PNHP

Mark Pauly’s answer to high drug prices: Walk away

Mark Pauly’s answer to high drug prices: Walk away

Maybe we are to blame in part for rising cancer drug prices

By Mark V. Pauly, PhD
Philly.com, May 9, 2016

The prices of oral cancer drugs are rising. This will come as no surprise to anyone who has cancer or who knows someone who has it.

Why did these prices increase at this pace?  My visceral reaction, which I suspect is the same as yours, is to rail against “corporate greed,” something we have seen on display for even old drugs to a spectacular extent lately.

But here is my guess. The combination of rising consumer income (even with the recession) and the spread of drug insurance meant that the maximum amount consumers or their insurers were willing to pay for these effective drugs for desperate situations grew. It was growth in demand or consumer value that persuaded drug firms to develop drugs that would be profitable if introduced at higher prices.

If we consumers want to do something about rising prices for cancer drugs, we need (according to the hard-hearted economist) to do what happens when prices for gas, or steak, or designer ties is rising — we need to walk away from them. A tepid demand response will itself temper prices as well as total spending, and perhaps offer a cautionary lesson for future health care price increases.

http://www.philly.com/philly/blogs/health-cents/Maybe-we-are-to-blame-in-part-for-rising-cancer-drug-prices.html

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S&P Healthcare Claims Index Monthly Report

Key 2015 Takeaways:

The December 2015 S&P Healthcare Claims Indices (the Indices) describe commercial healthcare costs that rose 50% more rapidly in 2015 than in 2014 – 6.50% vs. 4.33%.

Drug costs played a role by significantly increasing for the second straight year – rising 15.83% in 2015 (up from 12.58% in 2014 and 2.73% in 2013).

http://us.spindices.com/index-family/healthcare-claims/all

Drug prices are out of control. Wharton School’s Mark V. Pauly, PhD, of “moral hazard” fame, suggests that we, as consumers, can do something about it. We simply walk away from the high-priced drugs we need and then the markets will take care of the prices.

That might satisfy “the hard-hearted economist,” but there are other economic tools that can be used to achieve our objective: ensuring that everyone receives all essential health care services and products. Predominant amongst the alternative methods of health care financing would be single payer Medicare for all.

A publicly-financed system with government administered pricing and first dollar coverage is much more effective than markets in ensuring both appropriate pricing and access. Using the market tool of walking away eliminates access. That might be fine for designer ties, but it isn’t for health care.

There’s no place for rampant capitalism in treating the sick

By Michael Jones
Los Angeles Times, May 8, 2016

A good friend of mine recently found herself between jobs, with a gap in her health insurance and a recurrence of her kidney stones. What she needed were fluids and pain relief, fast. I’m a gastroenterologist, and hoping to minimize the financial impact, I went with her to our local ER and had a conversation with the attending physician. Maybe we could pass on the CT scan and extraneous lab work?

The attending was in her room for less than two minutes and never examined her. But the CT scan and blood work were ordered. My friend received intravenous fluids (about $1 worth), pain meds (about $5 worth of dilaudid), and a $10,000 bill from the hospital. To add insult to injury, the bill from the ER attending was for service at the highest billable level.

My friend had the good sense and gumption to call the ER group’s practice manager to point out that billing at that level was fraudulent. The ER group had the good sense to reduce the bill by half.

Shortly after that, I received a call from a patient on whom I had performed an upper endoscopy to remove a small gastric polyp. Because removing stomach polyps can be complicated by bleeding, I did the procedure in the hospital rather than an outpatient center. The whole thing took 15 minutes. Anesthesia wasn’t required, just routine conscious sedation. So, my patient wanted to know, what had I done that warranted an $18,000 bill from the hospital?

I had absolutely no explanation. For $18,000, you can just about buy your own endoscope. Amortized costs for an upper endoscopy at this hospital, including the use of the endoscopy unit, salaries for the whole staff, medication and equipment expenses is probably not more than $200 for 15 minutes. By the way, the doctor doing the procedure — in that case, me — typically gets about $175 for an upper endoscopy.

And then there are the costly procedures you could probably do without.

Recently, a surgical group owned by the same hospital hired a surgeon with an interest in esophageal disorders, particularly surgery for acid reflux — heartburn. He’s a good guy and capable.

So the hospital decided to create a “center of excellence” for esophageal diseases. A hurdle quickly became apparent. My town isn’t flush with esophageal experts. The hospital has excellent generalists who could contribute, but just one specialist surgeon who was retiring (hence the new hire). Still, the Joint Commission, an independent healthcare accreditation outfit, would certify the hospital’s new center if certain standards were met and a fee was paid. That’s not exactly the same as excellence.

A marketing plan was developed to get the word out. But really, far fewer than 1% of frequent heartburn sufferers will benefit from surgery. Most people with heartburn would be best served by getting help modifying their lifestyle. That’s particularly true because the behaviors associated with reflux (overeating, obesity, alcohol consumption and smoking, to name a few) are also risk factors for heart disease, diabetes and a variety of cancers.

However, lifestyle modifications are not profitable and surgery is very profitable. The surgeon (and his colleagues who agreed to work with the center) doesn’t want to perform surgery that’s inappropriate or not indicated. He’s not like that. But he’s employed by the hospital. You can see where this is going. The center is up and running.

The American healthcare system is capable of many wonderful things, but not all of them are about health or care. It is just as often about selling you things you probably don’t need at a ridiculous price, or finding ways to charge you a ridiculous price even for what you do need.

The folks driving it aren’t generally physicians, nurses or other “healthcare providers” (to use the parlance of the times). They are businesspeople — executives that run hospitals, pharmaceutical concerns and insurance companies — using healthcare as their instrument to make money. And sadly, the average physician doesn’t have a lot of choice about lashing his raft to these organizations if he wants to practice his trade.

As a nation, we spend far more than other developed countries for healthcare, and our outcomes are not as good. Those other countries generally have some form of a single-payer system. Here, we’re told single-payer horror stories: People are dying in Canada and England waiting for care.

I’ve got news from the front lines of the U.S. system. People are dying here, too, in large numbers, and at the same time they’re going broke paying the bills. Medical expenses, even now that many more people have some form of insurance, are a prime cause of bankruptcy and financial insecurity in the U.S.

