PNHP

How to lower the cost of prescription drugs

How to lower the cost of prescription drugs

By Leslie Hartley Gise, M.D.
The Maui (Hawaii) News, Letters, March 8, 2018

The high cost of prescription drugs is a common complaint and was in this newspaper in the Feb. 9 editorial, “Out-of-control health system.” The solution is simple. We have already done it. If our Congress would vote to allow Medicare to bargain with drug companies, like the VA already does, prices would drop significantly.

Drug companies were not penalized by the Affordable Care Act. Their profits and stock prices are soaring. Drug companies claim they need high costs to do research, but the vast majority of drug research is done by the government and at universities. Drug companies take over in the later stages when a drug is ready for testing on people. They focus on drugs that folks need to take for life and drugs that are still on patent. And they market aggressively.

They patent profitable “me too” drugs which are no better than the ones we already have. Their high costs are related to marketing, profits and administration. Drug companies spend enormous amount of money on lobbying and contribute massively to our legislators and to our FDA. We need to elect legislators who care about us and are not beholden to the pharmaceutical industry.

http://www.mauinews.com…

Worker health coverage needs rethinking

The recent contract negotiations between union workers and Hannaford provides an opportunity to examine the health care model.

By Daniel Bryant, M.D.
The Portland (Maine) Press Herald, Letters, March 8, 2018

Employment-based health insurance, now covering 56 percent of the nonelderly population, was introduced during World War II to help employers avoid wage controls. The issue of health care coverage in the recent contract negotiations between United Food and Commercial Workers Local 1445 and the company that operates the South Portland Hannaford distribution center provides an opportunity to examine that persisting model. When we do, several problems leap out.

• Employers are saddled with the unpredictable cost and hassle of insuring workers, while remaining vulnerable, as in the Hannaford case, to the threat of strikes. (A 2003 strike over health care benefits in Southern California cost three grocery chains over $2 billion.)

“In most labor negotiations during the past 30 years, more time and effort has probably been spent on the health care plans provided by labor agreements than on any other contract provisions, including pensions,” attorney Arthur Smith Jr. wrote in HR Magazine in 2013.

• Workers can’t see what they’re paying for health insurance within overall labor costs, have no guarantee that their plan or network will remain the same and risk losing coverage if they leave for any reason (the average worker has 11.9 jobs from age 18 to age 50, according to the Bureau of Labor Statistics). An employer’s retention advantage can be an employee’s job lock.

• When commercial insurers insure employees, they are cherry-picking the healthiest demographic, leaving the poorest, sickest and oldest pool to be funded by increased taxes and cost-shifting. And sometimes blamed (“state patients”).

The possibility of another strike at a Hannaford distribution center may not be as newsworthy as assault weapons or Russian meddling, but it should serve to remind us, when we get back to the issue of health care reform, that we should not let outdated conventions and entrenched interests keep us from rethinking the relevance of today’s workplace to today’s health care.

https://www.pressherald.com…

Doctors welcome Rep. Keith Ellison as new lead sponsor of Medicare for all bill

Unlike incremental reforms, single-payer plan is the only way to achieve both universal coverage and cost control

FOR IMMEDIATE RELEASE, March 7, 2018
Contact: Clare Fauke, communications specialist, 312-782-6006, clare@pnhp.org

Physicians for a National health Program (PNHP), the leading national physicians group advocating for single payer health care reform, welcomed Rep. Keith Ellison (D-Minn.) as the new lead sponsor of H.R. 676, the Expanded and Improved Medicare for All Act. That single-payer bill was modeled after a proposal originally crafted by PNHP that appeared in the Journal of the American Medical Association. It would improve Medicare’s benefits to include all medically necessary care, eliminate copayments and deductibles, and expand Medicare to cover everyone living in the U.S.

Universal health coverage has seen a surge in public support; a recent poll showed 92 percent of U.S. adults (including 82 percent of Republicans) believe that all Americans should have the right to affordable health care. H.R. 676 now has a record 121 co-sponsors, representing 63 percent of all House Democrats. PNHP, a nonprofit research and education organization with more than 22,000 members, notes that H.R. 676 would be far preferable to incremental reforms that would offer less comprehensive coverage at higher costs. Single payer would save an estimated $617 billion annually by slashing the administrative waste of private insurance and the paperwork insurers impose on hospitals and doctors ($504 billion), and bargaining down drug prices ($113 billion). That would free up enough money for universal, first-dollar coverage without any net increase in U.S. health spending.

“Everyone from Jeff Bezos to Paul Ryan is pushing ideas for how to reinvent health care,” said Dr. Carol Paris, a Nashville-based psychiatrist and president of PNHP. “Lots of groups claim they have a plan that can get to ‘universal coverage,’ but only a single-payer bill like H.R. 676 can get the cost savings that make universal coverage both feasible and sustainable. We welcome Rep. Ellison as the new lead sponsor of H.R. 676 and will work with him to win even more support for Medicare for all.”

Physicians for a National Health Program (www.pnhp.org) is a nonprofit research and education organization whose more than 22,000 members support single-payer national health insurance.

White House memo on ‘Obamacare Relief Provisions’

White House pitch to bolster Obamacare includes tough trade-offs for Democrats

By Paul Demko
POLITICO, March 6, 2018

The White House is seeking a package of conservative policy concessions — some of which are certain to antagonize Democrats — in return for backing a legislative package bolstering Obamacare markets, according to a document obtained by POLITICO.

The source of the document provided to POLITICO isn’t identified and it isn’t dated. The White House declined to comment on the document but didn’t question its authenticity. A spokesperson for HHS said the department does not comment on leaked documents.

Two health policy experts who have been in contact with White House officials indicated that the document is consistent with ideas the administration has discussed for creating more stability and flexibility in the insurance markets.

“It’s legit,” said one former White House policy official.

https://www.politico.com…

***

Unmarked memo purportedly from the White House

Obamacare Relief Provisions Congress Should Pursue

Obamacare has led to skyrocketing premiums and declining choices for American families. Middle-class families, in particular, have seen their premiums and deductibles soar year after year as a result of the law. Although congressional efforts to provide taxpayer money to prop up the exchanges is understandable, any such efforts must also provide relief to middle-class families harmed by the law and protect life. In order to support such efforts, the administration believes these three policies to provide greater choice and control for middle-class families must be included:

* Increase consumer options of more affordable, flexible insurance coverage by clarifying that issuers selling short-term, limited-duration insurance may offer renewals of that coverage to individuals without those individuals going through health underwriting.

* Increase control for middle-class families over their healthcare dollars by expanding Americans’ access to health savings accounts (HSAs). This will enable middle-class families to save pre-tax dollars for their healthcare expenses and help put them back in control of their healthcare. This can be accomplished by raising HSA contribution limits and allowing HSAs to be integrated with a broader number of plans.

* Modify age-rating requirements to permit premium variation of up to 5:1 in the individual and small group markets.

In addition to these three policies, any efforts to provide taxpayer money to stabilize the exchanges must be properly designed so that public dollars do the most good and that ensures all federal dollars are life-protected. The president also supports congressional efforts to fund and life-protect Obamacare’s cost-sharing reduction (CSR) payments after 2018. This would lower premiums for those who purchase their coverage on the exchanges as well as decrease federal spending due to a reduction in the premium tax credit amounts.

https://www.politico.com…

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Comment:

By Don McCanne, M.D.

This brief memo from the White House seems to be authentic. It lists three policies that the administration says must be included as part of “Obamacare relief provisions” that Congress should pursue.

Perhaps the most alarming must-include policy is making short-term, limited-duration junk insurance renewable without further health underwriting. Since these policies will be almost worthless as far as the benefits they will provide, they will have low premiums and thus be affordable for those who otherwise could not pay for ACA-compliant plans. They may become popular with the perception that these plans would be better than nothing at all, though that is questionable. And making them renewable means that they are no longer limited-duration plans, and thus may become the standard for those who are not eligible for subsidized plans. An increase in personal bankruptcies for those with greater health care needs would be inevitable.

