PNHP

California legislation would create single-payer health care system

California legislation would create single-payer health care system

By Emily Green
San Francisco Chronicle, Feb. 17, 2017

President Donald Trump caused a stir when he suggested Sunday that the Republican quest to repeal and replace the Affordable Care Act could continue through 2018. However, some Republicans think he’s on to something. Some think it’s more realistic to think that way. The current plan is a multi-step path, requiring the GOP to use the budget reconciliation process to partly repeal Obamacare by a majority vote.

A push for a single-payer health care system in California is making a comeback.

State Sen. Ricardo Lara, D-Bell Gardens (Los Angeles County) plans to introduce legislation Friday to create a single system that would provide health insurance to every California resident.

“This is our opportunity to put ourselves on the record and be proactive against a Trump administration that is hellbent on eliminating the Affordable Care Act,” Lara said.

The two-page bill contains no specifics. Friday was the deadline for introducing new legislation, and the bill will be fleshed out over the coming month, Lara said. It will first head to the senate Health Committee and then to the senate Appropriations Committee, which Lara chairs.

Previous efforts to create a single-payer system have failed. At least eight bills were introduced between 1992 and 2009 that attempted to create one. They failed to get through the Legislature or were vetoed by Republican governors.

Efforts to create a single-payer system in California ended after the passage of the Affordable Care Act under President Obama.

RoseAnn DeMoro, executive director of National Nurses United, the largest U.S. organization of registered nurses, said the union would mount a “major mobilization” to try to enact a single-payer system in California.

She said she believed it had a better chance than in years past because of President Trump’s efforts to overturn the Affordable Care Act, a more active political base, and a new crop of state legislators who are younger and more open-minded.

“It is one of the most salient issues of our time,” she said.

http://www.sfgate.com…

See also:

California Healthline: Single-Payer Health Care Bill To Be Introduced In California Senate
http://californiahealthline.org…

The Mercury News (Sacramento, Calif.): California lawmakers to introduce universal health care plan today
http://www.mercurynews.com…

Dismal projections for national health expenditures and the numbers of uninsured

National Health Expenditure Projections, 2016–25: Price Increases, Aging Push Sector To 20 Percent Of Economy

By Sean P. Keehan and colleagues at the CMS Office of the Actuary
Health Affairs, February 15, 2017

Abstract

Under current law, national health expenditures are projected to grow at an average annual rate of 5.6 percent for 2016–25 and represent 19.9 percent of gross domestic product by 2025. For 2016, national health expenditure growth is anticipated to have slowed 1.1 percentage points to 4.8 percent, as a result of slower Medicaid and prescription drug spending growth. For the rest of the projection period, faster projected growth in medical prices is partly offset by slower projected growth in the use and intensity of medical goods and services, relative to that observed in 2014–16 associated with the Affordable Care Act coverage expansions. The insured share of the population is projected to increase from 90.9 percent in 2015 to 91.5 percent by 2025.

http://content.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

Over this decade, with no further changes in our health care financing system, national health expenditures are expected to increase to one-fifth of our GDP. Unfortunately, our current health care financing system remains incapable of containing health care costs.

Perhaps more alarming is that this decade will reduce the numbers of uninsured by only six-tenths of one percent. Eight and one-half percent of the population will remain uninsured in 2025. Without change, our system will continue to fail to ensure that health care is a right for all.

On a personal note, our daughter-in-law is in Taiwan – her native country – where today she had major surgery for cancer. All went well.

Our son just sent a photo of the mission statement that is posted on the wall of her post-op room.

It begins,

Objective: To promote the basic human right of health

If only President Trump and his colleagues in the District of Columbia truly supported that concept and would act upon it…

Repealing Obamacare will create harm for millions

By Gene Bishop, M.D.
The Philadelphia Inquirer, Letters, Feb. 16, 2017

How can a physician oppose people getting health care? It’s a puzzle to me.

The nomination and confirmation of Dr. Tom Price – widely described in the media as a fierce Obamacare critic – as secretary of Health and Human Services set my physician mind to thinking how two people (Price and I) both trained as physicians, yet have come to dramatically different conclusions on what Americans want and need as patients.

Price once ran the orthopedic clinic at Emory Hospital in Atlanta. I once ran a primary care clinic at a Philadelphia hospital. Patients in both these settings are usually low-income – uninsured, if the clinic will take them, or insured by Medicaid. Before the Affordable Care Act – or “Obamacare,” as it has come to be known – low-income working adults were not eligible for Medicaid.

Without Medicaid either for the individual patients, or under a program of support to hospitals serving low-income populations, there is no care for these folks. The Affordable Care Act – in states that chose to do so – expanded Medicaid to the low-income working population. Repealing Obamacare would end this insurance.

In my training as a physician, I rejoiced to see my patients able to receive care for diabetes, hypertension and cancer.

Tell me, Dr. Price: If you oppose Obamacare and Medicaid expansion, do you envision the poor of Atlanta (or Pennsylvania) letting fractures heal without medical care or anesthesia? In your world, will only those able to pay be allowed to have a new knee or a new hip?

In my primary-care practice, patients and I made decisions together about the best treatment. I can’t remember a single instance – in over 30 years in practice – where the government (Medicare or Medicaid) interfered with that decision, except when a woman wanted an abortion and Medicaid did not pay. But I can think of numerous instances where private insurance companies – the very companies Price wants to strengthen – interfered with my decision-making. And most of the successful appeals were based on government regulations that safeguarded the rights of patients when private insurance ran amok.

So when Price is concerned that the government has “commandeered medical decision-making” – I ask him how? By protecting our seniors from astronomical medical bills because Medicare limits what physicians can charge? I was taught in medical school to put my patients first. Price, under the clever phrase of “empowering patients,” wants to put physicians first.

