PNHP

Students make their voices heard with ink

Students make their voices heard with ink

Resolution writing to spur change

By Anna Zelivianskaia
Chicago Medicine, April 2016

In a world with rapid news cycles and constant updates, medical students have found a way to make lasting change. Through the Chicago Medical Society they are introducing and advocating for resolutions on issues that are important to them. James Curry, an MD/MPH candidate at the University of Illinois at Chicago, submitted four resolutions for CMS Council approval. All were adopted on February 9. When a resolution is adopted, it becomes part of the CMS policy and advocacy agenda. Depending on the goals of a resolution, its outcome may be a research initiative, lobbying agenda, support for legislation, or another mechanism.

Curry describes this process: “To begin the process, you should ask yourself three questions: ‘what problem exists, what are we already doing about it, and what can or should we do to address it?’ The first and most important step is having an issue you are passionate about. Without that, everything seems like work.” Next, he recommends learning what the current CMS policy is and finding relevant language: “This answers, ‘what are we already doing?’ My process has always been to write the best supported resolution for the problem, regardless of current policy. Then, go back and tailor the resolution around existing policy.”

This process may require you to add a completely new policy, amend, or strike existing policy. Each resolution calls for a general type of outcome and has a specific structure. “There are three outcomes a resolution can seek to accomplish: an action, a position statement, or both. An action is anything that will be done by the organization. A position statement helps solidify or establish policy on what the organization believes. There are two parts to a resolution: the preamble and the resolves. Preambles or Whereas clauses explain the need for the resolution, while the Resolved clauses state what the new policies should be or what actions the organization should take. Resolved statements become the adopted policy; they must be written to stand alone, as self-contained, self- explanatory statements. Each clause is short, clear, and to the point, with appropriate citations.

One of Curry’s resolutions called for support of a single-payer healthcare system in the United States. This issue has been debated vigorously, and he did not feel it was controversial: “I was unaware that a single-payer style resolution was needed at CMS because the majority of medical organizations (student or physician) support so many of its core principles already. We should strive for a clear understanding, endorsement and action to accomplish healthcare for all and health justice. Resolutions and policy are the best starting point to address and materialize single-payer – not just give the impression.”

He based his resolution on one already proposed by Dr. Peter Orris, but with some amendments. Curry was thrilled that “the resolve (action) that survived and was adopted commits CMS to study the “benefits and difficulties of instituting and maintaining a single-payer healthcare system, in Illinois, and in the United States. This study will consider economic costs along with outcomes and improvements in health and health disparities.” Thus, the outcome is a CMS research initiative.

The resolution was subsequently considered by the Illinois State Medical Society, which recently voted to study a single-payer healthcare system.

Resolutions like this provide an example of CMS representing the policy interests of Chicago-area health professionals. These are fluid as medicine and policy constantly change, but guiding change requires speaking up.

Many health professionals and members of the public still feel healthcare reform is needed. It is a fact that the U.S. spends more per capita on healthcare than other developed nations in spite of having some of the worst health outcomes. When asked why he believes single-payer is the best strategy to bring about positive change, Curry answers: “Whether it’s family, friends, or ourselves, we have all fallen victim to thinking our health insurance is good, until we need it most (all the while, suffocated by enormous costs). After succumbing to the traps of bills, denials, approvals, changing physicians and care each year, I see the exact same thing from the other side of the table as a medical student, looking up to residents and attending physicians.”

Many people doubt change will come if there is no catalyst – if no one stands up and asks for it. That is simply untrue because many forces make change inevitable and we, as students and physicians, must work with them to transform our healthcare system into one we will still want to work in 10 or 20 years from now. Curry aptly summarizes: “Classes of health insurance mean classes of health. How am I to determine who to treat based on anything other than need?” Writing CMS resolutions is a powerful way to get heard.

Anna Zelivianskaia is fourth-year medical student at the University of Illinois at Chicago. Anyone with comments about this article may reach her at azeliv2@uic.edu.

http://www.cmsdocs.org/news-publications/chicago-medicine-magazine/2016-issues/April2016.pdf

Doubling Down on Errors: Urban Institute Defends Its Ridiculously High Single Payer Cost Estimates

By Steffie Woolhandler and David Himmelstein
The Huffington Post, May 22, 2016

Last week we posted a critique of the Urban Institute’s (UI) absurdly biased report that claimed Sen. Bernie Sanders’ proposal for single-payer health reform would cause a massive increase in health spending. Now, the report’s authors have issued a 12-page rejoinder to our criticism. But that response is riddled with distortions, misinterpretations and glaring factual errors. Moreover, they now make it clear that they didn’t even try to estimate the costs of Sanders’ (or our) single-payer proposals. Instead, they made up their own reform proposal and costed that out.

Our critique identified three main problems with the UI’s projection that implementing single payer would boost total health spending by $519 billion in 2017. First, UI ignored about 75 percent of the administrative savings that single-payer reform would achieve. Second, it substantially underestimated single payer’s savings on prescription drugs. And finally, it posited an absurdly large increase in the utilization of health care under single payer, far more than could possibly be provided by the current supply of doctors and hospitals.

Below, we briefly discuss the UI’s response to those criticisms, and the facts of the matter.

1. Administrative savings, Part 1: The original UI report projected that single payer could cut insurance overhead from the current 9.5 percent of health spending ($341 billion) to 6 percent ($215 billion). As they now admit, they were modeling a compromised single-payer system, in which private managed care insurers like UnitedHealthcare would continue to play a major role, as they do in the Medicare Advantage program. (Neither we nor Sanders have suggested such a continued role for private insurers.) We pointed out that Canada’s single-payer system runs for 1.8 percent overhead (a figure they impugn, but which is taken directly from Canada’s official health statistics), and is similar to the overhead in the traditional Medicare program. Reducing our insurance overhead to the Canadian level would mean cutting it to “only” $65 billion. There’s no reason to believe we can’t be as efficient as Canada if we, like Canada, proscribe participation by private insurers.

The UI rejoinder argues that “it would be inadvisable to cut administrative costs so much that important functions could not be carried out effectively under a new system. Such functions include rate setting for many different providers of different types facing different costs across the country; quality control over care provision; development, review, and revision of regulations; oversight for fraudulent activity; provider oversight and enforcement of standards; bill payment to providers; consumer services; and more.” Of course traditional Medicare (and Canada) are already doing all of those things, and the UI response gives no reason why $65 billion can’t do the job.

2. Administrative savings, Part 2: The original UI estimate projected that single-payer reform wouldn’t realize any savings on the vast amounts hospitals and doctors currently spend on billing and paperwork. Yet, Sanders’ (and our) proposals would enormously simplify this billing and paperwork. We noted that reliable studies published in the most respected medical and policy journals have documented these provider administrative savings, and that numerous single-payer estimates by the Congressional Budget Office, the Government Accountability Office and private consultants have all assumed that these savings would occur.

In response, our UI colleagues continue to project zero administrative savings for providers, but say: “We agree that administrative costs would fall, but we do not agree they would be close to zero as HW [Himmelstein and Woolhandler] assert.” Actually, we never asserted any such thing. We wrote that “U.S. hospitals spend one-quarter of their total budgets on billing and administration, more than twice as much as hospitals spend in single-payer systems like Canada’s or Scotland’s. Similarly, U.S. physicians, who must bill hundreds of different insurance plans with varying payment and coverage rules, spend two to three times as much as our Canadian colleagues on billing.” Our estimate that cutting U.S. providers’ administrative costs to Canadian levels would save about $2.57 trillion over 10 years was based on this well-established (and peer-reviewed) data.

3. Drug prices: The latest UI piece restated their conviction that a U.S. single-payer system could get only half the discounts that single-payer systems in other nations have gotten from drug companies (and would actually raise drug prices for patients currently on Medicaid). They continue to offer no reason why the discounts would be so small. Moreover, they now claim that Himmelstein and Woolhandler “argue incorrectly that we ignored savings from paying less for prescription drugs.” In fact we didn’t ignore their estimated savings, but said they should be two-fold higher than the 25 percent they projected.

