PNHP

Republicans are now supporting the private insurers in the exchanges

Republicans are now supporting the private insurers in the exchanges

Republicans, Aiming to Kill Health Law, Also Work to Shore It Up

By Robert Pear
The New York Times, February 12, 2017

After denouncing the Affordable Care Act as an abomination for seven years, Republicans in Congress, working with the Trump administration, are urgently seeking ways to shore up health insurance marketplaces created by the law.

While President Trump said as a candidate that “Obamacare is certain to collapse of its own weight,” Republicans fear such an outcome because, now that the fate of the health law is in their hands, they could be blamed by consumers and Democrats.

The administration is poised to issue a proposed regulation to try to stabilize insurance markets, and House Republicans are drafting legislation with a similar purpose. The regulation and the bills are intended to hold down insurance premiums and to lure insurers back into the public marketplaces from which they have withdrawn in the past couple of years.

https://www.nytimes.com…

***

Comment:

By Don McCanne, M.D.

There could not be better evidence that the Republicans never did have an effective plan to replace the Affordable Care Act than the fact that they are now advancing legislation to protect the private insurers in the ACA exchanges – reinforcing them rather than shutting them down.

So their strategy has changed from repeal and replace, and then to repeal and repair, and now simply to repair – repair that will protect the private insurers.

Many of the legislators are facing angry citizens at their town hall meetings who do not want to lose the health care benefits that they may have gained through ACA. That partially explains why they failed to deliver on their promise to “repeal Obamacare on day one.”

Many voters were supportive of repeal and replace, but the politicians and the voters had different objectives. The Republican politicians wanted to repeal the expansions of ACA and thereby reduce government spending on health care. Voters wanted changes (replacement) that would ensure that they could always receive health care that was affordable.

Considering this, it is understandable why the Republicans have not moved immediately forward with their replacement proposals. Reducing Medicaid funding through block grants would cause millions to lose their coverage. Switching Medicare to a voucher program would create greater financial burdens for Medicare beneficiaries. Changing market rules to promote bare-bones private plans is the Republican version of providing “access,” but that would make actual health care truly unaffordable for a majority of Americans with significant medical needs because the very high out-of-pocket expenses would be beyond the capabilities of most American family budgets.

The simmering anger is because ACA was inadequate for too many Americans, and it appears that the Republican “replace” proposals will leave millions worse off. The “replace” that people want is affordable health care, but not merely a continuation of the inadequate policies of the Affordable Care Act. What they really want, though some do not realize it, is an equitably funded, universal health insurance program – an improved Medicare for all. That would give all of us affordable access to health care, and not just access to nearly worthless private health plans.

Progressives will never give up dream of a healthcare system that is fair

By Linda DeFeo, M.D.
Cape Gazette (Lewes, Del.), Feb. 13, 2017

Mark Twain is quoted as saying “there are lies, damned lies and statistics,” although these days we could say there are facts and alternative facts.

As a retired emergency physician who worked in underserved city hospitals, I can say one of the points Mr. Beveridge makes is correct. When patients come to the ER we must by law see them without asking how they will pay. We do bill them later and, as he stated, we frequently do not get paid; how can someone pay a huge bill when they couldn’t afford health insurance to begin with? Having spent the last 20 years of my career in Maryland, I was sad that their all-payer system was not talked about more during the primaries (go to https://innovation.cms.gov/initiatives/Maryland-All-Payer-Model/ for more information).

He speaks of Sen. Sanders, and others’ idea of expanding to a Medicare for all system, slaps the dreaded socialized medicine label on it, and warns of the cost. Currently FICA withholding is 12.4 percent total split between employer/employee for Social Security and 2.9 percent total for Medicare. He then calculates that expanding Medicare would increase that deduction to 30 percent. I don’t know how he came up with that figure, or if it is correct, but let’s look at some of the factors he has not addressed.

The United States spends $9,403 per capita for healthcare compared to $5,292 for Canada and $817 for Cuba (http://data.worldbank.org/indicator). Are we getting our money’s worth? While we’re at it, can anyone explain how you take seniors, who we all agree are high resource consumers, from the Medicare system with a 4 percent overhead and put them into for-profit private insurance with a 12 percent overhead and save money? (Check out https://oig.hhs.gov/reports-and-publications/hcfac/index.asp for information about Medicare fraud.)

But I digress.

He suggests that while healthcare services would be available to all, you might have to wait a little longer for certain kinds of specialists. Where is his evidence that this leads to poorer outcomes? Comparing infant and child mortality rates and life expectancy statistics (2014 data from WHO) you find that the first two measures are actually lower in both Cuba and Canada than the United States, and that longevity is very similar, with them living just a bit longer than us.

His next point is that doctors will be employees of the government. That may be true in Cuba, but not Canada. Go to the Library of Congress website (if it hasn’t been taken down this week) (http://www.loc.gov/law/help/medical-malpractice-liability/canada.php) for an overview of the Canadian system.

He also suggests that doctors will not go to medical school if they will only earn as much as a mechanic. I don’t know about him, but I value my mechanics very much and hope they are well paid, however, most of us don’t go to medical school to become wealthy. If, as in Canada and Cuba, the cost of schooling combined with a less litigious society were in place here, it wouldn’t cost as much for us to train or pay malpractice insurance (a whole separate article can be written about defensive medicine) so we wouldn’t need to make as much money.

