PNHP

For Single-Payer Plan, Winds May Be Shifting

For Single-Payer Plan, Winds May Be Shifting

Amid the deconstruction of "Obamacare," public opinion and physician leaders seem to be moving toward a national health plan. But if it ever does materialize, it will be a long time in coming, experts say.

By Heather Boerner
Physician Leadership Journal, May 16, 2018

Some cases simply haunt Ed Weisbart, MD, CPE. That includes the 63-year-old woman who, caring for her grandchildren, had to choose between paying rent to stave off eviction and buying her blood pressure medicine. She chose the rent but hadn’t forgotten about her blood pressure, which was now measuring off the charts.

“How long can I live,” he remembers the patient asking, “without taking my blood pressure pills?”

It’s the kind of question medical school hadn’t prepared him to handle. And as the years passed, the Missouri physician has had to field such questions repeatedly. Whether it was because of insufficient coverage, high deductibles, inscrutable formularies or just a tight month, Weisbart said he found himself juggling increasing hours of billing and coding for a growing number of health insurance plans on one hand and the financial limits on his patients’ health on the other.

And he started to wonder: How do you do no harm in a health care system that doesn’t guarantee patients can afford their treatment?

“I can tell you hundreds of stories,” he said. “People are desperately sick. They need something and they know they need something. I want to give them the treatment and they want to get it. And they simply can’t afford to pay for it. And then they die. This is not the way it should be.”

The solution to this problem is far from settled. The Affordable Care Act tried a hybrid public-private model. Now, many in Congress are pushing less-expensive plans and high deductibles, trusting the free market to solve the problem. But after more than 30 years in practice, Weisbart has come to a different conclusion: It’s got to be coverage for all — something like Medicaid or Medicare expanded to everyone.

And he’s not alone. As Congress works to dismantle what the Obama administration established and moves to deregulate health care, there’s a growing appetite for the direct opposite — a public solution. But if it ever does materialize, it will be a long time in coming, experts say.

From Truman to Trump

The government has been trying to get it right on health care since the early 1900s, when Congress formed the Committee on the Costs of Medical Care. In 1945, President Harry S. Truman proposed that part of America’s “economic bill of rights” was “a right to adequate medical care and the opportunity to achieve and enjoy good health.” The other? The “right to adequate protection from the economic fears of…sickness.”

Months after that proposal, Truman fleshed it out, and the bill was, indeed, meaty. Not only did the bill provide for government-funded construction of hospitals in health care deserts, as well as funds for physicians and other health care providers to work in areas with none, but it also included a government health insurance program, available to all Americans, but not compulsory.

“The time has arrived for action to help them attain that opportunity and that protection,” Truman told Congress.

But, in fact, the moment hadn’t. Though the bill was introduced repeatedly, it never reached his desk.

That was followed by a proposal by Truman’s successor in the Oval Office, Dwight D. Eisenhower, to create a fund to help private insurance companies cover more people. Federal workers got public health insurance in 1960, followed by the enactment of Medicaid and Medicare under the Lyndon B. Johnson administration.

There have been several proposals since then: Richard M. Nixon’s Comprehensive Health Insurance Plan, Jimmy Carter’s Children’s Health Assessment Program, and Bill Clinton’s managed competition plan. But none passed until the ACA in 2010.

And with the ACA still targeted by President Donald J. Trump, people are asking what’s next.

The Trump Vision of Health Care

So far, what’s next is a return to many pre-ACA policies. Trump publicly has supported market-driven solutions, such as high-deductible plans and associated health savings accounts. He is also calling for a move back to buying insurance across state lines and health plans that don’t cover all of the ACA’s so-called essential health benefits, which include pregnancy. And recent announcements from the Centers for Medicare & Medicaid Services that the agency will allow waiver requests from states seeking to impose work requirements on enrollees could mean a drop in Medicaid rolls.

Harvard Business Review called 2017’s tax overhaul bill “the most important health care legislation enacted since the Affordable Care Act,” and here’s why: It repealed the ACA’s mandate that all Americans must have health insurance or pay a tax penalty. Without the penalty, the Congressional Budget Office estimates that 13 million people will lose their insurance or choose to abandon it by 2027.

And as people exit the exchanges, those with chronic conditions are expected to make up a larger proportion of the risk pool — meaning that premiums are expected to rise. A report from the Commonwealth Fund says, for instance, premiums for older adults could rise by $1,469 in Arizona and $1,817 in Nebraska.

Swing of the Pendulum

But Truman’s idea of a national health insurance plan never really went away. In June 2017, the California Senate passed a government health insurance program bill that would cover all state residents. Around the same time, New York state legislators reintroduced the long-standing New York Health Act — a universal coverage bill that has passed in the state Assembly several times.

Meanwhile, legislators in Colorado, Nevada and Vermont, among others, have been proposing universal coverage plans for years. The only states with anything approaching universal coverage are Hawaii, which in 1989 added a state health insurance plan to cover people who are not insured by Medicaid or Medicare but cannot afford private insurance, and Massachusetts, which has something resembling a universal plan.

It’s not just happening on the state level. Last year, Congress members introduced two bills proposing different ways to expand government health insurance from the elderly, the disabled, the indigent and veterans to encompass all Americans. So far, all the bills have stalled either in committee or in one house of state legislatures.

