PNHP

Lack of Health Insurance is Deadly: Annals of Internal Medicine

Lack of Health Insurance is Deadly: Annals of Internal Medicine

New comprehensive review finds that recent studies strengthen conclusions of landmark 2002 National Academy of Medicine report implicating uninsurance in thousands of deaths.

FOR IMMEDIATE RELEASE, June 26, 2017

Contact: Clare Fauke, PNHP communications specialist, 312-782-6006, clare@pnhp.org

Being uninsured substantially raises the risk of dying, according to a comprehensive review of studies published today in the Annals of Internal Medicine. The review updated a 2002 study conducted by the Institute of Medicine (IOM – now called the National Academy of Medicine) that concluded that 18,000 persons died each year from lack of health insurance.

The authors carried out an intensive search for all research examining whether health insurance coverage affects overall mortality among adults age 18-64. They found that multiple studies published since the completion of the IOM study have confirmed that insurance lowers mortality. They cite consistent findings from a randomized trial carried out in Oregon, as well as multiple quasi-experimental and observational studies. The studies indicate that insurance decreases the odds of dying among adults by at least 3% and as much as 29%.

The authors conclude that health insurance prevents deaths at least in part by improving the diagnosis and treatment of high blood pressure. The review cites results from several studies, including randomized trials, showing that uninsured and under-insured Americans are less likely to have their hypertension diagnosed; that insurance leads to lower and safer blood pressure levels; and that eliminating financial barriers to hypertension care dramatically decreases all-cause mortality. Studies have also shown that lack of coverage increases death rates in many other conditions, including breast cancer and major trauma.

Dr. Steffie Woolhandler, lead author of the article who is an internist in the South Bronx, Distinguished Professor of Public Health at the City University of New York at Hunter College (CUNY) and lecturer in medicine at Harvard noted: “In order to justify policies that strip coverage from millions, Republicans like Sen. Ted Cruz and Rep. Raúl Labrador claim that health insurance doesn’t save lives. But overwhelming scientific evidence says they’re wrong. Thousands of people are already dying each year because the Affordable Care Act (ACA) has left 28 million uninsured. The Republican health reform bills would increase that death toll.”

Study co-author Dr. David Himmelstein commented: “According to the CBO, the Senate Republicans’ plan would strip coverage from 22 million Americans. The best estimate based on scientific studies is that about 29,000 Americans would die each year as a result. We need to move forward from the ACA to a single payer reform that would cover all Americans, not backwards through repeal.” Dr. Himmelstein, like Dr. Woolhandler, is an internist, Distinguished Professor at CUNY and lecturer at Harvard.

*****

“The Relationship of Health Insurance and Mortality: Is Lack of Insurance Deadly?” by Steffie Woolhandler, M.D., M.P.H. and David U. Himmelstein, M.D. Annals of Internal Medicine. Published online, June 26, 2017. The Annals of Internal Medicine is the official journal of the American College of Physicians.

Disclosures: Drs. Woolhandler and Himmelstein co-founded Physicians for a National Health Program (www.pnhp.org), a nonprofit educational and research organization that supports a single-payer national health plan; they also served as advisers to Sen. Bernie Sanders’ presidential campaign. Neither the Sanders campaign nor PNHP played any role in funding or otherwise supporting the commentary. They tweet @shadowingTrump.

Blending Research & Advocacy

Interview With Dr. David Himmelstein

Review of Systems Podcast, July 11, 2017

EXCERPT (full interview above):

REVIEW OF SYSTEMS: For me, one of the appeals of a single-payer system is a better opportunity for cost control and reducing administrative waste. But at the same time, when you do that, it feels like one man’s waste may be another man’s job, and there may be a reduction in physician salaries [as well]. How do you account for these types of trade-offs? Does a single-payer system result in lost administrative jobs?

DAVID HIMMELSTEIN, M.D.: Well, I hope it does and I think it does, and we would need to make plans for re-training, and re-placing in new jobs, the roughly million people who are doing useless work.

In legislation that we’ve worked on helping to draw up, and in in proposals for reform that we’ve made, we’ve always included a provision that says we need to set aside several tens of billions of dollars to help transition those people to new jobs.

Now, most of the people who are going to be displaced are relatively low-wage clerical [workers] and they could be readily re-trained for the expanded workforce that we need to deliver more care in our society.

Our long-term care is terribly understaffed. Our nursing homes are hugely understaffed. We’re not doing the smoking prevention programs or hypertension or cholesterol screening that we ought to do. But we shouldn’t be employing people to do useless things in our health care system.

You know, the automobile put horseshoe makers out of work, and there had to be a transition there, but we didn’t say, “We can’t move forward into a new age because people who make horseshoes might lose their jobs.” Similarly, with health care, I think we need to use the resources we have in a rational way.

Now, there are some people who are not going to be able to find comparable jobs. The CEO of Aetna, for several years, was making $225,000 a day. We’re not going to be able to find him a comparable job, but luckily those folks have saved up enough that they probably don’t need to work anymore.

[Regarding physician pay], in countries that have implemented national health insurance, like Canada, doctors’ incomes don’t go down. They may equalize a little bit – the plastic surgeons may make a little less – but on average, doctors’ incomes in Canada have actually gone up faster than wages in the society as a whole.

But the doctors haven’t just benefited from having good incomes, they’ve benefited because their work lives are better. They don’t spend their lives filling out billing forms and checking boxes that have no use other than to support billing.

I think the vast majority of doctors would be much happier, not just financially but in everyday life, under a national health insurance system.

http://rospod.org…

Blending Research & Advocacy

Interview With Dr. David Himmelstein

Review of Systems Podcast, July 11, 2017

EXCERPT (full interview above):

REVIEW OF SYSTEMS: For me, one of the appeals of a single-payer system is a better opportunity for cost control and reducing administrative waste. But at the same time, when you do that, it feels like one man’s waste may be another man’s job, and there may be a reduction in physician salaries [as well]. How do you account for these types of trade-offs? Does a single-payer system result in lost administrative jobs?

