PNHP

Letter: Finally, a bill that can really save health care

Letter: Finally, a bill that can really save health care

By Robert S. Kiefner, M.D.
Concord (N.H.) Monitor, April 4, 2017

In a colossal setback for those who are indifferent to the health and well-being of their fellow Americans, the Republicans failed to repeal and replace Obamacare.

Ironically, it was the Freedom Caucus, a fraternity of cranky old white guys (and cranky younger white guys in training) who torpedoed the bill. By targeting the positive aspects of the ACA for repeal, they unwittingly enlightened and energized people with respect to the real value of the benefits.

There is now a unique opportunity to transcend the ACA, to dramatically decrease administrative overhead, drug costs, co-pays and deductibles while providing truly universal care.

HR 676, the Expanded and Improved Medicare for All Act, now awaits its day in Congress. Seventy-six co-sponsors have signed onto universal healthcare, publicly financed, but privately delivered with much lower costs. What’s not to like? HR 676 should be the bill that brings together the progressives who have long supported healthcare for every citizen, and the fiscal conservatives who want to decrease overall healthcare spending. The dissenters are mainly for-profit insurance companies and Big Pharma, for whom the bill provides long deserved corporate wedgies.

Encourage Reps. Annie Kuster and Carol Shae-Porter to sign on as cosponsors of HR 676. The time has come to really fix health care.

Dr. Robert S. Kiefner resides in Concord.

http://www.concordmonitor.com…

Two problems with a Medicaid work requirement

Don’t expect Medicaid work requirements to make a big difference

By Drew Altman, president and CEO of Kaiser Family Foundation
Axios, April 3, 2017

Medicaid “work requirements.” But their impact depends on how they are implemented and is likely to be very small — because most people on Medicaid who can work already are.

With Trumpcare dead for now, expect Republican governors to begin submitting waiver proposals to the Department of Health and Human Services to move their Medicaid programs in a more conservative direction. Medicaid “work requirements” are likely to be an element of many of those waiver requests, possibly from Republican-led states now looking to expand Medicaid under the Affordable Care Act.

During the Obama administration, HHS rejected mandatory work requirements as inconsistent with the purposes of the Medicaid statute, spurning requests from Arizona, Indiana, and Pennsylvania under a previous governor. Under the Trump presidency, HHS is expected to approve them.

Liberals find Medicaid work requirements repugnant because they believe that Medicaid beneficiaries want to work if they can, and that providing health coverage to people who cannot afford it is an obligation of any moral nation. Conservatives who favor work requirements see Medicaid coverage as another form of government welfare benefit, like cash assistance, requiring reciprocal obligations from beneficiaries, and a disincentive to work.

The reality, though, is that most Medicaid beneficiaries are working already, and the vast majority of those who are not working are likely to be exempted from all but the most draconian Medicaid work requirements when front-line caseworkers apply state rules.

* 59% of all Medicaid beneficiaries who were not on Supplemental Security Income — the program for low-income people with disabilities — were working full time (41%) or part time (18%) in 2015.

* That leaves 41% who were not working. Of those, the vast majority (89%) had reasons for not working, including that they were sick or had a disability (35%), were taking care of a family member (28%), or were in school (18%).

* Another 8% said they could not find a job which, when documented, usually satisfies work requirements.

* All told, just a tiny subset of Medicaid beneficiaries are-able bodied adults who do not have a reason for not working that would fail to pass muster with a state case worker.

https://www.axios.com…

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Comment:

By Don McCanne, M.D.

Why are some people opposed to other people having health care? In the case of Medicaid, some conservatives would deny people health care merely because they failed to meet certain work requirements. It is not as if this is a ubiquitous problem since, according to this report, only a tiny subset of Medicaid beneficiaries are able-bodied adults who do not have a reason for not working.

Is the denial of medical care a proper punishment for not being able to find a job? Only 3 percent of Medicaid beneficiaries fell into this category – lower than the national unemployment rate. And the conservatives would deny them care? This seems to be an unusually cruel punishment for what is largely a circumstance of fate.

The other issue is who really deserves to be denied health care? Nobody you say? Then why don’t we have a system that guarantees that everyone does have affordable health care when needed, like maybe an improved Medicare for all? Segregating people into arbitrary groups for health care coverage leaves many out, such as what would happen under these conservative work requirements for Medicaid.

HHS Secretary Tom Price and CMS administrator Seema Verma like these work requirements and are eager to grant states the right to exercise them. And we tolerate this in our government? What have we become?

Conyers: Medicare for All’s time has come

By John Conyers Jr.
Detroit Free Press, April 3, 2017

I’m as happy as anyone with the way the Republicans’ plan to wreck our healthcare system crashed and burned last week. And President Donald Trump is right: Republicans lost because Democrats beat them. We beat them because we were organized, we were unified and we were backed by unprecedented grassroots energy. Members of the U.S. Congress hosted dozens of rallies, advocacy organizations hosted hundreds more and constituents showed up in overwhelming numbers at town halls across this country to make their voices heard.

And what exactly was their message? One of the most poignant moments came at a town hall hosted by U.S. Rep. Diane Black, Republican of Tennessee, where a constituent explained her opposition to the GOP bill using faith. As a Christian, she said, her faith was rooted in helping the unfortunate, not cutting taxes on the rich, so why not expand Medicaid and allow everyone to have insurance? And she’s not alone. Last week, a Quinnipiac survey found that voters overwhelmingly oppose cuts to Medicaid — 74% of them — including 54% among Republicans.

Given the record high support for publicly funded healthcare, economists, policy experts and commentators everywhere have called on the Democratic party to build on our momentum by supporting a single payer system. But perhaps the most convincing case I heard came from Jessi Bohan, the teacher from Cookeville, Tennessee who spoke at Rep. Black’s town hall.

The week after her question went viral she wrote to the Washington Post that she was troubled to see her comments used as a “defense of Obamacare” instead of what they were: an indictment of any healthcare policy that leaves anyone out. As Bohan so eloquently put it, “it is immoral for health care to be a for-profit enterprise” that allows insurance companies to make “enormous sums of money off the sick while people are struggling to pay their medical bills.” If she had it to do over again, she wrote, she would have explained to Black “the Christian case for universal, single-payer health insurance, which would protect all Americans.”

While her message was targeted at Republicans, it is one that many of my colleagues in the Democratic Party need to hear as well. For two weeks, I’ve watched Democrats point to the Congressional Budget Office’s analysis of the Paul Ryan bill and express righteous outrage that it would lead to 24 million Americans losing their insurance. But that same CBO score says that 28 million Americans will still be without insurance even under the Affordable Care Act. I’m impressed that the ACA has expanded Medicaid eligibility in states that have adopted it and more than 20 million previously uninsured now have insurance, but universal healthcare it is not.