A Change in Momentum

None of the federal bills, of course, has a chance in the current political climate, says Jim Morone, professor of public policy at Brown University, who has written about the history of health care reform. But that doesn’t mean they are meaningless.

Indeed, he says, every president has had to address health care — and future presidents will, too. By following the politics of health care reform over the decades, he says he has learned a few things:

A president’s leadership is essential to get a health care bill passed.

There’s never a good time for reform — it’s always politically difficult, he said, and it’s never the right time economically.

And, if reform is going to happen, it’s going to happen in the first year of a president’s term.

“The electoral glow wears off quickly,” he says. “That’s why Clinton lost on health care. He didn’t submit it for a year after his election, and by then all anyone could think about was, ‘Will Republicans take Congress?’”

In this sense, he says, both Obama and Trump got it right, addressing health care at the very start of their terms.

The other thing he learned in his research — particularly on Truman’s health reform efforts — was that keeping up a drumbeat of moral outrage about the rightness of health care reform can work, even long after a bill is thought dead in the water.

“When Clinton lost health reform, what people said was that maybe it wasn’t the right proposal. Truman didn’t do that,” Morone says. “He said directly, ‘We lost because of politics, and this is still the right thing to do.’”

The result is that when Johnson signed the bill creating Medicare and Medicaid — an adoption of Truman’s plan — Johnson did it with the former president at his side. “In this way,” Morone says, “Bernie [Sanders] is doing it right.”

Physicians in the Lead

To a certain degree, that’s where physician leaders come in, Morone says.

And there are signs physicians may be ready to play that role. While physicians have typically come out against public insurance options — the American Medical Association has been among the most vocal opponents of such plans since the Truman administration — recent surveys suggest physicians are changing their minds.

In a recent survey by the market research group Merritt Hawkins, 35 percent of physicians strongly opposed single-payer health care. But the majority — 56 percent — supported it.

Those statistics conform to results of a June 2017 Pew Research Center poll, which found that not only did 60 percent of Americans say the government is responsible for ensuring all Americans have access to health care, but more than half of those people say they support a single-payer system, such as Medicare or Medicaid expanded to all Americans. That’s a 12 percent increase from 2014.

Weisbart is one of those leaders. He is spending his retirement doing something he never thought he’d do: After 20 years as a primary care physician in Chicago, and then another several years as chief medical officer of a mail-order pharmacy, he finds himself running the Missouri chapter of the Physicians for a National Health Program. The first year he worked with them, he gave 35 presentations around the state, mostly trying to explain what a national health program means. In 2017, he did 100 presentations.

“At first it was us pushing” to get in the door, he says. “That’s not the case anymore. Now most of the presentations I give, they come to me. They say, ‘We want a speaker on Medicare for all.’”

https://news.physicianleaders.org…

Urban Institute’s ‘Healthy America Program’

The Healthy America Program: Building on the Best of Medicare and the Affordable Care Act

By Linda J. Blumberg, John Holahan, Stephen Zuckerman
Urban Institute, May 14, 2018

Abstract

Since efforts to “repeal and replace” the Affordable Care Act (ACA) have failed, and bipartisan attempts to improve the law have stalled, some policymakers are now looking beyond incremental fixes. In this paper, Urban Institute researchers present a set of policy ideas that would provide universal access to comprehensive coverage but would also allow people to keep their employer-sponsored coverage, would offer a range of insurer options and ensure broad pooling of health care risk, would not have an employer mandate, would provide income-related federal assistance, and would create a more flexible individual incentive to remain insured than that under the ACA.

The proposal builds on components of the Medicare program and the ACA Marketplaces. However, it simplifies the current health insurance system by integrating Medicaid acute care for nonelderly people and the Children’s Health Insurance Program (CHIP)—while preserving access to their benefits—with coverage for people enrolled in private nongroup insurance and people currently uninsured. This large new Medicare-style marketplace, featuring a public plan and private insurer options, would contain costs by fostering competition among many insurers, capping provider payment rates, and addressing prescription drug pricing. This proposal is less ambitious than a single-payer system (i.e., Medicare for All), but it would get close to universal coverage with much lower increases in federal spending and less disruption for people currently enrolled in employer coverage or Medicare.

They estimate that the plan would result in 15.9 million fewer uninsured people and reduce total health care spending by $28.9 billion in its first full year of implementation.

Healthy America Compared with Other Proposals 

See Table 4 in the full article for other proposals – only Healthy America (HA) and Medicare for All by Sanders (MfA) are included here.

Who is eligible for the new program?

HA – All lawfully present people younger than 65

MfA – All US residents

What’s in the program?

HA – New public plan option, restructured private nongroup insurance market, enhanced premium and cost- sharing subsidies, new incentive to remain insured

MfA – Single-payer system enrolling all US residents in a single plan

Does the separate Medicaid program continue?

HA – Medicaid acute care program ends, with enrollees folded into other programs; long- term services and supports program continues as under current law

MfA – No

Are states required to make maintenance-of- effort contributions?

HA – Yes, but only for spending on acute care for the nonelderly

MfA – No

Does the separate Medicare program continue?

HA – Yes

MfA – No

Does the private insurance market remain?

HA – Yes, for group and nongroup private insurers; no firewall between employer coverage and new program

MfA – No

What benefits are offered?

HA – ACA essential health benefits

MfA – All medically necessary acute care and dental, vision, and hearing care; long-term services and supports stay the same as under current Medicaid program

How much are household premiums?

