PNHP

The role of Medicare in integrating the nation’s hospitals

The role of Medicare in integrating the nation’s hospitals

1965: The Year That Brought Civil Rights To The Nation’s Hospitals

By Michelle Andrews
Kaiser Health News, August 9, 2016

In his new book, David Barton Smith takes us back to the mid-1960s, when a small band of civil rights activists-cum-government bureaucrats toiled to get the nascent Medicare program up and running. In the process, they profoundly changed the way health care is delivered in this country.

It stands in marked contrast to the political turmoil over health care of recent years.

“In four months they transformed the nation’s hospitals from our most racially and economically segregated institutions to our most integrated,” Smith writes in “The Power to Heal: Civil Rights, Medicare, and the Struggle to Transform America’s Health Care System.”

“In four years they changed patterns of use of health services that had persisted for half a century. The fundamental moral imperative — that those needing medical care should receive it — began for the first time to reflect actual use of services. A profound transformation, now taken for granted, happened almost overnight.”

Michelle Andrews: Over the course of several months, a small group of government workers implemented the Medicare program. From the start, they said that hospitals that discriminated couldn’t participate. How did they manage it?

David Barton Smith: Wilbur Cohen and the people in the Social Security Administration were absolutely masterful in pulling this together in such a short period of time. They knew exactly how to get things done and they paid attention to the details. It’s remarkable that without the computers that we have today or the Internet, they were able to do this all in 11 months. They were just good professionals.

Michelle Andrews: There has been talk at various times about creating “Medicare for All.” Given what you know, what are the odds of that ever happening here?

David Barton Smith: The odds are better now than a few years ago. Because of the ACA, but also because people are beginning to understand some of the limitations of a privately insured system. It’s more complicated, it’s more costly, it’s harder to get good competitive pricing from hospitals or from drug companies. And this idea is something that’s been resisted by the insurance industry. But I get the sense that people are getting a little bit more impatient. Although a lot of Republicans bash Obamacare, I don’t hear a lot of them bashing Medicare. The resistance would be strong, certainly. This is a very interesting year.

http://khn.org/news/1965-the-year-that-brought-civil-rights-to-the-nations-hospitals/

***

Comment:

By Don McCanne, M.D.

The story of using Medicare to rapidly integrate our nation’s hospitals is inspiring. It should give us hope that an Improved Medicare for All could be used to leverage corrections of other health care injustices.

David Barton Smith reminds us that people are beginning to understand some of the limitations of a privately insured system and that they are becoming more impatient. Let’s leverage that.

The role of Medicare in integrating the nation’s hospitals

1965: The Year That Brought Civil Rights To The Nation’s Hospitals

By Michelle Andrews
Kaiser Health News, August 9, 2016

In his new book, David Barton Smith takes us back to the mid-1960s, when a small band of civil rights activists-cum-government bureaucrats toiled to get the nascent Medicare program up and running. In the process, they profoundly changed the way health care is delivered in this country.

It stands in marked contrast to the political turmoil over health care of recent years.

“In four months they transformed the nation’s hospitals from our most racially and economically segregated institutions to our most integrated,” Smith writes in “The Power to Heal: Civil Rights, Medicare, and the Struggle to Transform America’s Health Care System.”

“In four years they changed patterns of use of health services that had persisted for half a century. The fundamental moral imperative — that those needing medical care should receive it — began for the first time to reflect actual use of services. A profound transformation, now taken for granted, happened almost overnight.”

Michelle Andrews: Over the course of several months, a small group of government workers implemented the Medicare program. From the start, they said that hospitals that discriminated couldn’t participate. How did they manage it?

David Barton Smith: Wilbur Cohen and the people in the Social Security Administration were absolutely masterful in pulling this together in such a short period of time. They knew exactly how to get things done and they paid attention to the details. It’s remarkable that without the computers that we have today or the Internet, they were able to do this all in 11 months. They were just good professionals.

Michelle Andrews: There has been talk at various times about creating “Medicare for All.” Given what you know, what are the odds of that ever happening here?

David Barton Smith: The odds are better now than a few years ago. Because of the ACA, but also because people are beginning to understand some of the limitations of a privately insured system. It’s more complicated, it’s more costly, it’s harder to get good competitive pricing from hospitals or from drug companies. And this idea is something that’s been resisted by the insurance industry. But I get the sense that people are getting a little bit more impatient. Although a lot of Republicans bash Obamacare, I don’t hear a lot of them bashing Medicare. The resistance would be strong, certainly. This is a very interesting year.

http://khn.org/news/1965-the-year-that-brought-civil-rights-to-the-nations-hospitals/

The story of using Medicare to rapidly integrate our nation’s hospitals is inspiring. It should give us hope that an Improved Medicare for All could be used to leverage corrections of other health care injustices.

David Barton Smith reminds us that people are beginning to understand some of the limitations of a privately insured system and that they are becoming more impatient. Let’s leverage that.

What changes in ACA might the election bring?

Could Trump loss spur ACA deal with Clinton?

By Harris Meyer
Modern Healthcare, August 6, 2016

With Donald Trump’s presidential campaign faltering, Republican health policy experts are gaming out Plan B for working with a Hillary Clinton administration to achieve conservative healthcare goals.

Their focus is on a possible “grand bargain” that would give conservative states greater flexibility to design market-based approaches to make coverage more affordable and reduce spending in exchange for covering low-income workers in non-Medicaid expansion states. A key element, conservative experts say, would be for a Clinton administration to make it easier for states to obtain Section 1332 waivers under the Affordable Care Act. Those waivers allow states to replace the law’s insurance exchange structure with their own innovative models.

