Vermont health bill mislabeled 'single payer': doctors group
Physicians for a National Health Program says draft legislation gives wide berth to private insurers, falls far short of single-payer reform
FOR IMMEDIATE RELEASE
April 7, 2011
Contact:
Garrett Adams, M.D., president PNHP
David Himmelstein, M.D., co-founder PNHP
Andrew Coates, M.D., board member PNHP
Mark Almberg, communications director, (312) 782-6006, mark@pnhp.org
The following statement was released today by the national board of Physicians for a National Health Program.
Health reform legislation initiated by Vermont Governor Peter Shumlin was recently passed by that state’s House of Representatives and awaits action in the Senate.
Many journalists and commentators have portrayed this bill as fully embracing the single-payer approach to reform. We write to clarify the views of Physicians for a National Health Program on the Vermont legislation.
We appreciate the enthusiasm for progressive health reform shown by Gov. Shumlin and the many dedicated single-payer supporters in Vermont. However, it is important to note that the bill passed by the Vermont House falls well short of the single-payer reform needed to resolve the health care crisis in that state and the nation. Indeed, as the bill moved through the House the term “single payer” was entirely removed, and restrictions on the role of private insurers were loosened.
In its present form, the legislation lays out in considerable detail a structure to implement Vermont’s version of the federal reform passed in March of 2010, which would expand coverage by private insurers and Medicaid. However, it offers only a vague outline of the additional reform promised by the governor and Legislature at such time when states will be allowed to experiment with alternatives to the federal program in 2017 (or 2014, if the effort to move up the date succeeds).
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. 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.
Within the public program, the plan would continue to lump together payments for operating and capital costs, allowing hospitals and the newly established Accountable Care Organizations (ACOs) to use funds not spent on care for institutional expansion. Meanwhile, those with operating losses would shrink or close even if they were meeting vital health needs. This would perpetuate incentives for hospitals and ACOs to cherry-pick profitable patients and services, and hobble the health planning needed to assure rational investments in new facilities and high-technology care.
Under the legislation, many patients would continue to face co-payments that obstruct access to care, and the bill makes no mention of expanding coverage of long-term care. The legislation fails to proscribe the participation of for-profit hospitals and other providers (e.g. ACOs and dialysis clinics), which research has shown deliver inferior care at inflated prices.
Finally, the bill offers no concrete funding plan or structure for the public program that it promises.
We applaud the sentiments expressed by the governor and legislative leaders and remain hopeful that the legislation’s rhetorical commitment to further reform will become a reality. We urge the Vermont Senate to address the shortcomings in the House bill.
Much work, including efforts to enact federal enabling legislation – and continued advocacy by single-payer supporters – will be needed in the years ahead to achieve Vermont’s goal of universal access to high quality, affordable care.
*******
Physicians for a National Health Program (www.pnhp.org) is an organization of 18,000 doctors who support single-payer national health insurance, an improved Medicare for all. A March 26 rally at the Vermont Statehouse organized by medical and other health-professional students from PNHP and the American Medical Student Association drew over 200 attendees in support of single-payer health reform.
Ryan turns knife on Medicare, Medicaid
By Margaret Flowers, MD
FireDogLake, April 6, 2011
Rep. Paul Ryan of Wisconsin, the Republican chairman of the U.S. House Budget Committee, unveiled two proposals this week which if enacted would constitute a mortal threat to our nation’s health – particularly to the health of our seniors and our most vulnerable populations.
The first proposal, Senate Joint Resolution 10, would amend the Constitution by imposing rigid and arbitrary restraints on federal spending. The second, his fiscal year 2012 federal budget resolution (misleadingly and eerily called “The Path to Prosperity”), would essentially kill the Medicare program and gut Medicaid, among its other nasty effects.
Both proposals should be emphatically rejected.
Ryan clearly has health care on his hit list. He stressed the problem of health care costs during his final testimony to President Obama’s bipartisan National Commission on Fiscal Responsibility and Reform last December. He said then that he would borrow pieces of the commission’s report for the federal budget, but his latest proposals are in fact much more radical.
The Deficit Commission report stated that if the national health law did not control health care costs, then that ought to trigger more drastic changes in health care spending. Rather than wait for a trigger, Ryan is moving full steam toward the dismantling of our public health programs for the poor and elderly, and the creation of an even more fragmented, privatized and dysfunctional health care landscape than we have now.
Seniors to join the growing ranks of the under-insured
Ryan would change Medicare from a guaranteed benefit program to a limited spending program which pushes more seniors into the private market. Similar to the new federal health law, seniors would be given a defined amount of money that they could use to purchase private insurance on an exchange. Such subsidies are expected to grow more slowly than overall health care costs, so that as insurance premiums rise, seniors would be pushed into skimpier plans that would leave them unable to afford needed care and financially vulnerable should they have a serious accident or illness.
The dismantling and privatization of Medicare, which would be completed by 2022, would actually lead to higher overall health care costs and poorer health for our Medicare population. Health care costs would be higher because of the added private-insurer expenses of profit and inefficient administration. For example, Medicare Advantage plans, run by the insurers, currently cost about 10 times more to administer than the traditional Medicare program.
It is also possible that increased cost-sharing in the form of higher co-pays and deductibles would cause seniors to delay or forgo necessary care leading to greater costs on the back-end for a greater number of and lengthier hospitalizations. (In a darker, bone-chilling moment, one economist recently remarked that delayed care leading to early deaths results in reduced U.S. health spending.)
Further privatization of Medicare will also increase the fragmentation of our health care financing, which will weaken the program’s ability to negotiate fair prices for goods and services.
Ryan describes this change as similar to Medicare part D, for which he voted in 2003. This is another scary thought. The result of Medicare part D was greater confusion and obstacles for seniors, a huge new burden on taxpayers, and windfall profits for the pharmaceutical industry.
Medicaid will shrink in a time of growing need
Regarding Medicaid, Ryan proposes to change the federal portion of the program’s funding to block grants. This means that rather than deciding what part of the population qualifies for Medicaid and adjusting the amount of money allocated based on need, as we do now, states will instead receive a defined lump sum to use as they see fit.
This approach is misleadingly marketed as providing states with greater flexibility. However, Ryan also wants to cut Medicaid spending by $1 trillion over the next 10 years, which will effectively eliminate the Medicaid expansion envisioned under the federal health law and impose even more severe limitations on the number of people and services that will be covered.
