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With Epic GOP Failure, Dems Urged to Go Bold with Medicare-for-All

With Epic GOP Failure, Dems Urged to Go Bold with Medicare-for-All

Americans rallied against the GOP to defend their right to healthcare, Democrats are being urged to seize on the moment

By Lauren McCauley
Common Dreams, March 24, 2017

With the Republican attempt to replace the Affordable Care Act (ACA) going down in flames Friday as Americans rallied to defend their right to healthcare, Democrats are being urged, both by experts and constituents, to seize on the moment and counter with a plan that will truly provide coverage for all.

Uproar over the GOP’s American Health Care Act (AHCA), which was estimated to strip 24 million people of their healthcare by 2026, prompted a political firestorm as it drove voters across the nation to town halls and local legislative offices to demand that House Republicans vote against the bill.

After the White House called on House Speaker Paul Ryan (Wis.) to withdraw Friday’s scheduled vote (after an aggressive lobby effort on the part of both President Donald Trump and Ryan), many are looking to what happens next.

Though the Republican narrative that Obamacare is “imploding” has been proven to be an unfounded talking point, The Week’s Ryan Cooper argued Friday that Democrats “shouldn’t sit idly by and wait for Republicans to slowly bleed Obamacare to death by other means.”

“They need a counter-offer,” Cooper writes, “one that’s more compelling than the creaky status quo. They need a single-payer, Medicare-for-All plan.”

Similarly, RoseAnn DeMoro, executive director of National Nurses United (NNU), told Common Dreams that ultimately Democrats “are fighting for an unacceptable status quo,” noting that a private insurance market will always prove to be “unaffordable.”

In a press statement she expanded on this idea:

Many of the criticisms of the ACA are, in fact valid. For all the improvements under the ACA, primarily the expansion of Medicaid and crackdown on some insurance abuses, the ACA still left 28 million without health coverage, and millions more struggling with un-payable medical bills and escalating out of pocket costs.

Where the Democrats too fell short was their failure in drafting the ACA to refute the underlying source of the health care crisis in the first place, the contradiction between a health care system that should be based on patient need and the public health and well being, and the insatiable demand of health care corporations for profits first.

Dr. Carol Paris, president of Physicians for National Health Program (PNHP), which has long-advocated for single-payer system, said Friday’s failure by the Republican Party to pass their “slash and burn” healthcare bill “presents a unique opportunity to move beyond” a profit-based system.

Though Paris acknowledged the GOP plan would have “pushed millions more Americans off their health insurance, sending the rates of medical bankruptcy and preventable deaths skyrocketing,” she said the shortcomings of the ACA should not be ignored.

“The ACA left 29 million Americans uninsured and channeled billions of taxpayer dollars to a patchwork of wasteful private insurers, each one skimming off its own share of administrative costs and profit that should have been spent on patient care,” Dr. Paris noted. “Let’s clear the drawing board—it’s time to adopt a simple, commonsense approach to national health care.”

Pointing to the collapse of the GOP’s attempt at reform, DeMoro says it’s clear their party has no viable pathway towards a solution. “The Republicans are ideologically split it appears,” she said. “Trump is trying to maintain that everyone should have healthcare and the cost should go down—that solution, and the only possible solution is Medicare-for-All.”

In a Friday press statement, Rep. Luis  Gutiérrez (D-IL) echoed this call. “We have known for years that the only true healthcare reform that will work is a single-payer system where we take national responsibility for the health of our nation,” he said. “Now that this vote is over, I hope we can return to a serious and sensible discussion of strengthening our healthcare system and the improving the health of all Americans.”

In addition to Medicare-for-All being “quite clearly the best universal health-care policy option for the United States,” The Week’s Cooper also observed that “Obamacare did not finish the job of achieving universal health care, and this is a good chance to move the ball forward.”

The AHCA, Cooper continues, “is extraordinarily unpopular because it takes coverage and subsidies away from people, and a majority believe that it should be the government’s responsibility to make sure everyone is covered. Fundamentally, Medicare is very popular, a fact only partially covered up by generations of red-baiting and duplicitous austerian propaganda.”

Further, he notes that “it also makes an excellent organizing signpost. Medicare-for-All is simple, easy to understand, and hard to argue against or distort.”

The math works out too. Dr. David Himmelstein and Dr. Steffie Woolhandler, both of whom are closely associated with PNHP, published an analysis this week which found that replacing the ACA “with a universal, single-payer health system, along the lines of the Expanded and Improved Medicare for All Act, H.R. 676, would provide immediate coverage to the 26 million Americans who are currently uninsured, saving at least 20,984 lives in year one.”

This is in contrast to the Congressional Budget Office estimate that as many as 24 million people would lose health coverage by 2026 under the AHCA.

Responding to Friday’s developments, Sen. Bernie Sanders (I-Vt.) called the failure of the AHCA a “great victory,” but said that lawmakers’ work would not be complete until healthcare was guaranteed “to all people as a right”:

Contrary to Republican orthodoxy, many of Trump’s blue collar supporters voted for him specifically because he promised to “take care of everybody.” Speaking with some of those voters in West Virginia recently, Sanders found that many do believe that healthcare should be guaranteed as a human right.

Sanders, who made Medicare-for-All a key plank of his 2016 presidential campaign, said recently that the president’s supporters “are catching on that Trump lied.”

Robert Frank, an economics professor at the Johnson Graduate School of Management at Cornell University, argued in a New York Times op-ed Friday that the president could preserve the floundering effort to replace Obamacare while making good on his campaign promises by getting behind a Medicare-for-All, or single payer, healthcare plan.

Trump should use his “political leverage…to jettison the traditional Republican approach in favor of a form of the single-payer health care that most other countries use.”

This work is licensed under a Creative Commons Attribution-Share Alike 3.0 License

http://www.commondreams.org…

What Comes Next for Obamacare? The Case for Medicare for All

By Robert H. Frank
The New York Times, March 24, 2017

Republicans are in a bind. They’ve been promising to repeal Obamacare for seven years, and having won control of the White House and Congress, they had to try to deliver. But while their bitter denunciations of the Affordable Care Act may have depressed its approval numbers, they didn’t make replacing it any easier.

