PNHP

Single-Payer Health Care Is Seeing Record Support in Congress

Single-Payer Health Care Is Seeing Record Support in Congress

By Michael Corcoran
Truthout, April 16, 2017

The primary Medicare for All bill has more support in Congress now than it has ever before.

John Conyers’ Medicare for All bill (HR 676), which he has introduced in each Congress since 2003, has seen a recent surge of new cosponsors — 32 since March 8 and nine on April 3 alone. As of this writing there are 93 co-signers (and counting), representing more than 48 percent of the Democratic Caucus. This is the highest number of cosponsors ever, both in terms of members and as a percentage of the House Democratic Caucus. The count is up from just 62 cosigners — 33 percent of Democrats — in the last Congress, and an average of 37 percent since the bill was first introduced in 2003.

This is an astonishing development for many reasons. Just a year ago the Democratic establishment was recklessly (and disingenuously) maligning the policy to help keep Sen. Bernie Sanders from winning the Democratic Primary. Further, facing a large GOP majority, Democrats and activists have also been forced to “play defense” just to prevent Donald Trump and the GOP from kicking 24 million Americans off their insurance and doing away with essential benefits like mental health and emergency room visits. These, of course, are important benefits of the Affordable Care Act (ACA), which improved access to health insurance, but leaves about 30 million Americans uninsured. The ACA also can’t control rapidly escalating health costs, a trend which has long been a central problem of our health system.

Indeed, the need for reform beyond the ACA is becoming increasingly clear. A Monmouth poll from February showed that 25 percent of Americans view health care as “the biggest concern facing their family right now.” Health care was, by far, the most cited concern, dwarfing issues like immigration (3 percent) and terrorism (2 percent).

full article:
http://www.truth-out.org…

Single-payer works in other places, why not here?

By Dr. C.V. Allen
The Modesto (Calif.) Bee, April 15, 2017

Every three months there appears in my mailbox a 50-page magazine entitled PNPH Newsletter, the official publication of the Physicians for a National Health Plan.

The magazine is filled with comments and observations of America’s healthcare system. PNHP is strongly committed to the proposition that our system is excessively expensive, ineffective, unfair and should be replaced by a “Medicare for All” program.

Known also as the single-payer system, such plans are common in other industrialized nations. In virtually every instance, they out perform the American system in terms of cost, access and medical outcomes.

Among the many observations in the 2017 Spring edition:

▪ Obamacare, whatever the problems , reduced America’s uninsured population by 41 percent.

▪ In 2017 our healthcare spending is expected to rise by 5.4 percent to $3.5 trillion. That represents 18.3 percent of our gross domestic product, or $10,832 per person. Among other nations the highest GDP expense (Canada and Switzerland) is approximately 11 percent with average cost-per-citizen of about half ours – all while covering all citizens with medical outcomes better than ours.

▪ American employers are shifting healthcare costs to their employee. Deductibles have increased 63 percent from 2011 to 2015. Coinsurance costs for hospital care were 19 percent of charges.

▪ A RAND Corp. study of Oregon’s health system found that overhead costs would be reduced by $600 million by shifting to a single-payer system. A similar RAND study found that with a national single-payer system, the total national costs would be reduced $121 billion (administration costs would fall $556 billion, but medical costs would increase by $435 billion). Coverage would be 98 percent of the entire population.

▪ Longevity is related to economic status. The life expectancy gap between the richest 1 percent and the poorest 1 percent of America’s population is 15 years for men and 12 years for women. Meaning if you’re wealthy, you are likely to live that much longer than your impoverished cousin.

▪ The 8 richest people in the world – six are American – have global wealth equal to the poorest 50 percent of the world’s population.

▪ The five largest commercial health insurance firms made profits of $65 billion from 2011 (when Obamacare began) through 2015. Despite this, the largest firms have cited losses for their withdrawal from the individual insurance market.

▪ The pharmaceutical industry spends nearly $20 million per month lobbying Congress, far more than any other industry. The average profit margin for major drug firms in 2016 was 21.4 percent, far higher than the 7.5 percent margin in all other industries.

▪ Pharmacy firms spend more on administration and marketing than on research. (Novartis 2016 sales $49 billion, profit 36 percent, marketing and administration 29 percent and research 18 percent. For Gilead 11 percent for administration and marketing and only 9 percent for research.)

▪ Sixty percent of Americans say the government should be responsible for ensuring health care coverage for all Americans. The support was 80 percent of Democrats and 32 percent of Republicans. But of Republicans with incomes below $30,000 a year, support rose to 52 percent. All categories show an increasing support for universal healthcare coverage.

Given the failure of President Trump to overturn Obamacare last month, and his promises for “great health care” and a more “simplified” system” that provides “much better numbers,” and “lower deductibles,” and “insurance for everybody,” one might ask if he was thinking of a single-payer system. And if not, why not?

C.V. Allen is a semiretired Modesto physician active in health care reform issues.

http://www.modbee.com…

Medicare for all: Wisely used tax dollars can cover everyone

By Colleen C. Lyons, M.D.
Nevada Appeal (Carson City), April 15, 2017

Dr. Edward Gray’s commentary of April 2 regarding healthcare in America is another frustrating example of a lack of appropriate experience and background. Taking healthcare system advice from a dental subspecialist is certainly of questionable value, given the narrow vista point from which his views are generated.

As a family physician with more than 30 years of experience caring for all sorts of people, including kids and those with mental health concerns, I know one of American’s greatest problems is an ever increasing shortage of primary care doctors, the doctors in the trenches of American medicine. Primary care physicians (family physicians, pediatricians and internists) are the doctors providing the necessary care for nearly 90 percent of what ails you and assisting patients in knowing whether and what specialists to see. Primary care doctors care for their patients over many years and see them back after they’ve been to the specialist and rare subspecialist.

Every other nation in the world has a healthcare system in which primary care doctors represent 50 to 70 percent of the total physicians and surgeons. America’s oft heralded capitalist and free market system has over several decades resulted in a primary care physician workforce of only 30 percent. Numerous studies have shown significant cost savings and improved quality of care when there are higher ratios of primary care physicians per capita, while increased specialists per capita have demonstrated the exact opposite with higher costs and poorer health outcomes.

The 2014 Commonwealth Fund report: “How the Performance of the U.S. Health Care System Compares Internationally” found, yet again, the U.S. ranked last of 11 nations in quality, though we continue to rank No. 1 in cost. The report stated, “U.S. ranks last overall with poor scores on all three indicators of healthy lives — mortality amenable to medical care, infant mortality, and healthy life expectancy at age 60,” and, “U.S. physicians face particular difficulties receiving timely information, coordinating care, and dealing with administrative hassles as other countries have led in the adoption of modern health information systems.” The United Kingdom (Britain/England), maligned by Fred LaSor in his comments in support of Gray, ranked No. 1 in overall quality with the lowest cost of $3,400 versus America’s $8,500 per capita as of 2014.

