How California can survive Trumpcare

By Gerald F. Kominski
Los Angeles Times, November 18, 2016

No one knows exactly what Donald Trump’s pledge to “repeal and replace” the Affordable Care Act means. The hints, however, are troubling. No state has embraced the ACA — Obamacare — more enthusiastically and successfully than California. And no state has more to lose with Trumpcare.

The question is, what comes next? The Trump campaign was short on details. Suggestions included promoting health savings accounts linked to high-deductible health plans; allowing insurance to be sold across state lines in an effort to increase competition and thus affordability; and allowing everyone to deduct health insurance premiums from their taxes.

In one “replace” scenario — contained in Ryan’s 2016 “A Better Way” proposal — those tax credits would continue but would no longer be scaled to income as they are under Obamacare.

As for Medi-Cal, Trumpcare would fundamentally transform the program. Under Trumpcare, each state will instead receive a block grant program that fixes its allocation at a to-be-determined point in time. Because healthcare spending has always grown faster than inflation, the real value of Trumpcare block grants is guaranteed to shrink over time.

For Medi-Cal, the options are some combination of cutting eligibility, cutting benefits and raising taxes. Paying providers less won’t be viable because California already has some of the lowest rates in the country for its Medicaid program.

For Covered California, higher taxes will be required if the state wants to keep the program going with health plans and policies that meet Obamacare standards. Californians would have to agree to make up whatever the shortfall is between Trumpcare’s tax credits and Obamacare credits. The only other option is reduced benefits.

A brand new state “single payer” plan is another possibility, but it would face its own challenges, particularly under a Republican administration in Washington hostile to innovations that aren’t based on the mythical “free” market for health. The economics and administration of single payer work best if all government health insurance programs — including Medicare, the Veterans Administration system and the military’s Tricare program, as well as the state’s CalPERS program for public employees — are folded into one plan. The Trump administration is not going to easily grant permission for California to exit the federal programs taking its share of the taxes that support them.

California’s experience with Obamacare has been extremely positive, and there are already indications that state politicians will try to keep it alive regardless of what Washington does. As the details of Trumpcare come into focus, so will the state’s best strategies to close the expected funding gaps. All options need to be considered, and no option should be ruled out quickly because it appears too difficult or politically impossible. Californians dream big, and that’s what will be required to keep healthcare accessible in the Golden State.

Gerald F. Kominski is director of the UCLA Center for Health Policy Research.

http://www.latimes.com/opinion/op-ed/la-oe-kominski-how-california-can-survive-trumpcare-20161117-story.html

****

Comment:

By Don McCanne, M.D.

Quoting Professor Gerald Kominski:

“No option should be ruled out quickly because it appears too difficult or politically impossible.”

“The economics and administration of single payer work best if all government health insurance programs — including Medicare, the Veterans Administration system and the military’s Tricare program, as well as the state’s CalPERS program for public employees — are folded into one plan.”

We need to consider the possibility of “a ‘brand new’ state single payer plan.”

Obviously a national single payer program is what we really need, but that would require a total turnabout by Sen. McConnell and Speaker Ryan – a political shift that would be about as likely as electing Donald Trump president. But think about that for a minute. Think about what that means when someone says that it’s not politically feasible.

At any rate, California politicians have an excellent track record of supporting optimal policies. Just because they have been very successful in implementing the Affordable Care Act doesn’t mean that they should rest on their laurels and simply accept the intolerable deficiencies that remain.

It’s time for California to initiate another effort to move forward with enactment of whatever single payer policies are possible within federal restrictions that Congress refuses to waive – as an interim measure until we have an enlightened Congress and administration that will bring us a single payer national health program – an improved Medicare for all.

