PNHP

Medicare at 50 works: enhance it, expand it to all

Medicare at 50 works: enhance it, expand it to all

By Christine Adams
Health Care for All Texas, July 30, 2015

Thanks to Medicare, about 3 million Texans receive guaranteed health care benefits regardless of their medical condition or income.

The 50-year-old Medicare program currently provides health coverage for 55 million Americans – seniors and younger people with disabilities or end-stage renal disease. Medicare also pays for most physician residencies.

Before Medicare’s enactment in 1965, about 50 percent of seniors had health insurance. More than a third of the elderly lived in poverty. Then, even a minor illness or injury could bankrupt older Americans and their families.

Medicare changed all that. Suddenly millions of the elderly had access to care, easing their pain and suffering and reducing the prospect of their premature death.  Additionally it lessened their risk of impoverishment from high medical bills, reducing the financial strain on their families, too.

When President Lyndon Johnson signed the law authorizing Medicare in 1965, former President Harry Truman was by his side. Truman became the first Medicare beneficiary in honor of his steadfast commitment to universal national health care.

Promoting health care for all fit Truman’s sense of “moral” priorities. It also fit his understanding of the economic benefits of covering everybody for necessary medical care in an efficient yet equitable way.

Truman was a visionary leader who often risked his political career by supporting policies that protected the majority of Americans from exploitation by powerful vested interests. He desegregated the military and federal agencies and pushed for civil rights, voting rights, and fair employment.

Today the goal of universal, national health care is still in keeping with core American values of equal opportunity, fairness, compassion, and liberty.

It also fits with American priorities of getting the “best bang for the buck” by eliminating unnecessary costs while providing health care to the greatest number of people.

But while other industrialized nations in the postwar era moved toward some type of universal, national health program, the U.S. has moved increasingly away from it. We are paying a heavy price in lives and money for this uniquely American system of for-profit, private, employer-based health insurance.

Comparison research has long established that other industrialized nations cover their entire population and get as good or better medical outcomes as we do while spending only half as much money. Why should we continue to pay more for medical care but get less?

Texans do care deeply about health care not only for themselves and their families but also for others.  A recent Nielsen survey of Texans showed that 70 percent favor a national health system and 42 percent favor a Medicare-for-All system.

Our biggest challenge now is the steadily rising cost of health care. While the ACA was a baby step in the right direction, it will fail to provide affordable, much less universal, health care.

Why? Because it leaves the private health insurance industry, Big Pharma, the for-profit hospital chains and the medical supply companies in a position to dictate prices to us.

Medicare has been a sustainable program because it has had the market clout of a high volume buyer. It has been free of unnecessary and expensive private-insurance middlemen draining scarce health care dollars, free of the need to make profits, free to concentrate on the health of patients.

Truman said, “I trust the people, because when they know the facts, they do the right thing.”

Fifty years after Medicare’s passage, the right thing to do is to create a “gold standard” version of Medicare and extend it to everyone. More of us would live healthier lives. All would spend less on health care.

Christine Adams, Ph.D., is a licensed psychologist and board member of Health Care for All Texas. She resides in Houston.

www.healthcareforalltexas.org

What single payer advocates can learn from Australia

Australian Health Care — The Challenge of Reform in a Fragmented System

By Jane Hall, Ph.D.
The New England Journal of Medicine, August 6, 2015

The Australian health care system appears remarkably successful in delivering good health outcomes with reasonable cost control. Australians enjoy one of the longest life expectancies and a long healthy life expectancy, while costs as a proportion of the gross domestic product remain around the median among countries in the Organization for Economic Cooperation and Development (OECD). Universal, tax-financed comprehensive health insurance, Australian Medicare, has been largely stable for three decades. Yet this performance has been achieved through, or despite, the interplay of public and private financing, public and private service provision, and a division of responsibilities between the federal and state governments. The main political parties clash over the role of government and whether national health insurance in its current form should continue.

Australian Medicare was established in 1984, after a period of tumultuous change. Australia has moved through numerous approaches to health care financing: private insurance with public subsidies (pre-1974), publicly financed national universal health insurance (Medibank, 1974–1976), predominantly private insurance with public subsidies (1976–1984), publicly financed national universal health insurance (Medicare, 1984–1996), publicly financed national universal health insurance with publicly subsidized private health insurance (1996–2013), and publicly financed national universal health insurance with means testing for private insurance subsidies (2013 to present). The rationale for government subsidies for private insurers alongside a public universal insurance scheme has never seemed clear; perhaps it is best seen as the compromise between the “strife of interests masquerading as a conflict of principles” that, according to health planner Sidney Sax, characterizes the Australian system.

Another strife of interests afflicts intergovernment relationships. There are six states and two territories (hereafter all referred to as states), each of which retains its own government and the responsibility for public health and health care. The national government, the Commonwealth of Australia, holds the major revenue-raising powers, so states rely on financial transfers to provide services. The states operate public hospitals (which account for about two thirds of all hospitalizations and provide emergency department visits without charge), though funding them is a joint responsibility of both levels of government. The Commonwealth has responsibility for paying benefits through Medicare (for out-of-hospital medical care and in-hospital private medical services) and for the Pharmaceutical Benefits Scheme (covering most prescribed drugs), but funding arrangements for other services often involve both levels of government. The result is a complex set of overlapping and fragmented responsibilities.

A recent review concluded that “the complex split of government roles means no single level of government has all the policy levers needed to ensure a cohesive health system” and that the people who suffer the most from the lack of coordination are “patients with chronic and complex conditions, such as diabetes, cancer and mental illness, who regularly move from one health service to another.”

A change in national government in 2013 prompted substantial revision of many aspects of reform. In primary care, Medicare Locals were disbanded, and on July 1, 2015, they were replaced by 31 Primary Health Networks. The call for applications to establish these networks emphasized the eligibility of various organizations, including private health insurance funds, as contractors. The successful bids came mainly from consortia of Medicare Locals, some of them including insurers as partners. The networks may yet develop the potential to become purchasers and thereby provide impetus for integrated care, but given the challenge of setting up new entities, that transformation remains aspirational.