On the contrary, the repeal-and-replace bill designed by House Speaker Paul D. Ryan drew withering criticism from the left and the right. Liberals condemned its use of reductions in health coverage for the poor to pay for large tax cuts for the wealthy, while conservatives bemoaned its retention of many subsidies adopted under Obamacare.

In the end, the repeal effort’s biggest hurdle may have been loss aversion, one of the most robust findings in behavioral science. As numerous studies have shown, the pain of losing something you already have is much greater than the pleasure of having gained it in the first place. And the nonpartisan Congressional Budget Office estimated that Mr. Ryan’s American Health Care Act (A.H.C.A.) would have caused more than 14 million people to lose coverage in the first year alone, with total losses rising to 24 million over the next decade. Many Republicans in Congress were nervous about the political firestorm already provoked by the mere prospect of such losses.

Loss aversion actually threatened the repeal effort on two fronts: voters’ fear of losing their coverage, and lawmakers’ fear of losing their seats. Like the first fear, the second appeared well grounded. Republican voters wouldn’t have been the only ones losing coverage, of course, but early studies suggested that losses would have been concentrated among people who voted for President Trump. The Congressional Budget Office estimated, for example, that the A.H.C.A. would have caused premiums to rise more than sevenfold in 2026 for 64-year-olds making $26,500.

Now that Republicans have withdrawn Mr. Ryan’s bill from consideration, attention shifts to what comes next. In an earlier column, I suggested that Mr. Trump has the political leverage, which President Obama did not, to jettison the traditional Republican approach in favor of a form of the single-payer health care that most other countries use. According to Physicians for a National Health Program, an advocacy group, “Single-payer national health insurance, also known as ‘Medicare for all,’ is a system in which a single public or quasi-public agency organizes health care financing, but the delivery of care remains largely in private hands.” Christopher Ruddy, a friend and adviser of the president, recently urged him to consider this option.

Many Republicans who want to diminish government’s role in health care view the single-payer approach with disdain. But Mr. Trump often seems to take pleasure in being unpredictable, and since he will offend people no matter which way he turns, he may want to consider why liberals and conservatives in many other countries have embraced the single-payer approach.

Part of the appeal of Medicare for all is that single-payer systems reduce financial incentives that generate waste and abuse. Mr. Ryan insisted that by relegating health care to private insurers, competition would lead to lower prices and higher quality. Economic theory tells us that this is a reasonable expectation when certain conditions are met. A crucial one is that buyers must be able to compare the quality of offerings of different sellers. In practice, however, people have little knowledge of the treatment options for the various maladies they might suffer, and policy language describing insurance coverage is notoriously complex and technical. Consumers simply cannot make informed quality comparisons in this industry.

In contrast, they can easily compare the prices charged by competing insurance companies. This asymmetry induces companies to compete by highlighting the lower prices they’re able to offer if they cut costs by degrading the quality of their offerings. For example, it’s common for insurance companies to deny payment for procedures that their policies seem to cover. If policy holders complain loudly enough, they may eventually get reimbursed, but the money companies save by not paying others confers a decisive competitive advantage over rivals that don’t employ this tactic. Such haggling is uncommon under single-payer systems like Medicare (though it is sometimes employed by private insurers that supplement Medicare).

Consider, too, the mutually offsetting expenditures on competitive advertising and other promotional efforts of private insurers, which can exceed 15 percent of total revenue. Single-payer plans like Medicare spend nothing on competitive advertising (although here, also, we see such expenditures by supplemental insurers).

According to the Kaiser Family Foundation, administrative costs in Medicare are only about 2 percent of total operating expenditures, less than one-sixth of the rate estimated for the private insurance industry. This difference does not mean that private insurers are evil. It’s a simple consequence of a difference in the relevant economic incentives.

American health care outlays per capita in 2015 were more than twice the average of those in the 35 advanced countries that make up the Organization for Economic Cooperation and Development. Yet despite that spending difference, the system in the United States delivers significantly less favorable outcomes on measures like longevity and the incidence of chronic illness.

But advertising expenses and administrative costs are not the most important reason the United States spends so much more. The main difference is that prices for medical services are so much lower in other countries. In France, for example, a magnetic resonance imaging exam costs $363, on average, compared with $1,121 in the United States; an appendectomy is $4,463 in France, versus $13,851 in America. These differences stem largely from the fact that single payers — which is to say, governments — are typically able to negotiate more favorable terms with service providers.

In short, Medicare for all could deliver quality care at much lower cost than private insurers do now. People would of course be free to supplement their public coverage with private insurance, as they now do in most other countries with single-payer systems, and as many older Americans do with Medicare.

As a candidate, Mr. Trump repeatedly promised that everyone in the country would be covered at reasonable cost under an amazing new health plan. But it is now clear that the A.H.C.A. could not have delivered on that promise. The president, who has not always had a close relationship with Mr. Ryan, may consider changing course and working across party lines to develop support for universal access to Medicare.

Then again, he may fear that move would be seen as a sign of weakness or defeat. But the research findings on loss aversion make one thing clear: Any setback from that change in strategy would pale in comparison to the damage he would have suffered if the A.H.C.A. had actually become law.

Robert H. Frank is an economics professor at the Johnson Graduate School of Management at Cornell University.

https://www.nytimes.com…

Customized health insurance benefits do not pool risk

Late G.O.P. Proposal Could Mean Plans That Cover Aromatherapy but Not Chemotherapy

By Margot Sanger-Katz
The New York Times, March 23, 2017

Most Republicans in Congress prefer the type of health insurance market in which everyone could “choose the plan that’s right for them.”

Why should a 60-year-old man have to buy a plan that includes maternity benefits he’ll never use? (This is an example that comes up a lot.) In contrast, the Affordable Care Act includes a list of benefits that have to be in every plan, a reality that makes insurance comprehensive, but often costly.

Now, a group of conservative House members is trying to cut a deal to get those benefit requirements eliminated as part of the bill to repeal and replace the Affordable Care Act moving through Congress. (The vote in the House is expected later today.)