Having worked as a VA primary care physician for the last five years, I also take issue with the implication of poor quality care provided by the Veterans Health Administration. In truth the VA performs as well as or better than the majority of private sector providers in the United States on a wide variety of measures and certainly at far less expense. The VA has been a leader in initiating numerous safety protocols in hospitals, surgery suites and pharmacy services.

Of course the majority of physicians support malpractice reform and many cite defensive medicine as a significant contributor to healthcare costs in the US. But contrary to popular “wisdom,” studies of this issue don’t support their views regarding the cost of malpractice insurance and/or defensive medicine as a major factor in the overall cost of U.S. medicine.

I concur with Dr. Sean Lehmann’s April 9 rebuttal of Gray and support “improved Medicare for all” as proposed by Physicians for a National Health Plan (PHNP.org). Let us stop, as Lehmann says, “allowing insurance CEOs and shareholders to make all the decisions. Their only motivation being profit, which is a gross conflict of interest.” Trusting an insurance company with your healthcare seems equivalent to trusting a used car salesman; you just don’t. Our forefathers knew capitalism needed the oversight and restraints provided by government to curb excessive greed and abuse of the public good.

The 2010 World Health Report issued by the World Health Organization notes, “Abundant evidence shows that raising funds through required prepayment is the most efficient and equitable base for increasing population coverage. In effect, such mechanisms mean that the rich subsidize the poor, and the healthy subsidize the sick. Experience shows this approach works best when prepayment comes from a large number of people, with subsequent pooling of funds to cover everyone’s health-care costs.”

The Director-General of WHO states, “No one in need of healthcare, whether curative or preventive, should risk financial ruin as a result.” Unfortunately, in America that’s not infrequently the case. The majority of U.S. bankruptcies are due to medical expenses and the majority of those had health insurance at the onset of their illness. I find it necessary to point out the obvious, health insurance is not healthcare — I believe we in America too often discuss medical insurance coverage as though it were actual healthcare.

If we can’t find our way to “improved Medicare for all” and eliminate the insurance middlemen as Canada and France have done at a cost of $4,100 and $4,500 per capita, respectively, then let us at least have nonprofit insurance carriers like Germany and Switzerland have done with a 2014 Commonwealth Fund quality ranking of No. 5 for $4,500 and No. 2 for $5,600, respectively.

Thankfully, a former patient of mine was in Germany as a university student when he was diagnosed with a serious lifelong psychiatric illness. He received far superior care in Germany at no cost to himself than what we attempted to arrange for him upon his return to the U.S. Ultimately, his family realized it would be best to travel with him back to Germany until his symptoms were appropriately controlled with medications.

Interestingly, a recent analysis of U.S. taxpayer expense indicated we already pay more in taxes for healthcare than Switzerland pays in total. Switzerland, the second most expensive healthcare system in the world, provides universal coverage for all its citizens at a cost of approximately $6,200 versus our current $10,000 per capita. We spend tax dollars on the elderly, poor, disabled, veterans and public employees. For the same tax money we could cover everyone, if only we would spend our tax dollars wisely and efficiently on an actual healthcare system instead of the chaos we currently have.

For more information review the following books and/or website:

Regarding how we got in this mess: “SICK: The Untold Story of America’s Health Care Crisis — and the People Who Pay the Price” by Jonathan Cohn.

Regarding VA healthcare: “Best Care Anywhere: Why VA Health Care Would Work Better For Everyone” by Phillip Longman.

Regarding improved Medicare for all, see the Physicians for a National Health Program website at PNHP.org under the “Single Payer” tab. It includes a comparison to the Affordable Care Act (ACA/Obamacare).

Regarding other countries: “The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care,” a New York Times best seller by T. R. Reid.

Dr. Colleen C. Lyons practices family medicine in Carson City. She has more than 30 years of medical practice experience.

http://www.nevadaappeal.com…

CMS final rule benefits insurers, not patients

CMS issues final rule to increase choices and encourage stability in health insurance market for 2018

Centers for Medicare &  Medicaid Services, April 13, 2017

The Centers for Medicare & Medicaid Services (CMS) today issued the final Market Stabilization rule, to help lower premiums and stabilize individual and small group markets and increase choices for Americans.

The final rule makes several policy changes to improve the market and promote stability, including:

* 2018 Annual Open Enrollment Period: The final rule adjusts the annual open enrollment period for 2018 to more closely align with Medicare and the private market. The next open enrollment period will start on November 1, 2017, and run through December 15, 2017, encouraging individuals to enroll in coverage prior to the beginning of the year.

* Reduce Fraud, Waste, and Abuse:  The final rule promotes program integrity by requiring individuals to submit supporting documentation for special enrollment periods and ensures that only those who are eligible are able to enroll. It will encourage individuals to stay enrolled in coverage all year, reducing gaps in coverage and resulting in fewer individual mandate penalties and help to lower premiums.

* Promote Continuous Coverage: The final rule promotes personal responsibility by allowing issuers to require individuals to pay back past due premiums before enrolling into a plan with the same issuer the following year. This is intended to address gaming and encourage individuals to maintain continuous coverage throughout the year, which will have a positive impact on the risk pool.

* Ensure More Choices for Consumers:  For the 2018 plan year and beyond, the final rule allows issuers additional actuarial value flexibility to develop more choices with lower premium options for consumers, and to continue offering existing plans.

* Empower States & Reduce Duplication:  The final rule reduces waste of taxpayer dollars by eliminating duplicative review of network adequacy by the federal government. The rule returns oversight of network adequacy to states that are best positioned to evaluate network adequacy.

“CMS is committed to ensuring access to high quality affordable healthcare for all Americans and these actions are necessary to increase patient choices and to lower premiums,” said CMS Administrator Seema Verma. “While these steps will help stabilize the individual and small group markets, they are not a long-term cure for the problems that the Affordable Care Act has created in our healthcare system.”

https://www.cms.gov…

The final rule (139 pages):
https://s3.amazonaws.com…

***

Comment:

By Don McCanne, M.D.

Would people prefer that their health care coverage be adequate and affordable or would they prefer that their insurers thrive in the market even if to the detriment of the beneficiaries? That’s a ridiculous question though the Trump administration has given a ridiculous answer: cater to the private insurers and forget the patients.

The open enrollment period is essentially the only time individuals can enroll in the plans, and they are cutting the eligibility time in half. Further, they are closing the enrollment period two weeks before the end of the year which ensures that procrastinators who wait until the last two weeks before coverage begins are out of luck since they are prohibited from enrolling at all. This will have an obvious detrimental impact to those who tend to put things off or are simply unaware of the early cutoff date. The insurers can target their marketing to healthy populations and get them in quickly and then close the door before the sick people get wind of the short open enrollment period.