Unfinished Business: More than 20 Million Children in U.S. Still Lack Sufficient Access to Essential Health Care

Children’s Health Fund, November 2016

Children’s Health Fund (CHF) estimates that, at minimum, 20.3 million children in the United States (28% of all children) face barriers to accessing essential health care. This estimate covers children who are a) uninsured; b) children who don’t receive routine primary care; and c) publicly insured children who are connected to primary care but have unmet needs for pediatric subspecialty care when needed, such as pediatric cardiology or pediatric endocrinology.

Based on the collective reach and impact of Medicaid, CHIP, and ACA, the child uninsurance rate fell from 13.9 percent in 1997 (9.6 million) to 4.5 percent (3.3 million) in 2015—a drop of more than 67%. But there is still much to be done. We need to find ways to cover that remaining 4.5 percent—some 3.3 million children, many of whom are from the most marginalized communities and regions in the United States. And while important, uninsurance figures often promote the false dichotomy of “insured” versus “uninsured” children, ignoring the millions of children who are counted as insured but go without coverage for some portion of the year. Such coverage gaps matter. Discontinuous health coverage can negatively impact timely receipt of preventative and other crucial health care services.

Beyond the issue of coverage is an equally important question: Do children who receive some form of coverage actually access the care that that coverage is supposed to provide? The answer is often no. Based on data and our analysis, Children’s Health Fund believes that there are two main categories of barriers to obtaining health care: Financial and Non-financial.

Financial barriers refer to the costs imposed by a coverage plan that prevents children from accessing the care they need. Such barriers refer to costs such as high copays, high deductibles, and unaffordable prescription drug prices. CHF calculates that there are over 13.1 million children whose families report either having problems paying medical bills or being unable to pay medical bills. Provider-based barriers also contribute to the financial burden when clinics or providers won’t accept certain forms of insurance or create environments that promote insurance stigma.

Non-financial barriers most often take the form of either geographic barriers or informational barriers. Geographic barriers include issues of transportation, such as a lack of a car or poor public transit options, and federal-designated Health Professional Shortage Areas (HPSAs) where the number of health professionals in a given geographical area is insufficient for that population’s healthcare needs. CHF estimates that over 14 million children live in HSPAs. Informational barriers include parents’ health illiteracy, dauntingly complex language used in information about coverage eligibility and accessing care, and parents’ limited English proficiency.

https://www.childrenshealthfund.org/wp-content/uploads/2016/11/Unfinished-Business-Final_.pdf

***

Comment:

By Don McCanne, M.D.

In designing the Affordable Care Act, special attention was given to be sure that children were well covered by our system of public and private programs. Yet over 20 million children still have access barriers to essential health care services.

Look at some of the reasons for this impaired access and then imagine how it would be under a single payer system:

*  3.3 million children have no insurance at all. Single payer would automatically include everyone.

*  Millions who are counted as insured have frequent gaps in coverage for a variety of reasons related to the fragmented nature of health care financing post-ACA. Single payer covers everyone for life, so there would be no gaps in coverage.

*  High patient cost sharing and high prices frequently impair access to care. Under single payer, all essential services would be paid for in full, so there would be no financial barriers.

*  Frequently certain insurance plans are not accepted by many health care providers. Under single payer, there is only one plan that would be accepted by all providers since there is no other option.

*  The stigma of welfare plans such as Medicaid can interfere with access, especially for subspecialty care. Under single payer there is no separate welfare program for low-income individuals or families. Single payer would cover everyone, eliminating the stigma of assigning the poor to welfare programs.

*  Over 14 million children live in federally designated Health Professional Shortage Areas, potentially impairing access. A single payer system plans and budgets capital improvements, providing improved distribution of our health care resources.

The attitude today seems to be that we have done a pretty good job of covering children, though maybe we need a few more tweaks that might slightly improve access, though it is not practical to fill in all of the voids. Nonsense. All we need is a well designed single payer system. It would dramatically improve access for these 20 million children (and everyone else) without increasing spending over our current levels.