4. Utilization of care, Part 1: The original UI report estimated that single-payer reform would cause a $519 billion increase in health spending in 2017, even accounting for some savings on administration and drugs. But we noted that there just aren’t enough hospital beds or doctors to meet the huge surge in visits and hospitalizations they predict. To back up our claim we cited data from Canada (when its single-payer reform was implemented) and the U.S. (when Medicare and Medicaid were implemented). These data document that no, or very modest increases in society-wide use of care, occurred, and that instead care shifted from the rich and healthy to the sick and poor.

In response, the UI rejoinder says: “Contrary to HW’s [Himmelstein and Woolhandler’s] claim in their article, health care use and spending for the elderly population did increase substantially once the Medicare program was implemented in 1965.” Here (as in their claim about our statement on providers’ administrative costs) they have misquoted us. We wrote that “between 1964 (before Medicare) and 1966 (the year when Medicare was fully functioning) there was absolutely no increase in the total number of doctor visits,” and that “the same thing happened in hospitals.” While we are well aware that utilization by the elderly and the poor went up after Medicare and Medicaid were implemented, the point is that there was a compensatory, slight reduction in utilization by other Americans, reflecting the limitations imposed by the existing supply of hospital beds and doctors (most of whom were already working full time).

Here’s the actual data on the number of doctor visits per person (not just the elderly) before and after Medicare/Medicaid:

HuffPost UI Graph 1

And here’s the actual data on the total number of hospitalizations:

 HuffPost UI Graph 2

In sum, we were correct in stating that the overall utilization of care showed no surge.

5. Utilization of care, Part 2: We noted in our critique that the lack of a surge in overall utilization in Canada, or with the start-up of Medicare/Medicaid, reflected a shift of care, with the newly insured poor and sick patients getting more of the care they needed, and the healthy and wealthy getting less elective and unnecessary care.

The UI rejoinder disputes that such a shift could occur. “HW [Himmelstein and Woolhandler] indicate that use would increase for the newly insured but would decrease by a similar amount for those already covered as physicians cease unnecessary services for those otherwise covered and perform additional necessary care for those otherwise uninsured. This assumption is faulty for two major reasons. First, no uniform definition of what is necessary and unnecessary exists in medical care; if such a definition existed, insurers would stop paying for all unnecessary care under our current health system. Second, there is absolutely no reason to believe that higher-income, currently insured individuals would lower their use of care under provider supply constraints.”

Their puzzlement displays a lack of familiarity with the considerable literature on variability in the utilization of care between different areas in the U.S., as well as the actual practice of medicine. John Wennberg and colleagues long ago observed that the number of surgical operations in a community showed only modest correlation with needs of the population, but was strongly correlated (r=.64) with the supply of surgeons.

As any doctor knows, doctors play a large role in regulating the amount of care they deliver. If we have no free appointment slots for the next month we’re likely to put off seeing our healthy patients a bit longer. Gastroenterologists often perform unnecessary screening colonoscopies. That’s not something many patients would demand. Indeed, the Aday paper referenced (to support a different point) in the UI rejoinder makes exactly our point: “After Medicare and Medicaid were introduced, providers may have begun to ration the number of visits by the ‘well-to-do’ to accommodate the influx of low-income patients with newly acquired purchasing power and a backlog of unmet need.”

In sum, there’s considerable evidence that doctor routinely adjust the utilization of care by their patients, and that when many additional people gain coverage, doctors shift care to this newly insured group, and compensate by reducing unneeded care for the wealthy and healthy.

6. What system was the UI analyzing? The UI researchers claimed to be estimating the budgetary impact of Sen. Sanders’ proposal. Yet now they tell us, “To be politically acceptable, compromises would have to be made, and those compromises are reflected in our assumptions.” In other words, their estimates are not actually based on the reform that Sanders (or we) have recommended. Instead they assume that the insurance and drug companies are too powerful to really rein in.

Overall, the UI response misrepresents key elements of our critique, and fails to address the erroneous assumptions that underlay their original analysis. Single-payer systems elsewhere provide more and better care at a lower price than we pay. The administrative bloat of our market-driven payment system accounts for much of the difference. While we recognize that a transition to a true single-payer system faces stiff political headwinds, it’s medically and economically feasible. And as Sen. Sanders has shown, political climates can be changed.

Drs. Woolhandler and Himmelstein are internists in the South Bronx, professors at the City University of New York School of Public Health at Hunter College, and lecturers in medicine at Harvard Medical School. The opinions expressed do not necessarily reflect those institutions’.

http://www.huffingtonpost.com/steffie-woolhandler/urban-institute-errors-single-payer-costs_b_10100836.html

Here’s what CEOs think of candidates’ healthcare ideas

By Shannon Muchmore
Modern Healthcare, May 21, 2016

The CEO Power Panel includes 110 top leaders of hospitals, insurance companies, physician groups, trade associations and other not-for-profit advocacy groups. The second-quarter survey on policy options that the next president and Congress might address attracted 86 respondents, a 78% response rate.

Future of ACA

Do you support Congress and the next president in:

Repealing and replacing the Affordable Care Act?

2.3% – Yes
67.4% – No
29.1% – It depends on the details
1.2% – No opinion

Expanding the ACA’s subsidized private insurance plan system to achieve universal coverage?

34.9% – Yes
15.1% – No
48.8% – It depends on the details
1.2% – No opinion

Scrapping private insurance in favor of expanding an enhanced Medicare to cover the entire population (single payer)?

9.3% – Yes
61.6% – No
29.1% – It depends on the details

Other insurance issues

Allowing private insurers to sell individual and family policies across state lines under national rules that preempt state rules?

52.3% – Yes
20.9% – No
24.4% – It depends on the details
2.3% – No opinion

Expanding the use of health savings accounts to pay premiums and meet costs under high-deductible plans?

74.4% – Yes
11.6% – No
12.8% – It depends on the details
1.2% – No opinion

Creating subsidized high-risk pools to cover people with preexisting conditions?

43.0% – Yes
16.3% – No
36.1% – It depends on the details
4.7% – No opinion

Medicare

Raising Medicare eligibility to age 67?

54.7% – Yes
23.3% – No
22.1% – It depends on the details

Expanding means testing within Medicare, such as higher co-pays or reduced benefits for high-income seniors?

50.0% – Yes
18.6% – No
30.2% – It depends on the details
1.2% – No opinion

Moving to a universal Medicare Advantage system with a means-tested defined contribution (premium support) for seniors?

28.2% – Yes
20.0% – No
48.2% – It depends on the details
3.5% – No opinion

Gradually expanding Medicare to cover everyone over age 55 who doesn’t have private insurance?

21.4% – Yes
48.8% – No
28.6% – It depends on the details
1.2% – No opinion

Delivery system reform

Taking aggressive measures to curb rising prescription drug prices such as allowing imports and authorizing the CMS to negotiate prices?

70.6% – Yes
9.4% – No
20.0% – It depends on the details

Repealing delivery system reforms such as value-based payment, accountable care organizations and the use of quality measures included in the Affordable Care Act?

3.5% – Yes
83.5% – No
11.8% – It depends on the details
1.2% – No opinion

http://www.modernhealthcare.com/article/20160521/MAGAZINE/305219938/healthcare-ceos-reject-veering-sharply-from-acas-path

***

Comment:

By Don McCanne, M.D.

This poll of selected “top leaders of hospitals, insurance companies, physician groups, trade associations and other not-for-profit advocacy groups” can give us a rough idea of where the executive leadership of the health care industry stands today on health care reform. A few conclusions:

* These CEOs strongly support the Affordable Care Act (ACA). That is not surprising since these vested stakeholders were part of the process that created the legislation..

* They are uncertain on whether or not the private insurance plans should be expanded to achieve universal coverage, although one-third would agree with they should be. The majority may be concerned about the potential of being required to cover care for those with greater health care needs (adverse selection) without being able to transfer risk elsewhere..