To win GOP backing for measures to stabilize the exchanges, Republicans will seek changes to make ACA coverage more attractive and affordable for younger people, said James Capretta, a conservative health policy expert at the American Enterprise Institute. That includes allowing lower premiums for young people, a wider range of benefit designs and premium subsidies for plans bought outside the exchanges and easing minimum benefit requirements.

Clinton’s best opportunity might be to persuade GOP governors and lawmakers in non-expansion states to accept Medicaid expansion by giving them more leeway on program design.

http://www.modernhealthcare.com/article/20160806/MAGAZINE/308069967

***

Comment:

By Don McCanne, M.D.

Although elections can be unpredictable, this time we can make a couple of predictions that are a near certainty.

Donald Trump will not be able to change his image as a dangerous incompetent before the election, and Hillary Clinton will be elected by default, even though she will remain unpopular.

Gerrymandering as a result of the 2010 Census will remain unchanged in this election, so the Republicans will maintain control of the House of Representatives with Paul Ryan as the Speaker. Although the Tea Party faction will have been diminished in numbers, enough will be reelected such that Ryan will have to include them in legislative negotiations.

Although it is uncertain which party will hold the majority in the Senate, it is clear that each of the two major parties will still have the ability to block most legislation through the filibuster. For the Democrats, that means that they can forget about a Medicare buy-in starting at age 55, and they can forget about a government-administered public option to compete with the private plans. For the Republicans, that means that they can forget about a repeal of the Affordable Care Act, and they can forget about completing privatization of Medicare through premium support.

So for the time being, the Affordable Care Act is here to stay. Both sides will want changes in it, but only modest incremental changes will be possible, and they must satisfy both sides or they will not clear Congress.

Democrats will want expanded enrollment in the ACA exchanges and in Medicaid. Republicans will want less regulation in these programs. For the exchange plans both will want lower premiums to make insurance more affordable, and they may do that by easing the minimum benefit requirements, by allowing more flexible innovations in insurance design, by reducing premiums for young adults, and perhaps even by allowing premium subsidies for plans outside of the exchanges. For Medicaid, through waivers or through new legislation they may allow greater flexibility and further privatization to encourage non-participating states to join in the program to expand Medicaid.

These compromises will further reduce the numbers of uninsured and make health insurance more affordable, but affordable access to actual health care is already a major problem and these measures will make it much worse. Increasing the numbers of individuals who are nominally insured should not be considered a success when the tradeoff is the erection of financial and logistical barriers to essential health care services. Leaving patients sick and broke is not the direction in which we want to be headed.

What are the political prospects for single payer post-election? This January Hillary Clinton said, “I want you to understand why I am fighting so hard for the Affordable Care Act. I don’t want it repealed, I don’t want us to be thrown back into a terrible, terrible national debate. I don’t want us to end up in gridlock… People who have health emergencies can’t wait for us to have a theoretical debate about some better idea that will never, ever come to pass.”

Never, ever. The political barricade is up. It is up to us to break it down.

1965: The Year That Brought Civil Rights To The Nation’s Hospitals

By Michelle Andrews
Kaiser Health News, Aug. 9, 2016

In his new book, David Barton Smith takes us back to the mid-1960s, when a small band of civil rights activists-cum-government bureaucrats toiled to get the nascent Medicare program up and running. In the process, they profoundly changed the way health care is delivered in this country.

It stands in marked contrast to the political turmoil over health care of recent years.

“In four months they transformed the nation’s hospitals from our most racially and economically segregated institutions to our most integrated,” Smith writes in “The Power to Heal: Civil Rights, Medicare, and the Struggle to Transform America’s Health Care System.”

“In four years they changed patterns of use of health services that had persisted for half a century. The fundamental moral imperative — that those needing medical care should receive it — began for the first time to reflect actual use of services. A profound transformation, now taken for granted, happened almost overnight.”

Smith, a professor emeritus of health administration at Temple University in Philadelphia, spoke with Kaiser Health News consumer columnist Michelle Andrews about his book and the implementation of Medicare, which for the first time provided a guarantee of health insurance for the elderly. The promise of payment for care for the growing number of elderly patients was a big financial incentive for hospitals, even if it meant desegregating. “Basically the hospitals, except for a few very well-endowed ones, had a choice of participating in Medicare or going bankrupt,” he said.

Smith’s work is also the subject of a companion documentary under development, which is being funded by the National Endowment for the Humanities.

Here is an edited version of that conversation.

Q. It’s been exactly 50 years since the Medicare program began providing health coverage to older Americans. Given today’s political gridlock, it’s hard to imagine how such sweeping changes in health care could have been accomplished. What was different then?

Lyndon Johnson’s landslide election in 1964 made it possible for him to do almost anything. He had the Congress, the Senate and he had the ambition. What is strikingly different is the level of trust that Republican politicians had back then in some of the federal bureaucrats. The Social Security Administration was pretty much given a free hand in terms of translating the law and implementing it. I can’t imagine that happening today. Every step would be blocked.

Q. In your book, you describe how there were separate hospitals for blacks, for whites and for various religious groups. Hospitals that admitted both blacks and whites had segregated wings, waiting areas and patient rooms. To what extent did health care simply reflect prevailing norms of the day?

I would say it was even more rigidly segregated. The doctors were segregated and their patients were segregated. The degree of segregation between indigent patients and private patients was much more extreme than it is today. There were separate wings, separate china. Most medical offices in the South, particularly for primary care doctors, had separate waiting rooms, and black patients would be seen only after the white patients were seen.

One of the things that was strikingly different from today: At that time you talked about racial and ethnic differences in health care and in health. The implication was that there were cultural or even genetic differences that explained the differences in the use of health care and outcomes. Now we don’t talk about differences, we talk about disparities. The implication is that if there are differences, it’s the responsibility of providers and not the patients to correct them. Before, [the difference was attributed to] those ignorant people who don’t know how to use health care or take care of themselves.

