PNHP

BMJ: Failing health of the United States

BMJ: Failing health of the United States

The role of challenging life conditions and the policies behind them

By Steven H Woolf, Laudan Aron
BMJ, Editorial, February 7, 2018

Life expectancy in the US has fallen for the second year in a row. This is alarming because life expectancy has risen for much of the past century in developed countries, including the US. The decline in US health relative to other countries, however, is not new; it has been unfolding for decades. In 1960, Americans had the highest life expectancy, 2.4 years higher than the average for countries in the Organisation for Economic Cooperation and Development (OECD). But the US started losing ground in the 1980s. US life expectancy fell below the OECD average in 1998, plateaued in 2012, and is now 1.5 years lower than the OECD average.

A joint panel of the National Research Council and Institute of Medicine investigated the US health disadvantage in 2013. It found that Americans had poorer health in many domains, including birth outcomes, injuries, homicides, adolescent pregnancy, HIV/AIDS, obesity, diabetes, and heart disease. It also found that many factors contribute to the health disadvantage; for example, Americans are more likely to engage in unhealthy behaviors (such as heavy caloric intake, drug abuse, and firearm ownership), live in cities designed for cars rather than pedestrians or cyclists, have weaker social welfare supports, and lack universal health insurance.

The panel reported high death rates in the US from drugs, a problem that has grown over time. Between 2000 and 2014, the rate of fatal drug overdoses rose by 137%, a crisis fueled by the growing use of highly addictive opioid drugs. In 2015 alone, more than 64 000 Americans died from drug overdoses, exceeding the number of US casualties in the Vietnam war. Drug addiction is devastating families and the social fabric of communities. The country is belatedly scrambling to reduce access (with, for example, prescription drug monitoring and drug take back programs), improve emergency responses to reverse overdoses (such as naloxone programs), and enhance access to effective addiction treatment (such as medication assisted treatment).

But the opioid epidemic is the tip of an iceberg, part of an even larger public health crisis in the US: death rates from alcohol abuse and suicides have also been rising. Between 1999 and 2014, the suicide rate rose by 24%. These “deaths of despair,” as some have called them, are disproportionately affecting white Americans, especially adults aged 25-59 years, those with limited education, and women. The sharpest increases are occurring in rural counties, often in regions with longstanding social and economic challenges.

Why white Americans are dying at higher rates from drugs, alcohol, and suicides is unclear, complex, and not explained by opioids alone. The answer—likely some combination of factors in American life—must explain why the rise in mortality is greatest in white, middle aged adults and certain rural communities. Possibilities include the collapse of industries and the local economies they supported, the erosion of social cohesion and greater social isolation, economic hardship, and distress among white workers over losing the security their parents once enjoyed. By contrast, greater resilience might explain why black Americans—who have contended with longstanding structural disadvantages, discrimination, and higher all cause mortality—have not experienced a surge in drug deaths or suicides.

Other data are also enlightening. Over the three decades in which survival advances slowed in the US, educational performance weakened, social divides (including income inequality) widened, middle class incomes stagnated, and poverty rates exceeded those of most rich countries. The US is rich, but its wealth is not inclusive. Its social contract is weaker than in other countries—those in need have less access to social services, healthcare, or the prevention and treatment of mental illness and addiction. The “American dream” is increasingly out of reach, as social mobility declines and fewer children face a better future than their parents.

In theory, policy makers jolted by the shortening lifespan of Americans would hasten to correct these conditions. They would promote education, boost support for children and families, increase wages and economic opportunity for the working class, invest in distressed communities, and strengthen healthcare and behavioral health systems. But the pro-business policy agenda favored by elected officials rarely prioritizes these needs. On the contrary, recent legislation and regulations may prolong or intensify the economic burden on the middle class and weaken access to healthcare and safety net programs.

Ironically, leaders are outspoken about ending the opioid epidemic and bemoan spiraling and unsustainable healthcare costs. Solutions to both problems—which involve investment to support struggling families and communities and thereby improve public health—are often rejected, usually by leaders with competing self interests or ideological objections. The consequences of these choices are dire: not only more deaths and illness but also escalating healthcare costs, a sicker workforce, and a less competitive economy. Future generations may pay the greatest price.

http://www.bmj.com…

***

Comment:

By Don McCanne, M.D.

This editorial states that lack of universal health insurance is one cause of declining health and life expectancy in the United States, especially when contrasted with the superior performance of other OECD nations. But it is only one cause. We have much more that we need to do to reverse the increasing disparities and their unwelcome outcomes.

The people of the United States need an epiphany – the realization that we need to join together to improve understanding of our deficiencies and then to resolve to work together to fix them. The solutions lie primarily in the public arena. That means we need national political leadership that is dedicated to this cause. But that also means that the people will have to fire the obstructionist partisans. That would be easy except for the plethora of obstructionist partisan voters who are immune to epiphanies.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

Seema Verma’s policies can kill people

Trump Administration Says States May Impose Work Requirements for Medicaid

By Robert Pear
The New York Times, January 11, 2018

In a speech to state Medicaid officials in November, (CMS Administrator Seema) Verma indicated that the Trump administration would be receptive to work requirements and other conservative policy ideas to reshape Medicaid. And she criticized the Obama administration, saying it had focused on increasing Medicaid enrollment rather than helping people move out of poverty and into jobs.

“Believing that community engagement requirements do not support or promote the objectives of Medicaid is a tragic example of the soft bigotry of low expectations consistently espoused by the prior administration,” Ms. Verma said. “Those days are over.”

https://www.nytimes.com…

CMS letter to Medicaid Directors; “Opportunities to Promote Work and Community Engagement Among Medicaid Beneficiaries” (10 pages):
https://www.medicaid.gov…

***

State Waivers As A National Policy Lever: The Trump Administration, Work Requirements, And Other Potential Reforms In Medicaid

By Billy Wynne and Taylor Cowey
Health Affairs Blog, February 6, 2018

Despite repeat campaign promises from then presidential candidate Donald Trump that he had no interest in altering Medicaid and other entitlements, it was evident from the start of his administration that there would be big plans in the works for the low-income insurance program. This was evident, most notably, in his appointment of health policy consultant Seema Verma—architect of the uniquely conservative Medicaid expansion waiver in Indiana—to run the Centers for Medicare and Medicaid Services (CMS). Now, one year into the Trump presidency, after Congress’s attempts to cut and restructure Medicaid through legislation have proved unsuccessful, the administration has begun in earnest to pursue a regulatory pathway to state-by-state Medicaid reform grounded in Verma’s approach to Section 1115 Medicaid waiver design.

