The Human Face of ObamaCare: Promises vs. Reality and What Comes Next

By John Geyman, M.D.
Copernicus Healthcare, January 1, 2016

Preface

Now that the Affordable Care Act (ACA) has been upheld by the U.S. Supreme Court as the law of the land, it is the target of an intense partisan debate during this 2016 election cycle. Confusion, disinformation, and misleading rhetoric dominate the airwaves as politicians and their corporate backers offer up wildly different approaches to our health care problems and solutions.

After six years with the ACA, there is a large base of experience to draw upon to assess, on the basis of evidence, what has worked and not worked. So it is time to reassess its impacts on the problems it was intended to address–reduced access to health care, uncontrolled costs, increasing unaffordability, and unacceptable quality of care for our population.

Despite promises of the Obama administration before the law was passed that we can keep our insurance if we like it, stay with our same doctors, and save money at the same time, many millions of Americans have too often found these assurances to be empty. Having insurance “coverage” for many does not translate into having access to affordable necessary care. Instead, the largely for-profit “system” continues on, profiting and sometimes profiteering from expanded markets subsidized by us, the taxpayers. The original title of the ACA as the Patient Protection and Affordable Care Act (PPACA) has become a misnomer, not surprisingly little used today.

Too we are often bombarded by abstract numbers and statistics that neglect what they mean to ordinary Americans. This book takes a different approach, starting with stories of patients and their families, thereby putting a human face on the large body of experience and evidence about the effects of the ACA since its passage in 2010.  Far from isolated anecdotes, these are common stories that best illustrate national trends and problems in our increasingly dysfunctional market-based system.

The book is organized in three parts: Part One presents some 50 patient and family stories that represent problems confronted by implementation of the ACA since 2010. These are real people and their families drawn from press reports. Part Two looks at five major problems of the entire system, as we consider to what extent the ACA has addressed them, and find that we are far from the health care reform that we need. Part Three deals with where we are now, in the middle of an election year, faced with three main alternatives about where to go next: (1) stick with the ACA or try to improve it; (2) repeal and replace it with a Republican “plan”; or (3) move to single-payer system of national health insurance. You will notice that many of the chapters start with a heading, “The Promise”, “The Premise,” or “The Myth.” These denote either the promises made by the Obama administration about the ACA or the premises underlying it, which typically and ironically are based on earlier conservative ideas put forward by conservative organizations, such as the Heritage Foundation.

The stakes are too high to get health care wrong in this country. Our incremental reform attempts over many years have been compromised by the money and political power of corporate stakeholders that perpetuate many of our problems. We need objective evidence to combat the rhetoric and claims of the medical-industrial complex and direct our attention to the  real needs of patients and their families. It is my hope that this book will help in this process.

–John Geyman, M.D. 
Friday Harbor, WA
January 2016

http://www.johngeymanmd.org

Amazon:
http://www.amazon.com/gp/product/1938218027

***

Comment:

By Don McCanne, M.D.

Although many had high hopes for ObamaCare, as John Geyman shows us the human faces, we realize that reform fell too short for too many. He shows us not only those human faces but also the pained face of health care justice. He provides us with an understanding of what is wrong with our system, and then describes options for the future. He encourages us all to participate in the reform dialogue so that we can finally get this right. “The Human Face of ObamaCare” is a great place to start.

Maine Voices: ‘Medicare for all’ system makes so much sense on so many levels

With lowered costs and universal coverage, single-payer American health care would cure many ills

By David L. Adams, Special to the Press Herald
Portland Press Herald, December 26, 2015

COUSINS ISLAND, Maine — It is open enrollment time for Medicare. Many people are finding themselves totally perplexed by the need to evaluate the competing offerings of the different Medicare supplement plans and Part D drug plans they have to choose from before the Dec. 7 deadline for enrollment.

The problem is the choices are so complicated that comparisons of apples to oranges don’t begin to describe the difficulties.

So why not simplify things by going to a single-payer, Medicare-for-all system, as many industrialized countries around the world have done with striking success? That success can be measured by their administrative costs, which are less than half the costs of our system of private health insurance.

Another measure of success is that there are better outcomes of care in countries with universal coverage, such as those with single-payer health care. There were 15 countries around the world with single-payer systems as of 2009, and all but four had higher-rated health care systems (by the World Health Organization) than the United States.

