PNHP

HHS punts the essential benefits decision to the private insurers!

HHS punts the essential benefits decision to the private insurers!

Essential Health Benefits: HHS Informational Bulletin

U.S. Department of Health & Human Services
December 16, 2011

On December 16, 2011, the Department of Health and Human Services issued a bulletin outlining proposed policies that will give States more flexibility and freedom to implement the Affordable Care Act.

Intended Approach: Comprehensive and Flexible

HHS intends to propose that essential health benefits are defined using a benchmark approach. Under the Department’s intended approach announced today, states would have the flexibility to select a benchmark plan that reflects the scope of services offered by a “typical employer plan.” This approach would give states the flexibility to select a plan that would best meet the needs of their citizens.

States would choose one of the following benchmark health insurance plans:

* One of the three largest small group plans in the state by enrollment;
* One of the three largest state employee health plans by enrollment;
* One of the three largest federal employee health plan options by enrollment;
* The largest HMO plan offered in the state’s commercial market by enrollment.

If states choose not to select a benchmark, HHS intends to propose that the default benchmark will be the small group plan with the largest enrollment in the state.

The benefits and services included in the benchmark health insurance plan selected by the state would be the essential health benefits package. Plans could modify coverage within a benefit category so long as they do not reduce the value of coverage.

To prevent federal dollars going to state benefit mandates, the health reform law requires states to defray the cost of benefits required by state law in excess of essential health benefits for individuals enrolled in any plan offered through an Exchange.

These benchmarks are generally regulated by the state and would be subject to state mandates applicable to the small group market.  Thus, those mandates would be included in the state essential health benefits package if the state elected one of the three largest small group plans in that state as its benchmark.

This approach would provide maximum flexibility to states, employers and issuers while providing quality, comprehensive, coverage for consumers.

Coverage

Essential health benefits must include coverage of services and items in all 10 statutory categories. Based on our research, we believe that these benchmarks will cover most of the essential health benefits outlined by the Affordable Care Act. These categories include preventive care, emergency services, maternity care, hospital and physician services, and prescription drugs.

Allowing Plans Flexibility to Innovate and Consumers Greater Choice

To meet the EHB coverage standard, HHS intends to require that a health plan offer benefits that are “substantially equal” to the benchmark plan selected by the state and modified as necessary to reflect the 10 coverage categories. Health plans also would have flexibility to adjust benefits, including both the specific services covered and any quantitative limits, provided they continue to offer coverage for all 10 statutory EHB categories and the coverage has the same value.  Permitting flexibility will provide greater choice to consumers, promoting plan innovation through coverage and design options, while ensuring that plans providing EHBs offer a certain level of benefits.

Fact sheet:
http://www.healthcare.gov/news/factsheets/2011/12/essential-health-benefits12162011a.html

Essential Health Benefits Bulletin (15 pages):
http://cciio.cms.gov/resources/files/Files2/12162011/essential_health_benefits_bulletin.pdf

It looks like Health and Human Services has decided that the new standard for health insurance to be offered under the Affordable Care Act will be the cheapest of the three largest small group plans offered in any given state. There will be no national standard. Although they would allow states more generous options other than the skimpy small group plans, with today’s concerns over high health care costs, the cheapest option certainly will be selected by the state stewards.

There is a requirement that 10 categories of health benefits must be included, but the specific services covered within each category will be determined by the insurers. The insurers will retain the flexibility to adjust both the specific services and the amount of those services (quantitative limits).  HHS claims that this benefits us by providing greater choice for consumers and by providing insurers with the opportunity to innovate. Why they should deem that to be beneficial is astonishing when considering that insurer innovation means having to choose between various plans that take away, to varying degrees, choices of providers, benefits, and amount of financial security.

The essential health benefits do not define the cost sharing features of the plans such as deductibles, copayments and coinsurance. Guidance on that will be forthcoming, but we already know that the least expensive plan will be the bronze plan with an actuarial value of 60 percent (the plan pays 60 percent of only the covered health care services). Again, because of our high insurance premiums, most people will select the cheapest actuarial-value plan.

Can you think of anything worse than having cash-starved states selecting the cheapest private plans with the most spartan selection of benefits allowable – benefits selected by the private insurance industry –  and offering those plans to struggling middle-income Americans who will be mandated to purchase these plans when many of them will not be able to afford even the bottom bronze plans in spite of the subsidies? And don’t even think about how they’re going to pay the high out-of-pocket expenses when they actually need health care.

Dissecting out each individual policy perhaps can make them easier to understand, but when you patch them together, just try to explain the resulting health care financing infrastructure to the average individual who just wants health care when needed. Most individuals may not be able to understand the complexities of health policy, but once they’ve been exposed to the new standard, they certainly will understand what is meant by UNAFFORDABLE UNDER-INSURANCE.

Try this thought experiment. Since the common defect in these Quote of the Day policy messages seems to be the dominance of the private insurers, try constructing a health care financing system without the private insurers being included. Wow! That was easy!

All we need now is to elect leaders who are willing to dismiss the insurers so that we can get on with building a system that works for all of us.

Do we need health insurance?

By Philip Caper, M.D.
Bangor Daily News, Dec. 15, 2011

Do Americans need health insurance? The short answer is no — at least not in the form it currently exists in America.

It is true that in many wealthy countries private insurance companies are used in the financing of universal health care systems. But they are nothing like American companies. They are regulated public utilities and are told by their governments who to insure, what to cover and how much and when to pay. Most are prohibited from making a profit and are required to pay any willing provider. Not exactly the American model.

