PNHP

Bills calls for 'Medicare for all'

Bills calls for 'Medicare for all'

Assemblyman Gottfried urges single-payer health care system for state

By Casey Seiler
Albany Times-Union, March 8, 2013

ALBANY — Enacting a massive state takeover of the cost of health care for every New Yorker might seem like a heavy lift even in a deep-blue state like New York.

But that didn’t stop Assemblyman Richard Gottfried from rolling out the latest version of his perennial bill establishing a statewide single-payer health care system, a structure often shorthanded by advocates as “Medicare for all.”

Backed by nurses, physicians, anti-poverty activist Mark Dunlea and a clutch of his fellow Democratic lawmakers, Gottfried discussed the bill at a Thursday news conference.

The Manhattan Democrat’s legislation has 73 co-sponsors in his chamber — though Speaker Sheldon Silver is not among them — and about a dozen in the Senate, where the measure is carried by Bill Perkins, D-Harlem.

Even though the nation is only beginning to implement the federal Affordable Health Care Act, Gottfried said the Empire State shouldn’t have to wait years before seeing where it falls short. “Federal health care reform has done a lot of good, but it still leaves us in the hands of insurance companies,” Gottfried said. “New York can do better.”

The New York Health Act would replace all private insurance coverage with comprehensive, universal coverage for every New Yorker, he said.

“It would save the billions of dollars that we now spend on insurance company administrative costs. … You and your doctor would work to keep you healthy. New York Health would pay the bill with funding from broad-based revenue based on ability to pay,” Gottfried said.

The two sources of revenue: a progressive payroll tax paid for primarily by employers with contributions by workers, and a surcharge on investment income. It would also require the demise of the health insurance industry in New York — a development business groups view as only slightly preferable to the end of the world.

The bill’s only appearance on the floor of the Assembly was in 1992, when it passed before being promptly ignored by the Republican-controlled state Senate.

“In the intervening years, as Gilda Radner said, ‘It’s always something,'” Gottfried joked, referring to the late “Saturday Night Live” player.

“People who would have been focused on single-payer for a couple of years were focused on the Clinton health plan,” he continued. “Then here in New York people were focused on managed-care reforms and, for many years, fighting against drastic cuts in Medicaid that were on the table. And then for the last several years people were focused on getting health care reform enacted in Washington. … I think we are really ready to refocus on single-payer.”

Perkins struck a realistic tone about the bill’s chances, as well as its ultimate value.

“Listen, let’s be for real: There are a lot of monied interests that are involved in this,” Perkins said. “The privatized model is about profit; it’s about paying for policies that do not necessarily speak to the best interests of the community, to the best interests of people. And therefore, to some extent it measures how valuable this is — because there’s so much effort over the years to prevent (the bill) from even getting to daylight.”

 http://www.timesunion.com/local/article/Bills-calls-for-Medicare-for-all-4338038.php#ixzz2MzAGVaL9

Only 2% of individual plans meet "essential health benefit" requirements

Almost No Existing Health Plans Meet New ACA Essential Health Benefit Standards

By Kev Coleman
HealthPocket, March 7, 2013

Given that health insurance plans will have to meet new minimum coverage standards starting in 2014, HealthPocket examined the current marketplace of individual health plans to measure the market disruption that will occur as these plans are replaced by plans compliant with the new standards.

Our research took the Affordable Care Act’s Essential Health Benefits as our starting point. The Essential Health Benefits are the minimum categories of health insurance coverage that every qualified health plan must have starting January 1, 2014. HealthPocket then examined 11,100 individual health plans across the United States to see how many plans had coverage in each of the Essential Health Benefit categories.

The data shows that there will be a near complete transformation of the individual and family health insurance market starting in 2014. Less than 2% of the existing health plans in the individual market today provide all the Essential Health Benefits required under the Affordable Care Act (ACA).

On average, the health plans provided 76% of the ACA’s Essential Health Benefits. Benefits such as hospitalization, emergency care, and ambulatory services (such as visits to a primary care doctor or specialist) were covered by almost all plans in one form or another. A more detailed analysis of our results revealed that the missing 24% of Essential Health Benefits were concentrated around a few categories.

Dental and vision care for children was the least likely of the Essential Health Benefits to be provided in base benefits for a health insurance plan. Only one out of four plans nationally had these benefits within their base coverage. Looking at these benefits at a more granular level revealed that only 8% of plans provided coverage for dental check-up services. Maternity coverage was nearly as infrequent as pediatric dental and vision coverage. Two thirds of health plans did not offer their beneficiaries prenatal, delivery, and postnatal healthcare coverage. Substance Use Disorder Coverage was frequently absent in health insurance coverage as well. Only half of plans covered inpatient and outpatient services for substance use issues (e.g. alcohol or drug addiction). Mental health coverage was slightly better with six out of ten plans covering inpatient and outpatient treatment.

Implications for Health Insurance Premiums?

One of the questions raised by the results of this study is whether the coverage expansion required by the ACA will cause premiums to rise in 2014. Although the answer to that question is beyond the scope of this study, premiums could rise due to a combination of factors, including:

* The closing of the coverage gap as described in this study

* Guarantee issue provisions that will allow people with pre-existing medical conditions to enroll in health plans

* ACA actuarial value requirements on the maximum out-of-pocket costs that can be charged to beneficiaries

http://www.healthpocket.com/healthcare-resources/few-existing-health-plans-meet-new-aca-essential-health-benefit-standards#.UTnodq4tb3V

Comment:

By Don McCanne, M.D.

One of the problems that needed to be addressed by the Affordable Care Act (ACA) was the fact that health plans in the individual market have very skimpy benefits – benefit packages that were designed by private insurers who were attempting to keep their premiums competitive. This study confirms the extent of the inadequacies of these plans.

In response, ACA included a mechanism to require a minimum basic level of essential health benefits (EHB). The expansion of the benefits to be covered, along with guaranteed issue to those with preexisting disorders, and placing a maximum on out-of-pocket costs, will all result in significantly higher premiums for plans offered in the individual market. That is in spite of the fact that many will still find the benefits to be deficient, and will still face large out-of-pocket costs because of the low actuarial values of the plans that most people will select.

Even with subsidies, these plans will be expensive. And for those who do not qualify for subsidies? Maybe those potential purchasers would finally see the wisdom of establishing an equitable public system of financing health care through progressive taxes – a single payer national health program. They certainly aren’t going to like what they are going to get under ACA.

