PNHP

Single-Payer System: Why It Would Save US Healthcare

Single-Payer System: Why It Would Save US Healthcare

Why America Should Have a Single-Payer System

By Leigh Page
Medscape, Sept. 29, 2015

Donald Berwick, MD, helped launch the Affordable Care Act (ACA)—considered at the time to be the only health reform this country would need—when he was administrator of the Centers for Medicare & Medicaid Services (CMS) in 2010 to 2011.

But 5 years later, Dr Berwick and millions of other Americans are calling for a new round of reform that would involve much deeper changes: a single-payer system. Dr Berwick says he still supports the ACA—”It’s been a step forward for the country,” he says—but adds, “The ACA does not deal with problem of waste and complexity in the system.”

Other single-payer advocates are less forgiving. They think that the ACA has pampered the commercial insurance industry, providing it with millions more customers and allowing it to jack up charges to levels that fewer Americans can afford.

The single payer would be the US government.

Single-payer reform would take an audacious step. It would virtually eliminate the entire commercial insurance industry—with $730 billion in revenues and a work force of 470,000—and replace it with one unified payer. A small vestige of the industry would remain to cover nonessential services, such as LASIK surgery.

Advocates often envision a single-payer system as an expansion of Medicare, or “Medicare for all.” Single-payer systems in Canada, Australia, Denmark, Norway, and Sweden—as well as other types of centrally run systems—have much lower per capita health spending and generally better health outcomes than the United States.[1] However, this is also true for non–single-payer systems outside of the United States. The United States simply has the highest healthcare costs, regardless of the system.

The single-payer approach has a moral argument—that everyone should have a right to healthcare—but it also has a practical argument, says James Burdick, MD, a transplant surgeon at Johns Hopkins University School of Medicine and author of Talking About SINGLE PAYER!, which will be published later this year. “It’s a more economical way to use healthcare resources,” Dr Burdick says. “You could reduce expenses and still improve quality. That’s a tremendous opportunity that you don’t have in many other fields.”

According to a 2014 study,[2] the new, streamlined system would save US healthcare $375 billion per year, owing mainly to removal of the inefficient administrative costs of multiple payers. The authors calculated that the savings would cover millions of people who are still uninsured and terminate high deductibles and other out-of-pocket costs levied by commercial insurers.

Restoring Doctors’ Authority

Terrence McAllister, a pediatrician with a solo practice in Plymouth, Massachusetts, thinks that a single-payer system would restore the medical profession’s independence and authority. Dealing with multiple commercial insurers makes it very difficult to be independent. “The profession is becoming more and more dependent on employment, and that usually means serving the needs of hospitals,” he says.

Dr McAllister’s wife, Leann, who administers the practice, sees a renaissance for small practices under a single-payer system. In the United States, small practices often have to make do with lower reimbursements because they lack negotiating leverage with insurers. There are no such negotiations in a single-payer system. “I could build a business plan with far more certainty,” she says.

For all practices, administrative costs would plummet because there would be only one set of payment rules. Prior authorizations, narrow networks, and out-of-pocket payments would be eliminated, proponents of a single-payer system say.

Under the Canadian single-payer system, physicians turn in a slip of paper for each encounter. Dr Burdick says that a Canadian orthopedic surgeon who moved from the United States told him he was greatly relieved to no longer have an extra room in the back for coding clerks and claims files. “I fill out the chits for each encounter, and my secretary bundles them up and sends them in,” he told Dr Burdick. Indeed, a 2011 study[3] found that US doctors spend almost four times more money dealing with payers than do doctors in Ontario, Canada.

Dr Berwick did not support a single-payer system until late 2013—several months into his campaign to be the Democratic nominee for governor of Massachusetts, his first foray into electoral politics. While campaigning, “I became more and more familiar with all the obstacles people faced in education, housing, and employment,” he says. “I concluded that our healthcare system takes money away from these things.”

He thinks a single-payer approach could clean up a highly inefficient system. “There is too much complexity and administrative hassle in our healthcare system,” he says. “We need to simplify the payment structure.”

Evidence of Growing Physician Support

Dr Berwick lost the primary in September 2014, but during the campaign, he saw his single-payer message resonate with doctors. It definitely did so with the McAllisters. “He helped solidify our support for a single-payer system,” Leann McAllister recalls. In March, Dr McAllister joined Physicians for a National Health Program (PNHP), a single-payer advocacy group that has more than 19,000 members nationwide.

Are more doctors flocking to support a single-payer approach? The only known recent poll of doctors is a 2014 survey of Maine physicians[4] conducted for the Maine Medical Association (MMA). The poll found that nearly 65% of MMA members preferred the single-payer option over trying to fix the current system—up from 52% in a 2008 survey.

The MMA 2014 survey showed that a single-payer system is especially popular among primary care and employed physicians. For example, more than three quarters of family physicians endorsed a single-payer system, compared with one third of radiologists. And whereas only 40.7% of physicians at fully physician-owned practices endorsed single-payer, 72.6% of those in fully hospital-operated practices did so.

Physicians seem more open to a single-payer system as the profession moves toward the Democrat Party, a stronghold of support for this idea. According to a study[5] published in July, 55% of doctors making political contributions in the 2013-2014 election cycle gave to Democrats. That’s a substantial change from 18 years earlier, when 72% of contributing doctors gave to Republicans.

Proponents say there are plenty of reasons for doctors to like the single-payer approach. In addition to restoring physicians’ authority and simplifying claims, Dr McAllister says that a single-payer system would simplify the clinical process, thereby boosting the quality of care. “From a clinical perspective, the main advantage is that I don’t have to consider which insurance the patient has and make my plans for patients on the basis of that,” he says.

It is also being claimed that a single-payer system may reduce malpractice litigation. There might not be a need to file a lawsuit to get future medical care, because a single payer would cover it. Still, it would not cover pain and suffering or economic damage.

Americans Are Warming Up to Single-Payer

There are signs that the public is also warming up to a single-payer system. A slight majority of Americans (51%) support Medicare for all, according to a national poll[7] released in January for the Progressive Change Institute. The survey also found, however, that more than one third oppose Medicare for all. Also, there is a wide partisan divide. Whereas 79% of Democrats supported a single-payer system, only 23% of Republicans did so.

Interest in single-payer may continue to grow, owing to the rise of high deductibles and other out-of-pocket costs for patients, according to Steffie Woolhandler, MD, a Harvard internist and cofounder of the PNHP. Although the ACA expanded coverage to millions more Americans, she says it also accelerated the trend toward high deductibles. “Now people with insurance are finding that they can’t afford to use it,” she says. (The assumption is that a single-payer system will not include high deductibles.)

