PNHP

Time for single-payer health care

Time for single-payer health care

By Katie Myers
The Albuquerque Journal, Oct. 4, 2015

When I decided that I was going to be a doctor, I had many preconceived notions about what that meant.

I pictured myself coming upon a mass casualty accident and saving everyone’s lives single-handedly. I thought that I would make a difference every day by curing people’s ailments.

Obviously, I realize now, that saving everyone in a mass casualty accident is a bit grandiose, and as I progress further in my education I have come to the harsh realization that making a difference is often going to be out of my hands as a physician due to our current health care system.

The system is funded by more than 17 percent of our GDP – more than any other nation in the world – and it still leaves 29 million people in America uninsured.

This does not include the 31 million Americans that are underinsured, meaning that they pay over 10 percent of their household income on out-of-pocket medical expenses, even though they have insurance. And that doesn’t include premiums.

This leads to people not going to the doctor due to out-of-pocket costs that they cannot afford. It leads to debt and bankruptcy in families that are already dealing with the overwhelming stress that comes with illness.

These injustices are too real for those of us in the medical field and for our patients who are attempting to navigate this system.

Fortunately, there is a solution to this issue: single-payer health care.

Single-payer health care is the expansion and improvement of Medicare to everyone.

Often the topic of single-payer health care causes a negative reaction and people are quick to say, “This would never work in the U.S.” But, before you dismiss it, I urge you to take a moment and think about it.

Think about the last time you went to the doctor for yourself or with a loved one. During the visit, did you find yourself concerned with the cost of the treatment or test that had to be done? Were you worrying about whether your insurance was going to cover the procedure that you or your loved one needed to have done to feel better?

If you’re like me, you answered yes to these questions and you are directly affected by our failing health care system.

Now imagine going to the doctor and not worrying about these things. Imagine going to the doctor and worrying only about you or your loved one getting better.

Students for a National Health Program (SNaHP) is a growing organization in medical schools across the country. We are students that rally together to find new ways to advocate for this single-payer system.

We do this because every day we see the results of this failing health care system.

We do this for our future patients as well as our families, and our communities.

We do this because, when we received our white coats, we took an oath that we would consecrate our lives to the service of humanity and that the health of our patients would be our first consideration.

Our current health care system is hindering our ability to keep this oath.

For all of these reasons, SNaHP chapters across the country came together on Oct. 1st for a national day of action and demanded a system where our citizens will not go bankrupt paying for their medical bills. A system that is accessible to all. A system that is fair.

We held teach-ins, rallies, and a luminaria vigil to pay our respects to the tens of thousands of people who die each year due to lack of insurance.

This is not the end of our fight for an equitable health care system. We ask that you write your representatives and urge them to vote for the Expanded and Improved Medicare for All Act – H.R. 676.

We hope that you will be as inspired about this issue as we are so that we can all work together for a better, more just health care system. 

Katie Myers is a University of New Mexico medical student.

http://www.abqjournal.com/653709/opinion/time-for-singlepayer-health-care.html

#BlackLivesMatter: Physicians Must Stand for Racial Justice

By White Coats for Black Lives (WC4BL) National Working Group
American Medical Association Journal of Ethics, October, 2015

Racism is one of the major causes of health problems in the United States. Between 1970 and 2004, the Black-white mortality gap resulted in more than 2.7 million excess Black deaths1, making racism a more potent killer than prostate, breast, or colon cancer2. Physicians are intimately involved with institutions that contribute to the victimization of Black people and other people of color. As is widely documented, Black and Latino patients are less likely to receive the care they need, including adequate analgesia, cancer screening, and organ transplants3-6. This is due both to physician bias and to the health care payment structure’s financial disincentives for the care of people of color7—clinicians are paid less to care for patients who are uninsured, underinsured, or publicly insured, and these patients are disproportionately people of color. As a consequence, people of color are often denied access to the health care they need8,9.

These disparities in access to health care exacerbate the harm that social structures and policies cause to the health of people of color. Black and Latino people are disproportionately victimized by police violence, mass incarceration, and poverty10-12. Moreover, despite perceived improvements, rates of racial segregation across the country remain comparable to levels in the 1940s, and people of color face discrimination in their efforts to access adequate housing, quality education, and meaningful employment13-16. The harmful effects of structural inequity are augmented by the subjective experience of racism: for example, awareness of one’s race is correlated with increased diastolic blood pressure among Black patients17.

Addressing racism and its consequences, therefore, should be a central task of American medicine; physicians must work both within and outside the health care system to eliminate inequities in access to and delivery of care. Health professionals and community organizations ranging from the Black Panther Party to the National Latina Institute for Reproductive Health have long proposed effective strategies for addressing racism to improve the health of people of color, including expansion of free clinics, increased research on diseases affecting people of color, and legislative establishment of paid parental leave18,19. Recent incidents and protests in Charleston, Baltimore, New York, and other cities across the country have reminded us of the urgency of acting on these and other proposals to address racism in medicine.

In particular, we, as members of the National Working Group of the medical student organization White Coats for Black Lives, suggest four ways that physicians and other health professionals can immediately pursue racial justice. The first is to more aggressively recruit, support, and promote Black, Latino, and Native American people in medicine to ensure that the physician workforce reflects the diversity of the United States. Black and Latino people represent roughly 30 percent of our nation’s population but make up only 8.5 percent of the physician workforce20. Physicians of color are more likely to provide care for America’s underserved communities, and patients of color report higher satisfaction when their doctor shares their racial background21-23. Despite the Association of American Medical Colleges’ Project 3000 by 200024, the past three decades have witnessed little growth in the population of Latino, Black, and Native American physicians20. Increasing the numbers of Black, Latino, and Native American doctors is a key step in eliminating health inequities.

Secondly, hospitals and practices must take action to eliminate the significant impact of implicit racial biases on the care of patients of color7. To counteract these subtle forms of racism, institutions must routinely administer implicit association tests to their medical staffs to make them cognizant of their unconscious biases and then train their medical staffs to consciously overcome those biases when delivering care25. Furthermore, hospitals should create formal and informal structures to encourage accountability for incidents that may have involved racism. This can be done by fostering a work environment that makes it safe for colleagues to question each other’s biased actions and by using structured venues such as morbidity and mortality conferences to discuss ways that racism may have impacted the quality of patient care.