In medical school, I was taught to respect all patients, to take care of all those who needed care, regardless of income. Price must have been absent that day. I can’t imagine otherwise how he can propose a health-care system that discriminates against the sick, will be unaffordable for the more than 20 million people who have gained insurance under Obamacare and will favor doctors over patients.

Is there anything on which we might agree? He wants to “modernize” Medicare. But if we look closely, Price aims to replace Medicare – the most popular health-insurance plan in the country – with vouchers that will let people buy the amount of care “they need.” He doesn’t say whether we can all buy crystal balls, along with the vouchers, to see into the future. And me? I’d like to see improved Medicare for All – without private insurance companies, co-pays or deductibles. It would save our country, and individuals, billions of dollars. And allow all of us doctors to take care of everyone. I’d rather have that dream than the nightmare I see with Price in charge of health care.

It’s too late to send Price back to medical school to learn what it means to really support patients. But the prescription I write today is for everyone to let their elected officials know that health care for all is important – that we need to improve on Obamacare, but that the health of our state and nation will not be improved with millions losing health care.

Dr. Gene Bishop is clinical professor of medicine at the Perelman School of Medicine, University of Pennsylvania. He can be reached at drgenephilly@gmail.com.

http://www.philly.com…

Obamacare’s Original Sin

We can resist Republican efforts to repeal Obamacare without providing cover for the law’s deep ideological flaws.

By Adam Gaffney
Jacobin, Feb. 15, 2017

Republicans are struggling to find the proper pitch for their attack on the Affordable Care Act (ACA). “Repeal and replace” — the tried and true formulation — may be mutating into something mellower, albeit more vacuous. “Americans want the ACA repealed and repaired,” Republican strategist Frank Luntz recently told the Associated Press, using the new nomenclature.

Should this right-wing retreat — or rather, recalibration — be construed as a victory, however minor? Probably not, for two reasons.

First, whatever the tweak in marketing, the crux of the matter hasn’t changed: Republicans seem poised to engineer an enormous increase in uninsurance in the coming years (at the cost of countless lives).

And second, “repeal and repair” will double down on the worst elements of the status quo. Whatever term they use, Republicans never intended to remove the central pillar of the US health care system (and the ACA): private health insurance.

As two of my colleagues, David Himmelstein and Steffie Woolhandler, put it shortly after Trump’s election:

We suspect that the [Republican’s] likeliest replacement [for the ACA] is a meaner (and rebranded) facsimile of the ACA that retains its main structural element — using tax dollars to subsidize private insurance — while imposing new burdens on the poor and sick.

The 2016 health care reform framework of Paul Ryan and the House Republicans, for instance, would provide tax credits to help individuals and families purchase private plans “through multiple portals, including private exchanges.” Ryan’s tax credit scheme amounts to a more regressive version of the ACA’s subsidies for plans bought on the “marketplace” (also known as “exchange” or “Obamacare” plans).

In other words, we should expect the looming GOP health care overhaul to be more right-wing regression than reactionary revolution.

This relative continuity highlights an important point: one of the ACA’s key mechanisms for moving us toward universal health care — publicly subsidized, privately sold “marketplace” plans — was never going to achieve its goal.

Millions now rely on these plans, and we should defend them until we can win something better. But we also shouldn’t entertain any illusions: the ACA marketplaces rest on a flawed health care ideology that tellingly attracts many adherents on the Right, including Ryan.

What are the roots of this ideology — sometimes known as “managed competition” — and how can we move beyond it?

full article:
https://www.jacobinmag.com…

Adam Gaffney is an instructor in medicine at Harvard Medical School, a pulmonary and critical care doctor at the Cambridge Health Alliance, and a national board member of Physicians for a National Health Program. He blogs at theprogressivephysician.org.

New CMS rules take good care of insurers

CMS Issues Proposed Rule to Increase Patients’ Health Insurance Choices for 2018

Centers for Medicare & Medicaid Services (CMS), Press release, February 15, 2017

The Centers for Medicare & Medicaid Services (CMS) today issued a proposed rule for 2018, which proposes new reforms that are critical to stabilizing the individual and small group health insurance markets to help protect patients. This proposed rule would make changes to special enrollment periods, the annual open enrollment period, guaranteed availability, network adequacy rules, essential community providers, and actuarial value requirements; and announces upcoming changes to the qualified health plan certification timeline.

“Americans participating in the individual health insurance markets deserve as many health insurance options as possible,” said Dr. Patrick Conway, Acting Administrator of the Centers for Medicare & Medicaid Services. “This proposal will take steps to stabilize the Marketplace, provide more flexibility to states and insurers, and give patients access to more coverage options. They will help protect Americans enrolled in the individual and small group health insurance markets while future reforms are being debated.”

The rule proposes a variety of policy and operational changes to stabilize the Marketplace, including:

Special Enrollment Period Pre-Enrollment Verification:  The rule proposes to expand pre-enrollment verification of eligibility to individuals who newly enroll through special enrollment periods in Marketplaces using the HealthCare.gov platform. This proposed change would help make sure that special enrollment periods are available to all who are eligible for them, but will require individuals to submit supporting documentation, a common practice in the employer health insurance market. This will help place downward pressure on premiums, curb abuses, and encourage year-round enrollment.

Guaranteed Availability:  The rule proposes to address potential abuses by allowing an issuer to collect premiums for prior unpaid coverage, before enrolling a patient in the next year’s plan with the same issuer. This will incentivize patients to avoid coverage lapses.

Determining the Level of Coverage:  The rule proposes to make adjustments to the de minimis range used for determining the level of coverage by providing greater flexibility to issuers to provide patients with more coverage options.

