PNHP

Readmissions down; deaths up

Readmissions down; deaths up

While U.S. heart failure readmissions fall, deaths rise

By Mitchel L. Zoler
Internal Medicine News, September 20, 2017

U.S. hospitals have recently shown a consistent and disturbing disconnect between reductions in their heart failure hospital readmission rates and heart failure mortality. Readmissions have dropped while mortality has risen.

“Despite reductions in 30-day heart failure readmissions in 89% of U.S. hospitals” during 2009-2016, “30-day heart failure mortality rates increased at 69% of these ‘successful’ hospitals” during the same period,” Ahmad A. Abdul-Aziz, MD, said at the annual scientific meeting of the Heart Failure Society of America.

“The most concerning question we can ask is whether inappropriate discharges from emergency rooms and observation units” is a driving factor behind the mortality rise despite a readmissions drop, said Dr. Abdul-Aziz, a cardiologist at the University of Michigan in Ann Arbor.

These shifts in the outcomes of U.S. patients hospitalized for acute heart failure episodes are tied to the penalties that the Centers for Medicare & Medicaid Services began slapping on hospitals in 2013 for excess 30-day readmissions for heart failure patients and in 2014 for excess mortality. A problem with these two CMS programs is that the penalty on inferior readmissions performance is a lot stiffer than for excess mortality, Dr. Aziz noted: a 0.2% penalty on payments for high mortality, compared with a 3% penalty for excess readmissions, a disparity that can make hospitals focus more on the readmissions side, he suggested.

Dr. Aziz’s report isn’t the first to make this observation. Study results published earlier in 2017 used CMS Medicare data from 2008 to 2014 to show that during that period, heart failure 30-day mortality rates following hospital discharge rose by 1.3%, while 30-day readmissions fell by 2.1% (JAMA. 2017 July 18;318[3]:270-8). On the basis of these numbers, as many as 5,200 additional deaths to U.S. heart failure patients in 2014 “may be related to the Hospital Readmission Reduction Program” of CMS, Gregg C. Fonarow, MD, said during a separate talk at the meeting.

“CMS thinks that policy reform is the way to improve outcomes of patients hospitalized for heart failure. There was no evidence, no results from randomized trials, but they pushed it on the country. And it has reduced readmissions. But there have been unintended consequences of gaming the system, of keeping patients out of the hospital and giving them outpatient status, and these data raise concerns because 30-day mortality went up,” said Dr. Fonarow, professor and cochief of cardiology at the University of California, Los Angeles. “We should all be extremely concerned about the unintended consequences of payment reform strategies” that aim to improve the management of patients with heart failure.

http://www.mdedge.com…

***

Comment:

By Don McCanne, M.D.

Supposedly application of policy science provides higher quality care at lower costs, but in the case of heart failure, with no evidence, policy decisions were made to penalize hospitals 3 percent of their payments if their 30-day readmission rates went up, but only 0.2 percent if the patients died. Thus CMS rewards hospitals that follow the dictum, “Don’t readmit them, let them die.”

One of the criticisms of using Medicare as the model for a single payer system is its large centralized bureaucracy. Policy decisions often seem quite distant from decisions that should be made between health care professionals and their patients.

The Canada Health Act is only 14 pages and it would be half that except the text was repeated in French. The Canadian Medicare system is administered on the provincial level rather than through Ottawa. Likewise, in the United States it is recommended that administration be more decentralized – moving it from Washington, DC to greater state or regional control. That is one of the major reasons that we refer to an Improved Medicare for All.

Imagine making a decision for readmitting a patient with heart failure. Wouldn’t it be far better making that decision based on clinical need rather than being based on a penalty system out of Washington? Not that physicians would do such a thing, but then why do the numbers suggest that they do? An obvious solution is to shoo away the policy bureaucrats and simply do what is right for the patient.

Canada Health Act:
http://laws-lois.justice.gc.ca…

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

Health researchers: Graham-Cassidy bill would increase deaths by 41,600 annually

Doctors dub Graham-Cassidy “The Undertaker Full Employment Act”

FOR IMMEDIATE RELEASE, September 22, 2017
Contact: Clare Fauke, communications specialist, 312-782-6006, clare@pnhp.org

Physicians and public health researchers Drs. Steffie Woolhandler and David Himmelstein estimate that implementation of the proposed Graham-Cassidy legislation would push an additional 32 million Americans off their health insurance over the next decade, resulting in 41,600 additional deaths in 2027.

