PNHP

Trump’s health care policy appears heavy on complexity, light on mercy

Trump’s health care policy appears heavy on complexity, light on mercy

Letting the states decide how to insure residents might lead to a cobweb of unwieldy regulations

By Daniel C. Bryant, M.D.
Portland (Maine) Press Herald, Dec. 5, 2016

Will Donald Trump make our country’s health care system great again? Of course, for many it was never that great in the first place, but it is important to consider what changes may lie ahead during a Trump presidency. For this, we can turn to his website, where he promises to:

• Repeal the Affordable Care Act. Though Mr. Trump has suggested he may keep some features of the ACA, this may mean that 20 million people will lose their health insurance and millions more will find it increasingly hard to find affordable policies with reasonable coverage.

• Replace the ACA with health savings accounts. In the HSA scheme, individuals with high-deductible plans can set aside thousands of dollars of income a year, tax free, to pay future health care costs.

This, of course, limits HSAs to those with extra money to set aside, who will then be faced with the recurring quandary of whether a medical problem “deserves” their depleting their account or should be ignored because something worse might come along.

• Return health insurance regulation to the states. Dealing with 50 different sets of insurance regulations will be a challenge both to businesses with employees living in multiple states and to the companies that provide insurance to those businesses.

And people with costly medical problems will be tempted to move to states that require insurers to offer good coverage, thus burdening those well-intentioned states; while businesses will be tempted to move to states with low coverage requirements and premiums, thus forcing poorer policies on their employees.

• Maximize flexibility for states in administering Medicaid. Like the above, this “states’ rights” emphasis would give states so inclined a tool for modifying their demographics to their economic advantage: namely, by keeping out the poor and the sick.

• Enable people to purchase insurance across state lines. The resulting competition might well reduce premiums, but in order to maintain their bottom lines, for-profit insurers would have to compensate by reducing coverage or provider reimbursement. And it will be tricky, indeed, for insurers to sell group and individual policies across state lines if every state has a different set of regulations.

• Re-establish high-risk pools. By segregating the sick or likely-to-get-sick into “pools,” we shift some of the extra cost of their care to them, and away from the already more fortunate. The balance of the cost must then be paid by the government, which may or may not be willing to do so.

This all flies in the face of the basic idea of insurance, which is to spread cost over the fortunate as well as the unfortunate, not concentrate it. And what is even worse, it perpetuates a two-class system – normal people, and the sick and poor.

• “Modernize” Medicare. This is too vague a prescription to try to interpret at this point; it could mean anything from lowering the age limit and increasing coverage, to phasing out the program altogether.

Reviewing Mr. Trump’s likely health care policies, we can note two themes, both of concern – complexity and inequity.

Complexity, and its associated financial costs, would come from the co-existence of millions of HSAs, millions of individual and employer-sponsored insurance plans and a variety of Medicaid and other governmental programs, all operating within the competing regulations of the 50 different states among which people and businesses are constantly moving.

Inequity, and its associated social costs, would come from the vastly different access to health care that people of different means and locales would have.

The Affordable Care Act, too, is complex, and, though much more equitable than Mr. Trump’s policies, may well not survive. As for the system that the president-elect’s policies would lead to, it will be unlikely to survive either because of its own complexities, and should not because of its inequities.

In the aftermath of both Barack Obama’s and Mr. Trump’s efforts at health care reform, we will be left then to design a new system, preferably the one we should have had all along – a simple and equitable system of the single-payer, Medicare-for-All type, similar to those that every other industrialized country has adopted.

No, Donald Trump will probably not make our health care system great again, but he may, if inadvertently, help to make it great at last.

Daniel C. Bryant, M.D., of Cape Elizabeth is leader of the Portland chapter of Maine AllCare (maineallcare.org), an organization devoted to getting universal health care in Maine.

http://www.pressherald.com/2016/12/05/maine-voices-trumps-health-care-policy-appears-heavy-on-complexity-light-on-mercy/

Faster growth of national health spending

National Health Spending: Faster Growth In 2015 As Coverage Expands And Utilization Increases

By Anne B. Martin, Micah Hartman, Benjamin Washington, Aaron Catlin, the National Health Expenditure Accounts Team
Health Affairs, December 2016

Abstract

Total nominal US health care spending increased 5.8 percent and reached $3.2 trillion in 2015. On a per person basis, spending on health care increased 5.0 percent, reaching $9,990. The share of gross domestic product devoted to health care spending was 17.8 percent in 2015, up from 17.4 percent in 2014. Coverage expansions that began in 2014 as a result of the Affordable Care Act continued to affect health spending growth in 2015. In that year, the faster growth in total health care spending was primarily due to accelerated growth in spending for private health insurance (growth of 7.2 percent), hospital care (5.6 percent), and physician and clinical services (6.3 percent). Continued strong growth in Medicaid (9.7 percent) and retail prescription drug spending (9.0 percent), albeit at a slower rate than in 2014, contributed to overall health care spending growth in 2015.

http://content.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

As of 2015, our national health spending is $3.2 trillion or 17.8 percent of our GDP. That is a per capita spending of almost $10,000 ($9,990). Coverage expansions as a result of the Affordable Care Act certainly contributed to this 5.8 percent increase in spending.

The final sentence in the conclusion of this article: “While the 2014–15 period is unique, given the significant changes in health insurance coverage that took place, health spending is projected to increase as a share of the overall economy over the next ten years and will be influenced by the aging of the population, changing economic conditions, and faster medical price growth.”