A study[8] released by the Commonwealth Fund in May found that the proportion of US adults with high deductibles tripled from 2003 to 2014. It estimated that almost one quarter of insured US adults had such high out-of-pocket costs relative to their incomes that they were deemed to be underinsured. One half of this population reported problems with medical bills or debt, and more than 2 of 5 said that they didn’t seek needed care because of the cost.

“The trend in this nation is to shift the costs of healthcare more and more onto individual families,” Dr Berwick says. “High deductibles take money out of people’s pockets under the guise of personal responsibility. There is a great shift of wealth away from the middle class and working people.”

Dr Woolhandler says it may take years for many Americans with high deductibles to understand just how toxic they are. “People might need to have a major medical event to see how badly the system is failing them,” she says.

Leann McAllister makes an analogy to parents who deny pediatric vaccines until they understand that their own child could die without them. “Americans are often motivated by fear,” she says. “They may react only when they see that our healthcare system could fall apart.”

The Massachusetts practice administrator also says that high deductibles produce an imbalance in physician supply. In less wealthy areas, such as Plymouth, she says, patients faced with large out-of-pocket expenses simply forgo care, permanently reducing demand for doctors. She says no new physicians have come into the area for many years, despite a growing population.

Movement May Start on the State Level

The movement encountered a setback last December 2014, when Vermont pulled the plug on its single-payer initiative, the only one in the nation. The Vermont governor cited high projected costs for businesses and taxpayers, which cooled Vermonters’ enthusiasm and almost lost him his reelection bid the month before.

Dr Berwick says it’s only a temporary setback. “What happened in Vermont gives us lessons for the next wave of efforts,” he says. Advocates within the state are already working on new approaches. Deborah Richter, MD, a family physician in Berlin, Vermont, and a leader of the state’s single-payer movement, says she is working with legislators on a plan to publicly fund primary care activities only, and fold in specialists later. “We realize that you can’t just flip the switch and suddenly have a single-payer system,” she says.

The Vermont setback shows that people need to gain a better understanding of how a single-payer system would work, Dr Berwick adds. Although taxes and fees would rise substantially to pay for the system, these costs are less than what people had to pay for their own insurance. Businesses that already cover their employees would also see lower costs owing to efficiencies.

Dr Berwick thinks it’s possible that single-payer systems will initially emerge at the state level. “The current polarization in Washington makes it difficult to enact it on the federal level right now,” he says. Dr Richter likes the idea of state-operated systems within a national system, similar to the way in which Canada’s single-payer system is run by each province. The federal government would determine what services are covered, and each state would determine reimbursement levels.

Dr McAllister, however, doubts that a one-state single-payer system would work well. He recalls that when Massachusetts instituted its own pre-ACA version of health reform, out-of-state patients flocked to emergency departments there, driving up the program’s costs.

Public Distrust Must Still Be Overcome

One potential barrier for the movement is the public’s abiding mistrust of government. “A very big obstacle to progressing this policy is the widespread perception that government is unable to solve problems,” Dr Berwick told a national meeting of the PHNP last November.[9] “We need to make the case that government can solve problems and manage its business well.”

Dr Berwick and others in the movement see government as a mechanism for doing good. “Trying to make government look less functional, that’s the agenda on the right,” he says. But if anti-government attitudes prove insurmountable, he thinks that a single-payer operation could be handed over to an independent board.

Leann McAllister said that another unfair criticism of single-payer is that it would be bureaucratic. “We have an even bigger bureaucracy with commercial insurers,” she says. “They have plenty of unnecessary rules.” For instance, when patients in her practice move to a different plan, they sometimes are assigned a new doctor, even though her husband is in-network. “It takes a lot of paperwork to correct that,” she says.

Another potential downside that is cited for a single-payer system is waiting lists for elective procedures, such as those for hip and knee operations in Canada. The problem exists, but it’s “way overstated,” Dr Berwick says. “The fact is that Canadians wouldn’t trade their system for ours.”

Dr Burdick asserts that comparisons between US and Canadian waiting lists are unfair, because Canada scrupulously measures its waits and we don’t. “We know the numbers of Canadians on waiting lists because they are counted, but no one keeps track of how long you have to wait for care in the United States,” he says.

Dr Richter also discounts critics’ tales of a vast movement of Canadians to the United States to receive care denied back home. Most Canadians who get care in the States, she asserts, fell ill or had accidents while visiting.

What Would It Be Like for Doctors?

It’s hard to predict exactly how a single-payer system would affect US doctors, because it could be implemented in a variety of different ways. For example, Canadian doctors get fee-for-service payments, but Dr Berwick says US doctors could instead receive value-based payments, which Medicare is moving toward.

“There is really a wide range of choices,” says the former CMS administrator, who helped develop value-based payments for Medicare. “A global payment or capitated payment system could be quite flexible. This would allow funds to be easily shifted to where they’re most needed.”

Many specialists are concerned that their reimbursements would be slashed under a single-payer system, but Dr Burdick says that this doesn’t have to happen. “The spending problem in US healthcare does not really have to do with physician reimbursements,” he says. “It has to do with the payments that physicians are generating.”

Dr Burdick added that services covered by a single-payer system could be determined by a board of experts, like the United Kingdom’s National Institute for Health and Care Excellence (NICE). He wants the US board to be dominated by physicians—as NICE is—but it should also be completely independent of political influence, which he says NICE is not.

Dr Berwick agrees that physicians should have a central role on policy-making committees. “Doctors would have a voice in the terms of their work, and rules for paying them would have to be maintained in a fair way,” he says. “Right now, nobody knows how fees are set, and most doctors don’t at all feel that they’re in the driver’s seat.”

Dr Berwick is also a strong proponent of use of outcomes and quality data, as well as use of electronic medical records (EMRs). “Data would be an integral part of a single-payer system,” he says. “This is already going on with commercial payers, and they are using data in ways that are not accountable or transparent. You need rules so that the data aren’t misused and there are privacy protections.”

Under a single-payer system, EMRs would be simpler to use and there would be fewer data-reporting requirements, Dr Berwick says. “Right now, doctors are driven crazy by multiple reporting and payment structures,” he says. “It’s very complicated and highly demoralizing. A single-payer system would be a lot simpler.”

Conclusion

Dr Woolhandler says more work is needed before the United States embraces a single-payer system. “We have to get the word out about problems in the current system, and the ability of a single-payer system to resolve them,” she says. “And we need good political leadership that can explain the advantages. Political challenges in Washington make it very challenging to adopt a single-payer system right now, but the situation could change rapidly. Look at the late 1950s. Who could have predicted all the reforms that happened the 1960s?”

