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Government health spending is fiscally unsustainable?

Government health spending is fiscally unsustainable?

Census Numbers: The Trend Toward Government Coverage Continues

By Nina Owcharenko
Health Affairs Blog, September 14, 2011

(Condensed)

In its yearly survey of health insurance coverage, the U.S. Census Bureau published figures that underscore the trend toward greater dependence on government for coverage.

Most analysts, regardless of political views, generally agree that to make the system work better, there needs to be greater portability and continuity in health care coverage.

This, however, is where the philosophical divide occurs. Those on the left generally see a larger role for government-based coverage, while those on the right see a greater role for individuals. One only needs to look at the Patient Protection and Affordable Care Act (PPACA) to see this take shape. The PPACA puts the trend toward government-based coverage on the fast track. The law will add an estimated 26 million people to Medicaid alone.

Even without PPACA, existing government-based coverage (Medicare and Medicaid) is fiscally unsustainable.

Those on the right (including myself) who oppose the government-based model see an alternative path toward portability and continuity based on individual ownership and market-based competition. The Heritage Foundation’s Saving the American Dream plan empowers individuals and families to own and control their health insurance. It establishes individual tax relief for people to buy coverage in a marketplace where insurers and providers are accountable to meeting consumers’ needs of higher quality at lower costs. It also reforms Medicare and Medicaid, putting them on a sustainable path forward.

While discussion of the Census numbers typically focuses on changes affecting  the uninsured, the real story is the slow but steady trend away from private coverage and toward government coverage. Recent estimates by the CMS actuaries project that by 2020, government will control 50 percent of all health care spending in the country. Americans should take note that the health care system is moving to the tipping point where it will be more government-run than private.

http://healthaffairs.org/blog/2011/09/14/census-numbers-the-trend-toward-government-coverage-continues/

Response:

Don McCanne
September 18th, 2011

Why would health care be fiscally unsustainable when it is paid for through a government program, yet sustainable when it is paid for privately?

The fiscally unsustainable argument is based on the assumptions that the government would not introduce adequate cost containment measures, and that the government would not impose adequate taxes or tax equivalents to pay for the system. Based on the experience of other nations, both assumptions should be challenged.

Other nations use either government ownership or robust government regulation to slow the growth in health care costs. They also use government taxing authority or regulatory mandates to ensure that the health system is fiscally sustainable. Directly or indirectly, they function as a public monopsony. Although they may complain about their own rising costs, they certainly spend less money than we do, yet they are able to include essentially everyone in their comprehensive programs.

How would private control of health spending produce a fiscally sustainable system? The answer is that it would be fiscally sustainable only for the government. With a median household income of $49,000 and average health care expenditures of an insured family at $18,000 (Milliman Medical Index), health care costs for individuals and families are already unsustainable. (Median households and families with employer-sponsored plans are not the same, but these numbers still illustrate the enormity of the problem.)

Health consumer empowerment is being achieved by shifting more of the responsibility for payment directly to patients, especially through increased deductibles and other cost sharing. At today’s high heath care costs that means that many more patients would be foregoing beneficial health care services, simply because they can’t pay for them.

Now Medicare and Medicaid are being threatened with proposed reforms that allegedly would put them on the path of sustainability. Again, that might be sustainable for the government, but the proposed changes would shift more costs to patients, further impairing access because of increasing financial barriers to care.

Many of us were shocked recently during the Republican candidates’ debate when the moderator asked if a thirty year old, critically ill man should be allowed to die because he was uninsured, and members of the audience shouted, “Yes.” But that was only a very few voices from an anti-government Tea Party audience. Not only would citizens of other nations emphatically reject this view, it also decidedly violates American values.

Nina Owcharenko offers us the choice between consumer empowerment in which we can reject the health care we need but can’t pay for, or our own beneficent government monopsony that would ensure value in our health care purchasing so that all of us could have the health care that we need.

Although her blog entry and this response may appear to be merely a rhetorical game, the choice really is a matter of our nation’s health.

http://healthaffairs.org/blog/2011/09/14/census-numbers-the-trend-toward-government-coverage-continues/#comment-50117

Health Care Versus Wealth Care: Investors with a Conscience Should Divest from Health Insurance Companies

By Rob Stone
Tikkun Magazine, September 16, 2011

I was the doctor on duty one night in August when the ambulance rushed a man into our Midwestern hospital ER. As I walked into the room, the scene was right out of TV. A nurse was trying to start an IV. Someone was running an EKG. A student had just put oxygen in the patient’s nose. The room seemed crowded. The paramedics were sweating and slightly out of breath.

But my attention was on a pale, thin, fifty-five-year-old man sitting bolt upright on a gurney, clutching his chest and straining to breathe. Cold sweat dripped off his nose. I asked a couple of quick questions as I leaned him forward to listen to his lungs. Someone handed me his EKG showing an acute heart attack.

I slipped out of the room for a second to get the cardiologist on the phone. He would be right in, along with the rest of his team. But it was a Thursday night, late, and they were coming in from home. It would be at least twenty minutes until high-tech medicine could work its wonders, until the cardiologist could thread a thin plastic catheter into the patient’s heart and put in a stent to open his blockage.

I was back to the room in a flash, and he looked no better. We gave him intravenous nitroglycerin, morphine, and powerful blood thinners. He began to look less frightened and some color crept back into his face. We still had a few minutes before they would be ready for him in the cardiac catheterization lab.

Just then I became aware of a woman quietly sobbing in a chair in the corner of the room, probably his wife. I walked over toward her and, as I neared, I reached out to touch her shoulder. She suddenly turned a fierce face up at me, saying: “When he told you he’d been having pain for two hours, he was lying! He’s been having chest pains for the last two weeks!”

She didn’t let up: “We were in the ER six months ago with his chest hurting, and they told him to see his cardiologist, but we don’t have any insurance. They won’t see him again without cash up front! What are we supposed to do?”

Her voice rising, she added: “And you know what else? They’re suing us in small claims court right now over the bill from our last ER visit!”

Here was this poor woman, in my ER, not only deathly afraid that she might lose her husband tonight, but also afraid that whether he lived or died they might face an impossibly huge medical bill and lose their house, their car, everything.

The patient was a self-employed house painter, and he’d had a previous heart problem. Self-employed and a pre-existing condition — in America today with those two strikes, you are out. There is no way to afford health insurance. Is the Affordable Care Act going to fix this?

The Affordable Care Act and the Health Care Lobby

The Affordable Care Act (ACA) faces an uncertain future. The 11th Circuit Court of Appeals in August ruled the individual mandate unconstitutional. Judge Hull, who cast the deciding vote, was a Clinton appointee. Theverdict states:

This economic mandate represents a wholly novel and potentially unbounded assertion of congressional authority: the ability to compel Americans to purchase an expensive health insurance product they have elected not to buy, and to make them re-purchase that insurance product every month for their entire lives.

The ACA was essentially written in the Senate Finance Committee chaired by Max Baucus. The actual author was his chief health care aide, Liz Fowler. Her job before working for Baucus? Vice president of WellPoint/Anthem/Blue Cross, the country’s largest health insurer.

The health insurance industry played both sides against the middle during the congressional debate. While publicly claiming to be in favor of reform, they secretly funneled millions to front groups and organizations like the Chamber of Commerce, which fought the bill tooth and nail. What the insurers wanted most out of the deal was the individual mandate — a federally enforced requirement that all Americans buy their defective products, with taxpayer-financed subsidies for those who couldn’t afford the premiums. What they wanted least were regulatory burdens that might limit their profitability.

Not being able to buy insurance if you are sick is one of the catch-22 aspects of our crazy system. In the eyes of insurance bureaucrats, it seems that life itself is a pre-existing condition. The ACA’s ban on the use of pre-existing conditions to deny insurance coverage is scheduled to go into effect in 2014. Preventing that will be the next target of their lobbying fury.