Documentation requirements are being increased for special enrollment periods. Since many of those seeking to enroll outside of the open enrollment period do have medical problems that they need to have covered by insurance, the more stringent requirements will allow insurers to refuse coverage for this more expensive population simply because of inevitable difficulties that patients would have in complying with these requirements. Insurers benefit, and people who need care will go without.

People who are unable to pay their premiums because of often unavoidable circumstances, such as loss of employment, will be denied coverage until the delinquent premiums are paid. The insurers get to clear their rolls of poor credit risks while those who do have such problems may have them compounded by being denied insurance coverage.

The rule allows insurers to tinker with the actuarial values of the plans to allow “more choices” (of stripped down plans that offer less protection) and “lower premium options” (for those deficient plans). The insurers get more sales of plans that pay fewer benefits whereas the patients face greater financial hardship should they need health care.

The adequacy of provider networks is a serious problem now, and yet the new rule abandons the federal role in providing oversight of the adequacy off these networks, leaving it to the states, many of which show little regard for such oversight. The insurers profit by ratcheting down the numbers and fees of providers while the patients are left with less certainty that they can access the care they need.

Though we know what increasing choices and lowering premiums really means, our new CMS Administrator, Seema Verma, describes this as “ensuring access to high quality affordable healthcare for all Americans.” It is insurance, not health care, that they are trying to make more affordable, and they certainly are not making actual access to care affordable with the increases in out-of-pocket cost sharing.

We should be particularly concerned with Verma’s statement that these steps “are not a long-term cure for the problems that the Affordable Care Act has created in our healthcare system.” Listening to her answers to questions at her confirmation hearing, she was heavy on the “choice,” “higher quality at lower cost,” and “access” rhetoric while refusing to reveal any real policies that she had in mind. We only know that she, in her own words previously, wants patients to “have more skin in the game.” How can they when so many of them already have been skinned alive?

Northwoods residents gather to support Medicare For All bill

By Evan Verploegh
The Lakeland Times (Minocqua, Wisc.), April 14, 2017

A group of roughly 50 gathered at Torpy Park in Minocqua on April 7 to express their support for H.R. 676, also known as the Expanded and Improved Medicare For All Act.

With periodic support given by honks and thumbs up from passersby, the rally was deemed a success by the Northwood Progressive group, who organized the event. Attendees held signs and peacefully shared their encouragement for the bill to pass through congress.

“No one has given me ‘the finger’ yet,” said a participant of the rally after an hour. “There’s still time, though.”

H.R. 676 establishes the Medicare For All Act, which seeks to provide cost-free health services for medically-necessary care. This includes primary care and prevention, dietary and nutritional therapies, prescription drugs, emergency care, long-term care, mental health services, dental services, and vision care.

Under the bill, health insurers would not be permitted to sell health insurance that would duplicate the benefits of H.R. 676, but would be allowed to sell services deemed unnecessary, such as cosmetic procedures.

The program would be funding by five major sources: (1.) Existing sources of government revenues for health care. (2.) Increasing income tax on the top 5 percent earners in the United States. (3.) Instituting a progressive excise tax on payroll and self-employment income. (4.) Taxation of unearned income, such as interest, dividends and capital gains. (5.) Tax on stock and bond transactions.

The bill also includes language that would provide employment transition benefits for those who would lose their positions with the institution of H.R. 676.

Further, Indian Health Service would be integrated into the program after five years. Congress would also evaluate the current independence of Department of Veterans Affairs health programs.

The single-payer system was introduced to the U.S. House by Rep. John Conyers, Jr. (D-Mich.).

In the wake of administration change, the Northwoods Progressives have been ever-active in conducting similar rallies for causes such as the Women’s March and condemning President Trump’s travel ban for residents of selected Muslim countries.

“I’ve been protesting for over 20 years in the area, and I’ve never seen the kind of political activism that I have in the last few months,” Jerry Woolpy, Northwoods Progressives organizer said. “For awhile, I didn’t know if there was anyone else. The support that has been shown has been inspiring.”

The group will host a March for Science at 10 a.m. on Earth Day, April 22. Beginning at the Calvary Lutheran Church in Minocqua, those in attendance will march to Torpy Park, where a rally will be held.

http://www.lakelandtimes.com…

MedPAC questions effectiveness of MACRA’s MIPS

Evidence-Based Diagnosis and Faith-Based Solutions

By Kip Sullivan JD
The Health Care Blog, April 11, 2017

It’s official: the Medicare Payment Advisory Commission (MedPAC) has at long last decided that MACRA’s MIPS (Merit-based Incentive Payment System) can’t work. MedPAC reached this decision at its January 12 and March 2, 2017 meetings.

Its principle rationale was that measuring “merit” (quality and cost) at the individual physician level, which is what MIPS requires CMS to do, is not possible. As one MedPAC staff person put it at the January meeting, “A redesign of the MIPS program should build off a clear-eyed assessment of the limit of the national Medicare program’s ability to assess clinician performance.”

But the transcripts of the January and March meetings indicate that although MedPAC is now willing to say MIPS is a mess, the commission had not reached a decision about what to do about the mess by the close of the March meeting. The commission’s challenge is obvious. As its chairman Dr. Francis Crosson put it, the issue squarely before the commission now is “whether we just … sit there and watch a dysfunctional thing unravel, or whether we try to make some recommendations which are constructive….”

In previous posts  I have argued that both parts of MACRA – the MIPS program and the Alternative Payment Model (APM) program – can’t work and that MedPAC should recommend that Congress repeal or drastically amend MACRA (the Medicare Access and CHIP Reauthorization Act).

Here is how MedPAC staffer Kate Bloniarz summarized the commission’s indictment of MIPS at the March meeting:

“To reiterate some of the issues with MIPS, first, MIPS uses hundreds of clinician-reported quality measures. Second, two of the other components of MIPS, meaningful use and clinical practice improvement activities, only require attestation by a clinician and haven’t been proven to correspond to high-value care. Third, for any given clinician, there are a relatively small number of Medicare cases, which can contribute to noisy performance. Fourth, under MIPS each clinician is judged based on their own set of measures that they reported, and so the results aren’t comparable across clinicians. In total, we don’t expect that MIPS will be able to identify high- and low-value clinicians and will not be useful for beneficiaries, clinicians, or the program.”

I applaud the commission for being so forthright. I do wonder why it took them so long to reach this conclusion. This conclusion was obvious even before MACRA was enacted, which was two years ago.

http://thehealthcareblog.com…

***

Comment:

By Don McCanne, M.D.