Network Adequacy:  The proposed rule takes an important step in reaffirming the traditional role of states to serve their populations. In the review of qualified health plans, CMS proposes to defer to the states’ reviews in states with the authority and means to assess issuer network adequacy. States are best positioned to ensure their residents have access to high quality care networks. Also plans will now be required to include only one0fifth of essential community providers (ECPs) within their networks, removing from the patient the option of receiving care from the other four-fifths of ECPs.

Qualified Health Plan (QHP) Certification Calendar:  In the rule, CMS announces its intention to release a revised proposed timeline for the QHP certification and rate review process for plan year 2018. The revised timeline would provide issuers with additional time to implement proposed changes that are finalized prior to the 2018 coverage year. These changes will give issuers flexibility to incorporate benefit changes and maximize the number of coverage options available to patients.

Open Enrollment Period:  The rule also proposes to shorten the upcoming annual open enrollment period for the individual market. For the 2018 coverage year, we propose an open enrollment period of November 1, 2017, to December 15, 2017. This proposed change will align the Marketplaces with the Employer-Sponsored Insurance Market and Medicare, and help lower prices for Americans by reducing adverse selection.

https://www.cms.gov…

CMS Proposed Rule:
https://s3.amazonaws.com…

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Comment:

By Don McCanne, M.D.

CMS today released a new proposed rule allegedly designed to “protect patients” by stabilizing the plans offered in the ACA insurance exchanges. A cursory reading of the press release would tend to confirm this intent, but a careful reading of the release and especially the executive summary of the proposed rule will reveal that the rule is designed to improve the market for the insurers with a detrimental impact on potential enrollees of the insurance plans.

Revising the CMS rhetoric to match more accurately the actual impact on patients:

* Special Enrollment Period Pre-Enrollment Verification: Qualifying categories for special enrollment will be reduced, and documentation requirements increased. This will reduce the number of individuals with greater needs that the insurers would be required to accept outside of open enrollment – reducing adverse selection, but it will prevent many individuals who missed open enrollment because of the administrative burden from becoming insured.

* Guaranteed Availability: Insurers may apply premiums paid as a credit against unpaid premiums for the prior year, and then deny coverage because of non-payment for the current year. This will protect insurers from individuals who have difficulty paying the premiums, but at a cost of leaving individuals uninsured in spite of a good faith effort to pay current premiums.

* Determining the Level of Coverage: The insurers will be allowed greater flexibility in the variation of the actuarial values for the metal tiers. This greater flexibility will likely translate into less generous benefits for the beneficiary.

* Network Adequacy: The responsibility for regulatory oversight of network adequacy would be further shifted to the states. Although that would reduce the regulatory burden for the insurers, it would also threaten the adequacy of provider networks in states that have relaxed standards of how many physicians and hospitals would have to be included in the networks. Patients may find access to be impaired.

* Qualified Health Plan (QHP) Certification Calendar: Insurers would be allowed more time to incorporate benefit changes and maximize the number of coverage options available to patients. Allowing insurers more time to manipulate the benefits would allow them to reduce services more likely needed by the beneficiaries while increasing coverage for those services less likely to be used.

* Open Enrollment Period: The open enrollment period will be terminated six weeks earlier. This will protect insurers from many individuals with greater health care needs who often enroll later in the open period. This reduces adverse selection for the insurers but at a cost of leaving uninsured more individuals who have greater needs.

It is not only CMS that is catering to the insurers. Right now Congressional staff members are negotiating with representatives of the insurance industry to help write the replace and repair provisions promised by the politicians. It appears that the legislative proposals will be designed to protect and enhance the market for insurers, though at a cost of reducing the adequacy of coverage for the patients.

Why are we taking such good care of the insurers? We don’t even need them. We need a program that takes good care of patients – all patients. That would be an improved Medicare that includes everyone.

As a Christian, I defended Obamacare. But I really support single-payer.

Jesus doesn’t just love the poor. He loves them more.

By Jessi Bohon
The Washington Post, Feb. 15, 2017

A video of me questioning Rep. Diane Black (R-Tenn.) about how her party will replace the Affordable Care Act went viral last Friday. I had gone to her town hall meeting on Thursday near my home to ask what the poor and sick would do once they’re left without the law’s protections. The next night, I had the really weird experience of seeing myself on national television, and the even weirder experience of hearing and reading other people’s interpretation of my own words. My town hall question has been described as a “Christian defense of Obamacare” and “an impassioned case for the ACA’s individual mandate.”

But the truth is that I do not actually believe that the ACA is the best way to insure people. In fact, I am ashamed and afraid that this video might have done more harm than good. In my view, Christians shouldn’t be satisfied with health-care policy that leaves anyone out, especially those who need care most but can afford it least. Christians should support a universal, single-payer system.

I know what it’s like to need a hand. I grew up on an Appalachian hillside in a run-down trailer home with my mom and my two siblings. My mom was orphaned at a very young age, and we had no other family to help us, so we relied almost exclusively on government assistance to survive. Our little church had a van that would pick us up on Sunday, but that’s about all the charity that it could afford. We collected aluminum cans to exchange, walked for hours to and from the grocery store and wrapped up household items in old coupon ads to give to each other as Christmas presents. At age 12, I helped my grandfather, who had suffered a stroke, to walk to and from the bathroom because he and my grandmother couldn’t afford home health care. We were industrious and thrifty like the majority of people receiving government assistance who are working to barely get by. Growing up, I was surrounded by Christians whose politics informed their faith, not the other way around — conservatives who expect poor churches and charities to look after their poor congregations while wealthy people live in luxury.