At first glance, this may sound like a wonderful policy. Why should that 60-year-old man have to pay for maternity benefits he will never use? If 60-year-old men don’t need to pay for benefits they won’t use, the price of insurance will come down, and more people will be able to afford that coverage, the thinking goes. And people who want fancy coverage with extra benefits can just pay a little more for the plan that’s right for them.

But there are two main problems with stripping away minimum benefit rules. One is that the meaning of “health insurance” can start to become a little murky. The second is that, in a world in which no one has to offer maternity coverage, no insurance company wants to be the only one that offers it.

David Cutler, a professor at Harvard who helped advise the Obama administration on the Affordable Care Act, said he thinks the kind of insurance products that would be offered under the proposed mix of policies could become much more bare-bones than plans before Obamacare. He envisioned an environment in which a typical plan might cover only emergency care and basic preventive services, with everything else as an add-on product, costing almost exactly as much as it would cost to pay for a service out-of-pocket.

There is most likely a middle way. Republican lawmakers might be comfortable with a system that shifts more of the costs of care onto people who are sick, if it makes the average insurance plan less costly for the healthy. But making those choices would mean engaging in very real trade-offs, less simple than their talking point.

https://www.nytimes.com…

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NYT Reader Comment:

By Don McCanne, M.D.
San Juan Capistrano, CA

“There is most likely a middle way.”

Not really. Most of the 20 percent of people who use 80 percent of our health care cannot pay for it out of pocket. That is why we need to pool risk and fund it by all of us, certainly including the 80 percent who remain relatively healthy.

Our dysfunctional multi-payer system wastes a tremendous amount of resources in insurer administrative excesses that play games such as distributing the costs between a multitude of public and private programs, the variability and complexity in claims processing for the health care providers, and the allocation of out of pocket costs by individuals.

Over $500 billion of this waste is actually recoverable (Annals of Internal Medicine, Feb. 21, 2017) if we switched to a single payer national health program – an improved Medicare that covered everyone. The “middle way” would simply perpetuate this waste.

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Comment:

By Don McCanne, M.D.

A very common theme is that we can design insurance products to provide only the coverage that we need. By not covering everything, the premiums would be much lower and thus affordable to everyone. Problem solved. (Not so quick.)

The most obvious problem is that nobody knows when they may suffer a catastrophic medical event or experience the onset of a serious chronic disorder. The health care financing system should automatically cover such occurrences, but, in doing so, since much of our health care spending falls into these categories, the savings in the insurance premiums would not be enough to make them affordable for too many of us. The coverage that a person might decline, such as management of breast cancer for men or prostate cancer for women, would still have to be paid for either out-of-pocket or through additional riders on the insurance. As soon as you allow riders, the costs would go up because of adverse selection – the people selecting the riders would be the people who would need them.

So the system would have to cover that 80 percent of health care that is used by the 20 percent of people with greater health problems. What about the other 20 percent that is used by individuals in better health? That is where much of the administrative waste occurs in our health care system. The insurers create and market a variety of insurance products with varying provider networks and variable cost sharing which place an administrative burden on the providers of health care. That negatively impacts the 80 percent of us who are healthy. For the 20 percent who use 80 percent of our health care, once the cost sharing requirement is reached, the additional administrative burden is not that great. So the half trillion dollars of recoverable administrative waste is providing essentially no value since it is wasted on superfluous up front interactions with the health care system and its patients.

Other nations have shown us that we do not need to have cost sharing and fragmented risk pools in order to control spending. They deliver comprehensive services to everyone at a lower cost. Fragmenting risk pools would only increase the administrative waste while subjecting elective risk pools to adverse selection, making them unaffordable. Who would sign up for a rider covering HIV and AIDS? What would the cost be when that rider is added to the basic insurance that everyone needs? Fragmenting the risk pools would result in modest reductions in the basic premium but those adding the riders would have premiums that would be unaffordable except for the wealthy. Customizing insurance by fragmenting risk pools defeats the goal of removing financial barriers to care. If we pool all risks together the special needs that might occur in the future would balance out.

Crossing party lines

By Carol A. Paris, M.D.
The Tennessean, Letters, March 23, 2017

Re: “Walking a mile in Donald Trump supporters’ shoes,” by David Plazas, March 19.

I read David Plazas’ commentary on his experience walking last Wednesday from Capitol Hill to Municipal Auditorium to attend President Trump’s rally.

I find that his experience with President Trump’s supporters was much like mine. I arrived in the line at about 9:45 a.m. My line-mates included a mother and her grown daughter from Lebanon.

The mom explained that her husband couldn’t attend because he is ill with a chronic lung condition. I could relate; both of my parents had lung disease and I know the sadness of watching someone you love struggle to breathe.

We all were annoyed by the roadside preachers who shouted hell and damnation at us for hours. I, too, was offended by protesters who carried signs that seemed designed to inflame and promote anger rather than champion their issue.

I thought about Maya Angelou’s saying “We are more alike than we are unalike.” I thought about the late Marshall Rosenberg, whose teachings of nonviolent communication have informed my work as an advocate and an activist. He admonished us to listen not to what people are saying but rather to listen for their feelings and needs. Feelings and needs are universal.

Once inside, I tried to place myself strategically so that I could be seen and heard by the president and by the much-maligned press corps. I waited until Mr. Trump got to the topic of health care and then I seized my opportunity to stand and chant: “Put your name on a plan that works, Medicare for all.”

I chose this action to bring visibility to another option for addressing the health care crisis — one that I believe provides the optimal use of our hard-earned tax dollars to provide quality health care for everyone living in the United States.

Carol Paris, president, Physicians for a National Health Program, Nashville.

http://www.tennessean.com…

Doctors speak out against GOP’s ACA replacement bill

By Joyce Frieden
MedPage Today, March 23, 2017

WASHINGTON — As House Republicans wrestled with moving their Affordable Care Act (ACA) replacement bill along on Capitol Hill on Thursday, physicians who opposed the legislation also were making their voices heard.