Another must-include policy is expanding “access” to health savings accounts (HSAs), enabling families to “save” pre-tax dollars for their health care expenses. The main difference between an HSA and any other savings account is the tax benefit which is highly regressive since it provides a tax expenditure that is proportional to income. Those who pay no taxes receive no benefit whereas the wealthy receive the most. Also most families with only modest incomes are not able to fund their HSAs. Having access to an empty HSA is of no value. So HSAs really do work for the healthy and wealthy, but not for many of the rest of us who don’t have the funds in the first place.

The third must-include policy is to jack up premiums for older individuals in the individual and small group markets. This may provide some premium relief for the young invincibles, but many older individuals not yet eligible for Medicare will find it very difficult if not impossible to pay premiums that are five times what younger individuals would be paying. This defeats the fundamental insurance function of arranging a transfer from the younger and healthier to the older and more infirm.

One other item in this memo is the recommendation to fund ACA cost-sharing reduction (CSR) payments after 2018. This is not as altruistic as it seems. The CSR payments would reduce the costs to the insurers, allowing them to reduce the premiums thus reducing premium subsidies that the government would be paying. That would help to reduce the federal budget deficit – an important PR move in an election year and the primary reason for this recommendation. But wouldn’t the CSR payments offset that reduction? Simple. Though it is not stated in this particular memo, they have decided to move the CSR payments off-budget, just like they pay for wars.

And about the code language of “life-protected” federal dollars…

Again, the most important item in this memo is that they want to make cheap junk insurance the new standard in the private insurance market – by making it renewable. That would destroy the private insurance markets without providing any other option. The pain inflicted might increase support for a single payer Medicare for all program, but tolerating that much physical and financial suffering is a terrible way to drive the political agenda that we need. Let’s just go to single payer now before more harm is done.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

The West Virginia teachers’ strike is over. But the fight for healthcare isn’t.

The strike was largely about healthcare benefits, which the deal for the most part skirted

By Adam Gaffney, M.D.
The Guardian, March 7, 2018

A wildcat teachers’ strike that roiled West Virginia for nine long days ended on Tuesday, after the state government passed a 5% pay hike. For a state that doesn’t even allow state employees to engage in collective bargaining, this amounts to a historic victory. Yet much remains undone.

The strike was largely about healthcare benefits, which the deal mostly skirted. Even worse, the educators’ hard-won raise could come at the expense of other important state programs – potentially Medicaid, although this remains uncertain. Such an outcome only reaffirms a lesson made explicit throughout labor history: universal healthcare programs, rather than private benefits won through collective bargaining, must be a priority for organized labor.

Between rising healthcare costs on one hand and public austerity on the other, West Virginia’s teachers’ health insurance plans had grown gradually worse in recent years, reflecting the situation throughout much of the country. As one teacher told the Los Angeles Times, pay was “not what kept us out. It’s the insurance. That’s the big deal.”

A glance at the 64-page “Shopper’s Guide” teachers were forced to navigate illustrates just how hellish their options had become: in addition to rising monthly premiums, plan holders faced onerous deductibles, copays, and coinsurance for everything from prescription drugs to childbirth.

Most notoriously, they also faced coerced use of a patronizing app called Go365, a so-called “workplace wellness program.” “They implemented Go365,” one teacher told the New York Times “which is an app that I’m supposed to download on my phone, to track my steps, to earn points through this app. If I don’t earn enough points, and if I choose not to use the app, then I’m penalized…”

Such programs are being pushed on to workers everywhere. They were encouraged by the Affordable Care Act despite paltry evidence that they save money, much less improve health (although they may serve to push costs on to sicker workers). Workers, meanwhile, understandably find reporting their personal health information to their boss (much less being penalized for their cholesterol or BMI) paternalistic and Orwellian.

Go365 caused an uproar, and its penalties were dropped in January, while premium and deductible hikes have been deferred for now. However, the strike deal otherwise left healthcare untouched, apart from creating a taskforce to find solutions for the problem of rising costs. We can assume that its proposed solutions will be insufficient, at least in the long run: as long as health coverage remains a privatized benefit and not a public good, American workers’ healthcare will periodically return to the chopping block.

This is evident from Appalachia’s own long history of strikes over healthcare. In 1946, a strike by the United Mine Workers (UMW) ended with a famous agreement that brought its members comprehensive healthcare, paid for by a tax on coal.

The striking teachers have drawn inspiration from these “mine wars,” even brandishing the red bandannas said to have been worn by rifle-toting coalminers during the 1921 Battle of Blair Mountain, which pitched them against a powerful private militia in an epic gunfight over union rights.

Yet the teachers’ strike is connected to that bloody history in a more complex sense as well. As labor historian Alan Derickson has written, the UMW’s 1946 historic healthcare victory “gave other unions hope for gains in health benefits through collective bargaining,” but it also took the UMW away from the national health insurance cause.

Other big unions followed, such that by the late 50s, labor “had abandoned the goal of protection for the entire population.” The teachers’ inadequate healthcare coverage today, in other words, is in part the consequence of labor’s turn away from universal healthcare in history.

Unions, of course, must win benefits and protections for their workers in the short term. But the teachers – and organized labor as a whole – will have to go beyond what the miners long ago accomplished to make the rights of all workers secure, for a privatized welfare state cannot take the place of a public program of universal healthcare. That struggle remains ahead.

Dr. Adam Gaffney is an instructor in medicine at Harvard Medical School and a pulmonary and critical care doctor at the Cambridge Health Alliance. He is secretary and president-elect of the advocacy organization Physicians for a National Health Program.

https://www.theguardian.com…

CMS may be moving forward with Medicare vouchers

GOP’s proposed Medicare voucher program would lead to demise of the system

By Max Richtman
The Hill, March 5, 2018

A request for public comment from the Centers for Medicare and Medicaid Services (CMS) has caught the eye of a group of Democratic Senators, alarmed about its implications for the future of Medicare.

In February, 15 Senators sent a letter to CMS Administrator Seema Verma expressing concern over a Fall, 2017 Request for Information (RFI) regarding a “new direction” for Medicare’s Innovation Center — and the agency’s subsequent failure to make public the more than 1,000 comments it received.

At the heart of the Senator’s concerns is ambiguous language in the RFI that suggests a shift toward converting Medicare into a voucher program, which would, “fundamentally restructure the guaranteed benefit traditional Medicare provides to older adults and people with disabilities.” 

The Senator’s concerns are well-founded, since Republicans in Congress (most prominently, Speaker Paul Ryan) have long-dreamed of privatizing Medicare by turning it into a voucher system — something that we and other senior organizations adamantly oppose.

Under the GOP’s voucher system, private plans could tailor their benefits to attract the youngest and healthiest seniors, leaving traditional Medicare with older and sicker beneficiaries.

Their higher health care costs would lead to higher premiums that seniors would be unable or unwilling to pay, resulting in a death spiral for traditional Medicare. 

This latest action is part of an ideological tilt to the right by CMS under Verma’s leadership — with subversion of traditional Medicare as one of the apparent aims.

The agency has demonstrated a bias toward private Medicare Advantage plans over traditional Medicare.

In the case of the implicit shift toward privatizing Medicare, the 15 Senators suggest that CMS may be breaking the law.

“We believe you are violating statutory requirements to safeguard older adults and people with disabilities from paying onerous out-of-pocket costs and going without needed health care,” says their letter to Verma.

