PNHP

Is unaffordable underinsurance the best we can do?

Is unaffordable underinsurance the best we can do?

By Gordon Schiff, M.D.

The following text represents the prepared testimony of Dr. Gordon Schiff at a March 22 public hearing in support of single-payer legislation before the Massachusetts legislature’s Joint Committee on Health Care Financing. The hearings were held in the Gardner Auditorium at the State House in Boston. For more information, visit masscare.org.

My name is Dr. Gordon Schiff. I am a practicing general internist (primary care physician) and work at the Harvard Brigham Center for Patient Safety Research and Practice, as well an associate professor at Harvard Medical School.

It is time to get back on track on the road to providing health insurance, real universal health insurance to everyone in the U.S., and particularly everyone here in Massachusetts. We need to continue lead the way in our commitment to do this in the highest quality, most affordable and cost-efficient way.

Look at the national figures: of 41 million people uninsured before the Affordable Care Act; 16.9 million (41 percent) have gained health insurance (RAND 2015) – hardly a passing grade if our goal was 100 percent.

This leaves some 25 million still uninsured nationally. And for most of those who have gained insurance what they have “gained” is either Medicaid (historically a poor program for poor people, looking better only because the other options are looking so much worse) or high deductible health plans – a cruel hoax – with deductibles of $5,000 a year or more in addition to premium payments and out-of-network costs, meaning such people are so seriously underinsured they can’t pay their medical bills should they become ill –what insurance was supposed to provide.

We have a plan that falls far short of what was promised and what we need.

The Obama plan of course is based on the Massachusetts Plan which the president chose to emulate – individual mandates for private insurance, Medicaid expansion, and bizarre expensive purchasing bazaars to shop for the best plans. This is Romney-care that former Massachusetts Gov. Romney has recently admitted came directly from Newt Gingrich and the Heritage Foundation (an extreme right-wing think tank).

Obama chose this route, even after repeatedly acknowledging the single payer was best when he was a state senator in Illinois (where I was living at the time) in order to achieve “bipartisan support.” In the end not a single Republican supported the plan; so this failed strategy has left us with this suboptimal plan – a plan that in order to maintain the power of the insurance industry and other special interests is so complex, so inadequate, so riddled with disparities, that it is time to honestly reexamine if this is the best route for achieving universal coverage.

Is unaffordable underinsurance the best we can do? We need a better strategy one that Massachusetts physicians and their patients want and need. They are frustrated, confused, and discouraged by the complexity, high cost, and waste in the current system.

Other countries are succeeding where we are failing in both holding down costs and improving access care. They offer universal access and coverage, free choice of physicians, and achieve quality outcomes that are as good as or better than ours at half the cost. They are based on caring for everyone, rather than market systems that drive up costs.

How do they do it? I would like to touch on two central features for improved quality and lowered costs, something they have and we lack: Simplicity and continuity – two attributes our current system is failing at, and that single payer achieves.

Simplicity

Can you as a legislator, or a consumer, even begin to understand the following?

  • Health insurance Marketplaces
  • Special Enrollment Period (SEP) in the Marketplaces
  • Premium Stabilization Programs
  • The Transitional Reinsurance Program – Reinsurance Contributions
  • Medicare Access and CHIP Reauthorization
  • End of Benefit Year Risk readjustment
  • Cost-Sharing Reduction Component of Advance Payments for Benefit Years 2014 and 2015
  • The Transitional Reinsurance Program
  • Reinsurance, Risk Corridors and Risk Adjustment
  • Consumer Operated and Oriented Plan (CO-OP) Program
  • FFM – federally facilitated marketplace agents and brokers regulations
  • Metal Tiers: Bronze vs. silver vs. gold vs. platinum plans
  • In-network vs. out-of-network providers
  • The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

And a few additional insurance features unique to Massachusetts:

  • Children’s Medical Security Plan
  • Mass Health
  • Health Safety Net
  • Commonwealth Health Insurance Connector
  • Connector Care
  • Closed/vs. Open Enrollment periods
  • Special Coverage after a Qualifying Life Event

Do you understand all of these different programs? I certainly don’t. Not to mention hundreds of insurance plans each with different qualifying criteria, deductibles, coverage and products Massachusetts citizens are supposed to be able to choose from, every year.

Nor can I keep these straight from all the forms I have to respond to from all the different insurance plans and drugs benefit plans.

This leads to huge amount of confusion, complexity, and waste for physicians and patients and hospitals and doctors’ offices every day. Where do these costs show up? The beauty of the current system in its ability to hide, obscure and avoid accountability for all this waste and hidden costs, inherent in keeping the status quo.

All this goes away with the simplicity of single payer, where the eligibility the criteria is being born, and disenrollment criteria is dying.

Continuity of Care

Can you imagine my horror when I received an email from one of my very depressed patients, stating in the subject line “This is My Final Note to You”? I always had some reservations about allowing patients to email, but receiving what I thought was a suicide note was quite a jolt.

Turns out, reading the body of the email, I learned she had been involuntarily switched to a new Mass Health plan and I could no longer continue to be her primary care physician. Even though I knew this patient best, having cared for her for a number of years, Mass Health required her to switch to a new MD. This makes no sense from a quality or cost point of view.

Physicians and patients prefer the simplicity, continuity, choice, and affordability of single payer, as poll after poll has demonstrated. The status quo is neither desirable nor sustainable. We urge you to act affirmatively on the single-payer bills you have before you, for the sake of the patients and doctors and other staff.

Selected personal tributes to Dr. Quentin Young

The following tributes and reminiscences are among the messages that PNHP has received in response to Dr. Quentin Young’s death on March 7, 2016. We will continue to gather these. We invite you to submit your own comments to info@pnhp.org.

****

I feel so fortunate to have “known” him when I was infant in 1960 and bounced on his lap (my dad was a resident at UChicago, moonlighting in his office) … and then to have met him as an adult years later with PNHP. (Alas, the first newspaper blurb does not mention his role in the desegregation of Chicago health care and his fight for civil rights.)

He lives on forever in his acts of goodness while he was with us, and in the memories activism we carry on with him in our hearts.

– Steve Auerbach, M.D.

****

I was a young physician in Chicago in the late ’60s and early ’70s, feeling very lost in the maelstrom of conflicting ideologies and unsure of how to participate in reform. The Medical Committee for Human Rights, and in particular its president, Quentin Young, was a voice for reform and reason. His example and leadership over the last half century have been outstanding in the effort to reform American medicine.

Rest in Peace, Dr. Young.

– Martha Willi, M.D.
Peoria, Ill.

****

Dr. Quentin Young has had an immeasurable influence on my personal and professional life since my childhood in Hyde Park in Chicago. His progressive thought and influence was key in supporting the Chicago chapter of SNCC in the ’60s along with many other social organizations. He always encouraged me to excel.

He was a medical mentor of mine during my time at Cook County Hospital in the 1970s. (He prophesied that physicians should unionize before hospitals and insurance companies took over all facets of medicine). During the ’90s he readily convinced me that PNHP would give physicians a platform to survive in the 21st century, which it has done.

His loud voice for quality and justice will be sorely missed. He made it clear to me early on that a physician’s responsibilities extends far outside the framework of his/her office.

My condolences to his daughter Polly and the rest of the family. His loss truly represents the end of an era, but his message lives on.

– Dr. Oliver W. Crawford Jr.
Ozark, Alabama

****

I too am so sorry to hear this news. He leaves a very rich legacy to be carried on to achieve Good Health Care for All Humans!

– Norma MT Braun, M.D., FACP, FCCP, PNHP member

****

From social media: Very sad news, my beloved father-in-law, Dr. Quentin Young, passed today. Born in Chicago, he was a lifelong activist, and a stalwart supporter of social justice and single-payer health care. He fought against racial segregation at Chicago hospitals, and his friends and patients included Dr. Martin Luther King, Studs Terkel, Chicago Mayor Harold Washington, and many, many more. He was deeply proud of his children, the Youngs: Nancy, Polly, Barbara, Michael, and my husband, Ethan (a doppelganger for this old photo of Quentin), his 2nd wife Ruth’s children, William Weaver and Karin Weaver, and his hordes of brilliant and wonderful grandchildren. People often say they want to change the world, Quentin spent his life doing it.