No healthcare system is perfect, but here’s what the rest of the civilized world understands: Healthcare is a right. There is no place for rampant capitalism in treating the sick. This advice is harsh but true: When it comes to your healthcare, buyer beware.

Michael Jones is in private practice on the Eastern seaboard.

http://www.latimes.com/opinion/op-ed/la-oe-jones-healthcare-buyer-beware-20160508-story.html

Doctors Agree With Sanders on Universal Health Care; Interview With Dr. Adam Gaffney

By Viji Sundara
New America Media, May 7, 2016

Presidential hopefuls have their own ideas on what to do with the Affordable Care Act (ACA), President Obama’s signature legislation, when they move into the White House.

Sen. Bernie Sanders thinks it should be replaced with a single-payer health plan of the kind Europe and Canada have. This federally administered universal health care program would eliminate copays and deductibles. There’s currently a move afoot in Colorado to have such a plan.

Secretary Hillary Clinton would like to keep the ACA, with a few fixes.

Donald Trump says he will uproot the ACA, get Congress to allow the sale of health insurance across state lines and allow individuals to take tax deductions for insurance premium payments. But that would not help low-income Americans because they do not pay much in income taxes.

This week, the American Journal of Public Health carried a proposal by a working group of more than 2,000 physicians nationwide titled: Moving Forward from the Affordable Care Act to a Single-Payer system. The physicans warn that the risks of continuing the ACA will leave millions uninsured indefinitely.

NAM health editor Viji Sundaram interviewed Dr. Adam Gaffney, a co-chair of the working group.

Your proposal calls for a single-payer health care plan for the United States. Obamacare has helped 16.9 million people become newly insured. Would it not be less disruptive to expand the provisions in the ACA instead of repealing the law and replacing it?

The U.S. health system is highly disruptive as things stand now. You’re liable to lose your insurance at any time – for instance, if you change your job or get divorced. Similarly, those purchasing plans on the “marketplaces” may find that they can keep down premium increases by changing plans on an annual basis. Every time your insurance plan changes, you may need to change all of your doctors and hospitals in order to stay “in network.” This is enormously disruptive to people’s health care. In contrast, in a single-payer system, everyone has free choice of doctors and hospitals.

Your proposal promises health coverage for all. Does this include undocumented U.S. residents?

Yes, it would. The single-payer national health program we envision would include everyone regardless of country of origin, including undocumented residents. If we believe that health care is truly a human right, then this is the right thing to do. At the same time, it is also financially achievable. Immigrants, on average, have lower health care spending as compared to those born in the United States. One study demonstrated that immigrants actually pay more into Medicare than what they use in terms of health care. Everyone would be included in the national health program we envision.

Why do you think there would be no additional government spending if the United States has a single-payer health care plan? Countries such as Canada and the England run their national health program on the backs of taxpayers. Will that happen in the United States as well? Can it be done without raising taxes?

There would be additional government spending with a single-payer plan, but this would be offset by the elimination of spending by individuals and employers on premiums, co-payments, and deductibles. We can expand coverage to everyone in the country and eliminate co-payments and deductibles, and at the same time keep overall current health care spending roughly unchanged.

Some providers criticize single-payer plan as one that will force them to contract with the one payer available. Currently, providers have some choice of insurers. They can even opt out of Medicare and Medicaid.

There are many benefits for practices to have to contract with only one payer: it’s much simpler and is less costly from an administrative perspective.

How would you respond to the criticism of the single payer program as having the capacity to get doctors to sign in with fairly attractive reimbursement rates, but once in, those rates can come down, leaving providers helpless?

Because the vast majority of the nation’s doctors would participate in the national health program, there would be a powerful lobby fighting to ensure that reimbursements remain fair.

In countries that have a single-payer health care system, there seems to be a long waiting period before a patient can see a doctor. How can we keep that from happening in this country?

The problem of waiting times for care in other nations is often exaggerated. Moreover, where there are excessive waiting times for elective procedures, it is often due to underinvestment. We spend much more than other countries on health care, and have the resources to ensure that waiting times for elective procedures are reasonable. It’s also worth noting that we have waiting times in the United States also, though they are not as visible. Indeed, if you have the wrong insurance plan [currently], the waiting time for some providers may, so to speak, be infinite.

The UK allows people to be in both the national health plan as well as subscribe to a private insurance plan, which they can fall back on for expedited care. But your plan calls for an end to commercial insurance.

First, if providers must bill and contend with multiple different insurance plans, we lose the efficiency savings that come with a single universal system. Second, if we give the rich preferential access to superior and expedited care while relegating everyone else to an inferior tier, we make a mockery of the idea of an equal right to health care. Third, the best way to ensure that the quality of health care is superb is having everybody – whether rich or poor – in the same system together.

Medicaid and Medicare depend on the cost shift from private payers. Some providers say the only way doctors are willing to get into the Medicare network is because they get higher payment from commercial insurers.

Doctors would continue to do well under a Medicare-for-All system. The transition to a single-payer system would eliminate the need to bill and contend with a multiplicity of payers, producing substantial savings for practices (and hospitals).

How much could the United States save by switching to a single-payer health plan? What does it currently spend?

It is estimated that upwards of $400 billion a year could be saved from reduced spending on administration and billing that would occur through the transition to a single-payer plan. Additional money could be saved when the national health program enters into direct negotiations with pharmaceutical companies over drug prices. These savings could then be used to cover everybody in the country, while at the same time eliminating copayments and deductibles. Overall health care spending, at the end of the day, would be approximately the same as it is now, but nobody would ever again have to worry about losing insurance, about paying a big deductible if they got sick, or about not having access to the doctor or hospital of their choose.

Dr. Adam Gaffney, M.D. is in the Pulmonary and Critical Care Fellowship Program at Massachusetts General Hospital.

http://newamericamedia.org/2016/05/doctors-agree-with-sanders-on-universal-health-care.php

PNHP note: Physicians for a National Health Program (PNHP) is a nonpartisan educational and research organization. It neither supports nor opposes any candidate for public office.


