PNHP

How to provide Medicare for all

How to provide Medicare for all

By Marcia Angell, M.D.
The Boston Globe, May 17, 2016

Obamacare, aka the Affordable Care Act, became law six years ago. The intention was to ensure that nearly all Americans have health insurance, while controlling costs. How did that work out?

When the law was enacted, about 16 percent of Americans were uninsured. That has dropped to 10 percent. So instead of 50 million uninsured Americans, there are now about 30 million without insurance. That’s better, but hardly universal.

Health cost inflation slowed for a few years, probably because of the recession, but it’s now resuming its rapid growth. In total, the United States spent $8,400 per person on health care six years ago, or $2.6 trillion. Last year we spent $10,000, or $3.2 trillion.

Obamacare has no doubt provided health insurance to people who would otherwise have been without it, mainly through an extension of Medicaid in most states, and the creation of shopping exchanges to enable individuals to buy insurance, often with government subsidies. But insurance no longer means what it once did. Businesses are capping their contributions to employees’ health benefits, premiums are increasing, and deductibles and copayments are soaring. There are reports that people who have gained insurance can’t use it because of high out-of-pocket costs. Insurance is becoming hollowed out, and we are learning that health insurance is not the same as health care.

The reason Obamacare is unable to expand access and coverage while containing costs is that it made only marginal changes to the underlying factors that make the American health system the most expensive in the world. There are two: First is the spectacularly inefficient private insurance industry, which thrives by refusing coverage for expensive medical conditions and generally denying claims. These companies’ profits, marketing, and other overhead expenditures are so high that when Obamacare restricted them to 20 percent of premiums, it seemed draconian. Compare their costs to Medicare’s overhead of about 2 percent.

The second, and perhaps greater, underlying problem is the perverse incentives of providers to perform as many highly reimbursed tests and procedures as possible. These providers include hospitals, whether technically nonprofit or not, for-profit outpatient facilities, such as imaging and dialysis centers, and even specialists whose income is proportional to the high-tech procedures they perform. Other advanced countries spend on average less than half as much per capita on health care as we do, provide truly universal care, and get generally better results, because they have either a single-payer financing system or tightly regulated multiple payers, plus a largely nonprofit provider system.

When Bernie Sanders called for “Medicare for All” to replace Obamacare, he was met with objections that it would be too expensive. But that is because of a confusion between government expenditures for health care, and total expenditures, which include employer and individual out-of-pocket costs. Government officials and political candidates usually focus on government costs, particularly Medicare and Medicaid. It would be possible to increase government expenditures for health care, but offset that by eliminating premiums, reducing out-of-pocket costs, and freeing employers from the burden of providing health benefits.

The government now pays roughly 65 percent of health costs (including Medicare, Medicaid, government employees, and employer tax deductions). Medicare for All, according to an analysis just published in the American Journal of Public Health, would require that figure to rise to about 80 percent. But these costs would be almost totally repaid by the savings in premiums, deductibles, and other out-of-pocket costs. Moreover, with time, the greater efficiency of Medicare for All would slow health cost inflation. We could gradually adopt Medicare for All by lowering the qualifying age one decade at a time to reduce the disruption.

Hillary Clinton recently called for a public option in Obamacare (an idea scuttled in 2009) that would permit people in their 50s and early 60s to choose either Medicare or private insurance. The problem with that proposal is that private insurance companies would woo the healthiest people in that age group, and leave the sickest to Medicare. Medicare would then be subsidizing the for-profit insurance industry, and there would be little or no savings. It is much more efficient for everyone in an age group to be enrolled in Medicare, so there couldn’t be that kind of “cherry picking.”

But Medicare as it now stands is not perfect. Although it is a single-payer system within our larger market-based system, it uses the same profit-seeking providers, and its out-of-pocket costs are also growing. And it doesn’t cover everything – for example, long-term care. If the United States extended Medicare to the entire population, it would make sense also to convert to a largely nonprofit provider system. Reducing the perverse role of profit-seeking among providers, with the propensity to over-diagnosis and over-treatment, would yield much greater savings. We could then expand the Medicare benefit package and get rid of out-of-pocket costs altogether.

By eliminating the two drivers of health cost inflation in the United States – private insurers and a profit-oriented provider system – we would bring the United States into line with the rest of the advanced world. It will be argued that this idea is “politically unrealistic,” but that hardly justifies not even trying, or imagining that anything else will work. The first step is to tell it like it is.

Marcia Angell, M.D., is a 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.

https://www.bostonglobe.com/opinion/2016/05/17/how-provide-medicare-for-all/zPCz4u47JBO4kMG1OUilbJ/story.html

What’s Wrong with Margot Sanger-Katz’s Single Payer Analysis

By Adam Gaffney, M.D.
The Progressive Physician blog, May 17, 2016

Yesterday, New York Times health care reporter Margot Sanger-Katz, whose work I very much respect, entered the debate on the costs of Sanders’ single payer plan in a piece I find problematic, headlined “A Single-Payer Plan From Bernie Sanders Would Probably Still Be Expensive.” I should first concede, however, the central argument of her article: it is true that a US single payer system would still be relatively expensive as compared to other single payer systems. We would, that is to say, continue to spend more than the United Kingdom or Canada if we transitioned to single payer. At the same time, there would nonetheless be enormous savings from such a transition, and these savings would allow us to affordably achieve real universal health care. This, in my opinion, would still be an excellent deal.

The background to this debate are two analyses of the Sanders’ single payer proposal—the first by economist Kenneth Thorpe and the second by the Urban Institute—both of which claimed that the actual costs of Sanders’ single payer plan would be significantly higher than what his campaign has predicted. The assumptions of each have been convincingly contested by colleagues David Himmelstein and Steffie Woolhandler: among other points, they argue that both analyses underestimate administrative savings and overestimate the cost of increased health care use resulting from a coverage expansion.

