PNHP

CMS will likely continue to overpay Medicare Advantage plans

CMS will likely continue to overpay Medicare Advantage plans

Making Medicare Advantage Payments More Accurate

By Edwin Park
Center on Budget and Policy Priorities, February 16, 2016

Anticipating the Centers for Medicare and Medicaid Services’ (CMS) expected announcement Friday of preliminary payment rates and policies for Medicare Advantage insurers in 2017, insurers have pushed for changes to the “risk adjustment” system — which raises or lowers payments to plans based on their enrollees’ health.  Insurers claim the system undercompensates them for high-cost enrollees with chronic conditions.  We favor making the system as accurate as possible, but that should include reducing overpayments to insurers as well.

To be sure, risk adjustment tends to underpredict health spending for high-cost individuals in poorer health.  The Medicare Payment Advisory Commission (MedPAC) suggests that CMS make several changes to better account for higher spending by people with multiple chronic conditions and low-income beneficiaries eligible for both Medicare and Medicaid.

But Medicare Advantage risk adjustment also overcompensates insurers for healthier, low-cost enrollees.  For example, Avalere Health research, which insurers have cited favorably, shows risk adjustment overpredicting spending among people with no chronic conditions by 26.9 percent and among people with one or two chronic conditions by 5.1 percent.  That’s critical because Medicare Advantage enrollees are healthier than those in traditional Medicare, on average.

CMS could reduce Medicare Advantage overpayments by doing more to address “upcoding,” which the Congressional Budget Office, the Government Accountability Office (GAO), and academic research cite as a long-standing problem.  The risk adjustment system measures enrollees’ health using a “risk score” based on patient diagnoses; upcoding occurs when the risk scores that plans submit for their enrollees rise over time — making enrollees appear increasingly unhealthy — without actual changes in their health.

Risk scores have risen 9 percent faster in Medicare Advantage, on average, than in traditional Medicare for comparable beneficiaries, MedPAC estimates.  This leads to excessive payments to Medicare Advantage plans.

To compensate for upcoding, health reform requires CMS to adjust Medicare Advantage’s risk adjustment system by at least a minimum amount each year.  CMS has only applied the minimum required adjustment in recent years.  A larger adjustment, which MedPAC believes is warranted, would reduce overpayments to Medicare Advantage plans.

CMS could also reduce upcoding by excluding health assessments from risk score calculations unless they’re later confirmed in treatment settings, as MedPAC will likely recommend in its March report to Congress.  Medicare Advantage plans increasingly provide health assessments of their enrollees; for example, a nurse may come to a patient’s home to do a physical exam.  CMS has found that some insurers mainly use these assessments to “collect” diagnoses in order to raise enrollees’ risk scores for purposes of risk adjustment, rather than to improve follow-up care or identify illnesses requiring treatment.  In fact, CMS had proposed excluding these kinds of assessments but dropped this change in the face of industry opposition.

http://www.cbpp.org/blog/making-medicare-advantage-payments-more-accurate

***

2017 Medicare Advantage and Part D Advance Notice and Draft Call Letter

CMS.gov, February 19, 2016

Today, CMS released proposed updates to the Medicare Advantage (MA) and Part D programs through the 2017 Advance Notice and Draft Call Letter. Through these policies, CMS is proposing updates to the program designed to improve the accuracy of payments to plans serving beneficiaries who are dually eligible for Medicare and Medicaid.  

CMS is proposing updates to the Risk Adjustment Model used to calculate payments to Medicare Advantage plans and to the Star Rating system used to evaluate plan performance. In both cases, the updates reflect a public process through which CMS shared research findings and solicited public comment.

Expected Average Change in Revenue:  3.55%

Risk Adjustment Model

CMS is proposing to implement a new Risk Adjustment Model for 2017. The proposed new model has separate coefficients for partial benefit dually eligible beneficiaries, full benefit dually eligible beneficiaries, and non-dually eligible beneficiaries.  These proposed changes will improve the precision of the payments made to plans, including increases in payments for plans serving full benefit dually eligible beneficiaries.

Coding Pattern Adjustment

Each year, as required by law, CMS makes an adjustment to plan payments to reflect differences in diagnosis coding between Medicare Advantage organizations and fee-for-service (FFS) providers. In CY 2017, CMS proposes to make an adjustment reflective of the statutory minimum.

Using Encounter Data

CMS calculates risk scores using diagnoses submitted by FFS providers and by Medicare Advantage organizations. Historically, CMS has used Medicare Advantage diagnoses submitted into CMS’ Risk Adjustment Processing System (RAPS). In recent years, CMS began collecting encounter data from MA organizations to develop more accurate payment models. In 2016, CMS began using diagnoses from encounter data to calculate risk scores, by blending encounter data-based risk scores with RAPS-based risk scores. In 2017, CMS is proposing to continue using a blend, using a higher percentage of encounter data-based risk scores.

Star Ratings – Adjusting for Socioeconomic Status

CMS is proposing to implement a new analytical adjustment for a subset of Star Rating measures that is meant to adjust for plans serving dually eligible enrollees and/or enrollees receiving the low income subsidy, as well as enrollees with disabilities. Through this interim adjustment, CMS seeks to more accurately capture true plan performance, while work continues by the HHS Assistant Secretary for Planning and Evaluation (ASPE) and measure stewards in this important area.

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-02-19.html

CMS Advance Notice of Methodological Changes for Calendar Year (CY) 2017 for Medicare Advantage (MA) Capitation Rates, Part C and Part D Payment Policies and 2017 Call Letter (over 220 pages):

https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Advance2017.pdf

***

AHIP, Coalition for Medicare Choices Launch Nationwide Ad and Grassroots Campaign to Protect Medicare Advantage

AHIP, January 28, 2016

As CMS prepares to release proposed Medicare Advantage payment policies, AHIP’s Coalition for Medicare Choices (CMC) is launching a coast-to-coast mobilization of its 2 million Medicare Advantage beneficiaries who are calling on Washington to protect their coverage from further cuts.

“Medicare Advantage is the game-changer. It’s the foundation for innovative, high-quality care delivery that seniors and the country demand,” AHIP President and CEO Marilyn Tavenner said. “CMS should protect millions of beneficiaries who depend on Medicare Advantage and strengthen — not undermine — the program moving forward.”

https://www.ahip.org/News/Press-Room/2016/AHIP,-Coalition-for-Medicare-Choices-Launch-Nationwide-Ad-and-Grassroots-Campaign-to-Protect-Medicare-Advantage.aspx

***

Comment:

By Don McCanne, M.D.

Today CMS released proposed updates for the 2017 Medicare Advantage (MA) plans. It appears that, once again, CMS will be co-conspirators with the insurance industry in increasing net MA payment rates when the Affordable Care Act requires reduction of the MA overpayments.

The Medicare Payment Advisory Commission (MedPAC) has recommended that CMS apply a larger adjustment to the MA risk adjustment system to reduce overpayments to the MA plans. Yet, once again, as with prior years, CMS is making “an adjustment reflective of the statutory minimum.”

Another example is that the MA plans have been using “encounter data” to upcode the diagnoses of the MA patients. Home visits are made, not by the health care providers but by representatives of the MA insurance plans, in order to find other disorders that can be used to pad the diagnostic list, making these patients appear sicker than they really are, thus qualifying the MA plans for higher payments than warranted. MedPAC is expected to recommend excluding encounter data from risk score calculations unless they are later confirmed in treatment settings. Yet, CMS is instead proposing to use a higher percentage of encounter data-based risk scores.

Instead of a reduction in payments, CMS is proposing a 3.55% increase.

CMS invites comments through March 4, 2016 before the final publication on April 4, 2016. During that time, AHIP, the insurance lobby organization, will be negotiating with CMS for further adjustments that will favor the MA plans. Each year that has resulted in additional innovative chicanery that further thwarts the intent of ACA to reduce MA overpayments. Since the new President and CEO of AHIP is Marilyn Tavenner, the former Administrator of CMS, it is anticipated that the negotiations on behalf of the MA plans will be quite successful.

