PNHP

Why single-payer health insurance means better patient care

Why single-payer health insurance means better patient care

By Phil Kadner
Chicago Sun-Times, June 23, 2017

Most doctors believe a single-payer system “would offer the best health care to the greatest number of people,” according to a survey by the Chicago Medical Society.

More than 1,000 doctors from the Cook County region participated in the survey and 77 percent of those responding had an unfavorable view of the American Health Care Act passed by the U.S. House of Representatives as a replacement for Obamacare, also known as the Affordable Care Act.

In addition to supporting single-payer national health care, the doctors also expressed support for the Affordable Care Act, with 62 percent saying they had a “generally favorable” opinion of Obamacare.

Two out of three doctors, 67 percent, said they had a “generally favorable” view of a single-payer financing health care system.

The U.S. Senate version of health care reform had not been unveiled at the time of the survey, but given the response of the doctors, I think it is fair to say that it would not have received significantly greater support than the House version.

Dr. Ted Brown, president of the Chicago Medical Society, emphasized that the survey focused primarily on three options: Obamacare, AHCA — what is being called Trumpcare — and single-payer national health insurance.

I asked Brown why he believes most of the doctors responding to the medical society’s survey chose single-payer health insurance, which is available in the rest of the industrialized world.

His answer is likely to shock those who believe private industry is more efficient than the federal government.

Brown said that trying to comply with the regulations and paperwork required by dozens of private insurance companies offering hundreds of policies, along with Medicaid and Medicare, is burning doctors out and taking time away from patient care.

“As much as anything, it’s an administrative problem,” Brown said. Doctors may be required to take an opioid training course, for example, eight or nine times to satisfy eight or nine different insurance companies.

They would much rather have one administrative mandate handed down from the federal government.

The federal government? Can that be right.

“I don’t think I’ve ever heard a doctor complain about Medicare regulations,” Brown said. “They’re simple. They’re easy to understand. It’s easy to get an answer if you have a question.”

An astonishing 87 percent of the doctors surveyed agreed that in an ideal system basic health care would be available to all individuals as part of the social contract, a right similar to education, or police and fire protection.

I think the majority of people who oppose national health care don’t understand that private health insurance companies now dictate medical practice to doctors and many of their decisions are based on profit motives, having nothing to do with patient care.

And in many cases no one — including your doctor — knows who is actually making the health care decisions at the insurance companies.

Doctors are being forced to join health care groups and close their private practices because they do not have the time or the financial resources to comply with the paperwork demands of the private insurance companies.

And if doctors defend their patients too vigorously and refuse to comply with the demands of the insurance providers, they are cut out of the system.

“The results of the survey are very significant,” said Dr. Claudia Fegan, national coordinator for Physicians for a National Health Care Program, which has led the fight for single-payer universal health care.

“Practicing physicians do not want to see ACA repealed and they believe the best approach is single-payer.”

http://chicago.suntimes.com…

Why single-payer health insurance means better patient care

By Phil Kadner
Chicago Sun-Times, June 23, 2017

Most doctors believe a single-payer system “would offer the best health care to the greatest number of people,” according to a survey by the Chicago Medical Society.

More than 1,000 doctors from the Cook County region participated in the survey and 77 percent of those responding had an unfavorable view of the American Health Care Act passed by the U.S. House of Representatives as a replacement for Obamacare, also known as the Affordable Care Act.

In addition to supporting single-payer national health care, the doctors also expressed support for the Affordable Care Act, with 62 percent saying they had a “generally favorable” opinion of Obamacare.

Two out of three doctors, 67 percent, said they had a “generally favorable” view of a single-payer financing health care system.

The U.S. Senate version of health care reform had not been unveiled at the time of the survey, but given the response of the doctors, I think it is fair to say that it would not have received significantly greater support than the House version.

Dr. Ted Brown, president of the Chicago Medical Society, emphasized that the survey focused primarily on three options: Obamacare, AHCA — what is being called Trumpcare — and single-payer national health insurance.

I asked Brown why he believes most of the doctors responding to the medical society’s survey chose single-payer health insurance, which is available in the rest of the industrialized world.

His answer is likely to shock those who believe private industry is more efficient than the federal government.

Brown said that trying to comply with the regulations and paperwork required by dozens of private insurance companies offering hundreds of policies, along with Medicaid and Medicare, is burning doctors out and taking time away from patient care.

“As much as anything, it’s an administrative problem,” Brown said. Doctors may be required to take an opioid training course, for example, eight or nine times to satisfy eight or nine different insurance companies.

They would much rather have one administrative mandate handed down from the federal government.

The federal government? Can that be right.

“I don’t think I’ve ever heard a doctor complain about Medicare regulations,” Brown said. “They’re simple. They’re easy to understand. It’s easy to get an answer if you have a question.”

An astonishing 87 percent of the doctors surveyed agreed that in an ideal system basic health care would be available to all individuals as part of the social contract, a right similar to education, or police and fire protection.

I think the majority of people who oppose national health care don’t understand that private health insurance companies now dictate medical practice to doctors and many of their decisions are based on profit motives, having nothing to do with patient care.

And in many cases no one — including your doctor — knows who is actually making the health care decisions at the insurance companies.

Doctors are being forced to join health care groups and close their private practices because they do not have the time or the financial resources to comply with the paperwork demands of the private insurance companies.