Kids need healthy mothers

How Are Moms Faring under the Affordable Care Act? Evidence through 2014

By Michael Karpman, Jason Gates, Genevieve M. Kenney, Stacey McMorrow
Urban Institute, May 5, 2016

The number of uninsured mothers fell from 7.5 million in 2013 to 5.9 million in 2014, as the uninsurance rate for mothers reached its lowest point since 1997. The largest declines in uninsurance were found among low- and moderate-income mothers who were targeted by the ACA’s Medicaid expansion and the introduction of subsidized Marketplace coverage, respectively.

Despite these gains in coverage, nearly one in six mothers remained uninsured in 2014, and these mothers were disproportionately young, low-income, Hispanic, noncitizens, less educated, not married, and living in the South. One particularly concerning finding is that about one in five mothers who were likely to have the greatest physical and mental health care needs—those who reported being in less than very good health or having moderate or severe psychological distress—were uninsured.

When asked about the reasons why they do not have health insurance or stopped having coverage, 41.5 percent of uninsured mothers in 2014 said it was because the cost was too high. The next most frequently reported reason was that coverage stopped after pregnancy (18.7 percent). In addition, some mothers identified their inability to get employer-based coverage as a reason for being uninsured, either because they or the person in their family with coverage lost or changed jobs (18.0 percent) or because their current employer does not offer coverage (7.3 percent). Over 5 percent said they had lost Medicaid or other coverage because of a new job or increase in income, and 18.6 percent reported not having coverage for other reasons, such as divorce, separation, or death of a spouse or parent, becoming ineligible because of age or leaving school, denial of coverage from an insurance company, or not needing coverage.

http://www.urban.org/research/publication/how-are-moms-faring-under-affordable-care-act-evidence-through-2014

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Comment:

By Don McCanne, M.D.

Most would agree that having healthy mothers would be of benefit to their children. Suppose 5.9 million mothers were uninsured, wouldn’t it seem that we should enact health care reform that would address this problem? In fact, we did enact the Affordable Care Act, and between 2013 and 2014 the number dropped from 7.5 million to 5.9 million. Rather than celebrating the “success” of ACA reform, shouldn’t we be advocating for reform that really does work for everyone?

Yesterday, the Physicians’ Proposal for Single-Payer Health Care Reform was released. Under that proposal the number of uninsured mothers would drop to zero. At the following link you can read and download the Proposal and its supporting documents, and provide your personal endorsement:

https://www.pnhp.org/beyondaca

You don’t want to trouble yourself by providing an endorsement? But Mother’s Day is this weekend. Surely you’ll reconsider, you know, for Mom.

Growing Support for a National Health Program and Health Care as a Human Right

By John Geyman, M.D.
The Huffington Post, May 5, 2016

We can thank Bernie Sanders’ presidential campaign for putting single-payer national health insurance (NHI) on the front burner of today’s national political discussion. This is long overdue and especially timely as the two parties debate alternatives for future U. S. health care. It appears that political feasibility for NHI may finally be approaching a time of acceptance, if our democracy can prevail over oligarchy and plutocracy.

The 20,000 physician-strong Physicians for a National Health Program (PNHP) has released today a Physicians’ Proposal for Single-Payer Health Care Reform, updated from its 2003 proposal1, with an accompanying editorial.2 It describes how traditional Medicare can be expanded to cover our entire population for necessary health care, provide comprehensive benefits to all Americans, give us free choice of physician and hospital, reduce waste and bureaucracy, and save money at the same time.

This proposal by a non-partisan, not-for-profit national organization has been endorsed by more than 2,200 physician colleagues in all specialties.3 More recently, it has been endorsed by an additional 560 other health professionals and medical students.4 In its 2004 report, the Institute of Medicine (now the National Academy of Medicine) called for universal health care by 2010, listing single-payer NHI as one of the alternatives; none of the other alternatives could ever be expected to achieve universal coverage, as they remain part of the problem.5

This 2016 election season brings us three very different alternatives concerning future health care in this country: (1) continuation of the Affordable Care Act (ACA) with changes as necessary; (2) a Republican “plan” for health care; and (3) single-payer NHI. Despite some expansions of coverage, especially through Medicaid, the ACA has failed to make health care more affordable, has accelerated waste, bureaucracy and profiteering, and is unsustainable. Yet Hillary Clinton calls for expansion of the ACA to 100 percent coverage with no possible way of doing it by retaining some 1,300 private insurers. She also claims disingenuously that NHI will raise our taxes—without acknowledging that Gerald Friedman’s classic 2013 study found that 95 percent of Americans will pay less for insurance premiums, deductibles, co-payments, actual care and out-of-pocket payments, and that only the wealthiest five percent would pay more.6

Although no concrete plan has yet been advanced by the GOP, we can expect that it will repeal the ACA, then “replace” it with long discredited reliance on free markets in health care, consumer directed health care, health savings accounts, selling insurance across state lines, and high-risk pools.

Neither the ACA nor GOP options will make health care more affordable or accessible.

Single-payer NHI is the only alternative that will achieve universal coverage in an affordable and sustainable way. A strong case for it has been made elsewhere on economic, sociopolitical, and moral grounds.7 It will meet conservatives’ principles regardless of party affiliation, including efficiency, maximal choice, minimal waste, value, and everyone contributes in proportion to his or her income.8 Long an iconic guru of free-market economics, Kenneth J. Arrow has recently acknowledged that “a single-payer system is better than any other system,” as long as private practice is preserved (as it would be with NHI).9

We know that powerful forces are aligned against passage of NHI, including private insurers, Big PhRMA, medical device makers, and other members of the medical-industrial complex. They are empowered further by their hundreds of lobbyists and corporate money in our post-Citizens United world. As Bernie Sanders has observed: “the Koch brothers, as the second-wealthiest family in America with $82 billion in wealth, advocate destruction of federal programs that are critical to the financial and personal health of middle-class Americans.”10

Sorting through the three major financing alternatives for our health care will test whether or not we have a real democracy. Much of the corporate-owned media under-report the single-payer alternative, misinform the public, and perpetuate myths, such as we can’t afford NHI, net spending would go up because of increased taxes, or the government would ration care. These myths and memes have been discussed in detail elsewhere.11 Solid, reliable updated information on NHI can be found on PNHP’s website (www.pnhp.org).

