PNHP

How Anthem and Medicare control MRI prices

How Anthem and Medicare control MRI prices

Need An MRI? Anthem Directs Most Outpatients To Independent Centers

By Michelle Andrews
Kaiser Health News, September 26, 2017

Tightening the screws on pricey imaging exams, health insurer Anthem will no longer allow many patients to get MRIs or CT scans at hospital-owned, outpatient facilities, requiring them to use independent imaging centers instead.

Anthem says the change is aimed at providing high-quality, safe care while reducing medical costs.

But critics say that imposing a blanket rule that gives preference to freestanding imaging centers is at odds with promoting quality and will lead to fragmented care for patients.

Imaging tests are generally subject to preapproval by Anthem to confirm that they’re medically necessary. Under the new policy, AIM Specialty Health, an Anthem subsidiary, will also evaluate where they should be performed. Doctors who request non-emergency outpatient MRI or CT scans that can be done at an independent imaging center rather than one owned by the hospital will be given a list of centers eligible for patient referrals.

Hospital imaging is indeed pricier than imaging at freestanding centers. Average prices for MRI and CT scans ranged from 70 percent to 149 percent higher at hospitals, according to an analysis by the Healthcare Financial Management Association, a membership group for health care finance professionals.

But price isn’t the only important variable, and the perception that all imaging studies conducted by qualified providers generally yield comparable results is wrong, (said Leah Binder, president and CEO of the Leapfrog Group).

This is Anthem’s second coverage change this year attracting attention. Earlier, the company came under fire for a new policy under which it will no longer pay for emergency department visits that it determines after the fact weren’t emergencies. That decision raised concerns it could discourage people who might need emergency treatment from  seeking care.

Patient advocates and health care providers have also expressed concerns about the new imaging rule’s potential impact on patients.

Cancer patients who often are being treated at cancer centers within hospitals would feel the effect, noted Dr. J. Leonard Lichtenfeld, deputy chief medical officer for the American Cancer Society.

“They have to go to a new outpatient facility, get the film, get it read and transmitted back to the cancer center,” Lichtenfeld said. If, as often happens, the hospital and the imaging center’s computer systems don’t talk to each other, the patient may have to bring the results back to the doctor on a CD. “For that patient who’s in a lot of stress to begin with, it adds another level of stress,” he said.

Anthem isn’t the only insurer trying to find a way around hospitals’ steeper outpatient imaging costs, said Lea Halim, a senior consultant at the Advisory Board, a health care research and consulting company. The Medicare program is taking steps as well, although its approach doesn’t directly influence patient care in the same way.

In recent years, hospitals have been snapping up independent physician practices, outpatient imaging and testing facilities and then charging Medicare higher hospital outpatient fees for their services. In a bid to equalize payments, in January the Medicare program reduced by 50 percent the amount it pays some hospital-owned outpatient facilities, including imaging centers, that are located away from a hospital’s campus. A further reduction is proposed for 2018.

“So Medicare is doing something that’s in a way very similar to what Anthem’s doing,” Halim said.

http://khn.org…

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CMS Finalizes Hospital Outpatient Prospective Payment System Changes to Better Support Hospitals and Physicians and Improve Patient Care

CMS.gov, November 1, 2016

Focusing Payments on Patients Rather than Setting

CMS is finalizing policies to implement section 603 of the Bipartisan Budget Act of 2015, which requires that certain items and services furnished by certain off-campus hospital outpatient departments will no longer be paid under the OPPS beginning January 1, 2017. Currently, Medicare pays for the same services at a higher rate if those services are provided in a hospital outpatient department rather than a physician’s office. This payment differential has provided an incentive for hospitals to acquire physician offices in order to receive the higher rates. This acquisition trend and difference in payment has been highlighted as a long-standing issue of concern by Congress, the Medicare Payment Advisory Commission, and the Department of Health and Human Services Office of Inspector General. This difference in payment also increases costs for the Medicare program and raises the cost-sharing liability for beneficiaries.

This final rule with comment period describes which off-campus hospital outpatient departments are subject to this requirement and which items and services are “excepted” from application of these payment changes and will continue to be paid under the OPPS.

CMS is issuing an interim final rule with comment period (IFC) in conjunction with this final rule with comment period to establish new payment rates under the Medicare Physician Fee Schedule (MPFS) for the items and services provided by certain off-campus provider-based departments for CY 2017.

These new interim final rates being adopted in the IFC will permit hospitals to be paid for the furnishing of items and services that may no longer be paid under the OPPS, and we believe will reduce incentives for hospitals to acquire independent physician practices and convert the same service into more highly paid OPPS services.

https://www.cms.gov…

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Comment:

By Don McCanne, M.D.

Prices charged for MRI scans in hospitals and outpatient departments are higher than those charged in freestanding facilities. Both Medicare and the private, for-profit insurer Anthem are taking measures to correct this imbalance. Health care consultant Lee Halim says that “Medicare is doing something that’s in a way very similar to what Anthem’s doing.” But are they really similar?

The problem to be addressed is that the prices are too high. What is not a problem is the location of the facility. Hospital and outpatient facilities are located conveniently, enabling them to provide services integrated with the mothership.

Obtaining MRI scans in unrelated freestanding facilities can be disruptive. Imagine a patient receiving outpatient care in a cancer center having to go across town to obtain an MRI from a radiologist that is not part of the integrated team. Imagine the confusion as to the precise imagining features desired, the transfer of the images to incompatible equipment, and the communication difficulties between the patient’s cancer team and an outsider. Yet this is Anthem’s solution to obtaining lower prices.

What does Medicare do? It does not change the location, but rather it uses administered pricing to reduce the costs to appropriate levels. As the Medicare release states, they are “focusing payments on patients rather than setting.”

Medicare made these patient-friendly changes almost a year ago, and now Anthem is following through in the most patient-unfriendly manner – disrupting health care to save a buck.