It’s Good to Be an Insurance Company

In this down economy, there are few bright spots for investors. Thank God for health insurance.

The Big Five health insurers — WellPoint, UnitedHealth, Aetna, Humana, and CIGNA — together cover almost 100 million of us. Their profitsfrom April to June 2011 totaled over $3.3 billion, 13 percent over their second quarter profits in 2010. Last year was their best year ever. For the twelve months ending in July 2011, these giants saw their average stock price rise almost 50 percent. These are huge corporations: WellPoint and UnitedHealth are in the top fifty of the Fortune 500.

What to do with all that profit? WellPoint, the behemoth created a decade ago from formerly nonprofit Blue Cross plans in fourteen states, spent $67 million on lobbying over the past three years. They paid their CEO, Angela Braly, $13 million in 2010, but that was paltry compared to the reimbursement package of UnitedHealth CEO Stephen Hemsley, who cleared $37 million, including the stock options he exercised.

Those stock options take on extra significance when company stock repurchases are considered. WellPoint, to take only one example, spent $21.6 billion of patients’ premium dollars to buy back its own stock from 2003 through 2010.

Spending billions on stock buybacks benefits a tiny elite of CEOs, board members, and top officers, who are compensated largely with stock options. They buy the stock back to push the price upward. Their options increase in value as the share price rises. This is an enormous transfer of wealth from individuals and employers to top management. It benefits the largest Wall Street stockholders as well, but not you, not me, not patients.

This industry exists to collect premiums and process claims, and while they have no problems collecting our premiums, it’s a different story when they have to pay. The June 2011 AMA Health Insurer Report Card revealed commercial health insurers have an average claims-processing error rate of 19.3 percent, an increase of 2 percent compared to last year. The increase in overall inaccuracy represents an extra 3.6 million in erroneous claims payments compared to last year and added an estimated $1.5 billion in unnecessary administrative costs to the health system. Medicare, by comparison, had an error rate of less than 4 percent.

They are obviously not using their piles of cash to improve service. What about lowering premiums? In our dreams.

Health insurance premiums have more than doubled over the last ten years, rising at four times the overall rate of inflation. (Over the same period Medicare premiums have barely risen at all, with no increase in out-of-pocket expenses.) While premiums have risen, coverage has shrunk. Copays and deductibles increase every year. People with individual coverage can have annual deductibles of $10,000 and more. No wonder illness leads to bankruptcy, even if you have insurance.

Bankruptcy, Moral and Financial

Every business day in America, 3,700 families file for bankruptcy caused by illness and medical bills, and that number is rising. This shameful situation happens in no other wealthy democracy. It would be a scandal anywhere else. Most medically bankrupt families were middle-class before they suffered financial setbacks. Roughly 60 percent of them had attended college; twenty percent of families included a military veteran or active-duty soldier.

Most astoundingly, 60 percent of the individuals whose illness led to bankruptcy had private health insurance when they got sick. Don’t we buy health insurance to avoid financial ruin? High deductibles lead directly to bankruptcy and foreclosure. To make matters worse, they cause people to postpone needed care. All of which lead to higher insurance company profits.

The insurers don’t like to tell their customers this, but when they talk to their Wall Street masters, they sing a different tune. Angela Braly of WellPoint, speaking during a conference call for financial analysts in 2008, was asked if she would consider lowering premiums if that would increase enrollment in Anthem policies. Her reply, “We will not sacrifice profitability for membership,” was just what they wanted to hear.

That sentiment hasn’t changed. Recently Aetna’s chief financial officer, Joseph Zubretsky, made similar comments on a conference call. Concerned that investors might think Aetna was willing to grow by adding people to its rolls who could have substantial medical needs, Zubretsky soothed their fears, “We would like to have both profit and growth, but if you have to choose between one or the other, you take margin and profit and you sacrifice the growth.”

Recall that these are the same companies that developed algorithms to target women diagnosed with breast cancer so they could scour their health records for an excuse to cancel their policies. This inhuman practice, known as rescission, has supposedly been banned by the ACA.

Buying Doctors

If insurance companies are not lowering premiums to attract more customers or investing in infrastructure to reduce errors, what else besides their own stock (and some politicians) are they buying? Doctors! UnitedHealth is quietly buying medical groups who treat patients covered by its plans in several areas of the country. WellPoint announced in June that it would acquire CareMore, which operates twenty-six clinics in the Los Angeles area. CIGNA claims that it saves 9 percent on patients treated by doctors in a Phoenix medical group it controls. Is this a good thing?

In July, Kaiser Health News, in an article titled “Managed Care Enters The Exam Room As Insurers Buy Doctor Groups” said:

Some observers watching the developments say the health law, which in part was sold as a way to rein in insurers, has had the opposite result, opening the door for the companies to take control of even more parts of the health system.

“There’s a gigantic Murphy’s law emerging here,” said Ian Morrison, a California-based health care consultant who does some work for United, as well as most of its competitors. “The very people who were the demons in all of this, that the public can’t stand — managed-care firms — are the big winners.”

And the losers? Patients, and those of us paying premiums.

Health, Health Care, and Health Insurance

No other wealthy democracy spends as much on health care as we do. It’s not even close. Most of our peer countries spend about half as much per capita as we do.

If you hear politicians proclaim “America has the best health care in the world,” you can stop listening to them at that point. They are not reality-based. We may be paying the most on the planet for health care, but there is no objective evidence to support the claim that our health care is the best. Again, it’s not even close. The World Health Organization ranks U.S. health care thirty-seventh, just below Costa Rica.

No other wealthy democracy relies on for-profit insurance companies. Here we stand alone.

On August 10, 2011, the Saint Louis Post-Dispatch editorialized, “IfAmerica truly is serious about dealing with its deficit problems, there’s a fairly simple solution. But you’re probably not going to like it: Enact a single-payer health care plan.” The editorial goes on to explain that the “way for government to address its health costs is not to shift them, but to reduce them. This is what a single-payer health care system would do, largely by taking the for-profit players (insurance companies for the most part) out of the loop.”

The editorial asserts, “the ACA didn’t go far enough,” and concludes: “Eventually, the United States will have a single-payer plan. But we’ll waste a lot of money and time getting there.” Its authors could have added “and waste a lot of lives” too.

What is a “single-payer plan” like the Post-Dispatch endorses? Robert Reich, author, professor, and secretary of labor under Bill Clinton, explained it this way in February 2011:

If the individual mandate to buy private health insurance gets struck down by the Supreme Court or killed off by Congress, I’d recommend President Obama immediately propose what he should have proposed in the beginning — universal health care based on Medicare for all.

Medicare is a single-payer plan. Everyone over age sixty-five is covered by this simple, single plan, which is publicly financed and privately delivered. How would a single-payer plan save money? The Post-Dispatchexplains, “Streamlining payment through a single nonprofit payer would save more than $400 billion per year, enough to provide comprehensive, high-quality coverage for all Americans.”

The respected journal Health Affairs published more evidence of the economic advantage of a single payer system on August 19, 2011. The article “US Physician Practices Versus Canadians: Spending Nearly Four Times As Much Money Interacting With Payers” found that U.S. physicians’ office staff “spent 20.6 hours per physician per week interacting with health plans — nearly ten times that of their Ontario counterparts. If U.S. physicians had administrative costs similar to those of Ontario physicians, the total savings would be approximately $27.6 billion per year.”

The evidence is overwhelming: the for-profit insurance industry adds a huge amount of inefficiency, bureaucracy
and cost to our system while adding no value, only hassle. These companies are parasitic middlemen we would be better off without. Their interest is in wealth care, not health care.

On top of that, the insurance industry is the single greatest barrier to achieving an efficient and affordable system to cover all Americans. If you have any doubt, read Wendell Potter’s Deadly Spin: An Insurance Company Insider Speaks Out on How Corporate PR Is Killing Health Care and Deceiving Americans. During the debate over the ACA, health insurance lobbyists sank the president’s public option, even though 70 percent of the public favored it. Their war chests overflow with money and their influence grows every day.