Several doctors participated in a rally against the bill — known as the American Health Care Act (AHCA) — held here at Freedom Plaza, within sight of a hotel owned by President Trump, on the seventh anniversary of the Affordable Care Act’s enactment.

“I’m here to support the folks who want to make sure the ACA is not repealed,” said Manan Trivedi, MD, president of the National Physicians Alliance, a group that advocates for high-quality, affordable healthcare for all.

“This bill has gone from bad to worse in a matter of 24 hours or so. The same folks who criticize backroom deals and writing a bill in the middle of the night are doing [just] that, but much worse … They’re essentially taking away critical health benefits from poor and middle-class families just to give tax cuts to 0.9% of [wealthy] America. It’s unfathomable what they’re trying to do and how they’re trying to do it so quickly.”

If it ends up passing, the AHCA “would devastate so many of my patients,” continued Trivedi, an internist and hospitalist in the Washington area. “I’ve seen firsthand folks who couldn’t afford insurance now being able to come to the ER, be admitted, and get follow-up appointments because of the ACA” and who would be hurt if it were repealed. “And this is not to mention the disease outbreaks, childhood lead poisoning, and infections with superbugs that would likely increase because of the plan in this new legislation to eliminate the Prevention and Public Health Fund.”

The current efforts to push the bill through are “a game the Republicans are having because they don’t believe in healthcare as a human right,” said Harvey Fernbach, MD, a psychiatrist in College Park, Md., and a board adviser to Physicians for a National Health Program (PNHP), a group that supports single-payer health insurance. “Obamacare was a good effort but it’s not quite what we want … The simplest idea is to expand and improve Medicare for all.”

The bill the Republicans are proposing “is a major step backwards,” said Deborah Schumann, MD, a retired ophthalmologist from Bethesda, Md., who is active in PNHP and Healthcare NOW of Maryland. “The Republican plan, they call it ‘Obamacare light’ but it’s really ‘Obamacare draconian.’ It’s going to hurt a lot of people.”

“I have been a single-payer advocate for a long time, and I was not super happy about Obamacare, but we got it and it did give a lot of people insurance, although it didn’t give everybody affordable healthcare,” she said. “This is going to make healthcare even less affordable.”

Rally participants heard from several other speakers, including former congressman Keith Ellison (D-Minn.), who is now deputy chairman of the Democratic National Committee; Rep. Dan Kildee (D-Mich.), whose district includes Flint; and Cecile Richards, president of the Planned Parenthood Federation of America. After the rally ended, the group marched to the Trump hotel, chanting anti-AHCA slogans.

Richards also took part in a conference call Thursday morning with Hal Lawrence III, MD, CEO of the American Congress of Obstetricians & Gynecologists (ACOG); participants discussed what would happen if the Republicans were successful in their efforts — via a provision in the AHCA — to defund Planned Parenthood.

“The effort to defund Planned Parenthood would force the closure of clinics around the country and negatively impact patients and healthcare providers,” said Lawrence. “Planned Parenthood is where many of our members practice, and many patients go to get their healthcare needs met.”

While he couldn’t give a specific figure, Lawrence estimated that more than 1,000 ACOG members work at Planned Parenthood clinics. “If these clinics close, physicians could no longer practice there there and whether or not they have practice alternatives around the community, we don’t know,” he told MedPage Today. “They may be forced to leave the community or state. The other thing is patients will no longer have access to ob/gyns and … there are not other providers out there ready to absorb this number of patients.”

Joyce Frieden is news editor at MedPage Today.

https://www.medpagetoday.com/PublicHealthPolicy/repeal-and-replace/64095?xid=nl_mpt_DHE_2017-03-24&eun=g352547d0r&pos=3

ACA’s repeal would cause tens of thousands of deaths, while single payer would save 20,000 more lives than ACA: AJPH editorial

Researchers: Peer-reviewed evidence points to deadly consequences of being uninsured

FOR IMMEDIATE RELEASE, March 22, 2017
Contact: Clare Fauke, PNHP communications specialist, 312-782-6006, clare@pnhp.org

Repealing the Affordable Care Act without replacing it, as some conservative hardliners are demanding, would cost a minimum of 37,127 lives over the next two years (14,528 in 2018 and 22,599 in 2019), and perhaps as many as four times that number, according to scientific studies summarized in an editorial in this week’s American Journal of Public Health.

The new analysis of the effect of widespread insurance loss is particularly relevant in light of the report issued March 13 by the Congressional Budget Office. The CBO estimates that the American Health Care Act, the Republican plan to replace the ACA, would cause 14 million people to lose insurance in the first year alone. By 2026, 24 million would lose coverage, leading to a total of 52 million uninsured in that year.

In contrast, the editorial’s authors estimate the impact of replacing the ACA with a universal, single-payer health system, along the lines of the Expanded and Improved Medicare for All Act, H.R. 676, would provide immediate coverage to the 26 million Americans who are currently uninsured, saving at least 20,984 lives in year one.

Longtime health system researchers Drs. David U. Himmelstein and Steffie Woolhandler analyzed all of the peer-reviewed studies of mortality associated with losing or gaining insurance. Using the CBO estimates of how many people currently lack insurance and how many more would lose coverage if the ACA were repealed without replacement, they provide a range of estimates of the excess deaths or lives saved under different health reform options (see table below). The evidence indicates that one American dies for every 300 to 1,239 who go without health insurance.

Table of data on mortality and health insurance

(See full Himmelstein and Woolhandler editorial for details on methods and sources.)

“The ACA extended coverage to 20 million Americans. But it offered little help to 90 percent of the population, including the 26 million who remain uninsured and millions more with unaffordable copayments and deductibles,” said study co-author Dr. Woolhandler, an internist, professor of public health at the City University of New York at Hunter College (CUNY), lecturer in medicine at Harvard Medical School. “Clear evidence tells us that fixing these defects would save thousands of lives. But Republicans’ plans would move us backwards.”

Dr. Himmelstein, the lead author of the editorial, a primary care doctor and, like Woolhander, a professor at CUNY’s Hunter College and lecturer at Harvard Medical School, added, “The Republican plan to replace the ACA would leave 52 million people uninsured in 2026. We know that will lead to many deaths – at least 41,969 and perhaps many times that number.”