Time and time again I’ve heard Democrats dodge questions about their support for universal healthcare by saying they’re focused right now on defending the ACA. Now that we have repelled Paul Ryan’s attack and Donald Trump has signaled that Republicans will move on, the time for those excuses has passed.

For years, I’ve also watched as Democrats, including our presidential nominee last year, have avoided putting their name behind single payer by saying they’re focused on politically achievable short-term goals.

Single payer is politically achievable.

Gallup, the Kaiser Family Foundation, and other polling organizations have found that there is majority support for Medicare for All in America today. But more important, elected officials are not supposed to move to the political center, we are supposed to stake out the moral center and convince others to join us there.

November’s election results showed that we can’t just say “the other side is awful,” however true that may be, and expect Americans to flock to us. To win again, we must be a party of principles and present bold ideas and a vision for the future.

It is true that single-payer healthcare has been implemented in virtually every other advanced democracy on Earth. It is also true that in those countries, people live longer and healthcare is dramatically less expensive than it is here. And finally, it is true that Medicare for All is the direction Americans overwhelmingly want us to go. Nevertheless, I want my colleagues to join me in supporting single-payer not to save money or to win elections, but because it is the moral and just thing to do. If, like me, you believe healthcare is a right to everyone and not a privilege to those who can afford it, let’s be organized and let’s be unified in our support for Medicare for All.

John Conyers represents Michigan’s 13th District in the U.S. Congress. He has introduced H.R. 676 Medicare for All bill in every Congress since 2003.

http://www.freep.com…

When it comes to health care, why do we settle?

By Ellen Kaczmarek, M.D.
Citizen-Times (Asheville, N.C.), April 2, 2017

Competition! Americans thrive on it — it is virtually part of our national DNA. From sports to businesses (think free market economy and capitalism) to elections, competition is what we all understand. Being No. 1 is the goal we have been taught to seek.

Yet, we are totally complacent about being No. 37, according to the World Health Organization, in the world. Most of us don’t even realize that’s where the USA stands. In what, you ask? The answer is in health care.

How is this possible? What’s behind this number? This must be fake news! Are these alternative facts?

A flurry of questions accompanies this statement and it should.

For one, How is it possible that we rank No. 37 in health care?

Not to mention that life expectancy in the U.S. is shorter than most of the nations studied by the OECD (Organisation of Economic Cooperation and Development) by about 2 years (78.8 years in the U.S. in 2013 compared with 80.5 years for the OECD average). This is despite the fact that in the United States, health care spending remains much higher on a per capita basis than in all other OECD countries, and was two-and-a half-times greater than the OECD average in 2013 (though with the Affordable Care Act, there has been a notable slow-down in U.S. health spending growth).

The answer is that in most countries (with the exceptions of the U.S., Poland and Greece), universal health coverage ensures access to care for the whole population. This means that prevention of disease and promotion of healthy practices is paramount. It also provides financial protection from the cost of illness, so that medical bankruptcy is nonexistent in those countries.

Second, what is universal health coverage?

Universal health coverage means all citizens have health insurance. This is most cost-effective with a single payer health care system where a “single payer” fund, rather than private insurers, pays for health care costs. The “single payer” part refers to funding, not delivery.

In general, single-payer health care means that all medical bills are paid out of a single government-run pool of money. Under this system, all providers are paid at the same rate, and citizens receive the same health benefits, regardless of their ability to pay. A single-payer fund can have a private health care delivery system, a public delivery system, or a mix of the two (similar to the Medicare and supplemental “Medigap” insurance in this country.)

Isn’t a single payer plan socialism?

A single-payer system is not the same thing as socialized medicine. In a truly socialized medicine system, the government not only pays the bills but also owns the health care facilities and employs the professionals who work there. The Veterans Health Administration is an example of a socialized health system run by the government. The VA owns the health care facilities and pays the doctors, nurses and other health providers.

Medicare, on the other hand, is a single-payer system in which the federal government pays the bills for those who qualify, but hospitals and other providers remain private. (Again, many Medicare recipients purchase “Medigap” policies which cover the difference between the charges for their health care and what Medicare covers.)

Rather than tinker with a system like the ACA that was really only a compromise situation with insurance companies and other special interest groups at best, Americans need to demand a comprehensive reform that eliminates the profit motive from health care and provides a truly universal health coverage system. A single-payer health plan would fill this bill.

Who wants to be 37 when you can be No. 1?

Ellen Kaczmarek, M.D., is a member of Indivisible AVL.org, Health Care Justice of NC and Physicians for a National Health Program.

http://www.citizen-times.com…

New Bill Touts Improved, Expanded Medicare for All

By Ed Weisbart, M.D., CPE, FAAFP
Accountable Care News, April 2017

President Donald Trump has declared that the Affordable Care Act (ACA) needs to be replaced with “reforms that expand choice, increase access and lower costs, while providing better healthcare.”1 I agree with those goals and believe they can be accomplished without compromising the advances brought by the ACA—20 million fewer uninsured Americans, increased support for lower-income Americans and a host of reforms of insurance practices, such as guaranteed issue and prohibition against rescission and against annual or lifetime caps.

Despite these advances, many problems remain. Tens of millions of Americans remain uninsured. Many more are underinsured, finding the cost of care increasingly prohibitive and their choices of physicians and hospitals increasingly constrained by their insurance network administrators. Compared to other modern nations, our per capita healthcare costs remain outlandishly high and our life expectancy tragically short.

Only 72.7% of our healthcare dollar is spent on actual clinical care; 18% is spent on billing and insurance-related administration, including 7.5% by private insurers, 1.3% by public insurers, 2.7% by physicians, 2.8% by hospitals and 3.6% by other services. (An additional 9.4% of our total expense is on administration unrelated to billing and insurance.) If our billing and insurance-related administrative expenses were reduced to levels seen in most other modern nations, we would reap $375 billion in annual savings.2

Unable to address these wasteful inefficiencies, insurers have turned to financial barriers (copayments, coinsurance and deductibles) to reduce utilization and increasingly restrictive networks that inevitably conflict with patient choice. Our system is the most complex, redundant and least aligned with the interests of public health.

Public health campaigns do not align well with today’s business imperatives and simply cannot be given adequate support by the private insurance industry. Churning demands its own long-term strategies. There is no business case for public health.