The new government has also reversed the agreement that provided additional Commonwealth funding to public hospitals on the basis of efficient cost increases and volume growth. Beginning in July 2017, the Commonwealth’s additional contributions will be based only on population growth and inflation. This change presents a major challenge for states, whose public-hospital expenditure is a major budgetary commitment that isn’t matched by revenue-raising capability. It will therefore severely limit states’ flexibility in funding other programs, such as education and transportation, and in developing innovative health programs that might improve care integration and coordination.

An underlying concern is the extent to which the Commonwealth government intends to reduce its share of health care expenditure. In 2014, it attempted to reduce its outlays on Medicare by imposing patient copayments for GP visits — a tactic that was eventually dropped in the face of concerted opposition. But other cost-reduction avenues remain open, and recent announcements have, for example, targeted the cost of pharmaceuticals. Since 2002, the Commonwealth has produced a series of Intergenerational Reports predicting what government expenditures will be over the next 40 years if current policies remain in place. These reports show significant increases in health care spending, but they focus on the Commonwealth budget rather than the entire health sector. If reducing Commonwealth expenditures remains the primary objective for the health portfolio, it could lead to further fragmentation of care and missed opportunities for developing a coherent and efficient health system.

http://www.nejm.org/doi/full/10.1056/NEJMp1410737

Australian Government White Paper on Health Reforrm, December 2014: https://federation.dpmc.gov.au/sites/default/files/issues-paper/Health_Issues_Paper.pdf

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Medibank

Wikpedia

The company began business as an Australian government-owned private health insurer, established by the Whitlam Government in 1975 through the Health Insurance Commission (now known as Medicare Australia). It is Australia’s largest health insurance provider with 3.6 million members, 30% of the market, under two brands.

Medibank was set up to provide competition to private “for-profit” health funds. Although government owned, the fund has operated as a government business enterprise since 2009, operating as a fully commercialised business paying tax and dividends under the same regulatory regime as do all other registered private health funds. Highly regulated regarding the premiums it can set, the fund was designed to put pressure on other health funds to keep premiums at a reasonable level. In 2006, the Coalition Howard Government announced that Medibank would be sold in a public float if it won the 2007 election, however they were defeated by the Australian Labor Party under Kevin Rudd which had already pledged that it would remain in government ownership. Liberal leader Tony Abbott made the same pledge to privatize Medibank if it won the 2010 election but was again defeated by Labor. Privatisation was again Liberal party policy at the 2013 election, which the Coalition won. On 26 March 2014 Minister for Finance Mathias Cormann announced that Medibank would be sold through an initial public offering in the 2014-2015 financial year. The sale was completed with 100% of the company sold, listing on the Australian Stock Exchange under the code MPL on 25 November 2014, with 440,000 individual owners with a market capitalisation of A$5.921 billion.

https://en.wikipedia.org/wiki/Medibank

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Comment:

By Don McCanne, MD

Probably the greatest problem with government financed and government administered health care systems is that, whenever conservatives gain control of the government, they attempt to privatize the systems, believing that markets work better than the government. Currently we are seeing such efforts in England, Canada and Australia.

As today’s message demonstrates, Australia serves as a prime example of how the health care systems suffer under continuing shifts in political ideology, with the most damage being done under conservative rule. As their government leadership changes periodically, “Australia has moved through numerous approaches to health care financing.” 

Jane Hall, the author of the NEJM article above, writes, “The rationale for government subsidies for private insurers alongside a public universal insurance scheme has never seemed clear; perhaps it is best seen as the compromise between the ‘strife of interests masquerading as a conflict of principles’ that, according to health planner Sidney Sax, characterizes the Australian system.”

Thus Australia has ended up with a highly fragmented system, though shifting political winds make it likely that they have not seen the last change. (More information is available in the white paper produced by the current conservative Australian government – link above.)

One interesting observation in the NEJM article (which is available for free at the link above) is the contrast between the public and private sectors in delivering health care. An example is that “42% of private deliveries (unadjusted for risk factors) are caesareans, versus 29% of public deliveries.” Their private sector seems to have much in common with our medical-industrial complex.

Many single payer supporters in the United States continue to advocate for a “public option” – a government-run insurance that competes with the private plans – as an incremental step towards a universal single payer system. Australia’s Medibank began as such a program in 1975. The Wikipedia chronicle (above) of the history of Medibank reveals that it has transformed into the largest, private, shareholder owned insurance company in their nation. Although our efforts at establishing a public option never got off the ground, before the effort was abandoned, the concept had already evolved away from an expansion of Medicare into simply another player in the private insurance market, government in name only.

Our health care politics have much in common with Australia, and we both have fragmented health systems as a result. Our public Medicare program has already been partially privatized by using overpayments of taxpayer dollars to lure Medicare beneficiaries into the private Medicare Advantage plans. The conservatives are not through in that they want to shift the entire program into the private sector by use of “premium support” vouchers. Of course, the expansion of private insurance plans also perpetuates fragmentation, though currently efforts are being made to convert the insurers into private oligopolies – perhaps the worst model of health care reform that we could have.

So who ultimately controls the ideological complexion of the government? The voters, of course. That is why it is crucial that we continue to educate the public on single payer – an improved Medicare for all – contrasting it with the more dysfunctional models, with our present system being a prime example of dysfunction. The people can have a much better health care system, but they are going to have to understand what that is so that they will demand it of our politicians.

Medicare moves into its second half-century more important than ever

By Patsy Ouellette
The Bakersfield Californian, Aug. 6, 2015

According to my friend, Bernice Bonillas, it’s only warm bodies that drive movements. And so it was that I found myself returning from Los Angeles July 30 on a bus filled with other Bakersfield citizen activists, returning from a rally celebrating the 50th anniversary of Medicare.