Democracy can win, but we will need progressive leadership. It is encouraging that Bernie is leading in recent polls in a matchup against Donald Trump or any other Republican presidential nominee. With a large and growing grassroots support from across the country, Bernie should have considerable leverage on the Democratic platform, which hopefully can move Hillary to a progressive position on health care. Recall Hillary’s words in 1994, speaking to a group at Lehman Brothers Health Corporation:

“[I]f there is no health care reform this year, and if, for whatever  reason, the Congress doesn’t pass health care reform . . . I believe that by the year 2000 we will have a single-payer system . . . I don’t even think it’s a close call politically. I think that the momentum for a single-payer system will sweep the country . . . it will be such a huge popular issue . . . that even if it’s not successful the first time, it will eventually be.”12

Health care is too important to be gridlocked in polarized partisan camps. All Americans will win with NHI, including the business community, which will be relieved of its burden of paying growing costs of employer-sponsored health insurance. Time will tell whether or not the oligarchy wins again.

John Geyman is professor emeritus of Family Medicine at the University of Washington School of Medicine. Visit: http://www.johngeymanmd.org.

References

1. The Working Group on Single-Payer Program Design. Beyond the Affordable Care Act: A Physicians’ Proposal for Single-Payer Health Care Reform. Available a supplement online version of ref. 1 at http://www.ajph.org.

2. Gaffney, A, Woolhandler, S, Angell, M, Himmelstein, DU. Editorial. Moving forward from the Affordable Care Act to a Single-Payer system. Am J Public Health, 106 (6): e1-e2, June 2016.

3. Carroll, AE, Ackermann, RT. Support for national health insurance among U. S. physicians: five years later. Ann Intern Med 1481: 566-567, 2008.

4. Woolhandler, S, Himmelstein, DU. Setting the record straight on Medicare for All: An open letter from 560 physicians and medical students. The Huffington Post, February 28, 2016.

5. Committee on the Consequences of Uninsurance. Institute of Medicine. Insuring America’s Health: Principles and Recommendations. National Academies Press, Washington, D.C., 150-151, 2004.

6. Friedman, G. Funding H. R. 676: The Expanded and Improved Medicare for All Act. How We Can Afford a National Single-Payer Health Plan. Physicians for a National Health Program. Chicago, Il. July 31, 2013. Available at: https://www.pnhp.org/sites/default/files/Funding%20HR%20676_Friedman_final_7.31.13.pdf.

7. Geyman, JP. The Human Face of ObamaCare: Promises vs. Reality and What Comes Next. Friday Harbor, WA. Copernicus Healthcare, 199-202, 2016.

8. Light, DW. A conservative call for universal access to health care. Penn J Bioethics 9 (4): 4-6, 2002.

9. Arrow, KE. As quoted by Pro-Market. The blog of the Stigler Center at the University of Chicago Booth School of Business, March 15, 2016.

10. Sanders, B. This is what oligarchy looks like. Bernie 2016, January 4, 2016.

11. Geyman, JP. Myths and memes as barriers to health care reform. In Geyman, JP. How Obamacare Is Unsustainable: Why We Need a Single-Payer Solution for All Americans. Friday Harbor, WA. Copernicus Healthcare, 2015, pp. 223-241.

12. Clinton, H. Speaking to a group at Lehman Brothers Health Corporation, June 15, 1994, as reported by Health Care for All-WA Newsletter, Winter 2015, p 9.

http://www.huffingtonpost.com/john-geyman/growing-support-for-a-nat_b_9852148.html

Kids need healthy mothers

How Are Moms Faring under the Affordable Care Act? Evidence through 2014

By Michael Karpman, Jason Gates, Genevieve M. Kenney, Stacey McMorrow
Urban Institute, May 5, 2016

The number of uninsured mothers fell from 7.5 million in 2013 to 5.9 million in 2014, as the uninsurance rate for mothers reached its lowest point since 1997. The largest declines in uninsurance were found among low- and moderate-income mothers who were targeted by the ACA’s Medicaid expansion and the introduction of subsidized Marketplace coverage, respectively.

Despite these gains in coverage, nearly one in six mothers remained uninsured in 2014, and these mothers were disproportionately young, low-income, Hispanic, noncitizens, less educated, not married, and living in the South. One particularly concerning finding is that about one in five mothers who were likely to have the greatest physical and mental health care needs—those who reported being in less than very good health or having moderate or severe psychological distress—were uninsured.

When asked about the reasons why they do not have health insurance or stopped having coverage, 41.5 percent of uninsured mothers in 2014 said it was because the cost was too high. The next most frequently reported reason was that coverage stopped after pregnancy (18.7 percent). In addition, some mothers identified their inability to get employer-based coverage as a reason for being uninsured, either because they or the person in their family with coverage lost or changed jobs (18.0 percent) or because their current employer does not offer coverage (7.3 percent). Over 5 percent said they had lost Medicaid or other coverage because of a new job or increase in income, and 18.6 percent reported not having coverage for other reasons, such as divorce, separation, or death of a spouse or parent, becoming ineligible because of age or leaving school, denial of coverage from an insurance company, or not needing coverage.

http://www.urban.org/research/publication/how-are-moms-faring-under-affordable-care-act-evidence-through-2014

Most would agree that having healthy mothers would be of benefit to their children. Suppose 5.9 million mothers were uninsured, wouldn’t it seem that we should enact health care reform that would address this problem? In fact, we did enact the Affordable Care Act, and between 2013 and 2014 the number dropped from 7.5 million to 5.9 million. Rather than celebrating the “success” of ACA reform, shouldn’t we be advocating for reform that really does work for everyone?

Yesterday, the Physicians’ Proposal for Single-Payer Health Care Reform was released. Under that proposal the number of uninsured mothers would drop to zero. At the following link you can read and download the Proposal and its supporting documents, and provide your personal endorsement:

https://pnhp.org/beyondaca

You don’t want to trouble yourself by providing an endorsement? But Mother’s Day is this weekend. Surely you’ll reconsider, you know, for Mom.