Drs. Woolhandler and Himmelstein authored one of the early studies of the lethal effects of lacking health insurance, which President Obama cited in his push for the ACA. They, together with then-Harvard law professor Elizabeth Warren, led widely cited studies of medical bankruptcy.

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“Trumpcare or Transformation,” by David U. Himmelstein, M.D., and Steffie Woolhandler, M.D., M.P.H. American Journal of Public Health. Published online ahead of print, March 21, 2017. doi:10.2105/AJPH.2017.303729

A copy of the full article is available to media professionals upon request from Clare Fauke, PNHP communications specialist, clare@pnhp.org, (312) 782-6006.

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

Saving Obamacare Is Not Enough—We Need Medicare for All

The terms of the health-care debate must be shifted.

By Dennis Kucinich
The Nation, March 22, 2017

The health-care debate in America is essentially an argument over what kind of private insurance market people should have access to: President Obama’s, where the insurance companies made out like bandits, or President Trump’s, where insurance companies will make out like bandits.

Let’s change the debate by making it between for profit insurance vs. not for profit health-care. That’s what I and Congressmen John Conyers and Jim McDermott sought to do in 2003 when we wrote and introduced Medicare for All, HR 676, in the House of Representatives.

Six years ago, I was the last Democrat hold-out on “Obamacare.” My constituents desperately needed pre-existing coverage and insurance for their adult children. I reluctantly voted for it to prove that some reform was possible, not because it was an acceptable end-point.

It still left out millions and left consumers at the mercy of insurance companies. And everyone knows insurance companies make money by providing as little health-care as possible.

Here is what the for-profit insurance system brings:

  • Rising premiums and copays.
  • Diminishing coverage.
  • More government subsidy of private insurers.
  • Rising costs for prescription drugs.
  • More people going bankrupt because of hospital bills.
  • More people losing their homes because of hospital bills.

More seniors forced into poverty, losing everything they worked for their entire lives.

This is not about Democrats vs. Republicans, liberals vs. conservatives, left vs. right. This is about life vs. death.

This is about whether we, as Americans, can recognize a common interest in using the vast resources of our nation to insure the health of our people.

Heath spending approaches nearly 18 percent of the $20 trillion dollar GDP. Nearly a trillion dollars of that amount goes for corporate profits, stock options, executive salaries, advertising, marketing, and the cost of paperwork.

If we took all the money that people and the government are presently paying into the for-profit system and applied it to care for people in a not-for-profit system, we could provide for basic health care for all Americans, including prescription drugs, vision care, dental care, mental health, and long-term care.

That is what HR 676, Medicare for All, was all about.

Medicare for All is an idea whose time has come. Let’s make all Americans healthy and wealthy. Let’s lift up all of our families, save our homes, and help our businesses and industries. Let’s join every other industrialized nation in the world and offer health care to all of our people.

The terms of the debate in Washington must be shifted. We must not be stuck between competing for profit health insurance schemes. Let’s renew the debate: Medicare for All or profit for a few.

Dennis Kucinich, a former Chair of the Congressional Progressive Caucus, represented Ohio’s 10th District from 1997 to 2013.

https://www.thenation.com…

AJPH Editorial: ‘Trumpcare or Transformation’

By David U. Himmelstein, M.D. and Steffie Woolhandler, M.D., M.P.H.
American Journal of Public Health, March 21, 2017

Democrats as well as Republicans have offered too little that inspires and too much that appeases the rich and powerful. Trump won by attacking a status quo that is disastrous for many. In health care, the Affordable Care Act (ACA) extended coverage to 20 million and boosted funding for public health and community health centers. But it offered little help to 90% of the population, perpetuated a dysfunctional health care financing system, left 26 million uninsured, saddled covered families with unaffordable deductibles and narrow provider networks, and enriched drug firms, medical conglomerates, and insurers. Mobilizing for a reform that would fix these defects is a far better defense against Trump’s health-damaging plans than calls to retain the pre-Trump order.

Even before the inauguration, congressional Republicans initiated repeal of key pillars of the ACA. But although Republicans are unified in their desire to destroy what Obama wrought, crafting the replacement is more complicated. Unfortunately, going halfway — repealing without replacing — would likely cost thousands of lives (see numbers in PNHP release, below).

Potential Devastation

The health impacts of the administration’s antiscience bent are hard to gauge, but potentially devastating. Public health advance requires accurate data and honest assessment. When politicians threaten and muzzle scientists studying the environment, label inconvenient truths “fake news,” and propagate falsehoods under the guise of “alternative facts,” they chip at the foundations of scientific progress.

This grim litany reflects what President Trump and his allies want to do. But their agenda is already fraying under the pressure of popular opposition.

Backlash

Perhaps as important, Democratic politicians are feeling pressed and emboldened to embrace progressive policies.

Moving forward from the ACA to single payer would up-end the market-based approach that has hobbled reform, allowing the redirection of hundreds of billions now wasted on insurers’ overhead, providers’ billing-related paperwork, and excessive drug prices. With that money we could ensure access for all, lift the threat of bankruptcy attributable to illness, and free up funds for much-needed expansions of long-term and mental health care, as well as public health work.

http://ajph.aphapublications.org…

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ACA’s repeal would cause tens of thousands of deaths, while single payer would save 20,000 more lives than ACA: AJPH editorial

Physicians for a National Health Program, March 22, 2017

Repealing the Affordable Care Act without replacing it, as some conservative hardliners are demanding, would cost a minimum of 37,127 lives over the next two years (14,528 in 2018 and 22,599 in 2019), and perhaps as many as four times that number, according to scientific studies summarized in an editorial in this week’s American Journal of Public Health.

In contrast, the editorial’s authors estimate the impact of replacing the ACA with a universal, single-payer health system, along the lines of the Expanded and Improved Medicare for All Act, H.R. 676, would provide immediate coverage to the 26 million Americans who are currently uninsured, saving at least 20,984 lives in year one.

https://www.pnhp.org…

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Comment:

By Don McCanne, M.D.

