PNHP

Solidarity, Individualism and Public Goods

Solidarity, Individualism and Public Goods

Obama's Flawed Case Against Single Payer

By ALAN NASSER
Counterpunch
November 16, 2009

The liberal imagination has broadened the scope of what it wants to dismiss as unrealistic, utopian and unpragmatic, i.e. as for all practical purposes impossible. These claims have typically been accompanied by the assurance that “This is not something that Americans would go for – it’s not the American way.”  There are countless variations on this theme. Obama’s case against a single payer health care system  is a conspicuous case in point. What distinguishes Obama’s position on this issue is not merely the weakness of his “arguments”, but the straight-ahead factual falsehood of the some of the counterclaims he has put forward in order to turn the desirable into the impossible.

The Alleged Impossibility of Universal Health Care

In May and August, 2007 Obama stated his position on single payer:

“If you’re starting from scratch, then a single-payer system’-a government-managed system like Canada’s, which disconnects health insurance from employment-‘would probably make sense. But we’ve got all these legacy systems in place, and managing the transition, as well as adjusting the culture to a different system, would be difficult to pull off. So we may need a system that’s not so disruptive that people feel like suddenly what they’ve known for most of their lives is thrown by the wayside.” (May, 2007)

” [W]hen we had a healthcare forum before I set up my healthcare plan here in Iowa there was a lot of resistance to a single-payer system. So what I believe is we should set up a series of choices….Over time it may be that we end up transitioning to such a system. For now, I just want to make sure every American is covered…I don’t want to wait for that perfect system…” (August, 2007, at an Iowa roundtable)

Obama offers 5 reasons for not supporting single payer.

First: “..we’ve got all these legacy systems in place” simply means that our system is not single payer, and we’ve had it for a long time. Obama has turned himself into a bent sort of Burkean conservative: we have been marinating in a tradition which so permeates our way of being in the world that to do away with it would upset social life as we know it. This tradition includes…. insurance-industry-based health care! More mundanely: we haven’t got it, so we can’t have it.

Second: it would be hard to “manage the transition” from a deeply flawed system to a much better one. Harder than it was to effect the transition to Social Security, Medicare, Medicaid, desegregation, etc.? In each of these cases, what many people had “known for most of their lives” [was] “thrown by the wayside”. It belongs to the nature of any move from one way of doing things to a very different one that the transition will take some doing. That fact alone settles nothing. What matters is how urgent is the need for change. The US’s irrationally costly system which leaves millions uninsured, a fate suffered by the citizens of no other developed capitalist country, is surely intolerable. We have been given no reason to think that the cost of a transition to universal coverage is so great as to outweigh the massive benefits of  this tried and tested arrangement. Obama’s excuses amount to a cleverly disguised a-priori argument against any consequential transformation of the status quo.

Third: the “difficulty” [i.e. costs] of  “adjusting the culture to a different system”, given that there is “a lot of resistance to a single-payer system” , outweigh the benefits of single-payer. But what matters is not what a few selected Iowans are alleged to have felt about universal coverage. The demonstrated preferences of the democratic majority can’t be irrelevant. 

On this issue Obama clearly means to imply that “Americans” don’t support single-payer. This is factually false. It’s improbable that Obama is unaware of the results of many surveys on this issue, the most recent, to my knowledge, having been conducted between December 14-20, 2007. The results of this Associated Press-Yahoo poll are worth reproducing as they were reported:

Subjects were asked which of the following 2 views comes closest to their own view:

1. The United States should continue the current health insurance system in which most people get their health insurance from private insurers, but some people have no insurance.

2. The United States should adopt a universal health insurance program in which everyone is covered under a program like Medicare that is run by the government and financed by taxpayers.

A majority of 65% supported 2, 34% supported 1 and 2% did not respond.

Those polled were also asked “Do you consider yourself a supporter of a single-payer health care system, that is a national health plan financed by taxpayers in which all Americans would get their insurance from a single government plan, or not?”

55% answered Yes, 44% No and 2% did not respond. Single-payer still has a majority here, but a smaller one, probably due to the pollsters’ use of (what is to some) the red-flag term ‘single payer’. [View the full poll results at http://news.yahoo.com/]

Taxpayer funded, government-run health care insurance for all is a public, not a private, good, and it is the only political project that most Americans are on record as willing to pay higher taxes to achieve. There is in fact not “a lot of resistance” to a rational health care system. Obama knows this. But the interests of those who have heavily invested (literally) in him carry more weight than do the most pressing interests of the rest. 

The Ideology of Individual Choice and the Logic of Solidarity

Fourth: Obama claims that a health care plan based on “a series of choices” is superior to one that leaves no choice but instead saddles everyone with the burden of full and affordable coverage. Pity those poor Europeans, deprived of their right to liberty by forced access to first-rate health care. In the City on the Hill, few things are more important than the right to choose: which health care system gives us the most choice? This way of thinking is saturated with the ideology of individualism and its private goods, and functions to obliterate solidarity, as opposed to self-interest, as a political and moral value. This is especially pernicious since, as we shall see, it is only concerted action motivated by solidarity that can bring about a health care system from which no one is excluded because they can’t afford it.

When Obama contradistinguishes choice from universal coverage he unwittingly underscores the irrelevance of individual, self-interested choice to political goals motivated by a commitment to solidarity. Preoccupation with the choice between one doctor and another, one plan or another, conceals a crucial assumption, namely that the fundamental issue underlying the health care debate is one about choice and liberty. An individualist ontology implies that our collective fate is a function of whether or not each individual member of society is savvy enough to make the free choices most likely to promote his or her self-interest. But are people who worry about access to health care really concerned with choice? What weighs upon them is that they can’t afford health care. No individual can make on her own the choice to turn the US into a country that makes health care affordable, available to all. Such a choice is not a choice by an individual about her own well being. It is not even a choice about the aggregate sum of each and every individual’s well being. It is a choice we make together about the kind of society we want to live in. To worry about health care because one cannot affor
d it is, on reflection, to lament the non-existence of a  public good, universally accessible health care, one that can’t be reduced to the sum of all individual goods. The survey discussed above indicates that most Americans implicitly know this. The majority endorse a universally applicable measure, taxation, as a means to institute a universally available, i.e. public, good, access to health care. A universal tax, as for education, roadways, health care, is not an individual cost; it is a social cost. Correspondingly, universally accessible health care is not an individual good, it is a public good. The majority would prefer to live in the kind of society that features that public good. It’s a different kind of society from the one we’re currently stuck with.

That kind of society, and the public goods it prioritizes, can be achieved only if it is pursued as a goal by people acting in concert. That’s where solidarity is on display: in collective action motivated by the desire to achieve a public good.

The kinds of goals/goods in question typically involve bringing about a certain kind of society. For example: the kind of society that provides all with affordable health care, the kind of society that makes access to the means of life  -e.g. a living wage-  available to all, the kind of society that makes the meeting of human needs the principal motivator of economic production, the kind of society that assigns sufficient resources to the reduction of pollution and the preservation of nature,… Prattling on about individual choice creates a conceptual space within which considerations of solidarity and public goods cannot arise. Talking about solidarity in the language of individualism is like trying to score a field goal in baseball.

Obama references affordability in spite of himself when he  claims (falsely) that he wants to “make sure that every American is covered”. The fundamental virtue of single payer is that it detaches insurance from employment and thereby from one’s level of income, so that everyone can afford health care. The question of choice doesn’t even arise if you can’t afford to keep yourself healthy. And come to think of it, were health care universally available, the question of affordability would not arise. Talk of being able to “afford” access to health care would be as misplaced as talk of being able to afford access to elementary education.

Solidarity As a Familiar Phenomenon

The issue is worth dwelling on. In everyday life we are all familiar with the pursuit of irreducibly social goods. Think of a family with kids. A rare and highly desirable work opportunity, but far from home, arises for spouse #1. Spouse #2 has come upon a comparable golden opportunity, also far from home. The family wants to stay together. A decision based on the good of either individual spouse would break up the family. What to do? It’s not uncommon in such a situation for the adults to look to determine what would be good for the family. And what’s good for the family is not the sum of spouse #1’s good plus spouse #2’s good, plus the goods of each individual child.  We cannot commensurate and then sum up these different and sometimes incompatible goods. The good of the family is irreducibly social, just like universally accessible health care. Families and households act in solidarity all the time.