DAVID HIMMELSTEIN, M.D.: Well, I hope it does and I think it does, and we would need to make plans for re-training, and re-placing in new jobs, the roughly million people who are doing useless work.

In legislation that we’ve worked on helping to draw up, and in in proposals for reform that we’ve made, we’ve always included a provision that says we need to set aside several tens of billions of dollars to help transition those people to new jobs.

Now, most of the people who are going to be displaced are relatively low-wage clerical [workers] and they could be readily re-trained for the expanded workforce that we need to deliver more care in our society.

Our long-term care is terribly understaffed. Our nursing homes are hugely understaffed. We’re not doing the smoking prevention programs or hypertension or cholesterol screening that we ought to do. But we shouldn’t be employing people to do useless things in our health care system.

You know, the automobile put horseshoe makers out of work, and there had to be a transition there, but we didn’t say, “We can’t move forward into a new age because people who make horseshoes might lose their jobs.” Similarly, with health care, I think we need to use the resources we have in a rational way.

Now, there are some people who are not going to be able to find comparable jobs. The CEO of Aetna, for several years, was making $225,000 a day. We’re not going to be able to find him a comparable job, but luckily those folks have saved up enough that they probably don’t need to work anymore.

[Regarding physician pay], in countries that have implemented national health insurance, like Canada, doctors’ incomes don’t go down. They may equalize a little bit – the plastic surgeons may make a little less – but on average, doctors’ incomes in Canada have actually gone up faster than wages in the society as a whole.

But the doctors haven’t just benefited from having good incomes, they’ve benefited because their work lives are better. They don’t spend their lives filling out billing forms and checking boxes that have no use other than to support billing.

I think the vast majority of doctors would be much happier, not just financially but in everyday life, under a national health insurance system.

http://rospod.org…

An Independence Day call for universal health care

By Ivan J. Miller
Daily Camera (Boulder, Co.), July 11, 2017

On July 4, 1776, our Founding Fathers bravely declared independence, and established bold new governing principles:

We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty, and the pursuit of Happiness. –That to secure these rights, Governments are instituted among Men.

Our founders feared and disliked government. They were oppressed by the British monarchy. Many were refugees, people who fled religious persecution at the hands of government. Government colluded with corporate monopolies to take advantage of the colonists. When Parliament gave the East India Company a tax advantage resulting in monopoly control of tea sales in America, the colonists had finally had enough, and protested by throwing East India Company tea into the water at the infamous Boston Tea Party.

In “Common Sense,” Thomas Paine summed up the colonists’ view of government: “Government is at best a necessary evil.”

Although the colonists feared and distrusted government, when they came together in 1787 to write the Constitution, they agreed that:

“We the People of the United States, in Order to form a more perfect Union, establish Justice, ensure domestic Tranquility, provide for the common defence, promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity, do ordain and establish this Constitution for the United States of America.”

To have liberty and freedom, a person must have physical safety and the means to stay alive. In many areas, the government provides this safety best. To effect “safety and happiness” and “secure the blessings of liberty to ourselves and our posterity,” a government should provide police protection, fire fighters, a national defense, and safe drinking water. In 2017, financing health care is every bit as important as these other essential government protections.

Arguments that hold health care to be a personal responsibility only, or just another commodity, do not fit with reality. No one can take personal responsibility for their own health care when they first need it. With few exceptions, we enter this world through the medical system. Most, but not all, of us were fortunate enough to have mothers who received prenatal care. Some of us are born with complications or genetic birth conditions, and we all come with some genes that may cause medical problems later in life. None of us came with the ability to choose parents who would have good genes or medical coverage.

The high cost of health care in the United States puts the protection of life and safety out of reach for many. Hardworking Americans often cannot afford health care that is a matter of life or death. The financial strain of obtaining health care deprives many of the ability to enjoy liberty or freedom.

The health care system we have today, controlled by the health insurance industry, does not do enough to provide safety or protect life. It is universally criticized for being too expensive, too complicated, and leaving too many people out.

There is another way. The government can build on a system that is simpler, less expensive, and can cover everyone, using a foundation that is already in place: Medicare. Although it could use some improvement, Medicare works well; most people celebrate when they reach age 65 and know they’re covered.

All other advanced, industrialized countries protect citizens’ lives by financing health care just as they do police and fire protection. The cost is usually less than half of what the U.S. spends.

It is time to stand up against the profiteering corporations that dominate health care. They spend billions donating to the politicians that collude with them.

Let’s throw them overboard!

Let’s come together, as our Founders did, and demand the best possible, expanded and improved, Medicare for All.

Ivan J. Miller is executive director of the Colorado Foundation for Universal Health Care. He lives in Boulder.

http://www.dailycamera.com…

Patients in poor health leave Medicare Advantage plans

Medicare Advantage; CMS Should Use Data on Disenrollment and Beneficiary Health Status to Strengthen Oversight

United States Government Accountability Office (GAO), April 2017

If MAOs (Medicare Advantage Organizations) are meeting the needs of all their beneficiaries, we would expect that the rates at which beneficiaries disenroll would not vary by their health status. However, when beneficiaries in poor health are more likely to disenroll than those in better health—which we refer to as health-biased disenrollment—it may indicate that those beneficiaries could be facing problems with access to care or the quality of services provided. From an oversight perspective, contracts with health-biased disenrollment may not warrant extra CMS scrutiny if relatively few beneficiaries choose to leave the contract. However, contracts with both high overall rates of disenrollment and health-biased disenrollment may indicate potentially problematic contracts.