There are at least three important concepts in this AJPH editorial by PNHP co-founders David Himmelstein and Steffie Woolhandler:

1. They cite the civil rights and social justice successes of the 1950s and 1960s and describe how there seems to be a growing renewal of that spirit in response to the current political regime.

2. They quantify the tragic loss of life that occurs today because of the inadequacies of the Affordable Care Act, and the increase in loss that would occur under repeal of ACA, while providing very reassuring estimates of the number of lives that would be saved by replacing ACA with a single payer national health program – an improved Medicare for all.

3. By including in their publication this editorial which extols the virtues of moving forward from the ACA to single payer, the prestigious American Journal of Public Health (“One of the 100 Most Influential Journals in Biology & Medicine over the last 100 Years”) has helped to moved the concept of single payer into the mainstream in our national discourse on health care reform.

Will repealing Obamacare really kill 60,000 people?

By Carolyn Y. Johnson
The Washington Post, March 22, 2017

Is repealing Obamacare going to kill people?

If you’re one of the millions projected to lose your health insurance under the health care law’s proposed repeal, that’s the big question. And Washington has plenty of politicians, partisans and wonks ready to answer it for you.

Sen. Bernie Sanders (I-Vt.) tweeted his take: 36,000 more deaths per year. An analyst at the conservative Manhattan Institute analysis argued the true answer was zero. Individual anecdotes abound: Obamacare saved my life.

In a new analysis published this week in the American Journal of Public Health, a pair of doctors who advised Sanders’s presidential campaign found that a repeal of the law without a replacement could cost anywhere from 14,000 to 60,000 lives — in the next year alone.

It’s unsurprising that partisans arguing over what to do with the law — known officially as the Affordable Care Act — would disagree about the effect’s of repealing it. But even nonpartisan health policy experts are at a loss when asked for a figure on how many people would perish if the ACA comes off the books.

That’s because the law’s most widespread feature is helping people buy health insurance, and the link between being covered by health insurance and actually being healthier is not fully understood.

It isn’t that the question hasn’t been studied or that individual benefits of health insurance aren’t known. An Institute of Medicine report in 2009 rounded up the evidence that uninsured people fared worse after a heart attack, stroke, cancer, diabetes, congestive heart failure and trauma. But what does all that harm add up to in lives lost or saved?

To make their estimate, physicians Steffie Woolhandler and David Himmelstein extrapolated from a handful of studies published during the past 15 years that used a variety of data sets and situations — such as the expansion of Medicaid in Oregon through a lottery and the effects of health reform in Massachusetts.

“The common sense belief that if you lose your health insurance, it’s going to make your health worse and it might even kill you — that’s a common-sense belief that happens to be true,” Woolhandler said in an interview. “People cannot say we’re going to take health care away from 24 million people and say nobody’s going to die.”

But health is a cumulative, complex and long-term outcome, determined not only by health insurance status, but by socioeconomic factors, genetics, lifestyle and the neighborhoods where people live. The differences between having insurance and not having insurance often encapsulates a broad swath of other factors that affect people’s well-being.

“When you ask the question, then, what would be the effect of repealing the ACA, there’s no perfect way to answer this question,” said Benjamin Sommers, an associate professor of health policy and economics at the Harvard T.H. Chan School of Public Health.

One of the studies the researchers drew on to make their estimate was led by Amy Finkelstein, an economist at the Massachusetts Institute of Technology. Finkelstein said that the body of research, including her work on the effects of the 2008 Medicaid expansion in Oregon, have made her confident that health insurance improves health. That study found a significant drop in depression and an increase in people’s self-reported health among those who randomly received Medicaid compared with those that did not.

But receiving insurance did not lead to improvements in other areas, such as better management of blood pressure, cholesterol levels or blood sugar control over the two years of the study. And since death was — fortunately — a relatively rare event for people between the ages of 19 and 64 in the Oregon study, where the survival rate was higher than 99 percent, measuring the effect of insurance on mortality may not be the right way to make the case it was working.

“You can’t rule out that Medicaid saves a bunch of lives, but you also can’t rule out that it kills a bunch of people,” Finkelstein said of the Oregon data. She argued that while health insurance is aimed at improving health, it is also fundamentally a product aimed at protecting people against financial ruin, and another way to measure its effects — particularly in the short term — would be to examine how it helped financial security.

The Oregon study showed reductions in financial strain, and a working paper published last year estimated that people who gained coverage through the broader Medicaid expansion had anywhere from a $600 to $1,000 reduction in collection debt.

Sommers, whose work was also used to estimate the effect of ACA repeal, said that another challenge is knowing whether giving someone insurance — which is what happened in his study of health reform in Massachusetts — will have directly the opposite effect as taking it away.

Two of the studies the researchers cited examined large data sets and found an association between longer life and having health coverage, but could not determine that the insurance drove the effect. That leaves open the possibility that it isn’t coverage itself that caused the disparity, but might also be explained by other differences between people who have insurance and those who don’t.

In his work, Sommers compared the death rates of people in Massachusetts before and after the state implemented health reform in 2006 with people in similarly matched counties that did not expand insurance coverage. He found a decrease in deaths in Massachusetts — in just the kinds of deaths, such as cancer, diabetes, heart disease that they expected might shift due to access to insurance.

“The short answer is, these are challenging extrapolations,” Sommers said. “But I think what’s fair to say, based on our studies, is that giving people insurance can reduce mortality, so likely taking it away will cause an increase. … The exact number is much harder to pin down.”

https://www.washingtonpost.com…

Sticking points with multi-payer contracting in health care

Common-Agency Problems and Contracting in the U.S. Healthcare System

By Brigham Frandsen, Michael Powell, and James B. Rebitzer
National Bureau of Economic Research, NBER Working Paper No. 23177, February 2017

Abstract

We propose a “common-agency” model for explaining inefficient contracting in the U.S. healthcare system. In our setting, common-agency problems arise when multiple payers seek to motivate a shared provider to invest in improved care coordination. Our approach differs from other common-agency models in that we analyze “sticking points,” that is, equilibria in which payers coordinate around Pareto-dominated contracts that do not offer providers incentives to implement efficient investments. These sticking points offer a straightforward explanation for three long observed but hard to explain features of the U.S. healthcare system: the ubiquity of fee-for-service contracting arrangements outside of Medicare; problematic care coordination; and the historic reliance on small, single specialty practices rather than larger multi-specialty group practices to deliver care. The common-agency model also provides insights on the effects of policies, such as Accountable Care Organizations, that aim to promote more efficient forms of contracting between payers and providers.

