PNHP

The who and how of improving the U.S. health care system

The who and how of improving the U.S. health care system

From Last to First — Could the U.S. Health Care System Become the Best in the World?

By Eric C. Schneider, M.D., and David Squires, M.A.
The New England Journal of Medicine, July 14, 2017

Many Americans believe that the United States has the best health care system in the world, but surprisingly little evidence supports that belief. On the contrary, since 2004, reports from the Commonwealth Fund have consistently rated the performance of the U.S. health care system last among high-income countries, despite the fact that we spend far more on health care than these other countries.

Timely access for people at risk for poor health may be impeded by three features of health care systems: the cost of care and its affordability for individuals, the administrative burden (or hassle) that people confront as they obtain and receive care, and disparities or inequities in the delivery of care based on income, educational attainment, race or ethnic background, or other nonclinical personal characteristics.

The first challenge the U.S. health care system must confront is lack of access to health care. The high-income countries that are top-ranked according to the most recent Fund report (the United Kingdom, Australia, and the Netherlands) offer universal insurance coverage with minimal out-of-pocket costs for preventive and primary care. Affordable and comprehensive insurance coverage is fundamental. If people are uninsured, some delay seeking care, some of those end up with serious health problems, and some of them die.

The second challenge is the relative underinvestment in primary care in the United States as compared with other countries. Other countries make primary care widely, and more uniformly, available. In contrast to the United States, a higher percentage of these countries’ professional workforce is dedicated to primary care than to specialty care, and they enable delivery of a wider range of services at first contact, even at night and on weekends.

The third challenge is the administrative inefficiency of the U.S. health care system. Both patients and professionals in the United States are baffled by the complexity of obtaining care and paying for it. Clinicians and their staff spend countless hours completing documentation to prove that insurance coverage is active, that benefits and services are covered, that services were delivered, and that payment or reimbursement occurred. Coping with the byzantine layers of administration results in high levels of burnout for doctors and other professionals, which can reduce the quality of care. The complexity also affects patients, who receive confusing benefit descriptions, limited information about doctors and hospitals, unintelligible and often unexpected (or “surprise”) bills for services, and unpredictable copayments at labs and pharmacies. It is possible to reduce these barriers to adherence and follow-up by reducing complexity for patients and clinicians: if we changed our reimbursement systems to use global payments, fee schedules, formularies, and defined benefits, it would make benefits and costs more predictable for patients and revenue more predictable for clinicians.

The fourth challenge is the pervasiveness in the United States of disparities in the delivery of care. People with low incomes, low educational attainment, and other social and economic challenges face greater health risks and worse health in all countries, but especially in the United States, which has a less robust social safety net than other high-income countries. Other countries achieve better population health by spending relatively more on social services than on medical care. Along with making insurance coverage available to the poor and ensuring that primary care has a strong presence, dedicating resources through social spending to stable housing, educational opportunities, nutrition, and transportation may reduce the demand for emergency, hospital, and long-term care services.

The United States could achieve the best-performing health care system in the world by undertaking coordinated efforts that address each of these challenges. Ensuring universal and adequate health insurance coverage, strengthening primary care, reducing administrative burden, and reducing income-related disparities by strengthening behavioral health and social service supports could go a long way toward improving the health of the U.S. population.

http://www.nejm.org…

***

Mirror, Mirror 2017: International Comparison Reflects Flaws and Opportunities for Better U.S. Health Care

By Eric C. Schneider, Dana O. Sarnak, David Squires, Arnav Shah, and Michelle M. Doty
The Commonwealth Fund, July 2017

The United States ranks last in health care system performance among the 11 countries included in this study. The U.S. ranks last in Access, Equity, and Health Care Outcomes, and next to last in Administrative Efficiency, as reported by patients and providers. Only in Care Process does the U.S. perform better, ranking fifth among the 11 countries.

http://www.commonwealthfund.org…

***

Comment:

By Don McCanne, M.D.

This NEJM Perspective article is based on the 2017 update of The Commonwealth Fund’s ranking of health care systems in eleven wealthy nations. Once again, the United states ranks last in overall performance, ranking at or near the bottom on access, administrative efficiency, equity, and health care outcomes.

Note particularly the four challenges described in the NEJM commentary: 1) Impaired access, 2) Underinvestment in primary care, 3) Pervasive administrative inefficiency, and 4) Disparities in the delivery of care. These are challenges for which a well designed single payer system would be ideally suited to address, but it must be part of a comprehensive public program addressing other factors contributing to our poor performance, especially in the need for social services.

Canada has a single payer system yet they rank ninth of the eleven systems. This is not a criticism of single payer financing itself, but rather it is a call to be certain that we elect public stewards who design and administer the single payer system with continuing oversight and appropriate intervention in not just the financing of the health care system but also in ensuring appropriate, comprehensive social services.

The authors of “Mirror, Mirror 2017” say that high performance can be achieved with any of three systems: national health service (United Kingdom), single payer (Australia, which requires supplemental insurance), and competing private insurers (Netherlands).

Well, the Netherlands, with its competing private insurers, ranks low in administrative efficiency. Australia requires a combination of public and private insurance and ranks low in equity, wherein varying ability to afford the private plans likely contributes to the inequity. The United Kingdom ranks first overall, but it is unlikely that Americans would support the transfer of our private health care delivery system to the government anytime soon.

So a well designed single payer system seems most appropriate for the United States, and the four challenges described make it clear that the need is urgent.

***

Speaking of a well designed single payer system, nobody has contributed more to our understanding of single payer and its role in achieving health care justice for all than have the co-founders of Physicians for a National Health Program – Steffie Woolhandler and David Himmelstein. Thus it is with great pride that we present the following announcement from Hunter College:

“Hunter College is proud to announce that David Himmelstein and Stephanie Woolhandler – esteemed teachers, brilliant scholars and front-line leaders in the field of public health – have been named Distinguished Professors by The City University of New York.

“’Nationally and around the world, Professors Himmelstein and Woolhandler are known and admired not only for their knowledge, research and expertise, but also for their forceful activism for quality health care,’ said Hunter President Jennifer J. Raab. ‘No one is more deserving of the designation ‘distinguished professor’ than these longtime collaborators.’”

http://www.hunter.cuny.edu…

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

Medicare ACOs Won’t Tell How They Pay Doctors

AJPH Study: Organizations contracting to care for millions of Medicare enrollees won’t disclose whether they penalize doctors for ordering tests, referrals or other expensive care

Public Citizen/PNHP, July 12, 2017

Ninety-one percent of the accountable care organizations (ACOs) that provide care to 9 million Medicare enrollees refuse to disclose their physician payment incentives, according to new research published today in the American Journal of Public Health. ACOs, similar to the HMOs of the 1990s, receive capitation-like payments and keep a portion of savings if they reduce patients’ use of care. Critics worry that ACOs, like HMOs, might pressure their doctors to deny needed care.

The research team from Montefiore Medical Center in New York, City University of New York at Hunter College and the national consumer group Public Citizen surveyed all 426 ACOs participating in Medicare in 2015. The survey asked how each ACO paid its primary care (PCP) and specialist physicians, and whether doctors were financially penalized for ordering tests or making referrals. Despite repeated email and mail surveys directed to the ACO’s designated public contact person, only 39 ACOs (9.2 percent of all those surveyed) provided any information on their physician payment policies.

Among the few ACOs that responded, 85 percent indicated that they tied PCPs’ compensation to quality metrics. Almost half said they offered doctors incentives to reduce care, via bonuses or financial penalties depending on how much care individual doctors ordered for their patients; other times, physician reimbursement was tied to the bonuses or penalties that ACOs received from Medicare.

The researchers noted that in the 1990s there was widespread concern that HMOs were denying patients needed care. This concern led the Centers for Medicare and Medicaid Services (CMS) to survey HMOs in the 1990s regarding their financial incentives and to require that Medicare HMOs publicly disclose those incentives. However, CMS has inexcusably waived the disclosure requirement for ACOs, which started contracting with Medicare in 2011 and, like HMOs, may gain financially by denying care.

