PNHP

Are we ready for universal HIT and EHRs?

Are we ready for universal HIT and EHRs?

Tapping the Unmet Potential of Health Information Technology

By Ann S. O’Malley, M.D., M.P.H.
The New England Journal of Medicine
March 23, 2011

Although EHRs laudably provide immediate access to patient data and electronic messaging functions, clinicians have been frustrated by the difficulty of using them to support care delivery and coordination. Transforming EHRs into effective clinical tools rather than a means of capturing information primarily for documentation and billing purposes will require progress on multiple fronts.

Continued research on clinical care processes, the design and use of HIT, and payment reform, as well as ongoing support for clinicians, will be key to the effective and meaningful use of HIT. Today’s EHRs do not sufficiently support aspects of care delivery that are vital to improving care and controlling costs.

http://healthpolicyandreform.nejm.org/?p=14007&query=TOC

What is the current state of the development of health information technology (HIT) and electronic health records (EHRs)? Quoting from this NEJM article, “Today’s EHRs do not sufficiently support aspects of care delivery that are vital to improving care and controlling costs.”

We should continue with efforts to improve this technology, but, at this time, it is still too early to force universal adoption through government policies.


The health law at one year: Should we celebrate?

By Dr. Claudia Chaufan
OpEdNews.com, March 23, 2011
 
On March 23, a year after President Obama signed into law the Patient Protection and Affordable Care Act (PPACA), “the most expansive social legislation enacted in decades,” according to the New York Times, it’s worth taking a look at Massachusetts.
 
After all, PPACA was inspired in the Massachusetts health plan, which sought universal coverage through Medicaid expansions for individuals living under 150 percent of the federal poverty level (FPL), partial subsidies for those between 151 and 300 percent of the FPL, a state-based exchange to act as a one-stop-shopping place of private insurance plans, and a mandate to purchase one of those plans under penalty of a fine.
 
And yet, four years after implementation, health reform Massachusetts-style has failed a critical test. As a recent study in the American Journal of Medicine showed, the percentage of personal bankruptcies linked to medical bills and illness, at 52.9 percent, has not decreased significantly, and the absolute number of medical bankruptcies has increased, from 7,504 in 2007 to 10,093 in 2009. How so?
 
Well, it’s not hard to understand why. Health insurance is a means to an end. The end is health care. And skimpy policies with significant, and increasing, out-of-pocket costs are useless when people need care.
 
And in Massachusetts, skimpy policies are not even cheap. For example, as study authors pointed out, the least expensive individual coverage available to a 56-year-old Bostonian carries a premium of $5,616 and a deductible of $2,000, and covers only 80 percent of the next $15,000 in costs of covered services (uncovered services fall 100 percent on you).
 
This is not small change if your annual income is around $32,000, or 300 percent of the FPL, so you’re not entitled to subsidies (which, mind you, come from taxpayers’ pockets).
 
But what about at least slowing the increase in health care costs? Fail again. Double-digit increases in premiums have become routine in Massachusetts, and insurers have warned this will continue next year, even as “consumer-driven” policies that shift more costs to individuals multiply.
 
But won’t PPACA, a federal program, control costs in U.S. health care? No, at least if you go by its effect on California, where, maybe to celebrate PPACA’s first year anniversary, Blue Shield recently announced its third premium hike since October 2010. An outside consultant found, unsurprisingly, that the planned hike was “reasonable.” (PPACA does not forbid insurers to raise their prices; it only demands that they show that increases are deemed “reasonable” by authorities that have little power to enforce their standards of reasonableness anyway.”)
 
And what about the promise that kids with “pre-existing conditions” would not be charged more than other kids? Good luck with that one. This past October HHS Secretary Kathleen Sebelius already backed down on that promise, allowing insurers to charge more to cover sick kids to, according to the New York Times, “persuade companies to offer child-only policies.”
 
And Medicaid expansions, which would enroll at least 16 million individuals? Not a chance, especially after governors throughout the nation begin to implement the creative ideas offered by Sebelius explaining how, as state budgets collapse and nobody bails them out, Medicaid costs can be reduced “by cutting benefits,” as noted in California Healthlines.
 
Wait a minute, you might say. Whatever problems it may have, the law offers (near) universal coverage, no? Out of luck again. The law will leave around 23 million uninsured close to 10 years out from its implementation (and over 50 million annually over the next three years). Many of these will be undocumented immigrants, whom the law forbids to buy coverage from the insurance exchanges, even with their own money.
 
On the bright side, as the failure of the attempt to further strengthen the worst of the U.S. health care system — for-profit insurance for medically necessary care, and trading uninsurance for underinsurance — becomes increasingly apparent, a space will open up for Americans to demand real health care reform: a publicly financed, privately delivered health care system that provides comprehensive and equitable health care to everybody in the United States: an expanded and improved Medicare for All.
 
Take action. Write to your local newspaper or Congresspeople: Pass the Expanded and Improved Medicare for All Act, H.R. 676, and, in California, support S.B. 810.
 
Claudia Chaufan, M.D., Ph.D., is assistant professor at the Institute for Health and Aging at the University of California, San Francisco. She teaches sociology of health and medicine, sociology of power, public health, comparative health care comparative health care systems and sociological theory. Dr. Chaufan is also vice president of Physicians for a National Health Program-California (http://pnhpcalifornia.org/).
 
http://www.opednews.com/articles/The-health-law-at-one-year-by-Claudia-Chaufan-110321-519.html

Affirming Equity: Strengthening Health Care Financing and Delivery

PNHP Board member Dr. Andy Coates and Canadian health economist Bob Evans, Ph.D spoke on March 12, 2011, in Vancouver, British Columbia at the Affirming Equity: Strengthening Health Care Financing and Delivery conference, hosted by Simon Fraser University. Learn how Canadians students, researchers, health professionals, and health care providers are gathering to affirm equity in their health care system, and fight back against threat of profit-driven financing and delivery. Listen to the conference talks, and to an interview with Dr. Coates on Canadian radio.