– Mary Dore, New York

****

We need to be committed to work for single-payer health care especially at this moment. I found an article on the PNHP website, the last line of which shows us why we need to continue the fight: “‘I tell people that I will refuse to die until there is national health care,’ he laughed.” Dr. Young hoped that he would see Medicare for all in his lifetime.

– Pam Gronemeyer, M.D., Illinois

****

A personal story: Quentin’s passing also is one less link to my late father, Marian S. Tarzynski, M.D., who practiced with Quentin for a time in the 1950s and 1960s at the Union Health Service in Chicago. Whenever I saw Quentin at PNHP meetings he would always first ask me how my dad was doing. Another small example Quentin’s great humanity and caring.

– Stephen Tarzynski, M.D., California

****

We send our heartfelt condolences to Dr. Young’s family and PNHP colleagues.

Our family carries in our hearts Quentin’s compassion and support when we lost our son Nick. He was mentor, colleague and second family to Nick, making him pivotal in bringing Nick full circle in his adult life. Quentin heightened Nick’s sense of social justice and the common good especially in health care reform. Reading his memoir confirmed what we already knew – we were all fortunate to have a kind and amazing human being touch our lives.

We thank you for sharing him with us.

– The Skala Family, Judy, Ron and Eric

****

I’m very touched. Quentin served us all well. It was a privilege to have known him for a half century.

– Henry Kahn, M.D., Georgia

****

In 2002, at the time of one of the worst public health crisis in Argentina, I was invited by PNHP to talk about it in Philadelphia. It was then a joy and an honor to meet Quentin and get his support and friendly advice. My colleagues and I will be always grateful to PNHP and Quentin for that unforgettable experience. He will be forever in our hearts and minds.

– Carlos Trotta, M.D., Argentina

****

Dr. Quentin Young was my mentor and “kindred spirit.” In 2002-2003, when I served as president of the American Medical Women’s Association, I invited Quentin to speak at the AMWA national meeting on “single payer universal health care.” He REALLY opened the eyes of the women physicians and the medical students attending the annual meeting.

Subsequently, when Rep. John Conyers Jr. of Detroit, Mich., contacted Quentin and asked him if he could find a few physicians willing to write a single-payer universal health care bill for him to introduce to Congress, Quentin replied, “Yes, I’ll have a dozen or more for you in 10 days.” I was fortunate to receive a phone call from Quentin immediately asking if I would like to work on this project, and I said “Yes” and was happily one of 17 physicians who worked on the drafting of H.R. 676 “Medicare for All.”

I have continued to work passionately toward achieving single-payer universal health care for ALL residents of Colorado and am pleased to report that we will have on our Colorado ballot in November 2016 Amendment 69, “ColoradoCare.” If we are successful in educating a majority to vote for the “common good” and vote YES on Amendment 69, we will put single-payer universal health care in our state constitution. My goal has been to achieve single-payer universal health care in Colorado in my lifetime! And now we have the rare opportunity to accomplish this in Colorado. If we are successful, we can become a model for other states.

“Everybody In, Nobody Out.” Quentin Young’s vision, courage, optimism and persevering commitment to social justice and health care as a human right will continue to inspire and motivate us.

– Elinor T. Christiansen, M.D., Colorado

****

When I was a young position at Cook County Hospital I was in training in radiology; however, that specialty didn’t feel right to me and I went to speak with Quentin Young who was an internist. I spoke with him about my concerns and he suggested that I change to internal medicine. After year and a half in radiology, I spent the rest of the time in my training in internal medicine at Cook County Hospital. It’s served me in good stead. I have worked for the last 47 years in emergency medicine way before it became a specialty and I have been board certified for the last 30 years. In June I will have been a physician for 50 years. I have completely enjoyed my practice of medicine and I am grateful to him for directing me in the right way. He was an unbelievably compassionate, productive, joyful physician. I am grateful for having known him a little briefly and I have admired his work. To his family it is a loss; however, no one could have given us more than he has.

– Janet Magnani, M.D., M.P.H.

****

I knew Dr. Young over many years. He was above all a great physician. We need more like him.

– John E. Jacoby, M.D., M.P.H.

****

Dr. Young will be sorely missed. I am grateful for having known him!

– Katie Robbins, M.P.H., PNHP NY Metro

****

Quentin Young inspired me to get involved in work for health systems reform. The first time I attended a PNHP town hall meeting was on July 17, 2005, and Dr. Young was on the program. I brought an audio recorder and recorded the proceedings and made a transcript of Dr. Young’s talk. I showed him the transcript at a subsequent PNHP presentation and asked for permission to post it online. He read the transcript and agreed, so it has been online at an old blog site of mine ever since.

I went on to attend PNHP leadership training in Pittsburgh in December of 2005 (the annual meeting had been postponed because of Hurricane Katrina), and organized and took part in several health reform meetings over the next few years.

Regards,

– Hal Snyder, M.D.
Arlington Heights, IL

P.S.: “You can judge the effectiveness of your efforts by the vehemence of the opposition.” – Quentin Young

P.P.S.: “Our health system is amateur night in the lunatic asylum.” – Quentin Young

****

Dr. Quentin Young had me trained at the national office of Physicians for a National Health Program. Every morning he would ask “who are we fighting?” and then pause while I answered “the forces of reaction.” Then, on many occasions, he’d lay out his vision. We needed to build a movement. “A mooovement, baby” he’d say, reminding me with his slang that the 1960s were yesterday to him. He’d tick off his plan. We needed to organize the medical profession, primary care doctors and specialists and medical students. We had to reach out to labor unions of all kinds, from nurses to steelworkers, from the national and international federations to the smallest local. We needed to speak in churches and synagogues, to groups working with the disabled, and to seniors’ groups. Health care was being taken over by profit-seeking corporations damaging patient care. The pharmaceutical companies charged confiscatory prices. Single payer, Medicare for all was not just the best solution, it was the only solution. Satisfied that we shared the same views, he’d go off to return a call to the media seeking an interview or to phone one of his contacts, maybe Jesse Jackson or Dr. Ron Sable, often Rep. John Conyers or Pat Quinn. I’d work my way through a flood of inquiries, from physicians who wanted to start chapters of PNHP or needed slides for talks, to unions, churches and other groups who wanted a speaker on health care reform, to some member of the press, maybe Phil Kadner of the Daily Southtown, wondering if he could talk to Dr. Young. And it would go on like this, until the next morning, when I’d hear “Who are we fighting?”

– Ida Hellander, M.D.

****

Thank you for sharing Quentin with me and people like me — I am so very sorry for your loss.

– Love, Donna Smith, and the whole PDA family

****

Condolences from all of us on Quentin. He was a hero to all of us too.

– Chuck Idelson, National Nurses United

****

I dreamed I saw Joe Hill last night,
Alive as you and me.
Says I, “But Joe, you’re ten years dead.”
“I never died,” says he.
“I never died,” says he.

From San Diego up to Maine
In every mine and mill.
Where working men defend their rights,
It’s there you’ll find Joe Hill.
It’s there you’ll find Joe Hill.

As Joe Hill said, “Do not mourn. Organize!”

– Dick Gottfried, member of the N.Y. Assembly

****

Quentin was my hero since I was a staff nurse in Chicago in the early ‘70s and I would read about his work in the paper, but I realize it’s a much more personal loss for all of you. My thoughts are with you in Chicago. I hope it might be possible to have a memorial service at some point that is live-streamed to all of us PNHPers around the country. Crazy idea maybe, but please consider it.

– Betsy Todd

****

I wanted to pass along my deepest condolences to Quentin’s family and to our movement for health care justice.

I met Quentin in Chicago in the late ‘70s while working on OSHA issues. I was in awe of him. Our lives continued to intersect over the years. I especially remember his support and presence in Arkansas when Georgians for a Common Sense Health Plan mobilized caravans to go to Little Rock after Bill Clinton’s first election and demand that he support single payer. When Clinton wouldn’t come to us, it was Quentin who said ‘march to him’ and we did!