Conclusions

CMS is responsible for ensuring that all MA contracts offer care that meets applicable standards, regardless of beneficiary health status. However, as part of its routine oversight, CMS does not examine disenrollment rates by health status. Our analysis identified 35 contracts in 2014 where MA beneficiaries in poor health were more likely to disenroll than those in better health. These contracts with health-biased disenrollment had quality scores that were consistently and substantially below the scores of contracts without health-biased disenrollment. In addition, survey data indicate that beneficiaries who left these contracts reported problems with coverage of preferred doctors and hospitals as well as problems getting access to care as leading reasons they chose to leave their contracts. This type of information on disenrollment and beneficiary health status is available to CMS; however, by not leveraging it as part of its routine oversight of MA contracts, CMS is missing an opportunity to better target its oversight activities toward MA contracts that may not be adequately meeting the health care needs of all beneficiaries, particularly those in poor health.

https://www.gao.gov…

***

Comment:

By Don McCanne, M.D.

This GAO analysis shows that individuals enrolled in the private Medicare Advantage plans who were in poor health disenrolled at higher rates than those who were in better health. Reasons given included problems with coverage of their preferred doctors and hospitals (narrow networks) and problems getting access to care.

We know that private Medicare Advantage insurers game the system by selectively marketing to healthier patients and by upcoding to obtain higher risk adjustment payments. Although not discussed in this report, the exodus of patients in poor health could well represent intentional delivery of inferior services in an effort to encourage higher cost patients to leave.

This analysis also showed that healthier patients who left plans did so because of the cost of care, frequently switching to plans with lower costs.

This is how markets work. Healthy patients shop lower prices whereas patients with health care needs leave plans because of poor service. Is that really the way we want our health care system to work? Or would we prefer a system with greater choice in our health care professionals and institutions that strive more to bring us the health care that we truly need? A well designed single payer system would bring us the latter.

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

Patients in poor health leave Medicare Advantage plans

Medicare Advantage; CMS Should Use Data on Disenrollment and Beneficiary Health Status to Strengthen Oversight

United States Government Accountability Office (GAO), April 2017

If MAOs (Medicare Advantage Organizations) are meeting the needs of all their beneficiaries, we would expect that the rates at which beneficiaries disenroll would not vary by their health status. However, when beneficiaries in poor health are more likely to disenroll than those in better health—which we refer to as health-biased disenrollment—it may indicate that those beneficiaries could be facing problems with access to care or the quality of services provided. From an oversight perspective, contracts with health-biased disenrollment may not warrant extra CMS scrutiny if relatively few beneficiaries choose to leave the contract. However, contracts with both high overall rates of disenrollment and health-biased disenrollment may indicate potentially problematic contracts.

Conclusions

CMS is responsible for ensuring that all MA contracts offer care that meets applicable standards, regardless of beneficiary health status. However, as part of its routine oversight, CMS does not examine disenrollment rates by health status. Our analysis identified 35 contracts in 2014 where MA beneficiaries in poor health were more likely to disenroll than those in better health. These contracts with health-biased disenrollment had quality scores that were consistently and substantially below the scores of contracts without health-biased disenrollment. In addition, survey data indicate that beneficiaries who left these contracts reported problems with coverage of preferred doctors and hospitals as well as problems getting access to care as leading reasons they chose to leave their contracts. This type of information on disenrollment and beneficiary health status is available to CMS; however, by not leveraging it as part of its routine oversight of MA contracts, CMS is missing an opportunity to better target its oversight activities toward MA contracts that may not be adequately meeting the health care needs of all beneficiaries, particularly those in poor health.

https://www.gao.gov…

***

Comment:

By Don McCanne, M.D.

This GAO analysis shows that individuals enrolled in the private Medicare Advantage plans who were in poor health disenrolled at higher rates than those who were in better health. Reasons given included problems with coverage of their preferred doctors and hospitals (narrow networks) and problems getting access to care.

We know that private Medicare Advantage insurers game the system by selectively marketing to healthier patients and by upcoding to obtain higher risk adjustment payments. Although not discussed in this report, the exodus of patients in poor health could well represent intentional delivery of inferior services in an effort to encourage higher cost patients to leave.

This analysis also showed that healthier patients who left plans did so because of the cost of care, frequently switching to plans with lower costs.

This is how markets work. Healthy patients shop lower prices whereas patients with health care needs leave plans because of poor service. Is that really the way we want our health care system to work? Or would we prefer a system with greater choice in our health care professionals and institutions that strive more to bring us the health care that we truly need? A well designed single payer system would bring us the latter.

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

Dr. Margaret Flowers on ‘Washington Journal’

PNHP board adviser Dr. Margaret Flowers appeared on the C-SPAN program “Washington Journal” on July 10, 2017, to discuss the feasibility of single-payer reform in the U.S. She was joined by Michael Tanner of the Cato Institute, and presented the case for improved Medicare for all, including comprehensive coverage and greater efficiency.

Private Medicare Advantage plans associated with greater racial disparity

Medicare Advantage Associated With More Racial Disparity Than Traditional Medicare For Hospital Readmissions

By Yue Li, Xi Cen, Xueya Cai, Caroline P. Thirukumaran, Jie Zhou and Laurent G. Glance
Health Affairs, July 2017

Abstract

We compared racial disparities in thirty-day readmissions between traditional Medicare and Medicare Advantage beneficiaries who underwent one of six major surgeries in New York State in 2013. We found that Medicare Advantage was associated with greater racial disparity, compared to traditional Medicare. After controlling for patient, hospital, and geographic characteristics in a propensity score based approach, we found that in traditional Medicare, black patients were 33 percent more likely than white patients to be readmitted, whereas in Medicare Advantage, black patients were 64 percent more likely than white patients to be readmitted. Our findings suggest that the risk-reduction strategies adopted by Medicare Advantage plans have not been successful in lowering the markedly higher rate of readmission among black patients, compared to white patients.

http://content.healthaffairs.org…

***

Comment:

By Don McCanne, M.D.

