New York-based emergency physician Dr. Farzon Nahvi recorded a video op-ed that was posted to the “NowThis Politics” Facebook page on October 16, 2017. He said single-payer reform was needed to protect two distinct groups of patients: those without private health insurance and those with private health insurance.
By Paula L. Stillman, M.D., M.B.A.
Philadelphia Inquirer, October 16, 2017
I do not want to have to switch my health care coverage.
For the past 15 years, I have had multiple spinal epidural injections to relieve my sciatic nerve pain. The injection lasts for 4-6 months and I am pain free during that interval. All of my records and images are at a major hospital in Delaware where I worked for 8 years. When I left that position I went on Medicare. My injections continued without a copay. I now work at a major health system in Philadelphia and receive health coverage through that health care system.
Recently, I went down to Delaware for my epidural injection before a major out of town trip. The injection worked and I was pain free. Imagine my surprise when I received a bill for a copay for the hospital facility fee for over $1200. I did not realize that the hospital in Delaware was a tier 3 provider. I was never told this before the procedure or the amount of my copay. In fact, I received the bill almost 3 months after the procedure. I appealed this case to Blue Cross and am waiting their decision. I told them that I was never told about the co pay before the procedure and it was bad medicine for me to change providers. I am awaiting their decision.
I should be able to go to whatever health care system I choose and to stay with the hospital that has all of my records and has past experience with my problem. I do not want to switch. For years, I have been very satisfied with the care that I received in Delaware. I have been essentially pain free and able to travel, exercise and enjoy life. Just because my insurance coverage has changed, I should not have to switch my providers. This is bad medicine.
A single payer plan could solve this problem, and Bernie Sanders’ proposal would be a good first step. No one should have their care disrupted because they were forced to change insurance.
Dr. Stillman is Director of Community Engagement of The Institute of Emerging Health Professions at Jefferson University.
By Rian Podein, M.D.
Wisconsin State Journal (Madison, Wisc.), October 16, 2017
Medicare for all is patriotic.
Our nation proudly acts patriotic when we support our military troops. This patriotism naturally extends to supporting our neighbors too. Our brave military men and women are often placed in harms way sacrificing, life and limb.
The same is true of our courageous countrymen and women who may also find themselves in harm’s way, whether by natural disaster, national tragedy, mass shootings, terrorism or illness.
Rightfully, we have guaranteed our military personnel access to high quality and affordable health care via the Veteran’s Administration. We owe the same patriotic commitment to our neighbors.
Current legislation that can fulfill this patriotic commitment includes bills introduced in the U.S. House of Representatives by Rep. John Conyers, D-Mich., and more recently in the Senate by Sen. Bernie Sanders, I-Vt.
The time has come to support our troops and our neighbors with the right to health care.
Dr. Thomas Clairmont appeared on “The Senior View” on Portsmouth (N.H.) Public Media on October 14, 2017. He was joined by Dr. David Rutstein and other guests to discuss “health care in America.” The panel lamented the outrageous (and rising) cost of care and Dr. Clairmont pushed for single-payer reform to address this problem.
U.S. Department of Health & Human Services, October 12, 2017
U.S. Health and Human Services Acting Secretary Eric Hargan and Centers for Medicare & Medicaid Services Administrator Seema Verma released the following statement announcing that cost-sharing reductions payments will be discontinued immediately based on a legal opinion from the Attorney General:
“It has been clear for many years that Obamacare is bad policy. It is also bad law. The Obama Administration unfortunately went ahead and made CSR payments to insurance companies after requesting – but never ultimately receiving – an appropriation from Congress as required by law. In 2014, the House of Representatives was forced to sue the previous Administration to stop this unconstitutional executive action. In 2016, a federal court ruled that the Administration had circumvented the appropriations process, and was unlawfully using unappropriated money to fund reimbursements due to insurers. After a thorough legal review by HHS, Treasury, OMB, and an opinion from the Attorney General, we believe that the last Administration overstepped the legal boundaries drawn by our Constitution. Congress has not appropriated money for CSRs, and we will discontinue these payments immediately.”
HHS Memo with opinion of Attorney General Jefferson B. Sessions III:
https://www.hhs.gov…
CBO: The Effects of Terminating Payments for Cost-Sharing Reductions:
https://www.cbo.gov…
NYT: 12 ways Trump is scaling back Obamacare:
https://www.nytimes.com…
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The White House, October 12, 2017
Among the myriad areas where current regulations limit choice and competition, my Administration will prioritize three areas for improvement in the near term: association health plans (AHPs), short-term, limited-duration insurance (STLDI), and health reimbursement arrangements (HRAs).
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By Don McCanne, M.D.