His legacy with MCHR and contributions to Health PAC were enormously valued for always locating the right to health care for all within a broad social movement for justice and equality. Whether at APHA, PNHP or Healthcare-NOW, I always rejoiced at seeing him. He will be missed.

Rest in power, Dr. Quentin Young.

– Respectfully, Rita Valenti

****

Posted on the wall next to my desk at home is a poster from May, 1982: “WHO WILL CARE FOR THE PEOPLE? – SAVING SEATTLE’S PUBLIC HEALTH CARE SYSTEM.” Quentin was our keynote speaker. This was organized by the Public Health Care Coalition in the aftermath of the final closures in 1981 of what was left of the historic system of USPHS hospitals and clinics. Our coalition had fought successfully for 10 years against the closures and had helped turn the Seattle hospital into a national model of shifting the mission of the USPHS system towards working with community clinics and other local providers to serve the underserved, while at the same time continuing to serve the statutory beneficiaries – merchant seamen and commercial fishers, Native Americans, retired military personnel and dependents, refugees and more. Our coalition brought together all these constituencies under the banner “Health Care is a Right, Not a Business.” (The underlying bipartisan goal of the PHS closures since the mid-1950s was to turn delivery of care to federal health beneficiaries over to the private sector.) We and our national allies were strong enough to win from the new Reagan administration an agreement that these USPHS facilities could be turned over – with substantial seed money – to local nonprofit agencies willing and able to serve the same populations.

In Seattle at the time of the 1982 conference, we had just launched the Seattle Public Health Hospital under a charter from the city (later renamed Pacific Medical Center) and were facing an uncertain future. We brought Quentin to Seattle because of his stature as one of the greatest champions of health care as a right and a public health approach to delivery. He helped us think through what lay ahead and inspired us to keep our eyes on the prize.

Quentin came to Seattle again in 2007 and 2012 to speak at annual meetings of PHNP – Western Washington. He continued to help us think clearly and stay inspired. The struggle for health justice is a long one, and a key part of the broader struggles for a just and sustainable social order. We cannot afford to fail. So rest in peace, Quentin and I am sure we all accept your advice: “Don’t mourn – organize!”

– David Loud

****

My memories of Quentin date back to 1954 when I moved to Chicago I soon learned of an organization “Committee to End Discrimination in Chicago Medical Institutions.” At that time black physicians had hospital appointments only at the one black hospital, Provident Hospital. Quentin was a leader of this group which eventually succeeded in getting an appointment for a black physician at Michael Reese Hospital. Quentin continued as a leader in the civil rights movement throughout the sixties. He was a tireless fighter for human rights, as well as for national health insurance.

Although I left Chicago in 1977 I continued to meet with Quentin at annual APHA meetings where he was a leader in the fight for national health insurance. He will be badly missed.

– Joyce C. Lashof, M.D.

****

I had not heard that our good friend Quentin Young had passed away until today. What a great loss. He was an excellent comrade and a very good friend. I loved him dearly and we spent many interesting times together. We should do some homage to him, one way or another. Maybe we could dedicate a section in the website or something. My love to you as well.

– Vincente Navarro, M.D.

****

In 1967, I was president of Medical Professionals Against the War in Vietnam during a period when I was a Lieutenant Commander in the USPHS, a Research Fellow at Harvard Medical School and an early member of Physicians for Social Responsibility. Our organization planned a large demonstration around the White House, bitterly objecting to the enormous toll of USA bombing and ground fire on innocent Vietnamese civilians and children as well as the use of agent orange and other toxic, chemical warfare on the forests, farms and people of that country. We also fought against the military draft which was sending so many young men to fight in a war that was maiming so many of them. This was the last demonstration that surrounded and marched around the White House – President Johnson established a permanent prohibition of demonstrations circling the White House from thenceforth.

The demonstration was followed by a well-publicized press conference in a Washington hotel with esteemed physicians from academic and private practices giving talks to the Washington, D.C., press corps. One of those eminent physicians was Quentin Young, M.D. (another was Bernard Lown, M.D., then the president of Physicians for Social Responsibility). Dr. Young gave an impassioned talk about the contravening of medical ethics in the mass killing and maiming of Vietnamese civilians and the blot on our country’s democracy that this war was producing. His comments were quoted in the Washington Post, New York Times and carried by syndicated columns throughout the USA.

Quentin encouraged me to continue my pursuit of ending the war in Vietnam. He was a friend and an important role model for me in obliterating the boundaries between politics and medicine. I will always remember him saying, “In the USA, the political and financial tail wags the medical care dog.”

– Robert Paul Liberman, M.D.
Distinguished Professor of Psychiatry Emeritus

****

Dr. Young was my chief of medicine when I was an intern and resident at Cook County Hospital 1974-1977, and he helped me start the Freedom Center Clinic, the second satellite clinic of Cook County Hospital, at 1515 W. Monroe in 1977.

He was an encouraging, pleasant, stimulating influence and example for my development as a physician, stressing the societal, cultural, economic causes of illness and disability.

It was a privilege and honor to have worked with him.

Sincerely,

– Glenn Winter, M.D.

****

I first met Quentin when working in civil rights in Mississippi in the 1960’s, and continued to cooperate with him on various projects through the Health and Policy Research Group at Northwestern University.

What a great man, and what a character. Of the many wonderful stories about Quentin, this is one of the most memorable: When he was being interviewed by a panel of Chicago politicians overseeing Cook County Hospital for a leadership position, Quentin was very open about the radical changes he planned to introduce at the hospital.

One of the politicians is reported to have said, “Dr. Young, you’ll become the Medical Director at Cook County Hospital over my dead body.”

Quentin’s response: “It’s a deal.”

You fought the good fight, Quentin, on behalf of all of us. Rest in Peace.

– Andy Gordon
Professor Emeritus, Evans School of Public Affairs, University of Washington

****

The origin of Dr. Quentin Young’s slogan “Everybody in, nobody out” in the single payer movement:
 
Just about every other meeting of single payer advocates includes an interruption in the program that goes roughly like this: 

One activist will say that we shouldn’t call the program we favor “single payer” because nobody knows what that means.  A second person will say we should call our program “Medicare for All”, because single payer is like expanding Medicare to everyone, and Medicare is one of the nation’s most well-known and regarded social programs. There’ll be general agreement among those gathered that this is a great idea, but before long a third advocate will note that Medicare doesn’t really describe the program we want, because Medicare only covers half of the medical bills of the elderly, and it is rapidly being taken over by the private insurance companies.  Besides, someone else will note, Medicare is not even a single payer, but just one payer in our fragmented system.  A real single payer program would be much better.  If a physician is present, they might add that some doctors don’t like Medicare, and we need physicians on board.

Invariably there will be a discussion, mostly repeating these points, until someone will say we should call single payer “Improved Medicare for All.”  Most advocates will be satisfied with this answer, and then, before long, the group will return to talking about the need to build a movement for … single-payer.

In 1994, Quentin and I were sitting in my office at the Chicago headquarters of Physicians for a National Health Program (PNHP) talking about this perennial debate. (By headquarters I mean a few shabby offices we rented in the back of a large non-profit, the Community Renewal Society). I said it would be helpful if we had a catchier alternative to the term “single payer” than “Improved Medicare for All.”  There was always “national health insurance” like what they have in Canada, and a “national health service”  like what they have in the U.K., but some people had told me they thought those descriptions sounded like the names of insurance companies.

Quentin leaned back in his chair and said thoughtfully, “we need to find a way to express the idea that we want everybody in the same system, and we don’t want nobody out.”  The “nobody” was a bit of slang from Chicago’s south side, where Quentin had lived and worked his whole life.  “That’s it” I said. Quentin looked at me with surprise. “What, everybody in, nobody out?”  He tried it out a few times, eventually putting the emphasis on the first syllables.  “Everybody in, nobody out.” 