The Medicare Payment Advisory Commission (MedPAC) is an independent federal commission that advises Congress on the administration of Medicare. It currently is evaluating the Merit-based Incentive Payment System (MIPS) and the Alternative Payment Model (APM) established by the Medicare Access and CHIP Reauthorization Act (MACRA) – the replacement for the flawed Sustainable Growth Rate (SGR) method of determining Medicare payments.

There was much celebration when SGR was eliminated by MACRA since it would have caused a drastic reduction in Medicare payment rates, but too little attention was given to the substitution in spite of warnings from knowledgeable individuals such as Kip Sullivan. Why is it a problem? As yesterday’s Quote of the Day message indicated, “desktop medicine” has displaced half of face-to-face clinical contact with patients and MIPS is destined to expand the desktop component – a major factor in exacerbating the epidemic of physician burnout. Burned-out physicians glued to desktops cannot be good for patient care.

It took forever to get rid of SGR. It is likely that MedPAC’s recommendations for MIPS and APMs will be all too feeble – recommending bland modifications that will do little to address the fundamental structural problems with the program. As the MedPAC staff member Kate Bloniarz stated, “we don’t expect that MIPS will be able to identify high- and low-value clinicians and will not be useful for beneficiaries, clinicians, or the program.”

The wheel-spinning taking place right now is mostly about replacing volume with value when actual efforts have been quite unproductive. It would be far better to concentrate on reforming our financing system with a well designed single payer national health program – an improved Medicare for all. Once we get the financing right, we can concentrate on much more rational methods of fine tuning that financing.

Physician speaks out for single-payer healthcare: Insurers not salvation for private-sector health services

By J.P. Crumrine
Idyllwild (Calif.) Town Crier, April 13, 2017

Dr. Thomas Kluzak, a retired physician from Wichita and former head of the University of Kansas Medical School’s Pathology Department, spoke Saturday at the Idyllwild Library about a single-payer health insurance system. Kluzak is passionately in favor of a single-payer system.

A single-payer system is often referred to a “Medicare for All.” A single public or quasi-public agency organizes healthcare financing but the delivery of the care remains largely in private hands, according to the Physicians for a National Health Program.

“Practicing medicine and seeing what happens to people, the current system makes no sense,” he stated. “We need ‘Medicare for All’.”

He questions why the public accepts a “single-payer” system for police and fire protection, but opposes the concept for healthcare.

Hospitals with emergency rooms must accept, as a patient, someone with complaints regardless of whether they have insurance. In this limited instance, we are already paying for everyone’s care, Kluzak noted.

A single-payer system will benefit not only individuals, with or without insurance, but doctors, too, in Kluzak’s opinion. His strong feelings about this topic evolved over 30 years of looking through a microscope at the healthcare system.

“Essentially, we remove the intermediary — insurance companies — and create a savings,” he said. Administrative costs for Medicare are about 2 percent. For most insurance companies, administrative expenses approach or exceed 30 percent. These include advertising and sales staff. In addition, doctors and hospitals maintain administrative staff to submit bills and respond to insurance inquiries.

“Drug companies pay more on marketing and administration than research,” Kluzak said.

Besides the substantial financial savings, which Kluzak foresees, the quality of medical care will improve, too. No longer will insurance administrative staff have approval over your physician’s recommendations and actions caring for your health.

Not only will it eliminate the time insurance staff need to review and advise on the doctor’s orders, but will likely lead to elimination of excessive tests needed to justify a doctor’s decision.

Kluzak’s opinion is not an aberrant view among the medical professions. He is a PNHP member. A nonprofit research and education organization, PNHP is composed of more than 20,000 physicians who advocate a single-payer health system.

He and PNHP stress that a single-payer system is not “socialized medicine.” The doctors and hospitals remain private. They receive their compensation from the single-payer. Currently, payments come from a multitude of sources, including Medicare, Medicaid and private insurance companies.

Rep. John Conyers (D-MI) has authored House of Representatives 676, a bill to establish a single-payer system for the U.S. It authorizes a privately delivered, but publicly funded, universal healthcare system. He argues that the U.S. healthcare costs are double the costs in other countries with single-payer systems such as France, Germany and Canada.

Kluzak and his wife, Kathy, have been Idyllwild residents since January 2016. The uprooted Kansans followed their son and grandchildren to California. They found Idyllwild and are only a few hours from their family.

http://idyllwildtowncrier.com…

The surge of desktop medicine

Electronic Health Record Logs Indicate That Physicians Split Time Evenly Between Seeing Patients And Desktop Medicine

By Ming Tai-Seale, Cliff W. Olson, Jinnan Li, Albert S. Chan, Criss Morikawa, Meg Durbin, Wei Wang and Harold S. Luft
Health Affairs, April 2017

Abstract

Time spent by physicians is a key resource in health care delivery. This study used data captured by the access time stamp functionality of an electronic health record (EHR) to examine physician work effort. This is a potentially powerful, yet unobtrusive, way to study physicians’ use of time. We used data on physicians’ time allocation patterns captured by over thirty-one million EHR transactions in the period 2011–14 recorded by 471 primary care physicians, who collectively worked on 765,129 patients’ EHRs. Our results suggest that the physicians logged an average of 3.08 hours on office visits and 3.17 hours on desktop medicine each day. Desktop medicine consists of activities such as communicating with patients through a secure patient portal, responding to patients’ online requests for prescription refills or medical advice, ordering tests, sending staff messages, and reviewing test results. Over time, log records from physicians showed a decline in the time allocated to face-to-face visits, accompanied by an increase in time allocated to desktop medicine. Staffing and scheduling in the physician’s office, as well as provider payment models for primary care practice, should account for these desktop medicine efforts.

From the Discussion

Physician burnout with EHR use has been well documented. Some organizations are using medical scribes to reduce documentation burden. Intriguing findings from the recent AMA study on five specialists who had scribes (with their own user identification) suggested that those specialists spent 43.9 percent of their time on face-to-face visits, compared to 23.1 percent among specialists without scribes. Clearly, more studies (preferably with more physicians teamed up with scribes) on the impact of scribes are needed. Our data suggested that 34 percent of logged time (2.10/6.25) was spent on progress notes. Having scribes support this effort could potentially remove one-third of physicians’ work efforts and might reduce burnout.

Twenty-four years after the implementation of the RBRVS-based Medicare Fee Schedule, the Medicare Access and CHIP Reauthorization Act of 2015 established a new framework for Medicare physician payment: the Quality Payment Program. In this program, physicians have two tracks to choose from: the Merit-Based Incentive Payment System and the Advanced Alternative Payment Models. Furthermore, CMS has also launched the Comprehensive Primary Care Plus model. The model has a separate track for practices with relatively more experience in delivering advanced primary care. These practices will receive a hybrid payment of a per beneficiary per month care management fee and fee-for-service payment for claims for evaluation and management services.