In order to make health care more affordable for lower-income individuals, the Affordable Care Act required that credits (cost-sharing reductions or CSR) be paid to the insurers to cover a portion of the cost sharing. Republicans chose to block these payments by refusing to appropriate the funds required, forcing the Obama administration to use an alternative source of funds – a move which is now under legal challenge (use link above to see Attorney General Sessions’ opinion).
The Trump administration has now ordered the immediate termination of the CSR payments.
The Congressional Budget Office has previously provided an analysis of the consequences of terminating the CSR payments (see link above). There are too many variables to predict with certainty what will happen, but the action at least is likely to be disruptive to the silver plans offered in the exchanges (the silver plans being the ones that quality for the CSR payments).
Also yesterday President Trump issued an Executive Order instructing agencies to modify regulations for association health plans (AHPs), short-term, limited-duration insurance (STLDI), and health reimbursement arrangements (HRAs). Again, because of variables in implementation of this executive order, the impact is uncertain, but it is likely to be quite negative.
The New York Times has listed other ways in which Trump’s administration is scaling back the Affordable Care Act (see link above). All of these measures together will certainly increase the number of uninsured, reduce health care benefits covered by the innovative plans, while increasing exposure to financial risk. Too many patients will end up sicker and poorer.
At a time when there is a surge of interest in single payer reform – an improved Medicare for all – the pushback against the Trump chicanery could expedite the political processes required to advance health care justice to all. We should be sure that the nation understands that there is a much better way out, but also that they will have to demand that change.
Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.
By Richard C. Dillihunt, M.D.
Portland (Maine) Press Herald, October 13, 2017
Seventeen years ago, I wrote an op-ed for the Maine Sunday Telegram headlined “Universal Medicare: The time is coming” (Nov. 19, 2000). Apparently I jumped the gun, as it has not taken place yet.
Now I feel like a cicada, an insect that looks like a huge fly, emerging after 17 years of hibernation under the bark of a tree and emitting unique and characteristic shrill buzzing sounds to attract attention to itself. Now the sounds come from independent Vermont Sen. Bernie Sanders. The concern of our nation regarding health care for all is reaching a crescendo, and we need to address this. The resounding will of the people should be recognized and acted upon.
The recent and astounding conversion of now-retired Sen. Max Baucus, D-Mont., into a supporter of a system of single-payer care like that of Canada leaves one breathless. Baucus owed this to every American, having blocked single-payer eight years ago as an architect of the Affordable Care Act.
Today I repeat the message after all these years. The time for universal health care and single-payer is near, and the politicians of all parties have an obligation to awaken and do what hundreds of millions of Americans crave. Poll after poll expresses this desire.
Current efforts otherwise in Washington are dying day by day, and the gasping last breaths of politicians to repair, replace, revise, renew or whatever are just roadblocks and flimsy efforts to make an easy job impossible.
President Trump, Senate Majority Leader Mitch McConnell, House Speaker Paul Ryan and so many others should be ashamed they have not pushed the easy button bringing superior health care to every last citizen of America. Repeated tweaking of and failures to change the system with little study and no experience only expose amazing incompetence, lack of education and profound political positioning. Trying to solve these issues with political threats and outright lies rather than facts would be laughable if it were not such a serious matter, easily the most important domestic issue of our time.
We owe it to one another to bring about this change and elevate our position to the top. In a recently released, reliable comprehensive study of health care worldwide, our only top position is cost. We blow away every other nation as we spend $9,000 per capita yearly on care – about 17 percent of our gross domestic product.
However, we are far down the list, tied with Estonia and Montenegro, in quality of and access to health care. On a scale of 0 to 100, our overall grade point average is 81. That, to me, is a cruel joke. Top score went to Andorra, a little country in the Alps – boasting a score of 95. Big countries like Norway and Australia beat us with ease. Yes, this is hard to believe. Just check the article, published May 18 in The Lancet – the accurate, highly regarded journal from the U.K. It is all there.
Money is not the problem. How can we wear Gucci shoes while preemies die? How can we let our horn of plenty stop on Wall Street while addicts lives’ end as they wait in vain down the street for rehabilitation services? How can we spend $4 billion on another destroyer scraping its sides on the Panama Canal while health care-related bankruptcies humiliate Middle America?
Should we be sending billions to Egypt to buy tanks that shoot at each other? Or a billion to Ukraine for forgotten reasons?
I again submit: The time has come for Americans to take care of ourselves. Look over our northern border and we will see how it works – at huge savings. Note that the per capita cost of health care here has more than doubled since the publication of my 2000 Telegram op-ed – even though Canada has enjoyed both liberal and conservative governments during this time, with no change in the love for single-payer there.