* Over 60 percent oppose replacement of private plans with a single payer enhanced Medicare for all and another 30 percent say that it depends on the details. Only 9 percent support single payer outright. This suggests that ACA was indeed designed with these stakeholders in mind, rather than for the patients..

* At least three-fourths support health savings accounts, tacitly supporting high deductible health plans that are a source of financial hardship for far too many individuals who have health care needs..

* At least half support selling insurance across state lines even though that is not practical because of problems such as building new provider networks in other states..

* Close to half support creating subsidized high-risk pools to cover people with preexisting conditions, even though the experience with state high-risk pools has been very disappointing. They are too expensive so benefits have been too meager. Besides they have been unable to cover most eligible individuals in spite of the need..

* Over half support raising Medicare eligibility age to 67, cutting back on coverage when we need to do is increase it instead..

* They would expand means-testing of Medicare, risking support of higher income individuals for the program..

* Somewhat surprisingly there is less support for Medicare vouchers for private plans (premium support), but perhaps that is due to the fact that the premium support strategy is designed to eventually reduce government payments for Medicare. After half of a century, Medicare is here to stay, and the stakeholders do recognize the need for adequate government funds to support the program..

* Only one-fifth support allowing individuals the option of enrolling in Medicare at age 55. Half are clearly opposed. They do not want to displace employer-sponsored plans presumably because they pay higher rates than does Medicare..

* By far the strongest support is for “delivery system reforms such as value-based payment, accountable care organizations and the use of quality measures included in the Affordable Care Act.” Evidence to date with these “value over volume” proposals has been disappointing, demonstrating little savings and negligible impact on quality. One possible reason they may be popular for CEOs is that their companies have learned to game the system to collect the rewards offered by these programs.

It is likely that most of these CEOs are relatively conservative politically since they predominantly support policies advanced by the “repeal and replace” Republicans, even though they do support ACA. They also strongly oppose Medicare for all single payer in spite of it being supported by a majority of Americans. Some of the policies they support would make access and affordability worse for patients, yet these policies can be self-serving for their own entities.

This survey of health industry CEOs leads me to the conclusion that the wrong people were sitting at the table when ACA was designed. For our redo, we need people at the table who represent patients rather than the health industries. A system that takes care of patients automatically takes care of legitimate stakeholders, but the reverse has not been true. It’s time to change. Single payer.

Is Single Payer Our Health Salvation?

By Anne Scheetz, M.D.
The New York Times, Letters, May 23, 2016

Re: “Why a Single-Payer Plan Would Still Be Really Costly” (The Upshot, May 17):

Our health care costs more because our administrative costs, a result of a financing system that relies on for-profit insurance companies, are so high. Some of those costs are borne by physicians, who must pay for complex billing systems, denial management, preauthorization requirements, collections management and bad debt, as well as devoting patient time to discussing insurance coverage rather than medical issues.

If we substantially decrease those costs to physicians, as a single-payer system would do, we could decrease insurance payments to physicians and still give all of them a raise. No economic miracle involved; just a matter of the people who do the work, rather than a wasteful middleman, taking home the money.

The writer, a retired internist, resides in Chicago.

http://www.nytimes.com/2016/05/24/opinion/is-single-payer-our-health-salvation.html?_r=0

Is a Single-Payer System our Health Salvation?

By Gregory L. Sheehy, M.D.
The New York Times, Letters, May 23, 2016

Re “Why a Single-Payer Plan Would Still Be Really Costly” (The Upshot, May 17):

As a physician who favors a single-payer plan, I cannot disagree with your analysis about the high cost of moving to this type of health care plan.

Our present system is really all about profit — from the medical device makers to the pharmaceutical industry to health care workers and medical administrators to insurance companies. The challenge to bring down costs, under this system or single-payer, is large.

Yet we have seen what the free market has done over the last 70 years, and it has not been a success in terms of cost control. Indeed, health care costs are going to get significantly worse if we continue our present system, a combination of private and government payment.

Only a single-payer system has any chance to control costs yet guarantee that all citizens will have health care coverage. To stand pat with free-market fervor or to go backward, such as eliminating the Affordable Care Act, will deprive many of medical care while still driving up costs.

In the long run, the present system will cost far more than a single-payer option, and the sooner we proceed in that direction the better.

Dr. Gregory L. Sheehy is a retired internist. He resides in Middleton, Wis.

http://www.nytimes.com/2016/05/24/opinion/is-single-payer-our-health-salvation.html?_r=0

Saving the NHS

Britain’s junior doctors’ strike isn’t just about pay – it’s about preserving a health system based on need, not profit

By Adam Gaffney, M.D.
Jacobin, April 26, 2016

Today [April 26] in England, “junior doctors” – post-graduate physicians akin to residents and fellows in the United States – are walking out. This two-day strike represents a major intensification of actions that began in January. It was precipitated by last year’s breakdown in negotiations over a contract that the Conservative government of David Cameron has now proclaimed it will impose come hell or high water. But the stakes of the junior doctors’ strike are much higher.

Physicians’ strikes, it’s worth acknowledging, do not always seek progressive ends. The 1962 Saskatchewan Doctors’ Strike aimed to torpedo the province’s milestone single-payer legislation. But the current action in England, endorsed by a near-unanimous vote last year, is something different. Fundamentally, it’s aimed at the preservation – not the derailment – of universal health care.

The travails of the junior doctors are one part of a much larger campaign. Against austerity, of course. But also for the perseverance of the United Kingdom’s unique health care system – in substance, not merely in name – in the twenty-first century.

A Cracked Foundation

Every nation’s health system is split along a rights-commodity axis, ranging from a public system that provides a universal right to health care according to need, to a private enterprise that profitably provides care according to means. When the National Health Service was founded, notes scholar Rudolf Klein in The New Politics of the NHS, it was the first system that universalized government-provided care, and it thereby skewed health care toward the “rights” side of that axis. As he puts it,

“It [the NHS] was . . . the first comprehensive system to be based . . . on the national provision of services available to everyone. It thus offered free and universal entitlement to State-provided medical care. At the time of its creation it was a unique example of the collectivist provision of health care in a market society.”

In the 1980s, however, Margaret Thatcher’s government began an attack on the principles of the NHS that has not yet subsided. As public health doctor and scholar Allyson Pollock describes in NHS Plc: The Privatisation of our Health Care, Thatcher’s government imposed intermittent austerity funding and the incremental imposition of market-based reforms such as the “internal market” and the “private finance initiative,” signaling a retreat from the NHS’s initial collectivist provisions and a partial move toward commodification.

The Labour government of Tony Blair, as she notes, continued down the road first paved by Thatcher. However, Blair’s government did eventually initiate a much-needed increase in funding: to just under seven percent a year, almost twice the historical average of four percent. This overdue boost, however, would not survive the Great Recession.

In 2010, David Cameron’s Conservative-led government was elected and destabilized the NHS through two great upheavals. First, the government reorganized the NHS through the passage of the 2012 Health and Social Care Act; second, it instituted a period of funding austerity the likes of which the NHS had never seen.

The changes wrought by the 2012 law are complex, and the full ramifications not yet entirely clear. Health policy scholar John Lister described the law in a phone interview as a “massive top-down reorganization of the NHS” that pushes it further onto the free market, effectively displacing (some) care provision into the private sector.

And as Pollock and lawyer Peter Roderick – both supporters and advocates for a fully public NHS – wrote in the British Medical Journal last year, the law calls for a number of “reductions and restrictions [of health care that] pave the way for mixed funding arrangements and a gradual shift to private insurance and charges to patients.”

Essentially, they argue, the law “marked the end of the NHS in England” not only by encouraging further privatization and fragmentation, but by effectively ending the Health Secretary’s legal duty to provide comprehensive health services throughout the nation.

The Scrooge Model

Whether the law will fully undo the NHS or simply prove to be another incremental step remains to be seen. The more immediately harmful trend – and the one largely responsible for the junior doctors’ strike – has been the draconian austerity that the service now faces.

