PNHP

Despite critics, Medicare turns 50

Despite critics, Medicare turns 50

By C.V. Allen, M.D.
Modesto (Calif.) Bee, July 16, 2015

Happy 50th birthday, Medicare!

You were a long time coming. With the Great Depression of the 1930s came demand for both health insurance and old-age pensions. Conservatives and the American Medical Association raised the cry of “socialized medicine” – threatening to sink both efforts.

Bowing to reality, reformers cut the health insurance portion adrift and the pension benefits of Social Security became law in 1935.

In the 1940s, President Harry S. Truman proposed a national health care program, but this time it was a casualty of the Cold War – a frightened public was told government medicine was communism, guaranteed to destroy all our freedoms. Again, that propaganda came from the AMA and a growing health care industry.

Among the opponents was Ronald Reagan, then still an actor and unofficial messenger boy for the conservatives and the AMA, who saw in a national health plan the eventual invasion of “every freedom we have known.” Again, reform failed.

The early ’60s brought convergence of three forces – increasing cost and effectiveness of medical care, increasing public demand for health solutions and the leftward shift of the electorate. It was a time when “liberal” was not a dirty word and reform found new life.

So Medicare became law on July 30, 1965. But its passage came with a concession. There would be no national health care system. Period.

Partial reform came in two layers – Medicaid, a state program for the poor, and Medicare for the aged. Thus did the commercial health insurers fix responsibility for the poor and aged on government, retaining for themselves the affluent, employed, under-65 population from which profits could be made. Moreover, the health insurance industry initially demanded – and got – compensation guaranteed to be “usual, customary and reasonable” – which eventually became none of these things.

Over the next 50 years, Medicare proved its critics wrong. It became, along with Social Security, the most effective social program in America’s history.

With low administrative expenses, all-inclusive philosophy and unrestricted choice of providers, Medicare is the most popular medical insurance system in the nation – and the most efficient. But problems abound, including the annual increase in per-capita expenses (higher than inflation, but lower than the private sector), congressional restrictions on reasonable cost containment policies, a high rate of consumer fraud and an uncanny ability of the private insurance sector to find ways to divert public money into private hands.

Even 50 years later, critics see in Medicare a financial tsunami waiting to happen. Others see it as a solution to our present dysfunctional, fragmented health care system – the most expensive in the industrial world despite failing to insure a sixth of its population.

An updated and improved “Medicare for all” could well be the template for radical reform required to lower costs and provide universal coverage – “everybody in, nobody out,” a single set of regulations, low administrative expenses, and a partnership between a private delivery system and a government assuming administrative and financial responsibilities. An impossible dream? So was Medicare five decades ago.

Either way, 50 million Americans go to bed each night knowing medical care will be there if needed. Well done, Medicare, and many happy returns.

C.V. Allen is a semi-retired Modesto doctor.

Read more here: http://www.modbee.com/opinion/opn-columns-blogs/article27435397.html#storylink=cpy

Medicare for All should be the goal

By Eve Shapiro, M.D., and Richard Wahl, M.D.
Arizona Daily Star, July 21, 2015

Medicare, one of our nation’s most valuable and popular social programs, turns 50 on July 30. Medicare is a federal health insurance program that covers 55 million Americans — those over 65 and younger people with permanent disabilities, currently 17 percent of the population.

It was originally conceived as a first step toward covering everyone in the United States under a national health insurance program. Medicare has been a success — it has sharply reduced poverty among seniors and has reduced health disparities related to race, ethnicity and socioeconomic status.

Patients in Medicare can go to the physician and hospital of their choice. It is also economical — overhead costs are about 2 percent compared with 12 to 20 percent for the private insurance market and even higher for the individual market.

Medicare costs are going up due to an aging population and the higher costs of healthcare, including pharmaceutical prices. These higher costs can be easily met by an upturn in the economy, generating greater tax receipts, and tweaks to the payroll tax, which has not increased in 30 years.

