PNHP

Health Care Financing: It’s a tape worm

Health Care Financing: It’s a tape worm

By Ewell Scott, M.D., F.A.C.P.
The Morehead (Ky.) News, May 26, 2017

When Warren Buffett talks, everybody who is anybody sits right up and listens.

Mr. Buffett, living in Oklahoma in a modest ranch house situated in a middle class neighborhood, demands the attention of Wall Street Tycoons and Hedge Fund Managers as he has the uncanny ability of predicting the future in economic terms. He picks out the winners. His reputation for honesty, plain speaking and accuracy are legendary.

Well, just last week he described our current health care financing system a “tape worm.” WOW. I do not want to have a tape worm. Since childhood the image of a silent grisly creature eating away, living in my gut, was scary.

But I am afraid the shoe fits, as our private health insurance based system is literally wasting huge amounts of money.

We in the USA spend twice as much as any other civilized country but get less. Our military, the best and largest, consumes 5 percent of our gross domestic product while total health care spending is responsible for 18 percent. We needlessly spend ours on an inefficient, fragmented, confusing system.

Mr. Buffett’s co-executive at Berkshire Hathaway, Charlie Munger has recently called for adopting a single payer health care system with progressive financing to get rid of this unwanted situation. Medicare for All, new and improved, would do it.

Let’s tell our politicians we want a truly universal, affordable and comprehensive health care financing system.

http://www.themoreheadnews.com…

Take action to rein in pharmaceuticals

By Robert Blake, M.D.
The Missourian, May 26, 2017

Pharmaceutical companies are among the most profitable companies in the world, and their executives are among the highest paid. In recent years, drug prices have markedly increased, rendering more and more Americans unable to afford essential medications.

Companies incur legitimate expenses for research and development of new drugs; however, their combined expenditures for lobbying, contributions to political campaigns, direct advertisements to consumers and promotional efforts, including free gifts, targeting physicians far exceed what they devote to research and development. Furthermore, the National Institutes of Health and other federal sources provide significant funding for research of many drugs that become highly profitable for companies. Taxpayers subsidize the development of drugs that they later must pay high prices to obtain or cannot afford to buy.

The film, “Big Pharma – Market Failure,” recently shown at the Columbia Public Library, documents the failure of the market to supply many medications at a reasonable price. The film emphasizes the devastating effects of escalating drug prices on small businesses that provide health insurance for employees.

We can take actions to address this serious problem.

• The federal law that prohibits Medicare from negotiating drug prices with pharmaceutical companies must be repealed. By negotiating prices, the Veterans Affairs  provides essential drugs to veterans at lower prices; Medicare should be allowed to do this.

• American consumers should be legally able to purchase medications from legitimate foreign sources. Prices of the same drugs are much lower in countries like Canada. The ensuing competition will reduce prices in the U.S.

• The public should have input into the pricing of drugs that were developed with taxpayer assistance.

• We need effective limitations on lobbying and campaign contributions from wealthy corporations, which unduly influence lawmakers to the benefit of the companies and the detriment of the public.

• Patent laws should be reformed to prevent companies from perpetuating monopolies on drugs by making trivial changes that confer no therapeutic advantage.

We should no longer passively submit to harmful practices of drug companies.

Dr. Robert Blake is a Columbia resident.

http://www.columbiamissourian.com…

HHS Secretary Price on the CBO Report

H.R. 1628, American Health Care Act of 2017

Congressional Budget Office, May 24, 2017

CBO and JCT estimate that enacting the American Health Care Act would reduce federal deficits by $119 billion over the coming decade and increase the number of people who are uninsured by 23 million in 2026 relative to current law.

CBO Summary:
https://www.cbo.gov…

CBO Full Report (41 pages):
https://www.cbo.gov…

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HHS Secretary Price Statement on CBO Report

U.S. Department of Health and Human Services, May 24, 2017

Following the release of the Congressional Budget Office (CBO) report analyzing the American Health Care Act, Health and Human Services (HHS) Secretary Tom Price, M.D. released the following statement:

“The CBO was wrong when they analyzed Obamacare’s effect on cost and coverage, and they are wrong again. In reality, Americans are paying more for fewer healthcare choices because of Obamacare, and that’s why the Trump Administration is committed to reforming healthcare. In a new analysis released just last night, HHS reported that premiums in the individual market have more than doubled since many of Obamacare’s regulations and mandates were implemented.”

HHS released a new analysis yesterday that shows premiums have doubled for individual health insurance plans since 2013, the year before many of Obamacare’s regulations and mandates took effect.

https://www.hhs.gov…

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Comment:

By Don McCanne, M.D.

Even though we spend far more on health care than other nations, the market has not been effective in allocating our funds in a manner that would ensure adequate health care for all. This is a time and circumstance wherein we clearly need government leadership.

In response to a Congressional Budget Office report showing that the current proposed health reform legislation – American Health Care Act of 2017 – would likely cause another 23 million people to lose their health insurance, besides its other deleterious effects, HHS Secretary Tom Price fails to acknowledge the severe deficiencies of the legislation and instead condemns the report as being “wrong.” This is not a casual comment; he distributes this through an official HHS release of the U.S. government.

Of course, the report isn’t wrong; it’s a prediction, based on the best available information.

What is wrong is that we have in place a public servant who would destroy whatever he can of the important public health role served by the Department of Health and Human Services. He is driven by his nutty anti-government ideology and would sacrifice the health services of tens of millions of Americans simply for the expediency of implementing his destructive agenda.