Alignment with the program’s purpose—defined in statute (42 US Code Section1396) as “to furnish medical assistance on behalf of families … and … individuals … whose income and resources are insufficient to meet the cost of necessary medical services”—is a key requirement for waiver approval. CMS’s newly stated criteria no longer places an emphasis on coverage levels. Instead, it focuses on Medicaid’s sustainability over the long term, upward mobility, greater independence and beneficiary engagement, incentive structures and “responsible decision-making,” and commercial health insurance design features to “facilitate smoother beneficiary transition” off of Medicaid.

At the outset of the administration’s second year, CMS has unveiled highly anticipated guidance on how states can implement work, education, and job training requirements through Section 1115 waivers. Shortly after, HHS announced the approval of the first work requirement demonstrations in Kentucky and Indiana.

Pending Waivers to Watch

Work Requirements

Besides Kentucky and Indiana, eight other states—Arkansas, Arizona, Kansas, Maine, Mississippi, New Hampshire, Utah, and Wisconsin—have waivers pending at CMS that would impose a work requirement on Medicaid expansion or traditional adult Medicaid populations. As a feature of their proposed work requirements, some of these states are seeking to impose specific time limits on how long beneficiaries may stay enrolled in Medicaid coverage if they fail to meet engagement requirements.

Lifetime Caps

Several states, including Arizona, Kansas, and Utah, have gone a step beyond time limits tied to work and have proposed lifetime limits on Medicaid coverage for able-bodied adults, ranging from three to five years. If approved in Medicaid, it would constitute another monumental shift of the program design away from being a vehicle for health care and toward being treated as a conditional welfare program.

Lockouts

Time-limited periods of Medicaid ineligibility, or “lockouts,” resulting from nonpayment of premiums were previously approved by the Obama administration for certain expansion adults in only a small number of states. However, with approval of the Kentucky HEALTH waiver, premiums and lockouts may now apply to the traditional population as well. These policies present an additional administrative burden for states and create a yearly hurdle for enrollees to retain their coverage, which could lead to increased disenrollment and churn.

Hospital Presumptive Eligibility

Under the ACA, hospitals gained the option to make presumptive eligibility determinations for patients in need of immediate care. The policy provides greater access to Medicaid benefits for low-income individuals and protects participating hospitals from a percentage of uncompensated care costs. Where some states have previously been allowed to waive presumptive eligibility enrollment and retroactive coverage for pregnant women and children, it has not yet allowed a state to eliminate presumptive eligibility conducted by hospitals, as Maine and Utah are currently proposing to do.

Partial Expansion

Arkansas, which expanded its Medicaid program in 2014, has proposed to reduce eligibility for its expansion population down from the 138 percent of federal poverty level dictated by the ACA to 100 percent of poverty, while still maintaining the enhanced expansion funding for those who remain. Massachusetts later included a similar provision in its own pending waiver. Critics worry that approval of this “partial expansion” would set a precedent with budgetary and coverage consequences for low-income individuals in other states.

Exclusion Of Planned Parenthood

Separately from its actions on 1115 waivers, CMS recently issued a letter to state Medicaid directors rescinding previous guidance issued by the Obama administration regarding the “Free Choice of Provider” requirement in Medicaid, particularly in relation to providers of family planning and abortion services. The guidance had clarified that states may not exclude family planning providers from Medicaid reimbursement “solely because they separately provide family planning services or the full range of legally permissible gynecological and obstetric care, including abortion services.” This was widely understood to be in response to certain states seeking to prevent Medicaid dollars from going to Planned Parenthood. Citing “legal issues under the Administrative Procedure Act,” CMS has removed this guidance and opened the door to states that were previously seeking to exclude the organization.

Medicaid Drug Formularies

In response to the rising cost of prescription drugs, Massachusetts has proposed adopting a closed formulary for its Medicaid population. This would involve a waiver of the statute that otherwise requires Medicaid coverage of Food and Drug Administration-approved outpatient drugs provided the manufacturer participates in the Medicaid Drug Rebate Program.

Conclusion

From a state perspective, the Medicaid landscape has grown ever more complex as the program is increasingly found at the nexus of partisan debate and made the subject of major reform efforts that swing with the party controlling the White House or Congress.

With its solicitation of work requirement proposals and the other waiver reforms implemented in 2017, Verma and the Trump administration have decidedly swung the pendulum once more. Many states are responding in kind and ushering in an era of profound change for the decades-old program. But it remains to be seen if we will truly see work requirements and related reforms tested in the states as the legal and regulatory framework upon which this new paradigm is built is called into question in the courts. At the heart of the matter, as always, will be the question of how our nation views the core objectives of the Medicaid program—as health care or welfare for the nearly 70 million Americans enrolled.

https://www.healthaffairs.org…

***

After approving Medicaid work requirements, Trump’s HHS aims for lifetime coverage limits

By Tony Pugh
Lexington Herald-Leader, February 5, 2018

After allowing states to impose work requirements for Medicaid enrollees, the Trump administration is now pondering lifetime limits on adults’ access to coverage.

The move would continue the Trump administration’s push to inject conservative policies into the Medicaid program through the use of federal waivers, which allow states more flexibility to create policies designed to promote personal and financial responsibility among enrollees.

“I think you have to be very thoughtful here in a way that’s quite different from cash assistance,” said Gail Wilensky, a senior fellow at Project HOPE who ran the Medicaid program from 1990 to 1992 under President George H.W. Bush. “It depends on what the safeguards and defaults are in a program like this. Otherwise it does not make a lot of sense and seems to be cruel and inappropriate.”

http://www.kentucky.com…

***

Comment:

By Don McCanne, M.D.