CMS has indicated its intention to monitor practices to ensure the delivery of high-quality health care under the Comprehensive Primary Care Plus model. Access logs provide a simple and unobtrusive way for health care delivery systems to examine how their clinicians spend a significant portion of their time.

http://content.healthaffairs.org…

***

Comment:

By Don McCanne, M.D.

Health care is, or at least should be, about the patient. This study shows that physicians are splitting their time fairly evenly between direct face-to-face patient care and desktop medicine, especially through the electronic health record. Although desktop medicine does provide some patient benefits we certainly need to ask whether much of that time is wasted for purposes other than patient care.

There is no question but that desktop medicine is contributing to the growing epidemic of physician burnout. Yet desktop medicine is expected to grow further with implementation of the Medicare Access and CHIP Reauthorization Act (MACRA) and the Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (APMs). Far too much effort is being expended on these primarily administrative models rather than being used for what health care is all about: protecting and improving the health of patients.

Let’s get our priorities right.

How New York Could Set A Health Care Example For The Entire Country

By Jean H. Lee
Bustle, April 12 2017

Last month, the GOP raced to convince members of Congress to vote in favor of the American Health Care Act, but Congress ultimately rejected the Republican plan to repeal and replace the Affordable Care Act, getting a bill that would limit essential coverage for a number of social groups off the table. But as many celebrate the continued existence of Obamacare, it might be wise to question whether the it is the best possible option, because while it did remarkable things for a number of Americans, the ACA still left many uninsured or underinsured. Many New York healthcare advocates say there is the hope of a better alternative in the New York Health Act (NYHA).

The NYHA is a single-payer plan that would create a state healthcare system that is, as Assembly Health Committee Chair Richard Gottfried told the Village Voice, “funded entirely by broad-based taxes based on ability to pay.” This means that the NYHA would be funded by taxation on taxable income from employment, capital gains, interest, and dividends.

According to Physicians for a National Health Program, individuals and families would be the ones to choose “the delivery of care,” which means that there will be no network restrictions (like those of private insurers) that keep certain doctors out of reach. This is because when everyone is covered by the same single-payer plan, instead of a number of private insurance programs, everyone has access to the same comprehensive care. So instead of having individuals worry about whether a doctor is in their personal private insurance network and whether they can afford the co-pay, every doctor in New York state would be within reach.

“There is no question that we are in a unique political moment,” says Ursula Rozum, the Campaign for New York Health upstate campaign coordinator. “Now is the time for us to speak up and organize for a healthcare system that guarantees health care for all of us.”

The NYHA would provide any medical service currently required by New York state insurance law, including primary, preventive, specialist, hospital, mental health, reproductive health, vision, dental, and hearing care.

Passing the New York Health Act could also influence federal legislature in the future, considering how past state policies have changed federal ones. The Massachusetts healthcare model has striking similarities to the ACA and demonstrates how impactful state legislation can be. Katie Robbins, the executive director of Physicians for a National Health Program’s NY Metro Chapter (PNHP NY) tells Bustle that the ACA was actually first established in Massachusetts in 2006. “At the time it was known as RomneyCare, and had long been touted by the Heritage Foundation, a conservative think tank,” Robbins says. “Ironically, as soon as President Obama supported it, the Heritage Foundation started to oppose the policy.”

A 2012 article published by the Huffington Post outlined the similarities between the ACA and the Massachusetts model, which proves that a state healthcare model can be a significant influence for federal models. The importance of the New York Health Act — a system funded entirely by broad-based taxes — increases with the knowledge that it could be a model for federal legislation, like the Massachusetts model was.

The New York State Assembly passed a version of the New York Health Act in 2015, and then again in 2016, but it never got a committee hearing in the Republican-run state Senate. In previous years, the healthcare issues that were discussed centered on problems with the ACA. While Obamacare did remarkable things (like banning lifetime limits of healthcare cost) for a large population of Americans, the act still gave control to insurance companies. Many insurance companies demanded high — and quickly rising — insurance premiums and high deductibles that shift costs to the individual.

Robbins says the ACA expanded access to insurance for millions of Americans, but many New Yorkers remained underinsured, which means that many insured people can’t afford to use the insurance they gained access to because of the high deductibles and co-pays.

Economists Milton I. Roemer and John E. Roemer questioned the effectiveness of a healthcare system controlled by private insurance companies in their 1982 article “The Consequences of Free Trade in Health Care: A Public Health Response in Orthodox Economics.” The authors asserted that “only replacement of free trade by systematic social planning could hope to achieve a health care system that allocates resources and distributes services both efficiently and equitably.”

One way to look at how this theory relates to today is to consider that while the ACA covered many more Americans, there are competing private insurance companies with specific provider networks and out-of-network fees. Under the New York Health Act, every healthcare provider can participate in the program and there will be no specified networks. And while healthcare providers are not required to participate, there will be no other insurance coverage to pay a provider who decides not to participate, which incentivizes participation.

Another way to look at it is to consider that private insurance uses money from premiums to fund the needs of people in need of medical services, so insurance companies can set premiums that are quite high. According to the PNHP, the New York Health Act would eliminate these high premiums, deductibles, and co-pays set by insurance companies because, unlike the ACA, the NYHA would not be controlled by private insurance companies.

The NYHA would replace private insurance company coverage for all New York state residents. This is to ensure income equality under the plan by preventing a two-tier system of care, which is when there is a basic system of care and then a secondary option for wealthier people who can afford more, creating a segregated health system like Medicaid. In a two-tier system, people who can pay more often have access to better resources and those who can’t pay more don’t.

The NYHA wants to make sure that all people (wealthy and low-income alike) are equally invested in the healthcare system and have equal access to the same healthcare. To make this possible, there would be no private coverage offered by employers. Instead, every New York resident would have access to New York Health, and employers would pay at least 80 percent of the tax on payroll.

Robbins, the executive director of PHNP’s New York metro chapter, emphasizes that the NYHA would have an equalizing impact. “The New York Health Act guarantees that every resident of New York State will have access to publicly funded health insurance that covers all medically necessary care—no matter what their income, job, health, marital, or immigration status,” Robbins says. She notes that, in this time of immigration uncertainty, that the NYHA would be offered to anyone who could provide proof of residency, not citizenship, in New York State. This allows undocumented New York residents the same right to health care.

So while the ACA did extraordinary things — like making sure preexisting conditions don’t impact health coverage and expanding Medicaid — it’s not perfect, and it might be good to talk about a single-payer plan where the government funds all residents’ health care because this is a path to universal health care where all residents have health coverage. And, New York could soon be an example of universal healthcare for the United States.

https://www.bustle.com…

Watch out! Here comes Stephen Parente

ACA critic Stephen Parente nominated as HHS deputy secretary

By Dave Barkholz
Modern Healthcare, April 10, 2017

Stephen Parente, a healthcare economist, has been nominated to be HHS’ assistant secretary of planning and evaluation.