Only 2% of individual plans meet "essential health benefit" requirements

Almost No Existing Health Plans Meet New ACA Essential Health Benefit Standards

By Kev Coleman
HealthPocket, March 7, 2013
Given that health insurance plans will have to meet new minimum coverage standards starting in 2014, HealthPocket examined the current marketplace of individual health plans to measure the market disruption that will occur as these plans are replaced by plans compliant with the new standards.
Our research took the Affordable Care Act’s Essential Health Benefits as our starting point. The Essential Health Benefits are the minimum categories of health insurance coverage that every qualified health plan must have starting January 1, 2014. HealthPocket then examined 11,100 individual health plans across the United States to see how many plans had coverage in each of the Essential Health Benefit categories.
The data shows that there will be a near complete transformation of the individual and family health insurance market starting in 2014. Less than 2% of the existing health plans in the individual market today provide all the Essential Health Benefits required under the Affordable Care Act (ACA).
On average, the health plans provided 76% of the ACA’s Essential Health Benefits. Benefits such as hospitalization, emergency care, and ambulatory services (such as visits to a primary care doctor or specialist) were covered by almost all plans in one form or another. A more detailed analysis of our results revealed that the missing 24% of Essential Health Benefits were concentrated around a few categories.
Dental and vision care for children was the least likely of the Essential Health Benefits to be provided in base benefits for a health insurance plan. Only one out of four plans nationally had these benefits within their base coverage. Looking at these benefits at a more granular level revealed that only 8% of plans provided coverage for dental check-up services. Maternity coverage was nearly as infrequent as pediatric dental and vision coverage. Two thirds of health plans did not offer their beneficiaries prenatal, delivery, and postnatal healthcare coverage. Substance Use Disorder Coverage was frequently absent in health insurance coverage as well. Only half of plans covered inpatient and outpatient services for substance use issues (e.g. alcohol or drug addiction). Mental health coverage was slightly better with six out of ten plans covering inpatient and outpatient treatment.
Implications for Health Insurance Premiums?
One of the questions raised by the results of this study is whether the coverage expansion required by the ACA will cause premiums to rise in 2014. Although the answer to that question is beyond the scope of this study, premiums could rise due to a combination of factors, including:
* The closing of the coverage gap as described in this study
* Guarantee issue provisions that will allow people with pre-existing medical conditions to enroll in health plans
* ACA actuarial value requirements on the maximum out-of-pocket costs that can be charged to beneficiaries
http://www.healthpocket.com/healthcare-resources/few-existing-health-pla…

One of the problems that needed to be addressed by the Affordable Care Act (ACA) was the fact that health plans in the individual market have very skimpy benefits – benefit packages that were designed by private insurers who were attempting to keep their premiums competitive. This study confirms the extent of the inadequacies of these plans.
In response, ACA included a mechanism to require a minimum basic level of essential health benefits (EHB). The expansion of the benefits to be covered, along with guaranteed issue to those with preexisting disorders, and placing a maximum on out-of-pocket costs, will all result in significantly higher premiums for plans offered in the individual market. That is in spite of the fact that many will still find the benefits to be deficient, and will still face large out-of-pocket costs because of the low actuarial values of the plans that most people will select.
Even with subsidies, these plans will be expensive. And for those who do not qualify for subsidies? Maybe those potential purchasers would finally see the wisdom of establishing an equitable public system of financing health care through progressive taxes – a single payer national health program. They certainly aren’t going to like what they are going to get under ACA.

Teachers, colleges getting early lesson in Obamacare

By Eric Zorn
Chicago Tribune, March 5, 2013

They jokingly refer to themselves as “road scholars,” the part-time, often itinerate employees who teach the majority of the classroom hours at community colleges.

Without their willingness to work for modest pay, tuition at these colleges would be out of reach for many of those looking to put a foot on the first rung of secondary education.

And now some of these instructors are finding themselves among the first to be ensnared by a requirement of Obamacare — the Affordable Care Act — as their employers are planning to cut their teaching hours to make sure they don’t qualify for health care benefits under the new law.

Friday morning, adjunct professors and their supporters are planning a protest rally during an Illinois Council of Community College Presidents meeting in Lombard to urge leaders of the state’s community colleges to “Keep the ‘care’ in the Affordable Care Act,” as their promotional flier puts it.

Here’s the problem: Starting next year, Obamacare will require companies that employ more than 50 full-time workers to provide health insurance to employees who work 30 or more hours a week, or else pay a fine.

But what’s an “hour” for a college teacher? Depending on the subject matter, level of interaction with students and other factors, one hour in the classroom can require two, three or more hours of preparation, grading, conferences and so on.

“How do we account for all that time? How do we measure it?” asks David Baime, senior vice president for governmental relations for the American Association of Community Colleges, which represents 1,167 institutions nationwide. “With almost 70 percent of our (classroom) credits now taught by adjuncts, the colleges are extremely concerned about how the law will be interpreted and the extra costs they might get hit with.”

The Internal Revenue Service will hold a public hearing April 23 in Washington on this issue to attempt to sort out the concerns of the colleges and give them better guidance. But many schools are already planning out the 2013-14 school year, and some are erring on the side of caution, pre-emptively altering schedules and throwing some teachers into a panic.

Oakton Community College, with campuses in Des Plaines and Skokie, last month announced it would be cutting the hours of certain particularly active adjunct teachers starting this summer in order to make sure they won’t qualify as full-time employees under the Obamacare threshold when it kicks in.

Oakton’s marketing manager Janet Spector Bishop estimates 50 or fewer of the roughly 400 adjunct faculty members will lose hours when the somewhat complicated formula is applied.

Oakton’s Adjunct Faculty Association union President Barbara Dayton puts the number at 85.

Whichever number is correct, here’s the problem these teachers face: They’re already at the low end of the pay scale — a typical adjunct teaching two classes that meet four hours a week might make $8,000 for a semester, with no job benefits — and now they’re being told they’re going to make even less money right when the law will compel them to buy insurance.

“It’s a double whammy,” said Bill Silver, an Illinois Education Association union representative who’s helping organize Friday’s rally. “They’ll be earning 30 to 70 percent less money, then being told to go buy their (health) insurance on the exchanges.”

Students, he said, will see either fewer class offerings or classes being taught by less experienced part-timers.

Ideally, Silver said, all community colleges would offer health care benefits for their part-timers.

An administrative memo at Oakton said the additional costs associated with Obamacare stood to be “several million dollars” depending on how the law is ultimately applied. And this, of course, could result in higher tuitions, larger class sizes or both.

Either way, it looks like students lose.

And this is probably just the first example of the many similar issues that will arise as the big, clumsy law tries to blend the private, employer-provided insurance model with the idea of near-universal medical coverage.

Yet another lesson in Single-payer 101.

Comment on this column at chicagotribune.com/zorn

Proposal challenges TIAA-CREF on for-profit health insurance

By Robert Kropp
Social Funds, March 7, 2013

Advocacy groups urge the pension fund to divest its holdings in private health insurance companies, arguing that the industry has a well-documented history of unethical behavior and abuses.

SocialFunds.com — Should sustainable institutional investors hold the stocks of private health insurance companies in their portfolios? 

It’s a question that advocates for a single-payer healthcare system is asking the Teachers Insurance and Annuity Association – College Retirement Equities Fund (TIAA-CREF), the financial services organization and one of the nation’s largest pension funds. A signatory to the United Nations’ Principles for Responsible Investment (PRI), TIAA-CREF states in its investment philosophy that it seeks “to invest in areas that affect social change and environmental stewardship while also producing competitive financial returns.” 

There’s no doubt that private health insurance companies such as CIGNA, Humana, Aetna, Coventry, and WellPoint help TIAA-CREF’s portfolio produce competitive financial returns. According to Healthcare-NOW!, an organization advocating for the passage of single-payer healthcare legislation, average profits for the five companies increased by almost 50% during the fiscal year that ended in July, 2011. Meanwhile, 3,700 families file for bankruptcy every day in the US, and cite illness and medical bills as the primary causes. Sixty percent of those filing for bankruptcy had private insurance. 

A 2012 study by physicians associated with Physicians for a National Health Program (PNHP) found that Medicare had overpaid private insurance companies in the amount of $282.6 billion since 1985, most of which occurred in the last eight years. 

In 2011, Healthcare-NOW! and PHNP launched the Divestment Campaign for Health Care, which in 2012 informed TIAA-CREF of its intention to file a shareowner resolution calling for divestment from private health insurance companies. The Campaign withdrew the proposal for one year after TIAA-CREF and MSCI, its vendor for environmental, social, and corporate governance (ESG) ratings, agreed to dialogue. 

