PNHP

Futurist Ian Morrison on being "bronzed" in the exchanges

Futurist Ian Morrison on being "bronzed" in the exchanges

The Four Americas

By Ian Morrison
Hospitals and Health Networks, May 3, 2011

Health insurance exchanges could have a major impact on the health care marketplace.

Here are some things to watch for.

* We are all turning bronze. There is a growing body of evidence — from actuaries, academics, consultants and researchers — that when consumers in the exchange select insurance options, they will pick the bronze plan (a 60 percent actuarial value). By definition, these plans will have high out-of-pocket costs and may not cover as wide a range of benefits as the health reform enthusiasts intended.

Some in the health care delivery business see exchanges as a new source of patients with commercial insurance similar to the benefits that schoolteachers and firefighters enjoy. Not so fast. Not only will those schoolteachers and firefighters get their benefits rolled back as part of the global backlash against public employees, but those of us in the exchanges will be operating with skinny network, high-deductible plans.

* Exchanges could be a non-event or become the exchange that ate Manhattan. Depending on how exchanges are structured at the state level, they could have limited pickup. The proposed insurance exchanges have two huge advantages over some of the failed insurance exchanges across the country, such as California’s PacAdvantage program for small business. First, the proposed exchanges have subsidies. Second, they have enabling rules. However, there is still a huge opportunity for states to make exchanges highly dysfunctional by not regulating the behavior in the nonsubsidized individual and small group market.

What killed PacAdvantage was brokers taking good risks outside the exchange and dumping bad risks into the exchange. Unless state legislation prevents this, it is highly possible that exchanges get selected against and spiral downward. Conversely, if exchanges are up and functioning and acceptable, there could be massive growth over time as employers see the benefit of giving their employees incentives to move to the exchange. This won’t happen initially in 2014, but in a Cadillac tax world and with high-functioning exchanges, there could be massive growth. (And remember, we would all be pretty bronzed.)

http://www.hhnmag.com/hhnmag/HHNDaily/HHNDailyDisplay.dhtml?id=6270005407

Comment:

By Don McCanne, MD

If the stewards of the ACA-mandated state insurance exchanges are diligent, they may be able to avoid problems such as the death spiral of adverse selection. With careful design, they should be able to establish a functioning market of private health plans. What can we expect of this market?

The overwhelming majority of insurance shoppers will be purchasing their plans based on price, whether or not they qualify for subsidies. Since most will be relatively healthy, it will be the price of the insurance plans that will drive their purchasing decisions, rather than the unanticipated but potential out-of-pocket expenses that they would face only if they were unfortunate enough to develop significant medical  problems. For the price discount, most purchasers will take a chance, gambling that they will stay healthy.

What plans in the exchanges will offer the lowest prices? The bronze plans. These plans cover an average of 60 percent of the medical costs and the patient is responsible for the remaining 40 percent. Although many would be eligible for subsidies, a recent Commonwealth Fund analysis (Gruber and Perry) demonstrated that one-fourth of middle-income individuals with medical needs would not be able to afford the out-of-pocket medical costs after meeting other necessary expenditures in their budgets. Thus choosing these plans is definitely a gamble, but one they must take since they cannot afford the higher costs plans – especially the gold and platinum plans (which are not Cadillac plans since about all they do is reduce out-of-pocket spending for relatively standard benefits).

What innovations will insurers use to keep their premiums competitive within the exchanges? Although they will have to provide a basic set of regulated benefits, they will be able to keep premiums priced at the lower end of the market by requiring large deductible and coinsurance payments, and by limiting provider contracting to a narrow network of the cheapest physicians and hospitals. This is what Ian Morrison is referring to when he says, “those of us in the exchanges will be operating with skinny network, high-deductible plans.”

If the stewards do their job well and the exchanges are very successful in achieving massive growth – “the exchanges that ate Manhattan” – then, as Ian Morrison states, “we would all be pretty bronzed.”

So if the exchanges work like they’re designed to, what will we get, at best? Unaffordable deductible and coinsurance payments, with skinny networks which take away our choices of physicians, hospitals, and other health care providers, unless we’re eligible for Medicare by being over 65 or permanently disabled.

Say, did anyone ever think that maybe it would be better to improve Medicare and provide it to everyone? That way we would have our choices of our health care professionals and health facilities, and we wouldn’t have to face unaffordable out-of-pocket costs. This seems like an idea that maybe we should work on.

Senator Leno’s Single Payer Health Care Bill Passes Health Committee

Office of Sen. Mark Leno
Wednesday, May 04, 2011

SACRAMENTO – The Senate Health Committee today approved the California Universal Health Care Act, authored by Senator Mark Leno (D-San Francisco). Senate Bill 810 guarantees all Californians comprehensive, universal health care while containing ballooning health care costs and improving the quality of care and delivery of health services statewide. The legislation passed with a 5-3 vote.

“California is being overrun by out-of-control health care costs, which has a significant impact on the state budget, businesses and families,” said Senator Leno, D-San Francisco. “Our single payer plan not only guarantees universal coverage for all Californians, but also contains health care costs, which is essential to solving our state budget crisis in the long term.”

SB 810 creates a private-public partnership to provide every California resident medical, dental, vision, hospitalization and prescription drug benefits and allows patients to choose their own doctors and hospitals. This single payer, “Medicare for All” type of program works by pooling together the money that government, employers and individuals already spend on health care and putting it to better use by cutting out the for-profit middle man.

“We must continue to fight for healthcare for every Californian,” said DeAnn McEwen, President of the California Nurses Association and a nurse at Long Beach Memorial Medical Center. “Federal reform does not insure that all Californians will receive the care they need. President Obama noted that if states come up with a better plan, they could move forward. Californians deserve the best. Senate Bill 810 will provide every Californian with an excellent standard of care, improve health outcomes, and finally get healthcare costs under control.”