But my mom cared about politics, especially issues affecting the working class: She used to tell us that Jesus didn’t just love the poor — he loved them more. I’ve always carried that message with me, and I’ve paid attention to politics on and off over the years. I was unhappy with the Bush administration, but when Barack Obama won the election in 2008, I assumed things would look up, and I stopped paying attention. I worked hard, went to school and did my best to give back to my community as a high school teacher — something I felt I had to do as a Christian. But this election startled me out of my complacency. I followed the Democratic primary closely and cast my vote for Hillary Clinton in the general, but I was horrified by the outcome. I realized that if people of faith want a moral government, we can’t rely on people who call themselves Christians to build one for us. We’ll have to do it ourselves.

That’s why I went to speak to my representative directly. When I got up to speak to Black, I was nervous. My question came out a little jumbled, and I did end up making a faith-based argument for the individual mandate portion of the ACA. I was simply trying to point out the hypocrisy of Republican politicians who claim to be Christians and yet, time and time again, advocate for policies that hurt people.

This wouldn’t be the first time Republicans, who so often campaign under the banner of Christianity, have hurt needy people. Republicans’ refusal to expand the Medicaid component of the ACA in various states solely in the name of politics punished some of our nation’s poorest and likely led to thousands of untimely deaths. This indefensible decision to withhold insurance to millions of people also likely led to an increase in premiums for many people who were insured not only through the public exchanges but also privately.

These were grave injustices, and rolling back the ACA will be another. But refusing to expand Medicaid and threatening to place vulnerable people into high-risk insurance pools are wrong in my view because Christianity calls on us to look after the weakest and neediest people, including the poor and sick. If I had a chance to address our leaders directly again, I would say this: Christianity demands that we make sure all people have health coverage. In other words, I would have focused instead on the Christian case for universal, single-payer health insurance, which would protect all Americans. And if Republicans want to campaign as Christians, they should lead the way.

In my view, it is immoral for health care to be a for-profit enterprise. Insurance companies are making enormous sums of money off the sick while people are struggling to pay their medical bills. Patients even die sooner when nonprofit hospitals switch to making money.

Switching to single-payer wouldn’t necessarily be easy: Perhaps the hardest part of the reorganization of our health-care system to single-payer would be asking physicians to make much less money than they do now.1 But the directive in Luke 12:48 states that “everyone to whom much was given, of him much will be required, and from him to whom they entrusted much, they will demand the more.” America is one of the richest countries in the world. We have been given more than enough, and we need to share it with our most vulnerable. With what is left of the minute of fame that I have been given, I feel compelled to ask for forgiveness for not using my belief system to advocate more clearly for what I think is the best thing to do.

Jessi Bohon is a French teacher who lives in Cookeville, Tennessee.

https://www.washingtonpost.com…

1. PNHP Note: On the basis of the Canadian experience under national health insurance, we expect that average physician incomes should change little. However, the income disparity between specialties is likely to shrink. For more information, click here.

Senators Sanders, Cruz show fundamental differences on health care

By Jonathan Mizrahi, M.D.
St. Louis Post-Dispatch, Feb. 15, 2017

I hope many people were able to watch the debate that CNN hosted last week between U.S. Sens. Bernie Sanders and Ted Cruz. They spent over an hour fielding questions from spectators and moderators about the present and future of health care in the United States. Sen. Cruz provided a couple misleading answers and suggestions that I believe are worth clarifying.

First, he stated that his primary goal in repealing the Affordable Care Act was to remove government from the equation so that health care would be back in the hands of patients and their physicians. As appealing as he makes it sound, removing government-funded insurance would hardly make a dent in the amount of autonomy patients and their physicians have over their health care.

This is the case because nearly two-thirds of Americans have private insurance. The ever-present middlemen, these insurance companies very much dictate what medications you will have covered, which physicians and specialists you will be able to see and which exams and lab tests will be paid for. Removing government from the equation will not change this.

Second, Sen. Cruz used impressive-sounding statistics to make the case that the health care system in the U.S. is the best in the world. He quoted the higher number of mammograms and MRI scans that are performed in the U.S. compared to other developed countries.

While larger numbers surely do sound exciting, the number of MRIs physicians order for their patients in the U.S. is far too high. These are not true markers of health care performance, and instead are emblematic of the waste in our system. Do not get me wrong, MRIs are an invaluable tool in the arsenal of a physician, but they are too often ordered because our system of payment does not yet place a premium on cost-effectiveness.

This has caused the U.S. to spend more money per capita on health care than any other country in the world, while being ranked 11th out of 11 in overall health care among countries studied by the nonpartisan Commonwealth Fund, largely due to our poor rankings in access, equity and efficiency.

It is important to note that the U.S. indeed delivers effective and innovative health care. However, too often, only the wealthiest citizens with the most expensive insurance are able to benefit from it. There are still about 28 million uninsured Americans who are unable to access the best tests and treatments that physicians have to offer.

The Affordable Care Act has brought the number of uninsured down by 20 million, a significant number to be sure, but one that still has room for improvement. This is why building on the present law is needed, but calls to completely repeal it represent a callous and dangerous approach to those who have benefited most.

I point these two above examples out from the CNN special, but there were many other important takeaways from listening to these two senators debate. There is a fundamental difference in the approaches of Sens. Sanders and Cruz to U.S. health care. Sen. Sanders emphatically views the delivery of health care as an American right, while Sen. Cruz stated he views access to health care (i.e. through less expensive options by way of increased competition) as an American right. This distinction is not trivial.