Since the Congressional Budget Office could not conduct a timely analysis of the bill before its expected vote, the researchers—who have studied the effects of insurance coverage on health outcomes—analyzed the bill’s impact on insurance coverage and mortality.

“The Graham-Cassidy bill—what we’re calling ‘The Undertaker Full Employment Act’—would cut health coverage by 14 million Americans in 2020, rising to at least 32 million in 2027,” said Dr. Woolhandler, an internist in the South Bronx, Distinguished Professor of Public Health at the City University of New York at Hunter College (CUNY) and lecturer in medicine at Harvard. “That means 18,200 extra deaths in the first year, climbing to 41,600 annually within a decade.”

Drs. Woolhandler and Himmelstein studied CBO projections of previous GOP “repeal and replace” bills, and then extrapolated how many individuals would lose coverage per $1 billion in health spending cuts in the Graham-Cassidy bill between 2020 and 2027.

From there, the researchers projected the number of associated deaths based on their recent study published in the Annals of Internal Medicine, “The Relationship of Health Insurance and Mortality: Is Lack of Insurance Deadly?” The study concludes that for every 769 people who lose health coverage, one person will suffer preventable death. Health insurance prevents deaths in part by improving the diagnosis and treatment of high blood pressure; uninsured and under-insured Americans with hypertension are known to be less likely to have their blood pressure under control. Lack of coverage also increases death rates in several other conditions, including breast cancer and major trauma.

“We became doctors to save lives,” said Carol Paris, M.D., president of Physicians for a National Health Program. “As physicians, we cannot be silent while Congress plays political games with the lives of our patients.”

The Graham-Cassidy bill eliminates insurance subsidies provided through the Affordable Care Act to about 8 million Americans, and makes substantial cuts to state Medicaid programs that today insure more than 70 million Americans. The bill also allows insurers to charge more for patients with pre-existing conditions who would likely be priced out of the insurance market altogether.

Dr. Paris notes that instead of cutting coverage to millions of Americans, Congress should cut the number of uninsured to zero through a universal, single-payer health plan like Rep. John Conyers’  H.R. 676, the Expanded and Improved Medicare for All Act or Sen. Bernie Sanders’ S. 1824, The Medicare for All Act of 2017.

Dr. Steffie Woolhandler is an internist in the South Bronx, Distinguished Professor of Public Health at the City University of New York at Hunter College (CUNY) and lecturer in medicine at Harvard. Dr. David Himmelstein is also an internist, Distinguished Professor at CUNY and lecturer at Harvard. They are co-founders of Physicians for a National Health Program (PNHP). Dr. Carol Paris is a retired psychiatrist and president of PNHP, a nonprofit research and educational organization of more than 21,000 doctors and health professionals who support a single-payer national health program. It was founded in 1986.

Single payer ‘concern trolls’

There are 3 types of single-payer 'concern trolls' — and they all want to undermine universal healthcare

By Adam H. Johnson
Los Angeles Times, September 21, 2017

With momentum building for single-payer healthcare among Democratic voters and a growing number of 2020 hopefuls, Sen. Bernie Sanders unveiled a “Medicare for All” bill last week. Immediately, a number of pundits denounced the legislation as an “unrealistic” “bloated” “disaster” full of “magic math.”

Some of the naysayers are conservatives who simply abhor “big government.” Some have perfectly valid reasons to question the merits of single payer in general or Sanders’ methods in particular. Yet others claim they support universal healthcare in theory (one day, perhaps) but cannot do so now because of a “concern.” They are “concern trolls” — broadly defined as “a person who disingenuously expresses concern about an issue with the intention of undermining or derailing genuine discussion.”

The nuance troll: ‘We need more details!’

Less than 24 hours after the bill’s introduction, New York Magazine’s Jonathan Chait lamented that the bill gets America “zero percent” closer to single payer. While saying he agrees with single payer in theory, he insisted that the 155 million Americans who already have healthcare represent an insuperable barrier, and that the issue of how to move them all to a government-run system “is not a detail to be worked out. It is the entire problem.” After all, as he noted, Lyndon Johnson failed and Hillary Clinton failed and Barack Obama failed to undo the private system. So why bother? It’s too hard; everyone go home.

Nuance trolling is argument by way of tautology, an attempt to pass off power-serving defeatism as savvy pragmatism.

Even if Sanders did lay out how a single-payer transition would work in a technical sense, nuance trolls would find other nits to pick. Where would the money come from? How would you manage all the corporations disturbed? There’s always some essential detail that needs solving before Senate Democrats earn the right to support a bold policy.