Ensuring success of the MA plans is part of the plot to eventually privatize Medicare – converting it into a premium support system (vouchers) for a market of private plans that will displace the traditional Medicare program. The value of the voucher equivalents will erode with time, shifting ever more of the costs to the Medicare beneficiaries. It will be disastrous.

By this time it was expected that MA plan enrollment would begin to decline since the private insurance industry is incapable of providing comparable benefits at the same or lower costs than traditional Medicare, because their administrative costs are significantly higher than those of the traditional program, plus they need to return a profit to their investors. They have been profitable only because they have continued to be successful in enrolling healthier, less costly patients while at the same time receiving overpayments from the government.

Thus this conspiracy reenacted each year to use innovative payment schemes (chicanery) is vital to this industry. Members of AHIP’s Coalition for Medicare Choices will, once again, pressure members of Congress to cajole CMS into “saving” the Medicare Advantage plans through whatever accounting tools they can find (all with a wink and a nod). What is surprising is that this has not provoked the outrage of taxpayers. But maybe this is not so surprising after all since hardly anyone recognizes the terrible crime that is taking place before our very eyes.

CMS will likely continue to overpay Medicare Advantage plans

Making Medicare Advantage Payments More Accurate

By Edwin Park
Center on Budget and Policy Priorities, February 16, 2016

Anticipating the Centers for Medicare and Medicaid Services’ (CMS) expected announcement Friday of preliminary payment rates and policies for Medicare Advantage insurers in 2017, insurers have pushed for changes to the “risk adjustment” system — which raises or lowers payments to plans based on their enrollees’ health.  Insurers claim the system undercompensates them for high-cost enrollees with chronic conditions.  We favor making the system as accurate as possible, but that should include reducing overpayments to insurers as well.

To be sure, risk adjustment tends to underpredict health spending for high-cost individuals in poorer health.  The Medicare Payment Advisory Commission (MedPAC) suggests that CMS make several changes to better account for higher spending by people with multiple chronic conditions and low-income beneficiaries eligible for both Medicare and Medicaid.

But Medicare Advantage risk adjustment also overcompensates insurers for healthier, low-cost enrollees.  For example, Avalere Health research, which insurers have cited favorably, shows risk adjustment overpredicting spending among people with no chronic conditions by 26.9 percent and among people with one or two chronic conditions by 5.1 percent.  That’s critical because Medicare Advantage enrollees are healthier than those in traditional Medicare, on average.

CMS could reduce Medicare Advantage overpayments by doing more to address “upcoding,” which the Congressional Budget Office, the Government Accountability Office (GAO), and academic research cite as a long-standing problem.  The risk adjustment system measures enrollees’ health using a “risk score” based on patient diagnoses; upcoding occurs when the risk scores that plans submit for their enrollees rise over time — making enrollees appear increasingly unhealthy — without actual changes in their health.

Risk scores have risen 9 percent faster in Medicare Advantage, on average, than in traditional Medicare for comparable beneficiaries, MedPAC estimates.  This leads to excessive payments to Medicare Advantage plans.

To compensate for upcoding, health reform requires CMS to adjust Medicare Advantage’s risk adjustment system by at least a minimum amount each year.  CMS has only applied the minimum required adjustment in recent years.  A larger adjustment, which MedPAC believes is warranted, would reduce overpayments to Medicare Advantage plans.

CMS could also reduce upcoding by excluding health assessments from risk score calculations unless they’re later confirmed in treatment settings, as MedPAC will likely recommend in its March report to Congress.  Medicare Advantage plans increasingly provide health assessments of their enrollees; for example, a nurse may come to a patient’s home to do a physical exam.  CMS has found that some insurers mainly use these assessments to “collect” diagnoses in order to raise enrollees’ risk scores for purposes of risk adjustment, rather than to improve follow-up care or identify illnesses requiring treatment.  In fact, CMS had proposed excluding these kinds of assessments but dropped this change in the face of industry opposition.

http://www.cbpp.org/blog/making-medicare-advantage-payments-more-accurate

***

2017 Medicare Advantage and Part D Advance Notice and Draft Call Letter

CMS.gov, February 19, 2016

Today, CMS released proposed updates to the Medicare Advantage (MA) and Part D programs through the 2017 Advance Notice and Draft Call Letter. Through these policies, CMS is proposing updates to the program designed to improve the accuracy of payments to plans serving beneficiaries who are dually eligible for Medicare and Medicaid.

CMS is proposing updates to the Risk Adjustment Model used to calculate payments to Medicare Advantage plans and to the Star Rating system used to evaluate plan performance. In both cases, the updates reflect a public process through which CMS shared research findings and solicited public comment.

Expected Average Change in Revenue:  3.55%

Risk Adjustment Model

CMS is proposing to implement a new Risk Adjustment Model for 2017. The proposed new model has separate coefficients for partial benefit dually eligible beneficiaries, full benefit dually eligible beneficiaries, and non-dually eligible beneficiaries.  These proposed changes will improve the precision of the payments made to plans, including increases in payments for plans serving full benefit dually eligible beneficiaries.

Coding Pattern Adjustment

Each year, as required by law, CMS makes an adjustment to plan payments to reflect differences in diagnosis coding between Medicare Advantage organizations and fee-for-service (FFS) providers. In CY 2017, CMS proposes to make an adjustment reflective of the statutory minimum.

Using Encounter Data

CMS calculates risk scores using diagnoses submitted by FFS providers and by Medicare Advantage organizations. Historically, CMS has used Medicare Advantage diagnoses submitted into CMS’ Risk Adjustment Processing System (RAPS). In recent years, CMS began collecting encounter data from MA organizations to develop more accurate payment models. In 2016, CMS began using diagnoses from encounter data to calculate risk scores, by blending encounter data-based risk scores with RAPS-based risk scores. In 2017, CMS is proposing to continue using a blend, using a higher percentage of encounter data-based risk scores.

Star Ratings – Adjusting for Socioeconomic Status

CMS is proposing to implement a new analytical adjustment for a subset of Star Rating measures that is meant to adjust for plans serving dually eligible enrollees and/or enrollees receiving the low income subsidy, as well as enrollees with disabilities. Through this interim adjustment, CMS seeks to more accurately capture true plan performance, while work continues by the HHS Assistant Secretary for Planning and Evaluation (ASPE) and measure stewards in this important area.

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-02-19.html

CMS Advance Notice of Methodological Changes for Calendar Year (CY) 2017 for Medicare Advantage (MA) Capitation Rates, Part C and Part D Payment Policies and 2017 Call Letter (over 220 pages):

https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Advance2017.pdf

***

AHIP, Coalition for Medicare Choices Launch Nationwide Ad and Grassroots Campaign to Protect Medicare Advantage

AHIP, January 28, 2016

As CMS prepares to release proposed Medicare Advantage payment policies, AHIP’s Coalition for Medicare Choices (CMC) is launching a coast-to-coast mobilization of its 2 million Medicare Advantage beneficiaries who are calling on Washington to protect their coverage from further cuts.

“Medicare Advantage is the game-changer. It’s the foundation for innovative, high-quality care delivery that seniors and the country demand,” AHIP President and CEO Marilyn Tavenner said. “CMS should protect millions of beneficiaries who depend on Medicare Advantage and strengthen — not undermine — the program moving forward.”

https://www.ahip.org/News/Press-Room/2016/AHIP,-Coalition-for-Medicare-Choices-Launch-Nationwide-Ad-and-Grassroots-Campaign-to-Protect-Medicare-Advantage.aspx

Today CMS released proposed updates for the 2017 Medicare Advantage (MA) plans. It appears that, once again, CMS will be co-conspirators with the insurance industry in increasing net MA payment rates when the Affordable Care Act requires reduction of the MA overpayments.

The Medicare Payment Advisory Commission (MedPAC) has recommended that CMS apply a larger adjustment to the MA risk adjustment system to reduce overpayments to the MA plans. Yet, once again, as with prior years, CMS is making “an adjustment reflective of the statutory minimum.”