The purpose of health care financing systems should be — and is in all other wealthy countries — to facilitate the delivery of health care services, to protect individuals and families against huge medical care expenses and to avoid breaking the national bank while they do so. But in America, our private insurance system actually interferes with the delivery of health care and is rapidly becoming too expensive.

Last month I argued for adopting a universal health care system on moral, ethical and economic grounds. It is not only more humane but cheaper to cover everybody. We have moved in fits and starts toward that goal since the enactment of Medicare in 1965.

The recent federal health reform law took a few steps forward. But we are now taking a couple steps back, especially in Maine. Last week Gov. Paul LePage proposed disqualifying 65,000 beneficiaries of MaineCare. Earlier this year, the Legislature enacted PL90 that rolls back regulations intended to spread the financial risks of illness and improve access to health care for those most in need of it.

A little history may be informative. Private employment-based health insurance in America was not a planned system, but grew out of World War II wage and price controls. It was one of the few ways employers could attract and retain employees in a tight labor market. The spread of these benefits received a boost when the federal government exempted them from federal taxes.

Private health insurance was dominated by nonprofit Blue Cross and Blue Shield plans until about 1990. That changed when Blue Cross plans across the country began to convert to for-profit status, arguing that it would improve their efficiency. Maine Blue Cross made that transition in 2000 when it changed from a company whose mission was facilitating health care to one whose mission was maximizing shareholder wealth.

The business model of for-profit insurance companies is pretty simple. The creation of wealth for shareholders, including many of their executives, depends upon profitability. To maximize profitability they must charge premiums as high as the market will bear, offer skimpy policies that limit coverage, impose high deductibles and minimize what they must pay out for the services they do cover.

Maximizing premiums, imposing high deductibles and limiting the scope of coverage are pretty straightforward. Minimizing payouts for services they do cover is a little more complicated. Four techniques are used. First companies try to avoid insuring people likely to require health care, such as those with a history of illness or who are elderly or in dangerous occupations.

Second, they dispute the need for health care that is recommended or has already been provided to their customers by micromanaging the decisions of doctors and patients and denying as many claims as they can. This is a very expensive and contentious process that often damages the quality of care.

Third, they bargain down the prices health care providers charge as much as possible, shifting costs to other payers. This has created the curious and uniquely American situation where uninsured people pay the highest prices for health care products and services.

Fourth, many companies try to find a reason to retroactively dump sick customers who have filed claims by asserting that they have failed to accurately state their health care history, therefore defrauding the insurance company.

These people end up on public insurance or on the roles of the uninsured. This practice, called “rescission,” is particularly unfair but nevertheless appears to have become widespread. It has been banned by the new federal health care reform act.

What is the problem with this picture? It is not that for-profit insurance companies are failing in their mission. In fact, they are doing a very good job of exactly what their mission demands, maximizing the wealth of shareholders. The problem is that their mission fundamentally conflicts with the mission of a decent health care system.

What can we do to fix this problem? The obvious first step — but not the last — is to replace for-profit insurance companies. They are like a camel entered into the Kentucky Derby. No matter how much it is trained, how hard it tries, how hard it is whipped or who the jockey is, it never wins. It just wasn’t designed for the job.

Although insurance companies could play a role in a redesigned system by becoming public utilities, that is not the most efficient way to finance a system that includes everybody. For example, private insurance companies are currently fighting the new federal health care law’s requirement that they keep their overhead below 20 percent. Medicare, financed through publicly mandated premiums and taxes, spends less than 5 percent on overhead and interferes with health care decisions much less than private carriers.

Maybe it’s time to replace that camel with a racehorse. While we’re at it, why not go for a thoroughbred? An improved Medicare-like system for all Mainers could provide better coverage while spending less. What’s not to like about that?

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/2011/12/15/health/do-we-need-health-insurance/

Why is Wyden supporting Ryan's Medicare voucher proposal?

A Bipartisan Way Forward on Medicare

By Ron Wyden and Paul Ryan
The Wall Street Journal, December 15, 2011

Our plan would strengthen traditional Medicare by permanently maintaining it as a guaranteed and viable option for all of our nation’s retirees. At the same time, our plan would expand choice for seniors by allowing the private sector to compete with Medicare in an effort to offer seniors better-quality and more affordable health-care choices.

Under our plan, Americans currently over the age of 55 would see no changes to the Medicare system. For future retirees, starting in 2022, our plan would introduce a “premium support” system that would empower Medicare beneficiaries to choose either a traditional Medicare plan or a Medicare-approved private plan. Unlike Medicare Advantage, these private plans would compete head-to-head with traditional, fee-for-service Medicare on a federally regulated Medicare exchange.

Low-income seniors who qualify for both Medicare and Medicaid would continue to have Medicaid pay for their out-of-pocket expenses. Other lower-income seniors would receive fully funded savings accounts to help offset any increased out-of-pocket costs, while wealthier seniors would receive less help.

In the event that these efforts did not stem the rising tide of Medicare spending, there would be a cap on the program’s rate of growth. But unlike other proposals, spending that exceeds the cap would neither be addressed through bureaucratic cuts nor passed on to seniors by default as higher premiums.

Instead, Congress would be required to do its job: Determine why the costs exceeded the cap and – when the evidence merits – reduce payments to providers, drug companies, or others who may be responsible for escalating costs.

Our plan would also expand health-care options for working Americans by giving smaller businesses the opportunity to empower their employees to make their own health-care choices. Under this “free choice option,” employees take the amount that their employer was contributing toward their employer-provided health coverage and use it to purchase their own health insurance instead. The cost to the employer – and the tax-free benefit to the worker – would remain the same.