Although there are some checks and balances, nevertheless he is in a position to do considerable harm to America’s health care. He should not be left in office for four to eight years while we wait for the next president to replace him. Citizen action is required – now.

This is the opinion of the author is not an official view of Physicians for a National Health Program.

The US healthcare system is at a dramatic fork in the road

By Adam Gaffney, M.D.
The Guardian, May 25, 2017

The US healthcare system – and with it the health and welfare of millions – is poised on the edge of a knife. Though the fetid dysfunction and entanglements of the Trump presidency dominate the airwaves, this is an issue that will have life and death consequences for countless Americans.

The Congressional Budget Office’s (CBO) dismal “scoring” of the revised American Health Care Act (AHCA) on Wednesday made clear just how dire America’s healthcare prospects are under Trump’s administration. But while the healthcare debate is often framed as a choice between Obamacare and the new Republican plan, there are actually three healthcare visions in competition today. These can be labelled healthcare past, healthcare present, and healthcare future.

Let us begin with healthcare past, for the dark past is precisely where Republicans are striving to take us with the AHCA. The bill – narrowly passed by the House on 4 May – is less a piece of healthcare “reform” than a dump truck sent barreling at high speed into the foundation of the healthcare safety net.

Wednesday’s CBO score reflects the modifications made to the AHCA to pacify the hard-right Freedom Caucus, changes that allowed states to obtain waivers that would relieve health insurers of the requirement that they cover the full spectrum of “essential healthcare benefits”, or permit them to charge higher premiums to those guilty of the misdemeanor of sickness, all purportedly for the goal of lowering premiums.

In fairness, the CBO report did find that these waivers would bring down premiums for non-group plans. This, however, was not the result of some mysterious market magic, but simply because, as the CBO noted, covered benefits would be skimpier, while sicker and older people would be pushed out of the market.

In some states that obtained waivers, “over time, less healthy individuals … would be unable to purchase comprehensive coverage with premiums close to those under current law and might not be able to purchase coverage at all”. Moreover, out-of-pocket costs would rise for many, for instance whenever people needed to use services that were no longer covered – say mental health or maternity care.

Much else, however, stayed the same from the previous reports. Like the last AHCA, this one would cut more than $800bn in Medicaid spending over a decade, dollars it would pass into the bank accounts of the rich in the form of tax cuts, booting about 14 million individuals out of the program in the process. And overall, the new AHCA would eventually strip insurance from 23 million people, as compared to the previous estimate of 24 million.

It’s worth noting here that Trump’s budget – released Tuesday – proposed additional Medicaid cuts in addition of those of the AHCA, which amounted to a gargantuan $1.3tn over a decade, according to the Center on Budget and Policy Priorities.

The tax plan and budget – best characterized as a battle plan for no-holds-barred top-down class warfare drawn up by apparently innumerate xenophobes – would in effect transform the healthcare and food aid of the poor into bricks for a US-Mexico border wall, guns for an already swollen military, and – more than anything – a big fat payout to Trump’s bloated billionaire and millionaire cronies.

What becomes of this violent agenda now depends on Congress – and on the grassroots pressure that can be brought to bear upon its members.

But assuming the AHCA dies a much-deserved death – quite possible given the headwinds it faces in the Senate – we will still have to contend with healthcare present.

Last week, the Centers for Disease Control released 2016 results from the National Health Interview Survey, giving us a fresh glimpse of where things stand today. And on the one hand, the news seemed good: the number of uninsured people fell from 48.6 to 28.6 million between 2010 and 2016.

On the other hand, it revealed utter stagnation: an identical number were uninsured in 2016 as compared with 2015, with about a quarter of those with low incomes uninsured last year (among non-elderly adults). It also suggested that the value of insurance is declining, with “high-deductible health plans” rapidly becoming the rule and not the exception: for the privately insured under age 65, 39.4% had a high-deductible in 2016, up from 25.3% in 2010.

Healthcare present, therefore, is an unstable status quo: an improvement from healthcare past, no doubt, but millions remain uninsured and out-of-pocket health costs continue to squeeze the insured.

Which takes us to the third vision, that of healthcare future. As it happens, another recent development provided a brief glimmer of hope for that vision. As the Hill reported, the Democratic congressman John Conyers held a press conference yesterday (Physicians for a National Health Program, in which I am active, participated) to announce that his universal healthcare bill – the “Expanded & Improved Medicare For All Act” – had achieved 111 co-sponsors, amounting to a majority of the House Democratic Caucus and the most in the bill’s history.

This bill – like other single-payer proposals – is the precise antithesis of Paul Ryan’s AHCA. Rather than extract coverage from millions to provide tax breaks for the rich, it would use progressive taxation to provide first-dollar health coverage to all.

Which of these three visions will win out is uncertain, but the outcome of the contest will have a lasting impact on the country. We can only hope that the thuggish, rapacious vision championed by Trump and his administration does not prevail.

https://www.theguardian.com…

Single Payer Benefits

By Jack Mayer, M.D., M.P.H.
Vermont Public Radio, May 25, 2017

Winston Churchill once quipped that, You can always count on Americans to do the right thing – after they’ve tried everything else.

I like that quote because it allows me to be cautiously optimistic that in the end, the current chaotic health care debate may actually result in a Medicare-for-All, single payer system.

We already have a limited form of this in Medicare and Medicaid. Both work very well and provide excellent care for all who are eligible.