The per capita cost of health care in Canada is a little less than half of what we pay in the U.S. Politics should not lead the way on how to fix your mother’s hip – or how to pay for it. We need more civilized ways to face these responsibilities. Virtually all polls agree with this position.
Personally, I have more at stake here. I do not want to wait another 17 years to see a change that is so critically needed now. I am sick of living under the bark of a tree. Please study the issues on switching to universal health care and single-payer. Then join Bernie Sanders and a huge majority of our fellow Americans in supporting single-payer care.
By Howard Bauchner, MD (1); Frederick P. Rivara, MD, MPH (2); Robert O. Bonow, MD, MS (3); Neil M. Bressler, MD (4); Mary L. (Nora) Disis, MD (5); Stephan Heckers, MD (6); S. Andrew Josephson, MD (7); Melina R. Kibbe, MD (8); Jay F. Piccirillo, MD (9); Rita F. Redberg, MD, MSc (10); John S. Rhee, MD, MPH (11); June K. Robinson, MD (12)
JAMA (Published simultaneously in JAMA and the 11 JAMA Network Journals), October 9, 2017
Author Affiliations:
1) Editor in Chief, JAMA and The JAMA Network
2) Editor, JAMA Pediatrics and JAMA Network Open
3) Editor, JAMA Cardiology
4) Editor, JAMA Ophthalmology
5) Editor, JAMA Oncology
6) Editor, JAMA Psychiatry
7) Editor, JAMA Neurology
8) Editor, JAMA Surgery
9) Editor, JAMA Otolaryngology–Head & Neck Surgery
10) Editor, JAMA Internal Medicine
11) Editor, JAMA Facial Plastic Surgery
12) Editor, JAMA Dermatology
The shooting in Las Vegas, Nevada, that left 59 people dead, 10 times that number wounded, and thousands of people with the psychological distress from being present at the scene during and after the massacre has once again raised the issue of what we as a nation can and should do about guns. The solution lies in not just focusing on Las Vegas and the hundreds of other mass shootings that have occurred in the United States in the last 14 months, but rather to underscore that on average almost 100 people die each day in the United States from gun violence. The 36,252 deaths from firearms in the United States in 2015 exceeded the number of deaths from motor vehicle traffic crashes that year (36,161). That same year, the US Centers for Disease Control and Prevention reported that 5 people died from terrorism. Since 1968, more individuals in the United States have died from gun violence than in battle during all the wars the country has fought since its inception.
Guns do not make individuals, their families, or homes safer and they result in far more deaths to loved ones than to an intruder intending to cause harm. Often forgotten is that 60.7% of the gun deaths in 2015 in the United States were suicides. Means used to attempt suicide matter; guns will result in suicidal deaths well over 90% of the time, whereas ingestion of pills or wrist cutting will be unsuccessful more than 90% of the time. The majority of people who try to commit suicide but survive the attempt will not go on to die from suicide; if the attempt is with a gun, there will be no second chance at life.
The journals of the JAMA Network are dedicated to improving the health of people across the globe. We do so by addressing the most important public health problems harming people and publishing the best science that can be done. The journals have published important work on gun violence; in the past year this has included studies on differences in gun use during terrorist attacks in the United States compared with other countries, the effect of exposure to gun violence in the media on children’s interest in real guns, the relationship between firearm laws and firearm homicides and suicides, and the association of “stand your ground” laws with homicide and suicide. Research on gun violence is important, although Congress over the last 2 decades has placed limits on that science from being conducted. This attempt to suppress research into gun violence resulted in a 64% decline in the number of firearm studies per million citations in SCOPUS between 1998 and 2012.
Physicians and other health care professionals can do more. The US Court of Appeals for the 11th Circuit has ruled that attempts to prevent physicians from asking and counseling patients about guns violate the First Amendment. As with any epidemic, prevention is important. Physicians and others should ask about guns in the home, especially for high-risk patients, and advise about removal and safe storage. Good evidence has shown that safe storage of firearms is effective in reducing misuse. Physicians can conduct appropriate screening and early intervention for suicide, the most common cause of gun deaths.
We, as editors of the journals in the JAMA Network, are committed to providing policy makers, as well as the medical community and the US public, with accurate, timely information to guide interventions that will reduce injuries and deaths from guns. Numerous polls have shown that the majority of citizens want action that will make a difference. Other countries have acted: when a mass shooting happened in Australia 2 decades ago, the federal government responded with legislation within 2 weeks of the event banning semiautomatic rifles. Since 1996, there has not been a mass shooting on that continent.
Guns kill people. More background checks; more hotel, school, and venue security; more restrictions on the number and types of guns that individuals can own; and development of “smart guns” may help decrease firearm violence. But the key to reducing firearm deaths in the United States is to understand and reduce exposure to the cause, just like in any epidemic, and in this case that is guns.