“The lack of ACO transparency means that millions of Medicare patients can’t know how their doctors are being paid. Despite this, ACOs have garnered support from policymakers,” said study author Dr. Mayce Mansour, a primary care physician at Mount Sinai who was a lead author of the study and a resident at Montefiore when the study was initiated. “Since polls have shown that patients are wary of incentives for under-care, we wanted to learn more about compensation incentives that may drive physician behavior and could pose a conflict of interest.”

“Millions of Medicare patients now getting their care through ACOs would be anxious to know if their doctors have incentives to skimp on their care in order to do better financially,” said Dr. Sidney Wolfe, founder of and senior adviser to Public Citizen’s Health Research Group. “Most patients can’t currently find out about these incentives, and CMS’ failure to mandate their disclosure is unacceptable.”

“In 1995, I was fired by U.S. Healthcare — now called Aetna — for violating a ‘gag clause’ in my contract, and revealing that the HMO offered doctors big bonuses for denying care to our patients,” reported Dr. David Himmelstein, a distinguished professor at the City University of New York at Hunter College and lecturer in medicine at Harvard who was the study’s senior author. “In response to the ensuing public outcry, Medicare banned gag clauses and required HMOs to disclose how they pay physicians. The same rules should apply to ACOs, which are essentially the modern version of HMOs.”

Public Citizen
https://www.citizen.org…

PNHP
https://www.pnhp.org…

***

Accountable Care Organizations’ Payments to Physicians: Patients Should Have the Right to Know

By Mayce Mansou rMD, Nathan Favini MD, MS, Michael A. Carome MD, Sidney Wolfe MD, Steffie Woolhandler MD, MPH, and David U. Himmelstein MD
American Journal of Public Health (AJPH), August 2017 (online July 12, 2017)

http://ajph.aphapublications.org… (behind paywall)

***

Comment:

By Don McCanne, M.D.

As long as we leave our health care system under the control of the medical/industrial complex, things will never change. Apparently we didn’t learn much from the perversions of HMOs and the managed care revolution since we are granting similar rights to accountable care organizations (ACOs) that allow them to abuse the system and its patients.

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

Medicare For All Is Coming, No Matter What They Say

More than half of all Americans, 53 percent, now want a single-payer system.

By Richard Eskow
Moyers & Company, July 13, 2017

The idea of Medicare for all, or single-payer health care, has grown in popularity so quickly that it was recently an answer on the quiz show Jeopardy.

More than half of all Americans, 53 percent, now want a single-payer plan, up from 40 percent in 1998-2000.

But at the same time, Medicare for all suffers from the rise of a new growth industry: telling Americans what can’t be done to make their lives better. It seems like the nation that used to pride itself on its “can-do” spirit is constantly being told, “No, we can’t.” Why do critics oppose this idea, which could improve the lives of so many?
 
Bernie Opens the Door

Bernie Sanders’ presidential candidacy injected the single-payer idea into the political discourse. That created an opening for Democrats to embrace the idea as they seek to oppose Republican efforts to dismantle Obamacare. These include, significantly, Sen. Elizabeth Warren of Massachusetts.

“President Obama tried to move us forward with health care coverage by using a conservative model that came from one of the conservative think tanks that had been advanced by a Republican governor in Massachusetts,” Warren recently said. “Now it’s time for the next step. And the next step is single-payer.”

Yet even as the idea grows in popularity, opposition to it has become more vocal. Much of that opposition adopts the world-weary pose of the seasoned professional who has abandoned the idealism of his youth and is regrettably forced pass his disillusionment on to those who are more naïve.
 
Krugman for the Opposition

One example of this world-weary opposition is a 2016 column by economist Paul Krugman column entitled “Health Reform Realities.” Krugman argues that Obamacare is the left’s “biggest political success in almost half a century,” that “incumbent players” like insurance companies are “too powerful,” that there would be disruption in a switch to single-payer (more about that shortly), and that it would be “difficult to make that case to the broad public” that they will save more money from out-of-pocket health costs than they will spend in new taxes.

Krugman reiterates this argument in a recent op-ed, writing: “Most of the health economists I know would love to see single-payer — Medicare for all. Realistically, however, that’s too heavy a lift for the time being.”

Elsewhere, Krugman approvingly quoted Ezra Klein, another health care “realist,” for dismissing a major overhaul of the health system as “puppies and rainbows.” Condescending phrases like that are a key element of the “world-weary” style.

Krugman argues that Medicare for all is politically unachievable, despite its growing popularity. But when he’s confronted with a real political problem — Republican governors’ unwillingness to work with Obamacare’s Medicaid provisions — he waves the problem away, saying only that “Republicans show no interest in making that happen.”

A health plan whose ultimate success relies on cooperation from Republican politicians and for-profit insurance companies? Now that’s “puppies and rainbows.”
 
False Hopes

But then Krugman has been misjudging the politics of health care for at least a decade now. In the 2007 primaries, a mandate-driven plan much like “Obamacare” was proposed by John Edwards and quickly embraced by Hillary Clinton. Krugman insisted on characterizing it as “universal health coverage.” We chided him for it at the time, since it was always clear (or should have been) that many people would remain uninsured under such a program.

Krugman also misinterpreted a 2009 poll somewhat. The poll, conducted by The Boston Globe and the Harvard School for Public Health, found that 79 percent of Massachusetts residents wanted to keep the law. A closer reading indicated the political dangers facing Obamacare. Support for the law had begun to slip, even without the Republican onslaught that everyone should have seen coming at the national level. Residents were “evenly split” on whether the law could continue without changes. A majority wanted to see the law changed, with cost reductions being the primary concern.

Health care costs, even after the Affordable Care Act, are at crisis levels. The actuarial firm Milliman calculates that the average family of four with “good” employer-based PPO coverage will pay more than $11,000 in out-of-pocket expenses this year. So when Krugman writes that “most Americans under 65 are covered by their employers and are reasonably happy with that coverage,” and that “they would understandably be nervous about any proposal to replace that coverage with something else” — well, I wouldn’t be so sure about that.
 
The Trillion-Dollar Miscalculation

The Washington Post editorial board took a harder line than Krugman, weighing in recently with an editorial entitled, “Single-payer health care would have an astonishingly high price tag.” The “astonishing” figure is derived, not from a dispassioned analysis of all health plans, but from a single, highly controversial analysis of a single plan. The Urban Institute reviewed Bernie Sanders’ single-payer proposal in 2016 and concluded that it would increase government spending by $32 trillion over 10 years. Single-payer opponents have been citing that figure ever since.

But that figure is “ridiculous,” according to Steffie Woolhandler and David Himmelstein of the City University of New York School of Public Health and Harvard Medical School. In a detailed rebuttal, they note that the Urban Institute’s findings “project outlandish increases in the utilization of medical care, ignore vast savings under single-payer reform, and ignore the extensive and well-documented experience with single-payer systems in other nations — which all spend far less per person on health care than we do.”

The Post’s editors insist that “the public piece of the American health-care system has not proven itself to be particularly cost-efficient,” but this is misleading at best. Medicare, our country’s only nationally run health system, has much lower overhead costs and inflation rates than private-sector health care. You could even say they’re “astonishingly” lower:

Medicare’s overhead amounts to 2 percent of total costs, versus 12-14 percent for private insurers, while annual cost increases between 2010 and 2015 were 1.4 percent for Medicare and more than double that (3.0 percent) for private insurance.

It’s true that our government’s health care programs are costlier than their European equivalents. But what The Post’s editors fail to mention is that private profit-seeking is largely responsible for the additional cost. Medicare is forced to share the road with private-sector insurers who can drive rates up, especially when for-profit corporations are increasingly driving every aspect of treatment from hospital care to provider practice management. A single-payer health system could set rates and design treatment guidelines that are based on best practices and are subject to public debate, unlike private plans.
 
A Change is Gonna Come

The transition to a single-payer system will be complex, but despite what the no-can-doers say, it is achievable. None of the obstacles that are cited are insurmountable.

One-third of our health economy is already managed through government programs. Our best minds should be tackling the challenge of reforming the remaining two-thirds. We have already have built some of the infrastructure and expertise we will need.