Dr. Robert Evans’ Keynote Presentation: Affirming Equity
Audio Recording
Presentation Slides

Dr. Andrew Coates’ Keynote Presentation: Affirming Social Solidarity
Audio Recording *Note: YouTube videos played during the presentation can be heard but not seen.  For the visual aspect, please download the presentation slides and follow the links to the videos.
Presentation Slides

Dr. Andrew Coates, keynote speaker, was interviewed by Victoria radio station CFAX’s Murray Langdon prior to the conference.  To listen to the interview, download the file here.

http://affirmingequity.wordpress.com/

Vermont leads the way

By Suzanne L. King, M.D.
The Berkshire (Mass.) Eagle, Tuesday March 22, 2011

Writing about the Massachusetts health care reform program in a 2009 issue of the Wall Street Journal, Governor Deval Patrick stated, “Because of our reform, families are less likely to be forced into bankruptcy by medical costs.” Both Governor Patrick and President Obama have used the benchmark of medical bankruptcy as a key measure to prove the success of their health insurance reforms.

Unfortunately, according to a study this month from Harvard University by Dr. David Himmelstein and associates, the absolute number of medical bankruptcies in Massachusetts increased between 2007 and 2009, the years after health care reform had been enacted. Dr. Himmelstein commented, “Massachusetts health reform, like the national law modeled after it, takes many of the uninsured and makes them under-insured, typically giving them a skimpy defective policy that’s like an umbrella that melts in the rain. The protection’s not there when you need it.”

For example, in Boston, the least expensive individual coverage available to a 56-year-old carries an annual premium of $5,616 and a deductible of $2,000, and even then only covers 80 percent of the next $15,000 cost for covered services. Therefore, someone with a chronic condition like diabetes could have to pay $10,000 annually out of pocket, in addition to the premium.

The current Massachusetts heath care reform, on which President Obama has based his national reform legislation, is not adequate. Massachusetts reform has not ended medical bankruptcies in our state, a finding that strongly suggests that national reform won’t reduce medical bankruptcies nationwide.

While individuals, small businesses and towns struggle to pay for inadequate health care insurance, CEOs of non-profit health insurance companies continue to walk away with obscene amounts of our hard-earned dollars. Blue Cross /Blue Shield’s former chief executive, Cleve L. Killingsworth recently received an $11 million payout, while Blue Cross board members individually received up to $89,000 to rubber stamp Killingsworth’s compensation.

As many states and congressional Republicans look for ways to roll back President Obama’s signature health care law, Vermont is moving in a different direction. During his inaugural address, Governor Peter Shumlin proposed guaranteeing health insurance to all Vermonters, noting that current health care costs “[represent] an enormous hidden tax on families and small businesses across our state. If left untethered, the rising cost of health insurance will cripple us.” Shumlin has proposed the creation of a single-payer system for Vermont in which private delivery of healthcare would continue, but the government would act as everyone’s health insurer.

This “Expanded and Improved Medicare-for-all” option was barred from the national health reform debate by special interest groups. By choosing a single-payer program, Vermonters would divorce health insurance coverage from employment, and eliminate the administrative waste of private insurance companies, including outrageous CEO salaries.

Dr. William Hsiao, an international expert on health care reform at the Harvard School of Public Health, was commissioned by the Vermont Legislature to conduct a study about the best way to provide universal coverage, reduce the rate of cost increases, and create a primary care-focused, integrated delivery system. Hsiao stated, “The system capable of producing the greatest potential savings and achieving universal coverage was a single-payer system — one insurance fund that covers everyone with a standard benefit package, paying uniform rates to all providers through a single payment mechanism and claims-processing system. Our analysis showed that Vermont could quickly save almost 8 percent in health care expenditures through administrative simplification and consolidation, plus another 5 percent by reducing fraud and abuse. . . All told, we estimated that Vermont could save 25 percent in health care expenditures over 10 years.”

In the national health reform debate, Vermont, not Massachusetts, now leads the way.

Susanne L. King, M.D., is a Lenox-based practitioner.

http://www.berkshireeagle.com/columnists/ci_17669426

Docs Willing To Move To Vermont For Single Payer System

By Rachel Zimmerman
WBUR, March 22, 2011

More than 200 doctors from 39 states and the District of Columbia say they’d consider moving to Vermont if that state switches to a publicly financed single-payer health care system, according affiliates of Physicians for a National Health Program, an organization of physicians who advocate for single-payer national health insurance.

Many of the doctors mulling a move are in primary care, according to the Vermont chapter of the physician’s group, and while most are from nearby states, doctors from California, Oregon, Washington and Hawaii also said they’d consider moving to Vermont under a single-payer system.

The group asked physicians from around the nation to sign an open letter to the Vermont Legislature in support of the single-payer plan. Doctors could also check a box if they would consider moving to Vermont if a single payer system was enacted.

Eighty Massachusetts doctors signed the letter; 18 checked the box.

Dr. Rachel Nardin, a neurologist at Cambridge Health Alliance, is one of them. She said the current health care system, even with the reforms in Massachusetts, is so demoralizing, she would strongly consider leaving Massachusetts for Vermont if that state had a single-payer system.