Anyway, without delving into the details, there is something rather puzzling when looking at the analyses of Thorpe and the Urban Institute from a broader perspective. How is it that single payer would massively increase costs in the United States, as these reports contend, even while countries with single payer-type systems—like Canada and the United Kingdom—have much, much lower health care costs than we do?

To answer, a quick side note: our total health spending is, by definition, equal to the quantity of health services delivered multiplied by their price. The US does not consistently use more health services than other high-income nations. Therefore, the fact that we have higher health care costs is mostly explained by higher unit prices for services, as Sanger-Katz and others note. Now us single payer advocates cite lower administrative costs (and lower drug spending) as the major sources of savings under US single payer (effectively lowering the “price” side of the equation). But Sanger-Katz argues that this would be insufficient: prices would have to be slashed across the board, and some services would have to be cut:

“Making the American health care system significantly cheaper would mean more than just cutting the insurance companies out of the game and reducing the high administrative costs of the American system. It would also require paying doctors and nurses substantially lower salaries, using fewer new and high-tech treatments, and probably eliminating some of the perks of American hospital stays, like private patient rooms.”

Such a transition would, she notes, have some scary sounding downstream consequences: “…making big cuts all at once to doctors and hospitals could cause substantial disruptions in care. Some hospitals would go out of business. Some doctors would default on their mortgages and student loans.” My understanding is that we aren’t really allowed to effectively default on student loans, but admittedly this all sounds rather dicey.

But this frightful health care meltdown isn’t even in the cards. She is correct in a narrow sense: it’s true that immediately lowering US health care expenditures to, say, that of the United Kingdom — i.e. from 16.4% to 8.5% of gross domestic product — would require major, disruptive reductions in spending across the board. However, nobody is contending that we do that. The central claim for US single payer is more modest. Use the enormous administrative savings generated under single payer financing in combination with pharmaceutical savings to cover everybody with comprehensive benefits and no cost-sharing. Overall national health spending would, it is true, remain roughly the same (though we could better control cost growth moving forward). But this scenario of widespread hospital bankruptcies and the end of private (or semiprivate?) hospital rooms is a fantasy: nobody wants it to happen, and it’s not happening.

It’s worth noting that there is also a jarringly inconsistent aspect to single-payer critiques that warn of the threat to health care workers’ income. As Woolhandler and Himmelstein note in an article in the Huffington Post, the Urban Institute simultaneously asserted that the coverage expansion under single payer would lead to an enormous increase in spending on physician services — by $1.6 trillion over a decade!—while simultaneously asserting that physician salaries would be “squeezed.” Whatever one thinks of how much physicians should be paid, it’s hard how these would both happen at the same time.

Transitioning to single payer will not mean reducing our health care expenses to British levels: that is probably not possible, and is certainly not desirable. But that’s not to say that the savings from adopting a single payer financing system wouldn’t be substantial—we’re talking hundreds of billions annually on administrative savings alone, plus more by reducing drug prices to European levels. With that money, we’ll build a much more decent health care system for all to use without having to worry about the cost of being sick, of being pregnant, or simply of obtaining preventive care. No wonder a majority of the country wants it.

Dr. Adam Gaffney is a clinical and research fellow in pulmonary and critical care medicine at Massachusetts General Hospital. His writing has appeared in the New Republic, Los Angeles Review of Books, USA Today, Salon, CNN.com, Dissent, US News & World Report, Jacobin, In These Times, and elsewhere.

https://theprogressivephysician.net/2016/05/17/blog-post-whats-wrong-with-margot-sanger-katzs-single-payer-analysis/

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.

Medical school: An invitation for activism toward single-payer

By Josh Faucher
Students for a National Health Program blog, May 16, 2016
 
I’ve been a part of SNaHP since the beginning, watching our annual gathering grow from a few dozen people in a small conference room in 2012, to the massive turnout we had this spring with representatives from around the country.

Each year, I’m impressed with the reality that many of our most enthusiastic and active members are students early in their medical school journeys, many of whom haven’t had much contact with patients yet. When I first began medical school, it was easy to get caught up in the praise and aggrandizement that was heaped upon us – the constant congratulations for joining a profession as well-respected and impactful as medicine. It is true that physicians can have a profound impact on the lives of our patients, curing terrible diseases and lessening the suffering caused by chronic ailments. In looking at the nature of the health care system as a whole, however, I have seen clear examples of how access is rationed based on a patient’s financial resources, and how seeking health care can leave patients vulnerable to harm that affects their livelihoods and economic security.

As a new resident, when I look back on medical school, there were many things that left me less confident in my ability to avoid doing harm as a physician.

Take, for instance, the guest speaker we had during my second year of medical school, a young woman in her 20s (let’s call her Sarah) who recounted her battle with acute lymphocytic leukemia, a cancer that strikes suddenly and can be fatal in a matter of hours. Sarah described to us the physical challenges she faced while receiving chemotherapy, and the fantastic care she had received from her physicians. As I listened to her story, I wondered whether, as a young person who had just entered the workforce, she had the financial resources to pay for her care. At the end of her presentation, I asked her, and it turned out that cancer devastated more than just her body.

Sarah’s illness prevented her from working and when she eventually lost her job, she lost her insurance, too. The hospital bills that followed quickly depleted her savings until she was forced to go on Medicaid. She described this as an extremely difficult experience that caused her considerable shame. For some reason, to this patient and others who told us stories of illness, the consistent assumption seemed to be that future doctors didn’t need to hear about, or wouldn’t be interested in, the financial problems caused by our health care system.

I strongly believe that no one should experience shame or financial ruin just because they get sick. I think many of my classmates would agree, but if patients aren’t given a chance to share that side of their experience, we can’t expect their physicians to become aware of the problem solely through intuition.

