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

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

‘Nuf said. Time for Medicare-for-All.

Why haven’t the exchanges done more for us?

Cancer Patients Snagged in Health Law’s Tangled Paperwork

By Ricardo Alonso-Zaldivar
Associated Press, February 15, 2016

Hundreds of thousands of people lose subsidies under the health law, or even their policies, when they get tangled in a web of paperwork problems involving income, citizenship and taxes. Some are dealing with serious illnesses like cancer. Advocates fear the problems, if left unresolved, could undermine the nation’s historic gains in health insurance.

The government says about 470,000 people had coverage terminated through Sept. 30 last year because of unresolved documentation issues involving citizenship and immigration. During the same time, more than 1 million households had their financial assistance “adjusted” because of income discrepancies. Advocates say “adjusted” usually means the subsidies get eliminated.

“When people get that bill for a full-price plan, they panic and they cancel the insurance,” said Elizabeth Colvin of Foundation Communities, an Austin nonprofit that serves low-income people. Some worry the problem could undermine the law’s insurance markets, now in their third year.

“These problems can grow, and they can contribute to undermining consumer faith in the system, and that could lead to attrition,” said Rachel Klein of Families USA, an advocacy group that supports the health law.

Pressured by a Republican-led Congress hostile to Obama’s overhaul, the administration is highly sensitive to criticism that some people may be getting benefits they’re not legally entitled to. But Health and Human Services Secretary Sylvia M. Burwell recently acknowledged the paperwork tangle is more likely to trap the innocent than fraudsters.

http://hosted.ap.org/dynamic/stories/U/US_HEALTH_OVERHAUL_PAPERWORK_TRAP

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Costs, changes led Obamacare enrollment to fall short of earlier estimates

By Jayne O’Donnell
USA TODAY, February 16, 2016

The number of people who signed up for health insurance for 2016 on the state and federal exchanges was up to 40% lower than earlier government and private estimates, which some say is evidence that the plans are too expensive and that people would rather pay a penalty than buy them.

In 2010, the non-partisan Rand Corporation estimated 27 million people would have exchange policies this year and the Congressional Budget Office at that time was estimating 21 million for 2016. CBO even said last June that 20 million people would have plans purchased on the exchanges this year. Just 12.7 million signed up for plans, however, by the end of open enrollment Jan. 31 and about 1 million people are expected to drop their plans — or be dropped when they don’t pay their premiums.

http://www.usatoday.com/story/news/nation/2016/02/15/costs-changes-led-obamacare-enrollment-fall-far-short-estimates/80061050/

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Comment:

By Don McCanne, M.D.

Participation in the ACA exchanges is coming in at a much lower level than were the original predictions. Furthermore, significant numbers drop out each year, and many find that they receive significantly less financial assistance than they expected at enrollment.

Since the exchanges are not working as hoped, perhaps we need incremental innovations that would improve their functioning – you know, those incremental improvements some politicians and policy wonks keep telling us is all that we need to make ACA a universal, affordable system.

But what incremental change would expand coverage to absolutely everyone? What incremental change would make the plans affordable for everyone? What incremental change would ensure that access to care is affordable when facing very high deductibles? What incremental change would ensure that everyone would remain covered by their plans throughout the year, especially when there are so many different reasons that individuals lose their plans?

As mentioned many times before, the flawed health care financing infrastructure is not amenable to simple incremental patches. Keeping the same infrastructure will only perpetuate the severe deficiencies of our dysfunctional financing model. Many will remain uninsured. Many will not be able to afford health care, even if insured. And, worst of all, many will suffer and die.

Maybe we should start tallying the financial hardship, suffering and death in increments so that we can gradually feed that information to the incrementalists who insist this is a small price to pay for keeping intact the model that protects so well our private insurance industry. Maybe then they will understand the evil of defaulting to incrementalism.

Single payer would fix it.

What Obamacare Can’t Do

Single-payer is still the best way to achieve universal health care

By Adam Gaffney, M.D.
Jacobin, Feb. 11, 2016

As the Democratic presidential primary race tightens to a virtual tie nationally, the debate over single-payer health care is growing increasingly tense — and consequential.

In the past several weeks, Hillary Clinton and a host of pundits and policy wonks have articulated an evolving set of arguments about why “Medicare for All” is not affordable, achievable, or worth the effort. A number of rejoinders have made the case that it is, on the contrary, all of these things. More recently, a new line has emerged: yes, current reforms fall short of universal health care, but no, single-payer isn’t necessary to achieve it.

Clinton argued as much at the most recent debate: “I don’t want us to start over again . . . I want to build on the progress we’ve made. Go from 90 percent coverage to 100 percent coverage.” Scott Lemieux outlined a similar vision in a Guardian article last Friday headlined “Americans don’t need single payer healthcare to get universal coverage.” “Single payer healthcare,” Lemieux writes, is not interchangeable with “European-style healthcare.”

He notes that some continental European countries have non-single-payer systems that achieve universal coverage through a combined public/private model. We could thus follow the same path by expanding the Affordable Care Act (ACA) rather than charting a new, more disruptive one (i.e. single-payer).

But while the incremental approach might sound appealing, staying on the track set out by the ACA would be the wrong move. As other countries show, trying to achieve equitable, universal health care within the confines of a private insurance system is bound to result in disappointment.

The Dutch Road

Perhaps more than any other, the Netherlands’ health system is held up as a potential model for the US. Lemieux mentions it as a possible framework. And Paul Krugman describes the Netherlands (and Switzerland, which has a similar system) as having “near-universal coverage even though they rely on private insurers.”