First, a little history. During the Great Depression in 1935, President Franklin D. Roosevelt signed the Social Security Act. As remarkable as that was considering the economic difficulties the country was experiencing, the SSA did not complete his vision. As he noted, “This law, too, represents a cornerstone in a structure which is being built, but it is by no means complete.” He originally wanted to include health insurance coverage.

Subsequently, in 1945 President Harry S. Truman proposed the idea of National Health Care Insurance. Defeated by the American Medical Association and insurance industry opposition, he instead introduced the idea of expanding Social Security to include health care coverage for the elderly. This, too, was defeated.

Twenty years later, on July 30, 1965, President Lyndon Johnson signed Medicare and Medicaid into law. What has this landmark law meant to U.S. citizens? Rally speaker Mike Farrell, an actor and social justice advocate, reminded us that Medicare has lifted millions of people out of poverty. Since medical costs are the number one reason for personal bankruptcy claims, reducing such risks, the older population have been able to hang on to whatever family wealth they were able to accumulate over their working lives in the forms of home equity and savings.

These small nest eggs not only assisted the recipients themselves, but also could be passed down to the next generation, providing a step up via home ownership or education, opening every door across the nation to increased opportunities and a higher standard of living.

We also learned that though the Civil Rights Act of 1964 made discrimination in federally funded programs illegal, it wasn’t until 1965’s Medicare law that some of those civil rights were realized. In order to receive Medicare reimbursement, hospitals needed to be integrated. Consequently, more than 1,000 hospitals began to admit black patients and extended physician privileges to black doctors.

Another speaker, Sheila Kuehl, a Los Angeles County Supervisor, introduced the overriding theme for the day, that Medicare must be protected, improved, and expanded. Protected from those who want to weaken or even dismantle it, and improved by adding broader coverage. But she left it to the next speaker to explain the last, most controversial component, expanding it.

Yes, Medicare for All was the rallying cry from Dr. Paul Song. Referencing the Hippocratic Oath he took 25 years ago, he explained that though he promised to “refrain from being part of a system that was deleterious to a patient’s health, he has felt many times that he is part of just such a system,” sharing that “35,000 people in this country die every year because of a lack of health insurance.”

In fact, I learned there are two bills pending in Congress that would dramatically expand access to health care in the United States, HR 1200, The American Health Security Act of 2015, introduced by U.S. Rep. Jim McDermott, D- Wash., and HR 676, a bill to expand Medicare for All, introduced by U.S. Rep. John Conyers, D-Mich. Both bills would guarantee a full range of medical services, including primary care, dental, prescription drugs, mental health, long-term care, and place no restrictions on choice of physician or healthcare provider.

In President Truman’s message to Congress, Sept. 6, 1945, he proposed an Economic Bill of Rights, one of them was: “The right to adequate medical care and the opportunity to achieve and enjoy good health.” Another was the “right to adequate protection from the economic fears of … sickness…” Seventy years later, it’s time that we Americans fully acknowledge those rights.

Patsy Ouellette of Bakersfield is a retired teacher.

http://www.bakersfield.com/news/opinion/2015/08/06/happy-birthday-medicare.html

Let’s expand Medicare to everyone

By Meghan Geary, M.D.
The Providence (R.I.) Journal, Aug. 6, 2015

William Butler Years wrote: “From our birthday until we die, is but the winking of an eye.”

As in Yeats’s rhyme, I barely blinked and a year has gone by. In the time between the last two Julys, I completed my first year of residency training as an internal medicine physician at Brown University.

When I think back over the past year, one impression that stands out is this: What a difference the Medicare Program and Rhode Island’s expansion of Medicaid has made for my patients!

Medicare is observing its 50th birthday. In July 1965, President Lyndon B. Johnson signed legislation to implement Medicare. From its inception, Medicare experienced a rapid enrollment and the program gained widespread popularity.

Today, Medicare insures 55 million Americans, nearly everyone over age 65. We might take a moment to contrast Medicare’s rapid, relatively untroubled rollout — accomplished before the existence of the Internet — with the hassle and glitches of purchasing health insurance through the Affordable Care Act.

Since birthdays are a time for shared celebration, it is worthwhile to acknowledge that all of us have benefited from Medicare.

Medicare has added five additional years of life expectancy to those who reach 65. Many of them were my patients this past year. They were the retired baseball coaches, former businessmen, lifelong homemakers and loving grandparents.

I met them on the wards, in the Intensive Care Unit and in the Medical Clinic at Rhode Island Hospital.

However, those under age 65 continue to face serious financial barriers to care. In spite of expanded coverage through the Affordable Care Act, out-of-pocket costs remain high and many people continue to have insufficient coverage or, worse yet, remain uninsured.

Individuals without health insurance were also my patients. They included the father who suffered a stroke and the mother who had trouble obtaining the blood pressure medications she needed to prevent damage to her kidneys, brain, eyes and heart.

For these parents, timely access to health care depended upon their having insurance. Convincing, peer-reviewed research has shown that over 42,000 deaths would have been prevented in 2014 if everyone in America had health insurance.

Tragically, this means there are 42,000 individual stories of Americans who did not celebrate their birthdays this year in large part because they lacked coverage.

We could change this picture in the blink of an eye by expanding Medicare to cover all Americans. As we celebrate Medicare’s 50th birthday, we should resolve to establish a system that provides access to all medically necessary health care for everyone, from birth to death.

The Expanded and Improved Medicare for All Act, H.R. 676, a bill in Congress sponsored by U.S. Rep. John Conyers, D-Mich., and co-sponsored by 49 others lawmakers, would do just that. Under this legislation, all Americans would be covered for all medically necessary services, including doctor’s visits, hospital care, prevention programs, long-term care, mental health, reproductive health care, dental, vision, prescription drug and medical supply costs.

Skeptics may believe the cost of such a program would be prohibitive, but the administrative cost savings that we would obtain from having a streamlined, nonprofit, single payer of all medical bills — savings reliably estimated to be more than $375 billion annually — would not only allow us to cover everyone, but to eliminate all co-pays and deductibles.