Hoping Congress will fix this leads only to despair. We need new ways to weaken the death grip this powerful industry has on us.

Divestment

There is a battle going on for the soul of America. Before he died, Ted Kennedy wrote to President Obama about health care reform, calling it “the great unfinished business of our society.” Kennedy avowed, “What we face is above all a moral issue; that at stake are not just the details of policy, but fundamental principles of social justice and the character of our country.”

Back in the ER on that hot August night, I sent my man to the cath lab and they successfully stented his blockage. He went home the next day with a bill for $25,000. I tried to call him a few months later, but the phone number was “no longer in service.”

Congress and the politicians are “no longer in service.” We’ve got to look elsewhere.

Could we simply boycott health insurance? No, over 50 million are without insurance now, and they are living sicker and dying younger because they have barriers to care.

Stockholders with a conscience have tried for years to engage corporate leadership and have attempted shareholder resolutions to reform the industry from the inside. Despite their best efforts, they have had no significant positive effect so far.

It is time to move beyond resolutions and on to divestment.

The Divestment Campaign for Health Care is one group that is organizing a push in that direction.

From 1985 to 1990, over two hundred U.S. companies cut all ties with South Africa, resulting in a loss of $1 billion in direct American investment. This economic pressure hastened the fall of apartheid. It happened as a result of people power, democracy in action. Pension funds divested from companies doing business with South Africa. Faith communities declared they would not support injustice. Students called on their universities to cleanse their endowments. An idea was born — “socially responsible investing.”

There is nothing socially responsible about investing in the health insurance industry.

Up to now, they have received little scrutiny from investors. One exception is Domini Social Investments, whose Global Investment Standards give “support [for] government’s responsibility to provide basic public goods that are as varied as health care, prisons, primary school education, and national security.” Domini is “concerned about the extent to which health insurance privatizes a public good.”As a result, Domini has disqualified most health insurers from their portfolios.

In contrast, the $4 billion TIAA-CREF Social Choice Equity Fund holds $24 million in WellPoint stock, as well as Aetna and Humana from the health insurance Big Five. WellPoint stock may only represent 0.6 percent of the total fund, but in this large, diversified mutual fund, which includes over 800 individual stocks, WellPoint is in the top 5 percent of the fund’s largest holdings. TIAA-CREF has refused to exclude health insurance companies.

The Presbyterian Church USA, often in the vanguard of the faith community, is there again. Their General Assembly meets in the summer of 2012 and they will vote on an “Overture” to “implement divestment procedures as well as encourage individual Presbyterians and congregations to divest of holdings in the [publicly traded health insurance] companies.” Other faith groups cannot be far behind.

We have nothing to lose. Health insurance companies have everything to lose as their stock prices drop and their influence wanes. Go to your church, your union, your pension plan, your 401k advisor, your university endowment, your city council, your friends and neighbors, and tell them it’s time to get the health insurers out!

Who can defend these corporations? There is no business case, no health care case, no moral case to support their ongoing existence. They make their profits by avoiding taking care of sick people — by refusing to issue policies, canceling policies, or denying payment. I went to medical school in order to care for the sick.

The health insurance industry must go.

Rob Stone is a gardener, grandfather, and teacher. He has practiced emergency medicine in Bloomington, Indiana, since the early 1980s, and for the past year has been transitioning his medical career to hospice and palliative medicine. He is founder and director of Hoosiers for a Commonsense Health Plan and serves on the board of directors of Physicians for a National Health Program.

Uninsured patients in Massachusetts still predominantly the working poor, despite state’s health reform

Many still find insurance unaffordable and employer-sponsored insurance unavailable, Harvard Medical School researchers say

FOR IMMEDIATE RELEASE
Sept. 19, 2011

Contacts:
Danny McCormick, M.D., M.P.H.
Rachel Nardin, M.D.
Mark Almberg, PNHP, (312) 782-6006, mark@pnhp.org

Despite the implementation of the Massachusetts health care reform designed to bolster employer-based insurance and to provide no-cost or low-cost insurance to those unable to afford it, the uninsured in Massachusetts remain predominantly the working poor, according to a new study by researchers at Harvard Medical School just published online in the Journal of General Internal Medicine.

The 2006 comprehensive health care reform was designed to achieve “universal coverage” through new laws requiring that employers with more than 10 employees offer insurance and that all state residents obtain insurance or pay a fine. It also provided free or low-cost, subsidized insurance to state residents with low incomes.

Yet, most estimates put the number of uninsured in the state at well above a quarter million. For instance, last week the Census Bureau released its survey which found 370,000 people to be uninsured in Massachusetts — 5.6 percent of the state’s population.

To understand why people remained uninsured after the reform, the study authors surveyed 431 patients, ages 18-64, who were visiting the emergency room of Massachusetts’ second largest safety-net hospital.

The researchers found that of the 189 patients without health insurance, two-thirds (65.9 percent) were employed, but only a quarter had access to employer-sponsored insurance. In addition, about one-third (35.2 percent) of uninsured patients reported having lost previous insurance coverage, with the majority of these (51.9 percent) having lost their coverage due to loss of a job or transition from one job to another.

“These findings illustrate that tying insurance to employment can be an unstable mechanism for providing coverage,” said the study’s lead author, Dr. Rachel Nardin, a neurologist at Cambridge Health Alliance. “We found that employer-based coverage failed the self-employed; those who worked for firms that did not offer insurance, especially small firms exempt from a requirement to offer insurance; and the poor who could not afford employer-sponsored insurance even when it was offered to them. The system of coverage also failed those who lost their job, which is particularly problematic with the current economic downturn.”

More than 85 percent of the uninsured patients interviewed had incomes low enough to qualify them for free or low-cost, state-subsidized private insurance. Nonetheless, one-third reported being uninsured because they could not find affordable insurance.

In fact, although the majority of the uninsured were aware of the new legal requirement that they carry health insurance, nearly half reported that it motivated them to try to find insurance but that they had been unable to find insurance they could afford.

Senior author Dr. Danny McCormick, an internist at Cambridge Health Alliance, said: “It appears that for people with very low incomes, even state plans with subsidized insurance premiums may be too costly. Also, under the reform law workers who are offered employer sponsored insurance but decline it due to cost are not eligible for state subsidized insurance, no matter how poor they are.”

McCormick added, “If we are serious about the goal of universal coverage, we will need to further reduce or eliminate the financial barriers to getting insurance that still clearly exist in Massachusetts.”

The study also found that another common reason for losing previously held insurance was having had it cancelled without notice or because of lapsed paperwork. Only 5.6 percent of the interviewees were uninsured because they didn’t think they needed insurance, suggesting there were few seeking a so-called free ride.

“Our study shows the many ways that patients can get left out of a complex system for providing health insurance,” said McCormick. “While the reform substantially reduced the number of uninsured in our state, it failed to fully reach the demographic groups it targeted. Our findings emphasize the fragility of a reform requiring voluntary uptake, periodic renewal, dependence on employment and cost-sharing.”

The study authors also point out that the Massachusetts health care reform law served as the model for the national health reform law, the Affordable Care Act, and thus may suggest even larger difficulty ahead for national health reform.

Nardin commented: “In Massachusetts, we had about 10 percent uninsured before the reform. In many other states, the uninsured rate is in the 20-25 percent range. If our results are any indicator, the national reform may leave many working poor uncovered.

“Although arguments about political feasibility are a major challenge, our study suggests that a comprehensive reform guaranteeing coverage to all residents without eligibility restrictions — such as that provided by many single-payer systems — would be a more effective way to achieve universal coverage than the Massachusetts reform.”