There really is a difference in the patient service culture of our Medicare program and the strict business ethic of the for-profit insurers, not to mention that Medicare is providing us with a better deal anyway.

Medicare still doesn’t have everything quite right, and that is why we need an improved Medicare. But then we’ll have a program that will be nearly ideal for all of us, and one that we can afford.

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Why I’m the last happy doctor

By Marsha Fretwell, M.D.
The Charlotte Observer, September 26, 2017

When I retired at 70 years old as a practicing geriatrician in Wilmington and said farewell to my medical colleagues, I slowly began to realize that I might be “The Last Happy Doctor” in town. Why is this and how did it happen? First, let me lay out some of the realities of practicing medicine today.

The surgeon general has declared that, second only to opioid addiction, “burned out” physicians is our most critical issue in health care. In a recent survey of N.C. physicians, the most prominent reason given for their “burnout” was erosion of clinical authority and the requirement of excessive insurance paperwork in order to get paid. Only 11 percent of physicians felt they had the time they needed to provide the highest standards of care. In the next one to three years, 44 percent plan to cut back on direct delivery of care, retire, or seek work in non-clinical jobs.

So, how did I end up as the “Last Happy Doctor”? It was a series of responses I made as the insurance industry began to reshape health care as a for-profit efficiency driven business. The first choice was to resist reducing the time spent with my patients. When I refused to schedule less than one half hour per patient, it became obvious that I would need to start and manage my own practice. Because of my choice to focus primarily on caring for older patients, my revenue stream was approximately 96 percent Medicare funded. Unaware, I had wandered into a “Medicare for All” financed healthcare practice.

Knowing that all my patients had coverage was a great relief to me and my office staff. That allowed us to focus on truly caring for and about them. Having a predictable reimbursement allowed me to create a budget. The greatest bonus was the lower overhead. Because my practice did not need to spend hours on the phone with agents of the for-profit insurance companies, I could hire fewer staff. Additionally, not only was I making clinical decisions based on patients’ needs, I got to decide on clinician-friendly computer software for data collection. This reduced the other major reason physicians are “burned out” and leaving practice: spending excessive time using computer software that does not actually serve any meaningful purpose for clinical care.

The introduction of widespread for-profit insurance financing of health care in the 1970s is a major factor in the demoralization of physicians. The percentage of the health care insurance market served by for-profits rose from 16 percent in 1981 to 65 percent in 1997. In the for-profit setting, physicians are required to care for patients under constant time pressure and with the knowledge that the cost of care may send their patients into bankruptcy. This model does not work in health care at the practitioner level because it requires reduction of human contact time. Without this human contact, a loss of satisfaction occurs for both the physicians and patients. Critical to the discussion is the significant lowering of survival rates and desired patient outcomes since 1950, all in the context of rapidly rising costs.

In a humane society, universal health care is a given, and those involved in health care optimally come with a calling. Helping individuals improve their health requires trusting relationships over time. Creating a “Medicare for All” financing system and removing for-profit insurers from the equation is an appropriate pathway to less expensive care, better health outcomes, happier patients and happier doctors. I know because I have been there.

Dr. Fretwell is retired from active practice in geriatric medicine. She is now activity working with Healthcare for All of Western North Carolina seeking fundamental change in the financing of health care.

http://www.charlotteobserver.com…

Bernie Sanders is right – why not Medicare for all?

Private doctors and hospitals would still provide care under Bernie Sanders' Medicare for All plan, offering better care at lower cost.

By James E. Dalen, M.D., M.P.H., Sc.D. (hon)
Arizona Republic, September 26, 2017

Bernie Sanders is introducing a bill that would ensure that all Americans have access to health care. It is called “Medicare for all.”

Is this a wild socialist scheme?

Nearly every industrialized nation (except the U.S.) provides universal access to health care. They spend less on health care than the U.S., and nearly all have better health care outcomes because they provide ongoing primary and preventive care to all their citizens.

There are two ways to ensure care

There are two ways that a nation may ensure health care for all its citizens. It may directly provide the health care by employing all physicians and health-care workers, and owning all hospitals and clinics. The cost of health care is paid by taxes.

This is the English system established as the National Health Service in 1948. This is socialized medicine. There may be rationing or significant waiting times for certain tests or procedures. Many Scandinavian countries also have this system. Socialized medicine works well for them, but it would never be accepted in the U.S.

The second way to provide universal care is mandatory national health insurance paid by a payroll tax shared by the employee and the employer. Health care is provided by the private sector: private physicians and private hospitals and clinics. The government does not provide the care.

This system has worked well in Germany, France and many other European countries for decades. There is no rationing of care and no long waits for care. Health-care costs are lower and the quality of care is equal to or exceeds the U.S’s.

Nations with universal health care have a single payer for health care: either the government itself or a national health insurance plan.

Sanders’ plan offers a single payer

In the U.S. we have multiple payers. Most Americans have employment based insurance. Employers contract with various insurance companies to pay the medical bills of their employees. Physicians and hospitals send their bills to hundreds of different insurance companies, each company has its own forms and fee schedules. It is a very complex and very expensive system.

The other major payors are Medicare and Medicaid. Again, they have different fees and different billing procedures.

Sanders proposes that all U.S. health-care bills would have a single payer: Medicare. Medicare would set fees and pay health providers in much the same way it currently pays for care to Medicare patients. Billing would be much simpler: a single billing form and a single fee schedule. The administrative costs of Medicare are about 2 percent, compared to about 17 percent for U.S. private insurance. Medicare as a single payer would decrease U.S. health-care costs by billions of dollars.

Many Americans will object to the Sanders plan because they believe that the government should not be involved in health care. Yet our government is already heavily involved in health care. More than half of U.S. health care – Medicare, Medicaid, military and VA care – is provided by or administered by federal or state governments.

Government is already involved in care

Many Americans oppose mandatory health insurance, yet we have had it for more than 50 years. Medicare is mandatory health insurance administered by the federal government.

