PNHP

What would states do with greater flexibility through Medicaid block grants?

What would states do with greater flexibility through Medicaid block grants?

Both State, Feds May Seek Changes To Medicaid

By Shamane Mills
Wisconsin Public Radio, January 11, 2017

Wisconsin hopes to change Medicaid in several ways. The Walker administration would like participants to undergo drug testing, charge smokers more and put time limits on how long people could use Medicaid.

Gov. Scott Walker’s entitlement reforms come as top Republicans in Washington, D.C. are pushing for states to get federal block grants they could spend as they wish on Medicaid.

http://www.wpr.org…

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Missouri lawmakers seek to convert Medicaid to block grant

By David A. Lieb, AP
St. Louis Post-Dispatch, January 11, 2017

Not waiting for President-elect Donald Trump to act first, some Missouri Republican lawmakers are pressing for a health care overhaul that could convert the state’s Medicaid program into a block grant from the federal government.

Missouri Sen. David Sater said the state’s more than $9 billion Medicaid program — called MO HealthNet — is beset by “runaway spending” and lacks “personal accountability and responsibility.”

The Missouri legislation seeks to address that by requesting federal approval for the block grant to be adjusted for inflation, growth in the Medicaid rolls and other economic and demographic factors. It also seeks approval to potentially implement work requirements for able-bodied Medicaid enrollees and to require co-payments, premiums or health savings accounts for patients to “reward personal responsibility.”

http://www.stltoday.com…

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Comment:

By Don McCanne, M.D.

There are two main reasons that the Republicans want to convert Medicaid to block grants for the states. Instead of paying a percentage of Medicaid costs, block grants can be set at an amount of payment that is lower and that does not increase at the same rate as health costs, thus shifting Medicaid costs from the federal government to the states. Also, the states are given much greater leeway on how the block grant funds can be spent, reducing federal regulatory oversight.

Many state governments are concerned about the reduced funding that would be available for health care for the low-income sector. Most states operate on very tight budgets and would have difficulty assuming a significantly greater proportion of the costs. Some states simply do not have an adequate tax base that would support the needs of these individuals. Federal funding is much more equitable and egalitarian.

Granting greater leeway on how the Medicaid funds would be spent is very appealing to state ideologues. There is a push today to require greater personal responsibility through policies such as drug testing, penalizing smokers, failure to meet work requirements, requiring financial responsibility through premiums, cost sharing, and required contributions to health savings accounts in this population that has no discretionary income, and perhaps ejecting individuals from the program simply because they have been on it long enough.

These politicians seem to look upon Medicaid beneficiaries as people who are less  deserving because of their welfare status that they believe is due to their own volition. They believe that simply requiring more personal responsibility is the solution, except for those more severely handicapped. Most health professionals who work with these patients know differently and understand why they qualify for Medicaid.

But think of how it would be under a single payer national health program. Everyone would receive essential health care services regardless of socioeconomic status. The politicians certainly expect to have their care when they need it. Why shouldn’t everyone have the same expectation?

Social risk factors and performance measurements

Report to Congress: Social Risk Factors and Performance Under Medicare’s Value-Based Purchasing Programs

United States Department of Health and Human Services
Office of the Assistant Secretary for Planning and Evaluation, December 2016

Background

There is growing recognition that social risk factors – such as income, education, race and ethnicity, employment, community resources, and social support – play a major role in health. Despite ongoing efforts, significant gaps remain in health and in life expectancy based on income, race, ethnicity, and community environment.

At the same time, the health care system is increasingly moving towards higher levels of provider accountability for the quality, outcomes, and costs of care. Value-based or alternative payment models, which tie payment to the quality and efficiency of health care delivered, are in place in nearly all Medicare settings, including in hospitals, outpatient settings, and post-acute facilities.

These two issues are intersecting. If beneficiaries with social risk factors have worse health outcomes because the providers they see provide low-quality care, value-based purchasing could be a powerful tool to drive improvements in care and reduce health disparities. However, if beneficiaries with social risk factors have worse health outcomes because of elements beyond the quality of care provided, such as the social risk factors themselves, value-based payment models could do just the opposite. If providers have limited ability to influence health outcomes for beneficiaries with social risk factors, they may become reluctant to care for beneficiaries with social risk factors, out of fear of incurring penalties due to factors they have limited ability to influence.

This report, mandated by the Improving Medicare Post-Acute Care Transformation Act of 2014 or the IMPACT Act (P.L. 113-185), shares empirical analysis using existing Medicare data to help address these questions and provides considerations for policymakers while additional work using other data sources continues.

Findings

FINDING 1: Beneficiaries with social risk factors had worse outcomes on many quality measures, regardless of the providers they saw, and dual enrollment status was the most powerful predictor of poor outcomes.

FINDING 2: Providers that disproportionately served beneficiaries with social risk factors tended to have worse performance on quality measures, even after accounting for their beneficiary mix. Under all five value-based purchasing programs in which penalties are currently assessed, these providers experienced somewhat higher penalties than did providers serving fewer beneficiaries with social risk factors.

Strategies and Considerations

STRATEGY 1: Measure and Report Quality for Beneficiaries with Social Risk Factors

Consideration 1: Consider enhancing data collection and developing statistical techniques to allow measurement and reporting of performance for beneficiaries with social risk factors on key quality and resource use measures.

Consideration 2: Consider developing and introducing health equity measures or domains into existing payment programs to measure disparities and incent a focus on reducing them.

Consideration 3: Prospectively monitor the financial impact of Medicare payment programs on providers disproportionately serving beneficiaries with social risk factors.

STRATEGY 2: Set High, Fair Quality Standards for All Beneficiaries

Consideration 1: Measures should be examined to determine if adjustment for social risk factors is appropriate; this determination will depend on the measure and its empirical relationship to social risk factors.

Consideration 2: The measure development community should continue to study program measures to determine whether differences in health status might underlie the observed relationships between social risk and performance, and whether better adjustment for health status might improve the ability to differentiate true differences in performance between providers.

STRATEGY 3: Reward and Support Better Outcomes for Beneficiaries with Social Risk Factors

Consideration 1: Consider creating targeted financial incentives within value-based purchasing programs to reward achievement of high quality and good outcomes, or significant improvement, among beneficiaries with social risk factors.

Consideration 2: Consider using existing or new quality improvement programs to provide targeted support and technical assistance to providers that serve beneficiaries with social risk factors.

Consideration 3: Consider developing demonstrations or models focusing on care innovations that may help achieve better outcomes for beneficiaries with social risk factors.

Consideration 4: Consider further research to examine the costs of achieving good outcomes for beneficiaries with social risk factors and to determine whether current payments adequately account for any differences in care needs.

Conclusions

Social factors are powerful determinants of health. In Medicare, beneficiaries with social risk factors have worse outcomes on many quality measures, including measures of processes of care, intermediate outcomes, outcomes, safety, and patient/consumer experience, as well as higher costs and resource use. Beneficiaries with social risk factors may have poorer outcomes due to higher levels of medical risk, worse living environments, greater challenges in adherence and lifestyle, and/or bias or discrimination. Providers serving these beneficiaries may have poorer performance due to fewer resources, more challenging clinical workloads, lower levels of community support, or worse quality.

The scope, reach, and financial risk associated with value-based and alternative payment models continue to widen. There are three key strategies that should be considered as Medicare aims to administer fair, balanced programs that promote quality and value, provide incentives to reduce disparities, and avoid inappropriately penalizing providers that serve beneficiaries with social risk factors. Measuring and reporting quality for beneficiaries with social risk factors, setting high, fair quality standards for all beneficiaries, and the provision of targeted rewards and supports for better outcomes for beneficiaries with social risk factors, may help ensure that all Medicare beneficiaries can achieve the best health outcomes possible.

Next Steps

The findings outlined in this report represent only the beginning of a body of necessary work around fair and accurate quality measurement in the context of Medicare’s increasing use of value-based purchasing programs. The IMPACT Act lays out specific additional requirements for Study B, including the examination of specific social risk factors not currently available in Medicare data such as health literacy, limited English proficiency, and Medicare beneficiary activation (the degree to which beneficiaries have the knowledge, skill, and confidence to manage their health and health care). Based on the findings in this report, future work may also include examining the impact of measuring and accounting for functional status or frailty on the relationship between social risk factors and performance, and identifying care innovations associated with the achievement of good health outcomes for beneficiaries with social risk factors.

Full report (374 pages):
https://aspe.hhs.gov…

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Comment:

By Don McCanne, M.D.

One of the problems with the various pay-for-performance schemes is that social risk factors play a major role in health care outcomes. Dedicated physicians and hospitals who take care of patients with greater social risks tend to be penalized for factors over which they have no direct control. This 374 page ASPE report was generated at the request of Congress to define this problem and consider solutions.

