PNHP

Invitation to a Dialogue: A National Health Plan

Invitation to a Dialogue: A National Health Plan

Letter
New York Times, August 23, 2011

To the Editor:

In “Will Health Care Reform Survive the Courts?” (State of Play, Sunday Review, Aug. 21), Philip M. Boffey states that “reforms would work far less well without an individual mandate” that requires citizens to buy health insurance or pay a penalty.

I disagree. Health care reform could provide better care at less cost by replacing individual mandates with a single-payer national health care plan financed by taxes. Congress’s power to mandate purchase of private products sold at a profit is disputable, but Congress’s power to tax is not.

Other industrialized countries have national health plans providing care to more citizens at less cost with better outcomes than our system. And they don’t use mandates that allow insurers to charge different prices for different people.

These health care systems have three common properties: public subsidies ensure that everyone has access to care regardless of health, wealth or employment; primary care is encouraged; and publicly accountable, transparent, not-for-profit agencies transfer funds from patient to provider.

There is no need to experiment with mandates. Convert our current health care system into a national health plan.

SAMUEL METZ
Portland, Ore., Aug. 21, 2011

The writer, an anesthesiologist, is a founding member of Mad as Hell Doctors, which advocates a single-payer system.

Editors’ Note: We invite readers to respond to this letter for our Sunday Dialogue. We plan to publish responses and Dr. Metz’s rejoinder in the Sunday Review. E-mail: letters@nytimes.com

http://www.nytimes.com/2011/08/24/opinion/invitation-to-a-dialogue-a-national-health-plan.html

Will job insecurity lead to health insecurity?

When Unemployed Means Uninsured: The Toll of Job Loss on Health Coverage, and How the Affordable Care Act Will Help

By Michelle M. Doty, Sara R. Collins, Ruth Robertson, and Tracy Garber
The Commonwealth Fund, August 2011

Chronically high unemployment has left millions of Americans without health insurance, which disappeared along with their wages and other job benefits. Although continuing health coverage through COBRA is an option for some workers, the often prohibitively high cost means that relatively few elect to purchase it. When fully implemented in 2014, the Affordable Care Act will dramatically increase health insurance options for people who lose their jobs. Even so, gaps in coverage will remain a risk for many workers who become unemployed or are transitioning to a new job. To help bridge coverage gaps until 2014, policymakers should consider reestablishing the COBRA premium subsidies that helped millions of people who lost their jobs in 2008–2010.

http://www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/2011/Aug/1540_Doty_when_unemployed_means_uninsured_COBRA_reform%20brief.pdf

And…

Maintaining Coverage, Affordability, and Shared Responsibility When Income and Employment Change

By Pamela Farley Short, Katherine Swartz, Namrata Uberoi, and Deborah Graefe
The Commonwealth Fund, May 2011

The Affordable Care Act builds on existing sources of public and private health insurance, while creating new health insurance exchanges and subsidies. A potential disadvantage of preserving many sources of health insurance is the likelihood of abrupt changes in coverage or financial responsibility when individual circumstances change. This brief describes four policy challenges related to such changes: adjusting premium and cost-sharing subsidies when incomes change; coordinating eligibility for premium credits, Medicaid, and the Children’s Health Insurance Program; encouraging and facilitating continuous coverage; and minimizing transitions between individual and small-business exchanges. Policy recommendations to reduce uncertainty, simplify coverage decisions, and minimize insurance transitions include extending coverage to the open enrollment period at the end of the year, generous treatment of income gains in correcting premium tax credits, and unifying the small-business and individual exchanges.

http://www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/2011/May/1503_Short_maintaining_coverage_affordability_reform_brief.pdf

How many individuals continue in the same employment for their entire careers, with the same employer-sponsored health plan, with the same network of health care providers, with the same…? Well, we can stop there. Nobody does.

Generally, individuals in well-paid occupations in high demand who change their employment may face some transitional issues with health plans and provider networks, but usually they fare quite well, even if annoyed at the prospect of perhaps having to change their primary health care professionals, or whatever.

But what about low and moderate income individuals? Job instability is the norm. Income levels can fluctuate considerably. Periods of prolonged unemployment are now more common, and, based on economic projections, will likely persist into the foreseeable future.

The Affordable Care Act has so many slippery variables that it is almost impossible to predict what one’s coverage will be beyond a couple of years, if that. Eligibility can change sometimes on a monthly basis (exchange plans) or yearly basis (Medicaid) for various programs including employer-sponsored plans, Medicaid, CHIP, state exchange plans, or state Basic Health Plans. Eligibility for tax credits for premiums in the exchange plans and for cost sharing reductions can be very unstable because of fluctuations in income. Even waiver of the penalty for failure to purchase private insurance can trigger in or out quite abruptly.