Q. Title VI of the Civil Rights Act — which was passed into law only a year before Medicare — prohibits discrimination on the basis of race, color or national origin in programs that receive federal financial assistance. The way you tell it, applying Title VI to Medicare and prohibiting hospitals that discriminated from participating in the program wasn’t something that people focused on, at least at first. What happened?

In the entire debate over the passage of Medicare, there’s no mention of what the implications are, related to Title VI. It didn’t come up, nobody wanted to raise it. The assumption was that some accommodation would be made that would allow segregation to continue on a separate but equal basis. So everybody thought it was going to be business as usual.

The 1954 Brown v. Board of Education Supreme Court decision, which ended legal segregation in the schools, reinforced the assumption that little would happen because very little progress was being made in desegregating the schools. The decision ordered states to end segregation with “all deliberate speed” but that [meant] no deliberate speed. [So] the hospitals thought they would have to come up with a plan and would proceed very gradually and cautiously with doing this, which would mean it wouldn’t get done.

Q. But that’s not what happened. Over the course of several months, a small group of government workers implemented the Medicare program. From the start, they said that hospitals that discriminated couldn’t participate. How did they manage it?

Wilbur Cohen and the people in the Social Security Administration were absolutely masterful in pulling this together in such a short period of time. They knew exactly how to get things done and they paid attention to the details. It’s remarkable that without the computers that we have today or the Internet, they were able to do this all in 11 months. They were just good professionals.

What’s different is the Title VI enforcement part. The Public Health Service was responsible for enforcing the Medicare nondiscrimination provisions. That created an interesting takeover by the civil rights movement. The three people who were writing the rules were really committed civil rights activists. They wrote the regulations following the direction and pleading of the civil rights organizations: You cannot have “all deliberate speed,” you cannot let anybody in the program unless they’ve complied with some very specific requirements, including no discrimination in  terms of where patients are placed or where people could go to the cafeterias or where they could be employed.

Workers from the Social Security Administration and the Public Health Service volunteered to do the hospital inspections, people who were already committed to civil rights. What actually happened in many cases, if you read through inspectors’ site visit reports, they relied very heavily on local people and civil rights activists and black employees at the hospitals to tell them if the hospital was complying or not.

Q. To what extent does the Affordable Care Act help to address the economic and racial disparities that persist in health care today?

I think it’s a wonderful addition. I find it ironic that the hospitals in the same states that fought the desegregation with the implementation of Medicare are the states blocking the expansion of Medicaid. [The Medicaid program was signed into law the same day as the Medicare program and faced the same Title VI requirements.] Those are the states that are most in need and the hospitals are the ones that need the money. If they could, they’d sign on the dotted line.

Q. There has been talk at various times about creating “Medicare for All.” Given what you know, what are the odds of that ever happening here?

The odds are better now than a few years ago. Because of the ACA, but also because people are beginning to understand some of the limitations of a privately insured system. It’s more complicated, it’s more costly, it’s harder to get good competitive pricing from hospitals or from drug companies. And this idea is something that’s been resisted by the insurance industry. But I get the sense that people are getting a little bit more impatient. Although a lot of Republicans bash Obamacare, I don’t hear a lot of them bashing Medicare. The resistance would be strong, certainly. This is a very interesting year.

http://khn.org/news/1965-the-year-that-brought-civil-rights-to-the-nations-hospitals/

What changes in ACA might the election bring?

Could Trump loss spur ACA deal with Clinton?

By Harris Meyer
Modern Healthcare, August 6, 2016

With Donald Trump’s presidential campaign faltering, Republican health policy experts are gaming out Plan B for working with a Hillary Clinton administration to achieve conservative healthcare goals.

Their focus is on a possible “grand bargain” that would give conservative states greater flexibility to design market-based approaches to make coverage more affordable and reduce spending in exchange for covering low-income workers in non-Medicaid expansion states. A key element, conservative experts say, would be for a Clinton administration to make it easier for states to obtain Section 1332 waivers under the Affordable Care Act. Those waivers allow states to replace the law’s insurance exchange structure with their own innovative models.

To win GOP backing for measures to stabilize the exchanges, Republicans will seek changes to make ACA coverage more attractive and affordable for younger people, said James Capretta, a conservative health policy expert at the American Enterprise Institute. That includes allowing lower premiums for young people, a wider range of benefit designs and premium subsidies for plans bought outside the exchanges and easing minimum benefit requirements.

Clinton’s best opportunity might be to persuade GOP governors and lawmakers in non-expansion states to accept Medicaid expansion by giving them more leeway on program design.

http://www.modernhealthcare.com/article/20160806/MAGAZINE/308069967

Although elections can be unpredictable, this time we can make a couple of predictions that are a near certainty.

Donald Trump will not be able to change his image as a dangerous incompetent before the election, and Hillary Clinton will be elected by default, even though she will remain unpopular.

Gerrymandering as a result of the 2010 Census will remain unchanged in this election, so the Republicans will maintain control of the House of Representatives with Paul Ryan as the Speaker. Although the Tea Party faction will have been diminished in numbers, enough will be reelected such that Ryan will have to include them in legislative negotiations.

Although it is uncertain which party will hold the majority in the Senate, it is clear that each of the two major parties will still have the ability to block most legislation through the filibuster. For the Democrats, that means that they can forget about a Medicare buy-in starting at age 55, and they can forget about a government-administered public option to compete with the private plans. For the Republicans, that means that they can forget about a repeal of the Affordable Care Act, and they can forget about completing privatization of Medicare through premium support.

