PNHP

Universal coverage should be health goal

Universal coverage should be health goal

By Richard A. Damon, M.D.
The Billings (Mont.) Gazette, June 21, 2017

Everyone knows the Senate is trying to ram through their version of the GOP House health care bill called the American Healthcare Act behind closed doors and in secret. Both political parties routinely resort to underhanded ways to gain political advantage, placing party politics before population.

Gov. Steve Bullock, along with three other Democratic governors and three Republican governors, is urging the Senate to rethink the health care bill, which as yet has not been scored by the CBO. McConnell hopes to pass the Senate version before Americans can respond to knowing the devastating impact the bill will have on millions of Americans while giving tax breaks to the wealthiest Americans.

Major health insurers are fleeing the ACA market. The underlying reasons we are in crisis are that for-profit health insurers and drug maker stakeholders remain in legislative control of health care policy. There is no legislative congressional admission that the reasons for the health care crisis is because of the private insurer multi-payer system, while drug makers continue to be exempt from drug price regulation.

Transition to a Medicare for All single payer system, funded by modest equitable taxes, would initially be cost neutral because of increased expansion of coverage to every American. After initial transition costs, every American from birth to death would enjoy comprehensive benefits, saving over $450 billion a year in administrative costs, making Medicare for All an equitable sustainable system. We must not allow Congress to pass the underhanded, perverse bill excluding 23 million Americans from coverage and giving tax breaks to the wealthy.

http://billingsgazette.com…

Universal coverage should be health goal

By Richard A. Damon, M.D.
The Billings (Mont.) Gazette, June 21, 2017

Everyone knows the Senate is trying to ram through their version of the GOP House health care bill called the American Healthcare Act behind closed doors and in secret. Both political parties routinely resort to underhanded ways to gain political advantage, placing party politics before population.

Gov. Steve Bullock, along with three other Democratic governors and three Republican governors, is urging the Senate to rethink the health care bill, which as yet has not been scored by the CBO. McConnell hopes to pass the Senate version before Americans can respond to knowing the devastating impact the bill will have on millions of Americans while giving tax breaks to the wealthiest Americans.

Major health insurers are fleeing the ACA market. The underlying reasons we are in crisis are that for-profit health insurers and drug maker stakeholders remain in legislative control of health care policy. There is no legislative congressional admission that the reasons for the health care crisis is because of the private insurer multi-payer system, while drug makers continue to be exempt from drug price regulation.

Transition to a Medicare for All single payer system, funded by modest equitable taxes, would initially be cost neutral because of increased expansion of coverage to every American. After initial transition costs, every American from birth to death would enjoy comprehensive benefits, saving over $450 billion a year in administrative costs, making Medicare for All an equitable sustainable system. We must not allow Congress to pass the underhanded, perverse bill excluding 23 million Americans from coverage and giving tax breaks to the wealthy.

http://billingsgazette.com…

Burden of prior authorization getting worse

Payer prior authorization requirements on physicians continue rapid escalation: increasing practice overhead and delaying patient care

MGMA Poll, May 16, 2017

Medical practice leaders say that the burden of submitting prior authorization requests and supporting documentation to health plans is getting worse.

A May 16 MGMA Stat poll found 86% of respondents saying that prior authorization requests have increased in the past year, while 3% report those requests decreasing and another 11% saying they’ve stayed the same in the past year.

Agreements between health plans and their participating physicians routinely include a statement that the insurer has the right to determine the medical necessity of surgery, imaging studies, medication and many other procedures. Physician practices then devote clinical and administrative staff time and resources to submit preauthorization requests for each service, increasing overhead and often delaying patient care.

“Health plan demands for prior approval for physician-ordered medical tests, clinical procedures, medications, and medical devices ceaselessly question the judgement of physicians, resulting in less time to treat patients and needlessly driving up administrative costs for medical groups,” said Halee Fischer-Wright, MD, MMM, FAAP, CMPE, MGMA President and CEO.

http://www.mgma.com…

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Comment:

By Don McCanne, M.D.

Prior authorization requirements have always been a pain, and now, according to this poll, they’re getting worse. Not only do they add to our profound administrative waste in health care, they also may interfere with patient care by delaying or even preventing the delivery of appropriate services. They also waste valuable time of physicians and their staffs.

This report states, “Agreements between health plans and their participating physicians routinely include a statement that the insurer has the right to determine the medical necessity of surgery, imaging studies, medication and many other procedures.” Really? Insurers and other intermediaries have the right to determine medical necessity? Doesn’t that right belong to the patients in consultation with their health care professionals? Sure, insurers make payment decisions, and prior authorization may prevent retroactive denial of coverage. But how can they have to gall to usurp clinical judgment?

But suppose the services are unnecessary. Wouldn’t it be better to identify outliers and then attempt to educate them, reserving penalties for those remaining refractory to educational efforts? Taiwan has shown that that can work with a single payer system.

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

The Washington Post Is Selling Snake Oil

Our friends at the Washington Post are waging a brave campaign against Medicare for All.

By Adam Gaffney, M.D.
Jacobin, June 20, 2017

Over the weekend, the Washington Post editorial board took a bold stance: they argued that universal health care with single-payer financing is simply beyond reach.

That the Post felt the need to issue the editorial at this particular moment is a testament to single payer’s rising fortunes. From coast to coast, activists are on the march: against the widely loathed, upward-wealth-redistributing, health-care-stripping abomination known as Trumpcare, for sure — but also for real universal health care.

Yet the Post’s frail arguments should be confronted, because they repeat a number of common talking points that rest on flawed assumptions and that could do real harm.

The Post editorial board begins by briefly conceding that single payer does have “some strong advantages.” It notes that single payer would be less of a hassle for many people (a good point), that it would get employers out of the messy role of providing health-care benefits (reasonable), and finally that it would facilitate cost-effectiveness research by government investigators (fine I suppose, although this is unlikely to galvanize the average person).

At the same time, however, the Post entirely neglects any of single payer’s actual “strong advantages”: the elimination of uninsurance (28.6 million uninsured in 2016), the ending of underinsurance (most single-payer proposals and bills say that care will be free at point-of-use), or the expansion of health-care benefits (for example, long-term care and dental care).

