PNHP

Expanded Medicare is easy fix for health system

Expanded Medicare is easy fix for health system

By Johnathon Ross, M.D.
The Blade (Toledo, Ohio), March 25, 2017

As a physician caring for poor and uninsured patients for decades, I can tell you that the Medicaid expansion under the Affordable Care Act (Obamacare) has saved lives and saved money. It has allowed access to care for hundreds of thousands of low-income Ohioans, leading to early diagnosis and treatment of disease, thereby preventing more costly care, severe disability, or death.

Gov. John Kasich understood these benefits and accepted the Medicaid expansion under Obamacare despite ideologically driven resistance from his fellow Republicans in the General Assembly.

Republicans in Congress have now outlined several tired and unproven ideas to replace that will likely gut the ACA Medicaid expansion. They plan to repeal the taxes on health-care corporations, health insurers, and the wealthy — taxes that helped pay for the Medicaid expansion for the poor and near-poor.

It is beyond comprehension that Congress, in a misguided drive to completely repeal the ACA, would cut this beneficial safety-net care away from poor patients. Real lives are being saved. Cutting or cancelling the Medicaid expansion will lead to higher costs, real suffering, disability, and deaths preventable with appropriate care.

At the same time, it’s important to understand that the ACA did not solve our problems. It didn’t attack the fundamental disease of American health care — its complexity.

Across the world there are only three simple systems proven to work: 1.) a publicly financed national health service, where doctors and other caregivers are public employees (much like our fire departments are set up), and where hospitals are publicly owned and budgeted (Sweden and the United Kingdom); 2.) a single-payer system, where health care is publicly financed but where doctors’ practices and hospitals largely remain in private hands (with hospitals getting lump-sum, annual budgets), and where a public authority negotiates provider fees and prices for medications and supplies (Canada and Taiwan); and 3.) a system of multiple, highly regulated insurers who offer a common, comprehensive benefits package, and where publicly transparent negotiations between hospitals and caregivers produce a single fee schedule and pooling of insurance funds that prevents gaming the system to avoid the sickest patients (Germany, Switzerland, and the Netherlands).

An improved and expanded Medicare for all, as envisioned in legislation introduced by Rep. John Conyers Jr., H.R. 676, would be the embodiment of the second, highly efficient approach. Everyone would be covered and there would be no co-pays or deductibles. The vast majority of households, on the order of 95 percent, would end up saving money.

The Medicare law already exists. Amendments to improve and expand it would be easy to do, either piecemeal or in a sweeping way. Medicare has been improved by amendment many times in the past 50 years. What is needed is the political will.

We know Medicare works. It has been successfully covering the most expensive and complex patients (the chronically ill, elderly, and disabled) that the private insurers would not insure prior to its passage in 1965.

Multiple studies agree that the simplicity of Medicare for all provides hundreds of billions in administrative savings that allow first-dollar comprehensive coverage for all without cutting the pay of caregivers. Medicare allows complete choice of caregiver and hospital. It would save lives, save money, and take the burden of seeking and purchasing health insurance off of businesses and individuals. An improved and expanded Medicare could provide liberal benefits and conservative spending. It is the logical and effective plan that could replace Obamacare to the benefit of all.

Dr. Johnathon Ross is an internal medicine doctor in Toledo.

http://www.toledoblade.com/…

ACA and AHCA fall short, but so does the Commonwealth Fund solution

Where Both the ACA and AHCA Fall Short, and What the Health Insurance Market Really Needs

By David Blumenthal and Sara Collins
Harvard Business Review, March 21, 2017

To understand the ongoing battles about the individual, or non-group, markets and their reform, three points should be kept in mind.

First, these insurance markets were distressed before the enactment of the Affordable Care Act. Second, the ACA improved their functioning but was not sufficient as passed and implemented to stabilize all of them. Neither, however, is the American Health Care Act (AHCA), the repeal and replacement legislation proposed by House Republicans and embraced by President Trump. Third, the reforms that will improve individual markets, which we discuss below, are known. They include greater balance between premium subsidies and penalties for not taking up coverage, using proven mechanisms for stabilizing risks such as reinsurance, and accelerating efforts to control the costs of health care services. To date, the United States has just lacked the political will to adopt them.

What to do

There is no great mystery about how to shore up private insurance markets.

First, we need to create balanced risk pools that include both healthy and less healthy persons in individual insurance markets. This will require two types of actions. Subsidies for young healthy consumers must be increased without decreasing those for older Americans so that so-called young invincibles find the prices of insurance less off-putting but the neediest customers in individual markets can still afford to participate.

However, reducing financial barriers for good risks will not suffice. Unlike many other purchases in our lives, buying insurance is difficult, confusing, and provides little short-term gratification; so healthy young people will always tend to avoid it. That is why creating healthy risk pools for individual markets will require something like the individual mandate that has been so unpopular with conservatives. Unless consumers are required to purchase insurance — or face a meaningful penalty — individual markets may not function effectively over the long term. By meaningful, we mean a financial penalty that equals or exceeds the cost of buying insurance in the first place.