So for the time being, the Affordable Care Act is here to stay. Both sides will want changes in it, but only modest incremental changes will be possible, and they must satisfy both sides or they will not clear Congress.

Democrats will want expanded enrollment in the ACA exchanges and in Medicaid. Republicans will want less regulation in these programs. For the exchange plans both will want lower premiums to make insurance more affordable, and they may do that by easing the minimum benefit requirements, by allowing more flexible innovations in insurance design, by reducing premiums for young adults, and perhaps even by allowing premium subsidies for plans outside of the exchanges. For Medicaid, through waivers or through new legislation they may allow greater flexibility and further privatization to encourage non-participating states to join in the program to expand Medicaid.

These compromises will further reduce the numbers of uninsured and make health insurance more affordable, but affordable access to actual health care is already a major problem and these measures will make it much worse. Increasing the numbers of individuals who are nominally insured should not be considered a success when the tradeoff is the erection of financial and logistical barriers to essential health care services. Leaving patients sick and broke is not the direction in which we want to be headed.

What are the political prospects for single payer post-election? This January Hillary Clinton said, “I want you to understand why I am fighting so hard for the Affordable Care Act. I don’t want it repealed, I don’t want us to be thrown back into a terrible, terrible national debate. I don’t want us to end up in gridlock… People who have health emergencies can’t wait for us to have a theoretical debate about some better idea that will never, ever come to pass.”

Never, ever. The political barricade is up. It is up to us to break it down.

The 3Rs have failed to stabilize the exchanges

Struggling To Stabilize: 3Rs Litigation And The Future Of The ACA Exchanges

By Mike Adelberg and Nicholas Bagley
Health Affairs Blog, August 1, 2016

Six years after passage of the Affordable Care Act (ACA), the individual and small-group insurance markets — the markets that the ACA remade — are still having growing pains. Health insurers have endured large losses and a number of ACA-created co-ops and other small insurers have failed. Consolidation among providers and insurers is an increasing and concerning trend. And many insurers are poised to raise premiums substantially for 2017, further stoking frustration with the insurance industry.

Part of insurers’ difficulty is that the risk pool in the individual and small-group markets, particularly on the exchanges, is sicker and smaller than originally projected. But the three programs — reinsurance, risk corridors, and risk adjustment — that the ACA’s drafters hoped would help stabilize premiums in the revamped markets have also not performed as expected. Dashed expectations have led to market instability and to a flurry of lawsuits around the “3Rs.”

But make no mistake about it: trouble with the 3Rs has spooked insurers and raised questions about the viability of the ACA-reformed markets. Based on preliminary analyses, the 2017 exchanges will have fewer options, larger premium increases, and less generous benefits than any year since the ACA marketplaces came on line in 2014. Congressional intervention has damaged the ACA markets — hurting both insurers that sell health plans and the consumers who purchase them. Perhaps the exchanges will find their footing again, but the difficulties with the 3Rs serve as a stark reminder that ACA implementation remains much harder than supporters anticipated.

http://healthaffairs.org/blog/2016/08/01/struggling-to-stabilize-3rs-litigation-and-the-future-of-the-aca-exchanges/

***

Risk Adjustment Gone Wrong

By Jonathan Halvorson
The Health Care Blog, August 7, 2016

The Affordable Care Act was intended to usher in a new era of competition and choice in health insurance, and at first it succeeded. But increasingly, provisions in the law are undermining competition and wiping out start-up after start-up. If something isn’t done soon, the vast majority of new insurers formed in the wake of the ACA will fail, and many old-line insurers that took the opportunity to expand and compete in the new markets will leave.

Risk adjustment requires an insurer to report on the health risk of its members, and to do that it needs good data. Plans that played the game better from the start set a high priority on collecting and reporting on that information. However, it is much harder to get good data if a member just joined than if you have had that member enrolled prior to the ACA exchanges and can mine your data warehouse for all those ICD codes that boost the risk score. The dominant pre-ACA players had more years of member data, and mature analytics capabilities, to help them maximize their risk scoring. This has created a serious penalty for new entrants in the first few years which CMS has not addressed.

http://thehealthcareblog.com/blog/2016/08/07/risk-adjustment-gone-wrong/

***

Comment:

By Don McCanne, M.D.

The 3Rs – reinsurance, risk corridors, and risk adjustment – were designed to stabilize the ACA insurance exchanges, but we’re seeing market instability instead. Next year, only risk adjustment remains, and the insurers have demonstrated to us that they know how to game the system.

Considering that the exchanges insure less than four percent of our population, you might think that we would be ready to abandon this failed experiment and move on. But, no. The powers that be know that pressure will be on to enact their dreaded single payer system, so they struggle on. Far be it from us to enact a system that would actually achieve the goals of reform.

The 3Rs have failed to stabilize the exchanges

Struggling To Stabilize: 3Rs Litigation And The Future Of The ACA Exchanges

By Mike Adelberg and Nicholas Bagley
Health Affairs Blog, August 1, 2016

Six years after passage of the Affordable Care Act (ACA), the individual and small-group insurance markets — the markets that the ACA remade — are still having growing pains. Health insurers have endured large losses and a number of ACA-created co-ops and other small insurers have failed. Consolidation among providers and insurers is an increasing and concerning trend. And many insurers are poised to raise premiums substantially for 2017, further stoking frustration with the insurance industry.

Part of insurers’ difficulty is that the risk pool in the individual and small-group markets, particularly on the exchanges, is sicker and smaller than originally projected. But the three programs — reinsurance, risk corridors, and risk adjustment — that the ACA’s drafters hoped would help stabilize premiums in the revamped markets have also not performed as expected. Dashed expectations have led to market instability and to a flurry of lawsuits around the “3Rs.”