I’ve been a Vermont pediatrician for decades and I’ve been advocating for a single payer system since medical school. Obamacare – also known as the Affordable Care Act or the ACA – was a modest step towards universal coverage, but its repeal and the Republican bill to replace it will be dangerous for my patients, because there are multiple problems with the American Health Care Act – or what I prefer to think of as Trumpcare.

According to the Congressional Budget Office, if the proposed Trump/Republican health care plan passes, 23 million will lose insurance, premiums will rise, pre-existing condition protections will be at risk, Medicaid will be slashed, costs will be shifted to hospitals, clinics and states, and huge tax-breaks will accrue to people with incomes over $200,000, as well as big insurance and drug companies – while the rest of us get virtually no tax relief.

Almost every medical organization and AARP opposes this Republican plan.

But any insurance-based system will be dependent on the obsolete medical insurance industry, as it acts as an intermediary between providers and patients, without providing even one iota of care. And this places enormous administrative burdens on providers, while producing dubious outcomes. No other country pays as high a proportion of GDP towards health care and gets less quality and access than the United States.

A single payer plan would simplify the delivery of health care – and would do so with greater equity and fairness. Every other industrialized country provides a system of inexpensive, universal access to health care in recognition that health care is a human right, not a free-market commodity.

Without affordable access, children born into struggling families lose health insurance, and families go into debt or bankruptcy. Untreated children and adults suffer, thousands die.

Perhaps after trying everything else, Americans will finally see the wisdom in a system that would be equitable, simpler, less expensive, and provide excellent care for everyone.

audio here:
http://digital.vpr.net…

Ethics of equitable versus equal in health care

Health Insurance Benefits Should Be Equitable, Not Necessarily Equal

By Betsy Q. Cliff, Michael Rozier, and A. Mark Fendrick
Health Affairs Blog, May 22, 2017

As policy makers grapple with potentially undoing or modifying the largest expansion of health insurance in a generation, the cost and generosity of benefits hold center stage. Traditional underpinnings of insurance plans — premiums, deductibles, copayments, and coinsurance — frequently create barriers to the optimal use of these plans by consumers. They also can exacerbate inequities in health care, by inhibiting the use of services known to benefit health. Novel approaches to insurance plan design to produce a more equitable and efficient distribution of health care expenditures are warranted.

Following the principle of equality, insurance benefit designs traditionally have offered the same benefit structure to all enrollees. Consumer cost sharing at the point of service is typically uniform regardless of need or potential clinical benefit — often it’s based on the acquisition cost. This one-size-fits-all mentality seems like a great idea on the surface but can create deeply unfair outcomes.

Instead, we should be designing insurance coverage in a way that provides access to care for people who need it, when they need it. That requires a subtle but important shift from equal access to equitable access. The first approach treats all people, regardless of clinical need, the same. The second recognizes that clinical need is an essential factor in determining where to direct resources and does not apologize for treating people with different needs differently.

A feasible and effective approach to better aligning expenditures with patient-centered outcomes is value-based insurance design (VBID). VBID structures consumer cost sharing around the idea of clinical nuance, which recognizes that the value of medical services depends on who receives it, who provides it, and where it is provided. This nuanced strategy supports the goals of equity by reducing financial barriers to specific services for targeted populations who need them most. This approach can also be used to deter the use of services when there is low or no expected clinical benefit to the patient.

Equity Versus Equality

The concept of equity is most often applied to health outcomes, in terms of addressing the burden of disease borne by one group compared to another. The solution to these inequities often involves assessing the distribution of health determinants and allocating resources accordingly.

Equity is also embedded in the financing of our health system. For example, Medicaid Disproportionate Share Hospital payments follow the principle of equity rather than equality: Health care organizations that bear the greatest share of uninsured or underinsured patients receive the largest share of funds from this program.

In most situations, a fair health care system ought to concern itself more with equity than equality. If people responded identically to, and had equal need for, clinical services, then access to those services should be equal. Since this is clearly not the case, it makes sense to discriminate based on the likelihood of clinical benefit. In other words, we should not let the potential negative effects of “bad” discrimination (for instance, failing to prescribe a drug based on a person’s racial or sexual identity) obscure the potential advantages of “good” discrimination, which would make it easier for some groups to obtain a service based on clinical need. Equity is premised on the idea that some types of discrimination — treating unequals unequally — is not only good but also necessary.

In particular, tailoring insurance benefits in this way allows individuals to access the best care for their clinical situation. To help ameliorate disparities, patients who are in the most need and services shown to have the most benefit should be supported by their insurance coverage at the most generous levels.

Ensuring Access Through Equitable Benefits

Allowing benefit programs to adapt to those who are most likely to benefit from care could allow physicians to better tailor treatment to each patient and allow patients to better respond to evidence-based recommendations. Using VBID promotes this goal in three distinct ways.

First, VBID reduces cost sharing for specific services that are shown to have the highest clinical benefit.

Second, VBID enhances benefits for specific patient populations.

Third, whereas traditional benefit designs can keep people from accessing innovative medications due to higher cost, VBID can help tailor cost sharing to the specific clinical circumstance.

Coverage arrangements in most insurance plans are designed under principles of equality rather than equity. To fully realize the benefits of medical advances, ensure access for those who could benefit most, and enhance the efficiency of our health care expenditures, we need to change this paradigm. Equitable benefit design recognizes that many chronic conditions often require tailored therapies for achieving results and allows for discrimination based on clinical need. Better health outcomes, especially for those most in need, require us to apply principles of equity in all aspects of our health care system, including benefit design.

http://healthaffairs.org…

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Comment:

By Don McCanne, M.D.