After neglecting to mention the benefits that actually animate most single-payer advocates, the Post proceeds to critique what it views as single payer’s “astonishing” price tag. It notes that while single-payer proponents point to the much less expensive public health-care systems of other nations, public health-care spending in the United States is already quite high:

The public piece of the American health-care system has not proven itself to be particularly cost-efficient. On a per capita basis, US government health programs alone spend more than Canada, Australia, France and Britain each do on their entire health systems. That means the US government spends more per American to cover a slice of the population than other governments spend per citizen to cover all of theirs.

At first glance it seems here that the Post is making something of an argument for single payer, arguing — as colleagues have put it — that we are already “Paying For National Health Insurance — And Not Getting It.” But they aren’t. They are contending that US public health-care spending is inefficient relative to international comparators, so making the whole system public wouldn’t bring costs in line with other nations.

Now they are right that transitioning to single payer would not reduce US health-care spending, as a percentage of GDP, to the levels seen in the United Kingdom (nor would we want it to: the UK is currently spending too little on its National Health Service).

Nonetheless, the underlying logic of the editorial board’s argument is still very flawed. The Post fails to acknowledge a widely known fact: Medicare is run at a far lower rate of overhead as compared to private insurers, while a single-payer system would produce additional efficiencies throughout the system via reduced spending on administration and billing. Even if we didn’t reduce overall health-care spending through Medicare for All, there would still be enormous savings from the transition that we could use to cover single payer’s costs: more than $500 billion annually, by one estimate.

After essentially dismissing this as a source of savings, the Post proceeds to assert that if single payer is to wring any real savings out of the system, they will be by necessity painful and divisive. Here it engages in a divide-and-conquer approach which we will likely see more of in coming days: doctors will have to be paid less, rural America will have to give up its “expensive medical facilities that serve relatively few people,” and “patients would have to accept different [i.e. worse] standards of access and comfort.”

This is nonsense. Canadian doctors get reimbursed perfectly well for their labor. Rural areas might actually be better served, not worse, under a national health program (NHP) that consciously plans the construction of new health-care capital. And the whole point of single payer is to improve access for all patients: as we replace insurance networks with “one big network” of NHP providers, and eliminate uninsurance and underinsurance, barriers to care — financial and otherwise — will decline.

The editorial concludes by noting that “universal coverage” and controlling costs should still remain the goal, albeit within the edifice of the “Obamacare system.” Yet they neglect to demonstrate how any incremental reforms would actually take us to universal coverage.

The fact is, the major added cost of single payer is the price of covering the uninsured and expanding coverage for the rest of us. So if universal health care is “too expensive” with single-payer financing — with its widely agreed upon efficiencies and capacity to substantially reduce drug prices — it would be absolutely too expensive to attain without it.

It’s Washington Post editorial board writers — not single-payer proponents — that are selling snake oil.

https://jacobinmag.com…

New survey shows a majority of Chicago-area doctors support Medicare for all

90% of regional physicians believe that health care is a basic human right

FOR IMMEDIATE RELEASE, June 20, 2017

For a copy of the report please contact: Clare Fauke, communications specialist, Physicians for a National Health Program, clare@pnhp.org or 312-782-6006

A new poll of more than one thousand Chicago-area physicians finds that a majority support a universal, single-payer health system and an overwhelming number reject the American Health Care Act (AHCA), the Republican House plan to repeal and replace the Affordable Care Act (ACA). Chicagoland physicians prefer a single-payer plan two-to-one over the ACA, and three-to-one over the AHCA. By similar margins, physicians believe that improved Medicare for all is a preferable health financing system over both the ACA and the AHCA. The study was conducted in April and May by the Chicago Medical Society, which represents 17,000 physicians serving more than five million patients in the Chicago area.

The study’s key findings include:

  • Nearly 90% of respondents agreed that health care is a human right that should be made available to all individuals, similar to basic education, police and fire protection (70% agreed strongly and 18% agreed somewhat).
  • Asked to choose which proposal would provide “the best care to the greatest number of people for a given amount of funding,” 56% chose single-payer/improved Medicare for all, 26% chose the ACA and 18% chose the AHCA.
  • When asked to provide their views of competing health care systems, single payer was viewed favorably by 67% of doctors, the ACA was viewed favorably by 63% of doctors, and the AHCA was viewed favorably by only 23%.

“Because of our profit-driven, multi-payer health system, doctors are spending hours each day on paperwork and billing, hours that could have been spent on patient care,” said Claudia Fegan, M.D., a Chicago-based physician and national coordinator for Physicians for a National Health Program (PNHP). “Not surprisingly, a growing number of health care providers reject the AHCA and support the simplicity and efficiency of improved Medicare for all.”

Dr. Fegan notes that in contrast to the AHCA, H.R. 676, the Expanded and Improved Medicare for All Act, would provide immediate, comprehensive coverage to all Americans and yield more than $500 billion dollars in yearly administrative savings. H.R. 676 has gained a record 112 co-sponsors, which represents a majority of House Democrats.

PNHP encourages medical associations to respect the opinions of their members and formally support Medicare for all. At the recent meeting of the American Medical Association in Chicago, the AMA’s Medical Student Section unanimously adopted a resolution called “National Healthcare Finance Reform: Single Payer Solution” to “support the implementation of a national single payer system.”

Physicians for a National Health Program (www.pnhp.org) is a nonprofit research and educational organization of more than 21,000 doctors who support a single-payer national health program. PNHP had no role in funding or otherwise supporting the study described above.

Even the insured line up for charity

Even the Insured Often Can’t Afford Their Medical Bills

By Helaine Olen
The Atlantic, June 18, 2017

The current debate over the future of the Affordable Care Act is obscuring a more pedestrian reality. Just because a person is insured, it doesn’t mean he or she can actually afford their doctor, hospital, pharmaceutical, and other medical bills. The point of insurance is to protect patients’ finances from the costs of everything from hospitalizations to prescription drugs, but out-of-pocket spending for people even with employer-provided health insurance has increased by more than 50 percent since 2010, according to human resources consultant Aon Hewitt.

Even a gold-plated insurance plan with a low deductible and generous reimbursements often has its holes. Many people have separate—and often hard-to-understand—in-network and out-of-network deductibles, or lack out-of-network coverage altogether. While many plans cap out-of-pocket spending, that cap can often be quite high—in 2017, it’s $14,300 for a family plan purchased on the ACA exchanges, for example. Depending on the plan, medical care received from a provider not participating in a particular insurer’s network might not count toward any deductible or cap at all.