Obamacare is flawed, but there is a solution

The Affordable Care Act has increased access to health care, but it has serious drawbacks

That’s why a large, respected group of physicians is proposing a different, single-payer health care system

By Jessica Schorr Saxe, M.D.
The Charlotte (N.C.) Observer, May 5, 2016

Why, in the age of the Affordable Care Act, would a large, respected group of physicians develop A Physicians’ Proposal for Single-Payer Health Care Reform? On Thursday, this document was released by a panel at the National Press Club and published online in the American Journal of Public Health.

Are you or someone you know forgoing medical care for financial reasons, having trouble with medical bills, being forced to change providers due to network problems, or reeling from arbitrary increases in premiums or deductibles? If so, you know the ACA has drawbacks.

While the ACA has increased access to health care, it falls short in achieving the goals of making care available and affordable to all and controlling costs.

Although millions have gained insurance, the Congressional Budget Office estimates 28 million Americans will remain uninsured in 10 years when the law is fully operational.

Additionally, underinsurance is an increasing, often overlooked problem. The underinsured are those who, despite coverage, are not able to afford their deductibles or out-of-pocket costs. According to the Commonwealth Fund, this included 21 percent of adults below Medicare age in 2014. More than one-third of Americans did not get needed care due to financial barriers, and more than one-third have trouble paying a medical bill.

Free clinics, which expected declining numbers after the ACA, are seeing an influx of insured patients who cannot afford co-pays or deductibles.

Though health care inflation was relatively low for a few years, it is now rising. Currently at about 18 percent of gross domestic product (about twice that of most other developed countries), health care is projected to reach almost 20 percent by 2024.

Administrative costs consume an inordinate amount of our health care budget. Bureaucracy plagues providers and patients. If the forms now contained in the electronic record were hard copies, physicians would be crushed under their weight.

Surely we can agree that Americans are entitled to better care. The Physicians Proposal outlines a better course.

A single-payer health care system, sometimes referred to as Expanded and Improved Medicare for All, would provide comprehensive health care with no deductibles or co-pays. Financing would be federal, much like current Medicare, and paid for largely through progressive taxes. Even those who consider raising taxes anathema would likely be pleasantly surprised to find these taxes are more than offset by reductions in premiums, co-pays and other medical expenses.

Expanded (covering more people) and Improved (more comprehensive) services would be made possible by savings in many areas. Administrative costs would plummet by eliminating private insurance companies, the expensive middle men that siphon off dollars that could otherwise be spent on actual health care. Cutting administrative costs to the level of Canada would save about $500 billion annually. The National Health Plan would negotiate pharmaceutical prices, as do other countries, yielding further and extensive savings. For-profit hospitals and clinics, documented to be of poorer quality and more expensive, would be prohibited.

Single-payer health care is a financing mechanism. Current private hospitals and practices would continue to deliver health care, much as they do now, except that they would submit bills to a single entity. With a unified system, there would be no more separate networks. The opportunity to choose providers and relief from financial barriers would strengthen the currently endangered physician-patient relationship.

Critics insist widespread opposition is an obstacle. In fact, polls show rising support. In 2008, a national survey showed that 59 percent of physicians supported a national health insurance plan, and in December 2015, a Kaiser poll indicated that 58 percent of Americans support Medicare for All. As both physicians and patients feel more beleaguered by our current system, expect those numbers to rise.

Can we afford it? Yes. And, given current trends, we cannot afford to delay its implementation.

If you are or know an individual suffering from lack of access, oppressive medical bills, unbearable bureaucracy, or fear of your own rising medical costs or the collective burden on the U.S. economy, you, too, should support a single-payer health care system.

Dr. Jessica Schorr Saxe is chair of Health Care Justice NC, a chapter of Physicians for a National Health Program. Email: HCJusticeNC@gmail.com. The Physicians Proposal is available at: https://www.pnhp.org/beyond_aca/Physicians_Proposal.pdf.

http://www.charlotteobserver.com/opinion/op-ed/article75899102.html

A Physicians’ Proposal for Single-Payer Health Care Reform

AJPH Editorials: Moving Forward From the Affordable Care Act to a Single-Payer System

By Adam Gaffney, Steffie Woolhandler, David Himmelstein and Marcia Angell
American Journal of Public Health, June 2016
Published in advance online May 5, 2016

Conclusions

Despite the ACA, many serious problems remain in American health care. Uninsurance and underinsurance endure, bureaucracy is growing, costs are likely to rise, and caring relationships take second place to the financial prerogatives of health insurers and providers. A single-payer NHP offers a salutary alternative, one that a would at long last take the right to health care from the realm of political rhetoric to that of reality.

http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2015.303157

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Beyond the Affordable Care Act: A Physicians’ Proposal for Single-Payer Health Care Reform

By The Working Group on Single-Payer Program Design
Co-chairs: Adam Gaffney, M.D., David U. Himmelstein, M.D., Steffie Woolhandler, M.D., M.P.H., and Marcia Angell, M.D.

Abstract

Even after full implementation of the Affordable Care Act (ACA), tens of millions of Americans will remain uninsured or only partially insured, and costs will continue to rise faster than the background inflation rate. We propose to replace the ACA with a publicly financed National Health Program (NHP) that would fully cover medical care for all Americans, while lowering costs by eliminating the profit-driven private insurance industry with its massive overhead.  Hospitals, nursing homes, and other provider facilities would be nonprofit, and paid global operating budgets rather than fees for each service. Physicians could opt to be paid on a fee-for-service basis, but with fees adjusted to better reward primary care providers, or by salaries in facilities paid by global budgets.  The initial increase in government costs would be offset by savings in premiums and out-of-pocket costs, and the rate of medical inflation would slow, freeing up resources for unmet medical and public health needs.

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Download the full proposal
https://www.pnhp.org/beyond_aca/Physicians_Proposal.pdf

Summary of the Physicians’ Proposal
https://www.pnhp.org/beyond_aca/Physicians_Proposal_Summary.pdf

Background Fact Sheet for the Physicians’ Proposal
https://www.pnhp.org/beyond_aca/Physicians_Proposal_Fact_Sheet.pdf

PNHP Press Release
https://www.pnhp.org/beyond_aca/News_Release.pdf

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From the PNHP website

“Beyond the Affordable Care Act: A Physicians’ Proposal for Single-Payer Health Care Reform” establishes the vision and principles that will empower Americans to replace our expensive, inadequate, and inefficient collection of health care systems with an improved Medicare for All.

