PNHP

Why Did Single-Payer Health Care Fail in California?

Why Did Single-Payer Health Care Fail in California?

By Lenny Potash
Labor Notes, Feb. 17, 2012

Though it’s passed the legislature twice before, a bill to establish a single-payer universal health insurance system in California failed in the state senate in January.

Not surprisingly, the bill received no Republican votes, but it fell just two votes short of passage when two Democrats voted no and four Democrats failed to vote, despite intense lobbying efforts by community and some labor health care activists.

Angry activists pointed to the fact that five of the six errant Democrats had received money from the insurance industry and Big Pharma, ranging from $100,000 to over $250,000. Three of the six senators had been endorsed by the California Labor Federation which, along with unions such as the Service Employees and AFSCME, was on record supporting the single-payer bill. The California Democratic Party was also on record supporting it.

Similar bills passed the legislature fairly easily in 2006 and 2008, only to be vetoed by then-Governor Arnold Schwarzenegger. At a time when premiums were rising and there were few other proposals out there, it was an easy vote for Democrats certain of the governor’s veto.

But when Congress passed federal health reform in 2010, defending that bill, as well as President Obama, became paramount for many Democrats. It became more difficult for legislators to vote for a single-payer bill that might be interpreted as deserting the president, and the Democratic leadership refused to put the bill up for a final vote in the Assembly.

In 2011-12 the issue in some ways became even more loaded, with a Democratic governor facing massive budget deficits. Even though single payer would save Californians much more money in the medium term by reducing the huge overhead costs of insurance and drug companies, Governor Jerry Brown did not express support for the measure, and some Democrats feared to be seen backing an expensive bill.

Much of organized labor also hung back for similar reasons, despite the fact that almost all contract struggles and strikes today are to maintain health benefits. Insurance premiums have been rising four times faster than wages, and unions are battling employer efforts at shifting those costs to workers in every sector.

Unions that did back single payer this term included the California School Employees, California Nurses, both statewide teachers unions, and many locals who belong to the single-payer Campaign for a Healthy California.

The failure to pass single payer in California is a dose of reality for the movement. Although a 2009 New York Times/CBS survey confirms that 65 percent of Americans support a single-payer health care system, political and institutional support is lagging. Historically, labor’s support has been essential to the passage of any progressive social legislation, and that is even more important in the continuing face-off with the corporate health insurance behemoths.

“It will take a mighty grassroots movement to prevail over this concentrated corporate power and win health care for all,” said Mark Dudzic of Labor Campaign for Single Payer in a message to activists, adding that delegates from 28 unions, non-profits and grassroots organizations met in Portland two weeks ago to launch a new coalition to win universal health care in Oregon.

“Rather than starting off with a developed piece of legislation that would rely on the good will of the Democratic legislative caucus to advance, they have determined to focus first on grassroots community organizing and outreach,” he said, following the Vermont model.

Lenny Potash is a long-time AFSCME activist and is co-chair of Labor United for Universal Healthcare, a Los Angeles-based coalition of more than 40 unions in California.

http://labornotes.org/blogs/2012/02/why-did-single-payer-health-care-fail-california

Timothy Jost – Update on essential health benefits

Implementing Health Reform: Essential Health Benefits And Medical Loss Ratios

By Timothy Jost
Health Affairs Blog, February 18, 2012

On December 16, 2011, the Department of Health and Human Services issued a bulletin describing the approach that it intended to take to defining the essential health benefits (EHB) that individual (nongroup) and small group plans must cover under the Affordable Care Act.

The EHB bulletin raised a host of questions as to how this approach would work.  On February 17, 2012, HHS issued guidance in the form of an FAQ (frequently asked questions) addressing some of these questions. This post will discuss this FAQ.

Summing up:

The FAQ do go some distance toward clarifying a number of the issues left open by the initial bulletin, in particular how plan flexibility will (and will not) work, that states will not establish a new EHB every year, and that a state’s commercial plan EHB need not apply to Medicaid. The approach selected by HHS will allow states to maintain their coverage mandates (or at least those that apply to the small group market) until 2016, but will preclude the addition of new mandates. It is still hard to imagine how this is all going to work out in practice, however, and more to the point how plan compliance will ever be monitored, given the ability of plans to substitute services within categories. One must wonder whether in the end it might not have been more straightforward simply to come up with a federal menu of services.

http://healthaffairs.org/blog/2012/02/18/implementing-health-reform-essential-health-benefits-and-medical-loss-ratios/

CMS – FAQs on essential health benefits:
http://cciio.cms.gov/resources/files/Files2/02172012/ehb-faq-508.pdf

Comment: 

By Don McCanne, MD

Being the fine gentleman he is, Professor Jost politely states, “One must wonder whether in the end it might not have been more straightforward simply to come up with a federal menu of services.”

You don’t have to wonder. Not only should we have a national standard calling for comprehensive benefits for everyone, we also should have simplified the financing system to make it more equitable and much more efficient so that health care would be accessible and affordable for everyone.

Timothy Jost – Update on essential health benefits

Implementing Health Reform: Essential Health Benefits And Medical Loss Ratios

By Timothy Jost
Health Affairs Blog, February 18, 2012
On December 16, 2011, the Department of Health and Human Services issued a bulletin describing the approach that it intended to take to defining the essential health benefits (EHB) that individual (nongroup) and small group plans must cover under the Affordable Care Act.
The EHB bulletin raised a host of questions as to how this approach would work.  On February 17, 2012, HHS issued guidance in the form of an FAQ (frequently asked questions) addressing some of these questions. This post will discuss this FAQ.
Summing up:
The FAQ do go some distance toward clarifying a number of the issues left open by the initial bulletin, in particular how plan flexibility will (and will not) work, that states will not establish a new EHB every year, and that a state’s commercial plan EHB need not apply to Medicaid. The approach selected by HHS will allow states to maintain their coverage mandates (or at least those that apply to the small group market) until 2016, but will preclude the addition of new mandates. It is still hard to imagine how this is all going to work out in practice, however, and more to the point how plan compliance will ever be monitored, given the ability of plans to substitute services within categories. One must wonder whether in the end it might not have been more straightforward simply to come up with a federal menu of services.
http://healthaffairs.org/blog/2012/02/18/implementing-health-reform-essential-health-benefits-and-medical-loss-ratios/
CMS – FAQs on essential health benefits:
http://cciio.cms.gov/resources/files/Files2/02172012/ehb-faq-508.pdf

Being the fine gentleman he is, Professor Jost politely states, “One must wonder whether in the end it might not have been more straightforward simply to come up with a federal menu of services.”
You don’t have to wonder. Not only should we have a national standard calling for comprehensive benefits for everyone, we also should have simplified the financing system to make it more equitable and much more efficient so that health care would be accessible and affordable for everyone.