I have spent many years in executive roles within the health insurance industry and been frequently stymied by the industry’s fiduciary pressures against long-term, public health initiatives. Even when insurers want to pursue such initiatives, their 20% to 25% annual turnover in membership demands that such clinical initiatives quickly produce favorable financial results. For many insurers, roughly half of their membership today will have migrated to a competing plan within three years and been replaced by members from those same plans. Those who ignore this pressure find themselves improving the health of their competitors’ membership.

The ‘Replace’ Portion of ‘Repeal and Replace’

U.S. Representative John Conyers (D-MI), along with 59 cosponsors, recently introduced the most prudent solution to each of these problems, “Expanded and Improved Medicare For All,” as HR676.3 Politics aside, HR676 should be the “replace” portion of the demand to “repeal and replace” ACA. It alone meets each of the stated goals of our new president.

HR676 would address these and other concerns. It is a short bill, just 30 pages, and a relatively easy read.

At a high level, the bill says two things: Fix the problems with Medicare and expand it to all Americans. The bill calls for public funding of healthcare while preserving and enhancing support for private delivery. This is essentially the model used in Canada today.

Medicare would be improved by removing financial barriers and plugging gaps in coverage, providing a single comprehensive benefit design of all medically necessary services as articulated within the bill. It would be expanded to cover virtually all U.S. residents, with specific eligibility criteria established by the program’s director.

According to a recent article in Annals of Internal Medicine,4 the cost of these changes would be offset by a 68% reduction in insurance overhead and administration of public programs (saving $220 billion); a 52.6% reduction in billing and administration for hospitals (saving $149.3 billion); a 40.1% reduction in billing and administration for physicians (saving $75.3 billion); and an additional $59 billion in administrative savings for nursing homes, home care agencies, non-physician practitioners and employers.

The authors also project a 31.2% reduction in the cost of outpatient prescription drugs, representing $113.2 billion, bringing the total savings from these components to $616.8 billion. Of note, there are at least 25 other studies5 on both a state and federal level that consistently show these savings would fully pay for expansion and improvements.

HR676 calls for financing the program through the establishment of a new Medicare for All Trust Fund built from existing funding sources, including public programs and public employee benefits. In addition, it calls for increasing personal income tax on the top 5% of income earners, and modest and progressive taxes on payroll, self- employment income, unearned income and stock and bond transactions.

The overall program budget would be set through negotiations by providers, state directors and regional directors but ultimately approved and divided regionally by the program director. This budget would contain three discrete, non-fungible sections: operations, capital and education. Health professionals would either be reimbursed through a negotiated, fee-for-service schedule or a salary through a globally budgeted institution, group practice or non-profit, HMO. Balance billing of patients is expressly prohibited.

The bill establishes a diversely representative, 15-member National Board of Universal Quality and Access, with a director of quality of control appointed by the president with the advice and consent of the Senate.

Obviously, HR676 would transform the health insurance landscape, virtually eliminating the market for employer-based and individual private insurance, Medicaid, Medicare supplements, wraps and Parts C and D programs. Most of the employees displaced from their positions within the insurance industry would have a two-year, transition benefit up to $100,000 per year, plus first priority at retraining and job placement within the new system.

Perhaps most importantly, HR676 would establish the foundations of a business case for long-term improvements in public health—something nearly unobtainable in an insurance industry adapted to high levels of membership turnover.

In some ways, Medicare already accomplishes this for our seniors. The Institute of Medicine found that once Americans reach the age of eligibility for Medicare, our life expectancy as compared to that in 17 other modern nations begins to improve. Until age 65, we rank at or near the worst among our peers. Once we reach Medicare eligibility, our ranking by age improves until age 85, when our life expectancy has risen to among the best three nations.6

U.S. vs. Canadian Healthcare

We can also project the value of HR676 by comparing the results of our healthcare system with Canada’s. In 1971, President Richard Nixon signed into law the HMO Act, creating the managed care experiment. The same year, Canadian Medicare was fully implemented in all provinces. Until that point, our two nations were nearly identical in overall healthcare costs as a percentage of GDP, and our life expectancies were within one year of each other.

Since that milestone, our overall cost trends have remained unchanged whereas the trend in Canada nearly flattened out.7 Simultaneously, their life expectancy rate improved more rapidly than ours so that Canadians now enjoy a 2.5-year advantage.8 We were the same; now we spend much more, and they live longer.

Canadians have virtually no risk of bankruptcy from the costs of medical care—even when unable to continue working.

Like all others, the Canadian healthcare system is imperfect. Six percent of Canadians report having unmet health needs due to waiting lists or frankly unavailable services, compared to 1% of Americans reporting this. However, only 1% of Canadians report unmet health needs due to the cost of care, compared to 8% of Americans.9 We can do better than Canada, but their results today trump ours in many meaningful ways.

Among many similar studies, a recent Gallup poll found that 58% of Americans, including 73% of Democrats and 41% of Republicans, “support a federally funded, healthcare program for all Americans.”10

Fifty-nine percent of physicians want national health insurance.11 More than 2,500 prominent physicians have publicly endorsed the June 2016 proposal by the Working Group on Single-Payer Program Design.12

President Trump has called for a healthcare strategy that expands choice, increases access, lowers costs and provides better healthcare. An obvious solution is already in Congress—HR676.

Ed Weisbart M.D., CPE, FAAFP, chairs the Missouri chapter of Physicians for a National Health Program, a 30-year-old, non-profit research and education organization. He may be reached at pnhpMO@gmail.com. Visit pnhp.org/hr676 for more information on HR676.

Notes

1. Remarks by President Trump in Joint Address to Congress. Feb. 28, 2017.

2. Jiwani A, Himmelstein D, Woolhandler S, et al. “Billing and Insurance-Related Administrative Costs in United States’ Health Care: Synthesis of Micro-Costing Evidence.” BMC Health Services Research. Nov. 13, 2014.

3. “H.R.676—Expanded and Improved Medicare for All Act.” Congress.gov. Accessed March 10, 2017.

4. Woolhandler S, Himmelstein D. “Single-Payer Reform: The Only Way to Fulfill the President’s Pledge of More Coverage, Better Benefits, and Lower Costs.” Annals of Internal Medicine. Feb. 21, 2017.

5. “How Much Would Single Payer Cost?” Physicians for a National Health Program. Accessed March 10, 2017

6. “Shorter Lives, Poorer Health.” Institute of Medicine. Jan. 9, 2013.

7. “Canada’s Slow Health Spending Growth Continues.” Canadian Institute for Health Information. Oct. 29, 2015.