Our Revolution: A Future To Believe In

By Bernie Sanders

It has never made sense to me that the quality of care a person receives – indeed, whether that person receives any care – should be dependent upon the job that he or she has or the wealth of their family. It has never made sense to me that Americans should be forced into bankruptcy because of a serious illness. It has never made sense to me that some people will live and some people will die because of their health insurance status.

Most important, it has never made sense to me that our health care system is primarily designed to make huge profits for multibillion-dollar insurance companies, drug companies, hospitals, and medical equipment suppliers. Health care is not a commodity. It is a human right. The goal of a sane health care system should be to keep people well, not to make stockholders rich.

The bottom line is that in the United States we spend an enormous amount of money for a health care system that performs poorly. It’s time for a change – a real change.

According to a recent report drafted by thirty-nine physicians from the Physicians for a National Health Program (PNHP) and endorsed by some 2,500 medical doctors, a movement to “a single payer system would trim administration, reduce incentives to over-treat, lower drug prices, minimize wasteful investments in redundant facilities, and eliminate almost all marketing and investor profits. These measures would yield the substantial savings needed to fund universal care and new investments in currently under-funded services and public health activities – without any net increase in national health spending.”

From the Conclusion

Humanity is at a crossroads. We can continue down the current path of greed,consumerism, oligarchy, poverty, war, racism, and environmental degradation. Or we can lead the world in moving in a very different direction.

Yes. We can overcome the insatiable greed that now exists and create an economy that ends poverty and provides a decent standard of living for all. Yes. We can create a vibrant democracy where knowledgeable citizens actively debate the great challenges they face. Yes. We can create a health care system that guarantees health care for every man, woman, and child, and that focuses on disease prevention and keeping us healthy, not outrageous profits for insurance companies and the pharmaceutical industry. Yes. We can effectively combat climate change and transform our energy system away from fossil fuel and into energy efficiency and sustainable energy.

No. We will not be able to accomplish those goals if we look at democracy as a spectator sport, assuming others will do it for us. They won’t. The future is in your hands. Let’s get to work.

http://us.macmillan.com/ourrevolution/berniesanders

***

Comment:

By Don McCanne, M.D.

May this book become the bible of “our revolution.”

In New Survey of 11 Countries, U.S. Adults Still Struggle with Access to and Affordability of Health Care

By Robin Osborn, David Squires, Michelle M. Doty, Dana O. Sarnak, Eric C. Schneider, M.D.
The Commonwealth Fund, November 16, 2016

The Issue

Asking people directly about their experiences with the health care system can reveal valuable information about how well a country is meeting the needs of its population. A new Commonwealth Fund study in Health Affairs examines patients’ experiences based on responses to a 2016 survey of adults in 11 countries: Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States.

The Big Picture

Although the U.S. has made significant progress in expanding insurance coverage under the Affordable Care Act, it remains an outlier among high-income countries in ensuring access to health care. The authors point out that all of the other countries surveyed provide universal insurance coverage, and many provide better cost protection and a more extensive safety net.

The Bottom Line

Despite progress since passage of the Affordable Care Act, adults in the United States remain more likely to go without needed health care because of costs compared to adults in other high-income countries.

http://www.commonwealthfund.org/publications/in-the-literature/2016/nov/2016-international-health-policy-survey-of-adults

***

Comment:

By Don McCanne, M.D.

The Affordable Care Act (ACA) is now essentially fully implemented. So how are we doing? According to a new Commonwealth Fund study, “adults in the United States remain more likely to go without needed health care because of costs compared to adults in other high-income countries.” Although ACA brought some improvements, they are grossly inadequate by international standards.

Congress is about to reopen the health care reform process. Mere tweaking cannot repair our highly dysfunctional health care financing infrastructure. We need to make sure that a model that does work – a single payer national health program – is front and center in their negotiations.