And if doctors defend their patients too vigorously and refuse to comply with the demands of the insurance providers, they are cut out of the system.

“The results of the survey are very significant,” said Dr. Claudia Fegan, national coordinator for Physicians for a National Health Care Program, which has led the fight for single-payer universal health care.

“Practicing physicians do not want to see ACA repealed and they believe the best approach is single-payer.”

http://chicago.suntimes.com…

Dr. Steffie Woolhandler on ‘Democracy Now!’

PNHP co-founder Dr. Steffie Woolhandler appeared on “Democracy Now!” on June 23, 2017, to discuss the shortcomings of the Affordable Care Act, and of the Republican proposals to “repeal and replace” the law. She also noted that many Americans, including Republicans, are standing up to demand improved Medicare for all.

Medical loss ratio under the Senate ACA replacement proposal

H. R. 1628 – “Better Care Reconciliation Act of 2017”

U.S. Senate, June 2017

Title II

SEC. 205. MEDICAL LOSS RATIO DETERMINED BY THE STATE.

Section 2718(b) of the Public Health Service Act (42 U.S.C. 300gg–18(b)) is amended by adding at the end the following:

“(4) SUNSET.—Paragraphs (1) through (3) shall not apply for plan years beginning on or after January 1, 2019, and after such date any reference in law to such paragraphs shall have no force or effect.

“(5) MEDICAL LOSS RATIO DETERMINED BY THE STATE.—For plan years beginning on or after 24 January 1, 2019, each State shall—

“(A) set the ratio of the amount of premium revenue a health insurance issuer offering group or individual health insurance coverage may expend on non-claims costs to the total amount of premium revenue; and

“(B) determine the amount of any annual rebate required to be paid to enrollees under such coverage if the ratio of the amount of premium revenue expended by the issuer on non-claims costs to the total amount of premium revenue exceeds the ratio set by the State under subparagraph (A).”.

https://www.budget.senate.gov…

42 U.S.C. 300gg–18(b):
https://www.law.cornell.edu…

***

Comment:

By Don McCanne, M.D.

By now you likely know that the current Senate proposal to modify the Affordable Care Act (ACA) would sharply reduce spending for the Medicaid program and would result in higher insurance premiums for plans that provide less financial protection, while reducing taxes for the wealthy. The proposal has been appropriately labeled as being “mean.” But to get a feeling of the flawed policy process behind their proposal, let’s look at just one small example: the medical loss ratio.

Under ACA, all insurers, not just the insurers offering exchange plans, must spend a minimum percentage of their premium revenue on health care benefits – 80 percent for individual and small group plans and 85 percent for large group plans. Spending money on health care is considered a loss to the insurers and thus the percentage spent is known as the medical loss ratio. If they spend more than 20 percent or 15 percent, respectively, on administrative costs or profits, then they must provide rebates to the enrollees.

When ACA was crafted, it was acknowledged that the U.S. health care system wasted tremendous resources in administrative excesses. It was not uncommon for some private insurers to keep 30 percent or even more of the premiums for their own administrative costs and profits. By placing limits on the administrative costs, a dent could be made in reducing this waste. It is important to note that only a small fraction of the total waste in our system is recovered by establishing medical loss ratio minimums – only a tiny portion of what would be recovered if we switched to a single payer national health program. But it was a start.

Sec. 205 of Title II of the Better Care Reconciliation Act – the Republican bill – sunsets 42 U.S.C. 300gg–18(b) – the ACA medical loss ratio provisions (link above), eliminating the 80 and 85 percent federal ratio requirements. It transfers the responsibility to the states. This sounds like no big deal, but when we observe how many of the states are heartlessly refusing to expand their Medicaid coverage, it does not take much imagination that some states will establish policies that will enable private insurers to divert more of the premium dollars to investors and executives, at a cost to plan beneficiaries. After all, as many have reported, this entire scheme has been designed to take health care from the masses and give the monetary gains to the wealthy.

Former Congressman Henry Waxman, a leader in crafting the House version of ACA, states it well in a Los Angeles Times op-ed (June 22, 2017):

“Legislation needs to pass sufficient public scrutiny or it’s unworthy of becoming law. If monumental, transformative legislation can be written in the dark and enacted in a rush— and children’s lives are compromised or ruined so that billionaires can get tax cuts they don’t need — it would rank among the worst scandals in U.S. history. Americans of conscience must mobilize now to stop this from happening.”

The real scandal is that we continue to dink around with the most expensive and least efficient model of financing care – our dysfunctional, fragmented system composed of a multitude of private and public plans –  when what we really need is to fix Medicare and then include everyone. Under that more enlightened system money spent on health care is not considered a loss but rather a benefit for the health of each of us and the health of the nation at large.

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

Why Single-Payer Health Care Could Work in California

And why state-level reform is a risky proposition for most of the country.

By Natalie Shure
Pacific Standard, June 23, 2017

The California State Assembly will be busy this summer continuing to shape SB-562, a statewide universal health-care bill that passed the Senate last month. The legislation aims to create a so-called single-payer system: a unified public insurance pool that would cover all residents’ health-care costs, thereby extending coverage to three million previously uninsured Californians, and eliminating the private insurance industry central to the Affordable Care Act. While the bill has garnered widespread enthusiasm—72 percent of Californians reportedly support government-run universal coverage—it remains light on funding specifics. One analysis conducted by the University of Massachusetts–Amherst pinned the cost of the proposal at $331 billion annually—a sum well beyond California’s state budget of $180 billion, but below the state’s $368 billion in health-care spending overall. As legislators deliberate details like how much revenue should be raised through payroll or sales taxes, such unknowns have have made some lawmakers reluctant, including an allegedly skeptical Governor Jerry Brown.