Another example is that the MA plans have been using “encounter data” to upcode the diagnoses of the MA patients. Home visits are made, not by the health care providers but by representatives of the MA insurance plans, in order to find other disorders that can be used to pad the diagnostic list, making these patients appear sicker than they really are, thus qualifying the MA plans for higher payments than warranted. MedPAC is expected to recommend excluding encounter data from risk score calculations unless they are later confirmed in treatment settings. Yet, CMS is instead proposing to use a higher percentage of encounter data-based risk scores.

Instead of a reduction in payments, CMS is proposing a 3.55% increase.

CMS invites comments through March 4, 2016 before the final publication on April 4, 2016. During that time, AHIP, the insurance lobby organization, will be negotiating with CMS for further adjustments that will favor the MA plans. Each year that has resulted in additional innovative chicanery that further thwarts the intent of ACA to reduce MA overpayments. Since the new President and CEO of AHIP is Marilyn Tavenner, the former Administrator of CMS, it is anticipated that the negotiations on behalf of the MA plans will be quite successful.

Ensuring success of the MA plans is part of the plot to eventually privatize Medicare – converting it into a premium support system (vouchers) for a market of private plans that will displace the traditional Medicare program. The value of the voucher equivalents will erode with time, shifting ever more of the costs to the Medicare beneficiaries. It will be disastrous.

By this time it was expected that MA plan enrollment would begin to decline since the private insurance industry is incapable of providing comparable benefits at the same or lower costs than traditional Medicare, because their administrative costs are significantly higher than those of the traditional program, plus they need to return a profit to their investors. They have been profitable only because they have continued to be successful in enrolling healthier, less costly patients while at the same time receiving overpayments from the government.

Thus this conspiracy reenacted each year to use innovative payment schemes (chicanery) is vital to this industry. Members of AHIP’s Coalition for Medicare Choices will, once again, pressure members of Congress to cajole CMS into “saving” the Medicare Advantage plans through whatever accounting tools they can find (all with a wink and a nod). What is surprising is that this has not provoked the outrage of taxpayers. But maybe this is not so surprising after all since hardly anyone recognizes the terrible crime that is taking place before our very eyes.

Single-payer health system would cost less, provide more

By Katie Johnson
Post-Bulletin (Rochester, Minn.), Feb. 19, 2016

The presidential primaries have catapulted “Medicare for All,” or a single-payer health program, back into the national debate about how to fix our chronically ailing health care system. There’s no shortage of claims and counterclaims.

Here’s a question that cuts through the chatter: If you were offered a health plan that guaranteed all the care that you need — including prescription drugs, dental, vision and long-term care — for no more money, and likely less, than what you’re paying now, would you sign up for it?

What if such a plan also included free choice of doctor and hospital and also had no copays or deductibles?

Is this an unaffordable pipe dream? No. It’s the reality of a single-payer national health insurance program, as outlined in H.R. 676, the Expanded and Improved Medicare for All Act. The bill currently has 61 congressional sponsors.

Studies have shown such a program, if enacted, would reap huge savings — about $400 billion annually — by eliminating all the wasteful paperwork associated with our current (and very complex) multipayer system of paying for care.

The money we’d save by setting up such a streamlined, nonprofit system would be plowed back into covering everyone, improving benefits and retraining insurance company workers into more socially beneficial tasks such as providing actual care.

It’s not difficult to see why surveys have repeatedly found that two-thirds of Americans support this kind of “Medicare for All” approach when it’s been explained to them. It’s simple, efficient and equitable.

In the U.S., we spend $9,086 per person — that’s 17.1 percent of Gross Domestic Product — on health care, more than any other developed country in the world. Despite this, we have mediocre health outcomes. Compared to 34 other democratic nations, we rank 27th in life expectancy, 24th in cancer mortality and 31st in infant mortality.

The situation is dire. About 45,000 Americans die annually due to their lack of insurance. Medical bills contribute to two-thirds of personal bankruptcies. These problems are unheard of in other developed nations.

We spend 31 cents of every dollar on administrative tasks, most of it waste. This includes insurance company paperwork, overhead, CEO salaries and profits, not to mention all the paperwork inflicted on doctors, hospitals and patients.

Private insurers’ overhead ranges from 12 percent to 20 percent. In contrast, Medicare’s overhead is about 2 percent, and Canada’s single-payer system operates with about 1 percent overhead. So there would be big administrative savings right off the top.

Single payer is a national health insurance system in which a single public or quasi-public agency organizes health care financing, but delivery of care remains largely private. Single payer is an “everybody in, nobody out” system. Everyone is covered.

Single payer is not socialized medicine. Socialized medicine is publicly funded and publicly delivered, as in the British National Health Service or in our VA system. Single payer is publicly funded and privately delivered, much like Medicare works today for seniors.

The combination of public funding and private delivery ensures decisions about health care are made by you and your doctor — not by bureaucratic lobbyists, corporate influence or for-profit insurance companies.

Single payer is not Obamacare. Obamacare leaves profit-oriented private insurance companies at the heart of our system, with all the problems — denials of care, high overhead, siphoning of dollars away from care to corporate coffers — that entails. And Obamacare will leave an estimated 27 million Americans still without insurance coverage in 2025.

Single payer is not more expensive for families. A “Medicare for All” program would eliminate health premiums, deductibles, copays, co-insurance, replacing them with taxes based on ability to pay. One recent study shows 95 percent of U.S. households would end up saving money under H.R. 676 — and all would have ready access to care.

Educate your friends about single payer, and urge your lawmaker to co-sponsor H.R. 676. We’ll save lives and money, and we have no time to lose.

Katie Johnson, a fourth-year medical student at Mayo Medical School in Rochester, is pursuing a career in pediatrics.

http://www.postbulletin.com/opinion/katie-johnson-single-payer-health-system-would-cost-less-provide/article_115397d8-3ad3-5264-8c58-771ebee592e0.html

Medicare’s History Belies Claim That Medicare-for-All Would Disrupt Care

It Disrupted Jim Crow, but Otherwise the Transition Was Smooth

By Steffie Woolhandler and David Himmelstein
The Huffington Post, February 16, 2016

Hillary Clinton and others charge that Bernie Sanders’ Medicare-for-All plan would disrupt and threaten Americans’ health care. But the smooth rollout of Medicare-for-Seniors in 1965 — which many had also predicted would bring chaos — belies that charge.

Medicare, signed into law on July 30, 1965, went live just 11 months later. By then, 18.9 million seniors had signed up, 99 percent of those eligible.

To accomplish this feat (largely without computers) the Social Security Administration mailed an information leaflet and sign-up cards preprinted with each individual’s name and Social Security number (see example below) to seniors on the Social Security and railroad retirement rolls, as well as Civil Service annuitants and a million other seniors identified through IRS records.

Image: Social Security Administration History Archives

To contact hard-to-reach seniors, the federal government reached out to nursing and retirement homes, employers, unions and civic organizations offering to help people apply; organized hundreds of local information meetings; and enlisted postal workers, forest rangers and agricultural representatives to help locate residents of remote areas. The Office for Economic Opportunity hired 5,000 low-income seniors who went door-to-door in their neighborhoods.

All told, Medicare’s overhead costs for the first year totaled only $120 million (equivalent to $882 million in 2015). By comparison, setting up the insurance exchanges for private coverage under Obamacare cost more than $6 billion — about seven times as much. But even the modest figure for Medicare’s start-up costs is an overstatement since it includes the cost of processing six months’ worth of medical bills, not just the enrollment costs. Moreover, Medicare and Medicaid (which was passed at the same time) displaced several smaller federal health assistance programs, saving about $383 million (in 2015 dollars) on their overhead costs.

Even as it became clear that Medicare enrollment was proceeding smoothly, many saw disruption ahead. The Association of American Physicians and Surgeons (AAPS), a group to the right of the American Medical Association (AMA), threatened that 50,000 doctors would boycott Medicare. (Today, the AAPS is sounding the alarm that Medicare-for-All would take away “what remains of your doctor’s liberty.”) Wall Street Journal headlines warned that “Most MDs Won’t Cooperate,” and foresaw a “Patient Pileup,” as “flocks of Medicare beneficiaries … suddenly clog the nation’s 7,200 hospitals.”