Sandra Fox of the Campaign described the engagement in a recent blog post. “TIAA-CREF representatives indicated the company will continue to employ the ‘best in class’ approach and rely on MSCI’s ratings,” Fox wrote. “TIAA-CREF would not divest from health insurance companies but encouraged us to continue to provide information to MSCI relevant to our concern.” 

“We informed TIAA-CREF that we were not happy with their response and would resubmit our shareholders proposal in 2013,” Fox continued. 

The proposed resolution for 2013, submitted by Fox and Johanna W.H. van Wijk-Bos of the Presbyterian Church, states, “Health insurance companies make money by denying coverage, raising premiums, and increasing out-of-pocket costs, and spend 15-30% of the healthcare dollar on administrative overhead (including profit, exorbitant executive salaries, and marketing costs) compared to less than 2% for traditional Medicare.” 

Furthermore, the resolution continues, private health insurers “testified before the US House Subcommittee on Oversight and not only admitted to their company’s practice of rescission, or cancelling people’s insurance when they become very ill, but refused to stop the practice.” 

“Participants request that TIAA-CREF exclude health insurance companies from the portfolio fund of CREF-Social Choice, in accordance with reasonable expectations for socially responsible investing,” the resolution concludes. 

Institutional investors are typically more prone to engagement than divestment, and TIAA-CREF is not the only sustainable investor with holdings in private health insurers. The Interfaith Center on Corporate Responsibility (ICCR) says its members are “asking our health insurance companies to redesign their benefit models, provider networks and payment models to amplify access and to limit premium increases.” 

“Premiums for employer-provided family coverage increased 113% in 2011 over premiums in 2001, while workers’ share of cost for this coverage has increased 130% over the same period,” ICCR states. 

Meanwhile, Representative John Conyers of Michigan re-introduced the Expanded and Improved Medicare for All Act (HR 676) last month. “Many Americans are frustrated with high out-of-pocket costs, skyrocketing premiums, and many other serious problems that are part and parcel of a healthcare system dependent on private health insurance plans,” Conyers stated. “HR 676 would reform this broken system.”

http://dev.socialfunds.com/news/article.cgi/article3763.html

Private insurers continue with unreasonable premium increases

Blue Shield and Aetna to raise healthcare rates over state objections

By Chad Terhune
Los Angeles Times, March 6, 2013

Despite objections from regulators, health insurers Blue Shield of California and Aetna Inc. are proceeding with double-digit rate increases that state officials said were unreasonable.

Officials at the California Department of Managed Health Care said increases that average more than 11% for about 47,000 individual and small-business policyholders of Blue Shield and Aetna were unreasonable. But state officials don’t have the authority to reject changes in premiums, and increasingly health insurers refuse state demands to lower rates.

“I am disappointed that after lengthy negotiations, Blue Shield and Aetna were unwilling to bring their proposed health plan increases down to a reasonable level,” said Brent Barnhart, director of the Department of Managed Health Care.

Last year, Aetna led the way for the industry’s more defiant stance by proceeding with an 8% rate hike on some small-business policyholders despite objections from the state insurance department. In January, California Insurance Commissioner Dave Jones scolded Anthem for proceeding with an 11% premium hike for small businesses that he determined was excessive.

http://www.latimes.com/business/la-fi-health-insure-rates-20130307,0,1301629.story

Comment:

By Don McCanne, M.D.

It is no surprise that in California – a state that can review insurance premium increases but has no power to control them – private insurers are proceeding with premium increases deemed to be unreasonable. The surprise is that our elected representatives continue to keep in charge of our health care spending an industry that uses us as instruments to achieve their own business ends.

Imagine a scenario in which Medicare would demand unreasonable increases in premiums. It would never happen. Medicare is a service model designed to serve us, the people. Private insurers are business models designed to serve their own business interests.

Did anyone ever think that it might be a good idea to dismiss the private insurers and provide Medicare for all of us?

Private insurers continue with unreasonable premium increases

Blue Shield and Aetna to raise healthcare rates over state objections

By Chad Terhune
Los Angeles Times, March 6, 2013
Despite objections from regulators, health insurers Blue Shield of California and Aetna Inc. are proceeding with double-digit rate increases that state officials said were unreasonable.
Officials at the California Department of Managed Health Care said increases that average more than 11% for about 47,000 individual and small-business policyholders of Blue Shield and Aetna were unreasonable. But state officials don’t have the authority to reject changes in premiums, and increasingly health insurers refuse state demands to lower rates.
“I am disappointed that after lengthy negotiations, Blue Shield and Aetna were unwilling to bring their proposed health plan increases down to a reasonable level,” said Brent Barnhart, director of the Department of Managed Health Care.
Last year, Aetna led the way for the industry’s more defiant stance by proceeding with an 8% rate hike on some small-business policyholders despite objections from the state insurance department. In January, California Insurance Commissioner Dave Jones scolded Anthem for proceeding with an 11% premium hike for small businesses that he determined was excessive.
http://www.latimes.com/business/la-fi-health-insure-rates-20130307,0,130…

It is no surprise that in California – a state that can review insurance premium increases but has no power to control them – private insurers are proceeding with premium increases deemed to be unreasonable. The surprise is that our elected representatives continue to keep in charge of our health care spending an industry that uses us as instruments to achieve their own business ends.
Imagine a scenario in which Medicare would demand unreasonable increases in premiums. It would never happen. Medicare is a service model designed to serve us, the people. Private insurers are business models designed to serve their own business interests.
Did anyone ever think that it might be a good idea to dismiss the private insurers and provide Medicare for all of us?

Steven Brill explains his "Bitter Pill"

Coming up with “A Bitter Pill”

By Steven Brill
Reuters, March 5, 2013

For the past 10 days I’ve been interviewed on various television and radio shows about the article I wrote for the March 4 issue of Time, called “A Bitter Pill.”  It’s all about how exorbitant prices and profits are at the core of the crisis America uniquely faces when it comes to financing healthcare, the cost of which now accounts for roughly a fifth of our gross domestic product.

Invariably a question has come up in these interviews about how I thought of that approach. So, since this is supposed to be a column about good story ideas, I think I’ll use it to explain the genesis of “A Bitter Pill” in more detail than I’ve been able to on the talk show circuit.

During the long debate over President Barack Obama’s health insurance reform proposals, a question kept nagging at me: Everyone on all sides seemed to accept as a given that healthcare was wildly expensive, and the only debate seemed to be over who should pay for it. I wondered: Well, why is it so expensive in the first place?

I had no idea what the answers were. But it seemed obvious that there was only one way to find out: If you want to know why something is so expensive, figure out every element of its costs. In other words, follow the money.

As those who have read the article or heard about it now know, I found that all my initial suspicions were wrong. By following the money, I discovered that our healthcare prices are out of whack for a reason that was hiding in plain sight — a reason that should be obvious to anyone who has ever been a healthcare consumer, which means all of us: There is no such thing as a free market in healthcare, if one defines a free market as a place where there is some balance of power between the buyer and the seller. Instead, healthcare is – except when Medicare is the buyer – a lopsided seller’s market. That became clear at both ends of the money trails I followed – from the patients’ lack of any knowledge of what they were buying or its prices, much less any leverage to bargain over it, to the sellers’ ability and willingness to charge absurdly high prices on everything from gauze pads to ambulance services to cancer wonder drugs.

In other words, everyone along the supply chain – from hospital administrators (who enjoy multimillion-dollar salaries) to the salesmen, executives and shareholders of drug and equipment makers ‑ was reaping a bonanza. The only exceptions, I found, were those actually treating the patients ‑ the nurses and doctors (unless the doctors were gaming the system by reaping consulting fees from drug or device makers or setting up diagnostic clinics in their practices in order to steer patients there for expensive tests).

http://blogs.reuters.com/stories-id-like-to-see/2013/03/05/coming-up-with-a-bitter-pill/

Comment:

By Don McCanne, M.D.