Max Richtman is president and CEO of the National Committee to Preserve Social Security and Medicare.

http://thehill.com…

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Centers for Medicare & Medicaid Services: Innovation Center New Direction

Through this informal Request for Information (RFI) the CMS Innovation Center (Innovation Center) is seeking your feedback on a new direction to promote patient-centered care and test market-driven reforms that empower beneficiaries as consumers, provide price transparency, increase choices and competition to drive quality, reduce costs, and improve outcomes.

II. Provisions of this RFI

B. Potential Models

2. Consumer-Directed Care & Market-Based Innovation Models

CMS believes beneficiaries should be empowered as consumers to drive change in the health system through their choices. Consumer-directed care models could empower Medicare, Medicaid, and CHIP beneficiaries to make choices from among competitors in a market-driven healthcare system. To better inform consumers about the cost and quality implications of different choices, CMS may develop models to facilitate and encourage price and quality transparency, including the compilation, analysis, and release of cost data and quality metrics that inform beneficiaries about their choices. CMS will consider new options for beneficiaries to promote consumerism and transparency. For example, beneficiaries could choose to participate in arrangements that would allow them to keep some of the savings when they choose a lower-cost option, or that incentivize them to achieve better health. Models that we are considering testing include allowing Medicare beneficiaries to contract directly with healthcare providers, having providers propose prices to inform beneficiary choices and transparency, offering bundled payments for full episodes of care with groups of providers bidding on the payment amount, and launching preferred provider networks.

5. Medicare Advantage (MA) Innovation Models

CMS wants to work with Medicare Advantage (MA) plans to drive innovation, better quality and outcomes, and lower costs. CMS seeks to provide MA plans the flexibility to innovate and achieve better outcomes. CMS is currently implementing an MA plan model, the Medicare Advantage Value-Based Insurance Design (VBID) model, that provides benefit design flexibility to incentivize beneficiaries to choose high-value services; but this model could be modified to provide more flexibility to MA plans and potentially add additional states. More generally, CMS is interested in more models in the MA plan space and regulatory flexibility as necessary for purposes of testing such models. CMS is potentially interested in a demonstration in Medicare Advantage that incentivizes MA plans to compete for beneficiaries, including those beneficiaries currently in Medicare fee-for-service (FFS), based on quality and cost in a transparent manner. CMS is also interested in what additional flexibilities are needed regarding supplemental benefits that could be included to increase choice, improve care quality, and reduce cost. Additionally, CMS seeks comments on what options might exist beyond FFS and MA for paying for care delivery that incorporate price sensitivity and a consumer driven or directed focus and might be tested as alternatives to FFS and MA.

https://innovation.cms.gov…

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Letter to Ms. Seema Verma, Administrator, CMS

United States Senate, February 22, 2018

Excerpts:

We are writing to express our continued opposition to the concepts unveiled and the process used in a Request for Information (RFI) regarding “a new direction” for Center for Medicare and Medicaid Innovation (Innovation Center). …we continue to urge you to provide clarity on the specific model types under consideration.

In the RFI, CMS appeared to seek input on a possible model to restructure Medicare through a premium support or voucher program. We interpreted the RFI to mean that CMS is considering models that would fundamentally restructure the guaranteed benefit traditional Medicare provides to older adults and people with disabilities. Other Members of Congress, select journalists as well as patient and consumer advocates have expressed a similar interpretation and voiced concerns about the Innovation Center’s intentions.

While we understand that the RFI does not explicitly mention the terms ‘premium support’ or ‘voucher,’ the ambiguity of the proposal allows for a variety of interpretations… Absent further clarification, we do not believe Members of Congress, diverse stakeholders in the health community, and the public were provided a sufficient opportunity to comment on the model concepts outlined in the RFI.

Our concern is compounded by the fact that the proposals under consideration may not allow for Medicare beneficiaries to maintain choice and that beneficiaries may not have the ability to opt out of Innovation Center models.

Additionally, we remain troubled by the Innovation Center’s plans to develop and implement the payment model described as “…allowing Medicare beneficiaries to contract directly with healthcare providers.” We believe you are violating statutory requirements to safeguard older adults and people with disabilities from paying onerous out-of-pocket costs and going without needed care.

Again, we urge you to publicly post RFI comments instead of obfuscating regular process in order to withhold unfavorable comments from public view or decide against responding to certain comments.

Signed, Senators Casey, Nelson, Brown, Whitehouse, Gillibrand, Market, Donnelly, Shaheen, Reed, Warren, Blumenthal, King, Cardin, Menendez, and Smith

https://www.aging.senate.gov…

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Comment:

By Don McCanne, M.D.

Without waiting for Congress to act, the Trump administration is moving forward with policies to shift government health programs to the private sector. The conservatives have long desired to privatize Medicare through premium support (vouchers), and it appears that they have devised a deceptive means of sneaking it in through this Request for Information. We need to watch this process closely, even though it is taking place behind closed doors, lest we find that it is published in the Federal Register and becomes the regulatory law of the land by administrative fiat.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

The Humans in Health Care—A Review of The American Mercy Tour

By Christopher C. Muth, M.D.
JAMA, March 6, 2018

Under the influence of partisan politics, health insurance and pharmaceutical companies, and hospital administrators, the US health care system often seems to function at odds with the interests of primary care physicians working within the system and the patients the system is supposedly designed to help.

Two plays, Mercy Killers and Side Effects, provide a much-needed reminder of the humanity of these individuals, arguably the most-crucial and least-powerful players in the drama of US health care.

Both plays are 1-act solo performances written and performed by the lively and dynamic Michael Milligan, a veteran actor and playwright who recently staged them back-to-back as The American Mercy Tour at the Greenhouse Theater Center in Chicago, Illinois, and who will tour them nationally in 2018.

full article:
https://jamanetwork.com…

Health Care for All worth a look

By James Fieseher, M.D.
Foster’s Daily Democrat (Dover, N.H.), March 6, 2018       

To the Editor:

Consider this: Suppose there was a way to cut all medical costs by 50 percent, improve the quality of health care you get when you do need to see a health appointment, decrease the number of sick days a person has over a lifetime and increase the average age of a person’s lifetime? At the same time, we could decrease or eliminate a significant portion of overhead for New Hampshire’s businesses?

Before you call the mental health specialists to have me hauled away (unlikely, considering the decreasing number of mental health specialists we have left in the state), there is actually a bill brought before the state Legislature that has the potential to do all of that. It is HB 1241 and it is a bill the would have the state “study the benefits and costs of a Health Care for All program in New Hampshire.”

The United States spends at least twice as much money per person on health care as people in other industrialized nations. It consumes over 18 percent of our GNP. Other countries get better health care and their citizen on average live longer than we do according to every independent international survey. Their health care is not linked to employers or businesses, so their businesses do not have to provide health care as part of their overhead costs, which make their products more competitive on the open market.

Our health care system is based upon socioeconomic status. If you have enough money and a job with the right employer, you get health care. Your employer picks you plan options and determines what percentage of your plan you must pay for. Your choice of doctor depends entirely upon the health plan your employer picked. You may or may not get a pay raise in your job from one year to the next, but if your health costs go up every year, you’re losing money in the long run. As I write this letter, the teachers in West Virginia are on a prolonged strike for just that very reason: their health care costs have risen far higher than their salaries can afford. If it can happen there, it can happen here as well.

A “Health Care for All” plan is not a new idea. It has been tried and tested many times over. All other industrialized nations have some version of this plan. Many are single-payer systems, but there are other versions that involve multiple payers that work as well. We even have two systems here in the United States that provide terrific health care at a much smaller cost: the V.A. health system and Medicare.

There is no perfect system and each system has its flaws. But the point is, all of them work better and cover more people than what we have now.

So why should you consider the pros and cons of a “Health Care for All” system? Because your state legislature will not. When presented with a chance to even consider a plan that would give every man, woman and child health care at a total cost much less than what we’re paying now, they said they wouldn’t even consider it. When presented with the possibility to lower the overhead of all New Hampshire businesses and making New Hampshire a more business friendly environment, they said it wasn’t even worth thinking about.