In the United States, discussions around health policy generally revolve on how best to reduce excessive spending (especially the public variety). Globally, however, and particularly in low-income countries, insufficient public spending is frequently the larger problem. This is now also the case with the NHS, which was already quite efficient before the Cameron government came to power.

As a percentage of GDP, the United Kingdom currently has the cheapest health system among thirteen other high-income peer countries:

NHS Graph

Moreover, health spending in the UK as a percentage of GDP has actually fallen since 2009. As Klein wrote in an article last year, while historically NHS funding had grown at an average rate of almost four percent yearly, it is currently growing at a bit under one percent. Given population growth, he notes, such a rate of “increase” is in fact a per capita reduction.

Indeed, as John Appleby, chief economist of the Kings Fund noted in a blog post, spending increases under the Cameron government are the lowest of any government since the end of World War II. At that point, however, Great Britain was essentially penniless and in virtual ruins. Today, Ebenezer Scrooge–level miserliness has replaced frugal funding as a matter of choice.

What is obvious is that while the United Kingdom ostensibly maintains a social right to health care, the foundation of that promise is cracking.

The First Cut

It was amid all this tumult, Lister notes, that the government decided to move to what it called a “seven-day NHS,” extending the availability of (non-emergency) clinical services throughout the week. While not necessarily a bad idea – though there has been considerable controversy regarding the actual benefits of such a transformation – the change requires more money, not less. That is, unless you have junior doctors around to pick up the slack.

Increasing weekend staffing means “you either over stress the staff who are currently doing it or you actually reduce the cover during the week as a result,” Lister says. Although the government’s proposed contract would increase junior doctors’ base pay, it would also reduce existing premiums for night and weekend work. “Ministers have promised to protect the pay of existing doctors for the first three years,” the BBC notes, but at the same time “new doctors starting their career in the NHS under this contract may be worse off.”

Contract negotiations between the government and the British Medical Association (BMA) collapsed late last year over these issues, leading to a November strike vote with 76.2 percent turnout and 98 percent support. The first strike took place January 12 and the last was April 6. Today and tomorrow’s actions, however, raise the bar considerably: they are full walkout strikes, with emergency care provided by covering consulting physicians, some of whom have loudly expressed solidarity with their striking junior colleagues.

Like their American counterparts, junior doctors work hard and long hours. “I regularly work weekends and nights,” one said in a series of interviews published by the Mirror. “So far in the last 7 days I have worked over 80 hours, I will work at least another 10 hours tomorrow before I get a day off. I am absolutely shattered.”

Among strike supporters interviewed by the Mirror, a concern over pay was not prominent (indeed, one said he would financially benefit under the new contract). Instead, they emphasized patient safety, quality of care, and the potential for greater workforce strain caused by the changes.

The broader point, as Lister emphasizes, is that the move against the junior doctors may be the first stage in a larger campaign to save money by squeezing the health care workforce. “[B]ehind the junior doctors’ dispute,” he notes, “is the much bigger apple that they’re after which is to strip away the weekend enhancement payments and out-of-hours payments for over a million other health workers.” In other words, in the quest for NHS austerity, junior doctors may only be the first on the chopping block.

Which leads to another question: can the junior doctors’ strike advance the larger campaign to preserve and restore a fully funded, fully public NHS, or will it remain an isolated battle?

A Bigger Fight

Perhaps the most critical factor that will shape the battle over the NHS in coming months and years is the human impact of continued NHS austerity, which could produce grassroots protest.

A February report from the Kings Fund gives a clear sense of the service’s dire fiscal straits and some of its ramifications:

  • The report estimates that NHS trusts (provider organizations like hospitals) will be in the red by £2.3 billion by the end of the financial year;
    .
  • It reports a rising sense that patient care is worsening: for the first time, a majority of trust finance directors surveyed believed that patient care in their region had deteriorated over the past year;
    .
  • It notes a failure to meet targets for waiting time for care, including for cancer treatment.

None of this, of course, is particularly surprising: it’s the all-but-inevitable consequence of trying to squeeze more money out of an already lean healthcare system. The NHS’s current budget crisis and declining quality of care don’t reflect the flaws of a public approach to health care, but rather the penny-pinching prerogatives of a government committed to the preservation of concentrated wealth above good health.

In order to deal with the massive projected deficit, Lister emphasizes that at least some cuts in services will take place, as indicated by discussions to close A&Es (ERs) in the rural county of Lancashire.

Such reductions may become critical focal points for local grassroots movements: “[T]hese types of cuts,” he notes, “when they are made, they do have the power to mobilize all kinds of people who would never normally engage in any kind of political activity at all.”

Even though local battles against reductions in services or hospital closures may serve as important loci of resistance, action on the national level will be necessary to reverse course on NHS.

The election of Jeremy Corbyn to the leadership of the Labour Party could be a game changer in this regard. His campaign website calls for a “fully-funded NHS, integrated with social care, with an end to privatisation in health.” But Lister suggests that Labour, even under Corbyn, has been disappointingly tepid in its support of the NHS.

He notes that the party did not champion a bill drafted by Pollock and Roderick, the NHS Reinstatement Bill, which aimed to “fully restore the NHS as an accountable public service by reversing 25 years of marketization in the NHS.” (Corbyn, however, has supported it as an individual.)

Looking forward, Lister hopes to press Labour to adopt the bill’s principles, whatever they want to label it. More broadly, he hopes to see a coalition of NHS activists, labor unions and, one day, the Labour Party joined together in a “united campaign to challenge the Tory offensive.”

Defending the health care work force, restoring previous levels of health funding, rolling back privatization, and ejecting the powerful corporate health care sector from the NHS will clearly be a formidable feat. No doubt it will require a coalition of health workers, activists, politicians, parties, and unions to achieve it.

Like the fight for a single-payer health care system in the United States, health care activism necessitates a multifocal yet united movement. Neither campaign is impossible, but neither will be easy.

Finally, cooperation and solidarity among activists across national borders may provide yet another source of support: health care capital operates transnationally, and so too must like-minded health care workers, activists, and scholars.

The British NHS can only survive insofar as it can continue to provide, universally, the highest quality health care. But austerity makes that increasingly untenable. The junior doctors’ strike rejects this neoliberal squeeze. If successful, it might help lead the way to something more: the end of a series of setbacks for the NHS, and the first of many victories for those who believe in its basic principles.

Adam Gaffney is a physician whose work has appeared in Salon, Dissent, and In These Times. He blogs at theprogressivephysician.org.

https://www.jacobinmag.com/2016/04/nhs-junior-doctors-strike-health-privatization/

Support for ColoradoCare

By Penny Thron-Weber, M.D.
The Denver Post, Letters, May 23, 2016

Re: Hospitals, doctors differ on universal health care in Colorado, May 14 news story.

Thanks for your article about ColoradoCare. As a family physician, it is clear to me that while Obamacare has been a step forward in providing quality care to all, it is not enough. High deductibles, for example, keep the newly insured from getting sufficient care.

The opposition group Coloradans for Coloradans could more appropriately be named Insurance Companies for Their Self-Interest. I am aware that ColoradoCare is a complex proposal with many details still to be worked out. But let s not fool ourselves about what we have now: a very broken system that serves fewer and fewer people well. We need to try for something better.

Dr. Penny Thron-Weber resides in Arvada.

http://www.denverpost.com/2016/05/22/support-for-coloradocare-single-payer-program/

The business case for single payer

By Bennett Hall
Corvallis Gazette-Times, May 20, 2016

As the owner of MCS Industries, a Pennsylvania manufacturer of home décor products with 160 employees, Richard Master has firsthand experience with the relentlessly rising cost of health care, for both companies and workers.

Last year, he said, it cost his company $18,000 for each employee with a family health plan. This year that figure rose by more than 14 percent — the latest in a string of double-digit annual increases that have pushed MCS Industries’ bill for employee health coverage to $1.5 million a year.

Costs keep going up for his workers, as well.

