Massachusetts’ Plan: A Failed Model for Health Care Reform

Prepared by Dr. Rachel Nardin, Assistant Professor of Neurology, Harvard Medical School, with Drs. David Himmelstein and Steffie Woolhandler (both Associate Professors of Medicine, Harvard Medical School)
February 18, 2009

Executive Summary

The Massachusetts Health Reform Law of 2006 expanded Medicaid coverage for the poor and made available subsidized, Medicaid-like coverage for additional poor and near-poor residents of the state. It also mandated that middle-income uninsured people either purchase private health insurance or pay a substantial fine ($1,068 in 2009). Smaller fines (up to $295 per employee) were also levied on employers who fail to offer insurance benefits.

The reform law has not achieved universal health insurance coverage, although half or more of the previously uninsured now have some type of insurance policy.

The reform has been more expensive than expected, costing $1.1 billion in fiscal 2008 and $1.3 billion in fiscal 2009. In the face of a state budget crisis in fall 2008, Gov. Deval Patrick announced that he will keep the reform afloat by draining money from safety-net providers such as public hospitals and community clinics.

While the number of people lacking health insurance in Massachusetts has been reduced, several recent surveys demonstrate that substantial problems in access to care remain in the state. While the new health insurance improved access to care for some residents, many low-income patients who previously received completely free care under the state’s old free care program now face co-payments, premiums and deductibles that stop them from getting needed care.

In addition, cuts to safety-net providers have reduced health resources available to the state’s remaining uninsured, as well as to others who rely on safety-net providers for services in short supply in the private sector. These safety-net services include emergency room care, chronic mental health care, and primary care. The net effect of this expensive reform on access to care is at best modest, and for some patients, negative.

By mandating that uninsured residents purchase private health insurance, the law reinforced the economic and political power of health insurance firms. Thus, the reform augments the already high administrative costs of health care. Moreover, the agency that administers the new law (the “Connector”) adds an extra 4 to 5 percentage points to the already high overhead of private health insurance policies.

The reform failed to reduce overreliance on expensive, high-technology services. Indeed, some of its provisions such as changes in Medicaid rates and cuts to safety-net providers (who do more primary care) have further tilted health spending toward expensive, high-technology care.

A single-payer system of non-profit national health insurance could save about $8-$10 billion annually in the state through reduced administrative costs. This money could be used to cover all of the state’s uninsured residents and to improve coverage for those who now have insurance, without any increase in total health care costs.

The Massachusetts reform law is not providing universal access to care, even in a state with highly favorable circumstances, including previously high levels of spending on health care for the poor, high personal incomes, and low rates of uninsurance. It is not a model for the nation.

Report: Massachusetts’ Plan: A Failed Model for Health Care Reform
https://pnhp.org/mass_report/mass_report_Final.pdf

Press release: Massachusetts Is No Model for National Health Care Reform
https://www.pnhp.org/news/2009/february/massachusetts_is_no_.php

Comment:

By Don McCanne, MD

Those supporting the leading Democratic model for reform frequently cite the Massachusetts plan as an example of how building on our current system of health care financing is the best path to success. Unfortunately, they use selected positive numbers to define success, while ignoring the fact that Massachusetts has failed in its efforts to achieve the real goals of reform. You can understand how pathological the politics of reform has become when they have to dig into the data of a failed reform effort in order to redefine failure as a success.

Let’s look at some of the goals, and how Massachusetts has fared:

* Everyone should be included – We should quit being dishonest when we say universal, and start demanding that universal means absolutely everyone. The Massachusetts model has left perhaps five percent of individuals without any coverage whatsoever, and there is little likelihood that the numbers of uninsured will be reduced further because of serious flaws in their model.

* The growth in health care costs must be slowed – The Massachusetts model has been ineffective in addressing the primary causes of excess cost escalation.

* Health care must be affordable for each individual – Insurance premiums and cost sharing in private plans have remained unaffordable for many in Massachusetts, impairing access to care. Insurmountable debt or personal bankruptcy from medical bills remains a very real threat in Massachusetts.

* Under-insurance must be eliminated – Massachusetts has expanded the problem of under-insurance in an attempt to make premiums affordable, failing to achieve either goal of adequate plans or affordable premiums.

* Administrative waste must be reduced – Massachusetts has added complexity to an already complex financing system, significantly increasing the administrative waste in their system.

* Coverage should be automatic, portable, and permanent – Massachusetts has provided further confirmation that no model built on our dysfunctional financing system can achieve these goals.

* Health care must be accessible – The Massachusetts model has further exacerbated the deficiencies in the state’s primary care infrastructure, resulting in increased difficulty in accessing their system. Their fragmented financing model has very little capability of realigning resource allocation to improve access.

* Private intermediaries that waste resources and impair access must be eliminated – But isn’t this what the Massachusetts plan is all about? Their view is that we must use our public agencies and tax funds in an all-out effort to protect the private insurance industry, regardless of the harm to patients in the form of physical suffering and financial hardship.

Suppose Congress and the administration accept the message that the Massachusetts plan is the wrong model for reform. Will they then move forward with a single payer national health program – a model that would actually achieve our goals? It is unlikely, based on all signals emitting from Washington. Instead, they will develop a uniquely American plan designed for Americans.

It will be a plan built on our uniquely American, dysfunctional, fragmented system of financing health care. But it won’t be like the Massachusetts plan that was developed in a wealthy state with greater health care resources, and with fewer financing problems than the rest of the nation. No, it won’t be like Massachusetts. It will be much worse… much, much worse.

The Influence Game: Labor and business, joined in health care cause, now at odds on specifics

By Julie Hirschfeld Davis
Chicago Tribune
February 16, 2009
Labor unions and business groups have teamed up in a multimillion-dollar national lobbying campaign to pressure President Barack Obama and Congress for big changes in the nation’s health care system. But as they get down to the specifics, their strange-bedfellows alliance is quietly at odds.
After spending two years and more than $20 million to promote the idea, collaborators in the Divided We Fail coalition — a project of the seniors lobby AARP, the service workers’ union, and groups representing small business and the Fortune 500 — are indeed divided over key elements of how to fix health care.
Its members agree that something should be done to revamp health care in the United States, and there’s consensus on a vague set of general principles that include making coverage more accessible, affordable and efficient. But they differ over important details, including what roles the government and private businesses should play.
The emerging rifts highlight how difficult it will be for Obama and the Democratic-run Congress to deliver what they say they are committed to: a health care overhaul that would guarantee everyone affordable coverage.
They also illustrate the limits of one of lobbyists’ favorite tactics: banding together with partners to try to build support for a top priority. Such alliances are born and die all the time in Washington, often falling victim to internal disputes over policy.
The coalition is led by a handful of Washington’s most influential lobbyists — Bill Novelli of AARP, John J. Castellani of the Business Roundtable and Dan Danner of the National Federation of Independent Business — as well as Andy Stern of the Service Employees International Union, among the most politically active groups in organized labor.
They acknowledge, however, that keeping the coalition together is getting more difficult as Obama and Congress prepare to delve into specifics.
For instance, labor unions and liberal groups are pressing for a universal health coverage system in which the government provides insurance that competes with private plans. SEIU wants to give everyone health benefits similar to those enjoyed by federal employees. It backs Obama’s “pay or play” idea of forcing employers to either offer health insurance to their workers or pay a fee so they can get it elsewhere.
The Business Roundtable and National Federation of Independent Business, on the other hand, want a system based mostly on private health insurance and are against new requirements for employers. The Business Roundtable’s members include health-insurance giants CIGNA, Aetna and Humana, all of which would have to compete with the government if labor got its way.
There’s also a fight brewing between private insurers and consumer groups over how to ensure that everyone is covered. Insurers say they’ll agree to accept any patient regardless of pre-existing health conditions — but only if everyone is required to buy coverage. Consumer groups say that would turn the government into a collection agency for private insurance companies.
http://www.chicagotribune.com/news/nationworld/sns-ap-health-care-strange-bedfellows,0,6877237.story

