PNHP

Vermont moves closer to becoming first US state to provide 'socialised medicine'

Vermont moves closer to becoming first US state to provide 'socialised medicine'

By Jeanne Lenzer
BMJ, May 10, 2011

Vermont is set to become the first US state to launch a single payer healthcare plan after a bill passed both houses of the state’s legislature.

The plan is expected to be signed by Governor Peter Shumlin, who in February originally proposed the idea that would abolish most insurance plans and would instead provide healthcare to all residents through public funding. In the United States this is known as a “single payer” scheme and is fiercely opposed by many conservative politicians as “socialised medicine.”

Some doctors in Vermont are unhappy about the proposed changes. In an online poll of roughly 600 doctors conducted by the state representative George Till, a doctor who specialises in obstetrics and gynaecology, 28 percent said that they will stop practising medicine in the state if the plan is enacted. However, the poll by Dr Till, who opposes the governor’s plan, has been criticised for not preventing multiple responses from the same person or responses from people who weren’t doctors.

The man responsible for designing Vermont’s plan, William Hsiao, professor of economics at the Harvard School of Public Health in Boston, told the BMJ that he and his colleagues evaluated healthcare schemes around the globe and found that “fee for service is the worst payment [mechanism] in the world, [as] it’s inflationary—and it’s the incentive structure embedded in our healthcare system.” Costs spiral out of control, he said, because doctors and hospitals are paid more for doing more.

An analysis by Dr Hsiao, published in the New England Journal of Medicine (2011;364:1188-1190; doi:10.1056/ NEJMp1100972), concluded that the new plan is necessary because one in five Vermont residents have either inadequate or no health insurance and rising healthcare costs threaten the solvency of small businesses and citizens.

Dr Hsiao told the BMJ, “The US is the only advanced nation other than South Africa that builds health insurance on a free market of multiple private insurers” and conditional on employment. “We need to decouple employment and health insurance,” he said. “If you live in Vermont, you will be eligible for health insurance.”

The Vermont plan, Dr Hsiao’s analysis shows, could lead to cost savings of 25 percent over 10 years. Savings would come from “administrative simplification,” introduction of a no-fault malpractice system, elimination of “perverse [financial] incentives,” and by “insulating major decisions about healthcare spending from politics.” This last reform is especially needed in the US, Dr Hsiao told the BMJ, because politicians, whose campaigns are often underwritten by large contributions from industry, often support schemes that increase profits for drug companies, hospitals, and specialist groups.

One example, he says, is the Medicare plan passed under the former president George W Bush that prohibits Medicare from competitive bidding on drugs.

As for fears that doctors will leave Vermont, Dr Hsiao told the Boston Globe that he doubts doctors will actually leave the state (7 Apr, “With health costs rising, Vermont moves toward a single-payer system,” www.boston.com/bostonglobe/editorial_ opinion/blogs/the_angle/2011/04/vermonts_single.html). If they do, he said, communities and medical centres will not have trouble recruiting replacements.

Dr Hsiao acknowledges that the legislation has been weakened from its original version, owing to “politics.” He told the BMJ that, among other changes, the legislature defeated the no-fault insurance plan, instead calling for “further study.”

Stephanie Woolhandler, professor of medicine at Harvard Medical School and co-founder of Physicians for a National Health Program, told the BMJ that the Vermont legislation “falls well short of the single payer reform needed to resolve the healthcare crisis,” in part because it allows a “continuing role for private insurance, negating many of the administrative savings attainable through a single payer reform.” The plan, she said, would “force many patients to face copayments that obstruct access to care,” and it allows the participation of “for-profit hospitals and other providers, which research has shown deliver inferior care at inflated prices.”

But despite its shortcomings, the plan “may be a useful step toward progressive health reform,” Dr Woolhandler said.

Cite this as: BMJ 2011;342:d2921

Single Payer in Vermont? Well, Not Exactly

By Roger Collier
Healthcare Finance News, May 16, 2011

In just a few days, Vermont’s Governor Peter Shumlin will sign into law what the media is calling “single payer health care reform.” But is it?

Vermont has certainly demonstrated more enthusiasm for a single payer approach than any other state. The Governor and key Democratic legislators have supported the concept, the state has a well-organized lobbying group in Vermont for Single Payer, and a state-funded study earlier this year estimated that a single payer approach could dramatically reduce health care costs. The major result has been passage in the past month by both of the state’s legislative chambers of the bill that Governor Shumlin indicates that he will sign.