Changing demographics are expected, predictable, and manageable, but faster price growth remains a problem unique to our fragmented system of financing health care. We could fix that with a publicly-financed and publicly-administered single payer national health program, an improved Medicare for all.

Killing Obamacare? That’s the same as killing 16,000 Americans every year

By C.V. Allen, M.D.
The Modesto Bee, Dec. 3, 2016

Don’t look now, but our president-elect is on track to preside over the premature and preventable deaths of 16,000 Americans – each year.

Sound extreme? Read on.

Among Donald Trump’s “What I will do Day One” promises was his pledge to repeal Obamacare, a program to insure all the uninsured Americans who at one time numbered nearly 50 million. Though Trump has mildly backed down and now says he might keep the “good parts of the law,” his original intent remains unchanged.

Rising costs, low pay to providers and financial loses have caused insurance companies to withdraw from many regional markets, especially in rural areas, giving the Affordable Care Act a negative image. In more urban areas, where these things have not occurred, the program remains more popular.

But the major cause of failure is due to what is known by its technical term, “adverse selection.” That means the sickest people sign onto insurance while the younger, healthier people opt out, convinced they are going to live forever. The basic tenet of all insurance – auto, life or health – is that those who don’t use the services must outnumber those who do by a margin wide enough to lower the cost for all. Failure to have more non-users than users guarantees financial failure. For Obamacare, this was predicted by many.

Unrecognized by public and (often insured) critics is one of Obamacare’s stunning achievement – the numbers of uninsured dropped 40 percent, from 50 million to about 30 million. That was the largest decrease in our nation’s history. Twenty million people – a number equal to the combined populations of Norway, Denmark and Sweden – can now start each day reasonably certain that health care services will be available when needed and they won’t go bankrupt paying for them.

What will replace Obamacare?

Here the picture gets a bit vague. President-elect Trump has a few vague suggestions:

* “Let insurance work cross state lines” – but that will no effect on cost or availability;

* Issue “block grants to states” – same problem, it won’t increase availability or drive down costs for consumers.

More likely to be offered are yet-to-be-detailed “reforms” based on market forces and the assumption that providing health care is like selling cars. It isn’t.

Selling more Fords is good for Ford. Providing more health care is bad for insurers. In fact, the easiest way for those who sell health insurance to make money is to avoid as much as possible selling policies to the 10 percent of the population responsible for 90 percent of the costs – older Americans and those who are already sick. This is common practice in today’s commercial health insurance industry.

Those 16,000 deaths? It has long been known that those with access to health care lived longer than those without, but details remained scarce until a properly designed comparative study by the American Journal of Public Health showed us just how important health insurance really is. Two large groups of subjects – similar in gender, age, health status and all other factors except one – were compared over time. The only difference was that one group had health care insurance and the other did not. The end point was clear.

Applying the results of this study to the soon-to-be 20 million uninsured, it can be predicted about 16,000 Americans would die, unnecessarily, each year because they do not have health insurance.

Pulling the insurance rug from under 20 million people is risky for any politician, even Donald Trump. Clearly, some mix of vague “reforms” will be offered to fill the void, but most experts see the uninsured numbers and the deaths that inevitably will follow and continue to climb. True reform – universal health care – must wait for another day.

Dr. C.V. Allen is a semiretired Modesto physician active in health care reform issues. He wrote this for The Modesto Bee. Send comments or questions to columns@modbee.com.

http://www.modbee.com…

Doctors group calls on Trump to rescind nominations of Price, Verma to key health care posts

FOR IMMEDIATE RELEASE, December 2, 2016
Contact: Mark Almberg, PNHP communications director, (312) 782-6006, mark@pnhp.org

Dr. Robert Zarr, president of Physicians for a National Health Program, made the following statement today:

Physicians for a National Health Program decries President-elect Donald Trump’s plans to appoint Rep. Tom Price and Ms. Seema Verma to key health care posts in his administration. These appointments foreshadow policies that would to make Americans’ access to medical care even more difficult, costly and inequitable than it is today.

Price, Trump’s pick to head the Department of Health and Human Services, has proposed replacing the Affordable Care Act with a plan that would:

* Slash Medicaid funding and transfer much of the ACA’s health insurance subsidies from low-income to wealthier Americans, effectively depriving millions of coverage, and cause thousands of deaths each year.

* Allow the big insurers to sell bare-boned policies that have no minimum benefits, and allow them to drop people with pre-existing conditions from their rolls if the latter were to even briefly miss a premium payment.

* Turn Medicare into a voucher scheme that would undermine coverage and ship hundreds of billions of taxpayers’ dollars to private insurers.

Price’s biases against the special health needs of women, including the right to choose, and the LGBTQ community are a matter of record and portend increased discrimination and injustice. And even as he would cut public health programs, Medicaid and Medicare, he would work to lower taxes on the wealthy.

Verma, Trump’s pick to head the Centers for Medicare and Medicaid Services, was the architect of Indiana’s punitive restrictions on Medicaid patients. Her plan forced impoverished Medicaid enrollees to pay dearly for care, imposing unprecedented copayments and premiums on people with little chance of affording them; those who miss a payment are denied coverage. Her actions in Indiana signal that she will inflict cruel and unusual punishment on America’s most vulnerable citizens.

Physicians for a National Health Program calls upon the president-elect to rescind these appointments. We recognize that the health care status quo is unacceptable, but reject the backward steps that Price and Verma have championed. Instead, our nation should move forward to the only rational and effective solution for our broken health care system – a publicly financed, nonprofit single-payer system, 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 a single-payer national health program.