ACA Sec. 1104 – Administrative Simplification

Administrative Simplification: From compliance to competitive advantage

Deloitte

Administrative Simplification, part of the Patient Protection and Affordable Care Act of 2010 (ACA) signed into law on March 23, 2010, has an overarching goal of streamlining administrative interactions between health plans and providers to improve the patient experience and reduce costs throughout the health care system. Administrative Simplification provisions build on the electronic standards first defined in 1996 with HIPAA 4010 and accelerated in 2009 with passage of HIPAA 5010. While HIPAA addresses the technical structure of transactions, Administrative Simplification addresses how they are used.

Goals:

• Standardized business and operating rules to eliminate variability in transaction implementation, moving the industry toward commoditization of “back-end” transaction processing
• Standardized benefit coverage information to drive consistency of eligibility content, enabling providers to better understand financial liability
• Provision of patient financial liability at or before the point of care, enabling providers to improve the collections process
• Real-time electronic auto-adjudication and claims status, providing for automated reconciliation
• Automation of health plan utilization management and care management decision processes required to support real-time referrals and pre-authorizations

Key dates and scope:

• Wave 1 (January 1, 2013): Automation of point-of-care eligibility and claims status
• Wave 2 (January 1, 2014): Automation of claims payment remittance advice and electronic funds transfer
• Wave 3 (January 1, 2016): Automation of claims and encounters, enrollment/disenrollment, referral authorization, premium payments, and claim attachments

Deloitte – Administrative Simplification:
http://www.deloitte.com/assets/Dcom-UnitedStates/Local%20Assets/Documents/us_lshc_AdministrativeSimplification_021612.pdf

CMS – Administrative Simplification Provisions in the Patient Protection and Affordable Care Act of 2010 (ACA) (6 page pdf):
https://www.cms.gov/Affordable-Care-Act/Downloads/Summary%20of%20ACA%20provisions%20for%20Administrative%20Simplification.pdf

Comment:

By Don McCanne, MD

It has long been recognized that profound administrative waste is a unique feature of the U.S. health care system – waste that contributes to our unparalleled, sky-high health care spending. During the reform process, the subject of administrative waste was brought up repeatedly. In response, Congress included in the Affordable Care Act “Sec. 1104 Administrative Simplification.” What is that?

You can read either Sec. 1104 in ACA, or, better, you can read the six page summary by CMS (link above). However, easiest would be to read the excerpts above from the Deloitte report on Administrative Simplification. There is enough there to let you know what it is.

It will not take long for people who understand the administrative advantages of the single payer model to realize that Sec. 1104 has nothing to do with the administrative waste that is a result of our highly fragmented, dysfunctional health care financing infrastructure. Sec. 1104 is primarily revising the information technology systems of the insurers and then requiring the providers to become compliant.

An idea of what Sec. 1104 is really about can be gleaned from Deloitte’s discussion of a revolutionary scenario for administrative simplification:

“This scenario assumes that all stakeholders adopt real-time, end-to-end transaction processing, and that product standardization emerges. Implementation costs would be significant for both health plans and providers. Commercial health plans, in particular, would face a new strategic reality as claims transactions become a commodity, and health plan differentiation shifts to other areas, such as provider network and member experience. Such revolutionary change is possible if existing industry players and/or new entrants look for innovative ways to capitalize on market opportunities to affect health care cost and quality and make meaningful improvements to our health care system.”

Do not be misled when ACA supporters talk about “administrative simplification.” That’s their code language for “commoditization” and “innovative ways to capitalize on market opportunities.”

“Administrative simplification” is another term that they have stolen from the single payer community, and then bastardized it. Don’t let them get away with it. That’s our policy science.

Exchanges are mandated, but single payer the only real solution for Vermont

By Ellen Oxfeld
Vtdigger.org, Feb. 16, 2012

There has been a lot of discussion about the exchange – about bronze, silver and platinum plans. Vermont is required by federal law to implement the exchange in 2014. How can Vermont’s Legislature best configure the exchange? Many people are wondering what this all means for them.

Let’s remember that the exchange is just about a format to purchase private insurance. It is not the same as the single-payer system that Vermonters will be allowed to implement in 2017. Single payer is about financing health care for all Vermonters directly – without the waste and overhead of insurance company middlemen. A single payer system guarantees health care, divorced from employment, funded directly by the public. If you lose your job, you will still have health care in a single-payer system. If you are a small employer, you will not have to spend hours shopping around for different plans.

We all know that if the exchanges were able to deliver health care to all Vermonters when they needed it, and to control costs, we wouldn’t need a single-payer system in Vermont. However, we can’t establish a single-payer system until 2017, because we can’t get a waiver from the exchange until then. Therefore, we have to think about the exchange as temporary, and try to take advantage of the one thing the exchange does have to offer, namely federal dollars to help people purchase insurance premiums and to subsidize some out-of-pocket costs. Once Vermont establishes a single-payer system, we will be able to access these same federal dollars, but put them directly into our new single-payer system.

In the short run, we will have to devise rules for the exchange that do the least harm. We know that having plans with different levels is not what health care is all about. But, we also know that many small employers are well meaning, and if they could afford private insurance plans with more coverage, they would have purchased them in the first place.

The House Health Care Committee and the Shumlin administration have been trying their best to wrestle with these issues. I suggest that they let two guiding principles help them through this morass, and that they keep in mind that the exchange is temporary. First, despite the inclusion of bronze plans, there should be ways to create maximum incentives for silver plans.  I agree, you cannot force a small business to purchase a plan they can’t afford. However, incentives can maximize the choices of silver plans, and this may bring in more federal dollars, as well as keep to a minimum the number of people who are left holding the bag with high out-of-pocket costs.

Second, it will be very important to make sure that people currently on VHAP and Catamount experience as little deterioration in their experience of cost and coverage as possible. If the exchange results in a sharp deterioration of coverage or increase in cost, this will create real hardships for people. Such bad experiences with the exchange may also poison the well for single payer, because people will be turned off to the very idea of reform.

As we go through this process, however, let’s remember that single payer is based on completely different principles than the exchange. With single payer we will no longer be talking about bronze, silver and platinum plans, but guaranteed health care for all Vermonters without the excess cost of the insurance company middlemen. Single payer is the only real solution for individuals, for businesses, and for all Vermonters.

