PNHP

Medicare decreases spending without changing volume, compared to private insurers

Medicare decreases spending without changing volume, compared to private insurers

Traditional Medicare Versus Private Insurance: How Spending, Volume, And Price Change At Age Sixty-Five

By Jacob Wallace and Zirui Song
Health Affairs, May 2016

Abstract

To slow the growth of Medicare spending, some policy makers have advocated raising the Medicare eligibility age from the current sixty-five years to sixty-seven years. For the majority of affected adults, this would delay entry into Medicare and increase the time they are covered by private insurance. Despite its policy importance, little is known about how such a change would affect national health care spending, which is the sum of health care spending for all consumers and payers—including governments. We examined how spending differed between Medicare and private insurance using longitudinal data on imaging and procedures for a national cohort of individuals who switched from private insurance to Medicare at age sixty-five. Using a regression discontinuity design, we found that spending fell by $38.56 per beneficiary per quarter — or 32.4 percent — upon entry into Medicare at age sixty-five. In contrast, we found no changes in the volume of services at age sixty-five. For the previously insured, entry into Medicare led to a large drop in spending driven by lower provider prices, which may reflect Medicare’s purchasing power as a large insurer. These findings imply that increasing the Medicare eligibility age may raise national health care spending by replacing Medicare coverage with private insurance, which pays higher provider prices than Medicare does.

http://content.healthaffairs.org/content/35/5/864.abstract

***

Comment:

By Don McCanne, M.D.

This study looked at the changes in spending and volume of services for individuals who, at age 65, transferred from private insurance to the traditional Medicare program. The authors showed that the volume of services remained the same, but spending went down, which reflects the lower provider prices that Medicare pays compared to private insurers.

One suggestion that has been made to “save Medicare” from future federal budget deficits would be to increase the eligibility age from 65 to 67. They showed that this would actually increase our national health expenditures without changing the volume of services, not exactly the health care cost containment that we are seeking.

Conservatives and neoliberals might think that the increase in spending would be worth it just to advance their ideological goal of relying less on government spending and more on the private sector. But a portion of the reduction in federal spending would be offset by increased Medicaid coverage for those eligible, and increased ACA premium tax credits and  cost-sharing subsidies, resulting in tax revenue losses and greater outlays. Not a good deal at all.

Others have suggested that we should expand Medicare enrollment, perhaps by reducing the eligibility age in 5 year increments. Although it would be an extrapolation of this study, it is not unreasonable to assume that we could significantly reduce our expenditures without any change in the volume of services for those who otherwise would have been privately insured.

Or go all the way. Replace the private insurers with a Medicare for all program. Not only is Medicare a more efficient purchaser of health care services, the recovery of much of the profound administrative waste of our fragmented financing system would be enough to fully fund a health care system for all without increasing our national health expenditures from the current level.

Remember who the patient is. It is not the government budget. It is the people who need health care. Establishing a well-designed single payer Medicare-for-all system would take care of the people, and the government budget would perk along just fine.

Medicare decreases spending without changing volume, compared to private insurers

Traditional Medicare Versus Private Insurance: How Spending, Volume, And Price Change At Age Sixty-Five

By Jacob Wallace and Zirui Song
Health Affairs, May 2016

Abstract

To slow the growth of Medicare spending, some policy makers have advocated raising the Medicare eligibility age from the current sixty-five years to sixty-seven years. For the majority of affected adults, this would delay entry into Medicare and increase the time they are covered by private insurance. Despite its policy importance, little is known about how such a change would affect national health care spending, which is the sum of health care spending for all consumers and payers—including governments. We examined how spending differed between Medicare and private insurance using longitudinal data on imaging and procedures for a national cohort of individuals who switched from private insurance to Medicare at age sixty-five. Using a regression discontinuity design, we found that spending fell by $38.56 per beneficiary per quarter — or 32.4 percent — upon entry into Medicare at age sixty-five. In contrast, we found no changes in the volume of services at age sixty-five. For the previously insured, entry into Medicare led to a large drop in spending driven by lower provider prices, which may reflect Medicare’s purchasing power as a large insurer. These findings imply that increasing the Medicare eligibility age may raise national health care spending by replacing Medicare coverage with private insurance, which pays higher provider prices than Medicare does.

http://content.healthaffairs.org/content/35/5/864.abstract

This study looked at the changes in spending and volume of services for individuals who, at age 65, transferred from private insurance to the traditional Medicare program. The authors showed that the volume of services remained the same, but spending went down, which reflects the lower provider prices that Medicare pays compared to private insurers.

One suggestion that has been made to “save Medicare” from future federal budget deficits would be to increase the eligibility age from 65 to 67. They showed that this would actually increase our national health expenditures without changing the volume of services, not exactly the health care cost containment that we are seeking.

Conservatives and neoliberals might think that the increase in spending would be worth it just to advance their ideological goal of relying less on government spending and more on the private sector. But a portion of the reduction in federal spending would be offset by increased Medicaid coverage for those eligible, and increased ACA premium tax credits and  cost-sharing subsidies, resulting in tax revenue losses and greater outlays. Not a good deal at all.

Others have suggested that we should expand Medicare enrollment, perhaps by reducing the eligibility age in 5 year increments. Although it would be an extrapolation of this study, it is not unreasonable to assume that we could significantly reduce our expenditures without any change in the volume of services for those who otherwise would have been privately insured.

Or go all the way. Replace the private insurers with a Medicare for all program. Not only is Medicare a more efficient purchaser of health care services, the recovery of much of the profound administrative waste of our fragmented financing system would be enough to fully fund a health care system for all without increasing our national health expenditures from the current level.

Remember who the patient is. It is not the government budget. It is the people who need health care. Establishing a well-designed single payer Medicare-for-all system would take care of the people, and the government budget would perk along just fine.

Does the neoliberal label apply to our health care system?

Obamacare: The Neoliberal Model Comes Home to Roost in the United States — If We Let It

By Howard Waitzkin and Ida Hellander
Monthly Review, May 2016

(Excerpts)

Abundant data substantiate that the failure of Obamacare has become nearly inevitable. Even after the ACA is fully implemented, more than one-half of the previously uninsured population will remain uninsured — at least 27 million people, according to the non-partisan Congressional Budget Office — and at least twice that number will remain underinsured. Due to high deductibles (about $10,000 for a family bronze plan and $6,000 for silver) and co-payments, coverage under Obamacare has become unusable for many individuals and families, and employer-sponsored coverage is headed in the same direction. Private insurance generally produces administrative expenses about eight times higher than public administration; administrative waste has increased even more under Obamacare, and remains much higher than in other capitalist countries with national health programs. These administrative expenditures pay for activities like marketing, billing, denials of claims, processing copayments and deductibles, exorbitant salaries and deferred income for executives (sometimes more than $30 million per year), profits, and dividends for corporate shareholders. The overall costs of the health system under Obamacare are projected to rise from 17.4 percent of GDP in 2013 to 19.6 percent in 2022.

The overall structure of Obamacare is not new. Similar “reforms” have appeared in other countries over the last two decades.

Such proposals fostered neoliberalism. They promoted multiple competing, for-profit, private insurance corporations. Programs and institutions previously based in the public sector were cut back and, if possible, privatized. Overall government budgets for public-sector health care were reduced. Private corporations gained access to public trust funds. Public hospitals and clinics entered into competition with private institutions, their budgets were determined by demand rather than supply, and prior global budgets for safety net institutions were not guaranteed. Insurance executives made operational decisions about services, and their authority superseded that of physicians and other clinicians.