Yes, these are ambitious reforms, and while we are hopeful for the future, we are under no illusions that they will pass tomorrow. Nevertheless, we offer this plan as proof that Democrats and Republicans don’t have to spend next year making Medicare reform more difficult. Instead, our parties can work together on bipartisan reforms to save and strengthen Medicare.

(Mr. Wyden, a Democrat, is a U.S. senator from Oregon. Mr. Ryan, a Republican, is a U.S. representative from Wisconsin.)

http://online.wsj.com/article/SB10001424052970203893404577098681919780636.html

Press release:
http://wyden.senate.gov/newsroom/press/release/?id=02334291-9c60-4020-9a8d-e2b9d0f37422

White paper (13 pages):
http://budget.house.gov/UploadedFiles/WydenRyan.pdf

Comment: 

By Don McCanne, MD

Although Sen. Ron Wyden (D-Oregon) and Rep. Paul Ryan (R-Wisconsin) have released their white paper on a proposal for reforming Medicare, there is no intent on their part to follow it up with legislation during this session of Congress. Their stated intent is to initiate a bipartisan discussion on Medicare reform, but it appears instead that other political considerations prompted this proposal.

Paul Ryan was stung by the response to his original proposal to end the traditional Medicare program and replace it with a premium support (voucher) program of private health plans. The Congressional Budget Office reported that his plan would cause a major shift of costs from the government to Medicare beneficiaries, and his own constituents beat up on him back home. Also, the Republicans in the House of Representatives are now on record as having voted for the Ryan premium support plan, and the Democrats have made it clear that they will make this a major issue in the coming elections.

This white paper gives the Republicans an out. They can now claim that this is better than the original Ryan proposal because it protects Medicare by leaving it as an option while providing more choices of competing private plans. Obviously this takes away the sting of the Democrats’ attack.

Why would Ron Wyden cooperate with Paul Ryan in this effort to defuse the Democrats’ strategy of using the premium support vote against the Republicans? It is because he is more supportive of his own previous proposal for health care reform than he is for the Democrats to prevail in the next election. His Healthy Americans Act that he pushed throughout the reform process called for an individual mandate to purchase private plans, shifting the tax benefit from employers to individuals (a concept included in this white paper). He has said that Democrats want universal coverage, Republicans want choice, and his plan, and now the Ryan-Wyden proposal, would enable both.

The problem for single payer supporters is that this is a digression that shoves the concept of an improved Medicare for all further into the background. The substance of the debate will be over converting the Medicare Advantage plan into a voucherized program competing on price. Single payer supporters will not be welcome participants in that debate, nor should we.

We shouldn’t waste our resources on countering premium support. That’s the wrong debate. We need to continue with a very strong message on countering private, corporate control of health care, while promoting a publicly-financed and publicly-administered Medicare for everyone. That’s the message that America needs to hear.

Why I Protest: Dr. Arthur Chen of Oakland, Calif.

By Jason Motlagh
TIME, Dec. 14, 2011

PNHP note: This week Time magazine announced “The Protester: from the Arab Spring to Athens, from Occupy Wall Street to Moscow” as its Person of the Year. Among the persons profiled by Time as exemplars of the global upsurge for change was Dr. Arthur Chen, a longtime PNHP member who lives in the Bay Area.

A family physician, Dr. Arthur Chen, 60, was an unusual addition to the counter-culture of the Occupy Oakland movement. But the Connecticut-born Oakland resident who works in the city’s Chinatown had a cause — health care reform — and the protests gave him a forum. He spoke to TIME’s Jason Motlagh:

TIME: What was the event that precipitated your activism? And what made it personal?

Arthur Chen: I’m part of that 99%, proud to say, so it’s very relevant. And then in addition to that… I’ve been seeing patients that are low-income impacted, many of them unemployed, and then struggling for survival. They’re immigrants, and so I’ve seen the negative impacts in their lives from day to day. And I’ve seen uninsured patients who have to struggle with the recommendations that I make because of whether or not they can afford it. So it’s been real to me on a personal level, and looking at the population as a whole, looking at the patients that I see, and just knowing intellectually that there’s flaws in our current system. We’re taking capitalism and its negative sides head on, which I think is essential to a democracy. And hopefully preserve the positive side of capitalism, because I’m not totally against capitalism; I just think at this point it’s probably out of control.

How did you go about participating in the protests?

It was really hearing it in the news and hearing it through radio announcements, they’re just totally on top of that. Democracy Now, if you’re familiar with Amy Goodman. And so they were openly publicizing it and explaining it. So it was really helpful, and that prompted me to feel, okay, this is the moment and you really have to participate and you have to take time off and be there in solidarity with this and you know, help have representation. And then as a person of color, certainly here in Oakland, we have such a diverse population, but it’s really important for people to see that the whole spectrum of our demographics are there, and feeling the need to really participate and be counted.

How did protests in other parts of the world affect, influence, or inspire you?

The Arab Spring, very inspiring. Just to have seen what had happened in Tahrir Square, and Tunisia and the start of things. And that it was really young people who played a significant role in that. All of that activity, the demonstrations in London around students outraged about increase in tuitions, and all of this activity and in Wisconsin, where people really spoke out against the governor, who really wanted to strip labor of its rights at that time, of collective bargaining. It’s a combination of all of those things, and all of them, I think, again, representative about the growing resentment of the direction that our government is going, tax and policies that favor the rich, and don’t really allow for an even spread of the resources to address our more needy populations.

What was the funniest thing you saw during the protests?