“Practicing medicine in our current system is wretched,” Dr. Nardin said in an interview. “Instead of caring for people, we’re fighting with insurers to get what we need for our patients — it’s depressing. For the chance to just care for patients, and not have these fights, sure I’d move.”

Dr. Nardin, who is also co-chair of Massachusetts Physicians for a National Health Program, said she recently cared for an uninsured woman with Lou Gehrig’s disease, a progressive neurodegenerative disorder also known as ALS. “Because she had no insurance, I couldn’t get her a hospital bed, or a wheelchair, I couldn’t get her the most effective medication, I couldn’t get her anything that would maintain her dignity,” Dr. Nardin said. “It is so unnecessarily cruel.” (Ultimately, the patient received help from a private charity.)

“The beauty of single payer,” Dr. Nardin said, “is that people have insurance from cradle to grave and when you get sick, you can worry about being sick and how to get better, you don’t have to worry about how you’re going to pay for care.”

Here’s another Mass. doctor, Suzanne King of Lenox, advocating for the Vermont single payer plan in an opinion piece in The Berkshire Eagle today.

The Economist on the birthday of the Affordable Care Act

A not very happy birthday

The Economist
March 17, 2011

As for costs, Mr Obama’s reforms deserve praise for expanding coverage, but they do this by adding millions of people to an unsupportably expensive system. Analysts estimate that America’s health spending will continue to soar under the reforms. That is a point hotly contested by Mr Obama’s team, who usually point to theoretical future efficiency gains and innovations that will save pots of money.

So it came as a shock when Deval Patrick, the governor of Massachusetts and one of Mr Obama’s closest friends, took a different tack. Asked recently about the pioneering health reforms in his state, which served as a model for the national reforms, he first gave a backhanded compliment to Mitt Romney. Mr Patrick then revealed the dirty little secret of Obamacare: “What these folks did in Massachusetts is frankly the same thing that the Congress did, which is to take on access first, and come to cost-control next.” In other words, America will soon have no choice but to come to grips with costs. Whatever one thinks of Mr Obama’s reforms, there is no denying that they have brought that day of reckoning closer.

http://www.economist.com/node/18389179?story_id=18389179

Comment: 

By Don McCanne, MD

The Economist joins the chorus of those who say that “America’s health spending will continue to soar under the reforms.” Many have contended that it was a mistake to have expanded coverage without first controlling costs. The real mistake was not in reversing the order of coverage expansion and cost containment, rather it was in the failure to do both simultaneously through the adoption of a national single payer program.

The Economist on the birthday of the Affordable Care Act

A not very happy birthday

The Economist
March 17, 2011

As for costs, Mr Obama’s reforms deserve praise for expanding coverage, but they do this by adding millions of people to an unsupportably expensive system. Analysts estimate that America’s health spending will continue to soar under the reforms. That is a point hotly contested by Mr Obama’s team, who usually point to theoretical future efficiency gains and innovations that will save pots of money.

So it came as a shock when Deval Patrick, the governor of Massachusetts and one of Mr Obama’s closest friends, took a different tack. Asked recently about the pioneering health reforms in his state, which served as a model for the national reforms, he first gave a backhanded compliment to Mitt Romney. Mr Patrick then revealed the dirty little secret of Obamacare: “What these folks did in Massachusetts is frankly the same thing that the Congress did, which is to take on access first, and come to cost-control next.” In other words, America will soon have no choice but to come to grips with costs. Whatever one thinks of Mr Obama’s reforms, there is no denying that they have brought that day of reckoning closer.

http://www.economist.com/node/18389179?story_id=18389179

The Economist joins the chorus of those who say that “America’s health spending will continue to soar under the reforms.” Many have contended that it was a mistake to have expanded coverage without first controlling costs. The real mistake was not in reversing the order of coverage expansion and cost containment, rather it was in the failure to do both simultaneously through the adoption of a national single payer program.

One Year Anniversary: The Incredible Shrinking Obama Health Care Law

By Kevin Zeese
FireDogLake, Monday March 21, 2011

At its one year anniversary the Obama health care law is shrinking while the health care crisis grows.  Americans who lack any health coverage still exceeds 50 million, over 45,000 deaths occur annually due to lack of health insurance, and 40 million Americans, including over 10 million children, are underinsured.

Premiums are rising and coverage is shrinking a new norm is taking hold in America: ‘Unaffordable underinsurance.’  This month, the number of waivers granted to the Obama health law broke 1,000 protecting inadequate insurance plans. The expansion of health insurance to the uninsured is becoming a mirage. The Obama administration has told states they could reduce the number of people covered by Medicaid as well as reduce the services provided.  And, the centerpiece of the law is under court challenge – the mandate is the first time ever the federal government has forced Americans to buy a corporate product, private health insurance – is heading to a close Supreme Court decision.

The New Norm: ‘Unaffordable underinsurance’

To make insurance premiums affordable, the quality of insurance will need to be reduced so there is less coverage and more out-of-pocket costs, as Don McCanne, MD, Senior Health Policy Fellow for Physicians for a National Health Program writes:  “’Unaffordable underinsurance’ is rapidly becoming the new standard in the United States.”  The trend in health insurance is rising premiums and shrinking coverage for many Americans who get their coverage at work as well as on the individual insurance market.