So does this mean that Vermont is ready to upend its existing health care financing system and replace it with a French or British-style system? Not exactly.

The versions of the bill passed by Vermont’s House and Senate are each far, far more tentative than committed single payer advocates would wish, and have already been subject to scathing criticism by national single payer advocates. [PNHP note: The PNHP board’s April 7 statement on Vermont, hardly “scathing,” can be found here.] The bill provides for the creation of the legal framework of a public insurance program, to be called Green Mountain Care, but includes no funding mechanism, defines no benefit standards, is vague on the future roles of private insurers, and is silent on exactly how existing federal programs are to be incorporated.

What the bill does do is to establish the state exchange required by the Accountable Care Act, encourage experimental capitated payment structures, and create a Board for Green Mountain Care with responsibility for examining funding, benefit, and other issues, with recommendations to be submitted to the state legislature in 2013.

Even if the Board’s proposals are very strongly in favor of a single payer system, they will face some considerable obstacles to implementation.

Because the present bill’s approach to creation of a new system is to allow two years for development of recommendations, any implementing legislation will be delayed until 2013 at the earliest, giving opponents considerable time to organize and fund their fight. At the same time, whatever funding structure the Board recommends will inevitably result in some winners and some losers—who will almost certainly oppose the proposal—even if the net result is a gain for Vermont’s citizens.

While small businesses are expected to get coverage through the state’s planned exchange, and thus could be forced to participate in a future state-controlled single payer plan, larger employers present more of a problem. If a single payer plan could be shown to be less costly, such employers would presumably be willing to participate. If they are not persuaded of the merits of single payer, however, they could rely on ERISA law to keep their employees out of the new program.

The bigger obstacles, however, are likely to be at the federal level. The Accountable Care Act allows states to opt out of federal reform starting in 2017, but not before. (Although an earlier date has been proposed, it has limited support). The pooling of federal funds envisioned by Vermont’s single payer advocates would require negotiations with Medicare, Medicaid, TRICARE, and Public Health administrators, all in the face of opposition from lobbyists for insurers, providers, and businesses who fear the impacts of a single payer structure on their revenues and profits. And who would be willing to guess whether or not in 2013 the administration in Washington DC is favorable towards any kind of health care reform?

http://www.healthcarefinancenews.com/blog/single-payer-vermont-well-not-exactly

Not everyone buying into Vermont's single-payer plan

By Nancy Remsen
Burlington Free Press, May 16, 2011

MONTPELIER, Vt. — The headline “Green Mountain Dreams” over a David Weigel piece in the online news magazine Slate last week captured how many people view the health reform legislation that Gov. Peter Shumlin will sign into law May 26.

For advocates of a single-payer health care system, the bill the Legislature passed during the final days of the 2011 session is a dream come true. For the first time, policy-makers have put the state on a road leading toward a government-financed insurance program that would cover all Vermonters.

Supporters acknowledge much remains to be done before the dream can become reality. The bill poses dozens of questions that must be answered, lists a host of conditions that must be met and sets the likely start date far in the future — 2017, or 2014 if the federal government cooperates.

Still one local supporter, Walter Carpenter of Montpelier, said the legislation means the state now stands “on the doorstep of history.”

Outside Vermont, single-payer advocates have a more tempered reaction.

“They have announced an intention more progressive than other states have done,” said Dr. David Himmelstein, a founder of Physicians for a National Health Program. “It could be important if they go ahead and do it, but they haven’t done anything that I can tell.”

Opponents see the legislation’s stated intention — to establish Green Mountain Care to provide health insurance to Vermonters — as either a pipe dream or a nightmare.

Rep. Patti Lewis, R-Berlin, explained some of her concerns after voting against the bill.

“I cannot support a bill of this magnitude, when there is no true answer to how much this plan will cost. Our state is simply too small to finance this plan,” she said. She added, “This is like taking a prototype plane for its first flight.”

Darcie Johnston, executive director of a newly organized group, Vermonters for Health Care Freedom, fears the worst.

“As much as the governor would like to portray this bill as harmless, it is anything but,” Johnston said. “This bill will put into motion a process that will kill job growth and drive some of our doctors out of state or out of business. It will also require the Legislature to come back next year and pass the largest tax increase in Vermont history to begin paying for it.”

