PNHP

Cost sharing in Massachusetts is growing fast

Cost sharing in Massachusetts is growing fast

By John McDonough
Boston Globe, August 14, 2013

Fine story in today’s Globe by Liz Kowalczyk on the new state health data report showing, once again, the dominant economic power of Partners Healthcare in our health market. One beef — if you read you the story, you would have assumed that the annual report from the State’s Center for Health Information and Analysis (CHIA)  was all about Partners. There is  much more — go see for yourself.  and congrats to CHIA for an excellent report.

Here’s what struck me the most:

From the report:

“In a continuing trend, the health coverage available through Massachusetts employers in 2011 cost more and had lower benefit value. Between 2009 and 2011 premiums rose by 9.7% to pay for benefits that decreased by 5%. Consistent with this trend, employees are paying increasingly more out-of-pocket for their health care. Deductibles have grown in Massachusetts by more than 40% between 2009 and 2011, approaching the national average.”

Massachusetts has always been one of the most resistant states to high levels of patient cost sharing in the form of deductibles, co-pays, and coinsurance. If these new data are on the mark, no more. We’re just average — and a 40% uptick over three years! Ouch!! On average, with premiums up 9.7% and benefits down by 5%, that’s a 14.7% drop in value for consumers between 2009 and 2011, reinforcing the point, it’s not just about the premiums, even if that’s what gets all the attention.

Yes, Partners is big: see this pie chart for the evidence. And their 31% in 2012 share is rising, up from 28% in 2011:

And, let’s not forget, our major insurance carriers are pretty big, too.  Blue Cross, Harvard Pilgrim, and Tufts represent nearly 80% of the state’s commercial health insurance market, and their premiums are the highest among all carriers in the Massachusetts market. Whether it’s insurance, hospitals, or physicians, big means more costly.

In terms of the Commonwealth’s goal to eliminate most fee-for-service payment in favor of global payment – embodied in the State’s 2012 cost containment law, signed just one year ago — we have a high hill to climb. Fully 60% of commercial spending and 64% of private plan enrollment is fee-for-service. Global budgeting represents between 35 and 39% of the market. Is that high or low? That’s a judgment call, but here’s the benchmark to judge success or failure.

Helpful information and analysis from CHIA.

Expansion of Medicare is best health care solution

By Lynn Moses Yellott
The Journal (Martinsburg, W.Va.), Aug. 14, 2013

My husband, family physician Dr. Chess Yellott, and I celebrated Medicare’s 48th birthday on Capitol Hill, attending a congressional briefing by Dr. Gerald Friedman, University of Massachusetts professor of economics. Friedman showed how the U.S. could save enough — $592 billion in the first year alone — to provide health care for all and eliminate premiums, co-pays, and deductibles by expanding Medicare to everyone. Financing would be entirely tax-based, and 95 percent of us would pay lower taxes for our health care than we now pay in premiums and out of pocket expenses.

Some of the savings from expanding Medicare comes from eliminating private insurance companies, each with their own billing, claims, marketing and huge CEO salaries.

Doctors and hospitals would also save a huge amount on billing and overhead by dealing with only one insurer instead of thousands of different insurance plans. Additional savings would be found in negotiated pharmaceutical prices.

We are often asked “how can you advocate Medicare for all when Medicare will run shortfalls in the near future?”

Because Medicare for all — as embodied in HR 676, the Expanded and Improved Medicare for All Act — is so much more administratively efficient (overhead just 1.4 percent of revenues, compared to 20 percent for private plans). It is also better able to control costs than today’s Medicare, by globally budgeting hospitals (that is, eliminating per-patient hospital bills and paying the hospital in lump sums monthly), negotiating reasonable drug prices and negotiating fees with doctors. We could save $1.8 trillion over the next decade alone just through reducing health care costs inflation. This would make Medicare for all sustainable for future generations.

For more information: read the study, www.pnhp.org/system/assets/drupal/Funding HR 676-Friedman-7.31.13-proofed.pdf or the summary, www.pnhp.org/news/2013/july/’medicare-for-all’-would-cover-everyone-save-billions-in-first-year-new-study, or e-mail epspan@gmail.com.

Lynn Moses Yellot resides in Shepherdstown.

http://www.journal-news.net/page/content.detail/id/597631/Expansion-of-Medicare-is-best-health-care-solution.html?nav=5061

The anniversary of Medicare: A time to reflect and act

By State Sen. John Marty (DFL)
Spring Grove (Minn.) Herald, Aug. 13, 2013

Forty eight years ago this summer, President Lyndon Johnson signed Medicare into law, providing healthcare for millions of older Americans. As our state begins full implementation of the Affordable Care Act, it is appropriate to reflect on the progress we have made on giving healthcare access to Americans, and commit to delivering Medicare for All.