Second, we need to extend subsidies higher up the income scale than the ACA’s limit of 400% of the federal poverty level. This will enable more non-poor individuals — who tend to have lesser disease burdens — to purchase insurance. Unfortunately, health insurance has become so expensive in the United States that even many middle-income families cannot afford to purchase it without the kind of assistance that employers routinely offer their employees.

Third, if we want private insurers to participate in ensuring that Americans have access to affordable insurance, the business of selling this product must be viable. This means managing the inherent uncertainties associated with selling insurance in comparatively unpredictable individual markets. The most effective approaches — used in the Medicare private drug-insurance market without controversy — are reinsurance and risk corridors. The first of these means assuring that reinsurance is available and affordable for plans selling individual and small group products. Risk corridors protect plans that accumulate unexpectedly high risks by giving them access to funds collected from insurers that experience unexpectedly low risks.

Fourth, and perhaps most important, public and private stakeholders must accelerate efforts to control the costs of health care services, which are the primary determinants of the cost of health insurance in all markets, including employer-sponsored, individual, and public. One reason that other countries find it easier to insure their entire populations is that their costs of care are half or less what ours are.

The key to controlling health care costs in the United States is to implement aggressively the payment and delivery-system reforms that were included in the Affordable Care Act but rarely discussed in current debates.

The facts are clear. We can revive individual markets that were failing even before the ACA was enacted and are vital to making affordable care available to Americans. But we will have to pay for that revival — politically and fiscally.

David Blumenthal, M.D., is president of the Commonwealth Fund. Sara Collins is the Commonwealth Fund’s vice president for health care coverage and access.

***

Comment:

By Don McCanne, M.D.

It is quite appropriate that this article was published in the Harvard Business Review since it finds solutions to the deficiencies of both the Affordable Care Act (ACA) and the proposed American Health Care Act (AHCA) in the private health care insurance marketplace. The authors’ proposals are to use government regulations and funds to create a robust market for private insurance plans – an approach that Harvard MBAs understand and support.

They would make the individual mandate more effective by penalizing nonparticipants with a penalty equal to or larger than the insurance premiums. Forcing individuals to buy plans with excessive deductibles and inadequate provider networks is a cruel policy.

They would increase subsidies for middle-income individuals but that would still push individuals into low-actuarial value plans, not solving the problems of impaired access due to narrow networks and unaffordable out-of-pocket costs.

They would relieve insurers of bearing risk through the use of reinsurance and risk corridors. Insurers would be reduced to providing a profusion of expensive administrative functions, while being protected against the usual insurance function of bearing risk, allowing their actuaries to concentrate on profits instead of risk.

They would more aggressively control health care costs but do so through the payment and delivery-system reforms of ACA which have already proven to be quite ineffective. They acknowledge that other countries insure everyone at costs of care that are “half or less what ours are.”

Well how do those other nations include everyone and pay an average of half of what we do? Certainly not by embellishing the private insurance markets and throwing a bunch of government money at them. Yes, some countries do use private insurance but they are so heavily regulated that they qualify as social insurance programs. The governments require that the financing system serves first the needs of patients whereas we structure ours to serve first the needs of insurers while leaving patients exposed to financial hardship and impaired access.

Today we are at a decision point between ACA and AHCA. Absent any last minute back-door deals, the likely outcome will be the defeat of AHCA, and president Trump will walk, leaving ACA in place with little hope for even the very modest changes suggested by Commonwealth’s Blumenthal and Collins. And if it should pass in both the House and the Senate, an unlikely outcome, we will be even worse off than we are.

Instead of a debate between ACA and AHCA, the debate should have been between ACA/AHCA and an improved Medicare for all. We can still have that debate by continuing to educate the public on the deficiencies of ACA and the virtues of single payer Medicare for all, but we will have to make our presence felt lest we get lost in the next agenda item that the Republicans really want – altering the tax system to shift more income and wealth from the workers to the wealthy. That will really be bad for the physical and fiscal health of our nation and its people.

After Speaker Ryan pulls GOP ‘slash and burn’ health bill, doctors group urges passage of a single-payer health plan

Failure of AHCA ‘presents a unique opportunity to move beyond the Affordable Care Act,’ says group’s leader

FOR IMMEDIATE RELEASE, March 24, 2017

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

Physicians for a National Health Program (PNHP), a nonprofit research and education organization of 20,000 physicians, medical students and health professionals, responded to House Speaker Paul Ryan’s decision to cancel a scheduled vote on the American Health Care Act (AHCA). With the AHCA dead on arrival, PNHP urges Congress to instead pass H.R. 676, the Expanded and Improved Medicare for All Act, which would provide immediate, comprehensive coverage to all Americans.

“The Republicans’ slash-and-burn proposal would have pushed millions more Americans off their health insurance, sending the rates of medical bankruptcy and preventable deaths skyrocketing,” said Dr. Carol Paris, president of PNHP.

