PNHP

High-deductible health plans foster bad decisions by rich and poor

High-deductible health plans foster bad decisions by rich and poor

Health Care Use and Decision Making Among Lower-Income Families in High-Deductible Health Plans

By Jeffrey T. Kullgren, MD, MPH; Alison A. Galbraith, MD, MPH; Virginia L. Hinrichsen, MS, MPH; Irina Miroshnik, MS; Robert B. Penfold, PhD; Meredith B. Rosenthal, PhD; Bruce E. Landon, MD, MBA; Tracy A. Lieu, MD, MPH

Archives of Internal Medicine
November 22, 2010

From the Introduction:

In early 2009, 23% of all nonelderly adults with private insurance, and nearly 50% of adults who purchased coverage through the nongroup market, were enrolled in an HDHP (high-deductible health plan). Because of their relatively low premiums, HDHPs are also playing a prominent role in expanding insurance coverage. For example, most individuals who have purchased unsubsidized plans through the Commonwealth Connector, the new health insurance exchange in Massachusetts, have selected products like HDHPs that offer low premiums with high levels of cost-sharing.

As enrollment in HDHPs has grown, many analysts have voiced concerns about the impact these plans may have on low-income families. Decades of health services research have demonstrated that higher levels of cost-sharing reduce health care utilization, sometimes with greater adverse consequences for low-income patients.

From the Comment:

We found that lower-income families with at least $500 in annualized out-of-pocket expenditures in an HDHP were more likely than higher-income families to delay or forego health care services owing to cost (57% vs 42%).

Overall, we observed relatively high rates of delayed or foregone care in both income groups, with nearly half of all families having either delayed or foregone care in the last 6 months owing to the cost. These rates were substantially higher than the 20% of the US population reporting either unmet need or delayed care in the previous 12 months in the 2007 Heath Tracking Household Survey.

Beyond the implications for clinicians, our findings have important implications for federal health reform. Reform legislation that establishes an individual health insurance mandate could lead more families to enroll in plans with high levels of cost-sharing, as has been seen following the implementation of coverage mandates in Massachusetts.

http://archinte.ama-assn.org/cgi/content/abstract/170/21/1918

And…

Higher Deductibles, Lower Spending

By Reed Abelson
The New York Times
Prescriptions blog
November 22, 2010

As more families find themselves enrolled in health plans with high deductibles, they are increasingly likely to delay or forgo medical care because of the out-of-pocket cost, a new study shows (the study cited above).

Do you think people are better and more savvy consumers when they share in the cost of their medical care?

Three reader responses:

12. Anonymous BE, Belgium
November 23rd, 2010

NO. Medical care should be free at the point of service. The whole point of health insurance is that no one should be financially worse off because they have health problems. High deductible plans violate this maxim.

Furthermore, people are not in a position to judge what is necessary or not. People listen to what their doctor says, and they do it, unless their lack of insurance coverage makes it a financial problem. Patients are not evaluating the effectiveness of various treatments – that is a job for doctors and scientists, not patients. Patients are not consumers – they are people who are suffering who place themselves in the hands of the medical profession.

13. GoozNews, Washington, DC
November 23rd, 2010

RE: eliminating useful v. non-useful care via higher co-pays. It’s not an open question. The Rand Health Insurance Experiment, the only comprehensive study to date, showed that people were just as like to avoid necessary car as unnecessary care when forced to pay higher co-pays and deductibles. This is also common sense. When the quality of a good, in this case health services, has no relationship to price, and consumers lack accurate and timely information about what constitutes high quality, making rational decisions based on price is virtually impossible. It requires extensive research prior to the point of purchase — highly impractical when it comes to health care, which is usually purchased under the duress of immediate illness. Those who advocate “more skin in the game” as the cure for rising health care costs fail to acknowledge these all-too-human realities, or what an economist might call pervasive marketplace failures.

23. Don McCanne, San Juan Capistrano, CA
November 23rd, 2010

What really matters is our total national health expenditures. We are already spreading the risk by contributing to our public and private insurance pools through taxes and/or premiums. So we should decide whether the financial barriers to care that high-deductible health plans create are worth the projected savings in our total health care spending.

Only one-fifth of us use four-fifths of all health care. For this sector of our population, deductibles are rapidly exceeded and have virtually no impact on total national health care spending. (It is in this sector where most of the Dartmouth variations occur, but that is another topic.)

For the four-fifths of us who are relatively healthy, most of us would not decline clearly appropriate care even if it is below the deductible, providing that we had the ability to pay for it. Only the worried-well, perhaps with a common cold, might use the health care system more than necessary, but that doesn’t apply to most of us.

Although the trip to the doctor is almost always for legitimate reasons, perhaps ten percent of the time the marginal care offered might reasonably be declined, providing it is an informed decision. Studies show that about half of that care is still appropriate, so only five percent of care for healthier patients may be of no more value than receiving reassurance that no care is needed (which actually does have value in itself).

Since the four-fifths of us who are healthy consume only twenty percent of total health care, the five percent of our care that might deemed to be inappropriate constitutes only one percent of our national health expenditures (five percent of twenty percent). That one percent is the equivalent of only two or three months of health care inflation – not worthy of more than a footnote in our national health care budget.

We can control health care costs, but high-deductible health plans are not an effective mechanism. They certainly are not worth the price of denying beneficial care based on individual concerns over affordability.

Every other nation has controlled costs by establishing an effective model of social insurance. Unfortunately the model in the Patient Protection and Affordable care Act falls far short. What would work would be to improve the Medicare program and then include everyone. Several studies have shown that it would be the least expensive method of providing affordable care for absolutely everyone.

http://prescriptions.blogs.nytimes.com/2010/11/22/higher-deductibles-lower-spending/

Comment:

By Don McCanne, MD

This study of the impact of high-deductible health plans is unique in that it studied only families with over $500 in annual out-of-pocket medical expenses, thus they are families that do have some interaction with the health care system.

It is no surprise that 57 percent of these
lower-income families with high-deductible health plans delayed or had foregone health care. What is less intuitive is that 42 percent of the higher-income families with high-deductible health plans also delayed or had foregone health care. Other studies indicate that about half of that care would have been beneficial, so we really should question the policy of using high-deductible health plans as a method of containing health care costs.

Another important concern is that individuals purchasing plans from the Massachusetts health insurance exchange are choosing high-deductible plans because of the lower premiums. The state exchanges to be established under the Patient Protection and Affordable Care Act will offer low-actuarial value plans as the standard. These plans are high-deductible plans that will likely attract most buyers. Bad policy.

When the evidence so clearly indicts high-deductible plans, why did Congress adopt them wholesale? Simply to accommodate the private insurers in preserving their markets by trying to keep their premiums affordable (which they’re not anyway).

It’s time to dump the private insurers and establish an improved Medicare for all, with first dollar coverage. We can control costs far better with the other single payer tools that would be at our disposal.

New health care law fails to make the grade

By MARGARET FLOWERS
Capital Times (Madison, Wis.), Nov. 22, 2010

When it comes to health insurance coverage, Wisconsin receives a B in comparison to other states, but only because it’s graded on a curve. The state’s 9.5 percent uninsured rate falls considerably below the national average of 16.7, but that’s not much consolation to residents who remain uninsured or who are covered by skimpy policies with big deductibles and co-pays.

