PNHP

I watched my patients die of poverty for 40 years. It’s time for single-payer.

I watched my patients die of poverty for 40 years. It’s time for single-payer.

By David A. Ansell, M.D.
The Washington Post, September 13, 2017

Sarai was 25 years old when she died of Wilson’s disease, an inherited disorder that causes liver failure. A liver transplant could have cured her, but she was uninsured and was denied an appointment at two prominent Chicago transplant hospitals, including my own. Sarai’s plight was brought to my attention when a local religious group held a hunger strike advocating transplant access for Sarai and other uninsured patients. When she died, her congregation marched seven miles, holding her photograph and lugging coffins emblazoned with her name, to launch a sit-in in front of Northwestern University Hospital. Her death certificate named liver disease as her cause of death, but that’s not true. The real cause was inequality. If the United States had a Medicare-for-all health insurance system, she might have been saved.

In nearly 40 years as a doctor, I witnessed time and again how inequality kills. Those without health insurance, such as Sarai (there are almost 30 million in the country), often cannot access the most basic care, let alone complex specialty care. But the problem is more serious than a simple lack of health insurance. What insurance card you hold can literally be a matter of life and death.

Consider how our current multi-payer health insurance system affects hospitals, clinics and patients. I have practiced at three hospitals along a two-mile strip of Ogden Avenue in Chicago. I spent 17 years at Cook County Hospital, now the John H. Stroger Jr. Hospital of Cook County, rising from intern to chief of general medicine. When I practiced at Cook County Hospital, it was largely a hospital for the uninsured.  Despite many improvements, largely because of Medicaid expansion under the Affordable Care Act, many services, such as screening colonoscopies and hip replacements, are still beyond reach for patients and their doctors. I spent a decade at Mount Sinai Hospital, a not-for-profit hospital for the poor in North Lawndale, a neighborhood of concentrated poverty in Chicago. Sinai cares for a mostly minority population that is mostly uninsured or on Medicaid. In my 27 years at these two safety-net hospitals, not one of my patients received an organ or bone marrow transplant. Yet the organs that fed the transplant centers across the region came from the dying patients in these hospitals. Our patients — the poorest of the poor — gave, but they never received.

For the past 12 years, I have practiced at Rush University Medical Center, an academic medical center replete with the finest care biomedicine can offer. Because my hospital serves a variety of patients with different insurance types — many with private insurance, Medicare or Medicaid, and some uninsured — it is able to afford and offer a vast array of services. But those with the wrong insurance card cannot access the care at my hospital. In contrast, hospitals that only serve the poor and uninsured, such as my two prior hospitals, are more limited in their scope because the payment systems for the uninsured and those on Medicaid constrain their ability to buy new equipment or invest as they need.  Compared with Cook County and Mount Sinai, Rush felt like a different planet my patients and I had landed on, where previously out-of-reach medical care was now available.

I realized that all the doctors and nurses in the world could not cure health-care inequity if the insurance system itself was the problem.

I call my experience on Ogden Avenue “one street, two worlds” because that short stretch of asphalt separates two very different worlds of health and health care: one for those institutions who have patients with better health insurance, and one for those for hospitals who largely serve patients with limited or no insurance.

My experiences also reflect the observations of Princeton economist Angus Deaton, who noted that the United States virtually has an apartheid health-care system. As structural racism has concentrated black and brown poverty into certain Zip codes, the hospitals and clinics serving minority neighborhoods often face severe resource challenges compared with those serving affluent neighborhoods of concentrated advantage. This inequity is only magnified by the way health insurance has been distributed across America. But it not just the poorest who are at risk. Our current multi-payer for-profit health insurance system perpetuates premature death by putting many people at an extreme disadvantage when it comes to affording care. Those who have better health insurance policies can access better care. However, even patients with insurance cards face skyrocketing co-pays, deductibles and pharmaceutical prices that keep them from seeking care. Last year, 27 percent of Americans said they had postponed or avoided getting care they needed because of the cost; 23 percent said they had skipped a recommended test or treatment due to cost; and 21 percent said they had chosen not to fill prescriptions for medication because they couldn’t afford it.

Death rates tell the same story. Since 1980, there have been dramatic gains in life expectancy for the top 20 percent of U.S. earners. At the same time, the poorest 20 percent have seen their life expectancy plummet. While access to health insurance is not the only cause, it certainly contributes to the life expectancy gap. In Canada, with its single-payer health insurance, the life expectancy gap between the rich and the poor narrowed during the same period.

There are three fundamental problems with the patchwork U.S. health insurance landscape that a Medicare-for-all system would resolve. First, our current reliance on for-profit insurance forces working families to pay increasingly burdensome prices for health services and prescription drugs. The Affordable Care Act was never a viable solution, because it relies on the for-profit insurance industry, which is geared to maximize shareholder returns rather than high-quality, low-cost care for all. Meanwhile, taxpayers have funneled billions of dollars to support premiums for individuals and subsidies for insurance companies. Second, Medicaid, the health insurance program for the poor, shares many of these same flaws. The quality of the program varies by state and is a major burden on state budgets. Finally, the current system is inequitable for low-income or uninsured patients. Every day, people such as Sarai die when they could have been saved.