From then on, Quentin liked to chant “everybody in, nobody out” at rallies and insert it into his talks.  He’d ask “what’s so special about this phrase, after all it’s only four words, and “body” is repeated twice?”  Then he’d adopt a serious tone, and explain it something like this:  Well, the first two words are a political statement.  If we’re serious about our democracy, everyone must be included. Everybody in. The second two words, that’s a moral statement.  It would be immoral to exclude anyone needing health care.  Nobody out.  Then he’d break into his huge grin, and get the crowd chanting. 
 
A lot of single payer advocates picked up the expression from Quentin over the years, including a tall young organizer who sublet a few cubicles near ours for a get out the vote drive in the mid-1990s.  He used it in a now-famous talk before the Illinois AFL-CIO in 2003, but later abandoned these principles when he adopted a Republican, pro-Wall Street, health reform plan in his run for president.  When Quentin heard about the Obama health plan, which leaves at least 28 million people uninsured, and control of the health care system in the hands of the private insurance industry, he cursed like a character out of the TV western he liked, Deadwood. 

Quentin gave talks and interviews supporting single payer, Improved Medicare for all, H.R. 676 into his late 80’s.  Besides chanting “everybody in, nobody out” with a crowd, he liked to emphasize that single payer was no longer just the best solution, it was the only solution. 

Among those who carry on Quentin’s legacy are Senator Bernie Sanders, pictured below with Quentin in 2009.

– Ida Hellander, M.D.

Dr. Quentin Young and Sen. Bernie Sanders

Can churning be eliminated with a patch?

How to Stop the Bouncing Between Insurance Plans Under Obamacare

By Dhruv Khullar
The New York Times, March 23, 2016

Millions of Americans are finding Obamacare to be unstable ground.

Consider a young construction worker, a patient of mine, whose hours are cut during the winter. His income drops slightly, and now his family no longer qualifies for financial assistance through marketplace subsidies and must sign up for Medicaid. He had finally managed to control his diabetes with his primary care doctor, but when scheduling his next appointment, he is told his doctor doesn’t accept Medicaid.

When the summer rolls around, he picks up more hours, and starts making too much for Medicaid. He has to go back on a marketplace plan, a different one from before. Meanwhile, providers and insurance plans rack up administrative costs as they accommodate these changes.

Because of fluctuations in income, millions of Americans move back and forth between Medicaid and the Affordable Care Act’s insurance marketplace, leading to significant health and financial costs for individuals, states and insurance companies.

This cycling across different forms of insurance is called “churning.” Churning is not a new phenomenon. In the past, people who rolled off Medicaid simply became uninsured. But now many who become ineligible for Medicaid become eligible for marketplace subsidies, and vice versa.

The Affordable Care Act sets the eligibility divide between Medicaid and the insurance marketplace at 138 percent of the federal poverty level, or about $33,000 for a family of four — a threshold at which many people experience substantial income fluctuation. Up to 28 million people may move between plans annually, according to a 2011 study by Benjamin Sommers at Harvard and Sara Rosenbaum at George Washington University. Over the course of four years, only 19 percent of adults will remain continuously eligible for Medicaid and 31 percent continuously eligible for marketplace subsidies. Almost 40 percent will have churned more than four times during this period.

Churning is also costly for taxpayers. Research suggests that average monthly spending on individuals continuously enrolled in Medicaid is two-thirds what it is for those enrolled for just half the year. And the administrative costs can be considerable; one study found that it costs $280 to enroll a child in Medicaid.

What can be done? One option is to require states to guarantee 12 months of continuous eligibility when people sign up for Medicaid. Currently fewer than half of states do this for children and pregnant women, and only New York does it for all adults. An analysis by the Commonwealth Fund found that offering 12 months of continuous Medicaid eligibility would reduce churning by 30 percent. Guaranteeing coverage through the end of the calendar year would reduce churning by nearly 80 percent.

Another approach is to smooth the transition between Medicaid and the marketplace plans by aligning plans, benefits and networks of providers. States are increasingly relying on managed-care companies to provide Medicaid benefits; in 2015, the number of Medicaid beneficiaries using private insurance plans reached 46 million. Making sure people can use similar providers and services — regardless of which insurance they technically qualify for at that time — could help.

Washington is helping insurers in the marketplaces develop Medicaid managed-care plans. A more direct path is simply to allow Medicaid-eligible populations to buy private plans on the marketplaces.

While the patchwork of health care in the United States may make some amount of churning unavoidable, it is possible to create a less wasteful, more unified system that works better for patients and providers.

Dhruv Khullar is a resident physician at Massachusetts General Hospital and Harvard Medical School.

***

Published Comment:

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

Tweaking the alignment of Medicaid and the private ACA exchange plans still leaves in place a fragmented system of incongruous provider networks, and unstable cost sharing depending on plan actuarial values and sliding-scale subsidy qualifications. These efforts result in wasteful administrative excesses, inefficiencies and inequities in care.

A well designed single payer system – an improved Medicare for all – would provide stable health care coverage for life – totally eliminating churning. The savings from the administrative efficiencies would be enough to eliminate current financial barriers faced by the uninsured and the underinsured, while reducing inequities and ensuring access for all.

Tweaking a highly dysfunctional system just won’t get us there.

http://www.nytimes.com/2016/03/24/upshot/how-to-stop-the-bouncing-between-insurance-plans-under-obamacare.html

Dhruv Khullar has provided us with an important policy lesson. He seems to be amongst those who believe that we should accept Obamacare (ACA) as a given and build on it through incremental reform. Amongst the multitude of problems with ACA, he has selected as an example the issue of churning in and out of Medicaid and the private ACA exchange plans. What does he propose?

He suggests reducing churning by offering twelve-month eligibility for Medicaid, and he suggests aligning benefits and provider networks between Medicaid managed care and private ACA exchange plans – a proposal with obvious profound administrative complexity. Further, when these anti-churning measures are implemented, he concedes that “the patchwork of health care in the United States may make some amount of churning unavoidable.”

This is the policy lesson. Our fragmented, dysfunctional financing infrastructure is so highly flawed that patches to it will have very little impact in moving us closer to the ideal of a quality health care system that serves all of us well. In contrast, the patches themselves lead to further administrative waste with associated higher costs.

The obvious answer to churning is to have a single, well-designed Medicare for all program in which individuals are enrolled for life. That would also take care of most of the multitude of other health care financing problems that Dhruv Khullar nor I could address here.

Broken health care model deserves debate

By Sarah C. Heiner, M.D.
Las Vegas Business Press, March 21, 2016

What is our system of health care for?

Is it just another commodity, as this country has essentially handled it apart from the federal programs that cover the poor, children under 18 and the elderly?

Or, is it meant to deliver an essential service to a nation’s people, understanding that the nature of this service will at all times be complicated, capricious and never profitable?

Many health-care professionals who were educated and trained in the 1970s and 1980s have watched, appalled, at how the wealthiest nation on earth has allowed its citizens’ health to be hijacked by an enormous, for-profit infrastructure.

It is popular to blame all the woes of our health-care wallets on the 2010 Affordable Care Act. This is a vast oversimplification.

The best element of the ACA eliminated the longstanding discrimination by insurers against the sickest and most fragile Americans, many of whom were rendered uninsurable at birth or in their youth by conditions over which they had no control.

Secondly, the ACA stopped the arbitrary practice of pre-existing-condition cherry-picking for the insured seeking new health coverage.

Finally, it offered a needed expansion of Medicaid to low-income working adults without children. However, by letting insurers raise premiums unchecked to “make up for” the burden of covering all of the above, the law has added to rising costs.

Our problem originates with the implementation of the computerized coding systems 30 years ago that transformed how those in the non-medical-professional health-care industries categorized medical illness, prevention and the value of the services of individual doctors and hospitals.

The first of these systems, the CPT codes, was developed in 1966 by the independent physicians’ group, the American Medical Association, to standardize how individual physicians billed health insurers for their services. In 1983, the federal agency HCFA adopted these codes for billing Part B Medicare services and, in 1987, outpatient surgical services.

HCFA also developed a new series of codes for paying hospitals, called the DRGs, or “Diagnosis-Related Groups,” which it began using in 1983. With DRGs, a hospital receives a fixed payment for a specific diagnosis, no matter the length of stay. In 1987, the DRGs were adopted as the payment system for privately insured patients as well.