Premiums have been increasing with reports ranging from 20% to 60% increases for many Americans and businesses. Further, the law may decrease employment-based insurance by 3 million people by 2019, according to the Congressional Budget Office (CBO) and the Joint Committee on Taxation. This combined with high unemployment and underemployment will push people into the individual insurance market. The individual market is particularly at risk for increased premiums which is of growing importance because of high unemployment.  Blue Shield of California decided this month to withdraw a major hike in the face of public outcry.  This proposed 30%-35% increase would have been the third rate hike since October, the three increases would have raised rates by 59% to 87% for 200,000 policy holders.  While some hope the Obama health law will slow premium hikes, Claudia Fegan, MD of Physicians for a National Health Program writes under the Obama heath law “sudden premium hikes are still possible and, in my opinion, quite likely under the new law.”

Underinsurance, requiring Americans to pay more of the cost of health care, may become the norm because of the 2010 law. The new law will hasten the current trend toward underinsurance as plans where patients pay an average of 40% of their health care bills qualify to fulfill the employers’ obligations to provide coverage rather than pay an assessment. Massachusetts, the model on which the Obama reforms are based, recently found that medical bankruptcies have not decreased with the new law.  The lesson – it is not just health insurance, but the quality of the insurance that matters. After deriding merely adequate insurance as Cadillac Plans,” the Obama administration is showing support for high deductibility plans with large out of pocket costs that do not provide financial or health security.

One promise of the Obama health plan was that millions of underinsured would get decent insurance coverage because the “reform” required minimum levels of insurance.  But, waivers to the requirements of the 2010 law are being widely granted resulting in millions of Americans continuing to have inadequate health coverage.  Waivers allowing poor quality insurance affect 2.6 million people and are being granted rapidly to businesses, unions, insurance companies as well as states who cannot meet the Obama law requirements.  The administration says the purpose of the waivers is to avoid disruption in the insurance market, in clearer language it is to prevent employers from dropping coverage and insurance companies from leaving markets.  The requirement for a waiver is relatively simple; the applicant must show HHS “a significant increase in premiums or a decrease in access to benefits.” Ninety-four percent of requests for waivers have been granted, the largest area where waivers have been denied has been for unions.  Republicans have asked HHS for in-depth details about every waiver decision and request.

The major area of waivers are so-called mini-med plans, these are limited medical plans which provide workers with as little as $2,000 in health care coverage. The Obama health care law requires $750,000 minimum coverage in 2011. The mini-med plans do not provide security in the event of serious illness or accident. The vast majority of these waivers are for employment-based health coverage. Some of the initial waivers went to fast food chains like McDonalds and Jack-in-the-Box.  Unions, insurance companies and state governments have also received waivers. Four states have received waivers, Florida, New Jersey, Ohio and Tennessee.  Waivers are set to disappear in 2014, when people will be required to purchase insurance with tax payer subsidies – assuming that Obama health law survives and that low-paid workers can afford insurance even with a subsidy.

Expanded Numbers of Americans with Insurance Becoming a Mirage

The two largest areas of expansion, Medicaid and the insurance mandate are in jeopardy.  States are cutting the number of people covered by Medicaid and reducing health coverage.  The insurance mandate is under constitutional attack. And, there is little evidence that people are taking advantage of programs that provide coverage for those with pre-existing illnes
s.

The area with the biggest immediate impact on reduced coverage is the roll backs of Medicaid. Medicaid was projected to be the largest area of expansion of medical care under the Obama health care plan, covering 16 million more people, making up half the projected increase in additional Americans covered with some type of insurance under the Obama law. That is now becoming a mirage.

HHS Secretary Sebelius wrote the 50 states letting them know benefits could be cut, poor people could be required to pay a higher share of costs and that federal law allows states to reduce people covered by Medicaid.  Medicaid is health care for the poor and is jointly funded by federal and state governments. Medicaid currently covers 53 million poor children, poor pregnant women and disabled and extremely poor adults. Individuals must make less than $14,500 to be included in Medicaid.

More than half the states want permission to remove hundreds of thousands of people from Medicaid. Arizona alone is planning to reduce Medicaid coverage by 250,000 people and the Obama administration has indicated it will not oppose this reduction in coverage.  In Wisconsin, where Governor Walker has proposed deep cuts to Badgercare (which includes Medicaid and other programs) up to 350,000 could lose health care coverage.  Rather than an increase in the number of people covered, the nation is on a path to reduce total people covered.

Other states, like New York, Hawaii and California which are led by Democratic governors, are cutting benefits of Medicaid programs that already provide insufficient coverage.  Medicaid is often one of the largest expenses of a state but because the cost is shared with the federal government it is also a large source of revenue. As a result it takes more than $2 of Medicaid cuts to save a state $1.  When Medicaid is cut the economy is weakened and revenues reduced as for every dollar cut, health care jobs are lost. Cutting health care for the poor and disabled continues the downward economic spiral – the race to the bottom.

When it comes to people taking advantage of expected benefits of the health care law, thus far only 12,000 people have enrolled in the Pre-existing Condition Insurance Plan despite an aggressive marketing effort.  The Medicare actuary, Rick Foster, told The Hill the low enrollment is a “surprise,” given that “millions” are eligible for the coverage. The Medicare actuary had conservatively predicted the new pools would enroll 375,000 people by the end of 2010, but that projection has not been met because the insurance is too expensive for most people who need it.

Better results might be being seen for young adults.  Approximately 13.2 million 18-29 year olds are without insurance, 30% of that population.  Under the health care law these youth can stay covered under the parents’ health insurance.  There are no hard numbers for how many have taken advantage of this but the Obama administration estimates it could be as many as 1.2 million. As we see with the pre-existing illness option, predictions are one thing and reality is very likely another.  Covering each dependent will cost about $3,380 in 2011, so it is difficult to predict how many families can afford that cost in these difficult economic times when unemployment and underemployment are up and incomes are down.