At the signing of the Medicare law, President Johnson said, “No longer will older Americans be denied the healing miracle of modern medicine. No longer will illness crush and destroy the savings that they have so carefully put away over a lifetime so that they might enjoy dignity in their later years.”

The Medicare program has largely succeeded in fulfilling that promise. Seniors get the healthcare they need, when they need it. It still doesn’t cover all medical needs, but over the years, it has been expanded several times to increase the number of people covered, and the number of services provided. In 1972, people under age 65 who had long-term disabilities were included in Medicare. In 2003, prescription drug coverage was added.

More recently, the Affordable Care Act (often called ObamaCare) added preventive care services to Medicare, as well as mammograms and other health screenings, and it reduced the co-payments seniors pay for prescription drugs.

For older Minnesotans, Medicare has been a lifesaver.

Minnesotans under 65, however, have been covered – or not covered – under a fragmented and broken system of employer-based health insurance, private plans, public programs, or no insurance at all.

Fortunately, during the next five months, many previously uninsured Minnesotans will receive healthcare coverage through the MNSure insurance exchange of the Affordable Care Act (ACA). Those who were denied coverage because of preexisting conditions should no longer face that problem. Young adults whose parents have good coverage are now eligible for coverage through them.

Minnesota, under Gov. Dayton and the DFL legislature this year, is leading the nation in its thoughtful and comprehensive implementation of the ACA. By upgrading MinnesotaCare and expanding Medicaid, Minnesota will make healthcare accessible to hundreds of thousands of additional people.

However, the ACA is not Medicare. It does little to eliminate the bureaucratic waste in our current system or reduce the overall costs of our health care system – and it will not cover everyone.

Nationally, about two thirds of the low income people eligible for coverage under the ACA will not be covered because their states have chosen not to expand Medicaid. Minnesota is doing much better than those states, but there will still be a couple hundred thousand Minnesotans without coverage, and many more who have coverage will not have affordable access to some needed services. Although the ACA will close some gaps in our dysfunctional healthcare system, gaps will remain, and many people needing care will fall into those cracks.

As soon as the ACA is fully implemented, it is time to turn our attention to completing the promise of Medicare for all. Legislation to enact a proposed Minnesota Health Plan (MHP), a Medicare-style plan for everyone, is the only solution to rapidly rising medical costs.

The MHP would beef up the coverage that Medicare recipients get – including nursing home care and many other needed services – and extend those same benefits to everyone, regardless of age. The Minnesota Health Plan would cover all Minnesotans for all of their medical needs.

Yet the MHP would save money, eliminating the costly bureaucratic insurance system and delivering healthcare directly. And, in providing healthcare to all instead of health insurance for some, we would leave medical decision-making with patients and their doctors, not subject to government or insurance company interference. A growing number of Minnesota physicians and nurses are supporting the MHP, because they are tired of patients who get inferior treatment based on insurance company restrictions.

Two years from now, when the nation celebrates the 50th anniversary of Medicare, we want to be on the verge of passing the Minnesota Health Plan. Five decades after Medicare covered people over 65, it is time for Minnesota to cover people under age 65 as well, finally delivering Medicare for All.

John Marty is a Minnesota state senator affiliated with the Apple Pie Alliance, which works to strengthen the democratic process and promote ethics and integrity in public service. The alliance seeks to increase thoughtful discussion and to promote policies that will build a better society and healthy communities for the 21st century.

http://www.hometown-pages.com/main.asp?SectionID=26&SubSectionID=186&ArticleID=49829

Obamacare's pregnant politics

By Dan Carpenter
Indianapolis Star, Aug. 13, 2013

Republicans and their media allies may be feeling heightened urgency as they saddle up Obama-Scare for 2014, according to a guy who has his own reasons for dissatisfaction with the Affordable Care Act.

“While the Republicans are so incredibly strident about how the ACA will fail, if they really believed it would fail, they wouldn’t make so much noise,” said Robert Stone, M.D., a Bloomington emergency room physician and a high-profile advocate for health-care financing reform. “They obviously fear it won’t fail.”

Stone and his wife, Karen Green Stone, are among the leaders of Hoosiers for a Commonsense Health Care Plan. He also is a board member of Physicians for a National Health Program. Both these organizations of medical professionals and consumers seek a universal “single-payer” approach on the model of Medicare, which just celebrated its 48th anniversary as one of government’s most popular services after a birth greeted with conservative hysteria.

Obamacare is not the expansion of Medicare; in the eyes of Stone and his troops, it is a gift to the for-profit insurance industry that raises huge cost-control worries.

At the same time, it delivers goods for the people — to list just a few highlights, protection from being refused or dropped for being sick, inclusion of dependent coverage up to age 27, purchasing exchanges to help modest-income folks with costs, and the extension of Medicaid to an estimated 35 million poor people now uninsured.