Skim reading this report leads to the conclusion that the approach to evaluating the role of social risk factors in payment systems using value-based purchasing, alternative payments models and other forms of payment innovation results in profound administrative complexity, with all of its waste, and yet it is still not very effective in correcting payment injustices. And this 374 pages is only the bare beginning of a “a body of necessary work around fair and accurate quality measurement in the context of Medicare’s increasing use of value-based purchasing programs.”

We continue to head down the wrong path. Our target should be to establish universality in health care while financing the system equitably with a system that reduces administrative waste. Instead you would think, based on the responses of the policy community and government bureaucrats, that the problem is that we do not have enough administrative oversight, so they propose more and more and more!

Instead we should reduce administrative waste by establishing a single payer national health program and improve value through global budgets, negotiated payment rates, and administered pricing, plus separate budgeting of capital distribution and system capacity. The latter should help to improve care for patients with higher social risk factors, though we do need to improve social programs that would better address the fundamental factors resulting in otherwise amenable social risks.

Politicians ignore Medicare for all

By F. Douglas Stephenson, LCSW
Gainesville (Fla.) Sun, Jan. 11, 2017

In the current Affordable Care Act debate, the mainstream media has ignored a solution standing in plain sight. It is a more efficient and affordable system for universal coverage in the public interest: single-payer national health insurance. Instead, we are being led by politicians beholden to big-money interests serving the greed of today’s medical-industrial-Big Pharma-Big-Insurance complex.

The Republicans want to repeal much of the ACA and replace it with something similar. The Democrats want to preserve ACA pretty much as it is. From the global perspective, we’ll still be left with a highly dysfunctional health care financing system that will not cover everyone while perpetuating inadequate coverage for many of those who are insured.

Our health-care financing system is still in shambles. Tens of millions remains uninsured. The insured have increasing difficulties in obtaining care in the narrow provider networks, while facing financial hardship because of the insurers shifting ever-more risk onto the patients. Both political parties want to make this a choice between protecting the shambles versus making them even worse through Republican replacement policies that would further weaken health-care coverage.

The true replacement choice needs to be between accepting or tweaking a system in shambles or moving on to a well-designed single payer system — an improved Medicare for all that would provide affordable, accessible health care for everyone.

The ACA could be replaced by a publicly financed national health insurance program like the one outlined in H.R. 676, a bill filed in the last Congress. This legislation would fully cover health/medical care for all Americans, and significantly lower costs by eliminating the private health insurance industry with its massive overhead and immense profits.

H.R. 676, “The Expanded & Improved Medicare for All Act,” would establish a unique American universal health insurance program with single-payer financing. The bill would create a publicly financed, privately delivered health care system that improves and expands the existing Medicare program to all U.S. residents, and all residents living in U.S. territories.

The goal of the legislation is to ensure that all Americans will have access, guaranteed by law, to the highest quality and most cost effective health care services regardless of their employment, income or health care status. In short, health care becomes a fundamental human right, with no financial barriers or financial harm resulting from seeking care.

With at least 20 million uninsured Americans, and many millions more who are underinsured, the time has come to change our inefficient and costly fragmented non-system of health care. The current for-profit health care system in the U.S. is not financially sustainable over the long run, hence the need for a unique nonprofit, universal single-payer health care system.

University of Massachusetts economics professor Gerald Friedman estimates that under the single-payer system created by H.R. 676, “the U.S. could save an estimated $592 billion annually by slashing the administrative waste associated with the private insurance industry ($476 billion) and reducing pharmaceutical prices to European levels ($116 billion).”

He wrote that in 2014, the savings would have been “enough to cover all 44 million uninsured and upgrade benefits for everyone else. No other plan can achieve this magnitude of savings on health care. Specifically, the savings from a single-payer plan would be more than enough to fund $343 billion in improvements to the health system such as expanded coverage, improved benefits, enhanced reimbursement of providers serving indigent patients, and the elimination of co-payments and deductibles in 2014.”

A Medicare-for-all system would vastly simplify how the nation pays for care; improve patient health; restore free choice of physician, mental health and other health professionals; eliminate co-pays and deductibles; and yield substantial savings for individuals, families and the national economy.

As Dr. Robert Zarr, past president of Physicians for a National Health Program, a nonprofit research and educational group of 20,000 doctors nationwide, said: “The global evidence is very clear: single-payer financing systems are the most equitable and cost-effective way to assure that everyone, without exception, gets high-quality care.”

F. Douglas Stephenson, LCSW, LMFT, BCD, is a retired clinical social work psychotherapist in Gainesville.

http://www.gainesville.com…

For truly affordable health care, embrace single-payer

By John M. Rice
Pittsburgh Post-Gazette, Letters, Jan. 11, 2017

Two recent articles, “House Republicans Work to Dismantle ACA” (Jan. 5) and “Uncertainty Over the Future of Obamacare May Drive Insurers Away” (Jan. 3), have generated responses from people rightfully concerned about what the future holds for their prospects of getting or keeping “affordable” health care.

Concerns aren’t only with those covered by the ACA. Others like myself who have employer-provided health insurance are also facing uncertainties about their health insurance with increases in premiums outpacing earnings and inflation and deductibles rising faster than premiums (from JAMA).

Fortunately, there is a solution for everyone that is already supported by 58 percent of Americans: Move to a single-payer plan. Rep. John Conyers’ bill — HR 676, Expanded and Improved Medicare for All — can get the U.S. on par with most other industrialized nations and provide health care to all citizens regardless of their employment, income or status of their health.

One can easily Google and read the complete text of HR 676. At only 30 pages, the benefits are easily understood. Every American would be covered; no one would be excluded. This creates the largest and most efficient risk pool by spreading the costs for care over the entire population. All medically necessary care would be funded through the single payer, including doctor visits, hospital care, prescriptions, mental health services, nursing home care, rehab, home care, eye care and dental care. There would be no fees for any service at the point of delivery. No surprise medical bills, no co-pays, co-insurance or deductibles. Funding would come from the 60 percent of health care costs that are currently publicly funded, payroll taxes on employers and income taxes on individuals. Most people’s taxes would be lower than what they currently pay for health insurance. Administrative costs present in our fragmented system would be reduced for physician offices, hospitals and businesses providing health insurance coverage to their employees.

It wouldn’t take long to read the bill and a lot of other information on how single payer would work (see the Physicians for a National Health Program, pnhp.org, and the Western Pennsylvania Coalition for Single-Payer Healthcare, wpasinglepayer.org). Decide for yourself if it makes sense. If that is the case, contact your congressman and let him know how you feel. We’re about to take a step backward when we can, and should, do better.

The writer is a filmmaker at work on a film in support of single-payer healthcare. He resides in Mt. Lebanon.

https://www.post-gazette.com…

Overuse and underuse of health care

Right Care Series

The Lancet, January 8, 2017

Many countries struggle with the question about sustainability, fairness, and equity of their health systems. With the focus firmly on universal health coverage as a central part to the UN Sustainable Development Goals, there is an opportunity to examine how to achieve optimum access to, and delivery of, health care and services. Underuse and overuse of medical and health services exist side-by-side with poor outcomes for health and wellbeing. This Series of four papers and accompanying comments examines the extent of overuse and underuse worldwide, highlights the drivers of inappropriate care, and provides a framework to begin to address overuse and underuse together to achieve the right care for health and wellbeing. The authors argue that achieving the right care is both an urgent task and an enormous opportunity.

The full “Right Care” series is available for free through this link, though registration is required:
http://www.thelancet.com…

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Right Care 1: Evidence for overuse of medical services around the world

By Shannon Brownlee, Kalipso Chalkidou, Jenny Doust, Adam G Elshaug, Paul Glasziou, Iona Heath, Somil Nagpal, Vikas Saini, Divya Srivastava, Kelsey Chalmers, Deborah Korenstein

Overuse, which is defined as the provision of medical services that are more likely to cause harm than good, is a pervasive problem. Direct measurement of overuse through documentation of delivery of inappropriate services is challenging given the difficulty of defining appropriate care for patients with individual preferences and needs; overuse can also be measured indirectly through examination of unwarranted geographical variations in prevalence of procedures and care intensity. Despite the challenges, the high prevalence of overuse is well documented in high-income countries across a wide range of services and is increasingly recognised in low-income countries. Overuse of unneeded services can harm patients physically and psychologically, and can harm health systems by wasting resources and deflecting investments in both public health and social spending, which is known to contribute to health. Although harms from overuse have not been well quantified and trends have not been well described, overuse is likely to be increasing worldwide.