The Census Bureau reports that the number of uninsured in the U.S. jumped 10 percent to 51 million people in 2009. This is the greatest jump since data have been collected. The jump would have been more than 20 percent if not for public programs like BadgerCare.

No other rich nation experiences such high levels of people without access to health care and the resultant suffering and death. For example, a study in the American Journal of Public Health shows that in the United States nearly 45,000 deaths annually can be linked to lack of health insurance. That’s over 120 preventable deaths every day.

Even those who have health insurance are unprotected. A growing number of people have insurance policies that require high co-pays, deductibles and other out-of-pocket expenses. These “cost-sharing” measures are serious obstacles to getting care. The majority of people who go bankrupt from medical bills have insurance when they get sick. Private health insurance is like an umbrella that melts in the rain — it may not be there when you need it most.

Sadly, the new federal health law fails to make the grade. Even the Congressional Budget Office estimates that 23 million people will still lack coverage in 2019 after the health legislation is fully implemented. The Centers for Medicare and Medicaid Services reports that health care costs will rise more quickly under the new law than if there had been no health bill.

A potent example of what to expect occurred when the recent provision preventing health insurers from denying new policies to children with pre-existing conditions kicked in. The day before this protection went into effect, insurers like WellPoint, UnitedHealth Group, Aetna, Cigna and Humana announced that they would no longer offer new policies to individual children.

What can we conclude about the new legislation? It further enriches and empowers the very industries which are at the heart of the problem. As long as private insurers occupy a commanding role in our health system, we will never achieve universal or affordable care. Insurers make money by enrolling the healthy, screening out the sick, denying claims and raising premiums.

There is a solution that receives top marks: a single-payer national health insurance program, commonly referred to as improved Medicare for all. Single-payer means that our health care dollars are pooled in a single public fund that pays for a universal health care system. This is estimated to save $400 billion, which would cover those who need care. Surveys show this approach is supported by two-thirds of the population.

Improved Medicare for all means every person living in the United States would be guaranteed high-quality care from birth to death. Coverage would be comprehensive, including dental care, vision care, mental health services and prescriptions. And the working and middle class would pay less for health care because of the increased efficiency of a single-payer system.

Patients would choose their physician and health facility, and decisions about treatment would be made by patients and their health professionals without interference by insurance company bureaucrats.

While the health care crisis may not be obvious in Madison, the effects are felt in Wisconsin and across the nation. We must work with renewed energy and commitment for a national health program that addresses our fundamental problems. Everybody in, nobody out.

Dr. Margaret Flowers, who spoke recently in Madison, resides in Baltimore and serves as congressional fellow for Physicians for a National Health Program. She is also a board member of Healthcare-Now.

http://host.madison.com/ct/news/opinion/column/article_eda0df58-9679-5f14-8fed-d41921476906.html

High-deductible health plans foster bad decisions by rich and poor

Health Care Use and Decision Making Among Lower-Income Families in High-Deductible Health Plans

By Jeffrey T. Kullgren, MD, MPH; Alison A. Galbraith, MD, MPH; Virginia L. Hinrichsen, MS, MPH; Irina Miroshnik, MS; Robert B. Penfold, PhD; Meredith B. Rosenthal, PhD; Bruce E. Landon, MD, MBA; Tracy A. Lieu, MD, MPH

Archives of Internal Medicine
November 22, 2010

From the Introduction:

In early 2009, 23% of all nonelderly adults with private insurance, and nearly 50% of adults who purchased coverage through the nongroup market, were enrolled in an HDHP (high-deductible health plan). Because of their relatively low premiums, HDHPs are also playing a prominent role in expanding insurance coverage. For example, most individuals who have purchased unsubsidized plans through the Commonwealth Connector, the new health insurance exchange in Massachusetts, have selected products like HDHPs that offer low premiums with high levels of cost-sharing.

As enrollment in HDHPs has grown, many analysts have voiced concerns about the impact these plans may have on low-income families. Decades of health services research have demonstrated that higher levels of cost-sharing reduce health care utilization, sometimes with greater adverse consequences for low-income patients.

From the Comment:

We found that lower-income families with at least $500 in annualized out-of-pocket expenditures in an HDHP were more likely than higher-income families to delay or forego health care services owing to cost (57% vs 42%).

Overall, we observed relatively high rates of delayed or foregone care in both income groups, with nearly half of all families having either delayed or foregone care in the last 6 months owing to the cost. These rates were substantially higher than the 20% of the US population reporting either unmet need or delayed care in the previous 12 months in the 2007 Heath Tracking Household Survey.

Beyond the implications for clinicians, our findings have important implications for federal health reform. Reform legislation that establishes an individual health insurance mandate could lead more families to enroll in plans with high levels of cost-sharing, as has been seen following the implementation of coverage mandates in Massachusetts.

http://archinte.ama-assn.org/cgi/content/abstract/170/21/1918

And…

Higher Deductibles, Lower Spending

By Reed Abelson
The New York Times
Prescriptions blog
November 22, 2010

As more families find themselves enrolled in health plans with high deductibles, they are increasingly likely to delay or forgo medical care because of the out-of-pocket cost, a new study shows (the study cited above).

Do you think people are better and more savvy consumers when they share in the cost of their medical care?

Three reader responses:

12. Anonymous BE, Belgium
November 23rd, 2010

NO. Medical care should be free at the point of service. The whole point of health insurance is that no one should be financially worse off because they have health problems. High deductible plans violate this maxim.

Furthermore, people are not in a position to judge what is necessary or not. People listen to what their doctor says, and they do it, unless their lack of insurance coverage makes it a financial problem. Patients are not evaluating the effectiveness of various treatments – that is a job for doctors and scientists, not patients. Patients are not consumers – they are people who are suffering who place themselves in the hands of the medical profession.

13. GoozNews, Washington, DC
November 23rd, 2010

RE: eliminating useful v. non-useful care via higher co-pays. It’s not an open question. The Rand Health Insurance Experiment, the only comprehensive study to date, showed that people were just as like to avoid necessary car as unnecessary care when forced to pay higher co-pays and deductibles. This is also common sense. When the quality of a good, in this case health services, has no relationship to price, and consumers lack accurate and timely information about what constitutes high quality, making rational decisions based on price is virtually impossible. It requires extensive research prior to the point of purchase — highly impractical when it comes to health care, which is usually purchased under the duress of immediate illness. Those who advocate “more skin in the game” as the cure for rising health care costs fail to acknowledge these all-too-human realities, or what an economist might call pervasive marketplace failures.

23. Don McCanne, San Juan Capistrano, CA
November 23rd, 2010

What really matters is our total national health expenditures. We are already spreading the risk by contributing to our public and private insurance pools through taxes and/or premiums. So we should decide whether the financial barriers to care that high-deductible health plans create are worth the projected savings in our total health care spending.

Only one-fifth of us use four-fifths of all health care. For this sector of our population, deductibles are rapidly exceeded and have virtually no impact on total national health care spending. (It is in this sector where most of the Dartmouth variations occur, but that is another topic.)

For the four-fifths of us who are relatively healthy, most of us would not decline clearly appropriate care even if it is below the deductible, providing that we had the ability to pay for it. Only the worried-well, perhaps with a common cold, might use the health care system more than necessary, but that doesn’t apply to most of us.