“Reasons why patients remain uninsured after Massachusetts’ health care reform: A survey of patients at a safety-net hospital,” Rachel Nardin, M.D., Assaad Sayah, M.D., Hermione Lokko, B.Sc., Steffie Woolhandler, M.D., M.P.H., and Danny McCormick, M.D., M.P.H. Journal of General Internal Medicine, Sept. 16, 2011.

*******

Physicians for a National Health Program (www.pnhp.org) is an 18,000-member organization advocating a nonprofit, single-payer national health insurance program for the United States. PNHP had no role in funding the study mentioned above. To speak with a physician/spokesperson in your area, visit www.pnhp.org/stateactions or call (312) 782-6006.

Government health spending is fiscally unsustainable?

Census Numbers: The Trend Toward Government Coverage Continues

By Nina Owcharenko
Health Affairs Blog, September 14, 2011

(Condensed)

In its yearly survey of health insurance coverage, the U.S. Census Bureau published figures that underscore the trend toward greater dependence on government for coverage.

Most analysts, regardless of political views, generally agree that to make the system work better, there needs to be greater portability and continuity in health care coverage.

This, however, is where the philosophical divide occurs. Those on the left generally see a larger role for government-based coverage, while those on the right see a greater role for individuals. One only needs to look at the Patient Protection and Affordable Care Act (PPACA) to see this take shape. The PPACA puts the trend toward government-based coverage on the fast track. The law will add an estimated 26 million people to Medicaid alone.

Even without PPACA, existing government-based coverage (Medicare and Medicaid) is fiscally unsustainable.

Those on the right (including myself) who oppose the government-based model see an alternative path toward portability and continuity based on individual ownership and market-based competition. The Heritage Foundation’s Saving the American Dream plan empowers individuals and families to own and control their health insurance. It establishes individual tax relief for people to buy coverage in a marketplace where insurers and providers are accountable to meeting consumers’ needs of higher quality at lower costs. It also reforms Medicare and Medicaid, putting them on a sustainable path forward.

While discussion of the Census numbers typically focuses on changes affecting  the uninsured, the real story is the slow but steady trend away from private coverage and toward government coverage. Recent estimates by the CMS actuaries project that by 2020, government will control 50 percent of all health care spending in the country. Americans should take note that the health care system is moving to the tipping point where it will be more government-run than private.

http://healthaffairs.org/blog/2011/09/14/census-numbers-the-trend-toward-government-coverage-continues/

Response originally posted on the Health Affairs Blog

Response: Don McCanne
September 18th, 2011

Why would health care be fiscally unsustainable when it is paid for through a government program, yet sustainable when it is paid for privately?

The fiscally unsustainable argument is based on the assumptions that the government would not introduce adequate cost containment measures, and that the government would not impose adequate taxes or tax equivalents to pay for the system. Based on the experience of other nations, both assumptions should be challenged.

Other nations use either government ownership or robust government regulation to slow the growth in health care costs. They also use government taxing authority or regulatory mandates to ensure that the health system is fiscally sustainable. Directly or indirectly, they function as a public monopsony. Although they may complain about their own rising costs, they certainly spend less money than we do, yet they are able to include essentially everyone in their comprehensive programs.

How would private control of health spending produce a fiscally sustainable system? The answer is that it would be fiscally sustainable only for the government. With a median household income of $49,000 and average health care expenditures of an insured family at $18,000 (Milliman Medical Index), health care costs for individuals and families are already unsustainable. (Median households and families with employer-sponsored plans are not the same, but these numbers still illustrate the enormity of the problem.)

Health consumer empowerment is being achieved by shifting more of the responsibility for payment directly to patients, especially through increased deductibles and other cost sharing. At today’s high heath care costs that means that many more patients would be foregoing beneficial health care services, simply because they can’t pay for them.

Now Medicare and Medicaid are being threatened with proposed reforms that allegedly would put them on the path of sustainability. Again, that might be sustainable for the government, but the proposed changes would shift more costs to patients, further impairing access because of increasing financial barriers to care.

Many of us were shocked recently during the Republican candidates’ debate when the moderator asked if a thirty year old, critically ill man should be allowed to die because he was uninsured, and members of the audience shouted, “Yes.” But that was only a very few voices from an anti-government Tea Party audience. Not only would citizens of other nations emphatically reject this view, it also decidedly violates American values.

Nina Owcharenko offers us the choice between consumer empowerment in which we can reject the health care we need but can’t pay for, or our own beneficent government monopsony that would ensure value in our health care purchasing so that all of us could have the health care that we need.

Although her blog entry and this response may appear to be merely a rhetorical game, the choice really is a matter of our nation’s health.

Seven reasons single-payer health care will be great for Vermont business

By Bram Kleppner
Burlington Free Press, Sept. 15, 2011

One: Quality. Our health care system doesn’t produce very good health. Of the world’s 33 developed countries, the United States ranks near the bottom in health indicators like infant death, death that could have been prevented by proper health care, and life expectancy. From North America to Europe to the Middle East to Asia, people in countries with single-payer systems are consistently healthier than Americans.

Healthy workers do better work at lower cost than unhealthy workers. A single-payer system will provide Vermont companies with healthier workers.

Two: Hard costs. Judging by other single-payer systems around the world, going to single-payer should cut our health care costs roughly in half.

The report to the Vermont legislature recommended paying for single-payer with an 11 percent payroll tax. The legislature does not seem enthusiastic about this, and I expect we will end up with a combination of smaller taxes on payroll, income, and/or sales. However, even if we fund the system entirely with an 11 percent payroll tax, our small Vermont company would still have lower costs than under the current system; over the last five years, Danforth Pewter’s health care costs have averaged over 15 percent of payroll.

Three: Soft costs. How much time do you personally waste dealing with your health insurance every year? Multiply that across every employee in Vermont. Add the time everyone spends at benefits meetings trying to figure out the latest changes to their insurance. Add the additional time that the HR people at every Vermont company waste on health insurance administration every year.

Now imagine all that going away.

Four: Sales. Consumers will benefit directly from the lower costs of a single-payer system through much lower out-of-pocket expenses, and every dollar a consumer doesn’t spend on health care is a dollar he or she can spend on something more pleasant. Since Vermonters spend a big portion of their discretionary dollars on local goods and services, Vermont companies will see higher sales.

Five: Privacy. We’ve been getting our health insurance through our jobs so long that we’ve become used to having our companies know all about our private health status, but companies and employees will both be happier when we’re not forced into this uncomfortable intimacy.

Six: Freedom. You probably know people who dream of starting their own businesses, or joining their spouse’s business, but who can’t quit their day jobs because they need the health insurance. Imagine the boon to the economy if all those people become free to unleash their entrepreneurial passion. Imagine the great new products and services that they will create. Imagine how much happier those people will be working for themselves in a business they care about.

This will be good for Vermont business because first, some of those new products and services will help us run our businesses better; and second, honestly, we don’t want people around who are just punching the clock to get health insurance. Make it easy to go, and some of the dead wood will clear itself out.

Seven: Employment. Employees, companies and the economy will all benefit from another aspect of single-payer health care. If we remove the cost of health care from the cost of hiring a new employee, it becomes a lot easier to hire. Companies will be quicker to hire when they’re growing, and quicker to rehire when the economy starts recovering from recession.

With single-payer, Vermonters get better health, lower costs, more privacy, more freedom, a better economy and more jobs. Vermont companies get healthier and more motivated workers, a more flexible labor market, a better economy, lower costs, and more sales.

That sounds like good business to me.

Bram Kleppner is chief executive officer of Danforth Pewter in Middlebury.

http://www.burlingtonfreepress.com/article/20110915/BUSINESS08/110914020/Seven-reasons-single-payer-health-care-will-great-Vermont-business

Obama administration's dishonest promotion of Medicare Advantage

Medicare Advantage Premiums To Fall 4% Next Year

By Phil Galewitz
Kaiser Health News, September 15, 2011

The Obama administration on Thursday said the nearly 12 million senior citizens enrolled in Medicare health plans will see their monthly premiums drop by an average of 4 percent while benefits remain stable next year.