Although he would have written the ACA differently (and feels the insurance companies essentially wrote it), Stone likes these provisions and expects voters will also, as implementation swings into full bore in 2014.

“What Democrats are counting on, Republicans are fearing. It’s all so polarized. Both Republicans and Democrats see how the ACA plays out as crucial to their political ambitions. When I criticize the ACA, I offend my Democrat friends; and when I say something positive, I offend Republicans. I’m an equal opportunity critic.”

So much so, he sees even failure as an opportunity — perhaps.

With understated glee, he cites warnings by various conservatives that Obamacare will in fact lead to government health care because costs will rise to the point where the public will tire of the middleman — the insurance companies that must please their shareholders and enrich their executives on top of the bills they pay.

Or, maybe the middleman will get out on his own. Some health insurers already are diversifying as the law tips the scales more toward the customer and the gravy thins.

“The ultimate answer — and I’m impish here — to ‘Is the ACA a step in the right direction?’ is, yes, because it is a government takeover of medicine. There’s this underlying assumption the free market can do more, and government is inept. And yet, the irony is, in Indiana, for instance, they’re going to let Washington run the exchange.”

Chris Stack, a retired Indianapolis physician and leader in Hoosiers for a Commonsense Health Care Plan, agrees the next couple of years could be decisive in any direction.

“If it’s a fiasco, what will prevail?” he said. “Even conservative people can look at the economics of private insurance and see that it’s not working. It’s never worked. It’s possible the failure of Obamacare could lead to something more radical. There’s a glimmer.”

By “radical,” he actually means “established.”

“Medicare — you set the rules, you buy in bulk to keep costs down. Private insurance is in the game as long as it pays off. Then they’re gone.”

For most adult Americans, it would not be at all difficult to recall when we lived without them.

Carpenter is Star op-ed columnist.

http://www.indystar.com/article/20130813/OPINION/308130046/

Complexity of catastrophic cap on losses causes delay in full implementation

A Limit on Consumer Costs Is Delayed in Health Care Law

By Robert Pear
The New York Times, August 12, 2013

In another setback for President Obama’s health care initiative, the administration has delayed until 2015 a significant consumer protection in the law that limits how much people may have to spend on their own health care.

The limit on out-of-pocket costs, including deductibles and co-payments, was not supposed to exceed $6,350 for an individual and $12,700 for a family. But under a little-noticed ruling, federal officials have granted a one-year grace period to some insurers, allowing them to set higher limits, or no limit at all on some costs, in 2014.

Under the policy, many group health plans will be able to maintain separate out-of-pocket limits for benefits in 2014. As a result, a consumer may be required to pay $6,350 for doctors’ services and hospital care, and an additional $6,350 for prescription drugs under a plan administered by a pharmacy benefit manager.

Some consumers may have to pay even more, as some group health plans will not be required to impose any limit on a patient’s out-of-pocket costs for drugs next year. If a drug plan does not currently have a limit on out-of-pocket costs, it will not have to impose one for 2014, federal officials said Monday.

The health law, signed more than three years ago by Mr. Obama, clearly established a single overall limit on out-of-pocket costs for each individual or family. But federal officials said that many insurers and employers needed more time to comply because they used separate companies to help administer major medical coverage and drug benefits, with separate limits on out-of-pocket costs.

In many cases, the companies have separate computer systems that cannot communicate with one another.

http://www.nytimes.com/2013/08/13/us/a-limit-on-consumer-costs-is-delayed-in-health-care-law.html?ref=politics&_r=0&pagewanted=all

FAQs about Affordable Care Act Implementation Part XII

United States Department of Labor, February 20, 2013

Q2: Who must comply with the annual limitation on out-of-pocket maximums under PHS Act section 2707(b)?

The Departments have determined that, only for the first plan year beginning on or after January 1, 2014, where a group health plan or group health insurance issuer utilizes more than one service provider to administer benefits that are subject to the annual limitation on out-of-pocket maximums under section 2707(a) or 2707(b), the Departments will consider the annual limitation on out-of-pocket maximums to be satisfied if both of the following conditions are satisfied:

a. The plan complies with the requirements with respect to its major medical coverage (excluding, for example, prescription drug coverage and pediatric dental coverage); and

b. To the extent the plan or any health insurance coverage includes an out-of-pocket maximum on coverage that does not consist solely of major medical coverage (for example, if a separate out-of-pocket maximum applies with respect to prescription drug coverage), such out-of-pocket maximum does not exceed the dollar amounts set forth in section 1302(c)(1).

http://www.dol.gov/ebsa/faqs/faq-aca12.html

Comment:

By Don McCanne, M.D.

One of the most important benefits of Obamacare is the establishment of maximum out-of-pocket spending that any individual or family would have to face in any given year. Although the amounts will still be unduly burdensome for far too many, nevertheless, it does provide some protection against catastrophic loss.