8. “Comparing the U.S. and Canadian Health Care Systems.” The National Bureau of Economic Research. Accessed March 10, 2017.

9. Ibid.

10. Newport F. “Majority in U.S. Support Idea of Fed-Funded Healthcare System.” Gallup. May 16, 2016.

11. Carroll, A, Ackerman R. “Support for National Health Insurance Among U.S. Physicians: 5 Years Later.” Annals of Internal Medicine. April 2008; 148 (7): 567.

12. “Beyond the Affordable Care Act: A Physician’s Proposal for Single-Payer Health Care Reform.” The Working Group on Single‐ Payer Program Design. Accessed March 10, 2017.

To view a PDF version of this article, click here.

Mississippi shows us why we need a national health program

In the state with the highest medical debt, it’s the middle class who carries the burden

By Max Blau
STAT, March 24, 2017

Americans are no strangers to medical debt, and the burden is most severe in Mississippi, where nearly 40 percent of adults under age 65 owe hospitals or doctors, according to the Urban Institute. But the men and women carrying that debt are not always poor — they’re increasingly middle class.

And their inability, or refusal, to pay their bills is straining hospital budgets and threatening the availability of care.

Mississippi, where the median household income hovers near $40,000, has one of nation’s highest rates of uninsured and underinsured adults. As a result, the state has one of the highest percentage of adults who avoid doctors due to potential costs, said Therese Hanna, executive director at the Center for Mississippi Health Policy.

At the same time, medical debt remains the leading cause of bankruptcies, according to Roy Mitchell, executive director of the Mississippi Health Advocacy Program.

Over the past five years, James Henley Jr., a bankruptcy trustee in Jackson, said he has seen a sharp increase in the number of middle-class residents with bankruptcy claims after “extending their lines of credit, maxing out credit cards, [robbing] Peter to pay Paul.”

https://www.statnews.com…

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Welfare Audit Bill Passes With No Statistics Given on Fraud

By Sarah Smith
U.S. News & World Report, March 29, 2016

Mississippi could hire a private company to audit Medicaid, welfare and food stamp recipients and make sure they aren’t cheating the program under legislation approved by the Senate on Wednesday after a debate in which supporters offered no statistics about welfare fraud.

The bill, which is on its way to Gov. Phil Bryant, had already passed the House on Tuesday.

House Bill 1090 would let the state hire a contractor to help check that recipients live in Mississippi and are who they claim to be. The contractor would also check recipients’ income levels. The measure also requires able-bodied recipients to be working, and it tracks where recipients use their money.

Republican proponents say the bill will bring the state one-time savings of about $4 million to $5 million. Sen. Brice Wiggins, a Republican from Pascagoula who presented the proposal Wednesday, said the state Department of Human Services gave him the estimate.

But that number started to fall apart under questioning from Democratic Sen. Hob Bryan of Amory. He had never seen a number, he said. Could he take a look?

“I am told that — I’m not going to lie, numbers get thrown around all the time,” Wiggins said. “We need this bill to get to that.”

Bryan asked again if the figures came from the Department of Human Services.

“As I said, numbers were all over the place,” Wiggins replied.

Several Democrats pointed out the sponsors have no numbers on fraud.

“How many people are riding the system who aren’t deserving?” asked Sen. David Jordan, a Democrat from Greenwood. “Don’t you think you should have some statistics?”

Wiggins had no statistics to offer. Finding out just how much fraud is going on, he said, is part of the bill’s purpose.

“What is driving some of us up the wall is the notion that somehow the entire class of people receiving Medicaid or other benefits are a bunch of clever, crafty people out trying to steal money from hard working folks and if we could only crack down on this we could balance the state budget,” Bryan said.

https://www.usnews.com…

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Comment:

By Don McCanne, M.D.

The residents of Mississippi have a serious problem with medical bills and resulting debt impacting 40 percent of adults under 65. The fact that their state legislators are not particularly responsive to this problem is represented by the fact that they rejected an expansion of Medicaid under the Affordable Care Act which would have provided coverage to an additional 300,000 Mississippians.

Of course the medical debt problem persists, so the legislature finally acted. But talk about a non sequitur, in this case a double non sequitur.

First, defining the problem. These people needed medical care but did not have adequate means of paying for it and thus were saddled with medical debt. It seems that a logical response would be to set up a health insurance program to pay for the medical expenses. No, even a Medicaid program with 90 percent federal funding was rejected by the legislators.

So they had a second chance, and what did they do? They somehow decided that these people in need were a bunch of flakes who were just after free handouts, so, with no supporting evidence whatsoever, they voted to authorize a private contractor to ferret them out if they relied on public benefits. In spite of this double whammy of incompetence, it does look like the legislators have had one dubious success – they have managed to blame the victim.

Sometimes this states’ rights thing goes overboard. We cater to the legislators and governors of the states while we neglect the needs of the people. Mississippi desperately needs a universal insurance program. It is not as if the federal government has no rightful role because seniors and individuals with long term disabilities have the right to Medicare. Why shouldn’t we extend that right to everyone in Mississippi, or, for that matter, to everyone in the United States? Well, we should.

Several states have proven that it is unethical for us to continue to allow the states to make their own decisions about who should or should not be entitled to health care when so many are harmed by bad governing decisions. Limiting health care coverage to the gentry or whatever other qualifying social order is un-American. Mississippi shows us that it is an absolute imperative that we have a national health program that includes everyone and is effective in removing financial barriers to all needed care. That is just what an improved Medicare for all would do.

“…our fathers brought forth on this continent, a new nation, conceived in Liberty, and dedicated to the proposition that all men are created equal. Now we are engaged in a great civil war, testing whether that nation, or any nation so conceived and so dedicated…”

No, let’s not go there again. Let’s just get heath care out to everyone.

California’s single payer bill – full text of bill released

SB-562, The Healthy California Act

California Legislature, Amended in Senate March 29, 2017

This bill, the Healthy California Act, would create the Healthy California program to provide comprehensive universal single-payer health care coverage and a health care cost control system for the benefit of all residents of the state. The bill, among other things, would provide that the program cover a wide range of medical benefits and other services and would incorporate the health care benefits and standards of other existing federal and state provisions, including, but not limited to, the state’s Children’s Health Insurance Program (CHIP), Medi-Cal, ancillary health care or social services covered by regional centers for persons with developmental disabilities, Knox-Keene, and the federal Medicare program. The bill would require the board to seek all necessary waivers, approval, and agreements to allow various existing federal health care payments to be paid to the Healthy California program, which would then assume responsibility for all benefits and services previously paid for with those funds.