The Obama health care law may decrease employment-based insurance by 3 million people by 2019, according to the Congressional Budget Office (CBO) and the Joint Committee on Taxation. One estimate made by the CBO is that 8–9 million people currently covered under an employer plan would lose employer coverage because firms would choose to no longer offer coverage. They assume this would be balanced in part by those getting coverage on the exchange.

The other area where increased coverage was promised is the mandate forcing Americans to buy insurance.  The mandate is hotly contested in the courts with 27 states challenging the law and over 20 lawsuits filed it. The courts have split 3-2 in favor of the mandate thus far.  In the two decisions finding the mandate unconstitutional, a Virginia judge threw out only the mandate, while a Florida judge found the mandate so intertwined with the rest of the law that he would stop the whole law. The decisions have been issued along partisan lines, with three district judges appointed by Bill Clinton upholding the law; and two district judges — one appointed by Ronald Reagan and the other by George W. Bush — finding it unconstitutional.  The U.S. Supreme court has five Republican appointed justices and four appointed by Democrats.  It is generally viewed as four on the center-left, four on the right and Justice Kennedy as the swing vote.  The vote on the Supreme Court will be a close one.

The health care law faces a congressional challenge, especially from the Republican controlled House of Representatives which has already voted to repeal the law, but more importantly, promises to use the power of the purse to not fund its implementation.

Single Payer Rising: Why Not Just Improve and Expand Medicare to All?

The imploding health care law is creating an opening which may require a re-consideration of health care reform within the next five years.  Americans consistently favor simply expanding and improving Medicare to cover all Americans.  Terry Dougherty, director of MassHealth, from a state which the model for the Obama law is in place is reaching the obvious conclusion:  “I like the market, but the more and more I stay in it, the more and more I think that maybe a single payer would be better.”  He notes that unlike the insurance industry government costs less, with much lower administrative costs and “We don’t build big buildings. We don’t have high salaries. We don’t have a lot of marketing.”

The low cost of publicly funded health care is consistent with the experience of America’s single payer system – Medicare. The administrative cost of running the Medicare program has remained under 2%. But, the bureaucracy
of trying to control the insurance industry is already growing rapidly. The growth of the federal insurance bureaucracy, the federal office that regulates private insurance along with other important duties under the Obama health law, already has 252 employees and a budget of $93 million for 2012 budget requested by the White House.

While the single payer movement is growing stronger through groups like Health Care Now and Physicians for a National Health Program, the insurance industry is also getting stronger.  Not only will they receive hundreds of millions in new annual tax payer subsidies but they are taking over other parts of health care.  Kaiser Health News reports “Insurers have moved into technology, health-care delivery, physician management, workplace wellness, financial services and overseas ventures.” The Obama law is spurring the cancer of health insurance to spread throughout health care.

At the state level Vermont is striving toward single payer.  Governor Shumlin, his technical advisers and Vermonters support a single payer program, and are considering a bill that reduces the number of funding sources and if federal waivers are granted, which Obama reportedly supports, it will evolve into a single payer program.  The current version of the bill falls short of the goals of advocates who want health care treated as a human right as well as of physicians who seek a single payer program.

The “Expanded and Improved Medicare for All Act,” H.R. 676, a bill that sets up a single payer system has been introduced. It would provide health care to all and give consumers the most choice, provide strong health coverage as well as save money for government, business and individuals. Unlike the Obama law, improved Medicare for all would also be easier to implement.  Medicare transitioned Americans over 65 from private insurance to Medicare within a year and did so without computers.

The failing Obama reforms shows that the obvious must be faced: confront the health insurance industry which makes coverage of all Americans unaffordable. President Obama knew before running for president that single payer was the solution, but after receiving $20 million in donations from the insurance industry refused to let the only real solution, improved Medicare for all, be considered.  It is time to put in place a single payer health care program that ensures that all U.S. residents have quality health care at less cost than they currently pay.

Kevin Zeese is director of Prosperity Agenda.

http://my.firedoglake.com/kevinzeese/2011/03/21/one-year-anniversary-the-incredible-shrinking-obama-health-care-law/

Vermont's single payer proposal – listen to William Hsiao

State-Based, Single-Payer Health Care — A Solution for the United States?

By William C. Hsiao, Ph.D.
The New England Journal Of Medicine
March 16, 2011

The United States faces two major problems in the health care arena: the swelling ranks of the uninsured and soaring costs. The Patient Protection and Affordable Care Act (ACA) makes great strides in addressing the former problem but offers only modest pilot efforts to address the latter. Experience in countries such as Taiwan and Canada shows that single-payer health care systems can achieve universal coverage and control inflation of health care costs. Because of strong political opposition, however, the U.S. Congress never seriously considered a single-payer approach during the recent reform debate. Now Vermont, wishing to solve the intertwined problems of costs and access through systemic reform, is turning in that direction.