In comparison to Medicare, the health insurance options for all other Americans are problematic. Despite the improved access to care with the Affordable Care Act and the recent U.S. Supreme Court decision affirming people’s access to federal subsidies, the Congressional Budget Office estimates that 27 million Americans will remain uninsured.

In addition, many more Americans are feeling the effect of the cost shift to employees in the form of higher deductibles and copays. This creates underinsurance, defined as out-of-pocket costs more than 10 percent of income, which now faces more than 21 percent of adults. In addition, more than half of all bankruptcies in the U.S. are due to overwhelming health care costs.

What’s the solution? We need Medicare for All to ensure universal, comprehensive coverage with no copays and deductibles. This would include freedom of choice of one’s doctor and hospital, the ability to negotiate for more competitive drug prices, and the elimination of the approximately $400 billion administrative costs in our current system.

This system would be financed by a progressive tax that would cost the average family far less than they are paying now in health care costs. This is not “socialized medicine” because doctors would remain in private practice. Only the financing would change. It would not introduce rationing but would prevent the rationing we have now based on ability to pay.

A pipe dream? No. There is legislation in Congress, The Expanded and Improved Medicare for All Act, HR 676, which would put such a single-payer system in place. All other developed countries in the world have such a system, and provide for coverage for their citizens at a cost far lower than ours and at least equal in quality. Canada, for example, has had a system in place since 1971. Since then, they have spent far less than us on per capita health care costs (close to half), while living longer.

Let’s enable all Americans to take advantage of a single payer system, not just the elderly, and enact HR 676.

Eve Shapiro and Richard Wahl have been pediatricians in Tucson for many years and are members of Physicians for a National Health Program.

http://tucson.com/news/opinion/eve-shapiro-medicare-for-all-should-be-the-goal/article_6374c3c9-ebbf-50fe-9564-5eea664d13eb.html

Beware the fine print in private health plans

‘Illegal Activity’ Fine Print Leaves Some Insured, but Uncovered

By Roni Caryn Rabin
The New York Times, July 20, 2015

There’s no video of the altercation between Monroe Bird III, a 21-year-old sitting in a car with a friend, and Ricky Leroy Stone, 56, a security guard who found them one night in the parking lot of an apartment complex in Tulsa, Okla.

Mr. Stone, the security guard, told police he approached the car because he had been instructed to look out for couples having sex in the parking lot.

But the tragic culmination of their encounter is not disputed: Mr. Stone drew his gun and shot Mr. Bird, leaving him paralyzed from the neck down.

Three months later, as he lay in the hospital hooked to a ventilator, Mr. Bird’s insurance company declined to cover his medical bills. The reason? His injuries resulted from “illegal activity.”

Yet Mr. Bird was not convicted of any crime in connection with the incident. He was not even charged.

Without insurance, Mr. Bird’s family could not move him to a rehabilitation center specializing in spinal cord injuries. He was discharged from the hospital and died at home last month from a preventable complication often seen in paralyzed patients.

But Mr. Bird’s story comes with a particularly bitter sequel relevant to Americans of any background: The plan’s refusal to pay has left his family owing as much as $1 million in medical bills and, experts say, shines a light on a little-known loophole buried in the fine print of many health plans.

There are no firm numbers on how often insurers deny medical coverage based on allegations of illegal activity. But cases like Mr. Bird’s “are more common than people think,” said Crystal Patterson, an attorney in Minneapolis and chairwoman of the American Bar Association’s committee on fiduciary litigation.

Insurers have long relied on allegations of illegal activity to deny coverage to patients injured in a variety of contexts, from traffic infractions to gun accidents. The judicial rationale is that “we don’t want to reward illegal activity,” she said.

Insurance exclusions for illegal activity have been outlawed in some states, but state laws do not apply to health plans administered under the federal Employee Retirement Income Security Act, which sets standards for most pension and health plans in private industry.