Leigh Page is a freelance health care writer in Chicago.

http://www.medscape.com/viewarticle/851265

OECD: Fiscal sustainability of health systems

Fiscal Sustainability of Health Systems: Bridging Health and Finance Perspectives

OECD, September 2015

From the Forward

This book provides a synthesis of the work developed by the OECD Senior Budget and Health Officials Joint Network. Over the past four years, this joint network has been an important forum to promote the dialogue and mutual comprehension between Health and Finance Ministries. It has provided a platform for budget and health officials to discuss together possible solutions to fiscal sustainability challenges in health care. It describes a wide range of responses by countries to the crisis – some clearly beneficial, achieving better value for money, others less so, reducing services across-the-board and potentially leading to poorer health outcomes and financial hardship from increasing costs borne by patients. This book presents a strong case for timely reforms of health care systems, based on close collaboration between budget and health officials.

From Chapter 1: Fiscal sustainability of health systems – Why is it an issue, what can be done?

The main messages from this chapter are summarised below:

  • Fiscal sustainability requires governments to mange public finances credibly. Health systems are a key challenge to fiscal sustainability, since rising costs, new treatment possibilities and demand for continued improvements to the quality of care will exert pressure on public finances.
  • Health expenditure has typically outpaced economies growth. Whilst the global economic crisis moderated rapid growth in health spending, this is expected to be temporary. Indeed, projections forecast health expenditures to rise as a share of GDP.
  • Spending on health has been largely driven by new technologies and rising incomes, with demographic change and institutional characteristics of health systems relevant but less important factors in most countries.
  • The implications of rising costs are particularly important for public finances, since health care is predominantly funded from public sources. Moreover, aging may lead to shortfalls in payroll taxes to finance health.
  • Policy makers have three broad ways to ensure fiscal sustainability of health systems: raise more money for health, improve the efficiency of government health spending, and reassess the boundaries between public and private spending. Simpler blanket spending cuts can also evidently address fiscal constraints, but are more likely to have adverse effects.
  • Health care is highly valued by populations and is a major contributor to countries’ economies. Therefore spending more on health care is not automatically a problem, particularly if citizens are willing to pay for this through higher taxes or cuts in other areas of government spending. The challenge is to ensure any increase in spending respects fiscal sustainability constraints, and delivers good value for money.

Do not reduce population coverage, avoid across-the-board increases in cost sharing

Looking first at population coverage, leaving certain population groups to be voluntarily covered by private health insurance appears to be a logical policy option from a fiscal perspective. Indeed, the theoretical advantages of private health insurance are an expansion of individual choice, greater innovation and flexibility, as well as reduced public cost pressures. However, in practice the risks associated with private health insurance are numerous, including higher administrative costs, less bargaining power for insurers, pressure for tax incentives, and risk selection leading to inequitable coverage gaps.

Given these issues, and coupled with strong social justice arguments, universality of population coverage should be maintained. In terms of cost coverage, blanket increases in cost-sharing and other forms of out-of-pocket payments is also undesirable, since they can deter health-seeking behaviour and can lead to people facing financial hardship. Small, targeted co-payments that include exemptions could be considered, but are unlikely to generate substantial revenues.

From the Conclusion of Chapter 1

Finally, it is also important to remember that more health spending is not automatically a problem. Good health remains a critical part of human development and an important contributor to economic growth. Health care is also highly valued by society. Accommodating greater health spending as a share of government budgets is therefore not automatically a problem. The challenge is to ensure that any increase in spending respects fiscal sustainability constraints, and that money is effectively spent.

From Chapter 2: The challenge of budgeting for health care programmes

Meanings of “sustainability”

The United States currently spends a share of its GDP on health care which would seem unthinkable and horrifying to policy makers in any other country. It seems unnecessary and wasteful to many Americans. Yet the US economy certainly has survived that level of spending. If the United States can survive its much higher spending, why would that level be “unsustainable” for other countries?

The most plausible way in which spending could be “unsustainable” would be if political support for the expense could not be sustained. Fundamentally, this means political support for redistribution. In all modern economies, the average cost of medical care is now unaffordable for a significant proportion of the population. All health care finance systems accordingly redistribute not just from the healthy to the sick, but from those with higher incomes to those with lower incomes. Systems are funded roughly in proportion to ability to pay; if they are not, then some people are likely to receive much less care. Therefore the capacity to spend on health care for all citizens depends on the ability to collect the necessary funds from the higher income strata within the country.

As the United States is an extreme case that suggests doubts about economic unsustainability arguments, it provides the clearest evidence of the political sustainability problem. The United States faces the most extreme redistribution challenge both because spending is so high, making costs less affordable for individuals, and because incomes are especially unequal, making average costs even more daunting for the lower-income groups. In the United States, limits on redistribution work not to make national health insurance unsustainable, but to prevent its creation.

http://www.oecd-ilibrary.org/social-issues-migration-health/fiscal-sustainability-of-health-systems_9789264233386-en

***

Comment:

By Don McCanne, MD

Because of ever-increasing health care costs, all nations are concerned about the fiscal sustainability of their health care systems. The United States has the highest costs – theoretically the least sustainable system – thus this report should be useful for our policymakers since it describes various approaches to sustainability by economically-developed member nations of OECD, informing us on both beneficial and detrimental policies.

This 264 page report is accessible, without charge, for reading – in sections or in its entirety – at the link above. Be sure to keep the link for future review or reference.

A major theme throughout this report is that sustainability is achieved by close cooperation between Ministries of Health and Ministries of Finance, that is, collaboration between government health and budget officials. In one word: government.

Because of our high health care costs and our inordinate levels of income inequality, we have a greater need for redistribution, yet, compared to other economically-developed nations, our government policies are relatively weak. As this report states, in the United States, “limits on redistribution work not to make national health insurance unsustainable, but to prevent its creation.”

U.S. policies hinder good health care for all

By Anne Scheetz, M.D.
The State Journal-Register (Springfield, Ill.), Sept. 27, 2015

During September we observe Sickle Cell Disease Awareness Month with the goal of bringing greater attention to this genetic disease that affects 4,000 to 5,000 Illinoisans. 

A disease of red blood cells, SCD can affect many body organs, including brain, bones, heart and lungs. Some people have few symptoms; others suffer serious complications such as childhood strokes, pneumonia, episodes of severe pain (pain crises), leg ulcers and early death. Under the best conditions SCD causes great suffering to severely affected people. With inadequate care, suffering is much worse.