HA – Premiums range from 0 to 8.5% of income; premium subsidies are tied to 80% actuarial value plan

MfA – None

What are the cost-sharing requirements?

HA – Cost-sharing subsidies increase actuarial value above 80% for people with incomes up to 300% of FPL; cost- sharing options with actuarial value below 80% also available

MfA – None

Are people automatically enrolled?

HA – Only SNAP and TANF enrollees, who face no premiums, are autoenrolled; others without premiums can enroll in public plan at any time

MfA – Yes

Do individuals face a penalty for remaining uninsured?

HA – Yes, structured as loss of a tax benefit, which can be partially refunded if people enroll in coverage later

MfA – No, all are enrolled in a single plan

Are there limits on provider payment rates?

HA – Yes, for nongroup insurance markets

MfA – Yes

Do employers face a penalty for not insuring workers?

HA – No

MfA – No

Are there minimum standards for employer coverage?

HA – No

MfA – Not applicable; employer insurance eliminated

Does the program provide universal coverage?

HA – Close to universal for legal residents (not for undocumented people)

MfA – Yes

From the Discussion

Several proposals are being put forward to fix the ACA or to fundamentally reshape the US health insurance system. Proposals of significant restructuring are necessarily more complex than those focused on making the ACA work better. In Healthy America, we try to strike a balance by retaining Medicare and employer-sponsored insurance while significantly changing Medicaid and nongroup health insurance. Our goals are to keep what people like, change what is not working, and limit the increase in new federal costs.

https://www.urban.org…

Full Report (24 pages):
https://www.urban.org…

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Comment:

By Don McCanne, M.D.

Those looking for solutions other than a single payer improved Medicare for all may find Urban Institute’s Healthy America Program to be an attractive incremental approach since it leaves Medicare and employer-sponsored plans intact while making adjustments to Medicaid and the nongroup health insurance market. For single payer advocates, merely reading the comparisons between the two proposals is enough to show that the Urban proposal falls intolerably short of the reform goals of single payer.

A detailed critique of the full proposal could be prepared, but if you merely skim though the full report, it’s obvious that it is not worth the effort since they leave in place most of our highly flawed health care financing infrastructure.

Read the full report if you want to, but if you are primarily interested in refreshing in your mind what actually will work, spend your time reading once again the Physicians’ Proposal for Single-Payer Health Care Reform: pnhp.org/nhi.

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Framing health financing as wealth transfer ignores the moral imperative of social insurance

Health policy reform or wealth transfer?

By Gary Galles
The Orange County Register, May 9, 2018

Americans have been fighting over health insurance reform for years. Single-payer proposals, as most recently proposed in California’s legislature, are just the latest example. However, while rhetoric has focused on how many would supposedly gain or lose insurance, wealth transfers have been the real issue. As economist Henry Aaron estimated a quarter-century ago, implementing comprehensive national health insurance would redistribute more income than any single public policy then in existence.

We know insurance is not the real issue because claimed “reforms” violate so many principles of insurance.

The price controls reform proposals incorporate are also about transferring wealth, not health insurance. My age makes my actuarial risk six times that of my students. If, as Obamacare required, I could not be charged more than three times what they were, that really forces the young to subsidize the old, explaining why Obamacare imposed penalties to force acceptance of a bad deal.

Mandating coverage of pre-existing conditions also shows “reforms” are seldom really about insurance. It doesn’t reduce people’s risk exposure, it forces others to cover costs already known to be higher and deflects the blame to insurance companies who must charge others more. Such after-the-fact possibilities are not offered in fire, automobile or life insurance. Similarly, casinos don’t let you bet once the roulette ball or dice have stopped.

In addition, if health policy was truly aimed to benefit all Americans, rather than benefiting some by pick-pocketing others, it would not have been pushed with so many lies, damned lies and statistics.

Our health insurance debate has become so contentious largely because it has allowed massive wealth transfers to be mis-represented as improving health insurance. It helped dishonestly sell Obamacare, and now portrays reducing massive theft from those government targeted to hold the bag as imposing heartless harm on others. Such mis-representation cannot generate policies that advance either Americans’ or Californians’ well-being.

Gary M. Galles is a professor of economics at Pepperdine University, an adjunct scholar at the Ludwig von Mises Institute, a research fellow of the Independent Institute, a member of the Foundation for Economic Education faculty network, and a member of the Board of Policy Advisors at the Heartland Institute.

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Published comment:

By Don McCanne, M.D.

Wealth transfers have been the real issue? Isn’t the real issue rather ensuring that everyone has affordable access to essential health care services, as all other wealthy nations do?

We take for granted public services such as primary and secondary education, fire and police protection, public parks, highways and streets, national defense, Medicare, Social Security, the services of the National Institutes of Health, to mention a few. Most of the taxes used to fund these services are progressive to some degree – those with higher incomes pay more than those with lower incomes. Yet we do not refer to wealth transfer as being the primary policy that drives the existence of these services; it its the services themselves that are the primary public policies.

Health care stands out partly because of its very high costs. The cost of health care for the typical family of four receiving employer-sponsored PPO coverage is now $27,000 (Milliman). Median household income is now about $59,000. Although those are not identical family units, these numbers do make the general point that average-income families cannot possibly pay their proportionate share of global health care costs if they were evenly distributed amongst all of us (risk pooling).