“Divided We Fail” presented itself as a broad coalition of diverse interests that could come together and agree on health care reform. But it isn’t a broad coalition. It is a coalition that primarily represents business interests – big business through the Business Roundtable, and small business through the National Federation of Independent Business (NFIB).
Also supporting this effort is AARP, which is probably best characterized as a broker for UnitedHealth insurance products – also a business interest with its own concerns about the future of health care financing in the United States.
The other supporter is Service Employees Union (SEIU), a union that broke off from AFL-CIO partly in a dispute over health care benefits. AFL-CIO wants to be sure that the crucial contribution of employer funds for health care continues at least until a well-financed, universal program can be enacted. Our current system of financing health care would collapse without employer contributions. For SEIU, requiring employers to fund comprehensive benefits was a more difficult issue. Service employees are compensated at lower rates than are those in the manufacturing industries, and their more meager benefit programs reflect this. SEIU would prefer to negotiate for higher wages without the necessity of forgoing wage increases in exchange for health benefits. Although a labor union, SEIU’s position is quite convenient for businesses in the service industries.
This coalition was pro-business, but, in the end, they agreed on only one principle – private health plans should be the dominant player in any reform proposal. Even there, their concepts of the specific role of private insurers are quite different.
Business Roundtable members want to maintain control of their health benefit programs, but they also want relief from the costs. They want public subsidies of their fairly comprehensive programs (even though they are already shifting more costs to their employees), but they don’t want any government-managed insurance programs that compete with the private plans.
NFIB wants a market of very cheap, publicly-subsidized under-insurance products, if they are expected to offer coverage at all. They want relief from the regulatory oversight that would make insurance work. But they too are adamantly opposed to any effective government insurance program that might put their own efforts to shame because of the paltry benefits that they would offer. And they definitely do not want to be mandated to provide coverage for all of their employees.
AARP wants to move aggressively into the non-Medicare market with their brokered UnitedHealth plans. They know that they could never compete with a well designed Medicare-like program that would be available to everyone. They are careful in their public statements, mindful of prior credibility issues stemming from prior public positions such as their support of Medicare privatization. But even now, AARP’s Bill Novelli says that “it’s an inside-outside game.” Outside refers to their public marketing through “Divided We Fail,” whereas inside refers to their private lobbying of Congress. What do you suppose goes on behind those closed doors?
SEIU truly does have the welfare of its members at the forefront. Their president, Andy Stern, can and should be faulted for failing to support single payer based on the “lack of political feasibility” argument. Nevertheless, he does support a regulated market of comprehensive private plans, along with a Medicare-like public option that some believe would improve the private sector products through the forces of competition.
So, even though this pro-business coalition agrees on the common denominator of private insurance plans, they cannot agree on an adequate benefit package, on eliminating under-insurance, on individual mandates, on employer-mandates, on cracking down on wasteful middlemen brokers, on equitable tax policies to finance reform, nor on fundamental health policy issues such as community rating and guaranteed issue.
It looks like the pro-business “Divided We Fail” coalition has divided and failed.
To succeed, a coalition must put patients first, and place all others in a secondary position. Although no coalition could possible ever have all interests on board, a patient-oriented coalition should eventually be successful simply because patients are what our health care system is all about.
“Health Care for America NOW!” was such an effort, but they made a mistake. They decided to go for broader support, bringing more varied interests into their coalition, although most are from the progressive community. To do this, they decided that they must agree that single payer is not politically feasible. Consequently, they decided to support a regulated private market with a public insurance option, trading away many of the beneficial features of a single payer system, though with hopes that it could eventually evolve into single payer. SEIU has joined this coalition, whereas AARP, Business Roundtable, and NFIB have not, reflecting the fact that HCAN and SEIU are truly patient oriented. But the outside opposition to a public option and to an adequately regulated and mandated private insurance market is so great that this coalition is already failing.
“Healthcare-NOW!” is an organization that has been around longer, but differs in that they support health care reform that is designed exclusively to benefit patients – without compromise! All other interests benefit when patients fare well (except the private insurers). “Healthcare-NOW!” provides unwavering support for the principles and policies of the single payer model of a national health program. Although “Healthcare-NOW!” still has a long path to travel, “fail” is not a word in their vocabulary.
Healthcare-NOW Position Regarding Health Care for America Now:
http://www.healthcare-now.org/about/regarding-hcan/

By Julie Hirschfeld Davis
Chicago Tribune
February 16, 2009

Labor unions and business groups have teamed up in a multimillion-dollar national lobbying campaign to pressure President Barack Obama and Congress for big changes in the nation’s health care system. But as they get down to the specifics, their strange-bedfellows alliance is quietly at odds.

After spending two years and more than $20 million to promote the idea, collaborators in the Divided We Fail coalition — a project of the seniors lobby AARP, the service workers’ union, and groups representing small business and the Fortune 500 — are indeed divided over key elements of how to fix health care.

Its members agree that something should be done to revamp health care in the United States, and there’s consensus on a vague set of general principles that include making coverage more accessible, affordable and efficient. But they differ over important details, including what roles the government and private businesses should play.

The emerging rifts highlight how difficult it will be for Obama and the Democratic-run Congress to deliver what they say they are committed to: a health care overhaul that would guarantee everyone affordable coverage.

They also illustrate the limits of one of lobbyists’ favorite tactics: banding together with partners to try to build support for a top priority. Such alliances are born and die all the time in Washington, often falling victim to internal disputes over policy.

The coalition is led by a handful of Washington’s most influential lobbyists — Bill Novelli of AARP, John J. Castellani of the Business Roundtable and Dan Danner of the National Federation of Independent Business — as well as Andy Stern of the Service Employees International Union, among the most politically active groups in organized labor.

They acknowledge, however, that keeping the coalition together is getting more difficult as Obama and Congress prepare to delve into specifics.

For instance, labor unions and liberal groups are pressing for a universal health coverage system in which the government provides insurance that competes with private plans. SEIU wants to give everyone health benefits similar to those enjoyed by federal employees. It backs Obama’s “pay or play” idea of forcing employers to either offer health insurance to their workers or pay a fee so they can get it elsewhere.