Medical advances, including medications, blood transfusions and treatment of stroke risk, have improved symptoms, reduced organ damage and prolonged life for many people. All can have adverse effects. Stem cell transplants appear to cure select cases but carry a risk of death. 

Known ancestry does not reliably indicate risk, so all infants should be screened. But most patients are black. Being black and being sick are risk factors for poverty; personal poverty and living in poor neighborhoods in turn adversely affect health.

People with severe forms of the disease require a lot of care. But current U.S. policy systematically erects barriers to care. 

Doctors are supposed to keep patients healthy, and failure to do so is considered a sign of poor practice. Yet SCD is rarely curable, and many complications, including pain crises, are not preventable. Patients who suffer pain crises require frequent hospitalizations. Yet Medicare and Illinois Medicaid penalize hospitals for re-admissions. 

Despite increases in insurance coverage under the Affordable Care Act, people with SCD can find themselves uninsured. They can end up in high-deductible health plans. They may fail to get care or suffer financial hardship, and the stress of such pressures further worsens their health. 

Pre-authorization requirements make it difficult for patients to get wound care products and medications on time. Network restrictions prevent people from getting care from their doctors and hospitals of choice. Restriction to a single pharmacy, required under some health plans, prevents people from going elsewhere for out-of-stock pain medicines. Some essential services, such as dental care, which is important for good nutrition, are not covered for most people with SCD as for most Americans. 

U.S. health insurance plans are highly variable, and even the best do not cover all necessary care or provide first-dollar coverage. Insurance companies make their own determinations that certain treatments are experimental or not medically indicated, and drugs commonly used for chronic conditions may require high co-pays. 

In summary, people with SCD, like people living with other chronic diseases, suffer unnecessarily from policies that prevent good care. It doesn’t have to be this way. Lack of health insurance, unaffordable out-of-pocket costs, network restrictions, preauthorization requirements and penalties for readmissions all stem from our private-insurance-based system. 

Under a Medicare-for-all system every U.S. resident would have first-dollar coverage for all necessary care. Patients and their clinicians would make medical decisions. Everyone would have complete choice of hospitals, pharmacies and other providers. Financing by a progressive tax would transfer wealth from the top down, with the greatest benefit going to those currently most disadvantaged, including poor people, people of color and all sick people.

Instead of creating barriers to care, we would greatly simplify administration, saving $400 billion per year — more than enough to cover the uninsured and eliminate deductibles and co-payments for all of us. What better way to observe SCD Awareness Month than by pressing for a system that would allow us to provide the best care to people affected by this disease? 

Dr. Anne Scheetz is a founding member of the Illinois Single-Payer Coalition and a leader of the Illinois chapter of Physicians for a National Health Program. She lives in Chicago.

http://www.sj-r.com/article/20150927/OPINION/150929656

Want to see what Alabama insurance executives make? New law says that’s now secret

By Amy Yurkanin
The Birmingham News (AL.com), Sept. 28, 2015

If you want to know what the CEO of your health insurance company earned last year, don’t ask the Alabama Department of Insurance.

That information is no longer public – because of a new law that shields much of the information used to review the state’s insurance providers. The law reverses an open-book policy that had been in place for years.

Officials with the Alabama Department of Insurance sought the change during the regular legislative session – in an effort to comply with the requirements of an organization that accredits insurance regulators, said Chief of Staff Mark Fowler. The bill initially made work papers confidential, but included salaries after conversations with members of the insurance industry.

“That came from industry feedback,” Fowler said. “When we offered the bill up, we agreed to go along with it. We felt like there was no real regulatory aspect of that. It didn’t contribute to regulating those companies.”

The bill, sponsored by state Sen. Slade Blackwell (R-Mountain Brook), enjoyed near-unanimous support in the legislature and received the governor’s signature in May.

But some health insurance attorneys are concerned about the implications of the new law. In previous years, citizens had access to more information about how insurance companies spent their money. So if a member believed a rate increase was unreasonable, he could look at the documents and file a lawsuit based on that information, said Jim McFerrin, a health care attorney.

“Basically what it does is create a web of transparency so anyone who is interested can go in and take a look see at the numbers,” McFerrin said.

It will be much more difficult to determine how insurance companies are spending money in the future, and more difficult to challenge rate increases, McFerrin said.

“A decrease in transparency means a decrease in accountability,” McFerrin said.

The law will benefit some companies more than others. National health insurance companies such as UnitedHealthcare and Aetna report compensation and other information in annual reports to the Securities and Exchange Commission.

Blue Cross Blue Shield of Alabama, which dominates the health insurance market in Alabama, does not report to the SEC, and is not required by the IRS to file a form that shows executive compensation.

“We kind of felt like this ought to be confidential as well since it had to do with personal information.”

“We are not a charitable nonprofit required to file a Form 990, and we do not release our employees’ compensation information,” wrote Blue Cross spokeswoman Koko Mackin in an email.

The company’s high executive pay and generous bonuses have raised questions in the past. The top ten executives at Blue Cross Blue Shield of Alabama earned more than $1 million each in 2013, according to Al.com. President and CEO Terry Kellogg earned a total of $4.84 million that year. The top executives at the company collectively doubled their compensation between 2011 and 2013.

“If they can pay the salaries in secret, God knows how much they’re going to pay now,” said Joe Whatley, an attorney who is leading a class action lawsuit against Blue Cross Blue Shield.

Earlier this year, the company sought 24 percent average rate increase for individual plans available on the health insurance exchange.

Although the Department of Insurance will still receive salary information for its review, the information will no longer be subject to open records law or subpoena, according to the bill.

“We kind of felt like this ought to be confidential as well since it had to do with personal information,” Fowler said.

The agency needed to update its policies to comply with national standards, Fowler said. A loss of accreditation could be costly to the state’s insurance companies, he said.

“If another state could not accept an examination from Alabama, that company would have to essentially pay for two examinations,” Fowler said. “So it costs a lot of money and time for everybody.”

Whatley said state residents have an interest in knowing what is happening at Blue Cross, which is one of the state’s largest non-profits.

“Blue Cross claims all sorts of benefits from being a non-profit corporation and now it wants to keep information including the enormous salaries of its executives secret,” Whatley said. “If they earn their money, they ought to be proud of their salaries.”

http://www.al.com/news/index.ssf/2015/09/want_to_know_what_insurance_ex.html

Is There a Fox Guarding California’s Hen House?