This isn’t a novel pitch. In 2008, as health care reform was under intense debate in the US, an article in the journal Health Affairs noted that “Americans may be interested in the Dutch system” insofar as “it combines mandatory universal health insurance with competition among private health insurers.”

The Netherlands archetype is fairly new. Before 2006, Dutch health care wasn’t single-payer, but it was predominantly public: a social health insurance program covered some two-thirds of the population, and the wealthier minority relied on private insurance.

Though two-tiered, as AndrĂ© den Exter describes in “The Right to Health at the Public/Private Divide,” insurance status at this stage affected neither hospital reimbursement nor waiting time (and benefits were basically the same). Thus, he notes that “there was no incentive [for providers] to treat patients differently.”

If the concern was greater equity, the Dutch could have moved toward a single-payer system, perhaps by first extending the social insurance scheme to everyone. Instead, as Exter describes, the “radical” 2006 reforms did the exact opposite: the social insurance scheme was replaced by an individual mandate–based system for everybody, “carried out by for-profit insurance companies.”  In other words, Obamacare before Obamacare: a regulated, subsidized marketplace of competing private insurance plans (that, to be sure, cover more of the population at a lower cost than in the US).

The 2006 Dutch reforms were based in part on a school of health policy thought associated with the US economist Alain Enthoven, a man who got his start analyzing military strategy for the Pentagon before becoming the foremost proponent of competing private-sector health plans (so-called “managed competition”).

Outside the Netherlands, Enthoven’s ideas have influenced health reform efforts in both his home country — first under Bill Clinton, then President Obama — and in Britain, where Margaret Thatcher began the push to marketize the National Health Service (NHS) in the late 1980s. The 2006 Dutch reforms should therefore be seen as part of a wider, if uneven, neoliberal transition in health systems internationally.

A 2011 article in the New England Journal of Medicine captures the flaws of the Dutch system well. It counts four main shortcomings. First, the 2006 reform did not control expenditure growth — instead, the unwieldy attempt to introduce quasi-market competition “produced high administrative costs and complexity.” Second, uninsurance was not fully eliminated, so some residents still defaulted on their premium payments (and could then be dropped by their insurance company).

Third, the system of “consumer choice,” in which the Dutch are expected to shop around for new insurance plans, didn’t deliver higher customer satisfaction. In a poll cited by the authors, 65 percent of those insured said they had “low or very low levels of trust in private plans.” And finally, while the reform was intended to introduce more market competition, it still brought heavy doses of regulation and bureaucracy.

A less critical September 2015 review in the Journal nonetheless offered some similar conclusions on the Netherlands’ turn away from a public system: “Almost 10 years in, the reforms have not led to the desired cost containment or a leap in quality,” while at the same time “individuals increasingly worry about cost-related access problems.”

The reality is that fragmented, multi-payer systems invariably demand costly administrative apparatuses. A recent comparative study of hospital administrative costs in the US, Canada, and several European countries makes this particularly evident. Among other high-income countries, the United States was found to spend the most on hospital administration. Not far behind it, however, was the Netherlands:


Himmelstein DU, Jun M, Busse R, et al. “A Comparison Of Hospital Administrative Costs In Eight Nations: US Costs Exceed All Others By Far.” Health Affairs (2014).

Nor are these sums chump change. Indeed, in 2010, according to this study, 1.43% of US GDP went to hospital administration alone.

Now, it might seem surprising that England is right behind the Netherlands — doesn’t it have a single-payer system? To a large extent it still does. But as previously noted, Thatcher and her successors worked to inject an “internal market” into the NHS that — along with other pro-market initiatives — has created a much more administratively wasteful and privatized NHS in England. In contrast, the two nations with the lowest administrative spending — Canada and Scotland — have straightforward single-payer systems. The investigators thus conclude:

“In the United States, administration consumes an increasing share of hospital budgets — a share that is far higher than in nations with simpler and less market-oriented payment schemes . . . Reforming the US health care system so that it operated on a single-payer basis could result in large savings on administration.”

Equity and Solidarity

Not all universal health care systems are created equal. Genuine universal health care includes the following four features, at a minimum: universal coverage (i.e. none left uninsured or uncovered), the elimination of financial impediments to care (i.e. no copayments and deductibles), comprehensive coverage (including services currently uncovered or poorly covered in the US), and no inferior “tiers” of access for particular economic or demographic groups.

Achieving this would cost real money. Yet the transition to a single-payer system could achieve efficiency savings that would, as health policy scholars Steffie Woolhandler and David Himmelstein note in a recent op-ed, be “enough to cover all of the uninsured and eliminate co-payments and deductibles for the rest of us.” They estimate upwards of $400 billion annually in efficiency savings.

In contrast, reforms that fall short of single-payer — whether it’s the Dutch model of managed competition, “all-payer” initiatives, or even the “public option” — would not (among other shortcomings) generate those savings, making it more difficult to achieve universal health care worthy of the name.

Yet there is also a much larger political and philosophical issue at stake. For egalitarians, a just health care system must treat all equally. This is difficult — if not impossible — in systems with upper and lower tiers of coverage, with barriers that impede access to particular facilities or doctors for particular groups, and in which a for-profit ethos encourages excluding certain individuals or treatments. Exter raises similar concerns about equity in the case of post-2006 Netherlands:

“[T]he new liberalized health insurance scheme has resulted in preferential health care arrangements that significantly challenge the notion of equity or solidarity within the Dutch health care system . . . Given the limited options of unhealthy and more needy individuals, a substantial inequality in access to health care between several socioeconomic groups will likely emerge over time in the Dutch system.”

The same outcome could be expected in the US.