California currently spends $200 billion annually on a fragmented, inefficient health care system that wastes 30% of every dollar on administration. Under Senate Bill 810, that wasteful spending is eliminated. The bill creates no new spending, and in fact, studies show that the state would save $8 billion in the first year under this single-payer health care plan.

“Most doctors support a public-private partnership like Medicare, but with everybody covered, better benefits, and lower costs,” said Dr. Henry L. Abrons, president of Physicians for a National Health Program, California Chapter. “We need to spend our precious resources wisely. Federal reform won’t accomplish these things, but SB 810 will.”

“Health Care for All realizes that the only way to provide better health care for absolutely everyone, for less money than we’re now spending, and control rising costs, is to pass a bill like SB 810 and then make the necessary changes to finance it,” said Greg Brockbank, chair of Health Care for All, California. “We stand ready to do our part in making that happen, and then to help successfully implement it.”

SB 810 is sponsored and supported by a broad coalition of patients, nurses, doctors, teachers and school employees, small businesses, faith community members, retirees, local governments and school districts. These groups represent more than 2 million Californians. The bill is also sponsored by the California Nurses Association, Health Care for All California, California One Care, California School Employees Association, Physicians for a National Health Program-California, Single Payer Now, California Teachers Association, California Federation of Teachers, California Alliance of Retired Americans, Amnesty International, League of Women Voters, California Council of Churches, Progressive Democrats of America, California Consumer Federation, National Organization for Women-California, Vision y Compromiso, Wellstone Democratic Renewal Club, Dolores Huerta Foundation, California Health Professional Student Alliance and Courage Campaign.

http://dist03.casen.govoffice.com/index.asp?Type=B_PR&SEC={F0DFD1A5-1C7B-4F09-9F09-C48A423D1072}&DE={F086DD17-8BCF-4C38-8AA7-F4AA0DA99BB3}

Futurist Ian Morrison on being “bronzed” in the exchanges

The Four Americas

By Ian Morrison
Hospitals and Health Networks, May 3, 2011

Health insurance exchanges could have a major impact on the health care marketplace.

Here are some things to watch for.

* We are all turning bronze. There is a growing body of evidence — from actuaries, academics, consultants and researchers — that when consumers in the exchange select insurance options, they will pick the bronze plan (a 60 percent actuarial value). By definition, these plans will have high out-of-pocket costs and may not cover as wide a range of benefits as the health reform enthusiasts intended.

Some in the health care delivery business see exchanges as a new source of patients with commercial insurance similar to the benefits that schoolteachers and firefighters enjoy. Not so fast. Not only will those schoolteachers and firefighters get their benefits rolled back as part of the global backlash against public employees, but those of us in the exchanges will be operating with skinny network, high-deductible plans.

* Exchanges could be a non-event or become the exchange that ate Manhattan. Depending on how exchanges are structured at the state level, they could have limited pickup. The proposed insurance exchanges have two huge advantages over some of the failed insurance exchanges across the country, such as California’s PacAdvantage program for small business. First, the proposed exchanges have subsidies. Second, they have enabling rules. However, there is still a huge opportunity for states to make exchanges highly dysfunctional by not regulating the behavior in the nonsubsidized individual and small group market.

What killed PacAdvantage was brokers taking good risks outside the exchange and dumping bad risks into the exchange. Unless state legislation prevents this, it is highly possible that exchanges get selected against and spiral downward. Conversely, if exchanges are up and functioning and acceptable, there could be massive growth over time as employers see the benefit of giving their employees incentives to move to the exchange. This won’t happen initially in 2014, but in a Cadillac tax world and with high-functioning exchanges, there could be massive growth. (And remember, we would all be pretty bronzed.)

http://www.hhnmag.com/hhnmag/HHNDaily/HHNDailyDisplay.dhtml?id=6270005407

If the stewards of the ACA-mandated state insurance exchanges are diligent, they may be able to avoid problems such as the death spiral of adverse selection. With careful design, they should be able to establish a functioning market of private health plans. What can we expect of this market?

The overwhelming majority of insurance shoppers will be purchasing their plans based on price, whether or not they qualify for subsidies. Since most will be relatively healthy, it will be the price of the insurance plans that will drive their purchasing decisions, rather than the unanticipated but potential out-of-pocket expenses that they would face only if they were unfortunate enough to develop significant medical  problems. For the price discount, most purchasers will take a chance, gambling that they will stay healthy.

What plans in the exchanges will offer the lowest prices? The bronze plans. These plans cover an average of 60 percent of the medical costs and the patient is responsible for the remaining 40 percent. Although many would be eligible for subsidies, a recent Commonwealth Fund analysis (Gruber and Perry) demonstrated that one-fourth of middle-income individuals with medical needs would not be able to afford the out-of-pocket medical costs after meeting other necessary expenditures in their budgets. Thus choosing these plans is definitely a gamble, but one they must take since they cannot afford the higher costs plans – especially the gold and platinum plans (which are not Cadillac plans since about all they do is reduce out-of-pocket spending for relatively standard benefits).

What innovations will insurers use to keep their premiums competitive within the exchanges? Although they will have to provide a basic set of regulated benefits, they will be able to keep premiums priced at the lower end of the market by requiring large deductible and coinsurance payments, and by limiting provider contracting to a narrow network of the cheapest physicians and hospitals. This is what Ian Morrison is referring to when he says, “those of us in the exchanges will be operating with skinny network, high-deductible plans.”

If the stewards do their job well and the exchanges are very successful in achieving massive growth – “the exchanges that ate Manhattan” – then, as Ian Morrison states, “we would all be pretty bronzed.”

So if the exchanges work like they’re designed to, what will we get, at best? Unaffordable deductible and coinsurance payments, with skinny networks which take away our choices of physicians, hospitals, and other health care providers, unless we’re eligible for Medicare by being over 65 or permanently disabled.