And yet, Republican control over all three branches of federal government has seriously worsened the near-term outlook for equitable health care at the national level: After weeks of working in secret to retool the American Health Care Act, the GOP has finally released the bill it hopes will replace the ACA. It includes deep cuts to Medicaid, allows states to drop minimum coverage standards, and eliminates the taxes on the wealthy built into the ACA. The version passed by the House of Representatives would threaten to leave 23 million more Americans without coverage, beyond the 28 million already uncovered by the ACA. For many, politics surrounding the would-be repeal of Obamacare have crystallized Republican lawmakers’ willingness to lock millions of Americans out of the health-care system in exchange for upper-bracket tax cuts. And even if the AHCA remains a non-starter, there’s no shortage of ways Republicans can deliberately erode Obamacare—a system mired in problems even under better circumstances, that has failed to achieve universal coverage.

Given the fragility of a health-care system so recently overhauled, there’s been a resurgence of calls for single-payer health care in the United States. Bernie Sanders’ Democratic primary campaign reintroduced the concept of single-payer to a national audience, a message that many voters were acutely receptive to given a growing list of Obamacare bugs: declininginsurer participation, rising premiums, shrinking networks, rejected expansions of Medicaid in GOP-controlled states, and cost-sharing tactics by insurers that leave millions unable to afford to even use the insurance they pay for. There’s also mounting evidence that single-payer is more popular than ever: Videos of constituents at town halls calling for expanded Medicare-for-all have gone viral, and recent polls show 60 percent of Americans support the idea.

This groundswell of public enthusiasm has given rise to multiple initiatives to construct single-payer systems at the state-level, in places where local politics are more amenable to leftward reform than Washington’s. California’s bill advanced on the heels of a similar one in May that made it through the New York Assembly. Last week, Nevada’s legislature voted to allow anyone to buy into Medicaid coverage—a move that would effectually create a so-called “public option” that some argue could be a gateway toward single-payer. The overwhelming majority of proponents of state-level single-payer cite a unified national program as their endgame, and state-based overhauls may indeed by the most feasible route there. But using states as Medicare-for-all laboratories also comes with strings attached, and presents structural challenges that wouldn’t apply at the national level.

WHY SINGLE-PAYER COULD WORK IN CALIFORNIA

In many ways, California seems better poised for a single-payer coup than any other state. A Democratic supermajority controls both houses of the California legislature, which has already passed similar bills in 2006 and 2008 (albeit arguably underdeveloped ones, which were subsequently vetoed by Governor Arnold Schwarzenegger). California’s massive population and strong economy could also help it absorb shocks that might destabilize a single-payer system in a tinier state, and could also likely secure lower drug prices by commanding more leverage over negotiations.

California’s unique geographic realities also work in its favor here: Major Metro areas often span across state lines, which not only presents logistical complications surrounding out-of-state providers, but also makes it easier for wealthy taxpayers and health-care providers to relocate to a friendlier jurisdiction. California’s main population centers are practically all exempt from this problem. (Compare California’s situation to that of Vermont, where a single-payer program was abandoned in 2015: With fewer than one million Vermonters, even a mild contraction of the tax base could prove devastating, the state budget would be more vulnerable to recessions, and many state residents receive care at hospitals like Dartmouth, located outside of the state.)

But even beyond considerable political obstacles, the bigger hurdles for state single-payer are more likely to be legal, chief among them the reallocation of billions of federal dollars funneled to each state to bankroll already existing public health-care programs. A study conducted by the University of Massachusetts–Amherst on California’s SB-562 bill estimated these federal payouts were slated to account for over 70 percent of the program’s projected annual cost. But securing them won’t be easy. For one, there’s no existing mechanism to repurpose a state’s share of Medicare. And employer benefits are regulated at the federal level, leaving states without the authority to unilaterally disband the system of employer-provided coverage.

OBSTACLES TO STATE-LEVEL ACTION

While blue states embarking on progressive health-care projects may resent this bind, it’s crucial to remember that ceding control over federal health-care funds to states can just as easily limit access to health care as expand it. When it comes to “state innovation waivers” available through the ACA, Don McCanne, a health policy fellow with Physicians for a National Health Program, notes, “the waivers they want us to get are privatization waivers—they want us to take Medicaid and turn it over to private insurance companies … if California went to [the Trump administration] and said, ‘give us the waivers so we can set up a government-run insurance system,’ I know they would not ever agree to that … it’s totally opposed to their ideology.”

But giving states total freedom over whatever funds they receive could be even worse—this is the basic premise behind Medicaid “block grants,” a Republican proposal to distribute fixed amounts of money, over which each state would enjoy complete discretion. Such a scenario could stand to benefit those states progressive enough to build universal health-care systems, but would annihilate already precarious systems in poorer or GOP-dominated areas.