Medicare for all is not only achievable. It’s inevitable. Health-care costs are already too high for most Americans, even those with “good” insurance. The demand for a better-run public system will only grow in the years to come.

It’s easy to understand why The Washington Post, with its history of hostility to social spending, would oppose Medicare for all. But why is there such entrenched opposition among some liberals? Some Democrats want to defend the Affordable Care Act out of loyalty, because it’s a Democratic program.

Some people have developed deep expertise in the current, flawed system. Consciously or unconsciously, they will be inclined to resist changes that render their knowledge obsolete. Other people want to be proven right about politics, and they’ve staked their reputation on claiming that single-payer is a “hard sell” because it will raise taxes.

Actually, it’s an easy sell: I can save you thousands of dollars a year by replacing a terrible system with a much better one. People say Medicare for all is “politically unfeasible.” But the past 10 years have taught us that it’s politically unfeasible to aim for anything less.

Many single-payer advocates are also defending the ACA today for a very simple reason: People will die if it’s repealed. But people are dying right now because we don’t have a national health care system.

The best way to defend the ACA is the way Bernie Sanders is doing it. Sanders is barnstorming the country condemning Republican plans to gut the law, a move that would cause tens of thousands of needless deaths to give millionaires and billionaires a tax cut. But he is also making it clear that the ultimate goal — the goal that reflects both the public’s needs and our shared progressive values — is Medicare for all.

Until we achieve health care for all, it’s our health itself that is in jeopardy.

http://billmoyers.com…

Medicare For All Is Coming, No Matter What They Say

More than half of all Americans, 53 percent, now want a single-payer system.

By Richard Eskow
Moyers & Company, July 13, 2017

The idea of Medicare for all, or single-payer health care, has grown in popularity so quickly that it was recently an answer on the quiz show Jeopardy.

More than half of all Americans, 53 percent, now want a single-payer plan, up from 40 percent in 1998-2000.

But at the same time, Medicare for all suffers from the rise of a new growth industry: telling Americans what can’t be done to make their lives better. It seems like the nation that used to pride itself on its “can-do” spirit is constantly being told, “No, we can’t.” Why do critics oppose this idea, which could improve the lives of so many?
 
Bernie Opens the Door

Bernie Sanders’ presidential candidacy injected the single-payer idea into the political discourse. That created an opening for Democrats to embrace the idea as they seek to oppose Republican efforts to dismantle Obamacare. These include, significantly, Sen. Elizabeth Warren of Massachusetts.

“President Obama tried to move us forward with health care coverage by using a conservative model that came from one of the conservative think tanks that had been advanced by a Republican governor in Massachusetts,” Warren recently said. “Now it’s time for the next step. And the next step is single-payer.”

Yet even as the idea grows in popularity, opposition to it has become more vocal. Much of that opposition adopts the world-weary pose of the seasoned professional who has abandoned the idealism of his youth and is regrettably forced pass his disillusionment on to those who are more naïve.
 
Krugman for the Opposition

One example of this world-weary opposition is a 2016 column by economist Paul Krugman column entitled “Health Reform Realities.” Krugman argues that Obamacare is the left’s “biggest political success in almost half a century,” that “incumbent players” like insurance companies are “too powerful,” that there would be disruption in a switch to single-payer (more about that shortly), and that it would be “difficult to make that case to the broad public” that they will save more money from out-of-pocket health costs than they will spend in new taxes.

Krugman reiterates this argument in a recent op-ed, writing: “Most of the health economists I know would love to see single-payer — Medicare for all. Realistically, however, that’s too heavy a lift for the time being.”

Elsewhere, Krugman approvingly quoted Ezra Klein, another health care “realist,” for dismissing a major overhaul of the health system as “puppies and rainbows.” Condescending phrases like that are a key element of the “world-weary” style.

Krugman argues that Medicare for all is politically unachievable, despite its growing popularity. But when he’s confronted with a real political problem — Republican governors’ unwillingness to work with Obamacare’s Medicaid provisions — he waves the problem away, saying only that “Republicans show no interest in making that happen.”

A health plan whose ultimate success relies on cooperation from Republican politicians and for-profit insurance companies? Now that’s “puppies and rainbows.”
 
False Hopes

But then Krugman has been misjudging the politics of health care for at least a decade now. In the 2007 primaries, a mandate-driven plan much like “Obamacare” was proposed by John Edwards and quickly embraced by Hillary Clinton. Krugman insisted on characterizing it as “universal health coverage.” We chided him for it at the time, since it was always clear (or should have been) that many people would remain uninsured under such a program.

Krugman also misinterpreted a 2009 poll somewhat. The poll, conducted by The Boston Globe and the Harvard School for Public Health, found that 79 percent of Massachusetts residents wanted to keep the law. A closer reading indicated the political dangers facing Obamacare. Support for the law had begun to slip, even without the Republican onslaught that everyone should have seen coming at the national level. Residents were “evenly split” on whether the law could continue without changes. A majority wanted to see the law changed, with cost reductions being the primary concern.

Health care costs, even after the Affordable Care Act, are at crisis levels. The actuarial firm Milliman calculates that the average family of four with “good” employer-based PPO coverage will pay more than $11,000 in out-of-pocket expenses this year. So when Krugman writes that “most Americans under 65 are covered by their employers and are reasonably happy with that coverage,” and that “they would understandably be nervous about any proposal to replace that coverage with something else” — well, I wouldn’t be so sure about that.
 
The Trillion-Dollar Miscalculation

The Washington Post editorial board took a harder line than Krugman, weighing in recently with an editorial entitled, “Single-payer health care would have an astonishingly high price tag.” The “astonishing” figure is derived, not from a dispassioned analysis of all health plans, but from a single, highly controversial analysis of a single plan. The Urban Institute reviewed Bernie Sanders’ single-payer proposal in 2016 and concluded that it would increase government spending by $32 trillion over 10 years. Single-payer opponents have been citing that figure ever since.

But that figure is “ridiculous,” according to Steffie Woolhandler and David Himmelstein of the City University of New York School of Public Health and Harvard Medical School. In a detailed rebuttal, they note that the Urban Institute’s findings “project outlandish increases in the utilization of medical care, ignore vast savings under single-payer reform, and ignore the extensive and well-documented experience with single-payer systems in other nations — which all spend far less per person on health care than we do.”

The Post’s editors insist that “the public piece of the American health-care system has not proven itself to be particularly cost-efficient,” but this is misleading at best. Medicare, our country’s only nationally run health system, has much lower overhead costs and inflation rates than private-sector health care. You could even say they’re “astonishingly” lower:

Medicare’s overhead amounts to 2 percent of total costs, versus 12-14 percent for private insurers, while annual cost increases between 2010 and 2015 were 1.4 percent for Medicare and more than double that (3.0 percent) for private insurance.

It’s true that our government’s health care programs are costlier than their European equivalents. But what The Post’s editors fail to mention is that private profit-seeking is largely responsible for the additional cost. Medicare is forced to share the road with private-sector insurers who can drive rates up, especially when for-profit corporations are increasingly driving every aspect of treatment from hospital care to provider practice management. A single-payer health system could set rates and design treatment guidelines that are based on best practices and are subject to public debate, unlike private plans.
 
A Change is Gonna Come

The transition to a single-payer system will be complex, but despite what the no-can-doers say, it is achievable. None of the obstacles that are cited are insurmountable.

One-third of our health economy is already managed through government programs. Our best minds should be tackling the challenge of reforming the remaining two-thirds. We have already have built some of the infrastructure and expertise we will need.

Medicare for all is not only achievable. It’s inevitable. Health-care costs are already too high for most Americans, even those with “good” insurance. The demand for a better-run public system will only grow in the years to come.

It’s easy to understand why The Washington Post, with its history of hostility to social spending, would oppose Medicare for all. But why is there such entrenched opposition among some liberals? Some Democrats want to defend the Affordable Care Act out of loyalty, because it’s a Democratic program.