Even after passage of the Affordable Care Act, self-insured plans regulated under Erisa maintain wide latitude to determine coverage. These plans “can do pretty much what they want to do,” said Robert Laszewski, an insurance industry consultant in Washington.

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Comment:

By Don McCanne, MD

If a person is insured and needs medical care, is there any circumstance under which the health plan should not pay for that care when it is covered by the plan?

Insurers have always used loopholes to avoid paying for appropriate care. Some of these loopholes, such as rescissions, were patched by the Affordable Care Act. But as long as private insurance is based on a business model rather than a patient service model, insurers will continue to stealthily approach patients in need as being the enemy.

Health financing policies supported by conservatives often factor in blame-the-victim as an excuse to limit or deny private coverage, or at least to assess penalties. Examples include being overweight, smoking, drug dependency, or failure to achieve treatment goals in hypertension, diabetes, and other chronic conditions.

The tragic case of Monroe Bird III adds to this list injuries that result from illegal activity – an exclusion often found in the fine print of employer-sponsored health plans. In Monroe’s case, the illegal activity proved to be equivocal – shot in the back while fleeing a security guard (who had cannabinoids in his system) investigating him to see if he and a young lady were having sex in his car. The claim of “illegal activity” was so flimsy that, on appeal, the insurance administrator claimed that it was “hazardous activity,” another blame-the-victim reason for denial.

There is absolutely no question that Monroe Bird was insured and that he desperately needed medical care. The question came down to whether or not the health plan could get away with not paying for that care, based on a blame-the-victim clause in the fine print of his health plan.

We are often accused of challenging the ethics of the private insurance industry when they are simply businesses following standard business practices. But on the face of it, the refusal by the health plan administrator to pay the million dollar medical tab for Monroe’s injury is a contemptible act. It proves that the private insurance industry will commit evil acts if it furthers their own business interests.

If we close this blame-the-victim loophole the plans will find other innovative measures to chisel away at patient health care benefits. Narrow networks and unaffordable deductibles are only the beginning.

What we need is a universal system, serving the public, designed to remove financial barriers to care for patients in need – a single payer national health program, an improved Medicare for all. What we do not need are private administrators who deny us our plan benefits through the non sequitur that having sex in a car is a hazardous activity.

Charlotte doctors host advocate of Medicare for all

Despite ACA, doctor says need for reform remains * Says Medicare could expand to all ages * Free talk is 6 p.m. Thursday at Myers Park Baptist

By Karen Garloch
The Charlotte (N.C.) Observer, July 21, 2015

Dr. Andrew Coates agrees with some critics of the Affordable Care Act. In many ways, he says the federal law “reinforced or worsened some of the most egregious inequalities and injustices in the health system.”

Coates, a New York physician and immediate past president of Physicians for a National Health Program, suggests that the United States, like other developed nations of the world, should adopt a single-payer plan, such as Medicare. The federal program could be expanded to all citizens, not just those 65 and over or disabled.

He’ll be in Charlotte on Thursday, at the invitation of Health Care Justice-North Carolina, to make his case for expanding Medicare. His free talk is 6-7:30 p.m. at Myers Park Baptist Church, Heaton Hall, 1900 Queens Road.

As Medicare marks its 50th anniversary this year, Coates said it’s interesting to note the contrast between that popular “model of publicly financed comprehensive” health insurance compared with the “current mess” in the private health insurance market, “including the exacerbation of that mess by the Affordable Care Act.”

Like many others, Coates praises the ACA for expanding insurance coverage to many who previously had none or who were excluded because of pre-existing medical conditions. But he added that it “entrenched the interests of the private insurance companies.” He said that the mandate for electronic medical records was a good idea but has not produced the projected cost savings.

“In terms of sweeping health reform, we did not get that with the Affordable Care Act,” said Coates, chief of hospital medicine at Samaritan Hospital in Troy, N.Y., and assistant professor of medicine and psychiatry at Albany Medical College.