Of course, such explicit state disparities in health-care access are anathema to single-payer advocates, who, by definition, believe in universal coverage for all. A patchwork system that varies by state does little to alleviate the immorality underpinning the tiered system of coverage and care that has galvanized the single-payer fight in the first place. As such, the effectiveness of state-level single-payer experiments as a bridge toward federal reforms will depend on how local movements orient themselves toward national ones. Universal coverage activists often point to the example of Saskatchewan, whose successful provincewide universal coverage program acted as a springboard for Canada’s system. This model demands a sense of national solidarity absent from much of the political discourse in the U.S.

THE IMPORTANCE OF GRASSROOTS ORGANIZING

For activists like McCanne, the promise of state-level single-payer movements lie in their role as vehicles for education and mobilization. Even amid the protracted crisis facing America’s labyrinthine heath-care system, health-care policy is hardly intuitive—and a well-informed public will be better able to resist the messaging of powerful interest groups against single-payer. Such grassroots organizing—conversations about health-care reform on a house-by-house basis—is the kind of long-game political work that localized movements are uniquely able to deploy.

Ultimately, any movement to secure health-care justice for Californians or New Yorkers must also be understood as a fight for Arkansans and Wisconsinites, not only because the viability of any statewide system will depend on mobilizing pressure against the federal government, but because envisioning the battle for single-payer as an overly localized one risks inoculating us against suffering in red states as soon as blue ones get theirs.

https://psmag.com…

Support Grows for Single-Payer Medicare-for-All Plan Instead of Massive Cuts to Healthcare

Interview With Dr. Steffie Woolhandler

By Amy Goodman
Democracy Now!, June 23, 2017

PNHP Note: To view video of this interview, click here.

Health experts say, given the shortcomings of both the Affordable Care Act and Republican proposals, now is the time to move forward with a simple Medicare-for-all system, known as single payer. In 2015, even Donald Trump appeared to come out in favor of a form of single-payer health insurance. About 20,000 U.S. physicians now support single-payer healthcare, and National Nurses United, the biggest nursing union in the country, is also pushing for the program that would guarantee universal coverage. We speak with Dr. Steffie Woolhandler, a key advocate for Medicare for all.

TRANSCRIPT
This is a rush transcript. Copy may not be in its final form.

AMY GOODMAN: During a 60 Minutes interview in 2015, Donald Trump appeared to come out in favor of a form of single-payer health insurance for the uninsured. I wanted to play this clip.

DONALD TRUMP: Obamacare is going to be repealed and replaced. Obamacare is a disaster, if you look at what’s going on with premiums, where they’re up 45, 50, 55 percent.

SCOTT PELLEY: So how do you fix it?

DONALD TRUMP: There’s many different ways, by the way. Everybody’s got to be covered. This is an un-Republican thing for me to say, because a lot of times they say, “No, no, the lower 25 percent, they can’t afford private.” But—

SCOTT PELLEY: Universal healthcare.

DONALD TRUMP: I am going to take care of everybody. I don’t care if it costs me votes or not. Everybody’s going to be taken care of, much better than they’re taken care of now.

SCOTT PELLEY: The uninsured person—

DONALD TRUMP: Right.

SCOTT PELLEY: —is going to be taken care of how?

DONALD TRUMP: They’re going to be taken care of.

SCOTT PELLEY: How?

DONALD TRUMP: I would make a deal with existing hospitals to take care of people. And you know what? This is probably—

SCOTT PELLEY: Make a deal? Who pays for it?

DONALD TRUMP: The government is going to pay for it. But we’re going to save so much money on the other side. But for the most part, it’s going to be a private plan, and people are going to be able to go out and negotiate great plans with lots of different competition, with lots of competitors, with great companies. And they can have their doctors. They can have their plans. They can have everything.

AMY GOODMAN: That was Donald Trump in 2015. Dr. Steffie Woolhandler, can you respond? You’re one of the key advocates for Medicare for all. Where does that fit into this picture today? Do you think this is a moment where the time for Medicare for all can be pushed around the country in a very big way, as people across the political spectrum are horrified by the specter of, among other things, tens of millions of people losing their health insurance?

DR. STEFFIE WOOLHANDLER: Yeah, well, the ACA made some modest improvements to the healthcare system, and the Republicans would pull those all back. But the Affordable Care Act was never a very good bill. It left 28 million Americans completely uninsured and tens of millions more with these unaffordable gaps in their coverage, like copayments and deductibles and uncovered services. And that’s why the Affordable Care Act has been vulnerable to these Republican attacks, because people look at their own situation and say, “Even under Obamacare, under the Affordable Care Act, healthcare still not affordable to me.”

So the best way to fight the Republican attacks is to say, “Let’s move forward from the Affordable Care Act to a single-payer system, rather than backward through repeal.” The single-payer system works, because by having a single, simple Medicare-for-all system, you save so much money on administrative costs and overhead that you can cover all of the uninsured and improve coverage for everybody else who has gaps in their coverage without raising total healthcare costs. And that’s why about 20,000 U.S. physicians have come together into Physicians for a National Health Program to advocate single payer. That’s why the National Nurses United, the biggest nursing union in the country, is pushing single payer. It’s why Senator Sanders ran on single payer. And it’s why Congressman John Conyers has introduced a bill into Congress, with 112 co-sponsors, for single payer. So now is the time to be saying to the electorate, the ACA was a step forward, but not a big enough step. We need to be moving forward from the ACA to that single-payer, Medicare-for-all plan that Americans need and deserve.