These excepts from Steven Brill’s explanation of how he came to write “Bitter Pill,” his TIME special report on exorbitant prices and profits in U.S. health care, reveal that there are two elements that come out untarnished: 1) most of the doctors and nurses actually treating the patients, and 2) Medicare.

The first point is very reassuring, but the second point should be a call to action. As Brill writes, “healthcare is – except when Medicare is the buyer – a lopsided seller’s market.” We really do need to make Medicare, in an improved version, a buyer for all of us.

***

For those who have not yet read the 36 page report, “Bitter Pill,” it can be downloaded at the following link. The point to glean from the article is how well Medicare works, which should lead you to the conclusion that we need an improved Medicare for all of us, as opposed to merely accepting the relatively ineffectual tweaks that he suggests at the end of the article.

http://healthland.time.com/2013/02/20/bitter-pill-why-medical-bills-are-killing-us/

Steven Brill explains his "Bitter Pill"

Coming up with “A Bitter Pill”

By Steven Brill
Reuters, March 5, 2013
For the past 10 days I’ve been interviewed on various television and radio shows about the article I wrote for the March 4 issue of Time, called “A Bitter Pill.”  It’s all about how exorbitant prices and profits are at the core of the crisis America uniquely faces when it comes to financing healthcare, the cost of which now accounts for roughly a fifth of our gross domestic product.
Invariably a question has come up in these interviews about how I thought of that approach. So, since this is supposed to be a column about good story ideas, I think I’ll use it to explain the genesis of “A Bitter Pill” in more detail than I’ve been able to on the talk show circuit.
During the long debate over President Barack Obama’s health insurance reform proposals, a question kept nagging at me: Everyone on all sides seemed to accept as a given that healthcare was wildly expensive, and the only debate seemed to be over who should pay for it. I wondered: Well, why is it so expensive in the first place?
I had no idea what the answers were. But it seemed obvious that there was only one way to find out: If you want to know why something is so expensive, figure out every element of its costs. In other words, follow the money.
As those who have read the article or heard about it now know, I found that all my initial suspicions were wrong. By following the money, I discovered that our healthcare prices are out of whack for a reason that was hiding in plain sight — a reason that should be obvious to anyone who has ever been a healthcare consumer, which means all of us: There is no such thing as a free market in healthcare, if one defines a free market as a place where there is some balance of power between the buyer and the seller. Instead, healthcare is – except when Medicare is the buyer – a lopsided seller’s market. That became clear at both ends of the money trails I followed – from the patients’ lack of any knowledge of what they were buying or its prices, much less any leverage to bargain over it, to the sellers’ ability and willingness to charge absurdly high prices on everything from gauze pads to ambulance services to cancer wonder drugs.
In other words, everyone along the supply chain – from hospital administrators (who enjoy multimillion-dollar salaries) to the salesmen, executives and shareholders of drug and equipment makers ‑ was reaping a bonanza. The only exceptions, I found, were those actually treating the patients ‑ the nurses and doctors (unless the doctors were gaming the system by reaping consulting fees from drug or device makers or setting up diagnostic clinics in their practices in order to steer patients there for expensive tests).
http://blogs.reuters.com/stories-id-like-to-see/2013/03/05/coming-up-wit…

These excepts from Steven Brill’s explanation of how he came to write “Bitter Pill,” his TIME special report on exorbitant prices and profits in U.S. health care, reveal that there are two elements that come out untarnished: 1) most of the doctors and nurses actually treating the patients, and 2) Medicare.
The first point is very reassuring, but the second point should be a call to action. As Brill writes, “healthcare is – except when Medicare is the buyer – a lopsided seller’s market.” We really do need to make Medicare, in an improved version, a buyer for all of us.
***
For those who have not yet read the 36 page report, “Bitter Pill,” it can be downloaded at the following link. The point to glean from the article is how well Medicare works, which should lead you to the conclusion that we need an improved Medicare for all of us, as opposed to merely accepting the relatively ineffectual tweaks that he suggests at the end of the article.
http://healthland.time.com/2013/02/20/bitter-pill-why-medical-bills-are-…

Medicare Part D drug program wide open to conflicts of interest

Gaps in Oversight of Conflicts of Interest in Medicare Prescription Drug Decisions

Office of Inspector General
Department of Health and Human Services, March 2013

Objectives

1. To assess sponsors’ Pharmacy and Therapeutics (P&T) committees’ conflict-of interest-definitions.
2. To determine whether sponsors’ P&T committees established objective processes to determine and manage committee members’ conflicts of interest.
3. To determine whether the Centers for Medicare & Medicaid Services (CMS) oversee sponsors’ P&T committee compliance with conflict-of-interest requirements.

Findings

Most sponsors’ P&T committees had limited definitions of conflicts of interest, which could prevent them from identifying conflicts
  * Half of P&T committees’ definitions did not address conflicts prohibited by Federal regulations
  * P&T committees’ definitions did not always address relationships with other entities that could benefit from formulary decisions
  * More than two-thirds of P&T committees’ definitions did not address employment

Many sponsors’ P&T committees allowed members to determine and manage their own conflicts of interest
   * Nearly two-thirds of P&T committees relied on members to determine whether financial interests constituted conflicts
  * More than three-quarters of P&T committees relied on members to recuse themselves from discussions and votes

CMS does not adequately oversee sponsors’ P&T committee compliance with Federal conflict-of-interest requirements
  * CMS does not review P&T committee conflict-of-interest information
  * Data discrepancies would prevent CMS from identifying with certainty the members of each P&T committee

Conclusion and Recommendations

Our findings reveal that both sponsors and CMS conduct limited oversight of P&T committee conflicts of interest, compromising their ability to ensure that financial interests do not influence formulary decisions. Specifically, we found that without direction and oversight from CMS, many sponsors’ P&T committees have limited oversight of members’ conflicts of interest. Additionally, we found that CMS does not adequately oversee compliance with the Federal requirement that at least one physician and at least one pharmacist on each committee be free of conflict.

To address limitations in how P&T committee members’ conflicts are defined, determined, and managed, we recommend that CMS:

* Define PBMs as Entities That Could Benefit From Formulary Decisions

* Establish Minimum Standards Requiring Sponsors To Ensure That Safeguards Are Established To Prevent Improprieties Related to Employment by the Entity That Maintains the P&T Committee

* Establish Minimum Standards Requiring Sponsors To Ensure That an Objective Process Is Used To Determine Whether Disclosed Financial Interests Are Conflicts

* Establish Minimum Standards Requiring Sponsors To Ensure That an Objective Process Is Used To Manage Recusals Because of Conflicts of Interest

* Oversee Compliance With Federal P&T Committee Conflict-of-Interest Requirements and Guidance

Agency Comments and Office of Inspector General Response

CMS did not concur with our first and second recommendations, concurred with part of our third and fourth recommendations, and concurred with our fifth recommendation.

CMS maintained that it is not necessary to conduct additional P&T committee conflict-of-interest oversight because current formulary reviews and P&T committee audits appropriately protect beneficiaries from any adverse effects of potential conflicts of interest.

If conflicts of interest among P&T committee members are not addressed, beneficiaries may receive inferior therapies when safer or more effective therapies are available, limited Medicare dollars may be wasted to pay for inappropriate treatment, and public confidence in the Federal Government may be undermined. In contrast, CMS asserts that conflicts of interest would not disadvantage beneficiaries or the Federal Government because it believes that formulary decisions influenced by conflicts would result in higher premiums and the plan would be priced out of the marketplace.

https://oig.hhs.gov/oei/reports/oei-05-10-00450.pdf

Comment:

By Don McCanne, M.D.