And if the demand for nuance seems reasonable enough, consider that pundits rarely require it when it comes to military interventions — Chait and others set this issue aside when it came to invading Iraq in 2003, for instance.

The deficit troll: ‘How do you pay for it?’

Of all the water-muddying tactics, this one is the easiest to set aside. As I’ve noted in these pages before, deficit scare-mongering is used, almost exclusively, as a bludgeon to smear progressive policy proposals. When it comes to launching wars or bailing out banks, these fears vanish.

Money for war is magically always there; money for healthcare must be counted bean by bean.

The feasibility troll: ‘What about the GOP?’

Many pundits seem to believe that leftist politicians must preemptively agree internally to some assumed compromise that is “practical” even before attempting to change the conversation, much less the law. Thus feasibility trolls argue that GOP opposition to government-run health insurance renders futile any such proposal.

That’s ahistorical. Maximalist demands aren’t all or nothing, they’re about establishing broad moral goals that people can rally around.

Progressives lose nothing by setting bold targets right out of the gate. Why not make every Republican lawmaker go back to his or her constituents in 2018 and explain opposition to free healthcare? Force the issue, shift the debate, just as the far right has been doing for years.

President Eisenhower — an early practitioner of concern trolling — told the New York Times in 1957 that he supported integration “in principle” but said activists in the South risked going “too far, too fast.” Give it more time. We need more details.

All meaningful changes to society have been met with these types of objections. But the game of politics isn’t won by waiting for the ideal. Its most successful actors establish a moral goal and fight for it until reality catches up to them.

Adam H. Johnson is a media analyst for Fairness and Accuracy in Reporting.

http://www.latimes.com…

***

Comment:

By Don McCanne, M.D.

The concern trolls – nuance trolls, deficit trolls, and feasibility trolls – counter the vast superiority of the single payer model of health care reform with arguments that seem almost trivial (though sounding quite serious) when compared to the extraordinary social benefit that single payer would bring to America.

Why do they do that? What benefit is there in acknowledging that there is a far better alternative for reform, yet rejecting it based on a search for nuances, or based on hypothetical deficits that would not exist in a well designed program, or, even worse, based on supposed lack of political feasibility for a program that continues to grow in popularity?

Homo sapiens is a weird species.

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

The benefits of Bernie Sanders’ ‘Medicare for All’ plan

By Marcia Angell, M.D.
The Boston Globe, September 21, 2017

Bernie Sanders is right. Given the growing costs and shrinking benefits of Obamacare, and the flame-out of “repeal and replace,” America should transition to Medicare for All. Last week he introduced his Medicare for All Act of 2017, which would do exactly that, while retaining and improving Obamacare during a four-year transition.

Medicare, the current program for Americans over age 65, is a single-payer system, which means it is financed and overseen by the government, even though most providers are private. It is by far the most popular and efficient part of our health care system. In fact, many 64-year-olds can hardly wait to be 65 so they are eligible for it. Unlike private insurers, it doesn’t pick and choose which patients it will cover and for what medical conditions. All seniors are covered for the same package of benefits.

But Medicare isn’t perfect. Benefits aren’t comprehensive (for example, there is no dental coverage), copayments are rising, and there is profiteering by providers. Sanders’ plan would introduce reforms that would help with those problems. It would expand benefits greatly, and out-of-pocket costs would be eliminated except for a small copay for prescription drugs.

Even people who think this all sounds wonderful are concerned about the costs. Won’t taxes increase? How can we possibly afford single-payer health care? But in fact, this concern stems from a misunderstanding. Yes, income taxes and government expenditures would increase, but those increases would be offset by the enormous savings in premiums and out-of-pockets costs. This trade-off is not sufficiently understood, because the Congressional Budget Office estimates only costs to the federal government, not to patients. The fact is that if out-of-pocket costs are included, we would probably break even in the first year and in later years we would come out ahead, because inflation would be curbed.

Obamacare has many virtues. It expanded access to about 20 million people, and it ended some of the worst abuses of the private insurance companies, such as denying coverage because of preexisting conditions. But it did little to rein in cost inflation, because it left our health system in the hands of private insurance companies, profit-oriented providers, and the pharmaceutical companies, all of which could pretty much name their price. As expenses rose for employers who provide health insurance, their answer was to cap their contributions. And as expenses rose for insurance companies, their answer was to shrink benefits and increase deductibles and copayments. Americans found that having insurance was not the same thing as getting adequate health care. Moreover, about 30 million Americans remain uninsured.