Some people have developed deep expertise in the current, flawed system. Consciously or unconsciously, they will be inclined to resist changes that render their knowledge obsolete. Other people want to be proven right about politics, and they’ve staked their reputation on claiming that single-payer is a “hard sell” because it will raise taxes.

Actually, it’s an easy sell: I can save you thousands of dollars a year by replacing a terrible system with a much better one. People say Medicare for all is “politically unfeasible.” But the past 10 years have taught us that it’s politically unfeasible to aim for anything less.

Many single-payer advocates are also defending the ACA today for a very simple reason: People will die if it’s repealed. But people are dying right now because we don’t have a national health care system.

The best way to defend the ACA is the way Bernie Sanders is doing it. Sanders is barnstorming the country condemning Republican plans to gut the law, a move that would cause tens of thousands of needless deaths to give millionaires and billionaires a tax cut. But he is also making it clear that the ultimate goal — the goal that reflects both the public’s needs and our shared progressive values — is Medicare for all.

Until we achieve health care for all, it’s our health itself that is in jeopardy.

http://billmoyers.com…

Benefiting pharmaceutical rent seekers

The Private Equity Firm That Quietly Profits on Top-Selling Drugs

By Randall Smith
The New York Times, July 8, 2017

Cashing in on rising drug prices often unleashes an outcry from consumers and politicians.

But a little-known private equity investor, Royalty Pharma, has built an unusual investment portfolio valued at $15 billion — it buys up the rights to royalties on future drug sales — while largely avoiding public controversy. By its own count, Royalty Pharma owns partial rights to seven of the 30 top-selling drugs in the United States, including giants like Humira, the arthritis treatment that is the single biggest-selling medication in America. And its deals have been getting larger.

While Royalty Pharma has benefited by riding the rising tide of drug prices, the drug companies play the largest role in setting prices. George Lloyd, Royalty Pharma’s executive vice president and general counsel, said: “Royalty Pharma has no influence over how drugs in which it invests are priced. These prices are set by the marketer of the product, and we play no role in that process.”

To make big money on promising drugs, investors like venture capital firms and biotechnology funds typically place long-shot bets on drugs that are still in the development stage. Royalty Pharma, based in New York, steps in later in the game: It generally buys rights to the royalties on drugs that have already been approved for sale by regulators. It buys them from patent holders, often hospitals or universities, that want to convert their future royalties into cash right now.

Royalty Pharma has successfully created “a new segment of the investment management industry,” which has helped offset a decline in other types of funds for drug investments, said Andrew Lo, a finance professor at the Massachusetts Institute of Technology’s Sloan School of Management, in a 2014 study written with Sourya Naraharisetti of M.I.T. and Duke University.

Royalty Pharma’s revenues have risen an average of 30 percent annually, from $161 million in 2005 to $2.47 billion in 2016, according to company material.

https://www.nytimes.com…

***

Comment:

By Don McCanne, M.D.

As we look at some of the innovative approaches in health care financial management, we should always ask ourselves, how does this benefit the patient?

Here we have a financial intermediary placing bets that the pharmaceutical industry will continue to gouge its ultimate customers – the patients – using outrageous pricing practices for its pharmaceutical products. This intermediary provides us with a prime example of rent seeking – scooping up large amounts of funds without providing any tangible product.

And the benefit to the patient? None, but worse than that – the patient is harmed by having to pay higher prices, either directly or indirectly, when the entities pricing drugs include in their prices the funds drawn off by these superfluous intermediaries. Of course, there are many other useless intermediaries, not only in pharmaceuticals, but in the rest of the medical-industrial complex as well.

Isn’t it about time that we tailor our health care financing system to serve patients rather than rent seekers and others who drain our resources while shorting patients on essential health care services?

We desperately need to replace our dysfunctional health care financing system with a well designed single payer system. Instead of standing by and watching the politicians struggle with forcing upon us highly flawed health financing policies that cater especially to stakeholders, we should mobilize our forces of citizen action – now – because, if we don’t, they’re going to do it to us again.

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

Medicare ACOs Won’t Tell How They Pay Doctors: American Journal of Public Health Study

Organizations contracting to care for millions of Medicare enrollees won't disclose whether they penalize doctors for ordering tests, referrals or other expensive care

FOR IMMEDIATE RELEASE, July 12, 2017

Contact: Clare Fauke, PNHP communications specialist, 312-782-6006, clare@pnhp.org

WASHINGTON, D.C. – Ninety-one percent of the accountable care organizations (ACOs) that provide care to 9 million Medicare enrollees refuse to disclose their physician payment incentives, according to new research published in the American Journal of Public Health. ACOs, similar to the HMOs of the 1990s, receive adjusted per-person capitation-like payments and keep a portion of savings if they reduce patients’ use of care. Critics worry that ACOs, like HMOs, might pressure their doctors to deny needed care.

The research team from Montefiore Medical Center in New York, City University of New York at Hunter College and the national consumer group Public Citizen surveyed all 426 ACOs participating in Medicare in 2015. The survey asked how each ACO paid its primary care (PCP) and specialist physicians, and whether doctors were financially penalized for ordering tests or making referrals. Despite repeated email and mail surveys directed to the ACO’s designated public contact person, only 39 ACOs (9.2 percent of all those surveyed) provided any information on their physician payment policies.

Among the few ACOs that responded, 85 percent indicated that they tied PCPs’ compensation to quality metrics. Almost half said they offered doctors incentives to reduce care, via bonuses or withholds (financial penalties) on how much care individual doctors ordered for their patients; other times, physician reimbursement was tied to the bonuses or penalties that ACOs received from Medicare.

The researchers noted that in the 1990s there was widespread concern that HMOs were denying patients needed care. This concern led the Centers for Medicare and Medicaid Services (CMS) to survey HMOs in the 1990s regarding their financial incentives and to require that Medicare HMOs publicly disclose those incentives. However, CMS has inexcusably waived the disclosure requirement for ACOs, which started contracting with Medicare in 2011 and, like HMOs, may gain financially by denying care.

“The lack of ACO transparency means that millions of Medicare patients can’t know how their doctors are being paid. Despite this, ACOs have garnered support from policymakers,” said study author Dr. Mayce Mansour, a primary care physician at Mount Sinai who was a lead author of the study and a resident at Montefiore when the study was initiated. “Since polls have shown that patients are wary of incentives for under-care, we wanted to learn more about compensation incentives that may drive physician behavior and could pose a conflict of interest.”

Dr. Nathan Favini, also a lead author of the study, said, “The public’s trust is absolutely critical for any health reform effort to succeed. ACOs should learn from the backlash against HMOs, disclose how they pay their physicians and make sure their providers are not cutting back on necessary care.”

“Millions of Medicare patients now getting their care through ACOs would be anxious to know if their doctors have incentives to skimp on their care in order to do better financially,” said Dr. Sidney Wolfe, founder of and senior adviser to Public Citizen’s Health Research Group. “Most patients can’t currently find out about these incentives, and CMS’ failure to mandate their disclosure is unacceptable.”

“In 1995, I was fired by U.S. Healthcare — now called Aetna — for violating a ‘gag clause’ in my contract, and revealing that the HMO offered doctors big bonuses for denying care to our patients,” reported Dr. David Himmelstein, a distinguished professor at the City University of New York at Hunter College and lecturer in medicine at Harvard who was the study’s senior author. “In response to the ensuing public outcry, Medicare banned gag clauses and required HMOs to disclose how they pay physicians. The same rules should apply to ACOs, which are essentially the modern version of HMOs.”

*****

“Accountable Care Organizations’ Payments to Physicians: Patients Should Have the Right to Know,” by Mayce Mansour, M.D., Nathan Favini, M.D., M.S., Michael A. Carome, M.D., Sidney Wolfe, M.D., Steffie Woolhandler, M.D., M.P.H., and David U. Himmelstein, M.D. American Journal of Public Health.  Published online July 12, 2017.  A copy of the study is available to members of the media by contacting clare@pnhp.org.

Disclosures: Drs. Woolhandler and Himmelstein co-founded Physicians for a National Health Program (www.pnhp.org), a nonprofit educational and research organization that supports a single-payer national health plan.