Well it really wasn’t the funniest thing, but it made me think about a new generation. On the day of the general strike, when they started having speakers line up at the podium, right there at 14th and Broadway, one of the announcers said, we’re going to start speaking and you’re going to hear a lot of different views today. And you’re going to hear some things that you may totally disagree with. And I chuckled a little bit, and then I thought, this generation is about inclusiveness and transparency. It was very moving, because I thought of previous demonstrations and big rallies where I know how controlled the speakers list is. And then in this particular case, they were just going the opposite direction and saying everyone’s going to get a chance to speak. We aren’t screening your point of view. That goes in line with the general assemblies, because I sat through a couple of those, and the way in which they’re conducted, the inclusiveness, the way in which they ask us to sit down in groups with a few people around you. It’s a different approach: it’s horizontal. And so, it wasn’t funny, but it made me smile.

What’s an image of the protest you remember well?

The string people. They were expressing clearly the anguish and the pain of having to go through this economic downturn, but they were doing it with about four or five people caught up and tangled in string and rope.

What was the most memorable day of the protests in personal terms for you?

The most memorable day was when the camp was dismantled [which took place by around 5 a.m. on Nov. 14, 2011]. That day around 8:30 a.m. or so, I decided to swing by City Hall [outside of which the protesters were camped]. I wasn’t seeing patients that morning; I was going to do some administrative work. So I swung by and I walked out. I had to get past a police barrier. And I just told an officer, look I have a meeting over in this other building in the rotunda, where I knew people, and he let me through. And so I walked by, and it was like walking by a graveyard. It was so disheartening to see just nobody there. And I had been there before and it was vibrant and alive and there were people who were energized and feeling really positive about making a statement. And so it was disheartening; the mood was really somber. There was nobody there. Then I heard helicopters flying overhead. And then I slipped into a coffee shop, just so I could stay out of the range of the officer that had let me by — and went in to just buy a roll, and they were totally empty. During that time I saw a battalion of police marching by, there was about 20 or 25 of them. And it just sent a chill down my spine, of where things had amounted to. A peaceful, nonviolent protest around the economic conditions and what are the causes of that, and here we had folks just cleared out and arrested, and now we had an oppressive looking police tactical squad coming in. That was probably my worst day.

http://www.time.com/time/specials/packages/article/0,28804,2101745_2102138_2102252,00.html

Meet the new 1%: healthcare CEOs replace bankers as America's best paid

No bankers in top 10 of America's best-paid executives, but those in charge of healthcare and drugs firms are in the money

By Dominic Rushe
The Guardian, 14 December 2011

Pity Wall Street’s bankers. Once the highest-paid bosses in the land, they are now also-rans. The real money is in healthcare and drugs, according to the latest survey of executive pay.

There are no bankers in the top 10 of this year’s GMI survey of CEO pay. In fact, they have been out since 2007, when Goldman Sachs boss Lloyd Blankfein competed for the top slot with Richard Fuld, boss of soon-to-be-bust Lehman Brothers, and Angelo Morzillo, head of Countrywide, once the largest sub-prime home loan firm.

With the bankers still recovering from their tussle with hubris, old age and infirmity were 2010’s boom businesses – at least in terms of pay. Leading the pack was John Hammergren, chief executive of McKesson Corporation. The firm’s 52-year-old chairman, chief executive and president took home $145,266,971 in 2010.

McKeeson is probably the biggest company you’ve never heard of. Headquartered in San Francisco, the company is the largest pharmaceutical distributor in North America, distributing a third of the medicines used in the US. McKeeson’s sales topped $112bn last year.

Hammergren’s next closest rival was Joel Gemunder, outgoing boss of Omnicare, where he had been president since 1981. Omnicare is a pharmacy company that dispenses drugs in nursing homes – among other services – and had sales of $6.15bn last year. When Gemunder started at the firm it had sales of $150m. His 2010 total pay package was worth $98,283,242.

CVS Caremark, which operates 7,000 pharmacies across the US, awarded chief executive Thomas Ryan $68,079,823 in 2010. Caremark’s share price was $71.70 on 1 May 1998, when Ryan joined the firm, and ended 2010 at $34.29.

Ronald Williams, boss of health insurance giant Aetna, made $57,787,786 in 2010. Another recipient of a golden goodbye, Williams made $50.4m on his stock options last year. Williams is one of the US’s most prominent African American business leaders, and has campaigned against healthcare reforms that would have introduced a government-backed public insurance option to compete with private insurers. Since he became CEO, Aetna’s stock price declined by 70%.

http://www.guardian.co.uk/business/2011/dec/14/healthcare-ceos-americas-best-paid?newsfeed=true

Why is Wyden supporting Ryan’s Medicare voucher proposal?

A Bipartisan Way Forward on Medicare

By Ron Wyden and Paul Ryan
The Wall Street Journal, December 15, 2011

Our plan would strengthen traditional Medicare by permanently maintaining it as a guaranteed and viable option for all of our nation’s retirees. At the same time, our plan would expand choice for seniors by allowing the private sector to compete with Medicare in an effort to offer seniors better-quality and more affordable health-care choices.

Under our plan, Americans currently over the age of 55 would see no changes to the Medicare system. For future retirees, starting in 2022, our plan would introduce a “premium support” system that would empower Medicare beneficiaries to choose either a traditional Medicare plan or a Medicare-approved private plan. Unlike Medicare Advantage, these private plans would compete head-to-head with traditional, fee-for-service Medicare on a federally regulated Medicare exchange.

Low-income seniors who qualify for both Medicare and Medicaid would continue to have Medicaid pay for their out-of-pocket expenses. Other lower-income seniors would receive fully funded savings accounts to help offset any increased out-of-pocket costs, while wealthier seniors would receive less help.