Say, did anyone ever think that maybe it would be better to improve Medicare and provide it to everyone? That way we would have our choices of our health care professionals and health facilities, and we wouldn’t have to face unaffordable out-of-pocket costs. This seems like an idea that maybe we should work on.

Health Reform: Necessary, but will the Affordable Care Act be sufficient?

By Johnathon S. Ross, M.D., M.P.H.
Communique: Academy of Medicine of Toledo and Lucas County, April-May 2011
 
Many physicians care about the injustice of a health care system that leaves 50 million of our patients, friends and family uninsured, but it is health care spending that threatens to destabilize the entire U.S. economy. We need to cover the uninsured and control costs. There are 50 million uninsured Americans despite spending $2.6 trillion annually. This is about one-sixth of the entire country uninsured and spending is at 17 percent of our GDP.
 
The number of uninsured has grown by about a million each year for the past 20 years. Ohio has 1.48 million uninsured despite spending over $80 billion annually. Contrary to popular thinking, the uninsured are not the chronically unemployed or illegal immigrants. Almost 80 percent of the uninsured are working people and their children.
 
One of the reasons many of the working class uninsured cannot afford to purchase insurance is that their incomes have not kept up with medical cost inflation. In fact only the wealthiest 5 percent have come even close to keeping up. Medical inflation continues 3 percent to 5 percent above the overall inflation rate.
 
Over the past 30 years, working families would have needed above 100 percent real growth in income adjusted for underlying inflation in order to keep up with rising health care costs. Most have seen their incomes rise only a few percent or less.
 
We already have what it takes to take care of everybody. The fixed overhead costs (buildings, nurses, doctors and equipment) of the health care system result in a large and expensive infrastructure that we all need in case we get sick.
 
The infrastructure is maintained by patient use and payments. Since only a small number of individuals are actually receiving care at any time (20 percent of patients generate 80 percent of costs), these payments for fixed costs must be shared by everyone. If these fixed costs are not met, the infrastructure will shrink, degrade or even disappear.
 
These fixed costs make up over 60 percent of spending and must be in place before a single sick patient can receive comprehensive care. We all must contribute if we want the care to be there when we need it.
 
Public financing (taxes) already accounts for 60 percent of total spending (Medicare, Medicare, VA, public employees and the tax deductibility of health insurance). Business and personal out-of-pocket payments cover the rest. In the U.S., public spending alone exceeds the total per person health care costs of eight European countries that cover all their citizens with better health outcomes. Businesses only pay about 20 percent of the total cost, yet they seem to exert an undue amount of influence over U.S. health policy decisions. That’s because about 60 percent of Americans receive their insurance coverage as a benefit of employment. These working people and their kids are the healthiest in our society and cost less to cover than the elderly, disabled and poor who have been left to public programs to cover.
 
You will hear conservative pundits complaining about health reform. They characterize it as a giant government takeover that “will ruin best health care system in the world.” (John Boehner actually said this recently!) Do we have the best health care system in the world?
 
According to Organization for Economic Cooperation and Development, the best international comparison data show that Americans live shorter lives and lose more healthy years of life to treatable illness than most of our economic competitors. Our infant and maternal mortality exceeds theirs. We are not more expensive because we are older. We do not smoke or drink more, use more doctor visits or hospital days or overstaff with nurses. We are in the middle of the pack regarding use of technology, joint replacements, transplants and on medical research articles published based on relative population size. We do feel we have better access to technology, although physicians in several other countries feel they have about the same level of access.
 
The one place we clearly lead is in the cost of our system where we spend almost twice as much as our economic competitors per capita. These excess health care costs are built into every American product and reduce our economic competitiveness. Our costs are rising much more sharply, although all the western democracies are struggling to control health care costs. Although our outcomes may be better for a few specific types of illnesses (breast cancer for example) by almost every general measure our outcomes are worse and our costs are twice as high.
 
This is why health reform has been under serious ongoing discussion since the debate over Medicare which resulted in a universal national health insurance program, but only for those over 65 and the disabled. The passage of the Patient Protection and Affordable Care Act (ACA) is a continuation of that debate and has left us divided and confused. What has this law brought about so far and what does it hold for us in the future?
 
One year after the passage of the ACA several provisions have already gone into effect. The number of Ohioans affected is in parentheses:
 
· Young Ohioans can keep or obtain insurance coverage on their family plans until age 26 (35,000).
 
· Insurance companies are prohibited from denying coverage to children with pre-existing conditions. (Many insurers dropped “child-only” coverage in response.) (unknown)
 
· High Risk Pools funded by the ACA now subsidize the uninsurable (1,100).
 
· Insurance companies may no longer impose lifetime dollar caps on enrollees. (unknown)
 
· The Medicare Prescription Drug benefit “doughnut hole” is being closed (110,000).
 
· Medicare beneficiaries can receive wellness checks and other preventive care without a co-pay or deductible (150,000). All private insurers will need to completely cover preventive care also.
 
· An estimated 127,800 small businesses in Ohio are eligible for the ACA’s tax credit to help purchase health insurance for employees and of those, 38,900 are estimated to be eligible for the full credit. (unknown)
 
· Grants, matching funds and other resources now available will help transform the way Medicaid funds long term care by shifting away from institutional care toward home and community-based care. (unknown)
 
· Employers can obtain re-insurance to help subsidize coverage to early retirees 55+. This will be a major financial benefit to large employers and they are already taking advantage of it.
 
· Insurers will have to spend 80-85 percent of premiums on care. Primary care physicians will get increased payment from Medicare and Medicaid.
 