In addition, the new system’s bargaining clout would let us reduce and control the cost of medications and other supplies. We would also be better positioned to prevent or provide early treatment for chronic conditions that, left untreated, require more costly and complex medical care.

An improved Medicare for all is not socialism. As with Medicare presently, the government would not own hospitals or clinics. Patients would go to the doctor of their choice. Only the means of payment would change.

Enacting an improved version of Medicare for all would enable each and every one of us to have access to the medical care we need, and by extension to celebrate as many birthdays as our lives allow. That would truly be a cause for a celebration.

Meghan Geary, M.D., of Providence, is a second-year resident in internal medicine.

http://www.providencejournal.com/article/20150806/OPINION/150809604/2011

‘Superbug’ threat pales in comparison to going uninsured

By Robert Vinetz, M.D.
Los Angeles Times, Letters, Aug. 4, 2015

This article is a beautifully written, dramatically gripping presentation of the risks of lifesaving technologies available in the complex world of healthcare, and of the expert and passionate efforts to identify and control those risks and to prevent harm. (“A killer on the loose: UCLA doctors race to stop superbug outbreak and save patients,” Aug. 1)

Still, it is important to note that this front-page story focused on a single issue that caused the deaths, tragically, of fewer than five patients at UCLA (more nationally).

My hope is that similar reporting, focus and resources will be directed to another, much larger deadly epidemic: that of the more than 30 million people in our nation still uninsured, even with Obamacare, and the Harvard Medical School’s report in the American Journal of Public Health that 45,000 of them unnecessarily die every year for lack of insurance and access to high-quality healthcare.

Dr. Robert Vinetz resides in Los Angeles.

http://www.latimes.com/opinion/readersreact/la-le-0804-tuesday-ucla-superbug-20150804-story.html

In defense of single-payer: How it would reduce administrative waste

By Adam Gaffney, M.D.
KevinMD blog, Aug. 4, 2015

Would a single-payer national health program, at the end of the day, truly be sleeker and slimmer than our bloated and fragmented semi-private system?  Not according to Dr. Michel Accad, who takes on this important single-payer talking point in his post: “Will single-payer really reduce administrative waste?”

Given that savings from reduced expenditures on billing and overhead are a core argument that single-payer advocates (myself among them) employ to advance our cause, the piece caught my eye. To quote the proposal of the Physicians’ Working Group for Single-Payer Insurance (of note, I’m active in the organization Physicians for a National Health Program [PNHP], which was behind the proposal), published in JAMA in 2003:

“Our multiplicity of insurers forces US hospitals to spend more than twice as much as Canadian hospitals on billing and administration; forces US physicians to spend vast amounts on billing; and nourishes a panoply of business consultants, coding software vendors, and other satellite business.”

Had a new study been published demonstrating, contrary to all existing data, that private insurers somehow had lower administrative costs than Medicare?  Had Canadian expenditures on health care administration somehow suddenly vaulted ahead of that of the United States? No, neither had come to pass (not surprisingly).  In fact, Dr. Accad doesn’t really deal with any of the literature about the administrative efficiency of different types of health care systems.  Instead, he employs a “Hayekian perspective” to make the argument that central economic planning is inherently inferior to an atomized free market where individual economic actors buy and sell, rationally relying on their intimate knowledge of local market circumstances.  “Only in a decentralized system,” he argues, “of decision making, where price fluctuations can adjust to the reality of needs and provisions, are major gluts and shortages avoided.”  (For instance, no one knows the business of bread making better than the bread maker.)

Now on the one hand, it’s a bit quixotic to invoke the political philosophy of a neoliberal economist to argue against what is essentially empirical point: that the United States spends more on health care administration than nations that have a single-payer system.

For it clearly does.  One study found that the U.S. spent about three-times as much as Canada on health administration ($1,059 vs. $307 per capita, in 1999).  More recently, anotherstudy found that the U.S. had the highest hospital administrative costs among eight high-income nations (an astronomical 1.43 percent of GDP spent annually on hospital administration in the U.S., as compared to 0.41 percent in Canada).

Closer to home, Medicare — a single-payer-like system for older Americans — has an administrative overhead around 2 percent, as compared to the 13.6 percent in overhead and profits of privatized Medicare Advantage, which is run by private insurers.

I could quote my favored political philosophers here to counter Accad’s quotes from Hayek, but it’s really all beside the point.  As the Princeton health care economist Uwe E. Reinhardt wrote in the New York Times: “The question is how long American health policy makers, and particularly the leaders of our private health insurance, can justify this enormous and costly administrative burden to the American people and to the harried providers of health care.”

To be fair, Dr. Accad makes a good point ridiculing the extraordinarily complex and “byzantine scheme of codification” used by Medicare (and followed by private insurers) for billing purposes.  “[A] CPT code 99204-21 (new patient visit, E/M coding level 4, prolonged service) associated with ICD-9 code 786.50 (chest pain, unspecified),” he notes, “hardly conveys any real knowledge and cannot possibly be a basis on which relevant decisions can be made or value established.”

No, it can’t, but that’s not what such codes are used for: They’re used to determine reimbursement.  But they don’t have to be — and that’s where the administrative savings come in.

Under a single-payer system (as PNHP’s proposals describe), hospitals would receive a global lump sum budget to pay for all operating costs; there would be no need to monitor services used by individual patients, tabulate costs, or hire debt collectors.  Indeed, hospital billing could largely be eliminated from the ledgers of hospital operating expenses.

Simplified fee schedules, capitation, or salaries — without bonuses or penalties for more or less health care use — would be used to reimburse providers in the outpatient sector.  The name of the game would be “[s]implicity, simplicity, simplicity!” as one prominent New Englander put it in his important defense of a national single-payer system, Walden.

I share what I sense is Dr. Accad’s bitterness at onerous documentation obligations.  But a universal system would make much of that documentation irrelevant, and, therefore, unnecessary.  It would therefore be a win both for practitioners and for the public. (Though it would admittedly be a loss for many others, including those who profit from the system’s inefficiency, like the health insurance industry.)