The Dutch system’s deficiencies also reveal the pitfalls of counterpoising a private US system to the “universal” systems of other high-income nations. Even if European countries’ health systems outperform the United States’, speaking of “European” health systems in the aggregate obscures more than it reveals.

If the Netherlands model demonstrates anything, it’s that some forms of “universal” health care are less worthy of emulation than others. Expanding access the Dutch way (itself based on US policy ideas) would leave intact much of the waste of the current system — without achieving the equity implied by the term “universal health care.”

A single-payer national health program must therefore remain a central goal for progressives and the Left. Placating the private insurance industry isn’t a price we can afford to pay.

Adam Gaffney is a physician whose work has appeared in Salon, Dissent, and In These Times. He blogs at theprogressivephysician.net.

https://www.jacobinmag.com/2016/02/gaffney-single-payer-sanders-healthcare-obamacare-aca-clinton/

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

AFGE Endorses HR 676, National Single-Payer Bill

News release
Single Payer News, Feb. 16, 2016
 
The National Executive Council of the American Federation of Government Employees (AFGE) has unanimously endorsed HR 676, national single payer legislation sponsored by Congressman John Conyers of Michigan. The resolution was submitted by AFGE National Vice President Arnold R. Scott of District 6.
 
With 1,100 local unions, AFGE is the largest federal employee union and has 670,000 members across the country.
 
The text of the AFGE resolution is below:

Union Resolution in Support of HR 676, National Single Payer Legislation, Expanded and Improved Medicare for All

Submitted by:  NVP Scott
 
Whereas, America’s health care system is in deep trouble.  In spite of efforts to regulate the insurance industry for-profit health insurance companies are finding ways to skirt the law.  The Affordable Care Act, passed in 2010, made it possible for some of the uninsured to find coverage, but did not resolve the problem that health insurance companies are pricing care beyond our means, and
 
Whereas, unions have battled to achieve the highest standards of health care for members and their families, and those gains have lifted up health benefits for all workers, even those who have no union.  All of these achievements are now under constant attack as costs rise and employers seek to shift those costs to workers.  Union multiemployer health plans are struggling under the unfair advantages allowed to non-union companies.  Rising copays and deductibles make it more difficult for those who have insurance to get the care they need.  The excise tax of 2018 will make things worse, and
 
Whereas, employers seek to drop health benefits for early retirees, for spouses, for part-timers.  Some corporations use bankruptcy laws to shirk their contractual health care obligations.  The rising cost of health insurance is blocking progress in wages and other areas, and
 
Whereas, insurance companies rather than patients are deciding what doctors we can see and what hospitals we can use.  Drug company profits soar as, so far, congress has not used the power of bulk purchasing to bring down the prices.  The US spends double per capita what other industrialized nations spend, yet ranks far below in life expectancy and infant mortality, and
 
Whereas, we deserve better.  It doesn’t have to be this way.  Firefighters don’t ask us to pay before they save our families from burning houses.  They just proceed to do the right thing.  Health care is just as important as fire protection.  Lives are at stake and all of us should have the best care that this wealthy nation has the ability to provide.  Our tax dollars subsidize the research, the medical schools, and the hospitals.  Unions led the way in other industrialized countries to assure universal coverage with good care through a form of single payer, and Congressman John Conyers Jr. (D-MI) has introduced HR 676, Expanded and Improved Medicare for All.  HR 676 will establish a single payer health care system by expanding a greatly improved Medicare to cover everyone.  It will restore our right to choose our physicians and free us from insurance company interference in medical decisions.  It will free our health care from corporate control, and
 
Whereas, HR 676 will cover everyone for all necessary medical care including dental, prescription drugs, hospital, surgical, outpatient services, primary and preventive care, emergency services, mental health, home health, physical therapy, rehabilitation (including for substance abuse), vision care, chiropractic, eyeglasses, hearing aids, other medical devices and long term care.  HR 676 will end deductibles and copayments, and
 
Whereas, HR 676 will save hundreds of billions annually by eliminating the high overhead and profits of the private health insurance industry and by using our purchasing power to rein in the drug companies.  The transition to national health insurance would apply the savings from administration and profits to expanded and improved coverage for all, and
 
Whereas, standing up for all working people and leading the effort to win healthcare for all we will affirm labor’s rightful role as a leader in the fight for social justice.  Bold action by our unions can rally the nation to pass HR 676.
 
Therefore be it resolved, that AFGE wholeheartedly endorses Congressman Conyers’ bill HR 676, “Expanded and Improved Medicare for ALL,” a single payer health care program.
 
Be it further resolved, that AFGE will work with other unions and community groups to build a groundswell of popular support and action for single payer universal health care and HR 676 until we make what is morally right for our nation into what is politically possible.
 
And that AFGE will send a copy of this resolution to Congressman Conyers, to all members of the US House and Senate, to the AFL-CIO Executive Council, and to the news media.
 
And further, that AFGE will take other actions to mobilize our members and our community at the grassroots to encourage other members of the House to sign on as co-sponsors of HR 676 and to encourage Senators to introduce a companion bill in the Senate.
 
Passed unanimously by the National Executive Council of the American Federation of Government Employees, November 2015.
 
#30#

HR 676 would institute a single payer health care system by expanding a greatly improved Medicare to everyone residing in the U.S. Patients will choose their own physicians and hospitals.

HR 676 would cover every person for all necessary medical care including prescription drugs, hospital, surgical, outpatient services, primary and preventive care, emergency services, dental (including oral surgery, periodontics, endodontics), mental health, home health, physical therapy, rehabilitation (including for substance abuse), vision care and correction, hearing services including hearing aids, chiropractic, durable medical equipment, palliative care, podiatric care, and long term care.