CMS Administrator Seema Verma is critical of the Obama Administration because it used the Medicaid program to help low-income people receive the health care that they needed, just as the law requires. Referring to this as the “soft bigotry of low expectations,” Verma is encouraging states to apply for waivers that would use the deprivation of Medicaid benefits as a whip to move individuals out of poverty and into jobs. Instead of looking at Medicaid as a health care program that should be expanded to all who need it, she looks upon it as a welfare program that needs to be ratcheted down (presumably to reduce taxes for the benefit of the rich).

It is not only the work requirements that would reduce access to care for Medicaid eligible individuals; Verma is also considering other policies that would further reduce access. As the article by Billy Wynne and Taylor Cowey indicates, CMS also encourages lifetime caps that would arbitrarily throw individuals off of the program based simply on a time limit rather than on need; they would require premiums which could be a hardship for these vulnerable individuals; they would use lockouts perhaps as punishment for failure to comply with all details of the application process; they would eliminate presumptive eligibility prohibiting individuals from receiving coverage in an emergency even though obviously eligible; they would allow states to reduce their Medicaid expansion programs, keeping otherwise eligible individuals out of the program; they would allow states to exclude family planning and preventive services provided by Planned Parenthood, and they would allow closed drug formularies preventing individuals from obtaining excluded medications.

Obstructing the path to health care results in financial hardship, physical suffering, and sometimes even death.

Not even all of the conservatives can stomach this. Gail Wilensky, head of HCFA (precursor of CMS) under President George H.W. Bush, recognizes the difference between capping “cash assistance” welfare and capping a program designed to help people get the health care they need. As she says, a program capping health care “does not make a lot of sense and seems to be cruel and inappropriate.”

It’s true. Either actively or passively denying health care to anyone does not make a lot of sense and seems to be cruel and inappropriate. We need a well designed single payer national health program that takes care of everyone.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

How to create American jobs-health insurance for small business

By Jack Bernard
The Newnan (Ga.) Times-Herald, February 8, 2018

I’m a retired SVP with a publicly held health care corporation.

I now work as a volunteer with a wonderful non-profit organization, SCORE, which provides free mentoring to small businesses throughout the nation, including Georgia. It’s a fine program that I would recommend to anyone either starting a small business or expanding an existing one.

I strongly believe in the benefits of capitalism and have mentored hundreds of start-ups. Small business is the engine driving job creation in our nation…not tax cuts under the GOP tax proposal that primarily benefit international businesses, corporate officers and affluent investors like me. Per their own admission, these large corporations have no intention of adding jobs as a result of the GOP tax cut.

There are many, many obstacles in starting a new small business, among them health care insurance. The average health insurance cost for a family of four is now over $15,000 annually. If entrepreneurs have families with health issues, they may find themselves in an untenable position, seeking expensive insurance without government financial subsidies.

This is one key reason why the subsidies under the Affordable Care Act – ACA – Obamacare are so important.  Furthermore, Obamacare prohibits excluding coverage on the basis of pre-existing conditions. Thus, the ACA makes insurance more affordable for many of these entrepreneurs.

But, for those not getting the subsidies due to income restrictions – i.e. upper and upper middle- income wage earners, the choice is a stark one. They can follow their passion and start a business…or they can stay put on their current job, playing it safe and keeping health insurance.

This is not a choice entrepreneurs in other developed nations face, a competitive advantage for them. These nations have single payer, expanded Medicare to cover all or something like it.

The Commonwealth Fund recently (7-17) did an analysis of health care in 11 wealthy nations, all having full coverage except the USA. All were much less expensive than our country and had significantly better mortality and morbidity. For example, our cost per capita is over $9,000 annually. Italy is one-third that figure.

Short-term, the ACA is needed to help both entrepreneurs and others. And, the majority of Americans support it.

But, long-term we must have a comprehensive national health plan to control expenses while providing care for all citizens, creating high quality jobs for Americans as a result. Polls have shown that more and more Americans are coming to this point of view. Detailed information regarding Medicare for All, including funding specific sources, can be found on the website of Physicians for a National Health Plan at www.pnhp.org.

Interestingly, Trump was all for single payer decades ago, advocating for it frequently both in interviews and in writing. He even said during the campaign that it would be the best option if we were starting from scratch here.

Mr. President, are you now saying that you are unwilling to fight the entrenched drug and insurance interests and their lobbyists? What happened to draining the swamp?

Mr. President, with 12 percent of our population still uncovered – up from 9 percent because of health insurance market instability… purposefully created by you and Congress –  including many budding entrepreneurs, single payer is still the best option for both better health results and long-term small business job creation. Furthermore, with expansion of insurance will come the creation of more good paying jobs in the health care sector and related support services.

If you are really interested in job creation, and I believe that you are, it is past time to have Medicare for All in America.
 
Jack Bernard of Fayette County, a retired corporate executive, was a two-term county commissioner and former county Republican Party chairman in Jasper County.

http://times-herald.com…

Dr. Paul Song on ‘Rising Up With Sonali’

PNHP national board member Dr. Paul Song appeared on “Rising Up With Sonali” on Free Speech TV and Pacifica radio stations on February 8, 2018. He discussed the newly formed United States of Care organization, its reluctance to even utter the phrase “universal coverage,” and the ongoing need for single-payer reform.

Can Andy Slavitt keep politics out of ‘United States of Care’?

United States of Care, Accessed February 7, 2018

The mission of United States of Care is to ensure that every single American has access to quality, affordable health care regardless of health status, social need, or income.

A new non-partisan non-profit, we are building and mobilizing a movement to achieve long-lasting solutions that make health care better for everyone. United States of Care will help make it happen by working with Americans from across the country, policymakers, physicians and other clinicians, caregivers, and business, civic, and religious leaders.

We must change the conversation and create a new narrative that puts health care over politics by redefining the goal in human, not political terms, and supporting a positive, practical, and lasting approach.