What is going on here?

Consider this: contact your state representative and tell them to vote no on the motion to “ITL” (Inexpedient To Legislate) HB 1241. We should consider new ways of making New Hampshire a business friendly state and lowering the cost while raising the quality of health care for all citizens.

http://www.fosters.com…

CMS fails to verify benefits of waivered Medicaid demonstration projects

As Trump Pushes Medicaid Testing, the Grading Falls Short

By Robert Pear
The New York Times, March 4, 2018

The Trump administration is hoping to transform Medicaid by allowing states to test work requirements, premiums and other conservative policies, but a new government report says federal and state officials do not properly evaluate whether such experiments improve patient care or reduce costs.

Evaluations “generally lacked rigor,” and the findings were often kept secret for years, so they were of little use to policymakers, the Government Accountability Office, a nonpartisan investigative arm of Congress, said in the report issued last month.

Under federal law, the secretary of health and human services can waive certain Medicaid requirements so states can use federal money for the program in ways that would not ordinarily be allowed — for example, to cover people and services that would not otherwise be covered.

These waivers have been used for demonstration projects testing innovative ideas and involving millions of people and tens of billions of federal dollars. The Government Accountability Office said the number and scope of Medicaid waivers had grown in recent years, with demonstration projects now accounting for one-third of all federal Medicaid spending — and more than 75 percent in 10 states, including Texas.

The main purpose of the waivers, according to the report, is to test and evaluate new ways of providing coverage and care to people with modest incomes. But, it said, waivers have become a vehicle for wholesale changes in Medicaid, and neither federal nor state officials adequately assess the results. The evaluations have been plagued by “significant methodological weaknesses” and often leave critical questions unanswered, the report said.

The Trump administration has been flooded with requests from states seeking Medicaid waivers. They want to impose work requirements, charge premiums, suspend coverage for people who fail to pay premiums, and restrict eligibility or benefits in other ways. A few states would like to impose time limits on Medicaid coverage for some beneficiaries.

The Government Accountability Office found particular problems in the evaluation of a Medicaid waiver granted to Indiana. The state expanded Medicaid, as permitted under the Affordable Care Act, but obtained a federal waiver for policies emphasizing “personal responsibility,” including monthly premiums and incentives for healthy behavior.

The federal government wanted to know how Medicaid beneficiaries were affected by those changes, but it could not get the data it needed from the state, so its evaluation was severely limited, the Government Accountability Office said.

Conservatives see Indiana’s Medicaid program as a model, and other states are following suit. The architects of the Indiana plan include Vice President Mike Pence, who was the governor of Indiana from 2013 to January 2017, and Seema Verma, a consultant to the state who is now the administrator of the federal Centers for Medicare and Medicaid Services.

https://www.nytimes.com…

Government Accountability Office; Medicaid Demonstrations:
https://www.gao.gov…

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Success of Pence’s Medicaid expansion far from settled

By Virgil Dickson
Modern Healthcare, July 25, 2016

The success of the conservative approach to Medicaid devised by Indiana Gov. Mike Pence—Donald Trump’s pick for vice president—is a mixed bag so far, according to a report that offers fodder for both sides of the political spectrum.

A new analysis funded by the state shows both positive and concerning elements to Indiana’s alternative Medicaid expansion.

The report also comes as Indiana state officials continue to raise objections to the CMS performing its own analysis to see if Pence’s Medicaid expansion has been harmful to beneficiaries. Pence has argued there is no need for the agency to perform its own evaluation because the state already commissioned a report by the Lewin Group, an independent consultancy.

http://www.modernhealthcare.com…

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Trump approves Arkansas Medicaid work requirements

By Nathaniel Weixel
The Hill, March 5, 2018

Arkansas on Monday became the third state to get the Trump administration’s permission to impose work requirements on Medicaid beneficiaries.

The Centers for Medicare and Medicaid Services approved a Medicaid waiver that included a requirement for recipients to work, or participate in job training or job search activities for 80 hours a month.

State officials said they will begin implementing the work requirements June 1, making them the first state to do so. If a person fails to meet the requirements for three months, he or she will lose coverage for the rest of that calendar year.

http://thehill.com…

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Comment:

By Don McCanne, M.D.

Section 1115 Medicaid waivers allow states, with the approval of CMS, to establish demonstration projects that waive certain requirements of the Medicaid program as long as the objectives of the program are met. At the end of the waiver period, the results are to be formally evaluated. The GAO report shows us that these evaluations “lack rigor” and have not been released to provide important research results to the policy community.

Particularly important was the evaluation of the Indiana Medicaid waiver since it put into effect the conservative ideological preferences of Gov. Mike Pence (now vice-president) and Medicaid consultant Seema Verma (now CMS administrator). They contracted for a private study by the Lewin Group while fighting off a CMS evaluation. That is important because they both have touted the great advantages of their patient-empowerment Medicaid program when there is virtually no objective public data to show benefit – only the biased (and not all that impressive) report purchased from the Lewin Group.

Today, Arkansas followed Kentucky and Indiana to become the third state to be granted work requirements for Medicaid beneficiaries – a policy move based on conservative ideology rather than on patient benefit. We can anticipate a further expansion of anti-welfare warfare by the current administration.

When health care coverage is eventually expanded to cover everyone, it will be important to avoid segregating low-income individuals and families into an isolated welfare program. Such a program would always be vulnerable to attacks from anti-government political ideologues. Instead we need a universal egalitarian program that treats everyone fairly – a national single payer improved Medicare for all.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

Americans already believe that everyone should have the right to affordable health care

Americans’ Views on Health Insurance at the End of a Turbulent Year

By Sara R. Collins, Munira Z. Gunja, Michelle M. Doty, Herman K. Bhupal
The Commonwealth Fund, March 1, 2018

The Commonwealth Fund Affordable Care Act Tracking Survey interviewed a random, nationally representative sample of 2,410 adults ages 19 to 64 between November 2 and December 27, 2017.

Do you think all Americans should have the right to affordable health care?

92% – Yes
7% – No
1% – Don’t know/Refused

Asked of the 8% who said no or don’t know/refused:

What if everyone had to contribute financially over their lifetime in order to have the right to affordable health care? Under those circumstances would you consider affordable health care to be a right?

29% – Yes
58% – No
13% – Don’t know/Refused

From the Policy Implications:

This survey’s finding that strong majorities of U.S. adults, regardless of party affiliation, believe that all Americans should have a right to affordable health care suggests there may be popular support for a discussion over our preferred path.

http://www.commonwealthfund.org…

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Comment:

By Don McCanne, M.D.

It has often been said that we cannot enact single payer Medicare for all until Americans agree that health care is a right. This survey shows that 94 percent of adults under 65 already agree that “all Americans should have the right to affordable health care.” Most of those over 65 already have it.

Let’s move on. We have work to do.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

The Kerner Commission 50 years later

The Unmet Promise of Equality

By Fred Harris and Alan Curtis
The New York Times, February 28, 2018

“Our nation is moving toward two societies, one black, one white – separate and unequal.”

Fifty years ago, on March 1, 1968, these were the grim words of the National Advisory Commission on Civil Disorders, called the Kerner Commission after its chairman, Gov. Otto Kerner of Illinois.

President Lyndon Johnson had established the commission to examine the disorders and violent protests in Detroit, Newark and well over 100 other American cities during the summer of 1967, and earlier. What it found was searing. “What white Americans have never fully understood – but what the Negro can never forget – is that white society is deeply implicated in the ghetto,” the commission concluded. “White institutions created it, white institutions maintain it, and white society condones it.”