In times of growing unemployment and poverty, with more people needing Medicaid, there will be fewer dollars and no guarantee that people will be able to enroll. This will effectively leave millions of our most vulnerable citizens unable to receive necessary services, leading to increased suffering and deaths.
Ryan seriously suggests that those who qualify for Medicaid should be put into the private insurance market in the mistaken belief that this will provide greater choice and cost efficiency. But this is ludicrous, given the well-known track record of the private insurers.
Correct diagnosis, wrong prescription
Ryan does get one thing right: he correctly observes that health care costs are intimately tied to our nation’s budget problems. Health care expenses are expanding way out of line with our economic growth. And yet for all of this spending, a third of our population is either un-insured or under-insured, the medical bankruptcy rate is high, and our health outcomes are relatively poor.
What Ryan fails to understand is that Medicaid and Medicare are not the cause of our rising costs, but rather are the victims of our broken health care system. Medicaid and Medicare costs are actually rising more slowly than our private sector costs. For more on this, see this summary from a congressional briefing on Medicare and the deficit.
Ryan’s plans mirror the austerity measures being pushed in many states across the country and represent an escalation of the worst proposals put forth by the bipartisan Deficit Commission. These growing threats to our social programs require that we step up our defense of the public health infrastructure and make an even louder case for an improved Medicare for all.
As for Ryan’s proposal for a constitutional amendment to cap federal spending, one wonders how much of it is driven by political grandstanding.
S.J.Res.10 would limit federal spending to 18 percent of the gross domestic product, something that hasn’t occurred since 1966. (It’s currently around 24 percent of GDP.) This may sound like a laudable goal until one realizes that during an economic downturn, as we are currently experiencing, there is a much greater need for government spending on programs such as food stamps, unemployment benefits and public health insurance.
A new, arbitrary ceiling on federal outlays could prove disastrous. Noted economist Joseph Stiglitz makes the case that a temporary increase in investment in public prog
rams is required in a downturn in order to make economic recovery possible.
Rep. Ryan hinted at his true agenda during the final meeting of the Deficit Commission when he said that he liked discretionary caps. Significantly, his constitutional amendment would exempt military expenditures in times of war (a seemingly permanent condition for the U.S. today) from such caps.
Greater urgency to protect our right to health care
Section 4 of S.J.Res.10 is also a matter of concern, particularly for single-payer advocates. It states that any bill that raises taxes or imposes a new tax may only pass with a two-thirds majority vote in Congress. Because a national single-payer program would replace current health spending on insurance premiums and out-of-pocket expenses with a new, equitable, and progressive system of taxation to finance universal care, this undemocratic amendment would constitute another obstacle to enacting an improved Medicare for all.
Yet it is precisely single payer that’s the solution to our health care and economic crises: an improved and expanded Medicare-like system that covers everyone. This will achieve the goals of a universal, comprehensive health system which controls our health care costs, relieves businesses of the burden of providing health care coverage and provides a framework within which quality of care and health outcomes will improve. My testimony and that of others presented to the Deficit Commission last summer made that argument.
It is imperative that we take a strong stance to end this assault on our health. Speak to your elected officials today. Tell them to reject Ryan’s proposals. And tell them you want a real solution to our health care crisis: single-payer national health insurance as embodied in H.R. 676.
Margaret Flowers, M.D., is congressional fellow at Physicians for a National Health Program.
http://my.firedoglake.com/mflowersmd/2011/04/06/ryan-turns-knife-on-medicare-medicaid/
PNHP on Vermont’s “single payer” legislation
Vermont health bill mislabeled ‘single payer’: doctors’ group
Physicians for a National Health Program says draft legislation gives wide berth to private insurers, falls far short of single-payer reform
Physicians for a National Health Program
April 7, 2011The following statement was released today by the national board of Physicians for a National Health Program.
Health reform legislation initiated by Vermont Governor Peter Shumlin was recently passed by that state’s House of Representatives and awaits action in the Senate.
Many journalists and commentators have portrayed this bill as fully embracing the single-payer approach to reform. We write to clarify the views of Physicians for a National Health Program on the Vermont legislation.
We appreciate the enthusiasm for progressive health reform shown by Gov. Shumlin and the many dedicated single-payer supporters in Vermont. However, it is important to note that the bill passed by the Vermont House falls well short of the single-payer reform needed to resolve the health care crisis in that state and the nation. Indeed, as the bill moved through the House the term “single payer” was entirely removed, and restrictions on the role of private insurers were loosened.
In its present form, the legislation lays out in considerable detail a structure to implement Vermont’s version of the federal reform passed in March of 2010, which would expand coverage by private insurers and Medicaid. However, it offers only a vague outline of the additional reform promised by the governor and Legislature at such time when states will be allowed to experiment with alternatives to the federal program in 2017 (or 2014, if the effort to move up the date succeeds).
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. 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.
Within the public program, the plan would continue to lump together payments for operating and capital costs, allowing hospitals and the newly established Accountable Care Organizations (ACOs) to use funds not spent on care for institutional expansion. Meanwhile, those with operating losses would shrink or close even if they were meeting vital health needs. This would perpetuate incentives for hospitals and ACOs to cherry-pick profitable patients and services, and hobble the health planning needed to assure rational investments in new facilities and high-technology care.
Under the legislation, many patients would continue to face co-payments that obstruct access to care, and the bill makes no mention of expanding coverage of long-term care. The legislation fails to proscribe the participation of for-profit hospitals and other providers (e.g. ACOs and dialysis clinics), which research has shown deliver inferior care at inflated prices.
Finally, the bill offers no concrete funding plan or structure for the public program that it promises.
We applaud the sentiments expressed by the governor and legislative leaders and remain hopeful that the legislation’s rhetorical commitment to further reform will become a reality. We urge the Vermont Senate to address the shortcomings in the House bill.
Much work, including efforts to enact federal enabling legislation – and continued advocacy by single-payer supporters – will be needed in the years ahead to achieve Vermont’s goal of universal access to high quality, affordable care.
