific recommendation, but should be used to get people thinking about what type of structural reforms would best serve the interests of patients – all patients, not just Kaiser’s.)

Affordable Care Act's Achilles Heel? Blaming Patients, Not Profiteering

By Karen Higgins, R.N.
Common Dreams, June 12, 2013

With the one-year anniversary of the Supreme Court ruling upholding the Affordable Care Act near, it’s time to ask if the decision to put the burden of cutting costs on patients, not corporate healthcare profiteering, is the fatal flaw in the plan.

The law’s tepid cost control measures targeted at healthcare spending that is gobbling up an increasing percentage of the economy and pricing more people than ever out of access to care have been widely viewed as the ACA’s biggest pitfall.

But from the outset, the Obama administration dismissed the most effective means to reduce costs by:

  • refusing to consider a single payer alternative that combines genuine universal coverage not based on ability to pay with global budgeting
  • rejecting a proposal to authorize the federal government to negotiate bulk purchasing (a concession to the drug companies), and
  • failing to regulate price gouging by hospitals, drug companies, insurers and other healthcare corporations.

Those fateful decisions left only one option for significant reduction of overall health expenditures – saving money in the delivery of care by shifting costs to those who use health services and discouraging them from getting care even if they have insurance.

Perhaps that’s not surprising given the decision to craft the ACA in concert with pharmaceutical, insurance, hospital, and Chamber of Commerce lobbyists, and, as recently reported, top Wall Street investment firms and hedge fund executives.

Here are several ways the ACA shifts the hardship of cost cutting to those who need care, and promotes delivery models that result in limiting care, even among those with health insurance.

1. What they’re not telling us about the exchanges

The ACA health exchanges are marketplaces set up to enable the uninsured who the law requires to buy private insurance or pay a financial penalty to choose among competing private insurance and qualify for a federal subsidy to cover some of the costs.

But premiums, deductibles, co-pays and other fees can run to thousands of dollars. Even in the cheapest plans buyers are expected to pay 40 percent of the cost. Subsides may not make these plans “affordable.”

Many younger, healthier people are likely to select the cheapest plan, one outside the exchange with fewer covered services, or just go without coverage entirely and pay the fine.

Further, small businesses can buy coverage for employees through the exchanges, but the premium and co-pay subsidies will not cover family dependents, a huge hole that will leave many uncovered.

Insurers offering lower rates the first year in hopes of acquiring many new customers are likely to raise rates later, as has occurred in Massachusetts, the model for the ACA. A recent study in the journal Health Affairs found that 38 percent of families buying plans through the Massachusetts exchange reported a financial burden and 45 percent said costs were higher than they had expected.

2. The high cost of taxing health benefits

For the first time, the law will tax health benefits beginning in 2018 through the misnamed “Cadillac tax” a 40 percent excise tax on comprehensive health plans. The inevitable result will be fewer employers offering good health benefits, and far more people pushed into skeletal, high deductible plans with far less coverage and much higher out-of-pocket costs. The New York Times just reported that 17 percent of employers this year are stepping up cost shifting five years before the tax goes into effect.

3. An incentive to employers to cut coverage or full-time jobs

Under the ACA employers with 50 workers or more must offer coverage to full time employees or pay a fine, but not to part-timers. Nurses and other workers are increasingly in battles with employers who are demanding elimination of coverage for part time employees, citing the ACA as their pretext. Regal Entertainment, Papa John’s and other companies are reducing workers’ hours to under 30 per week.

4. The wellness scam

“Wellness” programs that enable businesses to transfer more healthcare costs to workers with “unhealthy” factors like smoking or high blood pressure or cholesterol levels are rapidly spreading, actively encouraged by the ACA which offers premium discounts to participating employees. However, health disorders are as likely to derive from chronic or genetic conditions as “life style choices” and economic factors which have a disproportionate impact on the poor.

The cost reductions also fall far short of the hype. The federal government apparently buried a report it mandated for the ACA from the Rand Corporation on wellness programs which showed the overall savings are, at best, modest.

The programs make insurance unaffordable for some workers, and “keep the sickest workers from affording the care they need,” said Alan Balch, vice president of the Preventive Health Partnership, an alliance of the American Cancer Society, the American Diabetes Association, and the American Heart Association.

5. Self-rationing on the rise

With its weak controls on pricing practices by the insurers and hospitals, and encouraging cost shifting and high deductible plans, the ACA provides no relief for those who postpone needed care because of the high price tag.

A survey by the Centers for Disease Control and Prevention just released in early June found that 20 percent of Americans, or 54.2 million people in 2011 said their families had difficulty paying for health care services including physician visits, hospital procedures and medications within the prior 12 months.

Among the effects, people delay getting care include less containment for the spread of infectious diseases and more people ending up in emergency rooms. ER visits as the point of entry for patients to needed healthcare have been on a big upswing, a worrisome trend for the increased pain and suffering for patients and the overall health expenditures.

6. New barriers to care

If Massachusetts is the political model of the ACA, the industry model is Kaiser Permanente by combining the roles of insurance company and medical provider with its network of hospitals and clinics.

As ACA implementation nears, Kaiser has stepped up practices once associated with the worst abuses of HMOs. These include delaying medical appointments, restricting hospital admissions, and rapid discharge of patients from the hospital care to other settings.

These include sending people home where the care burden is placed entirely on family members, or to outpatient facilities or nursing homes that have fewer regulations and f
ewer, typically lesser skilled, lesser paid staff where the patients receive less care than in hospitals.