Today’s failure to pass the AHCA presents a unique opportunity for Congress to move beyond the ACA toward a permanent, sustainable single-payer health program.

“The ACA left 29 million Americans uninsured and channeled billions of taxpayer dollars to a patchwork of wasteful private insurers, each one skimming off its own share of administrative costs and profit that should have been spent on patient care,” added Dr. Paris. “Let’s clear the drawing board – it’s time to adopt a simple, commonsense approach to national health care.”

Dr. Paris called on members of both parties to adopt H.R. 676, introduced by Rep. John Conyers Jr., D-Mich. The Expanded and Improved Medicare for All Act is a streamlined, single-payer plan that would expand coverage to all Americans and save millions in health care costs, achieving President Trump’s campaign promises of more coverage, better benefits and lower costs.

PNHP and other groups are planning a National Day of Action on Saturday, April 8, the first day of the congressional recess. Health care providers in at least a dozen cities will conduct coordinated actions in support of universal guaranteed health care. 

Physicians for a National Health Program (www.pnhp.org) is a nonprofit research and education organization of more than 20,000 doctors who support a single-payer national health program. It was founded in 1986.

Single payer make sense, financially and health-wise

By Maryanne Hidalgo Kehoe, R.N.
The Daily Star (Oneonta, N.Y.), March 24, 2017

Single-payer is not socialized medicine, it is socialized bookkeeping. It is the smart business method to reduce the cost of health care. Single-payer was supported by President Trump when he was still wearing his businessman’s hat.

Congressman Faso (Daily Star, 3/2/17) denies that there is significant cost savings with single-payer. In contrast, Dr. Antoinette Kuzminski (Daily Star, 2/18/17) writes, “Twenty-five percent of the American health care dollar goes to the care and feeding of private insurers — their bureaucracies, their shareholders, their CEOs.”

Savings estimates from moving to a single-payer system range from 11 percent to 31 percent, but it only takes common sense to know that removing the profit-motivated private insurance companies from the mix will save money; lots of money! Money saved would be more than the estimated yearly deficit reduction of $33.7 billion projected by American Health Care Act currently before Congress. Single-payer saves money AND would allow we the people to provide health care for all. Learn more about single-payer at:
https://www.pnhp.org/facts/single-payer-faq#what-is-single-payer

Write, email and call ALL your representatives in New York and Washington, including President Trump. As a businessman and our president, he needs to help all Americans struggling with our very confusing, inefficient and inequitable health care system. Please also support the cause for universal health care in New York. Single-payer Lobby Day and Rally in Albany is on Tuesday, April 04, 2017, at 10 a.m. For more information, go to: http://www.nyhcampaign.org/calendar.

Maryanne Hidalgo Kehoe, RN, MS, FNP, resides in Hartwick.

http://www.thedailystar.com/…

Eighteen-wheelers and Buick Enclaves

By Ewell Scott, M.D.
The Morehead (Ky.) News, March 24, 2017

Let us explore this analogy to better understand the advantages of selecting MEDICARE FOR ALL as the sole provider of health insurance financing. Note the key word is financing, not care.

Assume the need to travel to Louisville every day to purchase groceries. You have two choices of transportation. The first is to buy an 18-wheeler and use it.

The second option is a brand new Larry Fannin Buick Enclave, including a chauffeur. The groceries you purchase will be exactly the same, no matter how you get to the supermarket. Parking may be a bit more difficult with the truck. It takes very little wisdom to make the right pick, unless you just want to ride in an 18-wheeler. I would choose the Buick.

Now do this: replace multiple private health insurance companies for the truck and MEDICARE FOR ALL for the Enclave, and health care for groceries in the metaphorical scenario. What do you choose? Your health care would be exactly the same, but the cost will be lower with Medicare for All. How could this possibly be true? Well there are two very good reasons. First, Medicare has the ability to control costs, and Medicare can process your claims and collect the premiums much more efficiently. Remember Medicare’s overhead is 3 percent while private, for profit health care companies usually take 30 percent off of the top. Good Grief.

We here in the USA are wasting 600 billion dollars per year by persisting in our reliance on private health care companies. This is a big lot of loot, when you consider our entire Kentucky State Budget is about 9 billion. I ask anyone reading this article to give me a good reason to continue this insanity.

Happy Travels.

Ewell Scott, M.D., FACP, is a health care reform activist. He resides in Morehead.

http://www.themoreheadnews.com…

Insurance can’t be focus of improving healthcare

By Michael Sirr, M.D.
Bozeman (Mont.) Daily Chronicle, Letters, March 24, 2017

In my 30 years as an ER doctor, the insurance industry never helped me take care of a single patient. They did waste my time.

Notice how Medicare for all is not being discussed. Until Americans stop wasting 30 percent of their healthcare spending on insurance companies, we will never afford healthcare for all.