The newest Commonwealth Fund report addresses specifically the problem of coverage during intervals of unemployment. COBRA plans allow newly unemployed workers to continue with coverage under their former employer-sponsored plans but with the out-of-work former employees having to pay the full premiums. COBRA plans have had an unacceptably low participation simply because a person out of work cannot pay the premiums.

To address the problem of unaffordable COBRA premiums that became even more prevalent during the Great Recession, the American Recovery and Reinvestment Act (ARRA) authorized premium subsidies for the purchase of COBRA plans, but that program has expired.

To provide coverage during transitions of unemployment in the future, the authors of this report suggest that the subsidies be permanently resuscitated. The problem with this approach is, even with these temporary subsidies, the COBRA take-up rate was still well less than half of eligible former employees. Policies that don’t work shouldn’t take precedence over policies that do.

You can apply all of the patches that you can devise to the leaking ship of the Affordable Care Act, but it is still going to leak. As more patches are applied, it is further weighted down with greater expenses and with even more administrative burdens – enough to sink any ship.

You want something that floats? Try enrolling everyone at birth, permanently. The solid ship of Medicare for All would have no leaks to patch.

Is reducing hospital readmissions an answer?

Incidence of potentially avoidable urgent readmissions and their relation to all-cause urgent readmissions

By Carl van Walraven MD MSc, Alison Jennings MA, Monica Taljaard PhD, Irfan Dhalla MD MSc, Shane English MD, Sunita Mulpuru MD, Saul Blecker MD, Alan J. Forster MD MSc
CMAJ (Canadian Medical Association), August 22, 2011

Urgent, unplanned hospital readmissions are increasingly being used to measure institutional or regional quality of care. The public reporting of readmissions and their use in considerations for funding suggest a belief that readmissions indicate the quality of care provided by particular institutions. However, urgent readmissions are an informative metric only if we know what proportion of them are avoidable. If they are rarely avoidable, they would be a poor gauge of the quality of patient care.

Current estimates of the proportion of urgent readmissions that are avoidable are unreliable. In a systematic review of 34 studies that reviewed how many readmissions were avoidable, 3 of the studies relied solely on combinations of administrative diagnostic codes, and most used undefined or subjective criteria. In addition, most of the studies were conducted at a single centre and used only one reviewer. The proportion of readmissions deemed avoidable varied widely, from 5.1%6 to 78.9%,7 which reflected in part the lack of standardized and reliable methods to identify avoidable readmissions.

We conducted a multicentre prospective cohort study to elicit judgments from multiple practising physicians who used standard implicit review methods to determine whether urgent re admissions were potentially avoidable. We analyzed these judgments using a latent class analysis. We also measured the proportion of readmissions deemed avoidable and compared hospital-specific proportions of all-cause and avoidable readmissions.

Conclusion

Urgent readmissions deemed potentially avoidable were relatively uncommon, comprising less than 20% of all urgent readmissions following hospital discharge. Hospital-specific proportions of patients who were readmitted were not related to proportions of those whose readmissions were deemed avoidable.

Given the variety of causes and circumstances of the potentially avoidable readmissions in our study, interventions to decrease the risk of readmission need to be multifactorial in nature and malleable to be appropriately tailored for each situation.

Our study has important implications for research into the quality of hospital care. First, determining whether urgent readmissions were avoidable is a subjective judgment that requires detailed patient data, multiple reviewers and an analysis that accounts for differing reviewer accuracy when collating judgments. Such judgments cannot be determined accurately on the basis of administrative data alone, given the infinite combinations of patient, hospital, treatment and post-discharge factors that can influence urgent readmissions. Second, we found no association between hospital-specific proportions of all-cause and avoidable readmissions. Therefore, urgent readmissions should be used with caution to gauge the quality of hospital care.

http://www.cmaj.ca/content/early/2011/08/22/cmaj.110400.full.pdf+html

Comment: 

By Don McCanne, MD

This Canadian study provides a great example of how we, in the United States, “think up” policies to control health spending while improving quality, and then apply those policies simply because they “should work.” Many of these policy decisions are used to divert our attention from much more effective measures such as a single payer national health program.

In this instance, the theory is that unplanned readmissions after a previous stay in the hospital are avoidable with appropriate in-hospital and post-discharge management. If the professionals and other personnel would do their jobs right, quality would improve and the costs of re-hospitalization would be avoided.

Although the Canadians, with their single payer system, evaluated readmissions from the perspective of improving quality, the emphasis in the United States, with its market medicine, has been on costs (e.g., refuse payment for re-admissions).