There are many reasons for racial disparities in health care, and they are all bad, but some are worse than others.

In this study hospital readmissions within thirty days of undergoing any one of six major surgeries were greater in black Medicare patients than in white patients. However, the disparities were much higher in privately insured Medicare Advantage patients than they were in patients enrolled in the traditional Medicare program. Efforts must be directed to identifying and correcting the reasons for these disparities in all Medicare patients, but special attention should be given to those in the private Medicare Advantage plans, especially considering the greater prevalence of the problem.

Taxpayers are paying more for patient care in the private Medicare Advantage plans than they are for patients in the traditional Medicare program. The private insurance industry claims that they are providing greater value for that spending through higher quality care that is better coordinated, including better post-discharge followup care. However, this study shows that black patients are receiving worse followup care, resulting in higher readmission rates.

This particular disparity in care seems to be one of the worst since it combines the problematic background of disparities in care with the somewhat nefarious managed care techniques of the private insurance industry that are based more on greater profits (greed) than on their professed higher quality care. The private insurers are providing lower quality care at a higher cost – the exact opposite of what they claim.

The authors of this report conclude, “Further research is needed to understand whether newer health care delivery models, such as accountable care organizations, will help narrow the gap in readmission outcomes between black and white patients.” No. With this and a multitude of other studies, we have enough data already to warrant dismissing the private Medicare Advantage plans. Instead, we need to fix the traditional Medicare program, converting it into a model that would be ideal to expand to include everyone. That fix certainly should include addressing all of the reasons for racial disparities in care.

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

Three Doctors on What Works and Doesn’t Work in U.S. Health Care

By Scott Simon
NPR Weekend Edition, July 8, 2017

Doctors Julie Gunter, Rob Stone and Gary Sobelson talk with Scott Simon about the problems with American health care and what they think of the current Republican health care plan.

TRANSCRIPT

SCOTT SIMON, HOST: The United States spends about $9,000 per person per year on health care, the highest in the world. But our life expectancy is still lower than France, Switzerland, Japan, the United Kingdom, all of which spend less. With the Republican health care bill still on the Senate docket, we thought it would be a good time to hear from U.S. doctors. We have three with us now, Dr. Julie Gunther, a family doctor in Idaho, Rob Stone, an ER turned palliative care doctor in Indiana, and Dr. Gary Sobelson, a primary care doctor in New Hampshire. Thanks so much for being with us.

GARY SOBELSON: Thank you.

ROB STONE: Thank you.

JULIE GUNTHER: Thank you.

SIMON: Let me begin, if we can, with you, Dr. Gary Sobelson there in New Hampshire. Seven years since the Affordable Care Act – three since most of the changes went into effect. How is health care different? Is it better, worse?

SOBELSON: Much better coverage for our patients, particularly, in my case as a family doctor, for the working poor. I have people coming in for preventive services, for hypertension management, for cardiovascular disease prevention, for cancer screening who really had not been coming in except for the most acute needs. And that’s been meaningfully different.

SIMON: Dr. Rob Stone in Indiana, you were an ER doctor. You must have seen patients who who came to the ER because they didn’t have insurance to cover primary care visits. Has that changed under the Affordable Care Act for you?

STONE: It’s changed very noticeably. And a far smaller percentage of people are coming in uninsured, although we still continue to take care of those folks, too. Our hospital’s also affiliated with some very small-town hospitals in Bedford, Ind., Paoli, Ind. And in those areas in particular, I think the Medicaid expansion part of the Affordable Care Act has helped to solidify the financial standing of those hospitals, which was somewhat questionable earlier.

So I would say that’s all good. The downside – and this started before the Affordable Care Act – before Obamacare – is that co-pays and deductibles and premiums keep going up for the people who aren’t on Medicaid. And so people coming into the ER find themselves underinsured too often when they realize they can’t afford their co-pays or their deductibles.

SIMON: Dr. Julie Gunther, you’re a family doctor in Idaho. And I gather you’ve kind of opted out of the typical model and you have your own direct primary care practice.

GUNTHER: Yes, I have. I was a system-employed outpatient physician until 2014. And then I left and started a solo, independent, cash-based practice. So I no longer bill insurance.

SIMON: And why did you take that step?

GUNTHER: The simple answer is I had to leave the system to save myself to be the doctor I wanted to be. It’s valuable for me to hear Dr. Sobelson and Dr. Stone’s experiences. My experience was very, very different. Even before the Affordable Care Act – but especially after – the progressive amount of regulations made it almost impossible for me to serve people the way I was originally called to serve them as an outpatient family doctor.

And so I have built a rather successful cash-based practice that charges very, very little per month. The majority of my patients are either uninsured, underinsured or so frustrated with the current system and its barriers that they would rather pay a small amount out of pocket every month for more direct care.

SIMON: Well – and so I’m going to bring Dr. Rob Stone into this conversation because I’ve been told you’re an advocate for a single-payer system. Is Dr. Gunther onto something?

STONE: Well, I don’t know how generalizable it is widely – and particularly not to very poor areas like the inner city. But my feeling is that we have a good model for how to take care of everybody, which some people still think is kind of a pie-in-the-sky dream. But I’m still going to push for it. And I think that is expanding Medicare, which already takes care of everybody over 65. And I happened to turn 65 a couple months ago. And I’m on Medicare now. And I’m pretty happy with that.

SIMON: Dr. Gary Sobelson, are the high costs of health care unavoidable? Can’t we, after all, just do more for people – a lot more – than we could even 10 and 20 years ago?

SOBELSON: While there are many things that we can do, the high costs are things that the system itself brings about. We’ve designed a system that rewards high-reimbursement procedures, surgeries and undervalues the things that are cost-effective. And it doesn’t really matter how much we research this or prove this to ourselves within our profession. We don’t seem to move in that direction. We don’t have the political will.