Obama’s repeated insistence on the market as the primary agent in distributing resources precludes consideration of questions of solidarity from the outset. He is the instrument of domestic advisors benighted by preposterous economic theories hailing the efficiency and liberty-promoting virtues of the market. For these wags the pursuit of individual self-interest, plus competition, makes the world go round and secures for us all the freedom we (are allowed to) want. As we have seen above, the restriction of human-welfare-enhancing political choices to the realm of competition and self-interest deprives us of the freedom collectively to choose to live in the kind of society that provides copious public goods. That’s a big freedom lost.

The Political Psychology of Solidarity

A sense of solidarity is far more prevalent in much of Europe than it is in the Land of the Free. In a New York Times article titled “For the French, Solidarity Still Counts”  (by Youseff M. Ibrahim, Dec. 20, 1995), the author describes public reaction in France to a three-week strike by public workers supported by “hundreds of thousands of demonstrators who filled the streets of every major city in France.” Workers were protesting then Prime Minister Juppe’s proposal to slash medical, social welfare and benefit payments. According to the Times:

“Polls showed an astonishing amount of sympathy on the part of those who did not participate in the strike and who suffered the paralysis of mass transit and essential services. Many people explained that they supported the strike because the Government’s austerity programs are stripping layer after layer of subsidies that permitted French families of even the most modest means to sample the cultural and culinary treasures that only the rich can afford.”

One recipient of the social wage was a woman receiving the standard subsidy extended to pregnant women. The subsidy will continue, for each child, until the child reaches 18. Said the woman: “This is the foundation of our Republican system… Equality and fraternity are not mere slogans here. For me the engagement by the state is an expression of solidarity that gives us values… I think most French people want France’s values to be decided by this spirit, not by cold, remote, economic summits that speak of deficits and competition. That was the message of the strikes.”

This past March one million demonstrated across France in protest of proposed cutbacks in the wake of the financial crisis. I am currently living in France for a stretch of time and have witnessed frequent strikes and other expressions of resistance to neoliberal austerity measures. A sad and stark contrast to the sitting-duck posture of so many US workers.

The Times article provides an implicit explanation of why it is that in France and other European countries there is no general resentment of social benefits available, for example, to single mothers, while in the US more than a few working people oppose this kind of support. The Times reports that the subsidy offered to the woman quoted above “is extended to every mother in France regardless of economic or marital status.” In France benefits to single mothers are not regarded as “special treatment” denied to the responsible and hard-working. There is neither social nor psychological soil in which to plant the seeds of resentment, since the single mother is the recipient of a public good available to all mothers.

Fifth and finally: “I just want to make sure every American is covered…I don’t want to wait for that perfect system…” If the president truly wanted to guarantee universal coverage he would not have taken single-payer off the table before discussions began. Whatever is finally settled upon, government will neither negotiate drug prices nor regulate premiums, so we know now that millions will remain uninsured. Obama has known that all along.

Obama rigs the game by characterizing single-payer as “that perfect system”. One of the major weapons in the party-liners’ arsenal is to portray those who believe in greater possibilities as naïve utopians blind to the truism that a “perfect world” is impossible in what William F. Buckley liked to call “this veil of tears”. The logic is fine: since there are no finite limits to the greater possibilities of goodness, and perfection is conceived, as Anselm reminds us, as that greater than which none can be conceived, it follows that perfection is impossile down here. But whoever introduced mumbo-jumbo about perfection in the first place? Isn’t the elimination of a
great deal of unnecessary suffering enough? Last I recall, single-payer advocates claim merely (sic) that it is way better than what we are offered. That’s pretty good.

Obama’s case against single-payer frames health-care priorities in the language of atomic individualism. Hence, the range of possible outcomes is determined for the worse before discussion begins. I am suggesting that a good part of our resistance and organizing should consist in reminders that an alternative way of thinking and acting is already on display in some of our common practices, and in already existing benefits won for other populations by aiming at public goods to be achieved by concerted action in solidarity.

Hope that helps.

Alan Nasser is professor emeritus of Political Economy and Philosophy at The Evergreen State College in Olympia, Washington. He can be reached at nassera@evergreen.edu

http://www.counterpunch.org/nasser11162009.html

Clarifying what single-payer health care is and is not

By Howard Waitzkin
Taos News
Thursday, 18 July 2009

First I congratulate Justin Bailey, Erich Kuerschner, and all other people in the Taos area who are working hard to reform our health care system.

Although I support these efforts, I want to clarify what single-payer health care is and is not. In their articles, both Bailey and Kuerschner argued on behalf of a single-payer system but did not address several of its key features.

A single-payer health program basically would extend Medicare to the entire population. Although Medicare is not without problems, people over 65 years of age widely support the system and express satisfaction with it.

Under Medicare, the government occupies a very small role. The government collects payments from workers and employers and then distributes funds to health care providers for the services that Medicare patients receive.

Because it is such a simple system, the administrative costs under Medicare average between 3 and 5 percent, according to most studies. This small percentage means that the vast majority of Medicare expenditures pay for clinical services as opposed to administrative expenses.

On the other hand, private insurance generally shows administrative expenses between 20 and 30 percent. This much larger percentage means that about one quarter of every dollar spent on health care goes for administrative costs.

Many of these expenditures pay for activities such as billing, denial of claims, supervision of co-payments and deductibles, scrutiny of pre-existing conditions that disqualify people from care, and exorbitant salaries for executives (in many cases totaling between $10 and 20 million per year).

A single-payer national health program would achieve universal access to care by drastically reducing administrative waste. Because private insurance companies no longer could spend money keeping people out of the system, all of us would receive the care that we need without co-payments, deductibles, or other expenses at the point of service.

Under a single-payer system, the average family and the average business would spend the same or less than they currently spend on medical expenses.

Unfortunately, the Obama Administration and many of our Congressional representatives do not support the single-payer proposal, even though national polls consistently show that the majority of people in our country favor this approach.

The Obama administration has proposed a “mixed approach,” which includes a “public option,” organized along the lines of a single-payer system. However, the overall national health program would include the current private insurance industry and would therefore maintain a much higher level of administrative costs than a single payer approach.

Because the mixed approach will achieve much less savings by reducing administrative waste, the projected costs of the system have become prohibitive. Concern about these high costs has become the focus of the current debate in Congress.

On the other hand, there are two important bills in Congress that would achieve a single-payer system. In the House of Representatives, the bill is HR676, introduced by Rep. John Conyers and cosponsored currently by 85 other representatives. Sen. Bernard Sanders recently introduced a similar bill, S703, in the Senate.

These bills deserve our support because they truly would achieve a single-payer national health program that would guarantee universal access for all of us.

It is wonderful to realize that our own Rep. Ben Ray Lujan became a cosponsor of HR676 shortly after he entered Congress in early 2009.
Carlos Cisneros and Roberto (Bobby) Gonzales have introduced similar single payer legislation in the New Mexico Legislature.

Although Sen. Tom Udall did cosponsor single-payer legislation in previous sessions of Congress, he has not yet cosponsored 5703 since he entered the Senate this year.

Sen. Jeff Bingaman has not cosponsored S703, even though he generally supports improved access to health care.

President Obama consistently has argued that it is important to preserve the for-profit private insurance industry as part of his proposal – with even more tax subsidies for the industry. The Obama proposal essentially will compel families and individuals to buy insurance, from either the private industry or the government, with the poor assisted through a means-testing approach with huge administrative costs.

The mixed private and public approach has failed to achieve universal coverage in multiple states (most recently Massachusetts) and countries.

Let’s focus our attention and organizing on the real single¬ payer approach, which is the only way to avoid the failure to achieve universal health care which has plagued us for so many years.

As Winston Churchill said, “Americans will always do the right thing – after they’ve tried every other option.”