AMY GOODMAN: And how feasible do you think this is? I mean, Senator Bernie Sanders has yet to introduce this bill, the type that Conyers already has introduced in the House.

DR. STEFFIE WOOLHANDLER: OK, my understanding is Sanders is planning to introduce a bill over the summer. The Conyers bill has gained a lot of co-sponsors. More than half of all the Democrats in the House of Representatives now co-sponsor the Conyers bill. That’s more co-sponsors than any time in history. We’re seeing a lot of public support for the idea of single payer. We’re seeing a big movement for single payer at the state level in California. Obviously we’re getting a whole lot more discussion of single payer now than we’ve ever had before.

AMY GOODMAN: Let me ask you—

DR. STEFFIE WOOLHANDLER: I think we’re—

AMY GOODMAN: Let me ask you, very quickly. In California, it’s passed the state Senate. It’s got to go through the Assembly, and then it has to go to Governor Brown. Do you think that he will sign off on it, unlike what happened in Nevada, where the Republican senator, in that case, said no to Medicare for all, even though it was passed by the Nevada Legislature?

DR. STEFFIE WOOLHANDLER: OK, well, we’re only going to get single payer if the populace keeps the pressure on the politicians. It’s not going to happen automatically. It’s not going to happen because Governor Brown has occasionally in the past said he likes single payer. It’s going to happen because we have a movement that’s strong enough to counter the political power of these rich people, who are getting these huge tax cuts; of the insurance industry, who would have no place in an efficiently run single-payer system; of Pharma, who thinks that they’re going to have to accept lower prices under single payer. In fact, they’re right. So that’s a lot of political power. And the only way to push through that is to really build a movement. But, you know, that really seems possible right now, with polls showing that two out of every three Americans who have an opinion on healthcare think we need some sort of Medicare-for-all program. So, now is really the time to be pushing this—in fact, the only way to really counter the Republican momentum at this point.

AMY GOODMAN: Well, Dr. Steffie Woolhandler, I want to thank you for being with us, key advocate for Medicare for all—and again, when she referred to Pharma, meaning Big Pharma, the drug companies—and Dr. Willie Parker, who happens to be joining us from Aspen, Colorado, who is the chair of the board of Physicians for Reproductive Health.

https://www.democracynow.org…

Trumpcare is like a vampire, set on sinking its teeth into the poor

The relationship of the Republican bills to tax breaks resembles that of water crackers to cheese: a delivery device with little independent function of its own

By Adam Gaffney, M.D.
The Guardian, June 23 2017

“Dead on arrival,” some said. That was to be the fate of the House’s Obamacare repeal bill in the Senate. Yet Trumpcare has risen again: on Thursday, the Senate released its Obamacare repeal bill, though its fate is still uncertain. The Senate draft is in some respects a watered-down version of the House’s, yet it is no less toxic: watering down cyanide, you see, only makes it so safe.

But first, some credit where it is due. Senate majority leader Mitch McConnell was faced with a daunting task after the American Health Care Act (AHCA) slithered its way through the House last month: the creature was about as popular as Count Dracula.

In a late May Quinnipiac poll, a measly 20% of voters approved the bill, not surprising when one considers that the AHCA was arguably more vampiric than the Romanian nobleman. Whereas the latter would drain his victims one by one, the AHCA would extract health coverage from some 23 million to engorge the bank balances of the wealthy few.

Yet McConnell and colleagues rose to the challenge, and it is hard to not be impressed by their ruthless stealth and speed. The baker’s dozen of white men that crafted the bill kept it hidden not only from the public, but from their fellow Republican Senators.

The secrecy – nary a single committee hearing! – kept it out of the headlines, an admittedly savvy strategy in light of the AHCA’s utter unpopularity. As one senior aide told Axios, “We aren’t stupid.” Certainly not, though they are a coldblooded bunch.

Now the Senate bill is with us, and suffice it to say that Trumpcare hasn’t much changed. There is one major exception: the Senate bill features subsidies to help people buy private insurance plans that resemble those under Obamacare, though they are less adequate.

These subsidies would be indexed to income and available to those earning under 350% of the federal poverty level (as opposed to under 400% with Obamacare). Libertarians can whine with some justification that, in this respect, they are being served a glass of Diet Obamacare.

But in other respects, the Senate bill looks very much like the House’s, retaining, of course, the lavish tax cuts for healthcare corporations and the rich. Over a decade, the House version of the bill was estimated to redistribute $230.8bn to high income earners, $144.7bn to insurance companies, $28.5bn to pharmaceutical companies, and $19.6bn to medical device manufacturers (healthcare stocks are jumping accordingly).

The relationship of the Republican bills to these tax breaks increasingly seems to be that of water crackers to cheese: an effective delivery device with little independent function of its own.

Yet hundreds of billions of dollars of tax cuts do not, as the saying goes, grow on trees. And who easier to take the money from then the poor? Thus, the Senate bill, like the House’s, goes for Medicaid’s jugular, and in the long term, actually sinks its teeth deeper.