Dr. Stone’s comments about Medicare for all are not isolated to small groups of the population. We’ve studied this in New Hampshire, and over 80 percent of our primary care physicians are in favor of a system that some would call single-payer – and the majority of our overall doctors, even including specialists. And that’s been replicated across the country, too. We as Americans seem to value our independent decision-making over collective wisdom, though I would argue that when simple procedures like common arthroscopic knee surgery, something that takes 15 to 30 minutes, is costing $15,000 to $25,000 in community hospitals around our country – that no one has the freedom to make that decision.

GUNTHER: I was just going to say I normally talk about a single payer system. And we use Medicare as a model. My patients who have Medicare say that it works. My mother and father who are economically well off pay $150 a month towards their health care. My Americans who are age 30 to 60 are dropping their health care plans. And they come in, and they tell me, I can choose between putting food on the table, paying for my kid to go to college or getting a health plan that I can’t afford.

So it’s not that I oppose a broader solution. But I would contend we have a system that is completely crumbling and unsustainable. And in my opinion and experience, I don’t think Medicare is working all that well, especially not in a way that we could roll it out to our whole country in any sort of sustainable way. And the heart of it in my opinion is we talk a lot about who’s going to pay for health care. But what we should be talking about is the price of health care.

SIMON: Do we have an unrealistic expectation that health care costs can be reduced when we expect health care to do more and more?

GUNTHER: I think there’s great examples that current health care prices are upwards of a thousand times more than anywhere close to true cost. My patients can get a CAT scan – cash price for $300. If they go into the local ER, it’ll bill out at $2,400. So I think we need to start asking why. Because we keep talking about who should pay or how we should pay for health care.

But if we allow free market forces and competition to create price transparency, then we start to have the opportunity for price control, cost control. And then I think we can completely change the dialogue from who should pay and how should we pay too to what parts of health care do people need help paying for.

SOBELSON: I think Dr. Gunther is describing the problems that we’ve created by more or less – and this is a failing of the ACA – allowing corporate profitability to be the driving force of how we set these so. So, again, if you’re not under Medicare or Medicaid in this country, you’re depending on a private insurance industry to somehow control costs, when, in fact, it’s not really in their interest. They don’t have skin in the game here.

They make their profitability based on how much they collect in revenue. And, in fact, it’s written into the law. So, again, it’s not surprising that we’ve created a model where, in fact, more spending will be encouraged, not discouraged because the only people who really would care about it would be the consumers. And they don’t seem to believe that they can control it.

SIMON: Let me ask this finally, if I could. The Senate bill that’s under consideration right now may or may not be going anywhere. Could each of you give us one idea that you would like to see the government adopt that could improve health care in this country? – or not just the government. What can we do?

STONE: Well, I would say first that the Senate bill is a terrible thing that would set us back and would cost lives. And the people who would be hurt the worst would be children, the disabled and the elderly and nursing homes because of the ravages to Medicaid. So the first thing I would do would be, say, save Medicaid and continue to expand it. And then the second biggest problem in the Senate bill is that it would make health care very expensive for people ages 50 to 65 or 55 to 65 – would be to think about lowering the age of Medicare eligibility to, say, 55 and not cut those people out into the cold.

SIMON: That’s Dr. Rob Stone in Indiana. Dr. Julie Gunther, what would you suggest?

GUNTHER: I would agree with Dr. Stone. I don’t think the Senate bill provides the improvements to the Affordable Care Act or some of our biggest health care problems that we need. If I had one ask it would be that we allow consumers – we allow patients who do have health savings accounts to use those health savings dollars to pay their physician, whether it’s a periodic fee or a direct payment.

And one of my favorite quotes about health care in our country is that we continue to tape wings on a car and call it an airplane. I think we have to radically transform the system at its core if we hope to end up in a different place.

SIMON: And Dr. Gary Sobelson.

SOBELSON: Yeah. From my perspective in New Hampshire, I think the damages to Medicaid that the Senate bill would bring about would be devastating to us and take back so much positive progress we’ve had in terms of access and cost containment.

And if I had to add one thing to it, I think Dr. Stone’s idea of expanding Medicare to populations that traditionally have a hard time buying insurance could be extended into the whole idea of the ability of a public option, the ability of the Medicare and Medicaid programs to work out ways to compete with private insurers so that the public could become more comfortable with them.

SIMON: Doctors Rob Stone, Julie Gunther and Gary Sobelson, thanks so much for joining us.

GUNTHER: Thank you.

STONE: Thank you.

SOBELSON: Thank you.

http://www.npr.org…

Three Doctors on What Works and Doesn’t Work in U.S. Health Care

By Scott Simon
NPR Weekend Edition, July 8, 2017

Doctors Julie Gunter, Rob Stone and Gary Sobelson talk with Scott Simon about the problems with American health care and what they think of the current Republican health care plan.

TRANSCRIPT

SCOTT SIMON, HOST: The United States spends about $9,000 per person per year on health care, the highest in the world. But our life expectancy is still lower than France, Switzerland, Japan, the United Kingdom, all of which spend less. With the Republican health care bill still on the Senate docket, we thought it would be a good time to hear from U.S. doctors. We have three with us now, Dr. Julie Gunther, a family doctor in Idaho, Rob Stone, an ER turned palliative care doctor in Indiana, and Dr. Gary Sobelson, a primary care doctor in New Hampshire. Thanks so much for being with us.

GARY SOBELSON: Thank you.

ROB STONE: Thank you.

JULIE GUNTHER: Thank you.

SIMON: Let me begin, if we can, with you, Dr. Gary Sobelson there in New Hampshire. Seven years since the Affordable Care Act – three since most of the changes went into effect. How is health care different? Is it better, worse?