Organizing all of the provisions of our country’s health-care services into a system of codes to streamline payment for services also created an organizational structure for payers to compare apples to apples for every one of the tens of thousands of these codes. Over the 1990s, a pattern of competition emerged among insurers to drive down reimbursements for less valuable codes such as an office visit in favor of high-revenue-producing procedures such as elective outpatient surgery.

Hospitals caring for the sickest and poorest patients were labeled as providing “low-quality care” and many closed. By the mid-1990s, the number of American medical students choosing careers in primary care medicine — i.e. pediatrics, family practice or general internal medicine — plummeted.

Concomitantly, the non-medical infrastructure of insurers took off, and, in the roaring ’90s, these executives started to command salaries far exceeding those of many of the medical personnel actually creating the “product.” This trend continues.

In 2014 alone, the CEO of the U.S.’s largest private insurer, UnitedHealth Care, made $66.1 million. Ironically, last year UnitedHealth also began to threaten that, since it was losing money providing a low-cost product on the ACA’s health insurance exchange, it may pull out. The current system of regulations has no mechanism to stop this.

In addition, the nation’s five largest health insurers, accounting for more than 80 percent of the market, are gearing up to consolidate into three large carriers; UnitedHealth Care, and the merged insurers Aetna-Humana and Anthem-Cigna.

When, in the history of American business, has a monopoly been good for the general public?

Physicians for a National Health Program was founded in 1986 by a group of insightful health-care professionals who correctly predicted how the future would unfold. At the end of 2015, it counted 20,224 members and is growing steadily. The Nevada chapter was established last fall and we encourage anyone who is interested to visit the website at www.pnhp.org.

Rather than “socialized medicine” we advocate pragmatic discussion, free of partisan politics, about the need for a nationally funded basic health insurer not focused on corporate profits. Twenty years of statistics show this will be far more sustainable than our current system. We all deserve better.

Sarah C. Heiner, M.D., is a general internist who has practiced primary care medicine in Clark County since 1986. Solely, or with partners, she has run her own business for 27 years. She now lives and practices in Henderson. Dr. Heiner is a graduate of Northwestern University’s honors program in medicine and trained at Mt. Zion/UCSF Hospital in San Francisco.

http://businesspress.vegas/healthcare/broken-health-care-model-deserves-debate

The rent-seeking behavior of pharmacy benefit managers

Secret deals may mean consumers pay more for drugs

By Jayne O’Donnell
USA TODAY, March 21, 2016

Secret deals often prompt drug benefit companies to cover brand-name prescriptions when equally effective generic or even over-the-counter medications are available, several drug pricing experts say.

These companies, known as pharmacy benefit managers (PBMs), negotiate deals with drug makers that include rebates and other compensation to encourage certain drugs and come up with lists of drugs that their insurance plans will cover. Employers and insurance companies then determine which drugs to encourage on these formularies.

The process is so convoluted that even the United States’ largest insurer, Anthem, discovered what it said were $3 billion in overcharges by Express Scripts and filed suit Monday against the PBM for damages.

In their deals with drugmakers, PBMs agree to favor the high-cost drugs on the PBMs’ formularies and agree that they won’t place quantity limits — or prior authorization programs — on the drugs, even though doing so would help health plans save money and make medical sense, says Linda Cahn, founder and president of Pharmacy Benefit Consultants, which audits PBM contracts.

“What really gets me started is when PBMs sell their clients on programs that increase costs by encouraging brands so that the PBM can collect rebates,” says Susan Hayes, a principal in Pharmacy Outcomes Specialists, which represents plan sponsors and audits their PBM contracts.  “And many clients do not know the cost implications when they sign off on these programs.”

http://www.usatoday.com/story/news/nation/2016/03/21/pharmacy-benefit-firms-can-raise-drug-costs-despite-cheaper-choices/81767978/

***

Comment:

By Don McCanne, M.D.

Pharmacy benefit managers (PBMs) are yet one more example of how effective our policymakers have been in taking care of the medical industrial complex while perpetuating the highest level of health care spending of all nations. PBMs are superfluous pharmaceutical middlemen who further compound our uniquely-American, highly wasteful administrative excesses as a necessity to gain reward for their own rent-seeking behavior.

Rent-seeking is the use of a company, organization or individual’s resources to obtain economic gain from others without reciprocating any benefits to society through wealth creation. (Investopedia)

Rent-seeking is a creature of the medical-industrial complex. It should have no place in our health care system. If we established a single, universal, publicly-funded and publicly-administered health care financing infrastructure, it would function as a monopsony, representing the people, that would work for us to dramatically reduce administrative waste while preventing clandestine rent-seeking gains.

In the words of Nobel laureate Kenneth Arrow – the leading authority in markets and health care – single payer is “better than any other system.”

PNHP Report Card: 2016 Selected Presidential Candidates’ Health Proposals

By Ida Hellander, M.D.
Updated March 22, 2016

2016 Candidate Proposals

In alphabetical order, top 3 GOP candidates, 2 Democrats, and 1 Green:

1. Hillary Clinton
Defends the ACA. Promotes incremental reform. Advocates Medicare drug price negotiation “for high cost drugs.” Would allow drug importation from other countries, cap specialty drug out-of-pocket costs at $250/month, and allow three doctor visits before having to pay deductible. $5,000 tax credit to families with very high medical costs. (C+)

2. Ted Cruz
Proposes to raise Medicare age to 67 and turn the program into a voucher (“premium support” program). Has introduced legislation (“Health care choices act”) to repeal Title I of the ACA only (i.e. the insurance exchanges, tax subsidies, and mandate to buy coverage) but keep everything else intact (i.e. Medicaid expansion, Medicare ACOs, etc.). Would provide tax credits to purchase health insurance. Promotes health savings account and allowing insurers to sell bare bones policies across state lines. (F)

3. John Kasich
Proposes to repeal ACA. Promotes patient-centered medical homes for Medicaid. Promotes payment reform such as “bundled” payments. (F)

4. Bernie Sanders
Supports single payer national health insurance and allowing Medicare to negotiate drug prices with pharmaceutical companies. Opposed to the ACA’s 40 percent excise tax on high-cost private insurance (“Cadillac tax”). Would allow drug importation from Canada. (A)

5. Jill Stein (Green)
Longtime supporter of single payer national health insurance. (A)

6. Donald Trump
Would repeal the ACA. Would block grant Medicaid. Promotes health savings accounts as a way to save money that is exempt from estate taxes. Would allow importation of cheaper drugs from other countries. Promotes sale of insurance across state lines. Supports making health insurance premiums tax deductible and making health care prices transparent. (F)

Sources: Candidate websites, newspaper articles, media quotes, and interviews.

GLOSSARY OF SELECTED HEALTH REFORM TERMS

Voucher proposal for Medicare. Also known as “premium support,” a voucher program would replace Medicare with a defined-contribution or coupon for beneficiaries to apply towards the cost of private insurance. This approach would limit the government’s spending on Medicare, but raise costs for seniors and the disabled. In addition, private insurance plans have overhead seven-fold higher than Medicare, and have raised, not lowered, Medicare’s costs by selectively enrolling the healthy and dis-enrolling the sick. Proposed by Ted Cruz.

Block grant Medicaid. Medicaid is the jointly-funded federal-state insurance program for people with low incomes. Medicaid currently covers about 70 million people for a defined set of benefits. With a block grant, the federal government would give states a lump sum of money and let states determine how to use it. This is worrisome because the Medicaid program is already underfunded and varies substantially from state to state in eligibility standards, coverage, quality, and reimbursement. Proposed by Donald Trump.

Health savings accounts. Health savings accounts are a tax-free way of saving money for health care. In theory they reduce health care costs by making patients prudent shoppers for health care. In practice, patients with high-deductible health plans coupled with HSA’s reduce their utilization of health care across the spectrum of care, including prevention and primary care. A recent study of HSA’s found no evidence that patients shopped for cheaper care. HSA’s are inadequate for the sick and poor, who quickly deplete them. They are mostly funded by the wealthy, who use them as a tax shelter. Proposed by Donald Trump and Ted Cruz.