His last comments seem to suggest that if we get rid of Obamacare we will somehow fix long ER waits. I have no idea how he thinks that will happen. Repealing the ACA will increase the number of uninsured patients who then have no option except the emergency room. Every time I hear someone say “the American people know how to spend their healthcare dollars” I cringe. How can they possibly know how to navigate a system so complex? When your child or loved one is ill, do you ask who can help me for the lowest cost, or who is the best choice to help me, damn the cost?

Mr. Beveridge, you are correct. We progressives will never give up our dream of a healthcare system that is fair, efficient and available to all Americans.

Dr. Linda DeFeo resides in Lewes.

http://www.capegazette.com…

Tom Price as HHS Secretary: A Disaster for U.S. Health Care

By Dr. Carol Paris
Common Dreams, Feb. 11, 2017

The Senate’s vote to confirm Rep. Tom Price, R-Ga., as secretary of health and human services, while widely expected, should set off national alarm bells.

Price’s congressional track record, combined with his extensive health-policy paper trail, have shown him to be unabashedly pro-big-business and contemptuous of human needs – particularly when it comes to women’s and poor people’s needs. But the damage he will be able to do as HHS secretary will go far beyond that.

His appointment to the helm of HHS means he is now poised to wreak havoc on our already dysfunctional health care system, jeopardizing the lives of additional millions of Americans who desperately require medical care but can’t afford to get it.

Consider Price’s hostility to traditional Medicare, one of our nation’s most beloved social insurance programs. Together with Speaker Paul Ryan, R-Wis., Price has pushed for “premium support,” i.e. vouchers, whereby seniors would exchange their guaranteed health coverage under traditional Medicare (which they’ve paid into throughout their working lives) for a lump sum of money to go out shopping for a health policy on the private insurance market.

Can you imagine the chaos such vouchers would create among millions of seniors and their families? How much more precarious their health care – even their survival – would become?

“Premium support” is an underhanded prescription for the dismantlement – the destruction – of traditional Medicare. It would be the beginning of the end. The implementation of such a scheme would sharply increase out-of-pocket costs of our nation’s seniors and severely disabled, some of the most vulnerable parts of our population, even as it would bolster the profits (and CEO salaries) at the private health insurance, Big Pharma, and financial services industries.

Or take Price’s views on Medicaid. Much like President Trump’s nominee to head the Centers for Medicare and Medicaid Services, Seem Verma, has done, Price would embrace the conversion of today’s Medicaid program into federal block grants to the states. These block grants would give state governments wide latitude on how to use the money, opening the door to greater patient cost sharing among the poor (introducing copays, deductibles, or work requirements), even as it would enhance the already egregious profiteering by parasitic private Medicaid managed care companies.

Family planning? Price has displayed unconcealed hostility to women’s reproductive health, and his new position will allow him to literally place the health of millions of women at risk. His extreme views include opposition to abortion under almost all circumstances, a preference for “religious freedom” over access to contraception, and an obsession with eliminating federal funding for Planned Parenthood.

According to this week’s Monmouth University poll, Americans’ top worry today is with their mounting health care costs, more so than their job security, taxes or other household bills. With Price at the helm of HHS, this worry will mushroom.

I could go on – his unbridled animus toward LGBTQ rights, his fascination with discredited policies such as high-deductible health plans and allowing private insurers to sell policies across state lines, the threat he poses to our safety-net hospitals, etc. – but you get the picture.

Make no mistake: if Price’s policies are carried out, he will make an already bad system much worse. Research shows that repealing the Affordable Care Act, a cause for which Price has been a primary standard-bearer in the House, would likely result in 43,000 excess, preventable deaths.

In short, Price’s confirmation vote on Friday was a body blow to our nation’s health and welfare.

This is precisely the wrong direction we should be taking in health care. Rather than augmenting the power and profits of the medical-industrial complex (which, by the way, Price has a distinct affinity for), and cutting back on our people’s access to health care, we should be expanding high-quality care to one and all.

What we need to do – now more than ever – is to replace our fragmented dysfunctional system of health care with a streamlined, single-payer, Medicare-for-All system. The savings we’d reap from eliminating the wasteful bureaucracy and paperwork generated by our current multi-payer system – savings now estimated to be $500 billion annually – would be sufficient to cover everyone in the United States and to eliminate all copays and deductibles.

There were those in the 2009 health care debate who said, “Support the Affordable Care Act; it’s the only politically feasible plan; we’ll get to Medicare for All later.” But Congress passed the ACA, and six years later we’re still saddled with the most serious structural deficiencies of a private-health-insurance-based system, including 28 million uninsured. The ACA didn’t get us where we need to be.

Today, there are those who would say that all we should ask for is to retain the ACA. I’m sorry. As a physician, 28 million uninsured is unacceptable. Now is the time to go beyond the ACA, and to replace it with H.R. 676, the Expanded and Improved Medicare for All Act.

Unrealistic, you say? It’s remarkable what millions of people in motion – which is what it will take – can do. What’s truly unrealistic is thinking we can have truly universal care and control costs without a single-payer system.

We can’t afford to delay any longer. Too much is at stake. We have no time to lose.

Dr. Carol Paris is a psychiatrist and president of Physicians for a National Health Program. She was one of the “Baucus 8″ arrested with Dr. Margaret Flowers and others for protesting the absence of representation for single payer universal health care on the Baucus Senate Panel hearings.

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

http://www.commondreams.org…

GOP Docs Rise To Power As Congress Retools Health Care Law

By Phil Galewitz
NPR, Feb. 10, 2017

The confirmation of Tom Price, the orthopedic surgeon-turned-Georgia congressman, as secretary of Health and Human Services on Friday represents the latest victory in the ascendancy of a little-known but powerful group of conservative physicians in Congress — the GOP Doctors Caucus.