Thirdly, physicians should join community members in advocating for a single-payer health care system as a means of eliminating cost-associated barriers to care. In addition to improving access for all patients, a single-payer system would eliminate insurance-status discrimination and ensure that reimbursements for services provided to white patients and patients of color are equal.

Finally, health care workers must recognize that our responsibility to our patients goes beyond physical exams, prescriptions, and surgical interventions; we must work to alter socioeconomic and environmental factors, including structural racism, that directly affect our patients’ health. The manifestations of structural racism are varied and ubiquitous; addressing them will require joining movements to increase the minimum wage, end criminalizing school discipline practices, and develop mixed-income housing, among many others. In doing so, physicians will need to partner with and take direction from community members who have experienced systemic oppression and are dedicated to working to dismantle it. We will not be able to solve the problems of racism in our society and in our health care system without the input of those most affected by it. In working to combat structural racism, physicians must not only listen to people of color in their practices and communities, but also amplify those voices while advocating for equitable social structures. Theprivilege that physicians possess within society and within the professional hierarchy of medicine provides them with power that can be used to spearhead policy changes to advance racial justice locally and nationally. Using this “physician privilege” to advocate for social change is necessary if we are to eradicate the systemic illness that is racism.

References

  1. Rodriguez JM, Geronimus AT, Bound J, Dorling D. Black lives matter: differential mortality and the racial composition of the US electorate, 1970-2004. Soc Sci Med. 2015;136-137:193-199.
  2. American Cancer Society. Estimated deaths for the four major cancers by sex and age group, 2015. http://www.cancer.org/acs/groups/content/@editorial/documents/document/acspc-044509.pdf. Accessed June 28, 2015.
  3. Agency for Healthcare Research and Quality. 2014 National healthcare quality and disparities report. Rockville, MD: Agency for Healthcare Research and Quality; May 2015. http://www.ahrq.gov/research/findings/nhqrdr/nhqdr14/2014nhqdr.pdf. Accessed June 28, 2015.
  4. Tamayo-Sarver JH, Hinze SW, Cydulka RK, Baker DW. Racial and ethnic disparities in emergency department analgesic prescription.Am J Public Health. 2003;93(12):2067-2073.
  5. Agency for Healthcare Research and Quality. 2013 National Healthcare Quality Report. Rockville, MD: Agency for Healthcare Research and Quality; May 2014. http://www.ahrq.gov/research/findings/nhqrdr/nhqr13/2013nhqr.pdf. Accessed June 28, 2015.
  6. Churak JM. Racial and ethnic disparities in renal transplantation. J Natl Med Assoc. 2005;97(2):153-160.
  7. Chapman EN, Kaatz A, Carnes M. Physicians and implicit bias: how doctors may unwittingly perpetuate health care disparities. J Gen Intern Med. 2013;28(11):1504-1510.
  8. Hing E, Decker S, Jamoom E. Acceptance of new patients with public and private insurance by office-based physicians: United States, 2013. NCHS Data Brief. 2015;(195):1-8.
  9. Kaiser Family Foundation. Health coverage by race and ethnicity: the potential impact of the Affordable Care Act. March 13, 2013. http://kff.org/disparities-policy/issue-brief/health-coverage-by-race-and-ethnicity-the-potential-impact-of-the-affordable-care-act/. Accessed June 28, 2015.
  10. Sadler MS, Correll J, Park B, Judd CM. The world is not black and white: racial bias in the decision to shoot in a multiethnic context. J Soc Issues. 2012;68(2):286-313.
  11. Kramer MR, Hogue CR. Is segregation bad for your health?Epidemiol Rev. 2009;31(1):178-194.
  12. The Sentencing Project. Reducing racial disparity in the criminal justice system: a manual for practitioners and policymakers. Washington, DC: The Sentencing Project; 2008. http://www.sentencingproject.org/doc/publications/ rd_reducingracialdisparity.pdf. Accessed June 28, 2015.
  13. Shapiro T, Meschede T, Osoro S. Research and policy brief: the roots of the widening racial wealth gap: explaining the black-white economic divide. Waltham, MA: Brandeis University Institute on Assets and Social Policy; February 2013. http://iasp.brandeis.edu/pdfs/Author/shapiro-thomas-m/racialwealthgapbrief.pdf. Accessed June 28, 2015.
  14. Fryer RG Jr, Pager D, Spenkuch JL. Racial disparities in job finding and offered wages. J Law Econ. 2013;56(3):633-689.
  15. American Psychological Association Presidential Task Force on Educational Disparities. Ethnic And Racial Disparities in Education: Psychology’s Contributions to Understanding and Reducing Disparities. August 3, 2012. http://www.apa.org/ed/resources/racial-disparities.pdf. Accessed June 28, 2015.
  16. Williams DR, Collins C. Racial residential segregation: a fundamental cause of racial disparities in health. Public Health Rep.2001;116(5):404-416.
  17. Brewer LC, Carson KA, Williams DR, Allen A, Jones CP, Cooper LA. Association of race consciousness with the patient-physician relationship, medication adherence, and blood pressure in urban primary care patients. Am J Hypertens. 2013;26(11):1346-1352.
  18. Nelson A. Body and Soul: The Black Panther Party and the Fight Against Medical Discrimination. Minneapolis, MN: University of Minnesota Press; 2013.
  19. Center for Reproductive Rights; National Latina Institute for Reproductive Health; SisterSong Women of Color Reproductive Justice Collective. Reproductive injustice: racial and gender discrimination in US health care: a shadow report for the UN Committee on the Elimination of Racial Discrimination. 2014. http://www.reproductiverights.org/sites/crr.civicactions.net/files/documents/CERD_Shadow_US.pdf. Accessed July 24, 2015.
  20. Association of American Medical Colleges. Diversity in the physician workforce: facts & figures 2014. http://aamcdiversityfactsandfigures.org. Accessed June 28, 2015.
  21. Marrast LM, Zallman L, Woolhandler S, Bor DH, McCormick D. Minority physicians’ role in the care of underserved patients: diversifying the physician workforce may be key in addressing health disparities. JAMA Intern Med. 2014;174(2):289-291.
  22. Saha S, Komaromy M, Koepsell TD, Bindman AB. Patient-physician racial concordance and the perceived quality and use of health care.Arch Intern Med. 1999;159(9):997-1004.
  23. Cooper LA, Roter DL, Johnson RL, Ford DE, Steinwachs DM, Powe NR. Patient-centered communication, ratings of care, and concordance of patient and physician race. Ann Intern Med. 2003;139(11):907-915.
  24. Nickens HW, Ready TP, Petersdorf RG. Project 3000 by 2000: racial and ethnic diversity in US medical schools. New Engl J Med. 1994;331(7):472-476.
  25. Green AR, Carney DR, Pallin DJ, et al. Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients. J Gen Intern Med. 2007;22(9):1231-1238.