In the event that these efforts did not stem the rising tide of Medicare spending, there would be a cap on the program’s rate of growth. But unlike other proposals, spending that exceeds the cap would neither be addressed through bureaucratic cuts nor passed on to seniors by default as higher premiums.

Instead, Congress would be required to do its job: Determine why the costs exceeded the cap and – when the evidence merits – reduce payments to providers, drug companies, or others who may be responsible for escalating costs.

Our plan would also expand health-care options for working Americans by giving smaller businesses the opportunity to empower their employees to make their own health-care choices. Under this “free choice option,” employees take the amount that their employer was contributing toward their employer-provided health coverage and use it to purchase their own health insurance instead. The cost to the employer – and the tax-free benefit to the worker – would remain the same.

Yes, these are ambitious reforms, and while we are hopeful for the future, we are under no illusions that they will pass tomorrow. Nevertheless, we offer this plan as proof that Democrats and Republicans don’t have to spend next year making Medicare reform more difficult. Instead, our parties can work together on bipartisan reforms to save and strengthen Medicare.

(Mr. Wyden, a Democrat, is a U.S. senator from Oregon. Mr. Ryan, a Republican, is a U.S. representative from Wisconsin.)

http://online.wsj.com/article/SB10001424052970203893404577098681919780636.html

Press release:
http://wyden.senate.gov/newsroom/press/release/?id=02334291-9c60-4020-9a8d-e2b9d0f37422

White paper (13 pages):
http://budget.house.gov/UploadedFiles/WydenRyan.pdf

Although Sen. Ron Wyden (D-Oregon) and Rep. Paul Ryan (R-Wisconsin) have released their white paper on a proposal for reforming Medicare, there is no intent on their part to follow it up with legislation during this session of Congress. Their stated intent is to initiate a bipartisan discussion on Medicare reform, but it appears instead that other political considerations prompted this proposal.

Paul Ryan was stung by the response to his original proposal to end the traditional Medicare program and replace it with a premium support (voucher) program of private health plans. The Congressional Budget Office reported that his plan would cause a major shift of costs from the government to Medicare beneficiaries, and his own constituents beat up on him back home. Also, the Republicans in the House of Representatives are now on record as having voted for the Ryan premium support plan, and the Democrats have made it clear that they will make this a major issue in the coming elections.

This white paper gives the Republicans an out. They can now claim that this is better than the original Ryan proposal because it protects Medicare by leaving it as an option while providing more choices of competing private plans. Obviously this takes away the sting of the Democrats’ attack.

Why would Ron Wyden cooperate with Paul Ryan in this effort to defuse the Democrats’ strategy of using the premium support vote against the Republicans? It is because he is more supportive of his own previous proposal for health care reform than he is for the Democrats to prevail in the next election. His Healthy Americans Act that he pushed throughout the reform process called for an individual mandate to purchase private plans, shifting the tax benefit from employers to individuals (a concept included in this white paper). He has said that Democrats want universal coverage, Republicans want choice, and his plan, and now the Ryan-Wyden proposal, would enable both.

The problem for single payer supporters is that this is a digression that shoves the concept of an improved Medicare for all further into the background. The substance of the debate will be over converting the Medicare Advantage plan into a voucherized program competing on price. Single payer supporters will not be welcome participants in that debate, nor should we.

We shouldn’t waste our resources on countering premium support. That’s the wrong debate. We need to continue with a very strong message on countering private, corporate control of health care, while promoting a publicly-financed and publicly-administered Medicare for everyone. That’s the message that America needs to hear.

Critique of the Fraser Institute report on wait times

Waiting Your Turn: Wait Times for Health Care in Canada - 2011 Report

by Bacchus Barua, Mark Rovere and Brett J. Skinner
Fraser Institute, December 2011

This edition of Waiting Your Turn indicates that waiting times for elective medical treatment have increased since last year. Specialist physicians surveyed across 12 specialties and 10 Canadian provinces report a total waiting time of 19.0 weeks between referral from a general practitioner and receipt of elective treatment.

http://www.fraserinstitute.org/uploadedFiles/fraser-ca/Content/research-news/research/publications/waiting-your-turn-2011.pdf

And…

Wait Times in Canada—A Comparison by Province, 2011

Canadian Institute for Health Information (CIHI)

At least 8 out of 10 Canadian patients are receiving priority area procedures, such as hip replacements, cataract surgery and cancer radiation treatment, within medically recommended wait times, according to a new study from the Canadian Institute for Health Information (CIHI). The study provides the first comprehensive national picture of how long Canadians wait for care in priority areas as compared with evidence-based benchmarks of acceptable waits.

http://www.cihi.ca/cihi-ext-portal/internet/en/document/health+system+performance/access+and+wait+times/release_21mar11

Comment: 

By Don McCanne, MD

The Fraser Institute has released its 21st annual report on wait times for health care in Canada. This report is used widely to condemn Canada’s reliance on their single payer medicare program for the financing of health care. It helps to fulfill the Fraser Institute’s libertarian agenda of advocating for privatization of their health care system. Today’s comment takes a critical look at this report.

The findings in the report are based on the solicited opinions of Canadian physicians. Questionnaires were sent to 10,737 of the 68,000 active Canadian physicians. Of these, 1,696 physicians responded (15.8% response rate). Distributing these responses amongst the 12 specialties and ten provinces results in single digit tallies for 63 percent of the categories, and often only one physician falling into a given category. For instance, only one specialist in internal medicine represented the views of all internists in the province of Prince Edward.