“Reducing administrative waste” may not be the heady revolutionary slogan today’s millennial physician-activists are looking for, but it’s no less true for that — whatever the opinion of Hayek, Hegel, or Henry David Thoreau.

Adam Gaffney is a physician who blogs at the progressive physician, where a version of this article originally appeared.

http://www.kevinmd.com/blog/2015/08/in-defense-of-single-payer-how-it-would-reduce-administrative-waste.html

To fix what ails U.S. health care, expand Medicare — for all

By Chess Yellot, M.D.
Spirit of Jefferson (Charles Town, W.Va.), Aug. 5, 2015

Isn’t it time to have a serious conversation on the question: why aren’t we all covered by Medicare, regardless of age? 

More than 50 people, young and old, from the Eastern Panhandle turned out to publicly celebrate Medicare’s 50th birthday. Medicare is a popular program. The local celebrators joined others throughout the country to show their gratitude and to spread the message: “Medicare: As American as Apple Pie – Protect, Improve, Expand!”

Let me start the conversation by describing my experiences at an area community health center where I practiced for 14 years, until my recent retirement. I saw many working people without insurance. Tragically, some died because they could not afford the specialists or procedures they needed. Others suffered needless pain, discomfort, and disability. 

The Affordable Care Act, or Obamacare, enabled many of my West Virginia patients to obtain Medicaid. I saw a lot of new patients who had delayed care for years. They had gone months and years feeling fatigued, short of breath, depressed, in pain. Many times their problems would have cost the system much less if their conditions had been treated when symptoms began. 

Now, some middle-class families can obtain health insurance under the Affordable Care Act, but many are finding the co-pays and high deductibles unaffordable. Out-of-pocket costs continue to be a barrier to getting care. Still other patients find that insurance companies limit their choice of physician. The preferred provider might not be in the insurance company’s network. 

If we had improved and expanded Medicare for all, I would not have had patients who died and suffered needlessly. My patients would never have gone without needed care because they could not afford the deductibles and co-pays, or because the best specialist for them was out of network. 

Let’s look at a solution: A bill in Congress, HR 676, “The Expanded and Improved Medicare for All Act.” Under the simple, 30-page bill, every person in the U.S. would receive prescription drugs, vision, dental, and hearing services, long-term care, and all other medically necessary care. There would be no co-payments, no deductibles, no premiums, and no insurance companies. Funding would come from current federal financing for health care, increasing personal income taxes on the top 5 percent, a modest tax on some unearned income, a modest payroll tax, and a small tax on stock and bond transactions.

The great thing is that for 95 percent of households, these taxes would be less than what they now pay for premiums and out-of-pocket medical expenses. 

HR 676 also would mandate that drug prices be negotiated, resulting in huge savings. Currently, federal law prohibits Medicare from negotiating lower prices.

All practitioners providing medically necessary care would be in this one system, and their fees would be negotiated. This would again save money and everyone could choose their own provider. There would be no networks. As is the case now, most providers would be in private practice. We would have private providers and public financing.

A significant study indicates that because of the simplicity of the system described by HR 676, the health care funds currently diverted from our insurance premiums to company profits, high executive compensation, stockholder dividends, advertising, lobbying, and campaign donations would be spent on health care. Medicare’s overhead is around 2 percent. Compare this to private insurance overhead which runs 15 to 20 percent. Add in the amount hospitals and medical practices spend on billing, and this comes to a total of 30 percent. The savings made possible by a simple, single payment system would now go toward Medicare for all. And patients won’t be wasting time trying to figure out their medical bills!

No system is perfect. But if HR 676 became law, no one would suffer or die or go bankrupt due to lack of money to pay for the health care they need. HR 676 is affordable and the savings it provides would protect, improve and expand Medicare for all of us.

Dr. Chess Yellott writes from Shepherdstown.

http://www.spiritofjefferson.com/news/opinion/article_12adb3ca-3aff-11e5-8f79-4b271fb2140b.html

Ask our primary care clinicians how well reform is working

Primary Care Providers’ Views of Recent Trends in Health Care Delivery and Payment

By Jamie Ryan, Michelle M. Doty, Liz Hamel, Mira Norton, Melinda K. Abrams, Mollyann Brodie
The Commonwealth Fund and The Kaiser Family Foundation, August 5, 2015

In recent years, the U.S. primary care delivery system has experienced many changes in the way health care is organized, delivered, and financed. Some of these changes have been strengthened or accelerated by the Affordable Care Act (ACA). For instance, there has been an increased use of health information technology, a move toward team-based care and using nonphysician clinicians, an effort to better coordinate care through medical homes and accountable care organizations, and the introduction of financial incentives and quality metrics to determine how providers are paid.

Using data from the Commonwealth Fund/Kaiser Family Foundation 2015 National Survey of Primary Care Providers, this brief examines providers’ opinions about the changes in primary care payment and health care delivery. Between January 5 and March 30, 2015, a nationally representative sample of 1,624 primary care physicians and a separate sample of 525 midlevel clinicians (i.e., nurse practitioners and physician assistants) working in primary care practices were surveyed online and by mail.

CONCLUSION

New primary care payment and delivery models have emerged in recent years as part of efforts to improve patient outcomes and lower health care costs, with the Affordable Care Act accelerating many of these changes. It may be too early to reach a conclusion on the quality or cost effects of these primary care reforms, but assessing the perspective and experience of those on the front lines is critical to understanding the implementation of these reforms, including any challenges that could potentially undermine the process.

The survey results indicate that primary care providers’ views of many of these new models are more negative than positive. There are exceptions: health information technology gets mostly positive views and medical homes receive mixed opinions with a positive tilt. With regard to HIT, our study indicates that primary care providers generally accept the promise of HIT to improve quality of care even if previous research shows they dislike the process of transitioning from paper-based records. Our survey results also may reflect clinicians’ earlier exposure to certain models and tools National adoption of electronic health records received a boost from the Health Information Technology for Economic and Clinical Health (HITECH) Act of the federal stimulus package of 2009, while the four primary care specialty societies announced a joint statement regarding medical homes in February 2007, several years before passage of the Affordable Care Act.