Enrollment in the plans, which now have about a quarter of all Medicare beneficiaries, is expected to grow by 10 percent in 2012, said Jonathan Blum, deputy administrator for the Centers for Medicare and Medicaid Services.

He attributed the premium drop to the agency’s strong negotiations with plans as well as the companies’ continuing desire to serve the market.

Dan Mendelson, the chief executive of consulting firm Avalere Health, said plans are lowering premiums because their costs have fallen as their members have used fewer services in the midst of the economic downturn.

The plans were targeted by Democrats who complained that the government pays more per capita for beneficiaries in the private plans than it spends on those in traditional Medicare.

Federal payments were frozen to Medicare Advantage plans this year and are dropping by less than 1 percent in 2012.

The health care law softens the impact of Medicare Advantage cuts in 2012 by providing billions of dollars for quality bonuses for highly rated plans that received four or five stars in a government grading system.

In a policy shift last fall, HHS decided to lower the bar for bonuses. Average-quality plans garnering just three or three-and-a-half stars would also get bonuses, although at a lower percentage than top-tier plans.

The HHS decision means that nearly 90 percent of Medicare Advantage enrollees are in plans now eligible for a bonus. Under the tougher approach Congress took in the health law, only about 33 percent would have been in plans getting the extra payments.

http://www.kaiserhealthnews.org/Stories/2011/September/15/medicare-advantage-premiums-fall-next-year.aspx

Comment: 

By Don McCanne, MD

The Obama administration is countering Republican claims that the Affordable Care Act stole money from Medicare. They are trumpeting the facts that Medicare Advantage premiums are 4 percent lower, and enrollment is expected to be up by 10 percent. We really need to get past the deceptive rhetoric on both sides to understand what really is going on.

The Medicare Advantage program began as a fraud. These private plans were paid 113 percent of the costs of the traditional Medicare program so that they could offer extra benefits to entice individuals away from the public program. Once a sufficient number of individuals joined the private plans, funding for the public program would be slashed and patients would flee into the private plans. Only then would the public learn that the next planned step would be to shift to a Ryan-type voucher (premium support), which would dump much more of the costs onto patients.

The Affordable Care Act included a provision to gradually reduce these Medicare Advantage overpayments. The scheduled reduction for 2012 will be less than 1 percent. But members of the Obama administration have been listening to the insurers and the Republicans. They decided that this very modest reduction might make them more vulnerable to Republican attacks as we enter an election year. So what did they do?

They replenished the reductions with billions of dollars in quality bonuses designed for top tier 4 and 5 star plans, but they expanded the program to include 3 star plans. That way, plans covering 90 percent of Medicare Advantage enrollees would receive additional payments. A quality bonus for almost every plan is nothing more than a blanket payment increase. They have preserved this gift to the private insurers and then have the gall to claim that the programs are stronger and more popular as a result of their “strong negotiations” with the plans! Strength in politics seems to be proportional to the size of the gifts of cash, especially appalling when you realize that this is our tax money.

By the way, how much is that 4 percent reduction in premiums that the Medicare Advantage enrollees will be paying? It averages about $1.48 monthly per enrollee. That tough negotiating sure hit the insurers hard. $1.48! I can picture the insurers leaving the negotiations saying that they sure were hit hard this year, but they hope to do better in next year’s negotiations, as they collapse in hysterics right after the door closes.

One more important fact to keep in mind is that these extra insurance company bonuses are paid partly by our Part B premiums in the traditional Medicare program. Those of us who refuse to join the Medicare Advantage plans are paying higher premiums to buy more patient benefits, more insurer profits and more administrative services for those who have enrolled in the private plans. We now have an official government policy that requires us to pay more and get less if we don’t privatize ourselves!

Dishonesty is so prevalent in politics today that I think I almost understand the graffiti that we saw yesterday while hiking on our ridge trail: “The truth is a lie!”

Obama administration’s dishonest promotion of Medicare Advantage

Medicare Advantage Premiums To Fall 4% Next Year

By Phil Galewitz
Kaiser Health News, September 15, 2011

The Obama administration on Thursday said the nearly 12 million senior citizens enrolled in Medicare health plans will see their monthly premiums drop by an average of 4 percent while benefits remain stable next year.

Enrollment in the plans, which now have about a quarter of all Medicare beneficiaries, is expected to grow by 10 percent in 2012, said Jonathan Blum, deputy administrator for the Centers for Medicare and Medicaid Services.

He attributed the premium drop to the agency’s strong negotiations with plans as well as the companies’ continuing desire to serve the market.

Dan Mendelson, the chief executive of consulting firm Avalere Health, said plans are lowering premiums because their costs have fallen as their members have used fewer services in the midst of the economic downturn.

The plans were targeted by Democrats who complained that the government pays more per capita for beneficiaries in the private plans than it spends on those in traditional Medicare.

Federal payments were frozen to Medicare Advantage plans this year and are dropping by less than 1 percent in 2012.

The health care law softens the impact of Medicare Advantage cuts in 2012 by providing billions of dollars for quality bonuses for highly rated plans that received four or five stars in a government grading system.

In a policy shift last fall, HHS decided to lower the bar for bonuses. Average-quality plans garnering just three or three-and-a-half stars would also get bonuses, although at a lower percentage than top-tier plans.

The HHS decision means that nearly 90 percent of Medicare Advantage enrollees are in plans now eligible for a bonus. Under the tougher approach Congress took in the health law, only about 33 percent would have been in plans getting the extra payments.

http://www.kaiserhealthnews.org/Stories/2011/September/15/medicare-advantage-premiums-fall-next-year.aspx

The Obama administration is countering Republican claims that the Affordable Care Act stole money from Medicare. They are trumpeting the facts that Medicare Advantage premiums are 4 percent lower, and enrollment is expected to be up by 10 percent. We really need to get past the deceptive rhetoric on both sides to understand what really is going on.

The Medicare Advantage program began as a fraud. These private plans were paid 113 percent of the costs of the traditional Medicare program so that they could offer extra benefits to entice individuals away from the public program. Once a sufficient number of individuals joined the private plans, funding for the public program would be slashed and patients would flee into the private plans. Only then would the public learn that the next planned step would be to shift to a Ryan-type voucher (premium support), which would dump much more of the costs onto patients.

The Affordable Care Act included a provision to gradually reduce these Medicare Advantage overpayments. The scheduled reduction for 2012 will be less than 1 percent. But members of the Obama administration have been listening to the insurers and the Republicans. They decided that this very modest reduction might make them more vulnerable to Republican attacks as we enter an election year. So what did they do?

They replenished the reductions with billions of dollars in quality bonuses designed for top tier 4 and 5 star plans, but they expanded the program to include 3 star plans. That way, plans covering 90 percent of Medicare Advantage enrollees would receive additional payments. A quality bonus for almost every plan is nothing more than a blanket payment increase. They have preserved this gift to the private insurers and then have the gall to claim that the programs are stronger and more popular as a result of their “strong negotiations” with the plans! Strength in politics seems to be proportional to the size of the gifts of cash, especially appalling when you realize that this is our tax money.

By the way, how much is that 4 percent reduction in premiums that the Medicare Advantage enrollees will be paying? It averages about $1.48 monthly per enrollee. That tough negotiating sure hit the insurers hard. $1.48! I can picture the insurers leaving the negotiations saying that they sure were hit hard this year, but they hope to do better in next year’s negotiations, as they collapse in hysterics right after the door closes.

One more important fact to keep in mind is that these extra insurance company bonuses are paid partly by our Part B premiums in the traditional Medicare program. Those of us who refuse to join the Medicare Advantage plans are paying higher premiums to buy more patient benefits, more insurer profits and more administrative services for those who have enrolled in the private plans. We now have an official government policy that requires us to pay more and get less if we don’t privatize ourselves!