The Boilerplate Neoliberal Health Reform

Health reform proposals across different countries have resembled one another closely. The specific details of each plan appeared to conform to a word-processed, cookie-cutter template, in which only the names of national institutions and local actors have varied. Six broad features have characterized nearly all neoliberal health initiatives.

1. Organizations of providers. One element of neoliberal proposals involves large privately controlled organizations of health care providers. These organizations operate under the direct control or strong influence of private, for-profit insurance corporations, in collaboration with hospitals and health systems.

2. Organizations of purchasers. A second element of neoliberal proposals involves large organizations purchasing or facilitating the purchase of private health insurance, usually through MCOs.

3. Constriction of public hospitals and safety net providers. Public hospitals at the state, county, or municipal levels compete for patients covered under public programs like Medicaid or Medicare with private hospitals participating as subsidiaries or contractors of insurance corporations or MCOs. With less public-sector funding, public hospitals reduce services and programs, and many eventually close. Although community health centers (CHCs) sometimes enjoy temporary improvements in funding, as in Obamacare, they increasingly serve as the providers of last resort for the remaining uninsured and underinsured. As a result, CHCs remain vulnerable to cutbacks and face an insecure future.

4. Tiered benefits packages. Neoliberal proposals define benefits packages in hierarchical tiers. The national reform provides a minimum package of benefits that experts view as essential, and individuals or their employers can buy additional coverage. Poor and near poor people in the U.S. Medicaid program are eligible for benefits that used to be free of cost-sharing, but since Obamacare passed, states increasingly have imposed premiums and copayments.

5. Complex multi-payer and multi-payment financing. Financial flows under neoliberal health policies are very complex. The costs of administering these flows and other components of neoliberal policies also are quite high (about 25 to 28 percent of total health care expenditures) and keep increasing. Under Obamacare, administrative overhead — also referred to administrative “waste,” since the costs do not contribute to direct patient services — grew 10.6 percent in 2014, faster than any other component of health care except medications.

6. Changes in tax code. Partly because they increase administrative costs and profits, neoliberal reforms usually lead to higher taxes.

Many countries have rejected the neoliberal model, and have instead constructed health systems based on the goal of “health care for all” (HCA). Such countries strive to provide universal access to care without tiers of differing benefit packages for rich and poor. For instance, Canada prohibits private insurance coverage for services provided by its national health program. Because Canada’s wealthy must participate in the publicly financed system, the presence of the entire population in a unitary system assures a high-quality national program. In Latin America, countries trying to advance the HCA model include Bolivia, Brazil, Cuba, Ecuador, Uruguay, and Venezuela. The inevitable failure of Obamacare may open a space, finally, for even the United States to pursue a national health program that does not follow the neoliberal model.

The Single-Payer Proposal

The following features of a single-payer option come from the proposals of Physicians for a National Health Program (PNHP), a group of more than 20,000 medical professionals, spanning all specialties, states, age groups, and practice settings. According to the PNHP proposals, coverage would be universal for all needed services, including medications and long-term care. There would be no out-of-pocket premiums, copayments, or deductibles. Costs would be controlled by “monopsony” financing from a single, public source. The NHP would not permit competing private insurance and would eliminate multiple tiers of care for different income groups. Practitioners and clinics would be paid predetermined fees for services, without any need for costly billing procedures. Hospitals would negotiate an annual global budget for all operating costs. For-profit, investor-owned facilities would be prohibited from participation. Most non-profit hospitals would remain privately owned. To reduce overlapping and redundant facilities, capital purchases and expansion would be budgeted separately, based on regional health planning goals.

Funding sources would include current federal spending for Medicare and Medicaid, a payroll tax on private businesses less than what businesses currently pay for coverage, and an income tax on households, with a surtax on high incomes and capital gains. A small tax on stock transactions would be implemented, while state and local taxes for health care would be eliminated. Under this financing plan, 95 percent of families would pay less for health care than they previously paid in insurance premiums, deductibles, copayments, other out-of-pocket spending, and reduced wages.

Moving Beyond Single Payer

The coming failure of Obamacare will mark a moment of transformation in the United States, where neoliberalism has come home to roost. For that moment, those struggling for a just and accessible health system will need to address some profound changes that have occurred during the era of neoliberalism. These changes pertain to the shifting social class position of health professionals, and to the increasingly oligopolistic and financialized character of the health insurance industry.

Beyond the changing class position of health professionals, the transition as Obamacare collapses will need to address the oligopolistic character of the insurance industry, alongside the consolidation of large health systems. Obamacare has increased the flow of capitated public and private funds into the insurance industry and thus has extended the overall financialization of the global economy.

In this context, it is important to reconsider the distinction between national health insurance (NHI) and a national health service (NHS). NHI involves socialization of payments for health services but usually leaves intact private ownership at the level of infrastructure. Except for a small proportion of institutions like public hospitals and clinics, under NHI the means of production in health care remain privately owned. Canada is the best-known model of NHI. The PNHP proposal and Congressional legislation that embodies the singer-payer approach are based on the Canadian model of NHI.

The PNHP single-payer proposal emerged from a retreat in New Hampshire during 1986, where activists struggled with these distinctions. Although most participants at the retreat had worked hard for the Dellums NHS proposal, they reached a consensus — albeit with some ambivalence — to shift their work to an NHI proposal based on Canada. The rationale for this shift involved two main considerations. First, Canada’s proximity and cultural similarity to the United States would make it more palatable for the U.S. population, and especially its Congressional representatives. Secondly, a Canadian-style NHI proposal could be “doctor-friendly.” Under the PNHP proposal, physicians could continue to work in private practice, clinics, or hospitals. The main difference for physicians was that payments would be socialized, so that the physicians would not have to worry about billing and collecting their fees for services provided.

While PNHP has achieved great success in its research and policy work, these efforts, and those of many other organizations supporting single payer, have not yet generated a broad social movement working toward a Canadian-style NHI. Meanwhile, the neoliberal model, with all its benefits for the ruling class and drawbacks for everyone else, has solidified its hegemony. Partly as a result, physicians and other health professionals are becoming proletarianized employees of an increasingly consolidated, profit-driven, financialized health care system. And under Obamacare, the state has continued to prioritize protection of the capitalist economic system, in this case by overseeing huge subsidies for private insurance and pharmaceutical corporations.

http://monthlyreview.org/2016/05/01/obamacare/

***

Encyclopedia Britannica

Neoliberalism: ideology and policy model that emphasizes the value of free market competition.

Neoliberal ideology and policies became increasingly influential, as illustrated by the British Labour Party’s official abandonment of its commitment to the “common ownership of the means of production” in 1995 and by the cautiously pragmatic policies of the Labour Party and the U.S. Democratic Party from the 1990s.

http://www.britannica.com/topic/neoliberalism

***

A Neoliberal’s Manifesto

By Charles Peters, Founder and Editor
The Washington Monthly, May 1983

If neoconservatives are liberals who took a critical look at liberalism and decided to become conservatives, we are liberals who took the same look and decided to retain our goals but to abandon some of our prejudices. We still believe in liberty and justice and a fair chance for all, in mercy for the afflicted and help for the down and out. But we no longer automatically favor unions and big government or oppose the military and big business. Indeed, in our search for solutions that work, we have come to distrust all automatic responses, liberal or conservative.

http://www.washingtonmonthly.com/features/1983/8305_Neoliberalism.pdf

***

Comment:

By Don McCanne, M.D.