Coates acknowledges that a single-payer plan is not popular with leaders of either major political party. But he said there is agreement in the country that everyone should have comprehensive health insurance. “In Main Street America, that is absolutely a consensus. I’ve talked to big groups and small groups. Republican town councilmen and liberal Catholic clergy. The idea that everyone should have access to health care is not a real debate.”

Despite arguments to the contrary, Coates said a single-payer plan would not be “a government takeover.” Services would still be provided by private hospitals and doctors. The payment system would be administered by the federal government, and that would save millions of dollars in administrative costs that could then be spent on services, Coates said.

As Americans face higher deductibles and co-pays for insurance, the need for reform remains great, he says. “A health care crisis is still very likely to cause personal bankruptcy,” Coates said. And when that happens, it’s seen as a personal failure rather than a societal one.

“It’s kind of a private shame. You see the collection jars at the fire company or the church. It’s not seen as a collective shame and a scandal.”

You can reach Karen Garloch at kgarloch@charlotteobserver.com.

http://www.charlotteobserver.com/living/health-family/karen-garloch/article28011271.html#storylink=cpy

Gerard Anderson on new payment models

Will Hospitals Lose Money Under Obamacare?

By Kimberly Leonard
U.S. News & World Report, July 17, 2015

The portion of President Barack Obama’s health care law aimed at lowering the number of uninsured in the country has largely rolled out, leaving the administration increasingly turning its attention to another goal of the Affordable Care Act: controlling health care costs. It doesn’t appear, however, that the proposals will make a significant dent in government spending, and questions remain over whether providers – particularly hospitals – could see any benefit from the initiatives.

In recent months, Obama and Sylvia Burwell, the secretary for Health and Human Services, have touted a move toward payment models that reward better quality of care, rather than the current model that compensates health care providers for the number of medical services they provide.

The government has been testing several initiatives aimed at slowing or reducing health care spending, which grows faster than the rest of the economy and makes up one-fifth of the country’s expenditures. By 2018, the administration plans to place half of payments on Medicare – the government’s program for adults 65 and older – under new models.

Attempts at changing payment models in the past, however, have yielded only modest savings at best. Also, what remains unclear is why hospitals would buy into a payment system voluntarily that likely would reduce their bottom lines.

“The answer is: They wouldn’t,” says Gerard Anderson, director of the Center for Hospital Finance and Management at the Johns Hopkins Bloomberg School of Public Health.

Hospitals do participate in different payment models, he says, so they can be prepared if there is a change in the way payments are delivered.

There has been scant evidence that accountable care organizations can significantly reduce health care costs. Anderson points out that hospitals may not want to partake because the more they save, the less they ultimately make. “If I’m a hospital, why would I cut anything, because I’d rather have all of it? Most of them don’t, and that’s why it’s not working well,” he says.

Not everyone is optimistic that these various experiments can bring about significant savings. These alternative payment models are far from the norm. “There is a lot of confidence, and most of it is not warranted,” Anderson says. “There is nobody with significant power [in the health care industry] who wants to control health care costs. Until we have that, we will muddle along in terms of coming up with good ideas, implementing them and getting lukewarm results.”

Still, it’s difficult to say how much the country will suffer as a result of health care spending. Government officials warn decade after decade, year after year, that the country cannot sustain anymore spending on medical services. “We keep addressing the goal line of what’s acceptable as we reach it and pass it,” Anderson says. “It is cannibalizing other budgets, causing us to spend less on programs like education and housing.”

“The Affordable Care Act was really about coverage,” Anderson says. “It wasn’t about affordable care.” 

http://health.usnews.com/health-news/hospital-of-tomorrow/articles/2015/07/17/hospitals-have-little-to-gain-from-new-payment-models

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‘It’s the Prices, Stupid’: An Interview with Health Policy Expert Gerard Anderson

By Gerard Anderson, Elizabeth Palmberg
Sojourners, June 2011

Sojourners: What are some of the most important causes for why the U.S. is paying a lot more than other wealthy countries [in the OECD] for health care without getting improved results?