Medicare for all: The best replacement for Obamacare

By Justine McCabe, Ph.D., and John R. Battista, M.D.
Connecticut Viewpoints, July 12, 2017

The only viable solution to our ongoing national healthcare crisis has waited in the wings for a long time. Teddy Roosevelt included the idea in his 1912 platform. President Truman proposed it in 1945. President Johnson succeeded – partly – with Medicare. Now more than ever, single-payer national health insurance needs to move to the national stage for serious consideration.

Significantly, there is, again, growing public support for single payer. An April Economist/YouGov poll found that a majority of Americans support “expanding Medicare to provide health insurance to every American.” Last year, Gallup polling found 58 percent of Americans support replacing the ACA with a federally funded health insurance system for all.

Indeed, our CT Democratic legislators should take notice: in a 6/23/17 Pew poll, 52 percent of Democrats, 64 percent of liberal Democrats, and “Fully 66 percent of Democrats and Democratic leaners ages 18 to 29” support a single national health insurance system. An April survey found nearly half of physicians supported single payer, particularly because of its time-saving simplicity relative to the current multi-payer, for-profit system.

As health caregivers, our experience reflects public support for single-payer system despite an unresponsive federal government. For example, in 2000, we introduced a single-payer bill to the Connecticut General Assembly, “The CT Health Care Security Act.” Strikingly, people – often in other legislative hearings – showed up in large numbers to support our bill then before the Labor Committee (where it was passed, before dying). The CT Human Services Committee audience literally broke into applause at our suggestion that the committee reject proposed changes to Medicaid and transform the program into single-payer insurance for the state.

Yet, despite strong public support for single payer, our federal government has tried to suppress it, dismissing this option during the ACA hearings of 2009: no single-payer advocate was included in then-U.S. Sen. Max Baucus’ (D-Montana) health care hearings despite support by 60 percent of Americans. Those trying to speak from the audience were arrested.

Our government has even tried to hide public support. In our 2006 op-ed in The Hartford Courant (“Seeking Coverage for All”) we described a government-sponsored task force charged with seeking Americans’ opinion on improving our health care system. It found that people around the country – including CT – overwhelmingly supported a national health insurance program. Connecticut respondents ranked national health insurance first over all other possible reforms. Yet, in their final report (September 2006) this “Citizens’ Health Care Working Group” excluded citizens’ choice – single payer – from their recommendations to Congress.

Senate Republicans have tabled a vote on their approach to replacing the Obamacare/Affordable Care Act (ACA). A June PBS/Marist national poll reveals that only 17 percent of Americans approve of what they’ve seen of the plan – with good reason. According to the Congressional Budget Office, 22 million Americans would lose health insurance under this Republican proposal.

Moreover, according to the Centers for Disease Control, there are still another 28.6 million people with no health insurance despite the ACA. If the Republican bill passes, we, the wealthiest country in the world, would have 50 million people – about 16 percent of the population – without health insurance. That means less primary care, increased use of expensive “ER care,” as well as an increase in mortality associated with being uninsured. And even if our health care financing system remains the ACA, national health care expenditures are projected to increase from 17 to 20 percent of GDP by 2025 according to the actuaries of the Centers for Medicare and Medicaid Services (CMS).

Let’s face it. Our current health care financing system is simply incapable of containing costs.

How do we solve the two main problems constituting our health care crisis: lack of universality and uncontainable costs? For-profit private health system will never solve either of these central issues.

We need a paradigm change.

Single payer resolves these problems. Precisely because it is not-for-profit, unlike private health insurance, it does not spend 18 cents of each health dollar on administrative costs – advertising/marketing, policy underwriting, multimillion-dollar executive compensation, profits for investors. By contrast, Medicare, a single-payer system, is highly efficient with about 2 percent administrative cost.

So savings from our for-profit health care system to single payer could provide health insurance for everyone and keep costs down not only by eliminating the inherently high administrative costs of private health insurance, but also by negotiating global hospital budgets and prescription drugs in bulk. Single-payer systems succeed primarily because they spread risk across the whole population. Such a vast pool includes both young and old, healthy and ill, recognizing the reality that everyone eventually gets sick; everyone eventually dies.

Advocates of for-profit health insurance will tell you that we have the best health care in the world. True but only if you can pay for it. In reality, the U.S. spends twice as much as developed nations with national health insurance – we spend the most per capita anywhere – $9,237 – yet we have poorer health outcomes. For example, the U.S. ranks 12th in life expectancy among the 12 wealthiest industrialized countries, according to the Kaiser Foundation.

Single-payer health insurance, like Medicare, is not socialized medicine. It is a health insurance payment mechanism not a health delivery plan. Such a system would not own hospitals, or employ doctors and nurses. Like Canada’s national health insurance program, single payer/Medicare-for-all would continue the U.S. tradition of fee-for-service with choice of any willing provider. Imagine the boon to small businesses if every individual already had health insurance; for people who keep dissatisfying jobs just to keep their health insurance.

The current Republican challenge to the ACA provides another opportunity for Americans to insist on a health care plan that provides insurance for everyone while containing costs. Let’s insist that our representatives transform Medicare to Medicare-for-All.

Justine McCabe, Ph.D., is a clinical psychologist, and John Battista, M.D., is a psychiatrist at Riverbend Psychiatric Associates in New Milford.

https://ctviewpoints.org…

Medicare for All wins backing of conservative Southern Democrats

By Sue Sturgis
Facing South, July 12, 2017

As congressional Republicans try to pass an unpopular plan that would roll back the Affordable Care Act (ACA) and cause an estimated 22 million Americans to lose their health insurance, a House bill to expand the publicly-funded Medicare program from just senior citizens to every American is picking up record support — and not just among the usual progressive suspects but also from conservative Southern Democrats.

First introduced in 2003 by Rep. John Conyers, a Michigan Democrat and Congress’s longest-serving member, the Expanded and Improved Medicare for All Act (H.R. 676) would provide every U.S. resident with free medically necessary care including primary care and prevention, dietary and nutritional therapies, prescription drugs, emergency care, long-term care, mental health services, dental services and vision care.

It would be paid for with existing health care funds and by raising personal income taxes on the top 5 percent of income earners, instituting a progressive excise tax on payroll and self-employment income, and taxing unearned income and stock and bond transactions. U.S. Sen. Bernie Sanders (I-Vermont), who advocated for single-payer insurance during his unsuccessful 2016 presidential run, has said he will introduce similar legislation in the Senate following the vote on the Republican ACA rollback plan.

Medicare for All has the backing of numerous medical groups such as the American Nurses Association, the American Public Health Association and the American Medical Association’s student branch. Other groups that have endorsed it include the Consumer Federation of America, the League of Women Voters and the U.S. Conference of Mayors.

During the last Congress, Conyers’ bill picked up 62 cosponsors, all Democrats. Seven months into this Congress, it already has 113 cosponsors — a majority of the 193-member Democratic caucus.

That surge in support has come amid a public debate over health care that’s shifted the politics leftward. For example, a recent national survey by the Pew Research Center found that 60 percent of Americans now say the federal government should be responsible for ensuring health care coverage for all and 33 percent favor a single-payer approach like Medicare for All — up by 12 points since 2014 and 5 points just since January.

“I have never seen more enthusiasm and energy behind this issue than what I’m seeing today,” Conyers said in a statement. “I will keep introducing this bill as long as it takes because access to health care — not just health insurance, but quality, affordable care — is a universal right, not a privilege for those who can afford it.”

Blue Dogs sign on

The Medicare for All bill has long had strong support from Conyers’ fellow Congressional Black Caucus members and House progressives, and it continues to pick up new support among liberal and centrist Democrats.

For example, Rep. David Price of North Carolina’s 4th Congressional District — a safely Democratic district that includes parts of Raleigh and Durham and all of Chapel Hill — signed on as a cosponsor for the first time on April 3. That was less than a month after he told a constituent at a local town hall meeting where health care was a leading concern that now was not the time to press the single-payer option. Price spokesperson Lawrence Kluttz explained the lawmaker’s change of heart.