Health Reform in the Trump Era

A Big Step Back, But Possibilities for Bigger Steps Forward

By Steffie Woolhandler, M.D., M.P.H., and David U. Himmelstein, M.D.
Physicians for a National Health Program, November 16, 2016

The 2016 election turned on racism, xenophobia and anger at the status quo, including the Affordable Care Act (ACA). The law covered about 20 million, and modestly improved access to care. But it didn’t address the health care problems facing most working families, feeding the perception that the Democratic Party had neglected them. Trump seized on the ACA as a symbol of the establishment’s false promises, and has placed repeal at the top of his to do list.

There are many indicators of what Trump has in mind to replace the ACA, but they’re pointing in different directions. We suspect that the likeliest replacement 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.

For Republicans, the ACA poses a difficult dilemma. Its model was conceived by Richard Nixon’s henchmen in 1971, celebrated and elaborated by the Heritage Foundation in 1989, and first implemented by Mitt Romney in 2006. Obama’s version, like these earlier ones, called for sliding-scale public subsidies to help low-income individuals purchase private coverage through insurance exchanges, along with a mandate that individuals (and sometimes employers) buy coverage. For the poor, Obama (like Nixon) relied on expanding Medicaid, but almost all of the ACA’s new Medicaid coverage was channeled through private Medicaid-managed-care insurers. And Obama added progressive elements to the Republican formula, e.g. requiring insurers to cover essential benefits (notably contraception and preventive care) and a new “Medicare” tax on some investment income.

Will Republicans reclaim their health care heritage after years spent rabidly attacking its Obamacare variant? Paul Ryan’s recent pronouncements (and the abiding interests of powerful insurance, drug and hospital firms) suggest that they will. Ryan would rebrand the Obamacare premium “subsidies” as “tax credits,” but make them available to anyone who lacks employer-paid coverage, including the wealthy. In essence, he’d shift some of the subsidy money up the income scale and undermine employer-based coverage. He’d maintain (at least for the time being) Obamacare’s boost to Medicaid funding, but let states cut Medicaid coverage and divert the funds to other uses. And he’d hasten the privatization of Medicare, which has already been proceeding apace.

If there’s a brighter side to this dark picture, it’s that Trump and his allies will reclaim ownership of the Nixon/Heritage/Romney/ACA model. This shift seems likely to unmuzzle single-payer supporters who closeted themselves during the ACA era, fearful that calls for more radical reform would fan right-wing attacks. Already Elizabeth Warren, previously reluctant to criticize the ACA, has been liberated: “Let’s be honest: [The ACA’s] not bold. It’s not transformative. … I’m OK taking half a loaf if our message was ‘Here’s half, now let’s go get the rest.’”

A similar strategic perspective motivated PNHP’s founding at a conference of clinicians caring for the poor. After years spent parrying Reagan’s assaults on Medicaid and community clinics, we concluded that a defensive stance was untenable. The U.S. health care system, even with Medicaid intact, prioritized corporate greed over patients’ needs, and was politically indefensible. It wasn’t possible to fix health care for the poor without fixing it for everyone.

That conclusion holds today. For the working class, incomes have stagnated and out-of-pocket costs have soared. For whites without a college education, death rates are rising, driven by diseases of despair like suicide and substance use. Trump spoke (disingenuously) to that despair; Clinton failed to. The resonance of Bernie Sanders’ single-payer message is backed up by polls that show three-fifths of Americans – including a majority of those who want the ACA repealed, and 41 percent of Republicans – favor a “federally funded healthcare program providing insurance for all Americans.”

In health care, reform must address the pressing problems of the majority who have private coverage and Medicare, as well as those who are uninsured or on Medicaid. Only single payer can do that.

A few suggestions for work in the months ahead:

1. Colleagues are, more than ever, receptive to the single-payer message. Let’s talk about it in corridors, conferences, lecture halls and national meetings; use Facebook, Twitter, email and snail mail to recruit new PNHP members; and push journal editors to end their virtual blackout on single payer.