*******
Physicians for a National Health Program (www.pnhp.org) is an organization of 18,000 doctors who support single-payer national health insurance, an improved Medicare for all. A March 26 rally at the Vermont Statehouse organized by medical and other health-professional students from PNHP and the American Medical Student Association drew over 200 attendees in support of single-payer health reform.
https://pnhp.org/news/2011/april/vermont-health-bill-mislabeled-single-payer-doctors-group
Vermont is experiencing some of the problems that all state-level single payer efforts face. They are hindered by a complex quagmire of federal and state programs, laws and regulations, plus pressure from vested interests who would prefer other options, if not the status quo.
There is an understandable tendency to want to adopt simplistic strategies that hopefully eventually would lead to single payer. If we only included a public option in the insurance exchanges authorized by the Affordable Care Act (ACA), then we could expand that to become the single payer. If we only moved up the date for ACA waivers which would authorize state innovations in reform, then we could enact single payer systems on a state-by-state basis.
As much as we wish they would work, these simplistic measures don’t. Vermont is finding that out now. To comply especially with federal laws and regulations, Vermont has had to make so many changes in their bill that it is no longer a single payer model. Recognizing that, they even removed “Single Payer” from the title of the bill.
Health policy is now a relatively advanced science. You can predict with a great degree of certainty what the results of various policy decisions would be. In fact at PNHP we have done just that and have a batting average of 1000. We also have predicted the results of enacting a national single payer program. For those who complain that PNHP is too negative, look at our predictions for a bona fide single payer system. You could not find a more positive expression anywhere else.
We support Vermont’s effort to bring relief from physical and financial suffering for its residents. We encourage Vermont to move forward with policies that would bring them as close as possible to a single payer system. We encourage the people of Vermont and of the entire nation to elect individuals who will enact the federal legislation that would ensure health care justice for all – a single payer national health program.
Why did the PNHP board believe that we had to make a statement on the deficiencies of the Vermont effort? It is simply because the citizens of our nation are not keeping their eyes on the ball. Supporters of reform have been distracted by efforts to try to made ACA work, and by state-level efforts to try to get us closer to single payer. The ball we need to watch is comprehensive affordable care for everyone through true single payer reform. All of us must direct our attention and efforts to that above all else, even though we should continue to support state efforts in the interim that would provide some temporary relief before we can get to the national health program that we need.
Is Medicaid the best path to take for Health Care Reform?
By Laura Katz Olson
Columbia University Press Blog, June 4th, 2010
The following post is by Laura Katz Olson, author of The Politics of Medicaid.
As the only industrialized nation that does not have some type of universal health care, the United States has long been overdue for reform. Nevertheless, a question remains as to whether Medicaid is an appropriate foundation for such an expansion. In my new book The Politics of Medicaid, I ascertain whether building on the program—adding millions of low-income people to its rolls—is the best means of reducing the ranks of the medically uninsured. I argue that Medicaid is and has always been a precarious program. A labyrinth of fifty separate state plans that are regularly in flux their offerings depend on economic conditions, changing partisan politics, the diverse agenda of providers, and the ideological winds of the times. National regulations and guarantees are repeatedly put aside through the waiver process, adding to the instability of the program. Medicaid’s state-by-state approach to health insurance has fostered an inequitable, haphazard, unstable, and costly system of medical care for the poor. As a consequence, the type and level of services individuals obtain depend on their geographic location and which party or governor is in power at any particular time.
The recently enacted historic Patient Protection and Affordable Care Act, which seeks to insure 32 million more Americans, hinges on a massive expansion of Medicaid. Nearly half (16 million people) of the newly enrolled population is scheduled to participate in the program through Medicaid. Already serving more than 59 million low-income people, this $333 billion federal-state jointly funded plan will in 2014 include all households with incomes up to 133 percent of the Federal Poverty Level. This development is significant, fostering not only greater coverage but also fairness in coverage across the states and among their residents. Previously, income-eligibility levels depended on where you lived. Now there will be a nationwide floor. In addition, the states will no longer be allowed to exclude specific groups who qualify financially, including parents with grown children and childless adults.
Almost from the start, fiscal issues have dominated Medicaid policies. In the best of times, the program has proven to be a source of ongoing financial strain for the states. By the twenty-first century it had become the second largest item on most of their budgets, consuming an average of 20 percent of the total. During severe economic downturns, such as that experienced beginning in 2001 and again in 2008, states face even more severe monetary problems, fostering devastating effects on plan offerings everywhere. Unemployment, the number of medically uninsured households, and Medicaid caseloads all rise just as states confront sharp declines in their general revenues. In some places, the alternating spurts of enhancements and cutbacks of benefit packages leave chronically ill and disabled Medicaid beneficiaries—those whose medical needs remain constant— in a state of uncertainty, and often panic.
Over the decades, the states have been given progressively more flexibility to design their Medicaid plans through waivers and, more recently, the Deficit Reduction Act (DRA) of 2005. Because they must balance their budgets and Medicaid has consumed an ever-increasing share of available revenues, state policymakers increasingly sought permission to take advantage of the national “flexibilities,” some to rein in spending, others to tackle the thorny issue of medical coverage for their growing uninsured residents—and some tried to do both. The spread of Medicaid to more people was inextricably linked to an undermining of national guarantees: expansions generally entailed a restructuring of existing plans, reductions in “optional” benefits for current participants, lean benefit packages for new beneficiaries, greater cost sharing for everyone, lower provider fees, and frequently a combination of all these approaches. It also encompassed an ongoing abandonment of Medicaid’s “freedom-of-choice” provision by mandating managed care, often delivered through low-quality, Medicaid-only commercial insurance companies.
One of the primary motives for relying so heavily on Medicaid for coverage expansion under the 2010 health reform bill, rather than Medicare or fully on subsidized health insurance in the private market, results from the fact that the program is far less expensive. Drafters of the law laud the cost savings that will be achieved relative to other approaches for universal coverage. However, one reason that Medicaid saves money is because it shifts some of the financial burdens onto the states. A number of Republican leaders reacted vociferously against enlarging Medicaid eligibility because of the cost, but even supporters of the act are concerned with what most likely will be an untenable drain on state budgets.