The Business Roundtable and National Federation of Independent Business, on the other hand, want a system based mostly on private health insurance and are against new requirements for employers. The Business Roundtable’s members include health-insurance giants CIGNA, Aetna and Humana, all of which would have to compete with the government if labor got its way.

There’s also a fight brewing between private insurers and consumer groups over how to ensure that everyone is covered. Insurers say they’ll agree to accept any patient regardless of pre-existing health conditions — but only if everyone is required to buy coverage. Consumer groups say that would turn the government into a collection agency for private insurance companies.

http://www.chicagotribune.com/news/nationworld/sns-ap-health-care-strange-bedfellows,0,6877237.story

Comment:

By Don McCanne, MD

“Divided We Fail” presented itself as a broad coalition of diverse interests that could come together and agree on health care reform. But it isn’t a broad coalition. It is a coalition that primarily represents business interests – big business through the Business Roundtable, and small business through the National Federation of Independent Business (NFIB).

Also supporting this effort is AARP, which is probably best characterized as a broker for UnitedHealth insurance products – also a business interest with its own concerns about the future of health care financing in the United States.

The other supporter is Service Employees Union (SEIU), a union that broke off from AFL-CIO partly in a dispute over health care benefits. AFL-CIO wants to be sure that the crucial contribution of employer funds for health care continues at least until a well-financed, universal program can be enacted. Our current system of financing health care would collapse without employer contributions. For SEIU, requiring employers to fund comprehensive benefits was a more difficult issue. Service employees are compensated at lower rates than are those in the manufacturing industries, and their more meager benefit programs reflect this. SEIU would prefer to negotiate for higher wages without the necessity of forgoing wage increases in exchange for health benefits. Although a labor union, SEIU’s position is quite convenient for businesses in the service industries.

This coalition was pro-business, but, in the end, they agreed on only one principle – private health plans should be the dominant player in any reform proposal. Even there, their concepts of the specific role of private insurers are quite different.

Business Roundtable members want to maintain control of their health benefit programs, but they also want relief from the costs. They want public subsidies of their fairly comprehensive programs (even though they are already shifting more costs to their employees), but they don’t want any government-managed insurance programs that compete with the private plans.

NFIB wants a market of very cheap, publicly-subsidized under-insurance products, if they are expected to offer coverage at all. They want relief from the regulatory oversight that would make insurance work. But they too are adamantly opposed to any effective government insurance program that might put their own efforts to shame because of the paltry benefits that they would offer. And they definitely do not want to be mandated to provide coverage for all of their employees.

AARP wants to move aggressively into the non-Medicare market with their brokered UnitedHealth plans. They know that they could never compete with a well designed Medicare-like program that would be available to everyone. They are careful in their public statements, mindful of prior credibility issues stemming from prior public positions such as their support of Medicare privatization. But even now, AARP’s Bill Novelli says that “it’s an inside-outside game.” Outside refers to their public marketing through “Divided We Fail,” whereas inside refers to their private lobbying of Congress. What do you suppose goes on behind those closed doors?

SEIU truly does have the welfare of its members at the forefront. Their president, Andy Stern, can and should be faulted for failing to support single payer based on the “lack of political feasibility” argument. Nevertheless, he does support a regulated market of comprehensive private plans, along with a Medicare-like public option that some believe would improve the private sector products through the forces of competition.

So, even though this pro-business coalition agrees on the common denominator of private insurance plans, they cannot agree on an adequate benefit package, on eliminating under-insurance, on individual mandates, on employer-mandates, on cracking down on wasteful middlemen brokers, on equitable tax policies to finance reform, nor on fundamental health policy issues such as community rating and guaranteed issue.

It looks like the pro-business “Divided We Fail” coalition has divided and failed.

To succeed, a coalition must put patients first, and place all others in a secondary position. Although no coalition could possible ever have all interests on board, a patient-oriented coalition should eventually be successful simply because patients are what our health care system is all about.

“Health Care for America NOW!” was such an effort, but they made a mistake. They decided to go for broader support, bringing more varied interests into their coalition, although most are from the progressive community. To do this, they decided that they must agree that single payer is not politically feasible. Consequently, they decided to support a regulated private market with a public insurance option, trading away many of the beneficial features of a single payer system, though with hopes that it could eventually evolve into single payer. SEIU has joined this coalition, whereas AARP, Business Roundtable, and NFIB have not, reflecting the fact that HCAN and SEIU are truly patient oriented. But the outside opposition to a public option and to an adequately regulated and mandated private insurance market is so great that this coalition is already failing.

“Healthcare-NOW!” is an organization that has been around longer, but differs in that they support health care reform that is designed exclusively to benefit patients – without compromise! All other interests benefit when patients fare well (except the private insurers). “Healthcare-NOW!” provides unwavering support for the principles and policies of the single payer model of a national health program. Although “Healthcare-NOW!” still has a long path to travel, “fail” is not a word in their vocabulary.

Healthcare-NOW Position Regarding Health Care for America Now:
http://www.healthcare-now.org/about/regarding-hcan/

The Influence Game: Labor and business, joined in health care cause, now at odds on specifics

By Julie Hirschfeld Davis
Chicago Tribune
February 16, 2009

Labor unions and business groups have teamed up in a multimillion-dollar national lobbying campaign to pressure President Barack Obama and Congress for big changes in the nation’s health care system. But as they get down to the specifics, their strange-bedfellows alliance is quietly at odds.

After spending two years and more than $20 million to promote the idea, collaborators in the Divided We Fail coalition — a project of the seniors lobby AARP, the service workers’ union, and groups representing small business and the Fortune 500 — are indeed divided over key elements of how to fix health care.

Its members agree that something should be done to revamp health care in the United States, and there’s consensus on a vague set of general principles that include making coverage more accessible, affordable and efficient. But they differ over important details, including what roles the government and private businesses should play.

The emerging rifts highlight how difficult it will be for Obama and the Democratic-run Congress to deliver what they say they are committed to: a health care overhaul that would guarantee everyone affordable coverage.

They also illustrate the limits of one of lobbyists’ favorite tactics: banding together with partners to try to build support for a top priority. Such alliances are born and die all the time in Washington, often falling victim to internal disputes over policy.

The coalition is led by a handful of Washington’s most influential lobbyists — Bill Novelli of AARP, John J. Castellani of the Business Roundtable and Dan Danner of the National Federation of Independent Business — as well as Andy Stern of the Service Employees International Union, among the most politically active groups in organized labor.

They acknowledge, however, that keeping the coalition together is getting more difficult as Obama and Congress prepare to delve into specifics.

For instance, labor unions and liberal groups are pressing for a universal health coverage system in which the government provides insurance that competes with private plans. SEIU wants to give everyone health benefits similar to those enjoyed by federal employees. It backs Obama’s “pay or play” idea of forcing employers to either offer health insurance to their workers or pay a fee so they can get it elsewhere.