For the first year, 2014, the administration is allowing maximums to apply separately to both major medical coverage and prescription drug coverage, so patients could face twice the maximum in out-of-pocket spending. This transitional relaxation of the rules is to allow insurers to coordinate their computers that currently administer medical benefits and drug coverage separately.

We’ve discussed before the fact that losses in excess of the maximums may still occur because of limitations in benefits covered or from services provided outside of health plan networks. This one year transition not only will add to that exposure, but it also provides yet another example of the excessive administrative complexity of Obamacare. Wasting resources on excessive administrative services while exposing patients to potential financial hardship would be greatly diminished by changing to a single payer national health program.

America needs cost-effective universal health care

By Julie Pease, M.D.
Sun Journal (Lewiston, Maine), Aug. 4, 2013

In recent months, the people of Maine have witnessed activity by many different players in the health care system as Maine moves to implement the Affordable Care Act.

We’ve seen Gov. Paul LePage veto the expansion of MaineCare, which will leave 70,000 Mainers without access to health care. We’re watching MaineHealth and Anthem try to exclude local hospitals and providers in order to gain “market share” in the upcoming insurance exchange.

We’ve seen highly paid hospital lobbyists and executives successfully persuade Gov. LePage and the Legislature to repay the state’s hospital debt. We’ve learned that businesses are being granted a reprieve from the mandate to offer health insurance to their employees, although individuals remain subject to the mandate beginning in January 2014. Even with ACA subsidies, many of the individual insurance options in the marketplace will be either inadequate or unaffordable for many Mainers.

In the meantime, the problems in the health care system continue to grow. Patients are struggling. The costs of health care consume more than 20 percent of our state’s GDP.

In Maine, an estimated 1,800 individuals and families declared bankruptcy in 2012 due to medical costs. Although some of these people were insured, the majority had health insurance that was inadequate to cover the high costs of medical care. There are 130,000 Mainers who continue to have no health insurance at all; thousands more are under-insured.

When people are under-insured or have no insurance, they delay getting necessary health care and they don’t fill life-saving prescriptions due to cost. That leads to poor health outcomes. When people delay too long, the outcomes are catastrophic. In Maine, someone dies every three days because of lack of health insurance (over 130 deaths per year).

Despite these overwhelming problems in the health care system, there are some bright spots. Our own publicly-funded health care systems (Medicare and the Veterans Administration) remain highly popular and provide better care at lower cost to the most vulnerable patients.

Recently, Medicare passed its 48th birthday. Forty-eight years of experience demonstrates that Medicare, our cherished national public insurance system, could become the solution to the health care crisis in America.

On the occasion of the 48th anniversary of Medicare, I urge Congress to implement real health care reform by improving and extending Medicare to every person in the United States.

A single universal system would give everyone the same access to quality health care regardless of health, wealth, age or employment. It would allow patients to choose their physicians, rather than having insurance companies choose for them. It would spare people the specter of bankruptcy if any family member should have a serious accident or illness. It would help struggling families and small businesses by funding health care with progressive taxes rather than unaffordable insurance premiums. It would eliminate labor-management disputes over health care benefits.

An improved Medicare system would also allow the government to negotiate fair prices for pharmaceuticals, medical devices and health services, and would make it easier to identify and eliminate fraud. It would reduce costs of health care by eliminating the extraordinary and unnecessary administrative waste generated by the private health insurance industry and by the bureaucratic complexities of the Affordable Care Act.

America needs cost-effective universal health care as exists in every other industrialized country. No other nation uses our unique private insurance system which penalizes the sick by charging them more, by reducing their benefits, or by denying care altogether. None allow private insurance companies to place profit over coverage. All of them encourage health care by reducing or eliminating deductibles and co-pays. And all of them provide better care to more people for less money than we do.

Replacing the current health care system with an improved system of Medicare for all would improve this nation’s health. It would save lives and save money.

We must move beyond the bureaucratic, complex, expensive and limited reforms offered by the Affordable Care Act. Instead, let’s improve the popular Medicare program and expand it to cover everyone.

Dr. Julie Pease of Brunswick is a founding board member of Maine AllCare, a nonpartisan, nonprofit group committed to making health care in Maine universal, accessible and affordable for all.

http://www.sunjournal.com/news/columns-analysis/2013/08/04/america-needs-cost-effective-universal-health-care/1400924

Private insurance a flaw in ACA

By Ted Herman
The Journal News (LoHud.com, N.Y.),  Letters, Aug. 6, 2013

Re “Young people, employers lose in Obamacare,” Aug. 4 Commentary:

The young, employers, and frankly, all of us, are losing out in our broken health-care system, but not because of the issues raised by the writers from the Heritage Foundation, an organization that consistently opposes progressive governmental solutions to America’s most pressing societal challenges.