America’s health care mandate for President Trump

Kaiser Health Tracking Poll: November 2016

By Ashley Kirzinger, Elise Sugarman, and Mollyann Brodie
Kaiser Family Foundation, December 1, 2016

America divided on ACA next steps

What would you like to see President-elect Donald Trump and the next Congress do when it comes to the health care law?

30% – Expand what the law does

26% – Repeal the entire law

19% – Move forward with implementing the law as it is

17% – Scale back what the law does

03% – None of these/Something else

04% – Don’t know/Refused

Americans have favorable attitudes towards some ACA provisions

Percent who say they have a FAVORABLE opinion of each of the following provisions of the law (for now ignore percent in parenthesis):

85% (83%) – Allows young adults to stay on their parents’ insurance plans until age 26

83% (75%) – Eliminates out-of-pocket costs for many preventive services

81% (71%) – Closes the Medicare prescription drug “doughnut hole” so people on Medicare will no longer be required to pay the full cost of their medications

80% (72%) – Creates health insurance exchanges where small businesses and people can shop for insurance and compare prices and benefits

80% (68%) – Provides financial help to low- and moderate-income Americans who don’t get insurance through their jobs to help them purchase coverage

80% (66%) – Gives states the option of expanding their existing Medicaid program to cover more low-income, uninsured adults

69% (60%) – Prohibits insurance companies from denying coverage because of a person’s medical history

69% (62%) – Increases the Medicare payroll tax on earnings for upper-income Americans

60% (49%) – Requires employers with 50 or more employees to pay a fine if they don’t offer health insurance

35% (16%) – Requires nearly all Americans to have health insurance or else pay a fine

http://kff.org…

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Comment:

By Don McCanne, M.D.

Based on media reports for the past half year or so Americans seemed to be split on whether they want to keep Obamacare or to repeal it and perhaps replace it with an ill-defined Republican plan. As is usual during political campaigns, the rhetoric did not reveal much in the way of the true feelings of Americans about health care reform. This Kaiser poll provides us much better insight.

Based on the rhetoric, 49% want to move forward with implementing the law as it is (19%) or, even more, wanted to expand what the law does (30% – the largest fraction). In contrast, 43% wanted to repeal the entire law (26%) or scale back what the law does (17%).

But the rhetoric can be quite meaningless, so they polled Americans on what health reform policies they would support, devoid of political rhetoric. By wide margins they supported policies that would improve the functioning of our health care financing system. Most of these policies are supported by the Affordable Care Act. The only policy rejected was requiring Americans to pay a fine if they were unfortunate enough to be uninsured. (Notably absent were policies more specific to single payer, though other studies have shown broad support for such policies.)

So Americans are split on Obamacare but they clearly support the policies of the Affordable Care Act. That may seem ironic, but it exemplifies the difference between communicating with political rhetoric and communicating with policy facts.

Now look at the percentages in parentheses. They show only slightly less support than the cross section of Americans, but still support by a wide margin for policies that would improve health care financing, except for fines for not being insured or for small employers not providing insurance.

Nobody wants to be uninsured, and they would surely object to being fined because they weren’t. Even if we were trying to get everyone insured, fines are a terrible way to do it. Far better would be equitable financing through a single payer system.

So what are the numbers in parentheses? Those are the percentage of Trump voters who support those particular policies. Trump voters!

Imagine that. Trump supporters want beneficial health care policies that would make health care accessible and affordable for everyone. So Donald Trump does have a mandate, but it is to adopt beneficial health policies, not to pare them back nor replace them with market models that benefit insurers to the detriment of patients.

His selection of Tom Price for HHS and Seema Verma for CMS sends us in the wrong direction. It is imperative that the message gets through to Mr. Trump that he should withdraw these two nominations and move forward with appointing health care leaders who would work with Congress to bring us the health care system that Americans really want. With a little more objective thought and less rhetoric, the overwhelming majority, including Trump supporters, would want to see enactment of an improved Medicare for all.

We Condemn the AMA and AAMC Endorsements of Tom Price for HHS Secretary

By Janine Petito, Andrew Hyatt, and Michael Zingman
Common Dreams, December 1, 2016

Early Tuesday morning, President-elect Donald Trump announced his selection of Representative Tom Price (R-Ga.) for Secretary of Health and Human Services (HHS), to succeed Secretary Sylvia Mathews Burwell. Almost immediately, the American Medical Association (AMA) and Association of American Medical Colleges (AAMC) expressed strong support for this nomination.

As students and future health care professionals, we are deeply troubled by the AMA and AAMC endorsements of Rep. Price. The policies he has endorsed not only stand in stark contrast to our ideals, but also threaten the wellbeing of our patients. We question why these organizations—established to protect the interests of all physicians, students, patients, and communities—would ignore the priorities of those they represent. As HHS secretary, Dr. Price will endanger medical institutions and policies, as well as jeopardize our medical education and the very practice of evidence-based medicine.

Though Price, an orthopedic surgeon, claims to prioritize patient, family, and physician needs, his track record suggests decidedly otherwise. In 2015, as leader of the House Budget Committee, he proposed repealing the Affordable Care Act (ACA) in its entirety, privatizing Medicare, making enormous cuts to federal Medicaid funding, and abolishing the mandate that states use Medicaid dollars for patient care. These proposals would guarantee an immediate loss of health insurance for 22 million Americans; increase health care costs for the aged and disabled; and reverse recently-gained protections for vulnerable members of our society, abolishing protections of women’s health, addiction, LGBTQ+, and other necessary medical services.

Despite evidence of the substantial harm his policies would inflict upon patients, Rep. Price continues to advocate for them in his fiscal plan for 2017, promising to destroy the systems already in place to protect the neediest among us and placing the health of millions of Americans at risk.