The fundamental problem, the problem that underlies all the others, is that the United States has a market-based system. We’re the only advanced country that does. The systems in the other countries vary in details — some have single-payers like Medicare, others have tightly regulated private insurers — but they all have in common universal coverage in predominately nonprofit systems. In all of them, government sets benefits and prices in one way or another, including prices of prescription drugs, and administrative costs are much lower. And it works. Their health systems spend on average less than half as much per person as we do (that gap is growing), and their health outcomes are generally much better.

In contrast, we have chosen to entrust our health care mainly to the commercial market. But while markets are good for many things, they are terrible for health care. Markets seek to expand, and each element in a market (think cars) tries to grow its share of the total by attracting more paying customers. But we want the health care system to shrink, not to keep growing. Health markets also can’t distribute care rationally. The people who most need care are usually the least able to pay for it. So providing it according to the ability to pay instead of medical need inevitably introduces inefficiencies and inequities. Moreover, health businesses usually don’t compete on price, but by marketing to affluent customers.

Sanders’ Medicare for All Act envisages a four-year transition, which would begin by dropping Medicare eligibility from age 65 to 55, and enrolling all children 18 and under. Then, over the next two years, eligibility would be dropped one decade at a time, and in year four it would be extended to everyone. There would be no out-of-pocket costs, and the benefit package would be expanded. The system could be financed by an ear-marked 4 percent income tax. A family of four with an annual income of $50,000 would pay $844 a year, which is about $4,400 less than the average premium working families paid last year to private health insurance companies. I believe we would also need to move to a nonprofit provider system.

Health care is a social good, not a commodity, just as primary education, fire and police protection, and clean water are. A market-based system is not only wasteful, it’s immoral. Winston Churchill famously said, “The Americans always do the right thing, but only after they’ve tried everything else.” In health care, we’ve tried everything else. The time has come for the right thing.

Dr. Marcia Angell, former editor in chief of the New England Journal of Medicine, is a member of the Department of Global Health and Social Medicine at Harvard Medical School.

https://www.bostonglobe.com…

Shumlin explains what happened in Vermont

Shumlin reflects on single payer failure

By Neal P. Goswami
Vermont Press Bureau, September 19, 2017

Former Vermont Gov. Peter Shumlin said money, wary lawmakers and timing were the core challenges that ultimately caused his failure to deliver on a promise to implement a single-payer health care system in the state.

The former Democratic governor reflected on that failure Tuesday at a forum at Harvard’s T.H. Chan School of Public Health. Shumlin ran for governor in 2010 on a platform that promised voters a single-payer system.

But he announced after his 2014 re-election bid that his administration would not be moving forward with the plan. He cited the tremendous cost of the program and the burden that would be placed on the state’s limited tax base.

“When you actually get into the numbers and you describe to your people when you move to a premium-driven system to one that’s supported by taxes, the tax rates in Vermont were quite staggering compared to what other people were paying,” Shumlin said. “When I came out and said, ‘Listen, to move from a premium-driven system to a tax-based system you’re going to have an 11.5 percent payroll tax, you’re going to have to have a top 9.5 percent income tax on top of our current state income tax,’ I don’t think that was even the biggest problem.’”

The bigger problem, Shumlin said, was wary lawmakers who feared yearly tax increases to support the system because of growing health care costs.

“I couldn’t with a straight face turn to them and say, ‘No, we’ve got this figured out. There’s going to be so much cost-containment you won’t have to do that,’” the former governor said.

Another fiscal challenge also loomed large — how to build a big enough reserve for the expensive health care system. Shumlin said his administration determined that it would require all of the state’s bonding capacity for a decade to secure a reserve large enough to support the system. That would have prevented the state from bonding for infrastructure improvements during that time.

The changing political winds in Washington was another factor. Shumlin said the Republican takeover of the House and Senate limited the Obama administration’s ability to work with Vermont.

“The [Health and Human Services] secretary said to me, ‘Listen, we want to work with you, we wanted to work with you, but we don’t have the capacity to cut out special deals for Vermont while we’re up there on the hill trying to defend Obamacare,” Shumlin said.

Shumlin, like other governors, was also reeling from the disastrous rollout of the state’s online insurance exchange.

“There was no amending Obamacare because the Republican Congress refused.

“Those things all came together to deliver the most difficult thing I’ve ever had to do, which is turn to the people that elected me and say, ‘We’ve done the work, we’ve done the research, we know how the system would work. This is not fiscally responsible to do in Vermont right now.’”

Shumlin said he opted against forcing the issue on lawmakers who were likely to kill the proposal.