Other industry giants hope to follow this path, enrolling new members who are required to buy insurance, while they are more directly able to control their expenditures for care and can more easily slash spending. The ACA encourages care cutting practices through several mechanisms, including financial penalties for hospital re-admissions, an incentive to keep people out of the hospital, and rewarding providers who divert patients to outpatient clinics.

7. A tale of the 31 million

More than 48 million people are currently uninsured. A new study in Health Affairs estimates that even after full ACA implementation up to 31 million of those will still be without coverage.

That starts with the 14 states and counting who have rejected the expansion of Medicaid, the single most important provision in the ACA for expanding healthcare access, (with the help of the Supreme Court ruling gutting the federal sanction for opting out).  Others will lose their employer-sponsored coverage due to the ACA taxes on employers, the provision excluding dependent coverage for small businesses that enter the health exchanges, and all of those who will still find insurance far too costly to buy, especially in a recession that has never ended for millions of people.

Political posturing by those on the right opposed to any reform of our broken healthcare system and the bunker mentality of liberal allies of the Obama administration who for their own partisan reasons tend to gloss over serious flaws in the “legacy” law of the Obama years have obscured the reality that our healthcare crisis is far from over and in desperate need of more systemic overhaul.

Studies this year alone show the U.S. ranks last among 17 major industrial nations in life expectancy,  but is ahead of the others in first-day infant mortality rates. That will not end with the ACA.

Nurses will continue to make the case for joining the community of nations with a genuinely universal national or single payer healthcare system based on individual patient need, not corporate profits.

Karen Higgins is a registered nurse and co-president of National Nurses United.

Unraveling the Crisis in American Healthcare

By Joie Meissner, N.D.
Vital News (Seattle), Spring 2013

As N.D.s most of us are sole proprietors or in small group practices where we may feel cut off from the larger healthcare system. Yet what happens in the reform of our larger healthcare system will have an enormous impact not only on our practices and our patients, but also on our friends, families and on our own lives.

Ours is the most expensive healthcare system on earth. We spend billions more on healthcare than other industrialized nations yet we are the only industrialized country in the world that does not provide some type of universal health coverage to its people. No one dies due to lack of healthcare access in other industrialized countries, and yet a study done by Harvard Medical School and Cambridge Health Alliance found that nearly 45,000 deaths occur annually in our country due to lack of healthcare access. According to this study, there is a 40% increased risk of death in uninsured American adults.[1]

We spent $2.8 trillion in 2012 on healthcare. This is $750 billion or 27% more than the per capita costs of healthcare in other developed countries, yet WHO ranks our healthcare system’s performance 37th in the world.[2,3]

Despite its high cost, 50.7 million Americans do not have adequate access to healthcare.[4] Public outcry over the state of healthcare has already led to the attempt at nationwide healthcare reform known as Obamacare. The high cost of the multi-payer system is at the heart of our unsustainable healthcare costs, costs that can be predicted to lead to even more dramatic changes in the healthcare system in the years following full implementation of Obamacare.

The anticipated healthcare changes will affect all sectors, including naturopathic physicians, their patients and the treatments they often recommend. Understanding the shape that future reforms will likely take and our potential role in these reforms can help our profession and our patients have greater control over our destiny.

In order to understand the reforms necessary to solve our healthcare crisis, we first need to understand that unsustainable costs are occurring due to the lack of governmental and industry price controls and due to the expanded number of insurance plans and carriers, which respectively lead to skyrocketing hospital charges, and pharmaceutical prices as well as and excessive administrative costs in our current system.

Obscene Overpricing

Steven Brill, writing in Time magazine, uncovered the fact that hospitals set their fees for goods and services based on hugely inflated “chargemaster” pricing schemes that bear no relationship to costs, but which allow “non-profit” and for-profit hospitals to maintain plush surplus revenue and astronomical executive salaries.

Brill found that drug prices are so inflated under the current healthcare system that if pharmaceutical prices were controlled to the same degree that they are in other developed countries, we would save more than $90 billion annually and $25 billion/year in Medicare/tax payer savings.[5]

The Private Insurance System Jacks Up the Price of Healthcare

Between 25-30% of all US healthcare dollars go to pay for administration.[6] Because of the substantially higher administrative cost of the private insurance carriers as compared to non-privatized counterparts like Medicare or Medicaid and because of the logistical inefficiency inherent in having thousands of insurance plans and carriers, the private insurance system inevitably jacks up the price of healthcare.

According to healthcare economist Gerald Friedman, Ph.D., the inefficiencies in our healthcare system which lead to its unsustainable price tag are allowed to exist because the prevailing economic view sees the free-market as the remedy to healthcare overspending. He explains that the for-profit system economic framework that views healthcare spending as waste is why we have problems ensuring that all our citizens have access to healthcare.[8]

The For-Profit System; Cherry Picking and Lemon Dropping

Despite the fact that other economists like Paul Krugman, Ph.D., Nobel Prize-winning economist Kenneth Arrow, Ph.D., and Friedman himself would strongly disagree, Friedman asserts that the prevailing economic viewpoint holds that governmental health insurance promotes over-utilization of healthcare which, in turn, promotes wasted spending. He further asserts that this viewpoint leads the insurance carriers to engage in practices that results in lack of coverage for all Americans. He explains that profit in health insurance comes from a practice called ‘cherry picking’ and ‘lemon dropping’ in which insurance providers discourage the sickest patients, who incur 70% of healthcare costs, from being able to obtain insurance while providing membership incentives to the healthiest patients who incur only 10% of these costs.[9] The profit motive behind the mainstream practice of lemon dropping is the impetus for many of the rules and clauses in insurance policies such as the pre-existing condition clauses that denied many Americans medical insurance coverage.