Health care to Medicare patients is provided by private physicians and private hospitals and clinics; not the government as in England or Scandinavia. Patients have free choice of hospitals and physicians. All surveys have shown that quality of care is excellent and that seniors are pleased with their care. There is no rationing of care and no long waiting times for care.

Polls since 1945 have shown that most Americans favor national health insurance. A poll in 2007 showed that most U.S. physicians also favor national health insurance.

If we are looking for a way to provide comprehensive health care to all our citizens at less cost, it is in plain sight: Medicare for all.

Dr. James E. Dalen is dean emeritus at the University of Arizona Medical School and executive director of Weil Foundation in Tucson, which serves to advance integrated medicine.

http://www.azcentral.com…

USA TODAY: Obamacare or single payer?

Focus on Obamacare, not single-payer pipe dreams

By The Editorial Board
USA TODAY, September 25, 2017

Our view: Bernie Sanders’ Medicare for all is an unwieldy manifesto

Providing a Medicare-like public option alongside private insurers in ACA exchanges is another idea worth trying, particularly in any counties that go down to one or zero sellers. Allowing people 55 and older to buy into Medicare at the actual cost to government is another option.

But now, even with the Graham-Cassidy measure on life support, is the wrong time for Democrats to be focusing on Berniecare.

Reader Poll: What do you think of our view?

27% – Strongly agree

30% – Agree

6% – Don’t know

17% – Disagree

21% – Strongly disagree

(113 votes as of 2:20 PM Eastern)

https://www.usatoday.com…

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Bernie Sanders: Time is ripe for Medicare for all

By Bernie Sanders
USA TODAY, September 25, 2017

Opposing view: Eliminate insurance industry profits and reduce waste

The truth is that the only reason we, among all major countries, do not have universal health care has everything to do with politics and greed.

Now is the time to tell members of Congress that their job is to protect the American people, not the insurance companies and the drug companies. Now is the time for Medicare for all.

Reader Poll: What do you think of Sen. Sanders’ commentary?

69% – Strongly agree

11% – Agree

4% – Don’t know

4% – Disagree

12% – Strongly disagree

(745 votes as of 2:20 PM Eastern)

https://www.usatoday.com…

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Comment:

By Don McCanne, M.D.

This poll is not scientific, but it is interesting. As of this posting, 80 percent agree with Bernie Sanders position on single payer, whereas 57 percent agree with the USA TODAY editorial board that we should focus on Medicare instead of single payer “pipe dreams.” But make of it what you will, as of the moment this is written, almost seven times as many readers elected to vote on Bernie’s Sanders’ commentary (745) as voted on the USA TODAY editorial (113). That netted 597 votes for Sanders’ position to 66 votes for The Editorial Board position.

There is certainly more passion behind the single payer movement than there is behind skipping single payer and focusing on Obamacare. Let’s turn that passion into action.

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Five lessons from Canada on single-payer health care

By Colleen M. Flood and Allan Rock
Chicago Tribune, September 24, 2017

The United States is about to debate the merits of Bernie Sanders’ proposal for a single-payer health care system. While cost will be an issue, evidence shows that many countries provide access to quality care for all their citizens through a single-payer model while spending far less than the U.S. does now.

How can this be?

Single-payer systems are often promoted as a means to achieve social justice. But they are also more economically efficient than the private market alternative. Having one payer simplifies the administration of health care by avoiding multiple insurers processing claims.

Costly administration is one reason why the U.S. spends by far the greatest percentage of gross domestic product on health care in the Organization for Economic Co-operation and Development (while having the largest percentage of uninsured).

But not all single-payer models are created equal.

As Americans consider Sanders’ proposal, they should examine the successes and failures of single-payer systems elsewhere. Canada’s actual experience (and not the make-believe version portrayed by idealogues) might help Americans craft their own, better version.

We offer five lessons from Canada that Americans should take to heart.

• First and most important, a single-payer system does not and should not cover everything — just everybody. All health systems have their limits. But there must also be a process for deciding what services are insured. That list must change to keep pace with innovations and emerging needs.

Canada’s single-payer system is weak in this respect. It was created when health care meant doctors and hospitals, and so the Canada Health Act reflects that long-ago world.

The Sanders proposal is more modern, including long-term care [1], prescription drugs and other items important today (not covered in the Canadian model). But Sanders’ plan should include a fair process to periodically re-evaluate the services and treatments that are insured.

• Second, a single-payer system need not mean bleak government hospitals staffed by underpaid doctors. Single-payer can include a vibrant private sector both within and ancillary to the public plan.

Mythmaking aside, Canada’s system accommodates a major role for the private sector within the public system. Nothing in the Canadian model prohibits the private delivery of publicly paid services.

Indeed, most Canadian doctors are not salaried state employees but private contractors who are well remunerated — and who don’t have to manage multiple payers, chase accounts receivable and treat patients who can’t pay.

The private sector is also a complement to Canada’s public system, insuring services left out of the public plan. Some Canadians would prefer an even greater level of privately-insured care, which is an ongoing debate. Each single-payer system manages the public-private balance to best suit that country’s needs, values and priorities. Americans should consider how others have established that balance before determining their own.

• Third, single-payer need not mean reduced patient choice and increased wait times. Canadian patients can choose their own physicians and hospitals without the restrictions imposed by American “managed care.” While it is sadly true that Canada has struggled with wait times that are too long for some services, the problems derive not from the single-payer system itself but rather from issues of system management. The proof is found in many other single-payer systems that do not face the same issues.

Concerns with wait times should be addressed up-front in a U.S. single-payer plan, emulating successful models and setting maximum wait-times based on clinical evidence.

• Fourth, single-payer need not mean funding the system only from taxes. Canada’s experience is that tax funding alone can make the system vulnerable when economic downturns require steep government cuts. Wisely, the Sanders plan is in line with European models with a mix of funding sources, including premium payments by employers and employees together with some funding from tax revenues.