“I chose not to do that. I just felt that really, this was my idea, I owned it and I needed to own its failure,” he said.

Shumlin said he hopes political leaders will push for a national single-payer system as an economic issue and beyond its long-time status as a “fringe, lefty issue.”

“I was wrong. I don’t think little states like Vermont can go it alone,” he said. “I do think that the Vermont story should be an example of how a little state tried, learned, and the lesson should not be no, it should be Hell yes, let’s get it done and let’s do it right, let’s give this benefit to all Americans.”

http://www.vermontpressbureau.com…

***

In Pursuit of a Single-Payer Plan: Lessons Learned

By Peter Shumlin, former Governor of Vermont
Harvard T.H. Chan School of Public Health

30 minute video:
https://www.hsph.harvard.edu…

***

Comment:

By Don McCanne, M.D.

Although the reason often given for Gov. Peter Shumlin’s withdrawal of the single payer legislation for Vermont was that the taxes would be too high, there were other much more important reasons. The taxes would have been largely offset by reductions in health care spending made through the existing channels, so that wasn’t what was holding it back.

An underappreciated but extremely important factor is that Vermont needed the funds that were being used for Medicare, Medicaid and other federal programs. The glib claims that Vermont merely needed to obtain waivers were belied by the reality. The existing waiver programs would not permit Vermont to dump all funds into a single universal risk pool. The Republican Congress certainly was not going to enact the enabling legislation.

Vermont even dropped the single payer label from its legislation since it was clear that they would not be able to enact a bona fide single payer system. As a result, Vermont would not be able to achieve the savings that a single payer system would bring. Further, it could not establish efficient financing measures that would slow the increase in future health care spending to sustainable levels.

Although Shumlin says that little states like Vermont can’t go it alone, it is really not so much Vermont’s size as it is the hurdles built into the existing health care financing infrastructure. This does not mean that states should not move forward with beneficial measures that can provide some transitional relief until we can establish a universal single payer system.

But he does have a clear message for all of us: “I do think that the Vermont story should be an example of how a little state tried, learned, and the lesson should not be no, it should be Hell yes, let’s get it done and let’s do it right, let’s give this benefit to all Americans.”

Yes, let’s give this benefit to all Americans.

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

Single-payer health care – its time has come

By Mark Dimondstein
The Plain Dealer (Cleveland.com), September 20, 2017

WASHINGTON, D.C. – Congress is back from its summer recess and the problems with our nation’s health care system haven’t gone away. How to fix health care is once again being hotly debated. Recently, President Donald Trump warned Republican senators that they must do something or be confronted with the dangers of “single-payer” health care. But, single-payer shouldn’t be the boogeyman – its time has come.

As a postal worker and now president of the American Postal Workers Union, I’ve had many occasions to meet with Canadian postal workers. The lives and dreams of postal workers just across Lake Erie are similar to workers in Northeast Ohio and other parts of the United States. One huge difference stands out – Canadian health care. Canadians never worry about being denied access to medical care. Unlike in the United States, no one is forced to choose between food and medicine. A major illness won’t drive them to bankruptcy or out of their homes.

Canada’s single-payer health care system is similar to Medicare but in Canada every man, woman and child has cradle-to-grave coverage for their doctor, hospital and nursing care – with full choice of physicians. The government also negotiates affordable drug costs with pharmaceutical companies.

Imagine how much less stressful our lives would be without co-pays, deductibles, billing for services, lifetime limits or huge insurance premiums. According to University of Massachusetts Economics Professor Gerald Friedman, 95 percent of U.S. households would save money under a single-payer plan.

It is striking that the Canadian success is rarely discussed in the current health care debate. The leadership of both major political parties treat health care as a privilege rather than a human right. The profits of the medical industrial complex sadly take center stage over the people’s interests.

Most of the Democratic Party leadership is wedded to the Affordable Care Act (ACA). While some measures of the ACA should be preserved, such as coverage for the 153 million Americans with pre-existing conditions, the law has failed. It is not affordable. It contains no public option, does nothing to lower pharmaceutical prices, is a boon to the insurance companies and still leaves tens of millions uninsured and millions more with inferior insurance plans.

The failed legislation promoted by the Republican leadership is far worse. The GOP plans would gut Medicaid (used by one in five Americans and two-thirds of nursing home patients). Their plans would drive 22 million people from health insurance rolls, according to the Congressional Budget Office; incentivize employers to eliminate health coverage; limit coverage for pre-existing conditions; and drastically raise medical costs for seniors – all while giving billions in tax breaks to the wealthiest.