Key messages

• Overuse is difficult to measure and has not been well characterised
• Most studies of overuse have been done in high-income countries, but there is growing evidence that overuse is a global problem
• Overuse is likely to cause physical, psychological and financial harm to patients
• Overuse deflects resources from public health and other social spending in both low-income and high-income countries
• Overuse occurs across a wide range of medical specialties

“Though the doctors treated him, let his blood, and gave him medications to drink, he nevertheless recovered.” – Leo Tolstoy, War and Peace

http://www.thelancet.com…

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Right Care 2: Evidence for underuse of effective medical services around the world

By Paul Glasziou, Sharon Straus, Shannon Brownlee, Lyndal Trevena, Leonila Dans, Gordon Guyatt, Adam G Elshaug, Robert Janett, Vikas Saini

Underuse—the failure to use effective and affordable medical interventions—is common and responsible for substantial suffering, disability, and loss of life worldwide. Underuse occurs at every point along the treatment continuum, from populations lacking access to health care to inadequate supply of medical resources and labour, slow or partial uptake of innovations, and patients not accessing or declining them. The extent of underuse for different interventions varies by country, and is documented in countries of high, middle, and low-income, and across different types of health-care systems, payment models, and health services. Most research into underuse has focused on measuring solutions to the problem, with considerably less attention paid to its global prevalence or its consequences for patients and populations. Although focused effort and resources can overcome specific underuse problems, comparatively little is spent on work to better understand and overcome the barriers to improved uptake of effective interventions, and methods to make them affordable.

Key messages

• Underuse is responsible for substantial suffering, disability, and loss of life worldwide, in both high-income and low-income countries
• Underuse is prevalent across different types of health-care systems, payment models, and health services
• The causes of underuse are multi-layered:from inadequate access, health system failures, clinicians being unaware or unskilled to provide required interventions, and patients not accessing or declining them
• Underuse occurs alongside overuse, particularly in areas where there is competitive tension between profitable and low-cost interventions
• Policymakers, funders, clinicians, and civil society urgently need to recognise, invest, and resolve the slow uptake of effective, affordable, but non-promoted interventions

http://www.thelancet.com…

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Right Care 3: Drivers of poor medical care

By Vikas Saini, Sandra Garcia-Armesto, David Klemperer, Valerie Paris, Adam G Elshaug, Shannon Brownlee, John P A Ioannidis, Elliott S Fisher

The global ubiquity of overuse and underuse of health-care resources and the gravity of resulting harms necessitate an investigation of drivers to inform potential solutions. We describe the network of influences that contribute to poor care and suggest that it is driven by factors that fall into three domains: money and finance; knowledge, bias, and uncertainty; and power and human relationships. In each domain the drivers operate at the global, national, regional, and individual level, and are modulated by the specific contexts within which they act. We discuss in detail drivers of poor care in each domain

Conclusion

The provision of care is initiated by decision making within the doctor–patient relationship, but is substantially influenced by the resources available for health care within the society, its social and political contract, the state of global and local scientific knowledge, the configuration and capacity of the delivery system, and financing mechanisms.8,22,74,214 Achievement of the right care requires an understanding of and attentiveness to all these dimensions in the development of policy choices for promotion of care that is safe, effective, sensitive to personal preferences, and just.

Although no one factor results in the provision of right care, universal health coverage should be recognised as essential at the population level. Each factor can be deemed as equally necessary but equally insufficient by itself. Reducing the role of greed by structuring financial incentives to maximise true clinical benefits and social value is key. Ensuring vigilance against error and bias, broadening research aims, and a focus on meaningful outcomes are key goals in the production of knowledge. Therefore, re-addressing imbalances of knowledge and power, not only within the clinician–patient relationship but also within delivery systems, and more broadly in society, is equally crucial. There are potentially many levers to remedy poor care, but evidence of effectiveness is very modest.

Finally, as biological creatures conscious of our susceptibilty to injury, illness, and death, deep concerns about health are universal. Public support is therefore inevitably susceptible to manipulation for private gain. Active public education, engagement, and empowerment are crucial to ensure that the forces that shape health-care delivery worldwide are truly focused on delivering the right care.

http://www.thelancet.com…

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Right Care 4: Levers for addressing medical underuse and overuse: achieving high-value health care

By Adam G Elshaug, Meredith B Rosenthal, John N Lavis, Shannon Brownlee, Harald Schmidt, Somil Nagpal, Peter Littlejohns, Divya Srivastava, Sean Tunis, Vikas Sain

The preceding papers in this Series have outlined how underuse and overuse of health-care services occur within a complex system of health-care production, with a multiplicity of causes. Because poor care is ubiquitous and has considerable consequences for the health and wellbeing of billions of people around the world, remedying this problem is a morally and politically urgent task. Universal health coverage is a key step towards achieving the right care. Therefore, full consideration of potential levers of change must include an upstream perspective—ie, an understanding of the system-level factors that drive overuse and underuse, as well as the various incentives at work during a clinical encounter. One example of a system-level factor is the allocation of resources (eg, hospital beds and clinicians) to meet the needs of a local population to minimise underuse or overuse. Another example is priority setting using tools such as health technology assessment to guide the optimum diffusion of safe, effective, and cost-effective health-care services. In this Series paper we investigate a range of levers for eliminating medical underuse and overuse. Some levers could operate effectively (and be politically viable) across many different health and political systems (eg, increase patient activation with decision support) whereas other levers must be tailored to local contexts (eg, basing coverage decisions on a particular cost-effectiveness ratio). Ideally, policies must move beyond the purely incremental; that is, policies that merely tinker at the policy edges after underuse or overuse arises. In this regard, efforts to increase public awareness, mobilisation, and empowerment hold promise as universal methods to reset all other contexts and thereby enhance all other efforts to promote the right care.

Conclusions

The modern history of health care is littered with policy and practice inaction in the face of inappropriate care, often justified by an absence of evidence or uncertainty about what might result—Machiavelli’s “new order of things”. This lack of action should no longer be acceptable. Although the scale of the problem is vast and complex, a range of potentially effective remedies are available, with many more needed. Evidence-based medicine, HTA (health technology assessment), shared decision making, and countless other movements have surely nudged health systems to a point whereby we must ultimately acknowledge that a decision not to act is still a decision, and one with implications for people’s health. As efforts to improve the delivery of care continue worldwide, we must recognise that if the objective is to improve health, delivery systems need to be properly scaled and adapted to local needs and socioeconomic conditions to be maximally effective. Furthermore, delivery system leaders should remain humble about their systems’ contributions to health and should be unburdened from the task of substituting less effective medical spending for social spending. Transitions from the norm invariably cause conflict, but if efforts to achieve the right care are able to capture the full opportunity in front of us, the benefits to the wellbeing of patients, professionals, and the public as a whole are too great to condone inaction.

http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(16)32586-7.pdf

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Comment:

By Don McCanne, M.D.

Considering the amount of money we spend on health care in the United States, we should be making special efforts to see that we spend it right. This Lancet series, “Right Care,” is helpful because it defines for us where we are not providing enough care (underuse), leaving too many with unmet health care needs, and where we are providing excess care (overuse), wasting resources that could be used elsewhere, not to mention that excessive care is sometimes harmful.

Although many factors are involved in our misuse of health care, the financing system plays a significant role. We leave far too many people uninsured and underinsured which creates financial barriers to essential health care services. We have a maldistribution of our health care resources which impairs access to care in underserved areas.

By using a finance system that is based on business principles instead of public service, we are using financial disincentives, such as high deductibles, supposedly to discourage overuse but which, in fact, inappropriately incentivizes underuse. A well designed financing system, such as single payer, should go a long way toward addressing the problem of underuse, though other social factors would have to be addressed as well.

Overuse is a more difficult problem. Most health care is in a gray area. Obviously, expensive high-tech care that provides no benefit and is harmful is overuse and should be ferreted out of the system. But when high-tech care is beneficial it may be that it is no more beneficial than less expensive traditional care, but there inevitably would be disagreement on that, even after comparative effectiveness studies are completed. Many treatment regimens have potential adverse consequences, but that is often difficult to balance against the benefits that the patient may experience. Some low cost diagnostic and therapeutic interventions may lack scientific validation but if the interventions are essentially harmless and the patient is improved if for no other reason than reassurance, would this be considered overuse of our health care system? Although some might consider gray area medicine to be overuse, it would be very difficult to recover the costs of this care.

The “Right Care“ series addresses much more than the financing systems of health care, so it would be worthwhile to set time aside to read the articles (4 papers, 3 comments, and 1 perspective). It is imperative that we make “right care” a goal of reform.

But we really do need to get the financing system right. If we don’t, we’ll continue to see money wasted in more affluent areas where there is an excess capacity in high-tech care, and we’ll continue to see deficiencies in care for those who are not well served by our fragmented, dysfunctional system, market-based system.

Once we establish a publicly-financed and publicly-administered financing system, then we can work to improve the distribution and allocation of our resources to reduce waste while being sure that health care is there for people when they need it.

If Obamacare Is Repealed, Advocates Expect “Meaner and Skimpier” Replacement for the Poor

Interview With Dr. Steffie Woolhandler (Part 2)

By Amy Goodman
Democracy Now!, Jan. 10, 2017

PNHP Note: To view video of this interview (parts 1 & 2), click here. To read a transcript of part 1, click here.

As Republicans in the newly sworn-in 115th Congress are moving swiftly to repeal the Affordable Care Act, President Obama’s signature healthcare law, we continue our extended interview with Dr. Steffie Woolhandler, a primary care physician and co-founder of Physicians for a National Health Program.