None of this came to pass. Doctors continued to care for elderly patients, mostly accepted Medicare payment, and soon came to rely on Medicare as an economic pillar of their practices. Even the AMA, which had spent millions fighting Medicare’s passage (including an infamous ad campaign featuring then-actor Ronald Reagan) cooperated in the program’s implementation. Hospitals ran smoothly, with only a handful reporting more than minor of problems.

But Medicare did cause a major disruption, it disrupted Jim Crow hospital care.

The 1964 Civil Rights Act banned racial discrimination in facilities receiving federal funds (which included most hospitals), but enforcement was lax until Medicare. Many hospitals, particularly in the South, still refused to care for black patients at all, while others relegated them to separate entrances and shabby basement wards. Black physicians were often barred from hospital staffs, and in many locales ambulance services were separate, and distinctly unequal.

With Medicare on the horizon, federal officials made it clear to hospitals that segregated hospitals would be excluded from the program. In the spring of 1966, three months before Medicare took effect, 51 percent of American hospitals were still segregated. By August of that year, 99.5 percent had desegregated.

While Medicare ended overt racial segregation in hospitals, segregation by insurance remains legal and common — and often perpetrates de facto racial segregation. Most of New York City’s prestigious academic medical centers — and many hospitals elsewhere — maintain separate clinic systems, and even separate wards, for Medicaid patients (the 33 million uninsured need not apply).

Medicare-for-All would give all Americans complete and equal coverage, completing the disruption of hospital segregation that Medicare began a half century ago.

Aside from that welcome disruption, Medicare-for-All would greatly simplify life for hospitals and doctors. Instead of the laborious and expensive task of billing patients and their insurers for each Band-Aid and aspirin tablet, hospitals would receive a lump-sum budget, much as we pay for a fire station. Doctors would bill one plan, using one billing form instead of the dozens of complex billing schemes — each with its own rules and redundant documentation requirements — that we face today.

Most important, Medicare-for-All would end many of the disruptions that our patchwork coverage system currently inflicts on patients. All Americans would, for the first time, enjoy a free choice of doctor and hospital, and would never again be forced to change doctors merely because their insurance changed, or their doctor was dumped from their insurer’s network. And patients’ lives would no longer be disrupted by financial ruin from medical bills.

Drs. Steffie Woolhandler and David U. Himmelstein, professors of health policy and management at the City University of New York School of Public Health at Hunter College and Lecturers in Medicine at Harvard Medical School, co-founded Physicians for a National Health Program, a nonpartisan organization. The opinions expressed do not necessarily reflect those organizations’.

http://www.huffingtonpost.com/steffie-woolhandler/medicares-history-belies-_b_9245484.html

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

Return on investment in health care

Asymmetric Thinking about Return on Investment

By David A. Asch, M.D., Mark V. Pauly, Ph.D., and Ralph W. Muller, M.A.
The New England Journal of Medicine, February 18, 2016

Lately, we’ve attended many conferences about providing health care to patients with high medical and social needs — people with chronic illnesses who are frequently readmitted to the hospital. It seems as if every presentation refers to “return on investment” (ROI), which is invariably presented as a constraint — as in “Our program kept people out of the hospital, but we just couldn’t get the ROI to work.” Heads nod understandingly, and then participants move on to other topics.

At conferences about providing care for patients with cancer or other acute illnesses, by contrast, we almost never hear the term ROI. Instead, people talk about clinical gains, using understandable and patient-centered terms like “survival.” Though high drug prices are sometimes mentioned, no one ever says the ROI is prohibitive. No one mentions ROI at all.

There is no obvious reason why ROI is more relevant to some clinical situations than to others. So why do we focus so heavily on ROI when the topic is chronic illness but rarely mention it when the topic is cancer? A huge amount of the cancer care we deliver provides such small personal and social gains that, were those gains monetized, the endeavor’s ROI would be deeply negative. And yet we ask, “What’s the ROI of that program that keeps chronically ill patients out of the hospital?” but not “What’s the ROI of treating advanced lung cancer?”

Providing cancer care and averting hospitalizations are financed differently. It’s hard to create a favorable ROI for reducing volume in a system dominated by fee-for-service payments for delivering care. Sometimes a favorable ROI is achieved passively when, for example, avoiding care frees up capacity for patients whose care is more profitable. More actively, the avoidance of care can be financed by establishing punishments for delivering avoidable care (penalties for readmissions, for example) or by shifting its cost to the providers themselves (e.g., through capitated or bundled payments).

It might seem that we could make the ROI for appropriate care more favorable if we imposed higher penalties on inappropriate care, just as we could make the ROI for treating cancer less favorable by paying less for cancer treatments. Despite that apparent symmetry, the choice of financing mechanisms — payments versus penalties — determines how much a health care goal will be advanced. If the ROI didn’t work for some form of cancer care — because the payment received was lower than the cost incurred — doctors and hospitals would almost certainly argue for higher payments. But when the ROI doesn’t work for keeping challenging patients with chronic disease out of the hospital, it’s implausible that doctors or hospitals will plead for increased readmission penalties. There isn’t any mathematical reason to prefer payment in the form of rewards over payment in the form of avoided penalties, but you can typically generate more advocates for your cause by paying people to follow you than by penalizing them for going the other way.

So when advocates and organizations devoted to keeping people out of the hospital lament their inability to make the ROI work, they should know that the game is rigged against them. In the highly regulated context of health care, the amount and structure of financing are chosen rather than preordained. The ROI is favorable or unfavorable not because of the workings of some invisible hand, but because of choices someone — usually a private or public insurer — has made regarding what amounts will be paid for various types of care and what form payments will take.

What if the financing of cancer care and of efforts to achieve population health goals traded places? Suppose doctors and hospitals were paid for cancer care by capitation or bundles or through penalties for undesired outcomes and were paid directly and adequately to keep people out of the hospital. Oncologists might begin lamenting that although new approaches to cancer care helped patients, they just couldn’t get the ROI to work. And the outlook for population health might become less financially gloomy.

Rewards and penalties have the same ultimate effect on investment income, but they influence thinking in different ways. We might encourage greater effort and innovation in keeping people out of the hospital and coordinating care if we reframed its financing as positive payments for noble work rather than punitive revenue reductions. As U.S. health care financing begins again to shift risks to hospitals and physicians through bundled payments or readmission penalties, the financing of the care for our most challenging patients might be better shifted in the other direction.

http://www.nejm.org/doi/full/10.1056/NEJMp1512297

***

Comment:

By Don McCanne, M.D.

The concept of return on investment (ROI) in health care may represent what is wrong with our system that causes it to be so expensive yet often mediocre by international standards.

Most health care professionals and institutions are largely fixated on their efforts to provide the best patient care they can with the given resources. But much of the medical-industrial complex is fixated on ROI, as is obvious by the examples of the private, for-profit insurers and the pharmaceutical firms with their egregiously high profits.

The authors of this article discuss trying to take care of cancer patients in which ROI standards are not considered since “monetized” gains for cancer patients would be “deeply negative.” They contrast that with readmissions of patients with chronic illnesses in which the ROI is important based on the penalties assessed for failing to prevent the readmissions.

On the one hand, the professionals and institutions are simply paid for providing appropriate care. On the other, attempting to provide appropriate care is complicated by a necessity to consider the potential of a negative ROI because of financial considerations – penalties – which have nothing to do with the actual medical care being provided.

Instead of ROI driving motivation, the authors suggest that we reframe health care financing as “positive payments for noble work rather than punitive revenue reductions.”

They conclude, “As U.S. health care financing begins again to shift risks to hospitals and physicians through bundled payments or readmission penalties, the financing of the care for our most challenging patients might be better shifted in the other direction.”

Noble provision of health care services – a prime goal of a single payer national health program.

Return on investment in health care

Asymmetric Thinking about Return on Investment

By David A. Asch, M.D., Mark V. Pauly, Ph.D., and Ralph W. Muller, M.A.
The New England Journal of Medicine, February 18, 2016

Lately, we’ve attended many conferences about providing health care to patients with high medical and social needs — people with chronic illnesses who are frequently readmitted to the hospital. It seems as if every presentation refers to “return on investment” (ROI), which is invariably presented as a constraint — as in “Our program kept people out of the hospital, but we just couldn’t get the ROI to work.” Heads nod understandingly, and then participants move on to other topics.