The best solution is a national solution; one that has been implemented by nearly every other developed nation. Medicare, the popular insurance program for those over 65 and people with disabilities, has a 90 percent satisfaction rate. Under a Medicare-for-all program, every worker and business in America would pay into the system through a combination of payroll and other taxes and fees, just as we pay taxes and fees for schools, water and the military. There would be no complex health insurance payments to navigate, no prohibitive co-pays and deductibles, no corporate welfare to boost insurance company profits. Untangling health care from employment would not only free workers to change jobs or start new businesses, but would also eliminate the largest and most stealthy tax loophole in the U.S. tax code: the $250 billion annual tax-free subsidy of employer-based health insurance.

Medicare for all would solve the problems of health-care access for the poor and rural. Such a system would allow hospitals and clinics to survive at a time when many of them — often the largest employers in their communities — are threatened with extinction. Moreover, it creates the opportunity for America to eliminate health inequities and improve life expectancy because, by design, everyone will be in and no one will be left out.

As a doctor, I have a moral obligation to care for patients regardless of their insurance status or ability to pay. But America’s fragmented, for-profit health system forces doctors to violate their Hippocratic oath, the moral contract requiring  us to treat health as a basic human right. I speak for many American physicians when I say I am sick and tired of a health insurance system that harms our patients, many of whom are sick and tired themselves.

The right to health care in America is not an issue of the left or the right. It’s a matter of right and wrong. Winston Churchill reportedly said, “You can always count on the Americans to do the right thing … after they have tried everything else.” Today, Sen. Bernie Sanders (I-Vt.) will introduce a bill in the Senate that will provide a path forward for Medicare for all. Let’s do the right thing. We have tried everything else.

Dr. David A. Ansell is a professor of internal medicine, senior vice president for community health equity at Rush University Medical Center in Chicago, a member of Physicians for a National Health Program, and author of “The Death Gap: How Inequality Kills.”

https://www.washingtonpost.com…

Why We Need Medicare for All

By Sen. Bernie Sanders
The New York Times, September 13, 2017

This is a pivotal moment in American history. Do we, as a nation, join the rest of the industrialized world and guarantee comprehensive health care to every person as a human right? Or do we maintain a system that is enormously expensive, wasteful and bureaucratic, and is designed to maximize profits for big insurance companies, the pharmaceutical industry, Wall Street and medical equipment suppliers?

We remain the only major country on earth that allows chief executives and stockholders in the health care industry to get incredibly rich, while tens of millions of people suffer because they can’t get the health care they need. This is not what the United States should be about.

All over this country, I have heard from Americans who have shared heartbreaking stories about our dysfunctional system. Doctors have told me about patients who died because they put off their medical visits until it was too late. These were people who had no insurance or could not afford out-of-pocket costs imposed by their insurance plans.

I have heard from older people who have been forced to split their pills in half because they couldn’t pay the outrageously high price of prescription drugs. Oncologists have told me about cancer patients who have been unable to acquire lifesaving treatments because they could not afford them. This should not be happening in the world’s wealthiest country.

Americans should not hesitate about going to the doctor because they do not have enough money. They should not worry that a hospital stay will bankrupt them or leave them deeply in debt. They should be able to go to the doctor they want, not just one in a particular network. They should not have to spend huge amounts of time filling out complicated forms and arguing with insurance companies as to whether or not they have the coverage they expected.

Even though 28 million Americans remain uninsured and even more are underinsured, we spend far more per capita on health care than any other industrialized nation. In 2015, the United States spent almost $10,000 per person for health care; the Canadians, Germans, French and British spent less than half of that, while guaranteeing health care to everyone. Further, these countries have higher life expectancy rates and lower infant mortality rates than we do.

The reason that our health care system is so outrageously expensive is that it is not designed to provide quality care to all in a cost-effective way, but to provide huge profits to the medical-industrial complex. Layers of bureaucracy associated with the administration of hundreds of individual and complicated insurance plans is stunningly wasteful, costing us hundreds of billions of dollars a year. As the only major country not to negotiate drug prices with the pharmaceutical industry, we spend tens of billions more than we should.

The solution to this crisis is not hard to understand. A half-century ago, the United States established Medicare. Guaranteeing comprehensive health benefits to Americans over 65 has proved to be enormously successful, cost-effective and popular. Now is the time to expand and improve Medicare to cover all Americans.

This is not a radical idea. I live 50 miles south of the Canadian border. For decades, every man, woman and child in Canada has been guaranteed health care through a single-payer, publicly funded health care program. This system has not only improved the lives of the Canadian people but has also saved families and businesses an immense amount of money.