• Finally, the U.S. can learn from Canada’s vexed experience with federal-provincial negotiations about health care. If the federal government goes it alone in funding health care — as the Sanders plan seems to suggest — the difficult dynamic of federal-state negotiations will be avoided. But if the final plan involves federal grants to states, federal funding must have a guaranteed floor and be adjusted over time to fairly account for changing needs and technologies. There must also be a way to speedily resolve federal-state disputes when they arise.

As Canadians can attest, the single-payer health care model has enormous social and economic advantages. But its success in meeting the needs of a nation depends on its wise design and deployment. By considering the experience elsewhere, Americans have the historic opportunity to create a model that will be uniquely their own while capturing best practices everywhere.

Colleen M. Flood is associate vice president of research and director of the Centre for Health Law Policy and Ethics at the University of Ottawa. Allan Rock is president emeritus of the University of Ottawa and is a former Canadian minister of health.

PNHP Endnote:

1. In Sen. Sanders’ plan, long-term care would be administered by the states only for low-income individuals, similar to Medicaid today. PNHP believes long-term care should be provided to all as part of a national health plan.

http://www.chicagotribune.com…

Readmissions down; deaths up

While U.S. heart failure readmissions fall, deaths rise

By Mitchel L. Zoler
Internal Medicine News, September 20, 2017

U.S. hospitals have recently shown a consistent and disturbing disconnect between reductions in their heart failure hospital readmission rates and heart failure mortality. Readmissions have dropped while mortality has risen.

“Despite reductions in 30-day heart failure readmissions in 89% of U.S. hospitals” during 2009-2016, “30-day heart failure mortality rates increased at 69% of these ‘successful’ hospitals” during the same period,” Ahmad A. Abdul-Aziz, MD, said at the annual scientific meeting of the Heart Failure Society of America.

“The most concerning question we can ask is whether inappropriate discharges from emergency rooms and observation units” is a driving factor behind the mortality rise despite a readmissions drop, said Dr. Abdul-Aziz, a cardiologist at the University of Michigan in Ann Arbor.

These shifts in the outcomes of U.S. patients hospitalized for acute heart failure episodes are tied to the penalties that the Centers for Medicare & Medicaid Services began slapping on hospitals in 2013 for excess 30-day readmissions for heart failure patients and in 2014 for excess mortality. A problem with these two CMS programs is that the penalty on inferior readmissions performance is a lot stiffer than for excess mortality, Dr. Aziz noted: a 0.2% penalty on payments for high mortality, compared with a 3% penalty for excess readmissions, a disparity that can make hospitals focus more on the readmissions side, he suggested.

Dr. Aziz’s report isn’t the first to make this observation. Study results published earlier in 2017 used CMS Medicare data from 2008 to 2014 to show that during that period, heart failure 30-day mortality rates following hospital discharge rose by 1.3%, while 30-day readmissions fell by 2.1% (JAMA. 2017 July 18;318[3]:270-8). On the basis of these numbers, as many as 5,200 additional deaths to U.S. heart failure patients in 2014 “may be related to the Hospital Readmission Reduction Program” of CMS, Gregg C. Fonarow, MD, said during a separate talk at the meeting.

“CMS thinks that policy reform is the way to improve outcomes of patients hospitalized for heart failure. There was no evidence, no results from randomized trials, but they pushed it on the country. And it has reduced readmissions. But there have been unintended consequences of gaming the system, of keeping patients out of the hospital and giving them outpatient status, and these data raise concerns because 30-day mortality went up,” said Dr. Fonarow, professor and cochief of cardiology at the University of California, Los Angeles. “We should all be extremely concerned about the unintended consequences of payment reform strategies” that aim to improve the management of patients with heart failure.

http://www.mdedge.com…

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Comment:

By Don McCanne, M.D.

Supposedly application of policy science provides higher quality care at lower costs, but in the case of heart failure, with no evidence, policy decisions were made to penalize hospitals 3 percent of their payments if their 30-day readmission rates went up, but only 0.2 percent if the patients died. Thus CMS rewards hospitals that follow the dictum, “Don’t readmit them, let them die.”

One of the criticisms of using Medicare as the model for a single payer system is its large centralized bureaucracy. Policy decisions often seem quite distant from decisions that should be made between health care professionals and their patients.

The Canada Health Act is only 14 pages and it would be half that except the text was repeated in French. The Canadian Medicare system is administered on the provincial level rather than through Ottawa. Likewise, in the United States it is recommended that administration be more decentralized – moving it from Washington, DC to greater state or regional control. That is one of the major reasons that we refer to an Improved Medicare for All.

Imagine making a decision for readmitting a patient with heart failure. Wouldn’t it be far better making that decision based on clinical need rather than being based on a penalty system out of Washington? Not that physicians would do such a thing, but then why do the numbers suggest that they do? An obvious solution is to shoo away the policy bureaucrats and simply do what is right for the patient.

Canada Health Act:
http://laws-lois.justice.gc.ca…

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Health researchers: Graham-Cassidy bill would increase deaths by 41,600 annually

Doctors dub Graham-Cassidy “The Undertaker Full Employment Act”

FOR IMMEDIATE RELEASE, September 22, 2017
Contact: Clare Fauke, communications specialist, 312-782-6006, clare@pnhp.org

Physicians and public health researchers Drs. Steffie Woolhandler and David Himmelstein estimate that implementation of the proposed Graham-Cassidy legislation would push an additional 32 million Americans off their health insurance over the next decade, resulting in 41,600 additional deaths in 2027.

Since the Congressional Budget Office could not conduct a timely analysis of the bill before its expected vote, the researchers—who have studied the effects of insurance coverage on health outcomes—analyzed the bill’s impact on insurance coverage and mortality.