Perhaps we are at the dawn of systemic reform in U.S. health care. The Vermont single-payer plan will never be as efficient as Taiwan’s or Canada’s because it must work within the bounds of federal laws and programs and the realities of porous state borders. Nevertheless, it can produce substantial savings to fully fund universal coverage, reduce health care costs for most businesses and households over time, and reform a fragmented delivery system. Of course, someone will bear the burden — mostly the private insurance industry and high-wage businesses that don’t currently offer insurance. But if Vermont can navigate its political waters and successfully implement this plan, it will provide a model for other states and the country as a whole.

http://healthpolicyandreform.nejm.org/?p=13939&query=home

Also posted at:
https://pnhp.org/news/2011/march/state-based-single-payer-health-care-a-solution-for-the-united-states

Comment: 

By Don McCanne, MD

Many in the single payer community are looking at this as a great opportunity to do what Saskatchewan did – establish the first state (provincial) single payer system to serve as a model for the rest of the nation. This perception is right on – almost, but…

Saskatchewan began with a tabula rasa. They were not hindered by a quagmire of federal programs, laws and regulations. Vermont and all of the other states attempting to establish a single payer system must obtain waivers allowing them to be exempt from these federal constraints. The problem with that is that waivers do not exist for most programs and regulations, except for the subsidies in the insurance exchanges, and for Medicaid, but even these “1115” Medicaid waivers have very significant limitations on the modifications that can be made.

We still require comprehensive federal legislation if we are to achieve a true single payer system on the state level. The legislation to introduce a complex set of policies into the existing meshwork likely would be more complex than legislation to replace our current financing with a national single payer system. The political barriers would certainly be as great, if not greater.

The point is that we must not let up in the least in our efforts to educate the public on the financial and moral imperative of a national single payer program. Comprehensive national legislation is absolutely essential, even for state-based single payer systems.

In the meantime, state programs that adopt many of the features of a single payer system can serve to relieve to some degree financial hardship and physical suffering, as a temporary measure, until we can enact a national program. Efforts, such as that in Vermont, certainly deserve our support, but also would benefit from our efforts to have them include as many single payer policies as are possible under the current federal restraints. Partial successes on the state level can show the nation that we can do far, far better than we have done with the Affordable Care Act.

So let’s continue to support these state efforts. But rather than relaxing our stand on behalf of a national single payer system, we need to intensify our efforts since William Hsiao has shown us that “the Vermont single-payer plan will never be as efficient as Taiwan’s or Canada’s because it must work within the bounds of federal laws and programs and the realities.”

German health warning: don't burden doctors with a costly paperchase

By Polly Toynbee
The Guardian, Wednesday 16 March 2011

What would Professor Ulrich Frei, medical director of Berlin’s mighty Charité university hospital most wish for? “No more healthcare reform! At least for three years, please. Sometimes we have one a year, with no time to plan. It follows the electoral cycle and so does health funding, and that makes rational planning impossible.”

Sound familiar?

There are plenty of lessons for the UK to learn from German healthcare, as seen from this towering red-brick turreted institution. Founded in the 18th century by Frederick William I, the Prussian monarch, Charité was bombed to dust in the war, rebuilt as a concrete East German monument, right up against the wall. On reunification, it was reconstructed again, to its former splendour. But it’s in debt.

Across Europe the politics of health is intense. Everywhere, the mammoth generation born just postwar is reaching retirement, demanding more hi-tech treatment and better social care while projected to live longer than any previous generation. Each country responds as if it were uniquely burdened, frequent fidgety reorganisations, with health one of the most certain triggers of political indignation.

Systems differ, built on each country’s distinct social history, all reflecting national stories. But all are basically state-funded through taxation, even if at first glance they look like insurance schemes. Essentially, the working healthy pay for the sick and the old, who are the heaviest users of care.

A commitment to universal, collective provision distinguishes Europeans and divides them most strikingly from the United States (but not Canada). It has been this “socialised medicine” commitment that the Tea Party faction has fought so ferociously in its rejection of the Obama health plan. In Germany, the state pays for 77% of healthcare, in the UK it is 83%, while in the US the government covers only half as much.

Germany spends 10.4% of GDP on health (public and private), considerably more than Britain, which on 2007 figures was just below the EU average at 8.4%. How far are these ratios based on cultural and historical assumptions? Germans say they feel sicker: they certainly visit doctors a lot more than the British, on average 12 to 14 times a year.

Soaring costs are seen as a political crisis in Germany: home care for the frail rose by 11% last year. As Britain raced to catch up during the Labour years, Germany spent only an extra 1.7% each year. One result has been to push health up the political agenda: patients are complaining that it takes longer to get treatment.

Walk the wards of Charité and you witness state-of-the-art treatment and research. This year’s excitement is a new MRI scanner that is open, no longer a confining tube. It recently filmed the first-ever MRI birth, showing that babies’ heads are much more tightly compressed during birth than anyone had realised.

Whatever the German debates, its healthcare has been better funded for far longer than the UK’s, and it shows. Germany scores better than the UK on cancer and stroke survival, although overall survival rates are much the same. The health of nations, however, is less about healthcare than the way we live. Germany has more car accidents, more smokers, and more teenage suicides. Britain and Germany eat and drink about the same amount – too much – while UK infant mortality is worse. German life expectancy is a little higher.

What Britain might learn from Germany is not to turn our relatively efficient healthcare system into a bureaucratic paperchase between the funders and the providers of care. Superficially, their system looks quite different. All citizens belong to one of 160 insurance mutuals; the choice of fund seems relatively insignificant. They bear the footprint of Bismarck, who devised a social support system in the later 19th century to counter the threat of socialism. People used to join a mutual linked with their industry or sector.

For everyone, the same 15% is deducted from wages, with employers contributing about half. The state pays for those who can’t afford it, and about one in 10, the better off, insure privately, paying for faster and more luxurious treatment. Two-tier care seems to stir up more political resentment in Germany than the similar proportion going private in the UK.