Although the trip to the doctor is almost always for legitimate reasons, perhaps ten percent of the time the marginal care offered might reasonably be declined, providing it is an informed decision. Studies show that about half of that care is still appropriate, so only five percent of care for healthier patients may be of no more value than receiving reassurance that no care is needed (which actually does have value in itself).

Since the four-fifths of us who are healthy consume only twenty percent of total health care, the five percent of our care that might deemed to be inappropriate constitutes only one percent of our national health expenditures (five percent of twenty percent). That one percent is the equivalent of only two or three months of health care inflation – not worthy of more than a footnote in our national health care budget.

We can control health care costs, but high-deductible health plans are not an effective mechanism. They certainly are not worth the price of denying beneficial care based on individual concerns over affordability.

Every other nation has controlled costs by establishing an effective model of social insurance. Unfortunately the model in the Patient Protection and Affordable care Act falls far short. What would work would be to improve the Medicare program and then include everyone. Several studies have shown that it would be the least expensive method of providing affordable care for absolutely everyone.

http://prescriptions.blogs.nytimes.com/2010/11/22/higher-deductibles-lower-spending/

This study of the impact of high-deductible health plans is unique in that it studied only families with over $500 in annual out-of-pocket medical expenses, thus they are families that do have some interaction with the health care system.

It is no surprise that 57 percent of these lower-income families with high-deductible health plans delayed or had foregone health care. What is less intuitive is that 42 percent of the higher-income families with high-deductible health plans also delayed or had foregone health care. Other studies indicate that about half of that care would have been beneficial, so we really should question the policy of using high-deductible health plans as a method of containing health care costs.

Another important concern is that individuals purchasing plans from the Massachusetts health insurance exchange are choosing high-deductible plans because of the lower premiums. The state exchanges to be established under the Patient Protection and Affordable Care Act will offer low-actuarial value plans as the standard. These plans are high-deductible plans that will likely attract most buyers. Bad policy.

When the evidence so clearly indicts high-deductible plans, why did Congress adopt them wholesale? Simply to accommodate the private insurers in preserving their markets by trying to keep their premiums affordable (which they’re not anyway).

It’s time to dump the private insurers and establish an improved Medicare for all, with first dollar coverage. We can control costs far better with the other single payer tools that would be at our disposal.

CBO analysis of the Rivlin/Ryan Medicare voucher and Medicaid block grant proposals

Preliminary Analysis of the Rivlin-Ryan Health Care Proposal

(Analysis transmitted by letter from Douglas Elmendorf, Director of the CBO, to Rep. Paul Ryan)
Congressional Budget Office
November 17, 2010

For purposes of this analysis, CBO assumed that all individuals projected to enroll in Medicare would use the proposed voucher. Voucher recipients would probably have to purchase less extensive coverage or pay higher premiums than they would under current law, for two reasons. First, most of the savings for Medicare under the proposal stem from reducing the amounts that the federal government would pay for enrollees on a per capita basis, relative to the projections under current law. Second, future beneficiaries would probably face higher premiums in the private market for a package of benefits similar to that currently provided by Medicare.

Similarly, reducing federal payments for Medicaid relative to currently projected amounts would probably require states to provide less extensive coverage, or to pay a larger share of the program’s total costs, than would be the case under current law.

For both Medicare and Medicaid, the budgetary effects would become larger over time because federal payments would tend to grow more slowly under the proposal than projected costs per enrollee under current law. Although the level of expected federal spending and the uncertainty surrounding that spending would decline, enrollees’ spending for health care and the uncertainty surrounding that spending would increase.

http://www.cbo.gov/ftpdocs/119xx/doc11966/11-17-Rivlin-Ryan_Preliminary_Analysis.pdf

Comment: 

By Don McCanne, MD

Congressman Paul Ryan and former Clinton budget director Alice Rivlin are both members of the Bowles/Simpson deficit commission. They have asked the Congressional Budget Office to analyze their proposal to reduce future federal health care expenditures by converting Medicare to a voucher program for purchasing private health plans, and by converting Medicaid into a block-grant program for the states.

If you read the analysis found at the link above, you would see that the deficits related to future spending in the Medicare and Medicaid programs would be reduced by this proposal. If your only goal is to cut the federal deficit, then the analysis would predict success, but at what cost?

Compared to the current Medicare program, the vouchers would purchase less coverage, or the premiums paid by the beneficiaries would be higher, or both. Merely shifting to private plans alone would result in higher premiums if the benefits were to remain the same as in the traditional Medicare program. Many Medicare beneficiaries are already burdened with excess medical debt, and the voucher proposal would increase the burden by both lowering the federal contribution and increasing the administrative waste characteristic of private plans.

Converting Medicaid into a block grant program uses the same principle as converting defined benefit programs into defined contribution programs. The federal government ends its exposure to the risk of ever-increasing costs by fixing its contribution to the states through a defined block grant. The state then bears the risk for increases in health care costs.

Of course, states are already heavily burdened by the costs of their Medicaid programs. Adding more to that burden further strains state budgets. The states are then put into a position of trying to balance reductions in health services with the greater deficit holes punched into the state budgets. Passing the problem from the federal taxpayer to the state taxpayer accomplishes nothing.

As the CBO analysis states, “Although the level of expected federal spending and the uncertainty surrounding that spending would decline, enrollees’ spending for health care and the uncertainty surrounding that spending would increase.”

What is our goal here? Appeasing anti-government budget hawks? Or removing financial barriers so that people can get the health care that they need?

The budget hawks say that we need to make hard choices. So what about the choice of a single payer monopsony – an improved Medicare for all? That would solve the budget deficit problem while enabling everyone to have the care that they need – not really very hard choices. Maybe it would be a hard choice for the hawks to accept a government program that would actually work, but let’s hold them to their demand. If they think an improved Medicare for all is a hard choice, then so be it.

Health Care is a Human Rights Issue

By Ronald W. Pies, MD
Psychiatric Times, Nov. 15, 2010

COUCH IN CRISIS

Some see health care as a political or economic issue. They are correct, of course, on one level. But I believe that health care is fundamentally a moral issue; indeed, a matter of basic human rights. I do not believe that a nation as rich as ours (albeit with most wealth concentrated among the upper income levels) can shirk its moral responsibilities in the matter of providing basic health care for all its citizens. This doesn’t mean that everybody who wants a face-lift should get one on the taxpayer’s dime: I am talking about providing all citizens with the most basic health care, required to sustain life and limb. And, yes: I believe this is a right that any citizen may claim, particularly in a country purporting to be “civilized.”

I am hardly alone in this view, nor is my position new. In 1948, the General Assembly of the United Nations adopted The Universal Declaration of Human Rights, article 25 of which states:

“Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.”