Dishonesty is so prevalent in politics today that I think I almost understand the graffiti that we saw yesterday while hiking on our ridge trail: “The truth is a lie!”

Hospitals: All-payer or global budgets?

Maryland's Hospital Cost Review Commission at 40

By John A. Kastor, MD; Eli Y. Adashi, MD, MS
JAMA, September 14, 2011

In 1971, the state of Maryland established the Health Services Cost Review Commission (HSCRC) to regulate the rates that hospitals in the state could receive from Medicare, Medicaid, and private insurers. Although other states once regulated hospital rates, only in Maryland does the practice continue. In this Commentary, we describe the Maryland system, discuss why regulation in other states failed, and suggest that other states should consider regulating hospital rates.

In 1976, when the system began full operation, the adjusted costs per admission in Maryland hospitals were approximately 26% higher than the national average. Between 1977 and 2009, Maryland hospitals experienced the lowest cumulative increase in cost per adjusted admission of any state in the nation. For fiscal year 2009, the average cost per admission at Maryland hospitals increased by only 2% compared with an estimated 4.5% increase for the rest of the nation.​ Because the HSCRC regulates the amount hospitals can increase (“mark up”) their charges, Maryland also has the lowest absolute charges of any state.

Why has regulation succeeded in Maryland? First and foremost, there is the HSCRC’s enlightened design with its legislated independence, broad enforcement powers, and discretion to chart its own course. Accordingly, changes the HSCRC sees as advantageous can be instituted without additional legislative action. Most stakeholders—hospitals, payers, and patients—favor the system. Hospitals appreciate the transparency and equity of the rate-setting process, the enhanced compensation by public payers, and the elimination of protracted rate negotiations with each payer. Payers value the clarity and parity of the HSCRC-approved hospital rates, the absence of hospital-driven cost-shifting, and the containment of continually increasing costs. Patients welcome the unfettered access to care.

Although as many as 30 states once regulated hospital costs, by 1991, only Maryland continues to use an all-payer rate-setting system. While the reasons varied state by state, fundamental to the decrease in the rate-setting system was federal policy, beginning in the 1980s, that replaced the regulatory model with deregulatory market-driven schemes. Managed care, capitation, and diagnosis related groups, not rate regulation, became the mantra to control increases in health spending.

The Maryland experience demonstrates that an enlightened independent public utility can be empowered to successfully stem inflationary growth in hospital spending. Is this the time for other states to consider or reconsider using rate regulation to control hospital costs?

http://jama.ama-assn.org/content/306/10/1137.full?etoc

And…

A National Health Program for the United States: A Physicians’ Proposal

By The Writing Committee (PNHP’s proposal)
The New England Journal of Medicine, January 12, 1989

Payment for Hospital Services

Each hospital would receive an annual lump-sum payment to cover all operating expenses – a “global” budget. The amount of this payment would be negotiated with the state national health program payment board and would be based on past expenditures, previous financial and clinical performance, projected changes in levels of services, wages and other costs, and proposed new and innovative programs. Hospitals would not bill for services covered by the national health program. No part of the operating budget could be used for hospital expansion, profit, marketing, or major capital purchases or leases. These expenditures would also come from the national health program fund, but monies for them would be appropriated separately.

Global prospective budgeting would simplify hospital administration and virtually eliminate billing, thus freeing up substantial resources for increased clinical care. Before the nationwide implementation of the national health program, hospitals in the states with demonstration programs could bill out-of-state patients on a simple per diem basis. Prohibiting the use of operating funds for capital purchases or profit would eliminate the main financial incentive for both excessive intervention (under fee-for-service payment) and skimping on care (under DRG-type prospective-payment systems), since neither inflating revenues nor limiting care could result in gain for the institution. The separate appropriation of funds explicitly designated for capital expenditures would facilitate rational health planning. In Canada, this method of hospital payment has been successful in containing costs, minimizing bureaucracy, improving the distribution of health resources, and maintaining the quality of care. It shifts the focus of hospital administration away from the bottom line and toward the provision of optimal clinical services.

https://pnhp.org/publications/a-national-health-program-for-the-united-states

And…

Hospital Payment Policy in Canada: Options for the future

By Jason Sutherland
Canadian Health Services Research Foundation, March 15, 2011

Canada’s publicly funded healthcare system is facing increasing cost control pressures. Hospitals alone represent a substantial burden on provincial health budgets, accounting for 28% of total costs. Presently, in the Canadian system, the primary source of funding for hospitals is through a global budget. Under this model, a fixed (global) amount of funding is distributed to each hospital to pay for all hospital-based services for a fixed period of time (commonly one year). Global budgets:

* Are based on historical spending, inflation, negotiations and politics in many provinces, rather than on the type and volume of services provided.
* Constrain hospital spending growth and create budgetary predictability; however, its consequences may be decreased services and increases in waiting times.
* Do not provide incentives to improve access, quality or efficiency of hospital care.

Funding hospitals on the basis of the type and volume of services they provide has become the international norm. Known as activity-based funding (ABF), these systems have been systematically supplementing global budgets in public and private insurance-based health systems around the world. ABF:

* Provides powerful financial incentives to stimulate productivity and efficiency: efficient hospitals retain the difference between the payment amount and the hospital’s actual cost of production.
* Is associated with higher volumes of hospital care, shorter lengths of stay, and yet has not been linked to poorer quality of care.
* Is linked to higher overall spending, due to higher volumes of patients being treated, and evidence of lower cost per admission is mixed.

Combining properties of ABF and global budgets may optimize the strengths of both global budgets and ABF. Many countries that have ABF to fund their hospital systems utilize a blend of global budgets to control spending, while instituting an ABF mechanism to create incentives for hospitals to provide timely and equitable access, appropriate volume of care, and efficient care.

http://www.chsrf.ca/PublicationsAndResources/ResearchReports/CommissionedResearch/11-03-15/88814df8-66e9-4db0-9cd6-b48370af5f66.aspx

Comment:

By Don McCanne, MD

Much attention is being directed to Maryland’s all-payer system of rate setti
ng for hospitals since it has been effective in shifting Maryland from a state with amongst the highest hospital costs to a state with the lowest absolute charges. Should we ignore these findings and merely proceed with the relatively ineffectual tweaks of the Affordable Care Act? Or should we adopt an all-payer system for all hospitals? Or should we change to a system of global budgeting for hospitals?

Unfortunately, the Affordable Care Act provides only illusions of cost control for hospitals. As an example, the early experiences with accountable care organizations have failed to demonstrate any significant cost savings. If we really do want to improve value in our hospital spending, we are going to have to look beyond the Affordable Care Act.

What makes Maryland’s approach unique is that hospital rates are set by a commission that has the power to regulate the rates paid by all private and public payers, including Medicare and Medicaid. They have been able to get the pricing right, to the satisfaction of hospitals, payers and patients.

So why hasn’t their all-payer approach been adopted by more states or by the federal government? It is because those that support deregulated, market-driven schemes are in control of the political process. We are being guided by the philosophy that government is always bad, even when it’s good!

In  contrast to all-payer, a single payer approach establishes global budgets for hospitals, much like global budgets for police and fire departments, schools, public libraries, and other institutions serving the public interest. Negotiated global budgets are the most effective model of ensuring adequate hospital services and resources while preventing waste on superfluous services such as the large bureaucratic monoliths within their institutions. Global budgets provide the best value in hospital care purchasing.

If we can succeed in reestablishing a public service role for government, then wouldn’t it be reasonable to simply enact an all-payer system for hospitals? The problem is that it only makes one change in our fragmented, dysfunctional system of financing care, and not a complete change at that. Under all-payer, only the rates are controlled, but each service still must be accounted for and paid for independently, and the hospitals would still have multiple public and private payers with which they would have to interact.