SOBELSON: Much better coverage for our patients, particularly, in my case as a family doctor, for the working poor. I have people coming in for preventive services, for hypertension management, for cardiovascular disease prevention, for cancer screening who really had not been coming in except for the most acute needs. And that’s been meaningfully different.

SIMON: Dr. Rob Stone in Indiana, you were an ER doctor. You must have seen patients who who came to the ER because they didn’t have insurance to cover primary care visits. Has that changed under the Affordable Care Act for you?

STONE: It’s changed very noticeably. And a far smaller percentage of people are coming in uninsured, although we still continue to take care of those folks, too. Our hospital’s also affiliated with some very small-town hospitals in Bedford, Ind., Paoli, Ind. And in those areas in particular, I think the Medicaid expansion part of the Affordable Care Act has helped to solidify the financial standing of those hospitals, which was somewhat questionable earlier.

So I would say that’s all good. The downside – and this started before the Affordable Care Act – before Obamacare – is that co-pays and deductibles and premiums keep going up for the people who aren’t on Medicaid. And so people coming into the ER find themselves underinsured too often when they realize they can’t afford their co-pays or their deductibles.

SIMON: Dr. Julie Gunther, you’re a family doctor in Idaho. And I gather you’ve kind of opted out of the typical model and you have your own direct primary care practice.

GUNTHER: Yes, I have. I was a system-employed outpatient physician until 2014. And then I left and started a solo, independent, cash-based practice. So I no longer bill insurance.

SIMON: And why did you take that step?

GUNTHER: The simple answer is I had to leave the system to save myself to be the doctor I wanted to be. It’s valuable for me to hear Dr. Sobelson and Dr. Stone’s experiences. My experience was very, very different. Even before the Affordable Care Act – but especially after – the progressive amount of regulations made it almost impossible for me to serve people the way I was originally called to serve them as an outpatient family doctor.

And so I have built a rather successful cash-based practice that charges very, very little per month. The majority of my patients are either uninsured, underinsured or so frustrated with the current system and its barriers that they would rather pay a small amount out of pocket every month for more direct care.

SIMON: Well – and so I’m going to bring Dr. Rob Stone into this conversation because I’ve been told you’re an advocate for a single-payer system. Is Dr. Gunther onto something?

STONE: Well, I don’t know how generalizable it is widely – and particularly not to very poor areas like the inner city. But my feeling is that we have a good model for how to take care of everybody, which some people still think is kind of a pie-in-the-sky dream. But I’m still going to push for it. And I think that is expanding Medicare, which already takes care of everybody over 65. And I happened to turn 65 a couple months ago. And I’m on Medicare now. And I’m pretty happy with that.

SIMON: Dr. Gary Sobelson, are the high costs of health care unavoidable? Can’t we, after all, just do more for people – a lot more – than we could even 10 and 20 years ago?

SOBELSON: While there are many things that we can do, the high costs are things that the system itself brings about. We’ve designed a system that rewards high-reimbursement procedures, surgeries and undervalues the things that are cost-effective. And it doesn’t really matter how much we research this or prove this to ourselves within our profession. We don’t seem to move in that direction. We don’t have the political will.

Dr. Stone’s comments about Medicare for all are not isolated to small groups of the population. We’ve studied this in New Hampshire, and over 80 percent of our primary care physicians are in favor of a system that some would call single-payer – and the majority of our overall doctors, even including specialists. And that’s been replicated across the country, too. We as Americans seem to value our independent decision-making over collective wisdom, though I would argue that when simple procedures like common arthroscopic knee surgery, something that takes 15 to 30 minutes, is costing $15,000 to $25,000 in community hospitals around our country – that no one has the freedom to make that decision.

GUNTHER: I was just going to say I normally talk about a single payer system. And we use Medicare as a model. My patients who have Medicare say that it works. My mother and father who are economically well off pay $150 a month towards their health care. My Americans who are age 30 to 60 are dropping their health care plans. And they come in, and they tell me, I can choose between putting food on the table, paying for my kid to go to college or getting a health plan that I can’t afford.

So it’s not that I oppose a broader solution. But I would contend we have a system that is completely crumbling and unsustainable. And in my opinion and experience, I don’t think Medicare is working all that well, especially not in a way that we could roll it out to our whole country in any sort of sustainable way. And the heart of it in my opinion is we talk a lot about who’s going to pay for health care. But what we should be talking about is the price of health care.

SIMON: Do we have an unrealistic expectation that health care costs can be reduced when we expect health care to do more and more?

GUNTHER: I think there’s great examples that current health care prices are upwards of a thousand times more than anywhere close to true cost. My patients can get a CAT scan – cash price for $300. If they go into the local ER, it’ll bill out at $2,400. So I think we need to start asking why. Because we keep talking about who should pay or how we should pay for health care.

But if we allow free market forces and competition to create price transparency, then we start to have the opportunity for price control, cost control. And then I think we can completely change the dialogue from who should pay and how should we pay too to what parts of health care do people need help paying for.

SOBELSON: I think Dr. Gunther is describing the problems that we’ve created by more or less – and this is a failing of the ACA – allowing corporate profitability to be the driving force of how we set these so. So, again, if you’re not under Medicare or Medicaid in this country, you’re depending on a private insurance industry to somehow control costs, when, in fact, it’s not really in their interest. They don’t have skin in the game here.

They make their profitability based on how much they collect in revenue. And, in fact, it’s written into the law. So, again, it’s not surprising that we’ve created a model where, in fact, more spending will be encouraged, not discouraged because the only people who really would care about it would be the consumers. And they don’t seem to believe that they can control it.

SIMON: Let me ask this finally, if I could. The Senate bill that’s under consideration right now may or may not be going anywhere. Could each of you give us one idea that you would like to see the government adopt that could improve health care in this country? – or not just the government. What can we do?