The fact is that nearly any illness or injury can lead to unexpected bills, and few are able to absorb those shocks without difficulty. Yet, despite the commonness of such problems, there is little in the way of a system for helping people out through these times.

(The article discusses a multitude of funds with a mission to assist patients in paying their medical bills. The following comments are typical about many of these funds.)

The evidence is clear when you visit the websites of the funds. The Patient Advocate Foundation’s chronic pain fund? Its aid is limited to $1,500 and you need to apply when it’s taking applications. “Effective 01/18/2017, we are unable to process applications that are pending or accept new or renewal applications at this time. Should additional funding for Chronic Pain Fund applicants become available in the future, it will be necessary to re-apply if assistance is still needed.” The Patient Advocate Foundation’s multiple-sclerosis and renal-cell-carcinoma funds have been closed to new applicants since 2016.

And even when medical supplicants find programs, they are not guaranteed aid even if they meet all the eligibility requirements. “Then you call these services, not just for medical help, but any help. They tell you, ‘Oh, you have to hit us on this date,’ or ‘We get funding every month, but our funding is gone by the fifth of the month.’”

As for hospital-based charity, it can vary widely. Most studies find for-profit hospitals provide less charity care than nonprofit medical centers. But getting aid from a non-profit hospital isn’t exactly a gimme. A paper published by the Brookings Institution in 2015 pointed out that the non-profit hospitals with the most funds that could be devoted to charity care—that is, covering or forgiving medical bills of those who cannot pay full—are not located in the geographic areas where the need is greatest.

In an effort to cut down on uncollectable bills, a number of hospitals are now teaming up with financial services firms like Commerce Bank to offer time-limited interest free loans to patients something that, while helpful to some, most certainly is not charity.

Little wonder, then, that an increasing number of patients turn to crowdfunding even before they investigate more established charitable giving programs.

Yet for all the attention paid to crowdfunding, the limited evidence we have shows that for most people, the hype is better than the actual results.

(Ethan Austin, the co-founder of Give Forward) spoke to a group of students at New York University’s Stern School of Business about his (crowdfunding) site. He was blunt about one of the reasons he believed this segment of the online fundraising world had taken off so dramatically. “Our health-care system is shit and it’s trending shittier,” he told the group.

But there is more than simple embarrassment arguing against this system. It’s the equivalent of taping a few bandages over a gaping wound and hoping for the best. The cost of medical care is so high, and the personal finances of many Americans so tight,  it’s all but impossible for any organization—or all of them—to keep up, and that’s whether or not the charitable contributions they accept are part of the problem or the solution.

https://www.theatlantic.com…

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Comment:

By Don McCanne, M.D.

You really don’t need a long article like this to understand that our current health care financing system falls far short of preventing financial hardship for many with health care needs, insured or not, and that our various charitable resources hardly make a dent in the need.

We need a health care financing system that ensures access for all while eliminating financial barriers to care. Patches to the current fragmented system will do neither. A well designed single payer system – an improved Medicare for all – would fix the system so it works well for all of us. That’s what the people want. So let’s do it.

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

The advantages of getting sick elsewhere

By Louis Balizet, M.D.
The Pueblo (Colo.) Chieftain, Jun 17, 2017

Last month, a Pueblo woman, while on vacation far from home, developed chest pain, cough and shortness of breath.

She had had blood clots in her lungs previously, and feared a recurrence of this potentially deadly condition.

An ambulance was called and arrived in 20 minutes, having been dispatched from the local hospital. This was soon followed by another vehicle carrying a doctor, who assessed the woman inside the ambulance.

Her physical examination revealed severe bronchospasm (tightening and narrowing of the air tubes in the lungs). Medicines to reverse the bronchospasm were administered via nebulizer; an EKG was done; and the ambulance driver was directed to proceed to the emergency room, where another doctor assumed care. Blood tests, a chest X-ray, and a follow-up EKG were performed.

The emergency room doctor concluded that the woman’s condition was due to severe asthmatic bronchitis, with recurrent lung clots ruled out by one of the blood tests. Intravenous steroids, intravenous antibiotics and additional nebulizer treatments were administered.

After seven hours in the ER, the woman’s condition had improved, but not enough to permit discharge. She was admitted to an adjacent six-bed observation unit, where a third physician (like the first two, a woman) took over, and continued the regimen started in the ER.

After 12 hours in the observation unit, she had improved enough to be discharged, with prescriptions for oral steroids, oral antibiotics and asthma medicines to be administered by nebulizer.

After she was settled back in her hotel, the woman’s husband went to a nearby pharmacy and walked out 10 minutes later with her medicines and a rented nebulizer. The woman gradually improved and after four days was able to resume her vacation schedule.

The bill for the ambulance and hospital services, including all tests and physicians’ fees, was $137. The pharmacy bill came to $38; for locals, there would have been no charge.

In what fantasy land did this episode take place? It was no fantasy — it was Italy. I know, because the woman is my wife.

Why was my wife’s care not accompanied by a backbreaking and complicated bill, as it would have been here in the U.S.? Because Italy, along with every developed country except ours, has made a societal decision that needed medical care should be provided to all residents without crushing financial consequences to the sick person, and that the national government should guarantee, finance and organize this care.

The efficiencies that result enable Italy to cover everybody for a fraction of what we pay with equal, if not superior, outcomes.

Italy spends $3,272 per capita for medical care; we spend $9,471. Italians have a life expectancy of 82 years; ours is 79. At an individual level, my wife’s care in Montepulciano, Italy, was at least equivalent to what she would have received in Pueblo.

Since a system like Italy’s (or Canada’s, or Australia’s, or Germany’s) is so superior to ours, why don’t we change?

Despite the perils for individual patients, there are some that are doing very well under the status quo — chiefly medical insurers and pharmaceutical companies. These entities enjoy privileged and protected status in the American system that they don’t elsewhere. They also have the political, financial, and public relations resources to thwart any move to a system that favors them less.

With Obamacare threatened by internal structural weaknesses and external political attacks, we should be looking for alternatives. Other countries, like Italy, offer guidance about how to achieve universal, economical and effective medical care.