Most workers our union represents have employer-based health insurance. Every year we are paying more and receiving fewer benefits. A postal employee typically pays $6,000 a year for their share of family plan premiums – plus co-pays, deductibles and co-insurance. A “Canadian style” system would offer financial relief, even to those currently insured.

Donald Trump was right back in 2000 when he said: “We must have universal health care. Just imagine the improved quality of life for our society as a whole…The Canadian-style, single-payer system…helps Canadians live longer and healthier than Americans…There are fewer medical lawsuits, less loss of labor to sickness, and lower costs to companies paying for the medical care of their employees.”

According to the most recent figures, the United States spends 17.8 percent of GDP on health care – more per capita than any other country. More than 25 percent of health care expenses are administrative – money diverted to needless insurance industry overhead and profits. (Twice that of Canada.) U.S. citizens average $9,000 a year in health-related costs.

Yet, health outcomes are dismal. The United States ranks 34th in life expectancy. (Canada ranks 13.) A 2017 study by the Commonwealth Fund, found that the United States ranks last of the 11 most “developed” countries in health care quality, access, results and efficiency.

The ACA should be replaced with a better system. The recent debate between bad (“Obamacare”) and worse (“Trumpcare”) fails to meet the health care needs of the 99 percent. Let’s learn from our neighbor and demand single-payer universal health coverage – “Medicare for All!”

It is a proven, simple, cost-effective, and just way to heal what ails us.

Mark Dimondstein is president of the 200,000-member American Postal Workers Union and a vice president of the AFL-CIO.

http://www.cleveland.com…

E.J. Dionne’s inadvertent lesson for us

The priority is still to save Obamacare

By E.J. Dionne, Jr.
SouthCoastToday, September 16, 2017

Before supporters of universal health coverage get all wrapped up debating a single-payer system, they need to focus on a dire threat to the Affordable Care Act likely to come up for a vote in the Senate before the end of the month.

The latest repeal bill is an offering from Sens. Lindsey Graham, R-S.C., and Bill Cassidy, R-La., that would tear apart the existing system and replace it with a block grant to the states. Block grants — flows of money for broad purposes with few strings attached — are a patented way to evade hard policy choices. All the tough decisions are kicked down to state capitals, usually with too little money to achieve the ends the block grant is supposed to realize.

This is a matter of urgency because the authority the Senate has to pass Obamacare repeal with just 51 votes expires on Sept. 30. So if the bill comes up, it would likely hit the floor in the last week of this month. All who care about the expansion of health care coverage need to focus their energies on defeating this latest attack on Obamacare. However we eventually arrive at universal coverage, which we must, it will be far easier to get there by building on the ACA.

And assuming the latest repeal effort fails, last week’s push for a single-payer system could come to be seen as a useful initiative provided that “Medicare for All,” as its supporters like to call it, is treated as a goal, not a litmus test. Defining the left pole of the health care debate is helpful, in part because it shows how fundamentally moderate Obamacare is. It is not, as many conservatives have claimed, anything close to a socialist scheme.

And for those whose objective is single-payer, there are many options available that could gradually open the way for it. As Medicare for All’s leading advocate, Sen. Bernie Sanders, I-Vt., noted in an underappreciated tweet in July: “In the short-term, to improve the Affordable Care Act, we should have a public option in 50 states and lower the Medicare age to 55.” Many progressives and moderates who favor universal coverage but are not yet sold on single-payer would embrace options of this sort. Such measures would help a lot of people immediately and make any move to single-payer less disruptive.

http://www.southcoasttoday.com…

***

Comment:

By Don McCanne, M.D.

This column by E.J. Dionne is important because it represents the current most prevalent view on health care reform, written by an intelligent, highly respected journalist with great credibility and uncompromising ethics. We need to listen to him.

The more immediate issue that Dionne discusses is the cruel Graham/Cassidy proposal that would take health care away from millions of people. Since action on this bill is imminent, he calls for focusing our energies on defeating it. He is right. The bill needs to be defeated.

The larger issue here is that he demonstrates where the progressive/liberal camp is headed on long term reform. He describes single payer Medicare for all as the left pole of the health care debate, showing “how fundamentally moderate Obamacare is” in comparison. He then mentions what we are hearing from a multitude of reform advocates – that “there are many options available.” He then dials in on the dual option that has now become so prevalent in the national reform dialogue: “we should have a public option in 50 states and lower the Medicare age to 55,” even quoting Bernie Sanders as the authoritative source for this concept.