Rather than framing this primarily as wealth transfer it should be framed as social insurance covering the health care needs of the people. If the funding were not equitable (progressive), too many would have to do without health care. The most efficient and effective methods of financing happen to be either a single payer system – an improved Medicare that covers everyone – or a national health service – socialized medicine. Most Americans would prefer Medicare for all, and would consider it their earned right, just as we consider Medicare in retirement to be our earned right rather than being primarily a government wealth transfer program.

https://www.ocregister.com…

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Comment:

By Don McCanne, M.D.

Although it is usually not wise to repeat the deceptive rhetoric of the opponents of health care justice, it can be helpful to understand it and be able to respond when it is in your face. Professor Galles uses wealth transfer – a concept he apparently considers to be evil – to reject the concept of pooling risk for health care.

It’s really simple. Because health care needs are unequally distributed, we need to pool risk by transferring from the healthy to the infirm. Because average health care costs are beyond the means of those with average incomes we need to fund the risk pool equitably based on ability to pay.

This is a concept that is accepted throughout society. Tax-financed public services are largely funded progressively through tax policy. That is not evil, but good. It makes it possible to provide those services for everyone. We don’t suggest that individuals with lower incomes should be denied fire or police protection merely because it would results a transfer of wealth.

Galles condemns what he calls wealth transfer when it makes health care services available to those who otherwise could not afford them. Yet he remains silent on the massive wealth transfer that necessitates these public policies – the transfer of wealth from the workers whose productivity has grown the economy, to those already wealthy rentiers who provide little personal contribution other than their excess capital gained by market abuses. That’s the shameful wealth transfer that our public policies should be addressing.

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The Time for Single-Payer Is Now

Countering Corporate Lies, Doctors Run Ad Providing the Facts About Medicare for All

By Jake Johnson
Common Dreams, May 12, 2018

As momentum in the fight for Medicare for All continues to grow nationwide thanks to persistent grassroots organizing by nurses, democratic socialists, and progressive activists, a group of California doctors placed an unprecedented eight-page ad in a major Sacramento newspaper on Thursday in an effort to combat corporate lies about single-payer and provide “patients and physicians with the tools they need to be effective advocates for a system that provides high quality care, but doesn’t bankrupt the sick or the U.S. economy.”

What If

“We don’t have the deep pockets of the insurance industry or the pharmaceutical industry, which Californians may recall spent $109 million two years ago to defeat a ballot measure to reduce drug prices, but we are determined to get the facts about single-payer out in Sacramento and across the country,” Dr. Paul Song, a radiation oncologist and president of the California chapter of Physicians for a National Health Program (PNHP), said in a statement.

The full eight-page publication—which features articles from doctors explaining how a single-payer system would be more cost-effective and provide far better care than the for-profit status quo—can be read here.

Funded by local PNHP members, the ad campaign ran in 100,000 copies of the Sacramento News and Review, and copies of the insert were given to every member of the California state legislature before the publication ran this week.

“There’s a lack of informative, accurate coverage of single payer in the mainstream media,” Dr. Bill Bronston, chair of the Sacramento Chapter of PNHP, said in a statement.

In addition to pressuring lawmakers in California and nationwide to get behind Medicare for All—which has been surging in popularity over the past year and now has the support of the majority of the American public—the ad insert is also aimed at urging “patients to talk to their doctors about how single payer could dramatically reduce drug costs and allow patients to choose their physicians without co-pays, deductibles, and outrageous out-of-network bills,” Dr. Song said.

https://www.commondreams.org…

APA panel: Single-payer system is the solution for mental health care

Single-Payer System Is the Solution for Mental Health Care, Panelists Say

By Kelly Davio
AJMC, May 7, 2018

In a discussion during the American Psychiatric Association 2018 Annual Meeting, held in New York, New York, a panel of psychiatrists argued that private insurance is failing patients with mental health disorders, and that a single-payer system would provide better access and better care for the most seriously ill patients.

J. Wesley Boyd, MD, PhD, a psychiatrist who focuses on adult outpatient psychiatry in the Cambridge Health Alliance, explained that mental health disorders, which affect 1 in 5 adults, are the leading cause of disability in the United States. Additionally, only 20% of children and youth with mental health disorders will get treatment, and “The effects can be lifelong and potentially devastating, both in terms of inability to retain work, possible interactions with the justice system, you name it…the stakes are very high.” In Boyd’s view, “The insurance industry is not doing anyone a favor when it comes to mental health care.”

Insurance companies create obstacles to needed mental health care, Boyd argued, starting with prior authorizations. “Anytime I have called for a prior authorization, I set aside 40 minutes to do that. I call a number, inevitably it’s a wrong number…I’m counting on being transferred at least twice before I get the person I need.” To Boyd, the difficulty in reaching the right person to authorize care is not merely a hassle, but potentially a deliberate attempt by insurers to curb access to care. “They want to make it as difficult for us as possible,” he said.

According to Boyd, payment for psychiatric services by private insurers is so low that many facilities lose money for the services that they provide, and consequently reduce access to the services that they offer.

Boyd discussed a study that he and his colleagues conducted in which they phoned 64 in-network Blue Cross Blue Shield (BCBS) mental health facilities in the Boston area to assess a patient’s ability to gain treatment. Researchers able to get an appointment only 12% of the time. In 23% of cases, they received no return call after trying twice to reach the clinic. In 23% of cases, facilities’ representatives explained that the patient would be required to receive primary care at the facility in order to be eligible for mental health services.