The Kerner Commission recommended “massive and sustained” investments in jobs and education to reduce poverty, inequality and racial injustice. Have we made progress in the last 50 years?

A Return to Segregation

In many ways, things have gotten no better — or have gotten worse — since 1968. Public schools have been re-segregating for decades.

Inequality That Would Shock the Commission’s Members

The disheartening percentage of Americans living in extreme poverty — that is, living on less than half the poverty threshold — has increased since the 1970s.

The Tragedy of Mass Incarceration

At the time of the Kerner Commission, there were about 200,000 people behind bars. Today, there are about 1.4 million. Mass incarceration has become a kind of housing policy for the poor.

Fifty Years Later, We’ve Figured Out What Works

Policies based on ideology instead of evidence. Privatization and funding cuts instead of expanding effective programs.

We’re living with the human costs of these failed approaches. The Kerner ethos — “Everyone does better when everyone does better” — has been, for many decades, supplanted by its opposite: “You’re on your own.”

Today more people oppose the immorality of poverty and rising inequality, including middle-class Americans who realize their interests are much closer to Kerner priorities than to those of the very rich.

We have the experience and knowledge to scale up what works. Now we need the “new will” that the Kerner Commission concluded was equally important.

What Doesn’t Work and What Does

The Economic Playing Field

Doesn’t – Reduced health care for workers and low-income Americans
Does – Insured health care through a single-payer system

Doesn’t – Small, grudging increases to minimum wage
Does – Substantial increases to minimum wage

Doesn’t – No new tax credits or child allowances
Does – Expansion of the Earned Income Tax Credit to reduce gaps in wealth and income

Doesn’t – Supply-side, trickle-down economics for the rich and corporations; enterprise zones with corporate tax breaks
Does – Demand-side, full-employment Keynesian economics for all Americans

(Use the link to view what doesn’t and does work in the other categories of Jobs, Education, Housing, and the Justice System.)

Fred Harris, a former senator from Oklahoma, is a professor emeritus of political science at the University of New Mexico and the lone surviving member of the Kerner Commission. Alan Curtis is the president and chief executive of the Eisenhower Foundation, the private-sector continuation of the 1968 Kerner Commission and the 1969 National Violence Commission. The two are the co-editors of “Healing Our Divided Society: Investing in America Fifty Years After the Kerner Report.”

https://www.nytimes.com…

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Comment:

By Don McCanne, M.D.

There was some good news following the release of the Kerner Commission report half a century ago and that was that the nation made gains in addressing some of the social injustices described in the report. The bad news is that we have since regressed and in some ways are worse off, especially considering the negative consequences of the massive shift to greater inequality in income and wealth.

When you access the article through the link above, the tragic backsliding becomes obvious when glancing at the graphs presented.

However, there is a potential for good news in the future if we listen to the authors of this article – Fred Harris, the lone surviving member of the Kerner Commission, and Alan Curtis, the chief executive of the Eisenhower Foundation. In a table they show us what we have learned about what doesn’t work and what does. Social justice advocates will recognize that they have organized the basics.

One category – the economic playing field – is reproduced above. Single payer advocates do not need an explanation as to why the very first item listed that does work is “insured health care through a single-payer system.” But the other items in the original article are very important as well. That is why it is not enough to limit our advocacy to the one issue of single payer reform, even though that remains the mission of PNHP. We all have to work together in coalition efforts to move forward with the other policies that do work in order to achieve a more just and equitable society – one in which we all do well.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

The End Of Insurance?

Andrew Coates On Fixing Our Broken Healthcare System

By Tracy Frisch
The Sun, March 2018

As a boy growing up in rural upstate New York, Andrew Coates dreamed of becoming a physician. After high school he went through a period of rebellion, dropping out of college and supporting himself with jobs as a carpenter and in factories and restaurant kitchens. Returning to his education, he earned a master’s degree in American history before finally entering medical school at Columbia University at the age of thirty-two. Coates jokes that, unlike most doctors, he “once worked for a living,” adding that he believes his experiences as a young man have benefited him as a physician.

After a residency in internal medicine, Coates took a position at an Upstate New York hospital. There he saw how patients and their families were often made destitute by the high cost of healthcare. In particular, nursing-home care, a necessity for many who survive a devastating illness, is unaffordable for most people. Medicare covers everyone over the age of sixty-five but allows only limited stays in nursing facilities. Medicaid — a joint state-and-federal program for poor Americans — does cover long-term nursing-home care. But to become eligible for Medicaid, people must first empty out their bank accounts and sell their homes and other assets to pay medical bills. Coates saw medical expenses lead to the forfeiture of a family farm, even though three generations were living on the land.

Coates went on to further specialize in hospice and palliative care, which focuses on relieving the pain and stress of serious illnesses. (Hospice patients, for whom death is expected, make up a limited number of palliative-care patients.) In his palliative-care practice he helps people make difficult decisions about care, finding choices that reflect what’s most important to them, with an emphasis on quality of life for the patient and the family. Presently a full-time hospital-medicine physician, he also teaches medical students, interns, and residents at patients’ bedsides as well as in the classroom as a professor of medicine at Albany Medical College.

Coates’s early experiences in the profession have made him an advocate for a single-payer healthcare system, in which the government pays the medical bills of all its citizens, not just the poor and elderly. A public, national health-insurance program would eliminate the need for private health insurance altogether. Vermont senator Bernie Sanders made support for single-payer healthcare a centerpiece of his campaign for president in 2016. Coates believes we need to go a step further than Sanders proposes and also abolish profit-seeking in medicine.

I first became aware of Coates’s work many years ago when I heard him speak at a rally. He is the founder of the healthcare advocacy group Single Payer New York (singlepayernewyork.org) and past president of Physicians for a National Health Program, a physician organization that advocates for a single-payer healthcare system (pnhp.org). He and I spoke on a muggy evening last fall at his home, an old farmhouse surrounded by a suburban neighborhood. We talked for several hours about the inadequacies of the current U.S. healthcare system and his vision of what might replace it. He told me that he continues to find medicine an “incredibly compelling human endeavor.”

Frisch: You’ve been an outspoken champion of a single-payer (publicly funded) healthcare system, which is sometimes known as Medicare for All.

Coates: In my view, single-payer is an incremental step, a reform that pushes us toward a truly efficient and responsible system of healthcare. Single-payer is far from perfect and will not work without a few hard rules, including the elimination of out-of-pocket patient spending for necessary care, a system to annually budget for anticipated health needs for each community, and completely banning profiteering in medicine.

Frisch: Including for pharmaceutical companies and medical-equipment manufacturers?

Coates: Yes. There should be no profiteering in the delivery of healthcare. I’m not talking about whether highly trained physicians, nurses, or their support staff should be able to make a handsome middle-class living. As a society we should be proud to support professional caregivers. That’s different from people making money simply because they own the laboratory or the hospital or the distribution system. For example, nursing homes in the U.S. are mostly owned by private-equity firms like Warburg Pincus, Bain Capital, GE Capital, the Carlyle Group, and others. These corporate owners in turn hire myriad subcontractors to run every aspect of the home, from the kitchen to the janitorial service to the electronic health records to the laundry. And at every step there is someone taking a profit out.

I think it’s appalling that one person’s illness would be an opportunity for another to make money. The care of human beings should not be a commodity. Since the dawn of time people have done their best to tend to the injured or sick. That’s something very basic to humanity. When caregiving becomes a commodity, the goal of health collides with the goal of wealth. In American healthcare today an unbelievable number of interlopers have entered the fray. Their job is to figure out how to extract funds that could otherwise have gone to help the sick.

But the problem isn’t just that there’s money going out of the system. It’s also that this enormous, unnecessary insurance bureaucracy sits on top of the system, making it extremely inefficient.

Research shows that for-profit medical institutions produce inferior outcomes compared to not-for-profit institutions. If we change to a single-payer system, a bedrock requirement should be that all medicine be not-for-profit.