The bill would state the intent of the Legislature to enact legislation that would develop a revenue plan, taking into consideration anticipated federal revenue available for the Healthy California program. The bill would create the Healthy California Trust Fund in the State Treasury, as a continuously appropriated fund, consisting of any federal and state moneys received for the purposes of the act.

Sec. 1 (b)

(2) It is the intent of the Legislature for the state to work to obtain waivers and other approvals relating to Medi-Cal, the state’s Children’s Health Insurance Program, Medicare, the PPACA, and any other federal programs so that any federal funds and other subsidies that would otherwise be paid to the State of California, Californians, and health care providers would be paid by the federal government to the State of California and deposited in the Healthy California Trust Fund.

(3) Under those waivers and approvals, those funds would be used for health coverage that provides health benefits equal to or exceeded by those programs as well as other program modifications, including elimination of cost sharing and insurance premiums.

Sec. 2 TITLE 22.2. The Healthy California Act

Chapter 7. Funding

Article 1. Federal Health Programs and Funding

100650. (b)

(1) The board shall apply to the United States Secretary of Health and Human Services or other appropriate federal official for all waivers of requirements, and make other arrangements, under Medicare, any federally matched public health program, the Affordable Care Act, and any other federal programs that provide federal funds for payment for health care services that are necessary to enable all Healthy California members to receive all benefits under the program through the program, to enable the state to implement this title, and to allow the state to receive and deposit all federal payments under those programs, including funds that may be provided in lieu of premium tax credits, cost-sharing subsidies, and small business tax credits, in the State Treasury to the credit of the Healthy California Trust Fund, created pursuant to Section 100655, and to use those funds for the program and other provisions under this title.

(2) To the fullest extent possible, the board shall negotiate arrangements with the federal government to ensure that federal payments are paid to Healthy California in place of federal funding of, or tax benefits for, federally matched public health programs or federal health programs.

Article 2. The Healthy California Trust Fund

100655. (a) The Healthy California Trust Fund is hereby created in the State Treasury for the purposes of this title.

Article 3. Healthy California Financing

100657. (a) It is the intent of the Legislature to enact legislation that would develop a revenue plan, taking into consideration anticipated federal revenue available for the program. In developing the revenue plan, it is the intent of the Legislature to consult with appropriate officials and stakeholders.

https://leginfo.legislature.ca.gov…

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Comment:

By Don McCanne, M.D.

Now we have the full text of California’s new single payer bill – SB 562. It calls for comprehensive health care coverage for all residents of California with no premium, copayment, coinsurance, deductible, nor any other form of cost sharing, for all covered benefits. “Resident” means an individual whose primary place of abode is in the state, without regard to the individual’s immigration status. It’s the real thing.

Last week, Gov. Jerry Brown seemed to dismiss the idea of a single payer system with this response to reporters, “Where do you get the extra money? This is the whole question.”

Of course, the money is already there and being spent on health care. Current government and private spending combined is enough to pay for a comprehensive system for all residents wherein the administrative savings and other efficiencies frees up enough funds to pay for those currently uninsured and underinsured.

There are two issues that may have prompted the governor’s response: transferring current federal health care funds to the state, and establishing a state tax system to replace current private spending.

The excerpts from SB 562 posted above indicate that it is the “intent” to obtain “waivers and other approvals” that would enable the federal government to transfer to the state funds from Medicare, Medicaid, Chip, ACA, and other federal programs. The problem is that current waiver programs are inadequate to fully accomplish that, and new federal legislation would be required. Considering the composition of the current Congress, that could be a difficult task (a comment that does not require a mastery of understatement).

Health care spending through the private sector is relatively inefficient compared to spending in government programs such as Medicare. Yet when the taxes that would replace private spending are spelled out specifically, they seem overwhelming to the average individual with an aversion to taxes in general. It is difficult for them to see what they are already paying for our health care system that is not particularly transparent such as the component of employer-sponsored health plans that are only nominally paid by the employer, the tremendous tax expenditures for employer-sponsored plans that go disproportionately to higher income individuals, the huge spending for government employee health plans on the federal, state, and local level, and the costs of health care built into the prices of services and products to pay for employee coverage, worker’s comp, liability coverage, and the like. When that spending goes away and is replaced by government spending, the taxes to pay for that can look formidable. Just ask former Gov. Peter Shumlin of Vermont. Then try to sell that to the residents of California. When you try to explain to them that the tax system would be more equitable and efficient, and most would actually pay less overall, they are already blinded by the proposed tax increases that they do see (but are not yet spelled out in SB 562).

What we need is a well designed, national single payer health program. We should continue to pull all stops toward that goal, though it is difficult to see when we will reach the political threshold that will make that possible. Until then we should also support state efforts to relieve the physical suffering and financial hardship that is being wrought on our people by our dysfunctional health care financing system.

Thus we should strongly support SB 562. We should make every effort to obtain “waivers and other approvals,” as difficult as that will be. We should increase our efforts to educate the public on what a really good deal this would be for them, otherwise our efforts could be sunk by a few soundbites from the industries that profit excessively from our sick system (as they were in prior ballot measures in California, Oregon and Colorado).

But while we do this, we cannot let up the least in our advocacy for a national health program. Our brothers and sisters in other states desperately need our help.

New York State Inches Closer To Single-Payer Plan With Pickup Of New Support

But critics wonder whether the additional backing is merely symbolic.

By Ryan Grim, Daniel Marans, Jeffrey Young
The Huffington Post, March 30, 2017

The push to implement a “Medicare for all”-type system in New York state just took a significant step forward Wednesday. Sen. Jeffrey Klein, who heads the Independent Democratic Conference in the state Senate, plans to co-sponsor the measure, and will bring along the remaining holdout in his caucus, his spokeswoman Candice Giove told The Huffington Post.

That gives the measure the unanimous support of the IDC, a crucial, and often recalcitrant, bloc of lawmakers. “All members of the independent conference will become cosponsors of that bill,” Giove said.

In a statement, Klein cited President Donald Trump’s attempts to repeal the Affordable Care Act and the protections it provides as a reason he is backing the creation of a single-payer health insurance system in New York.

“A single-payer system would create the peace of mind that residents could have access to quality medical care including outpatient and inpatient medical care, primary and preventive care, prescription drugs and laboratory tests,” Klein said.

The New York Senate is a strange place. With 63 seats, 32 senators are needed for a majority. Republicans have only 31, but an additional Democrat, Sen. Simcha Felder, caucuses with Republicans, giving them control of the chamber. Meanwhile, the eight members of the IDC do not caucus with the rest of the Democrats.