On Wednesday I will introduce the Medicare for All Act in the Senate with 15 co-sponsors and support from dozens of grass-roots organizations. Under this legislation, every family in America would receive comprehensive coverage, and middle-class families would save thousands of dollars a year by eliminating their private insurance costs as we move to a publicly funded program.

The transition to the Medicare for All program would take place over four years. In the first year, benefits to older people would be expanded to include dental care, vision coverage and hearing aids, and the eligibility age for Medicare would be lowered to 55. All children under the age of 18 would also be covered. In the second year, the eligibility age would be lowered to 45 and in the third year to 35. By the fourth year, every man, woman and child in the country would be covered by Medicare for All.

Needless to say, there will be huge opposition to this legislation from the powerful special interests that profit from the current wasteful system. The insurance companies, the drug companies and Wall Street will undoubtedly devote a lot of money to lobbying, campaign contributions and television ads to defeat this proposal. But they are on the wrong side of history.

Guaranteeing health care as a right is important to the American people not just from a moral and financial perspective; it also happens to be what the majority of the American people want. According to an April poll by The Economist/YouGov, 60 percent of the American people want to “expand Medicare to provide health insurance to every American,” including 75 percent of Democrats, 58 percent of independents and 46 percent of Republicans.

Now is the time for Congress to stand with the American people and take on the special interests that dominate health care in the United States. Now is the time to extend Medicare to everyone.

https://www.nytimes.com…

Single-payer won’t pass now. But its popularity proves our morals are changing.

By Adam Gaffney, M.D.
The Washington Post, September 13, 2017

Single-payer universal health care — once cast as a radical daydream — has moved with staggering swiftness from purported fantasy to palpable possibility. Today, Sen. Bernie Sanders (I-Vt.) released his long-awaited single-payer bill, and a slew of senators now numbering in the double digits have announced their support. This bill will serve as a potent Senate counterpart to Rep. John Conyers Jr.’s (D-Mich.) single-payer bill, now co-sponsored by 117 representatives — a historic and unprecedented majority of House Democrats.  Far from being an impossibility, the idea that we might create a right to health care is starting to feel like an inevitability.

Just last week none other than former senator Max Baucus — a central player in drafting the Affordable Care Act and a previous foe of single-payer reform — embraced single-payer as the next step. As Baucus, quoted by the Bozeman Daily Chronicle, put it: “It’s going to happen.”

But is it? Probably not tomorrow. The regressive right-wing government that recently came within a hair’s breadth of repealing the ACA and gutting the existing health-care safety net — an undertaking it could attempt again — is rather unlikely to pass sweeping single-payer legislation anytime soon. So why do bills like this one deserve any attention?

For one reason: because aspirations structure reality.  And also because this political epoch will end, and with it the intensely unpopular presidency of Donald Trump, which will one day be a distasteful memory. Political change will thus invariably — even if only for a while — make transformative reform possible. And when it does, bills like that of Conyers and Sanders might move from ambition to achievement at a hurried pace.

This has happened before. Shortly after World War II, in 1945, the British Labour Party won a historic parliamentary victory, a contest tantamount to a mandate for a new Britain in which — as historian Donald Sassoon has written — the “citizenship rights which had been the rallying cry of the liberal-democratic condition…would be supplemented by new socio-economic rights” — including the right to health care. The following year, the Labor Parliament passed the National Health Service Act, and two years after that, the National Health Service went into operation: Everyone in that nation thereafter gained access to free, comprehensive health care — an advance that can be described without hyperbole as a civilizational breakthrough.

Circumstances there were, of course, unique. Could something similar happen in the United States? It could — and it has. In 1964, Democrats swept the congressional elections, and the following year, Lyndon B. Johnson signed Medicare and Medicaid into law.  Implementation of Medicare was even more rapid than that of the NHS: Within a year of the law’s signing, 99 percent of the nation’s seniors were enrolled in the universal part of the program.

There is simply no good reason (much less some titanium law of nature) that precludes us from universally expanding Medicare today, which is precisely what some of its architects had in mind decades ago. Nor must this necessarily hinge on some historic electoral sweep: As Baucus’s astonishing single-payer turn demonstrates, when activists transform the narrative around an issue — when they push a policy to center-stage — smart politicians will follow.

Feasibility, of course, is a separate issue from desirability — and what Americans desire is what is quickly changing, as our values evolve.

The gaps in the U.S. health-care system are simply too large to be plugged by the half-measures on offer. Even with the ACA, 28 million — or nearly 9 percent of the nation — remains uninsured. Single-payer would fix that, but covering the uninsured is far from its only goal: What single-payer is uniquely well-suited to do is reduce inequalities imposed by income, race, gender and a host of other factors.