Also conspicuously absent from the debate over health reform is that Medicaid is a bargain partly because of its comparatively low physician fees, resulting in concerns about access and quality of care. Because fees are established by the states, they vary widely across the nation and are subject to constant revision, often dependent on the locality’s fiscal situation. Overall, the level of reimbursements has been significantly lower than Medicare payments and even less relative to private commercial insurance, thereby fostering a dearth of private practitioners, especially specialists, willing to treat Medicaid patients. As a result, participants increasingly must rely on understaffed, inadequately funded clinics, public hospitals and emergency rooms, or practitioners offering perfunctory, substandard care. An addition of 16 million more Medicaid clients will only exacerbate the situation.
The evidence over the decades suggests that when state budgets are strained, as they undoubtedly will be when the health reform legislation is fully implemented, governors and legislators squeeze their Medicaid plans. For the most part, elected leaders have not been willing to raise taxes as a means of funding social programs. They are more likely to eliminate some or all of their plan’s “optional” benefits, or vastly reduce their amount, leaving enrollees without essential services. Many of them will initiate or raise premiums and co-payments for beneficiaries. State lawmakers could also be expected to restrict the type and number of prescription drugs, which may be fundamental to a participant’s health.
Moreover, under the reform legislation, newly eligible adults will be guaranteed only a benchmark benefits package that provides minimum medical services. The states also can—and many probably will—use stringent application and recertification procedures to save money, as quite a few of them have done in the past, to prevent families from enrolling or forcing them from the Medicaid rolls. Quality of care is at issue as well, a concern that, for the most part, has not been seriously addressed by the reform measure. The available data paint a disconcerting picture of significant treatment and outcome disparities between Medicaid participants and patients insured elsewhere.
In conclusion, the health reform law should be commended for expanding insurance coverage to a greater number of Americans, but Medicaid is not the most suitable means for doing so. Benefit packages will continue to hinge on where people live, economic conditions, and the political will of national and state officials, rather than on an individual’s medical needs. Clearly, it is not sufficient just to increase Medicaid caseloads, as is the situation with the Patient Protection and Affordability Act. Policymakers must also consider the availability of services, along with their scope, intensity, and quality of care.
Knowledgeable misinformation on reform
National Partisan Debate Elbows in on California
By David Gorn
California Healthline
April 5, 2011
A Field Poll on attitudes toward health care reform in California had some interesting results — including a much more positive feeling about reform among Californians than is found in national polls.
One of the main results this year and last, according to Field pollster Mark DiCamillo, is that opinions on health care are highly partisan.
“The data were very partisan last year, and the reality of the data is, we haven’t had that much of a change since then. The amount of knowledge people have about reform is not greater than last year, but there’s so much heat on this issue, so much of a partisan divide — it’s here, it has been here and I don’t expect it to go away anytime soon.”
That partisan element has not only influenced opinions, he said, but has reinforced factual misconceptions, as well. “The dissonance that’s going on is just amazing to me,” DiCamillo said. “The predispositions people have about health care are coloring what’s going on in reality.”
For instance, he said, 36% of Californians believe that undocumented residents will be better off from the health care reform law, despite the fact that the law specifically excludes undocumented residents from participating.
“We actually see the highest degree of confusion among people who say they have more knowledge [about health care reform issues],” DiCamillo said. “That’s consistent with Tea Party voters and Republicans,” he said, “and they’re also more likely to believe that illegal immigrants will benefit. So that self-reported knowledge, you have to take it with a grain of salt.”
And…
California Voters Remain Supportive of Health Care Law
By Mark DiCamillo and Mervin Field
The Field Poll
April 4, 2011
Table 2b
Opinions of the health care law by stated level of knowledge about the law
Oppose
57% – Very knowledgeable
39% – Somewhat knowledgeable
29% – Not too/not at all knowledgeable
Support
41% – Very Knowledgeable
56% – Somewhat knowledgeable
50% – Not too/not at all knowledgeable
Table 3b
Opinions of the health care law by media source
TV news source
Oppose
35% – CNN
73% – Fox News
37% – NBC
33% – ABC
31% – MSNBC
36% – CBS
14% – Univision/Telemundo
34% – Other TV/Local news
Support
56% – CNN
22% – Fox News
52% – NBC
55% – ABC
63% – MSNBC
51% – CBS
66% – Univision/Telemundo
52% – Other TV/Local News
http://www.field.com/fieldpollonline/subscribers/Rls2374.pdf
Comment:
By Don McCanne, MD
Those of us who are quite knowledgeable about health policy are often astounded by not only the amount of misinformation about health reform, but also by the self-confidence of those who are often the least well informed. This new California Field Poll provides some interesting observations in this regard.
As Field pollster Mark DiCamillo explains, 36% of Californians believe that undocumented residents will be better off from the health care reform law even though that is untrue and is spelled out in the law, and yet, “We actually see the highest degree of confusion among people who say they have more knowledge [about health care reform issues],” and “That’s consistent with Tea Party voters and Republicans.” The poll numbers confirm that those who oppose the Affordable Care Act claim to be more knowledgeable about the law whereas those who support it do not have the same level of confidence in their knowledge.
Look at the sources of their information. For those who oppose the law, many more rely on Fox News and not on the other television news sources. In contrast, those who support the law do not rely on Fox News but are fairly evenly distributed amongst the networks and CNN, with greater dependency on MSNBC and Univision/Telemundo. Considering the large Hispanic population in California, the last observation is particularly relevant.
In a land that values free speech so highly and has an abundance of information resources, how did we end up with such a large sector of our population so heavily reliant on a source so lacking in credibility? Even more perplexing, why do they rigidly insist that they are highly knowledgeable and that our very credible, well documented facts are wrong even when all of the objective data is presented to them? Is it just that these people are incapable of critical thinking, or is it that Fox News has discovered the secret of mass mesmerization? Either way, it’s scary.
Knowledgeable misinformation on reform
National Partisan Debate Elbows in on California
By David Gorn
California Healthline
April 5, 2011A Field Poll on attitudes toward health care reform in California had some interesting results — including a much more positive feeling about reform among Californians than is found in national polls.
One of the main results this year and last, according to Field pollster Mark DiCamillo, is that opinions on health care are highly partisan.
“The data were very partisan last year, and the reality of the data is, we haven’t had that much of a change since then. The amount of knowledge people have about reform is not greater than last year, but there’s so much heat on this issue, so much of a partisan divide — it’s here, it has been here and I don’t expect it to go away anytime soon.”
That partisan element has not only influenced opinions, he said, but has reinforced factual misconceptions, as well. “The dissonance that’s going on is just amazing to me,” DiCamillo said. “The predispositions people have about health care are coloring what’s going on in reality.”