TRANSCRIPT
This is a rush transcript. Copy may not be in its final form.

AMY GOODMAN: This is Democracy Now!, democracynow.org, The War and Peace Report. I’m Amy Goodman, as we continue with Part 2 of our conversation with Dr. Steffie Woolhandler, a professor at CUNY-Hunter College here in New York, a primary care physician, lecturer at Harvard Medical School, the co-founder of Physicians for a National Health Program, which did not, by the way, embrace Obamacare. But now, three years later, it looks like a record number of sign-ups on HealthCare.gov for 2017 health insurance coverage. CNBC reports federal health officials touted a record 6.4 million customer sign-ups on the federal Obamacare marketplace, HealthCare.gov, so far this enrollment season. That’s quite something for what Republicans are saying is an extremely unpopular program, and they say they are going to repeal it, perhaps as early as this week. Dr. Steffie Woolhandler, your response?

DR. STEFFIE WOOLHANDLER: Well, I’m very glad to see the Medicaid expansion. That was by far the best part of the Obamacare legislation. But there were a lot of very negative things. For one thing, it never got us anywhere close to universal healthcare. There are still close to 30 million Americans who are uninsured. So, the Obamacare legislation didn’t get us to universal. And frankly, it didn’t fix things for people who have insurance but are underinsured. That is, they have insurance, but there’s so many gaps, like copayments and deductibles and uncovered services, that they still can’t afford care. And that underinsurance problem was getting worse before Obamacare and continued to get worse under the Obamacare legislation. And that’s a lot of the reason, I think, why Obamacare was so unpopular. The Democrats were going around saying, “Look, we solved the problem. We have Obamacare. It’s great.” And a lot of people were looking at their own insurance, their own healthcare situation, and saying, “Gee, nothing improved for me.” Had the Obama and Clinton said, you know, “We got a little bit of improvement, and now we need to fight to get real universal coverage,” I think they would have had a lot of resonance with the electorate. Certainly, that’s what Bernie Sanders was saying. He voted for Obamacare and then said, “But let’s move on to Medicare for all.” That would have resonated, but the line they took, that, “Gee, we have the ACA. We’ve solved everything,” frankly, made them look like liars, you know. And they didn’t solve everything. They got some insurance for a lot of people. Twenty million people is a sizable number of people. But remember, there’s 310 million Americans, and most of them did not benefit under the Obamacare legislation.

AMY GOODMAN: So, let’s talk about the road to single payer. In Part 1 of our conversation, we played several clips of Donald Trump before he won the election, talking about single payer. Unlike other Republicans, who completely denigrate, for example, the Canadian system, he said it works great in Canada. He said it works great in Scotland, where he has his golf courses. He seems open. I mean, as a businessman, he didn’t want to pay for these astronomical costs in healthcare. What is the road to single payer? And what does Medicare for all look like?

DR. STEFFIE WOOLHANDLER: Well, you know, we have another election in less than two years, and I think we need to be looking forward to changing Congress and the Senate, if we’re going to get single payer. Donald Trump used to say a lot of liberal things. He’s not saying them very much anymore. He’s appointed extremely conservative people to his Cabinet, and particularly his health secretary and the head of the CMS, which runs Medicare and Medicaid, are very, very conservative people. So, we do not—

AMY GOODMAN: Congressman Pence’s head of Health and Human Services—

DR. STEFFIE WOOLHANDLER: —expect Donald Trump to be embracing single payer. What we do expect is that the American people are going to be thinking much more about single payer, and also, I think, Democratic legislators, as well, now that it’s clear that Obamacare is kind of played out. It was passed six years ago. It’s been up and running for nearly three years. And the electorate is saying, “No, this is not good enough. We need something better.” And, you know, in fact, the only thing that will work is a single-payer plan. That’s, by and large, because if you have a Medicare-for-all, single-payer-type system, you get tremendous administrative savings. You save about 14 percent of total healthcare spending just by reducing the paperwork in getting that single-payer system. So you have hundreds of billions of dollars in administrative savings that you can use to cover the uninsured and to improve coverage for people who now have only partial coverage. So, that’s the way single payer works. That’s the way it works in Canada, the way it works in Scotland. And that’s what we need to do to get healthcare to the American people.

AMY GOODMAN: But how exactly do you do that, when you have the Democrats who, in shaping Obamacare, really pushed aside all of you Medicare-for-all activists? I mean, remember Senator Baucus, his raucous caucus, trying to prevent people who advocated for this Medicare-for-all system from even being a part of the conversation before the legislation was written.

DR. STEFFIE WOOLHANDLER: Yeah, well, the Democratic Party has been changed a lot by this election. The person who was actually popular with working-class people, who actually generated excitement among young people, was Senator Sanders. And, of course, he won 20 states. He has now been incorporated into the Democratic Party leadership. And again, so his position is enhanced. The position of Elizabeth Warren is enhanced. So, Senator Sanders, as you know, ran on a platform of Medicare for all and has continued to say we shouldn’t be talking about a rollback, we should be talking about moving forward to making healthcare a right. So, I think the only way to defend the modest gains, if you will, that were made with the Affordable Care Act—the only way to defend those gains is to be saying to the American people, “Let’s move forward to Medicare for all and improve the situation for everyone, not just 20 or 22 million people, but for everyone.” So, I think the Democratic Party has been changed. They’re pretty aware of the fact that you actually have to do something for the majority of working families if you want to get their votes. And certainly single payer would be something that would very substantially improve the lot of Americans, America’s working families.

AMY GOODMAN: Can you explain Donald Trump’s pick of Seema Verma, who you mentioned, together with the Georgia congressman, Tom Price, who really would be the person who is in charge of looking at Medicare and Medicaid?

DR. STEFFIE WOOLHANDLER: Well, Seema Verma would be the administrator of Medicare and Medicaid, which is an extremely powerful position because of the, you know, hundreds and hundreds of billions of dollars federal government spends on those programs. Ms. Verma worked as a consultant in Indiana designing Indiana’s Medicaid—now, they call it the Medicaid reform, but it was really a rollback of Medicaid. It was an extremely punitive Medicaid program requiring very poor people to deposit money in a savings account every single month. And if they missed a payment, which can often happen with a very poor person—they may not have the money one month—they missed a single payment, they would lose their health insurance for six months, or they would get their insurance cut way back so they have to pay a copayment every time they went to see the doctors. So, it’s pretty much the most punitive Medicaid program in the country. And Seema Verma designed that program at the behest of then-Governor Pence. So, I think we know, both from Ms. Verma’s appointment and from what Paul Ryan has said, that they’re planning to really make Medicaid a very skimpy program that does not provide sick poor people with adequate access to care. Basically, it will pay the hospital, so the hospital bill is paid, but really will not allow poor people to get the full range of medical care they need to stay healthy.

Tom Price, you know, he’s trained as a doctor. Thankfully, his views do not represent the views of the majority of U.S. physicians. The majority of U.S. physicians support some form of national health insurance. And Tom Price has opposed Medicaid expansion. He wants to privatize the Medicare program. He wants to close down Planned Parenthood, restrict reproductive rights. Those views are very extreme both within American society and within the medical profession, where many physicians do support national health insurance, and 20,000 physicians have joined with us in Physicians for a National Health Program to support single-payer national health insurance.

AMY GOODMAN: Let me play for you the Senate minority leader now, Chuck Schumer’s response to Donald Trump’s choice of Georgia Congressmember Tom Price to be secretary of health and human services, Price now the chair of the House Budget Committee and member of the Tea Party Caucus and, again, of course, one of the leading opponents of Obamacare, as you point out, supporting privatizing Medicare, opposing abortion and voting to cut all federal funding for Planned Parenthood.

SEN. CHUCK SCHUMER: I was just so disappointed to see the president-elect nominate Congressman Price to serve as secretary of health and human services this morning. When it comes to issues like Medicare, the Affordable Care Act and Planned Parenthood, Congressman Price and the average American couldn’t be further apart. Between this nomination of an avowed Medicare opponent and Republicans here in Washington threatening to privatize Medicare, it’s clear that Washington Republicans are plotting a war on seniors next year. Every senior, every American should hear this loudly and clearly: Democrats will not let them win that fight.

AMY GOODMAN: So there you have the Senate minority leader, Chuck Schumer, talking about Tom Price, talking about senior citizens in this country. You were also talking about Planned Parenthood and the cutting of it. We’re talking about what those in power are doing. But, Dr. Steffie Woolhandler, aside from being a professor at Harvard and CUNY-Hunter College, you’re a primary care physician. You’re going to be in Albuquerque on Friday speaking for your group, the group that you founded, Physicians for a National Health Program. You’ll be participating in the Million Woman March, which is happening not only in Washington, but in Los Angeles, in Albuquerque, in Santa Fe. Talk about how women’s healthcare and reproductive rights fits into this picture and will be affected by what’s happening in Congress now, and how you’re organizing against it, what movements are doing.