When the conservatives enacted the Part D drug program for Medicare, they designed it as a private sector solution, using private insurer sponsors and private pharmacy benefit managers (PBMs), while specifically prohibiting any competing public drug plan.

An important function of these intermediaries is to select the drugs to be covered through their formularies, balancing the adequacy of drug selection with the opportunity for profit not only for the insurer sponsors and the PBMs, but also for the pharmaceutical firms supplying the drugs. This function is carried out by the sponsors’ own Pharmacy and Therapeutic (P&T) committees, and not by the government.

The potential for conflict of interest within these P&T committees is enormous. This is why this report from the Office of the Inspector General (OIG) is so important. The committee members are in a position to advocate for the interests of the insurer sponsors, or the PBMs, or the pharmaceutical firms. Decisions which benefit any or all of these would likely be detrimental to the patients who pay premiums and a portion of the Part D drug costs, and to the taxpayers who help fund the Part D program of Medicare.

But don’t worry. This program was set up to allow the free market to work its magic. Apparently this is not only the agenda of the conservatives who established this program, this laissez-faire approach is also being followed by the current “liberal” administration.

In her letter in response to the OIG report, acting CMS administrator Marilyn Tavenner wrote, “… if a P&T committee were to create a formulary while operating under a potential conflict of interest, because a discriminatory formulary would not be approved, the only potential impact would be that the bid could be more expensive and, therefore, less competitive. Beneficiaries could easily evaluate these higher premiums in the marketplace and choose a more efficient plan to meet their needs. As a result, we could expect that any authentic conflicts of interest, given our level of formulary review, would disadvantage the sponsor and not the beneficiary or Medicare program.” Note that this is the exact opposite of what is stated above.

Have you tried to shop for Part D plans? Though the premium might be the first feature you see, the complexity of the various benefits, and especially the differences in the formularies are very difficult to make sense of. How can you look up medications that may be prescribed for you next year when you don’t even know what those medications are? And are you really going to carry a formulary with you each time you see the doctor?

How nonsensical this dependency on the power of the market is can be understood by comparing the prices we get through the privatized version of the government Medicare Part D program, with the prices we get through the government purchases of drugs for the VA system. The VA pays about 40 percent less for drugs than paid under Medicare Part D (Austin Frakt). It seems that the only magic in the marketplace is the increased revenues that these intermediaries can glom off of us pathetic saps.

With HHS Secretary Kathleen Sebelius pushing private Medicare Advantage plans (yesterday’s message), and soon-to-be-confirmed CMS Administrator Marilyn Tavenner pushing private Medicare Part D drug benefits, we have
the private sector pretty well covered. One more step to the defined contribution premium support proposal and the private sector will have it locked up.

Our love of the marketplace brings to mind Puck’s comment to Oberon, “Lord, what fools these mortals be!”

Medicare Part D drug program wide open to conflicts of interest

Gaps in Oversight of Conflicts of Interest in Medicare Prescription Drug Decisions

Office of Inspector General
Department of Health and Human Services, March 2013
Objectives
1. To assess sponsors’ Pharmacy and Therapeutics (P&T) committees’ conflict-of interest-definitions.
2. To determine whether sponsors’ P&T committees established objective processes to determine and manage committee members’ conflicts of interest.
3. To determine whether the Centers for Medicare & Medicaid Services (CMS) oversee sponsors’ P&T committee compliance with conflict-of-interest requirements.
Findings
Most sponsors’ P&T committees had limited definitions of conflicts of interest, which could prevent them from identifying conflicts
* Half of P&T committees’ definitions did not address conflicts prohibited by Federal regulations
* P&T committees’ definitions did not always address relationships with other entities that could benefit from formulary decisions
* More than two-thirds of P&T committees’ definitions did not address employment
Many sponsors’ P&T committees allowed members to determine and manage their own conflicts of interest
* Nearly two-thirds of P&T committees relied on members to determine whether financial interests constituted conflicts
* More than three-quarters of P&T committees relied on members to recuse themselves from discussions and votes
CMS does not adequately oversee sponsors’ P&T committee compliance with Federal conflict-of-interest requirements
* CMS does not review P&T committee conflict-of-interest information
* Data discrepancies would prevent CMS from identifying with certainty the members of each P&T committee
Conclusion and Recommendations
Our findings reveal that both sponsors and CMS conduct limited oversight of P&T committee conflicts of interest, compromising their ability to ensure that financial interests do not influence formulary decisions. Specifically, we found that without direction and oversight from CMS, many sponsors’ P&T committees have limited oversight of members’ conflicts of interest. Additionally, we found that CMS does not adequately oversee compliance with the Federal requirement that at least one physician and at least one pharmacist on each committee be free of conflict.
To address limitations in how P&T committee members’ conflicts are defined, determined, and managed, we recommend that CMS:
* Define PBMs as Entities That Could Benefit From Formulary Decisions
* Establish Minimum Standards Requiring Sponsors To Ensure That Safeguards Are Established To Prevent Improprieties Related to Employment by the Entity That Maintains the P&T Committee
* Establish Minimum Standards Requiring Sponsors To Ensure That an Objective Process Is Used To Determine Whether Disclosed Financial Interests Are Conflicts
* Establish Minimum Standards Requiring Sponsors To Ensure That an Objective Process Is Used To Manage Recusals Because of Conflicts of Interest
* Oversee Compliance With Federal P&T Committee Conflict-of-Interest Requirements and Guidance
Agency Comments and Office of Inspector General Response
CMS did not concur with our first and second recommendations, concurred with part of our third and fourth recommendations, and concurred with our fifth recommendation.
CMS maintained that it is not necessary to conduct additional P&T committee conflict-of-interest oversight because current formulary reviews and P&T committee audits appropriately protect beneficiaries from any adverse effects of potential conflicts of interest.
If conflicts of interest among P&T committee members are not addressed, beneficiaries may receive inferior therapies when safer or more effective therapies are available, limited Medicare dollars may be wasted to pay for inappropriate treatment, and public confidence in the Federal Government may be undermined. In contrast, CMS asserts that conflicts of interest would not disadvantage beneficiaries or the Federal Government because it believes that formulary decisions influenced by conflicts would result in higher premiums and the plan would be priced out of the marketplace.
https://oig.hhs.gov/oei/reports/oei-05-10-00450.pdf