HR 676 ends deductibles and co-payments. HR 676 would save hundreds of billions annually by eliminating the high overhead and profits of the private health insurance industry and HMOs. In the current Congress, HR 676 has 60 co-sponsors in addition to Congressman Conyers.

HR 676 has been endorsed by 623 union organizations including 151 Central Labor Councils/Area Labor Federations and 44 state AFL-CIO’s (KY, PA, CT, OH, DE, ND, WA, SC, WY, VT, FL, WI, WV, SD, NC, MO, MN, ME, AR, MD-DC, TX, IA, AZ, TN, OR, GA, OK, KS, CO, IN, AL, CA, AK, MI, MT, NE, NJ, NY, NV, MA, RI, NH, ID.
 
For a list of union endorsers, or a sample endorsement resolution, contact:
 
Kay Tillow
All Unions Committee for Single Payer Health Care–HR 676
c/o Nurses Professional Organization (NPO)
1169 Eastern Parkway, Suite 2218
Louisville, KY 40217
(502) 636 1551
 
Email: nursenpo@aol.com
http://unionsforsinglepayer.org
https://www.facebook.com/unionsforsinglepayer

The $3 trillion elephant in the presidential campaign

By Ed Weisbart, M.D.
St. Louis Post-Dispatch, Feb. 16, 2016

Remember the heated discussions about health care in the Republican debates? No, you don’t, because they were arguing about things like fantasy football. In fact, all we heard about health care was, “Repeal Obamacare!”

We get it, being a member of The Repeal Obamacare Club is a prerequisite for running for president on the GOP ticket, as is having no plan with which to replace it.

Jeb Bush promotes tax credits for individuals to purchase “affordable” and “portable” plans. We hope Bush thinks “affordable” means less than 10 percent of annual income, but given that he wants to retain the same insurance industry whose bureaucracy now consumes 30 percent of every health care dollar, it’s unlikely.

Ben Carson supports health savings accounts, a great idea for healthy and wealthy individuals, but a terrible idea for everyone else who would be more deeply trapped in increasingly expensive plans. It’s a particularly bad idea for women, whose annual cost of care typically is $1,000 more than it is for men.

Ted Cruz crows, “Repeal every blasted word of Obamacare.” With what? All the problems Obamacare addressed? Crisis treatment in ERs instead of prudent prevention? Denials for pre-existing conditions? Denials for people with the audacity to get sick and actually use their insurance? Annual and lifetime caps?

Marco Rubio, like Jeb, would give you a refundable tax credit to purchase insurance. How does that control costs? And how is that so different from the premium subsidies provided by Obamacare, which Rubio opposes?

Donald Trump promises: “I am going to take care of everybody. I don’t care if it costs me votes or not. Everybody’s going to be taken care of much better than they’re taken care of now.” So far, Trump offers no details. He either doesn’t have them or doesn’t want us to know them. But when he does, they’ll be “fabulous!”

And what about the Democrats? Hillary Clinton would retain the Affordable Care Act and lower out-of-pocket and prescription costs, but she hasn’t said how. The Affordable Care Act has saved countless lives, but it is essentially an insurance-reform/subsidy program, not the comprehensive solution our nation needs to remedy our chronic bloating of health care costs.

Bernie Sanders supports HR 676, the Expanded and Improved Medicare for All Act, co-sponsored by Rep. William Lacy Clay and 63 other U.S. representatives. It’s a comprehensive plan with robust details. It provides full coverage without premiums, like people enjoy in all other advanced countries, at roughly half of what we spend per person in the United States today.

Any candidate who isn’t forthcoming with these details is ignoring our current dire reality. Our health care system has a literal death grip on this nation. It is the new “giant sucking sound” of money being vacuumed from our entire economy and into health care’s deep, private-profit pockets.

More than another cycle of modest reform, we need to base our solution upon our nation’s most successful health care system, Medicare. We need to divorce our health insurance from our employers, releasing businesses from that burden and giving job mobility back to employees. We need to implement universal access to health care, paid for by progressive taxes, delivered by the world’s best doctors and hospitals. We need to replace our woefully wasteful private insurance system with the efficiency of Medicare.

By eliminating sales, marketing, underwriting and other non-productive administrative functions required of private insurers, Medicare’s overhead is 2 percent; private insurance’s is 18 percent.

We have some of the best health care in the world, but far too many Americans can’t afford to use it, and everyone pays way too much for it. Medicare offers 50 years of proof that our government can administer health care as well or better than anywhere else in the world. Let’s make it available to each and every American, and demand that anyone running for high office explain how they could do better. They won’t because they can’t.

Dr. Ed Weisbart is chairman of Physicians for a National Health Program — Missouri chapter.

http://www.stltoday.com/news/opinion/the-trillion-elephant-in-the-presidential-campaign/article_ae4ef099-5c48-52c2-902d-7c1714f91730.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 for all is what U.S. needs

By Jack Bernard
The Citizen (Fayetteville, Ga.), Feb. 16, 2016

I enjoyed reading Dr. Scherz’s (opinion column, 1-10-16), which was well written. As a retired senior level healthcare exec and former GOP elected official, I understand his frustration with the downside of Obamacare (the ACA). I hear much the same from my two sons, who are practicing physicians.

But, I am not in agreement with Scherz’s suggested solution, i.e., going back to the time before we had primary care insurance and having individuals fend for themselves, negotiating direct agreements with each of their doctors. The paperwork, research, skill and time required on both sides would be immense.