At conferences about providing care for patients with cancer or other acute illnesses, by contrast, we almost never hear the term ROI. Instead, people talk about clinical gains, using understandable and patient-centered terms like “survival.” Though high drug prices are sometimes mentioned, no one ever says the ROI is prohibitive. No one mentions ROI at all.

There is no obvious reason why ROI is more relevant to some clinical situations than to others. So why do we focus so heavily on ROI when the topic is chronic illness but rarely mention it when the topic is cancer? A huge amount of the cancer care we deliver provides such small personal and social gains that, were those gains monetized, the endeavor’s ROI would be deeply negative. And yet we ask, “What’s the ROI of that program that keeps chronically ill patients out of the hospital?” but not “What’s the ROI of treating advanced lung cancer?”

Providing cancer care and averting hospitalizations are financed differently. It’s hard to create a favorable ROI for reducing volume in a system dominated by fee-for-service payments for delivering care. Sometimes a favorable ROI is achieved passively when, for example, avoiding care frees up capacity for patients whose care is more profitable. More actively, the avoidance of care can be financed by establishing punishments for delivering avoidable care (penalties for readmissions, for example) or by shifting its cost to the providers themselves (e.g., through capitated or bundled payments).

It might seem that we could make the ROI for appropriate care more favorable if we imposed higher penalties on inappropriate care, just as we could make the ROI for treating cancer less favorable by paying less for cancer treatments. Despite that apparent symmetry, the choice of financing mechanisms — payments versus penalties — determines how much a health care goal will be advanced. If the ROI didn’t work for some form of cancer care — because the payment received was lower than the cost incurred — doctors and hospitals would almost certainly argue for higher payments. But when the ROI doesn’t work for keeping challenging patients with chronic disease out of the hospital, it’s implausible that doctors or hospitals will plead for increased readmission penalties. There isn’t any mathematical reason to prefer payment in the form of rewards over payment in the form of avoided penalties, but you can typically generate more advocates for your cause by paying people to follow you than by penalizing them for going the other way.

So when advocates and organizations devoted to keeping people out of the hospital lament their inability to make the ROI work, they should know that the game is rigged against them. In the highly regulated context of health care, the amount and structure of financing are chosen rather than preordained. The ROI is favorable or unfavorable not because of the workings of some invisible hand, but because of choices someone — usually a private or public insurer — has made regarding what amounts will be paid for various types of care and what form payments will take.

What if the financing of cancer care and of efforts to achieve population health goals traded places? Suppose doctors and hospitals were paid for cancer care by capitation or bundles or through penalties for undesired outcomes and were paid directly and adequately to keep people out of the hospital. Oncologists might begin lamenting that although new approaches to cancer care helped patients, they just couldn’t get the ROI to work. And the outlook for population health might become less financially gloomy.

Rewards and penalties have the same ultimate effect on investment income, but they influence thinking in different ways. We might encourage greater effort and innovation in keeping people out of the hospital and coordinating care if we reframed its financing as positive payments for noble work rather than punitive revenue reductions. As U.S. health care financing begins again to shift risks to hospitals and physicians through bundled payments or readmission penalties, the financing of the care for our most challenging patients might be better shifted in the other direction.

http://www.nejm.org/doi/full/10.1056/NEJMp1512297

The concept of return on investment (ROI) in health care may represent what is wrong with our system that causes it to be so expensive yet often mediocre by international standards.

Most health care professionals and institutions are largely fixated on their efforts to provide the best patient care they can with the given resources. But much of the medical-industrial complex is fixated on ROI, as is obvious by the examples of the private, for-profit insurers and the pharmaceutical firms with their egregiously high profits.

The authors of this article discuss trying to take care of cancer patients in which ROI standards are not considered since “monetized” gains for cancer patients would be “deeply negative.” They contrast that with readmissions of patients with chronic illnesses in which the ROI is important based on the penalties assessed for failing to prevent the readmissions.

On the one hand, the professionals and institutions are simply paid for providing appropriate care. On the other, attempting to provide appropriate care is complicated by a necessity to consider the potential of a negative ROI because of financial considerations – penalties – which have nothing to do with the actual medical care being provided.

Instead of ROI driving motivation, the authors suggest that we reframe health care financing as “positive payments for noble work rather than punitive revenue reductions.”

They conclude, “As U.S. health care financing begins again to shift risks to hospitals and physicians through bundled payments or readmission penalties, the financing of the care for our most challenging patients might be better shifted in the other direction.”

Noble provision of health care services – a prime goal of a single payer national health program.

NYT Rounds Up ‘Left-Leaning Economists’ for a Unicorn Hunt

By Doug Henwood
Fairness and Accuracy in Reporting, FAIR.org, Feb. 17, 2016

With Hillary Clinton ramping up her attacks on Bernie Sanders as a budget-buster—in the February 11 debate, she claimed  his proposals would increase the size of government by 40 percent—the New York Times (2/15/16) offered a well-timed intervention in support of her efforts: “Left-Leaning Economists Question Cost of Bernie Sanders’ Plans.”

While the “left-leaning” is no doubt meant to suggest critiques from those who would be inclined to sympathize with Sanders, all the quoted economists have ties to the Democratic establishment. So slight is their leftward lean that it would require very sensitive equipment to measure.

Opinion pieces critical of Sanders often begin with a pledge of allegiance to his “impracticality.” This story, by Times reporter Jackie Calmes, is an “objective,” newsy version of that:

“With his expansive plans to increase the size and role of government, Senator Bernie Sanders has provoked a debate not only with his Democratic rival for president, Hillary Clinton, but also with liberal-leaning economists who share his goals but question his numbers and political realism.”

Though Sanders wants to increase federal spending on infrastructure, college tuition and childcare, as well as other programs, the bulk of his proposed increase would be for establishing a single-payer healthcare system, and that’s what Calmes’ piece focuses on. It would replace the current mix of multiple forms of public insurance (Medicare, Medicaid, state and local programs) and private insurance with a unitary federal system, much like what Canada has. It would not nationalize doctors and hospitals, as in Britain; only the payment side would be socialized. Sanders refers to it as Medicare for All, which is a simplification, but close enough for politics.

The liberal-leaning economists that Calmes rounds up suggest that Clinton may have been too modest in her accusation that Sanders wants to jack up the size of government by 40 percent. No, Calmes warns that “the increase could exceed 50 percent, some experts suggest, based on an analysis by a respected health economist that Mr. Sanders’ single-payer health plan could cost twice what the senator…asserts.”

As if that wasn’t scary enough, Calmes turns to mockery: “Alluding to one progressive analyst’s criticism of the Sanders agenda as ‘puppies and rainbows,’ Mr. Goolsbee said that after his and others’ further study, ‘they’ve evolved into magic flying puppies with winning Lotto tickets tied to their collars.’”

The theme of magic was further developed in a piece by New York Times op-ed columnist Paul Krugman, “My Magic Unicorn” (2/16/16), in which the word “unicorn” appears six times (not counting the headline). Krugman’s column, which denounces Sanders’ proposals as hopelessly unrealistic, refers to Calmes’ news story for support, a news story that itself reads like an op-ed in disguise. [Krugman illustrated his column with an image of this tapestry: Detail from “The Unicorn Defends Itself” (The Cloisters). If in his metaphor a single-payer healthcare system is a unicorn, then presumably the people poking it with spears are establishment journalists.]

The “Mr. Goolsbee” quoted in the story is Austan Goolsbee, who was a long-time adviser to Barack Obama before he became president, and then served on Obama’s Council of Economic Advisers. (During the 2008 campaign, Goolsbee was reported as having assured the Canadian government that Obama’s anti-NAFTA talk was “more reflective of political maneuvering than policy”—New York Times, 3/4/08.) Now Goolsbee teaches economics at the University of Chicago’s business school and is a consultant to hedge funds. A very left-leaning resume there.