Michael Sirr, M.D., resides in Bozeman.

http://www.bozemandailychronicle.com…

With Epic GOP Failure, Dems Urged to Go Bold with Medicare-for-All

Americans rallied against the GOP to defend their right to healthcare, Democrats are being urged to seize on the moment

By Lauren McCauley
Common Dreams, March 24, 2017

With the Republican attempt to replace the Affordable Care Act (ACA) going down in flames Friday as Americans rallied to defend their right to healthcare, Democrats are being urged, both by experts and constituents, to seize on the moment and counter with a plan that will truly provide coverage for all.

Uproar over the GOP’s American Health Care Act (AHCA), which was estimated to strip 24 million people of their healthcare by 2026, prompted a political firestorm as it drove voters across the nation to town halls and local legislative offices to demand that House Republicans vote against the bill.

After the White House called on House Speaker Paul Ryan (Wis.) to withdraw Friday’s scheduled vote (after an aggressive lobby effort on the part of both President Donald Trump and Ryan), many are looking to what happens next.

Though the Republican narrative that Obamacare is “imploding” has been proven to be an unfounded talking point, The Week’s Ryan Cooper argued Friday that Democrats “shouldn’t sit idly by and wait for Republicans to slowly bleed Obamacare to death by other means.”

“They need a counter-offer,” Cooper writes, “one that’s more compelling than the creaky status quo. They need a single-payer, Medicare-for-All plan.”

Similarly, RoseAnn DeMoro, executive director of National Nurses United (NNU), told Common Dreams that ultimately Democrats “are fighting for an unacceptable status quo,” noting that a private insurance market will always prove to be “unaffordable.”

In a press statement she expanded on this idea:

Many of the criticisms of the ACA are, in fact valid. For all the improvements under the ACA, primarily the expansion of Medicaid and crackdown on some insurance abuses, the ACA still left 28 million without health coverage, and millions more struggling with un-payable medical bills and escalating out of pocket costs.

Where the Democrats too fell short was their failure in drafting the ACA to refute the underlying source of the health care crisis in the first place, the contradiction between a health care system that should be based on patient need and the public health and well being, and the insatiable demand of health care corporations for profits first.

Dr. Carol Paris, president of Physicians for National Health Program (PNHP), which has long-advocated for single-payer system, said Friday’s failure by the Republican Party to pass their “slash and burn” healthcare bill “presents a unique opportunity to move beyond” a profit-based system.

Though Paris acknowledged the GOP plan would have “pushed millions more Americans off their health insurance, sending the rates of medical bankruptcy and preventable deaths skyrocketing,” she said the shortcomings of the ACA should not be ignored.

“The ACA left 29 million Americans uninsured and channeled billions of taxpayer dollars to a patchwork of wasteful private insurers, each one skimming off its own share of administrative costs and profit that should have been spent on patient care,” Dr. Paris noted. “Let’s clear the drawing board—it’s time to adopt a simple, commonsense approach to national health care.”

Pointing to the collapse of the GOP’s attempt at reform, DeMoro says it’s clear their party has no viable pathway towards a solution. “The Republicans are ideologically split it appears,” she said. “Trump is trying to maintain that everyone should have healthcare and the cost should go down—that solution, and the only possible solution is Medicare-for-All.”

In a Friday press statement, Rep. Luis  Gutiérrez (D-IL) echoed this call. “We have known for years that the only true healthcare reform that will work is a single-payer system where we take national responsibility for the health of our nation,” he said. “Now that this vote is over, I hope we can return to a serious and sensible discussion of strengthening our healthcare system and the improving the health of all Americans.”

In addition to Medicare-for-All being “quite clearly the best universal health-care policy option for the United States,” The Week’s Cooper also observed that “Obamacare did not finish the job of achieving universal health care, and this is a good chance to move the ball forward.”

The AHCA, Cooper continues, “is extraordinarily unpopular because it takes coverage and subsidies away from people, and a majority believe that it should be the government’s responsibility to make sure everyone is covered. Fundamentally, Medicare is very popular, a fact only partially covered up by generations of red-baiting and duplicitous austerian propaganda.”

Further, he notes that “it also makes an excellent organizing signpost. Medicare-for-All is simple, easy to understand, and hard to argue against or distort.”

The math works out too. Dr. David Himmelstein and Dr. Steffie Woolhandler, both of whom are closely associated with PNHP, published an analysis this week which found that replacing the ACA “with a universal, single-payer health system, along the lines of the Expanded and Improved Medicare for All Act, H.R. 676, would provide immediate coverage to the 26 million Americans who are currently uninsured, saving at least 20,984 lives in year one.”

This is in contrast to the Congressional Budget Office estimate that as many as 24 million people would lose health coverage by 2026 under the AHCA.

Responding to Friday’s developments, Sen. Bernie Sanders (I-Vt.) called the failure of the AHCA a “great victory,” but said that lawmakers’ work would not be complete until healthcare was guaranteed “to all people as a right”:

Contrary to Republican orthodoxy, many of Trump’s blue collar supporters voted for him specifically because he promised to “take care of everybody.” Speaking with some of those voters in West Virginia recently, Sanders found that many do believe that healthcare should be guaranteed as a human right.