Anderson: A higher health-care cost is pretty much because of what I call, “It’s prices, stupid.” We just pay approximately twice as much for each good and service that we utilize in the U.S. vis-a-vis other industrial countries. In fact, for a hospital visit it’s about three times more than other industrialized countries for a similar visit — in a shorter period of time that you’re in the hospital, we still spend about three times more. So it seems to be that we just pay more for identical services compared to other industrialized countries.

Sojourners: Why?

Anderson: Because, in most other countries they have a single purchaser, which is a very tough negotiator, whereas in the United States we have so many different purchasers that nobody has a lot of power.

Sojourners: If you didn’t have to think about political realities at all, what health-care policies would you suggest the U.S. adopt?

Anderson:  Basically, that everybody has the same health care and access to the same health care.

Sojourners: Through a single-payer system?

Anderson:  Well, that’s the payment side. And then access to the same delivery system as well.

Sojourners: So, both single-payer and a standardized quality of care?

Anderson:  Correct.

https://sojo.net/magazine/june-2011/its-prices-stupid-interview-health-policy-expert-gerard-anderson

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Comment:

By Don McCanne, MD

Gerard Anderson is a professor of health policy and management and professor of international health at the Johns Hopkins University Bloomberg School Public Health, and professor of medicine at the Johns Hopkins University School of Medicine. He may be most famous as co-author of the 2003 landmark Health Affairs article, “It’s the Prices, Stupid,” demonstrating that prices are much more important than quantity of services in explaining why health care spending is so high in the United States. He is as qualified as anyone to comment on the anticipated impact of the new payment models in health care.

The new models will pay for quality rather than quantity, thus supposedly controlling health care spending while maintaining quality.

What does Professor Anderson have to say about this? “There is a lot of confidence, and most of it is not warranted. There is nobody with significant power [in the health care industry] who wants to control health care costs. Until we have that, we will muddle along in terms of coming up with good ideas, implementing them and getting lukewarm results.”

As Anderson says, “The Affordable Care Act was really about coverage. It wasn’t about affordable care.”

What could we do? In an interview a year after the Affordable Care Act was signed into law, he indicated that the United States needed a single purchaser that could negotiate prices, providing everyone with the same health care and health care access – a single payer on the payment side, with ensured access on the delivery side.

These new models that attempt to convince providers that they need to reduce the volume of services, when the greater problem is prices, simply are not going to gain traction, other than token participation. Providers may be willing to work less, but they are not going to give up significant revenues.

Under single payer, we would receive the right volume, at the right prices. As long as the prices are fair, providers will participate.

Health insurance coverage in U.S. varies widely by county, pointing to need for further reform: study

FOR IMMEDIATE RELEASE
July 20, 2015

Contact:
Mark Almberg, PNHP communications director, 312-782-6006,  mark@pnhp.org

A new study conducted by a team of researchers at the University of New Mexico suggests that success in reducing the number of uninsured in the United States requires addressing the large inequalities in health insurance coverage at the county level.

It has long been known that health insurance leads to better health and quality of life, yet researchers found that some U.S. counties are characterized by an exceptionally high rate of uninsured residents, a problem that goes largely unrecognized in traditional state-and national-level health policy analysis.

Uninsurance rates in U.S. counties ranged from 3 percent to 53 percent (the latter figure corresponding to the Louisiana parish of Tensas), the researchers say. Their study appears in this month’s edition of the journal Health & Place.

The researchers found a number of predictors that impact insurance rates. Uneven economic development, differing local polices concerning access, and ideological predispositions that influence county policies on health care all emerged as conditions affecting the variation in insurance coverage.

The study, funded by the Robert Wood Johnson Foundation Center for Health Policy, is the first national research to examine multiple predictors explaining insurance coverage across all 3,112 counties in the U.S., said UNM Investigator Dr. Lisa Cacari Stone, an associate professor at the UNM Health Sciences Center Public Health Program.