Frisch: What’s wrong with a for-profit system?

Coates: For one, money is often spent in the wrong places. In our town there are two big hospitals, and both have fancy parking garages and gleaming pavilions with pianos that play themselves. I’m not sure how all of this has improved the quality of care.

Frisch: It sounds like they’re just trying to attract patients.

Coates: Sure, if you have a spiffy parking garage and a nice pedestrian bridge that leads right into the ambulatory-surgery center, maybe that gives you a leg up on the competition. These hospitals are not-for-profit, by the way, but they’ve learned to operate like for-profit hospitals in order to compete. Wouldn’t it be something if the people of the community could decide what the experience of getting care should be like, rather than having competition drive showy expenditures? We could address real concerns, such as preventive care.

Frisch: The Affordable Care Act — also known as Obamacare — required that certain preventative services, such as cancer screenings and immunizations, be offered without deductibles, to make it more likely that people will get them.

Coates: Ending out-of-pocket costs is another part of what I see as the bedrock of healthcare reform. When people have to pay out of pocket for necessary care, they often avoid getting it. The policy term for out-of-pocket payments — whether it’s copays, deductibles, coinsurance, or cash payments — is “user fees.” Study after study finds that user fees amount to bad health policy.

Frisch: But if there’s no cost to the patient, what will prevent people from willy-nilly asking for all kinds of tests and procedures and specialists? Wouldn’t we have a hypochondriac’s paradise?

Coates: There’s almost no evidence that this would happen. In places where there’s been an expansion of access to healthcare — like when the U.S. enacted Medicare in 1965 — the system was not sunk by a glut of people seeking unnecessary treatment.

Frisch: A few days ago I spoke to a man who had retired from the police force with good health coverage and was now on Medicare and purchasing supplemental private insurance. He insisted that everyone should pay for healthcare, even poor people on Medicaid.

Coates: What about the nursing-home patients who can’t possibly work because they need round-the-clock care? What about sick children who aren’t yet old enough to have a job or will never be able to work? Is there a right time of life to get cancer, or have a heart attack, or contract an overwhelming infection?

Frisch: I think this former police officer feels he paid his dues. Why should he pay more to care for someone who doesn’t work?

Coates: If we all pay a small percentage of our income into the system, we can ensure that everyone gets care. Sure, some of us, disabled by illness, will not be able to pay. But the rest of us should proudly contribute, with the understanding that we are building a system that protects us all. Who knows when we might suffer an illness that renders us unable to work and therefore unable to contribute? Providing care to the most vulnerable is not altruism. It’s a form of social solidarity that benefits us, too, because someday we will likely need that system ourselves.

Frisch: Some people think undocumented immigrants are abusing the system.

Coates: If you’re undocumented and receive a paycheck, as most undocumented workers do, money is withheld from that check for Social Security and Medicare benefits that you will never be eligible for, because you don’t have a legitimate Social Security number. All of that money goes into the public till. Incidentally, the retired police officer you mentioned, who’s getting Medicare benefits, has his healthcare paid for in part by undocumented laborers. Meanwhile an undocumented worker who paid into Medicare and Social Security will never receive either. Our country’s cruelty toward undocumented immigrants is most shockingly revealed by medical deportations. Sick, hospitalized patients are flown by air ambulance back to their country of origin. This is unethical and a violation of human rights. Some are patients who need dialysis to stay alive after kidney failure. Many times the patient’s home country lacks the infrastructure to provide dialysis, so deportation can amount to a death sentence.

Frisch: Was the Affordable Care Act a step forward?

Coates: The ACA was one step forward, two steps back. It expanded Medicaid eligibility — in the states that chose to participate in the expansion — and also increased funding to health centers that provide care for underserved populations. These measures helped patients gain access to healthcare who previously couldn’t afford it.

Frisch: What about the individual mandate, which requires everyone to buy insurance?

Coates: The mandate has a curious history. Originally thought up by the Heritage Foundation, a conservative think tank, it was first implemented in Massachusetts by the private-equity millionaire and Republican governor Mitt Romney. The idea was to bring the magic of the marketplace to health insurance by forcing everyone to buy it or pay a fine. Barack Obama, the Democratic president, chose to champion the idea for his signature reform effort, initially expecting bipartisan support.

Under the ACA around 20 million Americans gained coverage, mostly through the expansion of Medicaid. These people would not have had insurance otherwise, and I’m sure this saved lives. But many features of Obamacare got much more credit than they deserved. For example take the policy of letting parents keep grown children on their insurance up to the age of twenty-six. The twenty-somethings who benefited all had parents with adequate insurance. That’s a relatively affluent portion of the population. Millions of young adults whose parents had inadequate or no coverage were left out. Nevertheless, within that group who did benefit, there were people who had life-threatening illnesses caught early and as a result got treatment.

Frisch: That’s the one step forward.

Coates: Yes. Then there are the two steps back. To make premiums as low as possible, the Obama reform opened the door for more plans with high deductibles or narrow networks of providers. Deductibles have risen and risen. We routinely hear about patients spending thousands of dollars out of pocket before the insurance kicks in. In short, costs have been pushed onto the sick.

In addition, the Affordable Care Act led to an enormous wave of corporate conglomeration — among hospitals, primary-care networks, insurance companies, and pharmacies — creating huge new entities, all in the search for profit and market share. Large corporate healthcare companies drive costs up, not down.

Frisch: If we had a publicly funded system, wouldn’t there be a constant danger that the party in power might deprive it of resources?

Coates: Sure, but healthcare funding always requires public vigilance, scrutiny, and participation. What better way is there to monitor health outcomes than to make the system public? Some government services are already widely viewed as necessities: having an adequately equipped fire department, for example. An effort to turn firefighting to a private, profit-seeking venture seems ludicrous. In healthcare, if people were used to having access to top-quality care, I believe it would be difficult to starve the system of resources. The health of the people — I can’t think of a more legitimate topic of public discourse for any modern democracy.

Frisch: Would health-insurance companies disappear?

Coates: Hopefully, yes. Competing private health-insurance companies are a very inefficient way to fund healthcare. The idea of insurance is that the larger the risk pool, the more evenly the costs are distributed. So the most perfect risk pool would be everyone in, nobody out. But that’s not how private insurance works. Instead it’s a perverse competition. Insurance companies are not competing to give the best coverage to those who need it most: the sickest among us. They don’t even want those customers. Health-insurance companies compete to find the patients who are both healthy and wealthy, so they will buy policies but not use them.

Frisch: Many employers offer some form of health insurance to their employees. Does that system work?

Coates: Big corporate employers spend so much on healthcare that it affects other decisions they make. Some employers are starting to realize that universal access to healthcare would give them more freedom. There was an entrepreneur in West Virginia who wanted to start an aerospace manufacturing company about a decade ago. I met him. He wanted to put the plant near his hometown, but his investors insisted he put it in Ontario, Canada, because the company’s healthcare costs would be so much less there.

On the other hand, some employers use employer-sponsored health insurance as a form of control over workers.

Frisch: Because employees don’t dare quit?

Coates: There’s job lock. If you have a sick person in your family on your plan, you’re afraid to leave your job, because your loved one needs the coverage. But I’m also thinking of how messed up it is to depend on your employer or your spouse or your parents for health coverage. Other forms of social control include how some employers demand a note from a doctor if you take sick days. And when you start a new job, if it offers health insurance, there’s a probationary period — three, six, or even twelve months — before you have access to the benefits. And I’ve heard of other insidious practices, like smokers having to pay more than nonsmokers and employees having to prove that they exercise.

Frisch: Some employees go on strike because their healthcare is so bad.