Howard Waitzkin, M.D., a professor at the University of New Mexico-Albuquerque, lives and practices medicine in Taos. He helped write the single-payer proposal of Physicians for a National Health Program, a professional organization with about 20,000 members www.pnhp.org. This proposal led to the current legislative bills in Congress that would enact a single-payer national health program (HR676 and S703).

Why Health Care Should Be a Right

By Jamie Eldridge
Jamie’s Blog: The Dridge Report
November 2nd, 2009

On the morning of October 7th, 2009, I suffered a one-minute seizure that broke some of the bones in my back, strained my spine, and tore my right shoulder out of its socket. Given the seriousness of the injuries that I sustained, I was rushed to Mass. General Hospital.

I don’t remember any of the above — but I do remember being relieved that I was at MGH once I became aware of what was going on, because I knew that I’d be getting arguably the best medical care in the world to fix my injuries. Just taking in the scene of doctors and nurses looking after me, I felt extremely relieved to live in Massachusetts and have access to such excellent health care.

The reason I had access to this care was, of course, because I am lucky enough to have comprehensive health care through the state GIC, which would cover the three surgeries, extended care, and rehab necessary for me to recover from my injuries. It is impossible to overstate what peace of mind this gave me, my family and loved ones.

But what about those patients at MGH, and across the country, who don’t have health insurance as comprehensive as mine, or health insurance at all? What peace of mind is there for their families at an incredibly difficult time?

As a patient, I wanted to be sure I would receive the highest quality medical care possible, and that I would be able to enjoy the same basic quality of life I had before my injury. And of course my fellow patients at MGH, many of whom were less well-off than I was, had the same hopes and expectations.

But as I lay in bed, knowing that I was lucky enough to have excellent health insurance that would cover my treatment, I couldn’t help but thinking over and over about those who weren’t so lucky.

I’ve been a strong proponent of a “Medicare for All” health care system since first joining the Massachusetts Legislature seven years ago. I believe a single-payer system like this will best achieve the health care reform goals that many of us share, from providing health care coverage for the uninsured to improving coverage for current health insurance members, reducing health care costs, and simplifying the country’s health care delivery system.

But over the past month, as I have been focused on health care as a patient, rather than as an elected official, I’ve become more and more convinced that any health care reform we make – single payer or otherwise – must start with the agreement that access to quality health care should be a right in this country.

There is a basic quality of care we all deserve when we are sick or injured. Yet without establishing health care as a right, there is no guarantee that every other Massachusetts citizen would be treated like I have been. In fact, absence government intervention, there are strong market, financial, and societal incentives that make it highly likely that no basic standard of treatment will exist.

As a society, we all benefit when individual members have access to quality health care. In my case, had I not received the right treatment within a relatively short amount of time, my life would have been changed dramatically, limiting my ability to be the most productive citizen that I could possibly be, and my ability to contribute to society, .

It’s the same for anyone else in a similar situation: good health care improves productivity, and the lack of it worsens the quality of life for each of us.

In the United States, within the basic framework of positive and negative rights found in our U.S. or state constitutions, the establishment of a right ensures that regardless of a person’s background (economic circumstances, race, religion, ethnicity, gender, sexual orientation, etc.), he or she is able to freely access certain services from the government. In Massachusetts, this ranges from the right to free speech and assembly to the right to public education, with guaranteed equal treatment of all people by the government.

The facts that I have excellent health insurance, live in a state that has long prioritized health care towards its citizens and that is home to the best doctors and nurses in the country, and have a job that provides paid sick leave to allow me the time to properly recover without falling into deep economic insecurity all but guarantees I will make the best recovery possible (in my case, a full recovery). However, not every Massachusetts resident – and certainly not every American – is as fortunate as I am.

Until we define health care as a right, there will continue to be Americans like those I have met over the past month, whose lives will be irreversibly thrown off-track by an accident or illness, whose financial insecurity will lead to greater physical problems, whose lives will be changed forever because they lacked access to quality health care.

I can think of few other instances of government assistance that would have as dramatic an impact on people’s lives as a right to health care, and that would make every community richer.

http://www.senatoreldridge.com/the-dridge-report/1039/why-health-care-should-be-a-right

Uninsured trauma patients

Downwardly Mobile – The Accidental Cost of Being Uninsured

By Heather Rosen, MD, MPH; Fady Saleh, MD, MPH; Stuart Lipsitz, ScD; Selwyn O. Rogers Jr, MD, MPH; Atul A. Gawande, MD, MPH
Archives of Surgery
November 2009
The Centers for Disease Control and Prevention estimate that in 2004, there were 112 012 deaths related to unintentional injuries alone in the United States. Unintentional injury is within the top 10 causes of death for every age group and is the leading cause of death among persons aged 1 to 44 years.
Uninsured trauma patients in the NTDB (National Trauma Data Bank) had a statistically significant higher adjusted odds of mortality compared with insured trauma patients. Our subgroup analyses strongly corroborated these findings. In younger patients (aged 18-30 years), the adjusted odds of mortality after trauma remained higher for uninsured patients compared with insured patients, indicating that the differences persist in a relatively healthy cohort. In the subgroup analyses of head-injured patients and those with 1 or more comorbidities in the NTDB, the adjusted odds of mortality in the uninsured population remained significantly high.
Most recent research has concentrated on decreased (or lack of) access to care as a result of being uninsured. However, we found that, even after admission to a hospital, trauma patients can have worse outcomes based on insurance status. This concerning finding warrants more rigorous investigation to determine why such variation in mortality would exist in a system where equivalent care is not only expected but mandated by law.
We can only speculate as to the mechanism of the disparities we have exposed; the true causes are still unclear. Although the lack of insurance may not be the only explanation for the disparity in trauma mortality, the accidental costs of being uninsured in the United States today may be too high to continue to overlook.
http://archsurg.ama-assn.org/cgi/content/short/144/11/1006

Uninsured trauma patients are more likely to die than insured patients in spite of the fact that treatment is mandated by law. This study did not explain the reasons for the differences.
Delay? Different care? Lower health literacy? Or was there simply less enthusiasm on the part of the providers of care once it was realized that they would not be compensated for their efforts?
This study and several others have demonstrated that death can be a consequence of being uninsured. But there are other important consequences as well. Access to health care that can maintain or improve quality of life is impaired, with consequent adverse outcomes. Financial hardship is almost a given in uninsured individuals with significant health problems.
Instead of searching for alternative explanations for adverse outcomes in the uninsured, we should admit that being uninsured is bad for your health and bad for your finances, and then do something about it. Individual responsibility alone is not enough. Social solutions are required.

RAND and BR on "savings" through "bundled payments"

Health Care Reform: Creating a Sustainable Health Care Marketplace

By Hewitt Associates
Business Roundtable
November 2009

Payment Bundling

Establishing bundled payments would create more incentives for efficient treatments and could be adjusted based on outcomes. Health care reform proposals are moving toward bundled payments. Both the House and the Senate include provisions that focus on improved quality of care and patient outcomes.

The pilot program may cover the following services: acute-care inpatient hospitalizations; physician services delivered inside and outside of the acute-care hospital setting; outpatient hospital services, including emergency department visits; services associated with acute-care hospital readmissions; home health; skilled nursing; inpatient rehabilitation; and long-term care. The episode of care established in the pilot program would start three days prior to a qualifying admission to the hospital and span the length of the hospital stay and 30 days following the patient discharge.

The pilot program’s bundled payment would be made to a Medicare provider or another entity composed of multiple providers to cover the costs of acute-care inpatient and outpatient hospital services, physician services, and post-acute care. The bundled payment for each of the eight selected conditions would be based on the average hospital, physician, and post-acute-care payments made over the hospitalization period for the patient.