“Traditionally, we have looked at the effects of health care policies made at the national and state levels,” said Cacari Stone. “Examining how county-level health care decisions affect access helps us rethink the role of local governments, their political ideologies regarding reform and how that plays out at the front lines of policy implementation. Success in reducing the number of uninsured will require collaboration among the federal, state, tribal and county governments.”

Using public databases from 2008 to 2012, the group’s analysis suggested that poverty, unemployment, Republican voting, and percentages of Hispanic and American Indian/ Alaskan Native residents in a county were significant predictors of uninsurance rates.

In a comment today, Dr. Howard Waitzkin, distinguished professor emeritus at UNM who served as the project’s co-principal investigator, drew a broader conclusion from the group’s research.

“This study clearly shows the need for a uniform, single-payer national health program based on a Medicare-for-All model that would overcome local variability in access by giving everyone in the country full and equal insurance coverage for needed care,” Waitzkin said.

“The Affordable Care Act is tied to state differences in policies, but these can obscure the even greater differences seen for coverage at the local level,” he said.

“The ACA does not provide a consistent way of fixing the problem of local variability in coverage, whereas Medicare for All would directly resolve this very important problem.”

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“Place as a predictor of health insurance coverage: A multivariate analysis of counties in the United States,” by Lisa Cacari Stone, Blake Boursaw, Sonia P. Bettez, Tennille Larzelere Marley, and Howard Waitzkin. Health & Place, 34 (2015), 207-214.

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Physicians for a National Health Program (www.pnhp.org) is a nonprofit research and education organization of more than 19,000 doctors who support single-payer national health insurance. PNHP had no role in funding or otherwise supporting the study described above.

Medicare expanded for all would be better than ACA

By Kathryn Dean, M.D.
The Olympian (Wash.), Letters, July 18, 2015

“I need to admit you to the hospital for pneumonia,” I told my patient. He had reluctantly driven himself to the emergency room as his symptoms worsened. In between gasps, he asked, “How much will it cost?”

Many patients have asked me that question in moments where their health should have been the number one concern. But it is an important question. Sixty-two percent of all personal bankruptcies in the U.S. are linked to medical bills or illness. Three quarters of those bankrupted had health insurance when they got sick. One hospital bill could lead to the unraveling of your life.

Lyndon Johnson began to address this problem exactly 50 years ago when he signed Medicare into law in July 1965. President Johnson said, “There are those fearing the terrible darkness of despairing poverty -– despite their long years of labor and expectation –- who will now look up to see the light of hope and realization.”

The Affordable Care Act increased the number of Americans with insurance, but many still remain uninsured and far more are under-insured. Insurance companies have significantly contributed to the skyrocketing costs of U.S. health care as health outcomes have worsened.

A better solution would be to improve and expand Medicare to cover everyone. Legislation like “The Expanded and Improved Medicare for All Act,” H.R. 676, could make our health care system less costly and more fair. I look forward to the day when my patients and I can focus on health instead of health insurance.

Dr. Kathryn Dean resides in Olympia.

http://www.theolympian.com/opinion/letters-to-the-editor/article27459355.html

Medicare turns 50, and we have much to celebrate

By Theresa Chalich, R.N.
Pittsburgh Post-Gazette, Letters, July 19, 2015

Nicholas Kristof’s commentary “Poverty: Yes, It’s About Personal Responsibility but It’s Also About the Choices We Make as a Society” (July 12 Forum) on the need for collective responsibility was written at an opportune time. This July we celebrate the 50th anniversary of Medicare. What an impact this social program has made on improving health and financial stability.

This publicly funded program financed by our employee Medicare taxes has been and is a practical solution to a severe need. Fifty years ago one-half of seniors were without hospital insurance. One in three lived in poverty. Today nearly all seniors and younger people with permanent disabilities have access to affordable health care.

Mr. Kristof wrote about our nation’s blame-the-victim mentality. It is important to know that Medicare addressed our systemic problem of racism by stopping payments to segregated hospitals and by allowing African-American doctors to get hospital admitting privileges. For these doctors, the legacy of discrimination held back their economic growth. Medicare has truly been a collective response.