White Coats for Black Lives (WC4BL) is a national medical student organization devoted to safeguarding the lives of patients through the elimination of racism. The WC4BL National Working Group endeavors to raise awareness of racism as a public health concern that threatens the lives and health of people of color, end racial discrimination in the delivery of health care, and prepare future physicians to be advocates for racial justice. WC4BL encourages medical professionals to create a physician workforce that reflects the diversity of our nation by actively recruiting and supporting Black, Latino, and Native American people through medical school and into their careers.

http://journalofethics.ama-assn.org/2015/10/sect1-1510.html

Case Med Students Say Obamacare Doesn’t Cut It, Rally for Health Care Reform

By Sam Allard
Cleveland Scene, October 2, 2015

About 40 people gathered at Case Western Reserve University Thursday evening as a part of a national day of action calling attention to “America’s failing health care system.”  

More than 30 universities participated nationwide in the #TenOne (October 1st) “Health Care for All” event. At Case, the Students for a National Health Program (SNaHP), hosted a march, speakers, and a candlelight vigil. They’d been planning the event since April.

Second-year Case medical student Vanessa Van Doren was one of the national organizers and helped put together the local event, which also commemorated the 50th Anniversary of Medicare. 

“The Affordable Care Act is an improvement,” she told Scene, “but there’s still a lot to be done.” 

Van Doren mentioned that even with Obamacare, 30 million Americans are left uninsured, and that tens of thousands of people die every year due to a lack of medical care. 

“Medical bills are the leading cause of bankruptcy in the U.S., and research shows nearly 80 percent of those declaring bankruptcy due to medical debt had insurance at the onset of their illness,” read a SNaHP press release. “Our patients need and deserve better.”

Van Doren spoke Thursday evening, after students, carrying signs, processed around the medical campus and University Hospitals.

“Ultimately, we’re all here because we believe it is fundamentally wrong for some people to live shorter, sicker lives simply because they can’t afford medical care,” Van Doren said in her speech. “Tens of thousands of people in the U.S. die every year because they don’t have access to life-saving care. This is indefensible, and it needs to stop.”

Van Doren said the goal of the #TenOne national day of action was to bring awareness to America’s failing health system and to raise the alarm, especially among medical students, about the necessity of single-payer health care reform. 

http://www.clevescene.com/scene-and-heard/archives/2015/10/02/case-med-students-say-obamacare-doesnt-cut-it-rally-for-health-care-reform

Here they come again: Broader health care debate for 2016

By Ricardo Alonso-Zaldivar
WNYT.com (Albany, N.Y.), Oct. 2, 2015        

WASHINGTON (AP) — After seven years of the political drama known as “Obamacare,” you might think voters would be tired of big ideas for revamping health care. If so, the presidential candidates seem to have missed the memo.

The 2016 hopefuls in both parties are offering a full spectrum of options, from a system wholly run by the federal government to dialing back Washington’s lead role. Much is promised by the candidates, but each approach has pitfalls.

On the left, part of the appeal of Vermont independent Sen. Bernie Sanders is his years-long advocacy of “single payer,” a tax-supported, Medicare-like plan for all. The idea is in the political DNA of liberals, and Sanders as president would lead a movement to make it happen, his campaign says.

On the right are the Republicans, united on repealing President Barack Obama’s health care law, but unable to agree on what they would replace it with. They wouldn’t stop with the Affordable Care Act, either. Republicans also want curbs on Medicaid, to reduce spending and let states, not Washington, set the tone. Medicaid covers low-income and disabled people.

In the middle — if one still exists on such a polarized issue — is Democrat Hillary Rodham Clinton. She would keep the basic structure of Medicare, Medicaid and the Obama health law while making incremental changes. This week she proposed repealing an insurance tax in the health law that’s opposed by unions and big business but seen by experts as a needed brake on costs. She also wants to curb prescription drug prices and limit insurance cost-shifting to consumers.

“The only person not in favor of ‘repeal and replace’ is Hillary Clinton,” quips Republican economist Douglas Holtz-Eakin. “There is a debate being presented to the American people: Do you want to go further left, or do you want to go in the direction conservatives are advocating? The person who is basically arguing for the status quo is Hillary Clinton.”

A look at the three approaches, and their potential drawbacks:

SINGLE PAYER

If Sanders keeps gaining traction, the wonkish term for a government-run health care system could become a household word. His supporters say Obama’s hard-fought health overhaul hasn’t done nearly enough.

“People are still one illness away from becoming bankrupt,” said Dr. Deb Richter, who practices near Montpelier, Vermont, and focuses on addiction treatment. “Obamacare was hyped as this savior, and it has not been that.”

Supporters say having the government take charge of health care finances would slow the growth of spending, keep things affordable for patients, and improve overall quality.

A major pitfall is the switch from employer-based and private coverage to the single-payer plan. Money that employers and individuals now pay for premiums would have to be diverted to government coffers — a massive tax increase.

“It’s a dead end,” said Princeton sociologist Paul Starr, a historian of the U.S. health care system. Supporters “don’t face up to the significant tax changes that would be necessary.”

REPEAL AND REPLACE

The Supreme Court upheld Obama’s law, and the president won re-election in 2012. That didn’t settle the debate, but 2016 may.

“For Republicans it’s their last chance to litigate the Affordable Care Act,” said Jim Capretta, an expert on entitlement programs at the conservative Ethics & Public Policy Center in Washington. “If they lose the election, the ACA is likely to become even more entrenched.”

‘Repeal’ is a winning issue with the GOP’s political base, but the ‘replace’ part gets tricky because Republicans don’t agree on an alternative. In the general election, the GOP counterproposal will be measured against the health care law’s progress in reducing the number of uninsured. A plan that repeals federal mandates and reduces insurance subsidies would probably leave more people uncovered.