We pay considerably more for our health care, per person, than do people in any other country. Thanks to Congress, our current system prohibits negotiating about drug pricing, which is another source of cost savings in many countries. But our system does allow inflated salaries to the CEOs and administrators whose main function seems to be to refuse care whenever it will enhance their profit margin.

So, what are the drawbacks to single-payer Medicare for all, which have been cited by conservative Congresses since the 1960s?

• It’s socialized medicine: “Socialized medicine” refers to government-controlled medicine. Medicare for all is certainly not socialized medicine. The people providing your health care would not all work for the government. The decisions you and your health care provider make would continue to be private, without “death panels” or other suggested forms of government interference;

• It would lead to higher taxes: Because of potential savings on administrative costs and on negotiated drug prices, a recent study by economist Gerald Friedman showed that Medicare for all could save $592 billion per year in health care costs. These savings come from $476 billion saved if administrative costs were limited to the percentage spent on administration by Medicare, along with the $116 billion saved by negotiating pharmaceutical prices down to the levels charged in Europe.

This would be enough to offset cost increases for universal coverage. Gerald Friedman’s research shows that 95 percent of U.S. households would save money overall with Medicare for all.

Most importantly, by providing access to care for everyone, our health outcomes such as infant and maternal mortality, life expectancy and care for chronic illnesses, which now lag behind many developed countries, would improve.

Universal coverage and better outcomes at lower cost! So why not Medicare for all?

http://www.pressherald.com/2015/12/26/maine-voices-medicare-for-all-system-makes-so-much-sense-on-so-many-levels/

***

Comment:

By Don McCanne, M.D.

As we struggle to bring to America a better health care system for all, it seems appropriate to cap the year with the final words from David L. Adams, M.D. of Cousins Island, Maine.

Following is a note from the editor of the Portland Press Herald:

“EDITOR’S NOTE: David L. Adams, M.D., lived with his wife and family on Cousins Island in Yarmouth for almost 40 years.

“He retired in 1998 after 30 years in active practice with Maine Cardiology in Portland. He was a dedicated volunteer after retirement, winning several awards for his activities.

“A passionate advocate for single-payer health care, Adams was one of the organizers of a celebration of Medicare’s 50th birthday in Monument Square in Portland on July 30.

“As he became cognizant of his approaching death from cancer this fall, he wrote the following column as an act of devotion to his patients and his belief in the importance of affordable health care for all.

“Adams died Dec. 6, the day before the end of open enrollment for Medicare in 2015.”

The Health Gap: The Challenge of an Unequal World

By Michael Marmot

From Chapter 1 – The Organisation of Misery

I have used two terms, health inequalities and health inequities. From now on, I am going to use the term health inequities to refer to those systemic inequalities in health between social groups that are judged to be avoidable by reasonable means. Such an approach does not cut off debate. There is ample disagreement as to what are “reasonable means.” But it focuses the argument. Why is this fundamental? Because if people are suffering from ill-health in ways that could be remedied but are not, that is quite simply unjust.

From Chapter 9 – Fair Societies

Proportionate universalism

It was the evidence provided by our Nordic colleagues that led us, at the UCL Institute of Health Equity, to come up with the ugly neologism “proportionate universalism.” Let me explain.

When the British government was planning its Sure Start policy for early child development, I went to a meeting at Her Majesty’s Treasury to discuss the proposed programmme. It turned out that the initial plans for Sure Start were to target it at the most deprived communities. I showed the group the social gradient in literacy of young people according to parents’ education and pointed out that at the top, parents with the highest levels of education, our young people’s literacy levels were on a par with Sweden and Japan. But the gradient was steeper in Britain than in Japan and Sweden; the result was that the lower you go in the social hierarchy the worse our young people score compared with Sweden and Japan. The implication was that Sure Start should be for everyone, not only for the worst off.

The senior Treasury official, the wonderful Norman Glass (deceased sadly), said: “Don’t come to me with that Scandinavian nonsense about universal interventions. We’re Anglo-Saxons. We target and focus on the worst off.”

Anglo-Saxon? Norman was Irish-Jewish, but the point was well made. The default position of British social policy is to target interventions on the worst off. It seems to make sense. The problem with such “common sense” is that it ignores the gradient. All the social and related health problems that we see follow a social gradient. That disadvantage of focusing on the worst off is that you miss those, say, in the middle who have worse health than those at the top, albeit better than those beneath them on the ladder.