By 2014:
 
· Everyone will need to buy insurance or pay a fine. Those below 133 percent of poverty will be enrolled in Medicaid. Those from 133 percent of poverty to 400 percent of poverty will receive subsidies to purchase private insurance from among a range of insurers through state based insurance exchanges with standard benefits packages. Those who do not purchase insurance will be fined except for specific hardship cases. Cost sharing is limited to no more than 6 percent to 30 percent of premiums for those from 133 percent to 400 percent of poverty. There are no subsidies for those above 400 percent of poverty but they will be allowed to purchase insurance through the exchanges.
 
· Employers of more than 50 individuals must provide insurance or pay into a fund that will help subsidize coverage for the uninsured.
 
· The Congressional Budget Office estimates about 32 million of the 50 million uninsured will be covered, about half by exp
anded Medicaid and half by private coverage in the exchanges.
 
· Revenues needed for these programs are about $100 billion yearly (about a 4 percent increase in current annual spending). Physicians usually get about 20 percent of spending on health care so the ACA will likely increase physician incomes by $20 billion.
 
· Revenue is raised from taxing insurers and reducing excess payments to their Medicare Advantage plans, by taxing pharmaceutical companies and tanning salons, and by reducing the deductibility of some medical expenses and high cost health plan premiums. There are also assumptions of savings in Medicare and Medicaid based on changes in payment approaches. (See below)
 
· Five year grants for state based malpractice reforms are part of the ACA. Texas passed strong limits on malpractice awards seven years ago. This lowered malpractice premiums by over 50 percent, but has had little effect on health care cost growth.
 
There are many other good public health and quality improvement ideas in the ACA. Sadly, there are fewer that are likely to control costs. We already have evidence from the one state with ACA like reform-Massachusetts. They have reduced the number of uninsured to only 4 percent. This is less than one-fourth the national rate. However, costs continue to rise sharply despite reform.
 
It appears that you can cover most Americans with a mandate to buy private insurance, but if you leave the for-profit medical industrial complex untouched, costs will continue to rise unabated. Although some pundits claim that the health information technology, bundled payments and accountable care organizations promoted by the ACA will help to control costs, there is little supportive data from trials of these approaches under Medicare or to suggest that information technology will lower costs, though it might improve the quality of care.
 
If the ACA is unlikely to be highly effective in coverage and cost control, what are the alternatives? All the other advanced countries have covered everyone using one of three approaches.
 
A national health service (e.g. Great Britain, Sweden) is true socialized medicine where the doctors, nurses and other providers are public employees and the hospitals are publicly owned. A national health insurance with many not-for-profit insurers with a single negotiated fee schedule and very tight public insurance regulation (Germany, Netherlands, France) and lastly, single-payer national health insurance (Canada, Taiwan, Australia and our own version for seniors, Medicare). These are the systems that have been proven to provide universal coverage and cost half per capita.
 
It is worth noting that our own example of a single payer, Medicare, has actually had better cost control than private insurance over the past 40 years and has been more innovative (e.g. DRG’s, the RVU fee schedule, and public reporting of outcomes.)
 
Medicare is our best example of a successful American national health insurance system. It is funded by taxes that are placed in a trust fund (an efficient way to collect the needed revenue) and involves everyone in paying their fair share. A single insurer is hired, by competitive bid, to just process the Medicare bills according to a single fee schedule. This simplicity keeps insurance overhead for Medicare at less than 3 percent of premiums.
 
Private insurers will waste more than five times as much on administration and profits even with the restrictions of the ACA. Under traditional Medicare, doctors practice privately and are not employees of government. Hospitals are privately managed by their community based boards. Medicare is not socialized medicine. It is social insurance just like Social Security.
 
When we created Medicare in 1965, Canada created a Medicare system for Canadians of all ages. They even call it Medicare just as we do. Prior to 1965, Canada had a private insurance system just like ours. Their ability to control costs and provide care to all is proof that such a system can be changed and could work for all of us especially given our much more generous funding which is about twice as much per capita.
 
Taiwan also had a system like ours, but with many more uninsured (40 percent). Just over a decade ago, after study, they rejected the private insurance model and created a single-payer Medicare system for all Taiwan’s citizens. They made the transition in just a couple years and covered everyone with no significant increase in spending. The Canadians covered everyone, the Taiwanese covered everyone, and we did it for seniors with social insurance that provides better administrative value, better cost control and better outcomes.
 
The ACA continues under serious challenge politically. The individual mandate is possibly unconstitutional. Although there are many good aspects to the ACA as mentioned above, evidence suggests that the ACA will still leave almost 20 million Americans uninsured and will not control overall costs very effectively.
 
On the other hand, there is good evidence that an improved and expanded Medicare would cover everyone for no more than we spend now given the large administrative savings that would result from the simplicity of this type of reform. It would improve outcomes and control costs as similar systems have in other developed nations.
 
Medicare is constitutional. Many of the financial interests that are profiting form the current system will fight against the increased public accountability the ACA or an improved an expanded Medicare for all would bring to the health care system. Political challenges will remain either way.
 
An improved and expanded Medicare for all is likely to save more money, save more lives while allowing us to practice without the hassles that are the hallmark of the private health insurance system. Physicians must choose to show leadership on this tough political problem. We need to support covering everyone and cost control. Doing nothing is not an option.
 
http://www.toledomedicine.org/April_May_1_up%5B1%5D.pdf

Keeping Health Care Afloat: The United States vs. Canada

By Uwe E. Reinhardt
The Milken Institute Review, 2007

Many complain that a single payer system will inevitably lead to rationing.  Reinhardt explains how health care is rationed in the U.S today and why rationing by ability to pay is the most intolerable form of rationing.  “There is solid research showing the price system rations uninsured Americans out of the timely, early-stage primary and secondary care that might have avoided their serious or fatal illnesses.”

Read “Keeping Health Care Afloat: The United States vs. Canada”

Eric Cantor: "We're not for everyone having the same outcome guaranteed."