The University of Minnesota professor would fill a post vacated in June by Harvard economist Richard Frank. In that role, Parente would be a principal advisor to HHS Secretary Dr. Tom Price, consulting on policy, legislative efforts, strategic planning and research.

Parente is familiar with the work of Price. In 2013-2014, he analyzed Price’s ACA replacement proposal in conjunction with the conservative think-tank American Action Forum.

http://www.modernhealthcare.com…

The White House announcement:
https://www.whitehouse.gov…

***

Stephen Parente discusses a key option for the Affordable Care Act

By Christopher Snowbeck
StarTribune, December 3, 2016

With Republicans in Washington, D.C., promising to repeal the federal Affordable Care Act, or ACA, the focus is shifting to how the GOP might try to replace it. Stephen Parente of the University of Minnesota is well-positioned to describe what could be coming. In 2013-14, Parente worked with the American Action Forum, a conservative think tank, to evaluate the budget and coverage impact from the Empowering Patients First Act, an ACA replacement plan from U.S. Rep. Tom Price, R-Ga. Last week, President-elect Trump selected Price as his health secretary. More recently, Parente worked with staffers to model the economic impact of “Better Way,” the replacement plan put forward by House Speaker Paul Ryan.

Q: I gather that the dollar value of tax credits under Better Way would be smaller than with the Affordable Care Act, but this reduction fits with lower premiums for coverage, too. Is that right?

A: Correct. One of the biggest changes is the risk-rating piece. The ACA has a 3-to-1 ratio for modified community rating, which means insurers can’t sell coverage to an adult age 64 or older for more than three times what they’d charge a 21-year-old for the same health plan. Better Way proposes a 5-to-1 ratio.

There are fewer caps on deductibles and out-of-pocket spending with Better Way, so that’s another way deregulation brings lower premiums. Finally, fewer health benefits are required to be covered by health plans under Better Way, compared with the ACA.

Q: Minnesota is one of those blue states that has offered generous benefits via Medicaid, plus the MinnesotaCare health insurance program. Will federal funding for the state’s programs decrease?

A: I think many states are probably going to see less Medicaid funding, because it’s going to have to be spread around and there will be some budget constraints. There will definitely be, in that sense, some winners and losers.

http://www.startribune.com…

***

Comment:

By Don McCanne, M.D.

Stephen Parente is the policy genius behind Tom Price’s “Empowering Patients First Act” and Paul Ryan’s “Better Way” – two of the cruelest policy proposals of the past decade that shift health care costs from the government to patients in need – all under the guise of “it’s about access” (but not about being able to afford health care).

Parente says that there definitely will be winners and losers, but he didn’t specify that the winners will be wealthy taxpayers and the losers will be patients.

Now Stephen Parente is going to guide policy, legislative efforts, strategic planning and research for the Department of Health and Human Services, under the leadership of HHS Sec. Tom Price. When we desperately need new public policies to help make essential health care more affordable for all of us, the man in charge of policy will begin to tear down and destroy what we do have. He may become the most dangerous individual in government as far as our health care is concerned.

Remember that name – Stephen Parente – and be prepared to use all civil means available to ward off his pending nefarious ventures. Then go out into the streets and march for an improved Medicare for all.

Universal healthcare supporters see their chance: ‘There’s never been more support’

After Republicans’ failed attempt to replace Obamacare, activists across the country rally on behalf of a single-payer system: ‘It’s a right, not a privilege’

By Jessica Glenza
The Guardian, April 11, 2017

It was a cold, misty, gray, early spring day in Albany, New York – the kind of bone-chilling, turn-up-the-heat weather that encourages residents to flee to Florida.

But 500 New Yorkers were still out on the sidewalk lobbying for healthcare reform that has long seemed like a pipe dream: government-provided universal health insurance.

“I wanna make sure my children get healthcare,” said Minerva Solla, a 66-year-old organizer with the New York State Nurses Association. “It’s a right, not a privilege.” Moments earlier she riled the crowd with call-backs: “If they don’t pass it? Vote them out!”

Americans might know the liberal dream as “Medicare for all”. If it ever passed, it could be as comprehensive as the UK’s National Health Service.

Universal healthcare is not a new idea, but one with fresh energy since Republicans’ disastrous attempt to reform the American health system. In Albany, a record number of people turned out to a rally for universal healthcare in New York, several activists and one lawmaker said.

“It’s an uphill battle, and the Republicans are in control of Congress, and there’s no signal they would be willing to let this pass right now,” said Clare Fauke, spokesperson for Physicians for a National Health Program, which advocates for universal healthcare. “But we’ve been thinking in terms of the long game, and there’s never been more support for it than there is right now.”

In a universal healthcare system, New York would pay for every resident not covered by an existing federal health insurance program, like Medicare for the old or Medicaid for the poor. For-profit health insurance companies would be all but eliminated.

That would mean New Yorkers would be freed from “co-pays”, “deductibles”, and “premiums”, all insurance industry jargon for one thing: medical bills.

“We’re unanimous that this is the most logical system going forward,” said Phil DeSalvo, a 29-year-old medical resident from New York City. He and three fellow health workers traveled three hours north on their only day off to protest. Was universal healthcare gaining momentum?

“Absolutely, particularly with the collapse of the plan advanced by the Republicans,” he said. “This is the best solution going forward.”

Despite campaigning for seven years to “repeal and replace” the Affordable Care Act, better known as Obamacare, Republicans’ first attempt at a reform bill sank like a stone.

Trump and the Republican leadership’s concessions to both hardline conservatives and moderate Republicans made the bill a mishmash. Tax credits would have helped Americans buy private insurance, but the gutting of insurance regulations would have made policies practically meaningless. It would have left 52 million people uninsured by the end of the decade, at last estimate.

It had an abysmal 17% public approval rating, and lasted two weeks before it was pulled. It is Trump’s single largest loss to date. In the vacuum of ideas, liberals have conjured hope.

“I think fear of the Republican bill, and fear that it will come back in even worse form, is sparking support,” said Richard Gottfried, a New York City Democrat who has sponsored a universal healthcare bill since 1992.

Advocates of universal healthcare are not missing an opportunity to make a fuss. Physicians for a National Health Program held their first day of national rallies to coincide with the Congressional recess on Saturday. Protests were planned from Florida to New Hampshire, Oregon to North Carolina.

Bernie Sanders plans to introduce a bill in the US Senate to support single-payer healthcare. In the House, there is already a single-payer bill with 93 co-sponsors.

In an issue of the British medical journal the Lancet devoted to the US healthcare system this week, Sanders wrote the opening letter.

“The goal of a healthcare system should be to keep people well, not to make stockholders rich,” wrote Sanders. “The USA has the most expensive, bureaucratic, wasteful, and ineffective healthcare system in the world.”