DR. STEFFIE WOOLHANDLER: OK. Well, you know, the physician community is close to unanimous in supporting reproductive rights and reproductive healthcare. There are physicians who have a personal religious objection to abortion, but the overwhelming majority of physicians do support a woman’s right to choose. And that’s because it’s a very important public health issue that women have to be able to control their reproduction in order to maintain their own health, in order to maintain the economic security of themselves and their families, in order to plan for healthy families. So, there’s near unanimity in the medical community in support of reproductive rights, which is why the selection of Representative Price is—really, is outside of the mainstream, not just of the American people, but of the medical community.

One of the hospitals where I work in Boston, the doctors are saying that 500 of them are taking buses down to Washington on Saturday, January 21, for the Million Woman March, which is, frankly, extraordinary that doctors are, on their own time and own expense, participating actively. I mean, I do think that the one silver lining, if you will, in the very dark cloud of the Trump administration is that it is really mobilizing people to say, you know, “No more armchair commentary. It’s time to get out on the streets. It’s time to get out and really fight for what we believe.” And for the physician community, that includes reproductive rights. That includes the rights of immigrants, the rights of non-Christians, the rights of racial minorities, the rights of unions to organize. So, you know, I think we are seeing a real mobilization of the medical community.

There’s not only the Million Woman March, but there’s actions on January 13th in New York at 4:00 at Trump Tower, a mobilization for single payer. Senator Sanders has called for actions on January 15th. There’s people calling in to their congressmen supporting single payer on January 20th. And Physicians for a National Health Program, along with the American Medical Women’s Association, the American Medical Student Association, the student WhiteCoats4BlackLives, the Physicians for Social Responsibility, the National Nurses United, the largest nurses’ union in the United States, those groups are planning an action at workplaces the day that the Obamacare legislation is repealed, so at the places where people actually work, to support moving forward from Obamacare to universal coverage, but also supporting those other issues—immigrant rights, healthy environment, opposition to racism—all of the issues that are really under threat with the Trump administration and the Republican control of both houses. So, you know, we are mobilizing. We hope other people will want to join us in mobilizing, because that’s the way to protect American democracy and to make sure that eventually we do get a healthcare system that serves everyone in this country.

AMY GOODMAN: Last week, Planned Parenthood supporters tried to deliver petitions with—I think it was 87,000 “Stand with PP,” “Stand with Planned Parenthood,” petitions, telling Ryan not to defund Planned Parenthood. And he called out six security guards to block them. So, do you see single payer or Medicare for all, if it happens, starting in one state? Vermont attempted it, but it didn’t happen. Where do you see it possibly happening in the United States as a model, sort of like Canada, right? Wasn’t it Kiefer Sutherland’s grandfather, Thomas—Tommy Douglas, who did it in Saskatchewan, and then it became so popular, despite tremendous opposition of the American Medical Association, though that was in the United States, that it simply spread across Canada and was adopted? And he became one of the most popular Canadians of all time.

DR. STEFFIE WOOLHANDLER: Well, certainly, Physicians for a National Health Program has a lot of state chapters that work on state bills in trying to get single payer at the state level. And I’m a big supporter of that work. But we’re going to have to get a Congress and a president who’s going to allow the states to experiment with single payer, and right now we don’t have that. Now, we do have an election in less than two years that could change the nature of Congress and the Senate. So, we don’t have—it may not be that far away. But you do have to get Congress to allow you to incorporate Medicare and federal employees into a state single-payer bill, and that can’t just be done administratively. That has to be done by Congress. So, you do need to get a Congress and a Senate that will accept state experimentation. And, of course, we don’t really have that, at least in the short run.

AMY GOODMAN: And what’s going to happen to rural hospitals, to hospitals overall, with Obamacare being repealed?

DR. STEFFIE WOOLHANDLER: Well, that’s very much up in the air. Certainly, hospitals that are seeing a lot of Medicaid patients and getting a lot of their funding through Medicaid are very frightened about what’s going to happen under this new Republican administration, which does plan to cut way back on Medicaid. So, that would be a lot of our inner-city hospitals. A lot of our rural hospitals, you know, are really going to be facing some problems. I don’t expect very dramatic changes immediately. Even the Republicans seem to realize, if you’re going to make changes of that magnitude, you have to phase them in slowly. Nonetheless, I think there are going to be problems for hospitals that care for a lot of lower-income people.

AMY GOODMAN: And considering that Republicans, and many Democrats, stand for big business, the insurance industry is—aren’t they satisfied with Obamacare? Wouldn’t they be putting enormous pressure on the Republicans not to defund it?

DR. STEFFIE WOOLHANDLER: OK. Well, the thing the insurance companies have been happiest about are the Medicaid expansion, which has most been almost entirely done through private-managed Medicaid plans. So, most of the new Medicaid expansion has been through private plans. Similarly, there’s been a partial privatization of the Medicare program already through the so-called Medicare Advantage Plans, which are private plans that enroll seniors, and then the taxpayers pay the premiums. And for many years, the Medicare program has been overpaying private insurance companies for these Medicare Advantage Plans, and they’ve been quite profitable for the private insurance industry and have been expanding quite rapidly. So, we’re quite sure that the Obama administration [sic] and Price will be pushing for Medicare privatization. It may just be that they’re going to push to accelerate the expansion of these private Medicare Advantage Plans—

AMY GOODMAN: You mean the Trump administration.

DR. STEFFIE WOOLHANDLER: —rather than do the voucher system, which is—frankly, the Republicans have been talking about a voucher system for Medicare for about 20 years and have never gotten any traction with it. It’s wildly unpopular. So, I wouldn’t be surprised if they kind of shift gears and say, “OK, let’s just accelerate the privatization through Medicare Advantage.”

AMY GOODMAN: And the cost of drugs?

DR. STEFFIE WOOLHANDLER: Well, very good question. The Republicans have made it clear that they are not going to constrain the pharmaceutical industry. They’ve been talking about, “Oh, we need innovation,” which is a buzzword for saying, “Don’t let the FDA look, do a thorough look at the safety of drugs. Just have them pass everything through without a thorough review for safety.” They’re very pro-Pharma, and I think we’re likely to see a steady increase in pharmaceutical prices. We may occasionally get some grandstanding, where, over a particular drug, you know, the Congress or Senate makes a big deal and forces the drug industry to roll back. But overall, we’ve actually seen a steady increase in the price of all drugs over the past few years, including generic drugs. And the Republicans seem to be willing to tolerate that and allow that to continue.

AMY GOODMAN: And I wanted to ask you about mental health, a combination, actually, of mental health and the VA, because there’s been this discussion of President-elect Trump starting to talk about privatization of the VA, but these two coming together when you have the shooter in Fort Lauderdale, starting in Alaska, going to an FBI office, saying he’s hearing voices. He was in Iraq for years. He’s institutionalized for a day or two, and then he is released and is given his gun back. But not only soldiers and vets with PTSD, but the whole issue of mental health and what will happen to it in a Trump administration?

DR. STEFFIE WOOLHANDLER: Well, mental health is probably absolutely underfunded in the United States, particularly outpatient care for children and young adults. We’re really not seeing enough care being delivered, you know, in the community where people need it. We’ve also seen a cutback in the number of mental health hospital beds, which is what you need when somebody’s actively suicidal or homicidal, and yet those have been cut back. So, mental health, actually, needs a lot of attention. Even if we go to single payer, we’re going to have to pay a lot of attention to improving the mental health system and making sure that everyone who needs mental health gets it, a particularly big issue with veterans. You know, veterans have been trained to solve problems by shooting guns. And if they have mental health problems, they’ve very likely to pick up a gun and, you know, express their mental health problems through shooting.

But the VA has been, actually, a very good system. It’s a large system. And periodically there’s scandals, or there’s problems. But when you look overall at the data, it’s very clear that the average quality of care in the VA system is higher than the average quality in the—in the civilian sector. And that’s very clear in the medical literature. So, yes, there’s problems in the VA. There’s isolated problems that need to be fixed. But privatization would be a terrible, terrible mistake, because you’d be moving from a system that functions better, albeit with problems, to a system that’s more expensive and functions worse. So, privatization is a terrible idea. I was heartened to see that many veterans’ groups actually stood up and said, “No, we don’t want privatization. We want you to fix the problems that exist in the VA now, but we do not see privatization as the answer.”

AMY GOODMAN: Dr. Steffie Woolhandler, we thank you so much for spending this time, professor at City University of New York, CUNY, Hunter College, primary care physician, lecturer at Harvard Medical School, co-founder of Physicians for a National Health Program, one of the major organizations in this country that support Medicare for all. This is Democracy Now! I’m Amy Goodman. Go to democracynow.org for Part 1 of our conversation. Thanks for joining us.

https://www.democracynow.org…

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Obama to Republicans: Show me a better plan

Remarks by the President in Vox Live Interview

By Ezra Klein and Sarah Kliff of Vox
The White House, Office of the Press Secretary, January 6, 2017

Excerpts of the President’s comments:

“…the challenge of getting it passed was always the fact that, unlike other advanced countries, we didn’t start with a system in which everybody was covered, and we have a very complicated marketplace, and we have third-party insurers.  And what that meant was that even after we got the law passed anything that dissatisfied people about the health care system could be attributed to — quote, unquote — “Obamacare,” even if it had nothing to do with Obamacare.”