Our health care debate would profit from “A Taste Of Italy.”

http://www.chieftain.com…

Single payer systems have lower drug spending than do multi-payer systems

Drivers of expenditure on primary care prescription drugs in 10 high-income countries with universal health coverage

By Steven G. Morgan, PhD, Christine Leopold, PhD, Anita K. Wagner, PharmD, DrPH
CMAJ, June 12, 2017

Abstract

BACKGROUND: Managing expenditures on pharmaceuticals is important for health systems to sustain universal access to necessary medicines. We sought to estimate the size and sources of differences in expenditures on primary care medications among high-income countries with universal health care systems.

METHODS: We compared data on the 2015 volume and cost per day of primary care prescription drug therapies purchased in 10 high-income countries with various systems of universal health care coverage (7 from Europe, in addition to Australia, Canada and New Zealand). We measured total per capita expenditure on 6 categories of primary care prescription drugs: hypertension treatments, pain medications, lipid-lowering medicines, noninsulin diabetes treatments, gastrointestinal preparations and antidepressants. We quantified the contributions of 5 drivers of the observed differences in per capita expenditures.

RESULTS: Across countries, the average annual per capita expenditure on the primary care medicines studied varied by more than 600%: from $23 in New Zealand to $171 in Switzerland. The volume of therapies purchased varied by 41%: from 198 days per capita in Norway to 279 days per capita in Germany. Most of the differences in average expenditures per capita were driven by a combination of differences in the average mix of drugs selected within therapeutic categories and differences in the prices paid for medicines prescribed.

INTERPRETATION: Significant international differences in average expenditures on primary care medications are driven primarily by factors that contribute to the average daily cost of therapy, rather than differences in the volume of therapy used. Average expenditures were lower among single-payer financing systems that appeared to promote lower prices and the selection of lower-cost treatment options.

From the Methods

This is a comparative economic analysis of market research data from calendar-year 2015 for 10 selected, high-income countries with a variety of systems of universal health care coverage: Canada, Australia, New Zealand, Norway, Sweden, the United Kingdom, France, Germany, the Netherlands and Switzerland.

We chose these countries because they are all high-income countries offering universal health coverage, and all were part of a large study involving countries that have participated in the Commonwealth Fund’s International Health Policy surveys. We did not include the United States in this analysis because it is an outlier in 2 important ways: first, it has not yet achieved universal health coverage; second, it has such exceptionally high pharmaceutical expenditures that its inclusion in this analysis would skew comparisons among the 10 more comparable countries studied here.

Residents of all countries except Canada were eligible for universal health coverage that included universal coverage of outpatient prescription drugs. The systems of drug coverage in Australia, New Zealand, Norway, Sweden and the UK can be described as universal public systems. In these countries, prescription medicines are financed predominantly by government, and either government or an arm’s-length public body manages the selection and the price-setting of medicines to be covered by the universal system of public financing. Prescription drugs in France, Germany, the Netherlands and Switzerland are financed through multiple-payer, social insurance systems with various statutory policies governing minimum coverage and pricing for brand-name and generic drugs.

From the Interpretation

Across 10 high-income countries with universal health care systems, the average expenditure per capita on 6 of the largest categories of primary care medicines varied by more than 600%. The volume of therapies purchased varied by only 41%, which meant that most of the differences in average expenditure per capita were driven by differences in the average mix of drugs selected within therapeutic categories and differences in the prices paid for medicines prescribed. In New Zealand, estimated costs per day of therapy were about one-third the level in comparator countries; in Switzerland, estimated costs per day were nearly double the level in comparator countries.

Conclusion

Substantial international differences in average expenditures on primary care medications are driven primarily by factors that contribute to the average daily cost of therapy, rather than differences in the volume of therapy used. Average expenditures are lower among single-payer financing systems, which appear to promote lower prices and selection of lower-cost treatment options within therapeutic categories.

http://www.cmaj.ca…

Commonwealth Fund report on performance of health systems of 11 high-income nations:
http://www.commonwealthfund.org…

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Comment:

By Don McCanne, M.D.

This study of ten high-income countries with universal coverage demonstrated that those with single payer systems spent less on prescription drugs than did those with multi-payer systems. This is one more bit of evidence confirming that the United States is correct in continuing its pursuit of a national single payer financing system – an improved Medicare for all.

The ten nations studied were from those reported previously in the Commonwealth Fund studies of eleven nations in which the United States was ranked last overall on various measures of performance (link above). The United States was omitted from this study because it does not have universal health care coverage, and it has exceptionally high pharmaceutical expenditures that would have skewed the study.

Switzerland presents a special case that should be of interest to single payer supporters in the United States. Their system is financed by highly regulated private insurance plans  – a system which has been praised by U.S. advocates of consumer-directed health care for placing a greater financial burden on patients in need. Switzerland has twice rejected ballot measures which would have established a single payer system within their nation. As a result, amongst other features of their system, they now enjoy paying the highest drug costs of these nations – nearly double the level in comparator countries (but still far less than drug costs in the United States).

We can learn much about health care financing from other high-income nations with universal health care systems. Here we see that a universal system alone is not enough. It needs to be a well designed single payer system. We have the rudiments of that in our traditional Medicare program, but it still needs a lot of work.

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

Using automatic enrollment to cover everyone

The Senate Should Build Automatic Enrollment Into Health Reform. Here’s How.

By Lanhee Chen and James Capretta
Health Affairs Blog, June 5, 2017

As the discussion over the future of health reform continues in the United States Senate, some Republicans are looking for ways to boost coverage levels, help stabilize insurance markets, and lower health costs. For years, the U.S. has had insurance enrollment levels below what was possible because of lower than desirable take-up of existing options.

Currently, under the ACA, the markets are less stable than they could be, or should be, because there are too few younger and healthier enrollees. Automatic enrollment would boost enrollment into insurance among this group of potential customers, and thus help create a more balanced risk pool.

We believe that automatically enrolling Americans eligible for tax credits into no-premium health plans should be an important component of a renewed effort at health reform. Many of the uninsured who do not make plan selections on their own can be enrolled into plans that provide true insurance against significant or catastrophic health events. Individuals who are auto-enrolled will have the opportunity to opt-out of that coverage if they prefer; they will also be given the opportunity to switch to a different plan during the next available open enrollment period.