2. With Medicaid under attack, in many states we’ll need to join in its defense. But we must simultaneously declare that this halfway measure is no substitute for real reform. Let’s not repeat the error of ACA backers who tried to convince people that their health care problems had been solved. Similarly, defense of Medicare should not paper over that program’s flaws.

3. We need to help focus the anger at elites onto the real health care elites: insurance and drug firms, and corporate health care providers.

4. In the past PNHP has focused narrowly on single-payer reform, avoiding participation in most broad-based coalitions. We should reconsider that stance in the context of the broad opposition to the Trump regime, and the urgency of threats to our communities. Effective action will require coalitions that span many issues. We should participate in those that include a demand for single payer.

5. It’s time to ramp up organizing for H.R. 676. Politicians can no longer seek refuge in the fiction that health reform is a “done deal” and is working. While work for state-based reforms can provide a useful organizing tool, it cannot address the nation’s most acute health care problems, which are concentrated in states with little hope of local legislation.

https://www.pnhp.org/news/2016/november/health-reform-in-the-trump-era

***

Comment:

By Don McCanne, M.D.

Health care reform is once again on the national political agenda. It is time for action. The suggestions offered should provide guidance on how each of us can become personally involved.

We do not want a repeat of the process leading to the Affordable Care Act wherein the only ideas permitted were those supported by the medical-industrial complex – insurers and pharmaceutical firms being prime examples. We need to assume a leadership role, even if that means forcing our way into the process, figuratively.

The political insiders are moving into position with their highly flawed policy recommendations that will only make the situation worse. It will be easy to critique their proposals, but it will be crucial that we communicate loudly and clearly our very positive message of ensuring affordable and accessible care for all.

Those who can make it to the PNHP meeting in Washington, DC this weekend should try to do so. Although advance registration has closed, on site registration will be available. Use this link for more information:
https://www.pnhp.org/about/annual-meeting-leadership-training

Start this phase of your activism now.

US Election reaction

The Lancet, November 11, 2016

Dr. David U. Himmelstein, co-founder of Physicians for a National Health Program, was interviewed by Richard Lane, web editor at The Lancet.

Richard Lane, The Lancet: David, welcome. You’re a health policy expert. We want to talk a lot about health care. But first of all we’ve got to talk about the extraordinary night that was Tuesday evening. Can I get your reaction to the election? Did you have any sense that this might happen?

David Himmelstein, M.D.: Well, we were worried that it might happen after Brexit and other events elsewhere. And frankly Trump’s performance in the primaries gave some clue that the polls might be off. So I didn’t expect it, but I was worried that it might happen.

==

RL: One of the biggest problems with the implementation of the Affordable Care Act, as far as I could see as a non-American from outside, was the way it was implemented that led to some terribly bumpy things along the way, didn’t it? Just the launch of the insurance market was a disaster, with the internet systems not working. But more importantly, over and above that, and this was the political fuel that the Republicans were almost rubbing their hands with glee with at the rally in Philadelphia last week, were the rising prices of premiums, because the insurance companies couldn’t get enough people to enroll in the program. So even though the Affordable Care Act had very laudable aims to extend its reach, and it did to 20 million people, its implementation has been deeply flawed, hasn’t it?

DH: The program was deeply flawed from the outset. It was enormously complex, and really represented a compromise that was pushed by the insurance industry. Most of the additional coverage was purchased through private insurance plans and increased the revenues given to private insurers. The structure of the program, in order to try and make it work, was tremendously complex, and that’s what really created the disorder in its startup, because trying to enroll people in hundreds of different plans around the country, each with differing offers of coverage, and deductibles – the amount that one must pay before the insurance kicks in – varied from plan to plan, as did the level of co-payments (how much you pay in addition to the insurance at each visit).  Those things varied from plan to plan, so there was tremendous complexity really baked into the program. It’s quite striking in contrast to our Medicare program which is the single-payer program for the elderly. That federal government program, which started up some 10 months after its passage by the Congress back in the 1960s before we even had any computers, enrolled 99 percent of all eligible people within that 10-month window without any notable glitches or confusion. So it’s quite clear that the structure of Obamacare was deeply flawed from the outset. And, as you say, the prices of the insurance rose quite steeply because they relied largely on market forces. I think I’m not alone in saying that the market doesn’t actually work in health care and we know that the U.S., which has the most market-oriented of health care systems, has by far the highest cost of our health care system, and it is no surprise that costs rose partly because sicker people were the ones who took up the offer of the new coverage, and they’re the most expensive people.