The AMA’s support of Price lies in direct conflict with the organization’s purported values and its mission “to promote the art and science of medicine and the betterment of public health.” If the AMA is truly committed to promoting the science of medicine, it must recognize that this country cannot afford to place power in the hands of a man who opposes promising scientific breakthroughs like embryonic stem cell research. Similarly, it must ensure that the nation’s HHS secretary values the truth. On the contrary, Rep. Price has demonstrated a severe lack of respect for facts, exemplified by his false claims that women have always been able to afford birth control, and that “not one” has benefitted from the ACA’s contraceptive mandate.

If the AMA is truly concerned about the betterment of public health, it is frankly irresponsible to endorse a nominee who wants to decimate Medicaid—which serves more than 70 million Americans who cannot otherwise afford care—and privatize Medicare, creating narrow networks for enrollees, making seniors increasingly responsible for their health expenses, and decreasing access to needed care.

We find the AMA’s paradoxical endorsement objectionable, but unsurprising. This would not be the first time the organization has acted in the interest of profits over patients; it supported the ACA only begrudgingly, and has historically blocked every effort for universal health care reform, despite evidence of the innumerable benefits that a Medicare-for-All system would afford patients and providers alike. While the AMA has failed to represent the priorities and values of its member physicians for decades, the situation at hand poses too great a danger to our nation’s health for the medical community to remain silent.

The AAMC’s endorsement of Price is equally, if not more disturbing, given its role in molding future physicians and its mission to “serve and lead the academic medicine community to improve the health of all.” In its endorsement, the AAMC claims that Price “has long been a proponent of academic medicine.” This blatantly ignores the fact that the financial solvency of most academic medical centers depends directly on Medicare and Medicaid payments, given that individuals covered by these programs comprise a large percentage of those receiving care at these institutions. Without these programs, academic medicine as we know it would cease to exist.

If the AAMC truly wishes to “improve the health of all,” it cannot reasonably justify endorsing the nomination of a man who would strip 22 million people of health insurance, who has vocally opposed expanding health benefits for children, who believes our government has no responsibility to provide coverage to transgender individuals, and who ignores substantial evidence that access to preventative screenings, contraception, and abortion services have overwhelmingly positive impacts on women’s health.

As medical students and physicians, we condemn the AMA and AAMC endorsements of Price for HHS secretary, and are disheartened by professional organizations like the American Academy of Family Physicians (AAFP) and others choosing to follow suit. Price’s stances are incompatible with the values of the medical profession and with the stated missions of the above organizations. Their support reveals a warped set of priorities, with the short-term professional and financial interests of hospitals and physicians superseding the health and wellbeing of patients. We staunchly reject these endorsements and urge their immediate withdrawal.

In endorsing Price’s nomination and contravening their founding principles, the AMA and AAMC have failed to represent us, the future health care providers of this country. As members and supporters of Students for a National Health Program (SNaHP), we will combat every attempt to deny Americans the health care they deserve, and will fight to create a single-payer health care system that covers every person living in this country without discrimination. If the AMA and AAMC truly believe in their own missions, we urge them to join us in this fight.

Please consider adding your name to our statement to show your support in our condemnation of the AMA, AAMC, and others who endorse the nomination of Rep. Price for Secretary of Health and Human Services.

Janine Petito is a fourth-year medical student at Boston University School of Medicine, who plans to complete residency in internal medicine and pursue a career in adult primary care. She is co-chair of the Students for a National Health Program (SNaHP) Political Advocacy Team and a Physicians for a National Health Program (PNHP) student board member.

Andrew Hyatt is a third-year medical student at Boston University School of Medicine, an active member of Students for a National Health Program (SNaHP), and co-chair of the SNaHP Political Advocacy Team.

Michael Zingman is a first-year student at Columbia College of Physicians & Surgeons and active member of Students for a National Health Program (SNaHP).

http://www.commondreams.org…

The inadequate, shoddy debate over health care reform

By John Geyman, M.D.
The Hill, November 30, 2016

What does the recent election cycle portend for health care in America? Not good, if we go by the recent debate over further reform of our dysfunctional system. The non-debate has been shallow, barely covered by the mainstream media, and uninformative at this important juncture in deciding where to go next in U.S. health care.

In reality, we have three basic alternatives in how we finance health care: (1) continuation of the Affordable Care Act with changes as needed; (2) repeal of the ACA and replacement by a GOP “plan”; and (3) enactment of a single-payer Medicare-for-All system of national health insurance (NHI). But you would never know that from the debate, which is sketchy on the first two options and remains silent on the third.

Now that “conservatives” run the government in a new Trump administration, what can we anticipate? We are already seeing alarming evidence of racism, misogyny, bigotry, and authoritarianism at the highest levels of appointments in the White House and among some members of Congress.

In health care, we can expect efforts to dismantle the ACA, leaving more millions uninsured; to cut Medicaid through block grants to states; and to further the privatization of Medicare and Medicaid. We can also expect the easing of regulations on – and the protection of profits of – the big insurers, drug companies and other corporate stakeholders in our medical-industrial complex.

Continue reading:
http://thehill.com/blogs…

Will CMS push Seema Verma’s POWER accounts?

Trump’s CMS pick is viewed as both patient advocate and foe

By Virgil Dickson
Modern Healthcare, November 29, 2016

President-elect Donald Trump Tuesday announced that Seema Verma, the president, CEO and founder of SVC, a national health policy consulting company that has helped craft Medicaid expansion plans in Indiana, Iowa, Kentucky, Michigan and Ohio, would work under Rep. Tom Price, who currently is a congressman from Georgia but has been nominated for HHS secretary.