“The Graham-Cassidy bill—what we’re calling ‘The Undertaker Full Employment Act’—would cut health coverage by 14 million Americans in 2020, rising to at least 32 million in 2027,” said Dr. Woolhandler, an internist in the South Bronx, Distinguished Professor of Public Health at the City University of New York at Hunter College (CUNY) and lecturer in medicine at Harvard. “That means 18,200 extra deaths in the first year, climbing to 41,600 annually within a decade.”

Drs. Woolhandler and Himmelstein studied CBO projections of previous GOP “repeal and replace” bills, and then extrapolated how many individuals would lose coverage per $1 billion in health spending cuts in the Graham-Cassidy bill between 2020 and 2027.

From there, the researchers projected the number of associated deaths based on their recent study published in the Annals of Internal Medicine, “The Relationship of Health Insurance and Mortality: Is Lack of Insurance Deadly?” The study concludes that for every 769 people who lose health coverage, one person will suffer preventable death. Health insurance prevents deaths in part by improving the diagnosis and treatment of high blood pressure; uninsured and under-insured Americans with hypertension are known to be less likely to have their blood pressure under control. Lack of coverage also increases death rates in several other conditions, including breast cancer and major trauma.

“We became doctors to save lives,” said Carol Paris, M.D., president of Physicians for a National Health Program. “As physicians, we cannot be silent while Congress plays political games with the lives of our patients.”

The Graham-Cassidy bill eliminates insurance subsidies provided through the Affordable Care Act to about 8 million Americans, and makes substantial cuts to state Medicaid programs that today insure more than 70 million Americans. The bill also allows insurers to charge more for patients with pre-existing conditions who would likely be priced out of the insurance market altogether.

Dr. Paris notes that instead of cutting coverage to millions of Americans, Congress should cut the number of uninsured to zero through a universal, single-payer health plan like Rep. John Conyers’  H.R. 676, the Expanded and Improved Medicare for All Act or Sen. Bernie Sanders’ S. 1824, The Medicare for All Act of 2017.

Dr. Steffie Woolhandler is an internist in the South Bronx, Distinguished Professor of Public Health at the City University of New York at Hunter College (CUNY) and lecturer in medicine at Harvard. Dr. David Himmelstein is also an internist, Distinguished Professor at CUNY and lecturer at Harvard. They are co-founders of Physicians for a National Health Program (PNHP). Dr. Carol Paris is a retired psychiatrist and president of PNHP, a nonprofit research and educational organization of more than 21,000 doctors and health professionals who support a single-payer national health program. It was founded in 1986.

Single payer ‘concern trolls’

There are 3 types of single-payer 'concern trolls' — and they all want to undermine universal healthcare

By Adam H. Johnson
Los Angeles Times, September 21, 2017

With momentum building for single-payer healthcare among Democratic voters and a growing number of 2020 hopefuls, Sen. Bernie Sanders unveiled a “Medicare for All” bill last week. Immediately, a number of pundits denounced the legislation as an “unrealistic” “bloated” “disaster” full of “magic math.”

Some of the naysayers are conservatives who simply abhor “big government.” Some have perfectly valid reasons to question the merits of single payer in general or Sanders’ methods in particular. Yet others claim they support universal healthcare in theory (one day, perhaps) but cannot do so now because of a “concern.” They are “concern trolls” — broadly defined as “a person who disingenuously expresses concern about an issue with the intention of undermining or derailing genuine discussion.”

The nuance troll: ‘We need more details!’

Less than 24 hours after the bill’s introduction, New York Magazine’s Jonathan Chait lamented that the bill gets America “zero percent” closer to single payer. While saying he agrees with single payer in theory, he insisted that the 155 million Americans who already have healthcare represent an insuperable barrier, and that the issue of how to move them all to a government-run system “is not a detail to be worked out. It is the entire problem.” After all, as he noted, Lyndon Johnson failed and Hillary Clinton failed and Barack Obama failed to undo the private system. So why bother? It’s too hard; everyone go home.

Nuance trolling is argument by way of tautology, an attempt to pass off power-serving defeatism as savvy pragmatism.

Even if Sanders did lay out how a single-payer transition would work in a technical sense, nuance trolls would find other nits to pick. Where would the money come from? How would you manage all the corporations disturbed? There’s always some essential detail that needs solving before Senate Democrats earn the right to support a bold policy.

And if the demand for nuance seems reasonable enough, consider that pundits rarely require it when it comes to military interventions — Chait and others set this issue aside when it came to invading Iraq in 2003, for instance.

The deficit troll: ‘How do you pay for it?’

Of all the water-muddying tactics, this one is the easiest to set aside. As I’ve noted in these pages before, deficit scare-mongering is used, almost exclusively, as a bludgeon to smear progressive policy proposals. When it comes to launching wars or bailing out banks, these fears vanish.

Money for war is magically always there; money for healthcare must be counted bean by bean.

The feasibility troll: ‘What about the GOP?’

Many pundits seem to believe that leftist politicians must preemptively agree internally to some assumed compromise that is “practical” even before attempting to change the conversation, much less the law. Thus feasibility trolls argue that GOP opposition to government-run health insurance renders futile any such proposal.

That’s ahistorical. Maximalist demands aren’t all or nothing, they’re about establishing broad moral goals that people can rally around.

Progressives lose nothing by setting bold targets right out of the gate. Why not make every Republican lawmaker go back to his or her constituents in 2018 and explain opposition to free healthcare? Force the issue, shift the debate, just as the far right has been doing for years.

President Eisenhower — an early practitioner of concern trolling — told the New York Times in 1957 that he supported integration “in principle” but said activists in the South risked going “too far, too fast.” Give it more time. We need more details.

All meaningful changes to society have been met with these types of objections. But the game of politics isn’t won by waiting for the ideal. Its most successful actors establish a moral goal and fight for it until reality catches up to them.

Adam H. Johnson is a media analyst for Fairness and Accuracy in Reporting.

http://www.latimes.com…

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Comment:

By Don McCanne, M.D.