To be fair, the Senate bill does bleed the program a bit slower at first – funding for Obamacare’s Medicaid expansion will be phased out over three years. Yet like the House bill, it ends Medicaid as an entitlement program wherein state spending is matched by federal dollars, constraining it instead to a per capita capped system – a long-winded way of saying that Republicans will shrink the program. Indeed, the hemorrhage of cash will ultimately be more brisk in the Senate version, as the bill dials down the rate of growth of the program beginning in 2025.

Like the House bill, the Senate bill also aims to appease conservative true believers by allowing states to apply for waivers to weaken Obamacare’s insurance regulations (albeit now via Obamacare’s 1332 waiver program). The true believers assert that jettisoning such regulations – like those that require coverage of a full set of healthcare benefits – would bring down premiums.

They are obviously right. Similarly, as Megan McArdle recently argued in Bloomberg, requiring sprinklers in tall residential buildings like the one that burned to a crisp in London last week (current death toll: 79) increases, to some extent, the cost of housing construction.

Which is not to say that, as with housing, the affordability of healthcare is not an issue. When conservatives critique Obamacare by asserting that premiums and deductibles are unaffordable for many, they are right, albeit disingenuously so. Just as the solution to unaffordable housing is not to let more buildings go up in flames, the solution to high healthcare costs is not to make health insurance plans increasingly worthless.

In the case of healthcare, the answer to this conundrum is simple: fund the healthcare system not through premiums or deductibles, but instead through progressive taxes, such that nobody is liable to pay more for healthcare than they can afford.

Of course, if you are trying not to reduce inequality, but to exacerbate it, this makes little sense: better to bleed Medicaid, transfuse the cash into the pockets of the rich, and call the whole bloodsucking endeavor an exercise in “freedom.”

https://www.theguardian.com…

The Senate’s ‘Better Care Reconciliation Act of 2017’

Senate Health Care Bill Includes Deep Cuts to Medicaid

By Robert Pear and Thomas Kaplan
The New York Times, June 22, 2017

Senate Republicans, who have promised a repeal of the Affordable Care Act for seven years, took a major step on Thursday toward that goal, unveiling a bill to cut Medicaid deeply and end the health law’s mandate that most Americans have health insurance.

The 142-page bill would create a new system of federal tax credits to help people buy health insurance, while offering states the ability to drop many of the benefits required by the Affordable Care Act, like maternity care, emergency services and mental health treatment.

The Senate bill — once promised as a top-to-bottom revamp of the health bill passed by the House last month — instead maintains its structure, with modest adjustments. The Senate version is, in some respects, more moderate than the House bill, offering more financial assistance to some lower-income people to help them defray the rapidly rising cost of private health insurance.

But the Senate measure, like the House bill, would phase out the extra money that the federal government has provided to states as an incentive to expand eligibility for Medicaid. And like the House measure, it would put the entire Medicaid program on a budget, ending the open-ended entitlement that now exists.

It would also repeal virtually all the tax increases imposed by the Affordable Care Act to pay for itself, in effect handing a broad tax cut to the affluent, paid for by billions of dollars sliced from Medicaid, a health care program that serves one in five Americans, not only the poor but almost two-thirds of those in nursing homes. The bill, drafted in secret, is likely to come to the Senate floor next week, and could come to a vote after 20 hours of debate.

https://www.nytimes.com…

H.R. 1628 – “Better Care Reconciliation Act of 2017”:
https://www.budget.senate.gov…

Senate Budget Committee overview of H.R. 1628 (highly deceptive rhetoric):
https://www.budget.senate.gov/bettercare

***

Comment:

By Don McCanne, M.D.

No surprises. The discussion draft of the Senate repeal and replace legislation reveals that the legislators would reverse some of the beneficial features of the Affordable Care Act (ACA), which we knew, but the most important measure is the deep reduction in Medicaid funding, allowing them to repeal the tax increases that have paid for the expanded benefits of ACA.

At this point it does not seem that they have the votes to pass this legislation primarily because it does not repeal the fundamental structure of ACA, though negotiations are still taking place. The intent is to vote on it next week. That is a very short time to resolve deeply held ideological differences within the Republican caucus.

If the bill were to pass and be signed into law, it would open the floodgates of activism on behalf of Medicare for all. The Republicans surely do not want that. Yet a loss with the defeat of this legislation would equate to a phenomenal victory for the Republicans because it would have distracted us from following through on the surge of support for single payer reform that has been escalating this past year.

Even if the bill fails, the numbers who remain uninsured, the financial hardships that even many of the insured are facing, and the expensive and wasteful dysfunction of our fragmented health care financing system should still drive us to demand an improved Medicare for all. We cannot walk away from this pretending that a defeat of the Better Care Reconciliation Act of 2017 would equate to a victory for us. Real victory would be in finally achieving health care justice for all.