A particular organization with a sensible solution that I would like to highlight is Physicians for a National Health Program. With chapters across the country, including one here in Missouri, PNHP is a group of physicians that advocate for consideration of moving toward a single-payer system, similar to Medicare-for-all. Benefits of such a system include removing private insurers from the marketplace, helping to drive down costs, and allowing the national insurance program to negotiate drug prices with pharmaceutical companies, helping to curb the often-astronomical prices that patients must pay for brand-name therapies. This proposal is similar to the system that Canada has in place, and is essentially the same as what Sen. Sanders has been advocating for throughout his career. Reasonable people can disagree about the advantages and disadvantages of such a system, which takes me back to the debate.

While Sen. Sanders’ argument for universal health care will guarantee that no American is uninsured, Sen. Cruz’s plan will leave the number of Americans uninsured up to the marketplace. Whether the latter seems desirable or fair in the richest nation in the history of the world is the question we must ask ourselves.

http://www.stltoday.com…

We still know little about accountable care

Moving Forward With Accountable Care Organizations

By Carrie H. Colla, PhD; Elliott S. Fisher, MD, MPH
JAMA Internal Medicine, February 13, 2017

During the past 4 years, we have made great strides in advancing our understanding of the changes that hospitals and physician groups implement in response to changes in payment and how providers perform under alternative payment models. Accountable care organization contracts, one type of alternative payment model, hold groups of health care professionals responsible for the cost and quality of care delivered to patients. Accountable care organization programs attract a diverse array of providers with differing legal and governance structures, varied contracts, and mixed capabilities that span service dimensions. These capabilities may include care management personnel and programs, adoption of advanced analytics (eg, to estimate the risk of hospitalization), or support for shared decision making. On average, ACO patients are spending modestly less on health care services and are associated with improved patient satisfaction and other patient-reported measures, with gains often concentrated in high-need, high-cost populations. Previous exposure to risk-bearing contracts, greater numbers of dually eligible or disabled patients, and higher initial financial benchmarks have been associated with greater savings. At the same time, these results mask variation in performance, with some ACOs saving while others spend over their benchmark following ACO formation. In addition, these modest savings have come at a net cost to the Medicare program (both program costs and shared savings rewards) and, although some quality measures have improved, many have not.

The research presented in this issue of JAMA Internal Medicine provides insights from 3 different ACO payment models: the Medicare Shared Savings Program (MSSP), Colorado’s Accountable Care Collaborative, and Oregon’s Coordinated Care Organizations. All 3 programs show some degree of success, although the results continue to be modest in magnitude.

These findings are relevant to 3 major considerations facing policymakers: (1) concerns about the harms of consolidation, (2) the amount of risk bearing needed to produce changes in behavior, and (3) how to manage potential conflicts between alternative payment models.

Consolidation between clinical providers, such as purchase of physician groups by hospital systems, and striking the proper balance between facilitating clinical integration and limiting market power is a major concern. Many believe that continued survival of independent practices is critical, yet economic incentives favor consolidation due to higher reimbursement for the same service in a hospital-based office compared with a physician office. Hospital-physician group consolidation can also raise prices in less-competitive commercial markets through increased bargaining power vis-à-vis insurers.

Accountable care organizations are defined by their accountability for the cost and quality of care, but the degree of accountability for spending varies dramatically across contracts. The amount of financial risk bearing necessary to achieve behavior change is an important area of inquiry, in part because so little is known. The incentives in most existing alternative payment models, including ACOs, are commonly considered insufficient to result in behavior change.

A third issue concerns potential conflicts between Medicare alternative payment models and the poorly understood interplay of incentives across these reforms. Currently, hospitals retain savings within inpatient-initiated bundles for patients attributed to an MSSP ACO. Although incentivizing value within a bundle, bundled payment models do not eliminate the incentive to provide more bundles. As the Centers for Medicare & Medicaid Services expands alternative payment models, it is possible that bundled payment programs will undermine overall savings.

In summary, we still have much to learn. Accountable care organizations have been established across diverse market settings, using a multitude of organizational structures and approaches to governance and operations, and this heterogeneity is reflected in the heterogeneity of their performance. The 2 articles published in this issue add to a growing body of evidence on overall performance, several dimensions of quality, and spending. Nevertheless, we know little about the effects of ACOs on patients’ health and quality of life. Perhaps most important for ACO leaders and the long-term success of these programs, we know little about the key ACO capabilities that are important to ensuring their success in different organizational or market contexts. Although the Centers for Medicare & Medicaid Services has conducted rigorous evaluations of the Pioneer program, generalizable findings tailored to organizational contexts are few. A long-term commitment to alternative payment model evaluation is necessary to ensure effective, sustainable payment and delivery system reform.

http://jamanetwork.com…

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Comment:

By Don McCanne, M.D.

This lesson on accountable care, from the Dartmouth Institute, shows us that we still have much to learn. The respected authors state that a long-term commitment to alternative payment model evaluation is necessary. In the meantime, “we know little about the key ACO capabilities that are important to ensuring their success in different organizational or market contexts.”

We actually do have quite a bit of information, and it is unimpressive. What we cannot do is to allow a protracted course of many years or decades of studying accountable care to distract us from the urgent need to make changes that will ensure that everyone has affordable access to health care while dramatically reducing the profound administrative waste in our system.

The Affordable Care Act made some improvements, but not nearly enough as witnessed by the tens of millions uninsured and underinsured, by the failure to make health care affordable for too many of us, and by the perpetuation of the costly administrative excesses.

The next phase of reform being undertaken by our current Congress seems to be pending enactment of policies that would make markets work better for insurers but at a cost of leaving patients exposed to excessive out-of-pocket spending. They do not seem to be even pretending that accountability in shifting from volume to value is anything more than rhetoric (and the studies to date suggest this is true).

First things first. Let’s do what really works – enact a single payer national health program, an improved Medicare for all. It is a far better infrastructure to tease out data that might be used to actually improve quality while containing costs. But let’s not stall any longer on enacting the fundamental reform that we really need to make health care affordable for all of us.