Outside Vermont, Robert Zirkelbach, press secretary for America’s Health Insurance Plans, warned that Vermont’s legislation would take away the health insurance coverage that people like and rely upon, and “put Vermont taxpayers on the hook for the soaring cost of medical care.”

More than single-payer

Anya Rader Wallack, Gov. Shumlin’s special assistant for health reform, says the legislation is much more than a promise to explore consolidation of the state’s health insurance system.

For example, the bill responds to the federal mandate that states establish health benefit exchanges, or health insurance markets, by planning one for Vermont that would also simplify insurance purchases and claims processing.

“What makes Vermont stand out is it is taking the federal law and going a step further with it,” said Alan Weil, executive director of the National Academy of State Health Policy. “It is intriguing and exciting in the sense of seeing a state want to pursue its own approach within the national context.”

The legislation also tries to tackle the biggest problem in health care — its skyrocketing cost, Wallack said.

“In most states, the focus is on how to contain costs in the current budget year,” Wallack said. “We were able to pull together all the legislative leaders and the governor to look way out in the future.”

The bill creates a board charged with overseeing initiatives to control cost growth. Topping the list of initiatives the board must pursue: revamping the way doctors and hospitals are paid to move away from a system that encourages quantities of tests and procedures over efficiency and best practices.

Enrique Martinez-Vidal, vice president of AcademyHealth and director of its State Coverage Initiative, said many states are talking about provider payment reform, but few have laid the groundwork that Vermont has with its Blueprint for Health. Nor, he added, has any other state tried to “tackle that issue statewide.”

A lot of states will be watching Vermont’s payment reform efforts, Martinez-Vidal said.

“Vermont could be totally unsuccessful doing single-payer health care and be successful in payment reform, and that could be huge,” Martinez-Vidal said.

The third component of the legislation is the planning process it spells out to determine if and how the state could move to a more consolidated health coverage system.

“The fact that people were able to broadly agree that we need to go somewhere like single-payer is something to be proud of,” Wallack said. “There is a lot of work to do here. We know that.”

Himmelstein at Physicians for a National Health Program said he would have preferred legislation with more commitment to a single-payer system. Still, he added, “I’m not condemning what they did.”

“There are a lot of studies and reports, but that will provide a lot of information states will be interested in,” Martinez-Vidal said. “We applaud Vermont for taking the lead in that.”

In Vermont, supporters, critics and skeptics also wait anxiously for the reports that more than 50 people across state government have been charged with producing over the next one to two years.

Wendy Wilton, Rutland treasurer and former state senator, is among those eager for more details. Over several months, she gathered data to produce what she called her “back-of-the-envelope” analysis of the finances for Green Mountain Care.

She ended up with more questions than answers about the feasibility of a more consolidated insurance system, she said.

“Having done this process, I concluded the proposed system has the same damn problem as the current system — health care costs will increase faster than the economy grows.” she said.

“I know we need reform,” Wilton said, noting that health insurance represents one quarter of the payroll expense in Rutland where she is treasurer.

“This thing is monumental. It affects everyone. That is why it is so important to get this right,” Wilton said. “We have to have our eyes wide open going forward.”

http://www.burlingtonfreepress.com/article/20110516/NEWS03/110515016/Not-everyone-buying-into-Vermont-s-single-payer-plan

Funding for primary care panel blocked

Partisan fights in Congress stall panel on primary-health-care shortage

By Amy Goldstein
The Washington Post, May 13, 2011

When the government set out to help 32 million more Americans gain health insurance, Congress and the Obama administration acknowledged that steering more people into coverage had a dark underside: If it works, it will aggravate a shortage of family doctors, internists and other kinds of primary care.

So Page 519 of the sprawling 2010 law to overhaul the health-care system creates an influential commission to guide the country in matching the supply of health-care workers with the need. But in the eight months since its members were named, the commission has been unable to start any work.

The group cannot convene, converse or hire staff because $3 million that it needs for its initial year has been blocked by two partisan wars on Capitol Hill — strife over the federal budget and Republicans’ disdain for the health-care changes that Democrats muscled into law 14 months ago.

“We’ve been sort of hamstrung,” said Fitzhugh Mullan, a professor of medicine and health policy at George Washington University who is one of the 15 commission members appointed by the Government Accountability Office. The panel’s only activity so far, Mullan said, was a single conference call during which members were told they could not lobby members of Congress for funds or accept money to operate from foundations or anywhere else.