Patient advocacy and policy experts agree that Verma’s philosophy encourages people to take charge of their healthcare. Verma has supported charging premiums to individuals above and below the poverty line and freezing beneficiaries out of coverage if they don’t pay. She is also in favor of mandating enrollees search for work while being covered and that they are timely when reapplying for Medicaid coverage or else face a lockout period that could last a year.

Even small contributions can cause some low-income people to choose to bypass coverage, according to Judy Solomon, a vice president for health policy at the left-leaning Center on Budget and Policy Priorities.

For example, a recent state evaluation of Indiana’s HIP 2.0 waiver, which Verma helped develop, found that about one-third of those eligible don’t enroll because they can’t or don’t want to pay a premium, Solomon said.

http://www.modernhealthcare.com/article/20161129/NEWS/161129917

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Trump’s Pick To Run Medicare And Medicaid Has Red State Policy Chops

By Jake Harper
Kaiser Health News, November 29, 2016

On Tuesday, President-elect Donald Trump tapped Seema Verma, a health care consultant, to head the Centers for Medicare and Medicaid Services.

Her consulting firm, SVC, Inc., worked closely with Indiana Gov. Mike Pence to design Indiana’s Medicaid expansion under the Affordable Care Act. The expansion, known as the Healthy Indiana Plan or HIP 2.0, went into effect early last year.

Indiana’s unique Medicaid expansion was designed to appeal to conservatives. HIP 2.0 asks covered people to make a small monthly payment to access health insurance. A missed payment can result in six-month lockout from insurance coverage. Those provisions aren’t allowed under traditional Medicaid, but Indiana got special permission from CMS to implement them through a waiver.

Verma’s role in shaping Indiana’s health care policy has had some controversy. According to a 2014 report from The Indianapolis Star, she has received millions of dollars from the state through her work with the Indiana government. She was also paid by Hewlett-Packard, a Medicaid vendor that received more than $500 million in state contracts. Government ethics experts told the Star the arrangement presented a conflict of interest.

http://khn.org/news/trumps-pick-to-run-medicare-and-medicaid-has-red-state-policy-chops/

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Indiana: Health Care Reform Amidst Colliding Values

By Mitchell Roob and Seema Verma
Health Affairs Blog, May 1, 2008

In May 2007, Indiana enacted comprehensive health reform in the form of the Indiana Check-Up Plan and its centerpiece, the Healthy Indiana Plan (HIP).

HIP is the first Medicaid expansion in the nation to be modeled in the spirit of a high deductible health plan (HDHP)/ health savings account (HSA).

The many conservatives of our state initially balked at the idea of either establishing another entitlement program that could create budget shortfalls for future generations or creating another Medicaid plan that creates a platform for unhealthy lifestyles that leads to abuse of the healthcare system. We managed to overcome these obstacles and our experience provides several lessons for reformers elsewhere:

1) Inaction is not a market solution.

2) Choose reforms that help those who need it, but also increase personal responsibility and utilize market incentives.

Hailed by conservatives, HDHPs and HSAs promote the notion of consumerism and promise greater price transparency, competition and quality. By giving participants some “skin in the game,” they encourage healthy lifestyles and provide individuals a financial incentive to make cost- and value-conscious healthcare decisions, which in turn increases pressure on providers to demonstrate value and quality.

Following the HSA model, the Personal Wellness and Responsibility (POWER) Account is used to fund the deductible. Moving away from premiums and copays that are typically too low to incentivize collection by providers, HIP requires individuals to make mandatory monthly contributions – ranging from 2 percent to 5 percent of income, up to $92/month — to their POWER Account. To prevent participants from obtaining temporary coverage, penalties are stiff for payment lapses.

3) Be fiscally responsible.

The legislation restricts the State from providing services “beyond the level of state appropriations authorized for the plan.”

The implications of a non-entitlement program were enormous, as it gave many legislators the peace of mind to allow them to support the bill.

4) Reach out across party lines and to multiple constituencies.

5) Compromise and cut deals

In developing HIP, we never let the perfect be the impediment of the good.

6) With the exception of compromise, don’t take any of the above lessons too seriously.

Federal policy, and in particular CMS’ waiver process, should provide maximum leeway for this sort of state experimentation.

Through each round of review and approval the plan was tweaked, but with each turn, the health savings account model remained intact.

COMMENTS
May 1, 2008

Don McCanne:

Health savings accounts (HSAs) are specifically designed to use regressive tax policies to fund health care for higher-income individuals. They also reward individuals for being fortunate enough to remain healthy by allowing them to use those funds for other purposes in retirement, with the same tax benefits as an IRA.

Since HSAs are designed to benefit the healthy and wealthy, they are not the solutions that we need to address the very severe deficiencies in our health system. They are an especially lousy model to finance health care for lower-income individuals with greater health care needs.

The description of the POWER accounts as “following the HSA model” is particularly disingenuous. Although participants are required to deposit their own funds into the POWER accounts (on a sliding scale), they receive no tax advantage (though most of them wouldn’t anyway because of their low incomes). Unlike an IRA, they receive no income from the funds deposited in these accounts. When they leave the program, they may receive a pro-rated amount of their own contribution, but none of the state’s contribution. Since the account limit is $1100, it is likely that the individual’s pro-rated amount would be a relatively paltry sum given as a reward for remaining healthy, but would totally disappear quite rapidly as the $1100 is used for health care.