Canada has had tremendous success with its program of global budgeting for hospitals. As the article from the Canadian Health Services Research Foundation indicates, even the best of processes can benefit from refinement, though decisions will have to be made as to whether “activity-based funding” is a beneficial refinement.

We can applaud the efforts of Maryland which has proven for us that the health care system works better when the government is involved. Now we can go Maryland one better by establishing global budgeting for hospitals as part of a single payer national health program. Then we would have it all.

Uninsurance, poverty figures up — we need your help

Sept. 15, 2011

Dear PNHP colleague,

Our health care crisis continues to deepen. On Tuesday the Census Bureau announced that 50 million people lacked health insurance in 2010, about 1 million more than in 2009, according to the bureau’s new calculation method. It also said the number of people living in poverty in the United States had increased to 46.2 million, the highest number in the 52 years the bureau has been tracking it.

We need your support to bring about the only effective remedy for our nation’s health care woes: a publicly financed, single-payer national health insurance system, an improved Medicare for all.

Please help us build up single-payer activism by sponsoring a medical student’s participation in PNHP’s Annual Meeting on Oct. 29 in Washington. You can take action today that will help ensure that physicians will continue to be a strong force in our nation’s movement for single payer tomorrow.

We must raise $15,000 for our Nicholas Skala Health Activist Scholarship Fund to provide financial assistance to dozens of young leaders from throughout the United States, and can’t do it without the generosity of members like you.

Student PNHP members from across the country have submitted passionate essays on why the Annual Meeting would assist their development as physician-activists. Richard Bruno, a second-year medical student at Oregon Health and Science University and local student PNHP chapter leader, writes:

“For the past two PNHP annual sessions I have been inspired and challenged to lead efforts at my school and in my community. I am hoping to take the fight to more specialty societies and know that attending the Annual Meeting will help give me more resources to engage my colleagues.”

Your contribution of $100 will allow two additional students to register for the meeting. A contribution of $250 will allow a student from across the country to travel to our meeting to listen and learn from physicians and activists from around the world.

Please make a donation today. We want to bring as many student leaders to our Annual Meeting as possible to hear speakers such as Robert Evans, internationally esteemed Canadian health economist; the U.K.’s Jacqueline Davis, M.D., co-founder of Keep our NHS Public; Phillip Longman, an expert on the VA system; and the leaders of PNHP.

Please give generously to the Nick Skala Scholarship Fund. With 50 million uninsured and counting, our mission is more important than ever. Together we will hasten the day of achieving true health care justice.

Cordially,

Quetin Young Signature

Quentin Young, M.D., M.A.C.P.
National Coordinator

P.S. If you haven’t done so already, we cordially invite you to attend PNHP’s Annual Meeting on Oct. 29 in Washington, D.C., to help us strategize about the next steps forward for the single-payer movement. Register today! You’re also invited to register for our popular Leadership Training Institute the day before. For PNHP’s statement on the new Census figures, click here.

Is Poverty a Death Sentence?

By Bernie Sanders
CommonDreams.org, Sept. 13, 2011

The crisis of poverty in America is one of the great moral and economic issues facing our country. It is very rarely talked about in the mainstream media. It gets even less attention in Congress. Why should people care? Many poor people don’t vote. They certainly don’t make large campaign contributions, and they don’t have powerful lobbyists representing their interests.

Here’s why we all should care. There are 46 million Americans — about one in six — living below the poverty line. That’s the largest number on record, according to a new report released Tuesday by the Census Bureau. About 49.9 million Americans lacked health insurance, the report also said. That number has soared by 13.3 million since 2000.

Moreover, according to the Organization for Economic Cooperation and Development, the United States has both the highest overall poverty rate and the highest childhood poverty rate of any major industrialized country on earth. This comes at a time when the U.S. also has the most unequal distribution of wealth and income of any major country on earth with the top 1 percent earning more than the bottom 50 percent.

According to the latest figures from the OECD, 21.6 percent of American children live in poverty. This compares to 3.7 percent in Denmark, 5 percent in Finland, 5.5 percent in Norway 6.9 percent in Slovenia, 7 percent in Sweden, 7.2 percent Hungary, 8.3 percent in Germany, 8.8 percent in the Czech Republic, 9.3 percent in France, 9.4 percent in Switzerland. I suppose we can take some comfort in that our numbers are not quite as bad as Turkey (23.5 percent), Chile (24 percent) and Mexico (25.8 percent).

When we talk about poverty in America, we think about people who may be living in substandard and overcrowded homes or may be homeless. We think about people who live with food insecurity, who may not know how they are going to feed themselves or their kids tomorrow. We think about people who, in cold states like Vermont, may not have enough money to purchase the fuel they need to keep warm in the winter. We think about people who cannot afford health insurance or access to medical care. We think about people who cannot afford an automobile or transportation, and can’t get to their job or the grocery store. We think about senior citizens who may have to make a choice between buying the prescription drugs he or she needs, or purchasing an adequate supply of food.

I want to focus on an enormously important point. And that is that poverty in America today leads not only to anxiety, unhappiness, discomfort and a lack of material goods. It leads to death. Poverty in America today is a death sentence for tens and tens of thousands of our people which is why the high childhood poverty rate in our country is such an outrage.

Some facts:

• At a time when we are seeing major medical breakthroughs in cancer and other terrible diseases for the people who can afford those treatments, the reality is that life expectancy for low-income women has declined over the past 20 years in 313 counties in our country. In other words, in some areas of America, women are now dying at a younger age than they used to.

• In America today, people in the highest income group level, the top 20 percent, live, on average, at least 6.5 years longer than those in the lowest income group. Let me repeat that. If you are poor in America you will live 6.5 years less than if you are wealthy or upper-middle class.

• In America today, adult men and women who have graduated from college can expect to live at least 5 years longer than people who have not finished high school.

• In America today tens of thousands of our fellow citizens die unnecessarily because they cannot get the medical care they need. According to Reuters (September 17, 2009), nearly 45,000 people die in the United States each year — one every 12 minutes — in large part because they lack health insurance and cannot get good care. Harvard Medical School researchers found in an analysis released on Thursday.”

• In 2009, the infant mortality rate for African American infants was twice that of white infants.

I recite these facts because I believe that as bad as the current situation is with regard to poverty, it will likely get worse in the immediate future. As a result of the greed, recklessness and illegal behavior of Wall Street we are now in the midst of the worst economic downturn since the 1930s. Millions of workers have lost their jobs and have slipped out of the middle class and into poverty. Poverty is increasing.

Further, despite the reality that our deficit problem has been caused by the recession and declining revenue, two unpaid for wars and tax breaks for the wealthy, there are some in Congress who wish to decimate the existing safety net which provides a modicum of security for the elderly, the sick, the children and lower income people. Despite an increase in poverty, some of these people would like to cut or end Social Security, Medicare, Medicaid, food stamps, home heating assistance, nutrition programs and help for the disabled and the homeless.

To the degree that they are successful, there is no question in my mind that many more thousands of men, women and children will die.

From a moral perspective, it is not acceptable that we allow so much unnecessary suffering and preventable death to continue. From an economic perspective and as we try to fight our way out of this terrible recession, it makes no sense that we push to the fringe so many people who could be of such great help to us.

Bernie Sanders (I-Vt.) was elected to the U.S. Senate in 2006 after serving 16 years in the House of Representatives. He is the longest serving independent member of Congress in American history. Elected Mayor of Burlington, Vt., by 10 votes in 1981, he served four terms.

PNHP note: Sen. Sanders held a hearing on Sept. 13 on this topic where Dr. Garrett Adams, president of PNHP, was among those giving testimony. You can read Dr. Adams’ testimony here.

https://www.commondreams.org/view/2011/09/14-6

Hospitals: All-payer or global budgets?