The National Health Care Workforce Commission is intended as an ongoing brain trust to focus new energy on solving an old problem that will become increasingly severe. The law says the new commission will analyze primary-care shortages and propose innovations for the government — and medical schools — to help produce the doctors and other health workers the nation needs.

Proponents of the workforce commission say they were surprised that Republicans have balked, because there has, in the past, been little ideological schism over the need to bolster the supply of primary care — doctors, nurses, physicians assistants and others.

http://www.washingtonpost.com/national/health/partisan-fights-in-congress-stall-panel-on-primary-health-care-shortage/2011/05/09/AFCKBW2G_story.html

Comment: 

By Don McCanne, MD

Republicans and Democrats agree with the health policy community that we desperately need to reinforce our primary care infrastructure. The National Health Care Workforce Commission that would propose innovations to help build primary care requires a mere $3 million to establish operations, but the Republicans have blocked this authorization. Do they expect us to simply rely on the private sector to meet this need? How is that working for us so far?

Options for Bringing Down the Cost of Health Care

Letters, The New York Times, May 15, 2011

In “The Missing Fifth” (column, May 10), David Brooks says there are two basic ways to control health care costs: top-down government regulation (President Obama) and shifting costs to beneficiaries (Representative Paul D. Ryan). Neither approach alone or when combined is likely to work because neither improves health care or deals with the real drivers of medical inflation.

Fee-for-service payment, a fragmented and disorganized medical care system focused on providers’ income, and an investor-owned private insurance industry all contribute to rising costs. Fraudulent billing, duplicated and unnecessary services, and a large but unknown amount of defensive medicine compound the problem. These factors could be controlled in a public single-payer system that paid private not-for-profit organized groups of salaried physicians on a capitated basis to deliver quality care.

Difficult as such reform might be to achieve, there is hope in the fact that we are already spending enough to pay all the costs of a greatly improved system. Our problem is primarily political, and it should not take many more years for the general realization that major reform is not just the best, but the only, way to control costs.

ARNOLD S. RELMAN
Cambridge, Mass., May 10, 2011

The writer is professor emeritus of medicine and social medicine at Harvard Medical School and former editor in chief of The New England Journal of Medicine.

Private health insurance industry has failed patients

By Dr. Howard Green
Palm Beach Post, Sunday, May 15, 2011

All of the well-publicized political health care programs have one thing in common: They all seek to steer larger portions of Medicare and Medicaid through private insurance corporations. They differ only in their degrees of rationing, with President Obama’s plan restricting rationing for profit and Rep. Paul Ryan’s mandate allowing the most rationing by the health insurance industry.

What Republicans and Democrats fail to disclose is that for more than 40 years the middle man of American health care – the private insurance industry – has failed in almost every capitalistic, economic and medical measure to deliver for the American patient.

Unlike auto insurance, private medical insurance has failed to accept and spread risk, thereby preventing the delivery of quality, affordable health care .

All the private health insurers have failed to prevent personal bankruptcies due to medical illness. The administrative bureaucracy of private health insurers removes $500 billion a year from health care. Managed health care brokered by private insurance companies has failed to improve medical outcomes and lower morbidity (sickness) and mortality (death rates) for all Americans regardless of income, sex or location.

The private health insurance industry has needed massive taxpayer subsidies. It would not be profitable without a federal exemption from antitrust laws combined with a federal ban on collective bargaining by physicians. The private insurance companies would not be able to ration health care for profit without a federal law protecting the companies from malpractice lawsuits.

For over four decades private health insurance companies have decreased reimbursements to individual doctors, hospitals and therapists for care, while failing to lower the cost of care for insured citizens and business.

For 40 years, the private insurance industry has refused to invest in the development of integrated medical records and billing systems to prevent fraud and track outcomes and improve quality of care. Within the health insurance industry there is a failure to compete based on medical, surgical or preventative outcomes (the only product of health care). In addition, the health insurance industry has failed to operate profitably without massive diagnostic, treatment and reimbursement rationing of patient care by non-physician actuaries and insurance bureaucrats.

Private health insurance companies have failed to deliver to Americans low-cost medicines and drugs via competitive capitalistic bidding, even with massive federal Part D subsidies. With no real interest in our future health, the private health insurance industry has failed to contribute to meaningful medical or clinical research.

Health insurance companies can only claim success in diverting hundreds of billions of dollars of public and private money from health care providers and patients to profits and payoffs for their bondholders, shareholders, executives and political patrons.