This blog is read by members of the health policy community who understand health policy science. The authors impair their own credibility amongst these professionals when they use the “skin in the game” rhetoric of right-wing ideologues. Pretending that small, segregated accounts somehow constitutes a major policy breakthrough is an unproductive diversion from the dialogue on reform that we desperately need.

http://healthaffairs.org/blog/2008/05/01/indiana-health-care-reform-amidst-colliding-values/

For a critique of a more recent Health Affairs Blog on POWER accounts co-authored by Seema Verma:

https://www.pnhp.org/news/2016/august/indiana’s-phony-medicaid-health-savings-accounts

Comment:

By Don McCanne, M.D.

In media reports about her selection as CMS administrator, Seema Verma is being praised for her policy acumen and for being able to work across the isle, that is, as long as “the health savings account model (for Medicaid) remained intact.”

My comment on the POWER accounts (above), in response to the 2008 Health Affairs Blog that she co-authored, demonstrates that she lacks policy acumen. And the insistence that low-income Medicaid beneficiaries, even below the poverty level, must have “skin in the game” by contributing their own funds to their care is a concept that can be considered bipartisan when one or two neoliberal Democrats (or maybe more) join the Republicans in advancing this cruel health policy, even though it’s clearly a conservative concept.

It was not only in the 2008 article that the reference to “skin in the game” appeared, it was also repeated in the 2016 blog (link above): “Because HIP Plus members’ own dollars are at stake, they have ‘skin in the game’ and therefore an incentive to make cost-conscious health care decisions.”

Little does it matter that this ideological nonsense caused “one-third of those eligible (to not) enroll because they can’t or don’t want to pay a premium.” It is far more important to her to advance her ideology than it is to meet the health care needs of the targeted population. And, yes, those who fail to pay are punished by being denied certain benefits in the future – the nature of the punishment being dependent on variations in eligibility. Nice!

These articles were written eight years apart, and the second article, written after the negative impact was obvious, demonstrates that her soft manner and demeanor did not warm up her cold, cold heart.

The Kaiser Health News article reports that she “received millions of dollars from the state through her work with the Indiana government” while “also paid by Hewlett-Packard, a Medicaid vendor that received more than $500 million in state contracts.” Her cold heart allows her to feign obliviousness to this blatant conflict of interest.

And we are going to put her in charge of the Centers for Medicare and Medicaid Services, with its trillion dollar budget?!

Political divisiveness in health care

Learning to work together

By Ed Weisbart, M.D.
Minnesota Physician, November 2016

You wouldn’t know it by looking at the health care debate in America today, but one of our nation’s foundational pillars used to be political collaboration. Although the 2009 passage of the Affordable Care Act was intensely partisan, we have a proud, centuries-old legacy of collaboratively solving our problems despite our differences, and many of our past solutions were made stronger because of our differences.

I have had the honor of testifying on a variety of topics in a number of state legislatures across the nation. My experiences make me wonder how our noble national history led to political statements such as these that were said directly to me:

• From a cattle rancher serving as a state representative: “As a former embryo, I have expertise about women’s reproductive choices.” This was the basis for his ignoring medical evidence about conception, embryology, and the guidance of the American College of Obstetrics and Gynecology. It’s difficult to build an evidence-based strategy with a legislator who believes his personal history as an embryo gives him as much information about reproductive issues as being board-certified in ob-gyn.

• From an attorney serving as a state representative: “I oppose raising the tax on cigarettes because you can’t assure me the money won’t be used to clone humans.” It’s hard to determine the best strategy to prevent adolescent tobacco addiction without also having to weigh the risks and merits of stem cell research.

• From a psychiatrist serving as a state senator: “I think about all 12 antidepressants, and I think about my patient, and something inside me moves and tells me which one to prescribe.” I was a bit worried about what might be moving inside of him, but held my tongue in the interest of finding common ground.

• Finally, from another attorney serving as a state senator: “I acknowledge your evidence that expanding Medicaid would save many lives, but as a state senator I’m still going to block it for political reasons.” Rigorous analysis of the emerging clinical and economic data from expansion states has no place in a policy discussion when the decision has already been made based on political goals. At least this senator was willing to be open and direct.

How did we get to the point where reproducible evidence is valued as highly as uninformed conjecture, where attitude and philosophy are considered as independent truths, and politics trumps science even for professionals? And how do we get back to building public policies on evidence, reason, and collaboration? There is a body of science that can help us find our way back. The imperative is stronger, especially when it comes to health care.

full, feature article available here:
http://www.pnhpmo.org…

Ed Weisbart, M.D., is a family physician in St. Louis, MO. He volunteers in a variety of safety net clinics, and chairs the Missouri chapter of Physicians for a National Health Program.

A Free-Market Solution to Health Care?

By Elizabeth R. Rosenthal, M.D.
The New York Times, Letters, Nov. 16, 2016

“How Health Care Hurts Your Paycheck,” by Regina E. Herzlinger, Barak D. Richman and Richard J. Boxer (Op-Ed, Nov. 2), does a good job of explaining a problem with employer-provided health care. But the professors’ solution is not a good one. It will still leave many people one severe illness away from financial ruin, and many more underinsured.

I also know, from experience as a Medicare counselor helping seniors choose among many private health and drug plans under Medicare, that 80 percent do not choose the most affordable plan that meets their needs. This is because there are so many variables in all the choices that, without much more expertise than most possess, it is impossible to choose wisely.

Why could we expect a better outcome if employees were left to choose a health plan on the marketplace?

The solution proposed will not change us from a country where we get the health care we can afford to one where we get the health care we need. By changing to a single-payer, “Medicare for All” system we can increase paychecks while joining the rest of the industrialized countries where health care is provided as needed, regardless of income.