Sale of insurance across state lines. Permitting the sale of skimpy insurance plans – plans that don’t meet state standards for coverage – across state lines would increase the number of people who are underinsured and for whom an illness or injury could lead to bankruptcy. Insurers can already sell coverage that meets states’ standards across state lines, as proposed by Donald Trump, but they choose not to. The reason the state regulations are in place is to make sure insurers don’t sell worthless coverage, such as coverage that doesn’t cover hospital care, or that takes 50 percent of premiums for overhead, marketing, profit and huge CEO salaries. Promoted by Ted Cruz and Donald Trump.

Dr. Ida Hellander is director of health policy and programs at Physicians for a National Health Program.

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

Reducing the cost of Minnesota’s health care

By Charles R. Peterson, M.D., and Don Pylkkanen
Brainerd (Minn.) Dispatch, March 21, 2016

Some weeks ago a health care article in a major Minnesota newspaper reported, “This year, the average premium in the individual market is up 41 percent.” The state’s current total health care cost of about $50 billion is projected by a Minnesota Department of Health estimate to reach $76.5 billion in 2022. At that point it would represent 20 percent of the state economy. What can be done about this trend?

The answer is that the Affordable Care Act (Obamacare) provides an opportunity starting in 2017 for any state to improve its health care system with the law’s State Innovation Waiver. Both a state agency and a privately designed proposal are in the works under the waiver.

Last September the Minnesota Department of Health and Human Services presented a plan to improve Minnesota’s health system, primarily through increased use of existing and new Accountable Care Organizations. ACOs are large, physician-hospital groups voluntarily organized around cost-quality measurable benchmarks. Savings and risks are shared between payers and providers based on these performance standards.

The ACO concept was introduced about a decade ago on a premise that tightly integrated physician-hospital units with dollar-incentivized benchmarks would produce significant cost savings without compromising quality. However, multiple pilot and demonstration projects to date show that ACOs, like previous HMOs, PPOs, and other managed care systems have little, if any, effect on medical cost inflation.

A task force was legislated in 2015 with one of the major goals to explore ways “that reduce cost.” However, in its January 2016 final report, only some small savings “to the State and Federal government” were reported. No actual or projected savings on the total system were reported. One recommendation proposed a study to compare a “publicly-financed, private-delivered universal health care system” with other options. The task force did not address downside risks of ACOs such as merger-monopolies or provider dissatisfaction.

The other proposal is the Minnesota Health Plan, which was developed by a number of citizen groups and legislatively introduced in March 2015 by Sen. John Marty and Rep. Carolyn Laine. This “Medicare-for-all” model has been well tested in the U.S., Canada, and elsewhere in the world. It needs no “pilot project.” Physicians for a National Health Program of Minnesota, the Minnesota Nurses Association, COACT, and a number of other groups support this plan (see mnhealthplan.org and www.coact.org).

With MHP, all Minnesotans would be insured, have uninhibited choice of physicians, and would not lose coverage with job losses or changes. There would be no deductibles, and no co-pays for primary care. The plan’s volume purchasing of prescription drugs would reduce prices. In this single-payer proposal, providers are paid directly for medical care, thus avoiding the intermediate overhead costs of multiple insurers. The Lewin Group, commissioned by Minnesota Growth and Justice, has independently analyzed the proposal and judged it financially sound. Compared to projected cost increases, changing to the MHP would result in a 10-year statewide savings of over $100 billion.

In our view, the MHP has much greater potential for cost reduction than the ACO plan does, and it also achieves universal coverage at no risk to quality. ACO disciplines are not excluded as they can be applied to the MHP system just as they have been to the Medicare system.

But even without these direct comparisons, faced with unsustainable cost rises, it makes little sense to ignore the fact that on a global scale, U.S. health care costs are on average 50-70 percent higher than the other 20 most advanced countries of the world. And these nations have better longevity and disease-morbidity outcomes than the U.S. does. These countries started out with a moral commitment to insure everyone, without letting some inconvenience from delay in elective procedures stand in the way of universal and economically efficient basic coverage for all.

Significant changes in our expensive health care delivery are opposed by advocates of an unproven economic philosophy that presumes health care delivery costs respond to free market forces like most businesses do. Dr. Arnold Relman, a former editor of the New England Journal of Medicine, forcefully made this point in his book, “A Second Opinion.” Citing Nobel Laureate economist Kenneth Arrow, he pointed out that individual or family purchasers of health care do not shop for provider services on the basis of price. Disease is an existential threat that diminishes consumer cost concerns in favor of perceived quality. Physicians determine over 95 percent of the tests or procedures done. These plus other factors noted by Relman pressure costs upward.

On March 15, Governor Dayton’s Supplemental Budget was released. In it, he recommends “funding a study to compare costs and benefits of a universal/single-payer health care system versus a free market insurance-based approach.” This action follows one of the recommendations of the state task force.

Minnesotans should be informed on this issue and ask their legislators to support the governor’s proposal for an objective study. The high cost of the status quo deserves serious attention.

Dr. Peterson is retired from internal medicine practice at Park Nicollet Clinic. Pylkkanen is executive director, Minnesota COACT.

http://www.brainerddispatch.com/opinion/guest-opinion/3991907-guest-opinion-reducing-cost-minnesotas-health-care

The rent-seeking behavior of pharmacy benefit managers

Secret deals may mean consumers pay more for drugs

By Jayne O’Donnell
USA TODAY, March 21, 2016

Secret deals often prompt drug benefit companies to cover brand-name prescriptions when equally effective generic or even over-the-counter medications are available, several drug pricing experts say.

These companies, known as pharmacy benefit managers (PBMs), negotiate deals with drug makers that include rebates and other compensation to encourage certain drugs and come up with lists of drugs that their insurance plans will cover. Employers and insurance companies then determine which drugs to encourage on these formularies.

The process is so convoluted that even the United States’ largest insurer, Anthem, discovered what it said were $3 billion in overcharges by Express Scripts and filed suit Monday against the PBM for damages.

In their deals with drugmakers, PBMs agree to favor the high-cost drugs on the PBMs’ formularies and agree that they won’t place quantity limits — or prior authorization programs — on the drugs, even though doing so would help health plans save money and make medical sense, says Linda Cahn, founder and president of Pharmacy Benefit Consultants, which audits PBM contracts.

“What really gets me started is when PBMs sell their clients on programs that increase costs by encouraging brands so that the PBM can collect rebates,” says Susan Hayes, a principal in Pharmacy Outcomes Specialists, which represents plan sponsors and audits their PBM contracts.  “And many clients do not know the cost implications when they sign off on these programs.”

http://www.usatoday.com/story/news/nation/2016/03/21/pharmacy-benefit-firms-can-raise-drug-costs-despite-cheaper-choices/81767978/

Pharmacy benefit managers (PBMs) are yet one more example of how effective our policymakers have been in taking care of the medical industrial complex while perpetuating the highest level of health care spending of all nations. PBMs are superfluous pharmaceutical middlemen who further compound our uniquely-American, highly wasteful administrative excesses as a necessity to gain reward for their own rent-seeking behavior.

Rent-seeking is the use of a company, organization or individual’s resources to obtain economic gain from others without reciprocating any benefits to society through wealth creation. (Investopedia)

Rent-seeking is a creature of the medical-industrial complex. It should have no place in our health care system. If we established a single, universal, publicly-funded and publicly-administered health care financing infrastructure, it would function as a monopsony, representing the people, that would work for us to dramatically reduce administrative waste while preventing clandestine rent-seeking gains.

In the words of Nobel laureate Kenneth Arrow – the leading authority in markets and health care – single payer is “better than any other system.”

It’s all about the risk pool

Don’t Let The Talking Points Fool You: It’s All About The Risk Pool

By Linda Blumberg and John Holahan
Health Affairs Blog, March 15, 2016

Most people are healthy most of the time, and as a consequence, health care expenditures are heavily concentrated in a small share of the population: about 50 percent of the health care spending in a given year by those below age 65 is attributable to just 5 percent of the nonelderly population. The lowest spending half of the population accounts for only about 3.5 percent of health care spending in a year.