If any other American industry failed to competitively and profitably provide a quality product for all Americans for 40 years, it would either be outsourced to an emerging nation, or shut down.

Health insurance companies ensure neither quality affordable health care nor quality insurance for most Americans. With no real product to sell, the private health insurance industry would fail to exist without hundreds of millions of dollars in direct and indirect payments to the elected officials in the Congress, state legislatures and the administration.

After 40 years of market and medical failure, America needs to cut out the middle man and move to single-payer national health insurance for all Americans with private doctors, hospitals, clinics, therapists and drug companies competing based on the quality of medical, surgical and preventive outcomes.

Dr. Howard Green is managing partner of Dermatology Associates of the Palm Beaches and director of the Dermatology Division at St. Mary’s Medical Center in West Palm Beach.

http://www.palmbeachpost.com/opinion/commentary/private-health-insurance-industry-has-failed-patients-1477361.html

'What Matters Is What Works': The State and the National Health Service in Scotland and Wales

By Colin Leys

As expert commentators have amply shown, the Coalition’s plan to privatise the National Health Service (NHS) lacks any basis in evidence – no surprise there. What is less well recognised, and so far amazingly unmentioned in the debate – is that powerful evidence against privatization exists on our own doorstep – namely, the fact that in Scotland and Wales the NHS is working well as a publicly provided and managed system, based on planning and democratic accountability.

Marketization was tried, especially in Scotland, and rejected. The purchaser-provider split, which is at the root of the marketization project, was introduced but then abandoned in both countries, and neither Foundation Trusts nor payment by results were introduced in either of them. Private finance initiative (PFI) was used in Scotland under the first Labour government in Holyrood, and one private treatment centre for NHS patients was opened, but the Scottish National Party (SNP) has since scrapped the use of PFI and taken the treatment centre into public ownership. Wales has used neither PFI nor private treatment centres. The NHS in both countries is once again planned and managed through a mix of democratically accountable central and local structures, as it was in England before the 1990s.[1]

Democratic and Accountable Planning

But this doesn’t mean that the NHS in Scotland and Wales has reverted to the past. On the contrary, in both countries the NHS has been modernizing, but under the influence of very different drivers from those being promoted in England. Instead of fragmenting the NHS and opening it to commercial competition, Scotland and Wales have opted for democratic and accountable planning. There, the drivers of change are: a) the input of medical specialists and GPs (rather than businessmen) on the Area and Local Health Boards where key policies are developed; b) the input on the Boards of community health and social care/social work staff, crucial for integrating primary and secondary care efficiently; and c) in Scotland, input from members of the local community, elected to the Boards on a trial basis since 2009.

The restoration of full political responsibility for health services has led to further democratizing or redistributive measures, including the abolition of prescription charges, and the abolition of charges for personal care in Scotland, and their radical reduction in Wales. Equally significant, and contrary to the claims of marketizers in England, health services in Scotland and Wales have steadily improved, on various measures, including waiting times. Scotland’s have been among the shortest in the UK.

The contrast with England – where the NHS is now being driven into decline and, increasingly, into chaos, in the interest of privatization – is dramatic. If ‘what matters is what works,’ as Tony Blair liked to say (confident that the catch-phrase was enough to justify privatization), it is actually publicly-provided and democratically-managed health services that work, and the evidence for this is right here in the UK.

Lessons Learned

There is a wider lesson here for everyone concerned to defend the public sector. It shows the state working in its active role as the agent and shield of the majority. This needs emphasizing. After forty years of ideological onslaught the very idea of ‘the state’ is close to joining others, such as ‘collective’ (not to mention ‘socialist,’ and even ‘left’), in the depository of Unclean Concepts. ‘State bad, private good’ may be a crude slogan but it is the very real starting-point of many politicians and most media commentators and BBC interviewers today, from John Humphrys down.

‘State’ is so often coupled with ‘nanny,’ ‘bureaucratic,’ ‘inefficient,’ ‘wasteful’ or some other negative adjective, that this hardly raises an eyebrow. It is never called ‘rational,’ ‘efficient,’ or even ‘democratic’ – even though commentators and interviewers like to stress the accountability of government (state) to parliament (also part of the state, and always called democratic) when criticizing extra-parliamentary forms of political action.