A Political Opening for Universal Health Care?

The winner in the fight between keeping Obamacare and rolling it back might be something else entirely

By Vann R. Newkirk II
The Atlantic, Feb. 14, 2017

The Senate confirmed Tom Price as secretary of health and human services at 2 a.m. on Friday. After a contentious confirmation process, the Trump administration and the Republican-controlled Congress had finally installed one of the leading generals in its war on Obamacare in the department that oversees its programs. Price is a titan in the GOP camp that wants to repeal the health law, and is perhaps one of the few Republican lawmakers with both the vision and the experience needed to begin the daunting task.  

But the battlefield under Price’s feet has shifted substantially in the past few weeks. Republicans have splintered, the timeline for repeal has dragged on and on, alternative plans have propagated in the fertile soil of disunion, and some have lost their resolve. And in the turmoil over the fate of Obamacare, the idea of universal health care has emerged as a third way among voters in both parties. The health system the mainstream GOP opposes most is now one some of its voters support—potentially making Price’s task of replacing Obamacare all the more complicated.   

The political appeal of a single-payer, universal health-care system is perhaps best outlined by Jessi Bohon, a high-school teacher who attended a raucous and often angry town hall with Republican Representative Diane Black in Murfreesboro, Tennessee, last week:

Bohon was able to ask Black a question, and she began with a defense of Obamacare. “As a Christian, my whole philosophy in life is pull up the unfortunate,” she said, referencing the law’s individual mandate and how requiring healthy Americans to purchase insurance lowers costs for the sick. But Bohon went a step further in her support of expanding coverage and her criticisms of the private insurers who’ve complicated the law: “Why don’t we expand Medicaid, and have everybody have insurance?” she asked.

It’s possible that Bohon’s question was simply an attempt to ask Black to implement policies that already exist in the Affordable Care Act. States have the option to expand Medicaid to more low-income adults under Obamacare, though Tennessee, among others, has chosen not to accept federal funds to do it. But her query and criticisms of market-based plans raise a broader question: Why rely on private insurers at all?

Senator Bernie Sanders had also made the case for government-run health care in a CNN debate on Obamacare just the night before. Although he was ostensibly brought on to defend the law against interlocutor Senator Ted Cruz’s criticisms, Sanders used his platform to argue for Medicare for all. His strategy was not to forcefully defend the law against critiques from Cruz, CNN, and the audience; rather, he often agreed with Cruz that those critiques were valid. But his solution undercut Cruz’s message of limited government. Why continue a system that relies on premiums at all, Sanders asked—and why continue to enrich insurers that simply cannot be relied upon to act in patients’ best interests?

Although Bohon—a self-identified Hillary Clinton voter—and Sanders certainly represent liberal sensibilities, several polls show that universal coverage is gaining traction among Democratic and Republican voters. A January Pew Research Center survey showed that 60 percent of Americans believe that government “should be responsible for ensuring health-care coverage for all Americans”—the highest mark in nearly a decade—though they are divided on whether government should be the sole provider of insurance. The recent increases nationally in support for universal coverage are mostly attributable to low-income Republicans. Over half of all Republicans surveyed who have family incomes of less than $30,000 agreed with the idea. Twenty-eight percent of all people polled in a recent Gallup survey expressed support for a single-payer system run by the government.

To be sure, the conclusions that can be gleaned from the polling here are a bit murky. Last year, my colleague Olga Khazan explored how support for a single-payer, Medicare-like plan decreases dramatically when such a plan would necessitate tax increases, which it almost certainly would. Also, a Kaiser Family Foundation survey from February 2016 showed that the label matters as well. Over 70 percent of Americans support Sanders’s “Medicare for all” plan. But they weren’t as enthusiastic about “universal health care” or “single-payer” health care. Although there are some real potential differences in these concepts that voters might be responding to—the term “universal health care” doesn’t specify financing or delivery, and “single-payer” doesn’t specify how the scheme is actually administered—the KFF poll potentially illustrates that there are barriers to understanding whether the public actually wants and understands a universal health-care system.

Still, the upswing in support for the government provision of health care among low-income Republicans provides a real opportunity for politicians in both parties. Trump himself once promised to implement “insurance for everybody.” Though it’s easy to view that one-time vow as fluff or a misunderstanding of his own party line, it could be a lifeline for Republicans facing revolts back home in poor districts where constituents are fearful of losing their insurance coverage. An Obamacare replacement with an expanded public-insurance system would follow through on promises to repeal the ACA. And it could also replace an unstable and weakening exchange system—dominated by reviled insurance companies—with Medicare or state-branded Medicaid programs like Kentucky’s Kynect, which tend to be widely trusted.

That route might be too far-fetched or expensive for Republicans to pursue en masse. Although their current repeal plan might bend Republican rules on passing legislation that increases the deficit, demolishing or controlling health-care markets and extending tax-funded insurance would be outright heresy against the party line. The resistance to such an idea in the health-care industry, and among its lobbyists, might threaten Republicans in Congress who rebel, thereby reinforcing the market-based status quo.

But it’s not too far-fetched for Democrats, who could, by embracing universal coverage, force Republicans to at least consider altering the party line. Democrats don’t face the same political risks with health care as Republicans do, not only because universal health care exists within liberal theory of government, but because a Republican-dominated Congress effectively renders many of their platforms, votes, and draft bills symbolic. The same dynamic in reverse created the anti-Obamacare fervor among congressional Republicans in the first place, and has been one of the largest factors in the GOP’s electoral strength since 2010.

Were they to take the plunge, Democratic candidates could run as challengers in upcoming elections on a third way of health reform: neither extending unpopular pieces of a program nor rolling back coverage, but giving everyone Medicare. And if the Democratic Party were to support universal health care, that might put pressure on Republicans, who wouldn’t want to lose voters who fear loss of coverage or doctors under a massive repeal.