The Business Roundtable and National Federation of Independent Business, on the other hand, want a system based mostly on private health insurance and are against new requirements for employers. The Business Roundtable’s members include health-insurance giants CIGNA, Aetna and Humana, all of which would have to compete with the government if labor got its way.

There’s also a fight brewing between private insurers and consumer groups over how to ensure that everyone is covered. Insurers say they’ll agree to accept any patient regardless of pre-existing health conditions — but only if everyone is required to buy coverage. Consumer groups say that would turn the government into a collection agency for private insurance companies.

http://www.chicagotribune.com/news/nationworld/sns-ap-health-care-strange-bedfellows,0,6877237.story

Comment:

By Don McCanne, MD

“Divided We Fail” presented itself as a broad coalition of diverse interests that could come together and agree on health care reform. But it isn’t a broad coalition. It is a coalition that primarily represents business interests – big business through the Business Roundtable, and small business through the National Federation of Independent Business (NFIB).

Also supporting this effort is AARP, which is probably best characterized as a broker for UnitedHealth insurance products – also a business interest with its own concerns about the future of health care financing in the United States.

The other supporter is Service Employees Union (SEIU), a union that broke off from AFL-CIO partly in a dispute over health care benefits. AFL-CIO wants to be sure that the crucial contribution of employer funds for health care continues at least until a well-financed, universal program can be enacted. Our current system of financing health care would collapse without employer contributions. For SEIU, requiring employers to fund comprehensive benefits was a more difficult issue. Service employees are compensated at lower rates than are those in the manufacturing industries, and their more meager benefit programs reflect this. SEIU would prefer to negotiate for higher wages without the necessity of forgoing wage increases in exchange for health benefits. Although a labor union, SEIU’s position is quite convenient for businesses in the service industries.

This coalition was pro-business, but, in the end, they agreed on only one principle – private health plans should be the dominant player in any reform proposal. Even there, their concepts of the specific role of private insurers are quite different.

Business Roundtable members want to maintain control of their health benefit programs, but they also want relief from the costs. They want public subsidies of their fairly comprehensive programs (even though they are already shifting more costs to their employees), but they don’t want any government-managed insurance programs that compete with the private plans.

NFIB wants a market of very cheap, publicly-subsidized under-insurance products, if they are expected to offer coverage at all. They want relief from the regulatory oversight that would make insurance work. But they too are adamantly opposed to any effective government insurance program that might put their own efforts to shame because of the paltry benefits that they would offer. And they definitely do not want to be mandated to provide coverage for all of their employees.

AARP wants to move aggressively into the non-Medicare market with their brokered UnitedHealth plans. They know that they could never compete with a well designed Medicare-like program that would be available to everyone. They are careful in their public statements, mindful of prior credibility issues stemming from prior public positions such as their support of Medicare privatization. But even now, AARP’s Bill Novelli says that “it’s an inside-outside game.” Outside refers to their public marketing through “Divided We Fail,” whereas inside refers to their private lobbying of Congress. What do you suppose goes on behind those closed doors?

SEIU truly does have the welfare of its members at the forefront. Their president, Andy Stern, can and should be faulted for failing to support single payer based on the “lack of political feasibility” argument. Nevertheless, he does support a regulated market of comprehensive private plans, along with a Medicare-like public option that some believe would improve the private sector products through the forces of competition.

So, even though this pro-business coalition agrees on the common denominator of private insurance plans, they cannot agree on an adequate benefit package, on eliminating under-insurance, on individual mandates, on employer-mandates, on cracking down on wasteful middlemen brokers, on equitable tax policies to finance reform, nor on fundamental health policy issues such as community rating and guaranteed issue.

It looks like the pro-business “Divided We Fail” coalition has divided and failed.

To succeed, a coalition must put patients first, and place all others in a secondary position. Although no coalition could possible ever have all interests on board, a patient-oriented coalition should eventually be successful simply because patients are what our health care system is all about.

“Health Care for America NOW!” was such an effort, but they made a mistake. They decided to go for broader support, bringing more varied interests into their coalition, although most are from the progressive community. To do this, they decided that they must agree that single payer is not politically feasible. Consequently, they decided to support a regulated private market with a public insurance option, trading away many of the beneficial features of a single payer system, though with hopes that it could eventually evolve into single payer. SEIU has joined this coalition, whereas AARP, Business Roundtable, and NFIB have not, reflecting the fact that HCAN and SEIU are truly patient oriented. But the outside opposition to a public option and to an adequately regulated and mandated private insurance market is so great that this coalition is already failing.

“Healthcare-NOW!” is an organization that has been around longer, but differs in that they support health care reform that is designed exclusively to benefit patients – without compromise! All other interests benefit when patients fare well (except the private insurers). “Healthcare-NOW!” provides unwavering support for the principles and policies of the single payer model of a national health program. Although “Healthcare-NOW!” still has a long path to travel, “fail” is not a word in their vocabulary.

Healthcare-NOW Position Regarding Health Care for America Now:
http://www.healthcare-now.org/about/regarding-hcan/

The last Quote of the Day message discussed Medicare’s national coverage determinations process (NCD), using as an example the decision to decline coverage for computed tomography colonography (CTC) when it is used as a screening test for colorectal cancer.

New York Assemblyman Richard Gottfried responds:
email
February 13, 2009
All insurance plans make decisions about what they will cover. With employer-sponsored insurance, insurance carriers know that their client is the employer, whose only interest is keeping costs down. There is only downward pressure.
The people who run public insurance have pressure to keep costs down, but it is balanced by pressure from the public (to whom they are ultimately accountable, especially with a program like Medicare that is not only for the poor) to keep quality and services up. So there is a balancing of downward and upward pressure.
Even if we move from employer-sponsored coverage to individuals buying their own insurance, the pressure would still be overwhelmingly downward. When making the choice among possible plans to buy, individuals are also under enormous pressure to focus exclusively on price. Hardly anyone would ask whether CTC is covered.
Since someone is going to make choices about what gets covered, we’re all better off if it is done by publicly-sponsored, publicly-funded and publicly-accountable coverage.
Richard N. Gottfried
Chair, Committee on Health
New York State Assembly
822 Legislative Office Building
Albany, NY 12248
250 Broadway, #2232
New York, NY 10007
(518) 455-4941
(212) 312-1492
GottfrR@assembly.state.ny.us