I don’t pretend to be an expert on health care economics, and I am aware of significant logistical problems in some countries that provide health care to all their citizens; e.g., very long waiting lists for elective procedures. I am not advocating the infamous “government takeover” of health care that has been so much a part of recent political diatribes from some quarters. Rather, I favor a single-payer national health insurance system. One ambitious proposal describes this as

“…a system in which a single public or quasi-public agency organizes health financing, but delivery of care remains largely private. Under a single-payer system, all Americans would be covered for all medically necessary services, including: doctor, hospital, preventive, long-term care, mental health, reproductive health care, dental, vision, prescription drug and medical supply costs. Patients would [retain] free choice of doctor and hospital, and doctors would [retain] autonomy over patient care.” —Source: Physicians for a National Health Program

I would urge all psychiatrists to read over the FAQ section of this website. The PNHP site also notes the following:

“A number of studies (notably a General Accounting Office report in 1991 and a Congressional Budget Office report in 1993) show that there is more than enough money in our health care system to serve everyone if it were spent wisely. Administrative costs are at 31% of U.S. health spending, far higher than in other countries’ systems. These inflated costs are due to our failure to have a publicly financed, universal health care system. We spend about twice as much per person as Canada or most European nations, and still deny health care to many in need. A national health program could save enough on administration to assure access to care for all Americans, without rationing.” —Source: Physicians for a National Health Program

On the specific issue of mental health care, we have a long way to go as a nation. For example, many patients with depression—particularly some minority groups—are not being provided adequate care. Contrary to the much-ballyhooed claim that “depression is over-treated” in this country, a recent study1 suggests that many Americans with clinical depression are not getting any kind of care at all. As the lead author, Hector Gonzalez, MD, put it in an interview with the Wall Street Journal, ““Few Americans with depression actually get any kind of care, and even fewer get care consistent with the [best practice] standards of care.”2 Gonzalez and colleagues found, in particular, that Mexican American and African American individuals meeting 12-month major depression criteria “…consistently and significantly had lower odds for any depression therapy and guideline-concordant therapies.”1

In this country, according to a 2002 study by the Institute of Medicine, 18,000 Americans die every year because they don’t have health insurance.3 Almost certainly, some of these individuals die by their own hand, owing to untreated major depression. This is simply unconscionable, particularly in the nation with the highest GDP in the world. Recent changes in health care coverage will improve things for many thousands of Americans,4, but much more must be done. A publicly financed, universal health care system, while not without its own costs and problems, is worth trying—and is surely preferable to our current health care debacle. It is also the right thing to do.

For the Couch in Crisis blog that prompted Dr. Pies’ commentary, please see Diagnostic Criteria for PIISD – Private Insurance Induced Stress Disorder.

References
1. González HM, Vega WA, Williams DR, et al. Depression care in the United States: too little for too few. Arch Gen Psychiatry. 2010;67:37-46.
2. Wang SS. Studies: Mental Ills Are Often Overtreated, Undertreated. Wall Street Journal. Jan. 5, 2010. http://online.wsj.com/article/SB10001424052748703580904574638750777038042.html. Accessed November 15, 2019.
3. Care Without Coverage: Too Little, Too Late. http://www.iom.edu/Reports/2002/Care-Without-Coverage-Too-Little-Too-Late.aspx. Accessed November 15, 2019.
4. U.S. Department of Health and Human Services. Understanding the Affordable Care Act: Introduction. http://www.healthcare.gov/law/introduction/index.html. Accessed November 15, 2019.

http://www.psychiatrictimes.com/blog/couchincrisis/content/article/10168/1724080?GUID=5CD431AE-B535-439A-B654-871119CCDBBA&rememberme=1

Beware high out-of-pocket costs for Medicare recipients

Letters
The Seattle Times, Nov. 18, 2010

Froma Harrop’s column does a disservice to the deficit-reduction discussion by failing to mention that the co-chairs’ proposal would require Medicare recipients to pay more out-of-pocket costs, while reducing their benefits [“Give deficit plan a chance, liberals,” Opinion, Nov. 17]. Such barriers to care result in poorer health outcomes and increased suffering.

The typical Medicare beneficiary, already on low income, pays 15 percent of it on medical care, whereas health-policy experts consider spending more than 10 percent of income on health care as a real hardship, even for the average American family. Harrop asks Aunt Mary, a liberal scrambling to live on Social Security, to play her part in reducing our deficit by accepting the “hard choice” to pay more for her heart medications.

Skyrocketing health-care costs are a major component of our deficit and the new health-care legislation does little to change this trajectory. The best way to decrease the deficit would be to bring our health-care spending under control by enacting an improved and expanded Medicare for all, an equitable system similar to the rest of the industrialized world, where medical costs are half what we spend, with improved quality of care.

— David McLanahan, board member, Physician for a Nation Health Program, Western Washington Chapter, Seattle

http://seattletimes.nwsource.com/html/northwestvoices/2013466229_columnistharropdeficitplanyeswecan.html

Vital Signs: National organizers find Madison single-payer movement alive and kicking

By SHAWN DOHERTY
The Capital Times (Madison, Wis.), Nov. 21, 2010

Dr. Margaret Flowers, a leader of the single-payer health care movement, was in town this week to drum up support for the Madison chapter of Physicians for a National Health Program (PNHP). The Baltimore pediatrician was arrested on the floor of the U.S. Senate in 2009 during the health care hearings for trying to get a seat at the bargaining table. I decided to check out a couple of her events to see what she had to say now about the state of single-payer reform, commonly referred to as “Medicare for All.”

I also wanted to find out what her audience had to say. How were local health care activists feeling in the wake of a nasty electoral beating? Maybe I could blog about how depressed they all were, I thought. If they even showed up. A lot of “experts” have declared their cause a goner.

Well, the fight for single-payer health care reform ain’t dead yet. Or, if it is, some people are in denial.

Around 60 people showed up at Madison’s Labor Temple to talk with Flowers on Wednesday, and 40 at a Friday fundraiser at the EVP Coffee House on Mineral Point, and they seemed more fired up than they have been for a couple of years now, almost as fired up as they were in the heady days of the Obama campaign. Republican victories and problems with the national health care act have only made them more determined, some said. “It’s not depressing, it’s motivating,” said Meaghan Combs, a resident at the UW Madison School of Medicine.

Alexandra Thebert, PNHP’s national organizer, said fundraising and membership are growing faster this year than last year, when the group was shoved aside in the push to pass Obama’s more moderate reforms. “It’s more frenetic than ever,” she claims. “We’re swamped up to the gills.”

Are they in dreamland? Not at all, she said. But the rest of the country is. Our current system of is unsustainable, Thebert said. Even if Obama’s reforms withstand Republican attacks, they are “totally doomed,” she said. “Costs will skyrocket and millions of people still won’t be covered. What we’re doing is educating people so that when it collapses they know about a system that works.”

The mood at these gatherings was defiant. Flowers greeted the crowd Friday with a sarcastic joke. “I’m a little puzzled,” she said. “Why is everybody here? Didn’t we already pass health care reform?” “No!” the audience shouted. “We are undaunted,” Flowers said. “The insurance companies have tremendous resources, but we can match them with our spirit.”

At Wednesday’s session, a listener asked about what some people see as a downside of single-payer reform. “What will happen to the insurance companies?” she asked. “They’ll go to hell!” several audience members retorted, as others laughed.

There were the same old familiar faces, minus one of the most beloved, staunch single-payer champion Dr. Linda Farley, who died in 2009. Her husband, Dr. Gene Farley, showed up, with Wisconsin labor leader David Newby, now retired. State Sen. Mark Miller, D-Monona, was also there, and outgoing state Rep. Chuck Benedict, D-Beloit, both past sponsors of failed state legislation with single-payer provisions in them. And a passel of longtime activists and doctors, including Laurel Mark, head of the Madison PNHP chapter and a family practitioner with UW Health. Mark sported a pin she had first worn to a march in New York City in 1975. It read: “Healthcare for People Not Profit.”