But make no mistake about it: trouble with the 3Rs has spooked insurers and raised questions about the viability of the ACA-reformed markets. Based on preliminary analyses, the 2017 exchanges will have fewer options, larger premium increases, and less generous benefits than any year since the ACA marketplaces came on line in 2014. Congressional intervention has damaged the ACA markets — hurting both insurers that sell health plans and the consumers who purchase them. Perhaps the exchanges will find their footing again, but the difficulties with the 3Rs serve as a stark reminder that ACA implementation remains much harder than supporters anticipated.

http://healthaffairs.org/blog/2016/08/01/struggling-to-stabilize-3rs-litigation-and-the-future-of-the-aca-exchanges/

***

Risk Adjustment Gone Wrong

By Jonathan Halvorson
The Health Care Blog, August 7, 2016

The Affordable Care Act was intended to usher in a new era of competition and choice in health insurance, and at first it succeeded. But increasingly, provisions in the law are undermining competition and wiping out start-up after start-up. If something isn’t done soon, the vast majority of new insurers formed in the wake of the ACA will fail, and many old-line insurers that took the opportunity to expand and compete in the new markets will leave.

Risk adjustment requires an insurer to report on the health risk of its members, and to do that it needs good data. Plans that played the game better from the start set a high priority on collecting and reporting on that information. However, it is much harder to get good data if a member just joined than if you have had that member enrolled prior to the ACA exchanges and can mine your data warehouse for all those ICD codes that boost the risk score. The dominant pre-ACA players had more years of member data, and mature analytics capabilities, to help them maximize their risk scoring. This has created a serious penalty for new entrants in the first few years which CMS has not addressed.

http://thehealthcareblog.com/blog/2016/08/07/risk-adjustment-gone-wrong/

The 3Rs – reinsurance, risk corridors, and risk adjustment – were designed to stabilize the ACA insurance exchanges, but we’re seeing market instability instead. Next year, only risk adjustment remains, and the insurers have demonstrated to us that they know how to game the system.

Considering that the exchanges insure less than four percent of our population, you might think that we would be ready to abandon this failed experiment and move on. But, no. The powers that be know that pressure will be on to enact their dreaded single payer system, so they struggle on. Far be it from us to enact a system that would actually achieve the goals of reform.

We want true Medicare for all, not today’s semi-privatized mess

Don’t expand privatized system; go beyond to single-payer model.

By Rose Roach
Star Tribune (Minneapolis), Counterpoint, Aug. 5, 2016

In “What is implied by calls of ‘Medicare for all?’ ” (Aug. 2), Bryan Dowd used over-the-top rhetoric in suggesting that proponents of “Medicare for all” don’t understand Medicare. Medicare was conceived as a universal social insurance program providing health coverage to seniors regardless of income or health status, with all beneficiaries paying into the program through mandatory contributions from employees and employers. Prior to Medicare, half of seniors lacked health insurance and faced debt and poverty due to health care costs.

Unfortunately, in the last several years, the corporate health insurance lobby has tightened its grip on Medicare. Creeping privatization has made billions of dollars for the insurance industry while weakening the program.

Hefty contributions and constant lobbying on Capitol Hill by the insurance industry threatens one of the most efficient and popular universal public programs in our nation. For example, legislation passed in 2015 prohibits Medigap plans from covering Part B deductibles, forcing seniors to pay more for care, which we know tends to cause patients to delay or skip care until their illness is more serious and expensive to treat.

Another example is privatized Medicare (Medicare Advantage), which adds insurance companies as a middleman. Research has shown that Medicare Advantage costs taxpayers more than traditional Medicare and that it is less efficient.

More evidence that the Medicare system is needlessly convoluted to the advantage of the insurance companies: Kaiser Health News reported last week that health insurance companies are automatically enrolling members into their Medicare Advantage plans, rather than traditional Medicare, leaving many with surprise medical bills when they unknowingly go to out-of-network doctors and hospitals. When Dowd uses the words “turns out not to be very democratic” but rather “somewhat totalitarian,” he would be more accurately describing what is happening in Medicare Advantage than what supporters of universal health care seek. We support a system where people get to choose their doctors and medical providers, without interference from insurance companies.

Perhaps Prof. Dowd understands that we are pushing for something better than just an expansion of Medicare as it currently exists. The most efficient health care program would be a single national program, publicly financed and privately delivered, covering all Americans with one set of comprehensive benefits. No networks. No eligibility hoops or means tests. When advocates use the shorthand “Medicare for all,” that’s what we envision — not the distorted, semi-privatized, increasingly costly system seniors have to navigate today.

This is why the Minnesota Nurses Association advocates a system in which care is still provided by private providers but the government manages the finances. The current system is not sufficient: it is incredibly complex and wasteful, it is not controlling long-term health care costs, and it is not covering everyone. Your nurses think we can do better.

Rose Roach is executive director of the Minnesota Nurses Association.

http://www.startribune.com/counterpoint-we-want-true-medicare-for-all-not-today-s-semi-privatized-mess/389347521/

Insurance coverage as psychopathology; single payer as the cure

By Sharon R. Kahn, Ph.D.
The National Psychologist, July/Aug. 2016

Can you top this? “My client has PTSD and her insurance would only authorize 10 sessions.” Another adds: “My client has Major Depression and insurance will only authorize pharmacological treatment, no psychotherapy.”

Are we practicing evidence-based treatment modalities – or playing a deadly game of Go Fish? Clearly, we do not live in a sane society. How can we remediate this if we do not resurrect the zeitgeist of Erich Fromm, who drew back the curtain to show the “principle of free competition and the concomitant notion of the survival of the fittest called for individuals who were not inhibited by compassion in business dealing. Those who had the least compassion had the greatest chance of success.” Or, became insurance executives.