Sanders, who made Medicare-for-All a key plank of his 2016 presidential campaign, said recently that the president’s supporters “are catching on that Trump lied.”

Robert Frank, an economics professor at the Johnson Graduate School of Management at Cornell University, argued in a New York Times op-ed Friday that the president could preserve the floundering effort to replace Obamacare while making good on his campaign promises by getting behind a Medicare-for-All, or single payer, healthcare plan.

Trump should use his “political leverage…to jettison the traditional Republican approach in favor of a form of the single-payer health care that most other countries use.”

This work is licensed under a Creative Commons Attribution-Share Alike 3.0 License

http://www.commondreams.org…

What Comes Next for Obamacare? The Case for Medicare for All

By Robert H. Frank
The New York Times, March 24, 2017

Republicans are in a bind. They’ve been promising to repeal Obamacare for seven years, and having won control of the White House and Congress, they had to try to deliver. But while their bitter denunciations of the Affordable Care Act may have depressed its approval numbers, they didn’t make replacing it any easier.

On the contrary, the repeal-and-replace bill designed by House Speaker Paul D. Ryan drew withering criticism from the left and the right. Liberals condemned its use of reductions in health coverage for the poor to pay for large tax cuts for the wealthy, while conservatives bemoaned its retention of many subsidies adopted under Obamacare.

In the end, the repeal effort’s biggest hurdle may have been loss aversion, one of the most robust findings in behavioral science. As numerous studies have shown, the pain of losing something you already have is much greater than the pleasure of having gained it in the first place. And the nonpartisan Congressional Budget Office estimated that Mr. Ryan’s American Health Care Act (A.H.C.A.) would have caused more than 14 million people to lose coverage in the first year alone, with total losses rising to 24 million over the next decade. Many Republicans in Congress were nervous about the political firestorm already provoked by the mere prospect of such losses.

Loss aversion actually threatened the repeal effort on two fronts: voters’ fear of losing their coverage, and lawmakers’ fear of losing their seats. Like the first fear, the second appeared well grounded. Republican voters wouldn’t have been the only ones losing coverage, of course, but early studies suggested that losses would have been concentrated among people who voted for President Trump. The Congressional Budget Office estimated, for example, that the A.H.C.A. would have caused premiums to rise more than sevenfold in 2026 for 64-year-olds making $26,500.

Now that Republicans have withdrawn Mr. Ryan’s bill from consideration, attention shifts to what comes next. In an earlier column, I suggested that Mr. Trump has the political leverage, which President Obama did not, to jettison the traditional Republican approach in favor of a form of the single-payer health care that most other countries use. According to Physicians for a National Health Program, an advocacy group, “Single-payer national health insurance, also known as ‘Medicare for all,’ is a system in which a single public or quasi-public agency organizes health care financing, but the delivery of care remains largely in private hands.” Christopher Ruddy, a friend and adviser of the president, recently urged him to consider this option.

Many Republicans who want to diminish government’s role in health care view the single-payer approach with disdain. But Mr. Trump often seems to take pleasure in being unpredictable, and since he will offend people no matter which way he turns, he may want to consider why liberals and conservatives in many other countries have embraced the single-payer approach.

Part of the appeal of Medicare for all is that single-payer systems reduce financial incentives that generate waste and abuse. Mr. Ryan insisted that by relegating health care to private insurers, competition would lead to lower prices and higher quality. Economic theory tells us that this is a reasonable expectation when certain conditions are met. A crucial one is that buyers must be able to compare the quality of offerings of different sellers. In practice, however, people have little knowledge of the treatment options for the various maladies they might suffer, and policy language describing insurance coverage is notoriously complex and technical. Consumers simply cannot make informed quality comparisons in this industry.

In contrast, they can easily compare the prices charged by competing insurance companies. This asymmetry induces companies to compete by highlighting the lower prices they’re able to offer if they cut costs by degrading the quality of their offerings. For example, it’s common for insurance companies to deny payment for procedures that their policies seem to cover. If policy holders complain loudly enough, they may eventually get reimbursed, but the money companies save by not paying others confers a decisive competitive advantage over rivals that don’t employ this tactic. Such haggling is uncommon under single-payer systems like Medicare (though it is sometimes employed by private insurers that supplement Medicare).

Consider, too, the mutually offsetting expenditures on competitive advertising and other promotional efforts of private insurers, which can exceed 15 percent of total revenue. Single-payer plans like Medicare spend nothing on competitive advertising (although here, also, we see such expenditures by supplemental insurers).

According to the Kaiser Family Foundation, administrative costs in Medicare are only about 2 percent of total operating expenditures, less than one-sixth of the rate estimated for the private insurance industry. This difference does not mean that private insurers are evil. It’s a simple consequence of a difference in the relevant economic incentives.

American health care outlays per capita in 2015 were more than twice the average of those in the 35 advanced countries that make up the Organization for Economic Cooperation and Development. Yet despite that spending difference, the system in the United States delivers significantly less favorable outcomes on measures like longevity and the incidence of chronic illness.