On July 14 Pittsburgh City Council recognized the 50th anniversary of Medicare and its goals with a proclamation sponsored by Councilman Corey O’Connor.

So, happy birthday, Medicare! May our birthday wish be that we will have Medicare for all!

Theresa Chalich, R.N., resides in Squirrel Hill. She is a member of HealthCare 4 All PA.

http://www.post-gazette.com/opinion/letters/2015/07/19/Medicare-turns-50-and-we-have-much-to-celebrate/stories/201507170176

PNHP note: The text of the Pittsburgh City Council resolution cited in the letter above is as follows.

Resolution on Medicare’s 50th Anniversary

WHEREAS, on July 30, 1965, President Lyndon Johnson signed into law the Medicare program to provide health care insurance for the elderly with the intent purpose to reduce poverty among seniors and significantly improve the financial security of American families;

WHEREAS, the passage of Medicare led to the rapid desegregation of 99.6% of U.S. hospitals and continues to reduce health disparities related to race, ethnicity and socioeconomic status, and as a result, 55 million seniors and people with disabilities have access to guaranteed health care benefits; and,   

WHEREAS, Medicare is a model of how a publicly financed care program can assure millions of Americans access to medically necessary care while controlling costs, spending only about 2% on administration which is about 6 times less than what commercial insurers spend on overhead; and,

WHEREAS,  Medicare’s guaranteed benefit is a lifeline to millions of Americans. The evolution of the Medicare legislation has been built on President Johnson’s vision to “assure availability and accessibility to the best healthcare to all Americans, regardless of age or geography or economic status.”

NOW, THEREFORE BE IT RESOLVED that the Council of the City of Pittsburgh does hereby recognize and reflect on the critical role that Medicare plays in protecting the health and well-being of millions of families, setting standards for how care is delivered and having the ability to strengthen and improve health care for future generations. The Council of the City of Pittsburgh salutes Medicare on its 50th Anniversary and urges residents to find creative ways to celebrate this monumental Anniversary for our nation.

Passed in Council on Tuesday, July 14, 2015.

Bruce A. Kraus
President of Council

Attest: Mary Beth Doheny
City Clerk

Expand Medicare to improve nation’s health care system

By William M. Fogarty Jr., M.D.
St. Louis Post-Dispatch, Letters, July 20, 2015

On July 30, Medicare will celebrate its 50th birthday. This program has been a resounding success for the elderly and disabled of our country and is firmly embedded in our culture and medical care system. It has improved the health of the nation’s elderly and removed the threat of medical impoverishment that loomed over them before its enactment.

Medicare is not perfect and fails to cover many necessary services, but it is the basis upon which we can build a health care system that would cover all  Americans, improve the health, economy and security of the country and save billions of dollars every year.

We have a mechanism to replace our incredibly inefficient, wasteful and complex system right before our eyes. It is improved and expanded Medicare for All.

Dr. William M. Fogarty Jr. resides in Webster Groves.

http://www.stltoday.com/news/opinion/mailbag/expand-medicare-to-improve-nation-s-health-care-system/article_65b6c3c7-75a7-5fc4-844f-1519d0b8ccd7.html

Single-Payer Health Reform: A Step Toward Reducing Structural Racism in Health Care

By Dominic F. Caruso, MD/MPH Candidate, David U. Himmelstein, MD, and Steffie Woolhandler, MD
Harvard Public Health Review, July 20, 2015

Racial and income equality are too often absent from conversations about health care financing. Research continually exposes alarming health disparities in the United States, particularly impacting African Americans and Native Americans. These groups have lower life expectancies than non-Hispanic white Americans, and experience higher rates of most major causes of death including infant mortality, trauma, heart disease, and diabetes. Yet despite their greater need, access to care is worse for minority populations by most measures.