Cantor: Private healthcare rationing better than government's

By Julian Pecquet
The Hill, May 3, 2011

House Majority Leader Eric Cantor (R-Va.) said Tuesday that private healthcare plans ration care for profit but that consumers should be free to buy whatever coverage they can afford rather than depend on government rationing.

In remarks to the College of American Pathologists, Cantor warned that Democrats’ healthcare reform law mandates benefits that are too generous and will bankrupt the country as the government ends up having to offer ever increasing subsidies. That can only lead to government rationing, he said.

“That doesn’t mean those kinds of decisions aren’t being made now by the private sector,” Cantor added, “because they are.”

Cantor appeared to go further than Republicans have in the past by acknowledging that not all patients are certain to get optimal healthcare under a system of private insurance.

“I think that the fundamental nature of our system of third-party payer is the problem,” he said. Patients, he added, too often are left with “no decision about what they want and what they can afford.”

Later, Cantor said Republicans want a safety net for people who can’t afford care but that “we’re not for everyone having the same outcome guaranteed.”

http://thehill.com/blogs/healthwatch/health-reform-implementation/158979-cantor-private-healthcare-rationing-better-than-governments

Comment:

By Don McCanne, MD

It is somewhat refreshing to hear such a frank discussion of rationing by House Majority Leader Eric Cantor. He does not pretend that only government programs might lead to rationing, but concedes that the private sector already makes rationing decisions.

Cantor not only acknowledges that not all patients are certain to get optimal healthcare under a system of private insurance, but Republicans are “not for everyone having the same outcome guaranteed.”

Democrats appear to be in agreement. Under the Affordable Care Act, many will be left without coverage, and many more of those who have coverage through private health plans will not be able to afford the out-of-pocket expenses required for accessing health care, in spite of the subsidies. These financial barriers to access result in not everyone having the same outcome guaranteed, but the Democrats remain silent when confronted with this unacceptable deficiency in their version of health care reform.

There is already enough money in the health care system to ensure that everyone receives all essential health care services in a timely manner, with the same high quality outcomes guaranteed for all. The government rationing that Eric Cantor claims is inevitable occurs only if politicians are unwilling to budget through a single government program (single payer) the amount comparable to that we are already spending, publicly and privately.

Now if only the Democrats would admit that they have made a mistake in choosing a model of rationing that does not guarantee the same quality outcome for everyone, then maybe we could have a discussion of a model that would work. If so, then we could have the frank debate that Eric Cantor has initiated. Cantor says, “we’re not for everyone having the same outcome guaranteed,” but are the Democrats? Let’s ask them.

Eric Cantor: “We’re not for everyone having the same outcome guaranteed.”

Cantor: Private healthcare rationing better than government’s

By Julian Pecquet
The Hill, May 3, 2011

House Majority Leader Eric Cantor (R-Va.) said Tuesday that private healthcare plans ration care for profit but that consumers should be free to buy whatever coverage they can afford rather than depend on government rationing.

In remarks to the College of American Pathologists, Cantor warned that Democrats’ healthcare reform law mandates benefits that are too generous and will bankrupt the country as the government ends up having to offer ever increasing subsidies. That can only lead to government rationing, he said.

“That doesn’t mean those kinds of decisions aren’t being made now by the private sector,” Cantor added, “because they are.”

Cantor appeared to go further than Republicans have in the past by acknowledging that not all patients are certain to get optimal healthcare under a system of private insurance.

“I think that the fundamental nature of our system of third-party payer is the problem,” he said. Patients, he added, too often are left with “no decision about what they want and what they can afford.”

Later, Cantor said Republicans want a safety net for people who can’t afford care but that “we’re not for everyone having the same outcome guaranteed.”

http://thehill.com/blogs/healthwatch/health-reform-implementation/158979-cantor-private-healthcare-rationing-better-than-governments

It is somewhat refreshing to hear such a frank discussion of rationing by House Majority Leader Eric Cantor. He does not pretend that only government programs might lead to rationing, but concedes that the private sector already makes rationing decisions.

Cantor not only acknowledges that not all patients are certain to get optimal healthcare under a system of private insurance, but Republicans are “not for everyone having the same outcome guaranteed.”

Democrats appear to be in agreement. Under the Affordable Care Act, many will be left without coverage, and many more of those who have coverage through private health plans will not be able to afford the out-of-pocket expenses required for accessing health care, in spite of the subsidies. These financial barriers to access result in not everyone having the same outcome guaranteed, but the Democrats remain silent when confronted with this unacceptable deficiency in their version of health care reform.

There is already enough money in the health care system to ensure that everyone receives all essential health care services in a timely manner, with the same high quality outcomes guaranteed for all. The government rationing that Eric Cantor claims is inevitable occurs only if politicians are unwilling to budget through a single government program (single payer) the amount comparable to that we are already spending, publicly and privately.

Now if only the Democrats would admit that they have made a mistake in choosing a model of rationing that does not guarantee the same quality outcome for everyone, then maybe we could have a discussion of a model that would work. If so, then we could have the frank debate that Eric Cantor has initiated. Cantor says, “we’re not for everyone having the same outcome guaranteed,” but are the Democrats? Let’s ask them.

Update of the data on health care spending

Health Care Spending in the United States and Selected OECD Countries

Kaiser Family Foundation
April 2011

Compared to other developed nations, the U.S. spends more on health care per capita and devotes a greater share of its GDP to health. Since 1980, the U.S. also has had among the highest average annual growth rates in per capita spending on health care. Despite this relatively high level of spending, the U.S. does not appear to provide substantially greater health resources to its citizens, or achieve substantially better health benchmarks, compared to other developed countries. Faced with expanding public deficits, and growing health care costs, American policy makers may elect to examine the tools employed by other countries to rein in costs. The growing difference between America’s spending and other developed countries may encourage an examination of what people in the U.S. are getting for their healthcare dollar.

http://www.kff.org/insurance/snapshot/OECD042111.cfm

Comment: 

By Don McCanne, MD

This update of health care spending in the United States, as compared with other nations, provides useful graphs that define the magnitude of the problem which is only growing worse. Since the cost containment measures of the Patient Protection and Affordable Care Act will have very little impact on slowing the cost growth, we should consider the advice offered in this report: American policy makers should “examine the tools employed by other countries to rein in costs.” We need to bring single payer to the table – now!