But advertising expenses and administrative costs are not the most important reason the United States spends so much more. The main difference is that prices for medical services are so much lower in other countries. In France, for example, a magnetic resonance imaging exam costs $363, on average, compared with $1,121 in the United States; an appendectomy is $4,463 in France, versus $13,851 in America. These differences stem largely from the fact that single payers — which is to say, governments — are typically able to negotiate more favorable terms with service providers.

In short, Medicare for all could deliver quality care at much lower cost than private insurers do now. People would of course be free to supplement their public coverage with private insurance, as they now do in most other countries with single-payer systems, and as many older Americans do with Medicare.

As a candidate, Mr. Trump repeatedly promised that everyone in the country would be covered at reasonable cost under an amazing new health plan. But it is now clear that the A.H.C.A. could not have delivered on that promise. The president, who has not always had a close relationship with Mr. Ryan, may consider changing course and working across party lines to develop support for universal access to Medicare.

Then again, he may fear that move would be seen as a sign of weakness or defeat. But the research findings on loss aversion make one thing clear: Any setback from that change in strategy would pale in comparison to the damage he would have suffered if the A.H.C.A. had actually become law.

Robert H. Frank is an economics professor at the Johnson Graduate School of Management at Cornell University.

https://www.nytimes.com…

Customized health insurance benefits do not pool risk

Late G.O.P. Proposal Could Mean Plans That Cover Aromatherapy but Not Chemotherapy

By Margot Sanger-Katz
The New York Times, March 23, 2017

Most Republicans in Congress prefer the type of health insurance market in which everyone could “choose the plan that’s right for them.”

Why should a 60-year-old man have to buy a plan that includes maternity benefits he’ll never use? (This is an example that comes up a lot.) In contrast, the Affordable Care Act includes a list of benefits that have to be in every plan, a reality that makes insurance comprehensive, but often costly.

Now, a group of conservative House members is trying to cut a deal to get those benefit requirements eliminated as part of the bill to repeal and replace the Affordable Care Act moving through Congress. (The vote in the House is expected later today.)

At first glance, this may sound like a wonderful policy. Why should that 60-year-old man have to pay for maternity benefits he will never use? If 60-year-old men don’t need to pay for benefits they won’t use, the price of insurance will come down, and more people will be able to afford that coverage, the thinking goes. And people who want fancy coverage with extra benefits can just pay a little more for the plan that’s right for them.

But there are two main problems with stripping away minimum benefit rules. One is that the meaning of “health insurance” can start to become a little murky. The second is that, in a world in which no one has to offer maternity coverage, no insurance company wants to be the only one that offers it.

David Cutler, a professor at Harvard who helped advise the Obama administration on the Affordable Care Act, said he thinks the kind of insurance products that would be offered under the proposed mix of policies could become much more bare-bones than plans before Obamacare. He envisioned an environment in which a typical plan might cover only emergency care and basic preventive services, with everything else as an add-on product, costing almost exactly as much as it would cost to pay for a service out-of-pocket.

There is most likely a middle way. Republican lawmakers might be comfortable with a system that shifts more of the costs of care onto people who are sick, if it makes the average insurance plan less costly for the healthy. But making those choices would mean engaging in very real trade-offs, less simple than their talking point.

https://www.nytimes.com…

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NYT Reader Comment:

By Don McCanne, M.D.
San Juan Capistrano, CA

“There is most likely a middle way.”

Not really. Most of the 20 percent of people who use 80 percent of our health care cannot pay for it out of pocket. That is why we need to pool risk and fund it by all of us, certainly including the 80 percent who remain relatively healthy.

Our dysfunctional multi-payer system wastes a tremendous amount of resources in insurer administrative excesses that play games such as distributing the costs between a multitude of public and private programs, the variability and complexity in claims processing for the health care providers, and the allocation of out of pocket costs by individuals.

Over $500 billion of this waste is actually recoverable (Annals of Internal Medicine, Feb. 21, 2017) if we switched to a single payer national health program – an improved Medicare that covered everyone. The “middle way” would simply perpetuate this waste.

***

Comment:

By Don McCanne, M.D.

A very common theme is that we can design insurance products to provide only the coverage that we need. By not covering everything, the premiums would be much lower and thus affordable to everyone. Problem solved. (Not so quick.)

The most obvious problem is that nobody knows when they may suffer a catastrophic medical event or experience the onset of a serious chronic disorder. The health care financing system should automatically cover such occurrences, but, in doing so, since much of our health care spending falls into these categories, the savings in the insurance premiums would not be enough to make them affordable for too many of us. The coverage that a person might decline, such as management of breast cancer for men or prostate cancer for women, would still have to be paid for either out-of-pocket or through additional riders on the insurance. As soon as you allow riders, the costs would go up because of adverse selection – the people selecting the riders would be the people who would need them.