There was also the middle-aged man – I’ll call him Bill – who I met during one of my clinical rotations. Bill had a chronic mental illness and an unstable, intermittent employment status, but nevertheless was surviving on his own in the community. He presented to the clinic with shortness of breath after a temporary construction job had been halted because of the discovery that he and his co-workers had been exposed to asbestos. It took multiple visits for us to explain to him that asbestos causes disease many years after exposure, and that, instead, he was experiencing symptoms related to longstanding COPD. Worker’s comp, of course, would not pay to manage this chronic preexisting disease, and Bill experienced considerable distress until we were able to enroll him in Medicare because of his new disability. With a universal, comprehensive insurance system his disease might have been detected earlier, or smoking cessation therapy could have been emphasized when he was young. Instead, he’ll live with COPD for the rest of his life, and will probably die from it.

Then there’s me. I was born with a serious heart defect that required surgery when I was a toddler, and again when I was 13 years old. Despite facing health challenges during my own life, I consider myself privileged. I’m privileged to have had a better outcome than many others in the same situation; I’m privileged to have never missed one of the annual cardiologist visits that will determine when I need to have my next operation; and I’m privileged because I happened to have the best hospital in the country in-network on my insurance while attending medical school.

Nevertheless, despite having insurance, I have to pay hundreds or thousands of dollars in deductibles and copayments out-of-pocket every year to monitor a health condition I have through no fault of my own. If I was like millions of working Americans living paycheck-to-paycheck, unable to save money let alone pay thousands of dollars for medical bills, I might have to skip yearly checkups to take care of other necessities first. If I were truly poor and on Medicaid, I might have to travel long distances or wait many weeks to find a physician who would take me for an appointment. In either case, I might not get the care I need until I deteriorate to a point that would cause me permanent harm.

The Affordable Care Act has not done nearly enough to address the barriers to health care that exist due to our broken insurance system. Under Obamacare, the United States remains the only industrialized capitalist democracy on the planet that does not provide universal health care access to its entire population. Indeed, even if it works as well as it possibly can, Obamacare will leave over 30 million people uninsured and without access to basic care. Those benefiting from the law are forced into a relationship with private insurers, the same companies that previously denied people for preexisting conditions and cut policies when people got sick until those practices were outlawed by Congress.

Now, the insurance companies have a different approach to maximizing their revenue: they lure buyers on the exchange with low premiums, and then slam them with high deductibles. An annual deductible of thousands of dollars before insurance kicks in can quickly empty a family’s savings account, and does little to protect them from health care costs.

As a member of SNaHP and PNHP, I advocate for an alternative along with other medical students and physician: an improved version of Medicare that would apply to the entire population; a universal, single-payer, publicly financed and administered insurance system. By its very nature, such a system would apply to the entire citizenry from birth to death, and would reduce or eliminate out-of-pocket costs for medical care. It could be progressively financed while providing universal, equitable access. Unlike the hodgepodge of secretive private companies providing insurance right now, Medicare-for-all would be transparently financed and publicly accountable through the democratic process. With the entire population invested in the program, the adequacy of reimbursement for medical expenses would be a top priority.

Most importantly, a Medicare-for-all program would reduce our out-of-proportion spending on health care while at the same time expanding coverage and access to everyone. It would greatly reduce the need for providers to maintain complicated administrative structures for billing multiple insurers, and would act as a strong negotiator to prevent unfair profiteering by pharmaceutical and device manufacturers. An analysis by the Lewin Group in 2012 estimated that a single-payer system would have saved my state of Minnesota $4.1 billion in 2014, while economists estimate that single-payer on a national scale would save an estimated $592 billion annually.1 Think of the boost our economy would receive if people were no longer going bankrupt because of medical expenses. Medicare for all would also free the private sector from the burden of providing health insurance as an employee benefit, reducing wage stagnation and making our industries more competitive on the global market.

The need for single-payer health insurance is complex, but the concept itself is simple. The vast majority of my classmates are becoming young physicians with the goal of relieving suffering and providing patients the opportunity to live their lives to the fullest. As economic inequality comes to the forefront as a national issue, medical students are increasingly realizing that the current health insurance system frequently promotes that inequality rather than alleviating it, and just like me they are coming to recognize single-payer health insurance as a necessary, if not sufficient, step to make the provision of health care a tool for social justice.

Our movement has grown larger every year, and the reach of our message has never been broader. If our expanding membership continues to spread awareness about the problems of our health care system and the solutions offered by single-payer health care, our goal will soon be realized and I’ll be able to consider my involvement to be a success.

If you care about a health care system that serves the needs of everyone, not just the privileged or the wealthy, there is room for you in this movement.

Josh Faucher will graduate from Mayo Medical School on May 21 and is pursuing a career in emergency medicine. He co-founded the Mayo Medical School chapter of SNaHP, helped SNaHP grow as a student offshoot of PNHP with national scope, and currently serves as a student member on the PNHP Board of Directors. You can email him at josh.faucher@gmail.com

Reference note

1. Cost and Economic Impact Analysis of a Single-Payer Plan in Minnesota; http://growthandjustice.org/images/uploads/LEWIN.Final_Report_FINAL_DRAFT.pdf

https://student.pnhp.org/201-2/

Sanders’ health care plan

By Ernest A. Canning
Ventura County (Calif.) Star, May 16, 2016

Re: Martin Schram’s column May 13, “Sanders escapes watchdogs’ bark”:

Martin Schram underscores the wisdom behind Mark Twain’s observation that “a lie can travel halfway around the world while the truth is putting on its shoes.”

He repeats the canard, initiated by The Washington Post and reinforced by the billionaire-funded Brookings Institute, that Bernie Sanders’ single-payer health care plan would add $18 trillion to the deficit. In truth, as revealed by University of Massachusetts Amherst economist Gerald Friedman, a single-payer system would save $5 trillion.