The concern trolls – nuance trolls, deficit trolls, and feasibility trolls – counter the vast superiority of the single payer model of health care reform with arguments that seem almost trivial (though sounding quite serious) when compared to the extraordinary social benefit that single payer would bring to America.

Why do they do that? What benefit is there in acknowledging that there is a far better alternative for reform, yet rejecting it based on a search for nuances, or based on hypothetical deficits that would not exist in a well designed program, or, even worse, based on supposed lack of political feasibility for a program that continues to grow in popularity?

Homo sapiens is a weird species.

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The benefits of Bernie Sanders’ ‘Medicare for All’ plan

By Marcia Angell, M.D.
The Boston Globe, September 21, 2017

Bernie Sanders is right. Given the growing costs and shrinking benefits of Obamacare, and the flame-out of “repeal and replace,” America should transition to Medicare for All. Last week he introduced his Medicare for All Act of 2017, which would do exactly that, while retaining and improving Obamacare during a four-year transition.

Medicare, the current program for Americans over age 65, is a single-payer system, which means it is financed and overseen by the government, even though most providers are private. It is by far the most popular and efficient part of our health care system. In fact, many 64-year-olds can hardly wait to be 65 so they are eligible for it. Unlike private insurers, it doesn’t pick and choose which patients it will cover and for what medical conditions. All seniors are covered for the same package of benefits.

But Medicare isn’t perfect. Benefits aren’t comprehensive (for example, there is no dental coverage), copayments are rising, and there is profiteering by providers. Sanders’ plan would introduce reforms that would help with those problems. It would expand benefits greatly, and out-of-pocket costs would be eliminated except for a small copay for prescription drugs.

Even people who think this all sounds wonderful are concerned about the costs. Won’t taxes increase? How can we possibly afford single-payer health care? But in fact, this concern stems from a misunderstanding. Yes, income taxes and government expenditures would increase, but those increases would be offset by the enormous savings in premiums and out-of-pockets costs. This trade-off is not sufficiently understood, because the Congressional Budget Office estimates only costs to the federal government, not to patients. The fact is that if out-of-pocket costs are included, we would probably break even in the first year and in later years we would come out ahead, because inflation would be curbed.

Obamacare has many virtues. It expanded access to about 20 million people, and it ended some of the worst abuses of the private insurance companies, such as denying coverage because of preexisting conditions. But it did little to rein in cost inflation, because it left our health system in the hands of private insurance companies, profit-oriented providers, and the pharmaceutical companies, all of which could pretty much name their price. As expenses rose for employers who provide health insurance, their answer was to cap their contributions. And as expenses rose for insurance companies, their answer was to shrink benefits and increase deductibles and copayments. Americans found that having insurance was not the same thing as getting adequate health care. Moreover, about 30 million Americans remain uninsured.

The fundamental problem, the problem that underlies all the others, is that the United States has a market-based system. We’re the only advanced country that does. The systems in the other countries vary in details — some have single-payers like Medicare, others have tightly regulated private insurers — but they all have in common universal coverage in predominately nonprofit systems. In all of them, government sets benefits and prices in one way or another, including prices of prescription drugs, and administrative costs are much lower. And it works. Their health systems spend on average less than half as much per person as we do (that gap is growing), and their health outcomes are generally much better.

In contrast, we have chosen to entrust our health care mainly to the commercial market. But while markets are good for many things, they are terrible for health care. Markets seek to expand, and each element in a market (think cars) tries to grow its share of the total by attracting more paying customers. But we want the health care system to shrink, not to keep growing. Health markets also can’t distribute care rationally. The people who most need care are usually the least able to pay for it. So providing it according to the ability to pay instead of medical need inevitably introduces inefficiencies and inequities. Moreover, health businesses usually don’t compete on price, but by marketing to affluent customers.

Sanders’ Medicare for All Act envisages a four-year transition, which would begin by dropping Medicare eligibility from age 65 to 55, and enrolling all children 18 and under. Then, over the next two years, eligibility would be dropped one decade at a time, and in year four it would be extended to everyone. There would be no out-of-pocket costs, and the benefit package would be expanded. The system could be financed by an ear-marked 4 percent income tax. A family of four with an annual income of $50,000 would pay $844 a year, which is about $4,400 less than the average premium working families paid last year to private health insurance companies. I believe we would also need to move to a nonprofit provider system.

Health care is a social good, not a commodity, just as primary education, fire and police protection, and clean water are. A market-based system is not only wasteful, it’s immoral. Winston Churchill famously said, “The Americans always do the right thing, but only after they’ve tried everything else.” In health care, we’ve tried everything else. The time has come for the right thing.

Dr. Marcia Angell, former editor in chief of the New England Journal of Medicine, is a member of the Department of Global Health and Social Medicine at Harvard Medical School.

https://www.bostonglobe.com…

Shumlin explains what happened in Vermont

Shumlin reflects on single payer failure

By Neal P. Goswami
Vermont Press Bureau, September 19, 2017

Former Vermont Gov. Peter Shumlin said money, wary lawmakers and timing were the core challenges that ultimately caused his failure to deliver on a promise to implement a single-payer health care system in the state.

The former Democratic governor reflected on that failure Tuesday at a forum at Harvard’s T.H. Chan School of Public Health. Shumlin ran for governor in 2010 on a platform that promised voters a single-payer system.

But he announced after his 2014 re-election bid that his administration would not be moving forward with the plan. He cited the tremendous cost of the program and the burden that would be placed on the state’s limited tax base.

“When you actually get into the numbers and you describe to your people when you move to a premium-driven system to one that’s supported by taxes, the tax rates in Vermont were quite staggering compared to what other people were paying,” Shumlin said. “When I came out and said, ‘Listen, to move from a premium-driven system to a tax-based system you’re going to have an 11.5 percent payroll tax, you’re going to have to have a top 9.5 percent income tax on top of our current state income tax,’ I don’t think that was even the biggest problem.’”