Mark said she had invited the national organizers to come to town and stay at her house even before this month’s election to infuse the local movement with new energy, dollars, and members. “We’re not just going to sit in a corner and be depressed and suck our thumbs,” she said. “We are going to move this forward.”

It is time, Flowers told supporters, to shift their efforts from getting Obama elected, and then trying (mostly in vain) to have a say in the national legislation, to pushing for action at the state level. Vermont legislators have already hired a Harvard consultant to draft plans for a statewide single-payer program.

Our country pays more than any other industrialized country for its health care yet gets much less in terms of fairness and affordability, according to surveys. Republican and Tea Party critics of the current system blame big government; single-payer activists blame big industry. The U.S. is the only industrialized nation “stupid enough,” Dr. Farley said, to allow corporate profits to run the show. Rep. Benedict, a retired neurologist, also blamed our health care crisis on what he called “the profiteers,” noting that he believed “health care ought to be a right.”

Republicans like to interpret their recent victories as a mandate to dismantle health care reform. But polls show the situation is more nuanced than that. Many people unhappy with the national reforms are single payer advocates who felt it did not go far enough. So Republican efforts to dismantle it completely could backfire, activists say, leading to another electoral shakeup. “They might throw everybody out again in another two years and we’ve got to be ready,” said Susan Carson, a retired Madison physician. “The Republicans are going to do everything they can to bollix up reform,” agreed state Sen. Miller, soon to become the minority leader. “That can present us with another opportunity.”

There was a bit of an I-told-you-so feeling in the meetings I attended, a belief that if Obama had not backed away from his campaign support of single-payer reform then Democrats might not have been clobbered so heartily at the voting booths. Politicians would have been seen as more forceful, and progressive voters may have been more motivated to vote, the theory went. It’s not that hardcore single-payer supporters were gloating, exactly. But they were angry. “It’s important that people realize that the labor unions and more moderate health care organizations worked with Barack Obama to make sure we were marginalized,” said John Stauber, founder of the Center for Media and Democracy, at Wednesday’s meeting. “A lot of people in this room were played for suckers.”

Such bitterness creates what Mark called a “dilemma” for some of the activists, who wondered out loud whether they should bother to defend a national health care law they never really believed in or simply focus on pushing for a single-payer system again. Dr. Marc Hansen said Obama’s efforts deserved more support than the “faint praise” they were getting from the group. “We better protect what’s been gained before we kick it out the door,” he argued.

Several in the crowd compared the single-payer movement with all its ups and downs to the Civil Rights battle and the fight for a woman’s right to vote, and predicted that ultimately they will win this historical struggle, too. “We are not going to stop,” said Karen Matteoni, a Madison mother and retired utility worker.

Flowers also conducted grand rounds with doctors at local hospitals during the week and met with around 50 UW-Madison medical students, five of whom pledged to start a PNHP chapter at their school.

All in all, it was a good week, Mark said. “It was a disastrous election for us, let’s face it,” she said. “Nonetheless, I saw much more optimism than I had expected. People are still engaged and willing to keep working. And that’s what we need to do.”

http://host.madison.com/ct/news/local/health_med_fit/vital_signs/article_26495ce6-f4db-11df-ad34-001cc4c002e0.html

CBO analysis of the Rivlin/Ryan Medicare voucher and Medicaid block grant proposals

Preliminary Analysis of the Rivlin-Ryan Health Care Proposal

(Analysis transmitted by letter from Douglas Elmendorf, Director of the CBO, to Rep. Paul Ryan)
Congressional Budget Office
November 17, 2010

For purposes of this analysis, CBO assumed that all individuals projected to enroll in Medicare would use the proposed voucher. Voucher recipients would probably have to purchase less extensive coverage or pay higher premiums than they would under current law, for two reasons. First, most of the savings for Medicare under the proposal stem from reducing the amounts that the federal government would pay for enrollees on a per capita basis, relative to the projections under current law. Second, future beneficiaries would probably face higher premiums in the private market for a package of benefits similar to that currently provided by Medicare.

Similarly, reducing federal payments for Medicaid relative to currently projected amounts would probably require states to provide less extensive coverage, or to pay a larger share of the program’s total costs, than would be the case under current law.

For both Medicare and Medicaid, the budgetary effects would become larger over time because federal payments would tend to grow more slowly under the proposal than projected costs per enrollee under current law. Although the level of expected federal spending and the uncertainty surrounding that spending would decline, enrollees’ spending for health care and the uncertainty surrounding that spending would increase.

http://www.cbo.gov/ftpdocs/119xx/doc11966/11-17-Rivlin-Ryan_Preliminary_Analysis.pdf

Congressman Paul Ryan and former Clinton budget director Alice Rivlin are both members of the Bowles/Simpson deficit commission. They have asked the Congressional Budget Office to analyze their proposal to reduce future federal health care expenditures by converting Medicare to a voucher program for purchasing private health plans, and by converting Medicaid into a block-grant program for the states.

If you read the analysis found at the link above, you would see that the deficits related to future spending in the Medicare and Medicaid programs would be reduced by this proposal. If your only goal is to cut the federal deficit, then the analysis would predict success, but at what cost?

Compared to the current Medicare program, the vouchers would purchase less coverage, or the premiums paid by the beneficiaries would be higher, or both. Merely shifting to private plans alone would result in higher premiums if the benefits were to remain the same as in the traditional Medicare program. Many Medicare beneficiaries are already burdened with excess medical debt, and the voucher proposal would increase the burden by both lowering the federal contribution and increasing the administrative waste characteristic of private plans.

Converting Medicaid into a block grant program uses the same principle as converting defined benefit programs into defined contribution programs. The federal government ends its exposure to the risk of ever-increasing costs by fixing its contribution to the states through a defined block grant. The state then bears the risk for increases in health care costs.

Of course, states are already heavily burdened by the costs of their Medicaid programs. Adding more to that burden further strains state budgets. The states are then put into a position of trying to balance reductions in health services with the greater deficit holes punched into the state budgets. Passing the problem from the federal taxpayer to the state taxpayer accomplishes nothing.

As the CBO analysis states, “Although the level of expected federal spending and the uncertainty surrounding that spending would decline, enrollees’ spending for health care and the uncertainty surrounding that spending would increase.”

What is our goal here? Appeasing anti-government budget hawks? Or removing financial barriers so that people can get the health care that they need?

The budget hawks say that we need to make hard choices. So what about the choice of a single payer monopsony – an improved Medicare for all? That would solve the budget deficit problem while enabling everyone to have the care that they need – not really very hard choices. Maybe it would be a hard choice for the hawks to accept a government program that would actually work, but let’s hold them to their demand. If they think an improved Medicare for all is a hard choice, then so be it.

Sen. Bernie Sanders: 'Vermont stands a chance to be the first state in the nation to pass single-payer'

By Ezra Klein
The Washington Post, Nov. 18, 2010

Sen. Bernie Sanders (I-Vt.) has long supported state waivers in the health-care bill, and for a very specific reason: He’d like to see Vermont create the first single-payer system in the nation, as he believes it’ll demonstrate enough cost and quality advantages that other states will want to follow suit. We spoke by phone last night, and a lightly edited transcript of our conversation follows.