This study demonstrates that the reasons for readmission are very complex and highly variable and have very little relationship to either human or systems failure. Readmission rates should not be a major driver of policy.

Through this distraction, we’ve been fooled again. It’s not lousy health care professionals who are the source of our problems, it is the inhumane and outrageously expensive market-based health care financing and allocation system that is the problem. That’s what we need to fix. Then we could set aside issues of greed and concentrate on health care quality instead, like the Canadians are doing.

Is reducing hospital readmissions an answer?

Incidence of potentially avoidable urgent readmissions and their relation to all-cause urgent readmissions

By Carl van Walraven MD MSc, Alison Jennings MA, Monica Taljaard PhD, Irfan Dhalla MD MSc, Shane English MD, Sunita Mulpuru MD, Saul Blecker MD, Alan J. Forster MD MSc
CMAJ (Canadian Medical Association), August 22, 2011

Urgent, unplanned hospital readmissions are increasingly being used to measure institutional or regional quality of care. The public reporting of readmissions and their use in considerations for funding suggest a belief that readmissions indicate the quality of care provided by particular institutions. However, urgent readmissions are an informative metric only if we know what proportion of them are avoidable. If they are rarely avoidable, they would be a poor gauge of the quality of patient care.

Current estimates of the proportion of urgent readmissions that are avoidable are unreliable. In a systematic review of 34 studies that reviewed how many readmissions were avoidable, 3 of the studies relied solely on combinations of administrative diagnostic codes, and most used undefined or subjective criteria. In addition, most of the studies were conducted at a single centre and used only one reviewer. The proportion of readmissions deemed avoidable varied widely, from 5.1%6 to 78.9%,7 which reflected in part the lack of standardized and reliable methods to identify avoidable readmissions.

We conducted a multicentre prospective cohort study to elicit judgments from multiple practising physicians who used standard implicit review methods to determine whether urgent re admissions were potentially avoidable. We analyzed these judgments using a latent class analysis. We also measured the proportion of readmissions deemed avoidable and compared hospital-specific proportions of all-cause and avoidable readmissions.

Conclusion

Urgent readmissions deemed potentially avoidable were relatively uncommon, comprising less than 20% of all urgent readmissions following hospital discharge. Hospital-specific proportions of patients who were readmitted were not related to proportions of those whose readmissions were deemed avoidable.

Given the variety of causes and circumstances of the potentially avoidable readmissions in our study, interventions to decrease the risk of readmission need to be multifactorial in nature and malleable to be appropriately tailored for each situation.

Our study has important implications for research into the quality of hospital care. First, determining whether urgent readmissions were avoidable is a subjective judgment that requires detailed patient data, multiple reviewers and an analysis that accounts for differing reviewer accuracy when collating judgments. Such judgments cannot be determined accurately on the basis of administrative data alone, given the infinite combinations of patient, hospital, treatment and post-discharge factors that can influence urgent readmissions. Second, we found no association between hospital-specific proportions of all-cause and avoidable readmissions. Therefore, urgent readmissions should be used with caution to gauge the quality of hospital care.

http://www.cmaj.ca/content/early/2011/08/22/cmaj.110400.full.pdf+html

This Canadian study provides a great example of how we, in the United States, “think up” policies to control health spending while improving quality, and then apply those policies simply because they “should work.” Many of these policy decisions are used to divert our attention from much more effective measures such as a single payer national health program.

In this instance, the theory is that unplanned readmissions after a previous stay in the hospital are avoidable with appropriate in-hospital and post-discharge management. If the professionals and other personnel would do their jobs right, quality would improve and the costs of re-hospitalization would be avoided.

Although the Canadians, with their single payer system, evaluated readmissions from the perspective of improving quality, the emphasis in the United States, with its market medicine, has been on costs (e.g., refuse payment for re-admissions).

This study demonstrates that the reasons for readmission are very complex and highly variable and have very little relationship to either human or systems failure. Readmission rates should not be a major driver of policy.

Through this distraction, we’ve been fooled again. It’s not lousy health care professionals who are the source of our problems, it is the inhumane and outrageously expensive market-based health care financing and allocation system that is the problem. That’s what we need to fix. Then we could set aside issues of greed and concentrate on health care quality instead, like the Canadians are doing.

Jack Layton

March 5, 2006

“When you’re sick, you present your medicare card, not your credit card. New Democrats will not stand idly by. We will be fighting each and every day for our precious medicare system.”

Jack Layton
(July 18, 1950 – August 22, 2011)

http://www.vancouversun.com/health/Quotes+Jack+Layton+words/5289596/story.html

And..