Sixty-two percent of all American bankruptcies are due to unpaid medical bills; 78% of these were insured at the time.[10] Obamacare’s injunction against coverage caps was designed to prevent the growing number of medical bankruptcies. However, Obamacare does not prevent coverage caps from causing health insurance premiums to rise, thus allowing the high numbers of medical bankruptcies to continue.

Obamacare’s Exchange Benefit Plans Are Underinsurance Plans

Insurance policies sold on the exchanges created by Obamacare are only required to have actuarial values (AVs) of 60% (Bronze plan), 70% (Silver plan), 80% (Gold plan), and 90% (Platinum plan). This means that the actual health care expenses that a policy pays, on average, will be 60%, 70% and 80% respectively.[11] For example, the purchaser of a bronze level plan can expect to pay 40% of actual medical bills even after paying the premiums. Due to their lower cost, AVs of 60% and 70% are likely to be the predominant plans chosen and these plans are highly inadequate coverage for any serious illness such as cancer.

Not everyone who needs healthcare will qualify for healthcare subsidies under Obamacare. Although Obamacare enacts laws to address the problem of lack of healthcare access, the Congressional Budget Office and Joint Committee on Taxation estimate that at least through 2022, 30 million of the 50.7 million Americans who currently have no insurance will still have no insurance after Obamacare has been implemented. Sources project an increased number of Americans will have very inadequate insurance, leaving them bankrupt should they become seriously ill.[12,13]

Based on the need to maintain profits, the cost of insuring those who need it most will lead insurer’s to inflate overall premiums and cost sharing expenses. Even those who qualify for Obamacare’s expanded Medicaid coverage will still have some cost sharing expenses that for them may pose a financial hardship and the increased cost sharing expenses for those who do not qualify for subsidies especially for those with serious illnesses (the lemons) may lead to bankruptcies and/or avoidance of medical care they simply cannot afford.[14]

Sadly, these sorts of policies allowed under Obamacare will continue to result in extensive numbers of American medical bankruptcies and will not prevent insurers from shifting the costs of covering the sickest patients onto enrollees in the form of markedly increased premiums and cost sharing expenses (deductibles, coinsurance and co-pays).

Obamacare Isn’t Enough

The reasons why additional reforms beyond Obamacare are necessary is because Obamacare fails to ensure that
everyone is adequately covered, that those who are covered can actually afford to use healthcare services, and because Obamacare does not end the epidemic of medical bankruptcies or control the bloated costs that are bankrupting the American healthcare system.

To a large extent, Obamacare fails to control the unsustainable cost of American healthcare because it fails to use the government’s substantial purchasing power to bargain down prices for drugs and other medical goods and services and it fails to streamline excess administrative cost inherent in the private insurance system but instead it increases both the patient pool and the tax subsidies to the multi-payer system, the system that the prevailing economic paradigm lauds as the free-market solution.[15] This is because it does not address the basic precept held by prevailing healthcare economists and policy makers, namely the idea that the free-market can remedy all the nation’s healthcare woes.

Healthcare as Commodity or a Right?

Brill and others including healthcare economists like Kenneth Arrow, Paul Krugman and Gerald Friedman maintain that the very nature of healthcare being essential to life itself abrogates its ability to exist as a free-market commodity. They hold that because healthcare itself cannot obey the laws of supply and demand, it cannot be treated like a for-profit commodity. Common sense tells us that when we are having a heart attack, we are not going to be in any position to bargain over the cost of lab tests. Because of this, Brill insists that the healthcare market will always be a ‘seller’s’ market’ with the seller setting the price as far into orbit as our US promissory notes will stretch.[16]

The effects that the traditional “free”-market paradigm will continue to have on our ailing healthcare system are anticipated to lead to another public outcry for more healthcare reform. We are realizing that healthcare is too essential and too expensive to be treated like a commodity. The next outcry will be for something that goes beyond the for-profit-mindset: It will herald that healthcare is a human right, best supported by the implementation of a single-payer healthcare system.

We are the only industrialized country in the world that does not provide some type of universal health coverage to its people. A universal healthcare system such as single-payer is our long awaited reform that most other developed countries have already implemented.

Movement in the direction of a single-payer healthcare system has begun in our country. Vermont’s version of single-payer legislation was already passed by both houses, and that state is currently applying for a waiver allowable under Obamacare so that it can implement a state single-payer system. Most states have single-payer bills and there is a national bill called H.R. 676 that currently has 41 cosponsors.[17] The effects of the single-payer reform regarding how we practice medicine and how we are reimbursed will be substantial. As physicians we need to understand how we will be affected and also how we can be a part of the single-payer system that is in the future of American healthcare.

Special Thanks to Sherry Weinberg, MD, Don Bunger, Don Mitchell, MD, Jim Squire, MD, Marti Schmidt, JD, David McLanahan, MD, Kathleen Myers, DDS, Kathleen Randall, MA, and Helen Thorsen CDP.

Click here for references. This is the first of a three-part series.