When the conservatives enacted the Part D drug program for Medicare, they designed it as a private sector solution, using private insurer sponsors and private pharmacy benefit managers (PBMs), while specifically prohibiting any competing public drug plan.
An important function of these intermediaries is to select the drugs to be covered through their formularies, balancing the adequacy of drug selection with the opportunity for profit not only for the insurer sponsors and the PBMs, but also for the pharmaceutical firms supplying the drugs. This function is carried out by the sponsors’ own Pharmacy and Therapeutic (P&T) committees, and not by the government.
The potential for conflict of interest within these P&T committees is enormous. This is why this report from the Office of the Inspector General (OIG) is so important. The committee members are in a position to advocate for the interests of the insurer sponsors, or the PBMs, or the pharmaceutical firms. Decisions which benefit any or all of these would likely be detrimental to the patients who pay premiums and a portion of the Part D drug costs, and to the taxpayers who help fund the Part D program of Medicare.
But don’t worry. This program was set up to allow the free market to work its magic. Apparently this is not only the agenda of the conservatives who established this program, this laissez-faire approach is also being followed by the current “liberal” administration.
In her letter in response to the OIG report, acting CMS administrator Marilyn Tavenner wrote, “… if a P&T committee were to create a formulary while operating under a potential conflict of interest, because a discriminatory formulary would not be approved, the only potential impact would be that the bid could be more expensive and, therefore, less competitive. Beneficiaries could easily evaluate these higher premiums in the marketplace and choose a more efficient plan to meet their needs. As a result, we could expect that any authentic conflicts of interest, given our level of formulary review, would disadvantage the sponsor and not the beneficiary or Medicare program.” Note that this is the exact opposite of what is stated above.
Have you tried to shop for Part D plans? Though the premium might be the first feature you see, the complexity of the various benefits, and especially the differences in the formularies are very difficult to make sense of. How can you look up medications that may be prescribed for you next year when you don’t even know what those medications are? And are you really going to carry a formulary with you each time you see the doctor?
How nonsensical this dependency on the power of the market is can be understood by comparing the prices we get through the privatized version of the government Medicare Part D program, with the prices we get through the government purchases of drugs for the VA system. The VA pays about 40 percent less for drugs than paid under Medicare Part D (Austin Frakt). It seems that the only magic in the marketplace is the increased revenues that these intermediaries can glom off of us pathetic saps.
With HHS Secretary Kathleen Sebelius pushing private Medicare Advantage plans (yesterday’s message), and soon-to-be-confirmed CMS Administrator Marilyn Tavenner pushing private Medicare Part D drug benefits, we have the private sector pretty well covered. One more step to the defined contribution premium support proposal and the private sector will have it locked up.
Our love of the marketplace brings to mind Puck’s comment to Oberon, “Lord, what fools these mortals be!”

Vermont report: Pre-existing conditions

By Leslie Wright
Vermont Life, Feb. 20, 2013

In May 2011, Gov. Peter Shumlin signed legislation that set the state on a path toward its own brand of health care, a made-in-Vermont “single-payer” system that would leave no Vermont resident without insurance. Many hurdles remain, but the target date is 2017. If successful, the plan would be the first of its kind in the country and a historic change in the way health care is delivered in the United States.

Why did this happen in Vermont?

Part One: A Steady Drumbeat

In 1990, Ethan Parke was dairy farming in Irasburg, running a small operation with 35 head, 12 miles south of the Canadian border. It was a hardscrabble existence at best. He couldn’t afford health insurance. His wife had a difficult childbirth that, after several trips to the hospital and 40 hours of labor, required a caesarean section that came with complications.

The hospital bill induced another kind of pain and some frustration. Since he’d be paying every penny, Parke scrutinized the invoice, which was yards long. Some of the charges seemed astronomical; others were puzzling, like $20 for slippers they never saw.

Five years later, his 5-year-old daughter landed in the emergency room with a broken leg, and he got another unpleasant look at the cost of health care. “We had to pay three different doctors for the diagnosis of broken leg — even though the emergency room doc showed me the X-ray, and it was plain to see,” Parke recalled. “We paid an amount for the hospital diagnosis, another amount for the radiologist’s diagnosis and a third amount for the orthopedic doctor’s diagnosis. These are things you never see or never worry about if you are well-insured. But when you are a self-pay patient, you are acutely aware of the overcharging and unnecessary stuff that goes on.”

Parke didn’t need an X-ray to see problems in the health care system. While searching for remedies, he discovered a book called “In Critical Condition.” “The final chapter of that book gave a very detailed conclusion that the country needed a universal, publicly financed health care system, and although I don’t think the book uses the term single-payer, that’s exactly what he described,” Parke said. The book, by Sen. Edward Kennedy, was published in 1972.

In a single-payer system, hospitals, doctors and other health care providers are paid for their services by one entity, typically a government-run organization, instead of multiple insurance companies, as is now the case.

Proponents believe single payer is more efficient, more affordable and a more equitable way to cover the entire population than today’s multi-payer system. Opponents view single payer as creating an unnecessary and inefficient government bureaucracy with high-risk consequences for taxpayers that would also erode the quality of health care.

Whatever the benefits and drawbacks of single payer, the fact is that Vermont is vigorously pursuing it. An act of legislation signed in 2011 aims to deliver a single-payer health care system to all 626,000-plus Vermont residents by 2017. Many important aspects, including how such a system would be financed, are still to be determined. But if it unfolds as envisioned, Vermont would be the first state to divorce the only health care system most Americans have known, replacing it with one much more familiar in other parts of the world, and, some believe, paving the way for the country.

“If Vermont can pass a strong single-payer system and show it works well, it will not only be enormously important to this state, it will be a model,” said Vermont Sen. Bernie Sanders, an Independent who has pushed single-payer for decades. “If we do it and do it well, other states will get in line and follow us, and over years, it will take years, we will have a national system.”

That Vermont is trailblazing may not be so surprising, at least to students of Vermont history. Vermont has led the way on many major social changes, dating back before statehood, when the Republic of Vermont’s constitution abolished slavery in 1777. (Vermont wouldn’t become a state for 14 years, and slavery wouldn’t be outlawed for another 88.) Vermont was a leader in environmental regulation when Act 250 was adopted in 1970, a law still in effect today. The state was the first to recognize civil unions in 2000.

How Vermont came to be at the forefront on single-payer health care is a tale of a passionate, persistent and sometimes quixotic group of activists. Among them are a dairy farmer, a doctor and a college professor who kept up a steady drumbeat — hosting forums, mailing newsletters, organizing rallies, arranging dinners in their homes, testifying to lawmakers and even helping draft legislation. They rode out early attempts at change that failed miserably and kept trying until slowly, eventually, over decades, the stars began to align and their dream was within reach. From the late 1980s through to today, a core group never stopped writing and meeting and speaking and believing that change could happen.

Parke was one of the core activists. He was in on the ground floor, motivated by his experiences with his family’s health care. A lanky, soft-spoken Vermonter, Parke immersed himself in learning about the health care system and possible alternatives. In the 1990s, he would serve as a low-income representative on a state board that scrutinized hospital expenditures. He didn’t consider himself an activist like some single-payer advocates who had been organizing on other progressive issues. He just felt compelled to act because the system seemed so dysfunctional and he saw the potential for change. He saw strength in numbers because he was not alone in his struggle to pay medical bills. “It was a lot of the people I knew in the Northeast Kingdom, a lot of self-employed people, farmers, small-business people, loggers. They all had their stories of dealing with the health care system, and I just felt, as Sen. Kennedy’s book made clear, there is a better way to do this, a more equitable way,” Parke recalled on an evening after work in the book-lined living room of his modest two-story home in Montpelier. No longer dairy farming, he works for Vermont Housing and Conservation Board, conserving farm land.

“I started looking around, listening to other people’s stories, and felt like something is politically possible because the people I was talking to certainly didn’t have the skepticism or the fear of socialized medicine or government control. What you hear from the typical opposition, I wasn’t hearing that from the people I knew. Certainly not from farmers and the self-employed. I thought maybe we could work on something in Vermont,” Parke said.

Part Two: Footholds and Failures

In the 1970s, as Sen. Kennedy’s book appeared, health care was just incubating as a national issue. Still, Congress was concerned about rising costs, and in 1979, as a result of federal legislation, Vermont stepped up scrutiny of new health services and hospitals’ major building projects. Eight years later, single payer blipped on the radar screen in Burlington. The city’s wild-haired and obstreperous socialist mayor, Bernie Sanders, dispatched a task force to look to Canada’s government-run system for ideas on how to tamp down health care costs.