Maryland’s Hospital Cost Review Commission at 40

By John A. Kastor, MD; Eli Y. Adashi, MD, MS
JAMA, September 14, 2011

In 1971, the state of Maryland established the Health Services Cost Review Commission (HSCRC) to regulate the rates that hospitals in the state could receive from Medicare, Medicaid, and private insurers. Although other states once regulated hospital rates, only in Maryland does the practice continue. In this Commentary, we describe the Maryland system, discuss why regulation in other states failed, and suggest that other states should consider regulating hospital rates.

In 1976, when the system began full operation, the adjusted costs per admission in Maryland hospitals were approximately 26% higher than the national average. Between 1977 and 2009, Maryland hospitals experienced the lowest cumulative increase in cost per adjusted admission of any state in the nation. For fiscal year 2009, the average cost per admission at Maryland hospitals increased by only 2% compared with an estimated 4.5% increase for the rest of the nation.​ Because the HSCRC regulates the amount hospitals can increase (“mark up”) their charges, Maryland also has the lowest absolute charges of any state.

Why has regulation succeeded in Maryland? First and foremost, there is the HSCRC’s enlightened design with its legislated independence, broad enforcement powers, and discretion to chart its own course. Accordingly, changes the HSCRC sees as advantageous can be instituted without additional legislative action. Most stakeholders—hospitals, payers, and patients—favor the system. Hospitals appreciate the transparency and equity of the rate-setting process, the enhanced compensation by public payers, and the elimination of protracted rate negotiations with each payer. Payers value the clarity and parity of the HSCRC-approved hospital rates, the absence of hospital-driven cost-shifting, and the containment of continually increasing costs. Patients welcome the unfettered access to care.

Although as many as 30 states once regulated hospital costs, by 1991, only Maryland continues to use an all-payer rate-setting system. While the reasons varied state by state, fundamental to the decrease in the rate-setting system was federal policy, beginning in the 1980s, that replaced the regulatory model with deregulatory market-driven schemes. Managed care, capitation, and diagnosis related groups, not rate regulation, became the mantra to control increases in health spending.

The Maryland experience demonstrates that an enlightened independent public utility can be empowered to successfully stem inflationary growth in hospital spending. Is this the time for other states to consider or reconsider using rate regulation to control hospital costs?

http://jama.ama-assn.org/content/306/10/1137.full?etoc

And…

A National Health Program for the United States: A Physicians’ Proposal

By The Writing Committee (PNHP’s proposal)
The New England Journal of Medicine, January 12, 1989

Payment for Hospital Services

Each hospital would receive an annual lump-sum payment to cover all operating expenses – a “global” budget. The amount of this payment would be negotiated with the state national health program payment board and would be based on past expenditures, previous financial and clinical performance, projected changes in levels of services, wages and other costs, and proposed new and innovative programs. Hospitals would not bill for services covered by the national health program. No part of the operating budget could be used for hospital expansion, profit, marketing, or major capital purchases or leases. These expenditures would also come from the national health program fund, but monies for them would be appropriated separately.

Global prospective budgeting would simplify hospital administration and virtually eliminate billing, thus freeing up substantial resources for increased clinical care. Before the nationwide implementation of the national health program, hospitals in the states with demonstration programs could bill out-of-state patients on a simple per diem basis. Prohibiting the use of operating funds for capital purchases or profit would eliminate the main financial incentive for both excessive intervention (under fee-for-service payment) and skimping on care (under DRG-type prospective-payment systems), since neither inflating revenues nor limiting care could result in gain for the institution. The separate appropriation of funds explicitly designated for capital expenditures would facilitate rational health planning. In Canada, this method of hospital payment has been successful in containing costs, minimizing bureaucracy, improving the distribution of health resources, and maintaining the quality of care. It shifts the focus of hospital administration away from the bottom line and toward the provision of optimal clinical services.

https://pnhp.org/publications/a-national-health-program-for-the-united-states

And…

Hospital Payment Policy in Canada: Options for the future

By Jason Sutherland
Canadian Health Services Research Foundation, March 15, 2011

Canada’s publicly funded healthcare system is facing increasing cost control pressures. Hospitals alone represent a substantial burden on provincial health budgets, accounting for 28% of total costs. Presently, in the Canadian system, the primary source of funding for hospitals is through a global budget. Under this model, a fixed (global) amount of funding is distributed to each hospital to pay for all hospital-based services for a fixed period of time (commonly one year). Global budgets:

* Are based on historical spending, inflation, negotiations and politics in many provinces, rather than on the type and volume of services provided.
* Constrain hospital spending growth and create budgetary predictability; however, its consequences may be decreased services and increases in waiting times.
* Do not provide incentives to improve access, quality or efficiency of hospital care.

Funding hospitals on the basis of the type and volume of services they provide has become the international norm. Known as activity-based funding (ABF), these systems have been systematically supplementing global budgets in public and private insurance-based health systems around the world. ABF:

* Provides powerful financial incentives to stimulate productivity and efficiency: efficient hospitals retain the difference between the payment amount and the hospital’s actual cost of production.
* Is associated with higher volumes of hospital care, shorter lengths of stay, and yet has not been linked to poorer quality of care.
* Is linked to higher overall spending, due to higher volumes of patients being treated, and evidence of lower cost per admission is mixed.

Combining properties of ABF and global budgets may optimize the strengths of both global budgets and ABF. Many countries that have ABF to fund their hospital systems utilize a blend of global budgets to control spending, while instituting an ABF mechanism to create incentives for hospitals to provide timely and equitable access, appropriate volume of care, and efficient care.

http://www.chsrf.ca/PublicationsAndResources/ResearchReports/CommissionedResearch/11-03-15/88814df8-66e9-4db0-9cd6-b48370af5f66.aspx

Much attention is being directed to Maryland’s all-payer system of rate setting for hospitals since it has been effective in shifting Maryland from a state with amongst the highest hospital costs to a state with the lowest absolute charges. Should we ignore these findings and merely proceed with the relatively ineffectual tweaks of the Affordable Care Act? Or should we adopt an all-payer system for all hospitals? Or should we change to a system of global budgeting for hospitals?

Unfortunately, the Affordable Care Act provides only illusions of cost control for hospitals. As an example, the early experiences with accountable care organizations have failed to demonstrate any significant cost savings. If we really do want to improve value in our hospital spending, we are going to have to look beyond the Affordable Care Act.

What makes Maryland’s approach unique is that hospital rates are set by a commission that has the power to regulate the rates paid by all private and public payers, including Medicare and Medicaid. They have been able to get the pricing right, to the satisfaction of hospitals, payers and patients.

So why hasn’t their all-payer approach been adopted by more states or by the federal government? It is because those that support deregulated, market-driven schemes are in control of the political process. We are being guided by the philosophy that government is always bad, even when it’s good!

In  contrast to all-payer, a single payer approach establishes global budgets for hospitals, much like global budgets for police and fire departments, schools, public libraries, and other institutions serving the public interest. Negotiated global budgets are the most effective model of ensuring adequate hospital services and resources while preventing waste on superfluous services such as the large bureaucratic monoliths within their institutions. Global budgets provide the best value in hospital care purchasing.

If we can succeed in reestablishing a public service role for government, then wouldn’t it be reasonable to simply enact an all-payer system for hospitals? The problem is that it only makes one change in our fragmented, dysfunctional system of financing care, and not a complete change at that. Under all-payer, only the rates are controlled, but each service still must be accounted for and paid for independently, and the hospitals would still have multiple public and private payers with which they would have to interact.

Canada has had tremendous success with its program of global budgeting for hospitals. As the article from the Canadian Health Services Research Foundation indicates, even the best of processes can benefit from refinement, though decisions will have to be made as to whether “activity-based funding” is a beneficial refinement.

We can applaud the efforts of Maryland which has proven for us that the health care system works better when the government is involved. Now we can go Maryland one better by establishing global budgeting for hospitals as part of a single payer national health program. Then we would have it all.