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By Don McCanne, M.D.
Suppose we identified a public health hazard that caused 36 deaths. There would certainly be considerable interest in the nature of the problem and what could be done about it. Suppose that were 360 deaths instead. That would be national news that would be followed up with Congressional hearings. Suppose it were 3,600 deaths. Whoa. Yet, in 2015, there were 36,252 deaths from firearms in the U.S.
So where is Congress on this? The latest gun tragedy in Las Vegas included the use of bump stocks – devices that allow semi-automatic weapons to fire in rapid succession just like machine guns. So bipartisan legislation was introduced to ban these devices. Speaker Paul Ryan responded by saying that this was a matter for the regulators, so no legislation will be introduced on the House floor. The National Rifle Association – NRA – still owns Congress.
Unfortunately, the well meaning editorial by the 12 JAMA Network editors is all too typical of the responses to these tragedies. Gun violence is tragic, and we should do something about it. Pause. (Time to get back to work.)
Since 1968, more U.S. residents have died from gun violence than have have died in battle during all the wars the country has fought since its inception.
It’s time to get serious about gun violence. Let’s sit down at the negotiating tables with an opening position that all guns throughout the nation be collected and melted down – no compromises – though we would listen to counter proposals.
What does this have to do with single payer? Eliminating gun violence would reduce our national health expenditures in a beneficial way – one of the prime goals of an improved Medicare for all.
Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.
By Greg Silver, M.D.
Orlando Sentinel, October 12, 2017
The patient looked terrified when she showed me her broken arm that wouldn’t straighten out. “What am I supposed to do?” she asked.
She was a waitress, about 25 years old, working to support her family. She had broken her right arm near the elbow several weeks prior and was seen in a local emergency room. Since she had no insurance, she couldn’t afford the follow-up visits. So the arm healed crooked, and it was now difficult and painful for her to hold a tray.
She was scared of losing her job. I wished I could tell her everything would be OK, but that wasn’t true. What should have been a straightforward treatment process was cut short due to cost, and now she would need surgery to fix it. Without insurance, she couldn’t possibly afford surgery, but she also couldn’t afford to lose her job. I didn’t have an answer.
I’ve been a primary-care physician for 30 years, and these conversations have become heartbreakingly routine. Consider the 45-year-old hairdresser with severe hip arthritis, in constant pain, barely able to stand and work. He badly needs a hip replacement but, without insurance, what is he supposed to do? Or the 63-year-old paralyzed on his left side from a stroke, but who can’t afford to see his doctor or buy his medicine. He knows that he is at high risk for another stroke, or worse. Feeling hopeless he told me, “I hope the next one just kills me.”
Sadly, these stories are uniquely American. Only in America do we force millions of fellow citizens to beg for charity care, suffer the economic cost of huge medical bills or file bankruptcy. Not surprisingly, we live shorter lives with worse health outcomes — life expectancy and infant mortality, for example — than most other industrialized nations. According to the Annals of Internal Medicine, 18,000 Americans die each year from a lack of insurance.
It doesn’t have to be like this.
In the richest nation on Earth, we already spend more than twice as much as other nations that actually provide universal health care. Even with the Affordable Care Act, we leave 28 million people without any coverage. Those with workplace insurance plans face skyrocketing costs: The average family of four pays $11,685 in premiums and out-of-pocket costs per year, and from 2005 to 2015, average deductibles rose 229 percent. Sixty percent of those filing medical bankruptcy actually had insurance coverage when they got sick.
The root cause of our system failure is the private insurance industry and its wasteful bureaucratic complexity, fragmentation and profit motive. We desperately need a streamlined single-payer program that would provide universal coverage for all Americans, such as Rep. John Conyers’ House Resolution 676 and Sen. Bernie Sanders’ Senate Bill 1804. This type of “Medicare for all” system works like today’s Medicare, when all medical bills are paid for by a single government fund, and patients can visit the hospital or doctor of their choice for all medically necessary care.
Can the U.S. afford this? We currently spend more than $3 trillion per year on health care; nearly two-thirds of that is already paid for by your tax dollars. By cutting out the private insurance middlemen and negotiating drug prices, we could easily save $500 billion per year, enough to expand coverage to everyone.
As noted Princeton Professor Uwe Reinhardt once said, “The issue of universal coverage is not a matter of economics. Little more than 1 percent of gross domestic product assigned to health could cover all. It is a matter of soul.”
Medicare for All is efficient, it has been proved, and it’s simply the right thing to do. One day I hope that when a patient looks me in the eye and asks, “What am I supposed to do?” I’ll have a real answer for them.