The majority of Americans would like to see a high quality health care system that is affordable and accessible for everyone. We do not have that now. Why not?

Progressives/liberals generally recognize that costs and market dysfunctions require a major role of government in financing health care. Conservatives/libertarians believe that free markets can fulfill that role with the exception that those impoverished not by choice need private charity or the helping hand of government. But it is those in the middle – the moderates – who determine policy through the election process. So who are they?

They are both Republicans and Democrats. In health care, they support private financing, primarily through insurance, though they support public tax expenditures to help pay for the most common coverage – employer-sponsored plans. They also support Medicare for seniors and those with disabilities, and most support Medicaid for low-income individuals and families.

In fact, President Obama abandoned single payer in favor of the Heritage Foundation proposal, based on these principles, since it had broad bipartisan support – or so he thought, until the Republicans decided that a political defeat for Obama was more important than improving our health care system.

So what happened to these moderates? The Republicans have retreated toward the right where they would try to tolerate the conservative tea party faction. The moderate Democrats did not move to the left but instead also moved somewhat toward the right into the pro-market neoliberal niche. Following the groundwork laid by President Reagan, President Bill Clinton followed a neoliberal path in which “the era of big government is over” (State of the Union, 1996). The neoliberals then became the establishment force in the Democratic Party. President Obama, whether voluntarily or through political obstructionism, did not change the direction of the party. The likely next president has indicated that she will follow the neoliberal Clintonian path as well and not change direction in health care.

Today’s article describes how neoliberalism and its advocacy of using markets instead of the government to control the financing of health care has resulted in our overpriced and underperforming health care system, as if the neoliberals have failed to see the irony of a health care system that is already 60 percent funded through the tax system and that has failed to conform to free market dynamics.

Whatever labels are used, the majority of Americans support Medicare. If we already had an improved version of Medicare that included everyone, the support would be near unanimous. The neoliberals either need to take a reality check on their ideology, or they need to attend the next local tea party function and listen to the voices extolling the virtues of a society without a functioning government.

Letter: Frayed health care

By Dr. Arthur J. Sutherland III
The Commercial Appeal, May 1, 2016

MEMPHIS — Recent articles in local and national publications have documented increasing stress in health care for the providers.

Locally, Dr. Frank Masur wrote about finding a sense of helplessness in physicians that can lead to depression and thoughts of early retirement.

Nationally, ethicist Arthur Kaplan sees physician burnout as a public health crisis. He quotes a recent study from the Mayo Clinic documenting burnout rising from 45.5 percent of doctors in 2011 to 54.4 percent in 2014.

This is a real problem, since doctors who feel this way can commit more errors. They suffer from compassion fatigue from their own emotional issues. Four hundred doctors committed suicide in 2015, which is double the rate of the population average. So there is trouble for patients in having a workforce that is burned out, and trouble for doctors in terms of their own health and wellness.

Dr. Don McCanne, senior scholar for Physicians for a National Health Program, feels that this crisis of professional burnout also undermines the all-important physician-patient relationship.

A major contributor to burnout is the subversion of physician independence to the massive misdirected oversight interposed by public and private insurance bureaucracies that waste tremendous resources while creating havoc in our health care delivery system.

We need to understand that public policies that make health care worse are unethical policies. We need to expand and improve Medicare for All, a single-payer system that would bring health care equity and justice to everyone in the U.S.

http://www.commercialappeal.com/opinion/letters-to-the-editor/Letter-Frayed-health-care-377665261.html

Colorado Weighs Replacing Obama’s Health Policy With Universal Coverage

By Jack Healy
The New York Times, April 28, 2016

DENVER — For years, voters in this swing state have rejected tax increases and efforts to expand government. But now they are flirting with a radical transformation: whether to abandon President Obama’s health care policy and instead create a new, taxpayer-financed public health system that guarantees coverage for everyone.

The estimated $38-billion-a-year proposal, which will go before Colorado voters in November, will test whether people have an appetite for a new system that goes further than the Affordable Care Act. That question is also in play in the Democratic presidential primaries.

The state-level effort, which supporters here call the ColoradoCare plan, would do away with deductibles. It would allow patients to choose doctors and specialists without distinguishing between those “in network” and those “out of network.” It would largely be paid for with a tax increase on workers and businesses, and cover everyone in the state. Supporters say most people would end up saving money.

Insurance groups, chambers of commerce and conservatives have already lined up in opposition. They say the plan’s details are vague, its size and cost galling. The proposed health system would have a budget bigger than that of Colorado’s entire state government. A new 10 percent tax on payroll and incomes to pay for the system would push Colorado’s tax rates to some of the highest in the nation.

The proposal’s chance of success is dubious. Colorado has a mixed record when it comes to ballot measures, though it has passed some notable ones over the years, including marijuana legalization and the Taxpayer Bill of Rights, an anti-tax, anti-spending constitutional amendment.

But the proposal had enough support to garner 100,000 signatures, which put it on the ballot. It has also worried insurers, and some in the medical community and the business community, enough for them to organize in opposition, even enlisting a Democratic former governor to help in their campaign.

In this season of political discontent, the notion of dismantling the health insurance system has tapped an aquifer of frustration from voters. People say that even after the Affordable Care Act, they still pay too much in premiums, plus thousands in deductibles, and still have to worry about being bankrupted by a disabling car crash or an extended hospital stay.

“I think insurance is one of the biggest jokes and crooks,” said Brandon Barta, 38, of Denver. He said his father, Dixon, who worked at a gas station, never received aggressive enough treatment for his prostate cancer. He died last May at the age of 64.

“He was overlooked,” Mr. Barta said.

Mr. Barta said he was intrigued by the idea of a universal health plan that covered maternity care, checkups, emergency room visits and hospital stays, all the way through end-of-life care. Like millions of Americans, he has health insurance tied to his work. His coverage lapsed recently when he switched jobs to start working for a golf entertainment complex, and he is still waiting for his new plan to kick in.

Still, he has questions about how universal coverage would work and how much it would cost taxpayers like him.

The answers: If a majority of voters say yes, the system would start running in 2019, and essentially be a start-up health cooperative bigger than companies like Nike and American Express, according to the Colorado Health Institute, an independent policy group. A 21-person elected board would set the benefits and budgets. The system would be financed by payroll taxes of 3.3 percent for workers and 6.7 percent for employers. It would impose a 10 percent tax on investment income, people who are self-employed and some small-business income.

In the contest for the Democratic presidential nomination, Hillary Clinton, echoing many moderate Democratic leaders here, has said that she wants to keep and improve the Affordable Care Act, Mr. Obama’s signature legislative legacy. But her opponent, Senator Bernie Sanders, who won Colorado’s Democratic caucuses last month by nearly 20 points, has advocated abandoning the health law for a “Medicare for all” approach. His proposal is similar to the ColoradoCare plan.

The campaign over the Colorado initiative has had the unusual effect of putting conservative critics in the position of defending Mr. Obama’s health plan against an assault from the left. At the same time, it is energizing progressives, who say the Affordable Care Act was a giveaway to the insurance industry that, even with an estimated 20 million people newly insured, has left too many others without coverage.

“No matter how long we hang in there with the Affordable Care Act, we will never cover everybody,” said Jeanne Nicholson, a former Democratic state senator and nurse who is a leading supporter of universal care here. “We don’t understand why we should compromise and say some people can have bronze coverage, some can have silver and some can have gold. Why can’t we all have platinum plus?”