And, there it is a certainty that the consumer would pay more due to paucity of easily obtainable comparative data and lack of any leverage when dealing with providers. In other words, Medicare can get better rates than an individual because many providers cannot afford to lose the government’s business, accounting for over half of all U.S. healthcare expenditures.

Along the lines of the Scherz approach, a conservative friend mentioned to me the other day that he agreed with Gov. Mike Huckabee on healthcare. The problem with Americans is that we do not know the cost of healthcare services, so we want everything.

True, there are problems with our insurance system, some of which were identified by Dr. Scherz. Health insurance certainly does insulate the patient from costs. That is what all insurance is supposed to do; should we eliminate all types of insurance? Plus, we are already less insulated than other nations (see study cited below).

One alternative is to have no health insurance for anyone, an impractical suggestion advocated by the then-head of the Georgia Medical Association in response to one of my earlier Atlanta Journal-Constitution editorials. Dr. Scherz seems to suggest something similar for primary physician care, although he does not mention the hospital side where much of the cost, and possibly waste, resides.

Another alternative often suggested by conservatives is to have deductibles so high (one physician I know suggested $10,000) that most patients pay just about everything out of pocket. Does anyone other than the 1 percent really think that is an optimum solution? Unfortunately, due to inaction by Congress, the private insurance system seems headed that way now.

Huckabee, Scherz and others are subtly building on the healthcare establishment’s historical position: “We have the best health care in the world.” The real problem is patients and their reliance on insurance to insulate them from costs. So why change anything on the financing end through government programs like Obamacare (the Affordable Care Act, ACA)?

But, how do other nations view our system? The Journal of the Royal Society of Medicine (the UK’s AMA) did a comparative study in 2011 of 19 countries and found: “In cost-effective terms, i.e., economic input versus clinical output, the USA healthcare system was one of the least cost-effective in reducing mortality rates.”

Our own National Institute of Health (NIH) issued a study (1-9-13) which detailed many problems with our lifestyle, but it also criticized our access problems, stating that 50 million residents had no health insurance. Regarding access, all nations studied did better than the U.S., except Turkey, Chile and Mexico. (Note: Despite its problems, the ACA has made a significant dent in this figure via Medicaid expansion and the healthcare exchanges.)

Specifically, NIH criticized the private-public-provider-payer morass that constitutes American health care delivery and financing, stating that U.S. patients do not receive the care that they need and sometimes receive care that they do not need. It further indicated that “Americans do not experience optimal quality when they do receive health care” due to the “fragmented” nature of our system, creating “inefficiencies and coordination” problems that other nations do not have.

The report also referred to a Commonwealth Fund study which found that Americans were more uncertain than others that their treatments would be adequate if they were seriously ill.

And, NIH found that Americans already had higher deductibles, copayments and out of pocket expenses versus other nations, with 40 percent of those under 65 with insurance reporting access problems due to cost.

As opposed to what many on the right say, the study found that our citizens were more likely than other countries to experience delays when seeing a physician for serious ailments. The study also reported that other studies have shown hospital readmission rates to be higher here, an indicator of lower quality care.

All told, it is a damning indictment of how we get health services in the United States … the result of our excessively expensive but deeply flawed system.

What can we do about the situation? First, stop buying false arguments about the only problem being the patient. We have identifiable access, cost and quality issues.

The website of Physicians for a National Health Program (PNHP) outlines another solution, used by many of the nations who are clearly ahead of us: true national health insurance covering everyone.

With Medicare as the sole payer, not only can costs be controlled and universal access guaranteed, but we can institute national quality measures as well.

Will this grand plan happen tomorrow? No, it will take time. But, if we push our legislators to logically look at facts and science, versus the histrionics of TV entertainers and politician skeptics, that day will come.

Jack Bernard resides in Peachtree City, Ga. His former chairman of a county commission (Jasper County) and chair of the Republican Party there. He is also a a retired healthcare executive and the former director of Health Planning for the state of Georgia. His website is http://universalhealthreform.wordpress.com/.
 
http://thecitizen.com/letters-editor/medicare-all-what-us-needs

Why haven’t the exchanges done more for us?

Cancer Patients Snagged in Health Law’s Tangled Paperwork

By Ricardo Alonso-Zaldivar
Associated Press, February 15, 2016

Hundreds of thousands of people lose subsidies under the health law, or even their policies, when they get tangled in a web of paperwork problems involving income, citizenship and taxes. Some are dealing with serious illnesses like cancer. Advocates fear the problems, if left unresolved, could undermine the nation’s historic gains in health insurance.

The government says about 470,000 people had coverage terminated through Sept. 30 last year because of unresolved documentation issues involving citizenship and immigration. During the same time, more than 1 million households had their financial assistance “adjusted” because of income discrepancies. Advocates say “adjusted” usually means the subsidies get eliminated.

“When people get that bill for a full-price plan, they panic and they cancel the insurance,” said Elizabeth Colvin of Foundation Communities, an Austin nonprofit that serves low-income people. Some worry the problem could undermine the law’s insurance markets, now in their third year.

“These problems can grow, and they can contribute to undermining consumer faith in the system, and that could lead to attrition,” said Rachel Klein of Families USA, an advocacy group that supports the health law.

Pressured by a Republican-led Congress hostile to Obama’s overhaul, the administration is highly sensitive to criticism that some people may be getting benefits they’re not legally entitled to. But Health and Human Services Secretary Sylvia M. Burwell recently acknowledged the paperwork tangle is more likely to trap the innocent than fraudsters.

http://hosted.ap.org/dynamic/stories/U/US_HEALTH_OVERHAUL_PAPERWORK_TRAP

***

Costs, changes led Obamacare enrollment to fall short of earlier estimates

By Jayne O’Donnell
USA TODAY, February 16, 2016

The number of people who signed up for health insurance for 2016 on the state and federal exchanges was up to 40% lower than earlier government and private estimates, which some say is evidence that the plans are too expensive and that people would rather pay a penalty than buy them.