Dr. Meissner is a member of the Washington Association of Naturopathic Physicians and a primary care physician in Seattle’s Capital Hill area. Currently on the board of directors Physicians for a National Healthcare Program of Western Washington, her personal interests include food safety, securing a universal healthcare system and clinical research on multiple sclerosis at Bastyr University.

http://www.wanpnews.com/2013/04/16/unraveling-the-crisis-in-american-healthcare-part-1-of-a-3-part-series/

Are physicians driven by profits or fear?

Appropriate Use of Myocardial Perfusion Imaging in a Veteran Population: Profit Motives and Professional Liability Concerns

By David E. Winchester, MD, MS; Ryan Meral, BA; Scott Ryals, MD; Rebecca J. Beyth, MD, MSc; Leslee J. Shaw, PhD
JAMA Internal Medicine, June 10, 2013

Myocardial perfusion imaging (MPI) is performed millions of times annually in the United States to assess patients for coronary ischemia. Some have expressed concern that MPI is being used inappropriately, possibly because of self-referral profit motives and professional liability fears. To inform clinicians about situations in which patients are likely to benefit from MPI testing, appropriate use criteria (AUCs) for MPI were developed, last revised in 2009. Prior investigations have applied AUCs to describe the magnitude and patterns of inappropriate testing. Rates of inappropriate testing have ranged from 7% to 24%. We hypothesized that the single-payer environment of the Veterans Affairs (VA) health system, which eliminates self-referral profit motive and limits liability concern, will result in less inappropriate use of MPI.

Results

For all but 4 patients (1%), an indication from the 2009 AUCs could be identified. Study indications were 78% (n = 259) appropriate, 13% (n = 42) inappropriate, and 8% (n = 27) uncertain. The most common inappropriate MPI indications included testing of patients with low pretest probability who could have undergone treadmill electrocardiogram testing (7 patients [16.7% of total inappropriate MPI]) and asymptomatic patients with low coronary heart disease risk (7 patients [16.7% of total inappropriate MPI]).

Discussion

In this retrospective cross-sectional investigation regarding the appropriate use of MPI in a VA health care setting, we observed that a substantial portion of MPI tests were ordered for inappropriate indications. The findings are in contrast to our initial hypothesis but are similar to those of another VA-based investigation, the results of which were published during our investigation.

Our hypothesis was based on unique characteristics of the VA patient care environment. First, no self-referral or profit motives exist. Second, whereas the Federal Tort Claims Act permits medical malpractice lawsuits against federally employed physicians, the substantial majority of claims are resolved through administrative processes.

We did not detect a significant reduction in inappropriate testing in the VA environment, which suggests a lesser role of defensive medicine and self-referral in the inappropriate use of MPI.

Reasons for the observed patterns of ordering MPI are unclear. Conceivably, commonalities in medical training, independent of postgraduate practice environment, could contribute to an exaggerated perception of benefit of MPI in asymptomatic patients and those at low risk of coronary heart disease.

http://archinte.jamanetwork.com/article.aspx?articleid=1696189

Comment:

By Don McCanne, M.D.

This study has two important lessons for health reform advocates – one obvious and the other not so obvious.

The obvious lesson is that “excessive” medical interventions occur even in the absence of greed or fear. In this study, since VA physicians receive no additional income with an increased volume of services – in this case the ordering of myocardial perfusion imaging – the tests that were inappropriate were not done to increase personal income. Also, since most VA malpractice claims are resolved administratively, there is a much lower fear factor that would cause physicians to order tests to reduce the risk of liability lawsuits.

This is good news in the respect that we can dismiss any nefarious motives on the part of most physicians who are recommending interventions that seem to be excessive. Policy corrections should be directed instead to the more important causes of excessive medical interventions.

This leads to the more subtle lesson of this study. What retrospectively is considered to be inappropriate medical management was done by physicians who, at the time, thought that they were doing the right thing for the patient. The policy recommendation that should follow is that we should continue to identify best practices and continue to educate our health professionals on just what those best practices are.

We are already doing this in the form of medical research and continuing medical education. The process can be enhanced by greater reliance on organizations such NICE, Cochrane, and several others. If we want to reduce unnecessary care, our resources should be directed to these efforts rather than being wasted on administrative excesses such as accountable care organizations that rely on feeble measurements that are used to distribute nominal rewards and punishments – not really much of a motivator but more of an insult for dedicated physicians.

Physicians appreciate receiving good information and will use that in their practices. Let’s make better use our public agencies, such as the NIH, that are dedicated to the health of patients, rather than private agencies that jerk our health care dollars around to conform to their business models.

Single payer really would shift the motive from “money first” to “patients and their health first.”

The Affordable Care Act and single payer

By Alec Pruchnicki, M.D.
WestView News (New York City), June 2013

Part 1: How Does the Affordable Care Act Affect Us?

The Affordable Care Act (ACA), sometimes referred to as Obamacare, will affect us. It is a complex area of law with many pieces. In 2010, it passed Congress with many compromises, and mostly survived a Supreme Court challenge. Here are a few of its major provisions.

From the start, insurers can no longer cancel coverage if you become sick; there will be no lifetime limits on total cost of coverage, and more preventive care will be covered. Young adults (up to 26 years of age) can usually stay on their parents plan, and denials for pre-existing conditions will start to decrease. Drug costs under Medicare will start to decrease in addition to reimbursements for Medicare Advantage plans (Medicare MOs). A significant new provision requires insurance companies to spend at least 85 percent of their budgets on medical care. If they do not, they must send a refund to their enrollees.