Dr. Greg Silver practices urgent care in Pinellas and Pasco counties. He is a Florida-based member of Physicians for a National Health Program.
By Jack Bernard
The Birmingham (Ala.) News, October 12, 2017
A bitter and anxious public is fed up with the inertia in Congress and politicians arguing but getting nothing done. Gallup found that approval ratings for Congress are at historical lows, 16 percent, whereas as recently as February they were at 28 percent.
The last President campaigned on hope and change, but was inconsistent. When running for the Senate, Obama stated at the AFL-CIO Human and Women’s Rights Conference (per Politifact) “A single-payer health care plan, a universal health care plan. That’s what I’d like to see.”
But, by the time he started his Presidential run in April 2007, the Chicago Trib. reported a different take: “He has said he is reluctant to switch to a ‘single-payer’ national health insurance system because of the difficulty in making a quick transition from the employer-based private system.” In other words, he was clearly afraid to make major changes to our healthcare system and guarantee Medicare for all.
Instead, he inexplicably took a conservative program designed by the right wing Heritage Foundation (which feeds Republican policy wonks) and adopted it as his very own.
Romneycare, with its known pros (increased access) and cons (high cost, dependency on private insurance companies), overnight became Obamacare. And, because he was overly idealistic and very inexperienced in national politics, he naively expected GOP support. Obviously, it never came.
So, given this precedent, the switch by the incoming President away from Medicare for All to the market-based (i.e. you are on your own and good luck) Ryan-Price inspired Trumpcare should not be a shock.
For decades, Trump praised the Canadian single payer system. In the Republican debate, he said: “As far as single payer, it works in Canada. It could have worked in a different age, which is the age you’re talking about here.” True, it works in almost every developed nation and at a fraction of what we pay with everyone covered…just not here.
But by January 2016, his tune had changed, as he indicated on ABC’s “This Week”: “We’ll work something out, that doesn’t mean single payer.” And, it has evolved into support for Trumpcare, which the CBO states would have resulted in a loss of insurance for tens of millions of Americans, as well as a major tax break for the wealthy and corporations.
According to a June 2017 Pew poll, 58% of the public believes the federal government is responsible for guaranteeing that all Americans have healthcare insurance. Single payer is specifically mentioned by the majority of them. Frankly, it is the only reasonable option left to control cost and ensure access for everyone.
So, why haven’t Schumer and Pelosi, and GOP politicians in general, signed as co-sponsors of Bernie Sanders’ bill? Why did both Obama and Trump both run away from the best solution to our health care crisis?
The answer is clear. Always concerned with their bottom line and little else, the healthcare-industrial complex is determined to keep us, the American people, fighting amongst ourselves while their profits rise and their CEOs make millions in bonuses and stock options.
The Trump administration, campaigning on draining the swamp, has instead appointed self-serving crocodiles. Installing Rep. Tom Price as Secretary of DHHS stands out as one particularly egregious move.
Price is a total hypocrite. He criticizes Pelosi for taking one private jet flight. Then, when he gets the chance, he wastes over a million dollars of taxpayer money on private planes. He even had the audacity to take one from DC to Philadelphia, a short drive.
When Price was in Congress, he was the beneficiary of sweetheart healthcare stock deals that enabled him to amass a fortune. These were the same companies that he was regulating via legislation. No wonder he is now worth $14 million (per Open Secrets.org), making him the 50th wealthiest member of Congress.
But, much worse, Price is dedicated to destroying both Medicare and Medicaid, as we can see from the Trumpcare bill based on his ideas. Per the CBO, it targeted the 24 million poor and working class, mostly white and lacking a college education, who would lose health insurance if the Obamacare is repealed. They would rejoin the 30 million the ACA failed to cover.
And, per the CBO, the rich would have gotten richer through $600 million in tax cuts for those making over $250,000. The average southern family makes about $50,000.
Price has been pushed out, but there is a much larger issue. There are bills that have been introduced in both the Senate and the House to enact Medicare for all, ensuring full access and controlling cost. But, with the moneyed interests on the other side, it will not happen unless taxpayers (you) put pressure on elected officials to do it.
Jack Bernard is a retired health care executive and the former Director of Health Planning for the State of Georgia. He was also on the Jasper County Board of Health and County Commission.
Bain & Company
The US healthcare industry is still in search of a cure—a breakthrough model that can deliver high-quality care at lower cost. Over the past five years, hospitals, healthcare groups and medical practices have adopted new management structures and systems to curb spiraling costs. But none has proven to be a compelling way forward, and the pace of change since 2015 has slowed substantially.
The US healthcare model remains firmly centered on physicians.