CBO does not score savings for this provision, mainly because the language above suggests that Medicare will pay the same as it would otherwise have paid, instead of some lower amount per episode. Over time, however, we believe substantial savings can be achieved by both removing the financial incentive to provide marginally effective services, as well as through the active management of the rate of increase in the bundled reimbursement rate.

http://www.businessroundtable.org/system/assets/drupal/Hewitt_BRT_Sustainable%20Health%20Care%20Marketplace_Final.pdf

And…

Controlling U.S. Health Care Spending — Separating Promising from Unpromising Approaches

By Peter S. Hussey, Ph.D., Christine Eibner, Ph.D., M. Susan Ridgely, J.D., and Elizabeth A. McGlynn, Ph.D.
The New England Journal of Medicine
November 11, 2009

We identified 8 options that evidence suggests have the potential to reduce spending and are broadly applicable to the United States. For these options, we developed high and low estimates of cumulative cost savings over 10 years. The graph (clink on link below) lists the options, ranked according to their savings potential, and shows the percentage change in spending that we estimate could be achieved if that policy alone were implemented.

Among the most promising options are those related to changing the payment methods for health care services. (In the graph, bundled payment stands out as the option that would have by far the greatest impact in reducing spending.)

A “bundled-payment” approach would provide a single payment for all services related to a given treatment or condition, causing providers to assume risk for preventable costs; this approach has proved effective in limited demonstration projects. Bundled payment provides a mechanism for reducing both the volume of services and the prices charged for them. We estimate that under optimistic scenarios and with broad use of the Prometheus model of bundled payment for six chronic conditions and four acute conditions or procedures requiring hospitalization, national health care spending could be reduced by 5.4% between 2010 and 2019. This estimate assumes that providers can achieve a reduction of 25 to 50% in the costs associated with avoidable complications by providing higher-quality, more collaborative care.

http://healthcarereform.nejm.org/?p=2301&query=home

And…

Building a Bridge from Fragmentation to Accountability — The Prometheus Payment Model

By François de Brantes, M.S., M.B.A., Meredith B. Rosenthal, Ph.D., and Michael Painter, J.D., M.D.
The New England Journal of Medicine
September 10, 2009

Most experts agree that some sort of bundled, episode-based payment would help to move the system in the right direction. Our own approach, the Prometheus Payment model, for instance, bundles services and provides a budget with three components: evidence-informed base payment with patient-specific severity adjustments and an allowance for potentially avoidable complications.

The model encourages two behaviors that fee for service discourages: collaboration of physicians, hospitals, and other providers involved in a patient’s care; and active efforts to reduce avoidable complications of care (and the costs associated with them). It accomplishes these goals by paying for all the care a patient needs over the course of a defined clinical episode or a set period of management of a chronic condition, rather than paying for discrete visits, discharges, or procedures.

When incentives are used to drive changes in behavior, it is important that people and organizations are held accountable only for the variables that are actually under their control. That’s why, in designing the Prometheus model, we decided to focus on the potentially avoidable costs of patient care. We separated the costs attributable to patient-related factors from those attributable to providers’ actions. These latter costs are critically important in terms of accountability. In Prometheus, these potentially avoidable costs are called PACs and are recognized as the result of “care defects” — problems necessitating technical care that are under the professionals’ control and that, with the best professional standards, could have been avoided. PACs might include the cost of hospitalization of a patient with uncontrolled diabetes or the readmission for a wound infection of a patient who had recently been discharged after cardiac bypass surgery.

Unlike the current payment system, Prometheus provides larger profit margins for providers who can eliminate these complications, since they keep any unused PAC allowance — they profit by delivering optimal care, not a greater volume of care.

One lesson from our pilots is that hospital-centric provider organizations can expect increased internal tension when they implement an episode-of-care payment system. Prometheus does provide a sort of bonus to the hospital and physicians for working together to avoid readmission. However, physician groups that are paid under the model for managing chronic conditions have substantial opportunities to increase the profits that come from avoiding expensive hospitalizations. This incentive can highlight potential conflicts between the financial interests of physicians and those of hospitals and cause us to question the proposition that hospital-centric provider organizations will deliver the best results for the country.

The Prometheus model, by contrast, can be implemented in a fragmented, largely fee-for-service delivery system if the payer retains the role of financial integrator. Over time, as providers collaborate to improve patient care and optimize their margins, they could more formally integrate into accountable organizations. However, it will and should be their choice to do so.

http://content.nejm.org/cgi/content/full/361/11/1033

Comment:

By Don McCanne, MD

Peter Hussey and his colleagues at RAND, in their NEJM article, try to make the case that a “bundled payment” approach would be one of the
most promising options for controlling health care spending. The Prometheus model of bundled payment, described the other NEJM article cited above, would shift the risk for preventable costs from the payer to the providers of health care services.

Here’s how it would work. The payer (e.g., Medicare) would determine what the costs of all services would be for a given clinical problem under the current system (fee-for-service plus DRGs). All services would be bundled under a single fee that would be discounted by about five percent. That discount represents current preventable costs such as “excessive” days of hospitalization, “unnecessary” imaging studies, “preventable” complications such as wound infections, and “unnecessary” re-hospitalizations for “inadequate” post-discharge followup. If the medical team of professionals and institutions failed to prevent these or other “additional” costs, the team would bear the loss.

Well fine. But how many of these costs are truly preventable? At the time that services are rendered, almost all decisions are clinically appropriate. It is only in retrospect that an occasional decision might have been changed, but most would not have been. Then there is the fallibility of the human mind. Just as no person could be expected to have a perfect score on every exam taken throughout life, no health care professional can be expected to have a perfect score on all clinical decisions, especially when the perfect response is often still an unknown.

Another problem is that bundling requires organizing individuals and institutions together based on a single clinical entity. The composition of the team would vary depending on the nature of the clinical problem. The team would accept the one bundled payment but then internal disputes over the distribution of the funds certainly would be inevitable. Although the payer is relieved of the administrative services of allocating these funds, the process does not bode well for creating a harmonious, collaborative environment for high quality patient care. Those who believe that these arrangements could evolve into “accountable care organizations” are delusional.

In spite of RAND’s optimism, “bundling payments” will not reduce costs. It will only reduce prices, while actually increasing costs by introducing yet greater administrative complexity.

Purists in written composition might contend that I’ve overused “quotation marks” in my comments. My defense is that health care reform should not be based on “quotation marks” and a “wink.” It should be based on sound health policy science (no quotation marks).

RAND and BR on “savings” through “bundled payments”

Health Care Reform: Creating a Sustainable Health Care Marketplace

By Hewitt Associates
Business Roundtable
November 2009

Payment Bundling

Establishing bundled payments would create more incentives for efficient treatments and could be adjusted based on outcomes. Health care reform proposals are moving toward bundled payments. Both the House and the Senate include provisions that focus on improved quality of care and patient outcomes.

The pilot program may cover the following services: acute-care inpatient hospitalizations; physician services delivered inside and outside of the acute-care hospital setting; outpatient hospital services, including emergency department visits; services associated with acute-care hospital readmissions; home health; skilled nursing; inpatient rehabilitation; and long-term care. The episode of care established in the pilot program would start three days prior to a qualifying admission to the hospital and span the length of the hospital stay and 30 days following the patient discharge.

The pilot program’s bundled payment would be made to a Medicare provider or another entity composed of multiple providers to cover the costs of acute-care inpatient and outpatient hospital services, physician services, and post-acute care. The bundled payment for each of the eight selected conditions would be based on the average hospital, physician, and post-acute-care payments made over the hospitalization period for the patient.

CBO does not score savings for this provision, mainly because the language above suggests that Medicare will pay the same as it would otherwise have paid, instead of some lower amount per episode. Over time, however, we believe substantial savings can be achieved by both removing the financial incentive to provide marginally effective services, as well as through the active management of the rate of increase in the bundled reimbursement rate.

http://www.businessroundtable.org/sites/default/files/Hewitt_BRT_Sustainable%20Health%20Care%20Marketplace_Final.pdf

And…

Controlling U.S. Health Care Spending — Separating Promising from Unpromising Approaches

By Peter S. Hussey, Ph.D., Christine Eibner, Ph.D., M. Susan Ridgely, J.D., and Elizabeth A. McGlynn, Ph.D.
The New England Journal of Medicine
November 11, 2009

We identified 8 options that evidence suggests have the potential to reduce spending and are broadly applicable to the United States. For these options, we developed high and low estimates of cumulative cost savings over 10 years. The graph (clink on link below) lists the options, ranked according to their savings potential, and shows the percentage change in spending that we estimate could be achieved if that policy alone were implemented.

