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Importance of Medicaid in public health emergencies

Importance of Medicaid in public health emergencies

U.S. Senate, July 2017

H.R. 1628

AMENDMENT IN THE NATURE OF A SUBSTITUTE

This Act may be cited as the “Better Care Reconciliation Act of 2017.”

SEC. 1903A. PER CAPITA-BASED CAP ON PAYMENTS FOR MEDICAL ASSISTANCE.

(b) ADJUSTED TOTAL MEDICAL ASSISTANCE EXPENDITURES

(6) AUTHORITY TO EXCLUDE STATE EXPENDITURES FROM CAPS DURING PUBLIC HEALTH EMERGENCY.—

(A) IN GENERAL.—During the period that begins on January 1, 2020, and ends on December 31, 2024, the Secretary may exclude, from a State’s medical assistance expenditures for a fiscal year or portion of a fiscal year that occurs during such period, an amount that shall not exceed the amount determined under subparagraph (B) for the State and year or portion of a year if—

(i) a public health emergency declared by the Secretary pursuant to section 319 of the Public Health Service Act existed within the State during such year or portion of a year; and

(ii) the Secretary determines that such an exemption would be appropriate.

(B) MAXIMUM AMOUNT OF ADJUSTMENT.—The amount excluded for a State and fiscal year or portion of a fiscal year under this paragraph shall not exceed the amount by which—

(i) the amount of State expenditures for medical assistance for 1903A enrollees in areas of the State which are subject to a declaration described in subparagraph (A)(i) for the fiscal year or portion of a fiscal year; exceeds

(ii) the amount of such expenditures for such enrollees in such areas during the most recent fiscal year or portion of a fiscal year of equal length to the portion of a fiscal year involved during which no such declaration was in effect.

(C) AGGREGATE LIMITATION ON EXCLUSIONS AND ADDITIONAL BLOCK GRANT PAYMENTS.—The aggregate amount of expenditures excluded under this paragraph and additional payments made under section 1903B(c)(3)(E) for the period described in subparagraph (A) shall not exceed $5,000,000,000.

https://www.budget.senate.gov…

***

Medicaid And The Latest Version Of The BCRA: Massive Federal Funding Losses Remain

By Sara Rosenbaum
Health Affairs Blog, July 14, 2017

Where Medicaid is concerned, the most notable thing about the latest version of the Better Care Reconciliation Act (BCRA) is that despite the drama of the past two weeks—the flood of news coverage regarding the potential impact of the losses; mounting concerns raised by Senators from expansion and non-expansion states alike; and the massive outcry from hospitals, physicians, insurers, and health care organizations—the new iteration leaves untouched the fundamental Medicaid contours of the earlier version.

By 2036, CBO reports, federal Medicaid funding would be about 35 percent below current law, a catastrophe of epic proportions.

The Illusion Of A Public Health Emergency Exemption To The Per Capita Cap

One of Medicaid’s most important dimensions is its irreplaceable role in addressing the immediate and long-term effects of public health crises. Medicaid is by far the nation’s biggest single source of health care financing for dealing with critical public health threats. These threats may begin with an initial, recognized period of a formally declared emergency. They then can morph into events with very long-term effects felt for years or decades after. This was the case with the World Trade Center attacks, which led to an immediate surge in health care spending, followed by years of elevated spending to address the long-term health fallout triggered by the emergency itself. One need think only about Zika or the opioid crisis now gripping the nation to understand the near-term/long-term nature of public health threats.

Medicaid enrollees are disproportionately likely to live in poor communities, and poor communities are disproportionately likely to face public health threats ranging from environmental hazards to infectious disease. These communities also are inherently less likely to have resources to cope with the effects of an emergency. Thus, a program such as Medicaid is crucial in its ability to deploy health care financing resources to the hardest-hit populations. Indeed, two thirds of all Louisiana Medicaid beneficiaries lived in the parishes affected by Hurricane Katrina.

Section 319 of the Public Health Service Act authorizes the HHS Secretary to declare the existence of a public health emergency arising from events such as a “disease or disorder,” “significant outbreaks of infectious diseases or bioterrorist attacks,” or other events identified as public health emergencies by the HHS Secretary. Whether to declare an emergency is entrusted to the Secretary’s judgment, and during the immediate emergency period, the Secretary enjoys expanded powers to deploy resources to designated populations or geographic areas. These special powers end when the declared emergency period ends. In the aftermath, states and local communities effectively are on their own, relying on the resources they have.

In and of itself, a loss of federal health funding as large as that imposed by BCRA elevates the threat risk. This risk grows exponentially when a true crisis hits, if Medicaid is crippled in its ability to provide a large-scale surge in public health care spending both during the emergency and thereafter. To understand how little the revised bill does to mitigate the crippling impact of the initial draft one need only look carefully at what the revisions would do when a true emergency strikes.

The press release accompanying the new draft states that “if a public health emergency is declared, state medical assistance expenditures in a particular part of the state will not be counted toward the per capita caps or block grant allocations for the declared period of the emergency.” But a close read of the actual bill text reveals its fundamental inadequacy.

First, the period of exemption lasts only five years, from January 1, 2020 through December 31, 2024. Emergencies happening after this date won’t qualify for the spending adjustment. Second, the bill provides no additional federal spending during the period of a declared emergency. The draft simply allows states to eventually qualify for additional federal funding in the years following the emergency if they can prove to the Secretary that their spending on the affected population went up compared to prior years and then only for immediate emergency costs. What state will have the money in advance? And what state will be able to take a chance on spending more given the purely speculative nature of whether an emergency will be declared and emergency expenditures recognized?

Third, states would receive no additional funding ever unless the HHS Secretary actually declares an emergency in the affected portion of the state or for the state’s affected populations. Many public health threats may not rise to a level that triggers a formal Secretarial determination, and the Secretary may be inclined not to make such a determination because of other, spillover effects that come with such a determination, such as the elevated demand for other types of resources.

Fourth, the additional amount of federal funding made available would be limited to the difference between what the state spent on the population in connection with the emergency and the state’s previous expenditures for the same population. Expenditures to cope with the emergency aftermath would not count, and of course these expenditures likely would not occur simultaneously with the emergency expenditures. For example, Zika has triggered emergency expenditures aimed at preventing the spread of the virus, but the true costs of Zika will roll out slowly in the form of babies left permanently and severely disabled by the virus.

And here is where the public health implications of BCRA become clear: other than exempting state expenditures on children classified as disabled from the caps, the revised bill, like its predecessor, makes no adjustment for long-term consequences. To be sure, as just mentioned, BCRA does exempt state expenditures on severely disabled children from the federal cap. But because the vast majority of children qualify for Medicaid based on poverty, this type of cramped classification system for measuring exemptions is sure to exclude spending for millions of children in severely compromised health from the exemption process.

Fifth, the bill allows only $5 billion in the aggregate for all additional federal funding over the five-year time period covered by the emergency exemption. In other words, the bill essentially creates a five-year, $5 billion mini-block grant to help all states address Medicaid spending for all emergencies occurring during this time period. The incredibly small size of the block grant alone would be likely to incentivize the HHS Secretary to avoid declaring emergencies out of concern that the money won’t be there to cover them.

In the end, the newest iteration of BCRA does nothing to alleviate the catastrophic effects of its predecessor: the difference in magnitude between what Medicaid can do today and what it will be capable of doing in the future is incalculable.

http://healthaffairs.org…

***

Comment:

By Don McCanne, M.D.

Based on some of the rhetoric being tossed around during the debate on repealing and replacing the Affordable Care Act you might think that the politicians currently in charge of the process do not believe that the government should play much of a role in health care. However, based on today’s excerpt from their “Better Care Reconciliation Act,” it almost seems that they do believe that the government should step up during a public health emergency. Or do they?

There are many government agencies that might play a role during a public health emergency. One of the more important is providing victims with Medicaid funding during these emergencies and for the essential services required in followup. Yet the massive reductions proposed for the Medicaid program by the Republican legislation (close to a trillion dollars over the next decade – “a catastrophe of epic proportions”) would cripple this important resource for emergency coverage.

The Republicans seem to have been caught off guard by the intensity of the reaction to the cruelty inherent in their reform proposals. Taking a second look at what they crafted, it apparently occurred to them that their substitute legislation should be modified to be sure that public health emergencies were covered.

So what did they propose? A mini-block grant capped at a maximum of $5 billion over five years, and, at that, with many restrictions. As Sara Rosenbaum states in her Health Affairs article, “the incredibly small size of the block grant alone would be likely to incentivize the HHS Secretary to avoid declaring emergencies out of concern that the money won’t be there to cover them.” Based on his track record, it would not be difficult to imagine HHS Secretary Tom Price withholding funds for an emergency just because there wouldn’t be any funds left over for inevitable public health emergencies to come, providing him with an excuse for being the heartless skinflint that he is.

Thus, amongst the many other profound deficiencies, the Republicans in their repeal and replace legislation do not make a serious attempt to ensure that the government would have the ability to respond in fulfilling one of the more crucial essential functions of government – providing assistance in a public health emergency. These guys really don’t believe in government.

We need to replace not only the health care financing infrastructure with one that ensures that government will be there for us when we have health care needs, but we also need to replace the stewards of the program with people who understand that we are all in this together and we take care of each other in times of need. We do believe that don’t we?

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

Importance of Medicaid in public health emergencies

U.S. Senate, July 2017

H.R. 1628

AMENDMENT IN THE NATURE OF A SUBSTITUTE

This Act may be cited as the “Better Care Reconciliation Act of 2017.”

SEC. 1903A. PER CAPITA-BASED CAP ON PAYMENTS FOR MEDICAL ASSISTANCE.

(b) ADJUSTED TOTAL MEDICAL ASSISTANCE EXPENDITURES

(6) AUTHORITY TO EXCLUDE STATE EXPENDITURES FROM CAPS DURING PUBLIC HEALTH EMERGENCY.—

(A) IN GENERAL.—During the period that begins on January 1, 2020, and ends on December 31, 2024, the Secretary may exclude, from a State’s medical assistance expenditures for a fiscal year or portion of a fiscal year that occurs during such period, an amount that shall not exceed the amount determined under subparagraph (B) for the State and year or portion of a year if—

(i) a public health emergency declared by the Secretary pursuant to section 319 of the Public Health Service Act existed within the State during such year or portion of a year; and

(ii) the Secretary determines that such an exemption would be appropriate.

(B) MAXIMUM AMOUNT OF ADJUSTMENT.—The amount excluded for a State and fiscal year or portion of a fiscal year under this paragraph shall not exceed the amount by which—

(i) the amount of State expenditures for medical assistance for 1903A enrollees in areas of the State which are subject to a declaration described in subparagraph (A)(i) for the fiscal year or portion of a fiscal year; exceeds

(ii) the amount of such expenditures for such enrollees in such areas during the most recent fiscal year or portion of a fiscal year of equal length to the portion of a fiscal year involved during which no such declaration was in effect.