Editor’s note: This op-ed is by Ellen Oxfeld, who is a founder of the nonprofit Vermont Health Care for All. It first appeared on Vermont for Single Payer.

http://vtdigger.org/2012/02/16/exchanges-are-mandated-but-single-payer-the-only-real-solution/

ACA Sec. 1104 – Administrative Simplification

Administrative Simplification: From compliance to competitive advantage

Deloitte
Administrative Simplification, part of the Patient Protection and Affordable Care Act of 2010 (ACA) signed into law on March 23, 2010, has an overarching goal of streamlining administrative interactions between health plans and providers to improve the patient experience and reduce costs throughout the health care system. Administrative Simplification provisions build on the electronic standards first defined in 1996 with HIPAA 4010 and accelerated in 2009 with passage of HIPAA 5010. While HIPAA addresses the technical structure of transactions, Administrative Simplification addresses how they are used.
Goals:
• Standardized business and operating rules to eliminate variability in transaction implementation, moving the industry toward commoditization of “back-end” transaction processing
• Standardized benefit coverage information to drive consistency of eligibility content, enabling providers to better understand financial liability
• Provision of patient financial liability at or before the point of care, enabling providers to improve the collections process
• Real-time electronic auto-adjudication and claims status, providing for automated reconciliation
• Automation of health plan utilization management and care management decision processes required to support real-time referrals and pre-authorizations
Key dates and scope:
• Wave 1 (January 1, 2013): Automation of point-of-care eligibility and claims status
• Wave 2 (January 1, 2014): Automation of claims payment remittance advice and electronic funds transfer
• Wave 3 (January 1, 2016): Automation of claims and encounters, enrollment/disenrollment, referral authorization, premium payments, and claim attachments
Deloitte – Administrative Simplification:
http://www.deloitte.com/assets/Dcom-UnitedStates/Local%20Assets/Documents/us_lshc_AdministrativeSimplification_021612.pdf
CMS – Administrative Simplification Provisions in the Patient Protection and Affordable Care Act of 2010 (ACA) (6 page pdf):
https://www.cms.gov/Affordable-Care-Act/Downloads/Summary%20of%20ACA%20provisions%20for%20Administrative%20Simplification.pdf

It has long been recognized that profound administrative waste is a unique feature of the U.S. health care system – waste that contributes to our unparalleled, sky-high health care spending. During the reform process, the subject of administrative waste was brought up repeatedly. In response, Congress included in the Affordable Care Act “Sec. 1104 Administrative Simplification.” What is that?
You can read either Sec. 1104 in ACA, or, better, you can read the six page summary by CMS (link above). However, easiest would be to read the excerpts above from the Deloitte report on Administrative Simplification. There is enough there to let you know what it is.
It will not take long for people who understand the administrative advantages of the single payer model to realize that Sec. 1104 has nothing to do with the administrative waste that is a result of our highly fragmented, dysfunctional health care financing infrastructure. Sec. 1104 is primarily revising the information technology systems of the insurers and then requiring the providers to become compliant.
An idea of what Sec. 1104 is really about can be gleaned from Deloitte’s discussion of a revolutionary scenario for administrative simplification:
“This scenario assumes that all stakeholders adopt real-time, end-to-end transaction processing, and that product standardization emerges. Implementation costs would be significant for both health plans and providers. Commercial health plans, in particular, would face a new strategic reality as claims transactions become a commodity, and health plan differentiation shifts to other areas, such as provider network and member experience. Such revolutionary change is possible if existing industry players and/or new entrants look for innovative ways to capitalize on market opportunities to affect health care cost and quality and make meaningful improvements to our health care system.”
Do not be misled when ACA supporters talk about “administrative simplification.” That’s their code language for “commoditization” and “innovative ways to capitalize on market opportunities.”
“Administrative simplification” is another term that they have stolen from the single payer community, and then bastardized it. Don’t let them get away with it. That’s our policy science.

Four ways communities are turning health care delivery on its head

By Philip Caper, M.D.
Bangor Daily News, Feb. 15, 2012

When veteran print and TV journalist T.R. Reid visited Maine last fall, he claimed we could provide health care for everybody and do it for less money with better results. At 3:30 p.m. Sunday, the Maine Public Broadcasting Network will air his latest documentary, “U.S. Health Care: The Good News,” which shows how it can be done.  [PNHP note: The documentary premieres Feb. 16 on PBS. Check local listings.]

We spend almost $3 trillion nationwide on health care, about twice the average of all other wealthy nations. Our health care system has plenty of problems, but a shortage of money is not one of them. Historically, we in the U.S. have responded to problems in health care by throwing money at them. This mountain of money has led to a lot of wasteful spending.

High health care costs have raised taxes and insurance premiums, depressed wages and eroded public budgets. The more money we pump into our health care system, the worse it seems to get.

We spend so much because we have the highest prices for products and services in the world and often overuse them. Experts estimate that 30 percent of health care services provided in the U.S. offer little or no benefit to patients.

At the same time, we provide too few services to others. More than 50 million Americans, including 125,000 Mainers, lack coverage, and many more are inadequately insured. Underinsured people tend to put off medical care until they become very ill, often forcing them to go to the emergency room where the expense is far greater. Someone else usually pays the bill.

We learn in Reid’s documentary that costs often are driven more by a community’s supply of health care facilities and technology than by the amount of illness, contributing to large geographic differences in health care spending.

Our patchwork system of public and employment-based private insurance is inherently inefficient. There are literally thousands of insurance plans and tens of thousands of different policies in the U.S., all with different rules. Insurance companies spend megabucks trying to deny claims, and doctors, hospitals and patients spend more trying to get paid. This imposes hundreds of billions of dollars in administrative costs nationwide, with few or no medical benefits.

With so many private insurers, each one has little power to bargain down the prices charged by increasingly bottom-line-driven health care providers. Doctors and hospitals attempt to maximize their revenues by skewing their mix of services toward those that are most profitable, sometimes doing unnecessary procedures. Product manufacturers try to maximize their prices and generate demand, shamelessly peddling their goods to the public. While the insurance and health care industries game the system, patients pay the costs in more ways than one.

Each of these problems presents an opportunity to do more with less.

But tinkering with the status quo will not fix the problem. Reid suggests some promising solutions from several U.S. communities that have some important features in common.

First, they cover everybody in one communitywide insurance program. This facilitates preventive care, treats everyone by the same rules, cuts administrative costs and dramatically increases the public’s sense of fairness, community and confidence in the system. Recent changes in Maine law that will increase the number of companies in the state selling insurance go in the opposite direction.