Nathan Wilkes, 42, who lives in the Denver suburbs, said that years of trying to get care for his son, who has hemophilia, had worn his family thin and made him an advocate for universal coverage. He said the family had spent thousands of dollars and destroyed its credit because of insufficient coverage. The Affordable Care Act offered some benefits, he said, but its gaps were still too big and “not sustainable.”

Unlike its conservative neighbors, Colorado jumped to get on board with the Affordable Care Act. It set up its own insurance marketplace and expanded Medicaid coverage for poorer residents. But there have been stumbles. People in mountain towns with few providers faced eye-popping premiums for coverage. Colorado’s biggest health cooperative, Colorado HealthOP, shut down in October, forcing more than 80,000 people to find new plans.

Colorado’s plan would replace many private workplace plans, but it would sit alongside Medicare and federal health coverage for veterans, and private insurers could still sell coverage to people who wanted more.

The Colorado Health Institute, an independent policy group, said the plan’s passage would be “the most far-reaching health care reform in any state” since the Affordable Care Act.

“It’s replacing a system that I think has become really dysfunctional,” said Irene Aguilar, a Democratic state senator and physician who is leading the effort. “The game has been rigged by the for-profit corporations to ensure they win.”

Opponents say that it could wreck the state’s humming economy and drive away doctors and businesses, and that its costs could spiral out of control.

If it passes, ColoradoCare would become part of the state Constitution, and become virtually impossible to significantly alter without a statewide vote. It would also fall outside the reach of the Taxpayer Bill of Rights, a 1992 amendment to the Colorado Constitution that put strict limits on spending and new taxes.

“It would be a disastrous economic impact on the state,” said Walker Stapleton, Colorado’s treasurer and a co-chairman of the opposition campaign. “If you think legalized pot brought a lot of people to Colorado, you should try free health care.”

Like many other Republicans here, Mr. Stapleton opposed the Affordable Care Act and continues to criticize how it has been put in place. But to defeat the new initiative, he now finds himself defending the federal health law.

Sean Duffy, a Republican and a spokesman for the opposition campaign, said many of his neighbors in the conservative Denver suburb of Highlands Ranch had eagerly signed the petition to put the question on the November ballot because they saw it as a way to get rid of Obamacare.

Some Democratic officials also oppose the state’s universal care effort. They include Gov. John Hickenlooper, who said during his 2014 re-election fight that he was “no big fan of the Affordable Care Act.”

Colorado’s previous Democratic governor, Bill Ritter, also opposes it.

Michelle Lucero, general counsel at Children’s Hospital Colorado, is among the health care officials lining up against the measure. (The hospital itself also opposes it.) She worries that it could threaten research dollars or drive away doctors.

“They’re going to choose to go to a state that’s not hamstrung by this,” she said.

http://www.nytimes.com/2016/04/29/us/colorado-weighs-replacing-obamas-health-policy-with-universal-coverage.html?_r=1

Does the neoliberal label apply to our health care system?

Obamacare: The Neoliberal Model Comes Home to Roost in the United States — If We Let It

By Howard Waitzkin and Ida Hellander
Monthly Review, May 2016

(Excerpts)

Abundant data substantiate that the failure of Obamacare has become nearly inevitable. Even after the ACA is fully implemented, more than one-half of the previously uninsured population will remain uninsured — at least 27 million people, according to the non-partisan Congressional Budget Office — and at least twice that number will remain underinsured. Due to high deductibles (about $10,000 for a family bronze plan and $6,000 for silver) and co-payments, coverage under Obamacare has become unusable for many individuals and families, and employer-sponsored coverage is headed in the same direction. Private insurance generally produces administrative expenses about eight times higher than public administration; administrative waste has increased even more under Obamacare, and remains much higher than in other capitalist countries with national health programs. These administrative expenditures pay for activities like marketing, billing, denials of claims, processing copayments and deductibles, exorbitant salaries and deferred income for executives (sometimes more than $30 million per year), profits, and dividends for corporate shareholders. The overall costs of the health system under Obamacare are projected to rise from 17.4 percent of GDP in 2013 to 19.6 percent in 2022.

The overall structure of Obamacare is not new. Similar “reforms” have appeared in other countries over the last two decades.

Such proposals fostered neoliberalism. They promoted multiple competing, for-profit, private insurance corporations. Programs and institutions previously based in the public sector were cut back and, if possible, privatized. Overall government budgets for public-sector health care were reduced. Private corporations gained access to public trust funds. Public hospitals and clinics entered into competition with private institutions, their budgets were determined by demand rather than supply, and prior global budgets for safety net institutions were not guaranteed. Insurance executives made operational decisions about services, and their authority superseded that of physicians and other clinicians.

The Boilerplate Neoliberal Health Reform

Health reform proposals across different countries have resembled one another closely. The specific details of each plan appeared to conform to a word-processed, cookie-cutter template, in which only the names of national institutions and local actors have varied. Six broad features have characterized nearly all neoliberal health initiatives.

1. Organizations of providers. One element of neoliberal proposals involves large privately controlled organizations of health care providers. These organizations operate under the direct control or strong influence of private, for-profit insurance corporations, in collaboration with hospitals and health systems.

2. Organizations of purchasers. A second element of neoliberal proposals involves large organizations purchasing or facilitating the purchase of private health insurance, usually through MCOs.

3. Constriction of public hospitals and safety net providers. Public hospitals at the state, county, or municipal levels compete for patients covered under public programs like Medicaid or Medicare with private hospitals participating as subsidiaries or contractors of insurance corporations or MCOs. With less public-sector funding, public hospitals reduce services and programs, and many eventually close. Although community health centers (CHCs) sometimes enjoy temporary improvements in funding, as in Obamacare, they increasingly serve as the providers of last resort for the remaining uninsured and underinsured. As a result, CHCs remain vulnerable to cutbacks and face an insecure future.

4. Tiered benefits packages. Neoliberal proposals define benefits packages in hierarchical tiers. The national reform provides a minimum package of benefits that experts view as essential, and individuals or their employers can buy additional coverage. Poor and near poor people in the U.S. Medicaid program are eligible for benefits that used to be free of cost-sharing, but since Obamacare passed, states increasingly have imposed premiums and copayments.

5. Complex multi-payer and multi-payment financing. Financial flows under neoliberal health policies are very complex. The costs of administering these flows and other components of neoliberal policies also are quite high (about 25 to 28 percent of total health care expenditures) and keep increasing. Under Obamacare, administrative overhead — also referred to administrative “waste,” since the costs do not contribute to direct patient services — grew 10.6 percent in 2014, faster than any other component of health care except medications.

6. Changes in tax code. Partly because they increase administrative costs and profits, neoliberal reforms usually lead to higher taxes.

Many countries have rejected the neoliberal model, and have instead constructed health systems based on the goal of “health care for all” (HCA). Such countries strive to provide universal access to care without tiers of differing benefit packages for rich and poor. For instance, Canada prohibits private insurance coverage for services provided by its national health program. Because Canada’s wealthy must participate in the publicly financed system, the presence of the entire population in a unitary system assures a high-quality national program. In Latin America, countries trying to advance the HCA model include Bolivia, Brazil, Cuba, Ecuador, Uruguay, and Venezuela. The inevitable failure of Obamacare may open a space, finally, for even the United States to pursue a national health program that does not follow the neoliberal model.