STONE: Well, I would say first that the Senate bill is a terrible thing that would set us back and would cost lives. And the people who would be hurt the worst would be children, the disabled and the elderly and nursing homes because of the ravages to Medicaid. So the first thing I would do would be, say, save Medicaid and continue to expand it. And then the second biggest problem in the Senate bill is that it would make health care very expensive for people ages 50 to 65 or 55 to 65 – would be to think about lowering the age of Medicare eligibility to, say, 55 and not cut those people out into the cold.

SIMON: That’s Dr. Rob Stone in Indiana. Dr. Julie Gunther, what would you suggest?

GUNTHER: I would agree with Dr. Stone. I don’t think the Senate bill provides the improvements to the Affordable Care Act or some of our biggest health care problems that we need. If I had one ask it would be that we allow consumers – we allow patients who do have health savings accounts to use those health savings dollars to pay their physician, whether it’s a periodic fee or a direct payment.

And one of my favorite quotes about health care in our country is that we continue to tape wings on a car and call it an airplane. I think we have to radically transform the system at its core if we hope to end up in a different place.

SIMON: And Dr. Gary Sobelson.

SOBELSON: Yeah. From my perspective in New Hampshire, I think the damages to Medicaid that the Senate bill would bring about would be devastating to us and take back so much positive progress we’ve had in terms of access and cost containment.

And if I had to add one thing to it, I think Dr. Stone’s idea of expanding Medicare to populations that traditionally have a hard time buying insurance could be extended into the whole idea of the ability of a public option, the ability of the Medicare and Medicaid programs to work out ways to compete with private insurers so that the public could become more comfortable with them.

SIMON: Doctors Rob Stone, Julie Gunther and Gary Sobelson, thanks so much for joining us.

GUNTHER: Thank you.

STONE: Thank you.

SOBELSON: Thank you.

http://www.npr.org…

Three Doctors on What Works and Doesn’t Work in U.S. Health Care

By Scott Simon
NPR Weekend Edition, July 8, 2017

Doctors Julie Gunter, Rob Stone and Gary Sobelson talk with Scott Simon about the problems with American health care and what they think of the current Republican health care plan.

TRANSCRIPT

SCOTT SIMON, HOST: The United States spends about $9,000 per person per year on health care, the highest in the world. But our life expectancy is still lower than France, Switzerland, Japan, the United Kingdom, all of which spend less. With the Republican health care bill still on the Senate docket, we thought it would be a good time to hear from U.S. doctors. We have three with us now, Dr. Julie Gunther, a family doctor in Idaho, Rob Stone, an ER turned palliative care doctor in Indiana, and Dr. Gary Sobelson, a primary care doctor in New Hampshire. Thanks so much for being with us.

GARY SOBELSON: Thank you.

ROB STONE: Thank you.

JULIE GUNTHER: Thank you.

SIMON: Let me begin, if we can, with you, Dr. Gary Sobelson there in New Hampshire. Seven years since the Affordable Care Act – three since most of the changes went into effect. How is health care different? Is it better, worse?

SOBELSON: Much better coverage for our patients, particularly, in my case as a family doctor, for the working poor. I have people coming in for preventive services, for hypertension management, for cardiovascular disease prevention, for cancer screening who really had not been coming in except for the most acute needs. And that’s been meaningfully different.

SIMON: Dr. Rob Stone in Indiana, you were an ER doctor. You must have seen patients who who came to the ER because they didn’t have insurance to cover primary care visits. Has that changed under the Affordable Care Act for you?

STONE: It’s changed very noticeably. And a far smaller percentage of people are coming in uninsured, although we still continue to take care of those folks, too. Our hospital’s also affiliated with some very small-town hospitals in Bedford, Ind., Paoli, Ind. And in those areas in particular, I think the Medicaid expansion part of the Affordable Care Act has helped to solidify the financial standing of those hospitals, which was somewhat questionable earlier.

So I would say that’s all good. The downside – and this started before the Affordable Care Act – before Obamacare – is that co-pays and deductibles and premiums keep going up for the people who aren’t on Medicaid. And so people coming into the ER find themselves underinsured too often when they realize they can’t afford their co-pays or their deductibles.

SIMON: Dr. Julie Gunther, you’re a family doctor in Idaho. And I gather you’ve kind of opted out of the typical model and you have your own direct primary care practice.

GUNTHER: Yes, I have. I was a system-employed outpatient physician until 2014. And then I left and started a solo, independent, cash-based practice. So I no longer bill insurance.

SIMON: And why did you take that step?

GUNTHER: The simple answer is I had to leave the system to save myself to be the doctor I wanted to be. It’s valuable for me to hear Dr. Sobelson and Dr. Stone’s experiences. My experience was very, very different. Even before the Affordable Care Act – but especially after – the progressive amount of regulations made it almost impossible for me to serve people the way I was originally called to serve them as an outpatient family doctor.

And so I have built a rather successful cash-based practice that charges very, very little per month. The majority of my patients are either uninsured, underinsured or so frustrated with the current system and its barriers that they would rather pay a small amount out of pocket every month for more direct care.

SIMON: Well – and so I’m going to bring Dr. Rob Stone into this conversation because I’ve been told you’re an advocate for a single-payer system. Is Dr. Gunther onto something?

STONE: Well, I don’t know how generalizable it is widely – and particularly not to very poor areas like the inner city. But my feeling is that we have a good model for how to take care of everybody, which some people still think is kind of a pie-in-the-sky dream. But I’m still going to push for it. And I think that is expanding Medicare, which already takes care of everybody over 65. And I happened to turn 65 a couple months ago. And I’m on Medicare now. And I’m pretty happy with that.

SIMON: Dr. Gary Sobelson, are the high costs of health care unavoidable? Can’t we, after all, just do more for people – a lot more – than we could even 10 and 20 years ago?