By 2014, all denials for pre-existing conditions are to be eliminated. Medicaid coverage will be expanded for millions of individuals and essential benefits will define minimal coverage for policies. Individuals will be required to have coverage which could be purchased through newly established health care exchanges, with subsidies for those with low income. Persons who do not purchase or have their own insurance will pay a penalty that will eventually rise to $695 for individuals and $2,085 for families, or 2.5 percent of income. Employers with 50 or more workers will be required to provide coverage, or face a tax penalty. Employers with less than 50 workers will not be required to provide coverage, but subsidies will exist to encourage them to do so.

Although the ACA establishes many reforms in the area of health care and is one of the major pieces of legislation in this field since the 1960s when Medicare and Medicaid were established, there are significant weaknesses. Progressive politicians tried to include a “public option” in the bill, or at least a possible buy-in to Medicare or Medicaid. However, these were never included and now much of the increased coverage will be channeled through private plans, both profit and non-profit, rather than any government program. This will expand, and sometimes subsidize, the private sector often with government enforcement or government funds.

The exchanges set up within the states are still being established and their goal of significantly decreasing costs and widening consumer options has yet to be determined. Furthermore, since the Medicaid reforms were not supported by the Supreme Court decision, many states have refused to implement them. Whether or not these refusals persist and states continue to reject substantial federal funds also remains to be seen.

Possibly the greatest problem with the ACA is that only half of those without medical insurance will be covered by the provisions of the act, even if more states agree to participate in Medicaid reform, and as many as 31 million people will still not have coverage. Supporters of the act point to Massachusetts where a similar plan led to more coverage than projected, while critics of the act also point to Massachusetts for failure to adequately control costs, either on a state-wide or individual basis, and the coverage that does exist is often insufficient and leads to under-insurance.

As this complex act is implemented, its strengths and weaknesses will become more apparent and the need for further health care reform may arise at some time in the future, possibly very soon.

http://westviewnews.org/2013/06/how-does-the-affordable-care-act-affect-us/

Part 2: What Is Single-Payer Health Care?

Single-payer national health insurance is a system in which one entity (usually a government agency) organizes the financing of health care, leaving the delivery of care mostly in private hands.

All residents would be automatically enrolled in the program at birth and be covered for life. Everyone would have equal access to comprehensive, high- quality health care, with no premiums, co-pays or deductibles.

Financed by a system of progressive taxation, the program would pay for all necessary medical expenses, including doctor, hospital, preventive, long-term care, mental health, reproductive health care, dental, vision, prescription drug, and medical supply costs. Patients would have free choice of doctor and hospital. People would no longer be afraid of unaffordable medical bills and would never be bankrupted by medical expenses.

In some single-payer systems, such as in Canada, hospitals receive lump-sum government payments rather than depend on piecemeal billing and negotiations with insurance companies. Had we such a system, it’s likely we would have prevented the closing of St. Vincent’s Hospital and many other hospitals around New York City.

There is a bill in Congress, the Expanded and Improved Medicare for All Act, H.R.676, that would establish such a program. Polls show that its principles have solid majority support, including among physicians and nurses. The bill has been endorsed by many unions, civic, and faith based organizations.

Why do we need it?

We already spend twice as much as other industrialized countries on health care but we receive mediocre results. Some Americans benefit from very good health care but millions do not. Fifty-four percent of Americans report delaying needed care in 2010, while 25 percent report having trouble paying medical bills. Many must choose between paying for medicine and paying for food or rent.

Approximately 45,000 deaths each year in the U.S. are associated with a lack of health insurance. Sixty-two percent of personal bankruptcies are a result of illness and medical bills.

We spend 17.7 percent of our GDP on health care and this is a terrible drain on our economy. Our reliance on private, for profit health insurance companies wastes billions of dollars every year on administrative costs. This money could be going towards providing health care if we eliminated this expensive middleman who adds cost but no value to the system.

How do we know it would work?

We already have a single-payer-like system in this country and it has been working well for nearly 50 years: Medicare. We also have publicly financed nonprofit health care for the military, veterans, and the poor. They all could be improved but they work and pay half of our country’s health care bill.

A single-payer system would bring health care justice to our country. It would be transparent, publicly accountable, fair, and efficient. It is time to end the immorality of our unequal, chaotic, inefficient health care “non-system” and join the rest of the industrialized world in providing equal access to high-quality health care for all our people.

Dr. Alec Pruchnicki practices internal and geriatric medicine and serves on the board of the N.Y. Metro chapter of Physicians for a National Health Program (pnhpnymetro.org). He resides in the West Village.

http://westviewnews.org/2013/06/what-is-single-payer-health-care/

Central labor councils to AFL-CIO: Strengthen Social Security & pass Improved Medicare for All

By Kay Tillow
Single Payer News, June 2, 2013

Four central labor councils have passed an identical resolution calling upon the September AFL-CIO convention to organize an offensive campaign for expanding Social Security financing and passing improved “Medicare For All” legislation.

The resolution, which was initiated by the Troy Area Labor Council, has also been passed by the Greater Louisville Central Labor Council, the Greater Green Bay Central Labor Council and the Capital District Area Labor Federation in Albany, N.Y.

The resolution calls upon the AFL-CIO to organize a Solidarity Day march on Washington and on the West Coast “to demand an expansion of Medicare to cover everyone and to defend Social Security by removing the cap on income and tax all income in a similar fashion.”