Letter from Jack Layton, MP, Député Toronto – Danforth

Leader of the Official Opposition/Chef de l’Opposition officielle
Leader, New Democratic Party/Chef, Nouveau Parti démocratique
August 20, 2011
Toronto, Ontario

Dear Friends,

(excerpt)

To young Canadians:

All my life I have worked to make things better. Hope and optimism have defined my political career, and I continue to be hopeful and optimistic about Canada. Young people have been a great source of inspiration for me. I have met and talked with so many of you about your dreams, your frustrations, and your ideas for change. More and more, you are engaging in politics because you want to change things for the better. Many of you have placed your trust in our party. As my time in political life draws to a close I want to share with you my belief in your power to change this country and this world. There are great challenges before you, from the overwhelming nature of climate change to the unfairness of an economy that excludes so many from our collective wealth, and the changes necessary to build a more inclusive and generous Canada. I believe in you. Your energy, your vision, your passion for justice are exactly what this country needs today. You need to be at the heart of our economy, our political life, and our plans for the present and the future.

My friends, love is better than anger. Hope is better than fear. Optimism is better than despair. So let us be loving, hopeful and optimistic. And we’ll change the world.
 
All my very best,
 
Jack Layton

http://antemedius.com/files/Jack_Layton_s_lett_1310744a.pdf

Jack Layton

March 5, 2006

“When you’re sick, you present your medicare card, not your credit card. New Democrats will not stand idly by. We will be fighting each and every day for our precious medicare system.”

Jack Layton
(July 18, 1950 – August 22, 2011)

http://www.vancouversun.com/health/Quotes+Jack+Layton+words/5289596/story.html

And..

Letter from Jack Layton, MP, Député Toronto – Danforth

Leader of the Official Opposition/Chef de l’Opposition officielle
Leader, New Democratic Party/Chef, Nouveau Parti démocratique
August 20, 2011
Toronto, Ontario

Dear Friends,

(excerpt)

To young Canadians:

All my life I have worked to make things better. Hope and optimism have defined my political career, and I continue to be hopeful and optimistic about Canada. Young people have been a great source of inspiration for me. I have met and talked with so many of you about your dreams, your frustrations, and your ideas for change. More and more, you are engaging in politics because you want to change things for the better. Many of you have placed your trust in our party. As my time in political life draws to a close I want to share with you my belief in your power to change this country and this world. There are great challenges before you, from the overwhelming nature of climate change to the unfairness of an economy that excludes so many from our collective wealth, and the changes necessary to build a more inclusive and generous Canada. I believe in you. Your energy, your vision, your passion for justice are exactly what this country needs today. You need to be at the heart of our economy, our political life, and our plans for the present and the future.

My friends, love is better than anger. Hope is better than fear. Optimism is better than despair. So let us be loving, hopeful and optimistic. And we’ll change the world.

All my very best,

Jack Layton

http://antemedius.com/files/Jack_Layton_s_lett_1310744a.pdf

Employers continue to shift health care costs to employees

Large Employers’ 2012 Health Plan Design Changes

National Business Group on Health
August 18, 2011

Medical Plan Costs

In 2012, 63% of employers will increase the employee percentage contribution to premium costs, and 39% will increase in-network deductibles.

Consumer-Directed Health Care

More employers will be offering a consumer-directed health plan (CDHP) in 2012 than in previous years, with 73% planning to offer at least one CDHP next year. In addition, 17% of employers have or will move to a full replacement CDHP design in 2012. The most common type of CDHP employers will offer next year is a high-deductible health plan (HDHP) with a health savings account (HSA) (75%).
 
The most common method employers use to load health accounts is by contributing a predetermined amount per participant, with 59% of employers with HSAs doing so, and 84% doing the same for health reimbursement accounts (HRA).

Pharmacy Benefits

To manage pharmacy benefits, most employers use prior authorization (76%). The next most popular techniques are:
• quantity limits (72%)
• step therapy (65%)
• three-tier design (59%)

Retiree Health

Fewer employers offer retiree benefits to current active employees, with 26% covering all current actives and 38% covering a portion of their actives. Very few employers offer retiree health benefits for new hires, with 12% offering coverage to pre-65 retirees and 7% offering post-65 supplemental coverage to new hires.
 
The top strategies being used to control retiree health care costs are capping company contributions (45%), increasing employee contributions (31%) and eliminating coverage for future retirees (28%).

http://capsules.kaiserhealthnews.org/wp-content/uploads/2011/08/2012-NBGH-Plan-Design-Survey-Report-Embargoed-Edition.pdf

And…

Survey: Employers shift rising health costs to their workers

By Sam Baker
The Hill, August 18, 2011

Businesses are shifting away from co-pays, wherein employees pay a fixed dollar amount for healthcare services and the plan picks up the rest. Instead, they’re charging workers a percentage of the total costs. That can help make consumers more aware of the total cost of the healthcare they use.