It has been repeated so many times that a Medicare buy-in and a public option will lead to single payer that it has become a meme. Everyone knows it’s true, well… just because it is.

A Medicare buy-in would have almost no resemblance to the existing traditional Medicare program. It is much more likely that private plans similar to Medicare Advantage plans would be modified to fit a new market, though difficulties would remain in risk pool management, reinsurance, benefit design, and other features that would require the support of Congress, much as they are now supporting the Medicare Advantage plans to give them an advantage over the traditional Medicare program.

A public option would have basically the same problems – creating a plan which will be public in name only but structured like private plans, except that it would be stripped of essential features to avoid giving it an “unfair” advantage over competing private plans. In fact, this is what Congress did with the public option that was part of the Affordable Care Act before it was pulled from the legislation because of Joe Lieberman’s tantrum.

If we follow either or both of these routes we will end up not only with inferior plans but also with none of the efficiencies or benefits of a single payer system. That will then be used as “proof” that single payer cannot work in the United States. Any further transition to single payer would be aborted.

But then there will be other ways we can do it. We’ll just have to turn everything over to the private insurers, except for high risk patients whose care we taxpayers will have to fund. Then we will have the hybrid system which our progressive friends are clamoring for.

It doesn’t have to be this way, but it could happen unless we mobilize the masses.

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

Dr. Carol Paris on ‘Rising Up With Sonali’

PNHP president Dr. Carol Paris appeared on “Rising Up With Sonali” on Free Speech TV and Pacifica radio stations on September 19, 2017. She discussed the GOP’s latest attempt to repeal the Affordable Care Act (aka Graham-Cassidy) and contrasted this effort with Sen. Bernie Sanders’ recently introduced Medicare For All Act.

Carroll, Frakt, Garthwaite, Reinhardt, and Jha help us choose the best health care system

The Best Health Care System in the World: Which One Would You Pick?

By Aaron E. Carroll and Austin Frakt
The New York Times, September 18, 2017

To better understand one of the most heated U.S. policy debates, we created a tournament to judge which of these nations has the best health system: Canada, Britain, Singapore, Germany, Switzerland, France, Australia and the U.S.

“Medicare for all,” or “single-payer,” is becoming a rallying cry for Democrats.

This is often accompanied by calls to match the health care coverage of “the rest of the world.” But this overlooks a crucial fact: The “rest of the world” is not all alike.

The commonality is universal coverage, but wealthy nations have taken varying approaches to it, some relying heavily on the government (as with single-payer); some relying more on private insurers; others in between.

Experts don’t agree on which is best; a lot depends on perspective. But we thought it would be fun to stage a small tournament.

We selected eight countries, representing a range of health care systems, and established a bracket by randomly assigning seeds.

To select the winner of each matchup, we gathered a small judging panel, which includes us:

* Aaron Carroll, a health services researcher and professor of pediatrics at Indiana University School of Medicine

* Austin Frakt, director of the Partnered Evidence-Based Policy Resource Center at the V.A. Boston Healthcare System; associate professor with Boston University’s School of Public Health; and adjunct associate professor with the Harvard T.H. Chan School of Public Health

and three economists and physician experts in health care systems:

* Craig Garthwaite, a health economist with Northwestern University’s Kellogg School of Management

* Uwe Reinhardt, a health economist with Princeton University’s Woodrow Wilson School of Public and International Affairs

* Ashish Jha, a physician with the Harvard T.H. Chan School of Public Health and the director of the Harvard Global Health Institute

So that you can play along at home and make your own picks, we’ll describe each system along with our choices (the experts’ selections will decide who advances).

(Interactive comparisons follow.)

Conclusion

(The conclusion is available at the link but is omitted here for those who wish to make their own choices in the matchups before knowing the final conclusion.)

https://www.nytimes.com…

***

NYT Reader Comment:

By Don McCanne, M.D.

Although this is an interesting exercise, it might be more productive to look at these systems from the perspective of the major problems that we have and what features of other systems might ameliorate them.

The uninsured: Make enrollment automatic. A mandate falls short because of compliance problems.

The underinsured: Reduce cost sharing to levels that will not create financial barriers to care.

High costs: Publicly-administered pricing comes closest to getting it right – legitimate costs plus fair margins.

Lack of choice of physicians and hospitals: Do not create artificial panels that serve third party payers at the cost of patient choice.

Impaired access to specialized services: Do not segregate low-income individuals into chronically underfunded welfare programs.

Profound administrative waste: Hundreds of billions of dollars could be recovered with a much more efficient financing system.