Update of the data on health care spending

Health Care Spending in the United States and Selected OECD Countries

Kaiser Family Foundation
April 2011

Compared to other developed nations, the U.S. spends more on health care per capita and devotes a greater share of its GDP to health. Since 1980, the U.S. also has had among the highest average annual growth rates in per capita spending on health care. Despite this relatively high level of spending, the U.S. does not appear to provide substantially greater health resources to its citizens, or achieve substantially better health benchmarks, compared to other developed countries. Faced with expanding public deficits, and growing health care costs, American policy makers may elect to examine the tools employed by other countries to rein in costs. The growing difference between America’s spending and other developed countries may encourage an examination of what people in the U.S. are getting for their healthcare dollar.

http://www.kff.org/insurance/snapshot/OECD042111.cfm

This update of health care spending in the United States, as compared with other nations, provides useful graphs that define the magnitude of the problem which is only growing worse. Since the cost containment measures of the Patient Protection and Affordable Care Act will have very little impact on slowing the cost growth, we should consider the advice offered in this report: American policy makers should “examine the tools employed by other countries to rein in costs.” We need to bring single payer to the table – now!

Vt. lawmakers resolve immigrant health care issue

By Dave Gram
Forbes, May 3, 2011

MONTPELIER, Vt. (AP) — Vermont Senate negotiators dropped an amendment to bar illegal immigrants from coverage under a new state health care program, delivering a victory Monday evening to human rights activists who had rallied repeatedly at the Statehouse to demand the change.

Instead, the three senators serving on a House-Senate conference committee suggested studying the issues surrounding providing health care to an estimated 1,500 to 2,500 undocumented farmworkers in the state, as well as others in Vermont illegally. Their House counterparts readily agreed to the proposal.

The fight over coverage for illegal immigrants was a late-session storm in otherwise smooth sailing for the centerpiece of Gov. Peter Shumlin’s legislative agenda: a publicly financed, universal health care system that had broad support from Shumlin’s fellow Democrats who control both houses of the General Assembly.

After the Senate last week adopted the amendment proposed by Sens. Randy Brock, R-Franklin, and Richard Sears, D-Bennington, activists with the Health Care is a Human Right Campaign of the Vermont Workers’ Center, who had been providing strong grass-roots support for the health reform measure, turned on the senators.

Brock continued to defend his amendment Monday night, arguing that it is in keeping with federal law, and that if Vermont wants the federal permissions it needs to pursue its envisioned health system reform, it can’t flout federal immigration law.

“It’s clear we need a federal immigration policy that makes sense, and we need a guest worker program,” Brock said. “But it’s also clear that Vermont cannot and should not provide insurance coverage to people who are not here lawfully.”

Brock is not on the conference committee, and the senators who are showed their willingness to jettison his and Sears’ amendment under pressure from the activists.

Sen. Claire Ayer, chairwoman of the Senate Health and Welfare Committee and the leader of the Senate conferees, read from proposed legislative findings that pointed out apparent contradictions in federal law:

“Federal law requires certain health care providers to provide emergency treatment to all individuals, regardless of immigration status. Federal law prohibits coverage of undocumented immigrants through Medicaid and through the Exchange,” a new health insurance marketplace that the Vermont bill calls for setting up, in keeping with the federal health care law passed last year, the proposed findings said.

The Senate proposal called for asking the Green Mountain Care Board, which already is to conduct several other studies to get the state ready for universal health care, to add the immigration issue to its list.

House conferees quickly agreed.

“The human rights perspective certainly is a worthy one,” Rep. Michael Fisher, D-Lincoln, vice chairman of the House Health Care Committee and a member of the conference committee, said in an interview shortly after Monday evening’s session. “There’s also financial issues that warrant our attention, and legal ones.”

http://www.forbes.com/feeds/ap/2011/05/03/business-us-vt-health-care-immigrants_8446801.html

Previously:

Activists decry exclusion of undocumented workers from Vermont’s H.202

By Anne Galloway
Vtdigger.org, May 2, 2011

An undocumented Mexican migrant worker named Javier wouldn’t give his full name or say what county he lives in for fear of deportation. In spite of his apprehensions, however, he stood in front of the Statehouse on Sunday and told a crowd of May Day activists that the health care reform bill they had worked hard to support included a provision that discriminates against undocumented workers. Javier’s remarks were translated by an interpreter.

“This amendment appears to be a discriminatory act to exclude us from the health care proposal,” Javier told the crowd.

Javier, who has farmer’s lung, said he would not be able to receive medical attention if H.202 passes because he would not be able to afford to pay for his care out of pocket. Doctors have suggested that he undergo testing because they suspect he has fibrosis. Javier said the expense makes further diagnosis impossible.

The Vermont Farmworker Solidarity Project and the Vermont Workers Center has organized a lobby day today to pressure lawmakers to reverse the amendment, which they say runs counter to the fundamental principles of health care for all. They are also holding a press conference on the Statehouse steps to make their case to reporters at noon on Monday.

About 1,500 to 2,000 undocumented dairy workers from Mexico are employed by Vermont farmers and they are credited with helping to keep the dairy industry solvent at a time when few Vermonters are willing to work on farms.

Universal health care means universal, David Karindler, an organizer with the center, said.