The Single-Payer Proposal

The following features of a single-payer option come from the proposals of Physicians for a National Health Program (PNHP), a group of more than 20,000 medical professionals, spanning all specialties, states, age groups, and practice settings. According to the PNHP proposals, coverage would be universal for all needed services, including medications and long-term care. There would be no out-of-pocket premiums, copayments, or deductibles. Costs would be controlled by “monopsony” financing from a single, public source. The NHP would not permit competing private insurance and would eliminate multiple tiers of care for different income groups. Practitioners and clinics would be paid predetermined fees for services, without any need for costly billing procedures. Hospitals would negotiate an annual global budget for all operating costs. For-profit, investor-owned facilities would be prohibited from participation. Most non-profit hospitals would remain privately owned. To reduce overlapping and redundant facilities, capital purchases and expansion would be budgeted separately, based on regional health planning goals.

Funding sources would include current federal spending for Medicare and Medicaid, a payroll tax on private businesses less than what businesses currently pay for coverage, and an income tax on households, with a surtax on high incomes and capital gains. A small tax on stock transactions would be implemented, while state and local taxes for health care would be eliminated. Under this financing plan, 95 percent of families would pay less for health care than they previously paid in insurance premiums, deductibles, copayments, other out-of-pocket spending, and reduced wages.

Moving Beyond Single Payer

The coming failure of Obamacare will mark a moment of transformation in the United States, where neoliberalism has come home to roost. For that moment, those struggling for a just and accessible health system will need to address some profound changes that have occurred during the era of neoliberalism. These changes pertain to the shifting social class position of health professionals, and to the increasingly oligopolistic and financialized character of the health insurance industry.

Beyond the changing class position of health professionals, the transition as Obamacare collapses will need to address the oligopolistic character of the insurance industry, alongside the consolidation of large health systems. Obamacare has increased the flow of capitated public and private funds into the insurance industry and thus has extended the overall financialization of the global economy.

In this context, it is important to reconsider the distinction between national health insurance (NHI) and a national health service (NHS). NHI involves socialization of payments for health services but usually leaves intact private ownership at the level of infrastructure. Except for a small proportion of institutions like public hospitals and clinics, under NHI the means of production in health care remain privately owned. Canada is the best-known model of NHI. The PNHP proposal and Congressional legislation that embodies the singer-payer approach are based on the Canadian model of NHI.

The PNHP single-payer proposal emerged from a retreat in New Hampshire during 1986, where activists struggled with these distinctions. Although most participants at the retreat had worked hard for the Dellums NHS proposal, they reached a consensus — albeit with some ambivalence — to shift their work to an NHI proposal based on Canada. The rationale for this shift involved two main considerations. First, Canada’s proximity and cultural similarity to the United States would make it more palatable for the U.S. population, and especially its Congressional representatives. Secondly, a Canadian-style NHI proposal could be “doctor-friendly.” Under the PNHP proposal, physicians could continue to work in private practice, clinics, or hospitals. The main difference for physicians was that payments would be socialized, so that the physicians would not have to worry about billing and collecting their fees for services provided.

While PNHP has achieved great success in its research and policy work, these efforts, and those of many other organizations supporting single payer, have not yet generated a broad social movement working toward a Canadian-style NHI. Meanwhile, the neoliberal model, with all its benefits for the ruling class and drawbacks for everyone else, has solidified its hegemony. Partly as a result, physicians and other health professionals are becoming proletarianized employees of an increasingly consolidated, profit-driven, financialized health care system. And under Obamacare, the state has continued to prioritize protection of the capitalist economic system, in this case by overseeing huge subsidies for private insurance and pharmaceutical corporations.

http://monthlyreview.org/2016/05/01/obamacare/

***

Encyclopedia Britannica

Neoliberalism: ideology and policy model that emphasizes the value of free market competition.

Neoliberal ideology and policies became increasingly influential, as illustrated by the British Labour Party’s official abandonment of its commitment to the “common ownership of the means of production” in 1995 and by the cautiously pragmatic policies of the Labour Party and the U.S. Democratic Party from the 1990s.

http://www.britannica.com/topic/neoliberalism

***

A Neoliberal’s Manifesto

By Charles Peters, Founder and Editor
The Washington Monthly, May 1983

If neoconservatives are liberals who took a critical look at liberalism and decided to become conservatives, we are liberals who took the same look and decided to retain our goals but to abandon some of our prejudices. We still believe in liberty and justice and a fair chance for all, in mercy for the afflicted and help for the down and out. But we no longer automatically favor unions and big government or oppose the military and big business. Indeed, in our search for solutions that work, we have come to distrust all automatic responses, liberal or conservative.

http://www.washingtonmonthly.com/features/1983/8305_Neoliberalism.pdf

The majority of Americans would like to see a high quality health care system that is affordable and accessible for everyone. We do not have that now. Why not?

Progressives/liberals generally recognize that costs and market dysfunctions require a major role of government in financing health care. Conservatives/libertarians believe that free markets can fulfill that role with the exception that those impoverished not by choice need private charity or the helping hand of government. But it is those in the middle – the moderates – who determine policy through the election process. So who are they?

They are both Republicans and Democrats. In health care, they support private financing, primarily through insurance, though they support public tax expenditures to help pay for the most common coverage – employer-sponsored plans. They also support Medicare for seniors and those with disabilities, and most support Medicaid for low-income individuals and families.

In fact, President Obama abandoned single payer in favor of the Heritage Foundation proposal, based on these principles, since it had broad bipartisan support – or so he thought, until the Republicans decided that a political defeat for Obama was more important than improving our health care system.

So what happened to these moderates? The Republicans have retreated toward the right where they would try to tolerate the conservative tea party faction. The moderate Democrats did not move to the left but instead also moved somewhat toward the right into the pro-market neoliberal niche. Following the groundwork laid by President Reagan, President Bill Clinton followed a neoliberal path in which “the era of big government is over” (State of the Union, 1996). The neoliberals then became the establishment force in the Democratic Party. President Obama, whether voluntarily or through political obstructionism, did not change the direction of the party. The likely next president has indicated that she will follow the neoliberal Clintonian path as well and not change direction in health care.

Today’s article describes how neoliberalism and its advocacy of using markets instead of the government to control the financing of health care has resulted in our overpriced and underperforming health care system, as if the neoliberals have failed to see the irony of a health care system that is already 60 percent funded through the tax system and that has failed to conform to free market dynamics.

Whatever labels are used, the majority of Americans support Medicare. If we already had an improved version of Medicare that included everyone, the support would be near unanimous. The neoliberals either need to take a reality check on their ideology, or they need to attend the next local tea party function and listen to the voices extolling the virtues of a society without a functioning government.

Focus groups confirm that ACA is not affordable for many

Is ACA Coverage Affordable for Low-Income People? Perspectives from Individuals in Six Cities

By Jennifer Tolbert, Robin Rudowitz, and Melissa Majerol
Kaiser Family Foundation, April 21, 2016

Millions of people have gained access to health insurance coverage under the Affordable Care Act (ACA) through Medicaid and the Marketplaces. While research shows that coverage improves access to care and promotes financial stability, issues around access and affordability remain, and are more acute for the low-income population. To learn more about how low-income individuals have fared with their new coverage, we conducted nine focus groups (three groups with Medicaid enrollees and six groups with low-income Marketplace enrollees) in six states (California, Florida, Maryland, Missouri, Ohio, and Virginia).  Many participants were struggling financially and reported substantial debt (including medical debt). Many had ongoing physical and mental health needs and were accessing health services to treat those conditions. Following are key themes from the groups:

1.  New coverage did not change underlying financial struggles and hardship due to medical debt incurred prior to gaining coverage. Many participants were stretched financially, had limited capacity to absorb unexpected costs, and struggled with finding secure employment in their area.