During the Obama administration, the caucus regularly sought to overturn the Affordable Care Act, and it’s now expected to play a major role determining the Trump administration’s plans for replacement.

Robert Doherty, a lobbyist for the American College of Physicians, the professional organization for internal medicine doctors, says the GOP Doctors Caucus has gained importance with Republicans’ rise to power. “As political circumstances have changed, they have grown more essential,” Doherty says.

“They will have considerable influence over the discussion on repeal and replace legislation,” he says.

Price’s supporters have touted his medical degree as an important credential for his new position, but Price and the caucus members are hardly representative of America’s physicians in 2017.

The “trust us, we’re doctors” refrain of the caucus obscures its conservative agenda, critics say.

“Their views are driven more by political affiliation,” says Mona Mangat, an allergist-immunologist and chair of Doctors for America, a 16,000-member organization that favors the current health law. “It doesn’t make me feel great. Doctors outside of Congress do not support their views.”

For example, while the American College of Obstetrics and Gynecology has worked to protect access to abortion, the three obstetrician-gynecologists in the 16-member House caucus are anti-abortion and oppose the ACA provision that provides prescription contraception without copays.

While a third of the U.S. medical profession is now female, 15 of the 16 members of the GOP caucus are male, and only eight of them are doctors.

The other eight members are from other health professions, including a registered nurse, a pharmacist and a dentist. The nurse, Rep. Diane Black of Tennessee, is the only woman.

On the Senate side, there are three physicians, all of them Republican and male: Sen. John Barrasso, an orthopedic surgeon from Wyoming; Sen. Bill Cassidy, a gastroenterologist from Louisiana; and Sen. Rand Paul, an ophthalmologist from Kentucky.

While 52 percent of American physicians today identify as Democrats, just two out of the 14 doctors in Congress are Democrats, Reps. Ami Bera and Raul Ruiz, both of California.1

About 55 percent of physicians say they voted for Hillary Clinton and only 26 percent voted for Donald Trump, according to a survey by Medscape in December.

Meanwhile, national surveys show doctors are almost evenly split on support for the health law, mirroring the general public. And a survey published in the New England Journal of Medicine in January found almost half of primary care doctors liked the law, while only 15 percent wanted it repealed.

Rep. Michael Burgess, R-Texas, a caucus member first elected in 2003, is one of the longest serving doctors in Congress. He says the anti-Obamacare Republican physicians do represent the views of the profession.

“Doctors tend to be fairly conservative and are fairly tight with their dollars, and that the vast proportion of doctors in Congress [are] Republican is not an accident,” he says.

Price’s ascendency is in some ways also a triumph for the American Medical Association, which has long sought to beef up its influence over national health policy. Less than 25 percent of practicing physicians are in the AMA, the organization says.

Price is an alumnus of a boot camp the AMA runs in Washington each winter for physicians contemplating a run for office. Price is one of four members of the caucus who went through the candidate school. In December, the AMA immediately endorsed the Price nomination, a move that led thousands of doctors who feared Price would overturn the health law to sign protest petitions.

Even without Price, Congress will have several GOP physicians in leadership spots in both the House and Senate.

Those include Rep. Phil Roe of Tennessee, the caucus co-chair, who also chairs the House Veterans Affairs Committee, and Burgess, who chairs the House Energy and Commerce subcommittee on health. Sen. Cassidy sits on both the Finance and the Health, Education, Labor and Pension Committees. Sen. Barrasso chairs the Senate Republican Policy Committee.

Roe acknowledges that his caucus will have newfound influence. Among his goals in molding an ACA replacement are to kill the requirement that most people buy health insurance (called the individual mandate) as well as to kill the requirement that 10 essential benefits, such as maternity and mental health care, must be in each health plan.

He says the caucus will probably not introduce its own bill, but rather evaluate and support other bills. The caucus could be a kingmaker in that role. “If we came out publicly and said we cannot support this bill, it fails,” Roe says.

The GOP Doctors Caucus has played a prominent role in health matters before.

For example, in 2015, when former House Speaker John Boehner needed help to permanently repeal a Medicare payment formula that threatened physicians with double-digit annual fee cuts, he turned to the GOP Doctors Caucus. It got behind a system to pay doctors based on performance — the so-called “doc fix.”

“When the speaker had a unified doctors’ agreement in his coat pocket, he could go to Minority Leader Nancy Pelosi and show that, and that had a lot to do with how we got this passed,” Roe says.

But not all doctors are unified behind the caucus. Ruiz, one of the two physicians in the House who are Democrats, says he worries because few doctors in Congress are minorities or primary care doctors.

Ruiz, an emergency room physician who was elected in 2012, says he is wary about Price leading HHS because he is concerned Price’s policies would increase the number of Americans without insurance.

Indeed, many doctors feel the caucus’ proposals will not reflect their views — or medical wisdom.

“My general feeling whenever I see any of their names, is that of contempt,” says Don McCanne, a family medicine physician in California who is past president of the Physicians for a National Health Program. “The fact that they all signed on to repeal of ACA while supporting policies that would leave so many worse off demonstrated to me that they did not represent the traditional Hippocratic traditions which place the patient first.”