Republican front-runner Donald Trump says his replacement plan would be different. He’d make sure everybody in the country is covered, something not even Obama accomplishes. Trump says he’d make a deal with hospitals, and most people would still have private coverage.

“There is not nearly enough to go on from Trump’s statements to assess what he actually has in mind,” said Capretta.

But the biggest pitfall for Republicans could be Medicare, not “Obamacare.” The party has previously advocated privatizing the insurance program for older Americans. In 2016, that would be asking for trouble.

“Seniors have been tilting Republican in the last elections,” said Robert Blendon, a public opinion expert at the Harvard T.H. Chan School of Public Health. “The only thing that could get them to tilt the other way is a Medicare proposal.”

CONTINUITY, MOSTLY

Hillary Clinton established her credentials on health care in the 1990s, although she and her husband, then-President Bill Clinton, failed to pass the overhaul legislation they proposed. She lost the 2008 Democratic nomination to Obama, but he adopted key parts of her health plan.

This time, Clinton is promising to build on Obama’s coverage expansion and smooth its rough edges, while keeping Democrats’ traditional commitment to Medicare and Medicaid.

The drawback is that Clinton’s middle way may be seen as uninspiring. “I think there is a hunger among Democrats to see something more happen,” Blendon said.

http://wnyt.com/article/stories/s3923639.shtml

Can Sec. 1557 be used to prevent discriminatory adverse tiering?

The Section 1557 Regulation: What’s Missing, And How We Can Include It

By Douglas Jacobs
Health Affairs Blog, September 21, 2015

Kristin Agar, a 63-year-old social worker, was diagnosed with lupus in 2008, a rare disease in which the body’s own immune system can cause serious damage to the kidneys, brain, skin, and joints. Unfortunately, despite having insurance coverage, Kristin has found that the drug she needs to treat her lupus is unaffordable. All around the United States, Kristin joins other patients with chronic conditions like HIV, Hepatitis C, Multiple Sclerosis, Rheumatoid Arthritis, and Leukemia, who are having trouble paying for their medications.

In June, Robert Restuccia and I wrote a Health Affairs Blog post showing that discrimination in our health care system is evolving. Some insurers that once refused outright to offer coverage to patients like Kristin are now resorting to more surreptitious means to discourage enrollment, like increasing the cost of all medications for certain conditions. This practice, called “adverse tiering,” has been regulated under Section 1302 of the Affordable Care Act (ACA), which grants the Department of Health and Human Services (HHS) the authority to define essential health benefits under the ACA.

However, the Section 1302 regulation has so far been limited. The rule states that adverse tiering may be discriminatory, but also appears to allow an exemption for expensive drugs like Kristin’s lupus medication. Additionally, insurers that are “caught” practicing adverse tiering only have to provide written justification for their actions to HHS or comply by fixing their benefit design.

Even without practicing adverse tiering, insurers could discourage the most expensive beneficiaries from enrolling by increasing the cost of wheelchairs, nursing homes, or even specific surgeries. If HHS wanted to categorize any future insurance practices as discrimination under Section 1302, the regulatory process could take years. As such, these new forms of discrimination have prompted many to call on the Obama Administration for a stronger response.

The Section 1557 Regulation

Earlier this month, over five years after the Affordable Care Act was adopted, the Obama Administration finally proposed the highly anticipated rule that implements the ACA’s main nondiscrimination provision: Section 1557. The rule prevents discrimination on the basis of race, color, national origin, sex, age, and disability, and broadly applies to all health programs and activities that receive assistance through HHS.

For those who have experienced discrimination in its many forms, the regulation includes a number of provisions to protect consumers. Each health entity must provide appropriate aids and services to those with limited English proficiency and disabilities. The rule extends protections for transgender persons unlike ever before, including it as a form of sex discrimination. Furthermore, all services must be made available for gender transition (like a hysterectomy) that are available to a person seeking non-transition related care. All transgender persons must be treated consistent with their own gender identity.

The proposed rule also establishes a private right of action, giving individuals the ability to file a lawsuit under Section 1557 (courts had already begun to authorize private Section 1557 lawsuits, but this makes it official). This is an important step forward, because unlike the Section 1302 regulation, insurers will be highly motivated to comply with the 1557 regulation or face costly litigation. Insurers will think twice about changing their benefit design to discourage enrollment by individuals of a certain race, color, national origin, sex, age, and disability. Instead of taking years to pass a new regulation, a private cause of action allows the justice system to “keep pace” with quickly evolving insurer practices.

However, these positive developments are tempered by some noticeable omissions. Namely, the rule is conspicuously silent about discrimination on the basis of health status. As Timothy Jost stated in his recent post, “Surprisingly, the proposed rule does not directly address one of the most salient current discrimination questions: whether insurers can impose high cost sharing or otherwise limit access to expensive drugs needed by certain disabled populations.”

Kristin Agar, who can’t afford her lupus medication, may not be assisted by the Section 1557 regulations. Insurers could continue to discourage enrollment by the sickest consumers through manipulation of their benefit designs.

Without directly addressing the issue, HHS seems to have made a distinction between two different types of discrimination: discrimination by categorically excluding certain individuals from care, and discrimination by “pricing out” certain enrollees by making specific services unaffordable. In other words, making drugs or services unaffordable seems to be an effective way for insurance companies to discourage enrollment and improve their bottom lines.

The reticence to address “price-based” discrimination likely stems from insurers historically charging different prices for medications and services. Insurers argue that this pricing structure allows them to encourage the use of more low-cost services and medications.

However, this omission even has the potential to undermine the very forms of discrimination that the proposed Section 1557 regulation aims to protect against. For example, despite the new transgender protections in the rule, plans could still discriminate against transgender people by making hormonal treatments and transition-related care unaffordable. A plan could more broadly still discriminate on the basis of sex by increasing costs for medications predominantly used by women (like breast cancer treatment), increasing costs for pregnancy care, or severely limiting the number of gynecologists in the plan network. It is clear that in order to have a strong Section 1557 regulation, HHS must also address cost.

A Way Forward

HHS should adopt a standard way of addressing cost-based discrimination in the final Section 1557 rule. When does changing the cost of a drug or service make it “unaffordable,” thus discouraging enrollment and constituting discrimination? The answer to this question appears in other ACA regulations.