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The cruelty of using Medicaid as a tool to reduce budget deficits

The Effects of Premiums and Cost Sharing on Low-Income Populations: Updated Review of Research Findings

By Samantha Artiga, Petry Ubri, and Julia Zur
Kaiser Family Foundation, June 1, 2017

Key Findings

Recently, there has been increased interest at the federal and state level to expand the use of premiums and cost sharing in Medicaid as a way to promote personal responsibility, prepare beneficiaries to transition to commercial and private insurance, and support consumers in making value-conscious health decisions. This brief reviews research from 65 papers published between 2000 and March 2017 on the effects of premiums and cost sharing on low-income populations in Medicaid and CHIP. This research has primarily focused on how premiums and cost sharing affect coverage and access to and use of care; some studies also have examined effects on safety net providers and state savings. The effects on individuals, providers, and state costs reflect varied implementation of premiums and cost sharing across states as well as differing premium and cost sharing amounts. Together, the research finds:

* Premiums serve as a barrier to obtaining and maintaining Medicaid and CHIP coverage among low-income individuals. These effects are largest among those with the lowest incomes, particularly among individuals with incomes below poverty. Some individuals losing Medicaid or CHIP coverage move to other coverage, but others become uninsured, especially those with lower incomes. Individuals who become uninsured face increased barriers to accessing care, greater unmet health needs, and increased financial burdens.

* Even relatively small levels of cost sharing in the range of $1 to $5 are associated with reduced use of care, including necessary services. Research also finds that cost sharing can result in unintended consequences, such as increased use of the emergency room, and that cost sharing negatively affects access to care and health outcomes. For example, studies find that increases in cost sharing are associated with increased rates of uncontrolled hypertension and hypercholesterolemia and reduced treatment for children with asthma. Additionally, research finds that cost sharing increases financial burdens for families, causing some to cut back on necessities or borrow money to pay for care.

* State savings from premiums and cost sharing in Medicaid and CHIP are limited. Research shows that potential revenue gains from premiums and cost sharing are offset by increased disenrollment; increased use of more expensive services, such as emergency room care; increased costs in other areas, such as resources for uninsured individuals; and administrative expenses. Studies also show that raising premiums and cost sharing in Medicaid and CHIP increases pressures on safety net providers, such as community health centers and hospitals.

Conclusion

Recently, there has been increased interest at the federal and state levels to expand the use of premiums and cost sharing in Medicaid as a way to promote personal responsibility, prepare beneficiaries to transition to commercial and private insurance, and support consumers in making value-conscious health decisions. Current rules limit premiums and cost sharing in Medicaid to facilitate access to coverage and care for the low-income population served by the program, who have limited resources to spend on out-of-pocket costs. This review of a wide body of research provides insight into the potential effects of increasing premiums and cost sharing for Medicaid enrollees. It shows that premiums serve as a barrier to obtaining and maintaining coverage for low-income individuals, particularly those with the most limited incomes, and that even relatively small levels of cost sharing reduce utilization of services. As such, increases in premiums and cost sharing result in increased barriers to coverage and care, greater unmet health needs, and increased financial burdens for families. Further, the research suggests that state savings from premiums and cost sharing in Medicaid and CHIP are limited and that increases in premiums and cost sharing in Medicaid and CHIP can increase pressures on safety-net providers.

http://www.kff.org…

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Republicans see Medicaid as welfare. Most Americans don’t.

By Drew Altman
Axios, June 21, 2017

Republicans want to roll back the Medicaid expansion, cap federal Medicaid spending increases, and add work requirements, drug testing, time limits, copays and premiums to some state Medicaid programs. But almost no one else wants to do these things. One poll finding goes a long way toward explaining why: Republicans view Medicaid as a form of welfare, and pretty much everyone else views it as a government insurance program.

Why it matters: Welfare remains unpopular in our country; it’s always popular to limit or cut “welfare”. Whether it should be, and what this says about us, is a different question.

Perceptions of Medicaid as welfare don’t seem bothered much by facts, such as, for example, that two thirds of Medicaid spending goes for the low income elderly and disabled who don’t fit the Ronald Reagan era image of the welfare king or queen. But it’s not the majority view in any case. A little less than a third of voters identify as Republicans today, and about half of them see Medicaid as welfare.

https://www.axios.com…

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Comment:

By Don McCanne, M.D.

Tomorrow the Republicans in the Senate are expected to release their proposal to repeal and replace the Affordable Care Act. Although there will likely be some modest detrimental changes recommended for the individual market insurance exchanges, the largest impact will likely be in changes recommended for the Medicaid program. Today’s message explains why that would be a grievous mistake.

Medicaid is the largest insurance program in the United States, serving over 74 million people. These are low-income individuals who do not have assets that could pay for their proportionate share of America’s health care bill. Most of us consider Medicaid to be an essential insurance program for these individuals and families (in the absence of a single payer system). However, new poll results by Kaiser Foundation show that one-half of Republicans (Republicans being one-third of the population) consider Medicaid to be predominantly a welfare program, and those Republicans now control our government. The political representatives of one-sixth of our population are about to take a budget ax to this crucial program, because, after all, it is merely a welfare program and one that we can no longer afford to maintain (Republican view).

The consequences of the various policies under consideration are dire. They are considering allowing states to impose premiums that would create a barrier to Medicaid coverage, leaving those vulnerable without insurance. They are considering allowing the states to use cost sharing to make Medicaid beneficiaries better health care shoppers, but it has been shown that even small out-of-pocket costs create barriers to care for this population. They likely will dramatically reduce over time the federal contribution to the state Medicaid programs which may cause even more states to limit eligibility, keeping out individuals who may be impoverished but still have barely enough income to have a cellphone (as if cellphone fees were enough that they could be used instead to purchase health plans in the individual market).

What we will see tomorrow will be legislative recommendations to the Republicans in the Senate. It remains to be seen whether or not they will conveniently fail to find the votes to pass their proposal so that they will not all be labeled as having stone-cold hearts.