Thus the precariousness of the Republicans’ position. With Price atop the national public-health system and already empowered by an executive order from the White House, Republicans in the executive branch and Congress have run out of excuses to do the job they came to do. But they face an ever-mobilizing opposition that extends across both parties, and immediate decisive action carries significant risks of causing a conflagration if people lose coverage. Paradoxically, delays give more time for the party to splinter and lose momentum, and for the idea of universal care to take root as a viable alternative as the stresses of an unfixed existing system mount. For at least some Republicans, that option might now be the most attractive now.

https://www.theatlantic.com…

Republicans are now supporting the private insurers in the exchanges

Republicans, Aiming to Kill Health Law, Also Work to Shore It Up

By Robert Pear
The New York Times, February 12, 2017

After denouncing the Affordable Care Act as an abomination for seven years, Republicans in Congress, working with the Trump administration, are urgently seeking ways to shore up health insurance marketplaces created by the law.

While President Trump said as a candidate that “Obamacare is certain to collapse of its own weight,” Republicans fear such an outcome because, now that the fate of the health law is in their hands, they could be blamed by consumers and Democrats.

The administration is poised to issue a proposed regulation to try to stabilize insurance markets, and House Republicans are drafting legislation with a similar purpose. The regulation and the bills are intended to hold down insurance premiums and to lure insurers back into the public marketplaces from which they have withdrawn in the past couple of years.

https://www.nytimes.com…

***

Comment:

By Don McCanne, M.D.

There could not be better evidence that the Republicans never did have an effective plan to replace the Affordable Care Act than the fact that they are now advancing legislation to protect the private insurers in the ACA exchanges – reinforcing them rather than shutting them down.

So their strategy has changed from repeal and replace, and then to repeal and repair, and now simply to repair – repair that will protect the private insurers.

Many of the legislators are facing angry citizens at their town hall meetings who do not want to lose the health care benefits that they may have gained through ACA. That partially explains why they failed to deliver on their promise to “repeal Obamacare on day one.”

Many voters were supportive of repeal and replace, but the politicians and the voters had different objectives. The Republican politicians wanted to repeal the expansions of ACA and thereby reduce government spending on health care. Voters wanted changes (replacement) that would ensure that they could always receive health care that was affordable.

Considering this, it is understandable why the Republicans have not moved immediately forward with their replacement proposals. Reducing Medicaid funding through block grants would cause millions to lose their coverage. Switching Medicare to a voucher program would create greater financial burdens for Medicare beneficiaries. Changing market rules to promote bare-bones private plans is the Republican version of providing “access,” but that would make actual health care truly unaffordable for a majority of Americans with significant medical needs because the very high out-of-pocket expenses would be beyond the capabilities of most American family budgets.

The simmering anger is because ACA was inadequate for too many Americans, and it appears that the Republican “replace” proposals will leave millions worse off. The “replace” that people want is affordable health care, but not merely a continuation of the inadequate policies of the Affordable Care Act. What they really want, though some do not realize it, is an equitably funded, universal health insurance program – an improved Medicare for all. That would give all of us affordable access to health care, and not just access to nearly worthless private health plans.

Progressives will never give up dream of a healthcare system that is fair

By Linda DeFeo, M.D.
Cape Gazette (Lewes, Del.), Feb. 13, 2017

Mark Twain is quoted as saying “there are lies, damned lies and statistics,” although these days we could say there are facts and alternative facts.

As a retired emergency physician who worked in underserved city hospitals, I can say one of the points Mr. Beveridge makes is correct. When patients come to the ER we must by law see them without asking how they will pay. We do bill them later and, as he stated, we frequently do not get paid; how can someone pay a huge bill when they couldn’t afford health insurance to begin with? Having spent the last 20 years of my career in Maryland, I was sad that their all-payer system was not talked about more during the primaries (go to https://innovation.cms.gov/initiatives/Maryland-All-Payer-Model/ for more information).

He speaks of Sen. Sanders, and others’ idea of expanding to a Medicare for all system, slaps the dreaded socialized medicine label on it, and warns of the cost. Currently FICA withholding is 12.4 percent total split between employer/employee for Social Security and 2.9 percent total for Medicare. He then calculates that expanding Medicare would increase that deduction to 30 percent. I don’t know how he came up with that figure, or if it is correct, but let’s look at some of the factors he has not addressed.

The United States spends $9,403 per capita for healthcare compared to $5,292 for Canada and $817 for Cuba (http://data.worldbank.org/indicator). Are we getting our money’s worth? While we’re at it, can anyone explain how you take seniors, who we all agree are high resource consumers, from the Medicare system with a 4 percent overhead and put them into for-profit private insurance with a 12 percent overhead and save money? (Check out https://oig.hhs.gov/reports-and-publications/hcfac/index.asp for information about Medicare fraud.)

But I digress.

He suggests that while healthcare services would be available to all, you might have to wait a little longer for certain kinds of specialists. Where is his evidence that this leads to poorer outcomes? Comparing infant and child mortality rates and life expectancy statistics (2014 data from WHO) you find that the first two measures are actually lower in both Cuba and Canada than the United States, and that longevity is very similar, with them living just a bit longer than us.

His next point is that doctors will be employees of the government. That may be true in Cuba, but not Canada. Go to the Library of Congress website (if it hasn’t been taken down this week) (http://www.loc.gov/law/help/medical-malpractice-liability/canada.php) for an overview of the Canadian system.