The concepts of equitable and equal, as applied to health care, are certainly crucial. It is imperative that health care and the financing of it be equitable – fair – but it does not necessarily have to be equal. This article discusses these concepts in regard to value-based insurance design (VBID), appropriately reflecting the biases of a University of Michigan health management and policy professor (and a partner in V-BID Health), A. Mark Fendrick, and two of his graduate students.

It is clear that our fragmented, multi-payer health care system is neither equitable nor equal. Because of the great variety of health care financing systems in the United States, or lack thereof, people certainly do not have equal access to health care services and products. Nor is the system equitable since some are served very well when in need, and others are served poorly, if at all. There is an inherent unfairness in having impaired access to the most expensive health care system in the world.

The authors recognize that insurance design contributes to these inequities. They suggest that they could be diminished by redesigning benefits so that they are value-based. But they limit their considerations by adhering to the ideology of consumer-directed health care in which patients share in the costs of health care services as they are accessed (deductibles, copayments, coinsurance, tiering of benefits, penalties for out-of-network care, etc.). Thus their emphasis is on insurance design rather than on more direct financing of essential health care services.

This approach perpetuates and adds to the complexity and waste of our uniquely American health care financing system that is weighted down by profound administrative excesses. Tweaking benefits within an individual plan certainly does not make the benefits equal to those in a multitude of other private and public plans. Even if value-based tweaks were adopted by many other plans and programs, the overall impact on health care would be almost infinitesimal compared to the great needs we have in health care reform.

Much more important than not creating equality, VBID also would have too small of an impact on health care equity. Jiggering benefits would not begin to address the deficiencies that the uninsured and underinsured face, perpetuating our profound unfairness in health care access and affordability.

So let’s set private insurance plans aside and look at these concepts in the single payer model of health care financing. How do you make the system equitable – fair? You make it accessible and affordable for everyone. Central planning and budgeting of capital improvements ensures that health care facilities and professionals are as available as the logistics and resources would allow.

Affordability? Considering the profound inequality in income and wealth and the very high costs of health care, payment into the common risk pool must be based on ability to pay if financing of the system is to be equitable. This is accomplished through progressive tax policies. There could not be a more ethical example on why our health care system must be equitable, but not necessarily equal. An equitable system would be designed to make sure that essential health care benefits are available to all, and thus equal (though benefits that should not be funded by a public system would not be equal), but the financing, to be equitable, must not be equal.

We can forget about the value-based benefit tweaks for private consumer-directed health plans. We need real fixes in our health care system that are universally equitable.

Dr. Phil Verhoef speaks at Medicare-for-all press conference

Transcription by Kay Tillow
Daily Kos, May 24, 2017

A few hours before the CBO announced that 23 million Americans would lose their health insurance under the Republican health care bill passed by the House, Congressman John Conyers, seven co-sponsors of HR 676, and representatives of physicians and nurses groups gathered near the Capitol to announce the amazing growth of both public and Congressional support for single payer.

The following remarks were made by PNHP board adviser Dr. Phil Verhoef:

So I’m an ICU physician at the University of Chicago and as an ICU physician I depend on research and evidence to help inform me about how to practice medicine, how to take care of critically ill kids and adults in the ICU.

But I look at our current health care system, and when I look at the evidence and when I look at the research, I’m pretty sure that our health care system is also critically ill. Why do I say that? Well, look, based on research published last week we ranked 80th out of 195 countries and that is by far the worst of the developed countries in this world.

But more importantly we have 30 million uninsured patients in this country. What that means based on research and evidence is that we will have no less than 20,000 deaths this year because of that lack of insurance. That is unacceptable.

On top of that costs are out of control.

We spend the most per person out of pocket on health care. We spend the most per person per GDP. We spend the most on every possible measure that you can think of.

And so we are failing on every front…this is a critically ill health system. So I say, as a critical care physician, What’s the solution?

Well, one solution has been proposed in Trumpcare and I can tell you that I’m pretty sure, even without CBO’s report which we expect later today, that this is actually going to make our critically ill system even worse.

It’s a little bit like giving grandma a heart attack when she is already in the ICU for pneumonia And so ultimately why would that happen? So look, if 24 million people lose health insurance, that’s another 20,000 deaths that we can lay at the feet of the architects of this awful bill.

Second, this bill (Trumpcare) achieves financial responsibility by providing a humongous tax cut to actually destabilize Medicare at same time that it guts Medicaid. So what that really means is that we are balancing the books on the backs of senior citizens, children, people with disabilities and the poor.

And this just doesn’t make any sense to me.

But we have a solution, we have a therapy for this critically ill patient, our health care system, and that is HR 676, improved and expanded Medicare for All.

Again I turn to research and evidence based on studies from other countries around the world that use similar systems, it saves lives, it saves money, it improves health outcomes.

The thing that burns me up is that we have a solution on the books and there is not political will to move forward with it except for Congressman Conyers and the 111 cosponsors that have been supportive.

As an ICU physician, I know what the solution to our critically ill system is and that’s HR 676 Improved and Expanded Medicare for All and I hope to see political will to stop the deaths of people for lack of health insurance.

full press conference transcription:
http://www.dailykos.com…

full press conference video:

Single Payer In California? Can We Afford It? Can We Afford Not To?