The resolution calls for taxing all income for the purpose of Social Security including dividends, interest, capital gains, and rental income as well as removing the cap on wages and salaries now set at $113,700. Currently, those who earn up to $113,700 pay 6.2 percent in Social Security taxes on every dollar. Those who earn over that amount do not pay taxes on their earnings above that level even if they make millions. Currently the income of the wealthy in dividends, interest, capital gains, etc. is not taxed at all for Social Security.

On Medicare the resolution calls for “implementing a single Payer Medicare for All system as outlined in H.R. 676,” Congressman John Conyers’ single-payer legislation which has 43 House co-sponsors. The legislation would cover everyone for all medically necessary care without co-pays, deductibles or premiums. The removal of the private health insurance industry would bring costs under control while expanding care.

In Minnesota, the Machinists’ State Retirees’ Council (IAM) is sending the resolution to all central labor councils in that state. In Pittsburgh, the president of a steelworkers local (USW) is submitting it to the Allegheny County Labor Council.

The AFL-CIO convention opens Sept. 8 in Los Angeles, Calif. Central Labor Councils, Area Labor Federations, and State AFL-CIO Federations as well as international unions may submit resolutions. Resolutions can be sent to Elizabeth Shuler, Sec.-Treas. AFL-CIO, 815 16th St. NW, Washington, DC 20006.

The resolutions can be found here: http://unionsforsinglepayer.org/tools/clc_resolutions

Text of resolution:

Resolution for Action in Defense of Social Security and Medicare

Whereas: Both Social Security and Medicare are hard fought fundamental gains for all working people.

And Whereas: Cutting Social Security and Medicare benefits would mean destitution for millions of workers and their families.

And Whereas: The social insurance Social Security and Medicare provide is now under sustained attack by Wall Street interests which seek to direct these funds into private hands for private profit.

And Whereas: Removing the cap on income taxed for Social Security would both solve any financial issues the fund might have and end the unfair advantage of those making over the current capped level.

And Whereas: Implementing a Single Payer Medicare for All system as outlined in HR 676 would both cover everyone and save billions of dollars over the current private health insurance industry.

Therefore: The Troy Area Labor Council AFL-CIO urges that the AFL-CIO, within this calendar year, organize a Solidarity Day of Action in Washington and on the West Coast which calls all affiliates and labor allies to mobilize their members to demand an expansion of Medicare to cover everyone and to defend Social Security by removing the cap on income and tax all income in a similar fashion.

Distributed by:
All Unions Committee for Single Payer Health Care–HR 676, c/o Nurses Professional Organization (NPO), 1169 Eastern Parkway, Suite 2218, Louisville, KY 40217. Phone: (502) 636-1551. E-mail: nursenpo@aol.com. http://unionsforsinglepayer.org

Does the nation support health care as a right?

Summary Memo on National Poll Findings of Public Opinion on U.S. Healthcare System

The Morning Consult, June 11, 2013

This bipartisan poll included a national sample of 1,000 likely voters and was conducted May 22 to May 26, 2013 by Republican pollster John McLaughlin of McLaughlin & Associates and Democratic pollster Margie Omero of Momentum Analysis.

Q6:  In general, do you view health care as a right guaranteed to all citizens or is it something that citizens should be primarily responsible for providing for themselves?

44% – Guaranteed right
47% – Citizens responsibility
 9% – DK/Refused

Q8:  In your own personal opinion, which of the following do you see as the  biggest problem facing health care today?

58% – Too expensive
11% – Too many uninsured
17% – Not worth the price
 5% – Accessing quality doctors
 9% – DK/Refused

Q10:  And who do you believe is most responsible for the cost of health care coverage?

44% – Insurance companies
10% – Hospitals
 4% – Doctors
12% – Drug companies
 1% – Medical device companies
 9% – Individuals
19% – DK/Refused

Q40:  Currently, health care benefits provided by an employer are tax-free for both employers and employees. On the other hand, health insurance benefits are not tax-free for people who either buy insurance themselves or do not receive benefits from their employers. Knowing this, do you favor or oppose changing the law so health insurance benefits provided by employers are taxed?

 9% – Strongly favor
15% – Somewhat favor
20% – Somewhat oppose
43% – Strongly oppose
13% – Neither

http://themorningconsult.com/summary-memo-on-national-poll-findings-of-public-opinion-on-u-s-healthcare-system/

Comment:

By Don McCanne, M.D.

Three-fourths of likely voters believe that the biggest problem in health care today is that it is too expensive or not worth the price. When allowed to select only one option as to who is responsible for the costs, close to half blame the insurance companies, with far less blame placed on others. It seems like the voters would want something done about costs, but there is no voters’ revolt in sight. Maybe we have a problem with framing.

Although most outspoken supporters of a truly universal health program claim that health care should be a right, just as many believe that it should be an individual responsibility. The social justice argument is not going to sway those who have views opposed. Shoving a “Health Care Is a Right” placard in their faces only turns them off even more. Framing health care as a right is too polarizing.

Regarding employer-sponsored health plans, only about one-fourth favor ending the income tax exemption of the benefits, whereas about two-thirds would oppose taxing these benefits. Just as with their views on high health care costs, voters are also concerned about preserving an existing government tax policy that helps give limited relief of their costs – their own personal costs, that is.