***

“…whenever you look at polls that say 40-something percent are supportive of the law and 40-something percent are dissatisfied — in the dissatisfied column are a whole bunch of Bernie Sanders supporters who wanted a single-payer plan.  (Laughter.)  And so the problem is not that they think Obamacare is a failure; the problem is that they don’t think it went far enough and that it left too many people still uncovered, that the subsidies that people were getting weren’t as rich as they should have been, that there’s a way of dealing with prescription drug makers in a way that drives down those costs.”

***

“If it works, I’m for it.  If something can cover all Americans, make sure that if they have a preexisting condition they can still get coverage, make sure that prescription drugs are affordable, encourage preventive measures to keep people healthy, that makes sure that in rural communities people have access to substance abuse care or mental health care, that Medicare and Medicaid continue to function effectively — if you can do all that cheaper than we talked about, cheaper than Obamacare achieves and with better quality and it’s just terrific, I’m for it.”

***

“In fact, if you look at how this law evolved — and I’ve said this publicly before, if I was starting from scratch, I probably would have supported a single-payer system because it’s just easier for people to understand and manage.  And that’s essentially what Medicare is, is a single-payer system for people of a certain age.  And people are very satisfied with it and it’s not that complicated to understand or to access services.  But that wasn’t available; we weren’t starting from scratch.”

***

“From the very start, in the earliest negotiations in 2009, 2010, I made clear to Republicans that, if they had ideas that they could show would work better than the ideas that we had thought of, I would be happy to incorporate them into the law.  And rather than offer ideas, what we got was a big no, we just don’t want to do this.”

***

“After the law passed, for the last six, seven years, there has been the argument that we can provide a great replacement that will be much better for everybody than what the Affordable Care Act is providing.  And yet, over the last six, seven years, there has been no actual replacement law that any credible health care policy experts have said would work better.  In fact, many of them would result in millions of people losing coverage and the coverage being worse for those who kept it.

“And so now is the time when Republicans, I think, have to go ahead and show their cards.  If, in fact, they have a program that would genuinely work better and they want to call it whatever they want — they can call it Trumpcare, they can call it McConnellcare, or Ryancare.  If it actually works, I will be the first one to say, great, you should have told me that back in 2009.  I asked.  (Laughter.)  I suspect that will not happen.”

***

“I am saying to every Republican right now, if you, in fact, can put a plan together that is demonstrably better than what Obamacare is doing, I will publicly support repealing Obamacare and replacing it with your plan.  But I want to see it first.  (Applause.)  I want to see it first.”

***

“This idea that somehow, oh, this is about Obama preserving his legacy — keep in mind, I’m not the one who named it Obamacare.  (Laughter.)  They were the ones who named it Obamacare, because what they wanted to do was personalize this and feed on antipathy towards me in their party as an organizing tool, as politics. 

“But I don’t have a pride of authorship on this thing.  If they can come up with something better, I’m for it.  But you have to show — and I would advise every Democrat to be for it — but you have to show that it’s better.  And that’s not too much to ask.”

***

“…the answer is the Republicans, yes, will own the problems with the health care system if they choose to repeal something that is providing health insurance to a lot of people, and providing benefits to every American who has health insurance even if they’re getting it through the job, and they haven’t shown us what it is that they’re going to do.  Then they do own it.  Because that is irresponsible.  And even members of their own party, even those who are opposed to me, have said that that is an irresponsible thing to do.”

***

“So if you look at the things that people are frustrated about with Obamacare, the Affordable Care Act, the big things are the subsidies aren’t as high as they’d like and they don’t have as many options as they’d like.  And I’m happy to provide both those things.  I’d sign on to a Republican plan that said we’re going to give more subsidies to people to make it even cheaper, and we’re going to have a public option where there isn’t an option. 

“Here’s the problem.  I don’t think that’s the thing that they want — (laughter) — to do.“

***

“And my advice to the President-elect — in fact, we talked about this when I met with him for an hour and a half right after he got elected — I said make your team and make the Republican members of Congress come up with things that they can show will actually make this work better for people.  And if they’re convincing, I think you would find that there are a lot of Democrats out there — including me — that would be prepared to support it.  But so far, at least, that’s not what’s happened.”

***

“Well, look, this is the irony of this whole debate, is the things that people are most dissatisfied with about Obamacare, about the Affordable Care Act, are things that essentially in other countries are solved by more government control, not less.  (Laughter.)  And so Republicans are pointing at these things to stir up dissatisfaction, but when it comes to, all right, what’s the solution for it, their answer is less government regulation and letting folks charge even more and doing whatever they want and letting the marketplace work its will.”

***

“If we want to control prices for consumers more, then the marketplace by itself will not do that.  And the reason is because health care is not exactly like other products.  It’s not like buying a flat-screen TV.  If you’re sick, or if your kid is sick, most of the time you’re not in a position to negotiate right there and then.  You can’t walk out of the store and say, well, I’m going to see if I can get a better deal.”

***

“The problem is, is that that’s not what’s being proposed by Mitch McConnell, the senator from Kentucky.  Instead what he’s proposing, I gather, is you’re going to repeal the law, then you’re going to come up with something, except you will have taken away all the — the way we pay for the subsidies for working people is we’re taxing wealthier folks at a little bit higher.  So he wants to cut those taxes, and that money would be gone right away.  And then he’s going to promise you, or those people who you’ve been signing up, better health care, except there’s not going to be any money to pay for it.  And nobody has explained to me yet how that’s going to work.”

***

“…then at the very least you should be putting pressure on your members of Congress to say, show us exactly what the deal is going to be for us before you take away the deal that we got.”

***

“The way this process is going to work, there’s this rushed vote that’s taking place this week, next week to — quote, unquote — “repeal Obamacare.”  But really all that is, is it’s a resolution that is then instructing these committees in Congress to start actually drafting a law that specifically would say what’s being repealed and what’s not.  Then, after that, they’d have to make a decision about what’s going to replace it and how long is that going to take.  And that stretches the process out further. 

“And so I think, whether you originally supported Obamacare or you didn’t, whether you like me or you don’t, the one thing I would just ask all the American people to do is adopt the slogan of the great state of Missouri — “Show me.”  (Laughter.)  Show me.  Do not rush this process. 

“And to Republicans, I would say:  What are you scared of?  If you are absolutely convinced, as you have been adamant about for the last seven years, that you can come up with something better, go ahead and come up with it.  And I’ll even cut you some slack for the fact that you’ve been saying you can come up with something better for seven years and I’ve never seen it.  (Laughter.)  But we’ll restart the clock.”

***

Video (1 hour, 9 minutes):
https://www.whitehouse.gov…

Transcript:
https://www.whitehouse.gov…

***

Comment:

By Don McCanne, M.D.

What is the point of today’s message? Virtually everyone wants affordable access to health care, for themselves at least. Most want a better system than what we have under the Affordable Care Act. But the nation is divided as to whether ACA needs to be repealed prior to improving the functioning of our health care financing system.

So the point is that there is broad agreement that we want the system improved, but the Republicans, who are in control, are hamstrung by their anti-government ideology which prevents them from offering the government solutions that we would need that would actually be effective in improving the system.

Repealing ACA would further impair the functioning of our system, so the Republicans would have to introduce effective policies that would more than compensate for the deficiencies that would be created by repeal. Almost any piecemeal solution would require greater regulation and more government spending, anathema to the Republicans. Suggestions to date coming from their camp would leave us worse off than what we currently have. It is no wonder that they refuse to tell us what their replacement proposal would be.

If they really do want to improve the system, and they say they do, then they have two choices. Either provide beneficial tweaks to the current system, which will cost more and require greater regulation, yet fall far short of reform goals, or replace the current system with a single payer national health program – an improved Medicare for all. The latter would greatly improve the financing of health care, ensuring true universality, improved access, greater choice in care, and affordability for each and every individual. And we could do that without increasing spending above our current level.

The Republicans have an opportunity to provide us with a replacement program that would be vastly superior to building on our current dysfunctional system. Both President Obama and President-elect Trump have acknowledged the clear superiority of a single payer system. Most progressives, a majority of moderates and a plurality of conservatives agree. Now all the Republicans need to do is show us.

Dr. Steffie Woolhandler on ‘Democracy Now!’

PNHP co-founder Dr. Steffie Woolhandler appeared on “Democracy Now!” on Jan. 9, 2017, to discuss the prospective repeal of the Affordable Care Act. She predicted that the structure of the law – originally a Republican proposal – would stay in place, albeit in a “meaner” version. She also noted that the health care crisis could not be truly addressed until single-payer legislation was signed into law.