SOBELSON: While there are many things that we can do, the high costs are things that the system itself brings about. We’ve designed a system that rewards high-reimbursement procedures, surgeries and undervalues the things that are cost-effective. And it doesn’t really matter how much we research this or prove this to ourselves within our profession. We don’t seem to move in that direction. We don’t have the political will.

Dr. Stone’s comments about Medicare for all are not isolated to small groups of the population. We’ve studied this in New Hampshire, and over 80 percent of our primary care physicians are in favor of a system that some would call single-payer – and the majority of our overall doctors, even including specialists. And that’s been replicated across the country, too. We as Americans seem to value our independent decision-making over collective wisdom, though I would argue that when simple procedures like common arthroscopic knee surgery, something that takes 15 to 30 minutes, is costing $15,000 to $25,000 in community hospitals around our country – that no one has the freedom to make that decision.

GUNTHER: I was just going to say I normally talk about a single payer system. And we use Medicare as a model. My patients who have Medicare say that it works. My mother and father who are economically well off pay $150 a month towards their health care. My Americans who are age 30 to 60 are dropping their health care plans. And they come in, and they tell me, I can choose between putting food on the table, paying for my kid to go to college or getting a health plan that I can’t afford.

So it’s not that I oppose a broader solution. But I would contend we have a system that is completely crumbling and unsustainable. And in my opinion and experience, I don’t think Medicare is working all that well, especially not in a way that we could roll it out to our whole country in any sort of sustainable way. And the heart of it in my opinion is we talk a lot about who’s going to pay for health care. But what we should be talking about is the price of health care.

SIMON: Do we have an unrealistic expectation that health care costs can be reduced when we expect health care to do more and more?

GUNTHER: I think there’s great examples that current health care prices are upwards of a thousand times more than anywhere close to true cost. My patients can get a CAT scan – cash price for $300. If they go into the local ER, it’ll bill out at $2,400. So I think we need to start asking why. Because we keep talking about who should pay or how we should pay for health care.

But if we allow free market forces and competition to create price transparency, then we start to have the opportunity for price control, cost control. And then I think we can completely change the dialogue from who should pay and how should we pay too to what parts of health care do people need help paying for.

SOBELSON: I think Dr. Gunther is describing the problems that we’ve created by more or less – and this is a failing of the ACA – allowing corporate profitability to be the driving force of how we set these so. So, again, if you’re not under Medicare or Medicaid in this country, you’re depending on a private insurance industry to somehow control costs, when, in fact, it’s not really in their interest. They don’t have skin in the game here.

They make their profitability based on how much they collect in revenue. And, in fact, it’s written into the law. So, again, it’s not surprising that we’ve created a model where, in fact, more spending will be encouraged, not discouraged because the only people who really would care about it would be the consumers. And they don’t seem to believe that they can control it.

SIMON: Let me ask this finally, if I could. The Senate bill that’s under consideration right now may or may not be going anywhere. Could each of you give us one idea that you would like to see the government adopt that could improve health care in this country? – or not just the government. What can we do?

STONE: Well, I would say first that the Senate bill is a terrible thing that would set us back and would cost lives. And the people who would be hurt the worst would be children, the disabled and the elderly and nursing homes because of the ravages to Medicaid. So the first thing I would do would be, say, save Medicaid and continue to expand it. And then the second biggest problem in the Senate bill is that it would make health care very expensive for people ages 50 to 65 or 55 to 65 – would be to think about lowering the age of Medicare eligibility to, say, 55 and not cut those people out into the cold.

SIMON: That’s Dr. Rob Stone in Indiana. Dr. Julie Gunther, what would you suggest?

GUNTHER: I would agree with Dr. Stone. I don’t think the Senate bill provides the improvements to the Affordable Care Act or some of our biggest health care problems that we need. If I had one ask it would be that we allow consumers – we allow patients who do have health savings accounts to use those health savings dollars to pay their physician, whether it’s a periodic fee or a direct payment.

And one of my favorite quotes about health care in our country is that we continue to tape wings on a car and call it an airplane. I think we have to radically transform the system at its core if we hope to end up in a different place.

SIMON: And Dr. Gary Sobelson.

SOBELSON: Yeah. From my perspective in New Hampshire, I think the damages to Medicaid that the Senate bill would bring about would be devastating to us and take back so much positive progress we’ve had in terms of access and cost containment.

And if I had to add one thing to it, I think Dr. Stone’s idea of expanding Medicare to populations that traditionally have a hard time buying insurance could be extended into the whole idea of the ability of a public option, the ability of the Medicare and Medicaid programs to work out ways to compete with private insurers so that the public could become more comfortable with them.

SIMON: Doctors Rob Stone, Julie Gunther and Gary Sobelson, thanks so much for joining us.

GUNTHER: Thank you.

STONE: Thank you.

SOBELSON: Thank you.

http://www.npr.org…

A health care solution is on the table

By Ahmed C.K. Kutty, M.D.
Concord Monitor, July 7, 2017

With the turmoil surrounding the current healthcare bill in the Senate, a solution hiding in plain sight deserves every concerned American’s attention.

Medicare For All fits the bill as a worthy replacement for the much maligned Affordable Care Act.

Having been around for 52 years, Medicare is familiar and popular, efficient with an overhead of 3 percent, contrasted with 30 percent in the private sector plans, and is available to all seniors and the disabled, regardless of economic status.’

Medicare for All will be eminently affordable with savings of $500 billion predicted, from $3.4 trillion that is the current health care tab for the whole country. Financed publicly. No premiums, deductibles and copays will be due at the point of care. Delivery will remain largely private, as under the current system.

The time is now for an improved Medicare to be expanded to cover all 320 million of us in a single national risk pool.

Did Winston Churchill know something about our national character we did not when he remarked: “Americans can be counted on to do the right thing after they have tried all else.”?

http://www.concordmonitor.com…