2.  Medicaid stands up well for the lowest income participants in terms of ease of enrollment, out-of-pocket costs and affordability, and ability to find providers and access care. A small number of participants reported trouble affording care that wasn’t covered (particularly for vision or dental) and difficulty finding some providers, including mental health providers.

3.  Largely due to premium tax credits in the Marketplace, premiums were generally affordable, but out-of-pocket costs weighed heavily on Marketplace participants, especially those with high deductible plans. Many reported being overwhelmed by plan choices. Some were able to make trade-offs to purchase higher cost plans with lower deductibles to meet anticipated care needs, but not everyone was able to afford higher premiums.

4.  The fear of unknown costs was a constant worry for many Marketplace participants. Many got bills for services they thought were covered, such as screenings, colonoscopies and mammograms when issues were discovered and treated. These bills caused many to avoid getting needed care. Marketplace participants also reported trouble affording care that wasn’t covered by their plan, notably vision and some dental services.

5.  Most participants had accessed care and were positive overall about new ACA coverage through Medicaid and the Marketplace. They were grateful that coverage was available to them, particularly those who had been previously ineligible for Medicaid or barred from private coverage due to pre-existing conditions. However, many Marketplace participants wanted coverage to be more affordable.

While people were grateful for coverage, unexpected bills, dealing with insurance companies, and facing known deductibles were sources of stress which made those with Marketplace coverage fearful to use the coverage they had. They were particularly frustrated by the out-of-pocket costs, which were unaffordable to many and wanted insurance that didn’t come with so many hidden costs.

http://kff.org/health-reform/issue-brief/is-aca-coverage-affordable-for-low-income-people-perspectives-from-individuals-in-six-cities/

Issue Brief:

http://kff.org/report-section/is-aca-coverage-affordable-for-low-income-people-perspectives-from-individuals-in-six-cities-issue-brief-8867/

***

Comment:

By Don McCanne, M.D.

This report of nine focus groups confirms that real people have found that the Affordable Care Act (ACA) often fails to provide access to affordable care.

Although the leading candidate for president has said that she wants to build on ACA, reducing premiums and deductibles pours yet more tax money into what is the most expensive and least efficient model of health care financing. The model cannot really be fixed if we want true value in health care. It needs to be replaced with a model that does work – a single payer national health program – Improved Medicare for All.

Focus groups confirm that ACA is not affordable for many

Is ACA Coverage Affordable for Low-Income People? Perspectives from Individuals in Six Cities

By Jennifer Tolbert, Robin Rudowitz, and Melissa Majerol
Kaiser Family Foundation, April 21, 2016

Millions of people have gained access to health insurance coverage under the Affordable Care Act (ACA) through Medicaid and the Marketplaces. While research shows that coverage improves access to care and promotes financial stability, issues around access and affordability remain, and are more acute for the low-income population. To learn more about how low-income individuals have fared with their new coverage, we conducted nine focus groups (three groups with Medicaid enrollees and six groups with low-income Marketplace enrollees) in six states (California, Florida, Maryland, Missouri, Ohio, and Virginia).  Many participants were struggling financially and reported substantial debt (including medical debt). Many had ongoing physical and mental health needs and were accessing health services to treat those conditions. Following are key themes from the groups:

1.  New coverage did not change underlying financial struggles and hardship due to medical debt incurred prior to gaining coverage. Many participants were stretched financially, had limited capacity to absorb unexpected costs, and struggled with finding secure employment in their area.

2.  Medicaid stands up well for the lowest income participants in terms of ease of enrollment, out-of-pocket costs and affordability, and ability to find providers and access care. A small number of participants reported trouble affording care that wasn’t covered (particularly for vision or dental) and difficulty finding some providers, including mental health providers.

3.  Largely due to premium tax credits in the Marketplace, premiums were generally affordable, but out-of-pocket costs weighed heavily on Marketplace participants, especially those with high deductible plans. Many reported being overwhelmed by plan choices. Some were able to make trade-offs to purchase higher cost plans with lower deductibles to meet anticipated care needs, but not everyone was able to afford higher premiums.

4.  The fear of unknown costs was a constant worry for many Marketplace participants. Many got bills for services they thought were covered, such as screenings, colonoscopies and mammograms when issues were discovered and treated. These bills caused many to avoid getting needed care. Marketplace participants also reported trouble affording care that wasn’t covered by their plan, notably vision and some dental services.

5.  Most participants had accessed care and were positive overall about new ACA coverage through Medicaid and the Marketplace. They were grateful that coverage was available to them, particularly those who had been previously ineligible for Medicaid or barred from private coverage due to pre-existing conditions. However, many Marketplace participants wanted coverage to be more affordable.

While people were grateful for coverage, unexpected bills, dealing with insurance companies, and facing known deductibles were sources of stress which made those with Marketplace coverage fearful to use the coverage they had. They were particularly frustrated by the out-of-pocket costs, which were unaffordable to many and wanted insurance that didn’t come with so many hidden costs.

http://kff.org/health-reform/issue-brief/is-aca-coverage-affordable-for-low-income-people-perspectives-from-individuals-in-six-cities/

Issue Brief:

http://kff.org/report-section/is-aca-coverage-affordable-for-low-income-people-perspectives-from-individuals-in-six-cities-issue-brief-8867/

This report of nine focus groups confirms that real people have found that the Affordable Care Act (ACA) often fails to provide access to affordable care.

Although the leading candidate for president has said that she wants to build on ACA, reducing premiums and deductibles pours yet more tax money into what is the most expensive and least efficient model of health care financing. The model cannot really be fixed if we want true value in health care. It needs to be replaced with a model that does work – a single payer national health program – Improved Medicare for All.

Paul Ryan does not seem to understand high-risk pools

Ryan wants to end Obamacare cost protections for sick consumers

By David Morgan
Reuters, April 27, 2016

U.S. House of Representatives Speaker Paul Ryan called on Wednesday for an end to Obamacare’s financial protections for people with serious medical conditions, saying these consumers should be placed in state high-risk pools.

In election-year remarks that could shed light on an expected Republican healthcare alternative, Ryan said existing federal policy that prevents insurers from charging sick people higher rates for health coverage has raised costs for healthy consumers while undermining choice and competition.

The rule, a cornerstone of President Barack Obama’s Affordable Care Act, has been praised by patient advocates for providing access to medical care for people who previously could not afford private health insurance. The Affordable Care Act also bars insurers from excluding coverage for pre-existing conditions.

“Less than 10 percent of people under 65 are what we call people with pre-existing conditions, who are really kind of uninsurable,” Ryan, a Wisconsin Republican, told a student audience at Georgetown University.

“Let’s fund risk pools at the state level to subsidize their coverage, so that they can get affordable coverage,” he said. “You dramatically lower the price for everybody else. You make health insurance so much more affordable, so much more competitive and open up competition.”