Even if Medicaid does get a reprieve, we still cannot relax. It will continue to be vulnerable to attacks by those who consider it to be welfare and thus a tool to reduce budget deficits. Medicaid must be replaced by a program that provides access to comprehensive health care benefits while removing financial barriers to care – not just for lower-income individuals, but for all of us. Regardless of the Republican replacement proposal we need to intensify our advocacy for replacement with an improved Medicare for all.

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Universal coverage should be health goal

By Richard A. Damon, M.D.
The Billings (Mont.) Gazette, June 21, 2017

Everyone knows the Senate is trying to ram through their version of the GOP House health care bill called the American Healthcare Act behind closed doors and in secret. Both political parties routinely resort to underhanded ways to gain political advantage, placing party politics before population.

Gov. Steve Bullock, along with three other Democratic governors and three Republican governors, is urging the Senate to rethink the health care bill, which as yet has not been scored by the CBO. McConnell hopes to pass the Senate version before Americans can respond to knowing the devastating impact the bill will have on millions of Americans while giving tax breaks to the wealthiest Americans.

Major health insurers are fleeing the ACA market. The underlying reasons we are in crisis are that for-profit health insurers and drug maker stakeholders remain in legislative control of health care policy. There is no legislative congressional admission that the reasons for the health care crisis is because of the private insurer multi-payer system, while drug makers continue to be exempt from drug price regulation.

Transition to a Medicare for All single payer system, funded by modest equitable taxes, would initially be cost neutral because of increased expansion of coverage to every American. After initial transition costs, every American from birth to death would enjoy comprehensive benefits, saving over $450 billion a year in administrative costs, making Medicare for All an equitable sustainable system. We must not allow Congress to pass the underhanded, perverse bill excluding 23 million Americans from coverage and giving tax breaks to the wealthy.

http://billingsgazette.com…

Universal coverage should be health goal

By Richard A. Damon, M.D.
The Billings (Mont.) Gazette, June 21, 2017

Everyone knows the Senate is trying to ram through their version of the GOP House health care bill called the American Healthcare Act behind closed doors and in secret. Both political parties routinely resort to underhanded ways to gain political advantage, placing party politics before population.

Gov. Steve Bullock, along with three other Democratic governors and three Republican governors, is urging the Senate to rethink the health care bill, which as yet has not been scored by the CBO. McConnell hopes to pass the Senate version before Americans can respond to knowing the devastating impact the bill will have on millions of Americans while giving tax breaks to the wealthiest Americans.

Major health insurers are fleeing the ACA market. The underlying reasons we are in crisis are that for-profit health insurers and drug maker stakeholders remain in legislative control of health care policy. There is no legislative congressional admission that the reasons for the health care crisis is because of the private insurer multi-payer system, while drug makers continue to be exempt from drug price regulation.

Transition to a Medicare for All single payer system, funded by modest equitable taxes, would initially be cost neutral because of increased expansion of coverage to every American. After initial transition costs, every American from birth to death would enjoy comprehensive benefits, saving over $450 billion a year in administrative costs, making Medicare for All an equitable sustainable system. We must not allow Congress to pass the underhanded, perverse bill excluding 23 million Americans from coverage and giving tax breaks to the wealthy.

http://billingsgazette.com…

Burden of prior authorization getting worse

Payer prior authorization requirements on physicians continue rapid escalation: increasing practice overhead and delaying patient care

MGMA Poll, May 16, 2017

Medical practice leaders say that the burden of submitting prior authorization requests and supporting documentation to health plans is getting worse.

A May 16 MGMA Stat poll found 86% of respondents saying that prior authorization requests have increased in the past year, while 3% report those requests decreasing and another 11% saying they’ve stayed the same in the past year.

Agreements between health plans and their participating physicians routinely include a statement that the insurer has the right to determine the medical necessity of surgery, imaging studies, medication and many other procedures. Physician practices then devote clinical and administrative staff time and resources to submit preauthorization requests for each service, increasing overhead and often delaying patient care.

“Health plan demands for prior approval for physician-ordered medical tests, clinical procedures, medications, and medical devices ceaselessly question the judgement of physicians, resulting in less time to treat patients and needlessly driving up administrative costs for medical groups,” said Halee Fischer-Wright, MD, MMM, FAAP, CMPE, MGMA President and CEO.

http://www.mgma.com…

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Comment:

By Don McCanne, M.D.

Prior authorization requirements have always been a pain, and now, according to this poll, they’re getting worse. Not only do they add to our profound administrative waste in health care, they also may interfere with patient care by delaying or even preventing the delivery of appropriate services. They also waste valuable time of physicians and their staffs.

This report states, “Agreements between health plans and their participating physicians routinely include a statement that the insurer has the right to determine the medical necessity of surgery, imaging studies, medication and many other procedures.” Really? Insurers and other intermediaries have the right to determine medical necessity? Doesn’t that right belong to the patients in consultation with their health care professionals? Sure, insurers make payment decisions, and prior authorization may prevent retroactive denial of coverage. But how can they have to gall to usurp clinical judgment?

But suppose the services are unnecessary. Wouldn’t it be better to identify outliers and then attempt to educate them, reserving penalties for those remaining refractory to educational efforts? Taiwan has shown that that can work with a single payer system.

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