United States of Care’s principles are:

* Affordable Source of Care: Every American should have an affordable regular source of care for themselves and their families

* Protection from Financial Devastation: All Americans should be protected from financial devastation because of illness or injury

* Political and Economic Viability: Policies to achieve these aims must be fiscally responsible and win the political support needed to ensure long-term stability

Board of Directors

Andy Slavitt, Former acting Administrator of the Centers for Medicare and Medicaid Services

Steve Beshear, Former Governor of Kentucky (Democrat)

Kristie Canegallo, Former Deputy White House Chief of Staff to President Obama

Jim Douglas, Former Governor of Vermont (Republican)

Dave Durenberger, Former United States Senator from Minnesota (Republican)

William Frist, M.D., Former United States Senate Majority Leader from Tennessee (Republican)

Rhonda Medows, M.D., Executive Vice President, Providence St. Joseph Health

For the 52 members of the Founder’s Council, use this link:
https://unitedstatesofcare.org/about-us/

United States of Care
https://unitedstatesofcare.org

***

Comment:

By Don McCanne, M.D.

“The mission of United States of Care is to ensure that every single American has access to quality, affordable health care regardless of health status, social need, or income.” That can be accomplished by enacting a well designed single payer national health program. In contrast, building on our current dysfunctional system will always fall short.

In establishing this organization, Andy Slavitt says that we must put “health care over politics.” Yet the several politicians involved are either Republicans (majority) or conservative neo-liberal Democrats (minority). The 52 members of the Founder’s Council (link to list above) include many strong supporters of the Affordable Care Act. There are many representatives of the health care industry. There are many outspoken opponents to single payer reform, aka Medicare for all. Yet there is not one individual who has taken a prominent stance in favor of single payer, even though a majority of Americans do support Medicare for All.

This organization that professes to place itself above politics is already smothered in anti-single payer politics and is doomed to fail. Sad.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

Amazon’s health care experiment shows exactly why we need Medicare for All

We have to remove profit from the health care equation, just like Amazon, Berkshire Hathaway and JPMorgan Chase intend to do.

By Richard Master
USA Today, Feb. 7, 2018

Amazon, Berkshire Hathaway and JPMorgan Chase announced last week that they would be forming a new company aimed at reducing employee health care costs. This decision was a response to what small, mid-sized and large business owners and CEOs have known for a long time: The private insurance system is strangling the U.S. economy.

As the founder and CEO of a mid-sized company that employs 180 people in the United States, I know this well. In 2018, we will pay $2.8 million to insure our workers and their families. Year after year, we have wrestled with the costs of our health care plans. And despite trying every trick in the book, our per-employee costs have tripled over the past 14 years.

A family plan in 2018 will cost us $27,000, which is higher than the annual salary of one-third of all working Americans. To put it another way, we are paying $13.50 per hour per employee just to cover the health care benefit. It’s a model that’s completely unsustainable, and needs to change.

According to their statement, this new health care company will pursue technology solutions to provide health care and lower costs. The real game-changer is that the company will be “free from profit-making incentives and constraints.”

They’re inches away from a major revelation: The way to fix health care for all people — not just those who are employed by monolithic corporations — is to de-commercialize the health insurance system.

In announcing the new partnership, Berkshire Hathaway Chairman Warren Buffett called the costs of healthcare “a hungry tapeworm on the American economy.” He’s right. But, combined, these three companies employ about 1.1 million people. Even accounting for dependents, this new company will, at best, serve 1% of the population. I’m looking for a solution that would help the other 99%: Medicare for All.

In the United States, we rely on private, for-profit insurance companies to finance our health care system. Over 157 million Americans are getting their coverage from employer based plans. Another 21.9 million have purchased insurance individually.

In theory, an insurance company exists to help negotiate with providers, and minimize the amount that patients and families are paying for healthcare. However, health insurance executives have the same motivation as the leader of any other company: profit.

That motivation is holding patients, workers and every other sector of our economy hostage to high premiums, and large out of pocket expenses. It is no coincidence that while health insurance companies are using hundreds of billions annually for their own sales and marketing, administrative overhead and profits, we are suffering under the most complex and expensive system in the world.

This is an existential threat to our businesses and our economy.

The high costs of health care, fueled by the profit motivation in the private insurance system, can be directly linked to the decreased take-home pay for workers; businesses not having capital to expand to new markets, create new jobs, or invest in new technologies; and medical bills as the number one cause of bankruptcy in the United States.

While some companies have the resources to do what Berkshire Hathaway, Amazon and JPMorgan Chase are doing, most don’t.

I certainly couldn’t do it for my employees, even though I wish I could. That’s why, if we are going to achieve an improved system for all of our citizens, what we really need is Medicare for all. Whether they know it or not, the leadership of these three companies made a strong case for removing profit from our health care system, and I hope our politicians are listening.

Richard Master is founder and CEO of MCS Industries, executive producer of multiple documentaries on the U.S. health care system, and founder of the Business Initiative for Health Policy.

https://www.usatoday.com…

Single payer at play in Germany’s talks to build a coalition government

Parties enter final round of talks to build new German coalition government

Deutsche Welle, February 4, 2018

More than four months after holding general elections, Germany remains in political limbo without a new government.

Negotiations between the CDU/CSU (Christian Democrats and Christian Social Union) and the SPD (Social Democratic Party) have entered what many hope could be the final round, with a number of issues still unsettled between the parties.

The parties managed to reach agreement on energy and agriculture issues as well as on the divisive issue of refugee family reunifications, but there’s still no consensus, especially over healthcare reforms. The conservative CDU/CSU bloc have squarely rejected SPD calls for introducing sweeping changes to Germany health insurance system which would see the country’s universal multi-payer health care system replaced by a national single-payer model.

“We’ll have to negotiate very, very intensively on these issues today and I think agreements are possible but they still haven’t been reached,” (SPD leader Martin) Schulz told reporters.

http://www.dw.com…

***

Germany’s divided SPD: the ultimate grand coalition decider

Deutsche Welle, February 4, 2018

After German reunification in 1990, the Social Democratic Party (SPD) boasted nearly a million members. These days, that figure is just over 440,000. But the members that remain are set to play a crucial role in the future of the center-left party.

The Christian Democrats (CDU), the Christian Social Union (CSU) and the SPD have set a Sunday deadline for concluding coalition talks, though party leaders have agreed to a two-day grace period in the event they have yet to overcome key differences.

But without the consent of SPD party members, Germany will not be governed by a so-called grand coalition. Once talks have concluded, a copy of the coalition treaty will be sent to each of them for review. When going over the document, the key issue will be: Does the proposed government agenda bear the stamp of the Social Democrats in a clearly perceptible manner, or were the SPD’s negotiators shortchanged by their conservative counterparts?