It is not just from the Nordic countries that we learned the importance of universalist policies. In Chile they talk of Chile Solidario. The aim is to bring the most socially excluded into the mainstream of society, to emphasize their rights and entitlements, not to see the state as a charitable institution handing out help to a grateful poor. Proportionate universalism is an attempt to marry the obvious need to work hardest on behalf of those in greatest need while preserving the universalist nature of social interventions. Services for the poor are poor services. We should want everyone to gain the benefits of universal policies while putting in effort proportionate to need. A key principle is social cohesion.

**

Key to living in society is empathy and connectedness – genuine feeling for our fellow members of society. The separate, compartmented lives of people at the top, middle and bottom damage this vital ingredient of society. The previous chapters spell out, in detail, how this lack can damage health through the life course and in communities.

From Chapter 11 – The Organisation of Hope

What the figures on income and wealth show is that there are oceans of money sloshing about. It is not easy to maintain the fiction that we do not have enough money to do good things. The problem is that, within countries, the concentration of wealth is becoming more extreme. That was the message of Piketty’s “Capital in the Twenty-First Century.” At the same time as wealth concentration is increasing, all across Europe and the US we are being lectured to on the dire importance of austerity. Public services have to be cut back because… because… we cannot afford them?

John Maynard Keynes, immediately after the Second World War, wrote: “The day is not far off when the economic problem will take the back seat where it belongs, and the arena of the heart and the head will be occupied or reoccupied, by our real problems – the problems of life and human relations, of creation and behavior and religion.” In country after country, too much of our public conversation is about how we can grow national income, too little about how we can improve society.

**

One senior Conservative politician in Britain put it to me that my agenda is closer to social democratic than to Conservative thinking. I have tried studiously in public, and in this book, to make my case on the evidence, not on prior political beliefs. My response to this politician was that avoidable health inequality, health inequity, was the deepest injustice in our society. Was he saying that only social democratic politicians cared? I hoped not. Further, showing that politicians distort the evidence to suit their political ends was not a party-political act; it should be aimed at all our political leaders whatever their makeup. No political party has a monopoly on purveying misleading information.

**

If you are in a country with poorly developed social systems, do something. It will make a difference. If your country is on the way, do more. And if you are in the Nordic countries, do it better.

Do something. Do more. Do it better.

(Sir Michael Marmot is professor of epidemiology and public health at University College London, and current president of the World Medical Association.)

http://bloomsbury.com/us/the-health-gap-9781632860798/

***

Comment:

By Don McCanne, M.D.

As Michael Marmot explains so well in “The Health Gap,” our health inequities stem from our failure to implement “proportionate universalism,” which he describes in the excerpts above – a must read. In fact, after reading the excerpts, you may agree that his entire book is a must read.

A single payer system standing alone would not be enough to ensure health equity, as Marmot explains in “The Health Gap,” but it would mesh perfectly with proportionate universalism. We just have to do more and do it better.

Value in Medical Care

The New York Times, Letter, December 22, 2015

To the Editor:

We applaud expanding reimbursement analysis beyond Medicare data to include commercial insurance.

It is essential to differentiate locally provided care from complex specialty care best provided by destination medical centers. Future payment models should recognize making an accurate diagnosis, providing appropriate treatment and achieving the best results.

It will be through a commitment to work collaboratively that payers, providers and policy makers build a sustainable, value-based health care delivery system in our country.

John H. Noseworthy
President and Chief Executive
Mayo Clinic, Rochester, Minn.

http://www.nytimes.com/2015/12/22/opinion/value-in-medical-care.html?partner=rssnyt&emc=rss

***

Payment for Medical Care

The New York Times, Letter, December 29, 2015

To the Editor:

I take issue with the “value-based payment models” for medical care promoted by John H. Noseworthy, the president of the Mayo Clinic, in his letter to the editor (“Value in Medical Care,” Dec. 22).

When he says, “It is essential to differentiate locally provided care from complex specialty care best provided by destination medical centers,” is he suggesting that his destination medical center should be paid more than local care providers for the same work?

It is my understanding that all doctors are being evaluated equally on the accuracy of their diagnoses, the appropriateness of their treatments and the quality of their results. They should be paid accordingly.

Value-based payment models are used by the pharmaceutical industry to justify a drug price many times greater than the cost to bring it to market and manufacture it. The drug company decides how much “value” its drug provides to the patient who takes it.