So the system would have to cover that 80 percent of health care that is used by the 20 percent of people with greater health problems. What about the other 20 percent that is used by individuals in better health? That is where much of the administrative waste occurs in our health care system. The insurers create and market a variety of insurance products with varying provider networks and variable cost sharing which place an administrative burden on the providers of health care. That negatively impacts the 80 percent of us who are healthy. For the 20 percent who use 80 percent of our health care, once the cost sharing requirement is reached, the additional administrative burden is not that great. So the half trillion dollars of recoverable administrative waste is providing essentially no value since it is wasted on superfluous up front interactions with the health care system and its patients.

Other nations have shown us that we do not need to have cost sharing and fragmented risk pools in order to control spending. They deliver comprehensive services to everyone at a lower cost. Fragmenting risk pools would only increase the administrative waste while subjecting elective risk pools to adverse selection, making them unaffordable. Who would sign up for a rider covering HIV and AIDS? What would the cost be when that rider is added to the basic insurance that everyone needs? Fragmenting the risk pools would result in modest reductions in the basic premium but those adding the riders would have premiums that would be unaffordable except for the wealthy. Customizing insurance by fragmenting risk pools defeats the goal of removing financial barriers to care. If we pool all risks together the special needs that might occur in the future would balance out.

Crossing party lines

By Carol A. Paris, M.D.
The Tennessean, Letters, March 23, 2017

Re: “Walking a mile in Donald Trump supporters’ shoes,” by David Plazas, March 19.

I read David Plazas’ commentary on his experience walking last Wednesday from Capitol Hill to Municipal Auditorium to attend President Trump’s rally.

I find that his experience with President Trump’s supporters was much like mine. I arrived in the line at about 9:45 a.m. My line-mates included a mother and her grown daughter from Lebanon.

The mom explained that her husband couldn’t attend because he is ill with a chronic lung condition. I could relate; both of my parents had lung disease and I know the sadness of watching someone you love struggle to breathe.

We all were annoyed by the roadside preachers who shouted hell and damnation at us for hours. I, too, was offended by protesters who carried signs that seemed designed to inflame and promote anger rather than champion their issue.

I thought about Maya Angelou’s saying “We are more alike than we are unalike.” I thought about the late Marshall Rosenberg, whose teachings of nonviolent communication have informed my work as an advocate and an activist. He admonished us to listen not to what people are saying but rather to listen for their feelings and needs. Feelings and needs are universal.

Once inside, I tried to place myself strategically so that I could be seen and heard by the president and by the much-maligned press corps. I waited until Mr. Trump got to the topic of health care and then I seized my opportunity to stand and chant: “Put your name on a plan that works, Medicare for all.”

I chose this action to bring visibility to another option for addressing the health care crisis — one that I believe provides the optimal use of our hard-earned tax dollars to provide quality health care for everyone living in the United States.

Carol Paris, president, Physicians for a National Health Program, Nashville.

http://www.tennessean.com…

Doctors speak out against GOP’s ACA replacement bill

By Joyce Frieden
MedPage Today, March 23, 2017

WASHINGTON — As House Republicans wrestled with moving their Affordable Care Act (ACA) replacement bill along on Capitol Hill on Thursday, physicians who opposed the legislation also were making their voices heard.

Several doctors participated in a rally against the bill — known as the American Health Care Act (AHCA) — held here at Freedom Plaza, within sight of a hotel owned by President Trump, on the seventh anniversary of the Affordable Care Act’s enactment.

“I’m here to support the folks who want to make sure the ACA is not repealed,” said Manan Trivedi, MD, president of the National Physicians Alliance, a group that advocates for high-quality, affordable healthcare for all.

“This bill has gone from bad to worse in a matter of 24 hours or so. The same folks who criticize backroom deals and writing a bill in the middle of the night are doing [just] that, but much worse … They’re essentially taking away critical health benefits from poor and middle-class families just to give tax cuts to 0.9% of [wealthy] America. It’s unfathomable what they’re trying to do and how they’re trying to do it so quickly.”

If it ends up passing, the AHCA “would devastate so many of my patients,” continued Trivedi, an internist and hospitalist in the Washington area. “I’ve seen firsthand folks who couldn’t afford insurance now being able to come to the ER, be admitted, and get follow-up appointments because of the ACA” and who would be hurt if it were repealed. “And this is not to mention the disease outbreaks, childhood lead poisoning, and infections with superbugs that would likely increase because of the plan in this new legislation to eliminate the Prevention and Public Health Fund.”

The current efforts to push the bill through are “a game the Republicans are having because they don’t believe in healthcare as a human right,” said Harvey Fernbach, MD, a psychiatrist in College Park, Md., and a board adviser to Physicians for a National Health Program (PNHP), a group that supports single-payer health insurance. “Obamacare was a good effort but it’s not quite what we want … The simplest idea is to expand and improve Medicare for all.”

The bill the Republicans are proposing “is a major step backwards,” said Deborah Schumann, MD, a retired ophthalmologist from Bethesda, Md., who is active in PNHP and Healthcare NOW of Maryland. “The Republican plan, they call it ‘Obamacare light’ but it’s really ‘Obamacare draconian.’ It’s going to hurt a lot of people.”