I became a psychologist to heal and repair the psychic ruptures in people’s souls. But I can’t repair when the access is blocked. I cannot repair when a third party is reading my notes, deliberating if it looks substantial enough to reimburse for a 45-minute session –  or if reimbursing only for the lower, 30-minute rate is justified.

It’s not just psychologists who suffer a loss of income. Over 33 percent of Americans cannot access needed medical care due to money. In fact, the United States is the only country in the world where citizens declare bankruptcy due to costs of medical treatments.

Most countries already have a national health care system. Some are socialistic in nature; others are a single­ payer system set within a capitalistic economy, such the Canadian model.

The difference between Canadian capitalism and the American is merely over who the payer is: the government, as opposed to diverse insurers. With the latter, payments are pawns to a false philosophy put forth by the insurance executives: Patients are wiser utilizers of medical services when they have “skin in the game” (i.e. copay).

Skin in the game restricts access, as between patients and practitioners when patients wonder whether practitioners recommend treatments based on what insurers will pay or patients reject recommended praxis due to fiscal concerns.

Access is further restricted when insurers use clerical personnel to review records and decide to reduce reimbursements based on their assessment of what best praxis should cost. Throw in a lack of true parity for mental health, vision and dental care and one can only wonder why a latter-day Samuel Adams (a disabled American) has not thrown all health insurers into some harbor.

The hypothesis of “skin in the game” has been disproven over and over. Medical costs become a de facto method to ration care, not rationalize it. A single-payer system would restore trust, increase access and reduce health care costs by paying hospitals, clinics and professionals a lump sum monthly.

Single payer is not socialistic, as professionals and hospitals remain privatized – they negotiate patient care with the patient – not with a third party. Professionals bill and are reimbursed by the state health department. Never again would clients hear that their insurance will not cover additional sessions. Or that their insurance insists that they take medications. No one receiving in-patient care will be harassed when their insurer calls and informs them they don’t merit that level of care.

Under the Affordable Care Act (ACA), states are encouraged to innovate in health care systems. Every legal state resident would be covered regardless of age, income, savings or employment. A person desirous of medical care would simply flash an eligibility card in front of the receptionist to receive services. There are no co-pays or deductibles. Professionals bill the health department for services. Tests and prescriptions are all covered. True parity would be offered, not only medical, but mental health, dental and vision care.

The money is there, via the state’s payroll taxes (paid 80 percent by employers, 20 percent by employees and I 00 percent by the self-employed). Non­ payroll income, such as capital gains, dividends and interest would also be used to fund single payer. Perhaps overall, taxes would rise – however, overall, costs for the individual would decrease – no more premiums, deductibles, co-pays and out-of-network minimums.

The average cost of an employer­provided family plan today is over $17,500 with an average family deductible of over $2,200. The average individual spends over $6,000 a year for health care premiums.

Overall health care costs will decrease as the profit that insurance companies demand (up to 30 percent of the health care dollar) will disappear. Administrative costs will decrease, as there will be no billing specialists whose job is to negotiate with insurance companies.

Under single payer, federal funds currently utilized for Medicare, Medicaid, Family Health Plus and Child Health Plus would be combined with the state revenue in a health trust.

The ACA (Obamacare) has failed to ensure universal coverage. It was based on the notion that federal aid would enable citizens to buy insurance via subsidies – it did not predict that insurance companies would then raise premiums to ensure profits would never be used to pay for health care costs, a perpetual game of keep away. Keep away does not bring down health care costs, as insurers are for-profit ventures with no incentives to make costs transparent.

The growth in the net cost of health insurance is due to administrative waste and executive profits. A single-payer plan would reduce spending by 15 percent by terminating billing expenses, administrative waste and fraud.

ACA further assumed that states would expand Medicaid coverage – and approximately half did not. One-third of Americans report they are now unable to access needed medical care due to cost. Thus current practice only serves to ration care; single payer offers a rational path to the sane society.

There is no justification for what passes for psychotherapeutic praxis today. True therapeutic conditions arise when clients and psychologists are freed to discuss all the empirically proven options. Psychologists once more could heal psychic deficits, offering the intensity of care individually titrated to the client’s needs. It will happen when psychologists become so frustrated as to make their desires known to elected state and federal representatives. Single payer offers the route to a saner society replete with life, liberty and the pursuit of happiness.

References available from author.

Sharon R. Kahn, Ph.D., is a medical expert for the Social Security Administration and a consultant to the New York Metropolitan Transit Authority s Access-A-Ride program. She completed post-doc studies in narcotic and drug research. She resides and practices in New York, N.Y., where she advocates for a single-payer plan. Her email address is drsrkalm@gmail.com.

Tory plans for NHS privatization revealed

Tory plans for NHS privatisation released during parliamentary recess

By Alex Scott-Samuel
The BMJ, August 5, 2016

July 2016 saw the very quiet publication of two key documents charting the route to the privatisation of the NHS in England. Firstly, from NHS England, came Strengthening Financial Performance and Accountability in 2016-17. This is the latest set of instructions on the implementation of NHS chief executive Simon Stevens’s Five Year Forward View (5YFV).

The 5YFV is increasingly coming to resemble one of Stalin’s Five Year Plans from the 1950s. As the new guidance makes clear, Stevens’s latest collectivisation strategy, the Sustainability and Transformation Plans (STPs), is being rigidly imposed across England.

My alternative title for the guidance document would be “Policing the government’s privatisation plans.” Having constructed, with help from the Treasury, a universal set of NHS trust financial deficits based on arbitrarily imposed cash limits, NHS England is now using those deficits to legitimise impossibly tight controls on hospital trusts, clinical commissioning groups (CCGs), and other NHS agencies to ensure they conform to central proposals for cuts and mergers between NHS institutions.