Deciding how much of total health care expenditures should be shared across the population and how to share it is the fundamental conundrum of health care policy. There is more risk pooling the larger the share of health expenditures included in the insurance as covered expenses (i.e., the fewer benefits excluded and the lower the out-of-pocket cost requirements), the larger the number of both the healthy and the sick insured, and the lower the variation in premiums across different enrollees. Sharing the costs of the sick across the broader population (a.k.a., risk pooling) increases costs for the healthy to the benefit of those with health problems; this creates more financial losers than winners at a point in time, since there are many more healthy people than sick in a given year. Segmenting risk pools has the opposite effect, savings for the currently healthy while increasing costs for those with health problems.

The health policies of the two political parties and their presidential candidates differentiate themselves clearly along the lines of pooling philosophies: the Democrats generally advocate broad-based pooling of health care risk and the Republicans generally advocate more individual responsibility and are willing to accept much greater segmentation of health care risk. These positions have dramatically different implications for individuals when they experience significant health problems, and they also have very different implications for low- and middle-income populations as compared to those with high incomes. As a consequence, each health care policy proposal should be evaluated as to its ramifications for risk pooling.

Left unchecked, people who perceive themselves healthy will tend, if they are pursuing their own near-term financial self-interests, to separate themselves from sick people—either by avoiding health insurance entirely, purchasing insurance products sold predominantly to other healthy people, or purchasing insurance products offering limited benefits that likely are not attractive to those requiring significant medical care. Those supporting public policies that allow or encourage this type of separating of health care risks often argue that they are placing greater personal responsibility on each individual, who will in turn make better decisions about the use of medical services. However, the burden of that increased responsibility falls most heavily on those with health problems, since it places larger financial costs on those with medical care needs at the time those needs arise, reducing costs for individuals while they are healthy.

Depending upon the extent of the risk segmentation created, these policies can effectively deny care to those that need it. Those who are well off financially can finance a considerable amount of necessary care out-of-pocket; a low- or middle-income individual experiencing a health crisis cannot. Thus, policies that separate risks will not only harm the sick, they will decrease access to care most heavily for the non-wealthy with health problems. Therefore, the amount of risk pooling versus risk segmentation is a fundamental choice.

**

The degree of risk sharing under current law varies by the insurance market. Public insurance (e.g., Medicare, Medicaid) represents the most pooling of risk. All beneficiaries are eligible for the same health insurance benefits, and the cost of providing those benefits is largely financed by broad-based revenue sources (e.g., income or payroll taxes), completely separating enrollee health status from financing of the programs’ benefits. Public programs that include deductibles, co-insurance, or co-payments or limit covered benefits reduce the sharing of risk to some extent, as these provisions increase financial burdens directly with medical care use.

**

Risk pooling approaches promote broad access to affordable medical care regardless of income or health status, while the risk segmenting approaches do not and would in fact reduce access relative to current law. Advocates of the latter generally employ terms such as individual responsibility, skin in the game, consumer choice, and market competition, but make no mistake about it: it is all about the risk pool.

http://healthaffairs.org/blog/2016/03/15/dont-let-the-talking-points-fool-you-its-all-about-the-risk-pool/

***

Comment:

By Don McCanne, M.D.

Risk pooling is the most fundamental concept in health care financing. Funds are paid into a common pool to cover the health care needs of those insured by the pool. Although that is a simple, basic concept, this article explains the complexities of risk pooling, with special attention to policies that promote greater risk pooling and policies that decrease pooling, separating the risks. The consequences are immense.

The politicians are discussing various concepts of health care reform ranging from incremental changes to the Affordable Care Act (ACA), to various concepts of replacing ACA, to establishing a single payer national health program. The most important differences between these models are in how they pool risk. The least effective are the ACA replacement proposals, and the most effective is a universal single payer system (an improved Medicare for all).

Even though it is easy to explain risk pooling, it is important to be able to respond to each proposal for reform with a precise explanation of how that proposal impacts risk pooling. The reason is that it’s all about the risk pool. A well designed universal risk pool ensures that health care will be affordable for each of us whenever we need it.

The full article by Linda Blumberg and John Holahan should be downloaded, studied, and saved as a reference to be used in health policy advocacy. We won’t get risk pooling right until we have everybody in, nobody out! (Thanks, Quentin.)

Health care in America: On single-payer systems

By Bryce Zedalis
Albuquerque Journal, March 20, 2016

Debates about policy approaches to health care continue. With the rise to prominence of Sen. Bernie Sanders as a candidate for president, politicos and citizens alike have rekindled discussions concerning the adoption of a “Medicare-for-all,” single-payer health system. Among the goals of such a system, the most salient is guaranteed health care for everyone.

A 2013-2014 American Community Survey showed New Mexico with an uninsured rate roughly 4 percent above the national level. New Mexico continues to face a critical health insurance problem.

Single-payer health systems, while capable of eliminating the problem of the uninsured, remain controversial for two primary reasons: the resultant expansion of government and the perception of diminished point-of-care service.

Regarding the first, government administration of the health care system would necessitate an expansion of oversight and the conversion of quasi-private markets to those controlled by bureaucrats.

Regarding the second, much of the discussion is informed by political ideology. Yet the actual, real-life experience of receiving health care within a single-payer system provides a nice contrast to such an ideological perspective.

To the ideologue, many stereotypes exist, including notions of long waits and impersonal care. Such stereotypes, however, were never verified in my experience within Scotland’s single-payer National Health Service.

While a graduate student at the University of Edinburgh, I’ve had roughly a half dozen experiences with NHS Scotland.

Most followed a standard procedure. At 8:30 a.m., I would call the local NHS clinic and arrange to be seen during that day’s “open surgery” – a time when patients, without an appointment, met with doctors.

Check-in at 10 a.m. was quick and required only name and date of birth; co-pays didn’t exist. I was always seen within 25 minutes of check-in and met with a doctor each time.

If a prescription was ordered, I would immediately take the script to my local pharmacist, and within 10 minutes, and without charge, it would be filled.

Even in acute or more complex situations, service was equally as efficient and effective. In fact, my first NHS Scotland experience was just that – occurring on a Saturday shortly before a first lunch date with a young Scottish woman.

To my dismay, I awoke that morning with a fever. I contacted the 24-hour NHS telephone operator. After answering several questions, I was patched through to a doctor, and an appointment was scheduled for that afternoon at the Royal Infirmary.

Knowing that I’d be seen that day, I nonetheless met my date and, upon arriving, half-jokingly uttered, “I have the most romantic thing to tell you – I have to go to the hospital at 3 o’clock.” I was in luck, as my date had a car and drove me to the hospital after lunch. Unfortunately, however, not even the prompt and excellent health service was able to ensure a second date.

Similarly, upon returning to Edinburgh from Italy with an ailment necessitating a chest X-ray, I found the process to be very straightforward.

After meeting with the doctor at my local clinic, she handed me a single-page print-out with my medical details and the location of the nearest X-ray clinic. The wait for the X-ray was merely half an hour.

The procedure took only a few moments, and within a couple of days, my local clinic had my “boringly normal” X-ray results. All free of cost and hassle.

Obviously, my point-of-care experiences within NHS Scotland are not predictive of the potential experiences of individuals within a single-payer health system in America. They do, however, serve to challenge the stereotypes we’ve attached to such systems.

Given this, when reflecting on improvements to our health care system, it’s essential to approach such with impartial understanding of single-payer systems, as opposed to one blinded by ideological predispositions.

Bryce Zedalis holds an MBA from the University of New Mexico and is a Ph.D. candidate in Social Policy at the University of Edinburgh.

http://www.abqjournal.com/743107/opinion/headline-490.html

High price of health care

Trade agreement could be a bad deal for medicine

By Anna Zelivianskaia, M4
Chicago Medicine, February 2016

In the middle of a busy emergency room, a resident tells me, “I just found out how much a brand-name proton pump inhibitor costs – a 400 percent markup from generic and a few pills cost over $200!” Unfortunately, this is nothing new. And, in my opinion, the problem will only worsen under what’s known as the Trans-Pacific Partnership (TPP) trade agreement. The TPP was negotiated between the United States and 11 Pacific Rim countries, and now awaits congressional approval. Based on the final text, which was released in November 2015, the TPP will negatively impact public health in the signatory countries, including the U.S.