He also suggests that doctors will not go to medical school if they will only earn as much as a mechanic. I don’t know about him, but I value my mechanics very much and hope they are well paid, however, most of us don’t go to medical school to become wealthy. If, as in Canada and Cuba, the cost of schooling combined with a less litigious society were in place here, it wouldn’t cost as much for us to train or pay malpractice insurance (a whole separate article can be written about defensive medicine) so we wouldn’t need to make as much money.

His last comments seem to suggest that if we get rid of Obamacare we will somehow fix long ER waits. I have no idea how he thinks that will happen. Repealing the ACA will increase the number of uninsured patients who then have no option except the emergency room. Every time I hear someone say “the American people know how to spend their healthcare dollars” I cringe. How can they possibly know how to navigate a system so complex? When your child or loved one is ill, do you ask who can help me for the lowest cost, or who is the best choice to help me, damn the cost?

Mr. Beveridge, you are correct. We progressives will never give up our dream of a healthcare system that is fair, efficient and available to all Americans.

Dr. Linda DeFeo resides in Lewes.

http://www.capegazette.com…

Tom Price as HHS Secretary: A Disaster for U.S. Health Care

By Dr. Carol Paris
Common Dreams, Feb. 11, 2017

The Senate’s vote to confirm Rep. Tom Price, R-Ga., as secretary of health and human services, while widely expected, should set off national alarm bells.

Price’s congressional track record, combined with his extensive health-policy paper trail, have shown him to be unabashedly pro-big-business and contemptuous of human needs – particularly when it comes to women’s and poor people’s needs. But the damage he will be able to do as HHS secretary will go far beyond that.

His appointment to the helm of HHS means he is now poised to wreak havoc on our already dysfunctional health care system, jeopardizing the lives of additional millions of Americans who desperately require medical care but can’t afford to get it.

Consider Price’s hostility to traditional Medicare, one of our nation’s most beloved social insurance programs. Together with Speaker Paul Ryan, R-Wis., Price has pushed for “premium support,” i.e. vouchers, whereby seniors would exchange their guaranteed health coverage under traditional Medicare (which they’ve paid into throughout their working lives) for a lump sum of money to go out shopping for a health policy on the private insurance market.

Can you imagine the chaos such vouchers would create among millions of seniors and their families? How much more precarious their health care – even their survival – would become?

“Premium support” is an underhanded prescription for the dismantlement – the destruction – of traditional Medicare. It would be the beginning of the end. The implementation of such a scheme would sharply increase out-of-pocket costs of our nation’s seniors and severely disabled, some of the most vulnerable parts of our population, even as it would bolster the profits (and CEO salaries) at the private health insurance, Big Pharma, and financial services industries.

Or take Price’s views on Medicaid. Much like President Trump’s nominee to head the Centers for Medicare and Medicaid Services, Seem Verma, has done, Price would embrace the conversion of today’s Medicaid program into federal block grants to the states. These block grants would give state governments wide latitude on how to use the money, opening the door to greater patient cost sharing among the poor (introducing copays, deductibles, or work requirements), even as it would enhance the already egregious profiteering by parasitic private Medicaid managed care companies.

Family planning? Price has displayed unconcealed hostility to women’s reproductive health, and his new position will allow him to literally place the health of millions of women at risk. His extreme views include opposition to abortion under almost all circumstances, a preference for “religious freedom” over access to contraception, and an obsession with eliminating federal funding for Planned Parenthood.

According to this week’s Monmouth University poll, Americans’ top worry today is with their mounting health care costs, more so than their job security, taxes or other household bills. With Price at the helm of HHS, this worry will mushroom.

I could go on – his unbridled animus toward LGBTQ rights, his fascination with discredited policies such as high-deductible health plans and allowing private insurers to sell policies across state lines, the threat he poses to our safety-net hospitals, etc. – but you get the picture.

Make no mistake: if Price’s policies are carried out, he will make an already bad system much worse. Research shows that repealing the Affordable Care Act, a cause for which Price has been a primary standard-bearer in the House, would likely result in 43,000 excess, preventable deaths.

In short, Price’s confirmation vote on Friday was a body blow to our nation’s health and welfare.

This is precisely the wrong direction we should be taking in health care. Rather than augmenting the power and profits of the medical-industrial complex (which, by the way, Price has a distinct affinity for), and cutting back on our people’s access to health care, we should be expanding high-quality care to one and all.

What we need to do – now more than ever – is to replace our fragmented dysfunctional system of health care with a streamlined, single-payer, Medicare-for-All system. The savings we’d reap from eliminating the wasteful bureaucracy and paperwork generated by our current multi-payer system – savings now estimated to be $500 billion annually – would be sufficient to cover everyone in the United States and to eliminate all copays and deductibles.

There were those in the 2009 health care debate who said, “Support the Affordable Care Act; it’s the only politically feasible plan; we’ll get to Medicare for All later.” But Congress passed the ACA, and six years later we’re still saddled with the most serious structural deficiencies of a private-health-insurance-based system, including 28 million uninsured. The ACA didn’t get us where we need to be.

Today, there are those who would say that all we should ask for is to retain the ACA. I’m sorry. As a physician, 28 million uninsured is unacceptable. Now is the time to go beyond the ACA, and to replace it with H.R. 676, the Expanded and Improved Medicare for All Act.

Unrealistic, you say? It’s remarkable what millions of people in motion – which is what it will take – can do. What’s truly unrealistic is thinking we can have truly universal care and control costs without a single-payer system.

We can’t afford to delay any longer. Too much is at stake. We have no time to lose.

Dr. Carol Paris is a psychiatrist and president of Physicians for a National Health Program. She was one of the “Baucus 8″ arrested with Dr. Margaret Flowers and others for protesting the absence of representation for single payer universal health care on the Baucus Senate Panel hearings.

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

http://www.commondreams.org…