The bigger problem, Shumlin said, was wary lawmakers who feared yearly tax increases to support the system because of growing health care costs.

“I couldn’t with a straight face turn to them and say, ‘No, we’ve got this figured out. There’s going to be so much cost-containment you won’t have to do that,’” the former governor said.

Another fiscal challenge also loomed large — how to build a big enough reserve for the expensive health care system. Shumlin said his administration determined that it would require all of the state’s bonding capacity for a decade to secure a reserve large enough to support the system. That would have prevented the state from bonding for infrastructure improvements during that time.

The changing political winds in Washington was another factor. Shumlin said the Republican takeover of the House and Senate limited the Obama administration’s ability to work with Vermont.

“The [Health and Human Services] secretary said to me, ‘Listen, we want to work with you, we wanted to work with you, but we don’t have the capacity to cut out special deals for Vermont while we’re up there on the hill trying to defend Obamacare,” Shumlin said.

Shumlin, like other governors, was also reeling from the disastrous rollout of the state’s online insurance exchange.

“There was no amending Obamacare because the Republican Congress refused.

“Those things all came together to deliver the most difficult thing I’ve ever had to do, which is turn to the people that elected me and say, ‘We’ve done the work, we’ve done the research, we know how the system would work. This is not fiscally responsible to do in Vermont right now.’”

Shumlin said he opted against forcing the issue on lawmakers who were likely to kill the proposal.

“I chose not to do that. I just felt that really, this was my idea, I owned it and I needed to own its failure,” he said.

Shumlin said he hopes political leaders will push for a national single-payer system as an economic issue and beyond its long-time status as a “fringe, lefty issue.”

“I was wrong. I don’t think little states like Vermont can go it alone,” he said. “I do think that the Vermont story should be an example of how a little state tried, learned, and the lesson should not be no, it should be Hell yes, let’s get it done and let’s do it right, let’s give this benefit to all Americans.”

http://www.vermontpressbureau.com…

***

In Pursuit of a Single-Payer Plan: Lessons Learned

By Peter Shumlin, former Governor of Vermont
Harvard T.H. Chan School of Public Health

30 minute video:
https://www.hsph.harvard.edu…

***

Comment:

By Don McCanne, M.D.

Although the reason often given for Gov. Peter Shumlin’s withdrawal of the single payer legislation for Vermont was that the taxes would be too high, there were other much more important reasons. The taxes would have been largely offset by reductions in health care spending made through the existing channels, so that wasn’t what was holding it back.

An underappreciated but extremely important factor is that Vermont needed the funds that were being used for Medicare, Medicaid and other federal programs. The glib claims that Vermont merely needed to obtain waivers were belied by the reality. The existing waiver programs would not permit Vermont to dump all funds into a single universal risk pool. The Republican Congress certainly was not going to enact the enabling legislation.

Vermont even dropped the single payer label from its legislation since it was clear that they would not be able to enact a bona fide single payer system. As a result, Vermont would not be able to achieve the savings that a single payer system would bring. Further, it could not establish efficient financing measures that would slow the increase in future health care spending to sustainable levels.

Although Shumlin says that little states like Vermont can’t go it alone, it is really not so much Vermont’s size as it is the hurdles built into the existing health care financing infrastructure. This does not mean that states should not move forward with beneficial measures that can provide some transitional relief until we can establish a universal single payer system.

But he does have a clear message for all of us: “I do think that the Vermont story should be an example of how a little state tried, learned, and the lesson should not be no, it should be Hell yes, let’s get it done and let’s do it right, let’s give this benefit to all Americans.”

Yes, let’s give this benefit to all Americans.

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Single-payer health care – its time has come

By Mark Dimondstein
The Plain Dealer (Cleveland.com), September 20, 2017

WASHINGTON, D.C. – Congress is back from its summer recess and the problems with our nation’s health care system haven’t gone away. How to fix health care is once again being hotly debated. Recently, President Donald Trump warned Republican senators that they must do something or be confronted with the dangers of “single-payer” health care. But, single-payer shouldn’t be the boogeyman – its time has come.

As a postal worker and now president of the American Postal Workers Union, I’ve had many occasions to meet with Canadian postal workers. The lives and dreams of postal workers just across Lake Erie are similar to workers in Northeast Ohio and other parts of the United States. One huge difference stands out – Canadian health care. Canadians never worry about being denied access to medical care. Unlike in the United States, no one is forced to choose between food and medicine. A major illness won’t drive them to bankruptcy or out of their homes.

Canada’s single-payer health care system is similar to Medicare but in Canada every man, woman and child has cradle-to-grave coverage for their doctor, hospital and nursing care – with full choice of physicians. The government also negotiates affordable drug costs with pharmaceutical companies.

Imagine how much less stressful our lives would be without co-pays, deductibles, billing for services, lifetime limits or huge insurance premiums. According to University of Massachusetts Economics Professor Gerald Friedman, 95 percent of U.S. households would save money under a single-payer plan.

It is striking that the Canadian success is rarely discussed in the current health care debate. The leadership of both major political parties treat health care as a privilege rather than a human right. The profits of the medical industrial complex sadly take center stage over the people’s interests.

Most of the Democratic Party leadership is wedded to the Affordable Care Act (ACA). While some measures of the ACA should be preserved, such as coverage for the 153 million Americans with pre-existing conditions, the law has failed. It is not affordable. It contains no public option, does nothing to lower pharmaceutical prices, is a boon to the insurance companies and still leaves tens of millions uninsured and millions more with inferior insurance plans.

The failed legislation promoted by the Republican leadership is far worse. The GOP plans would gut Medicaid (used by one in five Americans and two-thirds of nursing home patients). Their plans would drive 22 million people from health insurance rolls, according to the Congressional Budget Office; incentivize employers to eliminate health coverage; limit coverage for pre-existing conditions; and drastically raise medical costs for seniors – all while giving billions in tax breaks to the wealthiest.