Though many providers are unsure of the impact of ACOs on quality of care, those physicians who do have an opinion are more likely to say ACOs are having a negative rather than a positive impact on quality of care. ACO implementation is a somewhat more recent development, and primary care providers are not as involved in the day-to-day management of organizational change. Primary care clinicians’ views are also decidedly negative when it comes to financial penalties and the increased use of quality metrics in judging their performance. It may be some time before they can become comfortable with these new payment models.

More primary care providers may be participating in ACOs and relying on quality metrics for performance assessment in the near future. In early 2015, the Centers for Medicare and Medicaid Services announced that 85 percent of Medicare fee-for-service payments should be tied to quality or value by 2016. And, by the end of 2018, 50 percent of all Medicare payments should be tied to quality or value through specific alternative payment models, like ACOs and bundled payments. Dissatisfaction with new models may not be solely attributable to a difficult transformation process; larger culture change within the practice of medicine may be a necessary first step before delivery system reforms such as ACOs and medical homes are fully accepted on the ground.

As primary care transformation efforts mature and spread, it will remain important to judge their effects on patients in terms of access, quality, and costs of care. However, it is also important to assess their effect on primary care clinicians. Of concern, nearly half of primary care physicians say that recent trends in health care are causing them to consider retiring earlier than planned. Market trends in health care have been affecting physicians’ satisfaction for more than 20 years. It will be important to monitor providers’ satisfaction with delivery reform efforts.

http://www.commonwealthfund.org/publications/issue-briefs/2015/aug/primary-care-providers-views-delivery-payment?omnicid=EALERT846316&mid=don@mccanne.org

***

Comment:

By Don McCanne, MD

The intent of health care reform, reinforced through the Affordable Care Act, was not only to improve the financing of health care by increasing the numbers insured and providing more government support through insurance subsidies and Medicaid, but it was also to improve the health care delivery system through structural changes that theoretically would improve quality while controlling costs.

Some of the structural reforms included increased use of health information technology (HIT), establishment of accountable care organizations (ACOs), reinforcing primary care through medical homes, use of alternative payment models with financial incentives, and quality metrics to determine how health care professionals are paid.

So far, evaluation of these efforts have provided us with mostly weak and inconclusive data, with initial results suggesting that the effectiveness in improving quality and controlling spending has been very unimpressive, with little positive impact.

Although the public and private bureaucracies are not providing us with enough impressive data to move forward aggressively with these programs, the physician and non-physician clinicians on the front lines can give us a better perspective of just what is happening. This report provides us with their insight.

A few conclusions:

  • The transition from paper to electronic records has been difficult, especially because of the amount of time required to interact with the HIT system, but clinicians believe that electronic records may improve quality through error reduction, though recent data has cast doubts on this as well.
  • Medical homes have increased administrative activities with mixed opinions as to their value, with “a positive tilt” in their views.
  • Many clinicians have not formed opinions on ACOs, but those who have are “more likely to say ACOs are having a negative rather than a positive impact on quality of care.”
  • Dissatisfaction with the new models do not seem to be limited to transition issues but challenge the very culture of the practice of medicine. Efforts to change the culture could further entrench dissatisfaction and have adverse consequences on the patient experience.
  • “Primary care clinicians’ views are also decidedly negative when it comes to financial penalties and the increased use of quality metrics in judging their performance.” With little evidence that these metrics improve quality, it seems that creating clinician animosity would be a reason to abandon this experiment.
  • Medicare’s requirement that payments be tied to quality or value through alternative payment models is an unwise policy decision of the CMS bureaucrats considering the lack of studies that support this move and the increased clinician animosity that will ensue.
  • “Of concern, nearly half of primary care physicians say that recent trends in health care are causing them to consider retiring earlier than planned.”

The Affordable Care Act and the various measures leading up to it did not adequately address the financing issues in that it left it place our expensive, dysfunctional, fragmented financing system and left far too many people uninsured and even more with under-insurance. Nevertheless, the legislators and bureaucrats have demonstrated even greater incompetence in putting into effect these changes supposedly designed to improve the health care delivery system, when the evidence does not support these particular transformational changes.

These screwball ideas simply thought up by non-clinician policy academics are wasting valuable resources while having negligible or negative impact on health care delivery. What is worse is that they have diverted us from proceeding with reform that would have a very positive impact on health care for all of us.

The greatest driver of quality is to have a system that delivers the right care to the right people at the right time. This is exactly what a single payer national health program is designed to do. Let’s do that instead of wasting our time and resources with measures that do not do much more than to alienate our clinicians.

Health care should be a birthright

By the Editorial Board
The Delaware County Daily Times (Secane, Pa.), Aug. 4, 2015

As the nation marks the 50th anniversary of Medicare the discussion of expanding the program and offering universal health care is resurfacing.

It’s not a new debate. Fifty years before Medicare’s enactment, progressives had fought unsuccessfully for universal, government-provided health insurance, wrote Nancy Altman, founding co-director of Social Security Works, for the Huffington Post.

In 1912, President Theodore Roosevelt’s Progressive Party platform advocated universal, government-sponsored, health insurance, but he was defeated in his re-election bid. In 1917, the California legislature approved universal health insurance, and the governor supported it, but it was defeated in a ballot resolution after a massive, well-financed business and physician-fueled campaign against it. President Franklin Roosevelt considered including national health insurance in his 1935 Social Security legislation, but decided against it out of fear that it would bring down the entire legislative package. President Harry Truman made universal health insurance a top priority, but got nowhere.

So progressives settled on first creating Medicare for seniors, with the goal of expanding coverage to other groups incrementally and ultimately offering universal coverage.