The proposal outlines the general structure of a single-payer system for the United States, including coverage and eligibility; physician and outpatient care payment; global budgeting of hospitals; health planning and capital investments; coverage for medications, devices, and supplies; the establishment of a national long-term care program; cost-containment; and single-payer financing. The proposal also demonstrates the shortcomings of alternatives to National Health Insurance, including the Affordable Care Act.

For further links, including downloading and endorsing the proposal:

https://www.pnhp.org/beyondaca

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Comment:

By Don McCanne, M.D.

If you have not done so already, please use the links above to endorse and download the Physicians’ Proposal, including the Summary and the Background Fact Sheet. It is imperative that we fix our dysfunctional health care system.

Doctors call for single-payer health reform, cite need to move beyond the Affordable Care Act

American Journal of Public Health publishes physicians’ call for sweeping single-payer reform with detailed proposal signed by over 2,200 doctors nationwide

Unveiling of proposal coincides with heightened debate on ‘Medicare for All’ in presidential primaries

FOR IMMEDIATE RELEASE, May 5, 2016
Contact: Mark Almberg, 312-782-6006, mark@pnhp.org

In a dramatic show of physician support for deeper health reform – and for making a decisive break with the private insurance model of financing medical care – 2,231 physicians called today [Thursday, May 5] for the creation of a publicly financed, single-payer national health program that would cover all Americans for all medically necessary care.

Single-payer health reform, often called “Medicare for All,” has been a hotly debated topic in the presidential primaries, thanks in part to it being a prominent plank in the platform of Sen. Bernie Sanders. The new physicians’ proposal is strictly nonpartisan, however.

The proposal, which was drafted by a blue-ribbon panel of 39 leading physicians, is announced today in an editorial titled “Moving Forward from the Affordable Care Act to a Single-Payer System” published in the American Journal of Public Health. The editorial links to the full proposal titled “Beyond the Affordable Care Act: A Physicians’ Proposal for Single-Payer Health Care Reform” and the names of all the signers, and it appeals for additional physicians to add their names as endorsers. The proposal currently has signers from 48 states and the District of Columbia.

“Our nation is at a crossroads,” said Dr. Adam Gaffney, a Boston-based pulmonary disease and critical care specialist, lead author of the editorial and co-chair of the Working Group that produced the proposal.

“Despite the passage of the Affordable Care Act six years ago, 30 million Americans remain uninsured, an even greater number are underinsured, financial barriers to care like co-pays and deductibles are rising, bureaucracy is growing, provider networks are narrowing, and medical costs are continuing to climb.

“Caring relationships are increasingly taking a back seat to the financial prerogatives of insurance firms, corporate providers, and Big Pharma,” Gaffney said. “Our patients are suffering and our profession is being degraded and disfigured by these mercenary interests.”

Dr. Steffie Woolhandler, a co-author of the editorial and proposal who is a professor of public health at the City University of New York’s Hunter College and lecturer at Harvard Medical School, commented: “We can continue down this harmful path – or even worse, take an alternative, ‘free-market’ route that would compound our problems – or we can embrace the long-overdue remedy that we know will work: the creation of a publicly financed, nonprofit, single-payer system that covers everybody. Today we’re saying we must quickly make that shift. Lives are literally at stake.”

Dr. Marcia Angell, a co-author of the editorial and proposal, co-chair of the working group, member of the faculty of global health and social medicine at Harvard Medical School and former editor-in-chief of the New England Journal of Medicine, said: “We can no longer afford to waste the vast resources we do on the administrative costs, executive salaries, and profiteering of the private insurance system. We get too little for our money. It’s time to put those resources into real health care for everyone.”

Under the national health program (NHP) outlined by the physicians:

* Patients could choose to go to any doctor and hospital. Most hospitals and clinics would remain privately owned and operated, receiving a budget from the NHP to cover all operating costs. Physicians could continue to practice on a fee-for-service basis, or receive salaries from group practices, hospitals or clinics.

* The program would be paid for by combining current sources of government health spending into a single fund with modest new taxes that would be fully offset by reductions in premiums and out-of-pocket spending. Co-pays and deductibles would be eliminated.

* The single-payer program would save about $500 billion annually by eliminating the high overhead and profits of insurance firms, and the massive paperwork they inflict on hospitals and doctors.

* The administrative savings of the streamlined system would fully offset the costs of covering the uninsured and upgraded coverage for everyone else, e.g. full coverage of prescription drugs, dental care and long-term care. Savings would also be redirected to currently underfunded health priorities, particularly public health.

* The “single payer” would be in a strong position to negotiate lower prices for medications and other medical supplies, yielding additional savings and reining in costs.

Surveys show strong, rising support for single-payer national health insurance among physicians. A 2008 survey of physicians found that 59 percent supported “legislation to establish national health insurance,” up from 49 percent five years earlier.

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“Moving Forward From the Affordable Care Act to a Single-Payer System,” by Adam Gaffney, M.D.; Steffie Woolhandler, M.D., M.P.H.; David U. Himmelstein, M.D.; Marcia Angell, M.D. American Journal of Public Health, June 2016, Vol. 106, No. 6, online first May 5, 2016, 1 p.m. Eastern. Includes link in text to full Physicians’ Proposal: www.pnhp.org/nhi. Article available at this link:
http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2015.303157

The full, six-page Physicians’ Proposal with reference citations and 2,231 signatures (titled “Beyond the Affordable Care Act: A Physicians’ Proposal for Single-Payer Health Care Reform,” written by a 39-member Working Group on Single-Payer Program Design) is also accessible at the following link: www.pnhp.org/nhi

PNHP’s summary of the Physicians’ Proposal is available here: https://www.pnhp.org/beyond_aca/Physicians_Proposal_Summary.pdf

PNHP’s fact sheet on U.S. health care is here: https://www.pnhp.org/beyond_aca/Physicians_Proposal_Fact_Sheet.pdf

Physicians for a National Health Program is a nonpartisan, nonprofit research and education organization founded in 1987. It includes physicians in every state and medical specialty. For local physician contacts or other information, contact PNHP’s headquarters in Chicago at (312) 782-6006. PNHP had no role in funding the articles described above.