As was the case four years ago, it’s the SPD that has the last word when it comes to signing a coalition treaty with Chancellor Angela Merkel’s CDU and their Bavarian sister party, the CSU.

In contrast to negotiations to form Germany’s previous government in 2013, which 76 percent of the SPD’s members approved, dissenting voices in the party have the opportunity to derail the current grand coalition at an early stage. Many Social Democrats already feel that some of their key demands are being overlooked.

http://www.dw.com…

***

Germany’s grand coalition talks enter second period of extra-time

Deutsche Welle, February 6, 2018

German officials remained positive on Tuesday morning that Chancellor Angela Merkel’s conservative bloc and the Social Democrats (SPD) would strike a deal to forge a new coalition government by the evening.

As she headed into the final round of talks, Merkel called on all sides to make the necessary concessions and strike a deal that would end months of political limbo.
“Each of us will still have to make painful compromises,” the chancellor said. “I am prepared to do that if we can be sure in the end that the advantages outweigh the disadvantages,” she added.

SPD leader Martin Schulz also said today’s decisive stalks were “about nothing less than building stable, lasting government in one of the largest industrialized countries in the world.”

However, the sides still remain divided on several issues, most notably labor and healthcare policy.

The CDU and its Bavarian sister party, the Christian Social Union (CSU), continue to reject any sweeping changes to Germany’s health insurance system. The SPD, meanwhile, wants to see Germany’s two-tier health system reformed with a new system that closes the care gap between citizens with private and statutory insurance.

The CDU’s Klöckner said her party wanted to see welcome changes to Germany’s healthcare model but warned that a “one-size-fits-all” system would be too expensive.

http://www.dw.com…

***

Comment:

By Don McCanne, M.D.

Germany has a multi-payer system for health care composed of competing, not-for-profit, nongovernmental health insurance funds (“sickness funds”) in the compulsory statutory health insurance (SHI) system, and those with higher incomes can choose private health insurance (PHI). PHI is especially attractive for young people with good incomes, as insurers may offer them contracts with more extensive ranges of services and lower premiums. Thus Germany has a two-tiered system with a “care gap between citizens with private and statutory insurance.”

Four months after their election, talks may finally conclude today on formation of a coalition government. One of the major issues still to be decided is whether or not the parties will agree to close the gap in their two-tiered system by replacing it with a national single payer model. Although the conservative opposition has not yet yielded, the success in forming a coalition government may be at stake. We may know the results later today.

The issue for us is that more egalitarian European systems, such as that in Germany, may still be inequitable if people are allowed to buy up out of the compulsory system. The fact that single payer has become a major negotiating issue in Germany shows that their citizens understand that as well. Although the divide is between center-left and conservative politicians, just as in the United States, is that where the people are? Or would they prefer that the politicians move past the polarization and adopt a fully egalitarian system?

(As of Feb. 6, 9:00 PM, Central European Time, there are no further media reports on the progress of the negotiations.)

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

Readers And Tweeters Add Two Cents On Amazon Venture To Repackage Health Care

By Carol Paris, M.D.
Kaiser Health News, Feb. 6, 2018

We were disappointed KHN’s “Expert Advice” did not include input from advocates for a single-payer system. So, here is an open letter to the CEOs of Amazon, JPMorgan Chase and Berkshire Hathaway.

Dear Messrs. Jeff Bezos, Warren Buffett and Jamie Dimon:

We agree with you that health care is among the greatest issues facing society today. Your tremendous resources provide a unique opportunity to advocate for a health program to benefit all Americans: a universal, single-payer system.

Mr. Buffett describes our profit-based health system as a “tapeworm,” a parasite whose survival depends on its ability to drain nutrients from the host. How did our health care system reach that sorry state?

Our nation faces a catastrophic failure on two levels. First, the market has failed to deliver affordable health care to those who need it most. More importantly, our elected officials have failed to enact the reforms that could remedy health care’s woes because they are unwilling to offend big donors from the insurance and pharmaceutical industries. Instead, they’ve nibbled around the edges with incremental reforms like the Affordable Care Act. The ACA not only failed to kill the tapeworm of profit-based health care, it fattened it up with government subsidies, fueling the twin drivers of health costs — profits and administrative bloat.

Adding one more well-intentioned layer to our labyrinthine health care financing arrangements cannot fix them. We must move to one simple, nonprofit financing system, known as single-payer or “Medicare for all.” Mr. Buffett recently said that as a nation “we can afford to do it.” Medicare for all would bring desperately needed financial stability to the lives of everyday Americans, to every unit of government, and to businesses large and small.

We urge you to meet with policy experts who have studied this problem for decades, as well as the health care professionals operating at the front lines. Physicians for a National Health Program is a 22,000-member nonprofit research and education organization that advocates for single-payer health care. Our “Physicians’ Proposal for Single-Payer Health Care Reform” is a research-based plan for expanding health coverage to all Americans while eliminating the waste and profiteering of private insurance, and the inefficiencies they inflict on doctors and hospitals.

Dr. Carol Paris is president of Physicians for a National Health Program.

https://khn.org…

Who will be next year’s high health care spenders?

Consistently High Turnover in the Group of Top Health Care Spenders

By William C. Johnson, Ph.D.; Niall Brennan, M.P.P.; Sally Rodriguez, M.P.H. & John Hargraves, M.P.P.; Health Care Cost Institute
NEJM Catalyst, February 1, 2018

The concentration of most U.S. health care spending in a small proportion of individuals is well documented. The notion that high health care spending only affects a small portion of people in a given year is particularly relevant to the ongoing policy debate about how to make health insurance affordable for all, while accommodating people with complex health care needs and accompanying higher costs.

To better understand the patterns of spending for higher-risk enrollees, the Health Care Cost Institute studied the distribution of health care spending among commercially insured individuals and how their spending changed over time. Specifically, we analyzed the annual health care spending of more than 9 million individuals under the age of 65 in each pair of years from 2008 to 2015. Because people may change insurers over time, within each pair of years we limited our sample to people with continuous enrollment and prescription drug coverage for the full 2 years. We found that top spenders (the top 5%) account for a growing share of health care spending, and there is consistent and substantial turnover among these top spenders.