For instance, he said, 36% of Californians believe that undocumented residents will be better off from the health care reform law, despite the fact that the law specifically excludes undocumented residents from participating.
“We actually see the highest degree of confusion among people who say they have more knowledge [about health care reform issues],” DiCamillo said. “That’s consistent with Tea Party voters and Republicans,” he said, “and they’re also more likely to believe that illegal immigrants will benefit. So that self-reported knowledge, you have to take it with a grain of salt.”
And…
California Voters Remain Supportive of Health Care Law
By Mark DiCamillo and Mervin Field
The Field Poll
April 4, 2011Table 2b
Opinions of the health care law by stated level of knowledge about the lawOppose
57% – Very knowledgeable
39% – Somewhat knowledgeable
29% – Not too/not at all knowledgeableSupport
41% – Very Knowledgeable
56% – Somewhat knowledgeable
50% – Not too/not at all knowledgeableTable 3b
Opinions of the health care law by media source
TV news sourceOppose
35% – CNN
73% – Fox News
37% – NBC
33% – ABC
31% – MSNBC
36% – CBS
14% – Univision/Telemundo
34% – Other TV/Local newsSupport
56% – CNN
22% – Fox News
52% – NBC
55% – ABC
63% – MSNBC
51% – CBS
66% – Univision/Telemundo
52% – Other TV/Local Newshttp://www.field.com/fieldpollonline/subscribers/Rls2374.pdf
Those of us who are quite knowledgeable about health policy are often astounded by not only the amount of misinformation about health reform, but also by the self-confidence of those who are often the least well informed. This new California Field Poll provides some interesting observations in this regard.
As Field pollster Mark DiCamillo explains, 36% of Californians believe that undocumented residents will be better off from the health care reform law even though that is untrue and is spelled out in the law, and yet, “We actually see the highest degree of confusion among people who say they have more knowledge [about health care reform issues],” and “That’s consistent with Tea Party voters and Republicans.” The poll numbers confirm that those who oppose the Affordable Care Act claim to be more knowledgeable about the law whereas those who support it do not have the same level of confidence in their knowledge.
Look at the sources of their information. For those who oppose the law, many more rely on Fox News and not on the other television news sources. In contrast, those who support the law do not rely on Fox News but are fairly evenly distributed amongst the networks and CNN, with greater dependency on MSNBC and Univision/Telemundo. Considering the large Hispanic population in California, the last observation is particularly relevant.
In a land that values free speech so highly and has an abundance of information resources, how did we end up with such a large sector of our population so heavily reliant on a source so lacking in credibility? Even more perplexing, why do they rigidly insist that they are highly knowledgeable and that our very credible, well documented facts are wrong even when all of the objective data is presented to them? Is it just that these people are incapable of critical thinking, or is it that Fox News has discovered the secret of mass mesmerization? Either way, it’s scary.
Congressman Ryan drags “premium support” out of the health policy trash heap
The Path to Prosperity
Fiscal Year 2012 Budget Resolution
Chairman Paul Ryan of Wisconsin
House Committee on the BudgetPremium support – a better way to deliver secure benefits
Starting in 2022, new Medicare beneficiaries will be enrolled in the same kind of health care program that members of Congress enjoy. Future Medicare recipients will be able to choose from a list of guaranteed coverage options, and they will be given the ability to choose a plan that works best for them. This is not a voucher program, but rather a premium-support model. A Medicare premium-support payment would be paid, by Medicare, to the plan chosen by the beneficiary, subsidizing its cost.
The premium-support model would operate similar to the way the Medicare prescription-drug benefit program works today. The Medicare premium-support payment would be adjusted so that wealthier beneficiaries would receive a lower subsidy, the sick would receive a higher payment if their conditions worsened, and lower-income seniors would receive additional assistance to cover out-of-pocket costs.
This approach to strengthen the Medicare program ensures security and affordability for seniors now and into the future. First, it ensures security by setting up a tightly regulated exchange for Medicare plans. Health plans that choose to participate in the Medicare exchange must agree to offer insurance to all Medicare beneficiaries, to avoid cherry-picking and ensure that Medicare’s sickest and highest-cost beneficiaries receive coverage.
While there would be no disruptions in the current Medicare fee-for-service program for those currently enrolled or becoming eligible in the next ten years, all seniors would have the choice to opt into the new Medicare program once it begins in 2022. No senior would be forced to stay in the old program. This budget gives seniors the freedom to choose a plan that works best for them and guarantees health security throughout their retirement years.
http://budget.house.gov/UploadedFiles/PathToProsperityFY2012.pdf
Under Republican control, the House Budget Committee proposes phasing out the traditional Medicare program and replacing it with an insurance exchange offering a variety of private plans with the government’s role limited to offering a premium support (same mechanism as a voucher) to apply toward the purchase of a plan. This converts Medicare from a defined benefit (specified benefits are covered) to a defined contribution (the premium support being a specified dollar amount contributed toward the purchase of a private plan).
This proposal treats the budget as the patient, curing the budget problems with the trade off of further burdening the Medicare beneficiaries who are already paying too much out of pocket. It shifts future increases in health care costs from the government to the beneficiaries. It is much easier for Congress to control federal spending by limiting the value of the premium support rather than trying to reduce the benefit package.
The proposal would adjust the premium support for those with greater health care needs, but that is very difficult to do in a timely manner in that an adjustment next year doesn’t help to relieve this year’s increased costs. Also risk adjusting is very difficult in that it requires having a precise assessment of each individual’s health status and anticipated needs. It is a profound change from the current Medicare program in which equitable funding through the tax system is divorced from the uniform benefit package which everyone shares.
The proposal also would reduce premium support for wealthier Medicare beneficiaries, requiring them to pay more for exchange plans. Actually this principle of progressive financing already exists. Although the current standard premium for Medicare Part B is $96.40 for most individuals ($115.40 for new beneficiaries), it is indexed to income. Those with an income of $214,000 pay $438.20 (including an added Part D premium only for higher-income individuals).
Although progressive financing is an equitable concept, it belongs over on the tax revenue side for funding of the entire Medicare risk pool. By having it as a progressive premium on the benefit side, it fractures solidarity by creating a desire for the wealthy to obtain their own coverage and care independently of Medicare, since they are paying higher premiums anyway. Once they are on their own, they would look upon Medicare as a welfare program, not unlike Medicaid except with much fewer benefits, and chronic underfunding would be inevitable.