And the “progressive analyst” who came up with the “puppies and rainbows” line is Ezra Klein, who in mid-January wrote a harshly disparaging piece, “Bernie Sanders’s Single-Payer Plan Isn’t a Plan at All,” on the website he co-founded, Vox (1/17/16). How times change: As long-time FAIR contributor Seth Ackerman showed in an incisive analysis (Jacobin, 1/25/16), Klein was once a strong proponent of a single-payer scheme.

In a 2007 piece for the American Prospect (4/22/07), Klein explored what he called “the best healthcare systems in the world,” including Canada’s, looking for lessons for the US. (Krugman liked the piece enough to put it on a 2012 syllabus for a Princeton class on the welfare state.) Klein’s conclusion, expressed in his opening sentence, was that while medicine is hard, health insurance is simple: We should emulate these other systems that achieve both universal coverage and cost control, like those of Canada, France, Germany and the UK. Though he now holds Sanders’ advocacy of single-payer in disdain, Klein specifically praised Canada’s single-payer system, citing a 2003 paper by Steffie Wooldhandler, Terry Campbell and David Himmelstein in the New England Journal of Medicine (8/21/03) that found that administrative costs were over three times as high in the US than in Canada, mainly because of the inefficiencies of private health insurance. Eliminate private insurance and you enjoy hundreds of billions in savings.

The “respected” health care economist—it’s funny how journalists stick that handle in front of some names and not others—that Calmes cites is Kenneth Thorpe of Emory University, who, as she discloses, “advised the Clintons in the 1990s.” Indeed he did; he served in Bill’s cabinet where, according to his Emory faculty bio, he “coordinated all financial estimates and program impacts of President Clinton’s healthcare reform proposals for the White House.”

Sanders has proposed paying for his single-payer health insurance program mainly by raising taxes on the rich and imposing a 6.2 percent payroll tax on employers and a 2.2 percent income tax on households (while fully exempting lower-income households and partly exempting middle-income ones from the tax). Those tax increases would replace current spending on private insurance, so it would be very wrong to call them new spending.

Thorpe’s paper argues that Sanders underestimates the cost of his single-payer health insurance scheme by close to half. More realistic assumptions would require substantial tax increases across the board and result in lower wages for the presently uninsured as employers compensate for the new payroll tax. Frightening, if true, and Calmes and her headline writer frame the article to persuade us that it is.

Woolhandler and Himmelstein, authors of the 2003 article on administrative costs that Ezra Klein used to like, are not persuaded by Thorpe. In a Huffington Post piece (1/29/16), they find his estimates of administrative savings from a shift to a single-payer system too low and his assumptions of an increase in demand for healthcare too high. He ignores the cost of tax breaks that would disappear under single-payer and assumes no savings on drugs and medical devices, despite the government’s strong bargaining position as the exclusive purchaser. (Calmes alludes to their critique in the piece with a single sentence: “Mr. Thorpe and Sanders aides and allies have been battling online.” The words “battling online” link to the Woolhandler/Himmelstein piece; a print reader would be totally in the dark.)

As Woolhandler and Himmelstein point out, in earlier studies—one done for the state of Missouri, and another for the National Coalition on Health Care—Thorpe projected large savings from single-payer reform. Now this former Clinton adviser finds the opposite.

There’s a political angle to Calmes’ piece as well, which she uses longtime Democratic economist Henry Aaron to deliver. (Aaron is a fellow at the Brookings Institution, a think tank that a congressional staffer once described to me as “a graveyard for conservative Democrats.”) Aaron calls the idea of single-payer a “fairy tale” in the current political climate. Citing the testimony of “other economists in a ‘lefty chat group’ he joins online,” Aaron believes that were Sanders elected, he’d destroy his political capital by fighting such a doomed fight.

I’m familiar with this line of argument from a liberal chat group I used to hang out with online (it takes its off-the-record secrecy with great seriousness)—it may be the same one, but I can’t tell for sure. It goes like this: The right so dominates the present scene that one can do nothing but play defense, hoping to salvage what remains of social spending but never daring to ask for more. Political capital, in this account, can only dwindle when put to work; unlike other forms of capital, it never pays returns. The right never thought that way when it was plotting its ascendancy from the 1950s through the 1970s.

Calmes gave the last word to Thorpe, who concludes from a failed attempt to bring single-payer to Vermont that it would be unworkable on a national scale. Vermont’s plan wasn’t really single-payer; providers would still have had to contend with multiple payers, thereby limiting administrative savings, and the state would have little bargaining power with drug and device manufacturers. The experience of a small state in a big country is hardly conclusive.

What might be more persuasive is the experience of our northern neighbor, a country very much like ours. Canada covers almost all its population at a cost of 10.2 percent of GDP. Even after Obamacare, about a tenth of the US population is uninsured, but that incomplete coverage costs us 16.4 percent of GDP.

Britain’s system costs 8.9 percent of GDP, a little over half what we pay. Both countries have longer life expectancies than we do. But we should be afraid of the unicorns.

Doug Henwood is the author of “My Turn: Hillary Clinton Targets the Presidency.”

You can send a message to the New York Times at letters@nytimes.com, or write to public editor Margaret Sullivan at public@nytimes.com (Twitter:@NYTimes or @Sulliview). Please remember that respectful communication is the most effective.

http://fair.org/home/nyt-rounds-up-left-leaning-economists-for-a-unicorn-hunt/

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

The Only Way the US Can Ever Get Affordable Health Care

By John Geyman, M.D.
Truthout, Feb. 17, 2016

Now that Bernie Sanders has brought forward his progressive agenda, including real health care reform through a single-payer universal Medicare for all program, the knives are out from the Republicans as well as Hillary Clinton to distort and discredit this option with false information.

Going forward, we have three basic alternatives to further reform our health care system: (1) continue with the Affordable Care Act (ACA) with improvements as needed (which Clinton supports with barely a hint of what those changes might be); (2) the Republican “plan,” including repeal of the ACA and emphasizing market-based “fixes,” such as health savings accounts, selling insurance across state lines, and further privatization of both Medicare and Medicaid; and (3) National Health Insurance (NHI) through a Medicare-for-all plan, as currently embodied in HR 676, legislation pending in the House of Representatives.

Let’s cut through the smoke and mirrors of the debate and compare each alternative in terms of costs, affordability, and what we get in terms of access, quality, and sustainability.

First, looking at costs, we have experience with market approaches to cost containment over the last three-plus decades – none have worked tocontrol either costs or prices. The ACA, with virtually no price controls, has given us, with various government subsidies, six years for private insurers, hospitals, drug companies, and others in the medical-industrial complex to expand their markets with minimal oversight.

Private health insurers have bulked up, consolidated, gamed the new “system” for profits and shareholder returns even as they complain of not making enough money and threatening to withdraw from the ACA’s exchanges. (1) The CEO of the largest insurer, UnitedHealthcare, Stephen Hemsley, pocketed $66.1 million ($254,328 per day) total compensation in 2014. (2)

Republican policies have accelerated privatization of Medicare and Medicaid, adding higher burdens of administrative overhead and profits at public expense. Their policies are based on the concepts that markets can fix our problems and patients’ demands are at the heart of inflating health care costs. Hence their reliance on “consumer directed health care,” with its high-deductible, low-value policies which have failed for many years.