Economic inequality and health inequality are deeply interwoven in 21st-century America. It was for a good and humane reason that the architects of the NHS — like the designers of the Canadian public health-care system — envisioned a universal program with “no charges, except for a few special items,” as an explanatory leaflet sent to each and every residence in Britain shortly before the launch of the service put it.  By covering everyone, while also eliminating co-payments and deductibles — as both bills prudently do (with the exception of prescription drugs in the Sanders’ bill) — we ensure that all receive care depending of their health needs, not their wealth.

But there are also some particularly American health-care inequalities — in race and gender — that must be addressed, and that single-payer could do much to diminish. For instance, today, Hispanics and blacks remain uninsured at substantially higher rates than whites. Moreover, it seems likely that racial minorities — in light of vastly lower average household wealth — are also harder pressed, dollar for dollar, by deductibles or co-payments, as noted in the Harvard Public Health Review.

And additionally, for all the enormous good done by Medicaid, its lower rates of provider payments sometimes contribute to a lower level of access, longer waits for appointments, and — in some instances — effective health-care segregation for the program’s mostly minority participants. Such inequities could be mitigated with a truly universal, single-tier program.

Then there are gender inequalities, namely inadequate access to reproductive health care, especially abortion. Admittedly, a number of policy reforms are needed in this area, but single-payer could make an enormous difference. For a variety of reasons, even insured women can face major barriers in obtaining abortions, and very infrequently rely on private insurance: In 2008, a mere 12 percent of women obtaining an abortion used private insurance to cover the cost, according to the pro-choice Guttmacher Institute. A single-payer program that included access to comprehensive reproductive health care while overriding Hyde — as Sanders’ bill appears to do — would represent an important step toward greater gender equity in health care.

Thus, taken together, the raison d’etre of single-payer reform, are primarily ethical, and only secondarily economic.  Indeed, rising support for single-payer should be seen as part of a larger shift toward more egalitarian values on a host of social and economic issues in America, including on gender and racial equity. At single-payer’s core is the age-old principle of basic human equality, translated to the arena of health. “Health care is a basic human right,” Sen. Elizabeth Warren wrote in an email to her supporters (quoted in Vox) announcing her support of Sanders’ bill, “and it’s time to fight for it.”

The movement for universal health care is, of course, an old one, with many defeats in the past. “Our new Economic Bill of Rights,” Harry S. Truman once said while advocating for a national health insurance program shortly after World War II, “should mean health security for all, regardless of residence, station, or race — everywhere in the United States.” But while Cold War-era scare tactics doomed that effort, they need not sink this one. The sheer popularity of single-payer (53 percent of Americans favor it) and the number of serious politicians now behind it show that we’re changing as a country — for the better.

Dr. Adam Gaffney is an Instructor in medicine at Harvard Medical School and a pulmonary and critical care physician at the Cambridge Health Alliance and serves on the board of directors of Physicians for a National Health Program. Follow him on Twitter @awgaffney.

https://www.washingtonpost.com…

Pharmaceutical firms are using inflated development costs to gouge us

Research and Development Spending to Bring a Single Cancer Drug to Market and Revenues After Approval

By Vinay Prasad, MD; Sham Mailankody, MBBS
JAMA Internal Medicine, September 11, 2017

Key Points

Question: What is the estimated research and development spending for developing a cancer drug?

Findings: In this analysis of US Securities and Exchange Commission filings for 10 cancer drugs, the median cost of developing a single cancer drug was $648.0 million. The median revenue after approval for such a drug was $1658.4 million.

Meaning: These results provide a transparent estimate of research and development spending on cancer drugs and show that the revenue since approval is substantially higher than the preapproval research and development spending.

From the Introduction

The cost of anticancer drugs continues to increase, with drugs routinely priced more than $100, 000 per year of treatment and some nearing the $200, 000 per year threshold. High drug prices have negative effects on patients and society, and groups of physicians, patients, and policymakers have voiced their opposition to these prices. However, one persistent argument in justification of high drug prices is the sizable outlay made by biopharmaceutical firms to develop new drugs. In a widely publicized analysis from the Tufts Center for the Study of Drug Development, the authors estimate $2.7 billion (inflation adjusted for 2017 US dollars) is needed to bring a single drug to the US market. This figure is more than 8 times higher than the $320.0 million (inflation adjusted for 2017 US dollars) estimate to develop one drug reached by the group Public Citizen. Given such divergent estimates, closer examination is warranted.

We focused on publicly traded pharmaceutical companies with only one US Food and Drug Administration (FDA)–approved drug. We used SEC filings from the approximate time of discovery or initial acquisition of the compound to drug approval to estimate the cost to bring one drug to market. Because, in all instances, these companies were simultaneously developing several compounds, our analysis considers the cost of failure (ie, we include R&D costs for each company’s entire portfolio of drugs, of which only one drug was ultimately approved).