(C) AGGREGATE LIMITATION ON EXCLUSIONS AND ADDITIONAL BLOCK GRANT PAYMENTS.—The aggregate amount of expenditures excluded under this paragraph and additional payments made under section 1903B(c)(3)(E) for the period described in subparagraph (A) shall not exceed $5,000,000,000.

https://www.budget.senate.gov…

***

Medicaid And The Latest Version Of The BCRA: Massive Federal Funding Losses Remain

By Sara Rosenbaum
Health Affairs Blog, July 14, 2017

Where Medicaid is concerned, the most notable thing about the latest version of the Better Care Reconciliation Act (BCRA) is that despite the drama of the past two weeks—the flood of news coverage regarding the potential impact of the losses; mounting concerns raised by Senators from expansion and non-expansion states alike; and the massive outcry from hospitals, physicians, insurers, and health care organizations—the new iteration leaves untouched the fundamental Medicaid contours of the earlier version.

By 2036, CBO reports, federal Medicaid funding would be about 35 percent below current law, a catastrophe of epic proportions.

The Illusion Of A Public Health Emergency Exemption To The Per Capita Cap

One of Medicaid’s most important dimensions is its irreplaceable role in addressing the immediate and long-term effects of public health crises. Medicaid is by far the nation’s biggest single source of health care financing for dealing with critical public health threats. These threats may begin with an initial, recognized period of a formally declared emergency. They then can morph into events with very long-term effects felt for years or decades after. This was the case with the World Trade Center attacks, which led to an immediate surge in health care spending, followed by years of elevated spending to address the long-term health fallout triggered by the emergency itself. One need think only about Zika or the opioid crisis now gripping the nation to understand the near-term/long-term nature of public health threats.

Medicaid enrollees are disproportionately likely to live in poor communities, and poor communities are disproportionately likely to face public health threats ranging from environmental hazards to infectious disease. These communities also are inherently less likely to have resources to cope with the effects of an emergency. Thus, a program such as Medicaid is crucial in its ability to deploy health care financing resources to the hardest-hit populations. Indeed, two thirds of all Louisiana Medicaid beneficiaries lived in the parishes affected by Hurricane Katrina.

Section 319 of the Public Health Service Act authorizes the HHS Secretary to declare the existence of a public health emergency arising from events such as a “disease or disorder,” “significant outbreaks of infectious diseases or bioterrorist attacks,” or other events identified as public health emergencies by the HHS Secretary. Whether to declare an emergency is entrusted to the Secretary’s judgment, and during the immediate emergency period, the Secretary enjoys expanded powers to deploy resources to designated populations or geographic areas. These special powers end when the declared emergency period ends. In the aftermath, states and local communities effectively are on their own, relying on the resources they have.

In and of itself, a loss of federal health funding as large as that imposed by BCRA elevates the threat risk. This risk grows exponentially when a true crisis hits, if Medicaid is crippled in its ability to provide a large-scale surge in public health care spending both during the emergency and thereafter. To understand how little the revised bill does to mitigate the crippling impact of the initial draft one need only look carefully at what the revisions would do when a true emergency strikes.

The press release accompanying the new draft states that “if a public health emergency is declared, state medical assistance expenditures in a particular part of the state will not be counted toward the per capita caps or block grant allocations for the declared period of the emergency.” But a close read of the actual bill text reveals its fundamental inadequacy.

First, the period of exemption lasts only five years, from January 1, 2020 through December 31, 2024. Emergencies happening after this date won’t qualify for the spending adjustment. Second, the bill provides no additional federal spending during the period of a declared emergency. The draft simply allows states to eventually qualify for additional federal funding in the years following the emergency if they can prove to the Secretary that their spending on the affected population went up compared to prior years and then only for immediate emergency costs. What state will have the money in advance? And what state will be able to take a chance on spending more given the purely speculative nature of whether an emergency will be declared and emergency expenditures recognized?

Third, states would receive no additional funding ever unless the HHS Secretary actually declares an emergency in the affected portion of the state or for the state’s affected populations. Many public health threats may not rise to a level that triggers a formal Secretarial determination, and the Secretary may be inclined not to make such a determination because of other, spillover effects that come with such a determination, such as the elevated demand for other types of resources.

Fourth, the additional amount of federal funding made available would be limited to the difference between what the state spent on the population in connection with the emergency and the state’s previous expenditures for the same population. Expenditures to cope with the emergency aftermath would not count, and of course these expenditures likely would not occur simultaneously with the emergency expenditures. For example, Zika has triggered emergency expenditures aimed at preventing the spread of the virus, but the true costs of Zika will roll out slowly in the form of babies left permanently and severely disabled by the virus.

And here is where the public health implications of BCRA become clear: other than exempting state expenditures on children classified as disabled from the caps, the revised bill, like its predecessor, makes no adjustment for long-term consequences. To be sure, as just mentioned, BCRA does exempt state expenditures on severely disabled children from the federal cap. But because the vast majority of children qualify for Medicaid based on poverty, this type of cramped classification system for measuring exemptions is sure to exclude spending for millions of children in severely compromised health from the exemption process.

Fifth, the bill allows only $5 billion in the aggregate for all additional federal funding over the five-year time period covered by the emergency exemption. In other words, the bill essentially creates a five-year, $5 billion mini-block grant to help all states address Medicaid spending for all emergencies occurring during this time period. The incredibly small size of the block grant alone would be likely to incentivize the HHS Secretary to avoid declaring emergencies out of concern that the money won’t be there to cover them.

In the end, the newest iteration of BCRA does nothing to alleviate the catastrophic effects of its predecessor: the difference in magnitude between what Medicaid can do today and what it will be capable of doing in the future is incalculable.

http://healthaffairs.org…

***

Comment:

By Don McCanne, M.D.

Based on some of the rhetoric being tossed around during the debate on repealing and replacing the Affordable Care Act you might think that the politicians currently in charge of the process do not believe that the government should play much of a role in health care. However, based on today’s excerpt from their “Better Care Reconciliation Act,” it almost seems that they do believe that the government should step up during a public health emergency. Or do they?

There are many government agencies that might play a role during a public health emergency. One of the more important is providing victims with Medicaid funding during these emergencies and for the essential services required in followup. Yet the massive reductions proposed for the Medicaid program by the Republican legislation (close to a trillion dollars over the next decade – “a catastrophe of epic proportions”) would cripple this important resource for emergency coverage.

The Republicans seem to have been caught off guard by the intensity of the reaction to the cruelty inherent in their reform proposals. Taking a second look at what they crafted, it apparently occurred to them that their substitute legislation should be modified to be sure that public health emergencies were covered.

So what did they propose? A mini-block grant capped at a maximum of $5 billion over five years, and, at that, with many restrictions. As Sara Rosenbaum states in her Health Affairs article, “the incredibly small size of the block grant alone would be likely to incentivize the HHS Secretary to avoid declaring emergencies out of concern that the money won’t be there to cover them.” Based on his track record, it would not be difficult to imagine HHS Secretary Tom Price withholding funds for an emergency just because there wouldn’t be any funds left over for inevitable public health emergencies to come, providing him with an excuse for being the heartless skinflint that he is.

Thus, amongst the many other profound deficiencies, the Republicans in their repeal and replace legislation do not make a serious attempt to ensure that the government would have the ability to respond in fulfilling one of the more crucial essential functions of government – providing assistance in a public health emergency. These guys really don’t believe in government.

We need to replace not only the health care financing infrastructure with one that ensures that government will be there for us when we have health care needs, but we also need to replace the stewards of the program with people who understand that we are all in this together and we take care of each other in times of need. We do believe that don’t we?

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

Health debate energizing Tucson ‘Medicare for All’ proponents

By Stephanie Innes
Arizona Daily Star, July 15, 2017

Universal health care is far from the plan Republican leaders are proposing, but it’s getting some love in Southern Arizona.

Advocates cite various factors fueling single-payer popularity.

These include fear about recent Republican efforts to repeal and replace the Affordable Care Act (ACA, also called Obamacare), a public that’s more well-versed in health care and a repackaged “Medicare for All” message that they say makes the single-payer concept more understandable and palatable.

Nowhere was local support for that kind of system more obvious than at a standing-room-only health forum hosted by Tucson Medical Center June 26. A question about single-payer health care drew cheers, not from one or two lone voices, but from a chorus across the room of 700 people.

While the response from expert panelists at the forum was tempered, the audience’s enthusiasm was clear. Signs saying “Healthcare not Wealthcare” and “No More Pay Up Or Die Plans!” dotted the entrance to the event. The crowd was energized.

“Back in 2009, I certainly didn’t know what Medicare for All was. Like most Americans, I knew about employer and non-group insurance. I was so naive,” said forum attendee Andrea Witte, a 52-year-old graphic designer who recently became a supporter of Medicare for All. “It’s just being discussed more, and when I go to events, I think people understand health care better.”

Witte says her personal evolution includes now seeing health care as a basic right — a moral imperative, “instead of a commodity to be rationed based on the size of one’s wallet or the profit-seeking of insurance companies.”

Increased support for Medicare for All is not just local — an April 2017 Economist/YouGov poll found a majority of Americans support “expanding Medicare to provide health insurance to every American.”

The Pew Research Center reported in June that 60 percent of Americans say the federal government is responsible for ensuring health-care coverage for all Americans, while 3 percent say it is not the government’s responsibility.

These views are unchanged from January, but the share saying health coverage is a government responsibility remains at its highest level in nearly a decade, the researchers found.

“Many like me who supported the ACA’s modest reforms now realize that keeping for-profit insurers involved still leaves too many Americans uninsured or underinsured and prevents us from controlling our skyrocketing health-care costs,” Witte said.

California recently considered its own form of single-payer health care, and other states are talking about it.

When people refer to single-payer health care, they are not always talking about the same thing, and some people give the various universal plans other names, such as “Medicaid for All,” referring to the government insurance program primarily for low-income people. The general commonality is one public entity handling health-care financing for the entire country.

The Medicare for All movement supports a system like traditional or original Medicare, which covers mostly people over the age of 65.

Such a plan has been introduced in Congress by U.S. Rep. John Conyers, a Democrat from Michigan. Conyers’ bill calls for a progressive tax based on income, similar to one in Canada, to fund expanded Medicare for all Americans. Democrat U.S. Reps. Raúl Gríjalva of Tucson and Ruben Gallego of Phoenix are among the bill’s 113 co-sponsors.

The main Republican argument against single-payer health care is that it is too much big government providing not enough choice for Americans. Sen. Jeff Flake, an Arizona Republican, says he’s against single payer because he believes the best way to provide affordable, quality care for everyone is through “choice and competition in a free-market health-care system.”

Arizona Sen. John McCain says he, too, supports “a free-market solution that would enhance competition, increase choices, drive down costs and improve health-care outcomes.”

Nearly 40 percent of Arizonans already are on government-sponsored insurance — 25 percent on Medicaid and 14 percent on Medicare. That number doesn’t take into account the additional Arizonans who get federal subsidies to help pay for their health insurance through the ACA marketplace.