Coates: If you try to organize a strike, you will find your health insurance canceled as soon as the strike starts. Most union contract bargaining gets stuck over health benefits these days. With universal healthcare, unions could instead focus on wages and working conditions. Single-payer reform would strengthen the unions and prove incredibly liberating for working people.

Frisch: What do you think fuels the intense antipathy toward universal healthcare among so many politicians in both major parties?

Coates: I can’t say. In my interactions with everyday people, I don’t find much, if any, antipathy toward universal healthcare. Last week I was in Long Lake, New York, in the Adirondacks. I didn’t hear opposition there to the idea that every human being who needs medical attention should get it. Politicians loudly oppose universal healthcare, and yet they stop short of openly advocating that some human beings should be denied the care they need. The author of a U.S. Senate bill that would have enormously curtailed Medicaid across the country, throwing millions of people off the rolls, went on TV and lied and said his bill wouldn’t hurt those people. Talk-show host Jimmy Kimmel, whose son was recently born with a congenital heart condition, called out his lies on late-night TV.

Virtually all developed nations provide universal access to healthcare in some way. The single-payer model has worked well in Taiwan and Canada. Germany is an example of a multi-payer system, but government regulation ensures that all costs are uniform, whether you’re insured through a community organization or a company or a religious group. Scotland has a purely public health service, where every physician and nurse gets a paycheck from the government. Spain has the right to healthcare in its constitution. We could go on. The only developed country that has designed its healthcare system to leave people out is the United States.

Frisch: How do U.S. health outcomes stack up against those in nations with universal healthcare?

Coates: Compared to other developed, wealthy nations, the U.S. comes in last across many indicators of health status. On a worldwide scale, dozens of countries have better health indicators than the U.S. Over the last couple of decades maternal mortality — the preventable death of pregnant women — has gone down in almost every nation on earth, but in the U.S. it has gone up. It’s shocking to think that our country, with so much talk about family values and so much debate about the unborn and so much attention to healthcare, would have worsening maternal mortality.

Frisch: Why is maternal mortality going up here?

Coates: The reasons are myriad, but the most glaring is that the wealthy have gotten super-wealthy, while the poor, who are many times more numerous than the rich, have gotten so much poorer. Women at the bottom aren’t getting proper prenatal care. Some life-threatening conditions that occur during pregnancy, such as eclampsia and gestational diabetes, can be prevented or treated if they are caught early. Too often they aren’t.

Frisch: Aren’t per capita healthcare expenditures in the U.S. also much higher than in other developed countries?

Coates: The U.S., on average, spends twice as much as most other developed nations on healthcare. That’s both per person and as a percentage of gross domestic product. We’re talking about a total of $3 trillion a year, or about ten thousand dollars per person annually. And more than half that money already comes from taxpayer dollars. In effect, we’re paying for national health insurance, but we’re not getting it.

Frisch: Where does all that taxpayer funding go?

Coates: Toward Medicare and Medicaid, health benefits for public employees, and tax credits that help employers pay private insurance companies. Of course taxes also fund veterans’ hospitals, the Indian Health Service, federally funded health centers, and research institutions like the Centers for Disease Control and Prevention and the National Institutes of Health and many other programs. The point is that public spending already allocated should be adequate to meet our full healthcare needs.

Cuba is an interesting comparison. It spends something like a fourth of what the U.S. spends on healthcare per person, but Cuban people have about the same health outcomes as Americans, including life expectancy, infant mortality, and so on. One reason for this is that Cuba has trained so many doctors. In fact, there are more doctors per person in Cuba than anywhere else in the world. And Cuban doctors learn not only to spend more time with their patients but to care for entire communities. What Cuba lacks in monetary resources appears to be compensated for by their many doctors.

Frisch: Could it be that our healthcare outcomes are worse because the pressures of contemporary American life and the food we eat are making us sick?

Coates: There are indeed great pressures. And it’s important for everyone to eat healthy, which is challenging for the poor, who often don’t have access to fresh fruits and vegetables in their neighborhoods. Yet comparative studies have been done, and controlling for the American diet and other lifestyle choices does not explain the inferior health outcomes in the U.S. For example, European nations with longer life expectancies actually have more smokers. In the U.S. we have many more people who live in poverty than European countries do. And we lead the world in incarceration. Poverty and the stress that comes with it have devastating health consequences. With growing income inequality, there’s a case to be made that Americans’ health is becoming worse, mostly for those at the bottom. People work two and three jobs and still can’t make ends meet. Intense social pressure leads to personal disaster. People become more prone to alcoholism and opiate addiction. Domestic violence devastates families. With economic insecurity people find themselves constantly on the move and without a sense of community. Many who are better off are now facing growing insecurity as the middle class disappears. In the hospital I see a stark picture that connects statistics with real human lives.

I’ve written about an uninsured landscaper who didn’t have a steady winter job. He ran a snowblower and drove a plow, but the work was pretty sporadic. When there was a major snowstorm, he tried to work a twenty-hour day, to make up for lost wages. But because he had an infected tooth and had not been able to eat much for a few days, he collapsed after sixteen hours. I ended up admitting him to the hospital.

Frisch: Did he survive?

Coates: Yes, he’s OK. I felt a little helpless, because all I could do for his tooth infection was prescribe antibiotics. We see so many social problems at the hospital, which often provides a refuge for people who have no place else to go. It’s distressing and makes me even more determined to fight for a single-payer healthcare system.

Frisch: Why didn’t the U.S. adopt some form of universal healthcare when other countries did?

Coates: The U.S. began to discuss national health insurance around the same time as European nations: in the early twentieth century. At the start of the 1930s a blue-ribbon commission called the Committee on the Costs of Medical Care recommended a system of compulsory insurance and healthcare planning for the whole country. The American Medical Association [AMA] attacked the idea as a communist plot, even though the panel was led by the Republican president of Stanford University, a medical doctor who had also once been the head of the AMA! President Franklin D. Roosevelt, who was inaugurated within weeks of the report’s release, chose to avoid the matter.

When World War II came along in the 1940s, the country entered an enormous industrial boom, and the government imposed a wage freeze to help the war effort. Looking to attract workers, employers offered healthcare benefits instead of higher wages. By the end of the war, employer-sponsored private health insurance was entrenched. After the war, in the United Kingdom, the Labour Party established the National Health Service, guaranteeing necessary medical care to everyone. As the troops came home in the U.S., the government expanded benefits and guaranteed healthcare for veterans, and President Harry Truman began to champion the idea of national health insurance. In response the AMA hired a Madison Avenue advertising firm to counter Truman’s initiative. They came up with the term “socialized medicine” to defeat Truman’s agenda, again disparaging the idea as a communist plot.

Frisch: Did the AMA represent the way most physicians felt?

Coates: That’s a good question. Probably not. I think the AMA was dominated by the most money-conscious members of the profession, who feared national healthcare would mean lower pay for the wealthiest doctors.

Frisch: One of the arguments against single-payer is that it can cause long waits for treatment. How do waits under Canada’s single-payer system compare with what we face in the U.S. today?

Coates: Let me tell you a story. I see many low-income patients. For example, a man may have a meniscus tear — a chronic knee injury that can be repaired with arthroscopic surgery — but he has no insurance. The elective surgery would require an exorbitant cash payment. His wait time for arthroscopic surgery is effectively infinite — or, at least, until he gets insurance that covers it. But no one is tracking those kinds of wait times in our country.

It’s true that, in Canada, wait times for elective surgeries — especially orthopedic surgeries — have sometimes been frustratingly long. A Canadian who needs arthroscopic surgery might not get into the operating room for many weeks. This has provoked public outrage in Canada, because it’s seen as a disgrace to the nation, as it should be. As a result of all this hue and cry, wait times for elective procedures are improving there. And I should emphasize that we’re talking about elective, not emergency, interventions.