Second, they put the whole array of services, from the ICU to home health care, within an organized system under a global budget — the only effective way to control overall costs. In Maine, Eastern Maine Healthcare Systems has been chosen to pilot a similar system for Medicare beneficiaries, a system that if proven cost effective could spread across the state.

Third, they reduce financial incentives that unduly influence clinical decisions. Fee-for-service payment to health caregivers is replaced by systems such as salaries and bonuses, eliminating the pressure on providers to chase dollars by doing expensive but unnecessary tests and procedures and giving them more time to spend with their patients.

Finally, they return the culture of health care to its healing mission and away from its excessive focus on the bottom line. As one doctor Reid interviews puts it, “Collaborate, do the right thing, don’t be greedy and work not out of self-interest but in the community interest.”

If these changes were easy, they would have been made already. But if they are made, we can provide health care for everybody at less cost. If they can do it in Washington state, Colorado and New Hampshire, we can do it in Maine. That really is good news.

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

http://bangordailynews.com/2012/02/15/health/four-ways-communities-are-turning-health-care-delivery-on-its-head/

Archer and Marmor on Medicare versus commercial insurance

Medicare And Commercial Health Insurance: The Fundamental Difference

By Diane Archer and Theodore Marmor
Health Affairs Blog, February 15, 2012

As the debate over Medicare continues in connection to America’s fiscal problems, it is critical to understand how Medicare differs from commercial health insurance for working people.  There is a fundamental difference between these two types of health insurance plans, one social and one commercial.

The basic difference between Medicare and commercial insurance is that Medicare is designed to absorb risk, serving individuals who have or may have costly and complex medical needs as well as the relatively healthy, whereas commercial insurance is required to protect its business interests by avoiding those most likely to use medical care.

****

But nothing can change the underlying reality that programs like Medicare are designed to absorb and broadly distribute risk, protecting everyone, while commercial insurers are designed to select and protect individuals with the fewest needs.

The belief that competition among private health insurance firms can produce cost savings or higher quality care represents the victory of illusion over evidence. We need to let the existing Medicare system do what it already does effectively: insulate Americans from risk, rather than shift risk to the most vulnerable citizens.

http://healthaffairs.org/blog/2012/02/15/medicare-and-commercial-health-insurance-the-fundamental-difference/comment-page-1/#comment-165108

Comment: 

By Don McCanne, MD

The fundamental difference between Medicare and commercial health insurance is very basic and easy to understand. Medicare is “designed to absorb and broadly distribute risk, protecting everyone, while commercial insurers are designed to select and protect individuals with the fewest needs.”

The explanation of this difference in this Health Affairs Blog entry by Diane Archer and Theodore Marmor should make us question once again why Congress and President Obama chose commercial insurers as the foundation for the Affordable Care Act when what we clearly needed was a universal public program based on improved version of Medicare.

You should read their fairly brief blog entry and then read the replies posted first by Vince Kuraitis and then by Don McCanne. They exemplify the differences between the commercial approach to insurance and the social function of Medicare.

It’s really an easy concept to grasp:

Commercial – “Of or relating to commerce, having profit as a chief aim”

Social – “Of, relating to, or occupied with matters affecting human welfare”

Addendum:  Since the reply submitted by Don McCanne has not yet been posted on the blog website, both the Kuraitis reply and McCanne reply are reproduced here.

Vince Kuraitis says:

You (Archer and Marmor) make a sweeping statement: No matter what regulations are instituted in an attempt to guarantee their good behavior, commercial insurers will still have an incentive to avoid risk, and they will do so insofar as it is possible.

An equally sweeping rebuttal: this problem is entirely fixable by risk adjusting — paying higher premiums for members that are less healthy. Medicare has already started doing this with Medicare Advantage plans.

Of course, the devil is in the details…and in a debate we’d probably come out in the middle somewhere. Risk adjustment is easier to conceptualize than to do accurately.

…but I think your broad, blunt assertion needs to be challenged.

Don McCanne says:

Vince Kuraitis writes that the authors’ statement on incentives for commercial insurers needs to be challenged. It is Mr. Kuraitis’ challenge that needs to be challenged since the authors’ statement is quite correct.

Commercial insurers do have incentives to avoid risk, and, if subjected to risk adjustment, they have incentives to game the system. This is not suggesting illegal activity. It merely represents “appropriate” commercial activity – activities that are rewarded on Wall Street.

Risk adjustment already takes place in the Medicare Advantage program. An NBER study (Working Paper No. 16977, April 2011) revealed that the Medicare Advantage plans were able to further increase their own advantage and transfer more resources from the relatively sick in the traditional program to the relatively healthy within their plans.

Quoting from the NBER report, “With social insurance programs, however, imperfect pricing can induce private firms to cream-skim, exacerbating the utility consequences of the underlying inequality the program was initially intended to mitigate. At least in the case of Medicare, we find little evidence that risk adjustment has solved this problem.”

And from the NBER Digest, “Thus the authors conclude that the Medicare Advantage program both increased total Medicare spending and transferred Medicare resources from the relatively sick to the relatively healthy, and that risk-adjustment was not able to address either of these problems.”

Archer and Marmor are precisely correct: “No matter what regulations are instituted in an attempt to guarantee their good behavior, commercial insurers will still have an incentive to avoid risk, and they will do so insofar as it is possible.” That is the nature of the commercial approach to insurance, which is in sharp contrast to the social function of the traditional Medicare program.

Archer and Marmor on Medicare versus commercial insurance

Medicare And Commercial Health Insurance: The Fundamental Difference

By Diane Archer and Theodore Marmor
Health Affairs Blog, February 15, 2012
As the debate over Medicare continues in connection to America’s fiscal problems, it is critical to understand how Medicare differs from commercial health insurance for working people.  There is a fundamental difference between these two types of health insurance plans, one social and one commercial.
The basic difference between Medicare and commercial insurance is that Medicare is designed to absorb risk, serving individuals who have or may have costly and complex medical needs as well as the relatively healthy, whereas commercial insurance is required to protect its business interests by avoiding those most likely to use medical care.
****
But nothing can change the underlying reality that programs like Medicare are designed to absorb and broadly distribute risk, protecting everyone, while commercial insurers are designed to select and protect individuals with the fewest needs.
The belief that competition among private health insurance firms can produce cost savings or higher quality care represents the victory of illusion over evidence. We need to let the existing Medicare system do what it already does effectively: insulate Americans from risk, rather than shift risk to the most vulnerable citizens.
http://healthaffairs.org/blog/2012/02/15/medicare-and-commercial-health-insurance-the-fundamental-difference/comment-page-1/#comment-165108