By Paul Y. Song, M.D.
HuffPost, May 24, 2017

This week, the California State Senate Appropriations Committee released their fiscal analysis of SB562 sponsored by Senators Lara and Atkins. Opponents immediately screamed that #SB562 would cost $400 billion per year, more than three times California’s $124 billion general fund budget for next year.

It is very important to understand that the author indicates that this analysis was done while much of the specific details of the proposed legislation are still not finalized, and therefore the assumptions are quite general and conservative. Still, the summary reports that annual government spending on health care is roughly $200 billion, while employers spend $100 to $150 billion towards covering their employees. Without any mention of what individuals currently pay for premiums, co-pays, deductibles, and prescription drugs, the additional required “total new spending” would therefore be $50 to $100 billion per year. So under this worse case scenario, this would be between $106 and $212 per month per Californian in additional taxes.

Now before everyone gets scared away by this daunting price tag, it is important to look at these two graphics to put this into a much needed perspective.

Fig. 1
Fig. 1

Over the past 16 years, workers have had to contribute 221 percent more toward their employer-sponsored premiums (Fig. 1), while premiums have increased 203 percent and wages and inflation have lagged far behind.

Fig. 2
Fig. 2

At the same time, in addition to contributing more towards their premiums, workers have also had to pay more (Fig. 2) in co-pays and deductibles (67 percent more over the last 5 years). Thus in reality, workers are getting squeezed on both ends while having less take home pay. Many would argue that they are already paying upwards of $106 – $212 a month towards medications, co-pays, deductibles with no end in sight. This all goes away under #SB562!!

Plus, if everyone has improved coverage, powerful hospitals can no longer gouge us upwards of 331 percent (Fig. 3) with exorbitant prices for aspirin, hospital stays, OR use, etc. (Fig. 4) under the guise that it is needed to pay for uncompensated care which many not-for-profits fail to provide inadequate amounts of (Fig. 5).

Fig. 3
Fig. 3

Fig. 4
Fig. 4

Fig. 5
Fig. 5

And when Kaiser and United Healthcare use their massive market share to negotiate steep drug discounts, it is considered good free market business sense. So why is it bad if our single payer negotiates similar discounts for all of us?!

Please do not let the sticker price scare you. Healthcare is indeed expensive and our current system is unsustainable not to mention immoral and broken. Left as is, it is estimated to consume 20 percent of our GDP by 2025 while tens of millions remain uninsured nationally unless we really do something about it. With a GOP congress which places trickle down ideology above compassion, the health of nearly 1 out of 3 Californians who are on Medicaid remains under constant threat, not to mention the millions with pre-existing conditions, women, and our older folks. SB562 is truly the only way to proactively protect our health security by fixing our badly broken system while providing every Californian with true healthcare peace of mind. And at a price which is more than reasonable in the context of no more outrageous premiums, co-pays, or deductibles.

Some say we cannot afford it. It is clear that we can no longer afford not to.

Dr. Paul Y. Song is a national board member of Physicians for a National Health Program and co-chair of the Campaign for a Healthy California.

http://www.huffingtonpost.com…

House Democrats See ‘Medicare For All’ As The Answer To Trumpcare

Rep. John Conyers’ single-payer bill has never been this popular.

By Daniel Marans
HuffPost, May 24, 2017

House Democrats on Wednesday touted unprecedented majority support for a bill that would expand Medicare to the entire U.S. population, reflecting a growing liberal consensus behind single-payer health insurance.

Rep. John Conyers (D-Mich.), who has been introducing single-payer legislation since 2003, said at a press conference that Democrats must counter the Republican bill to repeal the Affordable Care Act with support for “Medicare for all.”

“Obviously we’re all united in opposition to Trumpcare. That’s easy,” he said. “People know what we’re against, but we want to promote more what we are for.”

The press conference was scheduled to take place hours before the nonpartisan Congressional Budget Office released its assessment of the updated version of the Obamacare repeal bill that the House of Representatives passed earlier this month.

Conyers was joined by Democratic Reps. Bonnie Watson Coleman (N.J.), Steve Cohen (Tenn.), Ro Khanna (Calif.), Jamie Raskin (Md.), Keith Ellison (Minn.) and Mark Pocan (Wis.), the newly elected co-chair of the Congressional Progressive Caucus.

Like many progressives, Conyers has long said that the problems bedeviling the American health care system are rooted in its reliance on private insurance.

“We will never get universal care built on a foundation of private, for-profit insurers,” he said. “The only way we will get there is the way every other advanced country on the planet has, through a universal system like expanded Medicare.”

Critics like Conyers argue that Obamacare is flawed because of too little, not too much, government intervention.

The reform law enlarged private insurance rolls by requiring anyone in the individual market above a certain income level to seek coverage in government-regulated private insurance exchanges ― and providing them subsidies to do so. Now the number of insurance options in these markets has begun to dwindle because for-profit companies find it too costly to cover new enrollees, who tend to be sicker than the general population.

There are a number of ways that the federal government could entice insurers to stay in the exchanges, such as reimbursing them for their highest-cost cases and improving how they enforce the individual insurance mandate. But if private insurers were not part of the equation, these triage measures would be unnecessary.

Progressive single-payer advocates say that these challenges, along with the unprecedented political threat to Obamacare from President Donald Trump and congressional Republicans, have created the right political moment to push their ideal into the party’s mainstream.

Sen. Bernie Sanders (I-Vt.), who turned “Medicare for all” into a progressive rallying cry with his insurgent presidential campaign, plans to introduce companion legislation to Conyers’ bill in the Senate this summer. His single-payer bills have not attracted any co-sponsors in the past.