In 2010, the non-partisan Rand Corporation estimated 27 million people would have exchange policies this year and the Congressional Budget Office at that time was estimating 21 million for 2016. CBO even said last June that 20 million people would have plans purchased on the exchanges this year. Just 12.7 million signed up for plans, however, by the end of open enrollment Jan. 31 and about 1 million people are expected to drop their plans — or be dropped when they don’t pay their premiums.

http://www.usatoday.com/story/news/nation/2016/02/15/costs-changes-led-obamacare-enrollment-fall-far-short-estimates/80061050/

Participation in the ACA exchanges is coming in at a much lower level than were the original predictions. Furthermore, significant numbers drop out each year, and many find that they receive significantly less financial assistance than they expected at enrollment.

Since the exchanges are not working as hoped, perhaps we need incremental innovations that would improve their functioning – you know, those incremental improvements some politicians and policy wonks keep telling us is all that we need to make ACA a universal, affordable system.

But what incremental change would expand coverage to absolutely everyone? What incremental change would make the plans affordable for everyone? What incremental change would ensure that access to care is affordable when facing very high deductibles? What incremental change would ensure that everyone would remain covered by their plans throughout the year, especially when there are so many different reasons that individuals lose their plans?

As mentioned many times before, the flawed health care financing infrastructure is not amenable to simple incremental patches. Keeping the same infrastructure will only perpetuate the severe deficiencies of our dysfunctional financing model. Many will remain uninsured. Many will not be able to afford health care, even if insured. And, worst of all, many will suffer and die.

Maybe we should start tallying the financial hardship, suffering and death in increments so that we can gradually feed that information to the incrementalists who insist this is a small price to pay for keeping intact the model that protects so well our private insurance industry. Maybe then they will understand the evil of defaulting to incrementalism.

Single payer would fix it.

Concierge medicine at Mass General

Founded for the Poor, Mass General Looks to the Wealthy

By John Hanc
The New York Times, February 12, 2016

Can a hospital founded more than 200 years ago to treat the poor also adopt a form of medicine some criticize as health care for the rich?

The answer may come in August, when Massachusetts General Hospital, the third-oldest general hospital in the nation, plans to open a concierge medicine practice.

Based in Boston, the hospital, whose $800 million annual research budget is among the nation’s biggest, is affiliated with Harvard Medical School and is perennially ranked No. 1 in many categories of U.S. News & World Report’s listings of the country’s best hospitals.

Despite its reputation, Mass General — as it is known — was established in 1811 to care for the city’s poor and indigent. Patients in concierge medicine are likely to be anything but that.

The idea of wealthy people paying doctors a retainer for exclusive service is not new. With concierge medicine, which was introduced in the 1990s, patients pay physicians a monthly or annual retainer and expect more personalized care and greater access. “A concierge patient who signs up for a practice is not only looking for quality care, they are looking for unfettered access to their provider,” said Dr. Michael R. Jaff, the medical director of Mass General’s Center for Specialized Services and a professor at Harvard Medical School.

There are pros and cons to concierge medicine — or direct primary care, a similar model — which, according to the industry trade magazine Concierge Medicine Today, is embraced by about 6,000 doctors across the country.

“The upside is that it gives more time for patient-physician interaction, and the data shows that generally the more time a patient has with a physician, the better the outcome,” said Dr. Wanda D. Filer, president of the American Academy of Family Physicians. “The downside is that it can be very exclusive and difficult for middle- and low-income patients to afford. So there’s a concern that you’ll have a two-tier system.”

In recent years, concierge medicine and similar types of programs have spread from private practices to hospitals. Mass General’s embrace of it may prove influential.

To critics of concierge medicine, Mass General’s foray into the field is no cause for celebration. “It’s worrisome, unless you’re rich,” said Pauline Rosenau, professor of public health at the University of Texas Health Science Center in Houston. As for the hospital’s historical mission, she added, “I’d say it’s in jeopardy.”

The proximity to the main hospital will give concierge patients easy access to Mass General’s specialists (something not typically offered in private concierge services). “We’ve made the institutional commitment that these patients will get the best of the best at a phone call,” Dr. Jaff said. “So if I call and say I need a general surgeon, they’ll have a world-class general surgeon that day.”

As for benefits of the concierge practice for the rest of the hospital’s patients (Mass General has about 1.5 million outpatient visits a year), Dr. Jaff admitted they were a little less tangible, though still critical. “With dwindling reimbursement,” he said, “there needs to be other sources of revenue to help us support our mission to the community at large.”

What some call “health care for the rich,” the hospital says it believes, can be one such source.

http://www.nytimes.com/2016/02/14/your-money/founded-for-the-poor-mass-general-looks-to-the-wealthy.html?ref=health

***

Comment:

By Don McCanne, M.D.

Say it isn’t true. Mass General? Concierge hospital? Two-tier medicine? Selling the front of the queue to the wealthy?

Is the payment of a bribe to gain better health care access access ethical just because Mass General has given its stamp of approval? They say the money will help support their mission to the community at large, but how does pushing the entire queue back by giving the wealthy a ticket to butt in in front of everyone else help those with low or moderate incomes?

It gives a new meaning to triage. As we organize the delivery of care based on need and urgency, we now have a new paramount guideline, “Let the money in first!”