This story was produced through a collaboration between NPR and Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation. Follow Phil Galewitz on Twitter: @philgalewitz.

http://www.npr.org…

1. Doctors In The 115th Congress

House

Ralph Abraham, R-La., family doctor
Larry Bucshon, R-Ind., heart surgeon
Michael Burgess, R-Texas, ob-gyn
Scott DesJarlais, R-Tenn., family doctor
Neal Dunn R-Fla., urologist
Andy Harris R-Md., anesthesiologist
Roger Marshall, R-Kan., ob-gyn
Phil Roe, R-Tenn., retired ob-gyn
Ami Bera, D-Calif., internal medicine
Raul Ruiz, D-Calif., emergency medicine

Senate

Rand Paul, R-Ky., ophthalmologist
Bill Cassidy, R-La., gastroenterologist
John Barrasso, R-Wyo., orthopedic surgeon

Source: American Medical Association

Tom Price confirmed as HHS Secretary

How the GOP wants to fix health care

By Rep. Tom Price (Confirmed as HHS Secretary at 2:00 a.m. today)
Politico, July 30, 2009

I can attest that nothing has had a greater negative effect on the delivery of health care than the federal government’s intrusion into medicine through Medicare.

http://www.politico.com…

***

Comment:

By Don McCanne, M.D.

Man your stations.

Price’s confirmation is body blow to nation’s health: physician leader

FOR IMMEDIATE RELEASE, February 10, 2017
Contact: Mark Almberg, communications director, Physicians for a National Health Program, mark@pnhp.org, (312) 782-6006

Dr. Carol Paris of Nashville, Tenn., is president of Physicians for a National Health Program (www.pnhp.org). This morning, in response to the Senate’s vote to confirm Rep. Tom Price, R-Ga., as secretary of health and human services, Dr. Paris said the following:

“The Senate’s confirmation of Tom Price as health secretary is a body blow to the health and welfare of all Americans. According to this week’s Monmouth University poll, Americans’ top concern today is with their mounting health care costs, more so than their job security, taxes or other household bills. With Price at the helm of HHS, this concern is only going to escalate.

“Price’s vision for reforming U.S. health care would result in millions of Americans losing their existing health insurance coverage, and millions more having to make do with bare-bones policies that offer little to no meaningful protection. He can also be expected to push high-deductible health plans, which already result in millions of people forgoing needed care, and to undermine Medicare, the Medicaid program and safety-net hospitals.

“If Price’s policies come to pass, the free-market ideologues who supported them will no longer be able to hide behind false promises like ‘universal access.’ The results will be laid bare for everyone to see, and elected officials will have to answer to the poor, working-class, elderly, and chronically ill Americans who will suffer needlessly as a result. Studies show that about 43,000 people will die each year if such policies are implemented.

“Congress urgently needs to reverse course and embrace the obvious solution: an improved Medicare for all.”

Physicians for a National Health Program (www.pnhp.org) is a nonprofit research and education organization of more than 20,000 doctors who support single-payer national health insurance. It was founded in 1986. For more on PNHP’s assessment of Tom Price, click here.

Health care is top concern of American families

3-in-10 struggling to maintain current financial situation

Monmouth University Polling Institute, February 7, 2017

Paying for health care has emerged as the top concern of American families, according to the latest national Monmouth University Poll. Two years ago this concern was clustered with job security and other household bills as causing the most anxiety for American households.

Currently, 1-in-4 Americans (25%) report that the cost of health care is the biggest concern facing their family right now. Two years ago, 15% reported this as their family’s primary concern. Anxiety about meeting health care costs now outpaces job and unemployment worries (14%) as well as concerns about paying everyday household bills (12%). Health care is the top concern of American families regardless of income level or partisan identity. A variety of other concerns register in the single digits, such as school costs (4%) and taxes (4%).

“The top three concerns were clustered together just two years ago. Now, health care has jumped to the top of the list as Americans grapple with balancing their household budgets,” said Patrick Murray, director of the independent Monmouth University Polling Institute in West Long Branch, New Jersey. “It’s also worth noting that issues that have been dominating the news, such as immigration and national security, rank very low on the list of items that keep Americans up at night.”

19. Turning to issues closer to home, what is the biggest concern facing your family right now? [LIST WAS NOT READ]

25% – Health care costs

14% – Job security, unemployment

12% – Everyday bills, groceries, etc.

4% – College tuition, school costs

4% – Taxes

3% – Housing, mortgage, rent

3% – Social Security, seniors

3% – Family illness, health

3% – The economy

3% – Safety, crime

3% – Immigration

3% – Civil rights

2% – Retirement saving

2% – Terrorism, national security

1% – Quality of government

1% – Education policy

1% – Trump as president

1% – Climate change, environment

2% – Other

10% – Don’t know/No answer

https://www.monmouth.edu…

***

Comment:

By Don McCanne, M.D.

Without being given a list of choices, when asked “what is the biggest concern facing your family right now,” the most common response was “health care costs” (25%). That places this concern well in front of job security (14%) and household bills (12%) with which it was tied two years ago. Although the improvement in the economy has reduced other concerns, health care has become the top concern of American families.

Although the Affordable Care Act did bring improvements, concerns have not been allayed. As the Republicans fumble around with their rhetoric of “replace,” “repair,” and “access,” it becomes ever more clear that they do not have a program that will reduce the health cost burden on most American families. In fact, many of the policies they support will increase the financial burden on individuals and families.

House Speaker Paul Ryan says that they will have a proposal in place by the end of next month. We know that the policies under consideration will not provide individuals with relief from the high costs of health care.

Since health costs are the number one concern of Americans, it is imperative that we intensify our message that the current financing system, even with the Republican tweaks, will leave the public vulnerable to high health care costs. But we have an answer! A well designed single payer national health program – an improved Medicare for all – will ensure that everyone has access to all essential health care services without being burdened by unaffordable premiums or out-of-pocket costs.