The Internal Revenue Service (IRS) defines “unaffordable” in the ACA as a percentage of income, which could set a standard for price-based discrimination as well. An “unaffordable” medication or service would become discriminatory if there is no lower-cost, but similarly efficacious drug or service. This would preserve an insurer’s ability to encourage the selection of lower cost drugs and services, while still protecting consumers from discriminatory pricing schemes. Even if the final Section 1557 regulation does not include cost-based discrimination, standards of discrimination may evolve with ongoing litigation. As individuals increasingly file Section 1557 cases, it is entirely possible that courts will find cost-based discrimination unlawful.

However, Kristin Agar and others with chronic conditions need more than a federal regulation recognizing cost-based discrimination: HHS should ban discrimination on the basis of health conditions in their final rule. HHS has the authority to interpret Section 1557 broadly as part of an overall statutory and regulatory regime to make health care more accessible to those who need it the most, and also have the responsibility to counter long standing and pervasive discriminatory practices by insurers.

In the absence of an explicit ban, another way to achieve Section 1557 protection against discrimination is for HHS or courts to categorize certain diseases as “disabilities.” Courts have historically been reluctant to do this, defining a “disability” as being restricted to an “impairment that substantially limits one or more major life activities.”

However, this was before the passage of the Americans with Disabilities Act Amendments in 2008, and the subsequent final rule in 2011 that broadened the definition of disability to include impairments to bodily functions (such as the immune system, special sense organs, normal cell growth, and digestive, genitourinary, neurological, bowel, respiratory, cardiovascular, endocrine, hemic, lymphatic, musculoskeletal, and reproductive functions, among others). Since the amendments passed, courts have more broadly interpreted “disability,” although they continue to assess each case individually. This relatively untested new version of disability could include protections for Kristin and many others with chronic conditions under Section 1557.

Until HHS or a court decides, those with health conditions will continue to rely on the slow, partial protections of Section 1302. Kristin deserves a better system. She deserves a system that prospectively bans discrimination on the basis of her race, color, national origin, sex, age, disability, and health, either by being excluded from insurance plans or by being priced out of them. Kristin deserves to be able to file suit when she is being discriminated against. Kristin deserves to be covered by Section 1557.

http://healthaffairs.org/blog/2015/09/21/the-section-1557-regulation-whats-missing-and-how-we-can-include-it/

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Nondiscrimination in Health Programs and Activities

Federal Register, September 8, 2015

Summary

The Department of Health and Human Services (HHS or “the Department”) is issuing this proposed rule on Section 1557 of the Affordable Care Act (ACA) (Section 1557). Section 1557 prohibits discrimination on the basis of race, color, national origin, sex, age, or disability in certain health programs and activities. Section 1557(c) of the ACA authorizes the Secretary of the Department to promulgate regulations to implement the nondiscrimination requirements of Section 1557. In addition, the Secretary is authorized to prescribe regulations for the Department’s governance, conduct, and performance of its business, including, here, how HHS will apply the standards of Section 1557 to HHS-administered health programs and activities.

https://www.federalregister.gov/articles/2015/09/08/2015-22043/nondiscrimination-in-health-programs-and-activities

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Comment:

By Don McCanne, MD

Insurers will always try to find a way to avoid paying for health care whenever they can. This article explains “adverse tiering” – an innovation by the insurers wherein needed services or products used by individuals with high-cost disorders are placed in a higher tier of coverage in which patient cost sharing is much higher. This adverse tiering is being used by insurers to discourage enrollment in plans by people with disorders such as HIV, hepatitis C, multiple sclerosis, rheumatoid arthritis, or leukemia.

Section 1557 of the Affordable Care Act (ACA) – the nondiscrimination section – states that an individual shall not “be excluded from participation in, be denied the benefits of, or be subjected to discrimination under, any health program or activity, any part of which is receiving Federal financial assistance, including credits, subsidies, or contracts of insurance, or under any program or activity that is administered by an Executive Agency or any entity established under this title (or amendments).”

After five years, HHS has finally released a proposed rule for Section 1557 nondiscrimination under ACA. As Douglas Jacobs explains in the Health Affairs Blog, the proposed rule does not seem to adequately address adverse tiering discrimination. Banning such discrimination can be technically challenging since price tiering is encouraged by some in the policy community as a means of discouraging patients from receiving expensive care that they do not really need (the rhetoric of advocates of consumer-directed health care). Another possibility that Douglas Jacobs suggests is that the proposed rule could be modified to enable lawsuits under the amended Americans with Disabilities Act (ADA).

After reviewing the 200 page proposed rule and considering the complexities of defining how adverse tiering discrimination could be banned while still leaving tiering in place, or considering the complexities of lawsuits under ADA, even in defining whether these expensive conditions are disabilities, it does seem clear that these approaches further increase the wasteful administrative excesses that already plague our heath care system.

In contrast, a single payer national health program would eliminate cost sharing thereby eliminating the insurers’ tool of adverse tiering, not to state the obvious of eliminating the insurers themselves. Life for patients and their health care professionals would be so much simpler.

School of Medicine holds rally, vigil in support of Medicare

By Amanda Kaufman
The Daily Free Press (Boston), Oct. 2, 2015

Joining 30 other universities around the nation, the Boston University School of Medicine hosted a Medicare-for-All National Day of Action rally Thursday to advocate for single-payer health care reform. BU was the only university in Massachusetts to participate.

Organizers and attendees of the rally used the hashtag #TenOne, representing Oct. 1, on social media to spread the word about the cause and connect with the other universities.

BUSM students, professors and policymakers gathered on BU’s Medical Campus to discuss the current inadequacies of the United States’ health coverage system and to raise support for Medicare reform.

The rally ended with a candlelight vigil to honor the lives lost due to the lack of affordable healthcare. The rally’s attendees held candles and colorful posters decorated with phrases such as “Help heal American healthcare!” and “Patients over Profits,” while also participating in a thirty-three second moment of silence to honor the thirty-three million Americans that remain uninsured.

Students for a National Health Program, the student branch of Physicians for a National Health Program, organized the rally.