Sen. Michael Gianaris, the deputy leader of the state Senate’s mainstream Democratic conference, welcomed the IDC’s support, even as he lamented that their collaboration with Republicans helped prevent the bill’s passage.

“It’s nice that they are putting their names on the bill, but their partners in government are the ones with the power to prevent it from seeing the light of day,” Gianaris said.

Although Republicans have the majority without the IDC, thanks to Felder, Gianaris believes the breakaway caucus has made the problem worse.

“With the Democrats being divided in the Senate, we lose the ability to pressure Felder to come back or grow the conference in other ways, because we’re too busy dealing with each other,” Gianaris said.

But the support of the IDC is a critical development in the push for single-payer health care, as the state assembly is expected to easily pass its version of the bill in April or May, said one of the bill’s lead backers, Assemblyman Jeffrey Dinowitz, who represents the northwest Bronx.

The New York Assembly, the state’s lower legislative chamber, passed the same measure in 2015 and 2016, but it wasn’t considered in the state Senate, which Republicans control with the support of the Independent Democratic Caucus.

Despite being within striking distance of passing the single-payer bill in the New York Senate, victory for its proponents seems unlikely given GOP opposition. Rallies are planned in support of single-payer health care in New York City Saturday and Albany, the state capital, Tuesday.

It is not clear why IDC members chose this time to get behind legislation introduced by Sen. Gustavo Rivera, a member of the mainstream Senate Democratic caucus ― particularly since Republican control of the chamber forecloses the bill’s passage.

There are signs that the IDC is feeling pressure from a progressive Democratic base newly energized by Trump’s election. Over 100 protesters booed Sen. Jose Peralta for his IDC membership outside a February town hall in Queens. Anti-IDC activists have even formed their own group, “No IDC NY,” to oppose the renegade Democrats.

“The IDC has been feeling enormous pressure since the inauguration from voters in their districts who were shocked to find out the Democrats they elected have been propping up Trump Republicans in the state Senate,” Bill Lipton, the Working Families Party’s New York director, said in a statement. “Now they’re backing legislation that their own support of Republican leadership ensures will never even make it to the floor. That’s the height of cynicism and just more evidence of the heat they are feeling from the resistance.”

Whatever the outcome in New York, the failure of President Donald Trump and House Speaker Paul Ryan (R-Wis.) to repeal the Affordable Care Act and replace it with an alternate plan that would increase the number of uninsured Americans by 24 million has given a boost to progressives seeking to go beyond Obamacare.

Legislators in California have launched a new push to implement a single-payer program in the most populous state in the nation, although Democratic Gov. Jerry Brown has expressed misgivings about its cost.

The Affordable Care Act contains a provision that would allow states to make sweeping changes to their health care markets, including instituting a single-payer program that would replace the current private system, so long as the state programs cover as many people with equivalent benefits at no additional cost to the federal government. Vermont worked for several years after the Affordable Care Act’s passage to design a single-payer program, but abandoned the effort over its expense.

Excluding the IDC, the mainstream Democrats hold 22 seats in the New York state Senate and will soon hold 23 once a special election is held in a Democratic district.

But even with all mainstream Democrats and the IDC on board, they would remain one vote short, meaning Democrats need to either pick up a seat before 2018, persuade a Republican or win the chamber outright in 2018. This being New York, a Republican senator was coincidentally indicted just last week, so it’s always possible a new seat could become available.

If not, said Dinowitz, his hope is that the newfound energy among grassroots Democrats can translate into some Senate seat pickups in 2018. “We need to add one more person. I believe the only way to get to 32 is through the election process,” Dinowitz said. “There is a lot of energy now in my area and other areas. Meetings are attracting huge numbers of people, and a lot of people are coming out, most of whom have never been involved in this way. If it’s sustained it could really change the dynamics of the elections come 2018.”

Controlling the chamber is also crucial because the party in power controls the floor schedule. Even if Democrats persuaded a Republican to sign on, they’d need to similarly persuade the Republican leadership to allow a vote.

Dinowitz said that groups affiliated with Indivisible, a grassroots activism network that arose after the election, have been particularly active on the single-payer issue, and that in meetings with new activists, the number one issue they care about is health care, followed closely by immigration.

“In the wake of Trump being elected, the issue of health care has moved to the top of the agenda for a lot of people. If people think we can rest on our laurels because repeal of Obamacare collapsed, they’re mistaken. Obamacare was a compromise of a compromise,” Dinowitz said, noting that not only was it not the single-payer system many prefer, but the public option was traded away.

If both California and New York can implement a single-payer heath care system in the next few years, he added, something like a fifth of the country will be covered just by those two states.

http://www.huffingtonpost.com…

Trump was right about health care for most of his life

By Fareed Zakaria
The Washington Post, March 30, 2017

The recent Republican debacle on health care could prove to be an opportunity. It highlighted, yet again, the complexity of the U.S. system, which continues to be by far the most expensive and inefficient in the advanced world. But President Trump could actually use the legislative collapse to fix health care if he went back to basics and to his core convictions on the topic, which are surprisingly intelligent and consistent.

There is an understandable impulse on the right to assume that health care would work more efficiently if it were a free market, or a freer market. This is true for most goods and services. But in 1963, economist Kenneth Arrow, who later won a Nobel Prize, offered an explanation as to why markets would not work well in this area. He argued that there was a huge mismatch of power and information between the buyer and the seller. If a salesman tells you to buy a particular television, you can easily choose another or just walk away. If a doctor insists that you need a medication or a procedure, you are far less likely to reject the advice. And, Arrow pointed out, people think they don’t need health care until they get sick, and then they need lots of it.

Every advanced economy in the world has implicitly acknowledged his argument because they have all adopted some version of a state-directed system for health care. Consider the 16 countries that rank higher than the United States on the conservative Heritage Foundation’s Index of Economic Freedom. All except Singapore (which has a unique state-driven approach) have universal health-care systems that can be described as single-payer (Medicare for all), government-run (the British model) or Obamacare-plus (private insurance with a real mandate that everyone opt in). Hong Kong, often considered the most unregulated market in the world, has a British-style government-run system. Switzerland, one of the most business-friendly countries, had a private insurance system just like the United States’ but found that, to make it work, it had to introduce a mandate.