In fact, more than 60% of the physicians we surveyed believe it will become more difficult to deliver high-quality care in the next two years as they struggle to cope with a complex regulatory environment, increasing administrative burdens and a more difficult reimbursement landscape. After years of experimentation, physicians now want evidence that new models for care management, reimbursement, policy and patient engagement will actually improve clinical outcomes. Without it, they see little reason to alter the status quo and move toward widespread adoption.
Why change has slowed
Physicians and healthcare organizations have become more cautious about adopting new structures, systems and tools for several reasons. With the first wave of change well under way, many practices already have implemented changes that are easy or required, and are reluctant to adopt more-complex systems and tools. Physicians are particularly hesitant to embrace new systems when the clinical implications and the return on investment are unproven and the administrative burden significant.
Comparing our 2015 and 2017 survey findings, one notable slowdown has been in the adoption of value-based payment models. Many physicians anticipated a broad rollout of value-based care two years ago and a corresponding decline in practices using the traditional fee-for-service model. But few have been persuaded to switch, noting a lack of evidence that outcomes are the same or better using value-based care.
More than 70% of physicians prefer to use a fee-for-service model, citing concerns about the complexity and quality of care associated with value-based payment models. Fifty-three percent of physicians say that capitation reduces the quality of care, and most see little advantage from pay-for-performance models either. Further, many believe their organizations are not sufficiently prepared for the shift to value-based care.
The road ahead
After a decade of trying out new models, the US healthcare industry has yet to rally around an innovative approach that provides quality care at lower cost. In fact, a disruptive, technology-based solution like those that have transformed the telecom or retail industries may take much longer to develop for healthcare, although a comparable outcome seems inevitable. In the meantime, the industry will continue to innovate, with progress in fits and starts as different models gain traction in different places.
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By Don McCanne, M.D.
Bain & Company is a management consultancy organization. They are believed to have a good grasp of the business prospects of the health care industry. Their 2017 US Front Line of Healthcare Survey is important because it demonstrates that physicians do not believe that the current experiments in models of payment are the way forward.
The report states, “the US healthcare industry has yet to rally around an innovative approach that provides quality care at lower cost.” Dare we say that it is because we are turning to Bain-approved, value-based approaches more suited for the medical-industrial complex rather than being designed by placing the patient front and center?
The Bain report also states, “a disruptive, technology-based solution like those that have transformed the telecom or retail industries may take much longer to develop for healthcare, although a comparable outcome seems inevitable.” Inevitable? Some disruption is inevitable if we are to eliminate our current highly dysfunctional financing system that results in high costs, gaps in coverage, and mediocre quality. Technological advances may be helpful, but they need to be much better targeted than they currently are.
Instead of searching for nebulous, value-based, MBA-designed payment models, we need to adopt the already proven model of a well-designed single payer national health program. More physicians are now beginning to realize that a system designed to provide optimal care for the patients is a system in which physicians themselves will also thrive.
Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.
By Gary Claxton, Larry Levitt, Michelle Long and Erik Blumenkranz
Kaiser Family Foundation, Peterson-Kaiser Health System Tracker, October 4, 2017
Rising cost-sharing for people with health insurance has drawn a good deal of public attention in recent years. For example, the average deductible for people with employer-provided health coverage rose from $303 to $1,505 between 2006 and 2017.
To look at what workers and their families actually spend out-of-pocket for services covered by their employer-sponsored plan, we analyzed a sample of health benefit claims from the Truven MarketScan Commercial Claims and Encounters Database to calculate the average amounts paid toward deductibles, copayments and coinsurance.
We find that, between 2005 and 2015, average payments for deductibles and coinsurance rose considerably faster than the overall cost for covered benefits, while the average payments for copayments fell. As can be seen in the chart below, over this time period, patient cost-sharing rose substantially faster than payments for care by health plans as insurance coverage became a little less generous.
From 2005 to 2015, the average payments by enrollees towards deductibles rose 229% from $117 to $386. The average payments towards coinsurance rose 89%, from $134 to $253, while average payments for copays fell by 36%, from $218 to $139. Overall, patient cost-sharing rose by 66%, from an average of $469 in 2005 to $778 in 2015. Wages, meanwhile, rose by 31% from 2005 to 2015.
The relatively high growth in payments toward deductibles is evident in the changes over time in the distribution of cost sharing payments: deductibles accounted for 25% of cost sharing payments in 2005, rising to 50% in 2015.
Deductibles are the most visible element of an insurance plan to patients, which may help explain why consumers continue to show concern about their out-of-pocket costs for care. Although health insurance coverage continues to pay a large share of the cost of covered benefits, patients in large employer plans are paying a greater share of their medical expenses out-of-pocket. And, while health care spending has been growing at fairly modest rates in recent years, the growth in out-of-pocket costs comes at a time when wages have been largely stagnant.
https://www.healthsystemtracker.org…
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By Don McCanne, M.D.