Among the most promising options are those related to changing the payment methods for health care services. (In the graph, bundled payment stands out as the option that would have by far the greatest impact in reducing spending.)

A “bundled-payment” approach would provide a single payment for all services related to a given treatment or condition, causing providers to assume risk for preventable costs; this approach has proved effective in limited demonstration projects. Bundled payment provides a mechanism for reducing both the volume of services and the prices charged for them. We estimate that under optimistic scenarios and with broad use of the Prometheus model of bundled payment for six chronic conditions and four acute conditions or procedures requiring hospitalization, national health care spending could be reduced by 5.4% between 2010 and 2019. This estimate assumes that providers can achieve a reduction of 25 to 50% in the costs associated with avoidable complications by providing higher-quality, more collaborative care.

http://healthcarereform.nejm.org/?p=2301&query=home

And…

Building a Bridge from Fragmentation to Accountability — The Prometheus Payment Model

By François de Brantes, M.S., M.B.A., Meredith B. Rosenthal, Ph.D., and Michael Painter, J.D., M.D.
The New England Journal of Medicine
September 10, 2009

Most experts agree that some sort of bundled, episode-based payment would help to move the system in the right direction. Our own approach, the Prometheus Payment model, for instance, bundles services and provides a budget with three components: evidence-informed base payment with patient-specific severity adjustments and an allowance for potentially avoidable complications.

The model encourages two behaviors that fee for service discourages: collaboration of physicians, hospitals, and other providers involved in a patient’s care; and active efforts to reduce avoidable complications of care (and the costs associated with them). It accomplishes these goals by paying for all the care a patient needs over the course of a defined clinical episode or a set period of management of a chronic condition, rather than paying for discrete visits, discharges, or procedures.

When incentives are used to drive changes in behavior, it is important that people and organizations are held accountable only for the variables that are actually under their control. That’s why, in designing the Prometheus model, we decided to focus on the potentially avoidable costs of patient care. We separated the costs attributable to patient-related factors from those attributable to providers’ actions. These latter costs are critically important in terms of accountability. In Prometheus, these potentially avoidable costs are called PACs and are recognized as the result of “care defects” — problems necessitating technical care that are under the professionals’ control and that, with the best professional standards, could have been avoided. PACs might include the cost of hospitalization of a patient with uncontrolled diabetes or the readmission for a wound infection of a patient who had recently been discharged after cardiac bypass surgery.

Unlike the current payment system, Prometheus provides larger profit margins for providers who can eliminate these complications, since they keep any unused PAC allowance — they profit by delivering optimal care, not a greater volume of care.

One lesson from our pilots is that hospital-centric provider organizations can expect increased internal tension when they implement an episode-of-care payment system. Prometheus does provide a sort of bonus to the hospital and physicians for working together to avoid readmission. However, physician groups that are paid under the model for managing chronic conditions have substantial opportunities to increase the profits that come from avoiding expensive hospitalizations. This incentive can highlight potential conflicts between the financial interests of physicians and those of hospitals and cause us to question the proposition that hospital-centric provider organizations will deliver the best results for the country.

The Prometheus model, by contrast, can be implemented in a fragmented, largely fee-for-service delivery system if the payer retains the role of financial integrator. Over time, as providers collaborate to improve patient care and optimize their margins, they could more formally integrate into accountable organizations. However, it will and should be their choice to do so.

http://content.nejm.org/cgi/content/full/361/11/1033

Comment:

By Don McCanne, MD

Peter Hussey and his colleagues at RAND, in their NEJM article, try to make the case that a “bundled payment” approach would be one of the most promising options for controlling health care spending. The Prometheus model of bundled payment, described the other NEJM article cited above, would shift the risk for preventable costs from the payer to the providers of health care services.

Here’s how it would work. The payer (e.g., Medicare) would determine what the costs of all services would be for a given clinical problem under the current system (fee-for-service plus DRGs). All services would be bundled under a single fee that would be discounted by about five percent. That discount represents current preventable costs such as “excessive” days of hospitalization, “unnecessary” imaging studies, “preventable” complications such as wound infections, and “unnecessary” re-hospitalizations for “inadequate” post-discharge followup. If the medical team of professionals and institutions failed to prevent these or other “additional” costs, the team would bear the loss.

Well fine. But how many of these costs are truly preventable? At the time that services are rendered, almost all decisions are clinically appropriate. It is only in retrospect that an occasional decision might have been changed, but most would not have been. Then there is the fallibility of the human mind. Just as no person could be expected to have a perfect score on every exam taken throughout life, no health care professional can be expected to have a perfect score on all clinical decisions, especially when the perfect response is often still an unknown.

Another problem is that bundling requires organizing individuals and institutions together based on a single clinical entity. The composition of the team would vary depending on the nature of the clinical problem. The team would accept the one bundled payment but then internal disputes over the distribution of the funds certainly would be inevitable. Although the payer is relieved of the administrative services of allocating these funds, the process does not bode well for creating a harmonious, collaborative environment for high quality patient care. Those who believe that these arrangements could evolve into “accountable care organizations” are delusional.

In spite of RAND’s optimism, “bundling payments” will not reduce costs. It will only reduce prices, while actually increasing costs by introducing yet greater administrative complexity.

Purists in written composition might contend that I’ve overused “quotation marks” in my comments. My defense is that health care reform should not be based on “quotation marks” and a “wink.” It should be based on sound health policy science (no quotation marks).

U.S. Needs Health Care, Not Insurance

By Carol Miller
Albuquerque Journal
Sunday, November 15, 2009

A very complex, mandatory private insurance scheme recently passed the U.S. House. The public is being overwhelmed by sound bites on one hand about how great it is, on the other, how terrible. We are hearing few of the details that are actually in the bill. Having read the bill, it is clear now that what started as health reform has emerged from the political process as health “deform,” building on the worst, not the best of the current system.

It is still a toss-up as to whether the Senate will pass any bill this year. However, due to intense political pressure, the Senate is likely to pass a bill that will make some House provisions better and others worse. What actually comes out in the final conference-committee bill is anyone’s guess at this point — so little time, so many deals still to be made, so many political funders to be appeased.

A careful analysis of the bill shows that it is designed more for political goals than to eliminate financial barriers to health care. For example, the actual coverage doesn’t even begin until 2013, opportunistically after the next presidential election, in 2012. Run on having accomplished “historic reform” but before anyone actually experiences how bad it is? How cynical is that?

Yes, there are some good provisions. The best relate to improving existing programs like the Indian Health Service, community health centers, and health professionals education and training; all are important for New Mexico.

But there bad provisions, which comprise most of the 1,990 pages of the bill. Five key reasons this legislation must be stopped:

• If passed, this law will move the U.S. farther from universal health care, making it harder than ever to accomplish health care justice in the future. If Congress does not have the courage to stand up to the private insurance industry now, it will be even more difficult in the future, especially after giving the industry trillions of new dollars through this terrible legislation. Let’s call this what it is: another corporate bailout on the backs of working people.

Pay attention to your federal representatives as they carefully talk about “health insurance reform.” They aren’t talking about health reform any more. Congress could have defended and built up a system based on popular, high-quality government-run health programs like the military and veterans fully socialized health systems or Medicare, a single-payer program. Instead, the president and Congress let the corporations and government-haters take control of the agenda.

• The legislation institutionalizes permanent inequality in health care. Unlike Medicare where all beneficiaries have a single plan, this bill further divides the U.S. system into tiers based on ability to pay. It creates basic, enhanced, premium and premium-plus plans. A basic plan will provide only 70 percent of the coverage of a “reference benefit package,” one that includes even fewer services than most insured people have today. The bill doesn’t even mention coverage for essential services like vision and adult dental care except in the most costly premium-plus plan.

• Out-of-pocket costs remain sky high. Everyone will be required to pay monthly insurance premiums. Some low-wage workers will receive taxpayer subsidies on a sliding scale. The lowest income people will have full subsidies. But remember, this is not money for care, it is support only to buy insurance.