“We are clearly seeing a march toward a more aggressive consumerist system,” said Helen Darling, president of the National Business Group on Health.

Darling said Thursday that shifting from co-pays to coinsurance is “a more subtle way to increase what the consumer pays.” She predicted that eventually, only governments and unions will keep offering fixed co-pays.

http://thehill.com/blogs/healthwatch/health-insurance/177361-employers-shifting-healthcare-costs-to-workers

Comment: 

By Don McCanne, MD

Employers are reducing the transparency of the massive shift of health care costs to their employees by using many different methods that individually do not look too onerous, but cumulatively have a major impact.

Some of the methods of shifting more health care costs to their employees include greater premium contributions, greater use of large deductibles and consumer-directed health plans, greater restrictions on pharmacy benefits, and a sharp reduction or elimination of retiree health benefits. One of the more subtle but important methods is reducing the use of co-payments (a fixed dollar amount for a service or product) and instead using coinsurance (a percentage of the amount charged). The percentages are usually much larger than the co-payments would be.

Most of the businesses surveyed are very large corporations (83 percent have over 10,000 employees). Their corporate executives and their passive shareholders have done very well in the last few decades, being beneficiaries of the upward transfer of wealth in our society. Their employees have not done so well and have experienced greater difficulties in managing their personal finances.

Rising health care costs are a problem for all of us. They are now so great that we need progressive methods of financing health care. Yet shifting costs from the wealthy corporate plutocracy to the employees is a regressive form of financing.

Supposedly employers are still contributing a large share of the premium, but only nominally. Most economists agree that employees pay the employer component of the premium though forgone wage increases, and wages have certainly been flat. Again, this is regressive financing.

In crafting the Affordable Care Act, efforts were made to protect employer-sponsored plans so that they would still be the largest source of health care coverage. Is this wise?

Not only is the financing regressive, it leaves in place the administratively wasteful private health plans that intrude on health care by taking away certain benefits and taking away choices of health care providers. It leaves in place the fragmented financing model of private plans that has been incapable of slowing the rate of growth in costs to a level closer to those of other industrialized nations. Furthermore, it leaves health policy decisions in the hands of corporate executives who are beholden above all to their investors, whereas the employees are mere pawns to be used to create wealth for the investors. Why else would they be using so many means to shift more health care costs to the employees?

Every time I write one of these commentaries, I think that the logic of an improved Medicare for All would make it an imperative. Maybe the problem is that logic would lead to health care justice, and that seems to be unthinkable in the United States.

Employers continue to shift health care costs to employees

Large Employers’ 2012 Health Plan Design Changes

National Business Group on Health
August 18, 2011

Medical Plan Costs

In 2012, 63% of employers will increase the employee percentage contribution to premium costs, and 39% will increase in-network deductibles.

Consumer-Directed Health Care

More employers will be offering a consumer-directed health plan (CDHP) in 2012 than in previous years, with 73% planning to offer at least one CDHP next year. In addition, 17% of employers have or will move to a full replacement CDHP design in 2012. The most common type of CDHP employers will offer next year is a high-deductible health plan (HDHP) with a health savings account (HSA) (75%).

The most common method employers use to load health accounts is by contributing a predetermined amount per participant, with 59% of employers with HSAs doing so, and 84% doing the same for health reimbursement accounts (HRA).

Pharmacy Benefits

To manage pharmacy benefits, most employers use prior authorization (76%). The next most popular techniques are:
• quantity limits (72%)
• step therapy (65%)
• three-tier design (59%)

Retiree Health

Fewer employers offer retiree benefits to current active employees, with 26% covering all current actives and 38% covering a portion of their actives. Very few employers offer retiree health benefits for new hires, with 12% offering coverage to pre-65 retirees and 7% offering post-65 supplemental coverage to new hires.

The top strategies being used to control retiree health care costs are capping company contributions (45%), increasing employee contributions (31%) and eliminating coverage for future retirees (28%).

http://capsules.kaiserhealthnews.org/wp-content/uploads/2011/08/2012-NBGH-Plan-Design-Survey-Report-Embargoed-Edition.pdf

And…

Survey: Employers shift rising health costs to their workers

By Sam Baker
The Hill, August 18, 2011

Businesses are shifting away from co-pays, wherein employees pay a fixed dollar amount for healthcare services and the plan picks up the rest. Instead, they’re charging workers a percentage of the total costs. That can help make consumers more aware of the total cost of the healthcare they use.

“We are clearly seeing a march toward a more aggressive consumerist system,” said Helen Darling, president of the National Business Group on Health.