But the money the insurance funds pay out has been exceeding their income, and the federal government has been topping them up and insisting on increases in premiums; funds traditionally catering for manual workers have been running out of money first. Some funds tried adding small monthly surcharges only to see a mass exodus to other funds. But because insurance is compulsory and fees identical, what the Germans have is essentially a tax-based scheme. Reform is a hot political issue, not least because in a highly bureaucratic system, administrative costs are exorbitant and rose by 5.8% last year.

Professor Frei, pressing his fingertips together at his desk at the Charité, explains why – and the British “reformers” should attend. The process by which the insurance funds buy treatments is complex, generating wads of paperwork and many disputes that are resolved only by special medical tribunals. There is a perpetual tussle as the funds try to hold down costs and hospitals try to inflate them.

Only about a fifth of German doctors are in primary care, like GPs. In principle, all patients can look up a consultant in the yellow pages and refer themselves – although insurance will cover only one consultant for the same complaint every three months, for those who want second opinions. Ways to cap rising prescription costs, hospital bed use and doctor visits are politically controversial. Germany has a third more doctors and 8.2 hospital beds per 1,000 population compared with Britain’s more economical 3.4 beds. Insurance companies are starting to offer lower premiums to those who always agree to see a GP first.

Six years ago they moved to a US-style accounting system based on disease-related groups, which fixes a tariff for every treatment. An elderly patient entering hospital with a broken leg gets a set sum of money for the leg, but if she has complications later, no extra is paid. Hospitals play the system, trying to register patients as higher-tariff cases while insurance companies hire a fleet of their own doctors to challenge as many bills as they can.

Frei complains that a quarter of his doctors’ time is spent dealing with bureaucracy related to these payments. “If there is anything slightly technically wrong with the documentation, the insurance companies pounce on it as a reason not to pay. We lost €12m (£10.4m) that way last year.”

Worse, the system is creating perverse incentives for doctors and hospitals to over-treat. “Knee replacements went up by 18% last year. It’s why invasive treatment for heart arrhythmia in the over-70s rose by 10%. Everyone has back pain, but we operate more every year because it pays more. Is there evidence back operations are the best treatment? No. But then we don’t have a National Institute for Health and Clinical Excellence [Nice] like you do, to give a rational assessment of the relative value of treatments. I wish we did.” He is alarmed to hear the Cameron government has weakened Nice and truncated its remit.

Pressure of rising costs and suspicion that patients are being denied treatments for reasons of cost has the health system caught in the political crosswires. The Social Democrats on the left want to rationalise the system into a free service for all, cutting the paper trail. The health minister comes from the free-market Free Democrats and advocates the opposite – total privatisation of all hospitals (two-thirds are state or non-profit) with a flat rate, non-means-tested insurance payment, freezing employer payments. A flat-rate would hit the poorest har
dest. Angela Merkel’s Christian Democrats want a bit more privatisation.

Frei says the fifth of hospitals that are privately owned are indeed more efficient, better managed, and make a profit even though officially they can’t compete on price, with the same tariff per case. But, he complains: “They cherry-pick the easy cases, and although it’s illegal they offer backhanders to doctors to refer cases to them. In private hospitals, heads of department have it written into their contracts that they must go to outpatient clinics once a week to meet doctors in the community to drum up business and solicit referrals. That leaves us to do all the expensive tertiary cases.”

So what does he want? Some things that Britain has – or had. GPs to act as universal gatekeepers to limit use of specialists; a Nice to make sure all drugs and treatments are effective and good value; and less doctors’ time and money wasted on bureaucracy and bills.

“And please, no more politically motivated reforms for a while.”

http://www.guardian.co.uk/world/2011/mar/16/german-health-warning-doctors-paperchase

More than 200 doctors contemplate moving to Vermont if it adopts single-payer health system

‘Doctors want to practice medicine, not push paper,’ says Dr. Peggy Carey

FOR IMMEDIATE RELEASE
March 22, 2011

Contact:
Peggy Carey, M.D., Vermont Physicians for a National Health Program
Deborah Richter, M.D., Vermont for Single Payer
Plus physicians available for interview in 26 states via Mark Almberg, PNHP, (312) 782-6006, mark@pnhp.org

BURLINGTON, Vt. – A local affiliate of a national physicians’ group says it has collected the names of more than 200 doctors from 39 states and the District of Columbia who say they would seriously consider moving to Vermont if it were to adopt a publicly financed, single-payer health care system.

Many of the doctors are primary care physicians, who are in great demand in the state.

While most of these physicians reside in nearby states, doctors from as far away as California, Oregon and Washington state – and even Hawaii – would contemplate moving to the Green Mountain State if it adopted a single-payer, improved-Medicare-for-all system, said Dr. Peggy Carey, interim chairperson of the Vermont chapter of Physicians for a National Health Program (PNHP).

Another 54 doctors-in-training, medical students, from around the country have said they’d also consider such a move, Carey said. She pointed to a regional medical student rally set for this Saturday afternoon, March 26, at the Vermont Statehouse in Montpelier as further evidence of health-professional support for a single-payer system. Sen. Bernie Sanders and Gov. Peter Shumlin are among the speakers, she said.

One of the out-of-state doctors who would consider relocating is Scott Graham, a family physician in Marion, Ky. “I would certainly consider moving to Vermont if it passed single payer,” he said. “The idea of having one set of rules, one form for billing, and knowing that all patients are covered – that would be wonderful.”