For those who would benefit from an elevator speech:  We can pay for it by reducing the profound administrative waste of our fragmented, multi-payer system (the waste of private insurers and the burden they place on the system); we can each afford it by funding the system through equitable tax policies (contributing based on ability to pay), and we can eliminate the perversities of high deductibles and narrow provider networks, eliminating surprise bills while giving us free choices of our health care professionals and hospitals.

Let’s get the word out ASAP. Congress is getting ready to move!

Few poor or minority patients in New York City’s academic hospitals

By Lisa Rapaport
Reuters, Feb. 9, 2017

(Reuters Health) – Black patients are half as likely as white patients to get care at academic medical centers in New York City even after accounting for differences in health insurance, a recent study suggests.

Compared to privately insured patients, people with coverage through Medicaid, the government health program for the poor, are three times less likely to receive treatment at these elite New York hospitals, the study also found. Uninsured patients are five times less likely to get care at academic hospitals.

“Academic medical centers are generally better able to provide highly specialized care for patients with complex or rare illnesses,” said lead study author Roosa Sofia Tikkanen, a researcher at the University of Massachusetts Medical School in Worcester who completed the work while at City University of New York School of Public Health at Hunter College.

“Most experts believe unequal access to high-quality health care contributes to disparities in health outcomes,” Tikkanen added by email. “In New York City, life expectancy can differ by up to 10 years between two neighborhoods that are located just six subway stops apart.”

About 18 percent of patients at academic medical centers are black, compared with almost one-third at other hospitals in the city, the analysis of discharge data from 2009 and 2014 found.

At the same time, 22 percent of patients were insured by Medicaid at academic hospitals, compared with 42 percent at other hospitals in the city. And only 1 percent of academic hospital patients were uninsured, compared with 4 percent elsewhere.

While Medicaid and uninsured patients accounted for nearly half of all patients at non-academic hospitals in the city, they made up less than one-quarter of inpatients at academic medical centers. At one-third of academic hospitals, less than 10 percent of patients had Medicaid or were uninsured.

To see how race, ethnicity and payer status affect the likelihood of being treated at an academic medical center, researchers analyzed data on adults discharged from hospitals in New York City in 2009 and 2014, and they also looked at similar data for Boston hospitals in 2009.

In Boston, uninsured and Medicaid patients were just as likely to be treated at academic medical centers as at other hospitals. And racial and ethnic minorities were slightly overrepresented at academic hospitals.

It’s possible some of the differences between the two cities might be explained by the extensive public hospital network in New York, the authors note in the International Journal of Health Services.

All of the academic medical centers in Boston and New York are nonprofit hospitals, however, and enjoy tax exemptions worth tens of millions of dollars, the researchers point out. In exchange, they are expected to provide community benefits, including caring for Medicaid and uninsured patients.

One limitation of the study is that researchers didn’t account for patients’ diagnoses or severity of illnesses, which could influence which hospital they went to for care, the authors add. The analysis of two cities also might not reflect what happens in other communities.

The study also didn’t examine the role of residential segregation or neighborhood poverty on use of academic medical centers, noted Asal Mohamadi Johnson, a public health researcher at Stetson University in Florida who wasn’t involved in the study.

“The issue of equity and fairness is at stake here,” Johnson said by email. “Academic medical centers should be held to higher levels of ethical standards in providing care for low income and minority patients.”

When there are disparities in patients’ access to care, academic medical centers may not offer the best possible education to new doctors, Johnson added.

“Active participation of academic medical centers in caring for non-whites and the poor prepares a more qualified and culturally competent generation of physicians and health care providers who will have more familiarity with the unique circumstances and barriers confronting these patients,” Johnson said.

SOURCE: bit.ly/2kvPClc International Journal of Health Services, online February 2, 2017.

http://www.reuters.com…

Single-payer health system: the best solution

By Jessica Schorr Saxe, M.D.
Consumer Reports, Letters, March 2017

Re: “How to Get High-Quality, Low-Cost Healthcare,” January 2017:

Your entire article speaks to the need for a single-payer health system. All the problems you discuss would become obsolete. People would no longer avoid preventive and other necessary care due to anticipated expense. They would not need to invest time in comparison shopping, waste valuable time at doctor appointments discussing costs, schedule needed care around paying off deductibles, nor worry about in-network care (which can be difficult due to narrow, changing, or misleading networks). Other developed nations have some form of a single-payer system, which provides universal access, lower cost, better outcomes, and more choice than ours. Improving and expanding Medicare would mean that we could actually get health care instead of investing our personal (and collective) energy in strategizing about how to receive care.

Dr. Jessica Schorr Saxe is chair, Health Care Justice, Charlotte, N.C.

http://www.consumerreports.org…

Can high deductibles save money if the patient-consumer is informed?

I’ve put my family on a health insurance experiment. It’s been a challenge

By Ashish Jha
STAT, February 6, 2017

Enrollment in high-deductible health insurance plans has exploded over the past five years. I’m learning the hard way how these plans do — and do not — work.

About one-third of American workers covered by health insurance are now in high-deductible health plans, in which the policy holder pays a substantial portion of the cost of health care services out of pocket before insurance coverage kicks in. Many economists and health policy experts believe that these plans are a promising way to reduce health care spending.

So when a high-deductible plan became available through my employer, Harvard University, a couple years ago, I decided to enroll my family in it. If this is going to be a big national experiment, I thought that I, as a physician and a health policy scholar, ought to know what it’s like to live with this kind of health insurance. Debra, my wife, was not convinced.