Per capita, the U.S. spends three times as much for health care than the U.K., whose taxpayer-funded National Health Service provides health care to citizens without additional charges or co-pays. In 2013, U.S. taxpayers footed the bill for 64.3 percent of U.S. health care — about $1.9 trillion. Yet in the U.S. nearly 30 million of our citizens still lack any form of insurance coverage.

The for-profit U.S. health care system is corrupt, dysfunctional and deadly. In Canada, only 1.5 percent of health care costs are devoted to administration of its single-payer system. In the U.S., 31 percent of health care expenditures flow to the private insurance industry. Americans pay far more for prescription drugs. Last year, CNN reported, Americans paid nearly 10 times as much for prescription Nexium than it cost in the Netherlands.

Before Obamacare, 47 million Americans were uninsured. According to a pre-Obamacare Harvard study, 45,000 Americans died each year for lack of coverage. Through wasteful insurance subsidies, we’ve experienced a 36 percent reduction in the number of uninsured. Simple but ghastly arithmetic suggests our for-profit system is still killing 28,000 Americans each year.

In the U.K., no one one faces personal bankruptcy due to medical expenses. In the U.S., half of all personal bankruptcies are health care-related.

Ernest A. Canning resides in Thousand Oaks.

http://www.vcstar.com/opinion/letters-to-the-editor/Sanders-health-care-plan-379662041.html

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.

Dr. Sean Lehmann on ‘Nevada NewsMakers’

Dr. Sean Lehmann, chair of the Nevada chapter of Physicians for a National Health Program, appeared on “Nevada NewsMakers” with host Sam Shad on May 17, 2016. Dr. Lehmann discussed the urgent need for single-payer national health reform, and contrasted his experience billing Medicare with his experience billing private insurance companies. The segment with Dr. Lehmann begins at approximately the 2:36-minute mark.

For more information on PNHP activities in Nevada, please visit the Nevada state page on our website, and/or “like” the chapter’s Facebook page.

Gallup: Majority support federally funded health care system

Majority in U.S. Support Idea of Fed-Funded Healthcare System

By Frank Newport
Gallup, May 16, 2016

Presented with three separate scenarios for the future of the Affordable Care Act (ACA), 58% of U.S. adults favor the idea of replacing the law with a federally funded healthcare system that provides insurance for all Americans. At the same time, Americans are split on the idea of maintaining the ACA as it is, with 48% in favor and 49% opposed. The slight majority, 51%, favor repealing the act.

The results show that many Americans are OK with several ways of handling the ACA rather than favoring only one possibility. In particular, 35% of all Americans say they would favor keeping the ACA in place and separately say they favor the idea of replacing it with a federally funded universal health insurance system. Among Democrats and Democratic leaners, 59% favor both of these approaches. In short, many Americans would apparently go along with Clinton’s idea of keeping the ACA in place as it is now, or with Sanders’ bolder proposal to replace it with a Medicare-for-All system.

Gallup also asked those who favor either keeping the ACA in place or replacing it with a federally funded system to choose between these two options. The federally funded system wins among this group by a 2-to-1 ratio, 64% to 32%, meaning this system garners the most support among the initial favor/oppose questions and wins when those who like both approaches are forced to choose.

Additionally, 27% of Americans say they favor repealing the ACA and say they favor replacing it with a federally funded system. This means the group of Americans in this survey who favor the law’s repeal, a core policy proposal of many Republican presidential candidates during this campaign season, includes some who apparently want the ACA repealed to replace it with an even more liberal system. Only 22% of Americans say they want the ACA repealed and do not favor replacing it with a federally funded system.

The breakdown of reactions to these proposals by partisanship shows the expected patterns: Democrats and Democratic-leaning independents are highly likely to favor the two options put forth by the Democratic candidates, while Republicans and Republican leaners are highly likely to favor Trump’s position, repeal of the ACA.

One notable exception to the strong partisan skew in reactions to these proposals comes from Republicans when they are asked about replacing the ACA with a federally funded system. Forty-one percent of Republicans favor the proposal — much higher than the 16% who favor keeping the ACA in place. This may reflect either that Republicans genuinely think a single-payer system would be good for the country, or that they view any proposal to replace the ACA (“Obamacare”) as better than keeping it in place.

Bottom Line

Americans express considerable support for the idea of replacing the ACA with a federally run national healthcare system, which is similar to the proposal championed by presidential candidate Sanders. To be sure, many Americans, primarily Democrats, also favor the idea of just keeping the ACA in place. But given a choice, those who favor both proposals come down on the side of the Sanders-type proposal. Four in 10 Republicans also favor the idea of a federally funded system.

http://www.gallup.com/poll/191504/majority-support-idea-fed-funded-healthcare-system.aspx

***

Comment:

By Don McCanne, M.D.

Although this new Gallup poll has been widely interpreted in the media as showing strong national support for single payer reform, the actual question was about favoring or opposing “Replacing the ACA with a federally funded healthcare program providing insurance for all Americans,” and it was asked with two other options (repealing ACA, keeping ACA in place), any or all of which could be chosen. Replacing ACA with federally funded health care was supported by 58%, repeal ACA by 51%, and keeping ACA by 48%.

Perhaps one of the more important findings in this poll was that 27% of Americans favor both repealing ACA and replacing it with a federally funded system. Since 45% of all Americans support repeal of ACA, this means that over half of those favoring repeal want it replaced with a federally funded system. That gives a new slant to the repeal and replace clarion call of the Republicans.

In fact, 41% of Republicans favor replacing ACA with a federally funded system whereas only 16% of them prefer to keep ACA in place.

Based on this poll, it is no wonder that the May 16 headline in The Washington Post read, “Poll: Most Americans want to replace Obamacare with single-payer — including many Republicans.”

When those who favor either keeping the ACA in place or replacing it with a federally funded system were asked to choose between the two, 32% favored keeping ACA and 64% favored replacing it with a federally funded system.