Darling said Thursday that shifting from co-pays to coinsurance is “a more subtle way to increase what the consumer pays.” She predicted that eventually, only governments and unions will keep offering fixed co-pays.

http://thehill.com/blogs/healthwatch/health-insurance/177361-employers-shifting-healthcare-costs-to-workers

Employers are reducing the transparency of the massive shift of health care costs to their employees by using many different methods that individually do not look too onerous, but cumulatively have a major impact.

Some of the methods of shifting more health care costs to their employees include greater premium contributions, greater use of large deductibles and consumer-directed health plans, greater restrictions on pharmacy benefits, and a sharp reduction or elimination of retiree health benefits. One of the more subtle but important methods is reducing the use of co-payments (a fixed dollar amount for a service or product) and instead using coinsurance (a percentage of the amount charged). The percentages are usually much larger than the co-payments would be.

Most of the businesses surveyed are very large corporations (83 percent have over 10,000 employees). Their corporate executives and their passive shareholders have done very well in the last few decades, being beneficiaries of the upward transfer of wealth in our society. Their employees have not done so well and have experienced greater difficulties in managing their personal finances.

Rising health care costs are a problem for all of us. They are now so great that we need progressive methods of financing health care. Yet shifting costs from the wealthy corporate plutocracy to the employees is a regressive form of financing.

Supposedly employers are still contributing a large share of the premium, but only nominally. Most economists agree that employees pay the employer component of the premium though forgone wage increases, and wages have certainly been flat. Again, this is regressive financing.

In crafting the Affordable Care Act, efforts were made to protect employer-sponsored plans so that they would still be the largest source of health care coverage. Is this wise?

Not only is the financing regressive, it leaves in place the administratively wasteful private health plans that intrude on health care by taking away certain benefits and taking away choices of health care providers. It leaves in place the fragmented financing model of private plans that has been incapable of slowing the rate of growth in costs to a level closer to those of other industrialized nations. Furthermore, it leaves health policy decisions in the hands of corporate executives who are beholden above all to their investors, whereas the employees are mere pawns to be used to create wealth for the investors. Why else would they be using so many means to shift more health care costs to the employees?

Every time I write one of these commentaries, I think that the logic of an improved Medicare for All would make it an imperative. Maybe the problem is that logic would lead to health care justice, and that seems to be unthinkable in the United States.

David Brooks' view on Medicare mistaken

By Debra Walter, M.D.
Letters, Arizona Daily Star, June 14, 2011

Re: the June 8 column by David Brooks “Medicare proposals reflect parties’ worldviews”:

While I agree the debate really reflects broad philosophical differences, he is quite mistaken in assuming private insurance plans represent “local control.”

Blue Cross, United, Aetna and others are just as national and centralized as Medicare; they all have divisional levels of control.

Any physician will tell you that Medicare is the easiest and least controlling of all insurance choices.

The debate is really about the sanctity of corporate control versus allowing our government to assist us in pooling our resources and funding health care for all.

The continued fantasy that for-profit health insurance companies are acting in our collective best interest hasn’t proven to be true yet.

The continued drain of our health care dollars into profit, administration and advertising will keep draining our health as a nation until we as a country decide to take charge and take care of ourselves without the corporate middleman.

Debra Walter is a physician in Tucson.

Abortion Training, Childhood Obesity, Single Payer Catch Medical Students’ Attention

Richard Bruno, a third-year medical student, joined his peers in drafting policy recommendations for the American Association of Family Providers

By Christen McCurdy
The Lund Report, Aug. 17, 2011

Oregon Health and Science University medical student Richard Bruno has taken his passions – healthier diets for kids, improved working conditions for medical students, preserving access to abortion training and investigating the feasibility of a single-payer healthcare system – to a national level.

“If there’s anything that sort of underlies all this, it’s that medical student advocacy is really something that should be encouraged at medical schools,” Bruno said. “Medical students can be a voice for the voiceless, uninsured patients who are out there. If we teach them to harness the power of their short, white coats, they could really start to make a difference starting now and throughout their careers.”

At the end of July, the American Association of Family Providers (AAFP) held its annual conference – which included a student congress – in Kansas City. Bruno and several colleagues drafted policy resolutions that are expected to come before its Scientific Assembly in September.

As far as abortion training for medical students, which came under attack when the Foxx Amendment passed Congress recently, Bruno felt “we should take a stronger stance on this issue, especially given the national push.” That amendment restricts the ability of medical schools to receive federal funding if they teach students how to perform abortions.