From the Conclusion

In this paper we have developed a common-agency model for explaining inefficient contracting in the U.S. healthcare system. In our setting, common agency problems arise when multiple payers seek to motivate a shared provider to invest in improved care coordination. Our approach differs from other common-agency models in that we analyze sticking points, that is, equilibria in which payers coordinate around Pareto dominated contracts that do not offer providers incentives to implement efficient investments. These sticking points offer a straightforward explanation for three long-observed but hard to explain features of the US healthcare system: the ubiquity of fee-for-service contracting arrangements outside of Medicare; problematic care coordination; and the historic reliance on small single-specialty practices rather than larger multi-specialty group practices to deliver care. The common-agency model also provides insights on the effects of policies (such as Accountable Care Organizations) that aim to promote more efficient forms of contracting between payers and providers.

We have examined the common-agency market failure in the context of payers trying to induce providers to make efficient investments in care coordination. We focused on incentives for these investments because they have played an important role in recent health care reform initiatives. The common-agency market failure is, however, much broader than this specific application and is likely to play a role wherever multiple payers seek to influence the actions of a shared provider.

Given the number and diversity of payers, exploring more broadly the implications of common-agency problems in the U.S. healthcare system is likely to be a fruitful avenue for future research. For example, Cutler and Ly (2011) remarks that “insurers have little incentive to coordinate their credentialing and billing requirements, because the costs of imposing different rules are spread across insurers as a whole, not partitioned to any single insurer,” leading to persistently high administrative expenses.

http://www.nber.org/…

Comment:

By Don McCanne, M.D.

You do not have to be an economist to understand an important conclusion of this technical paper. Our complex multi-payer financing system results in persistently high administrative expenses.

In a health care system with multiple payers, sticking points result in the ubiquity of fee-for-service contracting arrangements outside of Medicare; problematic care coordination; and the historic reliance on small single-specialty practices rather than larger multi-specialty group practices to deliver care. The costs of imposing different rules are spread across insurers as a whole, not partitioned to any single insurer, leading to persistently high administrative expenses.

Rather than trying to understand and apply the economic theory of the common-agency model, Pareto-dominated contracts, sticking point equilibria, and the onerous quest for more efficient forms of contracting between multiple payers and providers, we can simply eliminate the multi-payer model by enacting a single payer national health program – an improved Medicare for all. That does away with the administrative excesses and inequities of the sticking points that would never be totally eliminated in a multi-payer system.

Mayo discriminates against Medicaid patients

Mayo to give preference to privately insured patients over Medicaid patients

By Jeremy Olson
StarTribune, March 15, 2017

Mayo Clinic’s chief executive made a startling announcement in a recent speech to employees: The Rochester-based health system will give preference to patients with private insurance over those with lower-paying Medicaid or Medicare coverage, if they seek care at the same time and have comparable conditions.

Mayo will always take patients, regardless of payer source, when it has medical expertise that they can’t find elsewhere, said Dr. John Noseworthy, Mayo’s CEO. But when two patients are referred with equivalent conditions, he said the health system should “prioritize” those with private insurance.

“We’re asking … if the patient has commercial insurance, or they’re Medicaid or Medicare patients and they’re equal, that we prioritize the commercial insured patients enough so … we can be financially strong at the end of the year to continue to advance, advance our mission,” Noseworthy said in a videotaped speech to staff late last year.

Mayo reported a sharp increase in the amount of unreimbursed costs related to Medicaid patients, from $321 million in 2012 to $548 million in 2016. The figures include its campuses in Arizona and Florida. Mayo nonetheless remained profitable in 2016, with income of $475 million.

(Allan Baumgarten, a Twin Cities health analyst) added that complaints about the rise in Medicaid patients should be tempered by the corresponding decline in uninsured patients. “Aren’t you better off having bad payment through Medicaid compared to next to nothing from a patient who is uninsured?” he asked.

http://www.startribune.com…

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Cherry-picking patients? Mayo Clinic aims to ‘prioritize’ privately insured

By Elizabeth Whitman
Modern Healthcare, March 20, 2017

Late last year, CEO John Noseworthy had a message for the staff of the Mayo Clinic: We want patients with commercial insurance over Medicare or Medicaid.

For the Mayo Clinic health system to articulate its preference for patients with commercial insurance, which pays better than government insurance, was disappointing and surprising, said Arthur Caplan, head of the bioethics division at NYU Langone Medical Center.

“A cornerstone of our ethical thinking is you get the same care whether you’re rich or you’re poor, and we don’t triage by the size of your wallet,” Caplan said.

Noseworthy’s statement was a rare articulation of a broader trend – trying to make up for losses from Medicare or Medicaid patients with commercially insured patients – that the industry tends to try to conceal.

“I’ve heard of hospitals trying to do this behind the scenes, but I’ve never heard anybody say it up front,” Caplan said. “This statement is taking that dirty secret and bringing it into the open.”

http://digital.modernhealthcare.com

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Comment:

By Don McCanne, M.D.

The mission of our health care delivery system should be to provide everyone with the highest quality care possible within the limits of the finite resources available. That is an opinion not shared by all. The fact is that the mission of some sectors of our health care delivery system is to maximize revenues, and that may mean that patients of limited resources without generous public or private insurance coverage would be avoided by them.

This is a view not often expressed in public. In fact, Mayo’s CEO expressed it only in private to Mayo employees. But from decades of my exposure to conversations in physician dining rooms and locker rooms and in confidential board meetings, you can be assured that it is an exceptionally prevalent view, particularly regarding Medicaid, uninsured, and undocumented patients. This reality drives many of us to carry on the fight for an equitable system that serves everyone well.