This should reinvigorate those of us who are working so hard to bring to America the health care system that we need and want – a single payer improved Medicare for all.

Single Payer, Susan Dentzer, and the Diane Rehm Show

By Russell Mokhiber
Single Payer Action, May 17, 2016

The Diane Rehm Show this morning was devoted to the topic — The Affordable Care Act Three Years In: What’s Working And What’s Not.

The guests on the show were Julie Rovner, senior correspondent, Kaiser Health News, Stephanie Armour, healthcare reporter, Wall Street Journal, and Susan Dentzer CEO of the Network for Excellence in Health Innovation (NEHI) — what Dentzer describes as “a non-profit think-tank.”

Just yesterday, the Washington Post ran an article about a Gallup poll under the headline — Most Americans want to Replace Obamacare with Single Payer — Including Many Republicans.

But single payer wasn’t raised as a possibility by any of the guests — until a caller raised it about three quarters of the way through the show.

In response, Armour, Dentzer and Rovner all talked about how much more expensive single payer would be than Obamacare.

Only Diane Rehm seemed sympathetic to single payer.

“Bernie Sanders Medicare for All program would create a single payer system,” Dentzer said. “It has very large payroll tax increases and income tax increases in it to fund it. A legitimate question is — is the American public ready to move from the system we have now — yes we have high deductibles for many people, yes they are paying high premiums — but are we willing to move and float all of the those expenses through the government coffers and pay much higher payroll taxes and much higher income taxes?”

Rehm asks Rovner — what would Bernie Sanders proposal cost?

“A lot more than he has floated in income tax increases,” Rovner said. “The Urban Institute last week estimated that it is $18 trillion short of paying for itself.”

With that statement, Rovner gave the back of her corporate hand to David Himmelstein and Steffie Woolhandler, who recently wrote that the Urban Institute’s estimates “are ridiculous.”

“They project outlandish increases in the utilization of medical care, ignore vast savings under single-payer reform, and ignore the extensive and well-documented experience with single-payer systems in other nations — which all spend far less per person on healthcare than we do,” they wrote.

Rovner said that “it’s important to know that what Bernie Sanders is proposing is not what Medicare is.”

“Medicare as it exists today has lots and lots of requirements for patients for co-pays,” Rovner said. “The deductibles are not that high in Medicare, although the hospital deductible is substantial. But the ongoing out of pocket costs can be enormous. That’s why most people who have Medicare have supplemental insurance. What Bernie Sanders is talking about is that there would be no need for supplemental insurance — that this new Medicare would pay pretty much for everything. That is what would make it so expensive. And that would be a level that even other countries who have single payer plans don’t have.”

Ignoring the results of the Gallup poll, Armour says that while single payer “has intrigued people for decades, it has never gotten a majority of support and in the current political climate, it would be very difficult.”

Given that Rehm had three guests dissing single payer, she felt she had to stand up for it. Since when, she asked, did Congress start ignoring “what people want”?

Armour said that while single payer has always had strong support, “it’s been a plurality, not a majority.”

“There simply isn’t fifty percent plus one and there hasn’t been,” Armour said. “What we are seeing now is the other side — give people more skin in the game. Make them pay more of their own health care bills. And maybe they will shop better.”

Shop better? You mean like in states like West Virginia where there is exactly one insurance company in the Obamacare marketplace?

Shop better?

The last time the Diane Rehm show devoted an hour to single payer was in May 2009.

The guests were Bernie Sanders, David Himmelstein, Roger Hickey — who was pushing a public option — and Susan Dentzer, who was then identified as senior policy adviser, The Robert Wood Johnson Foundation, and on-air analyst on health issues, PBS NewsHour.

During that show, Rehm asked Dentzer why we don’t have a single payer system in the United States and Dentzer replied — “we had a private insurance industry develop.”

“It now has revenues in excess of $400 billion a year. And it’s a very effective interest group,” Dentzer said.

Dentzer should know.

While Dentzer’s group calls itself The Network for Excellence in Health Innovation, in fact if you look at its board of directors, it’s dominated by executives affiliated with health insurance companies (Blue Cross Blue Shield of Massachusetts and HCA) and drug companies (Genzyme Corporation, Sanofi and Merck.)

No wonder she’s hostile to single payer.

Russell Mokhiber is editor of the Washington, D.C.-based Corporate Crime Reporter.  He is also founder of singlepayeraction.org, and editor of the website Morgan County USA.

http://www.singlepayeraction.org/2016/05/17/single-payer-and-the-diane-rehm-show/

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.

Gallup: Majority support federally funded health care system

Majority in U.S. Support Idea of Fed-Funded Healthcare System

By Frank Newport
Gallup, May 16, 2016

Presented with three separate scenarios for the future of the Affordable Care Act (ACA), 58% of U.S. adults favor the idea of replacing the law with a federally funded healthcare system that provides insurance for all Americans. At the same time, Americans are split on the idea of maintaining the ACA as it is, with 48% in favor and 49% opposed. The slight majority, 51%, favor repealing the act.

The results show that many Americans are OK with several ways of handling the ACA rather than favoring only one possibility. In particular, 35% of all Americans say they would favor keeping the ACA in place and separately say they favor the idea of replacing it with a federally funded universal health insurance system. Among Democrats and Democratic leaners, 59% favor both of these approaches. In short, many Americans would apparently go along with Clinton’s idea of keeping the ACA in place as it is now, or with Sanders’ bolder proposal to replace it with a Medicare-for-All system.

Gallup also asked those who favor either keeping the ACA in place or replacing it with a federally funded system to choose between these two options. The federally funded system wins among this group by a 2-to-1 ratio, 64% to 32%, meaning this system garners the most support among the initial favor/oppose questions and wins when those who like both approaches are forced to choose.