COMPLEXITY AND COST

Advocates say Medicare for All would provide health coverage to all Americans from birth to death and reduce two major problems with U.S. health care — complexity and cost.

“Health care should be like the fire department. … If your house is on fire, the fire department comes,” Tucson resident Kelly Strachan wrote in a recent letter to Flake and McCain.

“Not everyone’s house will burn, so we can create a big enough risk pool to truly control health-care costs (a large part of which is the profits of the insurance industry),” she wrote.

Eight to 10 years ago, many critics were quick to say socialized medicine would put us on a path to communism, says Strachan, a 56-year-old adjunct Spanish instructor at Pima Community College.

“They immediately would leap to repressive governments,” she said, adding there appears to be less hostility about the concept now.

Strachan frequently posts about single-payer health care on Facebook and chats about it with strangers she encounters in public places like movie theaters. She’s found people are generally willing to talk about it, even if they don’t always agree.

Writing in favor of a single-payer system in the University of Arizona’s Arizona Daily Wildcat on July 3, Andrew Paxton said millennials “would rather pay slightly higher taxes than worry about how to afford insurance, especially as our parents age and medical costs skyrocket.”

GOING BACK TO FDR

Single-payer health care in the U.S. is a concept that goes back as far as the Franklin D. Roosevelt presidency, when publicly funded health care was considered for inclusion in the national Social Security Act.

The public appears to be gaining a new understanding of what it means, says Dr. George Pauk, the Arizona representative on Physicians for a National Health Program. Debate over the Senate and House health bills, as well as the Affordable Care Act, fueled some of the interest, Pauk and others say.

“Almost everyone has a relative struggling to pay or going bankrupt because of medical bills,” said Pauk, a retired endocrinologist from Phoenix who has been campaigning for a single-payer system for 30 years. “We have a segregated health-care system in this country, and there’s been a lot of discrimination in the history of American health care.”

Annual per-capita health expenditures in the U.S. are the highest in the world despite a recent slowdown in spending, the Commonwealth Fund reports.

Insurance companies, acting as middlemen between providers and patients, add a layer of bureaucracy that is not only fueling that cost, but also making health care complicated for consumers, Medicare for All advocates say.

At the same time, the U.S. is not keeping pace on important health measures.

Infant mortality rates here are 5.8 per 1,000 live births, 71 percent higher than the comparable country average and twice the rate of Japan and Sweden, a Kaiser Family Foundation analysis of 2014 data found.

A Kaiser analysis of 2013 data found that for most of the leading causes of death, including disease of the circulatory and respiratory systems, mortality rates are higher in the U.S. than in comparable countries.

Pauk said in general, Americans have been indoctrinated that government is bad and too big.

But insurance companies are also too big, and they are “making a killing on health care,” he said.

It would cost less for doctors to remove insurance companies, he said, and save the U.S. between $300 billion and $500 billion per year.

“The average doctor would not have to have two or three or four people doing billing for them,” he said. “Can you imagine the savings, not having to have those employees?”

Some critics dispute the cost savings.

After Sen. Bernie Sanders proposed a single-payer system during his Democratic presidential run in 2016, the Urban Institute released an analysis that said Sanders’ plan would increase national health expenditures by nearly 17 percent or $6.6 trillion between 2017 and 2026, largely because of the cost of providing additional acute care to non-elderly people who currently have no insurance.

The Urban Institute concluded that physician payments would be squeezed, as would the pharmaceutical and medical-device industries, “perhaps more than is sustainable” and that people could wait longer for care.

The co-founders of Pauk’s group wrote a rebuttal calling the study ridiculous, saying among other things that it ignored the major savings on hospital administration and doctors’ billing that would occur under a streamlined single-payer system.

They also noted that no surge in care occurred in the 1960s when millions of previously uninsured seniors gained coverage through Medicare.

U.S. INDIVIDUALISM

When the single-payer issue came up at the recent TMC forum, Dr. Francisco Garcia, chief medical officer for Pima County, said U.S. individualism “and our reluctance to be told what to do” have always been issues with that route.

Therein lies a huge part of the public’s perception of the ACA — the unpopular mandate that all Americans have insurance, he said.

“That was the rallying cry, ‘I don’t want to be told to buy insurance.’ Whether rightly or wrongly, that has been the downfall,” said Garcia, who is also assistant county administrator for health services.

And yet the ACA was a compromise between those who wanted a single-payer system and people who prefer a more capitalistic, market-oriented approach to health care.

“I actually think that the ACA, with its sometimes significant limitations, was actually a really sane, rational middle-of-the road, market-oriented kind of solution,” Garcia said. “I think that was a good, realistic solution and I long for the day when we can get back there, though I don’t see it yet.”

But Tucson pediatrician Dr. Eve Shapiro says it was a “different time” when President Obama presented his health plan in 2010. Shapiro has advocated for single-payer health care through Physicians for a National Health Program for about 30 years.

“I think he could have gone further in pushing the single payer and ended up with more of a public option,” Shapiro said. “He chose not to. He chose to work with the insurance companies. But I think people are now fed up with the insurance companies.”

Under a pure single-payer system, Americans would pay a progressive tax with no direct health-care costs for premiums, deductibles or co-pays.

That would be cheaper for 90 percent of Americans, said Tucson family physician and University of Arizona professor Dr. Paul Gordon. Gordon is Shapiro’s husband and also a strong supporter of a national single-payer health program.

The public is more likely to support “Medicare for All” versus “single payer,” which is why the messaging is important, Shapiro and Gordon say.

“People think if it’s a government system, the government controls your health care. What we try to explain is that the single payer is a payment system, which means there are no insurance companies and payments go through the government,” Shapiro said.

“But the delivery system is the same — the doctors, hospitals, health centers — that is what we have to make clear to people. Their day-to-day experience of health care wouldn’t change. What would change would be the financing of it.”

$3.2 TRILLION

One thing is certain — for the more than $10,000 per person the U.S. spends on health care each year, we should be expecting “much better value for the dollar,” says health-policy expert Dr. Dan Derksen, a professor at the University of Arizona’s Mel and Enid Zuckerman College of Public Health.

“In 2015, the U.S. had $3.2 trillion in health expenditures. That’s more than twice what other developed countries spend, yet our population health outcomes are not as good as many countries who spend far less — whether it’s in terms of longevity, maternal and neonatal mortality, access to health care and preventive services, and most other parameters,” Derksen said.

“All of the developed countries except the U.S. have ‘single payer’ systems. Each country’s approach to single payer is quite different. Canada is often described as the country closest to what a ‘Medicare for All’ single-payer system looks like.”

Derksen wasn’t surprised by the enthusiasm he heard for single payer at the TMC forum, where he was a panelist. The audience was primarily made up of people who seemed upset about the House and Senate health bills, so single-payer support was to be expected, he said.

During the 2008 election season, there was a strong push for single payer, he says. But he notes one big difference between then and now — today’s general public is more educated about health care, likely because more people have health insurance.

Before 2014, 48 million Americans were uninsured. That number is now down to about 28 million. The newly insured have had to learn about concepts like deductibles, co-insurance and essential health benefits, and are better equipped to identify shortcomings in the system.

Still, Derksen is skeptical of any Medicare for All law happening in the near future, even with added public awareness.

“We’re some years out from that, pragmatically. Many components of the health industry benefit from keeping the status quo,” he said.

“The insurance industry has record revenues, and their stocks rise as consumer health-insurance protections are now on the legislative chopping block.

“Vested interests generally oppose changes that give the government more leverage in negotiating prices, such as the pharmaceutical industry, who would not want to have a single payer with monopoly power to get significant discounts in medications.”

SINGLE ISSUE

Grijalva has long been a supporter of Medicare for All. At a July 6 forum he hosted in Tucson, he said the way to achieve it may be through increments, such as initially lowering the Medicare age to 50.

But Witte and others want more sweeping action now.

“Right now is the perfect opportunity to push for it. People have started to see what profit is doing to health care,” said Lee Stanfield, a 74-year-old retiree who started the group Single Payer Now Tucson more than a decade ago.

“It is so complex, and it’s aided and abetted by the insurance industry. They like it that way.”

When attending public events such as the Fourth Avenue Street Fair, Stanfield has been buoyed by the number of people who say they strongly support Medicare for All and are willing to take flyers and even help hand them out.

“In particular, I am encountering far more young people who know about and favor single payer than in years past, when it was hard to even get them to accept a flyer,” she said. “Bernie Sanders really got the young people on board.”

If anything is to happen with universal health coverage, it’s going to come from people like Stanfield who are at the grassroots level, Shapiro predicts.

“Look what is happening at all these senators and representatives’ offices, with people sitting in and protesting,” Shapiro said.

“I think they are getting the message that they have to do something that is real, that will give people coverage.”

http://tucson.com…

Health debate energizing Tucson ‘Medicare for All’ proponents

By Stephanie Innes
Arizona Daily Star, July 15, 2017

Universal health care is far from the plan Republican leaders are proposing, but it’s getting some love in Southern Arizona.

Advocates cite various factors fueling single-payer popularity.

These include fear about recent Republican efforts to repeal and replace the Affordable Care Act (ACA, also called Obamacare), a public that’s more well-versed in health care and a repackaged “Medicare for All” message that they say makes the single-payer concept more understandable and palatable.

Nowhere was local support for that kind of system more obvious than at a standing-room-only health forum hosted by Tucson Medical Center June 26. A question about single-payer health care drew cheers, not from one or two lone voices, but from a chorus across the room of 700 people.

While the response from expert panelists at the forum was tempered, the audience’s enthusiasm was clear. Signs saying “Healthcare not Wealthcare” and “No More Pay Up Or Die Plans!” dotted the entrance to the event. The crowd was energized.

“Back in 2009, I certainly didn’t know what Medicare for All was. Like most Americans, I knew about employer and non-group insurance. I was so naive,” said forum attendee Andrea Witte, a 52-year-old graphic designer who recently became a supporter of Medicare for All. “It’s just being discussed more, and when I go to events, I think people understand health care better.”

Witte says her personal evolution includes now seeing health care as a basic right — a moral imperative, “instead of a commodity to be rationed based on the size of one’s wallet or the profit-seeking of insurance companies.”

Increased support for Medicare for All is not just local — an April 2017 Economist/YouGov poll found a majority of Americans support “expanding Medicare to provide health insurance to every American.”

The Pew Research Center reported in June that 60 percent of Americans say the federal government is responsible for ensuring health-care coverage for all Americans, while 3 percent say it is not the government’s responsibility.

These views are unchanged from January, but the share saying health coverage is a government responsibility remains at its highest level in nearly a decade, the researchers found.

“Many like me who supported the ACA’s modest reforms now realize that keeping for-profit insurers involved still leaves too many Americans uninsured or underinsured and prevents us from controlling our skyrocketing health-care costs,” Witte said.

California recently considered its own form of single-payer health care, and other states are talking about it.

When people refer to single-payer health care, they are not always talking about the same thing, and some people give the various universal plans other names, such as “Medicaid for All,” referring to the government insurance program primarily for low-income people. The general commonality is one public entity handling health-care financing for the entire country.