Dr. Elizabeth R. Rosenthal is a dermatologist. She resides in Larchmont, N.Y.

http://www.nytimes.com/2016/11/17/opinion/a-free-market-solution-to-health-care.html?partner=rssnyt&emc=rss&_r=0

PNHP note: Dr. Rosenthal is a member of the board of the New York Metro chapter of Physicians for a National Health Program.

Price to HHS, Verma to CMS, patients to purgatory

By picking Tom Price to lead HHS, Trump shows he’s absolutely serious about dismantling Obamacare

By Sarah Kliff
Vox, November 28, 2016

Rep. Tom Price (R-GA), President-elect Donald Trump’s pick for Health and Human Services secretary, already has a plan for how to abolish Obamacare.

Price will arrive with at HHS with a clear blueprint for what comes next. He is the author of the Empowering Patients First Act, one of the most thorough and detailed proposals to repeal and replace Obamacare.

It would replace the law with a plan that does more to benefit the young, healthy, and rich — and disadvantages the sick, old, and poor.

The biggest cut to the poor in Price’s plan is the full repeal of the Medicaid expansion, a program that currently covers millions of low-income Americans, which Price replaces with, well, nothing.

This change will likely make Price’s proposal significantly cheaper than those that do continue the Medicaid expansion, but it will come at the cost of throwing millions of Americans off of their health insurance.

The Empowering Patients plan, unlike Obamacare, would let insurers charge sick people more if they did not maintain “continuous coverage.”

It would invest $3 billion over three years in a high-risk pool to cover those with preexisting conditions who are unable to afford coverage on the marketplace.

Empowering Patients makes the individual market more advantageous for healthier people. It eliminates the essential health benefits package, which mandated that all insurers cover a set of 10 different types of care including maternity services and pediatric care. Empowering Patients would allow insurers to cut whatever benefits they no longer want to cover — they could stop covering maternity benefits, for example, to make their plans less attractive to women who plan to become pregnant. This would likely benefit healthy people, who generally want less robust coverage at a cheaper price. But it’ll send the cost of more comprehensive plans — the plans sicker people need — skyrocketing.

There are other ways Empowering Patients makes insurance better for young people too: by letting insurance plans charge them lower rates. It does this by allowing insurers to charge their oldest enrollees as much as they want.

Obamacare’s tax credits are based on income, with those who earn less getting more help. Empowering Patient’s tax credits would only be based on age, giving more help to those who are older (and who will presumably be charged higher premiums).

There is one important change the plan would make to employer-sponsored insurance: It would cap the tax exclusion for employer-sponsored coverage. Price’s bill proposes limiting the employer-tax exclusion for insurance to $8,000 for individual policies and $20,000 for families. As popular as this provision will be with economists, you can bet that the public will hate it, as it would make some health plans significantly more expensive — and face similar pushback to Obamacare’s Cadillac tax.

In choosing Price, Trump is signaling that he is serious about dismantling Obamacare. He has found one of the law’s most ardent, knowledgeable, and prepared opponents, and put him in charge of the effort.

http://www.vox.com/2016/11/28/13772342/trump-tom-price-obamacare

H.R. 2300 – Empowering Patients First Act of 2015:

https://www.congress.gov/bill/114th-congress/house-bill/2300

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Trump to pick Seema Verma for Centers for Medicare and Medicaid Services

Reuters, November 28, 2016

U.S. President-elect Donald Trump is set to name Indiana health policy consultant Seema Verma as his pick for administrator of the Centers for Medicare and Medicaid Services, a transition official told Reuters on Monday.

http://www.reuters.com/article/us-usa-trump-verma-idUSKBN13O09T

Indiana’s phony Medicaid health savings accounts:

https://www.pnhp.org/news/2016/august/indiana’s-phony-medicaid-health-savings-accounts

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Comment:

By Don McCanne, M.D.

President-elect Donald Trump is making good on his promise to repeal and replace Obamacare by appointing Tom Price as Secretary of Health and Human Services (HHS) and Seema Verma as administrator for the Centers for Medicare and Medicaid Services (CMS). There is trouble coming.

Tom Price was a co-founder of the conservative Congressional Tea Party caucus. He has long supported measures to reduce the role of government in health care, freeing himself and his fellow physicians to do whatever they want and collect whatever fees they desire. He has authored replacement legislation that has been included in House Speaker Paul Ryan’s “A Better Way” that will likely provide guideposts in the Republican effort to replace the Affordable Care Act. His legislation – Empowering Patients First Act of 2015 – is available at the link above.

Seema Verma worked with the Republican governors of Indiana, including Vice President-elect Mike Pence, to require low-income patients on Medicaid to establish POWER accounts – a bastardized health savings account – so that they would have “consumer empowerment” in shopping for health care. More information about these phony accounts is available at the link above.

It is likely that Trump will delegate these two to interact with the Republican-controlled Congress in designing the new way forward in health care. The only power Democrats have is to block onerous legislation through the filibuster, but several Democratic senators who are vulnerable in the 2018 elections have indicated a desire to work with Trump and their Republican colleagues in Congress in revising health care financing in the United States. That would give the Republicans enough votes to squelch a filibuster. This is a setup for compromise, but compromises that will be defined strictly on Republican terms.