Operationalizing The Idea

* Make State Participation A Condition Of Federal Funding Under Reform, And Provide Separate Funding For Administrative Costs

* Require Insurers To Offer Default Insurance Products In The Individual Insurance Market

* Establish Parameters For Default Insurance Plans

* Establish A Target Population For Automatic Enrollment Into No-Premium Coverage

* Repurpose And Supplement The IRS’ Income And Insurance Enrollment Data

* Establish A Process For Assigning Beneficiaries To Default Plans

* Provide Notification To Beneficiaries

* Recruit Hospital And Physician Cooperation

What Happens When The Tax Credits Exceed The Premiums Needed For Default Insurance?

In the event Congress adopts income-adjusted credits, there will be cases when people get placed into default plans with premiums that are less than the value of the credits for which they are eligible. In these cases, the person would forgo the balance of their credit until such time that they make a selection of a plan, or affirm the default option.

What Happens When The Credits Fall Short Of The Premiums For Default Coverage?

The system for identifying and placing individuals into coverage will be based on income and insurance enrollment data from two years prior to the placement into a plan. There will necessarily be cases when someone gets placed into coverage with a premium than ends up exceeding the value of the credit for which they are eligible. In these cases, the insurance plan receiving the credit, and the individual who was placed into coverage, should be held harmless for misestimated credit amounts. That is, the insurer should not be required to return the difference between the credit received for a default enrollee over the amount of the credit that should have been paid based on the person’s income. Nor should the default insurance enrollee be asked to cover the difference in a payment to the federal government or the insurance plan.

What Happens When A Person Has Had A Break In Coverage And Owes A Premium Surcharge?

In the House-passed AHCA, persons who experience a break in coverage are required to pay a surcharge equal to 30 percent of the premium of the plan which they are seeking to purchase. The main intent of an automatic enrollment process is to help people avoid breaks in coverage, and thus also the penalties associated with trying to re-enter the market. In that context, it would be best to provide some level of accommodation for people who end up being placed into default coverage after a spell of being uninsured. One approach would be to provide everyone who experiences a break in coverage a one-time waiver of the surcharge penalty when they first are placed into a default plan. After that first occasion, however, if someone experienced a break in coverage and then subsequently got placed into a default plan, the person would be required to pay the surcharge or would eventually be disenrolled from coverage.

The Value Of High-Deductible Insurance

Critics of this approach to automatically enrolling people into default insurance will argue that the coverage will be inadequate because the deductibles will be too high. It is certainly true that plans which require no premium payment from the enrollees are likely to have deductibles that are even higher than is typical in today’s marketplace. But, despite much criticism of high-deductible insurance from politicians in both parties, such coverage provides what consumers need most from these products, which is protection against major medical expenses.

From the Conclusion

For the most part, the uninsured do not have principled objections to enrolling in coverage; they remain without insurance out of inertia, or lack of information about their options or the financial assistance available to them. Automatic enrollment can give many of the uninsured coverage at no cost to themselves.

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Reader Comment:

By Don McCanne M.D.

Obviously automatic enrollment is a great idea. But why put up with the administrative complexity of the authors’ model which still leaves so many out of the system, not to mention leaving too many exposed to excessive financial barriers to care? Why not, instead, automatically enroll everyone, only once, for life? The administrative simplicity would carry through to management of health care benefits, greatly reducing the administrative waste inherent in our system. A recent estimate indicates that we would save half a trillion dollars in recoverable administrative waste, which is enough to remove financial barriers to care through the reduction of excessive patient cost sharing (Annals of Internal Medicine, online, Feb. 21, 2017).

Yes, that would be a single payer system – an improved Medicare for all – but is that any reason to dismiss it? Considering our high costs, profound waste, and inherent inequities, single payer has become an imperative. Let’s automatically enroll everyone.

http://healthaffairs.org…

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Comment:

By Don McCanne, M.D.

Looking at policy options in isolation can be informative, but, as this article by Lanhee Chen and James Capretta demonstrates, it is crucial to understand how the particular policy meshes with the entire package of health care reform.

Automatic enrollment into the health care financing system is a great idea, assuming that we want everyone covered. When Medicare was established, everyone eligible at age 65 was automatically enrolled in Part A – the hospital coverage. That has worked very well, as far as it went. In fact, the Supreme Court has ruled that if a person were to decline enrollment in Part A they would have to relinquish their Social Security benefits as well. That is a very powerful incentive for the individual to accept automatic enrollment.

Medicare for All supporters would improve Medicare benefits and remove the financial barriers to care and then would expand it to include everyone – through automatic enrollment.

But what do Chen and Capretta propose? They would include automatic enrollment in the AHCA repeal and replace proposal currently under consideration in the Senate. For a person eligible for a premium subsidy (tax credit), they would use the subsidy to purchase a plan in which the individual would be enrolled automatically. This would fall short since it would cover only individuals eligible for subsidies, so the program would still not be universal.

Worse, they propose that the plan would, in essence, have an actuarial value based on what the tax credit would purchase. For most individuals, that would be very little insurance. They tout the benefit of very high deductibles, stating, “such coverage provides what consumers need most from these products, which is protection against major medical expenses.” But how is an individual going to cover a $40,000 deductible with an annual income of $35,000?

Automatic enrollment is a great policy concept but it needs to be an element of a system of melded beneficial policies – like a well designed single payer system – an improved Medicare for all. Let’s set that up and then automatically enroll everyone in it.

In an Aging Nation, Single-Payer Is the Alternative to Dying Under Austerity

By Mike Ludwig
Truthout, June 14, 2017

Every day about 10,000 people turn 65 in the United States, and the number of people over the age of 85 will more than triple by 2050. As a result, the demand for long-term health care services and end-of-life care will surge in the coming decades, increasing pressure on a system that is already suffering from high costs and workforce shortages. Unless policymakers make serious changes to how we fund and operate the health care system, the process of confronting chronic illness and death in the United States could become increasingly expensive and difficult for everyone but the very wealthy.

This isn’t just bad news for the aging baby boomer generation, which is expected to increase the number of people over the age of 65 in the US from 48 million to 88 million by 2050. In the decades to come, many millennials may find themselves navigating the current health care system’s complicated mix of government benefits, out-of-pocket costs and private insurance offerings with their elderly parents.