Conclusions

Prior estimates for the cost to develop one new drug span from $320.0 million to $2.7 billion. We analyzed R&D spending for pharmaceutical companies that successfully pursued their first drug approval and estimate that it costs $648.0 million to bring a drug to market. In a short period, development cost is more than recouped, and some companies boast more than a 10-fold higher revenue than R&D spending—a sum not seen in other sectors of the economy. Future work regarding the cost of cancer drugs may be facilitated by more, not less, transparency in the biopharmaceutical industry.

http://jamanetwork.com…

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Comment:

By Don McCanne, M.D.

This study confirms that the pharmaceutical firms are using inflated costs of bringing a product to market in order to gouge us. This cries out for government intervention. A well designed single payer system would fix this while addressing a great many of the other problems with our dysfunctional system of financing health care that results in us paying too much for too little.

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

Dr. Adam Gaffney on ‘The Real News’

PNHP national board member Dr. Adam Gaffney appeared on “The Real News” on September 11, 2017 to preview Sen. Bernie Sanders’ Medicare for All Act. He discussed the growing movement for single-payer reform, as evidenced by citizen demands and by the number of legislators backing bills in both the House and the Senate.

Elizabeth Warren: Success is coming from grassroots efforts

Warren dismisses Dem divisions as lawmakers rally around single-payer

By John Bowden
The Hill, September 9, 2017

Massachusetts Sen. Elizabeth Warren (D) dismissed conflict inside the Democratic Party on Friday in a new interview, noting that Democrats are rallying around health care and other issues.

Warren told the editorial board of The Republican on Friday that the Democratic Party has found agreement on the idea that health care should be a guaranteed right for all citizens.

She added that the true strength of the Democratic Party doesn’t come from the party elites, but rather the grassroots activists who shifted the party left on health care.

“We don’t live in a world where a handful of insiders get to run the Democratic Party — we just don’t live in that world,” Warren insisted. “We live in a world where the heart and soul of the Democratic Party is down at the grassroots — this health care fight has shown the power of the grassroots.

“It’s not only that people have shown it to themselves and to each other, they’ve shown it to the leadership, as well,” she added.

Warren on Thursday announced she would join Sens. Kamala Harris (D-Calif.) and Sheldon Whitehouse (D-R.I.) in co-sponsoring legislation from Sen. Bernie Sanders (I-Vt) establishing a single-payer Medicare-for-all health care system.

“I believe it’s time to take a step back and ask: what is the best way to deliver high quality, low-cost health care to all Americans?” Warren said in a statement Thursday.

“Everything should be on the table — and that’s why I’m co-sponsoring Bernie Sanders’ Medicare for All bill that will be introduced later this month.”

http://thehill.com…

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Comment:

By Don McCanne, M.D.

For our purposes, Sen. Elizabeth Warren’s message is not what is happening within the Democratic Party but rather that the recent surge in support for single-payer Medicare for all has originated within the grassroots and not from the political elites.

Yes, the lead taken by Sen. Bernie Sanders certainly has helped to spark the movement. But it is not Bernie Sanders alone who is bringing other politicians on board. When those politicians went to their home districts, it was the demand of the people that woke them up. “Hey, this single payer movement is the real thing.”

The people lead, politicians follow, and that is not a phenomenon limited to the Democratic Party. So gather the grassroots together and lead. Be there, bring others, and do it.

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

Universal healthcare would save businesses billions

By Sunny Aslam, M.D.
Syracuse (N.Y.) Post-Standard, September 8, 2017

To the Editor:

Dr. Dennis Nave writes a vital prescription in “Working Americans need affordable health care, quality education,” (Sept. 1, 2017). Those who build our economy should have what all other developed countries have: universal, guaranteed healthcare. We simply need the political will to get there.

Not only workers benefit from universal healthcare; businesses do. The New York Health Act — one state Senate sponsor away from a majority — would save employers billions by providing a simplified plan that covers all medically necessary care. Imagine your business model if all of your employees and customers have health coverage! State Sens. John DeFrancisco, Patty Ritchie and Pam Helming could tip the balance by sponsoring the New York Health Act.

Medicare-for-all (HR 676) in the U.S. House of Representatives has 117 co-sponsors. We need Republicans like Rep. John Katko, who voted against the American Health Care Act and supports Medicare, to sign on to expanded Medicare-for-all.

Let’s build a grassroots movement to fight the special interests that drain profit and burden the system with huge administrative costs. It will be hard work, but it can be done.

I recently spent hours navigating our wasteful healthcare morass: filling out paperwork for denied medications, trying to get people without insurance the care they need. I would love to see the day when we don’t have to ask patients what type of insurance they have because they are all covered. Please join the fight to help us all.

Dr. Sunny Aslam is a member of Physicians for a National Health Program.

http://www.syracuse.com…

New arrival in the single payer camp: Max Baucus!

Baucus backs single-payer health system

By Gail Schontzler
Bozeman Daily Chronicle, September 8, 2017

It’s time for America to consider seriously a single-payer, government-run health system, says Max Baucus, Montana’s longest serving U.S. senator, former ambassador to China and one of the chief architects of Obamacare.