By Paul Y. Song, M.D., and Wendell Potter
The Huffington Post, Sept. 23, 2015

When the Affordable Care Act (ACA) became law in 2010, the individual health insurance market was highly concentrated, with little to no competition in most states. One or two insurers controlled the top 94 metropolitan markets in the United States. In 30 states and the District of Columbia, one major insurer had over 50% of the individual market and over 90% in Alabama alone.

The ACA implemented state-specific Health Insurance Exchanges, also called Marketplaces. These Marketplaces were intended to promote price comparison and competition in the individual and small group insurance markets through greater transparency. In the same time, consumers could obtain minimum essential coverage, receive federal subsidies, and be granted exemptions. With medical underwriting prohibited, premiums were easy to compare, focusing solely on competition of price. But in order for consumers to realize a maximum benefit from this Marketplace, there had to be ample choice and competition.

That is why it is so disturbing to see Peter Lee, the head of Covered California (California’s marketplace), publicly go out of his way to justify and advocate for the rapid wave of consolidation and mergers amongst the private insurance industry.

In a recent Wall Street Journal op-ed, Mr. Lee readily parrots the deep concern of the private insurance industry regarding the consolidation amongst hospitals and providers, but fails to mention his poor record on forcing participating insurers in California’s exchange to open up their narrow networks or the lack of effect such consolidations would have. It should be pointed out that Covered California has the 4th narrowest network in the U.S. and that 75% of all the policies negotiated by Mr. Lee already have 25% or fewer physicians in an area compared to 41% nationally.

While a dominant insurer may indeed be able to negotiate lower rates from hospitals, physicians, and big Pharma, there is absolutely no indication that these savings would be passed on to consumers. Mr. Lee claims savings would indeed be passed on because of the ACA provision that mandates insurers spend 80-85% of every premium dollar on consumer medical claims and activities that improve quality of care.

What Mr. Lee fails to mention, is that while the ACA does mandate a minimum level of spending on care, it fails to regulate the premiums that insurers can charge and poorly defines the activities that improve quality of care are. Does spending money on promotional ads really improve quality of care?

This is especially ominous in California where the private insurance industry and its allies spent over $55 Million to defeat a statewide initiative, Prop 45, which would have given the politically elected and publicly accountable California Insurance Commissioner the right to regulate such rates. Thus, while insurers are required to spend more of every healthcare dollar on actual patient care, they can make up for this lost revenue by charging higher unregulated premiums.

Due to the successful and expensive lies that were spread to defeat Prop 45, California consumers of which nearly half already find it difficult to pay their premiums, remain powerless, particularly when the politically appointed and unaccountable head of Covered CA appears to be an agent of the private insurance industry.

While Mr. Lee can claim smaller premium increases up to now in California compared to many other states, his recipe for insurance consolidation and a lack of insurance rate regulation will make sure that this will not endure. In the nine years prior to the ACA, California premiums increased 185% while insurers cherry picked the healthiest applicants and rejected many with pre-existing conditions or made coverage too cost-prohibitive, all the while issuing over 45.7 million denials. Now that they can no longer use pre-existing conditions to screen out and deny people coverage, it is only a matter of time before insurers find other ways to maximize profits.

A recent study from Harvard University’s Institute for Quantitative Social Science revealed that the largest insurer in each marketplace had a 75% higher premium increase from 2014 to 2015 compared to other same-state issuers. On average, the largest issuers raised rates by 23.9%, while the other issuers only raised rates by 13.7%. So, do we really want to increase the likelihood of this happening in California with less competition and choice through more consolidation?

It has been said that no one can serve two masters. It is clear by Mr. Lee’s op-ed who he serves.

Mr. Lee’s justification for consolidation in reality makes the de facto case for a single payer healthcare system. The real question is whether this single payer should be controlled by an entity that only makes money by denying patients care, or a government run Medicare for all system that has proven to be more cost effective, provide better coverage, and have greater patient satisfaction.

Finally, a word of caution to all who were fooled into voting against Prop 45. When you let the fox guard the hen house, there’s bound to be a lot of chicken dinners.

Dr. Song is a board certified radiation oncologist and the Executive Chairman of the Courage Campaign and Co-Chair for a Campaign for a Healthy California. Mr. Potter is a former Health Insurance Executive turned whistleblower, author, and an analyst at the Center for Public Integrity.

http://www.huffingtonpost.com/paul-y-song-md/is-there-a-fox-guarding-c_b_8171502.html

Lack of affordability is primary reason for not enrolling in exchange plans

To Enroll or Not to Enroll? Why Many Americans Have Gained Insurance Under the Affordable Care Act While Others Have Not

By Sara R. Collins, Munira Gunja, Michelle M. Doty, Sophie Beutel

The Commonwealth Fund, September 25, 2015

Exhibit 2.  Just under half of the adults who have visited the marketplace enrolled in a marketplace plan or Medicaid

52% – Did not select a private plan or enroll in Medicaid
30% – Selected a private health plan
15% – Enrolled in Medicaid
2% – Don’t know/refused

Exhibit 6.  Among market-place visitors who didn’t enroll, more than half said they couldn’t find an affordable plan

Can you tell me why you did not obtain a private health insurance plan or Medicaid coverage when you visited the marketplace? Was it because…?

Percent of adults ages 19-64 who visited the marketplace but did not select coverage

57% – Could not find a plan you could afford
51% – Obtained health insurance through another source
43% – Not eligible to enroll in Medicaid or for financial assistance
38% – Found the process of enrolling in a plan difficult or confusing
32% – Could not find a plan with the type of coverage you need
15% – Decided you did not need health insurance
14% – Did not know where to get help to sign up
23% – Some other reason

Affordability was a key reason people did not enroll in plans. More than half (57%) of adults who visited the marketplaces but did not enroll said they could not find a plan they could afford. Excluding the adults who also said they gained coverage elsewhere, the majority of those who did not enroll because they couldn’t find affordable plans had lower incomes. More than half (54%) had incomes in the range that made them eligible for subsidies (i.e., from 100 percent to 400 percent of the federal poverty level, or $11,670 to $46,680 in annual income for an individual). Thirty percent had incomes under 100 percent of poverty. An estimated 26 percent (and thus nearly all of those with incomes under 100 percent of poverty) were likely in the so-called Medicaid coverage gap. That is, they were living in states that had not expanded eligibility for Medicaid at the time of the survey and had incomes under 100 percent of poverty and thereby not eligible for marketplace subsidies. About 11 percent had incomes that exceeded the threshold that made them eligible for subsidies (i.e., 400 percent of poverty).