Monica Malowney, MPH, a consultant with the Public Consulting Group, added that in her own study, in which she and colleagues called 360 adult psychiatrists in 3 major cities using a provider list from BCBS, only 119 clinicians were reachable on a first round of calls. In another such study that focused on 913 psychiatrists in 5 major US cities who provide care to children, the researchers were able to get an appointment only 17% of the time.

Stephen Kemble, MD, who is retired from psychiatric practice, argued that value-based payment reform is compounding the problem of accessible care for patients with serious mental illnesses. According to Kemble, value-based models incentivize clinicians to avoid risky, more complex, socially disadvantaged patients because they may cost more to treat than other patients; “If you’re paid upfront, you want to avoid sick people. [You’re] cherry-picking.”

Kemble questioned whether the fee-for-service model itself is really to blame for the problem of high-cost, unnecessary care. Other drivers, such as lack of access to appropriate outpatient care, leads to unnecessary emergency department visits and hospitalizations.

Furthermore, the administrative burdens that come with a shift to value-based care, said Kemble, are creating physician burnout. In his experience in Hawaii, he has found that few private practice psychiatrists are willing to invest in the upgrades required to comply with reporting procedures associated with new payment models, so many clinicians simply stop accepting Medicare and Medicaid instead. As a result, he said, access in Hawaii is increasingly limited to community mental health centers and hospital clinics, so a number of seriously ill patients are unable to get urgently needed care.

Leslie Gise, MD, clinical professor of psychiatry at the John A Burn School of Medicine at the University of Hawaii and a staff psychiatrist at the Maui Health System, added that the current state of the healthcare system disproportionately disadvantages women in gaining access to mental healthcare, in part by charging women more for their coverage. The Affordable Care Act did not fully do away with the problem of “gender rating” enrollees, Gise said, because there are only nominal penalties for violating the law, an higher costs to employers to provide insurance to women can result in lower wages for female workers.

Furthermore, women who divorce often lose their private health insurance, she said, and the linkage of marital status and health insurance contributes to declines in women’s health. “Everyone should have adequate healthcare for life. Divorce should have nothing to do with it.”

A well-designed single-payer system that would cover all people for life, said Gise, would provide better outcomes, greater equality, and cost-reduction for the healthcare system at large.

http://www.ajmc.com…

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Comment:

By Don McCanne, M.D.

There has been a greater recognition of the need for mental health services at the same time that it has become clear that private insurers are failing us in providing adequate access to mental health care for those in need. It is hoped that our policymakers will listen to the recommendations of this panel that presented their case at the annual meeting of the American Psychiatric Association.

Their conclusion: “a single-payer system would provide better access and better care” for those in need of mental health services.

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A more accessible video on the BUSPH symposium on Trump and public health

Yesterday’s message was on the symposium presented at the Boston University School of Public Health on “The Trump Administration and the Health of the Public.”

A more accessible version of the archived video is now available on the PNHP website along with a program listing the speakers and their topics.

The three videos total 6 hours (if you skip the first 28 minutes of background music before the program started):

https://pnhp.org…

A BU Today article on the symposium (the article emphasizes the racial injustices covered during the session):

http://www.bu.edu…

If you are curious as to why this symposium was worth sending out a second notice, click the first link above and skim the program again. These topics must be a part of our national dialogue on the health of the public.

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Symposium on public policy and health in the Trump era

Dean's Symposium: The Trump Administration and the Health of the Public

Cosponsored with The Lancet Commission on Public Policy and Health in the Trump Era
Boston University School of Public Health, May 8, 2018

The day brought together public health scholars, journalists, thought leaders, and the wider public health community to discuss how we can view Trump-era policies and their impact on health more than a year into the new administration.

Agenda

OPENING REMARKS

Sandro Galea, Dean and Robert A. Knox Professor, Boston University School of Public Health

David U. Himmelstein, Distinguished Professor, School of Urban Public Health, Hunter College, City University of New York; Lecturer in Medicine, Harvard Medical School

Steffie Woolhandler, Distinguished Professor, Hunter College, City University of New York; Lecturer in Medicine, Harvard Medical School

KEYNOTE: FRAMING THE ISSUE—WHY THE TRUMP ADMINISTRATION MAY AFFECT HEALTH

Mary Travis Bassett, Commissioner, New York City Department of Health and Mental Hygiene

PANEL I: HEALTH OF PARTICULAR POPULATIONS – PART ONE

The Health of Immigrants
Altaf Saadi, Fellow, National Clinical Scholars Program, University of California, Los Angeles

The Health of Minority Populations
Zinzi Bailey, Assistant Scientist, Jay Weiss Institute for Health Equity, Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami

The Health of Children
Davida Schiff, Medical Director, HOPE Clinic, Massachusetts General Hospital

Moderator
Charles Kravetz, General Manager, WBUR

PANEL II: HEALTH AND BEHAVIOR

The Economy, and Its Impact on Health
Atheendar S. Venkataramani, Assistant Professor, Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania

Trump Policies on Food and Nutrition
Marion Nestle, Paulette Goddard Professor and Professor Emerita, Steinhardt School of Culture, Education, and Human Development, New York University