“My personal view is we’ve got to start looking at single-payer,” Baucus said Thursday night at Montana State University. “I think we should have hearings…. We’re getting there. It’s going to happen.”

It was a startling turnaround for Baucus, who eight years ago was chairman of the powerful Senate Finance Committee and a key Democratic leader in the political battles that ultimately passed the Affordable Care Act.

Back then, Baucus said, he felt adamantly that Congress wouldn’t pass a government-run system like Canada’s. So it was the one alternative he refused to put “on the table” for consideration.

But you can see the difference, Baucus said, when you visit hospitals on either side of the border. In Montana, half a rural hospital will be dedicated to processing medical insurance claims. In Canada, he said, just one small room is needed to verify that patients are residents.

And Americans pay much higher drug prices, he said, because the government can’t negotiate better prices with the drug industry, so U.S. patients end up subsidizing drug prices for the rest of the world.

http://www.bozemandailychronicle.com…

C-SPAN: The Baucus 8:
https://www.youtube.com…

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Comment:

By Don McCanne, M.D.

When Max Baucus was leading the legislative process that resulted in the Affordable Care Act, he refused to allow any formal consideration of single payer. In response, a group of notable single payer advocates – the Baucus 8 – protested at the Senate Finance Committee hearing that theoretically represented all views – except single payer, which was specifically excluded. The Baucus 8 got their message out, and Max Baucus got his capitol police to escort them out, one at a time.

The Baucus 8 did not give up. They have continued in their advocacy work for single payer reform, as have we all. As an example, one of them, Dr. Carol Paris, is now president of PNHP. Eight years later, Max Baucus now says that it is time to seriously consider a single-payer, government-run health system. “It’s going to happen,” he says.

It is tempting to celebrate this as a victory for the Baucus 8 over Max Baucus, but actually it is more than that. It is a bittersweet victory for all of us, including Max Baucus. It is tragic that that so many have continued to face unnecessary financial hardship, physical suffering and even death over the past eight years.

But the victory is that the message got through. Single payer is now inevitable. Although we have many to thank for that, at this moment of Max Baucus’ epiphany, we such give special thanks to the Baucus 8.

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

The Scandalous State of our Healthcare System

Why the Time is Now to Finally Make Healthcare a Right and Not a Privilege

By Paul Y. Song, M.D.
Huffington Post, September 7, 2017

Last week, Senator Kamala Harris boldly announced that she would co-sponsor Senator Bernie Sanders’ upcoming Medicare-for-all legislation and Senator Elizabeth Warren just agreed to do so as well. As the dust settles after yet another failed GOP attempt to repeal the Affordable Care Act (ACA), it is vitally important for everyone to understand why simply preserving the ACA is not good enough.

By now, many of us are aware that despite spending twice as much per capita on healthcare as any industrialized nation, we still have a healthcare system where 29 million Americans are uninsured, tens of thousands of people die each year simply because they lack coverage, and medical illness remains the top cause of bankruptcy.

Even more shocking however, is the 30+ million insured Americans who continue to have such high out-of-pocket costs and deductibles relative to their incomes that they are considered underinsured. Due to this dynamic, one out of three people with insurance will delay seeking care, leading to more advanced disease and poorer outcomes.

Because the ACA was largely written by the private insurance and pharmaceutical industries, it did not regulate insurance rates or address skyrocketing/unaffordable drug prices. As a result, a 2017 Kaiser Family Foundation study revealed that 37% of insured Americans reported difficulty paying their monthly premiums, up from 27% two years ago. For 2018, individuals who purchase coverage without subsidies are expected to get walloped once again with double digit increases in their premiums. And according to a recent study by Prescription Justice, 45 millions Americans did not fill their prescriptions last year because they could not afford to.

Staggering healthcare obligations are also having a negative impact on US business competitiveness. Prior to the bailout, General Motors spent more on healthcare than it did on steel to make cars. Each year, escalating premiums consume more and more of company budgets that could otherwise be used for capital improvements, R&D, and higher wages. With no end in sight, large employers report that health plans will cost more than $14,000 per employee in 2018. And a recent Kaiser Family Foundation study found that companies are shifting more and more of these costs to their employees. Despite stagnant wages, workers’ contributions towards their employer sponsored health insurance premiums rose 83 percent from 2005 to 2015, and the amount employees had to pay for deductibles increased 255 percent from 2006 to 2015. All of this leads to far less take home pay and disposable income. Money that could otherwise be used to help families and our economy is instead going into the pockets of insurance and pharmaceutical executives.

And while the Medicaid expansion was transformative in increasing coverage to many of our poorest disadvantaged communities, very low reimbursements have hindered the ability of these patients to find providers willing to treat them in a timely fashion. This lack of access has had a detrimental effect as many curable diseases are often caught too late.