Richard Gottfried points out an extremely important distinction between the nature of coverage decisions in public health care financing systems, and in private insurance financing systems, whether employer-sponsored or individual coverage.
Whether it is the employer or the individual who is making a decision on the purchase of insurance (not the purchase of health care), with our current very high health care costs there is tremendous downward pressure on insurance premiums.
Slowing the the rise in premiums for private plans can be accomplished only by reducing coverage – by reducing benefits covered (e.g., maternity, mental health services, restricted list of contracted providers, prior authorization requirements, etc.), or by increasing the out-of-pocket costs for the patients (e.g., higher deductibles, higher copayments, higher coinsurance percentages, tiering of coverage, capping total amount of coverage, etc.)
This is precisely the recent history of private health coverage. Premiums continue to increase, and, though less and less affordable, the increases have been slowed enough to still maintain a market of private plans, even though that continues to decline as the rate of employer-sponsored coverage continues to fall. The perverse tradeoff is that this downward pressure slowing the rate of premium increases has caused an intense upward pressure in out-of-pocket spending, often making health care no longer affordable for those who do have private insurance.
Contrast this with public health care financing. As Richard Gottfried points out, the downward pressure to control government health care spending is balanced by an upward pressure from the public to demand health care quality and adequate services.
Medicare is a prime example. The public is opposed to any reduction in Medicare benefits. In fact, increasing coverage by adding prescription drug coverage was due to public demand. They are now demanding that it be improved further through measures such as eliminating the donut hole.
What could explain the apparent dilemma that people seem to be quite willing to purchase inadequate private plans that may not provide the financial protection that they need, yet they are not willing to accept inadequate coverage in a public health care financing program such as Medicare? Part of the answer may lie in the subliminally perceived relative inequity of premiums for private plans versus taxes for public programs.
The premiums for private plans are determined directly by the benefits covered by the plan, minus the cost sharing shifted to the patient. Costs are now so high that either premiums will be unaffordable, or out-of-pocket payments will be unaffordable, or, in actuality, downward pressures in the face of high costs are making them both unaffordable. More people are beginning to recognize that this is an obsolete method of financing health care.
The level of tax contribution for a publicly-financed health care system is not related to the benefits that are offered, but is determined by the ability of the individual or employer to pay the tax. Polls demonstrate that individuals are willing to pay more taxes that would be spent on publicly-financed health care. People seem to realize instinctively the fairness in this.
They also realize that Richard Gottfried is right. The downward pressure on private plans has caused most of us to look for relief from a health care financing system that is so badly broken. At the same time, the balanced pressure on Medicare has caused us to be very protective of that program. Now if we could just extrapolate our thinking to support Medicare for everyone, we’d have it made.

The last Quote of the Day message discussed Medicare’s national coverage determinations process (NCD), using as an example the decision to decline coverage for computed tomography colonography (CTC) when it is used as a screening test for colorectal cancer.

New York Assemblyman Richard Gottfried responds:

email
February 13, 2009

All insurance plans make decisions about what they will cover. With employer-sponsored insurance, insurance carriers know that their client is the employer, whose only interest is keeping costs down. There is only downward pressure.

The people who run public insurance have pressure to keep costs down, but it is balanced by pressure from the public (to whom they are ultimately accountable, especially with a program like Medicare that is not only for the poor) to keep quality and services up. So there is a balancing of downward and upward pressure.

Even if we move from employer-sponsored coverage to individuals buying their own insurance, the pressure would still be overwhelmingly downward. When making the choice among possible plans to buy, individuals are also under enormous pressure to focus exclusively on price. Hardly anyone would ask whether CTC is covered.

Since someone is going to make choices about what gets covered, we’re all better off if it is done by publicly-sponsored, publicly-funded and publicly-accountable coverage.

Richard N. Gottfried
Chair, Committee on Health
New York State Assembly
822 Legislative Office Building
Albany, NY 12248
250 Broadway, #2232
New York, NY 10007
(518) 455-4941
(212) 312-1492
GottfrR@assembly.state.ny.us

Comment:

By Don McCanne, MD

Richard Gottfried points out an extremely important distinction between the nature of coverage decisions in public health care financing systems, and in private insurance financing systems, whether employer-sponsored or individual coverage.

Whether it is the employer or the individual who is making a decision on the purchase of insurance (not the purchase of health care), with our current very high health care costs there is tremendous downward pressure on insurance premiums.

Slowing the the rise in premiums for private plans can be accomplished only by reducing coverage – by reducing benefits covered (e.g., maternity, mental health services, restricted list of contracted providers, prior authorization requirements, etc.), or by increasing the out-of-pocket costs for the patients (e.g., higher deductibles, higher copayments, higher coinsurance percentages, tiering of coverage, capping total amount of coverage, etc.)

This is precisely the recent history of private health coverage. Premiums continue to increase, and, though less and less affordable, the increases have been slowed enough to still maintain a market of private plans, even though that continues to decline as the rate of employer-sponsored coverage continues to fall. The perverse tradeoff is that this downward pressure slowing the rate of premium increases has caused an intense upward pressure in out-of-pocket spending, often making health care no longer affordable for those who do have private insurance.

Contrast this with public health care financing. As Richard Gottfried points out, the downward pressure to control government health care spending is balanced by an upward pressure from the public to demand health care quality and adequate services.

Medicare is a prime example. The public is opposed to any reduction in Medicare benefits. In fact, increasing coverage by adding prescription drug coverage was due to public demand. They are now demanding that it be improved further through measures such as eliminating the donut hole.

What could explain the apparent dilemma that people seem to be quite willing to purchase inadequate private plans that may not provide the financial protection that they need, yet they are not willing to accept inadequate coverage in a public health care financing program such as Medicare? Part of the answer may lie in the subliminally perceived relative inequity of premiums for private plans versus taxes for public programs.

The premiums for private plans are determined directly by the benefits covered by the plan, minus the cost sharing shifted to the patient. Costs are now so high that either premiums will be unaffordable, or out-of-pocket payments will be unaffordable, or, in actuality, downward pressures in the face of high costs are making them both unaffordable. More people are beginning to recognize that this is an obsolete method of financing health care.

The level of tax contribution for a publicly-financed health care system is not related to the benefits that are offered, but is determined by the ability of the individual or employer to pay the tax. Polls demonstrate that individuals are willing to pay more taxes that would be spent on publicly-financed health care. People seem to realize instinctively the fairness in this.

They also realize that Richard Gottfried is right. The downward pressure on private plans has caused most of us to look for relief from a health care financing system that is so badly broken. At the same time, the balanced pressure on Medicare has caused us to be very protective of that program. Now if we could just extrapolate our thinking to support Medicare for everyone, we’d have it made.