Sanders called single-payer healthcare “as American as apple pie” – an attempt to throw off single-payer reform’s negative reputation as “socialized medicine”.

Meanwhile, the American healthcare system may be worsening inequalities, the the Lancet found. A widening income gap, paired with insurance companies’ increasing tendency to push health costs on to consumers, has resulted in a “regressive” system in which the richest 1% of Americans can now expect to live up to 15 years longer than the poorest 1%.

Even for those who have insurance, increasing monthly costs have eroded wage gains, the Lancet reported. Medical debt accounts for more than half (52.1%) of all unpaid personal debt.

“I could tell you this – I’ve been on the job for 25 years. When I first started, I paid nothing” for healthcare, said Chris Tague, who works in road construction. He is also a part-time town supervisor in Schoharie County, New York, which voted overwhelmingly for Donald Trump.

Tague’s health insurance costs grew to $20 per week, then to $50 per week, then $75, then to more than $200 per week, he said. Middle class Americans, he said, “work their asses off for nothing”.

The ACA insures more Americans than ever. Nevertheless, 9% of Americans, or 28 million people, remained uninsured in 2015, according to the Kaiser Family Foundation. Those people are predominantly in Republican-led southern states, which rejected an expansion of Medicaid, a federal program for the poor, even though the national government paid for it.

Even conservatives admit that government-run healthcare could save money.

“I mean look, you can save money with a single-payer system, don’t misunderstand me,” said Robert Moffit, a policy analyst at the conservative Heritage Foundation. “But the quality and supply of medical services is going to be determined by government officials.”

For this and other reasons, many argue single-payer reform simply is not viable.

“The history of healthcare reform in the US has dictated that it is politically untenable,” said Richard Boxer, a Los Angeles urologist who studies insurance reform. He pointed out that a public insurance option was proposed when the ACA was first under consideration in 2010. A Democratic Congress rejected the idea.

Grassroots efforts at the state level have also failed.

In Colorado, advocates tried to establish a state-funded universal health program through a ballot initiative last year. State residents would have paid a 10% payroll tax to fund the program.

Though the program would have insured all Coloradans, only 20% of voters favored the effort.

The insurance industry group Coloradans for Coloradans had a seven-to-one fundraising advantage at one point. The group raised more than $4m, its single-largest $1m donation coming from the insurance company Anthem. Comparatively, the pro-universal healthcare group ColoradoCareYES raised $902,000.

“The insurance companies, of course, were worried this would pass,” said Patricia Rice, a spokesperson for ColoradoCareYES. “Because it would signal a tidal wave. Once it passes in one state, I think it would just spread to other states and it would cut into profits.

“They were throwing everything they had at us, and we only had a few spots on television,” said Rice.

The economics of a public option

Most analyses of universal healthcare assume that money taxpayers once spent on private insurance would go to support a government program, and that the elimination of bureaucracy and profit would save money.

A 2015 analysis of single-payer health insurance in New York found the system would save $44.7bn in healthcare costs in the first year, assuming the state could negotiate with drug companies. Studies of single-payer healthcare at the federal level have also found savings. One 1998 study found that a single-payer health system would lead “to sizable savings in the future”.

Not all projections are rosy. The non-partisan Committee for a Responsible Federal Budget analyzed Sanders’ plan for universal health coverage in 2016, and found it would add $19tn to the federal debt.

New York’s latest battle to pass universal healthcare represents a theme in the long fight – so close to passage, but so far from enactment.

Gottfried’s bill is expected to pass the lower New York state assembly, but could run into trouble in the Republican-controlled senate.

The Republican senate majority leader may never let the legislation come to the floor, and it is an open question whether the moderate Democratic governor, Andrew Cuomo, would support the legislation.

If the bill did make it to the senate floor, just one Democrat stands in the way of a majority: Simcha Felder. He represents deeply conservative orthodox Jewish neighborhoods in Brooklyn, and often caucuses with Republicans.

“I do not have a position on the New York health act,” Felder said in an email. “This legislation would be a huge overhaul of the healthcare system in New York, and I would like to hear from experts and other senators on the committee.”

“Everybody’s calling about it,” said a worker in Felder’s office, as she folded a “Healthcare is a human right” sign in half and stuffed it into a wastebin.

Just an hour earlier, Dr Roona Ray was whipping up demonstrators, exclaiming, “We can have healthcare that covers everyone as a right and as a public good,” she said. “There will be no premiums, no co-pays, no co-insurance, no deductibles, no doughnut holes, no bills!”

“The other side has money,” she said, “but we have people.”

https://www.theguardian.com…

Conservative roadmap for improving AHCA

CBO Provides A Roadmap For Improving AHCA

By Joseph Antos and James Capretta, American Enterprise Institute (AEI)
Health Affairs Blog, April 4, 2017

The future of the American Health Care Act (AHCA), the GOP-drafted plan to repeal and replace the Affordable Care Act (ACA), is unclear after the bill was pulled before the House of Representatives could vote on it. But the debate over the ACA and proposals to replace several of its key provisions is unlikely to remain off the national agenda permanently.

The best place to start is with the cost estimate of (AHCA) produced by the Congressional Budget Office (CBO).

Trump administration officials, some members of Congress, and assorted commentators have criticized CBO for this estimate, arguing that it is a fundamentally inaccurate assessment of what would occur if AHCA passed. This criticism is misplaced. While some of CBO’s assumptions are indeed questionable, there is little doubt that the agency’s bottom line assessment is basically correct: The bill, as currently structured, would trigger a rise in premiums in the short-run, a sharp increase in the number of people without insurance over the next two years, and then also a steady increase in the number of uninsured Americans over the following eight years.

Instead of trying to discredit this finding, the authors of the legislation would be better off fixing the bill. CBO’s estimate provides a roadmap for what needs to be done to improve the chances the bill will produce the results its authors intend.

Changing the ACA’s insurance rules in a coherent and systematic manner in AHCA was difficult because the proposal’s sponsors were trying to pass the measure using the budget reconciliation process.

AHCA is thus an awkward proposal. It effectively eliminates the individual mandate while leaving in place the ACA’s rules prohibiting the use of health status in setting premiums or determining what is covered by insurance. The authors of the measure propose “continuous coverage protection” as a substitute for the individual mandate. Under that provision, insurers would charge a one-year, 30 percent surcharge on premiums to anyone who has experienced more than a two-month break in their insurance coverage.

This penalty is far too weak to work. A young, healthy consumer experiencing a break in coverage has a strong incentive to stay uninsured as long as possible. Once he decides to purchase health insurance, the consumer will be required to pay a 30 percent surcharge on his premium for one year. After that, the consumer will once again pay without penalty the same community rate as everyone else of the same age and gender.