Ezra Klein: You worked hard on getting the original version of the state waiver into the legislation. Why? Liberals aren’t usually associated with federalist approaches.

Bernie Sanders: As a single-payer advocate, I believe that at the end of the day, if a state goes forward and passed an effective single-payer program, it will demonstrate that you can provide quality health care to every man, woman and child in a more cost-effective way. So we wanted to make sure that states have that option, we wanted it to be available when the bill gets implemented in 2014. But we ran into the most insane objections from the Congressional Budget Office.

Is that why it got pushed back to 2017?

Our argument was we don’t want any more money from the federal government. When the bill is implemented, let the states use the money the federal government would already be paying to implement single-payer. The CBO came up with one of the weirder counterarguments we’ve ever heard. The CBO said we think the states are smarter than the federal government and they’ll outmaneuver the feds to get more money. So we were forced by the CBO — not by anybody in the Congress — to push it back to 2017. And I agreed to that very reluctantly.

So what happens if Scott Brown and Ron Wyden get their way and the waiver moves up to 2014? Will Vermont use it?

We believe Vermont stands a chance to be the first state in the nation to pass single-payer. The governor-elect campaigned on it, and we have support in the House and Senate. We’re not asking for one nickel more than we’d otherwise get. The other thing we think we have an opportunity to do is reach out to our conservative friends and say, hey, Vermont wants to go forward with a single-payer system, and Mississippi and Alabama don’t, but maybe they have other ideas. Now, we’re conscious of the need to make sure that the health-care reform bill’s standards aren’t diminished. So everyone needs to provide the same quality of health care as the bill provides and at the same, or lower, price. But if they can do that, then they should be able to go for it.

And then the various models can compete with one another and, presumably, spread to other states if successful?

Absolutely. And that’s what we wanted from it. In my state, it’ll be single-payer. In California, I think there’s a chance it could be single-payer. In other states, it will be something else. This makes the states laboratories for the system, and then other states can copy them. Now, you need a minimum level for coverage and quality. You can’t go lower than health-care reform.

Sen. Bernie Sanders: ‘Vermont stands a chance to be the first state in the nation to pass single-payer’

By Ezra Klein
The Washington Post, Nov. 18, 2010

Sen. Bernie Sanders (I-Vt.) has long supported state waivers in the health-care bill, and for a very specific reason: He’d like to see Vermont create the first single-payer system in the nation, as he believes it’ll demonstrate enough cost and quality advantages that other states will want to follow suit. We spoke by phone last night, and a lightly edited transcript of our conversation follows.

Ezra Klein: You worked hard on getting the original version of the state waiver into the legislation. Why? Liberals aren’t usually associated with federalist approaches.

Bernie Sanders: As a single-payer advocate, I believe that at the end of the day, if a state goes forward and passed an effective single-payer program, it will demonstrate that you can provide quality health care to every man, woman and child in a more cost-effective way. So we wanted to make sure that states have that option, we wanted it to be available when the bill gets implemented in 2014. But we ran into the most insane objections from the Congressional Budget Office.

Is that why it got pushed back to 2017?

Our argument was we don’t want any more money from the federal government. When the bill is implemented, let the states use the money the federal government would already be paying to implement single-payer. The CBO came up with one of the weirder counterarguments we’ve ever heard. The CBO said we think the states are smarter than the federal government and they’ll outmaneuver the feds to get more money. So we were forced by the CBO — not by anybody in the Congress — to push it back to 2017. And I agreed to that very reluctantly.

So what happens if Scott Brown and Ron Wyden get their way and the waiver moves up to 2014? Will Vermont use it?

We believe Vermont stands a chance to be the first state in the nation to pass single-payer. The governor-elect campaigned on it, and we have support in the House and Senate. We’re not asking for one nickel more than we’d otherwise get. The other thing we think we have an opportunity to do is reach out to our conservative friends and say, hey, Vermont wants to go forward with a single-payer system, and Mississippi and Alabama don’t, but maybe they have other ideas. Now, we’re conscious of the need to make sure that the health-care reform bill’s standards aren’t diminished. So everyone needs to provide the same quality of health care as the bill provides and at the same, or lower, price. But if they can do that, then they should be able to go for it.

And then the various models can compete with one another and, presumably, spread to other states if successful?

Absolutely. And that’s what we wanted from it. In my state, it’ll be single-payer. In California, I think there’s a chance it could be single-payer. In other states, it will be something else. This makes the states laboratories for the system, and then other states can copy them. Now, you need a minimum level for coverage and quality. You can’t go lower than health-care reform.

An Interview About National Health Insurance

By Ellen R. Hale
Louisville Medicine, Nov 2010

Garrett Adams, MD, MPH, spent 40 years practicing medicine as a pediatrician, as chief of Pediatric Infectious Diseases at the University of Louisville School of Medicine, and as medical director of communicable diseases at the Louisville Metro Department of Public Health and Wellness. In January, he will begin serving as the president of Physicians for a National Health Program, which since 1987 has been the only national physician organization in the United States dedicated exclusively to implementing a singlepayer national health program. As proposed by PNHP, the system would have public funding but private delivery of care. “Under a single-payer system, all Americans would be covered for all medically necessary services, including: doctor, hospital, preventive, long-term care, mental health, reproductive health care, dental, vision, prescription drug and medical supply costs,” according to www.pnhp.org. The Louisville Medicine Editorial Board drafted a list of questions for Dr. Adams. GLMS Communications Associate Ellen Hale interviewed him on the board’s behalf.

Q: How did you become involved in promoting a single-payer national health program?

A: In 2003, I read this JAMA article on the “Proposal of the Physicians’ Working Group for Single-Payer National Health Insurance.” I thought, that just makes sense. I went to the website and endorsed it. At that time, there were 8,000 physicians who had endorsed it; today there are 17,000. I began to think about the way medical care had changed during my years of experience. Doctors were taken away from their patients, and I began to realize that the way medical care was being paid for had really intruded into the physician-patient relationship.

A lot of Americans and even some physicians are not aware of the great disparity in the ability to deliver quality health care among the United States and other developed countries. We’re way behind in terms of the efficiency and in terms of quality. And there’s this unjustified idea that we have “the best health care in the world.” It may be true in isolated instances, but overall it’s just wrong. We’re being dragged back by this market-driven, profit-driven system that has really put a damper on our ability to provide quality care for everyone in this country.

Q: What do you hope to accomplish as president of PNHP?

A: We’d like to grow the organization, particularly in the South. One of our goals will be to spread the message of the advantages of a national health system to people who will benefit from it. Some of the worst health statistics are in the South. So these are the people who would benefit from a good national health system. I’d like to recruit physicians to the idea. There’s a lot of education that needs to be done. Our challenge is uphill because the private health insurance industry and the for-profit health industry are opposed to many of the ideas of a national health plan. A lot of their effort is misinformation and propaganda, so we want to try to counteract that with facts. For example, the term “socialized medicine” came about when Harry Truman proposed it. The insurance industry hired an advertising firm, and they came up with “socialized medicine.” That was during the McCarthy era, and people were just afraid. There’s a lot of fear and distrust of government. I’d like to replace the fear with knowledge and understanding and get our government leaders, physicians and the public to understand that we can do better. We’re hurting ourselves by not adopting a simplified system that is in the hands of the people rather than the corporate, profit-making organizations.