Improving the working conditions for medical students also caught Bruno’s attention. A recent article in the New York Times focused on the plight of sleep-deprived doctors, which led to patients receiving inferior care. “I’m just getting a taste of this as a third-year medical student,” Bruno said. “No one’s tracking my hours. No one’s telling me when to go home.”

Bruno also believes the AAFP should create a task force to research a single-payer healthcare system, referring to a study commissioned by Vermont published in the New England Journal of Medicine, which found that a single-payer system would not only save the state money, but be beneficial for everyone. 

Childhood obesity is another cause trumpeted by Bruno and his colleagues. Earlier this year the Oregon Medical Association rejected a resolution calling upon McDonald’s to stop marketing to children. “The OMA was trepidatious about calling out a single company,” he said.

Now Bruno is calling upon the AAFP to sever its ties to Coca-Cola, which advertises on that website.

“It’s pretty much a conflict of interest,” he said, because these advertisements contradict information on the same website, asserting that sugar-sweetened beverages are unhealthy.

http://www.thelundreport.org/resource/abortion_training_childhood_obesity_catch_medical_students%E2%80%99_attention

Be the second state to pass universal health care

By Mark Liebow, M.D.
Rochester (Minn.) Post-Bulletin, Aug. 18, 2011

Well, Vermont beat us to it. The people of Vermont decided correctly that the advances of the Affordable Care Act weren’t enough. They looked at Massachusetts and found that with that state’s plan, which serves as the model for the Affordable Care Act, costs continue to rise and the rate of medical bankruptcies didn’t go down.

In fact, Massachusetts now has the highest insurance premiums of all 50 states. Vermonters pushed their elected officials to pass legislation that aims to set up a state single-payer plan, the first in the United States. We could be next.

The new private insurance that some Minnesotans will buy under the Affordable Care Act will not cover all their medical expenses. They will still face deductibles and co-payments that deter them from getting medical care. Some may be forced to choose between care and food or rent. Insurers will still take a big chunk of the premium for administrative expenses and profits which do not help patients. The flaws in our current system remain. There is a better way.

The Minnesota Health Plan, if enacted, would be a public program that covers all Minnesotans with better coverage and substantially lower administrative cost. The plan will cover all medically necessary services without deductibles or co-payments. There will be no complicated enrollment procedures or eligibility requirements. Health insurance bureaucrats will not stand between patients and their doctors.

The plan will save billions of dollars a year for Minnesotans. Even the non-profit insurance companies we have in Minnesota use 15 percent to 20 percent of the dollars they collect in premiums for overhead. Doctors, hospitals, and other providers also spend a substantial percentage of what they collect on administrative costs. Most of that needless spending will end when the plan is enacted. We can use the savings to lower the cost of services and to improve quality. Beyond that, doctors and patients will appreciate having less paperwork and the end of tedious struggles with insurance companies.

Of course, we’ll have to pay for this. There will be new taxes, which will be assessed based on ability to pay. However, we will stop paying premiums, deductibles, and copayments. For the average Minnesotan, their new taxes will be less than they are paying now. Businesses will no longer have the burden of purchasing health insurance for employees and dependents. This should lower retail prices and lower our cost of living.

The plan will be a big help to Rochester. Covering everyone will allow more patients to come to Mayo Clinic and Olmsted Medical Center. Furthermore, Mayo and Olmsted will no longer need to provide charity care or rack up bad debt from the care given to Minnesotans. Mayo Clinic alone will save hundreds of millions in health care costs for its employees and dependents. Rochester health care organizations will save hundreds of millions more in reduced costs for billing and collections. This will allow them to grow and hire more clinical employees.

We will lose jobs by eliminating health insurance companies, thus making most people in health care organizations doing billing, collections, and negotiations with insurers unnecessary. Many of these workers have clinical backgrounds and can move back into health care organizations as they grow. Others will need retraining. Fortunately, the Plan sets aside money for retraining those who need it and, most importantly, people losing jobs will not also lose health care.

Many at Mayo worry that a single-payer system will not recognize that Mayo sees more complex patients than most practices and hospitals, making its costs higher. They also worry about whether there will be support for research and education. The plan will negotiate annual budgets with Mayo hospitals and can provide the budget that will cover the costs of complexity. It will also negotiate provider fees and can set a higher fee for care provided at academic institutions.

Some have been concerned about “rationing” in a single-payer system. The plan is prohibited from restricting, delaying, or denying care, or reducing the quality of care to save money. Rather, savings come from streamlining our current administrative spending. We already spend enough on health care. By increasing efficiency, we can provide needed care to all Minnesotans.