At the same time, private sector and insurance friendly “new models of care” are being imposed in community settings, further undermining NHS hospitals. The ultimate intended outcomes of this massive, dictatorial reorganisation process are privatisation, co-payments, charges, and insurance funded care.

These intentions are made clearer in a second policy paper, similarly released during the parliamentary recess when it is least likely to be noticed: the NHS Improvement Business Plan 2016/17. The plan states that providers will be required “to transform services in line with the 5YFV and this will include making use of new care models and innovative organisational forms.” A priority for 2016/17 is “to facilitate independent sector providers to form NHS partnerships.”

We are told that: “We intend to bring together the most promising potential areas for formal collaboration between NHS Improvement, providers, independent sector partners, NHS England, and other key stakeholders into a new work programme. The key elements of this programme in the first instance will examine the opportunities in the areas of:

  • mainstreaming clinical capacity for elective, outpatient, and diagnostic care;
  • joint ventures and/or outsourcing of new, novel, or restructured clinical services;
  • joint ventures and novel financing for facilities and/or technology;
  • independent sector management models to support capability and leadership challenges.”

In other words, before the end of the 2016-17 financial year, we will see the new Conservative government start to impose the large scale privatisation of clinical services, foreshadowed in the Health and Social Care Act 2012. In the event of any doubts regarding the obligatory nature of these policies, the NHS England report referred to earlier makes it clear that “special measures” (central takeover of local management) will be imposed if agencies fail to balance the books or deviate in any way from the government’s plans.

In this context, it’s ironic to recall all the fluffy political spin about “putting GPs in the driving seat” when CCGs were launched in 2012. By contrast, we are now told by NHS England that CCGs that fail to follow Stevens’s diktat will be disbanded and/or forced to become US style accountable care organisations (ACOs). This is with the aim of promoting mergers, cuts, and closures in the publicly provided NHS and introducing community based “integrated packages of care,” which are readily amenable to private sector provision and insurance funding—as occurs in the US ACOs on which this particular “new model of care” is based.

It is no coincidence that the House of Lords is currently calling for evidence to be submitted to its new select committee on the long term sustainability of the NHS.

This inquiry, supported by government ministers, is likely to make recommendations that will legitimise the aims of Stevens’s five year plan, including the “inevitability” of top-ups, co-payments, charges, and of the short term personal health budgets and longer term health insurance system that would be required to fund them. This toxic combination of an increasingly insurance based and increasingly privately provided health service will signal the final dismantling of what was once our National Health Service in England—a horrific and destructive act, which we now know to have been first proposed by Prime Minister Theresa May’s predecessor Margaret Thatcher in 1982.

http://blogs.bmj.com/bmj/2016/08/05/tory-plans-for-nhs-privatisation-released-during-parliamentary-recess/

***

Comment:

By Don McCanne, M.D.

We’ve been concerned for some time about the privatization of England’s National Health Service. The process is now underway. The Tory government is threatening the conversion of their delivery system into US style accountable care organizations, ignoring the fact that they have failed to improve quality or control costs. As we stumble along with our grossly inadequate efforts to reform our system, we can learn from the British how not to do it, which, as we see, bears an uncanny resemblance to what we are already doing.

Tory plans for NHS privatization revealed

Tory plans for NHS privatisation released during parliamentary recess

By Alex Scott-Samuel
The BMJ, August 5, 2016

July 2016 saw the very quiet publication of two key documents charting the route to the privatisation of the NHS in England. Firstly, from NHS England, came Strengthening Financial Performance and Accountability in 2016-17. This is the latest set of instructions on the implementation of NHS chief executive Simon Stevens’s Five Year Forward View (5YFV).

The 5YFV is increasingly coming to resemble one of Stalin’s Five Year Plans from the 1950s. As the new guidance makes clear, Stevens’s latest collectivisation strategy, the Sustainability and Transformation Plans (STPs), is being rigidly imposed across England.

My alternative title for the guidance document would be “Policing the government’s privatisation plans.” Having constructed, with help from the Treasury, a universal set of NHS trust financial deficits based on arbitrarily imposed cash limits, NHS England is now using those deficits to legitimise impossibly tight controls on hospital trusts, clinical commissioning groups (CCGs), and other NHS agencies to ensure they conform to central proposals for cuts and mergers between NHS institutions.

At the same time, private sector and insurance friendly “new models of care” are being imposed in community settings, further undermining NHS hospitals. The ultimate intended outcomes of this massive, dictatorial reorganisation process are privatisation, co-payments, charges, and insurance funded care.

These intentions are made clearer in a second policy paper, similarly released during the parliamentary recess when it is least likely to be noticed: the NHS Improvement Business Plan 2016/17. The plan states that providers will be required “to transform services in line with the 5YFV and this will include making use of new care models and innovative organisational forms.” A priority for 2016/17 is “to facilitate independent sector providers to form NHS partnerships.”

We are told that: “We intend to bring together the most promising potential areas for formal collaboration between NHS Improvement, providers, independent sector partners, NHS England, and other key stakeholders into a new work programme. The key elements of this programme in the first instance will examine the opportunities in the areas of:

  • mainstreaming clinical capacity for elective, outpatient, and diagnostic care;
  • joint ventures and/or outsourcing of new, novel, or restructured clinical services;
  • joint ventures and novel financing for facilities and/or technology;
  • independent sector management models to support capability and leadership challenges.”