Almost everyone will have to meet a deductible, capped in the bill at $1,500 a year, higher than most insurance-plan deductibles today. On top of this, insurance companies can charge even more under various “cost sharing” schemes for items like co-pays and co-insurance.

The bill puts a cap on cost sharing, but the total amount is obscene. The cap for an individual is $5,000 a year and for a family it is $10,000 before the plan must cover everything. Well, not exactly everything. Even after paying this huge amount of money, the legislation still allows the corporations to make us pay, billing for non-network providers and, since it is not a comprehensive benefit package, we are still on our own to pay for health care that the plans refuse to cover.

The legislation creates a law to let these corporations increase what they charge people as they get older. In fact, they can be charged up to twice as much as younger people for identical coverage.

• The legislation makes it illegal to not buy health insurance. The penalties are described in a section of the legislation called “Shared Responsibility.” This will let the IRS impose a tax of up to 2.5 percent of modified adjusted gross income for not having health insurance. People on the financial edge, people fighting foreclosure to stay in their homes or people who are unemployed all or part of a year will not be able to afford the insurance premiums or the penalties for not having insurance.

• We will all be drowning in paperwork, which will continue to drive up administrative costs. Right now, insurance administrative waste is about 30 percent of every health care dollar— or about $1 billion a day. Adding more people to an insurance-based system will result in even more money going into this bottomless pit.

As if this isn’t bad enough, the government will be setting up many new agencies to oversee the whole process including, at the top, the Orwellian Health Choices Administration, headed by the Health Choices Commissioner. This is not an agency to help us make health care choices, but to choose a health insurance company. The IRS will play a very large role in everything from certifying our income for subsidies to monitoring and taxing people who don’t buy insurance.

Health Insurance Exchanges will be created across the country with at least one in every state offering both Web sites and telephone assistance. This is where we will go every year to pick our insurance plan in an open enrollment period of at least 30 days between September and November. We can add this unpleasant task to all of our other fall chores.

It is hard to imagine the chaos and wasted resources with the entire country picking insurance plans at the same time, attended by marketing, billboards, advertising and misinformation. We will gamble as we choose a plan, decide which corporation will be the best for us, hoping we pick one that is not dominated by corporate bureaucrats focused on rationing care to maximize their profits. It is not an easy task and if a wrong plan is selected, we are stuck for a year, until the next national open enrollment cycle.

The United States can do better. We can build on a strengthened and well-funded Medicare program. In Medicare, when a person reached the age of eligibility or is determined to qualify because they have a permanent disability, they are in, and there is no re-enrollment.

Imagine real reform, as simple as adding people ages 55 to 65 years old to Medicare in 2010, 35-55 in 2011, and so on until everyone is included by 2013. The bills that promote this kind of reform are under 200 pages, they are simple to implement, cost effective and equitable. Choose a doctor, choose a hospital when needed and let the government pay the bills. Everyone in one system.

That is what real health reform would look like.

Miller is a long-time public health professional and health care advocate. She lives in Ojo Sarco.

Originally published under the title “N.M. Needs Health Care, Not Insurance”

http://www.abqjournal.com/north/opinion/1523131northopinion11-15-09.htm

In House, Many Spoke With One Voice: Lobbyists’

By ROBERT PEAR
New York Times
November 15, 2009

WASHINGTON — In the official record of the historic House debate on overhauling health care, the speeches of many lawmakers echo with similarities. Often, that was no accident.

Statements by more than a dozen lawmakers were ghostwritten, in whole or in part, by Washington lobbyists working for Genentech, one of the world’s largest biotechnology companies.

E-mail messages obtained by The New York Times show that the lobbyists drafted one statement for Democrats and another for Republicans.

The lobbyists, employed by Genentech and by two Washington law firms, were remarkably successful in getting the statements printed in the Congressional Record under the names of different members of Congress.

Genentech, a subsidiary of the Swiss drug giant Roche, estimates that 42 House members picked up some of its talking points — 22 Republicans and 20 Democrats, an unusual bipartisan coup for lobbyists.

In an interview, Representative Bill Pascrell Jr., Democrat of New Jersey, said: “I regret that the language was the same. I did not know it was.” He said he got his statement from his staff and “did not know where they got the information from.”

Members of Congress submit statements for publication in the Congressional Record all the time, often with a decorous request to “revise and extend my remarks.” It is unusual for so many revisions and extensions to match up word for word. It is even more unusual to find clear evidence that the statements originated with lobbyists.

The e-mail messages and their attached documents indicate that the statements were based on information supplied by Genentech employees to one of its lobbyists, Matthew L. Berzok, a lawyer at Ryan, MacKinnon, Vasapoli & Berzok who is identified as the “author” of the documents. The statements were disseminated by lobbyists at a big law firm, Sonnenschein Nath & Rosenthal.

In an e-mail message to fellow lobbyists on Nov. 5, two days before the House vote, Todd M. Weiss, senior managing director of Sonnenschein, said, “We are trying to secure as many House R’s and D’s to offer this/these statements for the record as humanly possible.”

He told the lobbyists to “conduct aggressive outreach to your contacts on the Hill to see if their bosses would offer the attached statements (or an edited version) for the record.”

In recent years, Genentech’s political action committee and lobbyists for Roche and Genentech have made campaign contributions to many House members, including some who filed statements in the Congressional Record. And company employees have been among the hosts at fund-raisers for some of those lawmakers. But Evan L. Morris, head of Genentech’s Washington office, said, “There was no connection between the contributions and the statements.”

Mr. Morris said Republicans and Democrats, concerned about the unemployment rate, were receptive to the company’s arguments about the need to keep research jobs in the United States.

The statements were not intended to change the bill, which was not open for much amendment during the debate. They were meant to show bipartisan support for certain provisions, even though the vote on passage generally followed party lines.

Democrats emphasized the bill’s potential to create jobs in health care, health information technology and clinical research on new drugs.

Republicans opposed the bill, but praised a provision that would give the Food and Drug Administration the authority to approve generic versions of expensive biotechnology drugs, along the lines favored by brand-name companies like Genentech.

Lawmakers from both parties said it was important to conduct research on such “biosimilar” products in the United States. Several took a swipe at aggressive Indian competitors.

Asked about the Congressional statements, a lobbyist close to Genentech said: “This happens all the time. There was nothing nefarious about it.”

In separate statements using language suggested by the lobbyists, Representatives Blaine Luetkemeyer of Missouri and Joe Wilson of South Carolina, both Republicans, said: “One of the reasons I have long supported the U.S. biotechnology industry is that it is a homegrown success story that has been an engine of job creation in this country. Unfortunately, many of the largest companies that would seek to enter the biosimilar market have made their money by outsourcing their research to foreign countries like India.”

In remarks on the House floor, Representative Phil Hare, Democrat of Illinois, recalled that his family had faced eviction when his father was sick and could not make payments on their home. He said the House bill would save others from such hardship.

In a written addendum in the Congressional Record, Mr. Hare said the bill would also create high-paying jobs. Timothy Schlittner, a spokesman for Mr. Hare, said: “That part of his statement was drafted for us by Roche pharmaceutical company. It is something he agrees with.”

The boilerplate in the Congressional Record included some conversational touches, as if actually delivered on the House floor.

In the standard Democratic statement, Representative Robert A. Brady of Pennsylvania said: “Let me repeat that for some of my friends on the other side of the aisle. This bill will create high-paying, high-quality jobs in health care delivery, technology and research in the United States.”

Mr. Brady’s chief of staff, Stanley V. White, said he had received the draft statement from a lobbyist for Genentech’s parent company, Roche.

“We were approached by the lobbyist, who asked if we would be willing to enter a statement in the Congressional Record,” Mr. White said. “I asked him for a draft. I tweaked a couple of words. There’s not much reason to reinvent the wheel on a Congressional Record entry.”

Some differences were just a matter of style. Representative Yvette D. Clarke, Democrat of New York, said, “I see this bill as an exciting opportunity to create the kind of jobs we so desperately need in this country, while at the same time improving the lives of all Americans.”

Representative Donald M. Payne, Democrat of New Jersey, used the same words, but said the bill would improve the lives of “ALL Americans.”