The Medicare for All movement supports a system like traditional or original Medicare, which covers mostly people over the age of 65.

Such a plan has been introduced in Congress by U.S. Rep. John Conyers, a Democrat from Michigan. Conyers’ bill calls for a progressive tax based on income, similar to one in Canada, to fund expanded Medicare for all Americans. Democrat U.S. Reps. Raúl Gríjalva of Tucson and Ruben Gallego of Phoenix are among the bill’s 113 co-sponsors.

The main Republican argument against single-payer health care is that it is too much big government providing not enough choice for Americans. Sen. Jeff Flake, an Arizona Republican, says he’s against single payer because he believes the best way to provide affordable, quality care for everyone is through “choice and competition in a free-market health-care system.”

Arizona Sen. John McCain says he, too, supports “a free-market solution that would enhance competition, increase choices, drive down costs and improve health-care outcomes.”

Nearly 40 percent of Arizonans already are on government-sponsored insurance — 25 percent on Medicaid and 14 percent on Medicare. That number doesn’t take into account the additional Arizonans who get federal subsidies to help pay for their health insurance through the ACA marketplace.

COMPLEXITY AND COST

Advocates say Medicare for All would provide health coverage to all Americans from birth to death and reduce two major problems with U.S. health care — complexity and cost.

“Health care should be like the fire department. … If your house is on fire, the fire department comes,” Tucson resident Kelly Strachan wrote in a recent letter to Flake and McCain.

“Not everyone’s house will burn, so we can create a big enough risk pool to truly control health-care costs (a large part of which is the profits of the insurance industry),” she wrote.

Eight to 10 years ago, many critics were quick to say socialized medicine would put us on a path to communism, says Strachan, a 56-year-old adjunct Spanish instructor at Pima Community College.

“They immediately would leap to repressive governments,” she said, adding there appears to be less hostility about the concept now.

Strachan frequently posts about single-payer health care on Facebook and chats about it with strangers she encounters in public places like movie theaters. She’s found people are generally willing to talk about it, even if they don’t always agree.

Writing in favor of a single-payer system in the University of Arizona’s Arizona Daily Wildcat on July 3, Andrew Paxton said millennials “would rather pay slightly higher taxes than worry about how to afford insurance, especially as our parents age and medical costs skyrocket.”

GOING BACK TO FDR

Single-payer health care in the U.S. is a concept that goes back as far as the Franklin D. Roosevelt presidency, when publicly funded health care was considered for inclusion in the national Social Security Act.

The public appears to be gaining a new understanding of what it means, says Dr. George Pauk, the Arizona representative on Physicians for a National Health Program. Debate over the Senate and House health bills, as well as the Affordable Care Act, fueled some of the interest, Pauk and others say.

“Almost everyone has a relative struggling to pay or going bankrupt because of medical bills,” said Pauk, a retired endocrinologist from Phoenix who has been campaigning for a single-payer system for 30 years. “We have a segregated health-care system in this country, and there’s been a lot of discrimination in the history of American health care.”

Annual per-capita health expenditures in the U.S. are the highest in the world despite a recent slowdown in spending, the Commonwealth Fund reports.

Insurance companies, acting as middlemen between providers and patients, add a layer of bureaucracy that is not only fueling that cost, but also making health care complicated for consumers, Medicare for All advocates say.

At the same time, the U.S. is not keeping pace on important health measures.

Infant mortality rates here are 5.8 per 1,000 live births, 71 percent higher than the comparable country average and twice the rate of Japan and Sweden, a Kaiser Family Foundation analysis of 2014 data found.

A Kaiser analysis of 2013 data found that for most of the leading causes of death, including disease of the circulatory and respiratory systems, mortality rates are higher in the U.S. than in comparable countries.

Pauk said in general, Americans have been indoctrinated that government is bad and too big.

But insurance companies are also too big, and they are “making a killing on health care,” he said.

It would cost less for doctors to remove insurance companies, he said, and save the U.S. between $300 billion and $500 billion per year.

“The average doctor would not have to have two or three or four people doing billing for them,” he said. “Can you imagine the savings, not having to have those employees?”

Some critics dispute the cost savings.

After Sen. Bernie Sanders proposed a single-payer system during his Democratic presidential run in 2016, the Urban Institute released an analysis that said Sanders’ plan would increase national health expenditures by nearly 17 percent or $6.6 trillion between 2017 and 2026, largely because of the cost of providing additional acute care to non-elderly people who currently have no insurance.

The Urban Institute concluded that physician payments would be squeezed, as would the pharmaceutical and medical-device industries, “perhaps more than is sustainable” and that people could wait longer for care.

The co-founders of Pauk’s group wrote a rebuttal calling the study ridiculous, saying among other things that it ignored the major savings on hospital administration and doctors’ billing that would occur under a streamlined single-payer system.

They also noted that no surge in care occurred in the 1960s when millions of previously uninsured seniors gained coverage through Medicare.

U.S. INDIVIDUALISM

When the single-payer issue came up at the recent TMC forum, Dr. Francisco Garcia, chief medical officer for Pima County, said U.S. individualism “and our reluctance to be told what to do” have always been issues with that route.

Therein lies a huge part of the public’s perception of the ACA — the unpopular mandate that all Americans have insurance, he said.

“That was the rallying cry, ‘I don’t want to be told to buy insurance.’ Whether rightly or wrongly, that has been the downfall,” said Garcia, who is also assistant county administrator for health services.

And yet the ACA was a compromise between those who wanted a single-payer system and people who prefer a more capitalistic, market-oriented approach to health care.

“I actually think that the ACA, with its sometimes significant limitations, was actually a really sane, rational middle-of-the road, market-oriented kind of solution,” Garcia said. “I think that was a good, realistic solution and I long for the day when we can get back there, though I don’t see it yet.”

But Tucson pediatrician Dr. Eve Shapiro says it was a “different time” when President Obama presented his health plan in 2010. Shapiro has advocated for single-payer health care through Physicians for a National Health Program for about 30 years.

“I think he could have gone further in pushing the single payer and ended up with more of a public option,” Shapiro said. “He chose not to. He chose to work with the insurance companies. But I think people are now fed up with the insurance companies.”

Under a pure single-payer system, Americans would pay a progressive tax with no direct health-care costs for premiums, deductibles or co-pays.

That would be cheaper for 90 percent of Americans, said Tucson family physician and University of Arizona professor Dr. Paul Gordon. Gordon is Shapiro’s husband and also a strong supporter of a national single-payer health program.

The public is more likely to support “Medicare for All” versus “single payer,” which is why the messaging is important, Shapiro and Gordon say.

“People think if it’s a government system, the government controls your health care. What we try to explain is that the single payer is a payment system, which means there are no insurance companies and payments go through the government,” Shapiro said.

“But the delivery system is the same — the doctors, hospitals, health centers — that is what we have to make clear to people. Their day-to-day experience of health care wouldn’t change. What would change would be the financing of it.”

$3.2 TRILLION

One thing is certain — for the more than $10,000 per person the U.S. spends on health care each year, we should be expecting “much better value for the dollar,” says health-policy expert Dr. Dan Derksen, a professor at the University of Arizona’s Mel and Enid Zuckerman College of Public Health.

“In 2015, the U.S. had $3.2 trillion in health expenditures. That’s more than twice what other developed countries spend, yet our population health outcomes are not as good as many countries who spend far less — whether it’s in terms of longevity, maternal and neonatal mortality, access to health care and preventive services, and most other parameters,” Derksen said.

“All of the developed countries except the U.S. have ‘single payer’ systems. Each country’s approach to single payer is quite different. Canada is often described as the country closest to what a ‘Medicare for All’ single-payer system looks like.”

Derksen wasn’t surprised by the enthusiasm he heard for single payer at the TMC forum, where he was a panelist. The audience was primarily made up of people who seemed upset about the House and Senate health bills, so single-payer support was to be expected, he said.

During the 2008 election season, there was a strong push for single payer, he says. But he notes one big difference between then and now — today’s general public is more educated about health care, likely because more people have health insurance.

Before 2014, 48 million Americans were uninsured. That number is now down to about 28 million. The newly insured have had to learn about concepts like deductibles, co-insurance and essential health benefits, and are better equipped to identify shortcomings in the system.

Still, Derksen is skeptical of any Medicare for All law happening in the near future, even with added public awareness.

“We’re some years out from that, pragmatically. Many components of the health industry benefit from keeping the status quo,” he said.

“The insurance industry has record revenues, and their stocks rise as consumer health-insurance protections are now on the legislative chopping block.

“Vested interests generally oppose changes that give the government more leverage in negotiating prices, such as the pharmaceutical industry, who would not want to have a single payer with monopoly power to get significant discounts in medications.”

SINGLE ISSUE

Grijalva has long been a supporter of Medicare for All. At a July 6 forum he hosted in Tucson, he said the way to achieve it may be through increments, such as initially lowering the Medicare age to 50.

But Witte and others want more sweeping action now.

“Right now is the perfect opportunity to push for it. People have started to see what profit is doing to health care,” said Lee Stanfield, a 74-year-old retiree who started the group Single Payer Now Tucson more than a decade ago.

“It is so complex, and it’s aided and abetted by the insurance industry. They like it that way.”

When attending public events such as the Fourth Avenue Street Fair, Stanfield has been buoyed by the number of people who say they strongly support Medicare for All and are willing to take flyers and even help hand them out.

“In particular, I am encountering far more young people who know about and favor single payer than in years past, when it was hard to even get them to accept a flyer,” she said. “Bernie Sanders really got the young people on board.”

If anything is to happen with universal health coverage, it’s going to come from people like Stanfield who are at the grassroots level, Shapiro predicts.

“Look what is happening at all these senators and representatives’ offices, with people sitting in and protesting,” Shapiro said.

“I think they are getting the message that they have to do something that is real, that will give people coverage.”

http://tucson.com…

The who and how of improving the U.S. health care system

From Last to First — Could the U.S. Health Care System Become the Best in the World?

By Eric C. Schneider, M.D., and David Squires, M.A.
The New England Journal of Medicine, July 14, 2017

Many Americans believe that the United States has the best health care system in the world, but surprisingly little evidence supports that belief. On the contrary, since 2004, reports from the Commonwealth Fund have consistently rated the performance of the U.S. health care system last among high-income countries, despite the fact that we spend far more on health care than these other countries.

Timely access for people at risk for poor health may be impeded by three features of health care systems: the cost of care and its affordability for individuals, the administrative burden (or hassle) that people confront as they obtain and receive care, and disparities or inequities in the delivery of care based on income, educational attainment, race or ethnic background, or other nonclinical personal characteristics.

The first challenge the U.S. health care system must confront is lack of access to health care. The high-income countries that are top-ranked according to the most recent Fund report (the United Kingdom, Australia, and the Netherlands) offer universal insurance coverage with minimal out-of-pocket costs for preventive and primary care. Affordable and comprehensive insurance coverage is fundamental. If people are uninsured, some delay seeking care, some of those end up with serious health problems, and some of them die.