“This is the first time such hateful language has been put in legislation,” Karindler said. “We’re all about inclusion in this state. This is the first time exclusion has become part of a bill. This is about undocumented people flocking to the state. Why would they flock to a place with no housing and no jobs?”

The Senate amendment to H.202, the universal health care bill, limits access to the state’s insurance exchange, which goes into effect in 2013, and Green Mountain Care, the single-payer system which could be implemented as early as 2014, to Vermont residents. Under the provision, individuals in the exchange are “reasonably expected to be during the time of enrollment, a citizen or national of the United States or a lawfully present immigrant in the United States as defined by federal law.”

The amendment is based on federal requirements under the Affordable Care Act, which restricts access to the state’s health care exchanges to legal residents of the United States. The Brock-Sears amendment would make it illegal for the state to provide federal funding for care through the exchanges. As it stands now, Medicaid money cannot be used to provide health care for undocumented residents. Legislative lawyers are re-evaluating the legal repercussions of the language in the amendment, according to Senate President Pro Tem John Campbell, D-Windsor.

“I doubt people are going to be moving up here,” Campbell said. Vermont already has more generous Medicaid benefits than those offered by other states and that fact hasn’t led to an influx of people to moving here, he said.

Senate Democrats voted overwhelmingly for the amendment in a 22-8 vote after Sen. Claire Ayer announced that the Senate Health and Welfare Committee had reviewed the amendment and took no position on it. Ayer later voted for the amendment, along with Sen. Tim Ashe, P/D-Burlington, and because they were called on first to vote (the roll call is given in alphabetical order), one observer speculated that this signaled a green light to other Democrats in the chamber. Campbell also voted yes.

James Haslam posted a statement about the vote on the left-leaning blog Green Mountain Daily last week that sparked a fierce debate in which the word “racist” emerged.

Campbell said there was some confusion in the Senate about the amendment. For that reason, he asked Shumlin administration lawyers to review the language and they gave senators the go-ahead.

“It came down a lot of things happening last week,” Campbell said. “This was not something on anyone’s radar until we saw the amendment with the assurance of certain individuals. You put faith and trust in that. If it’s determined to be a mistake, then as far as I’m concerned I’ll take the heat on that go ahead and cha
nge it. I don’t think Dick Sears or Randy Brock are racists or trying to be Arizona-like in their development of the law.”

Campbell described the provision as belt-and-suspenders legislation – essentially a restatement of the federal law.

Activists question why the amendment is necessary if it’s part of the federal law.

Karindler said Sen. Randy Brock, R-Grand Isle-Franklin, went out of his way to redefine what a resident was.

“It was strategic in its divisiveness,” Karindler said. “To suddenly frame things around undocumented workers seemed calculated.”

Peg Franzen, president of the Vermont Workers Center, said she thought the Senate debate on the amendment got confusing.

“We’re hoping people understand what it actually means,” Franzen said. “It actually refers to Green Mountain Care, which would not be set up until 2014 or 2017.”

Freshman Sen. Philip Baruth, D-Chittenden, who voted against the amendment, said it’s unfortunate that the attention is focused on the amendment when Senate Democrats evinced, “hard core serious unity” around support for H.202.

“I’m discouraged that this one stray amendment is now the story as though it’s indicating fractures in Democratic lines,” Baruth said. “It’s a shame. Instead of a victory lap we’re now in a simulated crisis. I don’t think it’s a crisis. It’s a bump and we will fix it. I hope people who voted for this will get a chance to vote for (the amendment) without it. There are people who did yeoman’s work on this bill who are being unfairly demonized in some quarters. It’s a shame all around that a victory lap morphed into something far less positive.”

Rep. Mark Larson, D-Burlington, and chair of the House Health Care Committee, said lawmakers will likely re-examine the amendment as part of a larger review of the legislation during the conference committees, which take place on Monday starting at 10 a.m., 1 p.m. and 4 p.m.

Larson is also dismayed by the turn of events.

“My focus is on trying to create a health care system that works for our state and I don’t want to get into a focus on whether my senate colleagues are racist or not,” Larson said. “I appreciate why people are upset about the amendment and the significance the issue has in terms of whether all people will be covered by Green Mountain Care. I also understand that national immigration policy isn’t very helpful at this point.”

In the past, Vermont used state dollars to cover health care costs for undocumented farm workers, according to Larson. Under federal rules, Medicaid money can’t be used. That policy would carry through under Green Mountain Care, Larson said, because part of the funding for the single-payer system would come from Medicaid. The state would have to come up with an alternative funding source. Currently, farmers, federal health centers and volunteer groups help workers with care, though in some cases health care providers end up shifting the cost to other patients.

http://vtdigger.org/2011/05/02/undocumented-workers-excluded-from-h-202/

Doctors order: Fix health care

After 22 years, someone might be listening

By Dave Gram
Greenfield (Ind.) Reporter, May 1, 2011

MONTPELIER, Vt. (AP) — Even now, Dr. Deb Richter is haunted by images of some of the patients she saw at inner-city clinics where she worked in Buffalo, N.Y., during the 1980s.

One young man without health insurance didn’t get the early intervention he needed for diabetes. He went blind, got an infection and died at 21. His sister, who also had lived with juvenile diabetes, delivered a baby three months premature. The baby died. Two years later, the 25-year-old woman suffered a heart attack and died during coronary bypass surgery.

“I had patients who were dying at young ages of preventable diseases,” Richter said.

One common symptom: Lack of health insurance.

The experiences prompted Richter, 55, to become an activist. She joined Physicians for a National Health Program. After moving with her family to Vermont in 1999, she continued to pursue her goal of a publicly financed universal health care system.

Richter watched last week as the Vermont Senate voted 21-9 to pass a bill setting the state on a path toward the universal, unified health care system that, she and other backers say, will take administrative costs and insurance company profits out of health care, cover all Vermonters — including the 45,000 now without health insurance — and save the state money.