Mr. Payne and Mr. Brady said the bill would “create new opportunities and markets for our brightest technology minds.” Mr. Pascrell said the bill would “create new opportunities and markets for our brightest minds in technology.”

In nearly identical words, three Republicans — Representatives K. Michael Conaway of Texas, Lynn Jenkins of Kansas and Lee Terry of Nebraska — said they had criticized many provisions of the bill, and “rightfully so.”

But, each said, “I do believe the sections relating to the creation of a market for biosimilar products is one area of the bill that strikes the appropriate balance in providing lower cost options.”

http://www.nytimes.com/2009/11/15/us/politics/15health.html

Health insurers could be allowed to bypass some key reforms

Senate bills would include loopholes for proposed 'exchange'

By David S. Hilzenrath
Washington Post
Sunday, November 15, 2009

Nobody wants to spend a lot of time and energy — and taxpayer money — and end up where they started. But that’s what could happen with one of the principal elements of health reform, the “exchange” or “gateway.”

Legislators are designing this new insurance marketplace to protect consumers from many of the pitfalls and inequities in the current system. But even as they focus on the details of how the marketplace will work, senators have indicated that they would allow insurers to continue operating outside it, much as the health-insurance lobby has sought.

One Senate bill would preserve the possibility that insurers could tailor policies to draw healthy individuals out of the new markets, leaving coverage less affordable for those who stay behind.

“It’s a leak in the system,” said Karen L. Pollitz, a professor at Georgetown’s Health Policy Institute. “It returns you to problems that we have today.”

Senate bills guarantee that certain basic reforms — such as requiring insurers to accept people regardless of preexisting medical conditions and banning annual and lifetime limits on coverage — would apply both inside and outside the new markets for individuals and small businesses. But that would not be true for a host of other requirements intended to help consumers compare health plans on an apples-to-apples basis and force insurers to compete more directly on price.

For example, the bill written by the Senate health committee would not require insurers operating outside the marketplace to provide standardized disclosures about what they cover.

It would not prohibit health plans outside the exchanges from using marketing practices that discourage the seriously ill from enrolling, nor would it demand that they offer “a wide choice” of medical providers — including “essential community providers . . . that serve predominantly low income, medically-underserved individuals,” as the bill prescribes for insurers inside the exchanges.

Perhaps the sharpest dichotomy is that, under the health committee’s proposal, certain standards governing the nature and extent of covered benefits would apply only to policies sold inside the exchanges.

All of those factors contribute to the possibility that insurers might offer cheaper, less comprehensive policies outside the exchanges and entice healthier people to leave the new markets. That would leave the exchanges responsible for sicker people who are more expensive to insure.

Similarly, outside the exchange, the bill drafted by the Senate Finance Committee would not regulate the marketing of individual coverage, nor would it require that health plans be rated based on quality and price.

The legislation is now in the hands of Senate Majority Leader Harry M. Reid (D-Nev.), who is merging the work of the finance and health committees into a single proposal that could be unveiled as early as next week.

Unlike the Senate bills, the one approved last weekend by the House says that all new policies for individuals would have to be sold within an exchange.

The Senate health committee would give plans operating outside the exchanges another break: Only those inside an exchange would have to pay a surcharge — as much as 4 percent of premiums — to defray the exchange’s overhead costs. That could allow outside plans to undersell inside plans. In a written response to questions, the committee’s Democratic staff said it would not work out that way because plans inside the exchanges would have to spend less on marketing.

Why would the health committee create an elaborate system of consumer protections and then allow insurers to operate outside it?

“Some people may not want to purchase insurance through a gateway. The bill is about creating and enhancing choice,” the committee’s Democratic staff said.

The main lobbying group for the health-insurance industry struck a similar theme in a July letter. Karen Ignagni, president of America’s Health Insurance Plans, wrote that offering plans to individuals outside the exchange would “improve choices for individuals and employers.”

In seeking to create a more standardized marketplace, lawmakers were taking aim at a fundamental problem: It is hard for individuals to comparison shop for health insurance, because policies contain myriad, complex variables. Many people fail to spot gaps in their policies until they become severely ill, Nancy Metcalf, an editor at Consumer Reports, said in June testimony to a Senate panel. Insurance companies “know exactly how to design and market plans whose gaping holes don’t become apparent until it’s much, much too late,” Metcalf said.

The health committee bill would cut through some of the confusion by offering three tiers of coverage within exchanges. Plans competing within each tier would be required to have the same actuarial value, meaning that overall they cover the same percentage of anticipated expenses.

But under the health committee bill, insurance policies offered outside the exchanges would not have to conform to the three tiers, leaving consumers with the challenge of having to make apples-to-oranges comparisons.

The secretary of Health and Human Services would be required to establish an “essential health benefits” package, but it would not be essential that policies outside the exchange include those benefits.

Outside the exchanges, people could buy policies that do not provide the basic coverage required to satisfy the terms of the individual mandate (the requirement that everyone have insurance coverage), thus exposing themselves to penalties.

Even within the exchanges, there could be limits to consumer protections. The health committee bill would not explicitly guarantee consumers the right to an external appeal when a health plan refuses to pay for medical services. The right to an external appeal is a hallmark of the health-benefits program for federal employees, which has served as a model for the proposed exchanges.

Sitting in for Healthcare

A new group takes the fight for a single-payer system directly to insurers—and politicians.

By Diana Novak
Nov. 16, 2009
In These Times

Since September 29, when Mobilization for Health Care for All organized its first sit-in at health insurer Aetna’s New York City offices, more than 147 activists with the group have been arrested in 24 actions around the country. Protesters, opposed to any healthcare reform short of a national single-payer system, have also occupied both Speaker of the House Nancy Pelosi’s office in San Francisco and Senator Joe Lieberman’s office on Capitol Hill.

Mobilization, a two-month-old conglomeration of healthcare action groups, organized the protests as part of a campaign for what it calls “Medicare for All.” Groups in each city work with the new umbrella organization to set up national days for civil disobedience. Since the Aetna sit-in in New York, thousands of protesters have joined the movement, refusing to allow insurance companies to continue to profit by denying care. Chanting “Patients, not profits,” they have entered insurance headquarters and blocked the doors, leaving only when either the company grants coverage of treatments for those with life-threatening conditions, or when they are arrested.

Kai Newkirk, National Coordinator for Mobilization, says that the campaign wants to spotlight the real cause of the heathcare crisis. “We are never going to get real reform until we are able to stand up to the insurance companies and dramatize how much incredible suffering they have caused because they deny care to maximize profit,” Newkirk says. “By spending money that should be going towards care on huge ad campaigns, lobbyists, and campaign contributions, they are trying to keep us from exercising our will on Congress. Until we get them out of our politics and separate them from our democracy, we won’t see reform.”

One man’s experience with coverage denial has motivated him to take his protest a step further. Sam Pullen, 31, was arrested during a sit-in at Blue Cross’s Los Angeles headquarters as he paid tribute to his mother’s quest for cancer treatment at the same office. When Pullen was a teenager, his mother Leanna Bell was diagnosed with multiple-myeloma. Blue Cross wouldn’t cover a recommended bone-marrow transplant, so she staged a one-woman sit-in at the office until the company agreed to pay. Receiving the transplant allowed her to live for five more years.

After being arrested, Pullen refused to post bail, electing to remain in jail until Blue Cross met with him to discuss his demands for universal coverage. Five days later, Pullen’s bail was waived and he was removed from jail against his will. Pullen says his discharge was the result of “mounting pressure from the public.”

According to Newkirk, “When people are willing to do more than just show up and chant, when they are willing to risk arrest…it shows the urgency. It moves people to believe, as we do, that healthcare is a right.”

The group hopes its actions will be the largest nonviolent protests since the civil rights movement. Within three weeks of its late September launch, the campaign received more than 850 pledges from Americans “willing to put their bodies on the line,” Newkirk says.