“Congressman Price co-sponsored the so-called Medicare for All bill in direct response to a request from his constituents; he also feels that it’s important to signal his support for universal health care,” Kluttz told Facing South. However, he noted, Price doesn’t believe the proposal is feasible under GOP leadership and intends to focus on defending the protections of the ACA.

Though Medicare for All might not be feasible right now, it’s starting to win over a tough crowd: conservative Democrats from red states in the South.

Of the bill’s 113 current cosponsors, four are members of the conservative Democrats’ Blue Dog Coalition. Two of them — Mike Thompson and Lou Correa — represent districts in California, which has been leading the state-level push for a single-payer health program, though the proposal was blocked recently by the Democratic leadership.

The other two Blue Dogs cosponsoring Medicare for All are from the South. Vicente Gonzalez, who was elected last year to represent South Texas’ 15th Congressional District, signed on on April 17. Jim Cooper, who has represented Middle Tennessee’s 5th Congressional District since 2003 and who served its 4th Congressional District from 1983 to 1995, signed on on April 25. Both seats are considered safely Democratic.

Neither Gonzalez nor Cooper released official statements announcing their cosponsorship. A spokesperson for Gonzalez’s office said on background that the congressman signed on after hearing concerns about health care from older constituents, while Cooper’s office did not immediately respond to a request for comment. But conditions in their districts and states, both of which declined to expand Medicaid under the ACA, offer clues as to why they might see a need for Medicare for All.

Gonzalez’s district stretches from east of San Antonio south to the Mexican border and is 80 percent Hispanic. Between 2013 and 2015, with the ACA in force, the number of uninsured residents there dropped by 13 percent, but 205,000 still lacked health coverage, according to the State Health Access Data Assistance Center (SHADAC). The Republican health care plan would result in an additional 105,000 district residents losing coverage, an analysis by the Center for American Progress (CAP) found.

The population of Cooper’s district, which includes Nashville and communities west of the city, is over 23 percent black compared to 17 percent of the state overall. The number of uninsured district residents dropped by over 22 percent between 2013 and 2015, but more than 92,000 still lacked health insurance, according to SHADAC. Under the current Republican health care proposal, the number of uninsured in the district could grow by 79,600, CAP found.

Cooper, who has called the GOP health care bill “a national tragedy,” has not always been a progressive on health care. In 1992, he was the co-author of a bipartisan health care reform plan that excluded employer mandates compelling universal coverage. Hillary Clinton, who at the time was leading a White House health care reform initiative as First Lady, strongly opposed the measure.

GOP goes on the attack

Other Southern Democrats who’ve signed on to the Medicare for All bill for the first time this year are Kathy Castor, Ted Deutch, Al Lawson and Darren Soto of Florida; Bennie Thompson of Mississippi; G.K. Butterfield of North Carolina; and Gene Green and Marc Veasey of Texas.

They join veteran Southern cosponsors Alcee Hastings and Frederica Wilson of Florida, Hank Johnson and John Lewis of Georgia, John Yarmuth of Kentucky, Alma Adams of North Carolina, Jim Clyburn of South Carolina, Steve Cohen of Tennessee, Al Green and Sheila Jackson Lee of Texas and Bobby Scott of Virginia.

Physicians for a National Health Plan (PNHP), which advocates for the Medicare for All proposal, has unveiled a list of likely and potential cosponsors. It includes two Blue Dog Democrats from the South, both representing Georgia: Sanford Bishop, who has served southwest Georgia’s 2nd Congressional District since 1993, and David Scott, who has represented suburban Atlanta’s 13th Congressional District since 2003.

The other likely Democratic cosponsors as identified by PNHP are Terri Sewell of Alabama, Lois Frankel of Florida, Cedric Richmond of Louisiana and Eddie Bernice Johnson of Texas.

PNHP also identifies 19 potential Republican cosponsors, four of whom are from the South: Carlos Curbelo and Ileana Ros-Lehtinen of Florida, Will Hurd of Texas and Barbara Comstock of Virginia. While Curbelo voted for the House ACA repeal bill, the other three voted against it.

For Comstock, for example, taking a more progressive stance on health care could be a political survival strategy in Northern Virginia’s increasingly moderate 10th Congressional District, where Clinton won 51 percent of the vote in last year’s presidential race. While the possibility of GOP lawmakers embracing Medicare for All might seem remote, another recent poll found that 40 percent of Trump voters and 46 percent of Republican voters overall support expanding Medicare to all Americans.

As the single-payer approach has gained popularity, the GOP has taken steps to discredit it. Earlier this month, the party’s Senate campaign committee launched Web ads against the 10 Senate Democrats up for re-election in states that Trump won, warning of “government health care” if they win. And the National Republican Congressional Committee has promoted a CNN interview in which Randy Bryce, an ironworker who’s challenging Speaker Paul Ryan for his Wisconsin House seat, was pressed about his support for a single-payer plan and the taxes it would require; the interviewer did not mention that Medicare for All would actually save money for 95 percent of U.S. households.

In the meantime, the Republican Party continues to struggle to win support for its own health care plan. Senate Majority Leader Mitch McConnell of Kentucky was unsuccessful in his efforts to take a vote before the July 4 recess, allowing time for concerned voters to reach out to their representatives at home. While he can afford to lose only two of his 52 Republican senators, 10 GOP senators have said publicly that they oppose the bill in its current form. They include Rand Paul of Kentucky, Ted Cruz of Texas and Shelley Moore Capito of West Virginia.

https://www.facingsouth.org…

Medicare for all: The best replacement for Obamacare

By Justine McCabe, Ph.D., and John R. Battista, M.D.
Connecticut Viewpoints, July 12, 2017

The only viable solution to our ongoing national healthcare crisis has waited in the wings for a long time. Teddy Roosevelt included the idea in his 1912 platform. President Truman proposed it in 1945. President Johnson succeeded – partly – with Medicare. Now more than ever, single-payer national health insurance needs to move to the national stage for serious consideration.

Significantly, there is, again, growing public support for single payer. An April Economist/YouGov poll found that a majority of Americans support “expanding Medicare to provide health insurance to every American.” Last year, Gallup polling found 58 percent of Americans support replacing the ACA with a federally funded health insurance system for all.

Indeed, our CT Democratic legislators should take notice: in a 6/23/17 Pew poll, 52 percent of Democrats, 64 percent of liberal Democrats, and “Fully 66 percent of Democrats and Democratic leaners ages 18 to 29” support a single national health insurance system. An April survey found nearly half of physicians supported single payer, particularly because of its time-saving simplicity relative to the current multi-payer, for-profit system.

As health caregivers, our experience reflects public support for single-payer system despite an unresponsive federal government. For example, in 2000, we introduced a single-payer bill to the Connecticut General Assembly, “The CT Health Care Security Act.” Strikingly, people – often in other legislative hearings – showed up in large numbers to support our bill then before the Labor Committee (where it was passed, before dying). The CT Human Services Committee audience literally broke into applause at our suggestion that the committee reject proposed changes to Medicaid and transform the program into single-payer insurance for the state.

Yet, despite strong public support for single payer, our federal government has tried to suppress it, dismissing this option during the ACA hearings of 2009: no single-payer advocate was included in then-U.S. Sen. Max Baucus’ (D-Montana) health care hearings despite support by 60 percent of Americans. Those trying to speak from the audience were arrested.

Our government has even tried to hide public support. In our 2006 op-ed in The Hartford Courant (“Seeking Coverage for All”) we described a government-sponsored task force charged with seeking Americans’ opinion on improving our health care system. It found that people around the country – including CT – overwhelmingly supported a national health insurance program. Connecticut respondents ranked national health insurance first over all other possible reforms. Yet, in their final report (September 2006) this “Citizens’ Health Care Working Group” excluded citizens’ choice – single payer – from their recommendations to Congress.

Senate Republicans have tabled a vote on their approach to replacing the Obamacare/Affordable Care Act (ACA). A June PBS/Marist national poll reveals that only 17 percent of Americans approve of what they’ve seen of the plan – with good reason. According to the Congressional Budget Office, 22 million Americans would lose health insurance under this Republican proposal.