The fundamental difference between Medicare and commercial health insurance is very basic and easy to understand. Medicare is “designed to absorb and broadly distribute risk, protecting everyone, while commercial insurers are designed to select and protect individuals with the fewest needs.”
The explanation of this difference in this Health Affairs Blog entry by Diane Archer and Theodore Marmor should make us question once again why Congress and President Obama chose commercial insurers as the foundation for the Affordable Care Act when what we clearly needed was a universal public program based on improved version of Medicare.
You should read their fairly brief blog entry and then read the replies posted first by Vince Kuraitis and then by Don McCanne. They exemplify the differences between the commercial approach to insurance and the social function of Medicare.
It’s really an easy concept to grasp:
Commercial – “Of or relating to commerce, having profit as a chief aim”
Social – “Of, relating to, or occupied with matters affecting human welfare”
Addendum:  Since the reply submitted by Don McCanne has not yet been posted on the blog website, both the Kuraitis reply and McCanne reply are reproduced here.

Vince Kuraitis says:
You (Archer and Marmor) make a sweeping statement: No matter what regulations are instituted in an attempt to guarantee their good behavior, commercial insurers will still have an incentive to avoid risk, and they will do so insofar as it is possible.
An equally sweeping rebuttal: this problem is entirely fixable by risk adjusting — paying higher premiums for members that are less healthy. Medicare has already started doing this with Medicare Advantage plans.
Of course, the devil is in the details…and in a debate we’d probably come out in the middle somewhere. Risk adjustment is easier to conceptualize than to do accurately.
…but I think your broad, blunt assertion needs to be challenged.
Don McCanne says:
Vince Kuraitis writes that the authors’ statement on incentives for commercial insurers needs to be challenged. It is Mr. Kuraitis’ challenge that needs to be challenged since the authors’ statement is quite correct.
Commercial insurers do have incentives to avoid risk, and, if subjected to risk adjustment, they have incentives to game the system. This is not suggesting illegal activity. It merely represents “appropriate” commercial activity – activities that are rewarded on Wall Street.
Risk adjustment already takes place in the Medicare Advantage program. An NBER study (Working Paper No. 16977, April 2011) revealed that the Medicare Advantage plans were able to further increase their own advantage and transfer more resources from the relatively sick in the traditional program to the relatively healthy within their plans.
Quoting from the NBER report, “With social insurance programs, however, imperfect pricing can induce private firms to cream-skim, exacerbating the utility consequences of the underlying inequality the program was initially intended to mitigate. At least in the case of Medicare, we find little evidence that risk adjustment has solved this problem.”
And from the NBER Digest, “Thus the authors conclude that the Medicare Advantage program both increased total Medicare spending and transferred Medicare resources from the relatively sick to the relatively healthy, and that risk-adjustment was not able to address either of these problems.”
Archer and Marmor are precisely correct: “No matter what regulations are instituted in an attempt to guarantee their good behavior, commercial insurers will still have an incentive to avoid risk, and they will do so insofar as it is possible.” That is the nature of the commercial approach to insurance, which is in sharp contrast to the social function of the traditional Medicare program.

Explaining regional variation in private health care spending

Health Status and Hospital Prices Key to Regional Variation in Private Spending

Research Brief by Chapin White
National Institute for Health Care Reform, February 15, 2012

Differences in health status explain much of the regional variation in spending for privately insured people, but differences in provider prices — especially for hospital care — also play a key role, according to a new study by the Center for Studying Health System Change (HSC) for the nonpartisan, nonprofit National Institute for Health Care Reform (NIHCR).

Based on claims data for 218,000 active and retired nonelderly unionized autoworkers and their dependents, the study found that health spending per enrollee in 2009 varied widely across 19 communities with large concentrations of autoworkers, from a low of $4,500 in Buffalo, N.Y., to a high of $9,000 in Lake County, Ill.  The autoworkers’ health benefits are essentially uniform nationally, so spending differences do not reflect benefit differences.

Differences in service quantities accounted for two-thirds of the overall spending variation, while differences in prices accounted for one-third, according to the study.

On the quantity side, differences in health status and other demographic factors explained most, but not all, of the variation in quantity. About 18 percent of the total variation in spending was a result of unexplained differences in service quantities. On the price side, the cost of doing business explained very little of the price differences, with almost all of the differences in prices unexplained, the study found.

http://www.nihcr.org/news_Spending_Variation.html

From the Research Brief:

Sources of health care spending variation across autoworker communities, 2009

Differences in spending due to quantities
37% – Differences in health status
10% – Differences in age and sex
18% – Differences in quantities (excess)

Differences in spending due to prices
2% – Differences in providers’ cost of doing business
33% – Differences in prices (excess)

Comparing Private Prices to Medicare

Physician office visits. The prices paid by the autoworker plan for physician office visits, on average, are only 3 percent higher than what Medicare would have paid for the same services.

Hospital inpatient care. The prices for inpatient hospital care paid by the autoworker plan are, on average, 55 percent higher than what Medicare would pay, and the price gap varies widely across communities.

Hospital emergency department care. The prices paid by the autoworker plan for hospital emergency department care are, on average, more than double the Medicare price, and the price gap varies even more widely across communities than for inpatient care.

Research Brief
http://www.nihcr.org/Spending_Variation.html
PDF version
http://www.nihcr.org/Spending_Variation.pdf

Comment: 

By Don McCanne, MD

Policy wonks likely will download this Research Brief since it will prove to be a landmark study explaining the wide variation in spending amongst privately insured patients – very useful information when designing policies to improve our health care financing.

We already have several landmark studies demonstrating the wide variations in quantity of services and in pricing of those services – both factors in determining the variations in health care spending.

What has not been so clear is whether the quantities vary based on the health status of the patients or based simply on variations in intensity amongst populations of comparable health (i.e., providing excess services to drive up revenues, though deficient services when system capacity is inadequate is an important but separate concern).

What also has not been so clear is whether price differences are primarily due to differences in costs of health system resources, or simply due to charging higher prices where private insurer market control is weaker.

This study provides very convincing data to explain the differences. Look at the percentage differences listed above.

Health status (37%) and age and sex (10%) explain almost half (47%) of the differences in spending. These are entirely appropriate differences and do not require policy intervention. The 18% that is not otherwise explained may well be excess quantity of services that perhaps could be moderated by judicious application of health policy.