Health Care
Adam Gaffney, Instructor of Medicine, Harvard Medical School; Pulmonary and Critical Care Physician, Cambridge Health Alliance

Moderator
Richard L. Berke, Founding Executive Editor, STAT

PANEL III: THE WORLD AROUND US

Global Health
Joia Mukherjee, Associate Professor of Medicine, Harvard Medical School; Chief Medical Officer, Partners In Health

The Environment
Martin McKee, Professor, European Public Health, London School of Hygiene and Tropical Medicine

Racism and Mental Health
Jacob Bor, Assistant Professor, Global Health, Boston University School of Public Health

Moderator
Carol Hills, Senior Producer, Reporter, and Host, PRI’s The World

PANEL IV: HEALTH OF PARTICULAR POPULATIONS – PART TWO

Native American Health
Michael E. Bird, National Consultant on Native American/Alaska Native Communities, AARP

The Health Crisis in Puerto Rico
Olveen Carrasquillo, Professor of Medicine and Public Health Sciences, Miller School of Medicine, University of Miami

Criminal Justice and Incarceration
Lello Tesema, Director of Population Health, Los Angeles County Correctional Health Services, Department of Health Services; Assistant Professor, Division of General Internal Medicine, University of Southern California; Gehr Fellow, Gehr Family Center for Implementation Science

Moderator
Jenifer McKim, Senior Investigative Reporter and Senior Trainer, New England Center for Investigative Reporting, Boston University College of Communication

CLOSING REMARKS

David U. Himmelstein, Distinguished Professor, School of Urban Public Health, Hunter College, City University of New York; Lecturer in Medicine, Harvard Medical School

Steffie Woolhandler, Distinguished Professor, Hunter College, City University of New York; Lecturer in Medicine, Harvard Medical School

https://www.bu.edu…

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Archived Video

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Comment:

By Don McCanne, M.D.

The next time you are in a mood to spend six hours or so on reading a book or whatever, use the time to view this symposium instead. This is as fine of a symposium on issues of health care justice as you’ll ever witness. And considering the challenges that our nation faces, this could not be more timely.

In his closing comments, David Himmelstein explains why we should be updating ourselves on these issues:

“Health professionals have a duty to play a role in the changes our country needs, not just coming from the top to change the politicians who lead us, but to change the sea that those politicians swim in, the data that they understand, and understand not just as dry facts that we feed them, but as things that motivate our citizens and that condition the lives of our nation. So we have a charge as public health and medical professionals to participate in the changes that our country needs.”

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Michael Marmot: Childhood poverty and health inequity

Achieving health equity in the Americas

By Michael Marmot
Harvard Chan School of Public Health, May 3, 2018

But poverty – what are health people doing talking about poverty? Can we do anything about poverty? Well, you can, actually.

These OECD countries – there’s the United States. It’s looking at child poverty defined as less than 60% median income. In the US, 29% of children are in poverty. In Mexico, 31.6% in poverty.

David (Satcher) will remember, four years ago I addressed the American Public Health Association meeting, 8,000 people. And I showed something similar to this, that the US has such high child poverty levels. And I said– this was four years ago. You had a different person in the White House.

And I said, you live in a democracy. This must be the level of child poverty that you want. Otherwise, you’d elect a government that did something different. But can you change that? Well, yes you can.

This is reducing child poverty by social transfers– taxes and benefits, welfare. Finland reduces its pretax child poverty by 2/3 by taxes and transfers, Iceland similarly, Norway, Denmark Ireland, Sweden, even poor old UK. Oh, you’d rather not use the tax and benefits system.

I was teaching a global health class. And we had a student from Sweden. And when I talked about child poverty and the effect of government policy, this student from Sweden was really confused. She said, you mean some countries just operate their tax and benefit system to have high levels of child poverty? She couldn’t understand why any country would do that.

It is difficult to understand, isn’t it? Why would any country do that? Why would your country only reduce poverty by 18% by taxes and transfers? Pretty rich place.

And my country has decided to make inequality worse. This is the long run impact of tax and benefit reforms in the United Kingdom between 2015 and 2019. Look at families, working age families with children by deciles of income.

If you’re in the bottom decile, the bottom 10%, the Minister of Finance has decreed changes to the tax and benefits system that will lead to your income dropping by 9.5% by 2019. If you’re in the second bottom decile, your income will drop by more than 12%. And then the higher your income, the less the drop. It’s quite possible for the Minister of Finance to redistribute income. Our minister of finance is doing it, just redistributing it upwards and making families with children worse off.

I had a senior politician in London say to me, I’ve been listening to the evidence you gave to the Scottish Parliament. And I thought, what? You’ve been doing what? You should get out more.

And he said, you’re anti-government. And I said, no, I’m not. I’m pro-health equity.

Any policy that’s likely to have an adverse effect on child poverty will have an adverse effect on health inequalities. And that’s what I’m against. And in the US, a less progressive tax code from the 1960s, this is the top 0.1%. From the 1960s to 2013, the top 0.1% had a reduction in their tax by 2.1 percentage points and the bottom 50% an increase by 4.3 percentage points. You’re doing what we’re doing, making the tax system more regressive.

And the much vaulted recent tax bill, by 2027, the top 0.1% will get a 3% reduction. And the bottom 50% will get a 2% reduction. This is what the evidence shows.

Michael Marmot is Professor of Epidemiology and Public Health at University College London and one of the world’s foremost researchers on health inequalities.