Taken together, we interpret these findings as evidence that as costs continue to rise, health insurance will play an increasingly important role in easing the financial burden of increased health care spending. For this reason, less comprehensive plans may be risky, even for consumers with low health care spending in previous years. These findings provide a timely reminder of the inherent uncertainty in health care spending in light of proposals to create significant changes in individual and group insurance markets, such as altering consumer protections created by the Affordable Care Act.

Large Degree of Turnover from Year to Year among Top Spenders

Simply put, three out of five top spenders in any given year were not top spenders in the prior year. In 2015, only 39% of the top 5% of spenders were in the top 5% of spenders in 2014. Moreover, this trend was consistent in each year from 2009 to 2015. These new top spenders came from all portions of the spending distribution. For example, in each year studied, almost 15% of top spenders were in the bottom 50% of spenders or had no spending in the previous year.

People who are new to the top 5% of spenders endure dramatic changes in their health care spending within a short period of time. The median newly top spender saw their total health care spending rise almost 800% from $4,528 in 2014 to $35,523 in 2015. While insurance plans insulated them from most of this spending increase, median out-of-pocket spending for this group also rose nearly 400% from $1,048 in 2014 to $4,067. These year-to-year changes in out-of-pocket spending are particularly jarring considering the Federal Reserve Board’s 2016 Survey of Household Economics and Decision, which reported that 44% of respondents could not afford a $400 emergency expense.

https://catalyst.nejm.org…

***

Comment:

By Don McCanne, M.D.

This report quantifies a well-known, important fact about health care spending. Consistently, year after year, three-fifths of the top 5 percent of health care spenders are new arrivals, with a median health care spending rise of 800 percent from the previous year. The population with high health care costs is unstable, year after year.

Those opposed to universal, comprehensive health care tell us that we should buy only the insurance that we need. Yet 3 percent of those under 65 without high health care costs will have health care spending the following year in the top 5 percent. It is almost impossible to know who most of those individuals are.

The authors state, “These findings provide a timely reminder of the inherent uncertainty in health care spending in light of proposals to create significant changes in individual and group insurance markets, such as altering consumer protections created by the Affordable Care Act.” Further, “These year-to-year changes in out-of-pocket spending are particularly jarring considering the Federal Reserve Board’s 2016 Survey of Household Economics and Decision, which reported that 44% of respondents could not afford a $400 emergency expense.”

The obvious conclusion is that everyone needs comprehensive insurance, including the young and healthy, because of the unpredictability of high health care costs. Even more important than financial security, a well designed single payer national health program would ensure that everyone would have health security as well.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

Single-payer health care betters costs, outcomes

By Mario L. Maiese, M.D.
Press of Atlantic City (N.J.), Letters, February 3, 2018

Regarding the Jan. 16 column by Betsy McCaughey, “Single-payer a danger for cancer patients”:

Most of the facts in McCaughey’s column regarding single-payer health care are correct, but she omits significant points.

The primary purpose of single-payer is to cover more people at decreased cost, so that everyone would be able to receive the advanced treatment she describes. Without insurance, people don’t have access to caregivers for the diagnosis and management of cancer and the other diagnostic and preventive services.

She fails to mention that the U.S. health-care system is last in overall outcomes performance among high-income countries, according to the Commonwealth Fund, even though we have the best cancer survival rates. We spend far more than these single-payer countries, where everyone has coverage. Our excessive uninsured population results in a far higher death rate from conditions that can be managed and treated effectively.

Additionally, a single-payer health-care system is the best way to manage and decrease cost. It decreases inefficiencies in management and can negotiate pharmaceutical prices and set prices for care. Most of the exact same medications are cheaper in these other countries and procedures cost less (current example: it costs four times as much for coronary bypass surgery here compared to the United Kingdom).

I believe that with our innovation and the proper management of a single-payer health-care system we can go from last to first.

https://www.pressofatlanticcity.com…

MedPAC: Repeal MIPS and replace it with VVP, whatever that is

MedPAC’s Repeal And Replace MIPs Campaign Will Not End Well

By Kip Sullivan
The Health Care Blog, January 28, 2018

“This is tough. I don’t know how to proceed…. Lord help the staff who must bring all this together.”

That was how Dr. Francis Crosson, chairman of the Medicare Payment Advisory Commission (MedPAC), reacted to the commission’s baffling discussion at its January 11 meeting moments before it voted 14-2 to replace the Merit-based Incentive Payment System (MIPS) with something called the “voluntary value program” (VVP). MedPAC’s staff must now summarize the January 11 discussion and prepare a report for inclusion in MedPAC’s March 2018 report to Congress.

MIPS is a pay-for-performance (P4P) scheme imposed on the traditional fee-for-service Medicare program by an act of Congress known as MACRA. MIPS requires that CMS measure performance on cost and quality at the level of the individual doctor, something MedPAC recently acknowledged can’t be done after spending 13 years claiming it could be done.

The portion of the commission’s January 11 discussion that focused on the repeal of MIPS was not hard to understand. The commissioners agreed that MIPS cannot work for multiple reasons, the most important being that the pools of patients treated by individual doctors are too small to permit accurate measurement of cost and quality. “MIPS will not succeed in helping beneficiaries choose clinicians, helping clinicians … improve value, or helping the Medicare program to reward clinicians based on value,” explained MedPAC staffer Kate Bloniarz.

It was the commissioners’ discussion about what to replace MIPS with that will be very difficult to summarize. That’s because the discussion consisted largely of expressions of doubt about the VVP, which is essentially a proposal that all doctors who treat Medicare patients either join a “group” (aka ACO) or lose 2 percent of their Medicare payments. The discussion, which followed a vague opening presentation by two MedPAC staff members, consisted of numerous questions posed to the staff that neither the staff nor Dr. Crosson could answer. Because so many issues remained unresolved, ten of the 16 commissioners (one was absent) expressed reservations about voting for the VVP. How does the staff or anyone else summarize a discussion like that? How does the staff explain why the commission voted to recommend the VVP to Congress when a majority of commissioners have multiple concerns about it?