When individuals have to buy their own insurance, they are very concerned about unaffordable premiums, and they blame the insurers for that. When they access health care, they are concerned about high out-of-pocket expenses, especially the deductibles. Even when they receive insurance through work, many realize that this insurance was paid for by forgoing wage increases. The high costs of health care are a personal matter for them, and they want relief.

Rather than talking about abstract health care rights, we should be framing the problem as an intolerable personal financial burden – one that is perpetuated through our reliance on expensive but ineffective private insurance plans. We need to explain that they can get relief from this burden on two fronts: 1) Free access to health care by curtailing out-of-pocket expenses, and 2) Replacing unaffordable premiums with equitable public funding.

The first point was covered yesterday with the brief from EPI titled, “Increased health care cost sharing works as intended – It burdens patients who need care the most.” We can get rid of this burden. People need to understand that many other nations provide care that is free at the time of service – no deductibles, no copays. That’s what they want to hear, though for those who are dubious that this is possible, we can explain that we can do this by replacing the private insurers with an efficient Medicare-like program.

For the second point, we can explain that, under an equitable tax system, individuals pay no more than they can afford, based on their income, and for most individuals that would be less than they are currently paying in both direct and hidden costs of health care.

So the framing needs to appeal to the individuals’ concerns about their personal high health care costs: Are you spending too much out-of-pocket for your health care and for your insurance? Would like like to be able to get rid of your private insurance and have health care free at the time you need it? We can do this if we make some modest improvements in Medicare and then provide it for everyone, paying for it through fair taxes.

You can work on the rhetoric. Just be sure that they hear that they will not have their health care threatened simply because they cannot afford to pay for it. Some may feel that it is their right, and some may not. But they all want to hear that in the future they finally can have relief from their own personal financial burdens of health care.

Single payer is needed cure

By Jack Bernard
Charlotte (N.C.) Observer, June 10, 2013

After spending 25 years in the health care field, most of it related to making hospitals more efficient and effective, I have become skeptical of many of Washington’s reform efforts, especially by my party, the GOP.

One of the biggest problems with health care is escalating, uncontrolled expenditures, taking a larger and larger proportion of our GNP. However, what Rep. Paul Ryan and the GOP want to talk about is the federal budget and cost-shifting via Medicare and Medicaid.

Experts in health care economics differ on many things. But one thing they all agree on is that raising the age for Medicare will do virtually nothing to reduce the overall cost of health care in this nation.

Under the Affordable Care Act, everyone must have insurance or be taxed. Medicare has a 3 percent administrative overhead while the private sector has run 28 percent, coming down to 20 percent as required by the ACA. Raising the Medicare age simply shifts the insurer from the government to less efficient private providers. This dumps the extra cost into the lap of the senior, who at 65 is probably unemployed and unemployable. There are no overall cost savings via efficiencies with Ryan’s Medicare “voucher” proposal.

Dr. Gerald Friedman, professor of economics at the University of Massachusetts, was in Charlotte recently for the launching of a physician advocacy group, Health Care Justice. Friedman indicated that U.S. per capita health care cost is $7,920. That compares with $3,323 in Sweden, $2,984 in Finland and only $2,686 in Italy. He points out that people in these countries are healthier than in our country and things are getting worse here. In 2001 among the non-elderly, 14 percent did not see a doctor for needed medical care. The figure rose to 26 percent in less than a decade.

Friedman pointed out that the most basic financial problem with U.S. health care is the for-profit insurance system. Insurance company profits have increased 250 percent in the last decade, Friedman said. The head of Cigna made a whopping $29 million in 2009 while health care premiums and increased deductibles are eating up more and more of workers’ wages.

He further pointed out that the administrative cost of health care insurance is one of the major drivers of escalating health care costs from 1980 to 2005. According to Friedman, the administrative cost of private insurance will be $200 billion in 2013. In the U.S. billing costs run $83,975 per doctor per year versus only $22,205 in Ontario.

This is waste, pure and simple. Although the Affordable Care Act pushed through by the Democrats does not do enough to solve the issue, the current GOP proposals totally ignore it.

A related area is prescription drugs. We pay 60 percent more than other countries. Our nation is in effect providing a subsidy to all the others. Why should we pay more to develop drugs that are used elsewhere, not just here?

What is the best course of action to provide better health care and reduce the growth of national health care expenditures? Dr. Friedman’s cure is to move to single payer.

Single payer would drive down costs because Medicare (or a utility-like private single payer insurer) would have leverage to keep costs down. With no other game in town, providers would be forced to operate more efficiently. Drug companies would be pressured to give Americans the same drug pricing that is found elsewhere.

Friedman pointed out that in multiple state studies (independently done by several groups), single payer turns out to save money. In his own studies, he has shown savings of around 20 percent for North Carolina, Pennsylvania and Massachusetts, and even more in Colorado and Maryland.

According to Friedman, a North Carolina single payer system would produce enormous savings, $18.7 billion per year. Surely, at a time when wage earners are being faced with ever increasing premiums and higher deductibles, we should at least consider Medicare for all or a similar single payer system.

The real question is whether either party is willing to stand up to the drug and insurance lobbies and do what is best for America.

Jack Bernard is a retired health care executive, former Jasper County, Ga., commission chairman and former chairman of the Jasper County Republican Party.

http://www.charlotteobserver.com/2013/06/10/4097735/single-payer-is-needed-cure.html##storylink=cpy

Medicaid expansion good thing, for now

By Brandon Sandine
Rockford Register Star, Letters, June 9, 2013

The Illinois General Assembly agreed to accept federal monies to expand Medicaid in our state beginning in 2014.