The debate that we should be having is over an improved Medicare for everyone. The sad state of politics today is certainly exemplified by the fact that those supporting the transfer of wealth from the masses to our plutocracy have been able to reframe the debate as a need to save our federal budget by cutting back on our social programs, especially Medicare and Medicaid (while reducing the tax rate on the wealthy from 35% down to 25%). What ever happened to common decency?
Beware of corporate influence in health reform
By Sue Deppe
Burlington (Vt.) Free Press, April 5, 2011
Vermont’s health reform bill, H.202, outlines a path toward a streamlined, publicly financed, single-payer health care system. There are huge profits at stake for insurance, managed care, and drug firms and their business allies.
So far, these groups are keeping a fairly low profile. But according to whistle-blower Wendell Potter, former head of corporate communications at CIGNA, you can bet that they’re working feverishly behind the scenes to derail reform.
In his book, “Deadly Spin,” from 1993 to 2008, he was a leader in industry efforts to kill every health reform bill threatening insurance company profits. He and his colleagues spent millions of patients’ and employers’ premium dollars to convince a good portion of the public that the United States has the “best health care system in the world,” despite overwhelming evidence to the contrary.
He continues, “And if you were persuaded that the health care reform bill President Barack Obama signed into law in March 2010 was ‘a government takeover of the health care system,’ my former colleagues and I earned every penny of our handsome salaries. Not to mention our bonuses.”
Phrases such as “government takeover” are carefully crafted and evaluated, at a cost of millions, to manipulate us. They are then echoed repeatedly by allies, including some in the news media, until people believe that they’re true.
Potter opens the health insurance lobby’s “playbook.” Watch for these tactics:
The fear mongering has begun! People predict “rationing” (which is already widespread due to denials and lack of coverage). Some say Vermont is moving too fast. While anxiety is understandable, we do have the careful study done by William Hsiao’s expert team.
Others distract people from the real problems — soaring costs, waste, inefficiency, widespread suffering and deaths — by promoting the market-based system which caused them.
Opponents say single-payer will kill jobs. Hsiao’s team reported it will fuel economic growth. (Toyota built its recent North American plant in Toronto so it wouldn’t have to provide health care.)
“Spin” may be an outright lie or encourage people to doubt scientific data. Some insist that Americans don’t want reform despite good evidence that the majority of citizens — and physicians — want a single-payer system.
Another lie is “The current system works for most people.” Thousands of Vermonters are suffering! The administrative and managed care burdens drive many doctors out of practice and reduce access.
Corporations use philanthropy and warm, fuzzy advertising to distract us from negative publicity. Or they may say one thing and do another. The insurance lobby claimed to support federal reform, while working in secret to defeat it.
Insurance allies rely on alleged “experts” and fake grassroots “Astroturf” front groups. Their trade group, AHIP, funneled millions to the U.S. Chamber of Commerce in 2009 to run ads opposing health reform.
How can we protect ourselves from propaganda and spin?
Be skeptical! If it sounds too good to be true, it probably is (Remember Big Tobacco’s youth smoking prevention campaigns?). Visit http://www.prwatch.org. Scroll down for Potter’s article on Vermont.
Beware of scare tactics and labels! Phrases like “socialized medicine” are used to manipulate you (In many single-payer systems, doctors can practice privately and patients can choose whom to see).
Watch for front groups. They often have feel-good names that stress freedom or “American values.” Check: www.sourcewatch.org.
Be skeptical of sources of data. Beware of people who are unwilling to have a nuanced discussion of all sides of an issue.
Finally, educate yourself about single-payer. Tweaking the edges of our health care system has not helped. The system itself is the problem.
Potter reminds us, “Always look behind any public argument to see how your emotions are being manipulated. And count on it: They are.” Vermonters are generally an independent lot. I’m willing to bet that we’re smart enough to do what’s right, not what’s best for corporate America.
Dr. Susan Leigh Deppe practices psychiatry in Colchester.
http://www.burlingtonfreepress.com/article/20110405/OPINION05/104050310
British rapper hits plan to privatize NHS
Success of YouTube video criticising Department of Health white paper prompts health minister to respond to rapper critic
By Esther Addley
The Guardian, Friday 25 March 2011
Three years ago, when he was 19, a young rapper calling himself MC NxtGen hoped he was on the verge of the big time. Performing at a “battle” at a nightclub in central London, he rapped: “To be found you gotta be loud and have a different sound, step out from the crowd, just rise from the underground!”
The crowd liked him but the title of Britain’s Next Urban Superstar was not to be his. He failed to make the final, and returned home to his dreams of superstardom and his job as a binman in Loughborough.
This week, however, Britain might just have been offered a second chance to turn NxtGen into a star, in the very unlikeliest of circumstances. The rapper, real name Sean Donnelly, has found himself a viral YouTube and Twitter celebrity after recording a track that certainly offers a “different sound”. Eschewing the traditional hiphop themes of bling, booty and babes, Donnelly has recorded a caustic three-minute rap about the Department of Health’s white paper “Equity and Excellence: Liberating the NHS“, and dedicated it personally – highly personally, one might say – to the health minister himself.
“Andrew Lansley, greedy! Andrew Lansley, tosser!” runs the refrain, repeated throughout the song, over a sample taken from The House of the Rising Sun. “The NHS is not for sale, you grey-haired manky codger!” But if Donnelly is far from polite in his political protest, he has certainly done his research.
“So the budget of the PCTs, he wants to hand to the GPs / Oh please. Dumb geeks are gonna buy from any willing provider, / Get care from private companies.”
Later, he offers a helpful parse of the white paper, saying Lansley’s plans are that “we’ll become more like the US / and care will be farmed out to private companies, / who will sell their service to the NHS via the GPs / who will have more to do with service purchase arrangements / than anything to do with seeing their patients.”
Finishing his shift on the bins on Friday (“I don’t think this is really anyone’s career choice”), Donnelly said he’d been overwhelmed by the response, which had seen his Facebook, Twitter and YouTube pages “going crazy” and even contact from TV companies. “I didn’t really plan for it all to be about me,” he says. “I just did it basically so I could speak to the youth.”