“Insurance comes with deductibles, co-pays and out-of-pocket expenses that make it not such a good deal,” he said in an interview this week. “And it doesn’t really have to be that way.”

Master is a convert to the cause of single-payer health care, a government-sponsored system that would eliminate the multipayer welter of private insurance carriers we have now and replace it with a single health plan for every American, a proposal sometimes known as Medicare for All.

He’s become so passionate about single payer that he’s produced a documentary on the subject called “Fix It: Healthcare at the Tipping Point,” and he’s been traveling the country screening the film and speaking to business people about a health care system he believes is crippling the economy.

Now he’s teamed up with Health Care for All-Oregon and the state chapters of Physicians for a National Health Program and the Main Street Alliance for a six-city swing through Oregon, including a stop next week in Corvallis.

On Wednesday, Master will meet for lunch with a group of local business leaders and elected officials, then host free public screenings of “Fix It” at 6 and 7:30 p.m. at the Darkside Cinema, 215 S.W. Fourth St. Each showing of the film will be followed by a discussion.

A single-payer system as envisioned by Master would use individual and employer taxes to cover all medically necessary care through the current private delivery system. By eliminating the administrative burden of multipayer billing and allowing the government to negotiate drug prices with pharmaceutical companies, he argues, Americans could slash about $500 billion a year from a national health care bill that currently runs to $3 trillion annually.

It’s an approach that’s already providing better outcomes at much lower costs in other developed nations such as Canada, Germany and France.

“The U.S. really is the anomaly,” he said. “We are the outlier, and the rest of the industrialized world is following a different model, a much more efficient model, and that is single payer.”

By focusing on issues of cost and inefficiency, Master is hoping to persuade other business leaders to back the movement to bring single-payer health care to the United States.

“What we say to them is that single payer costs less,” he said. “It costs less for the company in basic care, and it will take away from the company the requirement that they are responsible for providing medical care for employees.”

Removing that burden from U.S. businesses, he said, would make them more competitive in the global marketplace. In the meantime, American firms — and American workers — are struggling under health care costs that are much higher than they need to be.

“This is 18 percent of our entire economy right now. In other countries, it’s generally 9 to 11 percent,” Maser said. “We’ve got to get it under control.”

Reporter Bennett Hall can be reached at 541-758-9529 or bennett.hall@lee.net. Follow him on Twitter at @bennetthallgt.

http://www.gazettetimes.com/news/local/the-business-case-for-single-payer/article_b94831cf-ae52-5c4d-92d8-7d519d53c822.html

Here’s what CEOs think of candidates’ healthcare ideas

By Shannon Muchmore
Modern Healthcare, May 21, 2016

The CEO Power Panel includes 110 top leaders of hospitals, insurance companies, physician groups, trade associations and other not-for-profit advocacy groups. The second-quarter survey on policy options that the next president and Congress might address attracted 86 respondents, a 78% response rate.

Future of ACA

Do you support Congress and the next president in:

Repealing and replacing the Affordable Care Act?

2.3% – Yes
67.4% – No
29.1% – It depends on the details
1.2% – No opinion

Expanding the ACA’s subsidized private insurance plan system to achieve universal coverage?

34.9% – Yes
15.1% – No
48.8% – It depends on the details
1.2% – No opinion

Scrapping private insurance in favor of expanding an enhanced Medicare to cover the entire population (single payer)?

9.3% – Yes
61.6% – No
29.1% – It depends on the details

Other insurance issues

Allowing private insurers to sell individual and family policies across state lines under national rules that preempt state rules?

52.3% – Yes
20.9% – No
24.4% – It depends on the details
2.3% – No opinion

Expanding the use of health savings accounts to pay premiums and meet costs under high-deductible plans?

74.4% – Yes
11.6% – No
12.8% – It depends on the details
1.2% – No opinion

Creating subsidized high-risk pools to cover people with preexisting conditions?

43.0% – Yes
16.3% – No
36.1% – It depends on the details
4.7% – No opinion

Medicare

Raising Medicare eligibility to age 67?

54.7% – Yes
23.3% – No
22.1% – It depends on the details

Expanding means testing within Medicare, such as higher co-pays or reduced benefits for high-income seniors?

50.0% – Yes
18.6% – No
30.2% – It depends on the details
1.2% – No opinion

Moving to a universal Medicare Advantage system with a means-tested defined contribution (premium support) for seniors?

28.2% – Yes
20.0% – No
48.2% – It depends on the details
3.5% – No opinion

Gradually expanding Medicare to cover everyone over age 55 who doesn’t have private insurance?

21.4% – Yes
48.8% – No
28.6% – It depends on the details
1.2% – No opinion

Delivery system reform

Taking aggressive measures to curb rising prescription drug prices such as allowing imports and authorizing the CMS to negotiate prices?

70.6% – Yes
9.4% – No
20.0% – It depends on the details

Repealing delivery system reforms such as value-based payment, accountable care organizations and the use of quality measures included in the Affordable Care Act?

3.5% – Yes
83.5% – No
11.8% – It depends on the details
1.2% – No opinion

http://www.modernhealthcare.com/article/20160521/MAGAZINE/305219938/healthcare-ceos-reject-veering-sharply-from-acas-path

This poll of selected “top leaders of hospitals, insurance companies, physician groups, trade associations and other not-for-profit advocacy groups” can give us a rough idea of where the executive leadership of the health care industry stands today on health care reform. A few conclusions:

* These CEOs strongly support the Affordable Care Act (ACA). That is not surprising since these vested stakeholders were part of the process that created the legislation..

* They are uncertain on whether or not the private insurance plans should be expanded to achieve universal coverage, although one-third would agree with they should be. The majority may be concerned about the potential of being required to cover care for those with greater health care needs (adverse selection) without being able to transfer risk elsewhere..

* Over 60 percent oppose replacement of private plans with a single payer enhanced Medicare for all and another 30 percent say that it depends on the details. Only 9 percent support single payer outright. This suggests that ACA was indeed designed with these stakeholders in mind, rather than for the patients..

* At least three-fourths support health savings accounts, tacitly supporting high deductible health plans that are a source of financial hardship for far too many individuals who have health care needs..

* At least half support selling insurance across state lines even though that is not practical because of problems such as building new provider networks in other states..

* Close to half support creating subsidized high-risk pools to cover people with preexisting conditions, even though the experience with state high-risk pools has been very disappointing. They are too expensive so benefits have been too meager. Besides they have been unable to cover most eligible individuals in spite of the need..

* Over half support raising Medicare eligibility age to 67, cutting back on coverage when we need to do is increase it instead..

* They would expand means-testing of Medicare, risking support of higher income individuals for the program..

* Somewhat surprisingly there is less support for Medicare vouchers for private plans (premium support), but perhaps that is due to the fact that the premium support strategy is designed to eventually reduce government payments for Medicare. After half of a century, Medicare is here to stay, and the stakeholders do recognize the need for adequate government funds to support the program..

* Only one-fifth support allowing individuals the option of enrolling in Medicare at age 55. Half are clearly opposed. They do not want to displace employer-sponsored plans presumably because they pay higher rates than does Medicare..

* By far the strongest support is for “delivery system reforms such as value-based payment, accountable care organizations and the use of quality measures included in the Affordable Care Act.” Evidence to date with these “value over volume” proposals has been disappointing, demonstrating little savings and negligible impact on quality. One possible reason they may be popular for CEOs is that their companies have learned to game the system to collect the rewards offered by these programs.

It is likely that most of these CEOs are relatively conservative politically since they predominantly support policies advanced by the “repeal and replace” Republicans, even though they do support ACA. They also strongly oppose Medicare for all single payer in spite of it being supported by a majority of Americans. Some of the policies they support would make access and affordability worse for patients, yet these policies can be self-serving for their own entities.

This survey of health industry CEOs leads me to the conclusion that the wrong people were sitting at the table when ACA was designed. For our redo, we need people at the table who represent patients rather than the health industries. A system that takes care of patients automatically takes care of legitimate stakeholders, but the reverse has not been true. It’s time to change. Single payer.