The second challenge is the relative underinvestment in primary care in the United States as compared with other countries. Other countries make primary care widely, and more uniformly, available. In contrast to the United States, a higher percentage of these countries’ professional workforce is dedicated to primary care than to specialty care, and they enable delivery of a wider range of services at first contact, even at night and on weekends.

The third challenge is the administrative inefficiency of the U.S. health care system. Both patients and professionals in the United States are baffled by the complexity of obtaining care and paying for it. Clinicians and their staff spend countless hours completing documentation to prove that insurance coverage is active, that benefits and services are covered, that services were delivered, and that payment or reimbursement occurred. Coping with the byzantine layers of administration results in high levels of burnout for doctors and other professionals, which can reduce the quality of care. The complexity also affects patients, who receive confusing benefit descriptions, limited information about doctors and hospitals, unintelligible and often unexpected (or “surprise”) bills for services, and unpredictable copayments at labs and pharmacies. It is possible to reduce these barriers to adherence and follow-up by reducing complexity for patients and clinicians: if we changed our reimbursement systems to use global payments, fee schedules, formularies, and defined benefits, it would make benefits and costs more predictable for patients and revenue more predictable for clinicians.

The fourth challenge is the pervasiveness in the United States of disparities in the delivery of care. People with low incomes, low educational attainment, and other social and economic challenges face greater health risks and worse health in all countries, but especially in the United States, which has a less robust social safety net than other high-income countries. Other countries achieve better population health by spending relatively more on social services than on medical care. Along with making insurance coverage available to the poor and ensuring that primary care has a strong presence, dedicating resources through social spending to stable housing, educational opportunities, nutrition, and transportation may reduce the demand for emergency, hospital, and long-term care services.

The United States could achieve the best-performing health care system in the world by undertaking coordinated efforts that address each of these challenges. Ensuring universal and adequate health insurance coverage, strengthening primary care, reducing administrative burden, and reducing income-related disparities by strengthening behavioral health and social service supports could go a long way toward improving the health of the U.S. population.

http://www.nejm.org…

***

Mirror, Mirror 2017: International Comparison Reflects Flaws and Opportunities for Better U.S. Health Care

By Eric C. Schneider, Dana O. Sarnak, David Squires, Arnav Shah, and Michelle M. Doty
The Commonwealth Fund, July 2017

The United States ranks last in health care system performance among the 11 countries included in this study. The U.S. ranks last in Access, Equity, and Health Care Outcomes, and next to last in Administrative Efficiency, as reported by patients and providers. Only in Care Process does the U.S. perform better, ranking fifth among the 11 countries.

http://www.commonwealthfund.org…

***

Comment:

By Don McCanne, M.D.

This NEJM Perspective article is based on the 2017 update of The Commonwealth Fund’s ranking of health care systems in eleven wealthy nations. Once again, the United states ranks last in overall performance, ranking at or near the bottom on access, administrative efficiency, equity, and health care outcomes.

Note particularly the four challenges described in the NEJM commentary: 1) Impaired access, 2) Underinvestment in primary care, 3) Pervasive administrative inefficiency, and 4) Disparities in the delivery of care. These are challenges for which a well designed single payer system would be ideally suited to address, but it must be part of a comprehensive public program addressing other factors contributing to our poor performance, especially in the need for social services.

Canada has a single payer system yet they rank ninth of the eleven systems. This is not a criticism of single payer financing itself, but rather it is a call to be certain that we elect public stewards who design and administer the single payer system with continuing oversight and appropriate intervention in not just the financing of the health care system but also in ensuring appropriate, comprehensive social services.

The authors of “Mirror, Mirror 2017” say that high performance can be achieved with any of three systems: national health service (United Kingdom), single payer (Australia, which requires supplemental insurance), and competing private insurers (Netherlands).

Well, the Netherlands, with its competing private insurers, ranks low in administrative efficiency. Australia requires a combination of public and private insurance and ranks low in equity, wherein varying ability to afford the private plans likely contributes to the inequity. The United Kingdom ranks first overall, but it is unlikely that Americans would support the transfer of our private health care delivery system to the government anytime soon.

So a well designed single payer system seems most appropriate for the United States, and the four challenges described make it clear that the need is urgent.

***

Speaking of a well designed single payer system, nobody has contributed more to our understanding of single payer and its role in achieving health care justice for all than have the co-founders of Physicians for a National Health Program – Steffie Woolhandler and David Himmelstein. Thus it is with great pride that we present the following announcement from Hunter College:

“Hunter College is proud to announce that David Himmelstein and Stephanie Woolhandler – esteemed teachers, brilliant scholars and front-line leaders in the field of public health – have been named Distinguished Professors by The City University of New York.

“’Nationally and around the world, Professors Himmelstein and Woolhandler are known and admired not only for their knowledge, research and expertise, but also for their forceful activism for quality health care,’ said Hunter President Jennifer J. Raab. ‘No one is more deserving of the designation ‘distinguished professor’ than these longtime collaborators.’”

http://www.hunter.cuny.edu…

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

Medicare ACOs Won’t Tell How They Pay Doctors

AJPH Study: Organizations contracting to care for millions of Medicare enrollees won’t disclose whether they penalize doctors for ordering tests, referrals or other expensive care

Public Citizen/PNHP, July 12, 2017

Ninety-one percent of the accountable care organizations (ACOs) that provide care to 9 million Medicare enrollees refuse to disclose their physician payment incentives, according to new research published today in the American Journal of Public Health. ACOs, similar to the HMOs of the 1990s, receive capitation-like payments and keep a portion of savings if they reduce patients’ use of care. Critics worry that ACOs, like HMOs, might pressure their doctors to deny needed care.

The research team from Montefiore Medical Center in New York, City University of New York at Hunter College and the national consumer group Public Citizen surveyed all 426 ACOs participating in Medicare in 2015. The survey asked how each ACO paid its primary care (PCP) and specialist physicians, and whether doctors were financially penalized for ordering tests or making referrals. Despite repeated email and mail surveys directed to the ACO’s designated public contact person, only 39 ACOs (9.2 percent of all those surveyed) provided any information on their physician payment policies.

Among the few ACOs that responded, 85 percent indicated that they tied PCPs’ compensation to quality metrics. Almost half said they offered doctors incentives to reduce care, via bonuses or financial penalties depending on how much care individual doctors ordered for their patients; other times, physician reimbursement was tied to the bonuses or penalties that ACOs received from Medicare.

The researchers noted that in the 1990s there was widespread concern that HMOs were denying patients needed care. This concern led the Centers for Medicare and Medicaid Services (CMS) to survey HMOs in the 1990s regarding their financial incentives and to require that Medicare HMOs publicly disclose those incentives. However, CMS has inexcusably waived the disclosure requirement for ACOs, which started contracting with Medicare in 2011 and, like HMOs, may gain financially by denying care.

“The lack of ACO transparency means that millions of Medicare patients can’t know how their doctors are being paid. Despite this, ACOs have garnered support from policymakers,” said study author Dr. Mayce Mansour, a primary care physician at Mount Sinai who was a lead author of the study and a resident at Montefiore when the study was initiated. “Since polls have shown that patients are wary of incentives for under-care, we wanted to learn more about compensation incentives that may drive physician behavior and could pose a conflict of interest.”

“Millions of Medicare patients now getting their care through ACOs would be anxious to know if their doctors have incentives to skimp on their care in order to do better financially,” said Dr. Sidney Wolfe, founder of and senior adviser to Public Citizen’s Health Research Group. “Most patients can’t currently find out about these incentives, and CMS’ failure to mandate their disclosure is unacceptable.”

“In 1995, I was fired by U.S. Healthcare — now called Aetna — for violating a ‘gag clause’ in my contract, and revealing that the HMO offered doctors big bonuses for denying care to our patients,” reported Dr. David Himmelstein, a distinguished professor at the City University of New York at Hunter College and lecturer in medicine at Harvard who was the study’s senior author. “In response to the ensuing public outcry, Medicare banned gag clauses and required HMOs to disclose how they pay physicians. The same rules should apply to ACOs, which are essentially the modern version of HMOs.”

Public Citizen
https://www.citizen.org…

PNHP
https://www.pnhp.org…

***

Accountable Care Organizations’ Payments to Physicians: Patients Should Have the Right to Know

By Mayce Mansou rMD, Nathan Favini MD, MS, Michael A. Carome MD, Sidney Wolfe MD, Steffie Woolhandler MD, MPH, and David U. Himmelstein MD
American Journal of Public Health (AJPH), August 2017 (online July 12, 2017)

http://ajph.aphapublications.org… (behind paywall)

***

Comment:

By Don McCanne, M.D.

As long as we leave our health care system under the control of the medical/industrial complex, things will never change. Apparently we didn’t learn much from the perversions of HMOs and the managed care revolution since we are granting similar rights to accountable care organizations (ACOs) that allow them to abuse the system and its patients.

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

Medicare For All Is Coming, No Matter What They Say

More than half of all Americans, 53 percent, now want a single-payer system.

By Richard Eskow
Moyers & Company, July 13, 2017

The idea of Medicare for all, or single-payer health care, has grown in popularity so quickly that it was recently an answer on the quiz show Jeopardy.

More than half of all Americans, 53 percent, now want a single-payer plan, up from 40 percent in 1998-2000.

But at the same time, Medicare for all suffers from the rise of a new growth industry: telling Americans what can’t be done to make their lives better. It seems like the nation that used to pride itself on its “can-do” spirit is constantly being told, “No, we can’t.” Why do critics oppose this idea, which could improve the lives of so many?
 
Bernie Opens the Door

Bernie Sanders’ presidential candidacy injected the single-payer idea into the political discourse. That created an opening for Democrats to embrace the idea as they seek to oppose Republican efforts to dismantle Obamacare. These include, significantly, Sen. Elizabeth Warren of Massachusetts.

“President Obama tried to move us forward with health care coverage by using a conservative model that came from one of the conservative think tanks that had been advanced by a Republican governor in Massachusetts,” Warren recently said. “Now it’s time for the next step. And the next step is single-payer.”

Yet even as the idea grows in popularity, opposition to it has become more vocal. Much of that opposition adopts the world-weary pose of the seasoned professional who has abandoned the idealism of his youth and is regrettably forced pass his disillusionment on to those who are more naïve.
 
Krugman for the Opposition

One example of this world-weary opposition is a 2016 column by economist Paul Krugman column entitled “Health Reform Realities.” Krugman argues that Obamacare is the left’s “biggest political success in almost half a century,” that “incumbent players” like insurance companies are “too powerful,” that there would be disruption in a switch to single-payer (more about that shortly), and that it would be “difficult to make that case to the broad public” that they will save more money from out-of-pocket health costs than they will spend in new taxes.

Krugman reiterates this argument in a recent op-ed, writing: “Most of the health economists I know would love to see single-payer — Medicare for all. Realistically, however, that’s too heavy a lift for the time being.”