“Universal, government-sponsored insurance is the most effective and efficient way to cover everyone,” Altman wrote. “Insurance is least expensive when it covers the most people; the large size of government-sponsored health insurance provides economies of scale and the greatest ability to negotiate over prices and control costs. Moreover, unlike private health insurance, a government plan has no marketing costs and no high CEO salaries. It can provide health care less expensively and more efficiently for everyone.”

Compared to Medicare’s administrative costs of just 1.4 percent, the administrative costs of private health insurance by very small firms or purchased by individuals can run as high as 30 percent, Altman notes. Even for large companies the administrative costs run around 7 percent.

Unfortunately, politicking and heavy lobbying by the insurance industry over the years waylaid those efforts to expand Medicare. But there are still some pushing for real health care reform – not the Affordable Care Act version that still involves profit-motivated companies and isn’t quite so affordable for everyone.

Addressing a rally outside the Capitol to mark the 50th anniversary of Medicare last week, presidential contender and U.S. Sen. Bernie Sanders, I-Vt., said he will introduce legislation to provide Medicare-for-all health insurance.

He said providing health insurance for all Americans would result in better care, improved access and lower costs by eliminating the middle-man role played by insurance companies that now rake in billions of dollars in profits. Sanders’ bill would set federal guidelines and strong minimum standards for states to administer single-payer health care programs.

“The United States is the only major nation in the industrialized world that does not guarantee health care as a right to its people,” Sanders said. “Meanwhile, we spend far more per capita on health care with worse results than other countries.”

As Sanders noted, thousands of people die each year in the U.S. because they delay seeking care they cannot afford. Health care eats up one-fifth of our economy, but the U.S. ranks 27th among major, developed nations on life expectancy and 31st on infant mortality.

Sanders said his proposal also would rein in skyrocketing prices for prescription drugs. Americans pay pharmaceutical companies nearly twice for the exact same drugs manufactured by the exact same companies in other countries.

“This is unacceptable,” Sanders said. “Until we put patients over profits, our system will not work for ordinary Americans.”

In contrast to Sanders, GOP contenders are calling for the phasing out of Medicare.

As Altman wrote, “This upcoming presidential election could be a powerful defining moment. If each Party’s platform reflects these views, the American people will have a clear choice. … If we follow the lead of those visionary architects fifty years ago, those who come after us will inherit a nation where affordable, first class health insurance – Medicare for All – is a birthright.”

http://www.delcotimes.com/opinion/20150804/editorial-health-care-should-be-a-birthright

Celebrate Medicare’s 50th birthday with your support

By Patricia Downs Berger, M.D.
Wicked Local Brookline (Mass.), Aug. 4, 2015 

July 30 was the 50th anniversary of Medicare being signed into law by President Johnson. Fifty years of a national health program guaranteeing health coverage for all seniors is a cause for celebration! Medicare has saved millions of lives, provided quality medical care for our parents and older relatives, and significantly reduced the financial burden on younger family members caring for their parents. Medicare has provided dignity and peace of mind to our seniors, who no longer worry that they will be unable to pay for needed medical care.

Alas, this wonderful program is being threatened, and we need first of all to protect it, then improve it, and finally, we need to expand our incredible Medicare to cover everyone.

We have heard the cry, “Hands off my Medicare,” and there is a reason. There are forces trying to destroy it. Republican candidates for president and the Republican congressional leadership are saying they want to change Medicare from guaranteed medical coverage to a voucher program, leaving seniors to search for an appropriate private health insurance plan and pay for it with the voucher money allotted to them. With health costs rising, it is clear that vouchers will not keep up with the cost of private insurance, a disastrous outcome for seniors.

A second threat to Medicare is the effort by privatization groups to increase the number of seniors choosing Medicare Advantage plans. These plans are run by private health insurers and get special subsidies from the federal government to cover more benefits than standard Medicare so that no supplemental insurance is needed. Because of the added benefits in the Medicare Advantage plans, more and more seniors are signing up for them, even though they limit the network of eligible physicians. Unless the benefits in standard Medicare are improved, in 10 years, there may be more people in the private Medicare Advantage plans than in standard Medicare. In order to protect Medicare from privatization, we need to improve it so it can effectively compete with Medicare Advantage plans.

The most important improvement to Medicare would be to give it the power to negotiation with the drug companies for lower prices on medications the same way the Veterans Administration and Medicaid are able to. Medicare drug prices are 78 percent higher, on average, than prices for the same drugs for Medicaid, and 80 percent higher than for the VA. Most of the developed countries across the world have government-run health care systems that negotiate drug prices that are about half of Medicare’s. This negotiating power is especially important, since the trend is for drug companies to raise drug prices, in some instances to astronomical levels.

Another necessary improvement to Medicare is to cover the services that fall into the “gap” in standard Medicare plans so that “Medi-Gap” insurance would not be needed, and they could compete effectively with Medicare Advantage plans.

Finally, we need to expand an improved Medicare to cover everyone. Our present system under the Affordable Care Act is a market-based system where all the stakeholders in the system — hospitals, doctors, pharmaceutical companies, health insurers and medical device manufacturers — are looking for their opportunity to make a big profit. It is a profit-driven system, but lacks the power to control costs that are determined by the major stakeholders.

And who pays the bills? We, the patients, are the ones footing the bills! Patients only obtain medical care if they can pay the premiums and the out-of-pocket costs that include deductibles, co-pays and co-insurance. A new trend in our market-based system called “consumer-driven” health care is shifting responsibility for paying health care costs from insurers and employers to patients, making even “covered” visits to the doctor more difficult for patients to afford.

The rising cost of health care for the average patients perfectly exemplifies the simple truth that market-based economic policies do not work in health care. Medical care is not a commodity that can be bought and sold. When we are sick, we cannot spend time looking for the best quality doctor for the lowest price; we need a physician who knows us and is someone we trust. We need a health care system that puts the patient first and is not based on whether you have the money to pay. That is why we need an equitable system where everyone pays according to their means through fair taxation. The money that is raised goes to a government entity, like expanded Medicare for All, that will guarantee health coverage to everyone from cradle to grave.