Meanwhile, despite contributing over $12 billion in taxes each year, undocumented immigrants have been mostly excluded from all federal health programs, leading to more uncompensated care. Hospitals have then used this as an excuse to grossly inflate basic costs of good and services leading to higher liabilities that are passed onto all of us one way or another.

In 1972, the late Shirely Chisholm wrote:

“We have never seen health as a right. It has been conceived as a privilege, available to only those who could afford it. This is the real reason the American healthcare system is in such a scandalous state.”

Sadly, these words continue to ring true over four decades later, but the time is now to finally fix our broken and immoral healthcare system.

Instead of making drastic inhumane cuts or throwing good money after bad with incremental changes that maintain a broken status quo, we must demand bold action to establish a Medicare-for-all program where we no longer treat healthcare as a commodity.

It is the only comprehensive solution that can adequately address all of the significant issues listed above by removing the gross inefficiencies of a bloated fragmented system while controlling costs of premiums, pharmaceuticals, medical procedures, and medical devices through bulk purchasing and fair cost controls. At the same time, it will strengthen and enhance the current Medicare system by greatly expanding the risk pool with younger and healthier individuals.

Establishing Medicare-for-all is no doubt a daunting and complicated task, but not an impossible one. Every other industrialized country in the world covers all of their people at a much lower cost with better health outcomes.

We can too, but it will take serious time, effort, and commitment coupled with real political will.

Representative John Conyers has introduced H.R. 676 for the past 14 years, but for the first time has 118 sponsors. Along with Senator Sanders’ much anticipated Medicare-for-all bill, this will put forward a solid framework from which we can begin to finally have a serious discussion and earnest attempt to bring about the the type of healthcare system we truly deserve, but are just not getting.

Critics will say that we cannot afford this right now. They will point to an earlier Urban Institute study estimating the cost of such a plan at $32 trillion over 10 years. The reality is that we already spent $3.4 trillion on healthcare in 2016, and this is projected to increase an average of 5.6% per year per decade and cost $49 trillion over the next 10 years without addressing any of the serious problems discussed. And besides taxpayers are already paying for two-thirds of every dollar spent on healthcare

Support of Medicare-for-all is at an all-time high and what we cannot afford is to continue the same status quo. We must demand that the rest of our legislators follow Senator Harris’ lead and put their constituents’ health security before corporate interests once and for all.

Paul Y. Song, M.D., is a Board Member of Physicians for a National Health Program and Co-Chair for Campaign for a Healthy California.

http://www.huffingtonpost.com…

Breakthrough editorial in The San Diego Union-Tribune

Medicare for all? Let's copy what works with health care in other nations instead

By The Editorial Board
The San Diego Union-Tribune, September 5, 2017

It’s now clear that creating a single-payer health care system is the top priority of the Democratic Party and millions of Americans.

In California, Assembly Speaker Anthony Rendon, D-Lakewood, made the right call in June when he pulled the plug on a bill creating a state single-payer system. He did so because the measure, Senate Bill 562, didn’t explain how to cover its estimated $400 billion annual cost — triple the state’s general-fund budget. This reasonable decision led to national blowback. Now Rendon plans to hold hearings to discuss how to get to universal health care.

In Washington, the “Medicare for All” bill that Sen. Bernie Sanders, I-Vermont, plans to introduce this month is picking up support, including from Sen. Kamala Harris, D-California. It’s hard to imagine any Democrat winning the party’s presidential nomination in 2020 without backing single-payer.

But it’s time that Republicans started thinking big about health care as well — and stop equating any expanded government role with socialism. According to a study by the American Journal of Public Health, taxes already pay for 64 percent of U.S. health care. The study found that, “At $5,960 per capita, government spending on health care costs in the U.S. was the highest of any nation in 2013, including countries with universal health programs such as Canada, Sweden and the United Kingdom.”

It’s a stunning statistic. Here’s another: A 2015 Commonwealth Fund study found the U.S. spent per capita at least 47 percent more of its gross domestic product on health care than 12 other wealthy, First World nations — yet had among the worst health outcomes, with the exception of treating cancer. The U.S. had the lowest life expectancy.

Any CEO would look at this picture and say the U.S. must do better. Republicans must do the same. Instead of tinkering with — or gutting — the Affordable Care Act, the Trump White House and congressional GOP leaders should consider setting up a commission to examine how to emulate other nations which deliver better outcomes at a lower cost.

Some answers are obvious. In 2009, journalist T.R. Reid chronicled how 20 percent of U.S. health spending goes to “marketing, underwriting, administration and profit,” compared with 4 percent in France and 2 percent in Taiwan. This bloat is created both by the profit motive in insurers’ provision of essential care — which Reid says is unique in the developed world — and the vast complexity of U.S. health care, with dozens of government systems and hundreds of private systems. Simple is better.

“Given our remarkable medical assets … the United States could be, and should be, the best [at health care] in the world,” Reid argues. “To get there, though, we have to be willing to learn some lessons about health-care administration from the other industrialized democracies.”