Moreover, according to the Centers for Disease Control, there are still another 28.6 million people with no health insurance despite the ACA. If the Republican bill passes, we, the wealthiest country in the world, would have 50 million people – about 16 percent of the population – without health insurance. That means less primary care, increased use of expensive “ER care,” as well as an increase in mortality associated with being uninsured. And even if our health care financing system remains the ACA, national health care expenditures are projected to increase from 17 to 20 percent of GDP by 2025 according to the actuaries of the Centers for Medicare and Medicaid Services (CMS).

Let’s face it. Our current health care financing system is simply incapable of containing costs.

How do we solve the two main problems constituting our health care crisis: lack of universality and uncontainable costs? For-profit private health system will never solve either of these central issues.

We need a paradigm change.

Single payer resolves these problems. Precisely because it is not-for-profit, unlike private health insurance, it does not spend 18 cents of each health dollar on administrative costs – advertising/marketing, policy underwriting, multimillion-dollar executive compensation, profits for investors. By contrast, Medicare, a single-payer system, is highly efficient with about 2 percent administrative cost.

So savings from our for-profit health care system to single payer could provide health insurance for everyone and keep costs down not only by eliminating the inherently high administrative costs of private health insurance, but also by negotiating global hospital budgets and prescription drugs in bulk. Single-payer systems succeed primarily because they spread risk across the whole population. Such a vast pool includes both young and old, healthy and ill, recognizing the reality that everyone eventually gets sick; everyone eventually dies.

Advocates of for-profit health insurance will tell you that we have the best health care in the world. True but only if you can pay for it. In reality, the U.S. spends twice as much as developed nations with national health insurance – we spend the most per capita anywhere – $9,237 – yet we have poorer health outcomes. For example, the U.S. ranks 12th in life expectancy among the 12 wealthiest industrialized countries, according to the Kaiser Foundation.

Single-payer health insurance, like Medicare, is not socialized medicine. It is a health insurance payment mechanism not a health delivery plan. Such a system would not own hospitals, or employ doctors and nurses. Like Canada’s national health insurance program, single payer/Medicare-for-all would continue the U.S. tradition of fee-for-service with choice of any willing provider. Imagine the boon to small businesses if every individual already had health insurance; for people who keep dissatisfying jobs just to keep their health insurance.

The current Republican challenge to the ACA provides another opportunity for Americans to insist on a health care plan that provides insurance for everyone while containing costs. Let’s insist that our representatives transform Medicare to Medicare-for-All.

Justine McCabe, Ph.D., is a clinical psychologist, and John Battista, M.D., is a psychiatrist at Riverbend Psychiatric Associates in New Milford.

https://ctviewpoints.org…

Medicare for All wins backing of conservative Southern Democrats

By Sue Sturgis
Facing South, July 12, 2017

As congressional Republicans try to pass an unpopular plan that would roll back the Affordable Care Act (ACA) and cause an estimated 22 million Americans to lose their health insurance, a House bill to expand the publicly-funded Medicare program from just senior citizens to every American is picking up record support — and not just among the usual progressive suspects but also from conservative Southern Democrats.

First introduced in 2003 by Rep. John Conyers, a Michigan Democrat and Congress’s longest-serving member, the Expanded and Improved Medicare for All Act (H.R. 676) would provide every U.S. resident with free medically necessary care including primary care and prevention, dietary and nutritional therapies, prescription drugs, emergency care, long-term care, mental health services, dental services and vision care.

It would be paid for with existing health care funds and by raising personal income taxes on the top 5 percent of income earners, instituting a progressive excise tax on payroll and self-employment income, and taxing unearned income and stock and bond transactions. U.S. Sen. Bernie Sanders (I-Vermont), who advocated for single-payer insurance during his unsuccessful 2016 presidential run, has said he will introduce similar legislation in the Senate following the vote on the Republican ACA rollback plan.

Medicare for All has the backing of numerous medical groups such as the American Nurses Association, the American Public Health Association and the American Medical Association’s student branch. Other groups that have endorsed it include the Consumer Federation of America, the League of Women Voters and the U.S. Conference of Mayors.

During the last Congress, Conyers’ bill picked up 62 cosponsors, all Democrats. Seven months into this Congress, it already has 113 cosponsors — a majority of the 193-member Democratic caucus.

That surge in support has come amid a public debate over health care that’s shifted the politics leftward. For example, a recent national survey by the Pew Research Center found that 60 percent of Americans now say the federal government should be responsible for ensuring health care coverage for all and 33 percent favor a single-payer approach like Medicare for All — up by 12 points since 2014 and 5 points just since January.

“I have never seen more enthusiasm and energy behind this issue than what I’m seeing today,” Conyers said in a statement. “I will keep introducing this bill as long as it takes because access to health care — not just health insurance, but quality, affordable care — is a universal right, not a privilege for those who can afford it.”

Blue Dogs sign on

The Medicare for All bill has long had strong support from Conyers’ fellow Congressional Black Caucus members and House progressives, and it continues to pick up new support among liberal and centrist Democrats.

For example, Rep. David Price of North Carolina’s 4th Congressional District — a safely Democratic district that includes parts of Raleigh and Durham and all of Chapel Hill — signed on as a cosponsor for the first time on April 3. That was less than a month after he told a constituent at a local town hall meeting where health care was a leading concern that now was not the time to press the single-payer option. Price spokesperson Lawrence Kluttz explained the lawmaker’s change of heart.

“Congressman Price co-sponsored the so-called Medicare for All bill in direct response to a request from his constituents; he also feels that it’s important to signal his support for universal health care,” Kluttz told Facing South. However, he noted, Price doesn’t believe the proposal is feasible under GOP leadership and intends to focus on defending the protections of the ACA.

Though Medicare for All might not be feasible right now, it’s starting to win over a tough crowd: conservative Democrats from red states in the South.

Of the bill’s 113 current cosponsors, four are members of the conservative Democrats’ Blue Dog Coalition. Two of them — Mike Thompson and Lou Correa — represent districts in California, which has been leading the state-level push for a single-payer health program, though the proposal was blocked recently by the Democratic leadership.

The other two Blue Dogs cosponsoring Medicare for All are from the South. Vicente Gonzalez, who was elected last year to represent South Texas’ 15th Congressional District, signed on on April 17. Jim Cooper, who has represented Middle Tennessee’s 5th Congressional District since 2003 and who served its 4th Congressional District from 1983 to 1995, signed on on April 25. Both seats are considered safely Democratic.

Neither Gonzalez nor Cooper released official statements announcing their cosponsorship. A spokesperson for Gonzalez’s office said on background that the congressman signed on after hearing concerns about health care from older constituents, while Cooper’s office did not immediately respond to a request for comment. But conditions in their districts and states, both of which declined to expand Medicaid under the ACA, offer clues as to why they might see a need for Medicare for All.

Gonzalez’s district stretches from east of San Antonio south to the Mexican border and is 80 percent Hispanic. Between 2013 and 2015, with the ACA in force, the number of uninsured residents there dropped by 13 percent, but 205,000 still lacked health coverage, according to the State Health Access Data Assistance Center (SHADAC). The Republican health care plan would result in an additional 105,000 district residents losing coverage, an analysis by the Center for American Progress (CAP) found.

The population of Cooper’s district, which includes Nashville and communities west of the city, is over 23 percent black compared to 17 percent of the state overall. The number of uninsured district residents dropped by over 22 percent between 2013 and 2015, but more than 92,000 still lacked health insurance, according to SHADAC. Under the current Republican health care proposal, the number of uninsured in the district could grow by 79,600, CAP found.

Cooper, who has called the GOP health care bill “a national tragedy,” has not always been a progressive on health care. In 1992, he was the co-author of a bipartisan health care reform plan that excluded employer mandates compelling universal coverage. Hillary Clinton, who at the time was leading a White House health care reform initiative as First Lady, strongly opposed the measure.