The two questions that got the most discussion were: Will functioning ACOs (as opposed to Potemkin village ACOs that have no internal cohesion) be available for all doctors to join, and; won’t CMS’s crude method of measuring “performance” punish doctors who treat poorer and sicker patients? These and other issues were raised not only at the January 11, 2018 meeting, but at five previous meetings in 2017. That these questions were still unanswered after six meetings is compelling evidence Dr. Crosson and the staff cannot answer them and never will.

Chronology of MedPAC’s latest lead balloon

MACRA (Medicare Access and CHIP Reauthorization Act), which authorized MIPS, was signed by President Obama in April 2015. Although the fatal defects in MIPS were obvious the day Obama signed MACRA, MedPAC waited nearly two years to begin a discussion about whether MIPS could work. Instead of sounding the alarm immediately, MedPAC wasted the rest of 2015 discussing some vague principles that should guide CMS in developing the “alternative payment model” (APM) portion of MACRA.

I have no idea how to explain the delay between April 2015, when Obama signed MACRA, and January 2017 when MedPAC finally started talking about repealing MIPS. I do know what caused the failure to act between January 2017 and January 2018: That was Dr. Crosson’s and the staff’s insistence that MedPAC should propose a replacement for MIPS at the same time they recommended its repeal. This insistence manifested the staff’s near-religious devotion to P4P despite a large body of evidence indicating P4P does not work at any level – at the individual physician level, the clinic or hospital level, or even at the level of large pools of providers.

Because of this devotion, staff and Dr. Crosson could not bear the thought of repealing MIPS and thereby leaving 80 percent of the doctors and nurses who treat Medicare patients unmolested by P4P. (Eighty percent appears to be the commission’s latest estimate of the percent of Medicare “clinicians” who will not be in ACOs or other entities that qualify as “advanced alternative payment models” [APMs] under MACRA by 2019, the first year MIPS penalties and rewards kick in.) It was this blind insistence on forcing some form of P4P upon that 80 percent that caused the staff to link repeal with replacement right from the start of the repeal discussion in January 2017.

The staff presented its replacement proposal – what they would eventually call the “voluntary value program” (VVP) – at the January 2017 and March 2017 meetings. At both meetings, and at four subsequent meetings (October, November, and December 2017 and January 2018), commissioners peppered the staff with questions about the VVP – to no avail. Dr. Crosson and the staff resolutely refused to add any details to the vague VVP proposal first presented in January 2017. For example, all the staff would say about the “groups” that doctors would have to join in order not to lose 2 percent of their payments is that they must be “sufficiently large to have statistically detectable performance on population-based measures” such as use of “low-value” services and “healthy days at home.” That was their story, and they stuck to it. The skeleton-like proposal the commission voted on at the January 11, 2018 meeting was identical to the skeleton-like proposal they first heard in January 2017.

(The excerpts are truncated here. If you are interested in reading the process which resulted in the decision to replace MIPS with the nebulous VVP then click the link for the rest of the article. – DMc)

Lessons from another “repeal and replace” campaign

All sentient readers will recall the sad ending of another “repeal and replace” campaign. It had a sad ending because it was driven by ideology, not evidence. MedPAC appears hellbent on repeating the same mistake Republicans made in declaring their intention to “repeal and replace” the Affordable Care Act. MedPAC linked repeal of MIPS with its replacement before they had time to research the replacement. MedPAC might as well have said, “We will replace MIPS with something terrific!”

http://thehealthcareblog.com…

***

Principles for a Framework for Alternative Payment Models

By Sam Nussbaum, M.D.; Mark McClellan, M.D., Ph.D.; Grischa Metlay, Ph.D.
JAMA, January 29, 2018

The way physicians, hospitals, and other health care professionals are paid influences patient care because payment methods affect business models that clinicians and health care facilities use to prioritize investments, establish infrastructure, and design care processes. Fee-for-service medicine and its volume-based financial incentives can lead to overuse of low-value services and suboptimal care. A consensus is emerging among patients, health care professionals, payers, and purchasers that transitioning to alternative payment models (APMs) that better incentivize value for patients is essential for improving the quality and affordability of health care.

In 2014, the CMS published a system for classifying APMs.1 In the interim, the Health Care Payment Learning and Action Network (LAN), a public-private partnership driving multistakeholder consensus and coordinated action to accelerate the transition to APMs, built on, expanded, and refined the original system.

This Viewpoint reviews major themes in the framework principles as revised by LAN, illustrating how they are applied in the LAN classification scheme, and the LAN national goals for payment reform.

The Updated APM Framework

Category 1: Fee for service; no link to quality and value

Category 2: Fee for service; link to quality and value

1. Foundational payments for infrastructure and operations (eg, care coordination fees and payments for health care information technology investments)

2. Pay for reporting (eg, bonuses for reporting data or penalties for not reporting data)

3. Pay for performance (eg, bonuses for quality performance)

Category 3: APMs built on fee-for-service architecture

1. APMs with shared savings (eg, shared savings with up-side risk only)

2. APMs with shared savings and down-side risk (eg, episode-based payments for procedures and comprehensive payments with up-side and down-side risks)

Category 4: Population-based payment

1. Condition-specific population-based payment (eg, per-member per-month payments, payments for specialty services such as oncology or mental health)

2. Comprehensive population-based payment (eg, global budgets or full/percentage of premium payments)

3. Integrated finance and delivery system (eg, global budgets or full/percentage of premium payments in integrated systems)

The updated APM Framework rests on 8 principles, which can be summarized as follows:

1. Changing clinicians’ and health care facilities’ financial incentives is not sufficient to achieve person-centered care, so it will be essential to empower patients to be partners in health care transformation.b

2. Reformed payment mechanisms will only be as successful as the delivery system capabilities and innovations they support.b

3. The goal for payment reform is to transition health care payments from fee for service to APMs. While category 2C APMs can be the payment model for some clinicians and health care facilities, most national spending should continue moving into categories 3 and 4.b

4. Value-based incentives should ideally reach care teams who deliver care.

5. Payment models that do not take quality into account are not considered APMs in the APM Framework and do not count as progress toward payment reform.

6. Value-based incentives should be intense enough to motivate clinicians and health care facilities to invest in and adopt new approaches to care delivery without subjecting them to financial and clinical risk they cannot manage.b

7. Alternative payment models will be classified according to the dominant form of payment when using more than 1 type of payment.