Let’s not allow major destination medical centers to follow the same model. Better yet, let’s reverse the trend entirely.

Robert D. Schrock Jr.
Chapel Hill, N.C.

The writer is a retired orthopedic surgeon.

http://www.nytimes.com/2015/12/29/opinion/payment-for-medical-care.html

***

Comment:

By Don McCanne, M.D.

It seems that the current policy fixation in health care reform is on paying for value instead of volume. This really plays into the hands of the medical-industrial complex.

Currently the pharmaceutical industry is leading the way. A prime example is the new, outrageously priced drugs for hepatitis C. In explaining why the prices are so high, representatives of the industry indicated that the new standard for drug pricing should not be simply the usual costs such as research and marketing, but rather they should be priced on the value provided – the value of preserving quality of life that would be lost with progression of disease, and the value in preventing expensive care in the future, such as liver transplants. These executives have to gall to claim that the monetary value of the preservation of quality of life and the aborted potential future health care costs should accrue to them and their shareholders.

By that same reasoning, many of the high priced cancer therapy drugs should be repriced at pennies on the dollar since they have an almost negligible benefit on the quality of life, and they actually increase the cost of cancer care simply because of the very high prices of the drugs themselves along with the costs of administering and monitoring them. Of course, then instead of pricing based on value, they resort to their fallback position of the high cost of drug research and other corporate expenses, like executive compensation (plus an extra bonus because this is CANCER, after all).

Of great concern, the pharmaceutical industry was successful in including in the Trans-Pacific Partnership Agreement (TPP) this concept that “value” be included as a legitimate basis for determining the price of drugs – pocketing greater profits for this nebulous add-on to the drug itself.  This is one more reason that TPP should not be approved in its current form.

Now the president and CEO of Mayo tells us that the complex specialty care provided by “destination medical centers” implicitly is of higher value and thus presumably should be rewarded more highly through value-based payment models. If they offer unique specialty care that is not offered at other centers, then payment based on costs plus a fair margin would be appropriate. But care that duplicates quality care available in the community should not command higher prices.

We cannot underestimate the uncanny ability of the medical-industrial complex to innovate with policy concepts to further their own pecuniary interests.

This concept of rewarding value instead of volume has led to the implementation of numerous payment models that are backed by not much more than “wish-it-would-work” concepts from the policy community; the initial evidence of benefit is extremely limited. We know single payer works. That’s what we should be implementing instead.

If you wish more information, yesterday’s message, “No more SGR, but… here you go!,” discusses some of these wish-it-would-work concepts such as Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs) supposedly rewarding value instead of volume:

https://www.pnhp.org/news/2015/december/no-more-sgr-but…-here-you-go

CMS Quality Measure Development Plan: Supporting the Transition to the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs) (DRAFT)

CMS, December 18, 2015

Building on the principles and foundation of the Affordable Care Act, the Administration announced a clear timeline for targeting 30 percent of Medicare payments tied to quality or value through alternative payment models by the end of 2016 and 50 percent by the end of 2018. These are measurable goals to move the Medicare program and our healthcare system at large toward paying providers based on quality, rather than quantity, of care.

The passage of the Medicare Access and Children’s Health Insurance Program (CHIP) Reauthorization Act of 2015 (MACRA) supports the ongoing transformation of healthcare delivery by furthering the development of new Medicare payment and delivery models for physicians and other clinicians. Section 102 of MACRA requires that the Secretary of Health and Human Services develop and post on the CMS.gov website “a draft plan for the development of quality measures” by January 1, 2016, for application under certain applicable provisions related to the new Medicare Merit-based Incentive Payment System (MIPS) and to certain Medicare alternative payment models (APMs).

Merit-Based Incentive Payment System

Measures for use in the quality performance category are a specific focus of the MDP. MIPS will build upon existing quality measure sets from the Physician Quality Reporting System (PQRS), Value-based Payment Modifier (VM), and Medicare EHR Incentive Program for Eligible Professionals (EPs), commonly referred to as Meaningful Use.

To fill identified measure and performance gap areas, CMS will expand and enhance existing measures to promote alignment and harmonization in the selection of measures and specifications, while concurrently developing new (de novo) measures according to priorities described in Section IV.

To accelerate the alignment of quality measurement and program policies, MACRA sunsets payment adjustments for PQRS, VM, and the EHR Incentive Program and establishes MIPS.