Chicago Medical Society calls for study of single payer

By PNHP staff
PNHP Spring Newsletter, May 2016

The Chicago Medical Society has voted to create a “research committee to analyze the benefits and difficulties with instituting and maintaining a single-payer health care system in Illinois … and the United States, with consideration of both economic and health outcome and health disparity improvements.”

The action came at the society’s quarterly council meeting on Feb. 9, which drew about 80 participants, including a larger-than-usual group of medical students and residents.

The amended resolution passed unanimously, and it included a provision to forward the resolution to the Illinois State Medical Society and the AMA.

The measure that was ultimately adopted by the councilors, or delegates, was based in large part on the contents of an evidence-laden resolution titled “Single-payer health care: the logical solution that will not go away” introduced by Dr. Peter Orris, longtime CMS councilor and one of PNHP’s founding members.

Orris’ original resolution concluded by calling upon the CMS to formally endorse single payer. An active debate ensued. With the permission of the body, many students and some Chicago physicians who were not members of the council testified in favor of the proposal.

Speakers in support of the resolution pointed to the continuing financial hardships patients and their families are experiencing under the current multi-payer system, growing physician frustration with that system, and the moral imperative of achieving truly universal health care.

Strong opposition to the resolution was heard from a number of council members, with several confusing single payer with the underfunded socialized medical systems of the 1970s in Eastern Europe.

On a public “standing” vote, the “resolved” clause calling for CMS endorsement drew support from over one-third of the council members.

Orris notes that while this was more public support for single payer among the councilors than in the past, many members newly sympathetic to the single-payer alternative signaled a preference for a more deliberative approach.

Student Section member James Curry then offered an amendment changing the “resolved” language to a call for a CMS study of single payer’s economic and health impacts.

The amended resolution passed unanimously, including a provision to forward it to the Illinois State Medical Society and the AMA.

After the meeting, Curry said he was pleased that students from every medical school in the area were in attendance. “Single-payer health care means many things, but to its supporters, including medical students, it means one very fundamental thing: the right to health care.”

He said the society’s leadership has pledged to involve students in the organization of the society’s discussion of single payer, and has expressed a willingness to conduct a membership survey on the issue as well.

Woolhandler and Himmelstein respond to Urban Institute’s doubling down on errors

Response to Criticisms of Our Analysis of the Sanders Health Care Reform Plan

By Linda J. Blumberg, John Holahan, Lisa Clemans-Cope, Matthew Buettgens
Urban Institute, May 18, 2016

Abstract

The Sanders campaign and David Himmelstein and Steffie Woolhandler reacted with sharp criticisms to our recent report, The Sanders Single-Payer Health Care Plan: The Effect on National Health Expenditures and Federal and Private Spending. In this brief, we discuss our key assumptions in these areas of disagreement and highlight ways in which we may have actually underestimated overall costs of the Sanders proposal. By and large our assumptions are laid out thoroughly in the original paper, but here we use them to address the specific statements made by the campaign.

Conclusion

All cost estimates of new programs carry some uncertainty, but ours are based in the best empirical literature and data, methodological expertise, and a deep knowledge of the health care system. We believe we have made conservative assumptions with regard to this proposed plan, but it is possible we have somewhat overestimated administrative costs and underestimated long-term care and assorted other costs; we acknowledge this, of course. However, using reasoned analysis based upon empirical research and in-depth knowledge of the US health care system, there is no way to avoid the conclusion that the Sanders plan, while achieving universal coverage, would massively increase federal spending and require much larger tax increases than he has proposed.

http://www.urban.org/research/publication/response-criticisms-our-analysis-sanders-health-care-reform-plan

***

Doubling Down on Errors: Urban Institute Defends Its Ridiculously High Single Payer Cost Estimates

By Steffie Woolhandler and David Himmelstein
The Huffington Post, May 22, 2016

Last week we posted a critique of the Urban Institute’s (UI) absurdly biased report that claimed Sen. Bernie Sanders’ proposal for single-payer health reform would cause a massive increase in health spending. Now, the report’s authors have issued a 12-page rejoinder to our criticism. But that response is riddled with distortions, misinterpretations and glaring factual errors. Moreover, they now make it clear that they didn’t even try to estimate the costs of Sanders’ (or our) single-payer proposals. Instead, they made up their own reform proposal and costed that out.

Our critique identified three main problems with the UI’s projection that implementing single payer would boost total health spending by $519 billion in 2017. First, UI ignored about 75 percent of the administrative savings that single-payer reform would achieve. Second, it substantially underestimated single payer’s savings on prescription drugs. And finally, it posited an absurdly large increase in the utilization of health care under single payer, far more than could possibly be provided by the current supply of doctors and hospitals.

Below, we briefly discuss the UI’s response to those criticisms, and the facts of the matter.

1. Administrative savings, Part 1: The original UI report projected that single payer could cut insurance overhead from the current 9.5 percent of health spending ($341 billion) to 6 percent ($215 billion). As they now admit, they were modeling a compromised single-payer system, in which private managed care insurers like UnitedHealthcare would continue to play a major role, as they do in the Medicare Advantage program. (Neither we nor Sanders have suggested such a continued role for private insurers.) We pointed out that Canada’s single-payer system runs for 1.8 percent overhead (a figure they impugn, but which is taken directly from Canada’s official health statistics), and is similar to the overhead in the traditional Medicare program. Reducing our insurance overhead to the Canadian level would mean cutting it to “only” $65 billion. There’s no reason to believe we can’t be as efficient as Canada if we, like Canada, proscribe participation by private insurers.

The UI rejoinder argues that “it would be inadvisable to cut administrative costs so much that important functions could not be carried out effectively under a new system. Such functions include rate setting for many different providers of different types facing different costs across the country; quality control over care provision; development, review, and revision of regulations; oversight for fraudulent activity; provider oversight and enforcement of standards; bill payment to providers; consumer services; and more.” Of course traditional Medicare (and Canada) are already doing all of those things, and the UI response gives no reason why $65 billion can’t do the job.

2. Administrative savings, Part 2: The original UI estimate projected that single-payer reform wouldn’t realize any savings on the vast amounts hospitals and doctors currently spend on billing and paperwork. Yet, Sanders’ (and our) proposals would enormously simplify this billing and paperwork. We noted that reliable studies published in the most respected medical and policy journals have documented these provider administrative savings, and that numerous single-payer estimates by the Congressional Budget Office, the Government Accountability Office and private consultants have all assumed that these savings would occur.

In response, our UI colleagues continue to project zero administrative savings for providers, but say: “We agree that administrative costs would fall, but we do not agree they would be close to zero as HW [Himmelstein and Woolhandler] assert.” Actually, we never asserted any such thing. We wrote that “U.S. hospitals spend one-quarter of their total budgets on billing and administration, more than twice as much as hospitals spend in single-payer systems like Canada’s or Scotland’s. Similarly, U.S. physicians, who must bill hundreds of different insurance plans with varying payment and coverage rules, spend two to three times as much as our Canadian colleagues on billing.” Our estimate that cutting U.S. providers’ administrative costs to Canadian levels would save about $2.57 trillion over 10 years was based on this well-established (and peer-reviewed) data.

3. Drug prices: The latest UI piece restated their conviction that a U.S. single-payer system could get only half the discounts that single-payer systems in other nations have gotten from drug companies (and would actually raise drug prices for patients currently on Medicaid). They continue to offer no reason why the discounts would be so small. Moreover, they now claim that Himmelstein and Woolhandler “argue incorrectly that we ignored savings from paying less for prescription drugs.” In fact we didn’t ignore their estimated savings, but said they should be two-fold higher than the 25 percent they projected.