My family is now in its second year under a high-deductible plan. That means we are responsible for paying the first $6,000 of our health expenses for the year, for everything from a doctor visit for a flu shot to surgery.

It has been an educational enterprise.

Our experiment is showing me again and again that it’s extremely hard to be a health care consumer in Massachusetts — just as I’m sure it is in other states. Want to know how much a particular type of health care costs, like a visit to a specialist or getting a minor surgery? Good luck figuring it out. My insurance company’s online tool was hard to use and, even as a physician, I could almost never guess what sets of services a visit to the doctor might generate.

The second lesson was that being a health care consumer is stressful, at least the way the system is currently set up. Here’s an example. Our son had surgery last year. We got a call saying it was time for his one-year follow-up. Deb stressed for nearly two months over whether or not to make the appointment. Of course she wants our son to get the care he needs, but did he truly need this follow-up? That’s both the promise and the peril of high-deductible plans — they are supposed to make you think twice about consuming health care.

She eventually went with our son for his one-year follow-up — they spent two minutes with the surgeon — and paid $465 for the visit. I’m not sure my son, or my spouse, felt any better afterward. There were many examples like this sprinkled throughout the year, but the most profound one was the one I experienced for myself.

I have supraventricular tachycardia, a common heart rhythm problem. When it hits, my heart races at about 180 beats per minute. It comes on a couple of times a year, lasts a few minutes, and usually isn’t a big deal. But one morning I woke up with my heart racing. After 30 minutes, I wondered if I should go to the emergency department, knowing that I’d probably get stuck with a multi-thousand-dollar bill. So I kept waiting. After an hour, during which my heart kept beating furiously, my chest started to hurt. I knew what that meant — I was at risk of having a heart attack.

Deb asked me what I would tell a patient in this situation. That was easy: I’d tell him or her to call 911. But I kept waiting. Finally, about 15 minutes later, the abnormal rhythm finally broke and I felt my heart calm down. I was lucky — I had rolled the dice and things had worked out.

If we continue with high-deductible health plans the way they exist today, more and more people will experience what my family did — the stress of having to make medical decisions with little information and few choices. At best, we’ll have a health care system that might save a little money — but at the risk of harming the health of our citizens.

Ashish Jha, MD, is an internist at the VA Boston Healthcare System, and a professor of health policy at the Harvard T.H. Chan School of Public Health.

https://www.statnews.com…

***

Comment:

By Don McCanne, M.D.

There are two potential adverse consequences of requiring high deductibles in health insurance plans. Developing a serious medical problem can expose the individual to financial hardship. Even more serious is that the potential for financial exposure can cause an individual to make a terribly consequential decision in electing to forgo medical care because of the deductible.

Some say that we merely need to provide the patients with adequate information and then patients can make their own informed decisions. That is a fundamental principle in consumer-driven health care. But the rhetoric does not match the real world.

In this instance, a noted physician and professor of health policy, Ashish Jha, made a decision to protect his personal finances even though that decision could have cost him his life! As an optimally informed patient-consumer, he made the wrong decision, even though fortunately he escaped the worst consequences.

Several other nations that cover everyone at a cost much lower than ours are able to provide care with first dollar coverage – no need to use high deductibles in a misguided effort to contain spending. Surely the United States could do the same.

Medicare Advantage coding intensity could cost taxpayers $200 billion

Projected Coding Intensity In Medicare Advantage Could Increase Medicare Spending By $200 Billion Over Ten Years

By Richard Kronick
Health Affairs, February 2017

Abstract

Over the past decade, the average risk score for Medicare Advantage (MA) enrollees has risen steadily relative to that for fee-for-service Medicare beneficiaries, by approximately 1.5 percent per year. The Centers for Medicare and Medicaid Services (CMS) uses patient demographic and diagnostic information to calculate a risk score for each beneficiary, and these risk scores are used to determine payment to MA plans. The increase in relative MA risk scores is largely the result of successful efforts by MA plans to identify additional diagnoses, also known as coding intensity, and not of changes in enrollees’ true health. In this article I estimate the effects of coding intensity on Medicare spending over the next decade. Under the moderately conservative assumption that coding intensity will decelerate, Medicare expenditures are expected to increase by approximately $200 billion. CMS has implemented a variety of strategies since 2010 that lessened the impact of coding intensity on Medicare spending; it has a variety of policy responses at its disposal to mitigate the impact going forward. The problem could be largely solved if CMS adjusted for coding intensity using the principle that MA beneficiaries are no healthier and no sicker than demographically similar fee-for-service Medicare beneficiaries, returning to the budget-neutrality approach that was introduced in 2004 and later abandoned.

From the Introduction

In the three decades that Medicare has been contracting with health maintenance organizations and other health plans, figuring out how to pay the plans accurately and fairly has posed a persistent challenge. Rapid growth in enrollment in Medicare Advantage (MA) plans has raised the stakes involved in getting the answer right: Over 30 percent of Medicare beneficiaries are enrolled in Medicare Advantage and account for an estimated $200 billion in Medicare payments in 2017, or approximately 1 percent of the gross domestic product.

House Speaker Paul Ryan’s proposal to convert Medicare into a premium support system raises the stakes even further. In such a system, beneficiaries might be required to pay a larger premium for traditional Medicare than for Medicare Advantage. It is critically important that any premium differential between traditional Medicare and Medicare Advantage under premium support reflect differences in efficiency, quality, and covered benefits, and not differences in risk selection or coding practices.