Part One

Part Two

Repeal & Run? Republicans Move to Axe Obamacare, But What Will Replacement Look Like?

Interview With Dr. Steffie Woolhandler (Part 1)

By Amy Goodman
Democracy Now!, Jan. 9, 2017

PNHP Note: To view video of this interview (parts 1 & 2), click here. To read a transcript of part 2, click here.

Republicans in the newly sworn-in 115th Congress are moving swiftly to repeal the Affordable Care Act, President Obama’s signature healthcare law. By a vote of 51 to 48 last week, the Senate approved a procedural measure clearing a way for a budget resolution that could repeal major sections of the law. The charge was led by Vice President-elect Mike Pence, who admitted his party has not yet decided how to replace the Affordable Care Act. “The Republicans’ rebranded version of the Affordable Care Act will be much meaner and skimpier,” says Dr. Steffie Woolhandler, a primary care physician. She is a lecturer at Harvard Medical School. “It will have much more in the way of copayments and deductibles, particularly for poor people who are unable to afford it.” Woolhandler is a professor at CUNY-Hunter College and the co-founder of Physicians for a National Health Program.

TRANSCRIPT
This is a rush transcript. Copy may not be in its final form.

AMY GOODMAN: Republicans in the newly sworn-in 115th Congress are moving swiftly to repeal the Affordable Care Act, President Obama’s signature healthcare law. By a vote of 51 to 48 last week, the Senate approved a procedural method clearing a way for a budget resolution that could repeal major sections of the law. The charge was led by Vice President-elect Mike Pence, who admitted Republicans, well, haven’t yet decided how to replace the Affordable Care Act.

VICE PRESIDENT-ELECT MIKE PENCE: The President-elect and I, working with the leaders of the House and Senate, are determined to keep our promise to the American people. And that all begins with repealing and replacing the failed policy of Obamacare.

AMY GOODMAN: President Obama made a rare trip to Capitol Hill last week, where he told minority Democrats not to help Republicans pass replacement measures that he called “Trumpcare.” At the White House, Press Secretary Josh Earnest said the Republican plan would have devastating consequences.

PRESS SECRETARY JOSH EARNEST: Twenty-two million people are going to lose their health insurance if the Affordable Care Act is repealed. It’s going to rip a hole in the deficit, in the federal budget, and the deficit will go up, if the Affordable Care Act is repealed. That’s not just my conclusion; you can ask the CBO about that.

AMY GOODMAN: Senate Republicans are seeking to end billions of dollars in federal subsidies to states that have expanded Medicaid, as well as subsidies for private health coverage through health insurance exchanges.

For more, we head to Los Angeles, California, where we’re joined by Dr. Steffie Woolhandler, a professor at CUNY-Hunter College here in New York, primary care physician, lecturer at Harvard Medical School, co-founder of Physicians for a National Health Program.

Dr. Steffie Woolhandler, welcome to Democracy Now! In these last minutes we have left, we want to talk about two things. What’s happening? The Republicans call it “repeal and replace.” Democrats are calling it “repeal and run.” And then where you see—if you see there’s any road to single payer? But let’s start with what the Republicans are proposing—or not.

DR. STEFFIE WOOLHANDLER: Well, we think what the Republicans will do is they’ll rebrand the Affordable Care Act with a new name but keep the essential structure of the Affordable Care Act, which is that you use public money to purchase private insurance. The Republicans’ rebranded version of the Affordable Care Act will be much meaner and skimpier. It will have much more in the way of copayments and deductibles, particularly for poor people who are unable to afford it.

So, unfortunately, I think a lot of the structures of Obamacare were in fact structures first proposed by Republicans. They were first implemented in Massachusetts under Romneycare in 2006, first proposed by then-President Nixon and actually fully fleshed out by The Heritage Foundation. So, the very structure of Obamacare was a Republican idea. So I think the Republican replacement will at least structurally look like Obamacare, just be a much meaner—leaner, meaner, rebranded form of the Obamacare legislation.

AMY GOODMAN: Rebranded as Trumpcare. But what do you mean? For example, kids, until they’re 26, can be—can they be on their parents’ insurance? Pre-existing conditions? And what happens to the 20 million, 30 million people who are subsidized, who did not have insurance before, who are the poorest in this country?

DR. STEFFIE WOOLHANDLER: Well, a big issue is that the Republicans will be block granting Medicaid, so just turning over money to the states for Medicaid to pretty much do what they want with it. And we think that what the states will do is create very skimpy, very restrictive Medicare programs, as has happened in Indiana under Governor Pence—Vice President-elect Pence—where the minute a poor person misses a payment, they get thrown off of Medicaid for six months. They have to make copayments, which they can’t afford. And we do expect that that’s what Medicaid will look like going forward, is an extremely skimpy, stripped-down coverage that really does not allow people to get the healthcare they need.

We also anticipate that there will be more copayments, more deductibles for insured Americans. So, some of the protection under the Obamacare legislation will be removed. Probably there will be no guarantee of reproductive coverage, as there is under Obamacare. So, I think most of the punishment will be meted out against poor people, if you will, but will still probably have those structures of Obamacare.

The coverage up to age 26, frankly, that’s the thing that’s most likely to stay in a Republican plan. Pre-existing conditions? That will almost certainly change. According to the plans put forward by Representative Ryan, they’re only going to allow you the protection for your pre-existing conditions if you keep your insurance continuously throughout your life. And as many people know, that is something very, very difficult to do. Many people have a lapse of a day or a month in their insurance. And if you have that kind of lapse, you have no protection about pre-existing conditions, and your insurance company will be allowed to—new insurance company will be allowed to deny you coverage.

AMY GOODMAN: Donald Trump has talked about single payer in the past. And, you know, he’s talked about it on 60 Minutes. These were some of his comments during a Republican presidential debate in April.

DONALD TRUMP: As far as single payer, it works in Canada. It works incredibly well in Scotland. It could have worked in a different age, which is the age you’re talking about, here. What I’d like to see is a private system without the artificial lines around every state. I have a big company with thousands and thousands of employees. And if I’m negotiating in New York or in New Jersey or in California, I have like one bidder. Nobody can bid. You know why? Because the insurance companies are making a fortune, because they have control of the politicians—of course, with the exception of the politicians on this stage. But they have total control of the politicians. They’re making a fortune. Get rid of the artificial lines, and you will have yourself great plans. And then we have to take care of the people that can’t take care of themselves. And I will do that, through a different system.

AMY GOODMAN: And this is Donald Trump in an interview with Scott Pelley on 60 Minutes in 2015, coming out in favor of a form of single-payer health insurance.

DONALD TRUMP: Obamacare is going to be repealed and replaced. Obamacare is a disaster, if you look at what’s going on with premiums, where they’re up 45, 50, 55 percent.

SCOTT PELLEY: So how do you fix it?

DONALD TRUMP: There’s many different ways, by the way. Everybody’s got to be covered. This is an un-Republican thing for me to say, because a lot of times they say, “No, no, the lower 25 percent, they can’t afford private.” But—

SCOTT PELLEY: Universal healthcare.

DONALD TRUMP: I am going to take care of everybody. I don’t care if it costs me votes or not. Everybody’s going to be taken care of, much better than they’re taken care of now.

SCOTT PELLEY: The uninsured person—

DONALD TRUMP: Right.

SCOTT PELLEY: —is going to be taken care of how?

DONALD TRUMP: They’re going to be taken care of.

SCOTT PELLEY: How?

DONALD TRUMP: I would make a deal with existing hospitals to take care of people. And you know what? This is probably—

SCOTT PELLEY: Make a deal? Who pays for it?

DONALD TRUMP: The government is going to pay for it. But we’re going to save so much money on the other side. But for the most part, it’s going to be a private plan, and people are going to be able to go out and negotiate great plans with lots of different competition, with lots of competitors, with great companies. And they can have their doctors. They can have their plans. They can have everything.

AMY GOODMAN: So, that’s President-elect Donald Trump speaking before he was president-elect. Dr. Steffie Woolhandler, you were never a supporter of Obamacare. What do you think of what he’s saying, albeit a while ago?

DR. STEFFIE WOOLHANDLER: Well, I certainly agree with him that single payer works very well in other countries that have it. People in those countries spend about half what we do on healthcare. And they get free healthcare from the day they’re born to the day they die, without copayments or deductibles. I don’t think President Trump is going to enact single payer, but I do think there’s tremendous possibilities for moving forward to single payer. At this point, it’s pretty clear the American people got a good look at Obamacare and said, “This is not a solution. This is not working.” And many of them do in fact support the idea of a single-payer Medicare for all. And that’s what we need to be pushing right now.

AMY GOODMAN: So what is the road to that from here, Dr. Woolhandler?