Under a more egalitarian single payer system, at least the bribes would not be so flagrant.

Concierge medicine at Mass General

Founded for the Poor, Mass General Looks to the Wealthy

By John Hanc
The New York Times, February 12, 2016

Can a hospital founded more than 200 years ago to treat the poor also adopt a form of medicine some criticize as health care for the rich?

The answer may come in August, when Massachusetts General Hospital, the third-oldest general hospital in the nation, plans to open a concierge medicine practice.

Based in Boston, the hospital, whose $800 million annual research budget is among the nation’s biggest, is affiliated with Harvard Medical School and is perennially ranked No. 1 in many categories of U.S. News & World Report’s listings of the country’s best hospitals.

Despite its reputation, Mass General — as it is known — was established in 1811 to care for the city’s poor and indigent. Patients in concierge medicine are likely to be anything but that.

The idea of wealthy people paying doctors a retainer for exclusive service is not new. With concierge medicine, which was introduced in the 1990s, patients pay physicians a monthly or annual retainer and expect more personalized care and greater access. “A concierge patient who signs up for a practice is not only looking for quality care, they are looking for unfettered access to their provider,” said Dr. Michael R. Jaff, the medical director of Mass General’s Center for Specialized Services and a professor at Harvard Medical School.

There are pros and cons to concierge medicine — or direct primary care, a similar model — which, according to the industry trade magazine Concierge Medicine Today, is embraced by about 6,000 doctors across the country.

“The upside is that it gives more time for patient-physician interaction, and the data shows that generally the more time a patient has with a physician, the better the outcome,” said Dr. Wanda D. Filer, president of the American Academy of Family Physicians. “The downside is that it can be very exclusive and difficult for middle- and low-income patients to afford. So there’s a concern that you’ll have a two-tier system.”

In recent years, concierge medicine and similar types of programs have spread from private practices to hospitals. Mass General’s embrace of it may prove influential.

To critics of concierge medicine, Mass General’s foray into the field is no cause for celebration. “It’s worrisome, unless you’re rich,” said Pauline Rosenau, professor of public health at the University of Texas Health Science Center in Houston. As for the hospital’s historical mission, she added, “I’d say it’s in jeopardy.”

The proximity to the main hospital will give concierge patients easy access to Mass General’s specialists (something not typically offered in private concierge services). “We’ve made the institutional commitment that these patients will get the best of the best at a phone call,” Dr. Jaff said. “So if I call and say I need a general surgeon, they’ll have a world-class general surgeon that day.”

As for benefits of the concierge practice for the rest of the hospital’s patients (Mass General has about 1.5 million outpatient visits a year), Dr. Jaff admitted they were a little less tangible, though still critical. “With dwindling reimbursement,” he said, “there needs to be other sources of revenue to help us support our mission to the community at large.”

What some call “health care for the rich,” the hospital says it believes, can be one such source.

http://www.nytimes.com/2016/02/14/your-money/founded-for-the-poor-mass-general-looks-to-the-wealthy.html?ref=health

Say it isn’t true. Mass General? Concierge hospital? Two-tier medicine? Selling the front of the queue to the wealthy?

Is the payment of a bribe to gain better health care access access ethical just because Mass General has given its stamp of approval? They say the money will help support their mission to the community at large, but how does pushing the entire queue back by giving the wealthy a ticket to butt in in front of everyone else help those with low or moderate incomes?

It gives a new meaning to triage. As we organize the delivery of care based on need and urgency, we now have a new paramount guideline, “Let the money in first!”

Under a more egalitarian single payer system, at least the bribes would not be so flagrant.

The flip-flop behind the flawed attacks on Sanders’s single-payer plan

By David U. Himmelstein and Steffie Woolhandler
The Washington Post, Letters, Feb. 12, 2016

The Jan. 29 editorial “The real problem with Mr. Sanders” alleged that Sen. Bernie Sanders’s (I-Vt.) health-care plan “rests on unbelievable assumptions about how much he could slash health-care costs.” That dismissive claim was based on a deeply flawed analysis by Kenneth Thorpe, an Emory University professor and former Clinton administration official who, like Democratic presidential candidate Hillary Clinton, has done a recent flip-flop on the facts about single-payer.

So what has changed? In 2003, Thorpe calculated that single-payer would achieve huge administrative savings — more than 10 percent of total health spending, equivalent to $350 billion this year alone. Now he has cut that estimate by more than half, even though the costs of bureaucracy in the United States have continually climbed, while they’ve remained low in single-payer nations.

Thorpe previously predicted that single-payer would cause a modest uptick in the utilization of care. Now — despite the fact that fewer are uninsured — he has decided there would be a huge increase.

Finally, Thorpe says nothing about savings on drug prices, despite the fact that every nation with a national health-insurance program gets discounts of about 50 percent.

The old Kenneth Thorpe — like the old Hillary Clinton — acknowledged the facts about single-payer. The new one ignores them. The editorial board should know better.

David U. Himmelstein and Steffie Woolhandler are professors of health policy and management at the City University of New York School of Public Health and lecturers in medicine at Harvard Medical School. They reside in New York.

https://www.washingtonpost.com/opinions/the-flip-flop-behind-the-flawed-attacks-on-sanderss-single-payer-plan/2016/02/12/32e82bd0-c9d8-11e5-b9ab-26591104bb19_story.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. For a more detailed critique of Kenneth Thorpe’s flawed analysis, see this article by Drs. David Himmelstein and Steffie Woolhandler in The Huffington Post.