The key flaw in the Patient Protection and Affordable Care Act is that it preserves the private insurance-based model for financing health care in the U.S. — an approach that’s too expensive and wasteful, and one that has left millions of families exposed to crippling medical debt or without access to adequate services. These inequities undermine the health of our communities and the economic health of our nation.
New rules

To its credit, new rules under the ACA expand coverage options and outlaw some of the cruelest practices that have left individuals without coverage when they most need it. However inadequate and expensive, ACA offers essential protection for many who previously fell into the worst gaps in our system.

But millions will continue to pay dearly for the illusion of adequate coverage as they confront the harsh reality of having to allocate a disproportionate share of their income to pay for expensive premiums, deductibles, and co-pays, instead of paying their rent or putting food on the table.

Under ACA, the untenable administrative waste associated with private insurance will continue to be baked into the rising cost of American health care.

Alternatively, the U.S. Medicare system, remade to cover people of all ages, could save more than a half-trillion dollars in the first year of enactment alone — thereby providing excellent health care for everyone, for far less than we currently spend.

If you’re looking for substantive change, get behind H.R. 676, the Expanded and Improved Medicare for All Act introduced by Rep. John Conyers Jr., D-Mich., and co-sponsored by 45 other members of Congress.

The writer lives in Hasting-on-Hudson.

http://www.lohud.com/article/20130806/OPINION/308060057/In-reply-Private-insurance-flaw-ACA?odyssey=mod|newswell|text|Opinion|p

Medicare should be cheered, expanded

By Daniel C. Bryant, M.D.
Portland (Maine) Press Herald, Letters, Aug. 9, 2013

On July 30, 1965, Lyndon Johnson signed Medicare into law. As we note that anniversary, it is interesting to compare the health care news of our own day.

For instance, an article in the July 25 Portland Press Herald (“Briefcase: WellPoint stock sets record ahead of health care reform”) reports: “Shares of WellPoint Inc. hit an all-time high Wednesday, after the nation’s second-largest health insurer trounced second-quarter earnings expectations and detailed how it expects to benefit from the health care overhaul and other growth opportunities over the next few years.”

I’m no economist, but it seems to me that if the payer of medical bills is trouncing earnings expectations, then the payer of premiums must be paying for more than health care.

This is of particular note when we read the same day that Anthem, a subsidiary of WellPoint, is entering an exclusive partnership with the nonprofit MaineHealth (“Anthem-MaineHealth network approved — with conditions”). Is that a strategy to improve health, or to “benefit from growth opportunities”?

There’s other news, too: about whether to expand Medicaid coverage to the thousands of Mainers who have no insurance; about postponing the Affordable Care Act’s mandate; about the move by some employers to reduce workers’ hours so they can avoid providing health insurance.

All very complicated, not to mention distracting from the basic mission of health insurance — making medical care affordable by spreading its cost.

What a contrast is the Medicare story. Despite the program’s problems and the chronic, yet surely resolvable, issue of its funding, it has proved to be far more cost-effective than private health insurance (1 to 5 percent overhead cost versus 12 to 30 percent for private insurers, according to www.politifact.com), far more inclusive and certainly more efficient than the stopgap ACA.

Indeed, we should celebrate Medicare’s 48th anniversary by resolving to take it to the next level — Medicare for all.

Dr. Daniel C. Bryant resides in Cape Elizabeth.

http://www.pressherald.com/opinion/letters/medicare-should-be-cheered-expanded_2013-08-09.html

Harry Reid: Congress someday will end insurance-based system

Reid says Obamacare just a step toward eventual single-payer system

By Karoun Demirjian
Las Vegas Sun, August 10, 2013

In just about seven weeks, people will be able to start buying Obamacare-approved insurance plans through the new health care exchanges.

But already, Senate Majority Leader Harry Reid is predicting those plans, and the whole system of distributing them, will eventually be moot.

Reid said he thinks the country has to “work our way past” insurance-based health care during a Friday night appearance on Vegas PBS’ program “Nevada Week in Review.”

“What we’ve done with Obamacare is have a step in the right direction, but we’re far from having something that’s going to work forever,” Reid said.

When then asked by panelist Steve Sebelius whether he meant ultimately the country would have to have a health care system that abandoned insurance as the means of accessing it, Reid said: “Yes, yes. Absolutely, yes.”

The idea of introducing a single-payer national health care system to the United States, or even just a public option, sent lawmakers into a tizzy back in 2009, when Reid was negotiating the health care bill.

“We had a real good run at the public option … don’t think we didn’t have a tremendous number of people who wanted a single-payer system,” Reid said on the PBS program, recalling how then-Sen. Joe Lieberman’s opposition to the idea of a public option made them abandon the notion and start from scratch.