Elements of the state that the corporate world likes and needs are usually treated as somehow not part of the state. The armed forces, the police, the judiciary, the monarchy and the Church of England are never described as part of the nanny state, or as being bureaucratic or inefficient. The nanny, inefficient, etc. state just means, in practice, those parts of the state which provide social and cultural services for everyone – schools, social services, and not least the NHS – and which the right doesn’t like.

The effect of this incessant drip of denigration is to narrow down our concept of the state to just these parts of it, and to make us at best indifferent toward them. We unconsciously absorb the idea that they are by nature bureaucratic, inefficient, monopolistic, etc. Every fault they exhibit tends to be accepted as evidence of an inherently defective institution. We stop seeing them as the historic collective achievements they are, as expressions of what a mature society can accomplish through collective effort, achievements we have a collective responsibility to protect and sustain. Above all we are conditioned to think that if they need improving, we ourselves can have no role to play in doing so – and that the only route to improvement is via privatization.

Yet the NHS in Scotland and Wales provides a dramatic contradiction of this whole way of thinking. The Scots and the Welsh have used their devolved powers to keep and develop the NHS as part of the state. This is partly a reflection of the stronger hold of solidaristic values in Scotland and Wales – including within the political class and the commentariat, and the medical professions. It is also due to the fact that the voting system in both countries helps the majority to get the policies they want.

It will be very interesting and important to follow what further improvements are achieved in Scotland and Wales – and how what counts as an ‘improvement’ is defined when it is patients’ needs, rather than business values, that are the measure of it. At the same time we should not expect improvements to run ahead of changes in other parts of the state in Scotland or Wales. The state was famously defined by the young Karl Marx as ‘the table of contents of civil society’: it registers the balance of social forces, and the level of democracy and solidarity and civic energy, that exist in the wider society. Without an expansion of the notion of democracy beyond the skin-deep variety, consisting merely of periodic heavily-managed elections, the progress made with the NHS in Scotland and Wales is bound to run up against limits set by the wider context.

Yet the progress already made could itself encourage experimentation in other fields, from education to central government. And it offers a badly-needed antidote to right-wing ‘Anglo-Saxon’ ideology. At the very least, the ‘Celtic’ NHS shows that the state can be a democratic, rational, progressive state – if we want it to be. •

Colin Leys is an honorary professor of politics at Goldsmiths College London, and former Professor of Politics at Queen’s University in Kingston, Canada.

Endnotes:

1. The situation in Northern Ireland is more mixed, but essentially close to the Scottish and Welsh pattern. Further details on the NHS in Scotland and Wales are given in The Plot Against the NHS by Colin Leys and Stewart Player, Merlin Press 2011, but comparative work on what is happening to the NHS in all three countries is urgently needed.

From bad to worse: Medicare proposal will surely lead to de facto 'death panels'

By Robert Kiefner
Concord (N.H.) Monitor, May 14, 2011

Say a patient comes to see us with poor appetite, low-grade temperature and progressive right lower quadrant pain, classic symptoms of appendicitis. The cure will be a date with a good local surgeon, during which he will bid farewell to his appendix and be home in a day or two to resume the joy of living. If the appendix is not removed, he will suffer a miserable death from rupture of the appendix and peritonitis.

Let’s imagine that, for political causes or for reasons of institutional greed, the patient cannot avail himself of the cure. The appendectomy cannot be done because he does not have access to the surgeon or he decided to tough it out because he cannot afford the deductible and co-pays if insured, or the stratospheric costs if uninsured.

I’d like to apply that scenario to our current health care system, where we are, collectively, that patient with health care needs, forced to make life and death decisions based on cost. The Affordable Care Act may improve access to private insurance for a relative few, but does nothing to rein in costs. Our premiums will continue to rise unchecked, mirrored by rising co-pays and deductibles which will price many folks out of even using their insurance.

Now the brilliant Rep. Paul Ryan, whose credentials consist of being a political science major in college, wants to take the most medically vulnerable Medicare population and toss them into the for-profit insurance world with a pittance in their pockets to pay for their care. His plan would surely lead us down the path of de facto “death panels” for the elderly, who would be unable to negotiate the insurance nightmare, let alone afford it.

To be certain, Medicare needs to undergo a major overhaul – but it must be more widely applied, not abandoned. The overhead involved in the redundant hierarchies of private insurers amounts to $400 billion per year, enough to cover all of the uninsured for basic health care needs. For some reason (let me see, maybe the campaign contributions, the umpteen lobbyists, profound ignorance, or perhaps just callous disregard for their constituents), our elected officials continue to support the hideously expensive, inefficient and dangerous network of private insurers in this country.