Transcript, audio and video available through this link:
https://www.hsph.harvard.edu…

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Comment:

By Don McCanne, M.D.

The United States of America – the land with very high childhood poverty and associated health inequity. How would that placard look at our Fourth of July celebrations?

We can do something about it. As Michael Marmot says, we live in a democracy and thus we can have the level of child poverty that we want. Assuming that we would want it to be much lower than it is, why haven’t we done something already?

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Public Health Symposium at Boston University

PNHP leaders Drs. Steffie Woolhandler, David Himmelstein, and Adam Gaffney joined other public health luminaries on May 8, 2018 to discuss “The Trump Administration and the Health of the Public.” This daylong symposium was hosted by the Boston University School of Public Health, and cosponsored by the newly formed Lancet Commission on Public Policy and Health in the Trump Era. Click here for more details.

Merging insurers with the health care delivery system

Partners HealthCare, Harvard Pilgrim discussing possible merger

By Priyanka Dayal McCluskey
The Boston Globe, May 4, 2018

Hospital giant Partners HealthCare, looking to fortify its position in the rapidly changing health care market, is in potential merger negotiations with Harvard Pilgrim Health Care, one of the state’s largest medical insurers.

Executives from Partners, Massachusetts’ largest network of doctors and hospitals, and Harvard Pilgrim have been talking for several months, officials from both companies confirmed Friday in response to inquiries from the Globe. They are discussing a range of options, including an acquisition of Harvard Pilgrim by Partners.

The talks are taking place at a time of heightened deal-making in health care across the country, as hospitals, physician groups, insurers, and other companies pursue new strategies to manage costs and patient care. In Massachusetts, Beth Israel Deaconess Medical Center and Lahey Health are planning a big hospital merger to more aggressively compete with Partners.

Boston-based Partners is the parent company of Massachusetts General, Brigham and Women’s, and several other hospitals. Its expansion plans have been scrutinized in the past because the company is the most dominant health care provider in Massachusetts, and among the most expensive. Partners acquired specialty hospital Massachusetts Eye and Ear this year, and it’s negotiating a takeover of Care New England Health System in Rhode Island.

“Partners HealthCare is constantly exploring new partnerships and relationships with other providers and insurers with the goal of improving the delivery of health care to patients both locally and around the world,” Partners spokesman Rich Copp said. “Harvard Pilgrim is certainly among those organizations.”

“We’re looking at what we could do differently that brings value to our marketplace,” Harvard Pilgrim’s chief executive, Eric H. Schultz, said in an interview.

The US health care industry is in a time of rapid deal-making, with companies trying to cut costs by owning more pieces of the health care pie. CVS Health and the insurer Aetna have been working on a deal, for example.

In recent years, the lines between health care providers and health insurers have blurred.

Among the uncertainties around the combination of Partners and Harvard Pilgrim is what would happen to Partners’ existing insurance business, Neighborhood Health Plan.

Partners acquired Neighborhood in 2012. But instead of boosting Partners’ bottom line, Neighborhood — which traditionally focused on low-income individuals on Medicaid — contributed to historic financial losses at Partners.

Neighborhood shed many of its low-income members and worked aggressively to sell insurance to employers. But with about 142,000 members, it remains a small player compared with the state’s big three insurers: Blue Cross Blue Shield of Massachusetts, Harvard Pilgrim, and Tufts Health Plan.

https://www.bostonglobe.com…

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Comment:

By Don McCanne, M.D.

The potential merger between Partners HealthCare and Harvard Pilgrim Health Care is not just another routine merger and acquisition activity, but it is one occurring at the heart of the U.S. health care system – Massachusetts General Hospital being one of the oldest and most prestigious hospitals in the nation.

It is distressing to see multiple hospitals and physicians merge to gain market advantage, but it is even more disturbing when an integrated health care delivery system is merging with one of the state’s largest insurers. The implication that this is to serve the patients better is belied by the fact that Partners’ previous acquisition of a smaller insurer – Neighborhood – was followed by the shedding of its low-income members as it aggressively marketed itself to the more lucrative employer-sponsored insurance market.

Under a well designed single payer national health program, supposedly we would eliminate the private insurers and switch to a publicly-administered pre-paid health program. But what happens when the private insurers become an integral part of the actual health care delivery system? As is there weren’t enough problems already, obviously that would make implementation of a single payer system that much more difficult.

We’ve spent eight years talking about improving Obamacare by the feeble act of adding a public option, perhaps as a Medicare buy-in, when right under our noses this M&A activity has been taking place. They are building a health care delivery system that will be unassailable by social insurance programs. Are we going to wait until the only solution to bringing health care justice to all will be to nationalize our health care delivery system? How feasible is that?

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Docs talk single-payer at forum

Group wants to remove barriers to health care

By Ashley Sloboda
The (Fort Wayne, Ind.) Journal Gazette, May 7, 2018

Dr. Jon Walker didn’t pressure his audience of about two dozen Sunday to agree with his case for a single-payer health care system, also known as Medicare for all.

“You don’t have to accept this,” he said.

He did, however, encourage those at the Allen County Public Library meeting room to research the topic. He and others said they want the single-payer model to be considered.

“What we want is a discussion,” said Dr. Alison Case, who joined Walker as a panelist during a forum sponsored by Hoosiers for a Commonsense Health Plan.