In other words, before the end of the 2016-17 financial year, we will see the new Conservative government start to impose the large scale privatisation of clinical services, foreshadowed in the Health and Social Care Act 2012. In the event of any doubts regarding the obligatory nature of these policies, the NHS England report referred to earlier makes it clear that “special measures” (central takeover of local management) will be imposed if agencies fail to balance the books or deviate in any way from the government’s plans.

In this context, it’s ironic to recall all the fluffy political spin about “putting GPs in the driving seat” when CCGs were launched in 2012. By contrast, we are now told by NHS England that CCGs that fail to follow Stevens’s diktat will be disbanded and/or forced to become US style accountable care organisations (ACOs). This is with the aim of promoting mergers, cuts, and closures in the publicly provided NHS and introducing community based “integrated packages of care,” which are readily amenable to private sector provision and insurance funding—as occurs in the US ACOs on which this particular “new model of care” is based.

It is no coincidence that the House of Lords is currently calling for evidence to be submitted to its new select committee on the long term sustainability of the NHS.

This inquiry, supported by government ministers, is likely to make recommendations that will legitimise the aims of Stevens’s five year plan, including the “inevitability” of top-ups, co-payments, charges, and of the short term personal health budgets and longer term health insurance system that would be required to fund them. This toxic combination of an increasingly insurance based and increasingly privately provided health service will signal the final dismantling of what was once our National Health Service in England—a horrific and destructive act, which we now know to have been first proposed by Prime Minister Theresa May’s predecessor Margaret Thatcher in 1982.

http://blogs.bmj.com/bmj/2016/08/05/tory-plans-for-nhs-privatisation-rel…

We’ve been concerned for some time about the privatization of England’s National Health Service. The process is now underway. The Tory government is threatening the conversion of their delivery system into US style accountable care organizations, ignoring the fact that they have failed to improve quality or control costs. As we stumble along with our grossly inadequate efforts to reform our system, we can learn from the British how not to do it, which, as we see, bears an uncanny resemblance to what we are already doing.

Healthcare inequality on the rise

By Steffie Woolhandler and David U. Himmelstein
The Hill, Aug. 2, 2016

In healthcare, as in the rest of American life, the gap between rich and poor is growing. That’s the take-home message from our analysis of 50 years of data on healthcare use and expenditures that appears in the July issue of the journal Health Affairs.

In the bad old days of the 1960s—before Medicare and Medicaid—the wealthy got twice as much care as the poor. But those programs changed things. By 1977, the poor were getting 14 percent more care than the wealthy— an appropriate difference since the poor are sicker and need more care.
The pattern changed again in 2004. Over the next eight years, use of care by the wealthiest fifth of Americans grew by 19.7 percent, outpacing growth for the middle class by 57 percent. Meanwhile, care for the poorest fifth actually fell.

By 2012 the wealthy were getting 40 percent more doctor visits than other Americans. Overall, after adjusting for differences in age and health, the wealthy got 43 percent more care than the poor— $1,743 per person— and left the middle class in the dust too; the latter got $1,082 less care than the rich.

What’s behind widening healthcare inequality?

Ballooning copayments and deductibles are the most likely culprits.

As healthcare costs soared, employers shifted more and more of the burden to their workers.  Over the past decade, the average deductible in employer-sponsored health plans has risen 255 percent.

Where the copay for a trip to the doctor used to be a few dollars, now it’s often $50. An MRI or night in the hospital? We’re talking hundreds, or even thousands of dollars out of pocket.

With incomes of the poor and middle class stagnant or worse, many Americans don’t have that kind of money; half can’t afford an unplanned $400 expense without borrowing money or selling off a possession. That leaves many facing a choice between debt and care. Medical bills have become collection agencies’ biggest business.

Health policy wonks have applauded rising deductibles and copayments as the right way to get healthcare inflation under control —they call it giving patients more skin in the game.

But as doctors we’ve seen the human toll these policies exact: Women who waited and hoped that their breast lump would just disappear. Men with strokes because they couldn’t afford high blood pressure treatment.

Obamacare offered a partial solution to healthcare inequity by covering about half of the uninsured. But the health law is also part of the problem. The new insurance policies demand punishing deductibles—an average of $3,064 per person in the exchanges’ silver plans, and even more, $5,765, in the bronze plans. And after paying that, patients still face steep copayments.

That kind of insurance is akin to a hospital gown: it gives the impression that you’re covered, but doesn’t actually cover your butt.

The healthcare inequality we found is uniquely American. In every other wealthy nation, people are shielded from the costs of illness by a comprehensive and truly universal national health insurance program.

Every Canadian, for instance, has first-dollar coverage through a Medicare-for-all system (they actually call it “Medicare”) that distributes care according to need, not wealth. As a result, poor Canadians get 26 percent more care (and the middle class 11 percent more) than the wealthy.

The growing inequality in healthcare use in America is reflected in worsening outcomes for those with lesser incomes. While the health gap between rich and poor Canadians has been closing, ours has been widening. Today, the wealthiest American men live 15 years longer than their poor counterparts.

For the past decade or more U.S. health policy has blamed patients for skyrocketing health costs, and sought solutions in ever-skimpier insurance coverage and market-based competition.

Those policies have fueled a boom for giant insurers, drug firms and hospital chains. But they’ve been a bust for poor and middle-class Americans.

Drs. Steffie Woolhandler and David U. Himmelstein are primary care physicians, professors of health policy at the City University of New York at Hunter College, and lecturers in medicine at Harvard Medical School. They co-founded Physicians for a National Health Program (pnhp.org), a nonpartisan organization that advocates for single-payer health reform.

This article originally appeared at The Hill. The views expressed by contributors are their own and not the views of The Hill.

http://thehill.com/blogs/pundits-blog/healthcare/290128-healthcare-inequality-on-the-rise