But let’s not kid ourselves. Those who suggest that, based on the Dartmouth studies, close to 100% of the difference in quantity of services is excessive tend to support policies that would come as close as possible to eliminating the differences. Since this study shows that the excess quantity is only about 18% of the difference in spending (only slightly over one-fourth of the increased quantity in higher spending areas), it would be very difficult to design policies that would tease out this modest amount while leaving in place the other services that are clearly beneficial. That doesn’t mean that efforts shouldn’t be made to do so, but it does mean that great care must be taken to be certain that people still receive the services that they should have – a much more important priority than budget trimming.

Excessive prices (33%) appear to account for most of the differences in prices for services since differences in the providers’ costs of doing business account for a mere 2% of spending differences. Most of this excess pricing is found in hospitals and in their emergency departments. This finding screams out for a better method of controlling prices. All other wealthier nations use some form of government pricing to eliminate these excesses. We should too.

Uwe Reinhardt has provided convincing evidence that an all-payer system, such as the hospital price-setting system in Maryland, would capture much of this excess in pricing. That is true, though it would be more difficult for an all-payer system to address the problem of excess quantity.

Our objection to all-payer systems is that they address only this one issue and leave out the many other advantages of a single payer national health program. When we have a solution that would fix so many problems at once let’s go with that.

50 doctors for single payer urge Supreme Court to strike down individual mandate

By Single Payer Action
CommonDreams newswire, Feb. 14, 2012

PNHP note: An amicus curiae brief challenging the constitutionality of the individual mandate in the Affordable Care Act – and noting that, by contrast, a single-payer, Medicare-for-All or VA-for-All-type system would be constitutional – was filed Tuesday by 50 physicians who support single payer. While Physicians for a National Health Program has taken no position on the constitutionality of any of the ACA’s provisions, we think readers will find the brief described below makes some interesting points.

WASHINGTON — Fifty medical doctors who favor a single-payer health insurance system today urged the U.S. Supreme Court to strike down the individual mandate.

In a brief (pdf) filed with the Court, the 50 doctors and two nonprofit groups – Single Payer Action and It’s Our Economy – said that the Patient Protection and Affordable Care Act’s (ACA) individual mandate is unconstitutional.

The individual mandate is the provision of the ACA that requires Americans to purchase health insurance from private insurance companies if they do not otherwise have coverage.

The doctors are challenging the government’s claim that the individual mandate is necessary to reach Congress’ goal of universal coverage.

“The court should decide the constitutionality of the individual mandate based on the best available evidence,” said attorney Oliver Hall. “That’s why it is so important that these medical doctors provide the court with the information in their brief, which demonstrates that Congress can address the United States’ health care crisis by adopting a single-payer system.”

“It is not necessary to force Americans to buy private health insurance to achieve universal coverage,” said Russell Mokhiber of Single Payer Action. “There is a proven alternative that Congress didn’t seriously consider, and that alternative is a single-payer national health insurance system.”

“Congress could have taken seriously evidence presented by these single payer medical doctors that a single-payer system is the only way to both control costs and cover everyone,” Mokhiber said. “Instead, Senator Max Baucus (D-Mont.), chair of the Senate Finance Committee which drafted the law that became the ACA, had two of those doctors – Dr. Margaret Flowers and Dr. Carol Paris – arrested and thrown in jail. Those doctors are now two of the 50 who have signed onto this brief challenging the constitutionality of the ACA.”

“If the U.S. Congress had considered an evidence-based approach to health reform instead of writing a bill that funnels more wealth to insurance companies that deny and restrict care, it would have been a no brainer to adopt a single-payer health system much like our own Medicare,” said Dr. Margaret Flowers. “We are already spending enough on health care in this country to provide high quality, universal, comprehensive, lifelong health care. All the data point to a single-payer system as the only way to accomplish this and control health care costs.”

“People will have the greatest control of their own health care if the insurance industry is removed from between doctors and patients,” said Kevin Zeese of It’s Our Economy. “And, people will no longer be threatened with increased premiums, decreased coverage and financial ruin caused by a health crisis.”

Read the full brief here.

http://www.commondreams.org/newswire/2012/02/14-0

Universal: Medicare for all

By the Editorial Board
The Charleston (W.Va.) Gazette, Feb. 21, 2012

CHARLESTON, W.Va. — Various Republicans are pressing the U.S. Supreme Court to rule the 2010 Affordable Care Act unconstitutional because it requires millions of “working poor” Americans to buy health insurance from commercial carriers.

Surprisingly, a crusading liberal Charleston reformer and activist has joined a Supreme Court brief demanding exactly the same thing.

Retired anesthesiologist Hedda Haning — a leader of several social action committees and recent organizer of an Occupy the Court protest — says it’s wrong to let commercial carriers earn fat profits from America’s medical system.

Instead, she says, the nation should have a government-run “single-payer” universal plan providing treatment for every citizen, as other advanced democracies do. Simply expanding Medicare to cover all ages would achieve it. That would extend coverage to 50 million left-out Americans, and save billions now wasted on the bureaucracy of competing private insurers.

We agree — but we fear that Republicans in Congress would kill such a universal proposal, if they succeed in defeating the ACA.

Dr. Haning joined Russell Mokhiber of Berkeley Springs and others in filing a friend-of-the-court brief saying:

“The only solution to the healthcare crisis in the United States, which will both control costs and achieve comprehensive coverage for the entire population, is to adopt a national publicly-financed single-payer health insurance system.”

Such a system would lift a terrible burden off U.S. businesses and employers now paying extreme costs to insure employees.

“We pay twice as much for our health care in this country as many other industrialized countries do,” Haning told reporter Paul Nyden, “but we are far down the list in terms of results. Something you hear all the time is that we have the best health-care system in the world. We do not.

“Forcing uninsured Americans to buy health insurance is a very bad way to go to try to take care of everybody. The purpose of health insurance corporations is to make money. And they make money by not taking care of sick people. … We are dealing with the corporate takeover of medicine.”

Other democracies spend only half as much on medical care, yet they have better health and life expectancy. It’s shameful that America, the world’s richest society, can’t accomplish what other nations do.

http://wvgazette.com/Opinion/Editorials/201202210112

2 W.Va. liberals fight against Obama health care law

They want insurance firms out of equation completely

By Paul J. Nyden
The Charleston (W.Va.) Gazette, Feb. 18, 2012

CHARLESTON, W.Va. — Two West Virginia residents are among the people and groups who filed a brief with the U.S. Supreme Court last week, arguing that uninsured Americans should not be forced to buy health insurance from private insurance companies.

That requirement under the Patient Protection and Affordable Care Act, which President Obama signed into law on March 23, 2010, is scheduled to take effect Jan. 1, 2014.