DR. STEFFIE WOOLHANDLER: Well, we need to be saying that we need to go beyond the Affordable Care Act to a single-payer system. Merely trying to defend the Affordable Care Act at this point is not going to work. The American people have seen it for three years and rejected it. And, you know, 20 million people got insurance, and that’s great, but there were 280 million people who saw no improvements in their healthcare. They still can’t afford healthcare despite having private insurance, because of the copayments and the deductibles in those narrow networks. So we need to go to a system that fixes the healthcare system for everyone. And that’s what’s politically possible right now. Defending the Affordable Care Act looks like defending the status quo in healthcare, and that’s not acceptable to most American voters.

AMY GOODMAN: Dr. Steffie Woolhandler, what you’re saying is too important. We’re going to continue the conversation after the broadcast and post it online at democracynow.org. Is there a road to single payer under President Trump? This is Democracy Now! Dr. Steffie Woolhandler, founder of Physicians for a National Health Program, thanks for joining us.

https://www.democracynow.org…

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3 big reasons Republicans can’t replace Obamacare

The only practical answer to these three dilemmas is Medicare for all — a single-payer system

By Robert Reich
Salon.com, Jan. 9, 2017

Republicans are preparing to repeal the Affordable Care Act, promising to replace it with something that doesn’t leave more than 20 million Americans stranded without health insurance.

Yet they haven’t come up with a replacement. And they won’t, for three reasons.

First, Republicans say they want the replacement to be “market-based.” But Obamacare is already market based — relying on private, for-profit health insurers.

That’s already a problem. The biggest health insurers — Anthem, Aetna, Humana, Cigna and United Health — are so big they can get the deals they want from the government by threatening to drop out of any insurance system Republicans come up with. Several have already dropped out of Obamacare.

Even now they’re trying to merge into far bigger behemoths that will be able to extort even better terms from the Republicans.

Second, every part of Obamacare depends on every other part. Trump said he’d like to continue to bar insurers from denying coverage to individuals with preexisting conditions.

But this popular provision depends on healthy people being required to pay into the insurance pool, a mandate that Republicans vow to eliminate.

The GOP also wants to keep overall costs down, but they haven’t indicated how. More than 80 percent of Americans who buy health insurance through Obamacare receive federal subsidies. Yet Republicans have no plan for raising the necessary sums.

Which gets us to the third big reason Republicans can’t come up with a replacement. Revoking the tax increases in Obamacare — a key part of the repeal — would make it impossible to finance these subsidies.

The two biggest of these taxes — a 3.8-percentage-point surtax on dividends, interest and other unearned income; and a 0.9-percentage-point increase in the payroll tax that helps fund Medicare — are also the most progressive. They apply only to people earning more than $200,000 per year.

Immediately repealing these taxes, as the GOP says it intends to do, will put an average of $33,000 in the hands of the richest 1 percent this year alone and a whopping $197,000 into the hands of the top 0.1 percent, according to the Tax Policy Center.

It would also increase the taxes of families earning between $10,000 and $75,000 — including just about all of Trump’s working class voters.

Worse yet, eliminating the payroll tax increase immediately pushes Medicare’s hospital fund back toward the insolvency that was looming before Obamacare became law.

Ultimately, the only practical answer to these three dilemmas is Medicare for all — a single-payer system. But Republicans would never go for it.

So without Obamacare, Republicans are left with nothing. Zilch. Nada. Except the prospect of more than 20 million people losing their health insurance, and a huge redistribution from the working class to the very rich.

Robert Reich, one of the nation’s leading experts on work and the economy, is Chancellor’s Professor of Public Policy at the Goldman School of Public Policy at the University of California at Berkeley. He has served in three national administrations, most recently as secretary of labor under President Bill Clinton.

http://www.salon.com…

Medicare for all — use formula to replace ACA

By RoseAnn DeMoro
The Hill, Jan. 9, 2017

“Praying for health shouldn’t be the foundation of a modern healthcare system. But that’s where millions of uninsured Americans still find themselves,” wrote The Los Angeles Times columnist David Lazarus Jan. 6, quoting the fears of Los Angeles resident Madelyn Gilbreath about the expected vote by Congress to repeal the Affordable Care Act (ACA).

“I just need to make it one more year and then I’m eligible for Medicare (like her husband who is on Medicare),” Gilbreath told Lazarus. “For my son, I’m just praying he stays healthy.”

That’s a story nurses have heard before, including when a 64-year-old retired teacher asked an operating room nurse who was prepping him for heart surgery in San Diego, “can’t you wait one week until I turn to 65 and qualify for Medicare?”

Why should anyone have to wait to qualify for Medicare, one of the most popular reforms in U.S. history? Expanding Medicare to cover everyone remains a rarely discussed alternative to the reopening of a national healthcare debate.

Far fetched? Apparently not to the incoming President Donald Trump. “As far as single payer, it works in Canada. It works incredibly well in Scotland. It could have worked in a different age, which is the age you’re talking about here,” said Trump in a Republican debate in August, 2015. That age should be the present time.

full article:
http://thehill.com…

RoseAnn DeMoro, executive director of National Nurses United, has emerged as one of the nation’s preeminent advocates for genuine healthcare reform and working people. DeMoro also serves as national vice president and executive board member of the AFL-CIO.

Medicare for all should replace Obamacare

Republicans have no realistic alternative to the ACA. It’s time for single-payer.

By Marcia Angell, M.D.
USA Today, Jan. 6, 2016

Even before the election of Donald Trump, Obamacare was in trouble. Premiums on the government exchanges for individual policies are projected to increase an average of 11% next year, nearly four times the increase for employer-based family policies. And some large insurers are pulling out of that market altogether in parts of the country.

Those who buy insurance on the exchanges often find that even with subsidies, they can’t afford to use the insurance because of mounting deductibles (about $6,000 for individual Bronze plans). It’s become clear that health insurance is not the same as health care.

In 2010 when Obamacare was enacted, about 50 million Americans (16%) were without health insurance. The U.S. was then spending some $2.6 trillion per year on health care. Last year, about 29 million (9%) remained uninsured, and we spent $3.2 trillion on health care in 2015 — $600 billion more than in 2010, while insuring only an additional 7% of Americans. This comes to nearly $30,000 for each person newly insured. That doesn’t seem like much of a bargain. Costs matter. Expanding access to health care, as Obamacare does, is only half the job. The other half requires controlling costs, so the system can be sustained.

The problem is that the underlying causes of the cost inflation were left largely untouched by Obamacare. The system remains in the hands of investor-owned insurance companies, drug companies, and profit-oriented providers that can charge whatever the market will bear — and in health care, the market will bear much more than in most sectors of the economy. Like all markets, this one is driven to expand, and does. Moreover, these industries are consolidating, so that they behave more like oligopolies than competitive businesses. President Obama was so eager for the political support of the health industries that he naively assumed they would modulate their drive for profits in the public interest.

What will the Trump administration do? While Trump calls for “repealing and replacing” Obamacare, he has never said what he would replace it with. But isolated proposals have been offered by other Republicans: They would permit insurance to be sold across state lines, which means that companies in states with lax regulations would be able to sell substandard plans elsewhere; they would abolish the mandate that requires people to buy insurance, but keep the provision that requires insurers to cover people with pre-existing conditions (an idea that would cause premiums to skyrocket); and they would promote health savings accounts, which are essentially tax-free savings plans that favor the wealthy. What is absolutely certain, given the Republican rhetoric and Trump’s nomination of Rep. Tom Price for secretary of Health and Human Services, is that we will move very sharply toward an even more expensive, inadequate and unequal health system.

Bernie Sanders had it right. The best way to provide universal health care at a sustainable cost is to extend Medicare to everyone, while implementing some needed reforms. Medicare is essentially a single-payer system for those over age 65 — government financed, but privately delivered. Because it uses the same profit-oriented providers as the rest of the system, it would need some reforms. That would include shifting hospitals and other providers to a non-profit delivery system, admittedly a huge challenge that could prove as controversial as Obamacare itself. We could ease the transition by switching to universal Medicare one decade at a time, starting by dropping the eligibility age from 65 to 55.

Paying for Medicare for All would require an increase in taxes — perhaps an earmarked progressive income tax for the purpose — but that increase would be offset by the elimination of premiums and out-of-pocket costs, and the slowing of inflation that stems from our market-based system. As it now stands, some 65% of health costs are already paid by the federal government in one way or another. Health policy experts estimate this would increase to 80% with Medicare for All. Since employers would no longer have the expense of providing health insurance, they would be more competitive in global markets and would likely hire more workers.

We are now between a rock and a hard place. Obamacare is faltering and the incoming Trump administration has no realistic alternative. Paradoxically, this might be exactly the right time to push for a national health program. Yes, repeal Obamacare, but not without replacing it, and the best replacement is Medicare for All. Some polls suggest most Americans favor such a system; we should pick up our metaphorical pitchforks and torches and make that preference known.

Marcia Angell is a corresponding member of the Faculty of Global Health and Social Medicine at Harvard Medical School and Faculty Associate in the Center for Bioethics. She stepped down as editor-in-chief of the New England Journal of Medicine in 2000.

http://www.usatoday.com…