High-risk pools, which existed before the healthcare law, are state-level entities that guarantee coverage for people with health problems. Analysts say they can be prohibitively expensive and offer less than optimal health coverage.

http://www.reuters.com/article/us-usa-health-ryan-idUSKCN0XP00C

***

Comment:

By Don McCanne, M.D.

House Speaker Paul Ryan has promised to produce the Republican alternative to the Affordable Care Act, likely before the Republican convention in July. In his comments at Georgetown University yesterday he discussed what would be the most important policy supposedly designed to control health care spending for the vast majority of Americans: Establish state level risk pools for the 10 percent of people with the greatest health care needs. Let’s see what that means.

The top 10 percent of individuals in spending account for 65 percent of health care costs. By removing them from the standard insurance pools that means that the other 90 percent would have to pay insurance premiums that funded only 35 percent of total health care. Ryan says that this would lower insurance premiums through competition, but that is nonsense. Premiums would be much lower because two-thirds of health care costs are pulled out of the insurance plans in the marketplace. Surely most Americans would be happy with private insurance premiums that were one-third of what they would be if everyone were included. It would be a very popular program, and the Republicans would take credit for it.

But what about the 10 percent of people who account for two-thirds of our health care costs. Their premiums would have to be about 7 times what the premium would be if everyone were covered under a common risk pool, or about 20 times what everyone else is paying. As Paul Ryan says, they are “really kind of uninsurable.” So he proposes high-risk pools at the state level, with subsidized premiums. Expecting the states to subsidize two-thirds of our health care costs is a non-starter. Without massive increases in taxes, which are opposed by the Republicans anyway, the states would not be able to fund those pools.

We already have considerable experience with state high-risk pools. In recent decades, thirty-five states established such pools, and overall they were a spectacular failure. Also, the Affordable Care Act authorized temporary Pre-Existing Condition Insurance Plans (PCIP) which were also high-risk pools. These plans proved to be prohibitively expensive to administer, prohibitively expensive for consumers to purchase, and offered much less than optimal coverage, often with annual and lifetime limits, coverage gaps, and very high premiums and deductibles.

It is so obvious on the face of it. Most of us might be happy with our low premiums, but we would be very unhappy with the massive increases in regressive state taxes that would be enacted to pay for this. Vermont’s reform effort failed once the tax consequences were recognized, and that wasn’t even for high-risk pools.

As I wrote in a previous Quote of the Day, “With a single payer system this problem disappears. Funding is based on ability to pay, through the tax system, and not on the basis of anticipated medical expenses. Everyone receives the care they need, regardless of their health status. The fragmented plans supported by the repeal and replace people cannot do that.”

Paul Ryan does not seem to understand high-risk pools

Ryan wants to end Obamacare cost protections for sick consumers

By David Morgan
Reuters, April 27, 2016

U.S. House of Representatives Speaker Paul Ryan called on Wednesday for an end to Obamacare’s financial protections for people with serious medical conditions, saying these consumers should be placed in state high-risk pools.

In election-year remarks that could shed light on an expected Republican healthcare alternative, Ryan said existing federal policy that prevents insurers from charging sick people higher rates for health coverage has raised costs for healthy consumers while undermining choice and competition.

The rule, a cornerstone of President Barack Obama’s Affordable Care Act, has been praised by patient advocates for providing access to medical care for people who previously could not afford private health insurance. The Affordable Care Act also bars insurers from excluding coverage for pre-existing conditions.

“Less than 10 percent of people under 65 are what we call people with pre-existing conditions, who are really kind of uninsurable,” Ryan, a Wisconsin Republican, told a student audience at Georgetown University.

“Let’s fund risk pools at the state level to subsidize their coverage, so that they can get affordable coverage,” he said. “You dramatically lower the price for everybody else. You make health insurance so much more affordable, so much more competitive and open up competition.”

High-risk pools, which existed before the healthcare law, are state-level entities that guarantee coverage for people with health problems. Analysts say they can be prohibitively expensive and offer less than optimal health coverage.

http://www.reuters.com/article/us-usa-health-ryan-idUSKCN0XP00C

House Speaker Paul Ryan has promised to produce the Republican alternative to the Affordable Care Act, likely before the Republican convention in July. In his comments at Georgetown University yesterday he discussed what would be the most important policy supposedly designed to control health care spending for the vast majority of Americans: Establish state level risk pools for the 10 percent of people with the greatest health care needs. Let’s see what that means.

The top 10 percent of individuals in spending account for 65 percent of health care costs. By removing them from the standard insurance pools that means that the other 90 percent would have to pay insurance premiums that funded only 35 percent of total health care. Ryan says that this would lower insurance premiums through competition, but that is nonsense. Premiums would be much lower because two-thirds of health care costs are pulled out of the insurance plans in the marketplace. Surely most Americans would be happy with private insurance premiums that were one-third of what they would be if everyone were included. It would be a very popular program, and the Republicans would take credit for it.

But what about the 10 percent of people who account for two-thirds of our health care costs. Their premiums would have to be about 7 times what the premium would be if everyone were covered under a common risk pool, or about 20 times what everyone else is paying. As Paul Ryan says, they are “really kind of uninsurable.” So he proposes high-risk pools at the state level, with subsidized premiums. Expecting the states to subsidize two-thirds of our health care costs is a non-starter. Without massive increases in taxes, which are opposed by the Republicans anyway, the states would not be able to fund those pools.

We already have considerable experience with state high-risk pools. In recent decades, thirty-five states established such pools, and overall they were a spectacular failure. Also, the Affordable Care Act authorized temporary Pre-Existing Condition Insurance Plans (PCIP) which were also high-risk pools. These plans proved to be prohibitively expensive to administer, prohibitively expensive for consumers to purchase, and offered much less than optimal coverage, often with annual and lifetime limits, coverage gaps, and very high premiums and deductibles.

It is so obvious on the face of it. Most of us might be happy with our low premiums, but we would be very unhappy with the massive increases in regressive state taxes that would be enacted to pay for this. Vermont’s reform effort failed once the tax consequences were recognized, and that wasn’t even for high-risk pools.

As I wrote in a previous Quote of the Day, “With a single payer system this problem disappears. Funding is based on ability to pay, through the tax system, and not on the basis of anticipated medical expenses. Everyone receives the care they need, regardless of their health status. The fragmented plans supported by the repeal and replace people cannot do that.”

Why in Heaven’s Name Aren’t Teeth Considered Part of Our Health?

It is estimated that 108 million Americans have no dental insurance.

By Susan Sered
AlterNet, April 26, 2016

When we talk about the successes and shortcomings of the Affordable Care Act, and health care in the U.S. in general, little attention is given to dental care. While the ACA defines dental coverage as an essential benefit for those under 18, insurers aren’t required to offer dental coverage for adults. Medicare, the nation’s largest insurer, doesn’t cover routine dental work. And coverage for adults through Medicaid varies from state to state.

It is estimated that 108 million Americans have no dental insurance, and that one in four nonelderly Americans has untreated tooth decay.

Oral health isn’t just about nice teeth. As the surgeon general noted in a 2000 report, oral health is intimately connected to general health and can be implicated in or exacerbate diabetes, heart disease and stroke, and complications during pregnancy.

The absence of comprehensive dental care exacts a toll on millions of Americans in terms of poor health, pain and the social stigma associated with bad teeth.

People desperately need dental care.

In 2003 and 2004 (pre-Obamacare), I conducted a national study of uninsured Americans in southcentral Illinois, northern Idaho, the Mississippi delta, the Rio Grande Valley of Texas and in eastern Massachusetts.