Another is Dr. Jennifer Voorhees of Philadelphia, who said, “After I complete my family medicine residency, I would welcome practicing anywhere where there were no private, for-profit insurance companies and where everyone had access to health care.”

Yet another is Dr. Corinne Kalser, a hospitalist in Lakeville, Conn., who said, “I would definitely consider relocating. I am fed up with the way things are going, and if Vermont goes with single payer we will have half a chance – or at least one-fiftieth! – to change the national picture, too.”

Dr. Deb Richter, a family physician in Montpelier, is a leader of Vermont for Single Payer. She said: “It’s particularly encouraging to hear from primary care doctors around the country who say they would consider moving here if we had single payer. It would help alleviate a growing shortage of these physicians in our state and assure a good foundation for providing quality to care to all Vermonters.”

Carey, a family physician in Burlington, said: “It’s not surprising that physicians would consider relocating to a state that offered the kind of hassle-free environment that a publicly financed, single-payer system would create. Doctors are fed up with private insurance company dictates and the heavy load of unnecessary paperwork the insurers impose on our medical practices.”

“Like everyone else, doctors are also alarmed skyrocketing costs,” she said. “Every day they see the financial barriers to health care faced not only by uninsured Vermonters, but also by Vermonters who may have coverage but whose insurance policies include huge deductibles, co-pays and uncovered services.”

“Removing the costly middleperson in our state’s health system – the private insurers – and replacing them with a streamlined, nonprofit financing mechanism is the only way to assure high-quality, comprehensive, affordable and sustainable care for all Vermonters,” she said.

As further evidence of physician support for a single-payer plan, Carey pointed to the Jan. 27 “house call” at the Statehouse that featured about 50 doctors who described the difficulties faced by Vermonters in getting the care they need and how a single-payer system would remedy this problem. She also cited a study in the April 2008 edition of the Annals of Internal Medicine, which showed that 59 percent of U.S. physicians now favor government action to establish national health insurance, a jump of 10 percentage points from only five years before.

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The statement signed by the physicians in which they indicate that they would seriously consider moving to Vermont if it were to adopt a single-payer system can be found here.

Physicians for a National Health Program (www.pnhp.org) is an organization of 18,000 physicians who advocate for single-payer national health insurance, an improved Medicare for all. To speak with a physician/spokesperson in your area, visit www.pnhp.org/stateactions or call (312) 782-6006.

The good news about single-payer health care

By Maria Termini
The Bay State Banner, March 17, 2011

Health care in the United State  is in a crisis. Our present health care system is fragmented between multiple private insurance companies and government programs such as Medicare and Medicaid. The system is controlled by the profit making insurance industry and based on each person’s ability to pay and not based on needed medical care. Fifty million people do not have insurance at all. At least 25 million people are underinsured and do not have their medical needs covered. Some plans won’t cover important services, such as prescription drugs, and most plans impose out-of-pocket expenses such as co-payments and high deductibles. The costs of insurance premiums are rising rapidly and consume a huge part of the household budget, and medical costs have led to foreclosures and bankruptcy.

Our current system discriminates against low-income people and leads to poorer health in these communities. The U.S. spends more money on health care per person than any other country in the world, but the sad reality is that we do not have high quality care. Among industrialized nations, the U.S. ranks near the bottom in infant mortality, life expectancy, and the number of people receiving protective vaccines.          

The good news is that we can get out of this spiraling crisis by working together to create a system of single-payer health care that will cover everyone under a single publicly financed insurance plan. Single-payer health care will provide affordable, comprehensive health care, including vision and dental care. Everyone would be free to choose which doctors, hospitals and community health centers to use. All other developed countries have some form of single-payer health care, which has allowed them to guarantee health care for all their citizens and spend about half of what we spend in our country.

The incentive for a single-payer health care system is to keep people healthy with access to preventive care and a focus on early intervention that would catch illness and injury before they become serious and difficult to treat. The incentive for the private insurance industry is to avoid taking care of sick people because it costs them money and results in less corporate gain. Insurance companies make their money by denying policies to people with pre-existing conditions, by dropping coverage for those running up a big bill or having a serious illness and by choosing to insure the healthiest.            

The promise of single-payer health care in Massachusetts is within our grasp. A single-payer health care bill called “Medicare for All Massachusetts” has recently been filed in the legislature. This bill would provide every resident with first class health care and reduce costs to the state, employers, and households.  It will create a comprehensive, public plan, like improved Medicare for all, saving 15.7 percent of Massachusetts’ current health care funding.  Costs would be controlled by eliminating the middle men and administrative bureaucracy of private profit-making insurance companies and by creating one large risk group that includes all the residents of the state to bargain for the best prices for medical services, goods and drugs.  There would also be less overhead costs for providers and hospitals that will no longer need huge billing departments to deal with paperwork. With the current system the administrative costs are about 30 percent of the money spent on health care.  Medicare already works for senior citizens, with a 3 percent overhead cost.  Administrative savings, plus a small payroll tax as well as federal and state money already being used for Medicare, Medicaid and other programs, can fund single-payer health care and save money!

Let’s have Medicare for everyone! Imagine having a health insurance card granting you a full range of medical benefits, with no out-of-pocket expenses and bills! Families of middle and low-income earners would take home 7.3 percent to 15 percent more income after lifting the burden of premiums and other health care costs from their pay.   Single-payer health care can happen if we become educated about it and understand how only single-payer health care can control skyrocketing costs.

Maria Termini is a volunteer with Mass-Care, a coalition of more than 100 groups in Massachusetts working to make health care a right.

http://www.baystatebanner.com/local14-2011-03-17