While producing a CNN documentary on health-care systems around the globe, I was particularly struck by the experience of Taiwan, another free-market haven. In 1995, 41 percent of its population was uninsured and the country had very poor health outcomes. The government decided to canvass the world for the best ideas before instituting a new framework. It chose Medicare for all, a single government payer, with multiple private providers. The results are astonishing. Taiwan has achieved some of the best outcomes in the world while paying only 7 percent of its gross domestic product on health care (compared with 18 percent in the United States). I asked William Hsiao, an economist who helped devise the country’s model, what lessons they took, if any, from the United States. “You can learn what not to do from the United States rather than learn what to do,” he replied.

Americans often assume that despite its costs, American health care provides better services than others. We often hear about the waiting time for care in other countries. But according to the Commonwealth Fund, among industrialized countries the United States is in the middle of the pack for wait times, behind even Britain . Moreover, one of the world’s leading experts, Uwe Reinhardt of Princeton, has found that Americans use less care than the average for developed countries when it comes to things such as seeing a doctor and spending time in the hospital. The problem with the free market is that there is little profit in prevention and lots in crisis care.

Trump has now taken up the call to repeal Obamacare. But until recently, health care was actually one of the rare issues on which he had spoken out, before his campaign, with remarkable consistency. In his 2000 book “The America We Deserve,” he wrote:

“I’m a conservative on most issues but a liberal on this one. We should not hear so many stories of families ruined by healthcare expenses. . . . We must have universal healthcare. . . . The Canadian plan . . . helps Canadians live longer and healthier than Americans. There are fewer medical lawsuits, less loss of labor to sickness, and lower costs to companies paying for the medical care of their employees. . . . We need, as a nation, to reexamine the single-payer plan, as many individual states are doing.”

Trump was right on this issue for much of his life. He has now caved to special interests and an ideology unmoored by facts. He could simply return to his convictions, reach out to Democrats and help the United States solve its health-care crisis.

https://www.washingtonpost.com…

Justice Department joins in Medicare fraud lawsuit against UnitedHealth

Justice Department Joins Lawsuit Alleging Massive Medicare Fraud By UnitedHealth

By Fred Schulte
Kaiser Health News, March 28, 2017

The Justice Department has joined a California whistleblower’s lawsuit that accuses insurance giant UnitedHealth Group of fraud in its popular Medicare Advantage health plans.

Justice officials filed legal papers to intervene in the suit, first brought by whistleblower James Swoben in 2009, on Friday in federal court in Los Angeles. On Monday, they sought a court order to combine Swoben’s case with that of another whistleblower.

Swoben has accused the insurer of “gaming” the Medicare Advantage payment system by “making patients look sicker than they are,” said his attorney, William K. Hanagami. Hanagami said the combined cases could prove to be among the “larger frauds” ever against Medicare, with damages that he speculates could top $1 billion.

“This is a very big development and sends a strong signal that the Trump administration is very serious when it comes to fighting fraud in the health care arena,” said Patrick Burns, associate director of Taxpayers Against Fraud in Washington, a nonprofit supported by whistleblowers and their lawyers.

“This is not one company engaged in episodic bad behavior, but a lucrative business plan that appears to be national in scope,” Burns said.

When Congress created the current Medicare Advantage program in 2003, it expected to pay higher rates for sicker patients than for people in good health using a formula called a risk score.

But overspending tied to inflated risk scores has repeatedly been cited by government auditors, including the Government Accountability Office. A series of articles published in 2014 by the Center for Public Integrity found that these improper payments have cost taxpayers tens of billions of dollars.

http://khn.org…

***

Comment:

By Don McCanne, M.D.

Regular readers know that the private Medicare Advantage plans have been cheating the taxpayers by upcoding the diagnoses of insured patients to make them appear sicker than they really are in order to qualify for extra risk adjustment payments. This update confirms the seriousness of the allegations in that the Justice Department has joined the lawsuit against the insurers. Damages could top a billion dollars.

This is particularly pertinent right now since there is intense political pressure to reduce entitlement spending (Medicare and Social Security) in the forthcoming federal budget negotiations. A plan favored by HHS Secretary Tom Price, House Speaker Paul Ryan, and others in the Republican leadership would convert traditional Medicare into a defined premium (voucher) program, turning all of Medicare over to these crooks.

Although our first priority must continue to be advocacy of a single payer national health program – an improved Medicare for all – it is imperative that we protect the Medicare that we do have if we are going to use an improved version of it to provide health care to all.

Special credit should go to the author of this KHN/NPR article, Fred Schulte, who has done extensive investigative reporting on this topic, having authored the articles on it previously published by the Center for Public Integrity. Thanks, Fred!

American health care – what next?

Interview with Adam Gaffney, M.D. and Saurabh Jha, M.D.
The BMJ Podcast, March 29, 2017

Excerpt from Dr. Gaffney, responding to Dr. Jha’s charge that a single-payer national health program would provide overly generous benefits:

I agree that health care is not one size fits all. Health care is unique to the individual. We all have unique wishes, we all have unique wants, we all have unique medical problems, we all would want different things at the end of life, we all have different thoughts about various reproductive health care issues, and so on and so forth.

So health care is unique, but health coverage should be universal, and I think differentiating between those two things is fundamentally important.

Yes, we all have our own wishes and maybe someone who has different life experiences is going to seek out different care than someone who has another set of life experiences. But coverage should be universal. The full spectrum of comprehensive care should be covered.

[Opponents] might say that’s sort of a regressive tax on people who don’t use that much health care, but that is only true if the health care system is being funded in a regressive manner.

If we fund the health care system through progressive taxation, then people people pay in what they can afford to pay in on the basis of their income, and then they use the health care services that they need on the basis of their needs and of their wishes.

full interview:
https://soundcloud.com…

The BMJ Podcast is hosted by Peter Doshi. He was joined by Dr. Adam Gaffney, from Harvard Medical School, and Dr. Saurabh Jha, from the Hospital of the University of Pennsylvania.

Can more Republicans support single payer?

Republicans for Single-Payer Health Care

By David Leonhardt
The New York Times, March 28, 2017

Without a viable health care agenda of their own, Republicans now face a choice between two options: Obamacare and a gradual shift toward a single-payer system. The early signs suggest they will choose single payer.

That would be the height of political irony, of course. Donald Trump, Paul Ryan and Tom Price may succeed where left-wing dreamers have long failed and move the country toward socialized medicine. And they would do it unwittingly, by undermining the most conservative health care system that Americans are willing to accept.

You’ve no doubt heard of that conservative system. It’s called Obamacare.