The inclusion of diagnoses in the payment system creates strong incentives for MA plans to report as many diagnoses as they can legitimately support—incentives that are not present in traditional Medicare. As a result, the average risk score for MA enrollees has increased by approximately 1.5 percent per year more than the average risk score of fee-for-service (FFS) Medicare beneficiaries over the past decade, with little indication that the relative morbidity of MA enrollees has actually increased. If this remarkably consistent rate of increase in relative Medicare Advantage risk continues over the next decade, Medicare payment will increase dramatically.

Despite the attention given to coding intensity by CMS and Congress over the past decade, unless there is a further policy response, Medicare will substantially overpay MA plans over the coming decade—likely to the tune of hundreds of billions of dollars.

From the Discussion

Political And Technical Obstacles

The political obstacles to a robust solution are formidable. Aggressive action to mitigate the effects of coding intensity would raise the ire of the Medicare Advantage industry and might well engender a lobbying effort involving the spectacle of buses circling the Capitol, with multitudes of MA enrollees imploring members of Congress to protect their benefits. The Medicare Advantage industry and enrollees would be angered by the prospect that aggressive response to coding intensity would increase premiums or reduce supplemental benefits enabled by the rebates that plans receive for bidding below their benchmarks.

In addition, aggressive action to mitigate the effects of coding intensity might raise concern among some policy makers about the stability and growth of the Medicare Advantage program.

The technical obstacle is determining how to accurately measure coding intensity. As discussed more fully in the Appendix, various reasonable approaches exist to measure the effects of coding intensity.

Budget-Neutrality

As originally conceived, the budget-neutrality adjustment was not designed as an adjustment for coding intensity, but it could serve that purpose well moving forward. It rests on a simple principle: namely, that MA enrollees are no healthier and no sicker than demographically similar FFS Medicare beneficiaries. If one accepts that principle, then it follows that aggregate payments to MA plans should be equal to the amount that would have been paid using demographic risk adjustment. As shown in this article, if CMS were to calculate the coding intensity adjustment using this principle, payments to MA plans would be approximately $200 billion less over the next decade than if the coding intensity adjustment remained at the statutory minimum of 5.91 percent.

Although there is evidence that the introduction of diagnostic risk adjustment using diagnoses from ambulatory care encounters in 2004 reduced favorable selection into MA plans, analyses by Joseph Newhouse and colleagues show that favorable risk selection into Medicare Advantage likely remains to some degree. More recent evidence provided by Pete Welch and me, and extended in Exhibit A-2 of the Appendix to this article, also suggests that MA enrollees are no sicker, and may well be healthier, than demographically similar FFS Medicare beneficiaries. Thus, the budget-neutrality method of calculating the coding intensity adjustment will result in payments to Medicare Advantage that are at least fair, if perhaps still slightly too generous.

Conclusion

The analysis presented in this article cannot solve the political problem of creating support for a robust response to the problems created by differential coding in Medicare Advantage. I hope, however, that this work will create the foundation for a solution to the technical problem by fostering a discussion of how best to measure and adjust for differential coding between Medicare Advantage and fee-for-service Medicare. Solving this problem is an important prerequisite to the establishment of a stable and equitable future for the current Medicare Advantage program, and even more important if Congress were to convert Medicare into a premium support system.

http://content.healthaffairs.org…

***

Comment:

By Don McCanne, M.D.

Some long-time readers of these messages may be bored by yet another article confirming that the private Medicare Advantage plans have been successful in being paid significantly more than we are spending for comparable patients in the traditional fee-for-service Medicare program, but it is crucial to understand that this is a major part of the strategy to privatize the Medicare program, and we taxpayers are being cheated as they pull off their scheme.

This year we will see intensified efforts to convert to a premium support program (vouchers) which will enrich private insurers as costs are transferred onto the backs of Medicare beneficiaries, with the goal of privatizing the entire Medicare program. Insurers win, patients lose, and the libertarian ideologues snicker in the background.

There are two methods by which the private insurers are overpaid. They engage in favorable selection – using devious methods to enroll healthier patients – thus spending less than they would if their enrollees were of average health. They also have gamed risk adjustment – qualifying for extra payments by submitting claims indicating that their enrollees are sicker than they actually are.

About one-third of these extra payments are used to enhance benefits, thus enticing seniors to enroll in their plans instead of the traditional Medicare program. You can imagine how attractive lower deductibles could be to individuals who just turned 65 and are used to dealing with private plans. By marketing heavily to them they further improve their favorable selection since those just 65 years old are the healthiest and least expensive members of the Medicare population.

And that other two-thirds of the extra payments? They keep that to help pay for their high administrative costs that characterize the unique waste in the U.S. health care financing system.

But why should Medicare Advantage patients receive more benefits than those remaining in the traditional program? If the same extra payments were used to reduce deductibles and coinsurance in the traditional program then there would be no reason to select the private plans, especially since there are no network restrictions such as those instituted by the private plans. More choice, at no extra cost.

You say you don’t want to increase taxes to pay for better benefits in the traditional Medicare program? Then, for the sake of fairness, at least decrease the overpayments to the private Medicare Advantage plans to the same level that we are paying for the traditional program. Of course, because of their administrative excesses, they could never compete, and they would just go away (just as they were doing under the Medicare + Choice program that was discontinued when the insurers proved that it was impossible for them to provide higher quality at a lower cost).

The study author, Richard Kronick, suggests that we switch to a budget neutrality method of correcting the overpayments. That might reduce the problem of differential coding for risk adjustment, but we could still face the deceptive, opaque methods the insurers use to gain favorable selection.