NCA (national coverage analyses) Tracking Sheet for Screening Computed Tomography Colonography (CTC) for Colorectal Cancer

Centers for Medicare and Medicaid Services (CMS)
Issue
CMS covers colorectal cancer screening for average risk individuals age 50 and older using fecal occult blood testing, sigmoidoscopy, colonoscopy, and barium enema (42 CFR 410.37). On March 5, 2008, the American Cancer Society, the US Multi Society Task Force on Colorectal Cancer, and the American College of Radiology issued new cancer screening guidelines, including a recommendation that computed tomography colonography (CTC) be considered an acceptable option for colorectal cancer screening for such individuals. CTC, also referred to as virtual colonoscopy, uses computed tomography (CT) to acquire images and advanced 2-dimensional (3D) -image display techniques for interpretation. Neither the Medicare law nor the regulations identify the CTC test as a possible coverage option under the colorectal cancer screening benefit. However, under 42 CFR 410.37(a)(1), CMS is allowed to use the NCD process to determine coverage of other types of colorectal cancer screening tests that are not specifically identified in the law or regulations as it determines to be appropriate, in consultation with appropriate organizations.
Actions Taken
February 11, 2009:
CMS posts a proposed decision memo indicating our intent not to expand the colorectal cancer screening benefit to include coverage of this test. We are also posting a technology assessment, including a cost effectiveness analysis for use of this test as a screening test which was requested from the Agency for Healthcare Research and Quality. As with all national coverage analyses, the public may submit comments or additional evidence that cause us to reassess our evidentiary review and arrive at different conclusions.
Tracking Sheet:
http://www.cms.hhs.gov/mcd/viewtrackingsheet.asp?id=220
Technology Assessment Report: Cost-Effectiveness of CT Colonography to Screen for Colorectal Cancer (92 pages):
http://www.cms.hhs.gov/determinationprocess/downloads/id58TA.pdf
Links to other documents:
http://www.cms.hhs.gov/mcd/viewnca.asp?where=whatsnew&nca_id=220&basket=nca:00396N:220:Screening+Computed+Tomography+Colonography+%28CTC%29+for+Colorectal+Cancer:Open:New:8

This CMS decision to not pay for computed tomography colonography (CTC or “virtual colonoscopy”) when used as a screening test for colorectal cancer has already caused considerable controversy even before the final public comment period has closed. Before we start deciding who is right and who is wrong, we should look at the issues. (What? Make decisions based on facts!?)
Medicare, as a public health insurance program, has an obligation to finance health care for which the benefit to patients more than offsets any potential risks. Also, as a steward of taxpayer funds, Medicare has an obligation to see that those funds, which are finite, are used optimally to benefit the public good. Ah ha! Rationing! But is it?
Rationing is generally defined as distributing restricted allotments of a scarce resource. Current debates on rationing stem from concerns about the escalating costs of health care, creating an excessive demand on our limited resource of… dollars! So are dollars becoming so scarce that we have to cut back on beneficial health care services?
Let’s look at how Medicare approaches this problem. Medicare does not make treatment decisions, but rather makes decisions about whether or not to pay for certain services. These decisions are important not only for Medicare patients, but for other patients as well, since the commercial insurance industry often follows Medicare’s lead on whether or not to pay for these selected services.
Virtual colonoscopy (CTC) used as a colorectal cancer screening test serves as a good proxy for this decision process.
First, does CTC screening benefit the patient? No attempt will be made to summarize the massive amount of studies and documentation that has been used to answer this question, but only a couple of points will be made here. If a CTC test is positive, it then is followed up with colonoscopy, which has already been approved as a screening test for colorectal cancer. Thus the patient has received two uncomfortable, expensive screening tests when only one has sufficient data to confirm its unquestionable value in screening. Further, over one out of one thousand patients receiving CTC screening at age 50 will likely develop cancer as a result of the radiation exposure from this test, resulting in a negative impact on the benefit/risk ratio.
Second, is CTC screening a responsible use of taxpayer funds? The Technology Assessment Report indicates that, based on cost effectiveness, it would not be in our interests, as taxpayers, for our public stewards to pay for CTC screening.
Consequently Medicare has made a decision to not pay for CTC screening for CRC, unless new important information is provided during the pubic comment period, or if new studies in the future would warrant readdressing this issue. It is likely that several commercial insurers will follow Medicare’s lead on this.
So what is the controversy? It comes from two sources: 1) dedicated professionals who have legitimate disputes over the interpretation and weighting of the evidence, and 2) right-wing ideologues who see this as a golden opportunity to attack “government medicine.”
Innumerable studies confirm that a significant portion of wasteful spending stems from non-beneficial, high-tech excesses. Defining those excesses will always be controversial, but the process used by Medicare is precisely what we need, especially with the inevitable improved refinements in the process that we will see in the future. Those dedicated professionals who will be denied payment by these decisions will always have doubts about the process, but they will always have the opportunity to provide more data that would warrant reconsideration of the payment decisions.
What will we see from the right-wing non-think tanks? The government rations care. Government medicine kills people over 65 who have colon cancer. Government deprives patients of their health care decisions. Patients should own their own health care and get the government out of their lives.
Refuting their position, it is important to understand that this is not rationing. The government is not declining to pay for CTC testing in individuals for whom it is clinically indicated. They have merely made a decision to not pay for CTC screening when the clinical data and costs have not demonstrated that it has advantages that would warrant it being included as a screening option. The conservatives/libertarians would substitute for rational decision making by our public stewards, a chaotic health-business marketplace that would prevent the majority of us from receiving the care that we need merely because it isn’t affordable.
Medicare has shown that we can address wasteful, excess costs. The easiest measure would be to recover the costs of the administrative excesses – a process that would be made possible by providing everyone with Medicare. Reducing the waste of high-tech excesses is more difficult, but the national coverage determinations process (NCD) has shown us that it is not only possible, but that we must expand this important government function since it will help to guarantee that high-quality, affordable care will always be there for all of us.

Centers for Medicare and Medicaid Services (CMS)

Issue

CMS covers colorectal cancer screening for average risk individuals age 50 and older using fecal occult blood testing, sigmoidoscopy, colonoscopy, and barium enema (42 CFR 410.37). On March 5, 2008, the American Cancer Society, the US Multi Society Task Force on Colorectal Cancer, and the American College of Radiology issued new cancer screening guidelines, including a recommendation that computed tomography colonography (CTC) be considered an acceptable option for colorectal cancer screening for such individuals. CTC, also referred to as virtual colonoscopy, uses computed tomography (CT) to acquire images and advanced 2-dimensional (3D) -image display techniques for interpretation. Neither the Medicare law nor the regulations identify the CTC test as a possible coverage option under the colorectal cancer screening benefit. However, under 42 CFR 410.37(a)(1), CMS is allowed to use the NCD process to determine coverage of other types of colorectal cancer screening tests that are not specifically identified in the law or regulations as it determines to be appropriate, in consultation with appropriate organizations.

Actions Taken

February 11, 2009:
CMS posts a proposed decision memo indicating our intent not to expand the colorectal cancer screening benefit to include coverage of this test. We are also posting a technology assessment, including a cost effectiveness analysis for use of this test as a screening test which was requested from the Agency for Healthcare Research and Quality. As with all national coverage analyses, the public may submit comments or additional evidence that cause us to reassess our evidentiary review and arrive at different conclusions.

Tracking Sheet:
http://www.cms.hhs.gov/mcd/viewtrackingsheet.asp?id=220

Technology Assessment Report: Cost-Effectiveness of CT Colonography to Screen for Colorectal Cancer (92 pages):
http://www.cms.hhs.gov/determinationprocess/downloads/id58TA.pdf

Links to other documents:
http://www.cms.hhs.gov/mcd/viewnca.asp?where=whatsnew&nca_id=220&basket=nca:00396N:220:Screening+Computed+Tomography+Colonography+%28CTC%29+for+Colorectal+Cancer:Open:New:8

Comment:

By Don McCanne, MD

This CMS decision to not pay for computed tomography colonography (CTC or “virtual colonoscopy”) when used as a screening test for colorectal cancer has already caused considerable controversy even before the final public comment period has closed. Before we start deciding who is right and who is wrong, we should look at the issues. (What? Make decisions based on facts!?)