2,000 doctors say Bernie Sanders has the right approach to health care

By Carolyn Y. Johnson
The Washington Post, May 5, 2016

More than 2,000 physicians announced their support Thursday for a single-payer national health care system, unveiling a proposal drafted by doctors that appears to resonate with Bernie Sanders’ call for “Medicare for All.”

In an editorial and paper published in the American Journal of Public Health on Thursday, the doctors call out the “persistent shortcomings of the current health care system.” They warn about the risks of continuing along the path laid out by the Affordable Care Act: “down this road, millions of Americans remain uninsured, underinsurance grows, costs rise, and inefficiency and the search for profits are abetted.”

The future of health reform has been widely discussed in the presidential campaign, and for years health reform has sparked a raging and divisive political debate among politicians. The proposal, however, is endorsed by hundreds of physicians who have an inside view of the effects of the law on patients and medical care. It grew out of discussions in late 2014, when a small group of physicians began to assess the effects of health reform and found it coming up short.

“Those discussions led us to feel that we needed to put out in public, first of all, a clear statement that problems haven’t been solved,” said David Himmelstein, an internist who practices in the South Bronx and a professor at the City University of New York School of Public Health at Hunter College.

Himmelstein and his colleagues call the right to medical care “a dream deferred,” despite health reform.

About 12.7 million people are insured through the state and federal marketplaces created by the law, according to data released in February. But the Congressional Budget Office has estimated that about 28 million people will be uninsured in 2026.

On top of that, Himmelstein said he began to notice insured patients having more trouble paying for and accessing care, as their plans have been designed with narrower networks of physicians and growing deductibles — issues that Himmelstein argues are ripple effects of the law. That’s because the insurance policies sold through the marketplaces cover less than traditional employer plans did previously, “and we’re seeing employers race to the bottom, once the Affordable Care Act says that’s what coverage consists of,” Himmelstein said.

Jeffrey Flier, the dean of Harvard Medical School, said the proposal is “massively backward,” adding that the one thing it points out correctly is that health reform has been unable to deliver on its promise of affordable health care.

“I don’t think it’s a very meaningful contribution,” Flier said. “It conjures up five-year planning by Stalinists.”

The new single-payer proposal doesn’t get into many specifics of how it would be funded, other than to estimate that the increase in government health care spending would be balanced by  shrinking administrative costs and reductions in the cost of health care services and drugs. The doctors argue that a progressive tax, aimed at reducing income inequality would be an attractive way to fund the system.

“Frankly, there’s so much fat in the U.S. health care system — we’re wasting so much money — that we can afford to give everyone in this country everything that we know is useful without restriction,” Himmelstein said.

Kenneth Thorpe, a professor of health policy at Emory University who has been critical of the feasibility and expense of Sanders’ single-payer plan, said that the new proposal would cost more than the status quo. It overestimates the administrative savings that would be possible from a single-payer system,  Thorpe argues.

“You can’t do what they’re talking about doing with the same amount of money that we’re currently spending,” Thorpe said.

He said in addition to a switch to single-payer being disruptive, it’s likely to be politically unpalatable. Thorpe’s analysis has found that 71 percent of people with private insurance would pay more in a single-payer system than they currently do because taxes would outpace savings from premiums and other health care costs.

However, he noted that many of the ideas embedded in the proposal — such as new payment models — are already being experimented with today, under the current system.

Himmelstein said that today, hospitals must collect their operating budget “Band-Aid by Band-Aid and aspirin tablet by aspirin tablet, fighting with hundreds of different insurance plans.” The physicians propose funding hospitals with a lump sum to cover all operating expenses, bypassing the large billing departments that today accrue hospital income piecemeal. But Thorpe pointed out similar ideas are already being tested in Maryland hospitals.

“We don’t need to completely blow the system up and disrupt it to generate the savings,” Thorpe said.

https://www.washingtonpost.com/news/wonk/wp/2016/05/05/2000-doctors-say-bernie-sanders-has-the-right-approach-to-health-care/

‘We need fundamental changes’: US doctors call for universal healthcare

More than 2,000 physicians want a single-payer system similar to Canada’s and say the Affordable Care Act didn’t go far enough

By Olga Oksman
The Guardian, May 5, 2016

A group of more than 2,000 physicians is calling for the establishment of a universal government-run health system in the US, in a paper in the American Journal of Public Health.

According to the proposal released Thursday, the Affordable Care Act did not go far enough in removing barriers to healthcare access. The physicians’ bold plan calls for implementing a single-payer system similar to Canada’s, called the National Health Program, that would guarantee all residents healthcare.

The new single-payer system would be funded mostly by existing US government funding. The physicians point out that the US government already pays for two-thirds of all healthcare spending in the US, and a single-payer system would cut down on administrative costs, so a transition to a single-payer system would not require significant additional spending.

“Our patients can’t afford care and don’t have access to the care they need, while the system is ever more wasteful, throwing away money on bureaucratic expenses and absurd prices from the drug companies,” said David Himmelstein, a professor in the CUNY School of Public Health at Hunter College and lecturer on medicine at Harvard Medical School.

Himmelstein, one of the authors of the plan, said the proposal is meant as a rallying cry for physicians and other healthcare professionals around the cause of a single-payer model. According to the paper, even with the passage of the Affordable Care Act many patients “face rising co-payments and deductibles that compromise access to care and leave them vulnerable to ruinous medical bills”. Despite the current high healthcare spending levels in the US, healthcare outcomes are worse than in comparable well-funded countries.

“There has been a conviction that we can approach this incrementally and get there in small steps and one of the advantages of having passed the ACA is that modest steps can’t do the job, and in a way make it easier to make arguments that we need more fundamental changes,” said Himmelstein.

Under the proposal, all US residents would be able to see any physician of their choosing in the country and be treated at any hospital. With guaranteed coverage and no co-pays, deductibles and premiums, patients would not have financial barriers to seeking care, which would lead to greater utilization of the system and improved health outcomes, Himmelstein argues.