Elsewhere, Krugman approvingly quoted Ezra Klein, another health care “realist,” for dismissing a major overhaul of the health system as “puppies and rainbows.” Condescending phrases like that are a key element of the “world-weary” style.

Krugman argues that Medicare for all is politically unachievable, despite its growing popularity. But when he’s confronted with a real political problem — Republican governors’ unwillingness to work with Obamacare’s Medicaid provisions — he waves the problem away, saying only that “Republicans show no interest in making that happen.”

A health plan whose ultimate success relies on cooperation from Republican politicians and for-profit insurance companies? Now that’s “puppies and rainbows.”
 
False Hopes

But then Krugman has been misjudging the politics of health care for at least a decade now. In the 2007 primaries, a mandate-driven plan much like “Obamacare” was proposed by John Edwards and quickly embraced by Hillary Clinton. Krugman insisted on characterizing it as “universal health coverage.” We chided him for it at the time, since it was always clear (or should have been) that many people would remain uninsured under such a program.

Krugman also misinterpreted a 2009 poll somewhat. The poll, conducted by The Boston Globe and the Harvard School for Public Health, found that 79 percent of Massachusetts residents wanted to keep the law. A closer reading indicated the political dangers facing Obamacare. Support for the law had begun to slip, even without the Republican onslaught that everyone should have seen coming at the national level. Residents were “evenly split” on whether the law could continue without changes. A majority wanted to see the law changed, with cost reductions being the primary concern.

Health care costs, even after the Affordable Care Act, are at crisis levels. The actuarial firm Milliman calculates that the average family of four with “good” employer-based PPO coverage will pay more than $11,000 in out-of-pocket expenses this year. So when Krugman writes that “most Americans under 65 are covered by their employers and are reasonably happy with that coverage,” and that “they would understandably be nervous about any proposal to replace that coverage with something else” — well, I wouldn’t be so sure about that.
 
The Trillion-Dollar Miscalculation

The Washington Post editorial board took a harder line than Krugman, weighing in recently with an editorial entitled, “Single-payer health care would have an astonishingly high price tag.” The “astonishing” figure is derived, not from a dispassioned analysis of all health plans, but from a single, highly controversial analysis of a single plan. The Urban Institute reviewed Bernie Sanders’ single-payer proposal in 2016 and concluded that it would increase government spending by $32 trillion over 10 years. Single-payer opponents have been citing that figure ever since.

But that figure is “ridiculous,” according to Steffie Woolhandler and David Himmelstein of the City University of New York School of Public Health and Harvard Medical School. In a detailed rebuttal, they note that the Urban Institute’s findings “project outlandish increases in the utilization of medical care, ignore vast savings under single-payer reform, and ignore the extensive and well-documented experience with single-payer systems in other nations — which all spend far less per person on health care than we do.”

The Post’s editors insist that “the public piece of the American health-care system has not proven itself to be particularly cost-efficient,” but this is misleading at best. Medicare, our country’s only nationally run health system, has much lower overhead costs and inflation rates than private-sector health care. You could even say they’re “astonishingly” lower:

Medicare’s overhead amounts to 2 percent of total costs, versus 12-14 percent for private insurers, while annual cost increases between 2010 and 2015 were 1.4 percent for Medicare and more than double that (3.0 percent) for private insurance.

It’s true that our government’s health care programs are costlier than their European equivalents. But what The Post’s editors fail to mention is that private profit-seeking is largely responsible for the additional cost. Medicare is forced to share the road with private-sector insurers who can drive rates up, especially when for-profit corporations are increasingly driving every aspect of treatment from hospital care to provider practice management. A single-payer health system could set rates and design treatment guidelines that are based on best practices and are subject to public debate, unlike private plans.
 
A Change is Gonna Come

The transition to a single-payer system will be complex, but despite what the no-can-doers say, it is achievable. None of the obstacles that are cited are insurmountable.

One-third of our health economy is already managed through government programs. Our best minds should be tackling the challenge of reforming the remaining two-thirds. We have already have built some of the infrastructure and expertise we will need.

Medicare for all is not only achievable. It’s inevitable. Health-care costs are already too high for most Americans, even those with “good” insurance. The demand for a better-run public system will only grow in the years to come.

It’s easy to understand why The Washington Post, with its history of hostility to social spending, would oppose Medicare for all. But why is there such entrenched opposition among some liberals? Some Democrats want to defend the Affordable Care Act out of loyalty, because it’s a Democratic program.

Some people have developed deep expertise in the current, flawed system. Consciously or unconsciously, they will be inclined to resist changes that render their knowledge obsolete. Other people want to be proven right about politics, and they’ve staked their reputation on claiming that single-payer is a “hard sell” because it will raise taxes.

Actually, it’s an easy sell: I can save you thousands of dollars a year by replacing a terrible system with a much better one. People say Medicare for all is “politically unfeasible.” But the past 10 years have taught us that it’s politically unfeasible to aim for anything less.

Many single-payer advocates are also defending the ACA today for a very simple reason: People will die if it’s repealed. But people are dying right now because we don’t have a national health care system.

The best way to defend the ACA is the way Bernie Sanders is doing it. Sanders is barnstorming the country condemning Republican plans to gut the law, a move that would cause tens of thousands of needless deaths to give millionaires and billionaires a tax cut. But he is also making it clear that the ultimate goal — the goal that reflects both the public’s needs and our shared progressive values — is Medicare for all.

Until we achieve health care for all, it’s our health itself that is in jeopardy.

http://billmoyers.com…

Medicare For All Is Coming, No Matter What They Say

More than half of all Americans, 53 percent, now want a single-payer system.

By Richard Eskow
Moyers & Company, July 13, 2017

The idea of Medicare for all, or single-payer health care, has grown in popularity so quickly that it was recently an answer on the quiz show Jeopardy.

More than half of all Americans, 53 percent, now want a single-payer plan, up from 40 percent in 1998-2000.

But at the same time, Medicare for all suffers from the rise of a new growth industry: telling Americans what can’t be done to make their lives better. It seems like the nation that used to pride itself on its “can-do” spirit is constantly being told, “No, we can’t.” Why do critics oppose this idea, which could improve the lives of so many?
 
Bernie Opens the Door

Bernie Sanders’ presidential candidacy injected the single-payer idea into the political discourse. That created an opening for Democrats to embrace the idea as they seek to oppose Republican efforts to dismantle Obamacare. These include, significantly, Sen. Elizabeth Warren of Massachusetts.

“President Obama tried to move us forward with health care coverage by using a conservative model that came from one of the conservative think tanks that had been advanced by a Republican governor in Massachusetts,” Warren recently said. “Now it’s time for the next step. And the next step is single-payer.”

Yet even as the idea grows in popularity, opposition to it has become more vocal. Much of that opposition adopts the world-weary pose of the seasoned professional who has abandoned the idealism of his youth and is regrettably forced pass his disillusionment on to those who are more naïve.
 
Krugman for the Opposition

One example of this world-weary opposition is a 2016 column by economist Paul Krugman column entitled “Health Reform Realities.” Krugman argues that Obamacare is the left’s “biggest political success in almost half a century,” that “incumbent players” like insurance companies are “too powerful,” that there would be disruption in a switch to single-payer (more about that shortly), and that it would be “difficult to make that case to the broad public” that they will save more money from out-of-pocket health costs than they will spend in new taxes.

Krugman reiterates this argument in a recent op-ed, writing: “Most of the health economists I know would love to see single-payer — Medicare for all. Realistically, however, that’s too heavy a lift for the time being.”

Elsewhere, Krugman approvingly quoted Ezra Klein, another health care “realist,” for dismissing a major overhaul of the health system as “puppies and rainbows.” Condescending phrases like that are a key element of the “world-weary” style.

Krugman argues that Medicare for all is politically unachievable, despite its growing popularity. But when he’s confronted with a real political problem — Republican governors’ unwillingness to work with Obamacare’s Medicaid provisions — he waves the problem away, saying only that “Republicans show no interest in making that happen.”

A health plan whose ultimate success relies on cooperation from Republican politicians and for-profit insurance companies? Now that’s “puppies and rainbows.”
 
False Hopes

But then Krugman has been misjudging the politics of health care for at least a decade now. In the 2007 primaries, a mandate-driven plan much like “Obamacare” was proposed by John Edwards and quickly embraced by Hillary Clinton. Krugman insisted on characterizing it as “universal health coverage.” We chided him for it at the time, since it was always clear (or should have been) that many people would remain uninsured under such a program.

Krugman also misinterpreted a 2009 poll somewhat. The poll, conducted by The Boston Globe and the Harvard School for Public Health, found that 79 percent of Massachusetts residents wanted to keep the law. A closer reading indicated the political dangers facing Obamacare. Support for the law had begun to slip, even without the Republican onslaught that everyone should have seen coming at the national level. Residents were “evenly split” on whether the law could continue without changes. A majority wanted to see the law changed, with cost reductions being the primary concern.

Health care costs, even after the Affordable Care Act, are at crisis levels. The actuarial firm Milliman calculates that the average family of four with “good” employer-based PPO coverage will pay more than $11,000 in out-of-pocket expenses this year. So when Krugman writes that “most Americans under 65 are covered by their employers and are reasonably happy with that coverage,” and that “they would understandably be nervous about any proposal to replace that coverage with something else” — well, I wouldn’t be so sure about that.
 
The Trillion-Dollar Miscalculation

The Washington Post editorial board took a harder line than Krugman, weighing in recently with an editorial entitled, “Single-payer health care would have an astonishingly high price tag.” The “astonishing” figure is derived, not from a dispassioned analysis of all health plans, but from a single, highly controversial analysis of a single plan. The Urban Institute reviewed Bernie Sanders’ single-payer proposal in 2016 and concluded that it would increase government spending by $32 trillion over 10 years. Single-payer opponents have been citing that figure ever since.

But that figure is “ridiculous,” according to Steffie Woolhandler and David Himmelstein of the City University of New York School of Public Health and Harvard Medical School. In a detailed rebuttal, they note that the Urban Institute’s findings “project outlandish increases in the utilization of medical care, ignore vast savings under single-payer reform, and ignore the extensive and well-documented experience with single-payer systems in other nations — which all spend far less per person on health care than we do.”

The Post’s editors insist that “the public piece of the American health-care system has not proven itself to be particularly cost-efficient,” but this is misleading at best. Medicare, our country’s only nationally run health system, has much lower overhead costs and inflation rates than private-sector health care. You could even say they’re “astonishingly” lower:

Medicare’s overhead amounts to 2 percent of total costs, versus 12-14 percent for private insurers, while annual cost increases between 2010 and 2015 were 1.4 percent for Medicare and more than double that (3.0 percent) for private insurance.

It’s true that our government’s health care programs are costlier than their European equivalents. But what The Post’s editors fail to mention is that private profit-seeking is largely responsible for the additional cost. Medicare is forced to share the road with private-sector insurers who can drive rates up, especially when for-profit corporations are increasingly driving every aspect of treatment from hospital care to provider practice management. A single-payer health system could set rates and design treatment guidelines that are based on best practices and are subject to public debate, unlike private plans.
 