A coalition of medical doctors and nonprofit groups filed the friend-of-the-court brief Monday. They argue that the requirement to buy private insurance “exceeds the limits of Congress’ power to regulate interstate commerce.”

Hedda Haning, a retired Charleston physician and member of Physicians for a National Healthcare Plan, and Russell Mokhiber, a Berkeley Springs resident who edits the Washington, D.C.-based Corporate Crime Reporter newsletter, were among those signing the brief.

Unlike many of those who have challenged the Affordable Care Act in fede
ral court, Haning and Mokhiber argue that a single-payer system — like the United Kingdom’s National Health Service — is the answer to the country’s health-care woes. Mokhiber helped organize the group Single Payer Action.

“The only solution to the healthcare crisis in the United States, which will both control costs and achieve comprehensive coverage for the entire population,” the brief states, “is to adopt a national publicly-financed single payer health insurance system.”

Under that system, one public agency would handle all billing and administrative tasks, the brief points out.

Mokhiber said, “Under Obama’s law, individuals are required to purchase health insurance from a private health insurance company. This is the first time the federal government has ever required people to buy a health-insurance product from a private corporation.”

“That is very, very unpopular,” Mokhiber said. “Most Republicans and conservatives want to knock out that mandate, while Democrats and liberals have supported it.

“We are the only liberal, left-of-center group that says this requirement should be knocked out. And we believe there is a growing public sentiment supporting that. This law [ACA] keeps the insurance industry in the game.”

“I have been a strong supporter of single-payer health care for a long time. It is the only way we will be able to take care of all of our citizens and be able to afford it,” Haning said.

“We pay twice as much for our health care in this country as many other industrialized countries do, but … we are far down the list in terms of results. Something you hear all the time is that we have the best health-care system in the world. We do not.

“Forcing uninsured Americans to buy health insurance is a very bad way to go to try to take care of everybody. The purpose of health insurance corporations is to make money. And they make money by not taking care of sick people,” Haning said.

The brief states: “Nearly 50 million Americans risk denial of essential healthcare services because they lack insurance from private insurance companies.”

Many of those 50 million are working people paid low wages.

Haning said, “We are dealing with the corporate takeover of medicine.

“We have alternatives. Medicare has been wonderful. People who use Medicare, who are taken care of by Medicare, love it.”

The brief also points out, “Congress has already implemented successful single payer systems that provide universal coverage to certain subsets of the population, including Medicare for citizens aged 65 and older and the Veterans Health Administration for those who have served in the military.”

Adopting a single-payer system would not increase the costs of health care, the brief says.

The ACA, the brief argues, “does little to reduce the cost of healthcare administration, which accounts for 31 percent of all health spending in the United States. …

“Instead, it entrenches, by force of federal law, the private insurance companies that comprise the greatest source of administrative waste in the current system.”

The administrative costs for Medicare, the brief points out, “have remained steadily low – about 2 percent of program expenditures. …

“By contrast, private insurance companies estimate that their administrative costs, including ‘commission, premium tax and profit,’ range as high as 16.7 percent of overall spending.”

Canada’s single-payer health system uses an even lower percentage to administer its expenditures.

Today, salaries paid to some insurance executives range between $10 million and $20 million annually, the brief adds.

Haning said, “I practiced medicine for over 40 years and still have not gotten used to what the costs are. Some young women pay $50 a month, or more, for birth control pills.

“Many medications have been around for a long time. They are not expensive medications. There is no excuse for how much people have to pay.”

http://wvgazette.com/News/politics/201202180215

Utah doctors join push for single-payer health care system

By Kirsten Stewart
The Salt Lake Tribune, Feb. 14, 2012

Fifty medical doctors who want a single-payer health care system rather than the proposed federal reform have signed a legal document opposing the law.

Among them are two from Utah: Joe Jarvis and Clark Newhall.

In a “friend of the court” brief filed Tuesday with the U.S. Supreme Court, the doctors and two non-profit groups — Single Payer Action and It’s Our Economy — urge justices to overturn the Affordable Care Act’s requirement that everyone have insurance.

The high court is weighing a challenge to the constitutionality of the insurance requirement via a lawsuit filed by 26 states, including Utah.

The Obama administration argues the requirement is necessary to protect insurance companies from the risk of people waiting until they’re sick to get covered.

But in their legal brief, doctors contend the requirement isn’t necessary to reach Congress’ goal of universal coverage.

“Most people oppose the [law] without having an alternative in mind. That’s disingenuous,” said Jarvis of Salt Lake City.

A licensed doctor who no longer earns a living practicing medicine, Jarvis has long advocated for a better, cheaper and fairer way to deliver health care.

His decades-long push for a statewide health cooperative — a publicly-funded, nonprofit health insurance trust to cover every Utahn for all medically necessary care — has been a non-starter in conservative Utah. Chances of it gaining traction grew slimmer with passage of President Barack Obama’s health overhaul.

Jarvis isn’t a betting man. But he says the high court’s decision to consider multiple problems raised in opposition to the law, “shows they’re taking this seriously.”

Without the insurance mandate, the law can’t stand on its own, which could open the door to single payer, he says.

Single-payer means different things to different people. Newhall, a doctor and malpractice attorney, wants Medicare for all.

Under the model promoted by Jarvis, a Republican, people would still pay for coverage, but it would be subsidized and kept affordable by eliminating insurance middle men and simplifying payments.

It calls for the creation of a commission to squelch unnecessary tests and procedures ordered by doctors required to meet productivity targets or to fend off malpractice lawsuits. The commission, composed of medical experts, would determine which services are covered for given conditions based on research. It would also hear malpractice claims and insurance appeals.

Obama’s fix does nothing to curb health spending, Jarvis said. “It’s a propping up of the private insurance business model. What they’re trying to do is force us to buy, in most cases, poor quality health benefits.”

http://www.sltrib.com/sltrib/news/53512501-78/health-insurance-jarvis-doctors.html.csp

Doctors challenge health reform

Co
rvallis physicians sign brief attacking individual mandate

By Bennett Hall
Corvallis Gazette-Times (Ore.), Feb. 15, 2012

Fifty doctors who support single-payer health care — including two from Corvallis — petitioned the Supreme Court on Tuesday to strike down a key provision of federal health reform legislation.

The physicians joined with two nonprofit organizations, Single Payer Action and It’s Our Economy, to file a friend of the court brief arguing that the 2010 Patient Protection and Affordable Care Act is unconstitutional because it would require uninsured Americans to purchase private medical coverage.