8. Centers of excellence, accountable care organizations, and patient-centered medical homes are examples rather than categories in the APM Framework because they are delivery systems that can be applied to and supported by a variety of payment models.

Patient Protections

Payment reform is not an end; it is a means to supporting better, more coordinated care for patients. Accordingly, APMs must help make patients better health care consumers and mitigate perverse incentives that reward low-quality patient care.

Protections for Health Care Professionals

Reformed payment mechanisms that hold health care professionals increasingly accountable for cost and quality performance and that allow more flexibility in care delivery are central to any efforts to transform care delivery.

Value-Based Goals for Payment Reform

The value of an APM should be assessed not only by its design elements but also by how well it promotes person-centered care.

APM Framework and Progress Tracking

As the nation approaches 30% of payments in value-based arrangements, the LAN APM Framework could provide a useful platform for helping to accelerate progress on payment reform by outlining principles for APM design, differentiating APMs based on potential value, and offering a tool to consistently measure progress toward national goals.

https://jamanetwork.com…

***

Comment:

By Don McCanne, M.D.

Much of the history of health policy in the United States involves the application of policy concepts based on ideology rather than solid policy science. Policies are dreamed up and then executed broadly on a wish about what would happen rather than reliable predictions of what really will happen. The SGR, MACRA, MIPS, APM, and now VVP is a saga of such dreams in the policy community forced to meet reality.

SGR (sustainable growth rate) was a tool to slow the growth in health care spending. When implemented it was perceived to be too austere and thus annual adjustments were postponed until the cumulative deficit proved to be so great that SGR had to be abandoned. It was replaced by MACRA (Medicare Access and CHIP Reauthorization Act) which established MIPS (Merit-based Incentive Payment System) and APM (Alternative Payment Model).

MIPS has proven to be a dud, and thus MedPAC (Medicare Payment Advisory Commission) has recommended that it be abandoned and replaced with VVP (Voluntary Value Program). Kip Sullivan, who had previously warned us about MIPS (as did I), now explains why we should be concerned about VVP (and I emphatically concur). His full article available at The Health Care Blog website should be read to understand what a farce this is.

Recognizing the deficiencies in MIPS, many in the policy community have recommended that incentives be established to move everyone past MIPS into the Alternative Payment Models (APMs). But what are they? JAMA has just published the updated framework for APMs as established by LAN (Health Care Payment Learning and Action Network). Read the framework itself and the eight principles on which it rests. Then sit back and think about how this framework would define the future of our entire health care delivery system, putting the eight principles to work. In their dreams based on ideology, our policy community has come up with Comprehensive Revision of American Physician Payment Principles (CRAPPP).

Come on. We have solid policy evidence that a well designed single payer system would achieve their goals (and ours) of a high performance health care system that takes care of all of us and is affordable for each of us. Let’s cut out the CRAPPP and do it right.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

Single-payer health care cuts costs

Insurance administrators are not evil. They are, rather, a product of our uniquely dysfunctional health care system.

By Samuel Metz, M.D.
Portland (Ore.) Tribune, Feb. 1, 2018

Measure 101 barely saved Oregon’s Medicaid funding for two years, but our health care (like that in the 49 other states) is still the world’s most expensive.

For what Oregonians pay in health care taxes, insurance premiums, deductibles and co-pays, citizens in other countries receive 100 percent coverage for all treatable diseases. We Oregonians consider ourselves lucky if we dodge bankruptcy when our family needs care.

Why is health care in Oregon so expensive?

It’s not the usual suspects: Waste, fraud and abuse. It’s the unusual suspects: people who handle our insurance money.

Insurance administrators are not evil. They are, rather, a product of our uniquely dysfunctional health care system. Every billable health care event requires an insurance officer to determine:

• Was the patient insured?

• Did benefits cover the condition? Did benefits cover treatment?

• Did physicians follow preauthorization procedures?

• Was the physician in network?

• Did diagnosis and procedure codes match?

That’s a lot of time. Then they repeat 30 percent of this work because three of 10 first insurance claims are denied.

This process diverts 20 percent of insurance premiums away from health care and into administration. This loss does not include physician time lost to complete the claim in the first place. It does not include deductibles, co-pays or out-of-network expenses. It’s simply the cost of billing. Our billing costs are two to 10 times that of other countries.

Enter Bernie Sanders.

U.S. Sen. Sanders did not invent single-payer health care. He was not the first to introduce a single-payer bill. In fact, single-payer health care was invented before he was born, here in the Pacific Northwest.

An American industrialist, Henry J. Kaiser, guessed that keeping his employees and their families healthy without intervening private insurance companies would be good for his business (actually, the idea came from his company physician Dr. Sidney Garfield). Both were right.

The Sanders’ 2017 “Medicare for All” single-payer bill reflects Kaiser’s 1930s plan: include everyone, treat treatable conditions and pay physicians with administrative simplicity. These concepts are emulated by most large American businesses (using “self-funded” health care — private single-payer plans) and every other developed nation. The United States missed this message.

Most proposals save money by excluding sick people, withholding benefits, or underpaying providers. Single payer, in contrast, converts administrative overhead into health care.

Single-payer efficiency is validated daily by corporate single-payer plans in the United States and national single-payer plans in Australia, Taiwan, Denmark, Israel and a few dozen other countries.

All these single-payer plans provide better care to more people for less money.

Sen. Sanders may be the most dramatic American advocate, but he’s not alone. Four members of Oregon’s congressional delegation already endorse the single-payer system: Sen. Jeff Merkley and Reps. Earl Blumenauer, Suzanne Bonamici and Peter DeFazio.

The holdouts — Sen. Ron Wyden and Reps. Kurt Schrader and Greg Walden — need to hear from us. Oregonians want better care for more people for less money. Our congressional delegation should make it happen.

Oregon hasn’t solved its health care crisis by rounding up the usual suspects, nor by passing Measure 101. America’s biggest corporations and our international neighbors teach us the answer: single-payer health care. Call Sen. Wyden, Rep. Walden, and Rep. Schrader and give them the message. Oregon families will be grateful.

Dr. Samuel Metz is a private practice anesthesiologist who lives and works in Portland.

https://portlandtribune.com…