Medicare, as a public health insurance program, has an obligation to finance health care for which the benefit to patients more than offsets any potential risks. Also, as a steward of taxpayer funds, Medicare has an obligation to see that those funds, which are finite, are used optimally to benefit the public good. Ah ha! Rationing! But is it?

Rationing is generally defined as distributing restricted allotments of a scarce resource. Current debates on rationing stem from concerns about the escalating costs of health care, creating an excessive demand on our limited resource of… dollars! So are dollars becoming so scarce that we have to cut back on beneficial health care services?

Let’s look at how Medicare approaches this problem. Medicare does not make treatment decisions, but rather makes decisions about whether or not to pay for certain services. These decisions are important not only for Medicare patients, but for other patients as well, since the commercial insurance industry often follows Medicare’s lead on whether or not to pay for these selected services.

Virtual colonoscopy (CTC) used as a colorectal cancer screening test serves as a good proxy for this decision process.

First, does CTC screening benefit the patient? No attempt will be made to summarize the massive amount of studies and documentation that has been used to answer this question, but only a couple of points will be made here. If a CTC test is positive, it then is followed up with colonoscopy, which has already been approved as a screening test for colorectal cancer. Thus the patient has received two uncomfortable, expensive screening tests when only one has sufficient data to confirm its unquestionable value in screening. Further, over one out of one thousand patients receiving CTC screening at age 50 will likely develop cancer as a result of the radiation exposure from this test, resulting in a negative impact on the benefit/risk ratio.

Second, is CTC screening a responsible use of taxpayer funds? The Technology Assessment Report indicates that, based on cost effectiveness, it would not be in our interests, as taxpayers, for our public stewards to pay for CTC screening.

Consequently Medicare has made a decision to not pay for CTC screening for CRC, unless new important information is provided during the pubic comment period, or if new studies in the future would warrant readdressing this issue. It is likely that several commercial insurers will follow Medicare’s lead on this.

So what is the controversy? It comes from two sources: 1) dedicated professionals who have legitimate disputes over the interpretation and weighting of the evidence, and 2) right-wing ideologues who see this as a golden opportunity to attack “government medicine.”

Innumerable studies confirm that a significant portion of wasteful spending stems from non-beneficial, high-tech excesses. Defining those excesses will always be controversial, but the process used by Medicare is precisely what we need, especially with the inevitable improved refinements in the process that we will see in the future. Those dedicated professionals who will be denied payment by these decisions will always have doubts about the process, but they will always have the opportunity to provide more data that would warrant reconsideration of the payment decisions.

What will we see from the right-wing non-think tanks? The government rations care. Government medicine kills people over 65 who have colon cancer. Government deprives patients of their health care decisions. Patients should own their own health care and get the government out of their lives.

Refuting their position, it is important to understand that this is not rationing. The government is not declining to pay for CTC testing in individuals for whom it is clinically indicated. They have merely made a decision to not pay for CTC screening when the clinical data and costs have not demonstrated that it has advantages that would warrant it being included as a screening option. The conservatives/libertarians would substitute for rational decision making by our public stewards, a chaotic health-business marketplace that would prevent the majority of us from receiving the care that we need merely because it isn’t affordable.

Medicare has shown that we can address wasteful, excess costs. The easiest measure would be to recover the costs of the administrative excesses – a process that would be made possible by providing everyone with Medicare. Reducing the waste of high-tech excesses is more difficult, but the national coverage determinations process (NCD) has shown us that it is not only possible, but that we must expand this important government function since it will help to guarantee that high-quality, affordable care will always be there for all of us.

On January 23, a Quote of the Day message discussed an article in The New Yorker by Atul Gawande, Getting There from Here: How Should Obama Reform Health Care? Unfortunately, my response to that article was cluttered with comments about framing, linear polarity and other extraneous concepts that detracted from my primary message.
His theme was that health care reform in any nation is inevitably “path dependent,” building on “its own history, however imperfect, unusual, and untidy.” He applies this concept to the United States stating that we must build on what we have, selecting out features of our current fragmented system of financing health care that he says should be expanded to achieve our goals. It just happens that the features he selects are those in the current leading Democratic proposal for reform.
His article is very well written, and is quite convincing to those who have not been intensively involved in reform activities and have only a limited understanding of health policy. Since it is such a impressive article it now is being circulated widely as a statement that (superficially) seems to make sense as a guideline for reform.
The problem is that Atul Gawande is flat out wrong. He implies that other nations merely made adjustments in their existing systems to expand coverage to everyone. In fact, these were not simple adjustments to systems that weren’t working; they were revolutionary transformations of their health care financing systems. Some residuals incorporated into their new financing systems might be called “path dependent,” but a more appropriate framing would be the antithesis that the thrust of each reform effort was to eliminate the deficiencies and inadequacies of the existing financing system or non-system. This inevitably required new financing systems. The fundamentals of these new financing systems were not based on path dependency, but they were based on path trailblazing.
Gawande dismisses single payer supporters as reformers “on the left” who “reserve special contempt for the pragmatists, who would build around the mess we have.” He explains later that the path dependent, pragmatic approach that we must follow will still be “exasperating, even disappointing,” while still failing to give single payer even short shrift.
In a Common Dreams article, Russell Mokhiber provided a comment by Atul Gawande in which he expanded on his views of single payer, along with a response by David Himmelstein. When you hear people praise Gawande’s New Yorker article, you should provide them with the following comments.