Additionally, 27% of Americans say they favor repealing the ACA and say they favor replacing it with a federally funded system. This means the group of Americans in this survey who favor the law’s repeal, a core policy proposal of many Republican presidential candidates during this campaign season, includes some who apparently want the ACA repealed to replace it with an even more liberal system. Only 22% of Americans say they want the ACA repealed and do not favor replacing it with a federally funded system.

The breakdown of reactions to these proposals by partisanship shows the expected patterns: Democrats and Democratic-leaning independents are highly likely to favor the two options put forth by the Democratic candidates, while Republicans and Republican leaners are highly likely to favor Trump’s position, repeal of the ACA.

One notable exception to the strong partisan skew in reactions to these proposals comes from Republicans when they are asked about replacing the ACA with a federally funded system. Forty-one percent of Republicans favor the proposal — much higher than the 16% who favor keeping the ACA in place. This may reflect either that Republicans genuinely think a single-payer system would be good for the country, or that they view any proposal to replace the ACA (“Obamacare”) as better than keeping it in place.

Bottom Line

Americans express considerable support for the idea of replacing the ACA with a federally run national healthcare system, which is similar to the proposal championed by presidential candidate Sanders. To be sure, many Americans, primarily Democrats, also favor the idea of just keeping the ACA in place. But given a choice, those who favor both proposals come down on the side of the Sanders-type proposal. Four in 10 Republicans also favor the idea of a federally funded system.

http://www.gallup.com/poll/191504/majority-support-idea-fed-funded-healthcare-system.aspx

Although this new Gallup poll has been widely interpreted in the media as showing strong national support for single payer reform, the actual question was about favoring or opposing “Replacing the ACA with a federally funded healthcare program providing insurance for all Americans,” and it was asked with two other options (repealing ACA, keeping ACA in place), any or all of which could be chosen. Replacing ACA with federally funded health care was supported by 58%, repeal ACA by 51%, and keeping ACA by 48%.

Perhaps one of the more important findings in this poll was that 27% of Americans favor both repealing ACA and replacing it with a federally funded system. Since 45% of all Americans support repeal of ACA, this means that over half of those favoring repeal want it replaced with a federally funded system. That gives a new slant to the repeal and replace clarion call of the Republicans.

In fact, 41% of Republicans favor replacing ACA with a federally funded system whereas only 16% of them prefer to keep ACA in place.

Based on this poll, it is no wonder that the May 16 headline in The Washington Post read, “Poll: Most Americans want to replace Obamacare with single-payer — including many Republicans.”

When those who favor either keeping the ACA in place or replacing it with a federally funded system were asked to choose between the two, 32% favored keeping ACA and 64% favored replacing it with a federally funded system.

This should reinvigorate those of us who are working so hard to bring to America the health care system that we need and want – a single payer improved Medicare for all.

sdrawkcab reform

Sorry, We Don’t Take Obamacare

By Elisabeth Rosenthal
The New York Times, May 14, 2016

Amy Moses and her circle of self-employed small-business owners were supporters of President Obama and the Affordable Care Act. They bought policies on the newly created New York State exchange. But when they called doctors and hospitals in Manhattan to schedule appointments, they were dismayed to be turned away again and again with a common refrain: “We don’t take Obamacare,” the umbrella epithet for the hundreds of plans offered through the president’s signature health legislation.

“Anyone who is on these plans knows it’s a two-tiered system,” said Ms. Moses, describing the emotional sting of those words to a successful entrepreneur.

The goal of the Affordable Care Act, which took effect in 2013, was to provide insurance to tens of millions of uninsured or under-insured Americans, through online state and federal marketplaces offering an array of policies. By many measures, the law has been a success: The number of uninsured Americans has dropped by about half, with 20 million more people gaining coverage.

Yet even as many beneficiaries acknowledge that they might not have insurance today without the law, there remains a strong undercurrent of discontent. Though their insurance cards look the same as everyone else’s — with names like Liberty and Freedom from insurers like Anthem or United Health — the plans are often very different from those provided to most Americans by their employers. Many say they feel as if they have become second-class patients.

Some early studies of the impact of the Affordable Care Act plans are proving patients’ grumbling justified: Compared with the insurance that companies offer their employees, plans provide less coverage away from patients’ home states, require higher patient outlays for medicines and include a more limited number of doctors and hospitals, referred to as a narrow network policy. And while employers tend to offer their workers at least one plan that allows them coverage to visit doctors not in their network, patients buying insurance through A.C.A. exchanges in some states do not have that option, even if they’re willing to pay higher premiums.

The research thus far suggests that the differences between plans offered through the A.C.A. and those offered by employers may be quite significant. A study in the policy journal Health Affairs found that out-of-pocket prescription costs were twice as high in a typical silver plan — the most popular choice — as they were in the average employer offering. In research conducted with the Robert Wood Johnson Foundation, Dr. Polsky found that 41 percent of silver plans offered a “narrow or very narrow” selection of doctors, meaning at best 25 percent of physicians in an area were included. The consulting firm Avalere Health found that exchange plans had 42 percent fewer cancer and cardiac specialists, compared with employer-provided coverage.

When designing the new plans, for-profit insurers naturally tended to exclude high-cost, high-end hospitals with whom they had little clout to negotiate discounts. That means, for example, that as of late last year none of the plans available in New York had Memorial Sloan Kettering Cancer Center in their network — an absence that would be unacceptable to many New York-based employers buying policies for their employees.

And when Simon F. Haeder of the University of Wisconsin and his colleagues studied the plans sold on the California exchange, they found that they included 34 percent fewer hospitals than those sold on the open market and tended to exclude the priciest medical centers, like Cedars Sinai, a highly regarded hospital that runs the largest heart-transplant program in the country.

http://www.nytimes.com/2016/05/15/sunday-review/sorry-we-dont-take-obamacare.html

***

Special Enrollment Periods for the Health Insurance Marketplace

CMS.gov, May 6, 2016

Special Enrollment Periods

While SEPs provide a critical pathway to coverage for qualified individuals who experience qualifying events and need to enroll in or change qualified health plans (QHPs) outside of the annual open enrollment period, it’s equally important to avoid SEPs being misused or abused.  As it announced today, HHS is tightening the rules for certain special enrollment periods and making clear that SEPs are only available in six defined and limited types of circumstances.