Clara Zhu, one of the event’s chief organizers and a second-year BUSM student, said when organizing the event, the group wanted to focus on bringing together a variety of people to discuss the lack of healthcare in American and how it has affected patients.

“We have attending physicians, residents, lawmakers, people who specialize in policy and, of course, medical students, and the idea there is that when you have a problem that is so large, that’s so entrenched in our culture, it’s important to be able to have allies from different fields to be able to approach that problem,” she said.

Zhu said America’s hesitance toward single-payer health care in comparison to several other established nations around the world is astonishing.

“Every other major industrialized nation has government-supported healthcare and manages to insure its citizens,” she said. “The United States is the wealthiest nation in the world and somehow still a massive portion of our citizens are uninsured or underinsured.”

Jawad Husain, a third-year BUSM student, said the rally was partly inspired by last year’s White Coat Die-Ins movement, which highlighted police brutality in America.

Over 60 BUSM students participated in White Coat Die-Ins last December in support of the Black Lives Matter movement. The rally was mirrored at 75 other medical schools across the nation, he said.

“[Medicare-for-All] was inspired by what we saw as a big increase in medical student organizing after the Black Lives Matter movement,” Husain said. “We were really inspired by the mobilizing of social media and coordinating a day of action across multiple schools, so that’s how this event came to be.”

Janine Petito, a third-year BU medical student, said there’s a large amount of support among students to start working on real healthcare reform. She said as medical students, they realize they have a lot of privilege and access to a patient population that the rest of the world does not have.

“There’s enough stress that comes along with any illness, whether it’s a broken foot or terminal cancer, and the fact that you could be financially ruined by a diagnosis that’s completely out of your control is outrageous,” Petito said.

First-year BU medical student Alex Iwamoto said the current healthcare system is a mess that has to undergo a lot of change.

“It’s going to be really hard through a lot of incremental change to get to something like single-payer healthcare, I don’t know exactly what it’s going to take,” he said. “Our current system costs a lot of money yet is wildly inefficient.”

http://dailyfreepress.com/2015/10/02/school-of-medicine-holds-rally-vigil-in-support-of-medicare/

Medical Students Nationwide Rally for Medicare for All

By Robert Lowes
Medscape, Oct. 1, 2015

Hundreds of medical students in at least 16 states plan to demonstrate into the evening today in favor of extending Medicare coverage to all citizens, which would amount to a single-payer healthcare program for the United States.

The schedule of events include marches and teach-ins as well as candlelight vigils in honor of the estimated 35,000 American adults whose deaths last year, organizers said, could have been prevented had those individuals possessed health insurance coverage.

Today’s activism springs from the Students for a National Health Program (SNaHP), an arm of Physicians for a National Health Program. SNaHP has roughly 800 members in chapters at 43 US medical schools, according to Scott Goldberg, a member of the Physicians for a National Health Program board of directors and a fourth-year student at the University of Chicago Pritzker School of Medicine in Illinois. Most of the chapters are participating in what’s called the Medicare-for-All National Day of Action, which also goes by the Twitter hashtag #TenOne.

Joining SNaHP in the Medicare-for-All National Day of Action are:

  • the American Medical Student Association;
  • the Latino Medical Student Association;
  • Universities Allied for Essential Medicine;
  • Pre-Health Dreamers, consisting of undocumented students preparing for healthcare careers; and
  • #WhiteCoats4Black Lives, a group of medical students who conducted a nationwide “die-in” last year to protest police brutality against blacks.

The Medicare-for-All National Day of Action is timed to coincide with the 50th anniversary of Medicare, but not today’s debut of the International Statistical Classification of Diseases and Related Health Problems, 10th Revision, diagnostic codes, which has healthcare in a dither. “It happens to be a coincidence,” “Goldberg told Medscape Medical News.

Bryant Shuey, a second-year student at the University of New Mexico School of Medicine, who is helping organize #TenOne activities there, said his nascent clinical experiences have strengthened his belief in a single-payer system. Working in a family medicine practice, Shuey encountered a 65-year-old man who had just become eligible for Medicare. Up until that point, the patient had put off seeing a physician for years on account of the expense.

“He had a mass in his abdomen, weight loss, and changes in his stools,” Shuey told Medscape Medical News. “We ran tests and found out that he had colon cancer. It had pretty much progressed past the point of therapy.”

Blue State Tilt?

Tonight in Chicago, students from five local medical schools will hold a “funeral march” to commemorate uninsured patients who died of preventable causes as well as the hoped-for death of the private health insurance industry, “which places profits above patients,” Goldberg said. The march will end in front of an office for health insurer Humana, where participants will hear speeches and light candles.

“It’s an appropriate place to have it,” Goldberg said.

Press materials from SNaHP state that at least 36 chapters in 16 states intend to conduct marches and rallies today. Most of the 16 states are in the Northeast, North Central, and West Coast sections of the country, and all but two were blue states in the 2012 presidential election. By and large, #Ten10 is skipping over the South, the Great Plains, and the West, which are Republican bastions.

Goldberg said the national map for the National Day of Action reflects not so much political differences as it does the growth of SNaHP.

“We’ve only been around for 4 years,” he said. “Definitely there are chapters in Blue states that are maybe easier to recruit [in], but over the last 6 months to a year, a lot of growth has come from red states.” He pointed to a chapter that has just formed at the Washington University School of Medicine in St. Louis, Missouri.

“It’s not a red state or blue state issue. Medical students are entering into this profession because they see it as a service profession and they want to do what’s best for their patients.

“Clearly single-payer is the most evidence-based and comprehensive way to provide for all patients, regardless of their income or their race or ethnicity.”

http://www.medscape.com/viewarticle/852017

Academic leaders corrupting themselves in the medical-industrial complex

Prevalence and compensation of academic leaders, professors, and trustees on publicly traded US healthcare company boards of directors: cross sectional study

By Timothy S Anderson, Chester B Good, Walid F Gellad

BMJ, September 29, 2015

Abstract

Objective: To identify the prevalence, characteristics, and compensation of members of the boards of directors of healthcare industry companies who hold academic appointments as leaders, professors, or trustees.

Design: Cross sectional study.

Setting: US healthcare companies publicly traded on the NASDAQ or New York Stock Exchange in 2013.

Participants: 3434 directors of pharmaceutical, biotechnology, medical equipment and supply, and healthcare provider companies.