The brief contends that provision, known as the individual mandate, exceeds the scope of the commerce clause of the Constitution, which gives Congress the power to regulate interstate commerce.

The Supreme Court is expected to hear arguments next month on various challenges to the act, including a lower court ruling that found the insurance mandate unconstitutional. A number of individuals and organizations on both sides of the issue have filed amicus briefs in the case.

“It is not necessary to force Americans to buy private health insurance to achieve universal coverage,” Russell Mokhiber of Single Payer Action said in a prepared statement. “There is a proven alternative that Congress didn’t seriously consider, and that alternative is a single payer national health insurance system.”

A single payer system funded by taxes — sometimes referred to as Medicare for all — would provide medical coverage to all Americans while eliminating the need for private insurance.

Corvallis physicians Paul Hochfeld and Mike Huntington, co-founders of the single-payer advocacy group Mad As Hell Doctors, say they support some provisions of the Affordable Care Act, such as its emphasis on primary care and its prohibition against denying coverage for people with pre-existing conditions.

But they also say commercial insurance plans build added costs into the system and reduce access to care by making it unaffordable for some people, and that’s why they added their names to the brief.

“The mandate is not necessary, and in fact it detracts from what it was intended to do, which is to get affordable health care to more Americans,” said Huntington, a retired radiation oncologist.

“Unfortunately, using the individual mandate isn’t going to result in universal coverage because 27 million people will still be left out and countless others will face bankruptcy when faced with medical conditions which require expensive interventions,” added Hochfeld, an emergency room physician.

“The only way to cover everybody is to do just that, cover everybody and pay for it with tax dollars. Pretending that we have fixed the problem is not the same as fixing it.”

A pair of Portland physicians, Samuel Metz and Kris Alman, also signed the brief. Other signers included Dr. Margaret Flowers of Physicians for a National Health Program and Kevin Zeese of It’s Our Economy, both of whom will be in Corvallis on Friday to speak on the status of health care reform efforts nationally.

www.gazettetimes.com/news/local/doctors-challenge-health-reform/article_c3da0fa2-5743-11e1-b4f5-001871e3ce6c.html#ixzz1n7lBQthc

Explaining regional variation in private health care spending

Health Status and Hospital Prices Key to Regional Variation in Private Spending

Research Brief by Chapin White
National Institute for Health Care Reform, February 15, 2012
Differences in health status explain much of the regional variation in spending for privately insured people, but differences in provider prices — especially for hospital care — also play a key role, according to a new study by the Center for Studying Health System Change (HSC) for the nonpartisan, nonprofit National Institute for Health Care Reform (NIHCR).
Based on claims data for 218,000 active and retired nonelderly unionized autoworkers and their dependents, the study found that health spending per enrollee in 2009 varied widely across 19 communities with large concentrations of autoworkers, from a low of $4,500 in Buffalo, N.Y., to a high of $9,000 in Lake County, Ill.  The autoworkers’ health benefits are essentially uniform nationally, so spending differences do not reflect benefit differences.
Differences in service quantities accounted for two-thirds of the overall spending variation, while differences in prices accounted for one-third, according to the study.
On the quantity side, differences in health status and other demographic factors explained most, but not all, of the variation in quantity. About 18 percent of the total variation in spending was a result of unexplained differences in service quantities. On the price side, the cost of doing business explained very little of the price differences, with almost all of the differences in prices unexplained, the study found.
http://www.nihcr.org/news_Spending_Variation.html
From the Research Brief:
Sources of health care spending variation across autoworker communities, 2009
Differences in spending due to quantities
37% – Differences in health status
10% – Differences in age and sex
18% – Differences in quantities (excess)
Differences in spending due to prices
2% – Differences in providers’ cost of doing business
33% – Differences in prices (excess)
Comparing Private Prices to Medicare
Physician office visits. The prices paid by the autoworker plan for physician office visits, on average, are only 3 percent higher than what Medicare would have paid for the same services.
Hospital inpatient care. The prices for inpatient hospital care paid by the autoworker plan are, on average, 55 percent higher than what Medicare would pay, and the price gap varies widely across communities.
Hospital emergency department care. The prices paid by the autoworker plan for hospital emergency department care are, on average, more than double the Medicare price, and the price gap varies even more widely across communities than for inpatient care.
Research Brief
http://www.nihcr.org/Spending_Variation.html
PDF version
http://www.nihcr.org/Spending_Variation.pdf

Policy wonks likely will download this Research Brief since it will prove to be a landmark study explaining the wide variation in spending amongst privately insured patients – very useful information when designing policies to improve our health care financing.
We already have several landmark studies demonstrating the wide variations in quantity of services and in pricing of those services – both factors in determining the variations in health care spending.
What has not been so clear is whether the quantities vary based on the health status of the patients or based simply on variations in intensity amongst populations of comparable health (i.e., providing excess services to drive up revenues, though deficient services when system capacity is inadequate is an important but separate concern).
What also has not been so clear is whether price differences are primarily due to differences in costs of health system resources, or simply due to charging higher prices where private insurer market control is weaker.
This study provides very convincing data to explain the differences. Look at the percentage differences listed above.
Health status (37%) and age and sex (10%) explain almost half (47%) of the differences in spending. These are entirely appropriate differences and do not require policy intervention. The 18% that is not otherwise explained may well be excess quantity of services that perhaps could be moderated by judicious application of health policy.
But let’s not kid ourselves. Those who suggest that, based on the Dartmouth studies, close to 100% of the difference in quantity of services is excessive tend to support policies that would come as close as possible to eliminating the differences. Since this study shows that the excess quantity is only about 18% of the difference in spending (only slightly over one-fourth of the increased quantity in higher spending areas), it would be very difficult to design policies that would tease out this modest amount while leaving in place the other services that are clearly beneficial. That doesn’t mean that efforts shouldn’t be made to do so, but it does mean that great care must be taken to be certain that people still receive the services that they should have – a much more important priority than budget trimming.
Excessive prices (33%) appear to account for most of the differences in prices for services since differences in the providers’ costs of doing business account for a mere 2% of spending differences. Most of this excess pricing is found in hospitals and in their emergency departments. This finding screams out for a better method of controlling prices. All other wealthier nations use some form of government pricing to eliminate these excesses. We should too.
Uwe Reinhardt has provided convincing evidence that an all-payer system, such as the hospital price-setting system in Maryland, would capture much of this excess in pricing. That is true, though it would be more difficult for an all-payer system to address the problem of excess quantity.
Our objection to all-payer systems is that they address only this one issue and leave out the many other advantages of a single payer national health program. When we have a solution that would fix so many problems at once let’s go with that.