Et Tu, Atul?: Test-Case for a Single-Payer Hypothesis

by Russell Mokhiber
CommonDreams.org
February 10, 2009
As for (Gawande’s) opposition to single payer, he remains steadfast.
In a q/a with New Yorker readers last week, Gawande defended his opposition to single payer now.
“Replacing the entire health-financing system with Medicare would require most working-age people to leave their current insurance plans,” Gawande writes. “It would change the finances of every hospital and doctor in the country overnight. It would require replacing the premiums we pay with a tax, with massive numbers of both losers and winners. It seems simple in theory, but in practice it never is. This would be a whole new path for health care. No country has swept away their health system and simply replaced it like that. As I said in the article, one would have to be prepared for an overnight change in the way people get 3.5 billion prescriptions, 900 million office visits, 60 million operations – because how these are paid for is critical to whether and how they are provided. Doing away with private insurance coverage is no less sweeping than saying we’ll do away with public insurance programs or do away with employer-paid health care. No major country has simply swept away the way so many people’s care is paid for. And the reason is that people have legitimate fears about what will happen to them.”
Dr. David Himmelstein, a founder of Physicians for a National Health Program, calls this argument “bogus.”
“Patients do not care what their insurance plan is – just that it pays for the care they need. A transition from a system where virtually everyone has only partial coverage to one where they have full coverage is not a disruption for patients,” Himmelstein said when we asked him to respond to Gawande. “Several nations have made abrupt changes in the financing of care. The UK instituted the National Health Service – eliminating insurance and private payment for care at a stroke. Each Canadian province went from a private insurance system very like ours to its current system virtually overnight — though not all provinces underwent the change simultaneously. Taiwan changed to a single payer system about 10 years ago at a stroke.”
“Medicare replaced private coverage for the elderly — who account for about 30% of all hospital patients — about nine months after its passage. That occurred in an era before computers. The entire task of enrolling tens of millions of patients, inspecting virtually every hospital in the nation — to certify that they were desegregated, which was mandated by the Medicare law — and set up a new payment apparatus was carried out using paper records. Why is a shift of the other two-thirds of our system more difficult?”
“The new payment system would be far simpler than the current one — hospitals would receive a global budget, which initially would be based largely on their previous year’s revenues. Medicare currently collects all of the financial info needed to do such budgeting at the outset. Per-patient billing for hospital care would be eliminated. For doctors, Medicare already has a fee schedule, which should be modified somewhat, but already serves as the benchmark for most private plans. Expanding this payment system to cover all fee-for-service billings would be trivial. Paying for drugs is similarly pretty simple and straightforward, with most of the needed infrastructure already in place.”
“In sum, his arguments are bogus unless you assume that we are far less competent than people in other nations, and than we used to be,” Himmelstein said.
Mokhiber: Et Tu, Atul?: Test-Case for a Single-Payer Hypothesis
http://www.commondreams.org/view/2009/02/10-1
Gawande: Getting There from Here: How should Obama reform health care?
http://www.newyorker.com/reporting/2009/01/26/090126fa_fact_gawande
qotd: Gawande’s pseudo-pragmatism
https://pnhp.org/news/2009/january/gawandes_pseudopra.php

February 12, 2009

Comment:

By Don McCanne, MD

On January 23, a Quote of the Day message discussed an article in The New Yorker by Atul Gawande, Getting There from Here: How Should Obama Reform Health Care? Unfortunately, my response to that article was cluttered with comments about framing, linear polarity and other extraneous concepts that detracted from my primary message.

His theme was that health care reform in any nation is inevitably “path dependent,” building on “its own history, however imperfect, unusual, and untidy.” He applies this concept to the United States stating that we must build on what we have, selecting out features of our current fragmented system of financing health care that he says should be expanded to achieve our goals. It just happens that the features he selects are those in the current leading Democratic proposal for reform.

His article is very well written, and is quite convincing to those who have not been intensively involved in reform activities and have only a limited understanding of health policy. Since it is such a impressive article it now is being circulated widely as a statement that (superficially) seems to make sense as a guideline for reform.

The problem is that Atul Gawande is flat out wrong. He implies that other nations merely made adjustments in their existing systems to expand coverage to everyone. In fact, these were not simple adjustments to systems that weren’t working; they were revolutionary transformations of their health care financing systems. Some residuals incorporated into their new financing systems might be called “path dependent,” but a more appropriate framing would be the antithesis that the thrust of each reform effort was to eliminate the deficiencies and inadequacies of the existing financing system or non-system. This inevitably required new financing systems. The fundamentals of these new financing systems were not based on path dependency, but they were based on path trailblazing.

Gawande dismisses single payer supporters as reformers “on the left” who “reserve special contempt for the pragmatists, who would build around the mess we have.” He explains later that the path dependent, pragmatic approach that we must follow will still be “exasperating, even disappointing,” while still failing to give single payer even short shrift.

In a Common Dreams article, Russell Mokhiber provided a comment by Atul Gawande in which he expanded on his views of single payer, along with a response by David Himmelstein. When you hear people praise Gawande’s New Yorker article, you should provide them with the following comments.

Et Tu, Atul?: Test-Case for a Single-Payer Hypothesis

by Russell Mokhiber
CommonDreams.org
February 10, 2009

As for (Gawande’s) opposition to single payer, he remains steadfast.

In a q/a with New Yorker readers last week, Gawande defended his opposition to single payer now.

“Replacing the entire health-financing system with Medicare would require most working-age people to leave their current insurance plans,” Gawande writes. “It would change the finances of every hospital and doctor in the country overnight. It would require replacing the premiums we pay with a tax, with massive numbers of both losers and winners. It seems simple in theory, but in practice it never is. This would be a whole new path for health care. No country has swept away their health system and simply replaced it like that. As I said in the article, one would have to be prepared for an overnight change in the way people get 3.5 billion prescriptions, 900 million office visits, 60 million operations – because how these are paid for is critical to whether and how they are provided. Doing away with private insurance coverage is no less sweeping than saying we’ll do away with public insurance programs or do away with employer-paid health care. No major country has simply swept away the way so many people’s care is paid for. And the reason is that people have legitimate fears about what will happen to them.”

Dr. David Himmelstein, a founder of Physicians for a National Health Program, calls this argument “bogus.”

“Patients do not care what their insurance plan is – just that it pays for the care they need. A transition from a system where virtually everyone has only partial coverage to one where they have full coverage is not a disruption for patients,” Himmelstein said when we asked him to respond to Gawande. “Several nations have made abrupt changes in the financing of care. The UK instituted the National Health Service – eliminating insurance and private payment for care at a stroke. Each Canadian province went from a private insurance system very like ours to its current system virtually overnight — though not all provinces underwent the change simultaneously. Taiwan changed to a single payer system about 10 years ago at a stroke.”

“Medicare replaced private coverage for the elderly — who account for about 30% of all hospital patients — about nine months after its passage. That occurred in an era before computers. The entire task of enrolling tens of millions of patients, inspecting virtually every hospital in the nation — to certify that they were desegregated, which was mandated by the Medicare law — and set up a new payment apparatus was carried out using paper records. Why is a shift of the other two-thirds of our system more difficult?”

“The new payment system would be far simpler than the current one — hospitals would receive a global budget, which initially would be based largely on their previous year’s revenues. Medicare currently collects all of the financial info needed to do such budgeting at the outset. Per-patient billing for hospital care would be eliminated. For doctors, Medicare already has a fee schedule, which should be modified somewhat, but already serves as the benchmark for most private plans. Expanding this payment system to cover all fee-for-service billings would be trivial. Paying for drugs is similarly pretty simple and straightforward, with most of the needed infrastructure already in place.”

“In sum, his arguments are bogus unless you assume that we are far less competent than people in other nations, and than we used to be,” Himmelstein said.

Mokhiber: Et Tu, Atul?: Test-Case for a Single-Payer Hypothesis
http://www.commondreams.org/view/2009/02/10-1

Gawande: Getting There from Here: How should Obama reform health care?
http://www.newyorker.com/reporting/2009/01/26/090126fa_fact_gawande

qotd: Gawande’s pseudo-pragmatism
https://pnhp.org/news/2009/january/gawandes_pseudopra.php