Alternative Payment Models

MACRA establishes incentive payments for EPs participating in certain types of APMs. MACRA requires quality measures used in APMs to be comparable to the quality measures used in MIPS; therefore applicability of candidate measures to support a variety of future APMs is an important element of this MDP.

From the Conclusion

CMS is committed to reducing provider burden through the use of measures aligned across federal and private-payer quality reporting programs. We stress harmonization of data elements and specifications among measure developers, whose cooperation and sharing are essential to creating aligned measures. Toward that end, we also intend to leverage the optional pre-rulemaking process and MAP review for MIPS and to participate with other stakeholders in efforts that promote measure alignment. This draft MDP acknowledges the associated challenges and identifies opportunities for measure developers to share information to reduce duplication of efforts.

CMS Quality Measure Development Plan (MDP) – 61 pages:
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Draft-CMS-Quality-Measure-Development-Plan-MDP.pdf

MACRA, MIPS, APMs, MDP, and request for public comment:
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html

***

Comment:

By Don McCanne, M.D.

Physicians celebrated the passage of the Medicare Access and Children’s Health Insurance Program (CHIP) Reauthorization Act of 2015 (MACRA) since it brought an end to the much despised SGR (Sustainable Growth Rate) method of adjusting Medicare payment rates. Though SGR was rarely implemented, it carried forward a massive deficit that would have required major reductions in Medicare payment rates. Besides, MACRA included the reauthorization of the Children’s Health Insurance Program. The trade-off, which was largely ignored, was the requirement to establish the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). CMS has now released a draft of the Quality Measure Development Plan for transitioning to MIPS and APMs.

Perhaps the main reason that physicians, who happened to be aware of MIPS and APMs, were not concerned is that they replaced the Physician Quality Reporting System (PQRS), Value-based Payment Modifier (VM), and Medicare EHR Incentive Program for Eligible Professionals (EPs), commonly referred to as Meaningful Use. Many thought that this would bring efficiency to existing programs by coordinating them under MIPS.

There are three reasons that physicians should be concerned. The first is that these programs are not simply now coordinated, they are expanded and enhanced with the development of new de novo measures. Think of what that means for new administrative burdens added to existing ones.

Second, some physicians no doubt thought that they could escape the MIPS burdens since MACRA would allow physicians to move into Alternative Payment Models (APMs) – accountable care organizations, patient centered medical homes, or whatever. Don’t celebrate yet. MACRA requires that the quality measures used in APMs to be comparable to the quality measures used in MIPS. MIPS is now an obligation no matter where you turn.

Third, and most important of all, is that the PQRS, VM, and the EHR Incentive Program were highly flawed programs adding significantly to the excessive administrative burden that characterizes the U.S. health care system, while having a relatively negligible impact on improving health care quality. The proper policy step should have been to send these programs back to the drawing boards, and then when it became obvious that there was no there there, locking them in storage forever. The worst policy decision would be to expand these programs and force them on everyone, but that is precisely what they did.

Quality is not achieved by playing the alphabet games, with nominal penalties and rewards. It is achieved by instilling efficiency and equity into our health care delivery system. A well-designed single payer system does that. A paper written by a team led by Gordon Schiff, and published in JAMA two decades ago, defines quality and describes how it can be achieved by implementing a single payer national health program:

A Better-Quality Alternative: Single-Payer National Health System Reform
JAMA, September 14, 1994, Volume 272 Copyright 1994, American Medical Association

https://www.pnhp.org/publications/a_better_quality_alternative.php

How Much Do Marketplace and Other Nongroup Enrollees Spend on Health Care Relative to Their Incomes?

By Linda J. Blumberg, John Holahan, and Matthew Buettgens
Urban Institute, December 2015

In this paper, we examine premiums and out-of-pocket costs, as well as total financial burdens for individuals with different characteristics enrolled in ACA-compliant nongroup coverage. We show that despite the additional assistance available, individuals across the income distribution who are ineligible for Medicaid can still face very high expenditures. At the median, financial burdens can be reasonably high, particularly for those with incomes between 300 and 400 percent of FPL (Figure 1). As medical care needs increase, however, financial burdens grow appreciably across the income distribution. Even with federal financial assistance, 10 percent of 2016 nongroup marketplace enrollees with incomes below 200 percent of FPL will pay at least 18.5 percent of their income toward premiums and out-of-pocket medical costs. Ten percent of marketplace enrollees with incomes between 200 and 500 percent of FPL will spend more than 21 percent of their income on health care costs. Those in fair or poor health and those over age 45 are most likely to face high median financial burdens.

http://www.urban.org/sites/default/files/alfresco/publication-pdfs/2000559-How-Much-Do-Marketplace-and-Other-Nongroup-Enrollees-Spend-on-Health-Care-Relative-to-Their-Incomes.pdf

***

Comment:

By Don McCanne, M.D.