Can we compare wait times in Canada and the U.S. if we don’t keep records on wait times here, while the Canadian data is public? Wait times are an ideological talking point used by people who want to privatize even more of the healthcare system.

Frisch: Are you satisfied with the sort of care people get in the U.S. when they do go to the doctor?

Coates: No. In my experience it’s too often undignified. Countless patients have been refused care or misdiagnosed or given inappropriate prescriptions. We recently discharged a man from the hospital to home hospice because he had a terminal brain tumor. During the discharge meeting, his daughter and son told us how over the previous year his insurer had refused to pay for a scan of his brain, even though his cardiologist and his primary-care physician had ordered it. The man ended up in the hospital, where the emergency-room doctor ordered a CT scan and found the brain tumor within an hour. His children were left to wonder whether their father’s life could have been extended if the insurance company had allowed the test a year earlier.

This patient had a type of Medicare called Medicare Advantage: a program through which private insurers are paid to administer Medicare benefits. Medicare Advantage plans may offer frills like a gym membership to attract patients, but in return the insurers are allowed to chisel away important benefits, things that traditional Medicare would cover without question. This is what you get when you privatize Medicare.

These days, in almost every case, there’s some way in which profiteering intervenes. I discharged a woman with a prescription for a medication that was decades old and generic. It turned out that a big pharmaceutical company had recently cornered the market on it, and a medication that a few years ago cost pennies per pill now costs more than a thousand dollars a month. She couldn’t afford it, because her insurance required her to pay a percentage of the cost of each prescription.

Sometimes an ambulance ride is not covered. I once had a clinic patient who needed to be in the hospital, but she refused to take an ambulance after having previously been billed a large amount for one. So I drove her forty miles myself. Some of my colleagues were shocked to hear this, asking, “What if something had happened while she was in your car?”

Or take hepatitis C. Medications can now cure hepatitis C. So what’s the holdup? The pharmaceutical companies charge tens of thousands of dollars for these medications. Doctors have been fighting with state Medicaid agencies to cover these drugs, but the sky-high retail price remains an obstacle.

Frisch: Are most physicians upset about the things you’ve described?

Coates: I think there’s enormous moral distress within the profession. Physicians don’t feel able to live up to their calling. They don’t have good job satisfaction. They want to spend more time with patients.

Frisch: Senator Claire McCaskill claims this isn’t a good time for the U.S. to transition to single-payer, because we’re already having trouble paying for all the baby boomers going on Medicare.

Coates: Warnings that the Medicare trust fund is going bankrupt come and go despite the fact that the system basically works. Politicians have the nerve to talk about the impending bankruptcy of Medicare when out-of-pocket spending on healthcare is bankrupting families right now. The best way to save Medicare would be to expand it to include everyone. The real reason the powerful are so opposed to single-payer is not because it won’t work but because it will.

When Canada enacted its Medicare system in the early 1970s, Canada and the U.S. were tracking even in terms of per capita healthcare costs. Today Canada is spending half of what the U.S. spends and getting better outcomes, better access to care, and better quality of life. This shows that a single-payer model absolutely will work if the goal is to cover everyone and save costs. It won’t work if the goal is to protect the interests of private insurers. It won’t work if the goal is to maximize profits.

Frisch: I’ve noticed there are no longer any independent medical practices in my county. Now they’re all under the umbrella of a single hospital.

Coates: The advent of most physicians becoming employees within a large corporate structure is something the medical profession hasn’t really come to terms with. Physicians continue to have the small-shopkeeper mentality, and we do retain a great deal of professional autonomy. But now, as employees in vast systems, we have begun to lose say over many aspects of care.

Frisch: Some opponents of healthcare reform have proposed that patients should shop around by cost for tests, drugs, and hospital stays.

Coates: With healthcare there’s no way to be a fully informed consumer, because you can’t know precisely what your future needs will be. If you develop the worst headache of your life and are in excruciating pain, you can’t know whether you’re having a migraine or a brain hemorrhage. You might need ibuprofen, or you might need a neurosurgeon. The idea of going shopping during a possible intracranial hemorrhage is just silly. The only solution that makes sense is having a healthcare infrastructure at the ready when we need it.

Frisch: How should individual physicians be paid for seeing patients?

Coates: Personally I think the full-time-salary model is the most honorable, but that may not be for everyone. There’s no perfect way to pay doctors. If you pay them a fee for service, it may encourage some to provide unnecessary services. If you pay them by the hour, it may encourage some to work too many hours. If you pay them a salary, it may encourage some to go home early. The best system would be to assume that doctors are doing the best they can for patients and let them organize themselves to decide how they want to be paid.

Frisch: Uninsured people tend to be charged more for healthcare than people who are insured. Overall who pays more under the present system: the insured or the uninsured?

Coates: The uninsured pay with their lives. For every million people without health insurance in the U.S., about a thousand deaths occur that could have been prevented. But the costs of a catastrophic illness are unpredictable even for those with insurance. I met a colleague, a senior physician, in the supermarket the other day. She told me that she had taken early retirement. I was about to congratulate her when she explained that her granddaughter had been hit by an automobile and her daughter had been fired for missing too much work, because she had to be at the hospital. The daughter was able to regain employment, but the care needs of my colleague’s granddaughter remained so significant that my colleague was taking early retirement to be there for her family. How can we measure the cost of that to society?

Studies show that the burden of providing care near the end of life falls disproportionately on women family members. The costs are great: not just financially but also to the health of the caregiver. Data also show that if your spouse dies, you have a higher likelihood of dying soon after. This often has to do with the stress of providing care: the lost sleep, the lost resources, and, many times, the lost jobs. Who pays? We all do.

Frisch: Many people don’t have the option to provide care when family members need it.

Coates: I have patients who are hospitalized but can’t afford to miss work. They fear being fired, or they simply can’t do without the income. I’ve written letters to their employers in hopes of helping them negotiate a little more time for recovery.

Frisch: Is it legal to fire people because they’re sick?

Coates: They’re not fired because they’re sick. They are fired because they’re not at work. It’s cruel.

Frisch: Is it different in other countries?

Coates: Absolutely. Other countries have not only sick-leave protections but also maternity and paternity leave.

Frisch: Let me see if I understand the basics of the system you’re pushing for: The government would provide free healthcare for everyone, paid for by taxes. You would not have to enroll; you would just have it. And I assume you’d be able to choose your physician.

Coates: Right. Physicians who participated in the system would be forbidden from having a private practice on the side, outside of the system. Doctors who wanted to have a private, for-cash practice could conceivably do so. But with the entire population covered by public healthcare, that would make little sense. With almost all doctors taking part in the system, patients could choose from a wide selection of providers. This kind of competition for the best-quality providers might turn out to be healthy for all of us.

The role of the government in this system would be to pay the costs and protect the patient-provider relationship. Medical decisions should be made privately — by the patient and the doctor — and the government should respect whatever decision they make, providing that decision is within the realm of medical science.

Frisch: Would there be limits on allowable treatments for a given condition?

Coates: If a physician is proposing treatments that lack any credible evidence, then those treatments won’t be funded. On the other hand, if a treatment is supported by the medical evidence — and the patient and physician believe it’s worth a try — then that should be the patient’s personal decision.

Frisch: What are the chances that the system you envision will be enacted here?

Coates: I think the profound contradictions of the current system make it more likely: We have the contradiction that healthcare is so essential and yet so undignified in its delivery, with money always the underlying issue. Then there’s the contradiction that we’re paying so much more for healthcare compared with other nations but getting such inferior results. So everyone involved in the system gets progressively more frustrated and ground down. Yet we all know it doesn’t have to be this way.

I’m optimistic. Of all the social reforms that could transform the country, single-payer seems to me the most likely to happen. Still, we don’t have a mass movement of millions of people pushing for this, and that is what it will take.

https://www.thesunmagazine.org…