The growing level of support for Conyers’ bill suggests this time might be different. The legislation, known as the Expanded and Improved Medicare for All Act, has 111 co-sponsors ― including Dels. Eleanor Holmes Norton of D.C. and Gregorio Sablan of the Northern Mariana Islands, who can’t vote on legislation on the House floor. Still, it is a solid majority of the 193-member House Democratic Caucus and the most support such legislation has ever received. The bill has even attracted support from some fiscally conservative members like Rep. Jim Cooper (D-Tenn.).

The previous high-water mark for Conyers’ bill was in 2008, when 93 of his colleagues got behind it. The Democratic caucus was much larger at the time, however, so the bill’s supporters constituted a smaller proportion. Last Congress, the bill attracted just 63 co-sponsors.

House Assistant Minority Leader James Clyburn (D-S.C.) and Democratic Caucus Chair Joseph Crowley (D-N.Y.), both members of leadership, have co-sponsored the bill.

Yet single-payer legislation would undoubtedly face a steep climb, even if Democrats took back the House in 2018. Currently, Medicare requires co-payments from seniors and people with disabilities above a certain income level.

House Minority Leader Nancy Pelosi (D-Calif.) said earlier this month that “the comfort level with a broader base of the American people is not there yet,” and encouraged activists to try to enact single-payer plans at the state level first.

In addition to extending Medicare coverage to the whole population, Conyers’ bill would improve on Medicare’s coverage levels by having the government pick up the entire tab for everything from preventive care visits to dental care.

To pay for this expansion, the law would increase personal income taxes by 5 percent for higher earners, institute a new tax on worker payroll, and levy new taxes on investment income and financial transactions.

But Conyers’ bill is also deliberately vague on some of the details. Aside from the income tax hike, the legislation does not specify the levels of all the new taxes, or the earnings thresholds where they would take effect. But a 2013 analysis of the bill by Gerald Friedman, an economist at the University of Massachusetts, Amherst, assumed that the new high-income surtax would increase taxes on households earning $225,000 or more by 6 percent, and the payroll tax would levy new 3 percent or 6 percent taxes on employers of all workers.

Ultimately, the taxes on workers and employers would be a net financial win for the country, saving Americans nearly $600 billion a year in lower health care costs, according to Friedman.

But when the reality of those upfront tax increases sets in for members of Congress, it could be a tough sell.

What’s more, several efforts to wring savings from private health care providers during the crafting of Obamacare collapsed as Democrats succumbed to industry pressure en masse. Since Conyers’ bill envisions that the government will use its bargaining power to bring costs into line with those of other countries, it could face similar resistance from providers.

State-level experiments with single-payer health insurance face similar if not greater challenges due to the size of their risk pool. Vermont tried to adopt a single-payer health insurance plan in lieu of Obamacare, but gave up when the costs of transitioning to the the new system proved too great.

Some progressive groups, including the National Nurses United, are now throwing their weight behind a serious effort to create a single-payer health insurance system in California. The plan could cost as much as $400 billion a year, according to a legislative analysis released Monday and conducted at the request of state lawmakers promoting the policy. Half of that amount would have to be raised through new taxes.

Challenges notwithstanding, progressive activists and Democratic lawmakers are tired of asking for less than what they really want and encountering unified Republican opposition anyway.

Even if it stands no chance of approval in the short-term, they say that a push to expand the popular Medicare program is a political winner that can help Democrats take back Congress.

At Wednesday’s press conference, Pocan observed that town hall discussions about implementing “Medicare for all” draw a more enthusiastic response than any other issue. He said the issue was widely praised at a town hall he recently held in in Kenosha, Wisconsin, which is in Republican House Speaker Paul Ryan’s district.

Indeed, 60 percent of Americans favor extending Medicare to the entire population, according to an Economist/YouGov poll from April.

Ellison, who is deputy chair of the Democratic National Committee, emphasized that no one in the DNC would tell lawmakers and candidates what position to take on a given issue ― but the power of suggestion is fair game.

“I recommend that you win your election, and I think a good way to do it is to support the Conyers bill,” he said.

http://www.huffingtonpost.com…

Townie right on AHCA provisions

By Thomas O’Rourke, Ph.D., M.P.H.
The (Champaign, Ill.) News-Gazette, May 23, 2017

Kudos to Ryan Jackson (the Reluctant Townie) for his recent excellent article. “Rodney Davis voted for your death panel” by supporting the American Health Care Act that barely passed the House, 217-213.

Let me add a few other points. Besides taking $880 billion out of Medicaid, it would take another $312 billion out of subsidies that help working families buy private coverage through the Affordable Care Act exchanges. Instead of helping people get care, this money would be diverted to give an $800 billion tax break to people with incomes over $200,000.

Davis’s vote threatens to strip coverage from 57,300 people in our district.

But it doesn’t end there. If the ACA is entirely or partially repealed, 413,700 individuals in the district with employer-sponsored sponsored health insurance are at risk of losing important consumer protections such as coverage of pre-existing conditions and the prohibition on annual and lifetime limits.

Also, 377,200 individuals in our district with health insurance covering preventive services like cancer screenings and flu shots without any copay, coinsurance or deductibles stand to lose their access if the Republican Congress eliminates ACA provisions requiring health insurers to cover important preventive services without cost-sharing.

Undeniably, the ACA is flawed. It left 28 million Americans uninsured and millions more with unaffordable premiums, deductibles and copayments.