Meanwhile, the Republican plan to repeal the Affordable Care Act (ACA) that passed the House last month would gut ACA provisions that kept insurance companies from gouging older customers and cut $839 billion from Medicaid over the next decade. The bill would increase private insurance rates for older people with lower incomes and leave 5.1 million people between the ages of 50 and 65 without insurance by 2026, according to the Kaiser Family Foundation. Despite the popular misconception that Medicare covers all of seniors’ health care needs, millions of Americans over 65 are also enrolled in Medicaid. Elderly people would certainly suffer if the program saw deep cuts.

The proposed cuts to Medicaid are generally unpopular, and the Republican House bill has slumped in the polls. The repeal effort has recently stalled in the Senate due to deep divisions among Republicans. However, reports now indicate that Senate Majority Leader Mitch McConnell has been hammering out a compromise on Medicaid behind closed doors, with the goal of holding a vote on a Senate repeal package before a July 4 recess. A repeal is not a given, but it will take a sustained push from those who value affordable health care for low-income and working families to prevent a repeal while the GOP has a majority in Congress.

Amid this crucial resistance, a renewed push has also emerged for the creation of something different: a single-payer system. A House bill for a “Medicare for All” health plan has more co-sponsors than ever among progressive Democrats, and grassroots activists are rolling out campaigns across the country. When it comes to the issue of how to best serve elderly patients, advocates say guaranteeing health coverage for everyone would help prepare the system for an aging nation.

Medicaid and Elderly Americans

“The profit-seeking in end-of-life care is the real problem, and we could get rid of it,” said Dr. Andy Coates, an assistant professor of internal medicine and psychiatry at Albany Medical College in New York and a member of Physicians for a National Health Program (PNHP), the group of doctors and reformers backing single-payer legislation in Congress.

Coates told Truthout that many patients facing terminal conditions receive “palliative care,” which focuses on treating symptoms of serious illnesses, and then “hospice care” at the very end of life. Palliative specialists consider difficult questions posed by life-threatening illness: What treatments may be necessary or desirable, and what treatments would a patient want to avoid even if they could prolong life? How is the patient managing pain? What does the patient still need to get done in life before they die? Palliative specialists focus on both symptom management and psychological wellbeing.

New strategies for delivering care and reforms to Medicare under the ACA show promise for lowering costs and improving palliative and hospice care by empowering patients to take greater control of their medical decisions. Yet patients with chronic and life-threatening conditions are still bounced between providers and experience high rates of expensive and preventable hospitalizations.

While older people often juggle a number of medical expenses they must pay themselves, most also depend on the government’s main health programs for at least some of their care. Medicare provides insurance to people age 65 and older, and 8 out of 10 people who died in 2014 were in the program. Beneficiaries in their last year of life accounted for 25 percent of Medicare spending that same year.

While Medicare is the largest insurer of health care provided in the last year of life, Medicaid is the nation’s largest provider of long-term care services for elderly, chronically ill and disabled people. Medicare coverage tends to focus on short-term care that is medically necessary, such as providing devices after an accident or a nursing home stay for less than 100 days. Many older people in need of long-term care at home rely on Medicaid, often after spending off their personal assets on out-of-pocket costs in order to qualify. In 2011, 10 million people were enrolled in both programs, according to the Kaiser Family Foundation.

In a single-payer system, the government guarantees health care to everyone through a universal insurance program. In many countries with single-payer systems, private insurance is still available but tightly regulated, and many providers remain private. Together, Medicaid and Medicare already pay for the majority of long-term and palliative care services in the US, so some might say that the US has almost achieved “universal” coverage when it comes to end-of-life care — but without added benefits that could support low-wage workers and keep elderly folks from falling into poverty.

“We’re paying for a single-payer system, and we’re not getting it by any stretch of the imagination,” Coates said.

PNHP supports a single-payer proposal known as “Medicare for All,” but that doesn’t mean a transition to a single-payer system wouldn’t change things for seniors covered by Medicare. The single-payer legislation currently in the House, entitled the “Expanded & Improved Medicare for All Act,” would create a single, streamlined public agency that would pay health claims, rather than a profit-driven bureaucracy of competing insurance firms. “Expanded and improved” Medicare would mean that everyone, regardless of age, would be covered for all medically necessary services, including dental, vision and types of long-term care that Medicare does not currently cover.

Such a system would simplify how the nation pays for health care, and PHNP expects single payer to save hundreds of billions of dollars in administrative costs created by the insurance bureaucracy. These savings would be used to eliminate out-of-pocket costs such as copays and deductibles and provide patients with more freedom in choosing a doctor, according to PNHP.

“The country has the potential to have a great health system — truly great,” Coates said. “Instead, we have a mediocre health system and a bureaucratic mess, and everyone knows that.”

Low Wages and a Growing Shortage of Caregivers

As the nation ages, more people are trying to stay out of nursing homes as long as possible, and the government now promotes home care and assisted-living models as less costly alternatives. As the ACA expanded Medicaid, the Obama administration offered states waivers to spend Medicaid dollars on “home and community-based” services for those in need of long-term and palliative care. These programs allow families to hire home-care workers and nursing assistants or support themselves while caring for loved ones. This support is crucial for members of working families who often struggle to care for elderly and disabled relatives while maintaining low-wage jobs.

“Right now, end-of-life, physical care for patients who can’t get out of bed is done by the immediate women family members, who are often unpaid and financially devastated,” Coates said of working families. “If you are up all night caring for your dad and you are too tired to go to work, then you are going to lose your job.”

Physicians and policymakers alike say that using Medicaid waivers to shift care from expensive nursing facilities to home and community settings leads to better health outcomes, saves public resources and helps struggling families. The need for these waivers is expected to grow as the population ages, but the House bill to repeal the ACA would put these programs on the chopping block as states grapple with federal funding cuts.

Medicaid supports aging populations in another way: Many low-wage workers who provide long-term and palliative health services depend on the program for their own health care, according to Josephine Kalipeni, director of policy at Caring Across Generations, a think tank backed by labor groups that focuses on aging patients and their caregivers.

“When we think about aging baby boomers and people with disabilities who are able to be at home, a lot of that is being supported by the fact that a lot working people and home-care workers rely on Medicaid to get their health care,” Kalipeni said.