Main outcome measures: Prevalence, annual compensation, and beneficial stock ownership of directors with affiliations as leaders, professors, or trustees of academic medical and research institutions.

Results: 446 healthcare companies met the study search criteria, of which 442 (99%) had publicly accessible disclosures on boards of directors. 180 companies (41%) had one or more academically affiliated directors. Directors were affiliated with 85 geographically diverse non-profit academic institutions, including 19 of the top 20 National Institute of Health funded medical schools and all of the 17 US News honor roll hospitals. Overall, these 279 academically affiliated directors included 73 leaders, 121 professors, and 85 trustees. Leaders included 17 chief executive officers and 11 vice presidents or executive officers of health systems and hospitals; 15 university presidents, provosts, and chancellors; and eight medical school deans or presidents. The total annual compensation to academically affiliated directors for their services to companies was $54 995 786 (ÂŁ35 836 000; €49 185 900) (median individual compensation $193 000) and directors beneficially owned 59 831 477 shares of company stock (median 50 699 shares).

Conclusions:  A substantial number and diversity of academic leaders, professors, and trustees hold directorships at US healthcare companies, with compensation often approaching or surpassing common academic clinical salaries. Dual obligations to for profit company shareholders and non-profit clinical and educational institutions pose considerable personal, financial, and institutional conflicts of interest beyond that of simple consulting relationships. These conflicts have not been fully addressed by professional societies or academic institutions and deserve additional review, regulation, and, in some cases, prohibition when conflicts cannot be reconciled.

From the Introduction

As the for profit healthcare industry and academic medicine have grown closely intertwined, financial relationships between industry and academia and the risks of conflicts of interest have come under scrutiny. Physicians and the media have highlighted concerns that secondary financial interests of individuals and companies may create an undue influence on primary patient care, research, and education goals.

The attention of professional guidelines and the media has primarily focused on researchers and clinicians who receive financial payments for conducting industry research, providing consulting services, and giving promotional lectures. Less attention is paid to academic individuals who also serve on the boards of directors of for profit healthcare companies. Boards of directors are elected by shareholders annually, with responsibilities including oversight of executive officers, setting major strategic initiatives, and handling major financial decisions such as mergers. Similar to individuals engaging in consulting relationships, directors on industry boards enter a formal contract with the company and receive financial payment for services; however, they are subject to two important differences. Firstly, unlike consultants who are compensated to provide expertise on a specific issue, directors are subject to a fiduciary responsibility to company shareholders to advance the general interests of the company and increase profits. Secondly, directors are reimbursed both through larger cash fees than typical consulting contracts and through stock options, the value of which is directly tied to the financial success of the company. Serving as a director has largely been unaddressed in professional society guidelines.

Though the missions of academia and for profit companies can overlap, they may also diverge, specifically when the for profit mission of industry competes with the non-profit taxpayer funded clinical and research missions of academic medical and research institutions.

From the Discussion

Overall, 85 non-profit academic institutions, including many of the most renowned medical research and clinical centers had at least one leader, professor, or trustee who served as a director for a for profit healthcare company. The academic roles of directors ranged from clinical and research professors to trustees of academic institutions and hospitals to a large collection of senior leadership, including 17 health system chief executive officers and eight medical school deans. Directors received considerable cash compensation and owned a median of 50 000 stock shares tied to company performance. The dual obligations to industry and academia that these individuals hold create important conflicts of interest when the missions of their institutions diverge, while at the same time offering potential benefits when the missions overlap. Approaches to managing these competing interests have not been fully addressed in professional ethical guidelines.

Financial relationships between US academic leadership and the pharmaceutical industry have been well documented. A 2006 survey of department chairs found 60% of respondents had a relationship to industry, with 11% serving on a company board of directors. A 2009 study of medical school deans documented nine deans who served on company boards of directors, with a median compensation of over $200 000. We previously documented US academic leadership that held directorships at 19 of the 47 largest global pharmaceutical companies. This study extends the scope of our understanding of these dual roles in three key ways: by using company reported data to examine 99% of publicly traded US healthcare companies across all sectors, examining a wider spectrum of academically affiliated individuals beyond leaders, and providing a more detailed examination of the magnitude of financial relationships, including stock ownership.

http://www.bmj.com/content/351/bmj.h4826

***

Comment:

By Don McCanne, MD

For decades, Arnold (Bud) Relman had warned us about the medical-industrial complex that displaces the noble traditions and ethics of medicine in which patient service is paramount with the business model of health care in which patients become a means to build models in which success is measured by profits and stock performance. Did we listen?

One need only look at the behavior of pharmaceutical firms, for-profit hospital chains, private investor-owned insurance companies, medical device manufacturers, and other components of our health care system to recognize that we have been moving in the wrong direction. Even the architects of the Affordable Care Act ignored Dr. Relman’s call by expanding taxpayer support of the predominantly investor-owned private insurance industry, enhancing their performance in the stock markets, by enabling pharmaceutical firms freedom to charge outrageous prices, greatly increasing their profits, by motivating hospitals to consolidate, giving them greater market leverage, and by a massive infusion of funds into Medicaid programs as control is being transferred to private, investor-owned managed care organizations.

One would hope that our academic institutions, as centers of medical education, research, and patient care would take the lead in moving away from the commercialization of health care and, instead, reinforce the traditional values of the healing arts. Is there hope in today’s message?

We learn that the leaders, professors and trustees of our academic institutions are joining the boards of directors of for-profit health care companies. To assuage any disconcerting reservations they may have over their conflicts of interest, they are being soothed with cash (median $193,000 annually) and stock (median 50,000 shares). Whoa. What does that bode for the future when our newly minted professionals are groomed in this environment?

How does this comport with Bud Relman’s letter to his physician colleagues (A Second Opinion, 2007)? “Our failing, inequitable, and unaffordable health system will be reformed because it must be; because nothing else short of a major overhaul will do the job that a majority of citizens want done. It may begin as an extension of Medicare benefits to people below sixty-five, or as a trial of a new single-payer insurance system in one or more states, or there may be enough popular support to enable passage of landmark legislation that reshapes the entire system nationwide. Much of what happens in the near term will depend on what you decide to do.”