GOP goes on the attack

Other Southern Democrats who’ve signed on to the Medicare for All bill for the first time this year are Kathy Castor, Ted Deutch, Al Lawson and Darren Soto of Florida; Bennie Thompson of Mississippi; G.K. Butterfield of North Carolina; and Gene Green and Marc Veasey of Texas.

They join veteran Southern cosponsors Alcee Hastings and Frederica Wilson of Florida, Hank Johnson and John Lewis of Georgia, John Yarmuth of Kentucky, Alma Adams of North Carolina, Jim Clyburn of South Carolina, Steve Cohen of Tennessee, Al Green and Sheila Jackson Lee of Texas and Bobby Scott of Virginia.

Physicians for a National Health Plan (PNHP), which advocates for the Medicare for All proposal, has unveiled a list of likely and potential cosponsors. It includes two Blue Dog Democrats from the South, both representing Georgia: Sanford Bishop, who has served southwest Georgia’s 2nd Congressional District since 1993, and David Scott, who has represented suburban Atlanta’s 13th Congressional District since 2003.

The other likely Democratic cosponsors as identified by PNHP are Terri Sewell of Alabama, Lois Frankel of Florida, Cedric Richmond of Louisiana and Eddie Bernice Johnson of Texas.

PNHP also identifies 19 potential Republican cosponsors, four of whom are from the South: Carlos Curbelo and Ileana Ros-Lehtinen of Florida, Will Hurd of Texas and Barbara Comstock of Virginia. While Curbelo voted for the House ACA repeal bill, the other three voted against it.

For Comstock, for example, taking a more progressive stance on health care could be a political survival strategy in Northern Virginia’s increasingly moderate 10th Congressional District, where Clinton won 51 percent of the vote in last year’s presidential race. While the possibility of GOP lawmakers embracing Medicare for All might seem remote, another recent poll found that 40 percent of Trump voters and 46 percent of Republican voters overall support expanding Medicare to all Americans.

As the single-payer approach has gained popularity, the GOP has taken steps to discredit it. Earlier this month, the party’s Senate campaign committee launched Web ads against the 10 Senate Democrats up for re-election in states that Trump won, warning of “government health care” if they win. And the National Republican Congressional Committee has promoted a CNN interview in which Randy Bryce, an ironworker who’s challenging Speaker Paul Ryan for his Wisconsin House seat, was pressed about his support for a single-payer plan and the taxes it would require; the interviewer did not mention that Medicare for All would actually save money for 95 percent of U.S. households.

In the meantime, the Republican Party continues to struggle to win support for its own health care plan. Senate Majority Leader Mitch McConnell of Kentucky was unsuccessful in his efforts to take a vote before the July 4 recess, allowing time for concerned voters to reach out to their representatives at home. While he can afford to lose only two of his 52 Republican senators, 10 GOP senators have said publicly that they oppose the bill in its current form. They include Rand Paul of Kentucky, Ted Cruz of Texas and Shelley Moore Capito of West Virginia.

https://www.facingsouth.org…

Lack of Health Insurance is Deadly: Annals of Internal Medicine

New comprehensive review finds that recent studies strengthen conclusions of landmark 2002 National Academy of Medicine report implicating uninsurance in thousands of deaths.

FOR IMMEDIATE RELEASE, June 26, 2017

Contact: Clare Fauke, PNHP communications specialist, 312-782-6006, clare@pnhp.org

Being uninsured substantially raises the risk of dying, according to a comprehensive review of studies published today in the Annals of Internal Medicine. The review updated a 2002 study conducted by the Institute of Medicine (IOM – now called the National Academy of Medicine) that concluded that 18,000 persons died each year from lack of health insurance.

The authors carried out an intensive search for all research examining whether health insurance coverage affects overall mortality among adults age 18-64. They found that multiple studies published since the completion of the IOM study have confirmed that insurance lowers mortality. They cite consistent findings from a randomized trial carried out in Oregon, as well as multiple quasi-experimental and observational studies. The studies indicate that insurance decreases the odds of dying among adults by at least 3% and as much as 29%.

The authors conclude that health insurance prevents deaths at least in part by improving the diagnosis and treatment of high blood pressure. The review cites results from several studies, including randomized trials, showing that uninsured and under-insured Americans are less likely to have their hypertension diagnosed; that insurance leads to lower and safer blood pressure levels; and that eliminating financial barriers to hypertension care dramatically decreases all-cause mortality. Studies have also shown that lack of coverage increases death rates in many other conditions, including breast cancer and major trauma.

Dr. Steffie Woolhandler, lead author of the article who 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 noted: “In order to justify policies that strip coverage from millions, Republicans like Sen. Ted Cruz and Rep. Raúl Labrador claim that health insurance doesn’t save lives. But overwhelming scientific evidence says they’re wrong. Thousands of people are already dying each year because the Affordable Care Act (ACA) has left 28 million uninsured. The Republican health reform bills would increase that death toll.”

Study co-author Dr. David Himmelstein commented: “According to the CBO, the Senate Republicans’ plan would strip coverage from 22 million Americans. The best estimate based on scientific studies is that about 29,000 Americans would die each year as a result. We need to move forward from the ACA to a single payer reform that would cover all Americans, not backwards through repeal.” Dr. Himmelstein, like Dr. Woolhandler, is an internist, Distinguished Professor at CUNY and lecturer at Harvard.

*****

“The Relationship of Health Insurance and Mortality: Is Lack of Insurance Deadly?” by Steffie Woolhandler, M.D., M.P.H. and David U. Himmelstein, M.D. Annals of Internal Medicine. Published online, June 26, 2017. The Annals of Internal Medicine is the official journal of the American College of Physicians.

Disclosures: Drs. Woolhandler and Himmelstein co-founded Physicians for a National Health Program (www.pnhp.org), a nonprofit educational and research organization that supports a single-payer national health plan; they also served as advisers to Sen. Bernie Sanders’ presidential campaign. Neither the Sanders campaign nor PNHP played any role in funding or otherwise supporting the commentary. They tweet @shadowingTrump.

Blending Research & Advocacy

Interview With Dr. David Himmelstein

Review of Systems Podcast, July 11, 2017

EXCERPT (full interview above):

REVIEW OF SYSTEMS: For me, one of the appeals of a single-payer system is a better opportunity for cost control and reducing administrative waste. But at the same time, when you do that, it feels like one man’s waste may be another man’s job, and there may be a reduction in physician salaries [as well]. How do you account for these types of trade-offs? Does a single-payer system result in lost administrative jobs?

DAVID HIMMELSTEIN, M.D.: Well, I hope it does and I think it does, and we would need to make plans for re-training, and re-placing in new jobs, the roughly million people who are doing useless work.

In legislation that we’ve worked on helping to draw up, and in in proposals for reform that we’ve made, we’ve always included a provision that says we need to set aside several tens of billions of dollars to help transition those people to new jobs.

Now, most of the people who are going to be displaced are relatively low-wage clerical [workers] and they could be readily re-trained for the expanded workforce that we need to deliver more care in our society.

Our long-term care is terribly understaffed. Our nursing homes are hugely understaffed. We’re not doing the smoking prevention programs or hypertension or cholesterol screening that we ought to do. But we shouldn’t be employing people to do useless things in our health care system.

You know, the automobile put horseshoe makers out of work, and there had to be a transition there, but we didn’t say, “We can’t move forward into a new age because people who make horseshoes might lose their jobs.” Similarly, with health care, I think we need to use the resources we have in a rational way.

Now, there are some people who are not going to be able to find comparable jobs. The CEO of Aetna, for several years, was making $225,000 a day. We’re not going to be able to find him a comparable job, but luckily those folks have saved up enough that they probably don’t need to work anymore.

[Regarding physician pay], in countries that have implemented national health insurance, like Canada, doctors’ incomes don’t go down. They may equalize a little bit – the plastic surgeons may make a little less – but on average, doctors’ incomes in Canada have actually gone up faster than wages in the society as a whole.

But the doctors haven’t just benefited from having good incomes, they’ve benefited because their work lives are better. They don’t spend their lives filling out billing forms and checking boxes that have no use other than to support billing.

I think the vast majority of doctors would be much happier, not just financially but in everyday life, under a national health insurance system.

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