Under a well designed single payer system in which payment is the same for all and capital improvements are distributed efficiently and equitably, everyone would have access to the highest quality care available within the limitations of our resources. We must intensify our advocacy efforts because we are a long, long way from that ideal.

American Physicians Want Medicare for All

By Ed Weisbart, M.D.
LinkedIn, March 20, 2017

Why do so many physicians prefer single payer national health insurance? The answer is simple: we are on the front lines, seeing the needless suffering created by our current system, and we know the evidence points to a better way. We want to do better, and we know that requires a better system.

There is little more demoralizing than seeing the patient I saw the day before I wrote this piece. This was a 30 year-old construction worker who gradually began to have trouble with balance and cognition. He lost his steady job, lost the health insurance provided by that job, and finally presented with daily seizures. He was admitted, stabilized on an expensive antiepileptic regimen, and found to have a brain tumor. The hospital sent him home with a prescription that he could not afford to fill. He was instructed to file an application for public assistance, but navigating that process was beyond his increasingly limited cognitive abilities. He saw me at another hospital’s safety net clinic one month later, still having untreated daily seizures, and with nowhere to turn for further evaluation and treatment of his lesion.

Had he been insured, the first hospital would likely have completed his evaluation and offered definitive treatment. Instead, he was sent home with an unaffordable prescription, no follow-up plan, and continued daily seizures. It breaks my heart to see someone in America unable to get life-saving healthcare due to insurance barriers.

We each have endless stories like this, we have to take them in stride, but they corrode our passion for medicine. We want to be proud of the system we’ve built, but instead we see tragedies that should never happen. And we know there is a better way.

Physicians in nations that have adopted single payer systems are shocked when they hear such stories from us. They know that medicine is hard enough without the financial barriers and confusing paperwork we impose on care.

Physicians in those nations have no need to assess the economic value or liability their patients represent to their practice, spend far less time on non-clinical administration, have comparable earning potential, and are proud of their nations’ health outcomes. Small wonder so many of us support single payer.

American physicians are an unhappy lot. Other than German physicians, we’re the least satisfied in the modern world.1 One recent time/motion study suggested that we spend 48% of our time on our electronic health records and other desk work, and only 26% of our time with patients.2 Our career satisfaction inversely correlates with the hours we spend on non-clinical documentation and communication. Our most satisfied physicians average eight such weekly hours, and it gets worse after that.3 We’re unhappy because we know this is not necessary: Canadian family physicians average 2.4 hours per week on non-clinical administrative tasks.4

It’s easier to practice in Canada, and it’s also less expensive. Our practices’ overhead average 55% of our revenue;5 Canadians’ average 28.2%.6 In part this is because we absorb extraordinary costs for insurance billing and administration,7 and in part because Canadian malpractice insurance is dramatically less expensive.8 In Missouri, where I practice, the typical single physician practice has over $200,000 in accounts receivable, averaging nearly 12 months old.9 This is unheard of in single payer nations like Canada.10 At the end of the day, the average fee for service billings per full time Canadian physician was $337,767 in 2014 (Canadian dollars), with family physicians at $271,417, Internal Medicine at $378,468, Pediatrics at $292,242, and OB-Gyne at $405,504.11

Perhaps this explains the increased migration of American physicians into Canada since 2006,12 and the net repatriation of Canadian physicians since 2004.13 Or perhaps it’s because of the broader societal impact of a system modeled on universal access as compared to one modeled on managed care. Notice that these patterns preceded the enactment of the Affordable Care Act.

In 1971, President Richard Nixon signed into law the HMO Act, creating our managed care movement. At roughly the same time, Canada’s national health insurance was fully implemented across all provinces. Prior to 1971, outcomes in our two nations were remarkably similar. We were both spending roughly the same 6% of our GDP on healthcare and following the same overall cost trends. Our life expectancies were within one year of each other. Since 1971, our paths have diverged. Canadians now spend roughly half of what we spend,14 and live nearly three years longer than we do.15 They have fewer unmet health needs than we do; theirs are largely due to waiting lists, ours to unaffordable costs. Anecdotal evidence aside, we must remember that Canadian waiting lists are generally not for life-threatening concerns or their life expectancies would not now be so much better than ours.16 We were the same, we adopted different models, and now we are quite different.

There is a bill in the US Congress, HR676, that would improve the problems with Medicare (financial barriers, gaps in benefit design, and needless bureaucracy) and provide that to all Americans. Twenty-five analyses at the state and federal level confirm that the new savings of such a strategy would easily pay for the new expenses.17 It is a matter of political will, not economics.

To learn more, join Physicians for a National Health Program (www.pnhp.org), the non-profit organization of more than 20,000 physicians, medical students and others who support single-payer national health insurance.

Dr. Ed Weisbart is chair of Physicians for a National Health Program — Missouri chapter.

https://www.linkedin.com…

Endnotes

1. http://www.commonwealthfund.org…

2. Sinsky et al. Ann Int Med 9/6/2016

3. Woolhandler & Himmelstein. Int J Health Serv. 2014;44:635

4. 2013 National Physician Survey. CFPC, CMA, Royal College; http://www.cma.ca…

5. http://medicaleconomics.modernmedicine.com…

http://www.merritthawkins.com…

6. http://www.cmpa-acpm.ca

7. Jiwani et al. BMC Health Services Research 2014, 14:556 at http://www.biomedcentral.com…

8. Canadian Medical Protective Association at http://www.cmpa-acpm.ca

9. Private communication with Missouri State Medical Association

10. Glauser, W. Canadian Medical Association Journal. June 19, 2014

11. Canadian Institute for Health Information

12. https://www.cma.ca…

13. https://www.cma.ca…

14. Statistics Canada, Canadian Inst. for Health Inf., and NCHS/Commerce Dept.

15. http://stats.oecd.org…

16. NBER Joint Canada / US Survey of Health; http://www.nber.org… Table 12

17. https://www.pnhp.org…