In comparison with other industrialized countries, we spend twice as much per capita on health care, yet we rank 37th in the world relative to standard measures of health. Health care should not be a partisan issue. We need to do better with an informed citizenry and legislators who are willing to turn away from corporate special interest groups and ignore mind numbingly stupid extremist constituents.

So, back to the bedside of our patient. The doctors and nurses making that decision to take out the appendix need to make the decision to save the patient without regard for anyone’s political or financial interests. And for the rest of us, the collective patient, we need to truly reform health care, break the cost curve, and support universal health coverage, a single payer system which places patients ahead of profits. It is the fiscally and morally responsible thing to do.

Robert Kiefner is a family physician in Concord.

http://www.concordmonitor.com/article/257041/from-bad-to-worse

Corporations, Federal ‘Reform’ Keep Shifting Healthcare Costs to Workers

By Roger Bybee
In These Times, May 13, 2011

Despite its $14.2 billion in profits last year untouched by federal income taxes, General Electric is now demanding that its unionized workers accept a new high-deductible “Health Choice” health savings account plan.

GE’s demands are particularly obscene because it is sitting on $25 billion in savings and is threatening to close more U.S. plants, i.e. move more jobs to Mexico, China and elsewhere. And they’re particularly dangerous because GE is modeling bad behavior for other corporations to emulate.

As UE-GE Conference Secretary Steve Tormey has said, “Nobody is more symbolic of the assault on workers than General Electric.” The United Electrical workers union, one of a handful of unions now negotiating with GE, warned its members:

…numerous studies of these high-deductible plans…reveal that employees forced into plans like Health Choice are “significantly more likely to avoid, skip, or delay healthcare because of costs” than those with more comprehensive insurance. …

What GE is really saying with Health Choice is that medical expenses are no longer primarily their responsibility, but that of GE employees.

But GE is only the latest entrant among employers trying to establish a new healthcare normal by thrusting heavy additional costs onto the backs of working families. And the much-trumpeted federal healthcare “reform” legislation may actually exacerbate this race to the bottom.

(Of course, public employers—like the state of Wisconsin, led by labor’s arch enemy Gov. Scott Walker—have also been pushing to make public workers take up even more of the burden of healthcare costs. This despite the fact that, as David Cay Johnston has pointed out without managing to dent mainstream media coverage, public employees have always been paying 100 percent of their benefit costs. When they gained improvements in health and retirement benefits, they had to sacrifice on wage increases.)

How federal healthcare ‘reform’ helps drives the race to the bottom

The race to the bottom is, unfortunately, likely to be intensified as we get closer to fully implementing the Affordable Care Act in 2014. In fact, the ACA may well tend to establish a bare-bones, high-deductible policy as the new norm. The taxation of perversely mis-labeled “Cadillac” benefits has the very real potential of putting the squeeze on union-won healthcare benefits, especially in high-cost states. 

Despite the efforts of AFL-CIO Richard Trumka and others to limit the damage created when the Obama administration suddenly adopted John McCain’s regressive idea of taxing better benefit plans to fund expanded healthcare coverage for the uninsured, it may not take long before fast-rising medical inflation pushes the dollar value of union-won health benefits up to the Cadillac level, as IUE-CWA Local 201 President Jeff Crosby has noted.

As Dr. David Himmelstein and Steffie Woolhandler wrote recently,

The insurance required under the federal ACA is no better than Massachusetts’ bare-bones plans. And as employers emulate this inadequate coverage, the race to the bottom leaves an increasing number of Americans UNDER-insured. Public workers are just the latest group to see their coverage downsized.

What used to be called “health insurance” is now labeled “Cadillac coverage” – and reserved for those who drive Mercedes.

Himmelstein and Woolhandler remind us that the Democrats’ ACA plan was based on the Massachusetts model passed in 2006 with Gov. Mitt Romeny’s signature, and whose “achievements” are much less than splendid. Bankruptcies caused by catastrophic medical costs, which account for over half of all bankruptcies, are still rising in Massachusetts, they state:

While only 4 percent of the state’s residents remain uninsured, much of the new coverage is so skimpy that serious illness leaves families with crushing medical bills.

For instance, the cheapest (and most commonly purchased) coverage available to a 56-year-old Bostonian through the state’s health insurance exchange costs $5,616. Yet, if you’re sick, the policy doesn’t start paying bills until you’ve paid a $2,000 deductible. And even after that you’re responsible for 20 percent of the next $15,000 in medical expenses.