We should celebrate Medicare’s 50th birthday by joining millions of Americans who will protect Medicare from privatization, improve its coverage, and finally expand it to cover everyone. Everybody in, nobody out!

Dr. Patricia Downs Berger is co-chair of Mass-Care, the organization leading the campaign for single-payer health care for Massachusetts. She lives on Heath Street.

http://brookline.wickedlocal.com/article/20150804/OPINION/150808858

Medicare for all means equality for all

By William D. Clark, M.D.
Portland (Maine) Press Herald, Letters, Aug. 4, 2015

Medicare became law on July 30, 1965. Medicare runs economically. It’s equitable – we pay when working, not when sick!

Only months later, in March 1966, Dr. Martin Luther King Jr. clairvoyantly said, “Of all the forms of inequality, injustice in health care is the most shocking and inhuman.”

Fast forward 45 years, to 2010. Politicians promised that the Affordable Care Act would make health care universally accessible. But instead it delivered a tangle of rules and procedures. And health care spending is about $3 trillion, more than 17 percent of gross domestic product.

Profits are healthy in our capitalist system. But millions of people are worried sick and unhealthy – roughly one-third of that $3 trillion goes to profits and so-called overhead, not to health care.

Insurers and drug and device makers spend hundreds of millions on lobbying, blocking attempts to provide universal coverage that other developed nations enjoy. This waste of premium and tax dollars is unconscionable.

Unfortunately, current political discussion is dominated by hyperbolic summary statements, simplistic at best and often outright lies, instead of facts. Preservation of a profit-driven system overshadows provision of health care.

As Trudy Lieberman wrote in Harper’s magazine in June, the only solution is to attack the profit seekers’ stranglehold on the machinery of health care – “a bold move that has so far frightened away almost all contenders.”

So, what would Medicare for All provide? Simply stated: Everybody in, nobody out! Comprehensive coverage from your first breath to your last! And an economical and equitable system, based on 50 years’ experience.

Former Labor Secretary Robert Reich recently affirmed that providing Medicare for everyone would address inequality and injustice.

A united citizenry can become a contender. Join the Maine Nurses Association, the Southern Maine Workers Center, Maine AllCare, U.S. Rep. Chellie Pingree, D-1st District, and many others seeking Medicare for everyone.

Dr. William D. Clark resides in Woolwich.

Letter to the editor: Medicare for all means equality for all

Happy Birthday, Medicare

By Oliver Fein, M.D.
PNHP N.Y. Metro, July 30, 2015

The following are the prepared remarks of the speech that Dr. Oliver Fein delivered at the New York City celebration of the 50th anniversary of Medicare and Medicaid at the Professional Staff Congress CUNY in Manhattan on July 30.

We are gathered here today to celebrate the 50th Birthday of Medicare and Medicaid. At birth, Medicare was a fantastic program. The baby was really beautiful. Why?

  • Because every citizen who had a job contributed;
  • Because everyone who contributed had access to the same benefits;
  • Because access to benefits did not depend on how much you contributed or how much you earned;
  • Because enrollment occurred once in a lifetime, when you turned 65;
  • Because every hospital and more than 90 percent of doctors participated – it had as broad network of providers;
  • Because it was efficient: 97-98 percent of all dollars contributed to Medicare went to pay providers of health care – nurses, doctors, physician assistants, social workers, hospitals.

But the baby had some blemishes:

  • Health care was not free at the point of delivery: there were deductibles and co-payments;
  • Some benefits were not covered: preventive care, dental care, eye glasses and hearing aids, long-term care and prescription drugs;
  • Contributions were not progressive – they were the same percentage on all incomes;
  • People under 65 years of age were not covered.

Many of us assumed that when the baby grew up, all of these weaknesses would be overcome.

  • There would be no co-pays and no deductibles – health care would be free at the point of delivery.
  • When benefits were expanded to include medications, Medicare would be able to negotiate directly with pharmaceutical companies to lower prices on prescription drugs;
  • When the Medicare tax was increased, it would become more progressive like the income tax;
  • Medicare would be expanded to cover all residents of the United States.

But as Medicare has grown from 16 million enrollees in its first year to 55 million today, in its 50th year, it has become infected by potential deadly parasite, namely private, for-profit health insurance companies, which extracted over $34 billion in overpayments in 2012 alone. The private insurance companies accomplish this by attracting Medicare enrollees who are less sick and therefore less expensive, leaving those who are sicker and more expensive in the original program. If this continues, the original program will become the repository of the sickest, most expensive patients – resulting in an insurance death spiral, killing the original Medicare as we know it. We must work to phase out Medicare Advantage plans and work for an improved, Medicare-for-All – with no co-pays and deductibles, automatic enrollment of all residents of the United States, in a single-payer national health insurance program.

So what is to be done?

First, each of us should call our representatives in Congress in the House and the Senate with three demands to protect the Medicare program:

  • Do NOT raise the age of Medicare eligibility above 65 years, if anything lower it;
  • Allow Medicare to negotiate directly with the pharmaceutical industry for drug prices;
  • If any money is to be saved from Medicare, it must come from the overpayments to Medicare Advantage plans.

Second, each of us should write our member of Congress proposing they sign-on to an improved, expanded Medicare-for-All bill such as H.R. 676 (the Conyers bill) or S.B. 1782 (the Sanders bill). Thank them if they have signed on.

Third, each of us should try to meet with our New York State senator and assemblyperson and ask them to sign on to the New York Health Act (A5062 or S3525), a statewide single-payer bill for New York State.

Fourth, invite a friend or neighbor to join you for some apple pie and tell them what an improved, expanded Medicare-for-All would look like and invite them to join a single-payer advocacy group, such as Healthcare-NOW, the Campaign for the New York Health Act, union action committees, the New York State Nurses Association and Physicians for a National Health Program.

Happy Birthday Medicare! We pledge to protect, improve and expand you to everyone who lives in America.

Dr. Oliver Fein is the chair of the New York Metro chapter of Physicians for a National Health Program.