Health professions students want ‘Medicare for all’

By Jordan Centers
Illinois Single-Payer Coalition, Oct. 1, 2015

Despite the Affordable Care Act’s undeniable success in extending health coverage to more people and in curbing some of the health insurance industry’s worst practices, recent reports show our nation still has 33 million people who are uninsured, a comparable number who are inadequately insured, sharply rising deductibles and copays, and skyrocketing pharmaceutical drug prices.

The 2010 health law clearly did not go far enough.

Students in the health professions see this grim picture and want to do something to fix it. On Thursday, Oct. 1, here in Chicago – in tandem with students on more than 30 university campuses nationwide – health professional students will speak out against the continuing calamity in U.S. health care and call for an effective remedy: an expanded and improved Medicare for all Americans.

Such a fundamental reform is urgently needed.

The U.S. is the only industrialized nation without a system of national coverage. As a result, many Americans go bankrupt when they get sick. In fact, according to one study, more than 60 percent of personal bankruptcies in the U.S. are linked to illness and medical bills.

Even if you have insurance, you’re not safe: that same study showed that nearly 80 percent of those medical bankruptcies occur to those who are already insured.

Americans pay more for health care than anyone in the world, and yet in many categories our medical outcomes are subpar. Still worse: according to another study, an estimated 45,000 Americans die each year due to lack of coverage.

Our private-health-insurance “system,” which the ACA reinforced, is clearly failing us.

In contrast, since its inception over 50 years ago, Medicare has provided reliable, effective coverage for all Americans over 65. It’s not perfect. Despite its strengths, Medicare still requires too much cost-sharing and has too many coverage gaps. This is precisely why we are calling for an expanded and improved Medicare for all.

A single-payer, Medicare-for-All system would expand comprehensive health care coverage to everyone in the United States. Patients would have free choice of physicians and other clinicians, hospitals, and inpatient care facilities. There would be no copayments, deductibles, or coinsurance.

Rather, all services would be paid for by a national insurance fund, which would be funded through existing federal monies spent on care and on a system of progressive taxation. One study says such a plan would save 95 percent of U.S. households money.

While health care would be publicly financed, services would still be delivered by both public and private providers.

Having many payers, as we do now, is extremely inefficient. A 2003 study in the New England Journal of Medicine estimated that administration and bureaucracy consumes 31 percent of all health care expenditures in the U.S., most of it waste. Adopting a streamlined single-payer system would save more than $375 billion annually, money that we could redirect to care.

Additionally, a single payer would be able to negotiate much more effectively with pharmaceutical and medical supply companies for fairer prices, helping to slow health care spending.

As students, we have already seen the system fail so many of our patients. We entered the health care profession in order to help people live their lives to their fullest potential. The current system won’t allow us to do that. We demand better. We demand a system that provides care based on needs and not means. We demand a system that considers health a human right.

Please join health professional students from four universities at a candlelight vigil on Thursday, Oct. 1, at 5:15 p.m., at Heritage Green Park, 610 W. Adams, Chicago, to show your support in our fight.

Jordan Centers is a nursing student at Rush University in Chicago and a member of Students for a National Health Program.

FEHBP premium increases indicate that we have not controlled health care costs

Federal health-care plan costs to rise by most in five years

By Eric Yoder
The Washington Post, September 29, 2015

The enrollee share of premiums in the health insurance program for federal employees and retirees will rise by 7.4 percent on average in 2016, the largest increase since 2011, the government announced Tuesday.

Overall premium increases in the Federal Employees Health Benefits Program will average 6.4 percent, but because of the way the formula works for setting the employer and enrollee shares, the enrollee share on average is increasing by more.

The increases in enrollee premiums break down to an average of 6.5 percent for self-only coverage and 10.7 percent for self and family coverage. Current family plan enrollees who switch to self plus one will see their premiums rise by 4.9 percent on average, rather than the 10.7 percent increase for sticking with family coverage.

Within the averages, there is much variation among plans, with some even reducing their premiums while others are increasing them by well more than the average. There are about 250 participating plans, the large majority available only regionally. In the Washington, D.C., metropolitan area, there will be 33 choices.

Office of Personnel Management officials said the increases are in line with estimates of upcoming hikes in private-sector employer-sponsored health plans, which are in the 4 to 6 percent range. Increases in another large governmental plan to which the FEHBP is often compared, the one covering California state employees, will range from 7 to 11 percent depending on the coverage chosen.

Organizations representing federal employees and retirees decried the increases, pointing out that federal employees are in line for only a 1.3 percent raise in January on average, and that retirees likely will receive no cost of living adjustment, or only a minimal one, due to the overall low rate of inflation.

Rising health-care costs “could even mean reduced take-home pay for some federal employees,” while retirees “are facing an even worse situation,” National Active and Retired Federal Employees Association President Richard G. Thissen said in a statement.

http://www.washingtonpost.com/blogs/federal-eye/wp/2015/09/29/federal-health-care-plan-costs-to-rise-by-most-in-five-years/

***

Comment:

By Don McCanne, MD

The Federal Employees Health Benefits Program (FEHBP) is the epitome of the golden standard of employer-sponsored health insurance – the type of coverage that the Affordable Care Act was designed to protect. The claim that we have controlled health care costs is belied by the fact that FEHBP premiums are increasing by an average of 6.5 percent for individual coverage and 10.7 percent for families, when wage increases are relatively flat – only a 1.3 percent increase for next year.

Premium increases in CalPERS – a similar program for California state employees – will range from 7 to 11 percent, a large increase considering that a return to a robust economy does not seem imminent.

This is the best we have, and it is not working well enough. A major factor is that FEHBP and CalPERS use competing private insurers. We have more than ample evidence to show that, not only have the private insurers been ineffective in slowing cost increases to sustainable levels, they have also perpetuated and expanded the profound administrative waste characterizing our system, both through their own administrative excesses and through the tremendous administrative burden they place on the health care delivery system.

Yesterday’s message was on a new OECD report on fiscal sustainability of health systems of economically-developed nations. What these nations have in common that is working for them is a collaboration between government health and budget officials. The most effective models for the United States would be either a single payer national health insurance program or a government-owned and operated national health service.

Since most Americans are comfortable with and supportive of Medicare, the more pragmatic and politically feasible approach would be to enact the single payer model of an improved Medicare for all. Of course, we could certainly enact a national health service if people were to become well informed on the models and decided that’s what they wanted instead.