Q: How would the proposed national health program be in “the hands of the people” instead of “the hands of the government?”

A: Government is the people. There are American governmental institutions that function very well. Our plan envisages a board, such as the Federal Reserve Board, that would not be run directly by elected officials but more by professionals. Then regional boards would have citizens, physicians and professionals who would make judgments. Medicare in this country has been very successful. There are problems that should be fixed, but it’s made a huge difference in the health of our seniors and also in the financial health of our seniors. Without Medicare, so many people would be totally broke.

There are some institutions that do well as policies change and as the political power changes in Washington. For example, the Centers for Disease Control and Prevention is an outstanding example of an American government project that’s been very successful and effective. There are lots of things we can be thankful for and proud of that come out of the CDC.

Q: Everyone agrees that costs are rising at an unsustainable rate, but getting agreement on solutions to the problem of rising costs is more difficult. What sort of cost-cutting ideas do you think could get widespread public and political support?

A: A national health insurance model or single-payer model is the only model that will control costs. Second to improved quality and improved health care delivery, control of costs is one of the most important advantages of this system. Right away, you gain 30 cents of every dollar that goes into administrative costs. Twenty percent is the usual administrative expense of an insurance company and then the additional 10 percent is the cost of the providers working with the payers. A dermatologist colleague of mine here asked her billing clerk how many plans were represented in their current bills outstanding. It was 287 plans. That’s where a huge amount of expense and time on the part of the physician could be recouped immediately. Medicare, with its faults, has an administrative expense of 3 percent or less. National health insurance would increase it to be more in line with some other developed countries, around 12 percent. The number of billing clerks at Massachusetts General Hospital is about 300. Toronto General, a hospital of equal size, has three billing clerks.

The ability to purchase pharmaceuticals and supplies in volume bulk purchasing would save huge amounts of money. We’re paying roughly 40 percent more here per prescription. The Medicare Modernization Act of 2003 strictly forbade Medicare from negotiating with pharmaceutical manufacturers for volume discounts.

Q: As part of the new health reform law, there are incentives for providers to begin using more and more HIT tools. But to ensure that patients are receiving the most benefits from adoption of the tools, the law requires that providers meet certain “meaningful use” standards. In what ways can providers and your proposed singlepayer program work together to ensure patients are receiving the most benefits from the adoption of HIT tools?

A: The best example is in France where in 1998 they adopted a “carte vitale.” Every citizen has a card. This would be the ideal. It has all the information – the patient’s medical records, X-rays, consultation results and physicals. The mothers of children under 16 years of age carry the card for their children. So they come to the doctor’s office, the doctor swipes the card, and then he has his monitor and he can see all the information. It’s always updated after the visit. Patients can go to any doctor, any hospital, anywhere.

Q: Physicians currently have complaints about Medicare regarding payment and services covered, and getting Congress to permanently fix the SGR formula has been a problem for years. Why was Medicare chosen as the model for the national health program? In what ways would it be improved under the national health program?

A: The defects that are pointed out in that question would have to be corrected. We need higher reimbursements, and we foresee higher reimbursements in a standard formula that doesn’t change. The national health program would provide all comprehensive medically necessary care from birth to death. There are no bills to the patient. All the bills go directly to the NHI (national health insurance), and NHI pays. The bill in Congress that will be reintroduced in January – John Conyers’ House Resolution 676 – provides for payment within 30 days.

I just read that AARP reported that the number of doctors refusing Medicare patients is higher now than it’s ever been. If I’m asking for Medicare for all, then that means the doctors wouldn’t want that because they’re refusing Medicare patients. That’s why we say improved and expanded Medicare for all.

To quote our national coordinator, Dr. Quentin Young: “Medicare is not without its problems, of course. Its benefits package could be richer. It lacks authority to negotiate lower prices with drug companies. The reimbursement rate to physicians could be enhanced and stabilized, instead of depending on an annual cat-and-mouse game with Congress over a flawed accounting formula that only erodes physician confidence in the program … By replacing our crazy-quilt, inefficient system of private health insurers with a streamlined, publicly financed single-payer program, we would reap enormous savings.”

Q: How would a national health program affect physician income?

A: Higher and more dependable reimbursement for primary care physicians; dependable reimbursement for everyone. High-end specialists would probably make less, but they would still do fine. But the primary care physicians would get more, and they would always be paid. They’d have more time to spend with their patients, which is what most of them went into medicine for in the first place.

Q: In a national health program, would physicians still have the right and realistic ability to open a private practice of medicine in a meaningful manner?

A: Absolutely. They just submit their bills. The payment schedules will be adjusted regionally. Within a state, there would be negotiations between representatives of physician groups with the regional board for their payment schedule. Say a school physical exam is set at $60. The patient comes in, gets their exam, the office sends the bill to the NHI, and they get their $60.

Q: Do you foresee any problems with setting protocols for treatment based on the input of a small number of physicians, and then making those protocols the only services that will be covered?

A: No. The concept is very clear that all medically necessary services would be provided. The treating physician makes the choice of what should be done for a patient. Physicians would have muchimproved authority from what we currently have.

Q: Do you foresee any restrictions on a patient’s freedom to make decisions on the manner and scope of their medical treatment?

A: Much less so than now. I see much more freedom of choice for physicians under this program. There’s some evidence to support that claim, and that evidence is in Canada and in France. Those doctors are happy with what they can provide for their patients, and they’re not constricted by pre-approvals from the insurance company. We wouldn’t have to go through the insurance company’s denial management. There’s more freedom for physicians and better ability to prescribe patient’s treatment as they need it.

Q: In a national health program, would individuals have the right to opt out of the system and still purchase private health insurance?

A: No, because that could undermine the system.

Q: How do you foresee the role of restriction of choice in the overall ability to finance health care for all? Won’t it eventually lead either to a two-tier system in which the wealthy are still able to purchase care not available to the average consumer, or conversely to unconstitutional limits on the ability of citizens to spend their money the way they choose?

A: You can’t buy something that is provided by the system. The question presumes that it’s an American right to spend money and buy whatever you want to buy. I guess the answer is that national health insurance does interfere with that so-called right. If it’s not what’s considered medically necessary, then they can buy that. It’s an egalitarian system that provides the best for everyone.

Q: What else would you like Louisville’s physicians to know?

A: I would like to invite fellow GLMS members to go to the website of PNHP to read in depth the answers to all of these questions. I also invite them to join our chapter of PNHP in Kentucky. We have members across the state.

I want this idea to be apolitical. There is a moral premise of providing health care for everyone. This is a simple program. The House bill is 18 pages. Everybody deserves health care. Everybody. Good health care. That’s the bottom line. That’s where we’re starting from.

I like to look around when I’m out in public, say when I walk from here out to my car. I’ll see a dozen people, and I’d like to think each one of them has health care. I get choked up because it’s not that way now. But it could be, and it should be.

Will the Wyden/Brown state waiver enable single payer?

Senators push bipartisan state healthcare waiver

Reuters
November 18, 2010

A Democrat and a Republican teamed up in the Senate on Thursday to offer legislation that would give states the flexibility to implement their own healthcare approaches when the federal overhaul goes into full effect in 2014.