You can’t believe most of the claims that are being made about the costs of single-payer NHI. Clinton is saying that the middle class will be hit with a big tax increase without mentioning what patients and families will save and get with NHI. She says that Sanders’ numbers for savings for typical American families under NHI “don’t add up.” (3) Some economists are also jumping on the bandwagon to discredit NHI. Paul Krugman, still thinks it is “not politically feasible” because of the political and economic power of the medical-industrial complex, and worries about “disruption for patients” with the ACA, but doesn’t acknowledge the huge gains that NHI would bring with far more efficiency than our current multi-payer system. (4) Economist Kenneth Thorpe, an Emory University professor who served in the Clinton administration, claims that NHI would break the bank, and cost $1 trillion more a year than estimated as he grossly underestimated savings on overhead, drug costs, and other government expenses while assuming a grossly exaggerated increase in utilization by patients. (5)

Despite demagoguery on the issue, we have solid information on the costs – and savings – of NHI. The landmark 2013 study by Gerald Friedman, professor of economics at the University of Massachusetts, estimated that implementation of single-payer NHI will save $592 billion annually by cutting administrative waste of private insurers ($476 billion) and reducing pharmaceutical prices to European levels ($116 billion). Those savings would be enough to cover all the uninsured and provide comprehensive coverage for all other Americans, even including dental and long-term care. Co-payments and deductibles will be eliminated, savings will fund retraining of displaced workers and phasing out investor-owned for-profit delivery systems over a 15-year period. (6)

How will this be paid for? Table 1 proposes a progressive financing plan under which 95 percent of Americans will pay less than they do now for insurance premiums, deductibles, co-payments, and out-of-pocket payments for health care. Only 5 percent of high-income Americans will pay more. The payroll tax will become the main health care tax for people with annual incomes below $225,000 – $1,500 for those with incomes of $50,000, $6,000 for those earning $100,000, and $12,000 for those with incomes of $200,000.

With NHI, all Americans will have full choice of doctors and hospitals, quality of care for the whole population will improve, bureaucracy will be sharply reduced, and we will finally have a more accountable and sustainable system. (7) Employers will be relieved of their burden of providing health insurance for their employees and may be able to convert some of their previous contributions to employer-sponsored insurance to employees’ forgone wage increases as they gain a healthier workforce and become more competitive in global markets. Physicians and other health professionals will have a simplified billing system and more time for direct patient care.

We already pay much more in taxes each year for health care than we realize. In their just-published article in the American Journal of Public Health, Drs. Woolhandler and Himmelstein report that the US government, at taxpayer expense, is now paying 65 percent of the total annual tab for health care – $2.1 trillion last year, $6,560 per person, more per capita than people pay in taxes in any other advanced country with universal health insurance. As they report, much of this taxation is invisible to us, such as government spending to buy private health coverage for public employees and tax subsidies for private employer-sponsored insurance and other privately paid care. (8)

We have to recognize renewal of opposition to NHI for what it is – Clinton’s conflicts of interest and involvement with Wall Street, despite her denials (e.g. $2.8 million in speaker fees from the health care industry between 2013 and 2015) (9); corporate media beholden to Wall Street; and a Republican consensus to block whatever President Obama does at every turn, without giving us any assurance that they will govern in the public interest.

This really is a perilous moment in the history of US health care. The ACA is fundamentally flawed – a bailout to a failing private health insurance industry and other corporate stakeholders in the medical-industrial complex. Tweaks around the edges of the ACA will never bring us cost containment in a sustainable way. If Republicans gain more control of Congress, and even the presidency in 2017, health care for much of our population will get much worse in terms of access, affordability, and quality. Research over many years has shown that the majority of Americans want NHI.

We have to come to grips that we cannot afford our present multi-payer financing system. There is more than enough money in the system to pay for it, but its waste and profiteering prevent us from getting what we are already paying for. We have to get the politics right to get the system we need – single-payer financing that we all can afford.

Order a copy of The Human Face of Obamacare

Visit www.johngeymanmd.org and www.copernicus-healthcare.org

References:

1. Mathews, AW. Insurers flag deepening losses on health law. Wall Street Journal, February 11, 2016.
2. SEC 14A Schedules, Bureau of Labor Statistics, Current Population Survey, 2014.
3. Nelson, CM, Meckler, L, Nicholas, P. Clinton, Sanders clash over cost of plans. Wall Street Journal, February 12, 2016.
4. Krugman, P. Op-Ed. Health reform realities. New York Times, January 18, 2016.
5. Himmelstein, DU, Woolhandler, S. On Kenneth Thorpe’s analysis of Senator Sanders’ single-payer reform plan. The Huffington Post, January 29, 2016.
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: htpp://www.pnhp.org/sites/default/files/Funding%20HR%20676_Friedman_final_7.31.13.pdf
7. Ibid # 6.
8. Woolhandler, S, Himmelstein, DU. Single-payer health plan wouldn’t cost U. S. more. Philadelphia Inquirer, February 5, 2016.
9. Jilani, Z. Hillary Clinton’s single-payer pivot greased by millions in industry speech fees. The Intercept, January 13, 2016.

http://www.truth-out.org/speakout/item/34871-the-only-way-the-us-can-ever-get-affordable-health-care

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

Let’s dispense with myths about ‘Medicare for all’

By Dave Zweifel
The Capital Times, Madison.com, Feb. 17, 2016

Is Vermont Sen. Bernie Sanders’ idea to give Americans “Medicare for all” the bad idea that so many other politicians and media commentators claim it is?

As one who has editorially promoted a national single-payer health care system for the better part of my newspaper career, I suggest that most of the naysayers don’t know what they’re talking about.

The single-payer idea — and that’s what Medicare is for Americans over the age of 65 — has been around since 1948 when Harry Truman was president. Truman viewed it as a needed complement to Franklin D. Roosevelt’s social reforms, including the establishment of Social Security.

It’s been proposed several times since, but the medical establishment, including the insurance and pharmaceutical powers, has become so entrenched and influential that Congress has never given it serious consideration.

It’s curious that opposition to single-payer universal health coverage is a uniquely American malady. Our neighbor to the north, Canada, has had it for decades and Canadians like to point out that not one of their citizens has ever gone bankrupt because he or she got sick. We can’t say that in the U.S., where tens of thousands of families have been financially devastated by unconscionably uncovered medical bills. 

Meanwhile, our allies in Europe and other parts of the industrialized world long ago declared health care coverage a right of every one of their citizens. Yet most of our politicians and many citizens continue to demonize the idea. Even Obamacare, which has been a small step toward universal coverage, has been vilified, even though 11 million more people now have health insurance.

The nonpartisan Physicians for a National Health Program, which has been pushing for an American single-payer system for decades, a few weeks ago felt compelled to answer the misrepresentations that have popped up not only among the partisans running for office, but in several of the nation’s newspapers whose editorial writers and columnists can’t grasp what Sanders is talking about.

First, there’s the canard that a single-payer system would cost American families bundles of money. As the physicians point out, in reality single-payer would pay for itself. By replacing hundreds of insurers and thousands of different private health plans, each having their own marketing, enrollment, billing, actuaries and other duplicated services, with a single, streamlined, tax-financed, nonprofit program, more than $400 billion in health spending would be freed up to guarantee coverage to all of the 30 million Americans currently still uninsured and to upgrade the coverage of everyone else, including eliminating deductibles and co-pays.

One study concludes that 95 percent of U.S. households would come out ahead.

There’s also the claim that the American people are opposed to single-payer. A recent Kaiser Family Foundation survey showed that 58 percent of Americans support Medicare for all. That result jibes with other national surveys.

The biggest claim knocking the single-payer idea is that in the United States, it’s unrealistic or “politically infeasible.” There’s no doubt that it would face considerable opposition, particularly from the private insurers, the pharmaceutical cabal, and others who profit handsomely off the current health care system.

But should the prospect of a tough battle to once and for all fix America’s health care problems mean that the fight’s not worth fighting? If that be the case, we still wouldn’t allow women to vote, our elderly would still be living in poverty without a program called Social Security and there would be no Medicare even for folks over 65. They were all difficult fights, all considered unwinnable in their times, but the American people held their elected officials accountable and won those fights.

There’s a reason health care costs per capita in the U.S. are nearly double the costs in other developed countries around the world. We’ve created a system that’s inefficient and geared to maximizing profits for layer upon layer of bureaucratic administration.

A single-payer system would fix that. It’s not, as so many like to claim, a complicated and expensive alternative, but the exact opposite.

Dave Zweifel is editor emeritus of The Capital Times (Madison, Wis.). Contact him at dzweifel@madison.com.

http://host.madison.com/ct/news/opinion/column/dave_zweifel/plain-talk-let-s-dispense-with-myths-about-medicare-for/article_7b1d4b57-dcbc-5f28-83a6-c133c17b58f9.html

Single payer misdiagnosed

By Daniel Schaffer, M.D.
The Spokesman-Review (Spokane, Wash.), Letters, Feb. 13, 2016

Robert Samuelson (Feb. 8) claims to be an economist, but he has some obvious blind spots, health care financing being one.