Besides questioning whether these numbers are adequate to represent the views of all Canadian physicians, there are two other factors that may have skewed the results.

As an enticement to return the questionnaires the physicians were given the chance to win $2000. Physicians with an entrepreneurial mentality – those who more likely favor privatization of health care – might be more favorably inclined to try for this reward. More altruistic physicians who really care about the problem of queues might be insulted by this attempt to buy responses with a prize.

A great many Canadian physicians strongly support their medicare program and oppose the current efforts to privatize both the delivery system and the health insurance system. These physicians are acutely aware of the agenda of the Fraser Institute and would be much less likely to cooperate in their biased studies.

Thus it is unlikely that the sampling truly represents the views of mainstream Canadian physicians.

Another important consideration is that this study was heavily weighted toward elective surgeries. Emergency conditions were not included. Patients in Canada have excellent access when a true emergency exists. So this study is not looking at acute, urgent conditions.

Instead, this study was looking more at patients with chronic conditions which are usually managed over a long period of time, sometimes for a lifetime. Yet the authors imply that the disorders for which they are treated began at a single point in time in the generalist’s office.

In reality, when the physician and patient decide that it is time to consider more options for managing a chronic problem, often a decision is made to obtain a specialist’s consultation. These are not emergencies so a routine appointment is scheduled. Except for a few specialties, most of these appointments are within a reasonable time interval.

Once the patient sees the specialist, more time is consumed for appropriate comprehensive evaluation of the problem before a decision is made on definitive management. Again, these time intervals are mostly reasonable.

Once the decision is made to schedule the elective surgery or other procedure, then excessive waiting times can be more objectionable. But how long are these waiting times?

The specialists were asked what a reasonable waiting time was for their given procedures, and how long their patients had to wait. With the exception of plastic surgery and orthopedics, most waiting times were very close to those that the specialists considered to be reasonable. (Internal medicine was also an outlier for endoscopy and non-urgent angiography.)

The Fraser report is very deceptive because they add to the time between scheduling a procedure and completing a procedure the time for the routine request by a generalist for a consultation, and the time for the specialist to complete the full evaluation before deciding on the specific management. If you separate these out, most of the intervals are quite reasonable. The 19 week wait reported by Fraser has little meaning, since it does not represent the time between scheduling a procedure and completing it.

The much more credible study from the Canadian Institute for Health Information confirms that Canada is doing quite well in delivering care within medically recommended wait times.

This does not mean that there are no problems. There is a very major problem, and it is political. Conservative politicians who currently control much of the government would like to privatize the health care system. Their approach is to abandon their role as stewards of the health care system, deliberately allowing longer queues to develop. Then the public is told that the only way to fix these outrageous delays that are killing people is to turn to the private health care markets in order to bypass the queues. As this view gains traction there is greater support for what amounts to a two-tiered system – the best of care for the relatively wealthy, and an under-funded public program for the masses.

Sound familiar? Only we’re far ahead of them in fragmenting our system.

Business breakfast speaker discusses single-payer health care

By Josh Moniz, Staff Writer
The Journal (New Ulm, Minn.), Dec. 10, 2011

Physicians for a National Health Program-Minnesota hosted an informational presentation for business owners on single-payer health care Friday at the New Ulm Country Club.

Single-payer health care is funded by a single entity, usually a government, that collects all health care fees and pays out all costs. The method would allow universal health care, and hospital billings would be nearly eliminated.

The speaker for the event was David Steil, a Pennsylvania resident who served as a Republican legislator for 17 years and has been a business owner for 35 years. He is currently the president of Health Care for All-Pennsylvania.

Steil said his support for a single-payer system came from his time as a business owner and a legislator. He said he concluded that businesses were not the proper entity to provide health insurance.

“I quickly came to the conclusion, ‘Why am I involved in health care [as a business owner]?’ I don’t have the expertise. Many small businesses are in the same situation, but still need to offer health insurance to be competitive,” said Steil.

He said the current system causes premiums and health care costs to skyrocket while making it more difficult for people to get access. He said the current system is poised to implode the country’s health care system.

He said he came to support single-payer plans despite being a Republican legislator while researching methods for addressing the health care issues.

“I believe, as a fiscal conservative, you’ll ultimately have to accept some form of single-payer system,” said Steil. “My belief is that government exists solely to provide what we can’t do for ourselves. I consider health care the same as the government providing for the education system or filling a pothole in the street. Many of us don’t have the knowledge to do it ourselves.”

He said there would have to be several requirements for a single-payer system to be successful.

First, he said, it would have to be universally available to all.

Second, he said, it would have to be driven by the free market. He said the current problem with health care is that it is operating at the insurance company level instead of at the provider level.

“So much of the cost is driven up, even if insurance companies want to it lower, because of all the administrative costs. So many people are needed for the paperwork because its so inefficient,” said Steil.

He said a single-payer system would essentially eliminate massive administrative costs, making care more affordable, and it would make it possible for the government to keep costs under control.

Third, he said, a single-payer system would have to be funded by a naturally appreciating tax to keep pace with inflation and provide fairness for taxpayers.

“We’re still determining the right number, but we’re considering a 3 percent income tax on individuals and a 10 percent tax on payrolls for businesses in Pennsylvania,” said Steil. “People may jump at the 10 percent, but when we talked with U.S. Steel [in Pennsylvania] about the idea, they were already spending 17 percent on health care costs.”

He also said the 3 percent tax was almost guaranteed to be much smaller than what most people pay now for health care, especially when the administrative costs are reduced.