Eventually, Reid decided the public option was unworkable.

“We had to get a majority of votes,” Reid said. “In fact, we had to get a little extra in the Senate, we have to get 60.”

Reid cited the post-WWII auto industry labor negotiations that made employer-backed health insurance the norm, remarking that “we’ve never been able to work our way out of that” before predicting that Congress would someday end the insurance-based health care system.

http://www.lasvegassun.com/news/2013/aug/10/reid-says-obamacare-just-step-toward-eventual-sing/

Comment:

By Don McCanne, M.D.

Wow! Senate Majority Leader Harry Reid predicts that Congress will eventually end the private insurance-based financing system, acknowledging that “a tremendous number of people wanted a single-payer system.” What can we make of this?

We can only guess at the politics behind his statements, but the policy implications are monumental. He not only expresses the view, held by both liberals and conservatives, that employer-sponsored plans must be replaced, he also departs from some conservatives by implying that the private insurance-based system should be eliminated, replacing it with a single payer system.

Is this just a sop to single payer advocates? He and the other Democrats have continued to advocate vigorously for Obamacare. They have enough problems with the intense campaign mounted by the Republicans to repeal it. The efforts by single payer activists to educate the nation on the severe policy deficiencies of Obamacare certainly are a thorn in their side as they try to implement the program. If they could get single payer supporters to believe that Obamacare is an incremental step toward single payer, then maybe they could enlist our cooperation, or at least silence us for the time being.

Well, Obamacare departed in an entirely different direction from single payer, expanding the fragmentation and administrative complexity which are the opposite of the efficiencies that a single payer system would bring us. Obamacare is not an incremental step towards single payer.

In the meantime, conservatives will jump on Reid’s comments as proof of the conspiracy theory that all along Obamacare was a ruse to get us to single payer. Some ruse! It sets up a system that requires only a simple bill to remove tax expenditure incentives from employer-sponsored plans, freeing up individuals to rely on their own shopping skills to purchase the “highest quality and lowest cost” plans in the marketplace. We already know from decades of experience with private insurance markets what a terrible idea that is – much higher costs for poorer quality plans. Yet this “ruse” feeds right into the agenda of some conservatives who would keep government out of health care financing as much as possible.

The lesson here is that we cannot sit back and simply allow the “inevitable” transformation from employer-sponsored plans to single payer take place on its own. We still have to overcome the inertia of, “Yes, single pager would be the ideal system, but it’s not politically feasible at this time.” Thus this is not a time to relax because we won the contest of ideas. This is a time to greatly intensify our advocacy efforts so the nation understands why single payer is the reform that really will work.

Insufficient outrage: is health care about helping people or enriching providers?

By Joshua Freeman, M.D.
Medicine and Social Justice blog, Aug. 11, 2013

The New York Times has been running a series of articles on the cost of health care, which presumably have engendered anger and frustration in many, if not most, readers. I discussed one of them,  “The $2.7 Trillion medical bill”, on Jul 28, 2013 (The high cost of US health care: it’s not the colonoscopies, it’s the profit). It used colonoscopies as an example of why we have such high health care costs. A more recent piece on the cost of delivering a baby, Paying Till It Hurts: American Way of Birth, Costliest in the World (July 1, 2013) documents the cost of that procedure. Many letters followed, most irate and some discussing the conundrums; for example, our expectation of every birth and baby being perfect, backed up by the threat of lawsuits, requires the presence – and frequently deployment – of enormously high-tech resources for every normal delivery.

One particularly articulate and irate response came in an op-ed by H. Gilbert Welch, a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice, “Diagnosis: Insufficient Outrage”, published July 4, 2013. Welch states that he is “…not talking about a violation of federal or state statutes, like Medicare or Medicaid fraud, although crime in that sense definitely exists. I’m talking instead about the violation of an ethical standard, of the very “calling” of medicine.” He goes on to carefully describe both the incredible increase in prices for medical care and the excess use of the procedures that cost the most. He adds that the prices are only partially felt by the end-user (people) because Medicare, Medicaid and commercial insurers pay far lower amounts than the posted prices, but that the portion paid by people is going up, and of course the uninsured are charged full price. He notes that “They are largely young and employed (albeit poorly) and have little education,” although in fact many are older, and unemployed (remember Medicaid insures only poor people, but far from all poor people).

His description of the huge prices ($108 for a $5 tube of ointment, etc.) has become familiar, and is reminiscent of the $100 hammers bought by the Defense Department several decades ago. Less familiar, but at least as scary, is the increase he describes in charges that come solely from the purchase of physician practices by hospitals, which allows them to charge the higher fees that Medicare allows hospitals, called facility fees. In one place where this was done, the amount paid by Medicare for an electrocardiogram went up from $200 to $471, and for a colonoscopy from $2,000 to $8,000, in one year for the same procedure in the same location.