That’s good news for the residents of our state who are disabled or have an income at or below 133 percent the federal poverty level, or $15,281 a year.

Effective Jan. 1, 2014, some of the most vulnerable sections of our population will less frequently have to choose between paying food bills and seeking medical care. Much human suffering will be alleviated and many lives will be saved. An estimated 342,000 people are expected to benefit.

Medicaid is a federally and state-funded program. However, the financial risk that our state is taking on with the expansion of Medicaid is small. This expansion is almost completely funded by the federal government, and should the federal source of funding ever drop beneath 90 percent, the law will automatically cease.

While the financial pressures on the Illinois economy are very real, expanding Medicaid should not prove to be one of them. When it comes to the state’s pension funds, for example, the law certifies that its impact is null.

Illinois’ decision to support the provisions of the Affordable Care Act, President Obama’s landmark health law, is great news for our nation’s health. Yet even if the ACA takes full effect, an estimated 1.7 million residents of our state will still be left uninsured or underinsured.

In many ways the new health law is merely a Band-Aid fix. I believe single-payer health insurance is the only way to repair our broken, fragmented system, which currently wastes so much money on private insurance company paperwork and bureaucracy. What we really need is an improved Medicare for all.

Brandon Sandine of Machesney Park is a Master of Public Health candidate at the University of Illinois at Chicago.

http://www.rrstar.com/updates/x1466762604/My-View-Medicaid-expansion-good-thing-for-now#ixzz2Vp63AWzJ

Ball of confusion

Description fits both the Affordable Care Act and most of the GOP opposition to it

By Jack Bernard
Ledger-Enquirer (Columbus, Ga.), June 8, 2013

In my rural county, the Tea Party was started by, and is still headed by, a Republican blue-collar trade union worker from New Jersey who looks and sounds like someone you would see on “The Sopranos.”

He has not worked for years, is under 65, and gets health insurance through his trade union. He constantly and loudly complains about Obamacare, which when implemented will help older unemployed people like him (but not in a trade union) to get coverage. Influenced by extremist propaganda, I doubt he realizes that uninsured older workers currently either: (a) cannot get insurance at all, or (b) cannot afford the excessive age-adjusted and health-adjusted premiums charged by for-profit insurance companies.

Remember the contradictory signs carried in 2009 by Tea Party senior citizens saying “Stop Obamacare; keep the government out of my Medicare”? In 2010, Dr. Paul Broun, my own Tea Party-endorsed congressman (now running to succeed Senator Saxby Chambliss), declared that under Obamacare, “the elderly are gonna be denied the care to keep them living.” His weak rationale was that he bought the misleading and factually incorrect Sarah Palin “death panel” ruse.

Unfortunately, these are the confused folks at all levels who are still heavily influencing my party, the GOP, and its policy positions on health reform. Thus, we see the recent highly partisan 37th vote for repeal of Omamacare by our out-of-touch House of Representatives.

Am I a dyed-in-the-wool supporter of Obamacare? No, I am not. There is a much better alternative that I outline below. (The main thing I support about Obamacare is that at least it will help in providing coverage to some of the 50 million Americans who are currently without insurance.) But that does not mean that I endorse the misguided direction that my own party has taken on health care.

The GOP currently has two big new ideas regarding health reform, both doing away with so called “entitlements” that are very popular with taxpayers. Neither initiative makes any sense in the broader context of systemic cost reduction and quality improvement.

First, the GOP wants to change Medicare into a voucher program. Let’s be clear as to the underlying aim of this “premium support” proposal: A voucher system would cap expenditures by the federal government, period. It does nothing to make the health care system more effective, quality-wise or cost efficiency-wise. By providing vouchers, you just shift the burden of ever-increasing hospital, physician and pharma costs onto powerless, sick patients. Over time, this means that the elderly will not get the care they need … or they will go broke trying to pay for it. Is this an appropriate GOP national goal?

Second, the Republican Party proposes making Medicaid, the safety net for the poor for the last 50 years, into a block grant program. Again, costs to the federal and state government are capped. But that simply means that Medicaid beneficiaries, all very low-income people, will suffer tremendously and fail to receive needed care. Plus, most Americans are unaware that the largest payer for nursing homes is Medicaid. Do you really want a sick, frail, elderly person who has worked all his or her life to be out on the streets just because there is no government funding to put them into a nursing home?

The best solution is starring us in the face: Expand Medicare and make it the sole payer for all health care. It is one the few areas where government has proven to be more efficient than the private sector. Medicare administrative costs are 3% versus 20%-30% for private insurance companies, which have lots of administrative and marketing overhead.

When we look at European countries and Canada with similar systems, we find that statistically their quality of care is as good as or better than ours, and costs are much less. For example, the per capita cost of care in Canada is $4,205 versus $7,910 in the United States. France, with possibly the best health system in the world, costs only $3,835 per capita.

More on this topic can be found on the web site of Physicians for a National Health Program, PNHP. Go to www.pnhp.org for more regarding how a Medicare For All system would work and the clear benefits it would bring to all Americans.

Jack Bernard, a retired senior executive for several national health care corporations, is also the former Director of Health Planning for the state of Georgia and former chairman of the Jasper County Republican Party; Bernard_Jack@hotmail.com.

http://www.ledger-enquirer.com/2013/06/08/2535529/ball-of-confusion.html