Many adults (43%) said they did not enroll because they were not eligible for subsidized coverage or Medicaid. Again, excluding those who gained coverage elsewhere, most people who gave this reason had lower incomes: 50 percent had incomes that made them eligible for subsidies, and 33 percent had incomes under 100 percent of poverty. An estimated 27 percent — most of those with incomes under 100 percent of poverty — were likely in the Medicaid coverage gap. About 14 percent had incomes above the threshold that made them eligible for subsidies.

Other adults who did not enroll were overwhelmed by the process. About four of 10 adults (38%) who did not sign up for coverage said they found the process of enrolling difficult or confusing.

http://www.commonwealthfund.org/publications/issue-briefs/2015/sep/to-enroll-or-not-to-enroll

***

Comment:

By Don McCanne, MD

Is the Affordable Care Act a misnomer? Although half of the individuals who visited the insurance exchanges and did not enroll obtained coverage outside of the exchanges, the other half did not enroll because they found the plans unaffordable.

Making health care affordable for everyone was the primary goal of reform. It didn’t happen. But it would if we were to enact a single payer national health program.

Medical students to hold National Day of Action for ‘Medicare for All’ on Oct. 1

FOR IMMEDIATE RELEASE
September 28, 2015

Contact:
Mark Almberg, (312) 782-6006, mark@pnhp.org
See student contacts at 30 medical schools at end of this message

MEDIA ADVISORY

Citing the persistence of thousands of preventable deaths each year due to lack of health insurance, students at more than 30 medical schools across the country will hold teach-ins, rallies and candlelight vigils on Thursday, Oct. 1, to bring national attention to ‘our failing health care system’ and the need for single-payer health reform

What

Students for a National Health Program (SNaHP), the student arm of Physicians for a National Health Program – working in coalition with the American Medical Student Association, WhiteCoats4BlackLives, the Latino Medical Student Association, Universities Allied for Essential Medicine, California Health Professional Student Alliance, and Pre-Health Dreamers – will hold teach-ins, rallies, and candlelight vigils at more than 30 campuses to remember the millions of people in the U.S. who remain uninsured, underinsured and underserved by our current health care system. They will also underscore the need for a more fundamental health reform – a nonprofit, publicly financed, single-payer health system.

When

Thursday, Oct. 1, various times (see the #TenOne Facebook page for individual event details, or contact students at participating schools – see list below)

Who

Medical students other health professional students, along with allies on their campuses and from surrounding communities. The public is welcome to attend.

Where

Medical schools and a few public venues across the country, including but not limited to the list at the end of this advisory.

Why

The United States is the only industrialized nation in the world that does not guarantee universal health care. Unfortunately, the Affordable Care Act is neither universal nor affordable. It will leave 30 million Americans uninsured and a comparable number underinsured, vulnerable to financial distress in the event of illness. Sharply rising deductibles and copays are deterring the insured form seeking care, and skyrocketing drug prices are putting medications out of reach. Tens of thousands of people will continue to die every year just because they lack health insurance. Medical problems 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. Our patients need and deserve better.

This year marks the 50th anniversary of Medicare. As medical students, part of our mission is to ensure that everyone who needs care gets it. One way to achieve this goal is by improving the Medicare program and expanding it to cover all Americans. There is a bill in Congress, H.R. 676, that would do precisely that.

We urge our fellow students and the public to join us for this #TenOne: Medicare-for-All National Day of Action on Thursday, Oct. 1, to bring national attention to our failing health care system and the need for single-payer health reform.

For more of the thinking behind the #TenOne initiative, including patient stories, please see these posts on SNaHP’s official blog by medical students Vanessa Van Doren and Bryant Shuey.

Media visuals: Many of these events will have medical students in white coats, candles for evening vigils, signs and banners. In some cases there will be rallies with multiple speakers.

#TenOne Local Events

Teach-ins, rallies, and candlelight vigils

*Participating campuses and their SNaHP chapter leaders are updated daily.

CALIFORNIA

Coordinator: Angelica Ramirez, California Health Professional Student Alliance
Touro University California: Matthew Musselman
UC Berkeley: Ana Ibarra 
UC Davis School of Medicine: Umer Waris, Keyon Mitchell, Callum Rowe
UC Irvine: Michelle Crespo
UCLA: Jonathan Gomez
UC San Francisco: Nicolas Barcelo
UC San Diego (undergraduates and medical students): Firooz Kabir 

ILLINOIS

Chicago Medical Schools Coalition:
University of Chicago: Scott Goldberg
University of Illinois at Chicago: Kieran Holzhauer
Rush Medical College: Jordan Centers
Chicago College of Osteopathic Medicine: Jillian Caldwell 

IOWA

University of Iowa Carver College of Medicine: Lisa Wehr

KENTUCKY

University of Louisville School of Medicine: Brandi Jones

MAINE

University of New England College of Osteopathic Medicine: Natasha Neal

MASSACHUSETTS

Boston University School of Medicine: Andy Hyatt

NEW MEXICO

University of New Mexico School of Medicine: Bryant Shuey

NEW YORK

PNHP NY METRO (coordinators): Becca Mahn and Katie Robbins

Albany Medical College: Justin Pegueros
Albert Einstein College of Medicine: Tauhid Mahmud and Dahlia Kenway
Columbia University Mailman School of Public Health: Michael Zingman
Cornell University (Ithaca): Christine Liu
Icahn School of Medicine at Mt. Sinai: Alice Shen
New York University School of Medicine: David Wang and David Collins
SUNY Downstate: Keriann Shalvoy 
Weill Cornell Medical School: Claire Kenney 

OHIO

Case Western Reserve University School of Medicine: Vanessa Van Doren 

PENNSYLVANIA

Philadelphia Medical Schools Coalition:
Temple University: Emily Kirchner
University of Pennsylvania: Tony Spadaro and Dorothy Charles

TENNESSEE

Lincoln Memorial University-DeBusk College of Osteopathic Medicine: Aron Haire
University of Tennessee Health Science Center College of Medicine: Diana Alsbrook
Vanderbilt University School of Medicine: Mitchell Hayes

VERMONT

University of Vermont College of Medicine: Kelsey Sullivan

WASHINGTON

University of Washington School of Medicine: Darius Fullmer

Physician says ‘Medicare for all’

By Russell Noblett, M.D.
The Roanoke (Va.) Times, Letters, Sept. 27, 2015

On Sept. 16, the Census Bureau reported that in 2014 the number of uninsured Americans dropped by another 9 million. The estimates are that as many as 16 million more people now have health insurance since the Affordable Care Act was passed.

In addition to this, everyone who has health care now benefits from: protection for pre-existing conditions, no lifetime cap, and basic preventive care such as contraception and colonoscopy. This is huge. It marks a change in social standards.