In fact, experts say a growing labor shortage is a top concern. Nursing assistants, personal care aides and home-care workers who care for the elderly and disabled are leaving the industry in droves due to poor working conditions and extremely low wages. Meanwhile, demand for this labor is growing and will continue to grow as baby boomers age, medical advances allow people to live longer, and policy shifts put a greater emphasis on providing end-of-life care in domestic and community settings rather than in expensive nursing facilities.

“We are seeing shortages all around the country,” said Robert Espinoza, vice president of policy at the Paraprofessional Healthcare Institute (PHI), a group that tracks workers who spend the most time caring for elderly people and those with chronic illnesses and disabilities.

Espinoza said a lack of government data on this workforce makes it difficult to quantify just how bad this shortage is going to get and which parts of the country will be hit the hardest. What we do know is that these workers are most often women, and the number of working-age women willing to do the job is not keeping pace with the aging population. About 40 to 60 percent will leave their jobs within 90 days, most often citing low wages, a lack of career opportunities and difficult supervisors. Espinoza said workers often leave for higher paying but less arduous jobs in food service or retail, particularly in rural areas where the number of health care providers is already slim.

Home-care workers assist patients with intimate daily tasks, such as eating and bathing. Many also provide both physical and emotional comfort to the sick and dying, a form of emotional labor that’s hard to put a price on. It’s one of the fastest growing occupations in the country, but wages have stagnated in the past decade, with workers making a median wage of $10.11 an hour adjusted to inflation, according to PHI. The work is often part-time, with workers earning an average of $13,000 and receiving few benefits from employers. As a result, 1 in 4 home-care workers live below the poverty line and rely on public assistance like Medicaid.

Wages aren’t much better for the nursing assistants, who often work part time and earn a median income of $19,000 a year.

Government insurance programs keep these workers and their patients afloat. Medicare and Medicaid are the major public programs that provide about 72 percent of the home-care industry’s earnings and 73 percent of the nursing home industry’s $116 billion in annual revenue, PHI reports. In addition, Kalipeni said Medicaid relieves pressure from the Medicare system by helping low-income people stay healthier in the years before they qualify. So, what would happen if the GOP were to succeed in making drastic cuts to Medicaid?

Under the House bill, caps on Medicaid spending would be placed on states by 2020, forcing states to start making their own cuts to balance the books. States will focus remaining funding on the Medicaid services they are required by law to cover; home and community-based services and the waivers behind them are optional. States already limit funding for these services due to budget constraints, and they are likely to be dropped soon after federal Medicaid cuts hit state level, according to the Center on Budget and Policy Priorities.

“[The House bill] provides more flexibility of what states can do, but way less resources to be innovative and productive … and that just doesn’t make sense,” Kalipeni said.

Kalipeni has spent much of her career working on the ACA. She does not believe it’s a perfect law, but says it’s much better than the Republican proposal. Unlike the House bill, the ACA contains provisions to hire and train the workers needed to meet increasing demand for health care, particularly in poor and rural areas. She said the ACA did not go far enough with this and other reforms, but that it highlighted the importance of thinking ahead about the health care workforce.

“We want to ensure that the need to recruit and retain a well-paid workforce [is] an intentional component of any of the working family policies moving forward,” Kalipeni said. “This can’t be kicked down the line or moving on a parallel path. This has to be built in. Additionally, as this country continues to rely heavily on family caregivers, supports for family caregiving have to be seen as a critical part of any changes to our health care system.”

Seniors and the Single-Payer Future

The ACA is far from perfect, the House bill to repeal it is unpopular and Senate Republicans are starting to doubt whether they can agree on their own overhaul package anytime soon. Out of this policy void has come the renewed interest in a single-payer system. In addition to the House bill to establish Medicare for All, with its record 112 co-sponsors, single-payer legislation is on the move in New York and California. Sen. Bernie Sanders of Vermont, who ran for president on a single-payer platform, is under pressure to introduce single-payer legislation in the Senate.

Kalipeni said a move toward a single-payer or another type of universal system that could streamline services and increase spending on wages would be a powerful step forward for both elderly patients and their caregivers.

“We are one of the few developing countries that is behind in providing universal care in a way that increases access, shares costs and meets people’s needs,” Kalipeni said. “Streamlining health care in this way could help manage costs and improve people’s user experience with health care systems.”

Voters are catching on. In April, a Morning Consult/Politico poll taken found that more likely voters supported single payer than opposed the idea, including 37 percent of Trump voters. In January, before the Republican repeal proposals filled Capitol Hill with talk of cuts and millions losing health coverage, a Pew Research poll found that 60 percent of voters agreed that the government should be “responsible for ensuring health care coverage for all Americans.”

Advocates say much of the support for single payer comes down to the bottom line: We pay more for health care in the US than other industrialized countries, but have poorer health outcomes and shorter lifespans.

Coates is particularly concerned about private hospice providers who are incentivized to spend less than they receive from Medicaid and Medicare in order to turn a profit, particularly since the ACA extended Medicare’s hospice benefits. Currently, he said, there are so many “middle men” and incentives to cut corners at the expense of patients that it turns the act of dying into a “profit-making moment.” As private businesses, these providers don’t have to share their finances with the public. Under a single-payer system, there would be a political incentive to require private hospice providers to open their books in order to receive public funds.

Coates said some people believe a single-payer system would allow the government to make their health care decisions for them, but that’s simply not true. In reality, the government’s single-payer office would be in charge of protecting a patient’s right to privacy and autonomy while holding health care providers accountable for the services it’s paying for.

“We should have a system that provides dignity, and if you never have control of the money, then how are you ever going to transform it?” Coates said.

The Republican majority in Congress is sure to keep single-payer proposals stuck in committee, but advocates say now is the time to push establishment Democrats to embrace single payer as a bold alternative to the ACA and Republican austerity.

Coates said that most people already support the ideas behind single payer, and politicians in both parties are out of step. According to polls, most people agree that when someone suffers from a serious medical condition, the resources for treatment should be available to them, not locked behind sky-high premiums and out-of-pocket costs.

“Even well-to-do Trump supporters would still say that, if a kid has leukemia, then he should receive the best care this country has to offer,” Coates said.

The same goes for the elderly. As the shortcomings of the Medicare system illustrate, simply installing a single-payer system for a large group of people is not enough unless that system covers everything under the health care umbrella. A meaningful single-payer plan would include everything that Medicare already covers while meeting the rest of the needs that come with aging, including those currently supported by Medicaid, out-of-pocket costs and family members.