The proposal by Democrat Ron Wyden and Republican Scott Brown moves up the date when states can apply for waivers from the federal law in order to implement their own approaches.

The law, which passed in March, currently allows states to apply for waivers in 2017.

Under the Wyden and Brown proposal, states could apply for an exemption from some requirements of the reform law — including the mandate that everyone purchase insurance and the employer penalty for not providing coverage — if they offer an alternative that is considered at least as effective and affordable.

http://www.reuters.com/article/idUSTRE6AH4NT20101118

And…

S. 3958 (the entire bill)

To allow an earlier start for State health care coverage innovation waivers under the Patient Protection and Affordable Care Act.
IN THE SENATE OF THE UNITED STATES
NOVEMBER 17, 2010

Mr. WYDEN (for himself and Mr. BROWN of Massachusetts) introduced the following bill; which was read twice and referred to the Committee on Finance

A BILL
To allow an earlier start for State health care coverage innovation waivers under the Patient Protection and Affordable Care Act.

Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,

SECTION 1. SHORT TITLE.
This Act may be cited as the “Empowering States to Innovate Act”.

SEC. 2. EARLIER START FOR STATE HEALTH CARE COVERAGE INNOVATION WAIVERS.
Section 1332(a) of the Patient Protection and Affordable Care Act is amended—

  (1) by striking ‘‘January 1, 2017’’ in paragraph (1) and inserting ‘‘January 1, 2014’’, and
  (2) by inserting ‘‘beginning not later than 180 days after the date of the enactment of the Empowering States to Innovate Act’’ after ‘‘application’’ in paragraph (4)(B)(ii).

http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=111_cong_bills&docid=f:s3958is.txt.pdf

And…

Patient Protection and Affordable Care Act (excerpts):

PART IV–State Flexibility to Establish Alternative Programs

Sec. 1332. Waiver for State innovation.

  (a) Application.
    (3) Pass through of funding.–With respect to a State waiver under paragraph (1), under which, due to the structure of the State plan, individuals and small employers in the State would not qualify for the premium tax credits, cost-sharing reductions, or small business credits under sections 36B of the Internal Revenue Code of 1986 or under part I of subtitle E for which they would otherwise be eligible, the Secretary shall provide for an alternative means by which the aggregate amount of such credits or reductions that would have been paid on behalf of participants in the Exchanges established under this title had the State not received such waiver, shall be paid to the State for purposes of implementing the State plan under the waiver.

  (b) Granting of Waivers.
    (1) In general.–The Secretary may grant a request for a waiver under subsection (a)(1) only if the Secretary determines that the State plan–
      (A) will provide coverage that is at least as comprehensive as the coverage defined in section 1302(b) and offered through Exchanges established under this title as certified by Office of the Actuary of the Centers for Medicare & Medicaid Services based on sufficient data from the State and from comparable States about their experience with programs created by this Act and the provisions of this Act that would be waived;
      (B) will provide coverage and cost sharing protections against excessive out-of-pocket spending that are at least as affordable as the provisions of this title would provide;
      (C) will provide coverage to at least a comparable number of its residents as the provisions of this title would provide; and
      (D) will not increase the Federal deficit.

http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=111_cong_public_laws&docid=f:publ148.111

And…

Sen. Bernie Sanders: ‘Vermont stands a chance to be the first state in the nation to pass single-payer’

By Ezra Klein
The Washington Post
November 18, 2010

Ezra Klein:  So what happens if Scott Brown and Ron Wyden get their way and the waiver moves up to 2014? Will Vermont use it?

Bernie Sanders:  We believe Vermont stands a chance to be the first state in the nation to pass single-payer. The governor-elect campaigned on it, and we have support in the House and Senate. We’re not asking for one nickel more than we’d otherwise get. The other thing we think we have an opportunity to do is reach out to our conservative friends and say, hey, Vermont wants to go forward with a single-payer system, and Mississippi and Alabama don’t, but maybe they have other ideas. Now, we’re conscious of the need to make sure that the health-care reform bill’s standards aren’t diminished. So everyone needs to provide the same quality of health care as the bill provides and at the same, or lower, price. But if they can do that, then they should be able to go for it.

Ezra Klein:  And then the various models can compete with one another and, presumably, spread to other states if successful?

Bernie Sanders:  Absolutely. And that’s what we wanted from it. In my state, it’ll be single-payer. In California, I think there’s a chance it could be single-payer. In other states, it will be something else. This makes the states laboratories for the system, and then other states can copy them. Now, you need a minimum level for coverage and quality. You can’t go lower than health-care reform.

http://voices.washingtonpost.com/ezra-klein/2010/11/sen_bernie_sanders_vermont_sta.html

Comment: 

By Don McCanne, MD

The initial reaction to S. 3958, The Empowering States to Innovate Act, sponsored by Sen. Ron Wyden (D-OR) and Sen. Scott Brown (R-MA), is that the bill will enable states to bypass the requirements of the Patient Protection and Affordable Care Act (PPACA) and set up their own state-based programs, even single payer should the states prefer. But what does the bill actually say?

PPACA already authorizes a program for state waivers, but not until 2017. The Wyden/Brown bill does only one thing. It moves the state waiver program forward to 2014, the same year that the individual mandate and insurance exchanges go into effect. It does not change the waiver in any other way.

For those states that wish to establish their own programs, advancing the eligibility date removes the very burdensome task of complying with the insurance exchanges, mandates and other requirements for an interval of only three years, and then facing the additional costs and burdens of transitioning to their own programs. If you agree with the policy that states should be able to set up their own pr
ograms, then this is a very wise move.

Massachusetts already has a program similar to PPACA. Sen. Brown would much rather modify what they have by complying with the waiver than to have to comply with all details of PPACA for the first three years. For Sen. Wyden, his preferred model of reform was rejected by Congress, but he would still like to experiment with his model, as much as possible, within the state of Oregon, while protecting what innovative programs they already have.

So just how much leeway does the PPACA state waiver allow? It does allow innovations as long as coverage is at least as comprehensive, cost sharing is at least as affordable, at least as many residents would be covered, and as long as the federal deficit would not be increased. It also passes through to the state the funds that would have been used for premium tax credits, cost-sharing reductions, and small business credits. Is that enough funding to establish a single payer system?

What about the funds for Medicare? Medicaid? CHIP? Taft-Hartley plans? What about ERISA requirements? What about the multitude of other funding requirements such as the VA system, academic institutions, safety-net institutions, community health centers, the Indian Health Service, the U.S. Public Health Service, and the many others?

There is no authorization in the Wyden/Brown bill, PPACA, nor any other existing law or regulation to fold many or all of these programs into one single payer system. Think of trying to run a partial single payer system (an oxymoron) while still having to deal with the massive Medicare and Medicaid programs. The point is, don’t let up on your advocacy, thinking that Wyden/Brown is our entry to single payer. We would still have a highly fragmented financing system.

Our best option remains enacting a national single payer bill such as HR 676, which will be re-introduced in the next session of Congress. In lieu of that, we should continue with our efforts to enact single payer systems on the state level. Just don’t be fooled into thinking that a bill such as Wyden/Brown is the ticket. The enabling federal legislation that would be required for state programs would be as complicated, if not more so, than a bill establishing a national single payer program – an improved Medicare for everyone.

Vermont is a test. Without enabling comprehensive federal legislation, I’m already apprehensive.