A Change is Gonna Come

The transition to a single-payer system will be complex, but despite what the no-can-doers say, it is achievable. None of the obstacles that are cited are insurmountable.

One-third of our health economy is already managed through government programs. Our best minds should be tackling the challenge of reforming the remaining two-thirds. We have already have built some of the infrastructure and expertise we will need.

Medicare for all is not only achievable. It’s inevitable. Health-care costs are already too high for most Americans, even those with “good” insurance. The demand for a better-run public system will only grow in the years to come.

It’s easy to understand why The Washington Post, with its history of hostility to social spending, would oppose Medicare for all. But why is there such entrenched opposition among some liberals? Some Democrats want to defend the Affordable Care Act out of loyalty, because it’s a Democratic program.

Some people have developed deep expertise in the current, flawed system. Consciously or unconsciously, they will be inclined to resist changes that render their knowledge obsolete. Other people want to be proven right about politics, and they’ve staked their reputation on claiming that single-payer is a “hard sell” because it will raise taxes.

Actually, it’s an easy sell: I can save you thousands of dollars a year by replacing a terrible system with a much better one. People say Medicare for all is “politically unfeasible.” But the past 10 years have taught us that it’s politically unfeasible to aim for anything less.

Many single-payer advocates are also defending the ACA today for a very simple reason: People will die if it’s repealed. But people are dying right now because we don’t have a national health care system.

The best way to defend the ACA is the way Bernie Sanders is doing it. Sanders is barnstorming the country condemning Republican plans to gut the law, a move that would cause tens of thousands of needless deaths to give millionaires and billionaires a tax cut. But he is also making it clear that the ultimate goal — the goal that reflects both the public’s needs and our shared progressive values — is Medicare for all.

Until we achieve health care for all, it’s our health itself that is in jeopardy.

http://billmoyers.com…

Benefiting pharmaceutical rent seekers

The Private Equity Firm That Quietly Profits on Top-Selling Drugs

By Randall Smith
The New York Times, July 8, 2017

Cashing in on rising drug prices often unleashes an outcry from consumers and politicians.

But a little-known private equity investor, Royalty Pharma, has built an unusual investment portfolio valued at $15 billion — it buys up the rights to royalties on future drug sales — while largely avoiding public controversy. By its own count, Royalty Pharma owns partial rights to seven of the 30 top-selling drugs in the United States, including giants like Humira, the arthritis treatment that is the single biggest-selling medication in America. And its deals have been getting larger.

While Royalty Pharma has benefited by riding the rising tide of drug prices, the drug companies play the largest role in setting prices. George Lloyd, Royalty Pharma’s executive vice president and general counsel, said: “Royalty Pharma has no influence over how drugs in which it invests are priced. These prices are set by the marketer of the product, and we play no role in that process.”

To make big money on promising drugs, investors like venture capital firms and biotechnology funds typically place long-shot bets on drugs that are still in the development stage. Royalty Pharma, based in New York, steps in later in the game: It generally buys rights to the royalties on drugs that have already been approved for sale by regulators. It buys them from patent holders, often hospitals or universities, that want to convert their future royalties into cash right now.

Royalty Pharma has successfully created “a new segment of the investment management industry,” which has helped offset a decline in other types of funds for drug investments, said Andrew Lo, a finance professor at the Massachusetts Institute of Technology’s Sloan School of Management, in a 2014 study written with Sourya Naraharisetti of M.I.T. and Duke University.

Royalty Pharma’s revenues have risen an average of 30 percent annually, from $161 million in 2005 to $2.47 billion in 2016, according to company material.

https://www.nytimes.com…

***

Comment:

By Don McCanne, M.D.

As we look at some of the innovative approaches in health care financial management, we should always ask ourselves, how does this benefit the patient?

Here we have a financial intermediary placing bets that the pharmaceutical industry will continue to gouge its ultimate customers – the patients – using outrageous pricing practices for its pharmaceutical products. This intermediary provides us with a prime example of rent seeking – scooping up large amounts of funds without providing any tangible product.

And the benefit to the patient? None, but worse than that – the patient is harmed by having to pay higher prices, either directly or indirectly, when the entities pricing drugs include in their prices the funds drawn off by these superfluous intermediaries. Of course, there are many other useless intermediaries, not only in pharmaceuticals, but in the rest of the medical-industrial complex as well.

Isn’t it about time that we tailor our health care financing system to serve patients rather than rent seekers and others who drain our resources while shorting patients on essential health care services?

We desperately need to replace our dysfunctional health care financing system with a well designed single payer system. Instead of standing by and watching the politicians struggle with forcing upon us highly flawed health financing policies that cater especially to stakeholders, we should mobilize our forces of citizen action – now – because, if we don’t, they’re going to do it to us again.

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

Medicare ACOs Won’t Tell How They Pay Doctors: American Journal of Public Health Study

Organizations contracting to care for millions of Medicare enrollees won't disclose whether they penalize doctors for ordering tests, referrals or other expensive care

FOR IMMEDIATE RELEASE, July 12, 2017

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

WASHINGTON, D.C. – Ninety-one percent of the accountable care organizations (ACOs) that provide care to 9 million Medicare enrollees refuse to disclose their physician payment incentives, according to new research published in the American Journal of Public Health. ACOs, similar to the HMOs of the 1990s, receive adjusted per-person capitation-like payments and keep a portion of savings if they reduce patients’ use of care. Critics worry that ACOs, like HMOs, might pressure their doctors to deny needed care.

The research team from Montefiore Medical Center in New York, City University of New York at Hunter College and the national consumer group Public Citizen surveyed all 426 ACOs participating in Medicare in 2015. The survey asked how each ACO paid its primary care (PCP) and specialist physicians, and whether doctors were financially penalized for ordering tests or making referrals. Despite repeated email and mail surveys directed to the ACO’s designated public contact person, only 39 ACOs (9.2 percent of all those surveyed) provided any information on their physician payment policies.

Among the few ACOs that responded, 85 percent indicated that they tied PCPs’ compensation to quality metrics. Almost half said they offered doctors incentives to reduce care, via bonuses or withholds (financial penalties) on how much care individual doctors ordered for their patients; other times, physician reimbursement was tied to the bonuses or penalties that ACOs received from Medicare.

The researchers noted that in the 1990s there was widespread concern that HMOs were denying patients needed care. This concern led the Centers for Medicare and Medicaid Services (CMS) to survey HMOs in the 1990s regarding their financial incentives and to require that Medicare HMOs publicly disclose those incentives. However, CMS has inexcusably waived the disclosure requirement for ACOs, which started contracting with Medicare in 2011 and, like HMOs, may gain financially by denying care.

“The lack of ACO transparency means that millions of Medicare patients can’t know how their doctors are being paid. Despite this, ACOs have garnered support from policymakers,” said study author Dr. Mayce Mansour, a primary care physician at Mount Sinai who was a lead author of the study and a resident at Montefiore when the study was initiated. “Since polls have shown that patients are wary of incentives for under-care, we wanted to learn more about compensation incentives that may drive physician behavior and could pose a conflict of interest.”

Dr. Nathan Favini, also a lead author of the study, said, “The public’s trust is absolutely critical for any health reform effort to succeed. ACOs should learn from the backlash against HMOs, disclose how they pay their physicians and make sure their providers are not cutting back on necessary care.”

“Millions of Medicare patients now getting their care through ACOs would be anxious to know if their doctors have incentives to skimp on their care in order to do better financially,” said Dr. Sidney Wolfe, founder of and senior adviser to Public Citizen’s Health Research Group. “Most patients can’t currently find out about these incentives, and CMS’ failure to mandate their disclosure is unacceptable.”

“In 1995, I was fired by U.S. Healthcare — now called Aetna — for violating a ‘gag clause’ in my contract, and revealing that the HMO offered doctors big bonuses for denying care to our patients,” reported Dr. David Himmelstein, a distinguished professor at the City University of New York at Hunter College and lecturer in medicine at Harvard who was the study’s senior author. “In response to the ensuing public outcry, Medicare banned gag clauses and required HMOs to disclose how they pay physicians. The same rules should apply to ACOs, which are essentially the modern version of HMOs.”

*****

“Accountable Care Organizations’ Payments to Physicians: Patients Should Have the Right to Know,” by Mayce Mansour, M.D., Nathan Favini, M.D., M.S., Michael A. Carome, M.D., Sidney Wolfe, M.D., Steffie Woolhandler, M.D., M.P.H., and David U. Himmelstein, M.D. American Journal of Public Health.  Published online July 12, 2017.  A copy of the study is available to members of the media by contacting clare@pnhp.org.

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.

Medicare for all: The best replacement for Obamacare

By Justine McCabe, Ph.D., and John R. Battista, M.D.
Connecticut Viewpoints, July 12, 2017

The only viable solution to our ongoing national healthcare crisis has waited in the wings for a long time. Teddy Roosevelt included the idea in his 1912 platform. President Truman proposed it in 1945. President Johnson succeeded – partly – with Medicare. Now more than ever, single-payer national health insurance needs to move to the national stage for serious consideration.

Significantly, there is, again, growing public support for single payer. An April Economist/YouGov poll found that a majority of Americans support “expanding Medicare to provide health insurance to every American.” Last year, Gallup polling found 58 percent of Americans support replacing the ACA with a federally funded health insurance system for all.

Indeed, our CT Democratic legislators should take notice: in a 6/23/17 Pew poll, 52 percent of Democrats, 64 percent of liberal Democrats, and “Fully 66 percent of Democrats and Democratic leaners ages 18 to 29” support a single national health insurance system. An April survey found nearly half of physicians supported single payer, particularly because of its time-saving simplicity relative to the current multi-payer, for-profit system.

As health caregivers, our experience reflects public support for single-payer system despite an unresponsive federal government. For example, in 2000, we introduced a single-payer bill to the Connecticut General Assembly, “The CT Health Care Security Act.” Strikingly, people – often in other legislative hearings – showed up in large numbers to support our bill then before the Labor Committee (where it was passed, before dying). The CT Human Services Committee audience literally broke into applause at our suggestion that the committee reject proposed changes to Medicaid and transform the program into single-payer insurance for the state.

Yet, despite strong public support for single payer, our federal government has tried to suppress it, dismissing this option during the ACA hearings of 2009: no single-payer advocate was included in then-U.S. Sen. Max Baucus’ (D-Montana) health care hearings despite support by 60 percent of Americans. Those trying to speak from the audience were arrested.

Our government has even tried to hide public support. In our 2006 op-ed in The Hartford Courant (“Seeking Coverage for All”) we described a government-sponsored task force charged with seeking Americans’ opinion on improving our health care system. It found that people around the country – including CT – overwhelmingly supported a national health insurance program. Connecticut respondents ranked national health insurance first over all other possible reforms. Yet, in their final report (September 2006) this “Citizens’ Health Care Working Group” excluded citizens’ choice – single payer – from their recommendations to Congress.