In the past decade, payments for health insurance deductibles increased by 229% – over 7 times the 31% rate of increase in wages during that same period. The authors conclude, “Deductibles are the most visible element of an insurance plan to patients, which may help explain why consumers continue to show concern about their out-of-pocket costs for care.”
In yesterday’s Quote of the Day message, David Himmelstein, Carol Paris and Steffie Woolhandler explained why cost sharing, such as deductibles and copayments, are detrimental to health care and should be abandoned. If you do not yet have down pat an “elevator speech” on why cost sharing should be eliminated, perhaps you should read again (or for the first time) their background explanation, available at the following link:
Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.
By Natalie Shure
Jacobin, October 6, 2017
In the week preceding the release of Bernie Sanders’s Medicare for All bill, the Vermont senator’s office was flooded with calls — so many, in fact, that the legislative aides on the other line often guessed callers’ purpose before being prompted. At issue was whether the single-payer health care system Sanders’s bill envisions should include copayments, out-of-pocket payments for health services at the point of care.
For the single-payer advocacy group Physicians for a National Health Program (PNHP), the answer was a resounding “no.” So upon discovering that copays remained in Sanders’s penultimate draft, they sprang into action. After a week of open letters, tweets and appeals from like-minded organizations, Sanders ultimately struck copays from the bill’s final version.
Earlier versions of Sanders’s bill probably included copays for doctors visits and prescription drugs for the same reason that economists like them: they drive down health care usage and costs. After all the attacks branding Sanders’s relatively pedestrian social-democratic platform as fantastical promises of ponies for all, perhaps Sanders’s legislative aides believed meager copays gave their proposal an air of seriousness.
But the obliteration of copays isn’t a bug in the thinking behind Medicare for All — it’s the feature.
“Cost-sharing” features like copays, coinsurance, and deductibles are major manifestations of market logic in the US health-care system. If we want to overturn for-profit health care’s rebranding of “patients” as “consumers,” we have to eliminate financial barriers at the point of care.
The cliched justification for charging copays is to relieve doctors’ offices of the burden of patients showing up at the first sign of a sniffle. (Never mind that we observe no such behavior among the wealthy, for whom copays are no barrier.) But we do know that even meager copays make people seek less care, and that the poor suffer worse health outcomes as a result.
“I spent my entire career taking care of low-income people, and trust me — a copayment will keep people away from a doctor. I’ve seen it again and again in my practice,” Dr. Steffie Woolhandler, the co-founder of PNHP, told me over the phone. “It’s a huge amount of money for a low-income person.”
While several countries with universal health care systems do charge copayments at the point of use, they don’t tolerate the amount of poverty that we do in the United States. No other wealthy country does. In a grotesquely unequal society, a copayment doesn’t create “better consumers” of care — it helps us scrimp by shoving the most powerless out of the system.
Over decades of bending over backwards to accommodate the internal contradictions of the private health insurance industry, few made the one point that really mattered: we never built an insurance system that strove to guarantee universal health care; we built one that strove to protect capitalists’ profits. We can build one based on addressing all people’s health care needs right now.
Medicare for All could create a universal health-care system designed to provide health care for everyone. The logic of the market has no place in such a system. Winning a truly universal system means zero deductibles and zero copays.
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Physicians for a National Health Program, August 23, 2017
Dear Senator Sanders:
We are writing to express our concern about elements of your draft single payer legislation, especially the inclusion of copayments for medically-necessary care.
Copayments
Copayments undermine the goal of eliminating financial barriers to care, a goal that is at the heart of our single-payer advocacy. Copayments, even relatively modest ones, deter patients from seeking needed medical care.
For instance, in the Rand Health Insurance Experiment, compared to persons with entirely free care, those with copayments (as low as 16% of costs) reduced their use of essential and low-value medical services to a similar degree. Among non-poor adults, copayments reduced the use of “highly effective” care for acute conditions such as chest pain, urinary tract infections and fractures by 29% and “rarely effective” care (e.g. for a cold) by 22%. Highly-effective care for chronic conditions fell by 15%, and for acute-on-chronic conditions fell by 21%. For non-poor children, copayments reduced highly-effective care (e.g. for ear infections and strep throat) by 15%, and cut well-child visits by 21%. Cost sharing reduced prescriptions for several potentially life-saving medications such as insulin, asthma inhalers, and beta blockers by about 50% and oral contraceptive use by 25%. While the Rand Experiment was too small and too short to detect the expected deleterious outcomes of these shortfalls in care, it documented that copayments resulted in significantly worse control of blood pressure, a key cause of heart attacks, kidney failure and strokes.