Now look again at how the various systems address these issues. Oops. There is not enough information here since the field of health policy is so much more complex than can be boiled down to simple comparisons. But when you add the other features that cannot be included here, you would end up with a single, equitably-financed, publicly-administered program – not an exact duplicate of any of the nations listed. That could be accomplished by improving our Medicare program and expanding it to include everyone.

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

Should the United States go for single-payer?

By Jay Brock, M.D.
The Washington Post, Letters, September 18, 2017

Eugene Robinson was correct that Sen. Bernie Sanders’s (I-Vt.) proposal for a “Medicare for All” health insurance system is the “right thing to do” [“An idea no longer on the fringe,” op-ed, Sept. 15]. It would cover everyone with first-dollar coverage for all medically necessary care.

But “Medicare for All” is not socialized medicine, in which the government would own medical facilities and health-care providers would be government employees. Rather, this is socialized insurance, and it is enormously popular among conservatives and liberals already covered by Medicare. The excellent medical system we have now wouldn’t change; how we pay for it would.

Also, regarding those projected 10-year costs: We already spend a “staggering” $3.4 trillion each year on health care and still manage to leave 28 million people without any health insurance and tens of millions more greatly underinsured. An improved “Medicare for All” single-payer system would fix that, with a cost-effective system based on competition among providers that would be the continuing envy of the world. (That $3.4 trillion is enough to cover everyone. We just don’t spend it wisely because we waste as much as $500 billion on administrative costs to accommodate our multiple-payer system.)

It’s only a matter of time before the politicians catch up with the majority of Americans who already want a single-payer system.

https://www.washingtonpost.com…

Dr. Ed Weisbart on ‘The Real News’

PNHP-MO chair Dr. Ed Weisbart appeared on “The Real News” on September 18, 2017 to discuss the GOP’s latest push to repeal the Affordable Care Act. He discussed the disastrous effect Graham-Cassidy would have on American health care and urged Congress to reverse course and embrace a proven solution: improved Medicare for all.

Primary care EHR overload worse than many realize

Tethered to the EHR: Primary Care Physician Workload Assessment Using EHR Event Log Data and Time-Motion Observations

By Brian G. Arndt, M.D., John W. Beasley, M.D., Michelle D. Watkinson, M.P.H., Jonathan L. Temte, M.D., Ph.D., Wen-Jan Tuan, M.S., M.P.H., Christine A. Sinsky, M.D. and Valerie J. Gilchrist, M.D.
Annals of Family Medicine, September/October 2017

Primary care physicians spend nearly 2 hours on electronic health record (EHR) tasks per hour of direct patient care. Demand for non–face-to-face care, such as communication through a patient portal and administrative tasks, is increasing and contributing to burnout. The goal of this study was to assess time allocated by primary care physicians within the EHR as indicated by EHR user-event log data, both during clinic hours (defined as 8:00 AM to 6:00 PM Monday through Friday) and outside clinic hours.

From the Discussion

This study provides a validated mechanism for EHR task analysis using EHR system event logs to evaluate primary care physician workload. Our event logs indicate that family medicine physicians spend approximately 45% of their workday (4.5 hours) on the EHR. Direct observation data were consistent with this finding. The remaining 55% of the workday (5.5 hours) was spent on non-EHR activities such as direct patient care, team interactions and meetings, paperwork, e-mail, and other work. An additional 1.4 hours per day of EHR time was spent outside of clinic hours (before 8:00 AM or after 6:00 PM), including 51 minutes per weekend. This extra time equates to an average workday (excluding time providing care to patients in the hospital) of 11.4 hours, representing a considerable encroachment on physicians’ personal and family lives.

http://www.annfammed.org…

***

Comment:

By Don McCanne, M.D.

This is serious. In this study, not only did primary care primary care physicians spend almost half of their clinic hours on electronic health records (EHRs), outside of clinic hours they spent an average of an additional 7 hours and 51 minutes – the equivalent of an extra workday per week. Does this investment in time provide enough direct patient benefit to warrant it? Of course not.

We would hope that a single payer system would address this problem, but there is risk that the public stewards would rely heavily on EHRs for administrative purposes and for current data-intensive information technology trends.

Hopefully shifting the culture from the business-oriented medical/industrial complex to a patient-service environment, as should occur with implementation of a well-designed single payer system, would cause the stewards to wake up and take a serious look at such wasteful services that induce physician/nurse burnout and patient malcontentment.

Clearly, we cannot allow this to continue.

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