4. Utilization of care, Part 1: The original UI report estimated that single-payer reform would cause a $519 billion increase in health spending in 2017, even accounting for some savings on administration and drugs. But we noted that there just aren’t enough hospital beds or doctors to meet the huge surge in visits and hospitalizations they predict. To back up our claim we cited data from Canada (when its single-payer reform was implemented) and the U.S. (when Medicare and Medicaid were implemented). These data document that no, or very modest increases in society-wide use of care, occurred, and that instead care shifted from the rich and healthy to the sick and poor.

In response, the UI rejoinder says: “Contrary to HW’s [Himmelstein and Woolhandler’s] claim in their article, health care use and spending for the elderly population did increase substantially once the Medicare program was implemented in 1965.” Here (as in their claim about our statement on providers’ administrative costs) they have misquoted us. We wrote that “between 1964 (before Medicare) and 1966 (the year when Medicare was fully functioning) there was absolutely no increase in the total number of doctor visits,” and that “the same thing happened in hospitals.” While we are well aware that utilization by the elderly and the poor went up after Medicare and Medicaid were implemented, the point is that there was a compensatory, slight reduction in utilization by other Americans, reflecting the limitations imposed by the existing supply of hospital beds and doctors (most of whom were already working full time).

Here’s the actual data on the number of doctor visits per person (not just the elderly) before and after Medicare/Medicaid:

(Table in original article – link below)

And here’s the actual data on the total number of hospitalizations:

(Table in orignal article – link below)

In sum, we were correct in stating that the overall utilization of care showed no surge.

5. Utilization of care, Part 2: We noted in our critique that the lack of a surge in overall utilization in Canada, or with the start-up of Medicare/Medicaid, reflected a shift of care, with the newly insured poor and sick patients getting more of the care they needed, and the healthy and wealthy getting less elective and unnecessary care.

The UI rejoinder disputes that such a shift could occur. “HW [Himmelstein and Woolhandler] indicate that use would increase for the newly insured but would decrease by a similar amount for those already covered as physicians cease unnecessary services for those otherwise covered and perform additional necessary care for those otherwise uninsured. This assumption is faulty for two major reasons. First, no uniform definition of what is necessary and unnecessary exists in medical care; if such a definition existed, insurers would stop paying for all unnecessary care under our current health system. Second, there is absolutely no reason to believe that higher-income, currently insured individuals would lower their use of care under provider supply constraints.”

Their puzzlement displays a lack of familiarity with the considerable literature on variability in the utilization of care between different areas in the U.S., as well as the actual practice of medicine. John Wennberg and colleagues long ago observed that the number of surgical operations in a community showed only modest correlation with needs of the population, but was strongly correlated (r=.64) with the supply of surgeons.

As any doctor knows, doctors play a large role in regulating the amount of care they deliver. If we have no free appointment slots for the next month we’re likely to put off seeing our healthy patients a bit longer. Gastroenterologists often perform unnecessary screening colonoscopies. That’s not something many patients would demand. Indeed, the Aday paper referenced (to support a different point) in the UI rejoinder makes exactly our point: “After Medicare and Medicaid were introduced, providers may have begun to ration the number of visits by the ‘well-to-do’ to accommodate the influx of low-income patients with newly acquired purchasing power and a backlog of unmet need.”

In sum, there’s considerable evidence that doctor routinely adjust the utilization of care by their patients, and that when many additional people gain coverage, doctors shift care to this newly insured group, and compensate by reducing unneeded care for the wealthy and healthy.

6. What system was the UI analyzing? The UI researchers claimed to be estimating the budgetary impact of Sen. Sanders’ proposal. Yet now they tell us, “To be politically acceptable, compromises would have to be made, and those compromises are reflected in our assumptions.” In other words, their estimates are not actually based on the reform that Sanders (or we) have recommended. Instead they assume that the insurance and drug companies are too powerful to really rein in.

Overall, the UI response misrepresents key elements of our critique, and fails to address the erroneous assumptions that underlay their original analysis. Single-payer systems elsewhere provide more and better care at a lower price than we pay. The administrative bloat of our market-driven payment system accounts for much of the difference. While we recognize that a transition to a true single-payer system faces stiff political headwinds, it’s medically and economically feasible. And as Sen. Sanders has shown, political climates can be changed.

Drs. Woolhandler and Himmelstein are internists in the South Bronx, professors at the City University of New York School of Public Health at Hunter College, and lecturers in medicine at Harvard Medical School. The opinions expressed do not necessarily reflect those institutions’.

http://www.huffingtonpost.com/steffie-woolhandler/urban-institute-errors-single-payer-costs_b_10100836.html

***

Comment:

By Don McCanne, M.D.

The media continue to cite the flawed Urban Institute analysis of the costs of single payer while ignoring the actual facts as presented by David Himmelstein and Steffie Woolhandler. Yet the Urban Institute authors twice have felt compelled to answer the Himmelstein/Woolhandler criticism of their analysis. Woolhandler and Himmelstein respond here to Urban’s doubling down of errors in their second response.

The fundamental fact remains: “Single-payer systems elsewhere provide more and better care at a lower price than we pay.” The $3 trillion we are already spending on health care is enough to finance a comprehensive single-payer system here in the United States.

Shifting more health care spending to the federal budget is not a flaw of single payer, as Urban implies, but actually a benefit because it makes the funding more equitable and efficient.

We need to hold the media to the truth – the full truth.

Woolhandler and Himmelstein respond to Urban Institute’s doubling down on errors

Response to Criticisms of Our Analysis of the Sanders Health Care Reform Plan

By Linda J. Blumberg, John Holahan, Lisa Clemans-Cope, Matthew Buettgens
Urban Institute, May 18, 2016

Abstract

The Sanders campaign and David Himmelstein and Steffie Woolhandler reacted with sharp criticisms to our recent report, The Sanders Single-Payer Health Care Plan: The Effect on National Health Expenditures and Federal and Private Spending. In this brief, we discuss our key assumptions in these areas of disagreement and highlight ways in which we may have actually underestimated overall costs of the Sanders proposal. By and large our assumptions are laid out thoroughly in the original paper, but here we use them to address the specific statements made by the campaign.

Conclusion

All cost estimates of new programs carry some uncertainty, but ours are based in the best empirical literature and data, methodological expertise, and a deep knowledge of the health care system. We believe we have made conservative assumptions with regard to this proposed plan, but it is possible we have somewhat overestimated administrative costs and underestimated long-term care and assorted other costs; we acknowledge this, of course. However, using reasoned analysis based upon empirical research and in-depth knowledge of the US health care system, there is no way to avoid the conclusion that the Sanders plan, while achieving universal coverage, would massively increase federal spending and require much larger tax increases than he has proposed.

http://www.urban.org/research/publication/response-criticisms-our-analysis-sanders-health-care-reform-plan

***

Doubling Down on Errors: Urban Institute Defends Its Ridiculously High Single Payer Cost Estimates

By Steffie Woolhandler and David Himmelstein
The Huffington Post, May 22, 2016

Last week we posted a critique of the Urban Institute’s (UI) absurdly biased report that claimed Sen. Bernie Sanders’ proposal for single-payer health reform would cause a massive increase in health spending. Now, the report’s authors have issued a 12-page rejoinder to our criticism. But that response is riddled with distortions, misinterpretations and glaring factual errors. Moreover, they now make it clear that they didn’t even try to estimate the costs of Sanders’ (or our) single-payer proposals. Instead, they made up their own reform proposal and costed that out.

Our critique identified three main problems with the UI’s projection that implementing single payer would boost total health spending by $519 billion in 2017. First, UI ignored about 75 percent of the administrative savings that single-payer reform would achieve. Second, it substantially underestimated single payer’s savings on prescription drugs. And finally, it posited an absurdly large increase in the utilization of health care under single payer, far more than could possibly be provided by the current supply of doctors and hospitals.

Below, we briefly discuss the UI’s response to those criticisms, and the facts of the matter.