Regular readers know what the solution is. Throw out the private insurers, improve the traditional Medicare program, and then use it to cover everyone – greater value while ensuring health care access for all.

A Vote for Tom Price is a Vote to Destroy Medicare

By Nancy J. Altman
The Huffington Post, Feb. 7, 2017

No one voted to destroy Medicare. Yet, the first battle in the war over Medicare has arrived.

Why would anyone want to destroy Medicare? It has stood the test of time. The smart policy is to expand it to everyone. Medicare shows government at its best.

Government at its best! There’s the rub: Given Medicare’s proven success — its low administrative costs, its efficient coverage of those with the greatest medical needs and costs, and its enormous popularity — it is no wonder that anti-government zealots hate the program.

Medicare demonstrates that there are some services that the federal government provides better than the private sector. The mere existence of Medicare (and Social Security) puts the lie to the claim that everything should be privatized. For that reason, today’s Republicans, who hate government and want to privatize everything, are determined to end Medicare as we know it.

One of those anti-government zealots, Representative Tom Price (R-GA), has been nominated by Donald Trump to be the fox in the Medicare hen house — Secretary of Health and Human Services, the Department responsible for the administration of Medicare. He has made his antagonism to Medicare clear.

Against all evidence, Price claims that “nothing has had a greater negative effect on the delivery of health care than the federal government’s intrusion into medicine through Medicare.” Of course, the exact opposite is true. Medicare saves lives. It allows seniors and people with disabilities, those with the greatest health needs, to obtain life-saving health care.

With true radical zeal, Price has said “we will not rest until we make certain that government-run health care [e.g., Medicare] is ended.” If confirmed by the Senate, Price will be in a powerful position to carry out his threat to end Medicare.

There are two ways to destroy Medicare. One is legislatively. The other is administratively. If Representative Tom Price is confirmed to be the Secretary of Health and Human Services, he will be in a position to destroy it both ways, and along with it, Medicaid, the Affordable Care Act, and so many other programs vital to the health and well-being of all of us.

Let’s start with destruction by legislation. Right after the election, Speaker Paul Ryan made clear his plan to end Medicare legislatively. He falsely announced that repealing Obamacare requires “reforming” Medicare. His reform? Send seniors and people with disabilities into the private insurance market armed with nothing but an inadequate amount of cash. Anyone who knew the world before Medicare knows that seniors and people with disabilities were often unable to buy insurance at any price. Those who could were forced to pay exorbitant prices.

That is the world to which the aptly named Price wants to return us. Price, chairman of the Senate Budget Committee and Ryan co-conspirator, reinforced Ryan’s Medicare threat by revealing that the Republicans planned to enact Medicare privatization in the first six to eight months of the Trump administration.

As Secretary of Health and Human Services , Price would be in an even more powerful position to work to end Medicare. Rather than one of 435 members of the House of Representatives, he would, if confirmed, be the Trump administration’s chief Medicare spokesman.

And, as the top Medicare person, he could do even more destruction than pushing legislation that ends Medicare. As Secretary, he could revoke regulations that protect Medicare beneficiaries and could issue regulations that harm them. Moreover, policymakers, researchers and others rely on the Department of Health and Human Services for accurate, reliable data. In this world of alternative “facts,” could anyone trust the data put forward by a Department Secretary who is determined to end Medicare?

Senate Democrats recognize the threat. To deprive Price of all this power over Medicare, they boycotted the Committee vote on his nomination, since the rules require the presence of at least one member of the opposition party. So, what did their Republican counterparts do? They ignored the rules and unanimously voted him out of Committee with no Democrats present.

With the Muslim ban appropriately dominating the national news and with Senate votes coming up on so many nominees who want to undermine the very missions of the agencies they will control, it is easy to feel overwhelmed. Anti-public schools advocate Betsy DeVos was just confirmed as Secretary of Education after an unprecedented tie vote . Racist Senator Jeff Sessions may, in the next few days, be confirmed as Attorney General, and therefore be in charge of our civil rights.

But here is the oddly good news. Sessions’ confirmation vote is scheduled to come before the vote on Price. Outrageous as it will be, if Sessions is confirmed, it will mean that other Cabinet nominees, including Price, can be blocked with just two Republican Senators voting with the Democrats.

I am deeply suspicious that Senators Susan Collins’s and Lisa Murkowski’s votes against Betsy DeVos were not courageous and principled. Rather, I believe that they may have been just the opposite – cowardly and cynical. After all, if they really wanted to block DeVos they could have done it in committee. McConnell may have granted Collins and Murkowski permission to vote against DeVos, knowing their votes were not needed and recognizing that their constituents were strenuously opposed to DeVos’s confirmation.

Collins and Murkowski can prove me wrong by voting against putting Tom Price in charge of Medicare, a program that he himself has proclaimed he wants to end. After all, bad as DeVos is, education is still largely a state and local matter. Not true for Medicare, which is a completely federal program.

If Price is confirmed by all (or all but one) Republican Senator voting for confirmation, it will be clear that Collins and Murkowski acted cynically in voting for DeVos. It will also be clear that the Republican Party wants to destroy Medicare.

Those of us working to expand, not cut Medicare will do everything we can to assure that the American people understand that a vote for Price is a vote to destroy Medicare. We will do all we can to assure that the electorate never forgets who voted for Price, and, in so doing, voted to destroy Medicare.

That may feel like a threat. I prefer to think of it as a promise.

Nancy J. Altman is founding co-director of Social Security Works. Email your Senators today and tell them to oppose Tom Price’s confirmation as Secretary of Health and Human Services.

http://www.huffingtonpost.com…