Amen. This is why Democrats who want universal health care should look for inspiration from the rest of the world, not embrace “Medicare for all.” The same holds for Republicans who don’t like how much U.S. health care costs and who think Obamacare is a clunky mess. Americans’ national pride shouldn’t include reverence for a flawed, costly and eminently improvable health care system.

http://www.sandiegouniontribune.com…

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Comment:

By Don McCanne, M.D.

This is a truly remarkable editorial considering the conservative heritage of The San Diego Union-Tribune. Although the editorial board adheres to its conservative roots by dismissing the label, “Medicare for all,” it makes the case for abandoning our highly dysfunctional health care financing system and turning to models used successfully in other nations – universal systems in which governments play significant roles.

It is a breakthrough acknowledgment that Americans’ national pride shouldn’t include reverence for a flawed and costly system with the vast complexity of the dozens of government systems and hundreds of private systems. “Simple is better,” they state.

It is time that we quit arguing over labels and get down to seriously considering health policies that actually work. An honest assessment will lead to those policies included in the Physicians’ Proposal for Single-Payer Health Care Reform. We’re willing to negotiate changing the single-payer Medicare for all label; we just won’t negotiate exchanging beneficial policies for detrimental ones.

The Physicians’ Proposal:
https://pnhp.org/nhi

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Which emergency department visits are avoidable?

Avoidable emergency department visits: a starting point

By Renee Y. Hsia and Matthew Niedzwiecki
International Journal for Quality in Health Care, August 31, 2017

Abstract:

Objective
To better characterize and understand the nature of a very conservative definition of ‘avoidable’ emergency department (ED) visits in the United States to provide policymakers insight into what interventions can target non-urgent ED visits.

Design/setting
We performed a retrospective analysis of a very conservative definition of ‘avoidable’ ED visits using data from the National Hospital Ambulatory Medical Care Survey from 2005 to 2011.

Participants
We examined a total of 115,081 records, representing 424 million ED visits made by patients aged 18–64 years who were seen in the ED and discharged home.

Main outcome measures
We defined ‘avoidable’ as ED visits that did not require any diagnostic or screening services, procedures or medications, and were discharged home.

Results
In total, 3.3% of all ED visits were ‘avoidable.’ The top five chief complaints included toothache, back pain, headache, other symptoms/problems related to psychosis and throat soreness. Alcohol abuse, dental disorders and depressive disorders were among the top three ICD-9 discharge diagnoses. Alcohol-related disorders and mood disorders accounted for 6.8% of avoidable visits, and dental disorders accounted for 3.9% of CCS-grouped discharge diagnoses.

Conclusions
A significant number of ‘avoidable’ ED visits were for mental health and dental conditions, which the ED is not fully equipped to treat. Our findings provide a better understanding of what policy initiatives could potentially reduce these ‘avoidable’ ED visits to address the gaps in our healthcare system, such as increased access to mental health and dental care.

From the Discussion
Our findings serve as a start to addressing gaps in the US healthcare system, rather than penalizing patients for lack of access, and may be a better step to decreasing ‘avoidable’ ED visits.

https://academic.oup.com…

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Comment:

By Don McCanne, M.D.

This study is helpful in that the authors deliberately used a very conservative definition for which emergency department visits were avoidable. Under such a definition, 97% of visits were appropriate. The significance of this is that, instead of establishing often punitive policies to keep patients from supposedly abusing the emergency department, we should instead establish policies that would improve access for patients to more appropriate health care services and facilities.

A health care system designed to benefit the medical-industrial complex, including the private insurance industry, is going to use resources and incentives differently than a public system designed to benefit patients. Single payer supporters should have no difficulty in conceiving what those differences might be regarding urgent and emergency care.

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Anthem drops ACA coverage in only 17 Missouri counties

Anthem cuts back Obamacare coverage in Missouri to 68 counties

By Michael Erman
Reuters, September 1, 2017

U.S. health insurer Anthem Inc said on Friday that it will no longer offer Obamacare plans in 17 counties in Missouri but will remain in the bulk of the state, covering 68 counties that would not otherwise have Obamacare coverage for their residents.

https://www.reuters.com…

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Comment:

By Don McCanne, M.D.

Boring. Boring. Boring. So Anthem eliminated coverage in 17 Missouri counties. That is so commonplace that it is a wonder that Reuters even reported it. But this is precisely the problem. We have accepted as routine the fact that Anthem and the other private insurers will take care of themselves first and use patients merely as a tool to achieve their own ends.

Contrast that with what an improved Medicare for all would be like. The public administrators would be making efforts to see that all regions are covered. It’s time that we put patients first rather than the rentier shareholders of the private insurers. Our Security and Exchange Commission protects the rentiers with the complicity of Health and Human Services – an agency that should be serving patients instead.

The voters can change that, but we keep hearing that the politics are too difficult. Really?

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