An Interim Final Rule with Comment (IFC) published in the Federal Register provides that individuals requesting a “permanent move” SEP must have minimum essential coverage for one or more days in the 60 days preceding the permanent move, unless they were living outside of the United States or in a United State territory prior to the permanent move. This ensures that individuals are not moving for the sole purpose of obtaining health coverage outside of the open enrollment period.

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-05-06.html

***

Comment:

By Don McCanne, M.D.

When explaining that health care reform seems to be moving backwards, does it improve communication to discuss reform that is sdrawkcab (ananym of backwards)?

NYT’s Elisabeth Rosenthal has provided us with another great article that describes how some of the supposedly forward advances in reform are really backwards. The ACA exchange plans are undoing some of the financial protection that health insurance should afford us, while impairing access through narrower provider networks. If we said that this reform is sdrawkcab, would that help us understand it better?

As small business owner Amy Moses stated, “Anyone who is on these plans knows it’s a two-tiered system.” Does it not seem absurd that the policies inherent in ACA would place a business owner in the lower tier of a two-tiered system? Isn’t that sdrawkcab? Yes and no. Actually what is sdrawkcab is that we would even have tiers in our health care system when it would be much more efficient, more equitable, and more effective to have a single high level system for everyone – an improved Medicare for all.

A specific example of the wrong direction in which too much of our policy is headed is provided by the new CMS rule that describes yet another technical reason to prohibit individuals from obtaining coverage through special enrollment periods. Although health reform supposedly was designed to expand access to insurance plans, this rule is sdrawkcab in that it prohibits access for certain uninsured individuals. True, the rule was designed to protect insurers from individuals who might have an acute need for coverage outside of the open enrollment period, but the entire system should have been designed to automatically enroll everyone instead of ignoring individual needs while providing insurers with their optimal business model.

No more sdrawkcab reform. Everybody in, nobody out!

What single-payer healthcare would mean to doctors

By Liz Seegert
Medical Economics, May 25, 2016

Health insurance is again in the political spotlight as Democratic presidential candidate Bernie Sanders promotes his version of single-payer that he calls “Medicare for all.” He says it will improve care, reduce administrative burdens and allow physicians to focus just on practicing medicine. Dissenters say it’s a pipe dream that will only lead to rationed care, lower reimbursement rates and long waiting lists.

Single payer is held up by supporters as the ideal egalitarian healthcare model. If other nations can provide expansive medical care for their citizens, they ask, why can’t the U.S.? Opponents disparage the idea as anti-choice; they predict the implosion of the healthcare system and demise of physician autonomy.

Could single payer be the boon to medical practice its supporters insist? Or would we end up with a system that limits care and ignores best practices in favor of the bottom line? Who’s right?

The short answer is, both sides are.

Continue reading…

http://medicaleconomics.modernmedicine.com/medical-economics/news/what-single-payer-healthcare-would-mean-doctors

Single payer essential to controlling health-care costs

By David Woods
The Philadelphia Inquirer, May 16, 2016

One hears these days mutterings by disaffected Americans that if Donald Trump becomes president, they will pack their bags and leave for Canada. One assumes, of course, that no wall will be built along the border to thwart their exit.

I made the reverse trip. Having emigrated from Britain to Canada, where I became the editor in chief of the Canadian Medical Association Journal, I opted to come to the United States in 1988 for personal reasons.

But I was also taken with American rugged individualism and a health-care system focused on market forces and competition. I wrote articles for the Economist Intelligence Unit and other periodicals on the wonders of the American system. In print, I debated longtime advocates of single-payer national health insurance, extolling the virtues of the health-care market that others abhorred.

Gradually, though, I too began to have doubts about market-driven health care. Over the 25 years that I’ve lived on the U.S. side of the border, I’ve come to the view that the American health-care system – which still leaves 11 percent of the population uninsured, despite the Affordable Care Act – is inferior to the health systems in Canada and the United Kingdom.

One of the ACA’s architects, Dr. Ezekiel Emanuel, describes the U.S. health system as a “terribly complex, blatantly unjust, outrageously expensive, grossly inefficient, error-prone system.” Unfortunately, that’s still true, six years after the ACA’s passage.

The reform didn’t address the fundamental problem in U.S. health care: It’s more about profit than patients.

Controlling health-care costs is essential to the long-term financial health of the United States. A single-payer system would make truly universal coverage affordable, costing no more than we already spend on health care. Of the $3.1 trillion the United States will spend on health care this year, 63 percent is taxpayer-financed, funding Medicare, Medicaid, and Veterans Affairs, along with private coverage for government employees and tax subsidies for employers.

Because of its fragmented, profit-driven system, the United States spends 18.1 percent of gross domestic product on health care, compared with about 8 percent in Britain and 11 percent in Canada. Much of U.S. health spending is simply wasted. For example, 25.3 percent of hospital expenditures go to administrative costs, compared with 12.4 percent in Canada, where there is a single payer in each province and hospitals are mainly funded on a global or lump-sum basis.

Canadians also save money by training a higher percentage of primary-care doctors relative to specialists, negotiating drug prices with pharmaceutical companies, and prohibiting drug companies from advertising directly to consumers. These measures would save Americans billions annually. Americans spend $1,010 per capita on pharmaceuticals; Swedes spend less than half that, according to the Organization for Economic Cooperation and Development. The reason? Sweden doesn’t pay the list price.