“I have been a single-payer advocate for a long time, and I was not super happy about Obamacare, but we got it and it did give a lot of people insurance, although it didn’t give everybody affordable healthcare,” she said. “This is going to make healthcare even less affordable.”

Rally participants heard from several other speakers, including former congressman Keith Ellison (D-Minn.), who is now deputy chairman of the Democratic National Committee; Rep. Dan Kildee (D-Mich.), whose district includes Flint; and Cecile Richards, president of the Planned Parenthood Federation of America. After the rally ended, the group marched to the Trump hotel, chanting anti-AHCA slogans.

Richards also took part in a conference call Thursday morning with Hal Lawrence III, MD, CEO of the American Congress of Obstetricians & Gynecologists (ACOG); participants discussed what would happen if the Republicans were successful in their efforts — via a provision in the AHCA — to defund Planned Parenthood.

“The effort to defund Planned Parenthood would force the closure of clinics around the country and negatively impact patients and healthcare providers,” said Lawrence. “Planned Parenthood is where many of our members practice, and many patients go to get their healthcare needs met.”

While he couldn’t give a specific figure, Lawrence estimated that more than 1,000 ACOG members work at Planned Parenthood clinics. “If these clinics close, physicians could no longer practice there there and whether or not they have practice alternatives around the community, we don’t know,” he told MedPage Today. “They may be forced to leave the community or state. The other thing is patients will no longer have access to ob/gyns and … there are not other providers out there ready to absorb this number of patients.”

Joyce Frieden is news editor at MedPage Today.

https://www.medpagetoday.com/PublicHealthPolicy/repeal-and-replace/64095?xid=nl_mpt_DHE_2017-03-24&eun=g352547d0r&pos=3

ACA’s repeal would cause tens of thousands of deaths, while single payer would save 20,000 more lives than ACA: AJPH editorial

Researchers: Peer-reviewed evidence points to deadly consequences of being uninsured

FOR IMMEDIATE RELEASE, March 22, 2017
Contact: Clare Fauke, PNHP communications specialist, 312-782-6006, clare@pnhp.org

Repealing the Affordable Care Act without replacing it, as some conservative hardliners are demanding, would cost a minimum of 37,127 lives over the next two years (14,528 in 2018 and 22,599 in 2019), and perhaps as many as four times that number, according to scientific studies summarized in an editorial in this week’s American Journal of Public Health.

The new analysis of the effect of widespread insurance loss is particularly relevant in light of the report issued March 13 by the Congressional Budget Office. The CBO estimates that the American Health Care Act, the Republican plan to replace the ACA, would cause 14 million people to lose insurance in the first year alone. By 2026, 24 million would lose coverage, leading to a total of 52 million uninsured in that year.

In contrast, the editorial’s authors estimate the impact of replacing the ACA with a universal, single-payer health system, along the lines of the Expanded and Improved Medicare for All Act, H.R. 676, would provide immediate coverage to the 26 million Americans who are currently uninsured, saving at least 20,984 lives in year one.

Longtime health system researchers Drs. David U. Himmelstein and Steffie Woolhandler analyzed all of the peer-reviewed studies of mortality associated with losing or gaining insurance. Using the CBO estimates of how many people currently lack insurance and how many more would lose coverage if the ACA were repealed without replacement, they provide a range of estimates of the excess deaths or lives saved under different health reform options (see table below). The evidence indicates that one American dies for every 300 to 1,239 who go without health insurance.

Table of data on mortality and health insurance

(See full Himmelstein and Woolhandler editorial for details on methods and sources.)

“The ACA extended coverage to 20 million Americans. But it offered little help to 90 percent of the population, including the 26 million who remain uninsured and millions more with unaffordable copayments and deductibles,” said study co-author Dr. Woolhandler, an internist, professor of public health at the City University of New York at Hunter College (CUNY), lecturer in medicine at Harvard Medical School. “Clear evidence tells us that fixing these defects would save thousands of lives. But Republicans’ plans would move us backwards.”

Dr. Himmelstein, the lead author of the editorial, a primary care doctor and, like Woolhander, a professor at CUNY’s Hunter College and lecturer at Harvard Medical School, added, “The Republican plan to replace the ACA would leave 52 million people uninsured in 2026. We know that will lead to many deaths – at least 41,969 and perhaps many times that number.”

Drs. Woolhandler and Himmelstein authored one of the early studies of the lethal effects of lacking health insurance, which President Obama cited in his push for the ACA. They, together with then-Harvard law professor Elizabeth Warren, led widely cited studies of medical bankruptcy.

*****

“Trumpcare or Transformation,” by David U. Himmelstein, M.D., and Steffie Woolhandler, M.D., M.P.H. American Journal of Public Health. Published online ahead of print, March 21, 2017. doi:10.2105/AJPH.2017.303729

A copy of the full article is available to media professionals upon request from Clare Fauke, PNHP communications specialist, clare@pnhp.org, (312) 782-6006.

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