He says a single-payer system such as Medicare for All would not save any money, even though every other industrialized nation using one has been able to achieve significant savings. He says that the overhead of for-profit insurance companies is 6 percent, when every study that has been conducted, including that of the Rand Foundation, has put overhead at 20 percent to 30 percent. It’s about 3 percent for Medicare.

He makes the unsubstantiated claim that universal care will result in over-usage that will negate any savings. In Japan, people utilize the health care system three times more often than Americans do, yet Japan’s system represents only 11 percent of gross domestic product, in contrast to 18 percent for the United States.

Conservatives in other countries love publicly funded health care because it saves money and takes the burden of providing health care off the shoulders of business. Are their conservatives smarter than ours, or are ours just blinded by a misguided ideology?

Some type of universal coverage is inevitable because the current system is destined to crash.

Dr. Daniel Schaffer resides in Spokane.

http://www.spokesman.com/stories/2016/feb/13/universal-health-care-coverage-inevitable/

Criticism of Bernie Sanders’ health plan missed the mark

By Richard Weiskopf, M.D.
Syracuse.com (N.Y.), Letters, Feb. 16, 2016

I would like to respond to the Feb. 11 column by David Brooks about President Obama in which Brooks mentions Sen. Bernie Sanders’ health care plan to expand Medicare and have universal coverage. Brooks wrote, “Sanderscare would take employer coverage away from tens of millions of satisfied customers, destroy the health insurance business and levy massive new tax hikes. This is epic social disruption.”

According to Physicians for a National Health Program (PNHP), under the Affordable Care Act, 28.5 million people were uninsured in the first six months of 2015. And tens of millions more are underinsured. Under Obamacare, many more people are now covered, but it is not nearly sufficient. Many who are covered have policies that cover only catastrophic costs, leaving them to pay not only their insurance premiums but much of their health care costs. It is true, as Brooks points out, that people would lose coverage through their employers. He does not make clear however, that all would gain coverage under the government single payer plan. And yes, taxes would have to be raised to pay for it, but that would be balanced by not having to pay for the expensive premiums we have now.

Under the present system of multiple health insurers, a large percentage of of the money that private insurance companies collect in premiums is spend for administrative costs. Our current Medicare which covers the elderly is more efficient. A much lower percentage goes for administrative costs leaving more money to spend directly on health care.

Brooks’ dismissal of the single payer health plan advocated by Sanders fails to mention these important points.

For more information about the governmental single payer health plan, go to www.PNHP.org.

Dr. Richard Weiskopf is a member of Physicians for a National Health Program. He resides in Syracuse.

http://www.syracuse.com/opinion/index.ssf/2016/02/criticism_of_bernie_sanders_health_plan_missed_the_mark_your_letters.html

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

Medicare’s History Belies Claim That Medicare-for-All Would Disrupt Care

Medicare’s History Belies Claim That Medicare-for-All Would Disrupt Care

It Disrupted Jim Crow, but Otherwise the Transition Was Smooth

By Steffie Woolhandler and David Himmelstein
The Huffington Post, February 16, 2016

Hillary Clinton and others charge that Bernie Sanders’ Medicare-for-All plan would disrupt and threaten Americans’ health care. But the smooth rollout of Medicare-for-Seniors in 1965 — which many had also predicted would bring chaos — belies that charge.

Medicare, signed into law on July 30, 1965, went live just 11 months later. By then, 18.9 million seniors had signed up, 99 percent of those eligible.

To accomplish this feat (largely without computers) the Social Security Administration mailed an information leaflet and sign-up cards preprinted with each individual’s name and Social Security number (see example below) to seniors on the Social Security and railroad retirement rolls, as well as Civil Service annuitants and a million other seniors identified through IRS records.


Image: Social Security Administration History Archives

To contact hard-to-reach seniors, the federal government reached out to nursing and retirement homes, employers, unions and civic organizations offering to help people apply; organized hundreds of local information meetings; and enlisted postal workers, forest rangers and agricultural representatives to help locate residents of remote areas. The Office for Economic Opportunity hired 5,000 low-income seniors who went door-to-door in their neighborhoods.

All told, Medicare’s overhead costs for the first year totaled only $120 million (equivalent to $882 million in 2015). By comparison, setting up the insurance exchanges for private coverage under Obamacare cost more than $6 billion — about seven times as much. But even the modest figure for Medicare’s start-up costs is an overstatement since it includes the cost of processing six months’ worth of medical bills, not just the enrollment costs. Moreover, Medicare and Medicaid (which was passed at the same time) displaced several smaller federal health assistance programs, saving about $383 million (in 2015 dollars) on their overhead costs.

Even as it became clear that Medicare enrollment was proceeding smoothly, many saw disruption ahead. The Association of American Physicians and Surgeons (AAPS), a group to the right of the American Medical Association (AMA), threatened that 50,000 doctors would boycott Medicare. (Today, the AAPS is sounding the alarm that Medicare-for-All would take away “what remains of your doctor’s liberty.”) Wall Street Journal headlines warned that “Most MDs Won’t Cooperate,” and foresaw a “Patient Pileup,” as “flocks of Medicare beneficiaries … suddenly clog the nation’s 7,200 hospitals.”

None of this came to pass. Doctors continued to care for elderly patients, mostly accepted Medicare payment, and soon came to rely on Medicare as an economic pillar of their practices. Even the AMA, which had spent millions fighting Medicare’s passage (including an infamous ad campaign featuring then-actor Ronald Reagan) cooperated in the program’s implementation. Hospitals ran smoothly, with only a handful reporting more than minor of problems.

But Medicare did cause a major disruption, it disrupted Jim Crow hospital care.

The 1964 Civil Rights Act banned racial discrimination in facilities receiving federal funds (which included most hospitals), but enforcement was lax until Medicare. Many hospitals, particularly in the South, still refused to care for black patients at all, while others relegated them to separate entrances and shabby basement wards. Black physicians were often barred from hospital staffs, and in many locales ambulance services were separate, and distinctly unequal.

With Medicare on the horizon, federal officials made it clear to hospitals that segregated hospitals would be excluded from the program. In the spring of 1966, three months before Medicare took effect, 51 percent of American hospitals were still segregated. By August of that year, 99.5 percent had desegregated.

While Medicare ended overt racial segregation in hospitals, segregation by insurance remains legal and common — and often perpetrates de facto racial segregation. Most of New York City’s prestigious academic medical centers — and many hospitals elsewhere — maintain separate clinic systems, and even separate wards, for Medicaid patients (the 33 million uninsured need not apply).

Medicare-for-All would give all Americans complete and equal coverage, completing the disruption of hospital segregation that Medicare began a half century ago.

Aside from that welcome disruption, Medicare-for-All would greatly simplify life for hospitals and doctors. Instead of the laborious and expensive task of billing patients and their insurers for each Band-Aid and aspirin tablet, hospitals would receive a lump-sum budget, much as we pay for a fire station. Doctors would bill one plan, using one billing form instead of the dozens of complex billing schemes — each with its own rules and redundant documentation requirements — that we face today.

Most important, Medicare-for-All would end many of the disruptions that our patchwork coverage system currently inflicts on patients. All Americans would, for the first time, enjoy a free choice of doctor and hospital, and would never again be forced to change doctors merely because their insurance changed, or their doctor was dumped from their insurer’s network. And patients’ lives would no longer be disrupted by financial ruin from medical bills.

Drs. Steffie Woolhandler and David U. Himmelstein, professors of health policy and management at the City University of New York School of Public Health at Hunter College and Lecturers in Medicine at Harvard Medical School, co-founded Physicians for a National Health Program, a nonpartisan organization. The opinions expressed do not necessarily reflect those organizations’.

http://www.huffingtonpost.com/steffie-woolhandler/medicares-history-belies-_b_9245484.html

Comment:

By Don McCanne, M.D.

‘Nuf said. Time for Medicare-for-All.