In Fact, Argue Experts, Sanders’ Medicare-for-All Numbers ‘Do Add Up’

“It’s indisputable that single-payer systems in other countries cover everyone for virtually everything, and at much lower cost than our health care system,” PNHP co-founder says

By Nadia Prupis
Common Dreams, Feb. 12, 2016

During Thursday night’s Democratic presidential debate, Hillary Clinton criticized Bernie Sanders’ proposal for a “Medicare for All” healthcare program, stating, “the numbers just don’t add up.”

“A respected health economist said that these plans would cost a trillion dollars more a year,” Clinton said, likely referring to a recent analysis by Emory University professor Kenneth Thorpe, who helped craft a single-payer healthcare system in Sanders’ home state of Vermont, which said Sanders’ proposal was off by an extra $1.1 trillion annually.

“So if you’re having Medicare for all, single-payer, you need to level with people about what they will have at the end of the process you are proposing,” Clinton said. “And based on every analysis that I can find by people who are sympathetic to the goal, the numbers don’t add up, and many people will actually be worse off than they are right now.”

But according to other healthcare experts, both Clinton and Thorpe are working with false calculations.

Dr. Steffie Woolhandler, a professor in public health at City University of New York at Hunter College and co-founder of the advocacy group Physicians for a National Health Program, said Friday that the “numbers on single-payer do, in fact, add up.”

“It’s indisputable that single-payer systems in other countries cover everyone for virtually everything, and at much lower cost than our health care system,” Woolhandler said. “Experience in countries with single-payer systems, such as Canada, Scotland, and Taiwan, proves that we can have more, better and cheaper care.”

For example, “if the U.S. moved to a single-payer system as efficient as Canada’s, we’d save $430 billion on useless paperwork and insurance companies’ outrageous profits, more than enough to cover the 31 million Americans who remain uninsured, and to eliminate co-payments and deductibles for everyone,” she said.

In January, Woolhandler and her colleague Dr. David Himmelstein authored a response to Thorpe’s analysis that found it to be based on “several incorrect, and occasionally outlandish, assumptions,” including “administrative savings of only 4.7 percent of expenditures” and “huge increases in the utilization of care, increases far beyond those that were seen when national health insurance was implemented in Canada, and much larger than is possible given the supply of doctors and hospital beds.”

“Moreover, it is at odds with analyses of the costs of single-payer programs that he produced in the past, which projected large savings from such reform,” the professors wrote.

Woolhandler said Friday, “A single-payer system could save even more money by bargaining with drug companies for discounts on drugs. Other countries get discounts of about 50 percent, and as the biggest customer we could have the bargaining power to get similar savings…Finally, single-payer systems have been better at controlling costs over the long-haul.”

“Our medical arms race—with hospitals competing to offer expensive high tech care, even when they don’t do enough to be good at it—has driven up costs and compromised the quality of care. In contrast, single-payer nations have used thoughtful health planning, to invest in expensive high tech care where it’s needed, not just where it’s redundant but profitable,” she said.

During Thursday’s debate, Sanders rejected the argument that his plan was “unachievable.”

“Every major country on earth, whether it’s the UK, whether it’s France, whether it’s Canada, has managed to provide healthcare to all people as a right and they are spending significantly less per capita on healthcare than we are,” he said. “So I do not accept the belief that the United States of America can’t do that.”

“Please do not tell me that in this country, if—and here’s the if—we have the courage to take on the drug companies, and have the courage to take on the insurance companies, and the medical equipment suppliers, if we do that, yes, we can guarantee health care to all people in a much more cost effective way,” he said.

The charge that the numbers for a sweeping healthcare reform plan “don’t add up” is one that Clinton herself has been hit with in the past, regarding the Health Security Act—dubbed ‘Hillarycare’—introduced in 1993 under President Bill Clinton’s administration.

This work is licensed under a Creative Commons Attribution-Share Alike 3.0 License
 
http://www.commondreams.org/news/2016/02/12/fact-argue-experts-sanders-medicare-all-numbers-do-add

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

Single-payer would cut costs, improve care

By John Benziger, M.D.
Kennebec (Maine) Journal, Letters, Feb. 11, 2016

Just as the tobacco and fossil-fuel industries sponsored “experts” to perpetuate the idea that their industries were harmless, the for-profit American heath care industry is now engaging in misinformation claiming Bernie Sander’s single-payer system would “break the bank.”

The truth is that an “Improved Medicare For All” single-payer system would cut costs drastically and provide coverage for everybody. Virtually every other developed country has an affordable universal system that proves the point.

At issue is that single-payer threatens the multimillion-dollar paychecks of insurance companies and their CEOs, and the outrageous profits of drug and medical device companies and medical entrepreneurs. Under single-payer, private health insurance companies are gone and the system can negotiate for lower drug and medical device costs.

People are waking up to see that corporate greed is hurting Americans. We have a broken for-profit health care system. Quality is mediocre, and more than 25 million Americans are still uninsured. Medicare, Medicaid and hospitals are under threat of new cuts. Meanwhile the nation’s for-profit health industry nets billions in profits, and CEOs take home tens of millions in pay.

A single-payer “Improved Medicare For All” would cut costs dramatically by streamlining health care paperwork and making health care affordable. Savings would be enough to provide coverage for everyone, without ANY additional spending! The concept is popular with the American people and enjoys the support of most doctors.

Consult Physicians for a National Health Program (pnhp.org) and learn how you can help bring about a real universal health care system. Add your voice to the growing chorus, and tell our leaders to stand up for the health of the American people rather than the wealth of our richest firms.

Dr. John Benziger resides in South China, Maine.

https://www.centralmaine.com/2016/02/11/single-payer-would-cut-costs-improve-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.