1. Administrative savings, Part 1: The original UI report projected that single payer could cut insurance overhead from the current 9.5 percent of health spending ($341 billion) to 6 percent ($215 billion). As they now admit, they were modeling a compromised single-payer system, in which private managed care insurers like UnitedHealthcare would continue to play a major role, as they do in the Medicare Advantage program. (Neither we nor Sanders have suggested such a continued role for private insurers.) We pointed out that Canada’s single-payer system runs for 1.8 percent overhead (a figure they impugn, but which is taken directly from Canada’s official health statistics), and is similar to the overhead in the traditional Medicare program. Reducing our insurance overhead to the Canadian level would mean cutting it to “only” $65 billion. There’s no reason to believe we can’t be as efficient as Canada if we, like Canada, proscribe participation by private insurers.

The UI rejoinder argues that “it would be inadvisable to cut administrative costs so much that important functions could not be carried out effectively under a new system. Such functions include rate setting for many different providers of different types facing different costs across the country; quality control over care provision; development, review, and revision of regulations; oversight for fraudulent activity; provider oversight and enforcement of standards; bill payment to providers; consumer services; and more.” Of course traditional Medicare (and Canada) are already doing all of those things, and the UI response gives no reason why $65 billion can’t do the job.

2. Administrative savings, Part 2: The original UI estimate projected that single-payer reform wouldn’t realize any savings on the vast amounts hospitals and doctors currently spend on billing and paperwork. Yet, Sanders’ (and our) proposals would enormously simplify this billing and paperwork. We noted that reliable studies published in the most respected medical and policy journals have documented these provider administrative savings, and that numerous single-payer estimates by the Congressional Budget Office, the Government Accountability Office and private consultants have all assumed that these savings would occur.

In response, our UI colleagues continue to project zero administrative savings for providers, but say: “We agree that administrative costs would fall, but we do not agree they would be close to zero as HW [Himmelstein and Woolhandler] assert.” Actually, we never asserted any such thing. We wrote that “U.S. hospitals spend one-quarter of their total budgets on billing and administration, more than twice as much as hospitals spend in single-payer systems like Canada’s or Scotland’s. Similarly, U.S. physicians, who must bill hundreds of different insurance plans with varying payment and coverage rules, spend two to three times as much as our Canadian colleagues on billing.” Our estimate that cutting U.S. providers’ administrative costs to Canadian levels would save about $2.57 trillion over 10 years was based on this well-established (and peer-reviewed) data.

3. Drug prices: The latest UI piece restated their conviction that a U.S. single-payer system could get only half the discounts that single-payer systems in other nations have gotten from drug companies (and would actually raise drug prices for patients currently on Medicaid). They continue to offer no reason why the discounts would be so small. Moreover, they now claim that Himmelstein and Woolhandler “argue incorrectly that we ignored savings from paying less for prescription drugs.” In fact we didn’t ignore their estimated savings, but said they should be two-fold higher than the 25 percent they projected.

4. Utilization of care, Part 1: The original UI report estimated that single-payer reform would cause a $519 billion increase in health spending in 2017, even accounting for some savings on administration and drugs. But we noted that there just aren’t enough hospital beds or doctors to meet the huge surge in visits and hospitalizations they predict. To back up our claim we cited data from Canada (when its single-payer reform was implemented) and the U.S. (when Medicare and Medicaid were implemented). These data document that no, or very modest increases in society-wide use of care, occurred, and that instead care shifted from the rich and healthy to the sick and poor.

In response, the UI rejoinder says: “Contrary to HW’s [Himmelstein and Woolhandler’s] claim in their article, health care use and spending for the elderly population did increase substantially once the Medicare program was implemented in 1965.” Here (as in their claim about our statement on providers’ administrative costs) they have misquoted us. We wrote that “between 1964 (before Medicare) and 1966 (the year when Medicare was fully functioning) there was absolutely no increase in the total number of doctor visits,” and that “the same thing happened in hospitals.” While we are well aware that utilization by the elderly and the poor went up after Medicare and Medicaid were implemented, the point is that there was a compensatory, slight reduction in utilization by other Americans, reflecting the limitations imposed by the existing supply of hospital beds and doctors (most of whom were already working full time).

Here’s the actual data on the number of doctor visits per person (not just the elderly) before and after Medicare/Medicaid:

(Table in original article – link below)

And here’s the actual data on the total number of hospitalizations:

(Table in orignal article – link below)

In sum, we were correct in stating that the overall utilization of care showed no surge.

5. Utilization of care, Part 2: We noted in our critique that the lack of a surge in overall utilization in Canada, or with the start-up of Medicare/Medicaid, reflected a shift of care, with the newly insured poor and sick patients getting more of the care they needed, and the healthy and wealthy getting less elective and unnecessary care.

The UI rejoinder disputes that such a shift could occur. “HW [Himmelstein and Woolhandler] indicate that use would increase for the newly insured but would decrease by a similar amount for those already covered as physicians cease unnecessary services for those otherwise covered and perform additional necessary care for those otherwise uninsured. This assumption is faulty for two major reasons. First, no uniform definition of what is necessary and unnecessary exists in medical care; if such a definition existed, insurers would stop paying for all unnecessary care under our current health system. Second, there is absolutely no reason to believe that higher-income, currently insured individuals would lower their use of care under provider supply constraints.”

Their puzzlement displays a lack of familiarity with the considerable literature on variability in the utilization of care between different areas in the U.S., as well as the actual practice of medicine. John Wennberg and colleagues long ago observed that the number of surgical operations in a community showed only modest correlation with needs of the population, but was strongly correlated (r=.64) with the supply of surgeons.

As any doctor knows, doctors play a large role in regulating the amount of care they deliver. If we have no free appointment slots for the next month we’re likely to put off seeing our healthy patients a bit longer. Gastroenterologists often perform unnecessary screening colonoscopies. That’s not something many patients would demand. Indeed, the Aday paper referenced (to support a different point) in the UI rejoinder makes exactly our point: “After Medicare and Medicaid were introduced, providers may have begun to ration the number of visits by the ‘well-to-do’ to accommodate the influx of low-income patients with newly acquired purchasing power and a backlog of unmet need.”

In sum, there’s considerable evidence that doctor routinely adjust the utilization of care by their patients, and that when many additional people gain coverage, doctors shift care to this newly insured group, and compensate by reducing unneeded care for the wealthy and healthy.

6. What system was the UI analyzing? The UI researchers claimed to be estimating the budgetary impact of Sen. Sanders’ proposal. Yet now they tell us, “To be politically acceptable, compromises would have to be made, and those compromises are reflected in our assumptions.” In other words, their estimates are not actually based on the reform that Sanders (or we) have recommended. Instead they assume that the insurance and drug companies are too powerful to really rein in.

Overall, the UI response misrepresents key elements of our critique, and fails to address the erroneous assumptions that underlay their original analysis. Single-payer systems elsewhere provide more and better care at a lower price than we pay. The administrative bloat of our market-driven payment system accounts for much of the difference. While we recognize that a transition to a true single-payer system faces stiff political headwinds, it’s medically and economically feasible. And as Sen. Sanders has shown, political climates can be changed.

Drs. Woolhandler and Himmelstein are internists in the South Bronx, professors at the City University of New York School of Public Health at Hunter College, and lecturers in medicine at Harvard Medical School. The opinions expressed do not necessarily reflect those institutions’.

http://www.huffingtonpost.com/steffie-woolhandler/urban-institute-errors-single-payer-costs_b_10100836.html

The media continue to cite the flawed Urban Institute analysis of the costs of single payer while ignoring the actual facts as presented by David Himmelstein and Steffie Woolhandler. Yet the Urban Institute authors twice have felt compelled to answer the Himmelstein/Woolhandler criticism of their analysis. Woolhandler and Himmelstein respond here to Urban’s doubling down of errors in their second response.

The fundamental fact remains: “Single-payer systems elsewhere provide more and better care at a lower price than we pay.” The $3 trillion we are already spending on health care is enough to finance a comprehensive single-payer system here in the United States.

Shifting more health care spending to the federal budget is not a flaw of single payer, as Urban implies, but actually a benefit because it makes the funding more equitable and efficient.

We need to hold the media to the truth – the full truth.