Finally, he said the system would help address the biggest burden on health care systems, long-term or chronic illness, by being able to allow physicians to perform more preventative measures. He said the current problem is many don’t address serious issues, like diabetes, until they hit 65 and obtain government care. He said at that point, prevention is usually impossible and the situation is so severe little can be done.

Steil said his points were why he took issue with the health care overhaul passed under President Obama. He said it forced businesses to be the main supplier of health care while failing to address the root causes of increased health care cost.

Steil then addressed two criticisms of the single-payer plan.

He said many believe big government is completely incapable of administrating properly.

“That’s not right. Right now, between 40 and 50 percent of all health care is already delivered by the government. It’s done through Medicare, Medicaid and health care for the military,” said Steil.

He also said there was a concern of state sovereignty.

“That’s why we’re specifically pushing for state plans system. For example, Minnesota is already starting to work on one,” said Steil.

Additionally, he addressed what he called misinformation about other countries that used single-payer systems.

“The claims that Canada’s health care is so bad they come down here has absolutely no data to support it. Similarly, the claims that England has huge wait times is off. There is some waiting, but no more than you typically see here for some procedures. Also, you get to go in immediately if it’s an emergency,” said Steil.

He said there has also been misinformation denying how outsized U.S. health care cost are compared to other countries. He said the U.S. spend one-third to one-half more per capita on health care than any other country.

Steil answered some questions from those attending. One expressed concern about legislators being unable work together and the effect of this inability if they administered health care.

He said the system would be run by a board filled with people selected by the respective legislature, but the legislature would not have direct oversight and control of the board.

Another asked if people would have to make sacrifices under such a system because of set funding.

Steil said it would be addressed by allowing doctors to be more entrepreneurial.

“If they want to offer you services beyond the reimbursements, that’s fine. We want them to compete for your businesses to give you the best care,” said Steil.

Steil concluded by saying that businesses would have to take the lead in lobbying for a single-payer system. He said they would not only show legislators how much support there is, but they would also be addressing an issue that is poised to be a serious problem for them.

http://www.nujournal.com/page/content.detail/id/526980.html

Critique of the Fraser Institute report on wait times

Waiting Your Turn: Wait Times for Health Care in Canada – 2011 Report

by Bacchus Barua, Mark Rovere and Brett J. Skinner
Fraser Institute, December 2011

This edition of Waiting Your Turn indicates that waiting times for elective medical treatment have increased since last year. Specialist physicians surveyed across 12 specialties and 10 Canadian provinces report a total waiting time of 19.0 weeks between referral from a general practitioner and receipt of elective treatment.

http://www.fraserinstitute.org/uploadedFiles/fraser-ca/Content/research-news/research/publications/waiting-your-turn-2011.pdf

And…

Wait Times in Canada—A Comparison by Province, 2011

Canadian Institute for Health Information (CIHI)

At least 8 out of 10 Canadian patients are receiving priority area procedures, such as hip replacements, cataract surgery and cancer radiation treatment, within medically recommended wait times, according to a new study from the Canadian Institute for Health Information (CIHI). The study provides the first comprehensive national picture of how long Canadians wait for care in priority areas as compared with evidence-based benchmarks of acceptable waits.

http://www.cihi.ca/cihi-ext-portal/internet/en/document/health+system+performance/access+and+wait+times/release_21mar11

The Fraser Institute has released its 21st annual report on wait times for health care in Canada. This report is used widely to condemn Canada’s reliance on their single payer medicare program for the financing of health care. It helps to fulfill the Fraser Institute’s libertarian agenda of advocating for privatization of their health care system. Today’s comment takes a critical look at this report.

The findings in the report are based on the solicited opinions of Canadian physicians. Questionnaires were sent to 10,737 of the 68,000 active Canadian physicians. Of these, 1,696 physicians responded (15.8% response rate). Distributing these responses amongst the 12 specialties and ten provinces results in single digit tallies for 63 percent of the categories, and often only one physician falling into a given category. For instance, only one specialist in internal medicine represented the views of all internists in the province of Prince Edward.

Besides questioning whether these numbers are adequate to represent the views of all Canadian physicians, there are two other factors that may have skewed the results.

As an enticement to return the questionnaires the physicians were given the chance to win $2000. Physicians with an entrepreneurial mentality – those who more likely favor privatization of health care – might be more favorably inclined to try for this reward. More altruistic physicians who really care about the problem of queues might be insulted by this attempt to buy responses with a prize.

A great many Canadian physicians strongly support their medicare program and oppose the current efforts to privatize both the delivery system and the health insurance system. These physicians are acutely aware of the agenda of the Fraser Institute and would be much less likely to cooperate in their biased studies.

Thus it is unlikely that the sampling truly represents the views of mainstream Canadian physicians.

Another important consideration is that this study was heavily weighted toward elective surgeries. Emergency conditions were not included. Patients in Canada have excellent access when a true emergency exists. So this study is not looking at acute, urgent conditions.

Instead, this study was looking more at patients with chronic conditions which are usually managed over a long period of time, sometimes for a lifetime. Yet the authors imply that the disorders for which they are treated began at a single point in time in the generalist’s office.

In reality, when the physician and patient decide that it is time to consider more options for managing a chronic problem, often a decision is made to obtain a specialist’s consultation. These are not emergencies so a routine appointment is scheduled. Except for a few specialties, most of these appointments are within a reasonable time interval.

Once the patient sees the specialist, more time is consumed for appropriate comprehensive evaluation of the problem before a decision is made on definitive management. Again, these time intervals are mostly reasonable.

Once the decision is made to schedule the elective surgery or other procedure, then excessive waiting times can be more objectionable. But how long are these waiting times?