But the ACA was implemented as the regulation of a market-based system. So cost-shifting to the consumer is now taking place, as would be expected. This means higher deductibles and co-pays and cost-sharing, leaving a large number still under-insured even if they have coverage, and susceptible to financial stress, or illness due to postponing care.

As experience in other countries has demonstrated, affordable universal care is possible only through tighter market regulation approaching a single-payer model (such as Medicare or Canada’s system) or a single employer, such as the VAMC or the British system.

In 2014, the Commonwealth Fund reported that the British system, in comparison with the systems of 10 other countries (Australia, Canada, France, Germany, Netherlands, New Zealand, Norway, Sweden, Switzerland and the U.S.), was rated the best in terms of efficiency, effective care, safe care, coordinated care, patient-centered care and cost-related problems, and second for equity.

It would seem wise to repeal Obamacare only after we are able to replace it with a similarly effective program: Medicare for all.

Dr. Russell Noblett resides in Roanoke.

http://www.roanoke.com/opinion/letters/noblett-medicare-for-all/article_58cea875-ff14-5f34-9f82-18d4a283f53e.html

Q&A: Head of physician group makes case for single-payer system

He points to ‘tremendous gaps’ years after passage of health act

By Jenny Deam
Houston Chronicle, Sept. 25, 2015

Dr. Robert Zarr, president of the Physicians for a National Health Program organization in Washington, D.C., was in Houston this week speaking to physicians and medical students at Baylor College of Medicine, promoting the idea of a single-payer system of health care in this country.

He sat down with the Chronicle to share his views. Edited excerpts follow.

Q: We are 5½ years into the Affordable Care Act. Has it been a success?

A: It depends a lot on who you are. It depends a lot on where you live. It depends a lot on what life was like before the passage of ACA. But in terms of hard numbers we know now, the U.S. Census Bureau has come out with another report, and we’re down to 33 million uninsured in 2014, and that’s down from 42 million the year prior. So from that sort of bird’s-eye view, yes, more people have an insurance card in their back pocket. So that’s great.

Q: It feels like there’s a “but” coming.

A: There are tremendous gaps. There are approximately 31 million Americans underinsured, and that’s not something we talk a lot about. We’re all happy that we have this increase in insured, but what does it fully mean to have insurance? Does it mean you’re going to get the care you need? Does it mean you’re not going to be medically bankrupt? Does it mean you’re going to stop worrying about whether you can afford to buy that medicine your doctor prescribed? And in large part, the answer is no.

Under-insurance is better understood by looking at medical bankruptcies. I love to point this out because it is a shocker: If you have about a million bankruptcies claimed every year, about 60 percent of them, 600,000, are medical bankruptcies. They couldn’t pay their bills. What’s even more interesting is that of those 600,000 every year, what percentage had insurance when they got sick? Seventy-five percent.

Q: That’s an amazing statistic. What does that mean for people in this country?

A: What the ACA has done is made under-insurance the new norm. At the end of the day, you and I would like to be assured when we need care, we get it and we don’t spend enormous amounts of our money out of pocket to get it. I think one of the biggest flaws of the ACA is it has relied more on private insurance. The reality is that ACA has bolstered the private insurance industry.

Q: What is the solution?

A: I sometimes say that what needs to happen is we’re going to have to hate the insurance companies more than we fear the government to get to a sensible system. Even if you hate ACA, you very likely believe in entrepreneurship, you believe in free choice, you believe autonomy, and the only way to get to those things is through single payer.

Q: How would single payer work in this country?

A: Single payer is very simple, and that’s why I love it. It’s simply a progressive tax system. You generate the funds through a progressive tax, and you take that money and put it into a fund and you allow the private delivery of health care. So if you have a solo practice, or you have a family-owned pharmacy, or whatever you are, you keep doing what you are doing – except all of the bureaucracy of these hundreds of insurance companies disappears and you are left with one.

Q: What if you have a catastrophic illness versus someone who has the flu?

A: A runny nose, or a heart attack, a stroke, a dismemberment, it all gets paid for by this national health insurance fund. As a taxpayer you pay into that. It is the reality for most industrialized countries.

Q: The argument has often been the United States has the best standard of care in the world. Would such wholesale change jeopardize that?

A: The truth is we don’t have the best health outcomes, in part because for every 1 million uninsured, we have 1,000 excess deaths every year. The World Health Organization has ranked us 37th in the world in a number of categories.

Q: But what if you are poor and don’t pay taxes?

A: It’s a progressive tax, so if you make zero income, you put in zero but you still get services.

Q: Isn’t that where it all falls apart?

A: One day there is a good likelihood you will find yourself in a situation like the person you are talking about. We live in a civilized society. We care for each other. We know that people go through ups and downs in their lives.

Q: As a nation, can we afford this?

A: There have been all kinds of cost analyses on single payer, and at the end of the day, 95  percent of the population is going to pay what they pay now or less to get a ton more, and 5 percent will pay a little bit more.

Q: Still, how do we get from where we are now to there, especially in such a politically divided climate?

A: We’ve been polling Americans for more than 15 years on this issue, and every poll I’ve seen says the vast majority of Americans want the establishment of national health insurance. We have polled physicians. People think physicians don’t support this. They do. The public is onboard, the physicians are onboard, the unions are onboard. We have a lot of our country that wants this. Part of the problem is we’re used to life as it is. We’re willing on some level to accept it, and we hope it will get better. It’s hard to find the extra energy to see what the future holds for us.

http://www.houstonchronicle.com/business/medical/article/Head-of-physician-group-makes-case-for-single-6530082.php

Medical students rally for single-payer health care

By Sam Rappaport
Hyde Park Herald, Sept. 24, 2015

On Oct. 1, students at the University of Chicago Pritzker School of Medicine will join thousands of other medical students across the country in rallying for universal, single-payer health care reform. The event is called TenOne Medicare-for-All National Student Day of Action and is being organized by Students for a National Health Program (SNaHP), the student branch of Physicians for a National Health Program (www.pnhp.org), an organization of over 19,000 physicians, health professionals and medical students.

The Pritzker School of Medicine will host a daytime rally from 12-1 p.m. on Thursday, Oct. 1, at 5812 S. Ellis Ave. The rally will feature speeches from physicians, nurses, students and patients.

Later that evening from 5:30-8 p.m., Pritzker students will join activists from UIC, RUSH and Midwestern to hold a nighttime march and candlelight vigil at Heritage Green Park, 610 W. Adams St.

Scott Goldberg, a fourth-year medical student at Pritzker who is helping to organizer the event, said that most people are misguided about the reality of our current health care system and harbor unfounded fears of a single-payer alternative.