Sanders, who was the single-payer activists’ biggest political ally, said he knew then that a single-payer system was not a likely outcome at that time, but working toward that goal and educating people about alternatives was important. “The purpose was to say to the United States and Vermont, we’re behind the rest of the world in terms of guaranteeing health care as a right,” Sanders said. He would continue to draw attention to single payer throughout his political career, as mayor, as U.S. representative an
d as U.S. senator.

Near the end of the ’80s, Parke founded Vermont Consumers Campaign for Health, along with about a half dozen others. Because most Vermonters had never heard the term single payer, let alone pondered the concept, initial efforts were focused on getting the word out through newsletters, lectures and meetings.

While winning supporters across the state was important, systemic change could not happen without the Legislature.

In 1991, Sen. Cheryl Rivers, a progressive Democrat from Stockbridge, sponsored a single-payer bill that Parke had a hand in drafting. The bill never made it out of its legislative committee, but awareness that the system needed repair continued to grow. That same year, with 62,000 Vermonters, or 11 percent of the state’s population, uninsured, Republican Gov. Richard Snelling named a blue-ribbon commission to come up with a plan to cover all Vermonters. Snelling died in office at age 64 from a heart attack on Aug. 14, 1991. Lt. Gov. Howard Dean, a physician and Democrat, became governor.

Dean was a proponent of health care reform and a recognized expert on the matter. He was, however, against financing reform with income tax, a view that clashed with single-payer activists. He pushed for reform within the multi-payer system.

The next year, Rivers again introduced a single-payer bill. It lacked the support for passage, and Rivers agreed to scrap it, but Parke said Rivers made sure that as the state considered reform, single-payer was on the table. Indeed, Act 160, which created the Vermont Health Care Authority, called for study of both single-payer and multi-payer systems to determine the best way for the state to provide health care for all Vermonters. Act 160 passed.

The Health Care Authority was beset with troubles, according to Howard Leichter, a professor at Linfield College in Oregon, who analyzed the state’s health care reform efforts at the time. Internally, two of the three board members were in different camps on reform. Externally, interest groups on all sides complained they were not included. The single-payer activists felt that the Authority didn’t have a handle on how much money single payer would save. Dean’s administration started to work on a plan of its own, seemingly undercutting the work of the Authority. By 1994, the Legislature had a menu of reform plans to consider that ranged from single-payer to employer-mandated insurance coverage to coverage focused solely on the uninsured.

Rivers again introduced a single-payer bill. This time, she didn’t go it alone. Rep. Ann Seibert sponsored a bill on the House side. The Rivers and Seibert bills won 35 co-sponsors, a dramatically improved reception over Rivers’ attempt three years earlier. One of the sponsors of Rivers’ bill was Sen. Peter Shumlin.

With so much activity on health care reform, Parke’s group, Vermont Consumers Campaign for Health, saw an open window and began feverishly working to get a referendum on single payer on the ballots for Town Meeting Day, Vermont’s iconic exercise in grassroots democracy. The matter was far from being on ballots in all 246 town meetings across the state, but a majority of residents in 50 Vermont towns voiced their approval of single payer.

In the Legislature, Gov. Dean’s plan, which went through many iterations, was the one to survive for a vote in the House. In a Hail Mary move, representatives of the Progressive Party offered an amendment to Dean’s bill calling for a single-payer system. This was the first time that government-run single payer would be voted on by the Legislature. The amendment failed 112–29.

As Leichter noted in his analysis, “The prospects of Vermont’s going to a single-payer health care system in 1994 were remote: Republicans, who controlled the Senate, and Gov. Dean (‘I would never do a Canadian-style single payer’) both opposed the model.”

Stalled and with a lack of consensus on the best way to proceed, health care reform foundered after 1994. So did grassroots activism on single payer. By the end of 1995, Vermont Consumers Campaign for Health no longer had a paid staff person, and “discussion on single-payer strategies lacked the enthusiasm of earlier years,” Parke noted in an analysis he wrote on early reform efforts. “I was definitely discouraged. I kept looking for other avenues. My thinking at that time was, We are not going to get publicly financed universal health care, but maybe there are some things we can do that would help people that would be incremental steps toward a better health care system, but that would not disillusion people,” Parke said.

Part Three: Blowing in From Buffalo

About five years after the meltdown in 1994, a physician from Buffalo, N.Y., moved to Vermont. Dr. Deborah Richter was focused on single payer like Ahab searching for a white whale.

“Dr. Deb” sought out Parke to learn what was happening on single payer. Not much, was the answer. Richter was not dissuaded.

“It never dawned on me it wasn’t a good idea,” Richter recalled recently over the Sunday afternoon din at a popular Montpelier coffee shop. “They had already done a lot of the legwork, and I thought, OK, we’ll get it going again. I consider it kind of like trying to get a patient to quit smoking. It doesn’t just happen after one try. It happens after seven tries, and we’ll keep trying until it works.”

Self-assured but not brash, Richter possesses the tenacity of a salesperson working on commission softened by the listening skills and empathy of a healer. The source of her conviction came from a decade of treating poor, uninsured and predominantly minority patients in Buffalo. “I had people dying from preventable conditions like diabetes, high blood pressure, undiagnosed cancer with obvious signs. And they were young, in their 20s, 30s, people in their 50s, dying,” Richter said.

She had given up trying to change her home state. Politicians were inaccessible, and steering reform in a state so large was more than one doctor could manage. Vermont was another story. Right away she saw that things were different here. The state’s part-time lawmakers don’t have offices in the state capitol. They don’t even have staff. That meant, literally, there were no closed doors or protective gatekeepers for legislators to hide behind.

In 1999, Richter assembled an ad hoc group, Vermont Health Care for All, which would become a formal entity in 2003. Parke was among the original board members, and others from Vermont Consumers Campaign for Health would also join the emerging group. Searching for new strategies on single payer, Vermont Health Care for All made a bold proposition — amend the state’s constitution to declare health care a civil right. The proposal, which was Parke’s brainchild, drew little attention and had no hope of being taken up by the Legislature. Nevertheless, Vermont Health Care for All was in motion with its sights set on winning over doctors and business leaders.

Richter, meanwhile, was just revving up. She practiced medicine three days a week in Cambridge; the rest of the time, she advocated for single payer. She spoke to every Rotary Club in the state, sometimes rising well before dawn to make 7 a.m. breakfast meetings. Rotarians were in her sights because she believed businesses were an essential ally in the battle for single-payer. She gave 500 talks over 11 years.

When she wasn’t on the road, she was in the Capitol cafeteria, lobbying legislators as they grabbed coffee or ate lunch. Richter was surprised to learn that some of these lawmakers — many of whom were farmers, self-employed or the like — didn’t have health insurance.

As this second wave of activism gained traction, changes in the health care landscape cast single payer in a more favorable light. In the ’90s, the issue had been coverage for the uninsured. At the millennium, the und
erinsured became part of the equation. Inadequate health care wasn’t just about the marginalized — it was about the college-educated with jobs and mortgages. By 2000, health care spending by Vermonters had nearly doubled in eight years from $1.3 billion to $2.3 billion, a trajectory that would continue.

Sanders, meanwhile, continued to draw attention to the issue. Continuing his crusade for single payer, he began taking busloads of Vermonters to Canada to buy cheap prescription drugs, a move that garnered considerable media attention. At a rally in 2001, organized by Richter and other activists, more than 1,000 people turned out. That same year, the state-commissioned Lewin Report concluded that single payer would save $118 million annually, or 5 percent.

While support was growing, many were still unconvinced, particularly Republican Gov. Jim Douglas, who took office in 2003. Douglas was opposed to government-run single-payer health care and said he would veto any single-payer initiative that crossed his desk.