Podcast, 14 minutes:
http://www.thelancet.com/audio/us-election-reaction

Full transcript:
https://www.pnhp.org/news/2016/november/the-lancet-interviews-dr-david-himmelstein-on-the-us-election-results

Comment:

By Don McCanne, M.D.

Much of the interview is cloaked in uncertainty since we do not know yet precisely what Donald Trump, working with Congress, will do. But the discussion to date raises great concerns.

You would think from the media reports that there are only two positions – some form of repeal and replacement of the Affordable Care Act (ACA), or preserve and protect ACA. But the excerpt selected makes a very important point. The inherent fundamental defects in our existing health care financing infrastructure were not amenable to the tweaks of ACA. Although beneficial, ACA could not repair the glaring defects in the system.

So the battle should not be over protecting the existing financing system but rather it should be over what the replacement will be – a market-based system that leaves health care unaffordable for tens of millions, or a public single payer program that takes care of everyone? We have to be sure that Washington understands that this is the debate we should be having.

A call to action

November 14, 2016

Dear colleague,

Last week, our country witnessed a historic protest against the status quo, a protest fueled by frustration and anger.

The divide between haves and have nots has been widening. Millions of Americans suffer needlessly in this land of plenty, where maldistribution, not scarcity, leaves many without adequate food, shelter, education, parks, and health care.

We all deserve to be healthy, happy and proud of our heritage, and should feel no need to prop ourselves up at the expense of others. Our country is unique and strong because it was founded on the principles of liberty and opportunity, a bounty that has been expanded through struggle to groups that were once excluded.

I write these words as a physician who bears daily witness to the everyday tragedies of ordinary people, people of every shade, language, culture and income. My patients vary greatly. Some grew up milking cows, harvesting our food or butchering animals, some dodging bullets. Others build roads, teach or care for our kids, or nurture our minds and souls with music or verse.

As a doctor, listener and healer, I write to you, my partners, fellow physicians, nurses, physical and mental health therapists, students, and everyone who shares our common experience of listening to and helping others. Perhaps our greatest asset as healers is our ability to be resourceful, innovative, and creative in helping our patients overcome the seemingly insurmountable. We are expert at making lemonade out of lemons.

Our work helping one person at a time will never end, and will likely be intensified in the months and years ahead. But our work does not end in the exam room.

It is important, in this time of chaos and uncertainty, that health care professionals organize ourselves to take collective action and speak with a coherent voice. More than ever, our patients, and our country need us as activists, as well as healers.

No organization is better positioned than Physicians for a National Health Program to provide the tools and safe spaces for us to make our voices heard. And there is no more urgent time than the present to build a broad coalition and a fearless movement to bring us closer to a fair, just, and equitable world.

Sincerely,

Robert Zarr, M.D., M.P.H.
President
pres.zarr@pnhp.org

P.S. I encourage you to read an interview that Dr. David Himmelstein gave to The Lancet  just two days after Tuesday’s election; I think you’ll find it of interest. Second, at PNHP’s Annual Meeting this Saturday in Washington we’ll hear analyses of the Republicans’ health policy agenda, and begin the process of plotting the future of the single-payer movement and how to protect our patients during the difficult times ahead. It’s not too late to register. Please join us if you can. (Pre-registration ends tonight, but we will take registrations at the door.)

Comment:

By Don McCanne, M.D.

There is hope for the future of our health care system, and we can be the source of that.