While the plan can fix how we pay for care, it won’t fix problems in how we provide care, because it was never meant to fix those. We need to study those problems and figure out what we can do for them, since many will see the health care system as broken as long as the delivery of care is flawed. Still, fixing how we pay for health care at the state level would do many good things for Rochester, for Minnesota, and for Minnesotans. Vermont’s new law means we can’t be first, but we still can be the state with the best single-payer system. Let’s enact the Minnesota Health Plan (http://mnhealthplan.org).

Mark Liebow is a Rochester physician.

Open Letter on Health Care to Ohio Rep. Bill Hayes

By Brad Cotton, M.D.
Circleville (Ohio) Herald, Aug. 17, 2011

Rep. Hayes, I write you this open letter in response to your Circleville Herald column of 10 August, “Health Care Close to Home.”

I sincerely invite you to spend a shift or two with me in the emergency department to see and feel face to face the desperation of the tens of thousands of down-home Ohioans without access to health care.

These are not slackers or persons who just wish to freeload on your tax dollars, they are our neighbors and friends, the barber who cuts your hair, the server who waits on you, the clerk in the that large store. Often they are working two jobs trying to make ends meet, while cutting back on their own medicines to save for kid’s school supplies.

Come and feel the pain of real persons suffering and dying in your district having been abandoned by profitable insurance companies, whose profit margins are at record levels (“Health Insurers Make Record Profits as Many Postpone Care,” New York Times, 14 May 2011).

Like you, I too have problems with the Patient Protection and Affordable Care Act (PPACA), called “Obamacare” by detractors when “Romneycare” is in fact more accurate, as the PPACA is modeled after Massachusetts health care reform signed by Republican Gov. Mitt Romney in 2006.

I have problems with the PPACA not because of your concern that it is a government program controlled by inaccessible, far-away elected representatives, but because it keeps in place private health insurance companies controlled by even more inaccessible, often dishonest, and even farther away corporate boardrooms that I can’t even un-elect.

Dishonest a strong word? The Associated Press article “Insurers Allegedly Provided Inaccurate Medical-Loss Ratios” of 27 July notes several Florida insurance companies took advantage of lax oversight under Gov. Rick Scott, falsely claiming they spent funds on children’s Medicaid when in fact they pocketed the cash. Scott, a tea party favorite, presided as CEO of the Hospital Corporation of America/ Columbia Health Care when his company was fined one of the largest penalties ever levied by the federal government for insurance fraud.

Rep. Hayes, your column infers that the PPACA removes local choices that “are best handled by the people closest to home who know the situation best.” Ask your constituents how much honest close to home help they received from their health insurance company.

Rep. Hayes, Ohioans health is at risk not because of too much government, but of too little. We the people have failed to demand that our elected representatives appropriately oversee and regulate Wall-Street-traded health insurance giants that increase their bottom line by not keeping their word on the promise they offer: financial security in the face of illness.

Wendell Potter, former Cigna public relations officer turned whistleblower and author of “Deadly Spin: An Insurance Company Insider Speaks Out on How Corporate PR is Killing Health Care and Deceiving Americans,” warns, “One of the secrets to achieving these [record profits] is what the insurers euphemistically call ‘medical management.’ That often translates into denied claims and denied coverage for doctor-ordered care. The fewer claims they pay and the more procedures they refuse to pay for, the more money is left over for investors to put in their pockets. … It’s to the insurer’s advantage for it to be complicated and confusing and hard to deal with insurance companies. They profit as a result of the confusion.”

Private for-profit health insurance companies, these are the real death panels.

Rep. Hayes, for the sake of all Ohioans I urge you to support HB 287, the “Ohio Health Security Act,” introduced by Reps. Bob Hagan and Mike Foley. HB 287 would move Ohio closer to a single-payer model, shown throughout the industrialized world to be the most cost-effective and compassionate.

Vermont has just passed single payer – no one in Vermont will die for lack of health insurance. The prestigious American Journal of Public Health, December 2009, published “Health Insurance and Mortality in U.S. Adults,” estimating that 45,000 Americans die yearly from lack of health insurance. This does not include those who die as a result of denied claims. Some of these deaths are your constituents.

Rep. Hayes, until we reach single payer you can save the lives of many Ohioans by reining in the worst of health insurance company abuses by supporting the PPACA. Under these reforms no Ohioan can be denied insurance for pre-existing conditions, no neighbor of ours will find their insurance taken away when their care threatens company profits.

Arbitrary denials of claims by insurers will, for the first time, be subject to appeal, as will premium increases. Insurers will be forced to spend at least 80-85 percent of all premiums collected on direct patient care. Under the Patient Protection and Affordable Care Act, more Ohioans will live, certainly the best “down-home” neighborly gift we can give.

Brad Cotton, M.D., is an emergency physician and a member of Physicians for a National Health Program (www.pnhp.org).