The song came about, Donnelly, now 22, told the Guardian, because he has “close family and friends” – his girlfriend is one – “who want to work in the NHS in the future hopefully, but they’re worried about the cuts. So I researched it on the internet and I just did the song. I feel for the people that are ill in hospital. If they were privatised they wouldn’t be able to afford it.” And why focus on Lansley in particular? “Because I’m peed off with the guy.”
He insists he’d rather rap about “truth” than money, fast cars or sex. “That’s what sells, but I’m just not like that.”
Donnelly started MC-ing when he was 11 or 12, he says, when he first saw Eminem, whose wit he immediately loved. “It was just the funniness and this complete truth at the same time.” The Detroit rapper’s influence might be detected in the video to Andrew Lansley – which has been viewed on YouTube more than 30,000 times in 24 hours – in which he enlists shoppers in his home town to wave placards, wear David Cameron and Nick Clegg masks and mouth “Tosser!” and “greedy!” at the camera at apposite points in the song.
At one point, railing against Lansley’s involvement of the fast food industry in formulating health policy, Donnelly dons a mask of the health secretary and throws crisps at his face.
He even riffs on the health secretary’s expenses record, and – in what has a reasonable claim to be the unlikeliest rap lyric ever – on the controversial donation to Lansley’s office by the chairman of a private health company. “He’s been given cash / by John Nash / chairman of Care UK, / a private healthcare provider, / who, if they have their own way, / will be the biggest beneficiaries / of Conservative Lib-Dem policies / to privatise healthcare, pull apart the welfare state …” It’s some distance from 2 Live Crew’s Me So Horny.
He is now trying to release the track on iTunes – “I’ve had so many people saying, ‘Let’s get it to number one!'”. Then he’d love to quit his job on the bins. “The older I’ve got the more I’ve been worried, thinking I’m not going to make it.”
He’s made a wider impact now. By Friday night the viral video had infected the Department of Health, and Lansley himself was moved to comment. “We will never privatise the NHS,” he told the Guardian. “But I’m impressed that he’s managed to get lyrics about GP commissioning into a rap.”
http://www.guardian.co.uk/politics/2011/mar/25/andrew-lansley-rap-mc-nxtgen
Congressman Ryan drags "premium support" out of the health policy trash heap
The Path to Prosperity
Fiscal Year 2012 Budget Resolution
Chairman Paul Ryan of Wisconsin
House Committee on the Budget
Premium support – a better way to deliver secure benefits
Starting in 2022, new Medicare beneficiaries will be enrolled in the same kind of health care program that members of Congress enjoy. Future Medicare recipients will be able to choose from a list of guaranteed coverage options, and they will be given the ability to choose a plan that works best for them. This is not a voucher program, but rather a premium-support model. A Medicare premium-support payment would be paid, by Medicare, to the plan chosen by the beneficiary, subsidizing its cost.
The premium-support model would operate similar to the way the Medicare prescription-drug benefit program works today. The Medicare premium-support payment would be adjusted so that wealthier beneficiaries would receive a lower subsidy, the sick would receive a higher payment if their conditions worsened, and lower-income seniors would receive additional assistance to cover out-of-pocket costs.
This approach to strengthen the Medicare program ensures security and affordability for seniors now and into the future. First, it ensures security by setting up a tightly regulated exchange for Medicare plans. Health plans that choose to participate in the Medicare exchange must agree to offer insurance to all Medicare beneficiaries, to avoid cherry-picking and ensure that Medicare’s sickest and highest-cost beneficiaries receive coverage.
While there would be no disruptions in the current Medicare fee-for-service program for those currently enrolled or becoming eligible in the next ten years, all seniors would have the choice to opt into the new Medicare program once it begins in 2022. No senior would be forced to stay in the old program. This budget gives seniors the freedom to choose a plan that works best for them and guarantees health security throughout their retirement years.
http://budget.house.gov/UploadedFiles/PathToProsperityFY2012.pdf
Comment:
By Don McCanne, MD
Under Republican control, the House Budget Committee proposes phasing out the traditional Medicare program and replacing it with an insurance exchange offering a variety of private plans with the government’s role limited to offering a premium support (same mechanism as a voucher) to apply toward the purchase of a plan. This converts Medicare from a defined benefit (specified benefits are covered) to a defined contribution (the premium support being a specified dollar amount contributed toward the purchase of a private plan).
This proposal treats the budget as the patient, curing the budget problems with the trade off of further burdening the Medicare beneficiaries who are already paying too much out of pocket. It shifts future increases in health care costs from the government to the beneficiaries. It is much easier for Congress to control federal spending by limiting the value of the premium support rather than trying to reduce the benefit package.
The proposal would adjust the premium support for those with greater health care needs, but that is very difficult to do in a timely manner in that an adjustment next year doesn’t help to relieve this year’s increased costs. Also risk adjusting is very difficult in that it requires having a precise assessment of each individual’s health status and anticipated needs. It is a profound change from the current Medicare program in which equitable funding through the tax system is divorced from the uniform benefit package which everyone shares.
The proposal also would reduce premium support for wealthier Medicare beneficiaries, requiring them to pay more for exchange plans. Actually this principle of progressive financing already exists. Although the current standard premium for Medicare Part B is $96.40 for most individuals ($115.40 for new beneficiaries), it is indexed to income. Those with an income of $214,000 pay $438.20 (including an added Part D premium only for higher-income individuals).
Although progressive financing is an equitable concept, it belongs over on the tax revenue side for funding of the entire Medicare risk pool. By having it as a progressive premium on the benefit side, it fractures solidarity by creating a desire for the wealthy to obtain their own coverage and care independently of Medicare, since they are paying higher premiums anyway. Once they are on their own, they would look upon Medicare as a welfare program, not unlike Medicaid except with much fewer benefits, and chronic underfunding would be inevitable.
The debate that we should be having is over an improved Medicare for everyone. The sad state of politics today is certainly exemplified by the fact that those supporting the transfer of wealth from the masses to our plutocracy have been able to reframe the debate as a need to save our federal budget by cutting back on our social programs, especially Medicare and Medicaid (while reducing the tax rate on the wealthy from 35% down to 25%). What ever happened to common decency?