But the GOP plan would make things much worse.

Instead of moving backward, we should move forward and go from the ACA to a Medicare for All plan like the one proposed by Rep. John Conyers (H.R. 676).

http://www.news-gazette.com…

U.S. Health Care is Profiteered to Death

Interview with Susan Rogers, M.D.
Black Agenda Report, May 23, 2017

The following is an unofficial, lightly edited transcript of an interview that Dr. Susan Rogers, PNHP national board member, gave to Glen Ford, executive editor of the Black Agenda Report, on May 23. You can listen to the interview above.

Glen Ford: Obamacare remains in a kind of limbo in the U.S. Congress, having been repealed in the House but with no action pending in the Senate. On the single-payer health care front, a majority of House Democrats have finally signed on to Congressman John Conyers’ Medicare for All bill. However, Democratic Party leaders have not gotten behind the measure. And Bernie Sanders has not introduced a single-payer bill in the Senate. In Chicago we spoke with Dr. Susan Rogers, a board member of Physicians for a National Health Program.

Dr. Susan Rogers: I think that it’s just politically difficult for a lot of these congressmen to take a stand for single payer, although, clearly, they cannot support the Republican bill that has been passed in the House. And even the Affordable Care Act: many people know that there are some significant issues with that. There are some positives in the ACA, of course: the fact that people can get coverage for preexisting conditions, that kids can stay on their parents policy till they’re 26. But the Affordable Care Act doesn’t eliminate the whole issue of private-insurance-sponsored health care, which is – that’s the biggest problem. That’s where all the high deductibles are coming from, the copays, the tiered drugs and all of the expenses that are being shifted onto patients. That, the Affordable Care Act does not fix.

GF: I was surprised to see even a Republican seem to admit that single payer’s time has come. That person was defending the Republican bill that would allow states to opt-out or opt-into plans, as this congressman mentioned, “so they could have their single payer or they could have our plan,” which seemed to be an admission that single payer is on the horizon anyway.

SR: That is true. I think a lot of people will say that. However, to have just a small segment of the population in a single-payer system won’t work. That’s been the problem with the public option: the people who would end up being in the public option are people who couldn’t get affordable insurance elsewhere. So here you end up with a pool of people who have a lot of medical issues at high cost. And that’s why that public option or small single-payer systems would not work. I mean, if you look at Medicare, it covers everybody over 65. We all know that’s a very heterogeneous group, in terms of some people who are very, very healthy, and some people who are high utilizers of health care. The pool works because you’ve diluted the risk: you have healthy people and sick people in the same large pool. And that’s the way a single-payer system would work. Everybody has to be in it.

GF: Single payer seems to work in every industrialized country in the world. But folks in the United States, Democrats as well as Republicans, act as if the U.S., the richest country in the world, can’t afford it.

SR: Well, we still have this assumption that health care is a commodity and that the markets dictate how it functions. Buying health care isn’t like buying a car. Everybody needs the same coverage and health care. Everybody doesn’t need the same kind of car. Everybody doesn’t need the same kind of house. So that’s where the market comes in, it’s when people have choices with things. But people talk about choice of health care, which really, when you think about it, makes no sense. Do you know what your health care needs are going to be next week? You have no clue. You assume they’re going to be what they are today, but you don’t know. That’s the whole point of insurance, is to cover you for the unexpected. So to make buying health insurance a matter of choosing what’s best for you – the whole basis of that argument is false. It’s not applicable, because you don’t know what you’re going to need. So you have to be covered for everything. And that’s why people who buy private insurance often end up being exposed to the phenomenal bills, these high deductibles these co-pays, that send them into bankruptcy.

GF: And the net result is that the United States pays more per capita for health care than anybody else in the world – without assuring insurance for everybody

SR: Yes we do. And an interesting part of that number, too, is that the majority of those dollars are already government dollars. So the government is already paying the majority of that per capita expense. Not just Medicaid, not just Medicare, but in terms of the premiums for government employees – all teachers, all policemen, all firemen. All these people get their health premiums paid for in large part with government dollars. And then when you look at the tax write-off by employers for what they spend on employees’ premiums – that’s an additional cost to the government. So the government is already spending more than other countries, and that’s without the additional cost of the costs they’re putting on patients so they have so-called skin in the game. So the government is already paying more than everybody else, so the whole idea that there isn’t money is not true. We would save so much money by eliminating all the administrative costs. It’s ridiculous the amount of time and money that gets spent in administering a system like this that is so complex and so tedious. It’s difficult even for me as a physician who had some medical issues this last year. I found it difficult to navigate the system. So I can’t even imagine how someone who does not understand health care can figure a way through it. It’s impossible.

GF: So it’s not a question of expense which is already exorbitant, but who gets paid and who profits.

SR: That is exactly true. And the ones who are going to get paid are the health insurance companies. There’s no question about that. And if you look at a large hospital, I bet they’ve got more billing clerks than they do nurses per patient. That just tells you where the money is going. It’s not going to health care, it’s going to billing. And if you look at the electronic medical record, which was supposed to be developed to make health care better – so that if you go to a hospital in New York and then see somebody in California, the two doctors should be able to talk, but they often can’t or don’t. The drive for electronic health records, EHRs, was really driven by billing. It was not driven by the need to improve health care or clinical care. It was driven by a way to bill, and that’s the whole concept. So it really isn’t helping health care. It may be a little bit because we can read the notes now of physicians with poor penmanship, but it’s not lowering medical costs. In fact it’s driving costs up.