I asked nearly 150 interviewees: “If President Bush were to declare universal health care for everyone starting tomorrow, what is the first problem you would take care of?” The most common answer by a landslide echoed this respondent’s: “I’ll be waiting outside the dentist’s office at 5:00 in the morning waiting for it to open.”

Many of the people I interviewed lived with untreated diabetes, asthma or even cancer, yet their oral health problems presented the greatest challenges to their quality of life.

Recently I returned to these communities to reinterview the people I’d met over a decade earlier. Very little has changed. While the majority of the people I interviewed now had health care coverage of some sort (for nearly 20 percent of them, it was as a consequence of becoming sufficiently disabled to be eligible for Social Security), very few had managed to secure dental coverage.

Then and now, people told me about visiting emergency rooms in hopes of alleviating pain or using addictive pain medications to make it through the day. People even told me that they had resorted to pulling out their own teeth.

Take Misty, for instance. When I met her 12 years ago in Mississippi, she was a “dirt poor” (her words) married mother of five, and she was living with diabetes, domestic violence and excruciating headaches. Despite all of these quite serious problems, she told me that she was more troubled by her bad teeth than by anything else. In fact, Misty told me that she’d had such bad toothaches that she pulled her own teeth. When I asked her how she can face the pain of pulling out her own teeth, she said:

[the infected tooth] hurts so bad… it’s a relief just to get it out of there.… I’ve gone two weeks with just being able to eat soup, because they are just so bad.

By 2016 Misty had left her abusive husband, moved to Arkansas and was accepted onto disability (SSI), which allowed her to get health care coverage through Medicaid. Still, however, she suffered because of her teeth.

It can be very hard to find dentists who accept Medicaid, and when Misty finally did, she had the rest of her teeth—25 in all—pulled in one day.

Misty’s situation isn’t uncommon. I have met women and men of various ages who, like Misty, have pulled their own teeth. I’ve also met people who were able to get part of their dental needs taken care of during brief periods of Medicaid coverage but then were left with unfinished treatment when the coverage ended.

Insurance stops at the teeth

Even though the link between dental health and overall health is clear, insurance plans tend to ignore teeth.

As health insurance began to appear to appear in the U.S.—initially in the 1920s and then more widely during World War II and in the postwar era—dentistry wasn’t part of the standard package of covered services.

As the nation’s largest insurer, Medicare plays an important role in shaping health care coverage norms. Medicare does not cover dental care. Today, according to government estimates, 70 percent of seniors lack dental coverage.

Since Medicare doesn’t cover dental, Dr. David Kroll, senior program officer at the Robert Wood Johnson Foundation, argues that this “inertia spilled over into the ACA.”

Americans who purchase dental plans typically find that the plans aren’t cheap, and often don’t cover much beyond routine preventative care. Plans often require hefty copays for procedures beyond preventative care and no or very limited coverage for dentures, bridges or periodontic work.

And, in recent years, the cost of dental care has increased faster than the cost of other medical care. For those without dental insurance, there are few low-cost services available.

The ACA provided for an expansion of Medicaid eligibility, though not all states accepted the offer of federal funding to expand Medicaid coverage. Even in the states that expanded Medicaid under the ACA, strict limits on oral health care remain for most low- and moderate-income Americans.

There is one bright spot: children’s dental coverage is a required benefit included on all ACA compliant plans, and Medicaid as well. According to national calculations of the Health Policy Institute and the American Dental Association, dental care utilization among Medicaid-enrolled children increased from 35.3 percent in 2005 to 48.3 percent in 2013.

Oral health isn’t just about nice teeth

In the absence of coherent oral health services, too many Americans end up like Gina, a young Idaho woman who holds her hand in front of her mouth while she talks so that no one will see her rotted teeth. She can’t even get a job as a telemarketer because she cannot speak distinctly enough to be hired.

Many Americans incorrectly assume that rotten teeth are the product of bad decision-making; if someone had just brushed and flossed then they’d have nice teeth. But routine dental care—think of the twice-yearly checkups that are routine for people with dental insurance—keeps teeth healthy and can catch problems when they are easy to treat.

The reality is that tooth decay signifies poverty in pernicious ways. Without expanding insurance to cover oral health, millions of Americans will continue to live with pain, stigma and the risks of systemic diseases that could be averted through an accessible and integrated system of dental care.

Susan Starr Sered is Senior Research Associate at Suffolk University’s Center for Women’s Health and Human Rights.

http://www.alternet.org/personal-health/why-heavens-name-arent-teeth-considered-part-our-health

Health care needs single-payer system

By Morton Tavel, M.D.
The News-Press (Fort Myers, Fla.), April 20, 2016

When considering the best way to solve our country’s health care woes, I am reminded of Winston Churchill’s famous comment about democracy as a form of government, in which he stated, in effect: It’s a terrible system, but everything else is worse. This same statement might apply to a single-payer system in medical care as proposed by Bernie Sanders at a recent Democrat presidential debate, for it, too, probably beats everything else.

First, a truly effective system will not be achieved unless we solve the many associated issues that include tort reform to control the exorbitant costs of physician medical malpractice insurance in many states, excessively high cost of drugs, inappropriate use of expensive tests and treatments, and several others. But all these issues can be solved, given the desire and, hopefully, willingness of our legislative bodies to work together for the benefit of all.

Although the Affordable Care Act (ACA, “Obamacare”) has been a step forward, it fails to address the problem of waste and complexity in the system. A single payer system would eliminate the entire commercial insurance industry — with $730 billion in revenues and a workforce of 470,000. Not only would this provide a more economical way to use healthcare resources by reducing expenses, it would also likely improve quality, and restore doctors’ authority. For all practices, administrative costs would plummet because there would be only one set of payment rules and forms, with the result that prior authorizations, narrow networks, and out-of-pocket payments could be eliminated.

There also appears to be evidence of growing physician support for a single-payer system. For example, a 2014 survey of Maine physicians conducted found that nearly 65 percent of respondents preferred the single-payer option over trying to fix the current system—up from 52 percent in a 2008 survey. Physicians in general now seem more open to a single-payer system.

Notwithstanding the Republicans’ constant calls for abandoning ACA, a majority of the population (51 percent) now supports Medicare for all, according to a national poll released recently. Many experts, however, believe that the movement for a single-payer system may start at the state level, since much of the public continues to mistrust Washington.

Although a government-run, single-payer system is the only way to provide effective basic medical health therapy and management, for those who desire a higher level of care — and can afford it — there should be a private-pay system, in contrast to the Canadian system. This would constitute a two-tiered system. This might be objectionable to egalitarians that wish to have a “one size fits all” system, but would be the most pragmatic approach.

Usually those against single payer system trot out the usual vague objections that we are becoming “socialistic.”  But what about our current Medicare system and Social Security itself; are those not socialistic?

Whether we like it or not, basic healthcare is like a utility—something everyone needs, and in the best interest of our society, everyone should receive. Although there are variations of the general theme as I have enumerated above, we are probably moving inevitably toward a single payer system. When it finally arrives, I believe everyone will be relieved, if not pleased, even including our warring politicians!

Dr. Morton Tavel lives on Sanibel.

http://www.news-press.com/story/opinion/contributors/2016/04/20/healthcare-needs-single-payer-system/83226924/

PNHP note: Physicians for a National Health Program (PNHP) is a nonpartisan educational organization. It neither supports nor opposes any candidate for public office.