So if voters like government-provided health care and Republicans are going to undermine private markets, what should Democrats do? When they are next in charge, they should expand government health care.

https://www.nytimes.com…

***

The Republican Waterloo

By David Frum
The Atlantic, March 24, 2017

Seven years and three days ago, the House of Representatives grumblingly voted to approve the Senate’s version of the Affordable Care Act. Democrats in the House were displeased by many of the changes introduced by Senate Democrats. But in the interval after Senate passage, the Republicans had gained a 41st seat in the Senate. Any further tinkering with the law could trigger a Republican filibuster. Rather than lose the whole thing, the House swallowed hard and accepted a bill that liberals regarded as a giveaway to insurance companies and other interest groups. The finished law proceeded to President Obama for signature on March 23, 2010.

Over the next seven years, Republicans would vote again and again to repeal the Affordable Care Act. Total and permanent opposition to the law would become the absolute touchstone of Republican loyalty.

Some of the conservatives who voted “no” to the House leadership’s version of repeal may yet imagine that they will have some other opportunity to void the law. They are again deluding themselves. If the Republican Party tripped over its own feet walking across this empty ballroom, it will face only more fearsome difficulties in the months ahead, as mid-term elections draw closer. Too many people benefit from the law — and the Republican alternatives thus far offer too little to compensate for the loss of those benefits.

In that third week in March in 2010, America committed itself for the first time to the principle of universal (or near universal) health-care coverage. That principle has had seven years to work its way into American life and into the public sense of right and wrong. It’s not yet unanimously accepted. But it’s accepted by enough voters — and especially by enough Republican voters — to render impossible the seven-year Republican vision of removing that coverage from those who have gained it under the Affordable Care Act. Paul Ryan still upholds the right of Americans to “choose” to go uninsured if they cannot afford to pay the cost of their insurance on their own. His country no longer agrees.

Whatever else the 2016 election has done, it has emancipated Republicans from one of their own worst self-inflicted blind spots. Health care may not be a human right, but the lack of universal health coverage in a wealthy democracy is a severe, unjustifiable, and unnecessary human wrong. As Americans lift this worry from their fellow citizens, they’ll discover that they have addressed some other important problems too. They’ll find that they have removed one of the most important barriers to entrepreneurship, because people with bright ideas will fear less to quit the jobs through which they get their health care. They’ll find they have improved the troubled lives of the white working class succumbing at earlier ages from preventable deaths of despair. They’ll find that they have equalized the life chances of Americans of different races. They’ll find that they have discouraged workplace discrimination against women, older Americans, the disabled, and other employees with higher expected health-care costs. They’ll find that their people become less alienated from a country that has overcome at last one of the least attractive manifestations of American exceptionalism — and joined the rest of the civilized world in ameliorating and alleviating our common human vulnerability to illness and pain.

What I would urge is that those conservatives and Republicans who were wrong about the evolution of this debate please consider why they were wrong: Consider the destructive effect of ideological conformity, of ignorance of the experience of comparable countries, and of a conservative political culture that incentivizes intransigence, radicalism, and anger over prudence, moderation, and compassion.

https://www.theatlantic.com…

***

Comment:

By Don McCanne, M.D.

Asking whether more Republicans can support single payer is probably not the best question. A better question would be, what sort of health care system do Americans want and how can we achieve that?

The intense political divide in this nation really played out during the debate over the Affordable Care Act. Opponents were vociferous in condemning the program, pointing out its various deficiencies – high premiums, limited choice of health plans, loss of personal physicians, narrow provider networks, high deductibles and other cost sharing creating financial barriers to care, and endless other complaints.

Supporters were not quite as animated but were very rigid in insisting on protecting the gains that ACA brought us. In a nation that was already highly politically polarized, the two sides congregated around the two dominant political parties – Republican and Democratic – even though many classified themselves as independent. The camp supporting ACA aligned behind the Democratic candidate – Hillary Clinton. The camp opposed to ACA aligned behind the Republican candidate – Donald Trump. But as is so often the case, things are not so simple.

The left was actually a divided camp with very strong support expressed for Bernie Sanders, to a large extent because of his spirited advocacy for single payer Medicare for all. When Clinton won the nomination, the neoliberal faction enthusiastically supported her and ACA. The progressive faction lost their enthusiasm since the hopes of enacting single payer essentially vanished, leaving us with a mediocre, unsatisfactory model of reform – ACA. Many of them stayed home on election day.

But what about the right? They were divided as well. The conservatives were emphatically opposed to Obamacare, wanting it to be repealed, with some of them even opposing any replacement. Moderate Republicans supported repeal and replace. Trump promised that his replacement would cover everyone, provide better care, and cost less. That message resonated, giving him enough votes for an electoral college victory.

However, the replace of repeal and replace turned out to be a fraud. The Republican leadership in the House tried to pass legislation that would reduce the government role in health care by cutting back on Medicaid, greatly reducing the numbers insured, reducing subsidies that had helped to make plans affordable, and reducing taxes on the wealthy that were paying for many of the improvements brought by ACA. This is certainly not the replacement that most Republicans wanted and thought Trump would bring us, though a few mean-spirited, heartless conservatives were quite satisfied with the proposal. It was easy for most Republican legislators to walk away from this ill-conceived model of reform, and there certainly was no clamor to try to extract other ideas for reform when the leadership’s policy cabinet had been emptied. The status quo was not satisfactory, but it seemed that the only good ideas were in the camp of the political opponents (though there were some lousy ideas there as well).

In spite of the political divide, both sides are largely in agreement that the deficiencies of ACA, listed above, are a problem and require correction. Many, especially on the Republican side and amongst the progressives, are convinced that the ACA model should not be sustained because it is inefficient, too expensive, and not very amenable to legislative patches. Also there is broad agreement that the Republican replacement proposal would only have made things worse.

The awakening that is taking place is that the popular Medicare program has been functioning well, though it needs improvements (which are quite feasible), and that other nations really have provided truly universal, comprehensive coverage at much lower costs – like Canada’s Medicare, for instance. A large minority of Republicans do believe that we should join the rest of the civilized world “in ameliorating and alleviating our common human vulnerability to illness and pain,” in the words of David Frum.

Medicare is our most efficient, effective and affordable model for reform. Both sides need to step back for perspective. The neoliberals in the Democratic party need to acknowledge the superiority of improved Medicare for all and join with the progressives. The moderates in the Republican party also need to make the same acknowledgement and support the model as well. The Trump independents who wanted a better health care system should learn from the process that unfolded this past month and dig up the Trump statements on how single payer systems work well. It would not take much to convince him that single payer Trumpcare would bring to the nation our health care salvation. Even conservatives who care can come on board after giving thought to the concepts presented by David Frum (next to last paragraph above).

Just don’t bother doing it through the dominant political parties. Do it in the streets or anywhere else citizen action can gain traction.