The group is the Indiana affiliate of Physicians for a National Health Program, a nonprofit research and education organization of 19,000 physicians, medical students and health professionals who support single-payer national health insurance.

Under a single-payer system, a single public or quasi-public agency organizes health care financing, but the delivery of care remains largely in private hands, according to the national nonprofit. The organization expects benefits would include the elimination of financial barriers to care, such as deductibles.

All were welcome at Sunday’s forum, but many attendees indicated they work in health care.

Multiple speakers said the existing system is too expensive and, among other problems, leaves many underinsured or uninsured, resulting in people suffering and dying from illnesses they shouldn’t be suffering or dying from.

“This is a loss to our entire nation,” said Elaine Fazzaro, a retired registered nurse involved with Hoosiers for a Commonsense Health Plan.

As a physician, Case said, it’s frustrating that costs prevent patients from following treatment plans, such as people with diabetes not taking insulin because it’s unaffordable.

Panelist Dr. Tom Hayhurst recalled a 41-year-old man whose economic gamble cost him his life. Instead of immediately seeking medical treatment, financial reasons prompted the married father to wait until his temperature reached 104 degrees and he was gasping for air. By then, doctors couldn’t cure his pneumonia, Hayhurst said, calling the man’s death preventable.

Some attendees doubted the country will implement a single-payer system.

“Don’t give up. Let’s go to Washington,” Edith Kenna of the state organization said to a skeptical attendee.

Fazzaro agreed that it’s important to put pressure on lawmakers.

“Our politicians get so much influence from the…corporate side of it,” she said. “We have to have people understand what a single-payer health care plan would be.”

http://www.journalgazette.net…

There is a better way to deliver health care

By Herbert Keyser, M.D.
San Antonio Express News, May 5, 2018

About 20 years ago, I accepted a position to be the backup obstetrician for nine well-trained midwives in a large medical center.

The institution had decided that all deliveries would be done by them unless complications ensued. Under those circumstances I would be called upon to either assist in the management or take over the case.

It was a wonderful and gratifying experience. I learned a new way of looking at normal birth, based on constant supportive care during labor and delivery. The results were more than phenomenal. A national publication wrote an article describing our results as some of the best in the country.

I wanted to understand why that should be.

It wasn’t that we were smarter than all the physicians in facilities where all the babies were delivered by obstetricians. We were doing the same proportion of complicated cases as seen elsewhere. There had to be another answer.

Soon it became apparent to me.

When cases became complicated, I did the interventionist procedures that were required. But without complications the midwives spent long hours with these patients. That allowed these mothers to accomplish normal uncomplicated vaginal deliveries.

In the world of physician-delivered newborns, other factors intervened. Rarely did an obstetrician sit for hours with a patient in labor. Office hours and surgery all took time.

Commonly, physicians do not appear until the point of delivery. The earlier stages are managed by a labor room nurse who frequently has multiple patients in labor.

The explanation was simple.

The presence, uninterrupted, of a supporting person made all the difference. Without pressures to end the labor, do an unnecessary cesarean section, or intervene in any way, women had their babies with fewer complications and better results.

This year, my wife had a serious medical problem. I decided to seek help from the famed Mayo Clinic. Their national statistics are the top in American medicine. However, the reason for this superiority is a conundrum. There are great physicians all over this country.

So, why is the Mayo Clinic overwhelmingly evaluated as being at the top?

From the moment we arrived, I was impressed by the efficiency of this organization. It took several days to understand what made the difference. It was not dissimilar from my experience with the midwives.

Today’s private-practicing, fee-for-service physician knows that to make the practice work, it is necessary to turn over a great number of patients. Expenses have soared, with malpractice, office rental and labor costs constantly increasing, only a large volume of patients can sustain the economic forces.

That is not the world of the Mayo Clinic.

Every physician spent a great deal of time with us, frequently over an hour.

The answer was quite simple. There is no fee for service. There is no bonus system for productivity. Everyone is on a fixed salary, which varies by specialty and longevity. The average salary is less than in some parts of the country, but is not terrible — at just under $300,000 per year.

Every physician can refer any patient to another physician in every area of medicine to rule out other possible causes of an illness, with no pressure to produce, just the need to care for patients.

If Mayo can do that, why can’t everyone?

We are told “we can’t afford a single-payer system.” The real truth is that we spend so much per person for health care, that just spending the same amount in a single-payer system we can provide better care than any of the other countries of the world and care for everyone, not just three-fourths of our population.

Some will be unhappy.

The insurance industry will not be pleased.

The pharmaceutical industry will have to be content with reasonable rather than exorbitant profits.

The physicians who charge huge fees will have to be paid less, although physicians in general will be quite well compensated.

Then the Mayo Clinic will be just one of many places providing the highest quality care.

Spending quality time with each and every patient can be a wonderful benefit in finding our way out of the disgraceful health care system that this country maintains.

The political pressure exerted by all the forces previously mentioned that profit from our present system must somehow be overcome.

Americans really can have the kind of health care they pay for and deserve.

Dr. Herbert H. Keyser of San Antonio was the co-director of the Department of Obstetrics and Gynecology for one of the largest hospitals in Long Island, New York, for eight years, served as a lieutenant colonel in the United States Army Medical Corps, and for the last 25 years delivered babies primarily in poverty areas, Indian reservations and in locations of migrant workers.

https://www.mysanantonio.com…