The specialists were asked what a reasonable waiting time was for their given procedures, and how long their patients had to wait. With the exception of plastic surgery and orthopedics, most waiting times were very close to those that the specialists considered to be reasonable. (Internal medicine was also an outlier for endoscopy and non-urgent angiography.)

The Fraser report is very deceptive because they add to the time between scheduling a procedure and completing a procedure the time for the routine request by a generalist for a consultation, and the time for the specialist to complete the full evaluation before deciding on the specific management. If you separate these out, most of the intervals are quite reasonable. The 19 week wait reported by Fraser has little meaning, since it does not represent the time between scheduling a procedure and completing it.

The much more credible study from the Canadian Institute for Health Information confirms that Canada is doing quite well in delivering care within medically recommended wait times.

This does not mean that there are no problems. There is a very major problem, and it is political. Conservative politicians who currently control much of the government would like to privatize the health care system. Their approach is to abandon their role as stewards of the health care system, deliberately allowing longer queues to develop. Then the public is told that the only way to fix these outrageous delays that are killing people is to turn to the private health care markets in order to bypass the queues. As this view gains traction there is greater support for what amounts to a two-tiered system – the best of care for the relatively wealthy, and an under-funded public program for the masses.

Sound familiar? Only we’re far ahead of them in fragmenting our system.

Deb Richter: A Cure for Broken Health Care

The YES! Breakthrough 15: Meet the doctor who uprooted her life to bring universal health care to Vermont.

by Daniel Fireside
YES! Magazine, Oct 31, 2011


Photo by Kurt Budliger.

Deb Richter resolved to fix the health care system almost as soon as she began practicing medicine more than two decades ago in inner-city Buffalo. “I was very naive, I guess,” recalls Richter. “A lot of my patients didn’t have insurance. I would prescribe medicines for patients but they wouldn’t be able to afford them, and then they would just get sicker. I was mortified.”

It was the tragedy of a brother and sister who had been diagnosed with juvenile diabetes that brought things sharply into focus. “They kept up with their insulin and needles, but they often couldn’t afford the 50-cents-apiece test strips when they didn’t have insurance,” says Richter. By the time they became her patients, the siblings were in bad shape. The boy lost his vision, his health declined, and he died at 21. His sister had a fatal heart attack at 25.

Richter realized that she was facing a turning point. “I didn’t want to change where I practiced just so I wouldn’t have to witness this. I knew I couldn’t continue to practice if this situation continued. I didn’t want medicine to just be for wealthy people.”

Instead of hanging up her stethoscope, she joined Physicians for a National Health Program, a leading doctors’ group that advocates for universal health care coverage with just one insurance provider—the government. “What they had to say made sense to me—24 percent of health care was spent on paperwork and transaction costs. Other countries didn’t spend that.” She eventually served as the group’s president.

Richter became convinced that the likeliest route to a national single-payer system would be state by state. She and her husband and two young boys moved to Vermont in 1999, where they bought a house just two blocks from the statehouse in Montpelier. It suited a physician-activist who was raising a family. “I could testify before the legislature and walk home to do the laundry.”

Richter kept up her medical practice three days a week, while lobbying for a single-payer system the other two days. She cornered politicians, wrote editorials, spoke to Rotary clubs, and gave hundreds of talks. In 2005 the legislature passed a major health care reform bill, but the governor vetoed it. “That was one of my lowest points,” recalls Richter. Work and advocacy were taking up all her time. “I was hardly seeing my family. If we couldn’t get it done in Vermont, where was it ever going to work?”

Then Vermont voted in Governor Peter Shumlin, who recognized that skyrocketing health care costs had reached a crisis point for businesses and the middle class. The iconoclast Vermont politician Bernie Sanders moved from the U.S. House to the Senate, and was in a more powerful position to clear roadblocks at the federal level. Grassroots advocates focused their energies, as did Richter. This May, Vermont became the first state in the nation to pass a single-payer health care plan.

Richter is proud of the achievement, even though she concedes that Vermont’s health care bill is not quite comprehensive and could still get derailed before it’s fully enacted over the next six years. She continues giving public talks, shepherding the Vermont bill and lobbying for a national health care plan, as well as practicing medicine.

“This will be an enormous change for people without insurance,” says Richter of the Vermont bill, which will guarantee every resident an essential health benefit package from birth. “Now that we have this in Vermont, we need to make sure it happens everywhere.”

http://www.yesmagazine.org/issues/the-yes-breakthrough-15/deb-richter-a-cure-for-broken-health-care

On the costs of a premature baby

Letters, The New Yorker, Nov. 21, 2011

Re Jerome Groopman’s article “A child in time” (Oct. 24): Almost all the books on premature babies, it seems, are written in the United States. Because, as Groopman states, the average cost of delivering a premature baby is between a hundred thousand and a hundred and fifty thousand dollars, these books usually begin with advice about what to do when you lose your job, your car, and your house as you struggle with extended hospital visits and mounting bills.

Twenty-two years ago, when our daughter was born three months early, weighing one and a half pounds S.F.D. (small for date), I was in the hospital for months and had two operations. Emma’s twin had aborted a month earlier, but Emma held on to twenty-eight weeks’ gestation. She was in the I.C.U. for eighty-one days, saw every type of specialist, and needed to have nine blood transfusions.

When all was said and done, we paid five dollars for the birth of our daughter — to cover the parking. She is currently finishing her university undergraduate degree, and I am very grateful that she was born in Canada.

Lynne Milnes
Victoria, B.C.
Canada

http://www.newyorker.com/magazine/letters/2011/11/21/111121mama_mail5