Harmful provisions in the TPP would loosen patent requirements, prolong pharmaceutical monopolies, and tighten intellectual property regulations. Longer brand-name monopolies translate into limited generic usage. This is particularly worrisome for developing countries with less access to generics drugs.

According to Public Citizen’s Global Trade Watch, “The TPP would set the parameters” for future efforts by national and state legislatures to reduce the cost of medicines, protect public health and the nation’s fiscal health. Just one critical example: The TPP’s limits on future policy could shut down high-profile reform efforts, first and foremost, for Medicare Part D price negotiation.

Impact on biologic medicines

The most controversial TPP medicine-related provision concerns biotech drugs, or biologics – medical products derived from living organisms, Public Citizen states on its website. “Biologics include many new cancer treatments, now averaging around $190,000 per person per year. Most health systems cannot pay such prices without compromising other health care priorities. In the TPP, the pharmaceutical industry achieved its goal that every TPP country must provide new exclusivity periods for biologics.”

Provisions like these are particularly dangerous in a time when the face of poverty is changing and health care is becoming less affordable. Médecins sans Frontières (MSF) translated as “Doctors Without Borders,” relies mostly on generic drugs to treat many diseases – 80 percent of antiretroviral medicines used by the organization are generics.

In its early years, MSF worked mostly in low-income developing countries. However, poverty now exists and grows in countries with greater overall wealth. MSF today works in over 30 countries with incomes that are categorized as “middle” or “high” by the World Bank. Millions of people will be considered poor in TPP-participating countries once their country reaches middle- or high-income status.

For countries participating in the TPP, patent laws would be relaxed; it would be possible to patent a newer version of an existing medicine even though it has no new therapeutic benefit. The TPP would also extend current patent terms, which are usually 20 years, by five years if the company faces loosely defined “regulatory delays” during the patent process. In certain cases, individual governments can make medicines more affordable in their countries through price controls or reimbursement policies, but the TPP would also restrict the participating countries’ ability to alleviate health care costs using these techniques.

According to an MSF spokesman, “Data exclusivity blocks competing firms from using previously generated clinical trial data to gain approval for generic versions of these drugs and vaccines. If pharmaceutical companies have their way, the TPP will block generic producers of biologics from entering the market for at least 12 years.”

The argument for such regulations is that pharmaceutical companies need time to recoup costs lost during the development process; profit promotes innovation. However, the Federal Trade Commission found no evidence to support this and concluded that no years of exclusivity were necessary to promote innovation in biologic drugs. These regulations limit access to life-saving medications for the most underserved patients.

The TPP was negotiated using “fast-track” authority, which means that the final agreement is subject to a straight up-or-down vote by Congress, with little opportunity for debate or amendment. Most trade negotiations require this “fast-track” approach because other countries are unlikely to participate in negotiations if the final deal could have substantial changes or stall during the approval process.

As health care professionals, we have a responsibility to advocate on behalf of our patients. I believe that our efforts across the world will be severely limited if there are restrictions on affordable medications. And because of these threats to public health, I have written to Congress and President Obama to let them know I oppose the TPP.

Anna Zelivianskaia is a fourth-year medical student at the University of Illinois at Chicago.

http://www.cmsdocs.org/news-publications/chicago-medicine-magazine/2016-issues/February2016.pdf

It’s all about the risk pool

Don’t Let The Talking Points Fool You: It’s All About The Risk Pool

By Linda Blumberg and John Holahan
Health Affairs Blog, March 15, 2016

Most people are healthy most of the time, and as a consequence, health care expenditures are heavily concentrated in a small share of the population: about 50 percent of the health care spending in a given year by those below age 65 is attributable to just 5 percent of the nonelderly population. The lowest spending half of the population accounts for only about 3.5 percent of health care spending in a year.

Deciding how much of total health care expenditures should be shared across the population and how to share it is the fundamental conundrum of health care policy. There is more risk pooling the larger the share of health expenditures included in the insurance as covered expenses (i.e., the fewer benefits excluded and the lower the out-of-pocket cost requirements), the larger the number of both the healthy and the sick insured, and the lower the variation in premiums across different enrollees. Sharing the costs of the sick across the broader population (a.k.a., risk pooling) increases costs for the healthy to the benefit of those with health problems; this creates more financial losers than winners at a point in time, since there are many more healthy people than sick in a given year. Segmenting risk pools has the opposite effect, savings for the currently healthy while increasing costs for those with health problems.

The health policies of the two political parties and their presidential candidates differentiate themselves clearly along the lines of pooling philosophies: the Democrats generally advocate broad-based pooling of health care risk and the Republicans generally advocate more individual responsibility and are willing to accept much greater segmentation of health care risk. These positions have dramatically different implications for individuals when they experience significant health problems, and they also have very different implications for low- and middle-income populations as compared to those with high incomes. As a consequence, each health care policy proposal should be evaluated as to its ramifications for risk pooling.

Left unchecked, people who perceive themselves healthy will tend, if they are pursuing their own near-term financial self-interests, to separate themselves from sick people—either by avoiding health insurance entirely, purchasing insurance products sold predominantly to other healthy people, or purchasing insurance products offering limited benefits that likely are not attractive to those requiring significant medical care. Those supporting public policies that allow or encourage this type of separating of health care risks often argue that they are placing greater personal responsibility on each individual, who will in turn make better decisions about the use of medical services. However, the burden of that increased responsibility falls most heavily on those with health problems, since it places larger financial costs on those with medical care needs at the time those needs arise, reducing costs for individuals while they are healthy.

Depending upon the extent of the risk segmentation created, these policies can effectively deny care to those that need it. Those who are well off financially can finance a considerable amount of necessary care out-of-pocket; a low- or middle-income individual experiencing a health crisis cannot. Thus, policies that separate risks will not only harm the sick, they will decrease access to care most heavily for the non-wealthy with health problems. Therefore, the amount of risk pooling versus risk segmentation is a fundamental choice.

**

The degree of risk sharing under current law varies by the insurance market. Public insurance (e.g., Medicare, Medicaid) represents the most pooling of risk. All beneficiaries are eligible for the same health insurance benefits, and the cost of providing those benefits is largely financed by broad-based revenue sources (e.g., income or payroll taxes), completely separating enrollee health status from financing of the programs’ benefits. Public programs that include deductibles, co-insurance, or co-payments or limit covered benefits reduce the sharing of risk to some extent, as these provisions increase financial burdens directly with medical care use.

**

Risk pooling approaches promote broad access to affordable medical care regardless of income or health status, while the risk segmenting approaches do not and would in fact reduce access relative to current law. Advocates of the latter generally employ terms such as individual responsibility, skin in the game, consumer choice, and market competition, but make no mistake about it: it is all about the risk pool.

http://healthaffairs.org/blog/2016/03/15/dont-let-the-talking-points-fool-you-its-all-about-the-risk-pool/

Risk pooling is the most fundamental concept in health care financing. Funds are paid into a common pool to cover the health care needs of those insured by the pool. Although that is a simple, basic concept, this article explains the complexities of risk pooling, with special attention to policies that promote greater risk pooling and policies that decrease pooling, separating the risks. The consequences are immense.

The politicians are discussing various concepts of health care reform ranging from incremental changes to the Affordable Care Act (ACA), to various concepts of replacing ACA, to establishing a single payer national health program. The most important differences between these models are in how they pool risk. The least effective are the ACA replacement proposals, and the most effective is a universal single payer system (an improved Medicare for all).

Even though it is easy to explain risk pooling, it is important to be able to respond to each proposal for reform with a precise explanation of how that proposal impacts risk pooling. The reason is that it’s all about the risk pool. A well designed universal risk pool ensures that health care will be affordable for each of us whenever we need it.

The full article by Linda Blumberg and John Holahan should be downloaded, studied, and saved as a reference to be used in health policy advocacy. We won’t get risk pooling right until we have everybody in, nobody out! (Thanks, Quentin.)