The first sit-in in New York earned insurance coverage for a man with both cancer and AIDS. “We are already winning small victories in terms of individual cases,” says Pullen, “and once enough of these happen the industry as a whole…will say, ‘We need to stop trying to save money when people are dying because that is really going to get us bad publicity.’ “

Pullen recognizes the collective effort that healthcare reform will need in order to achieve the campaign’s goals. “This issue is so fundamental, and has affected so many people—this goes beyond race, class, gender—everyone has been affected by the profit-hungry, greedy insurance industry,” he says. “I’ve gotta tell you, it feels redemptive, it feels good, to stand up for what’s right.”

Editor’s note: The print version of this article has been edited slightly here to emphasize that Mobilization for Health Care for All exclusively advocates a single-payer system.

http://inthesetimes.com/article/5179/sitting_in_for_healthcare

What next for the single payer movement?

By National Nurses Movement
Thu Nov 12, 2009
Daily Kos

Does passage of a bill that funnels millions of additional Americans into the private insurance system, and the decision of House leaders to shut down debate on one single payer amendment and scuttle another, mean the end of the years of efforts by single payer activists to win the most comprehensive reform of all?

For the nation’s nurses and the many grassroots activists, the answer is clearly no.

In discussions and organizing, now occurring coast to coast, including a strategy conference this weekend in St. Louis hosted by Healthcare-NOW, many are charting a new course that turns next to the U.S. Senate, to the Senate-House Conference Committee, and then to state capitols from Sacramento to Harrisburg where vibrant single payer movements and campaigns continue to grow.

Most single payer advocates acknowledge some important reforms in the House bill, especially the expansion of Medicaid to millions of low income adults, increased regulation of the insurance industry, expanded public health funding for community programs for low income families, and a more progressive tax plan than the onerous tax on middle income health benefits proposed in the Senate.

But those who dismiss the weaknesses, coupled with the overhyped rhetoric comparing the bill to the civil rights legislation of the 1960s or passage of Social Security and Medicare, should be wary of the backlash when millions of Americans continue to face health insecurity and potential bankruptcy as their healthcare costs rise largely unabated and continue to experience denials of medical treatment insurance companies don’t want to pay for.  

As California Nurses Association/National Nurses Organizing Committee Executive Director Rose Ann DeMoro has written

Social Security and Medicare were both federal programs guaranteeing respectively pensions and health care for our nation’s seniors, paid for and administered by the federal government with public oversight and public accountability

By contrast, the main provision of the House bill, and its Senate counterpart, is to expand health care coverage by requiring everyone to “have insurance” — mostly buying private insurance (since the public option is open to so few). Ultimately whether some want to admit it or not, a massive bailout worth tens of billions of dollars to the insurance industry.

Further, while Social Security and Medicare were both significant expansions of public protection, the House bill actually reduces public protection for a substantial segment of the population, women, with its unconscionable rollback of reproductive rights in the anti-abortion amendment.

To that end, tempering some of the triumphalism would be advisable. Equally unfathomable is the threat by some liberal groups to target single payer proponents Dennis Kucinich and Eric Massa who voted against the anti-choice amendment as well as the full bill. (Massa, in particular, was elected with active support from the single payer community and took a principled stand in a swing district.)

Those who start down this road would do well to remember the nurses, physicians, and thousands of single payer grassroots activists who have carried the flame of genuine healthcare reform for years, and will certainly continue to make their voices heard, especially as employers continue to shift skyrocketing healthcare costs to workers and out-of-pocket costs eat up, by some accounts, 15 percent to 19 percent of family incomes.  

One of those suggesting that work must continue, even prior to the vote, was House Whip James Clyburn who told the Associated Press November 5:  

“I didn’t want anyone to think that if you don’t get everything you want in this health care bill right now, that’s the end of the game. What we need to do is lay a foundation. Get passed what we can pass that will have a meaningful impact on people’s lives — not put too many of our people in jeopardy — and then build upon it later. It’s a long road.”

For single payer proponents, the construction on that long road begins in the Senate now where Sen. Bernie Sanders plans to introduce single payer language. As he said on Vermont Public Radio this week:

“I believe that a single payer system is the most effective way to provide comprehensive, universal, cost-effective health care. … (Without single payer) that ain’t going to happen. The health insurance industry and the drug companies are too powerful.”

Sanders is also proposing a federal exemption of legal barriers for states that opt to establish single payer systems, similar to the Kucinich amendment that was stripped out of the House bill by House leaders in the hours leading up to its final vote.

The reason for the amendment, Sanders notes:

“So that if states like Vermont or California or Pennsylvania – states that are strong in a single payer movement – want to move in that direction that they will be able to do so. And I think … what you will probably end up seeing is we will move toward a Medicare for all program when one state does it and does it well. And other states say, ‘You know what? That looks like the most cost effective, fairest way to provide quality care to all people.'”

You can help. Contact your Senator, (202) 224-312, and urge them to join Sanders in supporting this important amendment. That’s what a lot of us will be working on next.

http://www.dailykos.com/story/2009/11/12/175652/94

Another Doctor Mad As Hell

By Dr. Susie Baldwin
Nov 12 2009
Published on RHRealityCheck.org

Congress has done it. They’ve thrown women’s reproductive rights under the bus. They’ve catered to religious extremists rather than protect the health of our mothers, daughters, and sisters. They’ve sacrificed the health of the American people on the altar of health insurance industry profits. They took an historic opportunity to improve the conditions in which Americans live and die, and squandered it to protect the status quo.
 
This is not the change we believed in. President Obama’s tiptoeing around our human rights is not the leadership we voted for.

The House health care reform bill, the “Affordable Health Care for America Act,” won’t actually create affordable health care for America. It will perpetuate our existing inefficient, often inhumane health care system, one that spends twice as much as any other nation on earth yet fails to meet the basic needs of many individuals and communities.  The convoluted logic of our existing health insurance-based system is echoed in the cumbersome pages of HR 3962.

Already, over 30% of each dollar of our insurance premiums goes not to cover actual health care costs, but instead to pay for the overhead and profits of the private health insurance industry. With the House version of health care reform passed last night, we’ll throw more of our tax money into this inefficient, for-profit system. (Medicare, a single payer, not-for-profit, government-run health plan for seniors and some disabled people, spends 2-3% on overhead.)

The health insurance industry, which exists not to care for sick people or keep us healthy, but to reap profits, is the big winner so far in health care reform. As of today, women are the biggest losers. With the addition of the Stupak amendment, health care reform further chips away at women’s fundamental right to abortion by eliminating coverage through health insurance plans associated with Health Insurance Exchanges (what’s left of the ‘public option’). Ironically, the agency overseeing the Exchanges is called the Health Choices Administration.  In fact, there will be no choice in the new health reform plans—the bill restricts any system funds from going to abortion care, even the premium monies women pay out of their own pockets.

The amended bill allows for “non federal entities” including local and state governments and individuals to “purchase supplemental coverage for abortion.” This provision would be hilarious in its absurdity if it were not so tragic. The point of health insurance—indeed, the point of all insurance—is to provide a safety net when life throws unexpected, difficult events our way. Of course, no one plans ahead for their abortion. When women and families are applying for insurance, they don’t think to themselves, “Well, are we going to need an abortion this year?”  Plus, most companies and government entities will surely be unwilling to pay for supplemental coverage of any kind, much less for supplemental coverage for one particular highly marginalized and stigmatized (yet common) reproductive health service.

The House legislation is not all bad. It’s good that the law would prohibit insurance companies from discriminating against people with pre-existing conditions, like me with my cystic fibrosis and breast cancer. It’s good, and about time, that preventive health services will be fully covered under Medicare and Medicaid. It’s a relief that our government will finally be able to negotiate drug prices directly with pharmaceutical companies for Medicare Part D plans.

But HR 3962 is not good enough. It does not provide universal coverage and it will not control health care costs. It does not eliminate or even rein in the private insurance companies, who waste $400 billion each year—enough to cover health care for all 46 million of the uninsured. The law, if passed, will blindside a lot of women, from all walks of life, who won’t care much about the abortion restrictions until life throws them a curveball. When they find themselves in a situation they did not and could not have planned for, they will learn, as do poor women in most states, Native American women, and our soldiers and veterans, that their choices have already been made, by bishops, by corporations, and by their Congress.