In 2005, with 10 percent of the state’s population without health insurance and health care costs growing by nearly the same percentage annually, controlling the spiraling cost of health care and covering the uninsured had the Legislature’s attention. Another single-payer health care bill was introduced. Although the activists felt it was weakened as it moved through the Legislature, the bill did pass, only to meet Gov. Douglas’ veto. That same session, yet another measure was adopted calling for a single-payer study.

That study was done in 2006 by Ken Thorpe, whose findings echoed the Lewin Report. Single payer was the most cost-efficient way to cover all Vermonters, the study said.

“Every study concluded that single payer would save money and cover everyone. Every single study. Lewin is not a progressive group, they just came to the conclusion. It’s not like they are pro-single-payer,” said Ellen Oxfeld, a single-payer activist and Middlebury College professor, who added that Thorpe was not particularly single-payer friendly either.

Part Four: The Velvet Hammer

An anthropology professor, Oxfeld helped found the state’s Progressive Party and has been a major organizer on single payer from the early days. Slight of stature, Oxfeld speaks in a gentle cadence that belies her laser-like focus. Oxfeld’s velvet hammer style makes activism personal. She wins people over in intimate settings like, for example, a lasagna dinner in her home where she invited Richter to give a presentation to local lawmakers and key community leaders on both sides of the issue.

She nudged Ann Ross, a retired schoolteacher, to hold a meeting at her house in Cornwall in the mid-2000s. Sensitive to the gap between the haves and have-nots, the 81-year-old Ross has long been active on social issues, helping to found the local United Way and regularly joining a Saturday morning peace vigil in Middlebury. Ross and her husband, Jim, retired business manager at Middlebury College, were what marketers would call opinion leaders in the community where they raised four children. About 20 carefully selected invitees attended the Rosses’ gathering, including the head of the local hospital. Small gatherings like these were a key component of the single-payer movement, and Oxfeld had a hand in many of them.

Meanwhile, the tides of Vermont politics were moving steadily leftward, and by 2008, Democrats had reached ironclad majorities in the Statehouse. A new approach to single payer took shape among lawmakers. Instead of aiming to transform the entire system, this time the plan was to institute single payer just in hospitals. (Canada’s system started this way in 1947 when the rural province of Saskatchewan instituted government-run health care in its hospitals.) Sponsorship came from an unlikely source — a maverick Republican representative named Topper McFaun, from Barre. McFaun introduced a bill, which Richter helped craft. It went nowhere, but kept the single-payer flame flickering.

While the activists continued to plug away, the movement was about to get a big boost from a small union-organizing group. The Vermont Workers’ Center had just two employees but was adept at leveraging the groups it had supported, such as the nurses at Fletcher Allen Health Care in Burlington, the state’s largest hospital. The Vermont Workers’ Center, which had worked alongside Richter’s group, was tired of the legislative logjam on single payer.

“Most legislators said it made a lot of sense, but year after year they said it just wasn’t politically possible. We wrestled with that,” said James Haslam, director of the Workers’ Center. “How do we make it in their best interest to do it? It’s not going to take a few people, a dozen people. It’s going to take thousands of people to make it possible.”

The cost of health care was affecting a broad swath of workers in the state, and the Workers’ Center sensed there was critical mass if only the masses were organized. Organizing the masses was something the Workers’ Center knew how to do. The group launched Health Care Is a Human Right, which played a key role by humanizing the issue and getting attention in a way that legislators couldn’t ignore.

A rally on May 1, 2009, drew more than 1,000 people, a similar turnout to the 2001 rally. As Health Care Is a Human Right was building, Vermont Health Care for All held a panel discussion with businesses. Shumlin, who by then had risen to Senate President Pro Tem, was there. Oxfeld, who keeps a library of legislative bill numbers in her head and an archive of single-payer articles and editorials in her computer, was stunned by Shumlin’s remarks. “I remember this like — I don’t know what like — but just so clearly in my head because he said, ‘They are not going to solve this in Washington. They are not going to come up with a solution, and we’ll have to do it here in Vermont,’” Oxfeld said.

Shumlin reiterated the message in June at another panel discussion the group held at a packed Congregational Church in Middlebury. Two months later, in August 2009, Gov. Douglas announced he would not seek re-election. It would be a wide-open race for governor in 2010, the chance of a lifetime for several Democrats, including Shumlin.

Part Five: A Rock Star, and the Final Star

As Oxfeld went about organizing forums and dinner parties, she also had a hand in bringing a big-name player to the state. William Hsiao, an economics professor at the Harvard School of Public Health, was a rock star in single-payer circles. He had designed the single-payer system for Taiwan, among other places, and his appearance before the state Legislature was a watershed moment in the single-payer movement.

Hsiao might never have appeared in Vermont at all but for a chance meeting between Shumlin and Oxfeld’s husband, Frank Nicosia, a history professor at the University of Vermont. In December 2009, as Shumlin was pondering a run for governor, Nicosia and Shumlin crossed paths in a Winooski restaurant. Nicosia told Shumlin that single-payer advocates were ready to get behind him, and suggested he talk to Hsiao. As Nicosia recalled, Shumlin “immediately reaches in his pocket and takes out a little notepad and says, ‘How do you spell his name?’”

After hearing about her husband’s encounter, Oxfeld followed up with Shumlin by e-mail, sending him contact information for Hsiao. She didn’t stop there, checking in to ask whether he got in touch with Hsiao. It turned out Hsiao missed a scheduled phone interview, Shumlin told her. She wished him luck, nudging him to keep trying. Shumlin did and invited Hsiao to speak to the Legislature. Hsiao declined.

“He said, ‘I’ve given up on America. I can’t help you.’ I said, ‘What do you mean?’” Shumlin recalled. “He said, ‘I work in countries that I can actually get some
thing done.’ I said, ‘Dr. Hsiao, I actually think we can get something done here in Vermont.’ I sort of pleaded with him to come talk to us, and he came up.”

In the wake of Hsiao’s appearance before the Legislature in March 2010, a bill passed that session calling for a study of three options for reform: government-run single payer; multi-payer in which public and private plans compete; and a public/private single-payer system administered by a competitively selected entity. This time the political will was there to make something happen. Hsiao won the contract to do the study. He concluded that the public/private single-payer model was the most cost-efficient way for Vermont to reform health care and the most politically appealing, saving 8 to 12 percent immediately and 12 to 14 percent over time.

The final star aligned in the single-payer constellation when Shumlin was elected governor in November 2010. Shumlin had survived a five-way primary by 203 votes, which was the margin by which he won Oxfeld’s home county, Addison County, Oxfeld noted. She believes the single-payer advocates delivered Shumlin the primary and the general election, which was also close.

Shumlin agreed.

“When I entered the five-way Democratic primary, I was the last candidate in, and I was polling fourth out of five. Most people thought it was a fruitless effort. I was the only candidate in America to make ads that said, ‘If you elect me governor, we are going to pass single-payer health care,’” Shumlin said. “The grassroots support I got from single-payer advocates made it possible for me to be governor. They knocked on doors. They poured their hearts out. They saw an opportunity, and I would not be here without them.”

After squeaking out a victory in 2010 and signing the milestone health care legislation in 2011, Shumlin faced the electorate again in November 2012, this time winning by a wide margin. Asked at his first post-election news conference about the outlook for health care, Shumlin said the push toward single payer would continue, with “a transparent discussion with every Vermonter who wants to participate about how we best move in 2017 from a premium-based system to a publicly financed system, where we all pay our fair share, and we get it off the backs of businesses and grow jobs and economic opportunities. That’s the plan.”

http://www.vermontlife.com/special-report-pre-exisiting-conditions/