Most workers our union represents have employer-based health insurance. Every year we are paying more and receiving fewer benefits. A postal employee typically pays $6,000 a year for their share of family plan premiums – plus co-pays, deductibles and co-insurance. A “Canadian style” system would offer financial relief, even to those currently insured.

Donald Trump was right back in 2000 when he said: “We must have universal health care. Just imagine the improved quality of life for our society as a whole…The Canadian-style, single-payer system…helps Canadians live longer and healthier than Americans…There are fewer medical lawsuits, less loss of labor to sickness, and lower costs to companies paying for the medical care of their employees.”

According to the most recent figures, the United States spends 17.8 percent of GDP on health care – more per capita than any other country. More than 25 percent of health care expenses are administrative – money diverted to needless insurance industry overhead and profits. (Twice that of Canada.) U.S. citizens average $9,000 a year in health-related costs.

Yet, health outcomes are dismal. The United States ranks 34th in life expectancy. (Canada ranks 13.) A 2017 study by the Commonwealth Fund, found that the United States ranks last of the 11 most “developed” countries in health care quality, access, results and efficiency.

The ACA should be replaced with a better system. The recent debate between bad (“Obamacare”) and worse (“Trumpcare”) fails to meet the health care needs of the 99 percent. Let’s learn from our neighbor and demand single-payer universal health coverage – “Medicare for All!”

It is a proven, simple, cost-effective, and just way to heal what ails us.

Mark Dimondstein is president of the 200,000-member American Postal Workers Union and a vice president of the AFL-CIO.

http://www.cleveland.com…

E.J. Dionne’s inadvertent lesson for us

The priority is still to save Obamacare

By E.J. Dionne, Jr.
SouthCoastToday, September 16, 2017

Before supporters of universal health coverage get all wrapped up debating a single-payer system, they need to focus on a dire threat to the Affordable Care Act likely to come up for a vote in the Senate before the end of the month.

The latest repeal bill is an offering from Sens. Lindsey Graham, R-S.C., and Bill Cassidy, R-La., that would tear apart the existing system and replace it with a block grant to the states. Block grants — flows of money for broad purposes with few strings attached — are a patented way to evade hard policy choices. All the tough decisions are kicked down to state capitals, usually with too little money to achieve the ends the block grant is supposed to realize.

This is a matter of urgency because the authority the Senate has to pass Obamacare repeal with just 51 votes expires on Sept. 30. So if the bill comes up, it would likely hit the floor in the last week of this month. All who care about the expansion of health care coverage need to focus their energies on defeating this latest attack on Obamacare. However we eventually arrive at universal coverage, which we must, it will be far easier to get there by building on the ACA.

And assuming the latest repeal effort fails, last week’s push for a single-payer system could come to be seen as a useful initiative provided that “Medicare for All,” as its supporters like to call it, is treated as a goal, not a litmus test. Defining the left pole of the health care debate is helpful, in part because it shows how fundamentally moderate Obamacare is. It is not, as many conservatives have claimed, anything close to a socialist scheme.

And for those whose objective is single-payer, there are many options available that could gradually open the way for it. As Medicare for All’s leading advocate, Sen. Bernie Sanders, I-Vt., noted in an underappreciated tweet in July: “In the short-term, to improve the Affordable Care Act, we should have a public option in 50 states and lower the Medicare age to 55.” Many progressives and moderates who favor universal coverage but are not yet sold on single-payer would embrace options of this sort. Such measures would help a lot of people immediately and make any move to single-payer less disruptive.

http://www.southcoasttoday.com…

***

Comment:

By Don McCanne, M.D.

This column by E.J. Dionne is important because it represents the current most prevalent view on health care reform, written by an intelligent, highly respected journalist with great credibility and uncompromising ethics. We need to listen to him.

The more immediate issue that Dionne discusses is the cruel Graham/Cassidy proposal that would take health care away from millions of people. Since action on this bill is imminent, he calls for focusing our energies on defeating it. He is right. The bill needs to be defeated.

The larger issue here is that he demonstrates where the progressive/liberal camp is headed on long term reform. He describes single payer Medicare for all as the left pole of the health care debate, showing “how fundamentally moderate Obamacare is” in comparison. He then mentions what we are hearing from a multitude of reform advocates – that “there are many options available.” He then dials in on the dual option that has now become so prevalent in the national reform dialogue: “we should have a public option in 50 states and lower the Medicare age to 55,” even quoting Bernie Sanders as the authoritative source for this concept.

It has been repeated so many times that a Medicare buy-in and a public option will lead to single payer that it has become a meme. Everyone knows it’s true, well… just because it is.

A Medicare buy-in would have almost no resemblance to the existing traditional Medicare program. It is much more likely that private plans similar to Medicare Advantage plans would be modified to fit a new market, though difficulties would remain in risk pool management, reinsurance, benefit design, and other features that would require the support of Congress, much as they are now supporting the Medicare Advantage plans to give them an advantage over the traditional Medicare program.

A public option would have basically the same problems – creating a plan which will be public in name only but structured like private plans, except that it would be stripped of essential features to avoid giving it an “unfair” advantage over competing private plans. In fact, this is what Congress did with the public option that was part of the Affordable Care Act before it was pulled from the legislation because of Joe Lieberman’s tantrum.

If we follow either or both of these routes we will end up not only with inferior plans but also with none of the efficiencies or benefits of a single payer system. That will then be used as “proof” that single payer cannot work in the United States. Any further transition to single payer would be aborted.

But then there will be other ways we can do it. We’ll just have to turn everything over to the private insurers, except for high risk patients whose care we taxpayers will have to fund. Then we will have the hybrid system which our progressive friends are clamoring for.

It doesn’t have to be this way, but it could happen unless we mobilize the masses.

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