Welch says that “The word ‘crime’ is awfully strong. Many prefer to call all this a problem of perverse incentives: good people, working in a bad system,” but it is pretty clear that he has not convinced himself, not to mention me. And yet, I know the pressures that physicians and hospitals are under to make more money. After all, hospitals are run by businessmen, and buying up all those physician practices and having to pay the doctors does not come cheap, especially when insurers, particularly Medicare, are focusing on saving money by reducing their reimbursements.  It is a fascinating, if not encouraging, situation, where I can read all these exposes of medical excesses and then go back to work and hear from our own hospital leaders what strategies that they are going to need to employ to continue to make money in a challenging and competitive environment.

Welch says that “Medical care is intended to help people, not enrich providers.” I agree, and maybe you do too, but there is an enormous industry built around medical care and lots of providers (doctors and hospitals and owners of various for-profit facilities, not to mention the pharmaceutical and device industries, and insurance companies) who are indeed getting very rich. And many of them are running very scared that their riches will decrease. If we want a medical care system that is indeed intended to help people rather than enrich providers, there needs to be a major change in the way that it is paid for. We need to devise a system that encourages the provision of high-quality, appropriate care to everyone who needs it. And does not provide unnecessary or potentially harmful care to anyone. And is not so complicated that it encourages work-arounds to cherry-pick profitable patients or do more profitable procedures.

For starters, we need to have one payer, a single payer for everyone so no people are “more desirable” or “less desirable” based upon their insurance coverage (or lack thereof). That system needs to have a component (not the RUC, see Changes in the RUC: None.. How come we let a bunch of self-interested doctors decide what they get paid?, July 21, 2013) that evaluates what a reasonable cost is for that care, including a reasonable profit margin for the provider. It needs to have a component that evaluates new technologies to assess whether they offer benefit over existing diagnostic and treatment modalities, and to whom, and to not encourage over-proliferation of expensive technologies (such as the proton-beam accelerators Welch describes) because  “if we don’t have one, they’ll go to the other guys”. Incredibly expensive technologies, such as proton-beam accelerators, should be purchased by the single-payer system, regionally administered, and available to everyone.

The profit-making competitive marketplace works for many goods and services. It has no place in our health care.

Dr. Joshua Freeman is chairman of the department of family medicine at the University of Kansas School of Medicine and a member of Physicians for a National Health Program (www.pnhp.org).

http://medicinesocialjustice.blogspot.com/2013/08/insufficient-outrage-is-health-care.html

Stand up for your health

By Dave Anderson
The Boulder Weekly, Aug. 1, 2013

In Denver and Fort Collins, activists with Health Care for All Colorado (HCAC) have just hosted 48th birthday celebrations for Medicare, the highly successful program that has provided comprehensive low-cost health care for older people and the disabled since 1965. HCAC wants a similar publicly funded “single payer” system for all Americans.

They are circulating a ballot petition for the 2014 election to establish a state constitutional right to health care. It asks voters to approve, “as a matter of human right and public good for all residing in Colorado, access to an appropriate single standard of high quality health care without financial barrier.”

It requires the legislature to create the framework for the universal system and the Colorado Department of Revenue to collect a premium that won’t exceed 9 percent of an individual’s income to fund it. This system could not be under the control of or administered by “a for-profit, nonpublic entity or corporation.” The initiative states, “Quality health care as a part of our individual and collective quality of life shall not be treated as a private, for-profit commodity in Colorado.”

HCAC has to collect 86,105 valid signatures by October to place the question on next year’s ballot. They are taking advantage of a provision in Obamacare (or ACA, the Affordable Care Act) that allows states to apply for a waiver to establish their own health care system.

Why should we support something like this? Why not wait to see if the ACA works? Because, unlike Social Security and Medicare, the ACA is a volatile compromise.

There are many good provisions, such as banning discrimination based on “pre-existing conditions,” free birth control and other preventive care, and allowing children up to 26 years to be included on their parents’ insurance policies.

However, there are serious concerns about costs. Particularly the growing trend of (euphemism alert!) “underinsurance.” This can mean not seeing the doctor when you are sick, not filling prescriptions, skipping diagnostic tests. It can also mean financial disaster. A recent study revealed that medical bills are the biggest cause of personal bankruptcies in this country. Three quarters of the “medical debtors” had health insurance at the time of their illness.

In an editorial in the “Journal of General Internal Medicine,” Steffie Woolhandler and David Himmelstein argue that the ACA may actually increase underinsurance.

“Obamacare is lowering the bar for health insurance,” said Himmelstein, a professor of public health at the City University of New York and a primary care doctor. “The new coverage sold through the insurance exchanges will leave many families paying 40 percent of their health costs out-of-pocket even after they’ve laid out thousands for premiums. And the administration is allowing states to institute co-payments under Medicaid, even for the poorest of the poor.”