AHCA also substitutes less generous age-based credits for the income-adjusted subsidies of the ACA for lower-income households, and repeals enhanced funding to the states for the Medicaid expansion population. As a result, younger and healthier consumers would have less of an incentive to buy coverage.

That is a recipe for even more adverse selection, driving up premiums for those who remain insured through the individual market.

Needed Adjustments

* Higher Financial Penalties For Failure To Maintain Coverage

The AHCA approach is an attempt to replace governmental force with personal responsibility. Under AHCA, no one is required to have insurance, but there are financial consequences for choosing to remain uninsured. However, rather than an arbitrary fixed surcharge, the penalty should be commensurate with the added costs imposed on the health system when such people decide not to buy insurance. For example, the penalty could include a premium surcharge that increases with time out of the market, and a waiting period could be imposed before benefits are paid. Such an approach would eliminate the perverse incentive of a fixed penalty that encourages individuals to remain uninsured, avoiding premium payments, for as long as possible.

* The ‘No-Premium’ Health Insurance Option And Automatic Enrollment

Another factor reducing CBO’s estimate of the AHCA’s take-up of insurance is some people’s unwillingness to pay a premium that is larger than the value of their credit. A comprehensive revision of AHCA could broaden the types of plans offered by insurers to include at least one plan available with a premium exactly equal to the credit. Such a plan would provide protection against catastrophic losses without requiring first-dollar coverage for routine expenses. To further improve insurance take-up, AHCA should allow states to automatically enroll uninsured individuals into “no-premium” plans, with an option to change plans or opt out entirely.

* A Compromise On Medicaid Eligibility Within A Reformed Program

A new uniform national income standard could be set at a level that would free up resources to provide stronger federal support for all state Medicaid programs. Non-expansion states would not be required to expand their Medicaid eligibility to the new standard, but they would receive additional funding through a block grant. Expansion states would likely phase down their programs to the new income standard. In addition, states would be given more control over the program, allowing them to operate Medicaid in ways that promote individual responsibility and ease the transition to private health coverage.

* Additional Support For Low-Income Households Above Medicaid Eligibility

Subsidies ranging from $2,000 to $4,000 per person are not sufficient to make non-group insurance affordable for many with low incomes. AHCA should be revised to provide additional support for these families.

Looking Forward

Instead of condemning or ignoring CBO, congressional leaders would be well-advised to take full advantage of the agency’s analytic expertise to make the needed adjustments to the AHCA plan. That will ensure all sides are better prepared for serious debate when health policy again moves back onto center stage.

***

Published Comment:

By Don McCanne, M.D.

Trying to tweak the lousy AHCA model to make it work better is not a rational approach when more fundamental policy defects are ignored.

Worrying about keeping down spending through the federal budget doesn’t make much sense when it is total spending on health care, public and private, that is important. Federal health care spending is more efficient than spending through private insurers. In fact, eliminating private insurers reduces the profound administrative waste of both the private insurers and the burden they place on health care providers. Thus increasing the federal health care budget in this manner would produce an even greater offset in private spending. That savings could then be used to pay for the uninsured and for the excess cost sharing of the underinsured.

Inducing “personal responsibility” in health care spending is code language of conservatives for erecting financial barriers to health care – a terrible policy choice. The financing system should encourage, not discourage, access to beneficial health care services. The administrators can make better decisions than an uninformed public on what care is detrimental and should not be covered.

We already know what happens when Medicaid decisions are turned over to the states, and often it is not good for patients in need. Besides, Medicaid has a welfare stigma and would continue to be underfunded. It would be far better to cover everyone under the same comprehensive program that ensures access for everyone to all essential health care services.

Even continuing with ACA is a mistake because no matter how many tweaks are applied, we will continue to perpetuate the uninsured, underinsured, narrow networks, and excessive cost sharing (to slow premium increases to protect the private insurers instead of patients). These policies are detrimental to patients.

The policies we need are an efficient, publicly-administered universal risk pool, equitable funding based on ability to pay, removal of financial barriers to care, and free selection of health care providers. These policies benefit patients, and the models that have been constructed and are in use in some other nations would provide much better value for our health care spending.

Besides, a majority of the population now understands the superiority of single payer, including many Trump supporters. The nation is now ready for a single payer, improved Medicare for all.

http://healthaffairs.org…

***

Comment:

By Don McCanne, M.D.

Although the ACA was an improvement, it still has fundamental structural defects that prevent us from achieving the goals of true universality, affordability, equity, efficiency and access, no matter how much it is tweaked. The Republican AHCA proposal was merely another set of tweaks that went in the wrong direction, and we would have fallen further behind in the goals of reform.

Joseph Antos and James Capretta understand policy well, but they have saddled themselves with the conservative ideology professing that much of the responsibility for containing health care costs should be placed in the hands of the patient-consumer. Models to do that do reduce government spending on health care, but at today’s very high costs they impair access to beneficial health care services because of the lack of affordability of the patient’s out-of-pocket component of the spending.

Some conservatives recognize that low-income individuals need greater government support, as do Antos and Capretta, but their consumer-directed models also place too much of a financial burden on America’s workforce and their families. Also their insistence on using private insurance plans in the marketplace perpetuates the profound administrative waste that uniquely characterizes the American health care financing system, and perpetuates the deleterious tools of the private insurance industry such as sky-high deductibles and ultra-narrow provider networks.

Look specifically at the policies that Antos and Capretta consider to be beneficial. They would assess a large, progressive premium penalty after an interval of being uninsured once that individual decides to purchase insurance – a clear disincentive to bringing the uninsured into the market when policies should be designed instead to be certain everyone is always covered, not to mention that the additional penalty would make the premium unaffordable for most individuals. They would create optional plans with premiums equivalent to the government credit – an approach only made possible by further increasing deductibles and other cost sharing to truly unaffordable levels, not only perpetuating but expanding the flawed policy of offering almost worthless coverage in order to make premiums affordable. They would reduce the federal support of and privatize the Medicaid program while increasing “individual responsibility” through out-of-pocket payments that Medicaid beneficiaries simply do not have (except for the insulting token payments promoted by Pence and Verma simply to satisfy their own conservative ideological preferences).

Antos and Capretta do not reject the principle of government spending since they recommend it for low- and middle-income individuals and families. But they are quite willing to sacrifice the efficiencies and equity of a single payer system simply to include conservative ideology that places individual responsibility over social solidarity. Other nations have shown that publicly administered single payer tools are capable of slowing the increase in health care spending in a patient-friendly manner. Requiring excess cost sharing and taking away provider choice certainly are not patient-friendly.

Forget trying to tweak AHCA by placing conservative principles above patient service. Also forget trying to tweak ACA by placing the concepts of incrementalism and supposed political feasibility above patient service. Let’s go for the model that places patient service first – a well designed, single payer national health program – an improved Medicare for all.