The additional funds would be made up by modest tax increases in exchange for abolishing insurance premiums, deductibles and co-pays.

“We would have to abolish the insurance companies, there is no way around that,” Himmelstein said. The employees at the private insurance companies would be retrained for other jobs, he explains, and receive job placement assistance. The insurance CEOs, who earn multimillion dollar salaries, would not get comparable job placement, Himmelstein said wryly.

Fees for medication would be negotiated with pharmaceutical companies the same way other countries with single-payer systems already negotiate for lower cost medications. Currently, US drug prices are some of the highest in the world.

While Himmelstein acknowledges that the physicians’ proposal would meet with political and business interest opposition, and he can’t say when such a system would realistically have the political backing needed to be implemented, he is hopeful that as more Americans view a single-payer system favorably, pressure will continue to mount on the government.

Proposing a single-payer system in the US is not new. Vermont previously attempted to implement a single-payer system, which passed the legislature but was shut down by the once supportive governor when cost estimates increased beyond what the state was able to afford.

Coloradans will vote this November on whether to institute a single payer system statewide. One of the leaders of the movement in Colorado is state senator Irene Aguilar, who is also a physician. The Colorado proposal would be financed by a payroll tax increase of 7% for employers and 3% for employees. For the self-employed, that would translate into a 10% tax increase.

But Himmelstein said this type of reform can’t be done state by state. The physicians’ plan depends in part on cost containment through having a single payer with the power to negotiate drug pricing with pharmaceutical companies as well as eliminating many levels of bureaucracy in billing and insurance registration.

The American Medical Association (AMA), which is the largest organization of physicians in the US, has opposed the idea of a single-payer model. When contacted, the AMA pointed to its policy regarding evaluating health reform proposals, which states in part that: “Unfair concentration of market power of payers is detrimental to patients and physicians, if patient freedom of choice or physician ability to select mode of practice is limited or denied. Single-payer systems clearly fall within such a definition and, consequently, should continue to be opposed by the AMA.”

But Himmelstein sees change around the corner. “I think the AMA and its member organizations are slowly starting to come around and I am confident that they will eventually come around.” He points to the passing of resolutions by a few of the state medical associations that make up the AMA membership to study the impact of a single-payer system as indicators of change.

For Himmelstein and the other writers of the editorial, the biggest indicator of change seems to be the talk of a single-payer system in the presidential primaries which has brought attention back to the issue.

“Bernie Sanders showed you can do extraordinarily well campaigning on this issue,” said Himmelstein, who is confident that if enough American people demand a single-payer system, Congress will eventually have no choice but to change their minds and support it. But what the American people really think of a single-payer system is a lot murkier. While in some polls show majority support for a single-payer system, deeper digging by some polls finds that support dwindles when individuals are asked about giving up their private health insurance and paying additional taxes.

http://www.theguardian.com/us-news/2016/may/05/us-doctors-calling-universal-healthcare-system-affordable-care-act

Doctor Group Pushes for ‘Single-Payer’ Model

The proposed solution for medical coverage would include immigrants who are in the country illegally

By Kimberly Leonard
U.S. News & World Report, May 5, 2016

As Republicans continue to debate how to “repeal and replace” President Barack Obama’s signature health care law, thousands of doctors are hoping to re-ignite the conversation about moving to a single-payer system as a way to achieve universal coverage.

A single-payer system, often dubbed by advocates as “Medicare for all,” would be funded by the government, and would fund all medically necessary care for all Americans, including people who are in the country illegally, said doctors led by Physicians for a National Health Program, which first proposed a single-payer system in 2003.

On Thursday, a working group comprising 39 doctors, some of whom are members of Physicians for a National Health Program, published the single-payer proposal in the American Journal of Public Health, which also was signed by more than 2,200 other physicians and medical students. Several physicians released an accompanying editorial about their support for a single-payer system.

The doctor group stressed that its proposal wasn’t partisan, noting that a single-payer proposal is advocated by Vermont Sen. Bernie Sanders, who is running for the Democratic nomination for president.

Though provisions in the Affordable Care Act have covered nearly 20 million people with public or private insurance who were previously without medical coverage, reports from government forecasters show that 28 million people will still be uninsured in a decade. Physicians also said they are concerned for people who have insurance but still face high medical costs.

In a statement, Dr. Adam Gaffney, lead author of the editorial and co-chair of the working group that produced the proposal, pointed to high co-pays and deductibles patients face. “Caring relationships are increasingly taking a back seat to the financial prerogatives of insurance firms, corporate providers, and Big Pharma,” said Gaffney, who is also a Boston-based pulmonary disease and critical care specialist. “Our patients are suffering and our profession is being degraded and disfigured by these mercenary interests.”

At an event held Thursday at the National Press Club in Washington, Gaffney said that patients often have to choose between their wallet and their lives.

Karen Higgins, president of National Nurses United, which has endorsed Sanders for president, said at the event that even after the passage of the health care law, nurses have seen patients go without medication, or are taking drugs in smaller doses or every other day, because they cannot afford them.

“We should always remember that health insurance is not health care, particularly with high deductible sand high costs,” she said.

Those advocating for the single-payer system say it would allow patients to go to any doctor or hospital they choose, and prescription drugs, mental health care, dental care and long-term care would all be included. The government would negotiate the prices of drugs.

The proposal differs from universal health care in other developed countries by allowing doctors and hospitals to remain privately owned and operated, though they would receive a budget from the government to cover all operating costs. Physicians could continue to practice on a fee-for-service basis, or receive salaries from group practices, hospitals or clinics.

The group disputed the argument from single-payer opponents that have said such a system would be too expensive. Government health spending, they say, would go into a single fund and “modest new taxes” would be offset by the fact that people wouldn’t be paying premiums or other out-of-pocket costs. A single-payer system, they say, would save $500 billion each year, by eliminating the paperwork doctors and hospitals have to fill out for private health insurance companies. These savings, the group wrote, should go directly to public health.

http://health.usnews.com/health-news/hospital-of-tomorrow/articles/2016-05-05/beyond-obamacare-doctor-groups-push-for-single-payer-health-care-plan