HHS/CMS proposed rule for accountable care organizations
Department of Health and Human Services
Centers for Medicare and Medicaid Services
For the reasons set forth in the preamble, the Centers for Medicare & Medicaid Services proposes to amend 42 CFR Chapter IV by adding part 425 to read as follows:
SUBCHAPTER B–MEDICARE PROGRAM
PART 425–MEDICARE SHARED SAVINGS PROGRAM
Subpart A–General Provisions
§425.2 Basis and scope.
(a) Basis. This part implements section 1899 of the Act by establishing a shared savings program that promotes accountability for a patient population, coordinates items and services under parts A and B, and encourages investment in infrastructure and redesigned care processes for high quality and efficient services. Under this program, groups of providers of services and suppliers meeting criteria specified by the Secretary may work to together to manage and coordinate care for Medicare fee-for-service beneficiaries through an accountable care organization (ACO). ACOs that meet quality performance standards established by the Secretary are eligible to receive payments for shared savings. During years in which the ACO is participating in a two-sided model, the ACO may be required to share losses.
(b) Scope. This part sets forth the following:
(1) The eligibility requirements for an ACO to participate in the Medicare Shared Savings Program (Shared Savings Program).
(2) Program requirements, including quality and other reporting requirements.
(3) The method for assigning Medicare fee-for-service beneficiaries to ACOs.
(4) Payment criteria and methodologies (one-sided model and two-sided model).
(5) Compliance monitoring and sanctions for noncompliance.
(6) Reconsideration of adverse determinations.
Proposed rule (429 pages):
http://www.ofr.gov/OFRUpload/OFRData/2011-07880_PI.pdf
Comment:
By Don McCanne, MD
Accountable care organization (ACO) is a concept that grew out of concerns over excessive levels of spending for health care that is often only mediocre. It was thought that health care professionals and facilities could organize themselves into integrated organizations through which they would become accountable for both the cost and the quality of health care.
The Affordable Care Act established the Medicare Shared Savings Program which would use ACOs to achieve savings in the Medicare fee-for-service program, and the savings would be split between the ACOs and the government. The proposed rule for ACOs has now been released. I’ll try to reduce the 429 pages down into a few salient comments.
* The ACO would be composed of professionals arranged in networks or in group practices, and may partner with or be employed by hospitals.
* The ACO is accountable for the quality, cost, and overall care of the Medicare fee-for-service (FFS) beneficiaries assigned to it.
* The ACO shall include primary care ACO professionals that are sufficient for the Medicare FFS beneficiaries assigned to the ACO (minimum 5000 beneficiaries).
* The ACO shall have in place a leadership and management structure that includes clinical and administrative systems.
* The ACO shall define processes to promote evidence-based medicine and patient engagement, report on quality and cost measures, and coordinate care, such as through the use of telehealth, remote patient monitoring, and other such enabling technologies.
* A benchmark will be established based on recent spending in the fee-for-service Medicare program.
* If spending for patients assigned to the ACO falls below the benchmark, the ACO will be rewarded with a portion of the amount saved, and the government keeps the rest.
* If spending for patients assigned to the ACO is more than the benchmark, then the ACO must pay a penalty of a portion of the excess (with a maximum two-year exemption for ACOs participating as a “one-sided” model with lower rewards but no penalty).
* The ACO must meet detailed quality requirements to qualify for the shared savings, but also may be terminated for failure to meet minimum standards.
* Patients will have free choice of any physician at all times, but will be assigned to an ACO based on plurality use of primary care services, for the purpose of assigning accountability for savings and quality. The ACO, which theoretically controls cost and quality for the patient assigned to it and will be rewarded or punished for the results, will have no control of the cost and quality of care delivered outside of the ACO.
* And over 400 pages of etc., etc.
Under the proposed rules, ACOs are not simple organizations formed on just a handshake. They require a formal legal structure with management, a specified governance board, a medical director, a quality assurance program, and more. They must implement evidence-based clinical guidelines. The required documentation of quality is particularly onerous. They must have an infrastructure, such as information technology, to collect and evaluate data, and provide feedback. They must comply with extensive legal, business, and clinical documentation requirements. Since ACOs often involve consolidation within the health care delivery system, they must coordinate with antitrust agencies.
Obviously, considerable time, effort and expense is involved, so the reward must be worthwhile. And what is that reward? If they can improve their productivity while meeting quality standards, the financial benefit accrues to the government, but the reward is that the government lets them have a fraction of their productivity gains, providing that they are compliant with the complex set of rules. Since it’s almost impossible to continue to improve productivity in health care year after year, the reward would dry up soon.
With the trend of increasing frequency and intensity of services, there is a risk that the ACO may exceed the benchmark and have to pay back to the government a portion of the higher spending as a penalty.
What would happen if a group of professionals who were considering forming an ACO decided not to? First, they wouldn’t have all of the extra expenses and effort that establishing an ACO would require. They certainly would not have an incentive to reduce Medicare’s spending (i.e., reduce their income) since they would keep all revenues and not have to share them with the government. And if their spending for Medicare exceeded the benchmark? They would still keep it all, and wouldn’t have to pay a penalty.
Since most people with any business sense would never participate in such a scheme, why is it that there seems to be such a rush to form ACOs? In my opinion, they are not looking for the Medicare fee-for-service business. They are forming commercial ACOs in the private sector, looking for the private insurance business that will expand greatly in the new insurance exchanges. They are taking advantage of the prevailing attitude that we must back off on enforcing antitrust regulations in order to provide flexibility for the ACOs. They are consolidating to gain greater market control. Many are using “accountable care organization” as a deceptive label for expanded managed care oligopolies and monopolies.
The notion of accountable care organization was originated as a well meaning, altruistic, aspirational concept by individuals who really care about the health care that all of us receive. To be successful in improving quality and reducing costs the concept would have to be dependent on patients and health care professionals and administrators who were determined to do the right thing regardless of pecuniary or other self-interests. Yet health care, as the business that it is – like it or not – cannot afford to embrace altruism, for it would fail in its business responsibilities to maximize market
opportunities.
Does it have to be this way? Do we really need to depend upon private stewards devoted to the amoral business ethic to administer the financing of health care? Well, when you think about it, a single payer system is an automated system of financing health care that does not depend on the altruism of its players. That’s because the single payer model is structured as an altruistic, aspirational system that, quite automatically, actually does, in itself, improve quality and control costs. It just works.