Insurers try blackmail

By basing itself on the Massachusetts plan which keeps for-profit insurers as the parasitic middlemen at the core of the healthcare system, the ACA sacrificed the potential for comprehensive, high-quality benefits covered from the first dollar.

This potential has been underscored in the fight over retaining ACA’s requirement that 80 percent of premium revenue be used by insurers to provide healthcare and improve quality, freeing up 20 percent for profit, bureaucratic overhead, and sales and promotion.

No less than nine states are seeking waivers from the 80 percent requirement, falling prey to insurers’ blackmail demands. Insurers are threatening to stop selling individual coverage in a number of states unless they can spend, in several cases, just 65 percent on paying for healthcare and quality improvements.

Both the states and the Obama administration are petrified by this coercive technique. The Obama administration’s timid mentality was revealed in this statement by Robert Laszewski, a consultant to the health care industry and a former insurance executive. “The last thing the Obama administration wants is the Des Moines Register writing about 500 people who lost their health insurance in Iowa because of the Obama health plan,” he chortled.

Singe-payer destiny?

The emerging situation is not pretty. Major corporations and right-wing state governments are fighting furiously to shift more costs onto workers and their families. Instead of setting a new, higher standard, ACA effectively serves to reinforce a new lower standard of “acceptable” coverage. Given this, the limitations of the ACA may become very obvious very quickly both to the public and Congress.

There may even be a possibility that that the essential need for maximum-strength single-payer or “Medicare for all” healthcare system—unburdened by for-profit insurers—will become evident much faster than most have imagined. (Sens. Bernie Sanders (I-Vt.) and Rep. Jim McDermott (D-Wash.) introduced  single-payer bills in Congress this week; Vermont has now passed its own single-payer system into law.)

Himmelstein and Woolhandler make the case concisely:

While the ACA can’t live up to its “affordable care” moniker, a single-payer reform could save $400 billion annually on administrative costs, enough to offer every American first-dollar, comprehensive coverage. While U.S. insurers fight tooth and nail against the 20 percent limit on overhead, Canada’s single-payer program runs for 1 percent.

http://inthesetimes.com/working/entry/7298/ge_other_employers_fight_to_set_lower_new_normal_on_healthcare_benefit/

Funding for primary care panel blocked

Partisan fights in Congress stall panel on primary-health-care shortage

By Amy Goldstein
The Washington Post, May 13, 2011

When the government set out to help 32 million more Americans gain health insurance, Congress and the Obama administration acknowledged that steering more people into coverage had a dark underside: If it works, it will aggravate a shortage of family doctors, internists and other kinds of primary care.

So Page 519 of the sprawling 2010 law to overhaul the health-care system creates an influential commission to guide the country in matching the supply of health-care workers with the need. But in the eight months since its members were named, the commission has been unable to start any work.

The group cannot convene, converse or hire staff because $3 million that it needs for its initial year has been blocked by two partisan wars on Capitol Hill — strife over the federal budget and Republicans’ disdain for the health-care changes that Democrats muscled into law 14 months ago.

“We’ve been sort of hamstrung,” said Fitzhugh Mullan, a professor of medicine and health policy at George Washington University who is one of the 15 commission members appointed by the Government Accountability Office. The panel’s only activity so far, Mullan said, was a single conference call during which members were told they could not lobby members of Congress for funds or accept money to operate from foundations or anywhere else.

The National Health Care Workforce Commission is intended as an ongoing brain trust to focus new energy on solving an old problem that will become increasingly severe. The law says the new commission will analyze primary-care shortages and propose innovations for the government — and medical schools — to help produce the doctors and other health workers the nation needs.

Proponents of the workforce commission say they were surprised that Republicans have balked, because there has, in the past, been little ideological schism over the need to bolster the supply of primary care — doctors, nurses, physicians assistants and others.

http://www.washingtonpost.com/national/health/partisan-fights-in-congress-stall-panel-on-primary-health-care-shortage/2011/05/09/AFCKBW2G_story.html

Republicans and Democrats agree with the health policy community that we desperately need to reinforce our primary care infrastructure. The National Health Care Workforce Commission that would propose innovations to help build primary care requires a mere $3 million to establish operations, but the Republicans have blocked this authorization. Do they expect us to simply rely on the private sector to meet this need? How is that working for us so far?