GF: As a physician, as a person as an activist medical person, what would you like to see happen to get the Congress off the dime on single payer?

SR: I would like to see Congress get educated about this. I have talked with many people who have gone to town hall meetings and had firsthand discussions with representatives across the country. I can speak mostly to people I know who have done so in Illinois. One thing that’s clear. They talk about is just how the congresspeople are so – they don’t know what the system is. They’re actually ignorant about the problems. I hate to use that word because it’s a strong word, but some of the comments that have been made, like “Nobody has died because they didn’t have access.” I mean, where does this person live? What bubble are they living in? And that’s part of the problem – these congressmen are living in bubbles and have no idea of what everyday people go through just to get their health care needs met. And then there is this other assumption too, that the biggest driver of costs in health care are the unhealthy lifestyles of people. That may be true in the sense that some behaviors do lead to more cardiovascular disease, for example, but we have to remember we are all mortal. We are all going to get sick whether we lead a perfectly healthy lifestyle or not. So we all are going to need health care.

GF: That’s right. Almost all of us will die of disease at some point.

SR: Exactly. And even if we die of trauma, there’s still health care in that issue. So the whole idea that staying healthy will prevent you from using health care dollars is a falsehood, because we will all eventually need health care. I know very healthy people who have gotten cancer. I know very healthy people who have gotten heart disease. I know very healthy people who unfortunately lived in an area with bad air and ended up with lung disease. So it’s not just because of poor lifestyles, because obesity is a big problem. Clearly that’s a factor. I’m not denying that. But that’s not what’s necessarily driving up health care costs.

GF: That sounds like the ever-present factor of prejudice in American political thought.

SR: Well, yes, if you look at the health care industry lobby, it’s a huge lobby that has poured billions and billions into congressional races and stuff. And so that’s who people are beholden to. And unfortunately it’s been clearly shown that the congressmen are voting for their donors, not for their constituents.

GF: That was Dr. Susan Rogers of Physicians for a National Health Program.

https://soundcloud.com…

Would California’s proposed single payer system bankrupt businesses?

California Senate Committee on Appropriations: SB 562 (Lara) – The Healthy California Act

By Brendan McCarthy (Consultant)
May 22, 2017

Bill Summary: SB 562 would create a universal, single-payer health care system in California.

Fiscal Impact: The fiscal estimates below are subject to enormous uncertainty. Completely rebuilding the California health care system from a multi-payer system into a single payer, fee-for-service system would be an unprecedented change in a large health care market.

The projected costs and revenue needs for the proposed Program are as follows. For a discussion of the underlying assumptions, see Staff Comments (link below).

* Total annual costs of about $400 billion per year, including all covered health care services and administrative costs, at full enrollment.

* Existing federal, state, and local funding of about $200 billion could be available to offset a portion of the total program cost.

* About $200 billion in additional tax revenues would be needed to pay for the remainder of the total program cost. Assuming this tax was raised through a new payroll tax (with no cap on the wages subject to the tax), the additional payroll tax rate would be about 15% of earned income.

It is important to note that the overall cost of those new tax revenues would be offset to a large degree by reduced spending on health care coverage by employers and employees. Although precise estimates of total spending for employer sponsored health insurance are not available, the best available information indicates that existing spending is between $50 and $100 billion per year. Therefore, total new spending required under the bill would be between $50 and $100 billion per year.

Administrative cost savings would be real, but limited

Under a single payer system, the overall administrative cost of the system would likely be lower than it is in the current multi-payer system. In the United States, the cost of the health insurance industry is about 7% of total costs. In addition, providers, such as hospitals and physicians, incur significant administrative costs to negotiate contracts and comply with health insurer billing requirements. If we assume that the costs on the provider side are equal to the costs of the insurance industry, then current administrative costs are likely to be about 15% of total spending. Administrative costs in the Medi-Cal fee-for-service system and Medicare are about 6% of spending. Assuming that dealing with a single payer system reduced provider administrative costs by half, total administrative costs of the system in the bill would likely be about 9-10% of total spending. This does represent a significant savings in a $400 billion health care system. However, administrative savings are not likely to substantially lower the overall cost of providing health care to the state, compared to costs associated with expanding coverage to the uninsured and increased utilization of services under the bill.

https://ww2.kqed.org…

***

Comment:

By Don McCanne, M.D.

With the release of this fiscal analysis of SB 562 – The Healthy California Act – the expected loud protests to the high costs of a single payer system have been forthcoming, especially that the costs would exceed the California state budget and that raising the additional funds required through a 15% payroll tax would bankrupt businesses. The opponents conveniently ignore the opening caution that “the fiscal estimates below are subject to enormous uncertainty.”

In fact, this 8 page analysis is loaded with assumptions and uncertainties based on the lack of detail specified in the proposed legislation, as the author indicates. Health care is almost one-fifth of our gross domestic product, and, by any accounting, that is very expensive. But this does not change fundamental single payer principles. All of the health care funds are moved into a single, publicly-administered system which is administered much more efficiently and which is funded on an equitable basis (which requires progressive taxes because of the decades-long shift of income and wealth to the top).

The opponents have already declared that this legislation is a failure based on the high global costs and the assumption that a payroll tax would replace current private spending. Reading the full report would provide a more objective perspective, in spite of the multitude of uncertainties.

At any rate, those who dismiss this legislation based on spending greater than the California state budget and a 15% payroll tax must be challenged. Our response? This bill would provide each Californian with all essential health care services at a price that each can afford.