Senate Republicans have tabled a vote on their approach to replacing the Obamacare/Affordable Care Act (ACA). A June PBS/Marist national poll reveals that only 17 percent of Americans approve of what they’ve seen of the plan – with good reason. According to the Congressional Budget Office, 22 million Americans would lose health insurance under this Republican proposal.

Moreover, according to the Centers for Disease Control, there are still another 28.6 million people with no health insurance despite the ACA. If the Republican bill passes, we, the wealthiest country in the world, would have 50 million people – about 16 percent of the population – without health insurance. That means less primary care, increased use of expensive “ER care,” as well as an increase in mortality associated with being uninsured. And even if our health care financing system remains the ACA, national health care expenditures are projected to increase from 17 to 20 percent of GDP by 2025 according to the actuaries of the Centers for Medicare and Medicaid Services (CMS).

Let’s face it. Our current health care financing system is simply incapable of containing costs.

How do we solve the two main problems constituting our health care crisis: lack of universality and uncontainable costs? For-profit private health system will never solve either of these central issues.

We need a paradigm change.

Single payer resolves these problems. Precisely because it is not-for-profit, unlike private health insurance, it does not spend 18 cents of each health dollar on administrative costs – advertising/marketing, policy underwriting, multimillion-dollar executive compensation, profits for investors. By contrast, Medicare, a single-payer system, is highly efficient with about 2 percent administrative cost.

So savings from our for-profit health care system to single payer could provide health insurance for everyone and keep costs down not only by eliminating the inherently high administrative costs of private health insurance, but also by negotiating global hospital budgets and prescription drugs in bulk. Single-payer systems succeed primarily because they spread risk across the whole population. Such a vast pool includes both young and old, healthy and ill, recognizing the reality that everyone eventually gets sick; everyone eventually dies.

Advocates of for-profit health insurance will tell you that we have the best health care in the world. True but only if you can pay for it. In reality, the U.S. spends twice as much as developed nations with national health insurance – we spend the most per capita anywhere – $9,237 – yet we have poorer health outcomes. For example, the U.S. ranks 12th in life expectancy among the 12 wealthiest industrialized countries, according to the Kaiser Foundation.

Single-payer health insurance, like Medicare, is not socialized medicine. It is a health insurance payment mechanism not a health delivery plan. Such a system would not own hospitals, or employ doctors and nurses. Like Canada’s national health insurance program, single payer/Medicare-for-all would continue the U.S. tradition of fee-for-service with choice of any willing provider. Imagine the boon to small businesses if every individual already had health insurance; for people who keep dissatisfying jobs just to keep their health insurance.

The current Republican challenge to the ACA provides another opportunity for Americans to insist on a health care plan that provides insurance for everyone while containing costs. Let’s insist that our representatives transform Medicare to Medicare-for-All.

Justine McCabe, Ph.D., is a clinical psychologist, and John Battista, M.D., is a psychiatrist at Riverbend Psychiatric Associates in New Milford.

https://ctviewpoints.org…

Medicare for All wins backing of conservative Southern Democrats

By Sue Sturgis
Facing South, July 12, 2017

As congressional Republicans try to pass an unpopular plan that would roll back the Affordable Care Act (ACA) and cause an estimated 22 million Americans to lose their health insurance, a House bill to expand the publicly-funded Medicare program from just senior citizens to every American is picking up record support — and not just among the usual progressive suspects but also from conservative Southern Democrats.

First introduced in 2003 by Rep. John Conyers, a Michigan Democrat and Congress’s longest-serving member, the Expanded and Improved Medicare for All Act (H.R. 676) would provide every U.S. resident with free medically necessary care including primary care and prevention, dietary and nutritional therapies, prescription drugs, emergency care, long-term care, mental health services, dental services and vision care.

It would be paid for with existing health care funds and by raising personal income taxes on the top 5 percent of income earners, instituting a progressive excise tax on payroll and self-employment income, and taxing unearned income and stock and bond transactions. U.S. Sen. Bernie Sanders (I-Vermont), who advocated for single-payer insurance during his unsuccessful 2016 presidential run, has said he will introduce similar legislation in the Senate following the vote on the Republican ACA rollback plan.

Medicare for All has the backing of numerous medical groups such as the American Nurses Association, the American Public Health Association and the American Medical Association’s student branch. Other groups that have endorsed it include the Consumer Federation of America, the League of Women Voters and the U.S. Conference of Mayors.

During the last Congress, Conyers’ bill picked up 62 cosponsors, all Democrats. Seven months into this Congress, it already has 113 cosponsors — a majority of the 193-member Democratic caucus.

That surge in support has come amid a public debate over health care that’s shifted the politics leftward. For example, a recent national survey by the Pew Research Center found that 60 percent of Americans now say the federal government should be responsible for ensuring health care coverage for all and 33 percent favor a single-payer approach like Medicare for All — up by 12 points since 2014 and 5 points just since January.

“I have never seen more enthusiasm and energy behind this issue than what I’m seeing today,” Conyers said in a statement. “I will keep introducing this bill as long as it takes because access to health care — not just health insurance, but quality, affordable care — is a universal right, not a privilege for those who can afford it.”

Blue Dogs sign on

The Medicare for All bill has long had strong support from Conyers’ fellow Congressional Black Caucus members and House progressives, and it continues to pick up new support among liberal and centrist Democrats.

For example, Rep. David Price of North Carolina’s 4th Congressional District — a safely Democratic district that includes parts of Raleigh and Durham and all of Chapel Hill — signed on as a cosponsor for the first time on April 3. That was less than a month after he told a constituent at a local town hall meeting where health care was a leading concern that now was not the time to press the single-payer option. Price spokesperson Lawrence Kluttz explained the lawmaker’s change of heart.

“Congressman Price co-sponsored the so-called Medicare for All bill in direct response to a request from his constituents; he also feels that it’s important to signal his support for universal health care,” Kluttz told Facing South. However, he noted, Price doesn’t believe the proposal is feasible under GOP leadership and intends to focus on defending the protections of the ACA.

Though Medicare for All might not be feasible right now, it’s starting to win over a tough crowd: conservative Democrats from red states in the South.

Of the bill’s 113 current cosponsors, four are members of the conservative Democrats’ Blue Dog Coalition. Two of them — Mike Thompson and Lou Correa — represent districts in California, which has been leading the state-level push for a single-payer health program, though the proposal was blocked recently by the Democratic leadership.

The other two Blue Dogs cosponsoring Medicare for All are from the South. Vicente Gonzalez, who was elected last year to represent South Texas’ 15th Congressional District, signed on on April 17. Jim Cooper, who has represented Middle Tennessee’s 5th Congressional District since 2003 and who served its 4th Congressional District from 1983 to 1995, signed on on April 25. Both seats are considered safely Democratic.

Neither Gonzalez nor Cooper released official statements announcing their cosponsorship. A spokesperson for Gonzalez’s office said on background that the congressman signed on after hearing concerns about health care from older constituents, while Cooper’s office did not immediately respond to a request for comment. But conditions in their districts and states, both of which declined to expand Medicaid under the ACA, offer clues as to why they might see a need for Medicare for All.

Gonzalez’s district stretches from east of San Antonio south to the Mexican border and is 80 percent Hispanic. Between 2013 and 2015, with the ACA in force, the number of uninsured residents there dropped by 13 percent, but 205,000 still lacked health coverage, according to the State Health Access Data Assistance Center (SHADAC). The Republican health care plan would result in an additional 105,000 district residents losing coverage, an analysis by the Center for American Progress (CAP) found.

The population of Cooper’s district, which includes Nashville and communities west of the city, is over 23 percent black compared to 17 percent of the state overall. The number of uninsured district residents dropped by over 22 percent between 2013 and 2015, but more than 92,000 still lacked health insurance, according to SHADAC. Under the current Republican health care proposal, the number of uninsured in the district could grow by 79,600, CAP found.

Cooper, who has called the GOP health care bill “a national tragedy,” has not always been a progressive on health care. In 1992, he was the co-author of a bipartisan health care reform plan that excluded employer mandates compelling universal coverage. Hillary Clinton, who at the time was leading a White House health care reform initiative as First Lady, strongly opposed the measure.

GOP goes on the attack

Other Southern Democrats who’ve signed on to the Medicare for All bill for the first time this year are Kathy Castor, Ted Deutch, Al Lawson and Darren Soto of Florida; Bennie Thompson of Mississippi; G.K. Butterfield of North Carolina; and Gene Green and Marc Veasey of Texas.

They join veteran Southern cosponsors Alcee Hastings and Frederica Wilson of Florida, Hank Johnson and John Lewis of Georgia, John Yarmuth of Kentucky, Alma Adams of North Carolina, Jim Clyburn of South Carolina, Steve Cohen of Tennessee, Al Green and Sheila Jackson Lee of Texas and Bobby Scott of Virginia.

Physicians for a National Health Plan (PNHP), which advocates for the Medicare for All proposal, has unveiled a list of likely and potential cosponsors. It includes two Blue Dog Democrats from the South, both representing Georgia: Sanford Bishop, who has served southwest Georgia’s 2nd Congressional District since 1993, and David Scott, who has represented suburban Atlanta’s 13th Congressional District since 2003.

The other likely Democratic cosponsors as identified by PNHP are Terri Sewell of Alabama, Lois Frankel of Florida, Cedric Richmond of Louisiana and Eddie Bernice Johnson of Texas.

PNHP also identifies 19 potential Republican cosponsors, four of whom are from the South: Carlos Curbelo and Ileana Ros-Lehtinen of Florida, Will Hurd of Texas and Barbara Comstock of Virginia. While Curbelo voted for the House ACA repeal bill, the other three voted against it.

For Comstock, for example, taking a more progressive stance on health care could be a political survival strategy in Northern Virginia’s increasingly moderate 10th Congressional District, where Clinton won 51 percent of the vote in last year’s presidential race. While the possibility of GOP lawmakers embracing Medicare for All might seem remote, another recent poll found that 40 percent of Trump voters and 46 percent of Republican voters overall support expanding Medicare to all Americans.

As the single-payer approach has gained popularity, the GOP has taken steps to discredit it. Earlier this month, the party’s Senate campaign committee launched Web ads against the 10 Senate Democrats up for re-election in states that Trump won, warning of “government health care” if they win. And the National Republican Congressional Committee has promoted a CNN interview in which Randy Bryce, an ironworker who’s challenging Speaker Paul Ryan for his Wisconsin House seat, was pressed about his support for a single-payer plan and the taxes it would require; the interviewer did not mention that Medicare for All would actually save money for 95 percent of U.S. households.

In the meantime, the Republican Party continues to struggle to win support for its own health care plan. Senate Majority Leader Mitch McConnell of Kentucky was unsuccessful in his efforts to take a vote before the July 4 recess, allowing time for concerned voters to reach out to their representatives at home. While he can afford to lose only two of his 52 Republican senators, 10 GOP senators have said publicly that they oppose the bill in its current form. They include Rand Paul of Kentucky, Ted Cruz of Texas and Shelley Moore Capito of West Virginia.

https://www.facingsouth.org…