He continued: “Under the ACA a 56-year-old making $46,100 will pay a premium of $10,585 for coverage through the exchange and still face up to $6,250 in co-payments and deductibles.”

Woolhandler, the lead author of the editorial, who is also a physician and professor of public health at CUNY, said, “Over the past 25 years the financial protection offered by health insurance has steadily eroded. The consequences are grave, not only financially but also medically. For instance, we know that heart attack patients who face high co-payments delay coming to the ER, threatening their lives.”

“Obamacare is making underinsurance the new normal,” said Woolhandler.

“It will reduce the number of uninsured from 50 million to 30 million, but the new coverage is full of holes. Americans deserve the kind of first-dollar, comprehensive coverage that Canadians already have. But that’s only affordable under a single-payer system that cuts out the private insurance middlemen.”

Barack Obama knows this. He strongly supported single payer when he was a state senator in Illinois. On the campaign trail and as president, he said single payer was the best system.

But he added that most people were “accustomed” to employer-based insurance.

Yes, and the vested interests in the private insurance industry, the for-profit hospitals and HMOs have become accustomed to making obscene profits and influencing the political process.

If we want change we can believe in, we’ll have to stand up for ourselves.

This opinion column does not necessarily reflect the views of Boulder Weekly.

http://www.boulderweekly.com/article-11454-stand-up-for-your-he.html

To celebrate Medicare’s 48th birthday, support Medicare for All

By Pat Berger, M.D.
Wicked Local News (Brookline, Mass.), Aug. 1, 2013

July 30, 2013, was the 48th anniversary of the signing of the Medicare act of 1965 into law. This very special birthday calls for acknowledging the vital role Medicare has played in the lives of our seniors over the last 48 years.

Before Medicare was enacted, the elderly faced poverty, the fear of being stricken by costly illness, and dependency on family or charity despite holding jobs for many years. We all know from our own families that Medicare coverage is a resource we count on for our grandparents, parents, and ourselves as we near the magic age of 65. What a lifesaver Medicare has been!

But why can’t we have a system that provides everyone with guaranteed medical care from birth to death?  All the other developed countries cover everybody, pay half as much for their health care as we do, and provide better outcomes. America is the only developed country allowing the health care system to be run by private corporations that have transformed medical care into a commodity to be bought and sold.

We are faced with premiums, co-pays, deductibles, co-insurance, means testing, and insurance caps that make health insurance unaffordable for almost 50 million Americans. It is shocking that in America, loss of a job because of illness can lead to loss of medical coverage, bankruptcy and even homelessness.

We are now beginning the implementation of the federal Affordable Care Act (ACA, or Obamacare). There are provisions in the law that will give patients some important protections, and will cover about 20 million more people. But Obamacare does not address the problem of the power of corporate interests and their focus on making money from health care. The ACA actually promotes business for the health insurance industry by mandating that everyone buy insurance or pay a stiff fine. Obamacare does not cover everyone, and most importantly, it does not have the ability to control the soaring cost of health care.

Efforts to slow the cost curve may be mildly successful in the short term using expensive and untried system tweaks, such as accountable care organizations, electronic medical records, and pay-for-performance. But these experiments create more bureaucratic and administrative regulations. The best part of the ACA is that it allows the states to set up their own health care systems in 2017, as long as they cover more people more effectively. Plans are being made now to establish a single-payer system for Massachusetts in 2017.

By achieving a true Medicare for All, or single-payer system in 2017, it would put patients first, cover everyone, be affordable and sustainable, be simple to understand, and allow choice of doctor with no insurance middleman interfering in the decisions between doctors and patients.  Medicare for All would have a single governmental agency that pays all the medical bills and is publicly funded through an equitable tax system. It would save money by eliminating the enormous administrative bureaucracy generated by the multiple health insurance companies. It would control costs by consulting with patient advocates, doctors’ groups, hospitals and public health programs in order to provide the best patient care in the most cost effective manner.

America now spends trillions on health care each year, and wastes at least a third of it on administration, profits from corporate entities, a fragmented system, and ineffective or unnecessary clinical care. Having one system that is accountable to the people, that is focused on quality patient care, and is based on medical need and not ability to pay, changes the whole vision of health care.

Our health is not a commodity, it is a human right. Let’s remember Medicare’s birthday by working for Medicare for All in 2017!

Dr. Pat Berger is a retired primary care physician and co-chair of Mass-Care, the organization leading the campaign for single payer health care reform in Massachusetts. She lives on Heath Street.

http://www.wickedlocal.com/brookline/news/x273443610/Column-To-celebrate-Medicare-s-48th-birthday-support-Medicare-for-All