“Tens of thousands of people die every year in this country just because they don’t have health insurance,” Goldberg said. “Medical problems are the leading cause of bankruptcy in the U.S. More absurdly, nearly 80% of those declaring bankruptcy due to medical debt already have insurance…This year marks the 50th anniversary of Medicare and our mission is clear–to institute truly affordable care by expanding Medicare to cover all Americans. The student single payer movement is growing with more than 650 members at 41 medical schools across the nation.”

For more information on the event, visit student.pnhp.org.

http://hpherald.com/2015/09/24/medical-students-rally-for-single-payer-health-care/

Premium is primary driver in plan selection

Are Marketplace Plans Affordable? Consumer Perspectives from the Commonwealth Fund Affordable Care Act Tracking Survey, March–May 2015

By Sara R. Collins, Munira Gunja, Petra W. Rasmussen, Michelle M. Doty, Sophie Beutel
The Commonwealth Fund, September 25, 2015

From the Conclusion

On average, larger shares of people with marketplace plans have high deductibles than those in employer plans, with the differences widest among enrollees with higher incomes. Among those with lower incomes, the cost-sharing reduction subsidies appear to have had the effect of narrowing the difference in deductibles between those in marketplace plans and employer plans. Still, a large share of people with low and moderate incomes in marketplace plans have deductibles of more than $1,000.

We know from the results reported in our companion issue brief that premium cost factors more heavily than do deductible size and copayments when people are choosing health plans.

Consistent with recent research by The Commonwealth Fund, the growing use and size of deductibles in both employer and marketplace plans as a means to lower premiums threatens to undermine the gains Americans have made in coverage since 2014

Adults in high-deductible health plans are less confident in their ability to pay for their care if they were to become seriously ill compared to those with lower deductibles. People with the lowest incomes in these plans are the most at risk of spending large amounts of their income on medical care. Their lack of confidence about the future suggests they are aware of their financial vulnerabilities. In an economy that is still struggling to deliver significant wage gains to working families, ever higher cost-sharing in health plans will further degrade their financial security.

http://www.commonwealthfund.org/publications/issue-briefs/2015/sep/are-marketplace-plans-affordable

Companion brief: http://www.commonwealthfund.org/publications/issue-briefs/2015/sep/to-enroll-or-not-to-enroll

***

Comment:

By Don McCanne, MD

How do people select their health plans? The most immediate concern to the plan purchaser is the premium that must be paid, and most will choose a plan with low net premiums. To gain greater market share, insurers will reduce premiums by shifting more of the health care costs to the patient, especially through higher deductibles.

It is not parsimony but rather an imposed frugality that motivates individuals to select plans with lower premiums. The high costs of health care and thus high premiums, combined with stagnant incomes, leave most individuals with little other choice.

People should not be have to be confronted with a decision that almost forces them to select a lower premium plan that could expose them to financial hardship should significant medical problems develop.

Under a well-designed single pager national health program, no decision would be necessary. Everyone would have the same comprehensive coverage with no need for premiums since the system would be funded through equitable taxes.

U.S. health care is overpriced

By Michael Huntington, M.D., and Bruce Thomson, M.D.
Corvallis (Ore.) Gazette Times, Sept. 4, 2015

The Money and Markets section of the Gazette-Times on Aug. 13 reported that stock values of the top four health insurance companies had increased 31 percent this year (S&P 500 companies were up “only” 5 percent). This news is welcome for some but bad for all, a perverse byproduct of an overpriced health-care industry.

We rarely can determine the likely cost of health care services before we receive them. Even if we could estimate price, when we are in crisis, we cannot comparison-shop. We essentially sign blank checks hoping that our insurance plan will cover the costs of care. The likelihood of adequate coverage diminishes each year as health-care costs escalate and insurance plans degenerate.

Furthermore, medical bills from hospitals and pharmacies are grossly inflated, not meant to be real. A neighbor’s hospital bill for his hip replacement last month was more than $50,000 (typical in the U.S. compared to $10,000 under publicly funded care in England or Switzerland). The insurance company followed industry standards by allowing a secretly negotiated “provider discount” of $42,000 and paid about $8,000 to the hospital, leaving the neighbor to pay $176 out-of-pocket.

But many people you may know have no insurance or poor insurance, even under the Affordable Care Act. They face much or all of a fully inflated health-care bill, and they risk their savings, credit ratings, dignity, and even their homes. Medical costs are still the leading trigger of personal bankruptcies. Most of the bankrupted families had health-care insurance they had trusted to protect them. 

Insurers make deals with pharmacies to involve insurance in prescription sales. Retail prices are set at three to six times those available in other countries and then “generously discounted” by the insurance plan. This appears to benefit patients but mainly benefits the insurance companies and pharmacies because of negotiated co-pay allowances. Some stores do forgo these insurance deals and offer customers $4 a month prescription plans. They can do this and still profit because the average wholesale price for most drugs is 3.5 cents per pill or about $1 a month (see Medicaid.gov, NADAC price list).

Ideal insurance would have each of us contribute money into a single risk pool so that when any one of us becomes ill or injured, there is more than enough money to pay for our treatments. But health insurance companies are not in business to pool our money and save it for our rainy days. They are in business to harvest our money from insurance premiums, and use as little of it as possible on our care. Thanks to the Affordable Care Act, insurance companies can no longer directly refuse to insure us, but they can and do bar us from care through unaffordable deductibles, denied/delayed claims, narrow provider panels, narrow drug formularies, hidden exclusions, and by driving doctors to despair and early retirement.

Please search online under price-gouging and bankruptcies in health care. Relevant reference sites are truecostofhealthcare.net, pnhp.org, hcao.org, mvhca.org, and foxbusiness.com (Feb. 18, 2014). These sites help us realize the need for a unified payment system that would allow the public to negotiate price with the health-care industry and assure transparency and accountability.

The cure for our tragic “sick care” system may come state by state. The Affordable Care Act allows states to design their own unified payer health-care plan if cost and services compare favorably with those of the act. HB 2828, approved by the 2015 Oregon Legislature, funds a study comparing several systems, one of which is a unified payer system. Please urge your legislators and acquaintances to study, compare, and then help create a unified system of payment for health care in Oregon. It’ll make us all better.

Michael Huntington is a retired radiation oncologist. Bruce Thomson is a retired family physician. Both live in Corvallis.

http://www.gazettetimes.com/news/opinion/as-i-see-it/as-i-see-it-u-s-health-care-is-overpriced/article_55f3b999-0cf1-5cc5-afb2-b472693d2fb6.html