Lobbying and influence-peddling by the pharmaceutical and insurance industries keeps the United States from adopting a single-payer health system. Several presidential candidates this season seemed completely under their hypnotic sway. The private insurance industry brazenly tells me, now a U.S. voter, which doctors I can see, charges me astronomical premiums, not to mention co-pays and deductibles, and then wants me to believe that having publicly funded health care that would allow me to go to any doctor in the United States without a $5,000 deductible would be “socialism.”

And don’t believe the widely held U.S. notion that Canadians suffer long waits for care. That’s a canard. We are not going to cut U.S. health spending to Canadian levels. With our much higher level of spending, waits would not be an issue, even with the population aging. Japan and many countries in Europe already have higher percentages of elderly citizens than the graying of the baby boomers is projected to produce.

In his book “In Search of the Perfect Health System,” British economist Mark Britnell notes that the British love their single-payer National Health Service because of its fairness; it’s available to everyone. He even quotes a former U.K. finance minister who said that the NHS is the closest thing the English have to a religion. Their single-payer system keeps quality indexes up and costs down for the population at large. This enables the British to invest additional funds in education and economic stimulation, areas that also contribute to health and well-being.

The United States should take a lesson from the example of nations with single-payer systems. They offer a measure of hope and optimism that high-quality health care can be the right of all Americans, if they demand it.

David Woods is a former editor in chief of the Canadian Medical Association Journal. hmi3000@comcast.net

http://www.philly.com/philly/health/20160516_Commentary__Single-payer_essential_to_controlling_health-care_costs.html

Why American doctors are calling for Canadian-style medicare

At a time doctors to the south are looking to Canada for answers, we are at risk of losing the health advantage we have

By Karen Palmer
Toronto Star, May 15, 2016

In a dramatic show of physician support for deep health care reform in the U.S., more than 2,200 physician leaders have signed a “Physician’s Proposal” calling for sweeping change.

The proposal, published May 5 2016 in the American Journal of Public Health, calls for the creation of a publicly financed, single-payer, national health program to cover all Americans for all medically necessary care.

If that sounds familiar, it should. These American doctors are calling for Canadian-style medicare. They want a decisive break from the expensive and inefficient private insurance industry at the heart of the U.S. health care system.

How ironic that at the same time U.S. physicians are calling for a single-payer health system like ours, Canada is in the midst of a legal battle threatening to pave the way for a multi-payer system resembling what has failed Americans.

What’s at stake? A trial about to begin in British Columbia threatens to make the Canada Health Act unenforceable.

The Canada Health Act is federal legislation that guides our health care system. It strongly discourages private payment for medically necessary hospital and physician services covered under our publicly funded medicare plans. This includes out-of-pocket payments in the form of extra billing or other user charges. Legislation in most provinces further prohibits private insurance that duplicates what is already covered under provincial plans.

If patients are billed for medically necessary hospital and physician care, the federal government is mandated to withhold an equivalent amount from federal cash transfers to provinces or territories violating the Act.

At least that’s what supposed to happen.

Unfortunately, the last decade saw a proliferation of extra billing in several provinces, and few instances of government clawing back fiscal transfers. Perhaps, things will change. Health Minister Jane Philpott recently said the government will “absolutely uphold the Canada Health Act.”

In B.C.’s upcoming trial, the plaintiffs — including two for-profit investor-owned facilities, Cambie Surgery Centre and the Specialist Referral Clinic — are attempting to have the court strike down limits on private payment. They support the creation of a constitutionally protected right for physicians to bill patients, either out-of-pocket or through private insurance, for medically necessary care, while also billing the public plan.

In other words, the plaintiffs want to undo our elegantly simple single payer system for hospital and physician care, creating instead a multi-payer system like the U.S. If their constitutional challenge is successful, the door will swing wide open in BC — and across Canada — for insurers to sell what will amount to “private queue jumping insurance” for those who can afford it, potentially harming the rest of us who can’t.

The outcome of this trial could be that those who can pay for care would jump the queue, drawing doctors and other resources out of the public system. Those who can’t pay would likely wait longer. Rather than a solution for wait times, private payment in the Canadian context would make them worse.

Global evidence shows that private insurance does not reduce public system wait times. The Achilles heel of health care in several European countries, such as Sweden, has been long waiting times for diagnosis and treatment in several areas, despite some private insurance. After Australia introduced private insurance to save the government money, those with private insurance have faster access to elective surgery than those without. Divisions in equitable access to care is one of the biggest challenges now facing countries that have adopted multi-payer systems.

Multi-payer systems are administratively complex and expensive, explaining why the U.S. health insurance industry spends about 18 per cent of its health care dollars on billing and insurance-related administration for its many private plans, compared to just 2 per cent in Canada for our streamlined single payer insurance plans. Hospital administrative costs are lowest in Canada and Scotland — both single payer systems — and highest in the U.S., the Netherlands, and the U.K. — all multi-payer systems.

For all of its warts in how we deliver health care in Canada, the way in which we pay for care — a single public payer in each province or territory — avoids the high administrative costs of multi-payer systems.

Abundant evidence shows private insurance is at the root of what ails the U.S. system. Dr. Marcia Angell, co-author of the Physicians’ Proposal, Harvard Medical School faculty and former editor-in-chief of the New England Journal of Medicine, sums it up: “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.”

A Canadian-style single payer financing system would save the U.S. about $500 billion annually.

Meanwhile, in Canada, abandoning our single payer health care system for a U.S.-style multi-payer system would be the worst possible outcome for Canadians. Let’s hope the evidence convinces the judge. The trial begins in September.

Karen Palmer is an advisor with EvidenceNetwork.ca, a health policy analyst, and adjunct professor in the Faculty of Health Sciences at Simon Fraser University.

https://www.thestar.com/opinion/commentary/2016/05/15/why-american-doctors-are-calling-for-canadian-style-medicare.html