To achieve a high quality of care under such a system, care workers must be fairly compensated. This is where the movement for health care as a human right intersects with so many others. A majority of home care workers are women of color, and many come from immigrant families. Kalipeni said that both the Fight for $15 campaign to raise the minimum wage, as well as the movements for racial justice and immigrant rights, are central to the health care fight, because they’re focused on improving conditions for the workers who will be caring for baby boomers at the end of their lives. If these workers can receive proper wages, benefits and training, then they can keep aging patients healthy and out of hospice, saving more health care dollars in the future — and saving lives.

When we look at health care reform through the lens of dying and death, suddenly our movements — and our very lives — become inextricably intertwined.

This piece is part of Fighting for Our Lives: The Movement for Medicare for All, a Truthout original series.

http://www.truth-out.org…

Chicago physicians favor single payer over ACA by a 2 to 1 margin

Survey: Physician Attitudes Shift To Single Payer

Chicago Medical Society, June 13, 2017

Nearly four in five Chicago area physicians are opposed to the American Health Care Act (AHCA) under consideration by the U.S. Senate as increasing numbers of physicians support a single-payer “Medicare-for-All” form of health insurance.

A survey of more than 1,000 physicians by the Chicago Medical Society about payment models indicates 77% of these doctors in Cook and its Illinois collar counties have a “generally unfavorable” view of the American Health Care Act, which was passed last month by the U.S. House of Representatives and is currently being debated in the U.S. Senate.

The AHCA, which would roll back the Medicaid expansion in 31 states, including Illinois, earned positive views from just 23.4 percent of physicians who said they were “generally favorable” about the legislation.

Rather, physicians voice support for single payer and and also support the Affordable Care Act (ACA) with some fixes. In the Chicago Medical Society survey, the ACA received a “generally favorable” view from 62.7% of Chicago area physicians and even more, or 66.8% have a “generally favorable” view of a single-payer financing health care system.  Given a choice between single payer, an improved ACA and the AHCA, Chicago physicians favored a single payer approach by 2 to 1 over the ACA and by 3 to 1 over the AHCA.

87.6% of physicians think “basic health care would be available to all individuals as part of the social contract, a right similar to basic education, police and fire protection.”

http://www.cmsdocs.org…

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Comment:

By Don McCanne, M.D.

Once again we have a report that shows that physicians and medical students believe that health care is a human right that should be made available to all and that a single payer, improved Medicare for All is clearly the preferred model of reform. This survey also adds the findings that single payer is preferred over the Affordable Care Act (Obamacare) by a margin of 2 to 1, and also preferred over the American Health Care Act (Republican Repeal and Replace) by an even larger margin – 3 to 1.

The people want Medicare for all, and physicians and other health professionals want Medicare for all. In health care, who else matters?

Health care is a gold mine for crowdfunding

America’s Health-Care Crisis Is a Gold Mine for Crowdfunding

By Suzanne Woolley
Bloomberg, June 12, 2017

Crowdfunding platforms such as GoFundMe and YouCaring have turned sympathy for Americans drowning in medical expenses into a cottage industry. Now Republican efforts in Congress to repeal and replace Obamacare could swell the ranks of the uninsured and spur the business of helping people raise donations online to pay for health care.

But medical crowdfunding doesn’t have to wait for Congress to act. Business is already booming, and its leaders expect the rapid growth to continue no matter what happens on the Hill.

At industry leader GoFundMe, medical is one of the biggest fundraising categories. CEO Rob Solomon has said it’s what “helped define and put GoFundMe on the map.”

With enough volume, the business of helping people raise money for medical care has a lot of profit potential. GoFundMe takes 5 percent of each donation, 2.9 percent goes to payment processing, and there’s a 30¢ transaction fee.

Indiegogo, which started out funding filmmakers, created a separate platform in 2015 called Generosity. Medical is a top category, and users pay a 3 percent payment processing fee and the 30¢. Now Facebook has jumped into the fray. On May 24, it began allowing users to launch fundraisers for personal causes or nonprofits on their pages. Medical is one of eight available categories. For personal cause campaigns, Facebook takes 6.9 percent of each donation plus 30¢.

Medical crowdfunding is “highly, highly scalable and has a ton of runway,” said Dan Saper, chief executive officer of YouCaring. “The growth rate of the industry is showing that this can absolutely be an impactful safety net for a lot of individuals and communities to help each other.”

The remarkably named Producing a Worthy Illness: Personal Crowdfunding Amidst Financial Crisis, a study published this year by the University of Washington/Bothell, offers a striking perspective on some of those communities. Personal medical campaigns on GoFundMe were likelier to come from people living in states that chose not to expand Medicaid under the ACA, preliminary results of the study showed.

“The more dramatic the need, the more successful” the fundraiser, said Adrienne Gonzalez, who follows the industry as the creator of GoFraudMe.com, a site that exposes fraudulent campaigns on GoFundMe.

“‘I need help with my deductible’—they are not going to be very successful,” said Gonzalez, who believes crowdfunding has done a lot of good but presents “this whole socioeconomic problem” because “you almost have to be a marketing guru” to create a successful campaign.

Slightly more than one in 10 health-related online campaigns reached their goal in the NerdWallet report.

“Is this something that is going to be a solution to a lack of health insurance?” said Jeremy Snyder, a health sciences professor at Simon Fraser University in Canada. “Absolutely not.”

https://www.bloomberg.com…

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Comment:

By Don McCanne, M.D.

In spite of the Affordable Care Act, medical debt remains a major problem in the United States. It is no surprise that crowdfunding – soliciting donations over the Internet – has become a means of trying to fill the void resulting from being uninsured or under-insured. And there are plenty of entrepreneurs who are quite willing to open these channels – for a percentage of the take – Facebook being one that takes 6.9% plus 30 cents per donation.

Just what we need – more administrative costs and profits consumed by middlemen entrepreneurs. This doesn’t even take into consideration the diversion of funds that can take place once they reach the beneficiaries or their handlers. Besides, the majority of those who depend on crowdfunding to pay their medical bills will be disappointed. Why would people donate funds to help pay someone else’s deductible when they have their own deductibles to worry about?

We can surely find a better way to fund health care, like maybe an improved Medicare that covered everyone. Depending on an industry that capitalizes on charity certainly is not the way to go.