This is just one more study that shows that far too many individuals who need health care still face excessive financial burdens in spite of being insured. Instead of merely trying to tweak our dysfunctional system, we should go ahead and replace it with one that works – a single payer national health program.

Medicare Drug Spending Dashboard

By Andy Slavitt, Acting CMS Administrator and Niall Brennan, CMS Chief Data Officer
The CMS Blog, December 21, 2015

Today, CMS is releasing a new online dashboard to provide information on Medicare spending on prescription drugs, for both Part B (drugs administered in doctors’ offices and other outpatient settings) and Part D (drugs patients administer themselves) to provide additional information and increase transparency.

In today’s announcement, the topline findings include:

* The diversity, growth, and impact of drug spending in the Medicare program – while the high-cost drugs include brand name Hepatitis C and cancer therapies, some generic drugs are seeing large price increases.

http://blog.cms.gov/2015/12/21/medicare-drug-spending-dashboard/

***

Competition Not Stopping Drug Price Hikes, Medicare Data Shows

By Brianna Ehley
Politico Pulse, December 23, 2015

If you think a marketplace monopoly is behind all massive drug price hikes you might want to take a look at the new CMS drug spending dashboard. Eight of the 10 drugs that had big cost increases between 2013 and 2014 were made by multiple manufactures. Among them were five drugs that more than doubled in price during that time. If you expand to taking a look at the 15 drugs with the largest increases, nearly two-thirds or 9 of the 15, were made by multiple manufacturers. This data may throw a wrench in a popular solution proposed by Congress to deal with exponential drug price hikes — have FDA review faster the generic applications for drugs with a market monopoly but no patent or exclusivity protection. Furthermore, only one drug in the top 15 for the biggest price hikes was listed on the FDA’s drug shortage list during 2013-2014, which means we can’t blame companies taking advantage of a limited supply either. Take another look at the drug spending dashboard released this week and play around with the information yourself: http://go.cms.gov/1PkbJEk

http://www.politico.com/tipsheets/politico-pulse/2015/12/obamacare-enrollment-climbs-to-93-million-in-septcompetition-not-curbing-drug-price-hikesutah-can-block-federal-grants-to-planned-parenthood-211914

***

Comment:

By Don McCanne, M.D.

Only Rip Van Winkle would not know that drug prices are totally out of control, yet the pharmaceutical industry tells us that there is no problem since the market will price drugs appropriately. But instead of competition bringing down prices, their concept of market dynamics is to push up the prices to the maximum that will be tolerated by patients who are partially insulated by various public and private payers.

If there is an area in pharmaceutical pricing in which competition should work, that would be the competition between generic products that are no longer under patent. But looking at the Medicare drug spending dashboard, it is obvious that the pharmaceutical firms have been able to push pricing of several generic drugs well above the levels that would be expected in a well functioning free market.

When the Republicans passed the Part D Medicare drug program, they prohibited Medicare from negotiating drug prices, instead insisting that the markets would be more effective in bringing drugs prices down. But instead the insurance and pharmaceutical industries have been allowed the freedom to essentially establish their own rules on how markets work. Their rules allow them to maximize their revenues while patients are being gouged, either directly or through taxes and higher insurance premiums. Adam Smith would agree that this corrupted version of markets is no market at all. They are using their control of essential medications to extort us. Extortion is not a tool of normal markets – quite the opposite.

We do not need to recite again the work by Nobel laureate Kenneth Arrow on why health care markets do not work. We have already proven that our reliance on markets is not effective by the mere fact that we spend, per capita, over two and one-half times as much on health care as the average of other wealthy nations.

We simply need to push the ideologues aside and put into place public policies that other nations have used to obtain value in their health care purchasing. The model most suitable for us would be a single payer national health program – an improved Medicare for all.