“This is a step in the right direction — finally,” Richter said after the Senate vote on legislation previously passed by the House. “This is the first time a state is actually establishing a true health care system, where everyone will be included. It’s going to have a budget. We’re going to have uniform payments, which will help reduce administrative costs.”

Richter came on the Vermont scene not long after an effort to bring about universal health care in the 1990s fizzled, and she quickly began trying to make political contacts.

She found it a lot easier in a state of 620,000 — she met fellow physician Gov. Howard Dean at a chicken dinner in Barre — than in New York, with its population of nearly 20 million, where she couldn’t get a meeting with her state representative.

She traveled around Vermont, giving more than 400 talks to Rotary Clubs, Chambers of Commerce and other groups.

She offered dramatic Statehouse testimony when she and a friend unfolded a list of the addresses of insurance companies and government insurance programs to which her five-doctor medical practice in Cambridge had to send bills.

The list was 190 pages long.

Even some of those who voted against the health care bill that passed last week credit Richter for her persistence.

“She began to advocate for a single-payer system soon after the last effort collapsed (in the 1990s), and oftentimes was a lone voice in the wilderness,” said Sen. Vincent Illuzzi, R-Essex-Orleans.

Those who share Richter’s support for a single-payer system sing her praises.

“The fact that we are as close as we are to passing a single-payer health care bill in Vermont is a tribute to a lot of grassroots work, but Deb Richter is the backbone of that work,” Gov. Peter Shumlin said. “She’s a doctor who practices every day, sees what’s wrong with the system and wants to right it. … She’s tenacious. She’s smart. She’s tough.”

The bill passed by the House and Senate would set up a new clearinghouse for health insurance policies in Vermont called an “exchange,” meeting a requirement that states establish such entities laid out in the federal health reform law passed last year.

It also would set up a new Green Mountain Care Board to set parameters for what health benefits would be offered. The administration would be responsible for coming up with a way to pay for the new system by January of 2013. A legislative consultant recommended a new payroll tax shared by workers and employers.

Not everyone agrees the bill goes far enough. Physicians for a National Health Program, the group Richter joined 22 years ago, said the bill stops well short of its goal of single-payer health care because it would still allow multiple insurers to operate in the state.

“The Vermont plan promises a public program open to all residents of the state in 2017, but even then it would allow a continuing role for private insurance,” the group said in a statement. “This would negate many of the administrative savings that could be attained by a true single-payer program, and opens the way for the continuation of multi-tiered care.”

Richter, though, says the bill puts Vermont on a path to real progress. “They want to get to the top of the mountain in one step. I’m willing to take smaller steps. … We just disagree.”

Richter said she has learned an important lesson during her years of advocacy. She began by seeing health care as a moral issue, but came later to believe that the way to get people to change their minds about it was to get to them through their wallets, rather than their hearts.

James Haslam, coordinator of the Health Care Is A Human Right campaign at the Vermont Workers’ Center, called Richter “awesome.” He said the work of Richter and her group Vermont Health Care for All and that of the Workers’ Center were complementary.

Richter’s strength is “particularly bringing voice on this issue to providers, to other doctors and also to the business community. She’s incredibly gifted at reaching them and going to where they’re at. We’ve been more focused on ordinary Vermonters and working-class folks,” Haslam said.

Richter said she strives for a practical approach that will appeal to all audiences. The health care system is like the fire department, she says — something people don’t want to use, but want in place, just in case.

Most people’s first impulse is to say, “You don’t want to pay for Joe,” and his hospitalization, Richter said. “But Joe’s in the bed you’re going to be in tomorrow. That’s why we have to have health care as a public good.”

http://www.greenfieldreporter.com/view/story/f5a45f862d644e4e8749aebde9ca954f/VT–Health-Care-Crusader/

Canadian health care misstated

Dr. Francis Pasley
Letters, Burlington Free Press, May 2, 2011

I am a medical doctor, semi-retired living in Vermont and having a limited practice. Prior to moving to Vermont two and a half years ago I practiced full time, dividing my practice between the Detroit area in Michigan and Windsor, Ontario, an hour drive from Detroit. Thus I have a substantial personal knowledge of medical practice in the USA and Canada.

I have been distressed to hear opinions by Vermont medical professionals and local conservatives about the poor care available in Canada, especially long waiting times for care, and the negative feelings of physicians who have moved here from Canada about the experiences they have had practicing medicine in Canada, suggesting no one would stay there by choice.

I moved to Vermont for family reasons and not to leave practice in Ontario, Canada. Indeed if I were younger I would far rather return to practice in Canada. Caring for patients without having to worry about their ability to afford medical care far outweighed any negatives. I knew doctors who chose to practice in Canada rather than the United States for the same reason. Some who trained in the U.S. and elected to locate in Canada.

In my opinion the waiting list issue is manufactured by people who wish to discredit a system that cares well for everyone with some minor inconveniences rather than one that denies care to millions while admittedly providing exceptional care to those well able to afford it. For those with urgent needs and serious medical problems, in my experience the care in Canada is equally exceptional and prompt.

The issues relating to medical care in every country are enormous and to raise concerns about waiting or the personal preferences of a few physicians trivializes it. We must rather decide what sort of society we wish to live in, what level of support we owe to all in our society, to whom we choose to deny adequate nutrition or healing efforts so that the privileged will be denied nothing or whether we choose to provide basic adequate sustenance to all. Hopefully we will choose the latter and then face the difficult task of defining what represents basic adequate sustenance.

Dr. Francis Pasley of Williston is a member of Physicians for a National Health Program.

http://www.burlingtonfreepress.com/article/20110501/OPINION02/105010333/My-Turn-Canadian-health-care-misstated