What might we expect? Perhaps elimination of the Medicaid expansion, reduction in subsidies for private insurance, waiving of the requirement to establish minimal plan benefits, loss of guaranteed issue if unable to pay the premium, dumping high risk patients into pools with grossly inadequate funding, expansion of health savings accounts that remain unfunded or underfunded except for the wealthy, higher premiums for older and sicker patients, premium support vouchers to further privatize Medicare, and other measures that reduce the protections provided by insurance while reducing government funding of health care, thereby making insurance more affordable for the young and healthy while sending those with needs to health care purgatory.

We are told that conservatives are caring people who want to make America great again. But Trump and Pence and Price and Verma and Ryan are not caring people. They would abandon the poor and infirm, based on a combination of ideology and greed.

There will be those who will fight to keep what we have. There will be those who will compromise to reduce the losses. But they are supporting our current health care injustices that will only be made worse.

No compromises. No defense of the status quo. Gear up for an all out battle for health care justice for all. We’ll need to take to the streets for this one, literally and figuratively.

Emergency department closures can be lethal

Geographical Distribution of Emergency Department Closures and Consequences on Heart Attack Patients

By Yu-Chu Shen Renee Y. Hsia
National Bureau of Economic Research, November 2016

NBER Working Paper 22861

Abstract

We develop a conceptual framework and empirically investigate how a permanent emergency department (ED) closure affects patients with acute myocardial infarction (AMI). We first document that large increases in driving time to closest ED are more likely to happen in low- income communities and communities that had fewer medical resources at baseline. Then using a difference-in-differences design, we estimate the effect of an ED closure on access to cardiac care technology, treatment, and health outcomes among Medicare patients with AMI who lived in 24,567 ZIP codes that experienced no change, an increase of <10 minutes, 10 to <30 minutes, and 30 minutes in driving time to their closest ED. Overall, access to cardiac care declined in all communities experiencing a closure, with access to a coronary care unit decreasing by 18.64 percentage points (95% CI -30.15, -7.12) for those experiencing 30-minute increase in driving time. Even after controlling for access to technology and treatment, patients with the longest delays experienced a 6.58 (95% CI 2.49, 10.68) and 6.52 (95%CI 1.69, 11.35) percentage point increase in 90-day and 1-year mortality, respectively, compared with those not experiencing changes in distance. Our results also suggest that the predominant mechanism behind the mortality increase appeared to be time delay as opposed to availability of specialized cardiac treatment.

From the Discussion

Our results suggested that when patients had to drive at least 10 more minutes to their next available ED upon local ED closure, time delay became the dominant mechanism in affecting health outcomes when local ED closure occurred, both directly (as time delays causes more severe infarction) and indirectly through its effect on access and treatment.

The adverse effect of time delay on mortality rates became evident in communities that experienced 10-30 min increase in driving time, and became substantial in communities that experienced more than 30-minute increase in driving time. The adverse effect did not resolve even after we controlled for access and treatment, suggesting that the time delays likely made the prognosis worse, directly affecting mortality rates.

Conclusions

Our study showed that patients with AMI whose driving time to the nearest ED after local ED closure increased by 10 minutes or more had a significant increase in mortality. Among those who experienced a closure that resulted in a drive time increase of 30 minutes or more, they experienced a 30% higher 90-day mortality and 21% higher 1-year mortality. Increased driving time due to a closure was also associated with an overall decrease in access to cardiac technology in the remaining hospitals. Our findings suggest that permanent ED closure has substantial consequences on patient outcomes, particularly among communities with limited resources for time-sensitive illnesses such as AMI. We find that the predominant mechanism by which patients’ outcomes decline is primarily due to time delay, as opposed to changes in availability of treatment. We can conclude that while provision of necessary cardiac technology is one important factor for remaining hospitals, the effects of a time delay due to an ED closure are not easily mitigated.

http://www.nber.org/papers/w22861

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Comment:

By Don McCanne, M.D.

Under our medical-industrial complex, decisions regarding location of facilities such as emergency departments are frequently based on business considerations of the market rather than on what would be optimal for the community. This NBER paper demonstrates that such decisions can be a matter of life or death. If closure of an emergency department results in more than a ten minute delay in access to the next closest hospital, mortality for an acute myocardial infarction is increased.

Under a well designed single payer system, planning is an integral part and is based on community need rather than on private profit potential. This is today’s message. What follows is a personal anecdote which you can skip unless you are curious.

Our community hospital in San Clemente, California – Saddleback Memorial Medical Center – is part of the MemorialCare Health System, located in Los Angeles and Orange Counties. It was decided that the San Clemente campus be converted from an acute care hospital into an outpatient center. After months of controversy and the inability to agree on this change, the owners decided to close our hospital, including the emergency department. It is now surrounded by a chain-link fence.

According to Google, the additional time required to travel to Mission Hospital in Mission Viejo is 13 minutes, longer than the ten minute delay than can increase mortality in the event of an acute myocardial infarction, according to this study. But our freeway is frequently heavily congested due to stop-and-go beach traffic, especially throughout the extended weekend. The alternate route over surface roads is 23 minutes, according to Google. People will die.

One tiny glimmer of hope is that the hospital has refused to release the portraits of the former chiefs of staff hanging in a hallway (mine included). This suggests that the hospital owners have not given up on the facility. However it is likely that they will continue their demand that it be converted to an outpatient facility.

Why would they do this? An outpatient facility can be used to feed lucrative elective cases to their larger facility – Saddleback Memorial Medical Center in Laguna Hills – whereas, as the only hospital in San Clemente, by virtue of EMTALA they would have to take all cases regardless of insurance status and profitability.

Even though MemorialCare is non-profit, it is still very much an active part of the medical-industrial complex. Although the delivery system can remain private, non-profit, we really do need a universal public financing system – a single payer improved Medicare for all. And we want our hospital back.