More recent studies confirm the health-endangering effects of out-of-pocket charges for care. Among persons with employer-paid coverage, raising out-of-pocket charges cut care much more for those in poor health. When Medicare added new copayments, outpatient visits dropped but hospitalizations rose. Among insured post-heart-attack patients, eliminating medication copayments increased compliance, and (for minority patients), led to a 35% reduction in major complications such as recurrent heart attacks. Similarly, among insured school-age children with asthma, those with higher copayments used fewer medications but had a 41% greater risk of asthma-related hospitalization. For nearly one- third of lower-income asthmatic children with high-cost-sharing coverage through the Kaiser Health Plan, parents reported delaying or avoiding outpatient visits, and 14.8% reported non-adherence to medications because of cost. The low income group in the study included those with family incomes up to 250% of poverty, some of whom would be hit by copayments under the proposed legislation. In that study, 15.6% of all parents (including those with higher incomes) reported borrowing money or cutting back on necessities to pay for their children’s asthma care.
Paradoxically, the reduction in care-seeking because of copayments may fail to cut system-wide utilization, instead shifting care from sicker and lower-income persons to the healthy and wealthy. When lower-income patients avoid care, doctors and hospitals fill the empty appointment slots and beds with less price-sensitive patients, an example of supply-sensitive demand.
International evidence indicates that cost-sharing is neither necessary nor particularly effective for cost control. Canada, which outlawed copayments and deductibles in 1981, has seen both faster health improvement and slower cost growth. Notably, Canada experienced no surge in care when it abolished copayments. Similarly, in the U.S. there was no overall increase in doctor visits or hospitalizations when Medicare and Medicaid were first implemented in 1966; care shifted from more affluent and healthier persons to those who were sicker and poorer. Scotland, which has eschewed patient payments—even going so far as to abolish parking fees—has costs about half those in the U.S. Strikingly, the U.S. has the world’s highest health care expenditures despite its extensive patient cost sharing.
The inclusion of copayments would also undermine the breadth of support for single-payer reform. Many Americans would see no improvement in their current coverage. In 2014, about 28% of Americans incurred no out-of-pocket costs, and 84.3% had out-of-pocket costs of less than $1,000. For them, the proposed coverage would not reduce out-of-pocket costs, at least in the short run. About 5% of those with employer coverage—about 8 million people—currently have plans with zero deductibles and zero copayments. They would have worse coverage under the proposed reform.
Finally, retaining copayments would substantially diminish the administrative savings achievable through a single-payer reform. In order to implement copayments, the single payer insurer would need to track individuals’ changing incomes, family status (to calculate their income relative to the poverty level) and their copayments to date (to ascertain whether they’ve exceeded the out-of-pocket cap), and make that information available in real time to every hospital, clinic, lab, doctor’s office, etc., in the U.S. Providers would need to collect the copays, and bill patients unable to pay at the time of a visit.
Conclusion
In sum, Physicians for a National Health Program cannot endorse or wholeheartedly advocate for a reform that includes copayments for medically-necessary services. While we would welcome the proposed reform as a useful step forward in advancing health justice, the persistence of copayments would unacceptably compromise the legislation’s ability to improve health and foster equality in care. We urge you to reconsider the inclusion of copayments.
Sincerely,
David U. Himmelstein, M.D., Co-founder PNHP
Carol Paris, M.D., President, PNHP
Steffie Woolhandler, M.D., Co-founder, PNHP
References available at link:
https://pnhp.org/docs/SandersLetter_2017.pdf
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By Don McCanne, M.D.
It is irrefutable that deductibles, copayments, and coinsurance cause patients to forgo beneficial health care services, and that often results in physical suffering and sometimes death. For those who cannot avoid health care, financial hardship is frequently a consequence.
A health care financing system should be designed to assist patients in getting the health care they should have by removing financial barriers to care. Since cost sharing has the opposite effect, it should be abandoned as a policy designed to reduce health care spending. There are other much more patient-friendly policies in a well-designed single payer system that are more effective in containing health care spending.
It is a specious argument that people who do not need health care will seek health care anyway simply because it is free. Some say that it would reduce low-value care, but what is low-value care? When a patient is legitimately concerned about his or her health but then doesn’t require any therapeutic intervention other than reassurance, is that low-value care? No. We want patients to come in to reassure them and ourselves that there isn’t anything more serious that requires medical intervention.
The letter by Himmelstein, Paris and Woolhandler provides an excellent explanation as to why cost sharing should be rejected – why individuals should be approached as patients rather than as consumers.
Their letter also demonstrates that it is imperative that we all continue to speak up with the truth about health care reform. Important people are listening.
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