Unequal medical care is often viewed as a consequence of broader social inequalities, but the current health financing system also reinforces and institutionalizes inequality; unequal care may be viewed as a form of structural racism.

While most Americans rely on private insurance, rates of private coverage are much lower for minorities and the poor.

The Patient Protection and Affordable Care Act (ACA) offered subsidies to expand private coverage, making insurance more affordable for many families. However, many of these new private plans carry high deductibles and co-payments. Deductibles for the ACA’s bronze and silver plans average over $5000 and $2900, respectively, for single coverage, and over $10,000 and $6,000, for family coverage.

Deductibles have also soared in employer-sponsored plans; in 2014, more than 40% of such plans carried a deductible of more than $999, up from just 10% in 2006. Moreover, while Medicaid traditionally imposed virtually no cost-sharing, several conservative state governors have extracted waivers from the Centers for Medicare and Medicaid Services allowing the imposition of cost-sharing on recipients as a condition for implementing the ACA’s Medicaid expansion.

High cost-sharing particularly impacts minority families, whose average incomes are far lower than those of non-Hispanic whites. Yet even figures on income disparities understate minorities’ disadvantage when confronted with high out-of-pocket costs. With medical bills often reaching into the thousands for even routine care such as childbirth and appendectomy, many families must tap savings or other assets like housing equity, and racial/ethnic disparities in assets dwarf the differences in income. African American and Hispanic median household income was 58 percent and 70 percent, respectively, that of non-Hispanic whites in 2011.  In contrast, the median net worth of black and Hispanic householders was $6,314 and $7,683, respectively, vs. $110,500 for non-Hispanic whites, a 15-fold difference. Hence, the average family deductibles for bronze and silver plans would bring financial ruin to most African American and Hispanic households. Even the lower cost-sharing now increasingly common under Medicaid may be prohibitive for poor families, many of whom have zero or negative net worth.

The ACA’s drafters erred in relying on private, for-profit insurers to fund health care. Health insurance’s social purpose is to pay for care in order to promote access to health services and prevent financial hardship. For-profit insurers’ purpose is to maximize shareholders’ profits, a goal that provides strong incentives to maximize premiums and minimize the health care they pay for. Historically, this incentive led to such practices as denying coverage for pre-existing conditions and canceling policies for expensive enrollees. Although the ACA prohibits these tactics, recent evidence indicates that insurers are finding ways to subvert these regulations, e.g. through tiered pharmacy benefits that discriminate against enrollees with potentially expensive illnesses such as HIV, Parkinson’s, seizures, psychosis and diabetes.

The persistence of our corrupt and irrational insurance system may stem in part from the way Americans (and particularly health professional students) are taught to think about health care. In a recent conversation with a Canadian student at Harvard’s school of public health, he expressed surprise that many of his U.S. classmates perceive health care interactions as business transactions, and reflected that Canadians, who have a publicly-funded universal coverage system, view health care as a fundamental right to be provided for all.

Should we in the U.S. continue to treat health care as a commodity distributed according to financial ability, or shift to a financing system that assures it as a right equally available to all without regard to income, health status, race or ethnicity? While market theorists might claim that a commodity-based approach to care breeds efficiency, facts on the ground argue otherwise. At present, we have the world’s highest per-capita health care expenditures, yet tens of millions remain un- and under-insured, and our health outcomes trail most other wealthy nations.

This isn’t just an indication of failed policy, it’s a national embarrassment. We have the resources to provide everyone in the U.S. with access to health care. And Canada provides a working model for how to put those resources to good use: a public, single-payer, national health insurance program, similar to an expanded and improved Medicare for all.

In our view a national single-payer health insurance program offers the best possibility for equitable financing of U.S. health care. It would eliminate the motive to deny needed care or discriminate against the expensively ill for the sake of profit. A national public insurance system would provide coverage based on residence in the U.S., not employment status, income level or ability to pay, as in the current regime. A program that abolished co-payments and deductibles would level the playing field for minorities and the poor who generally lack the assets to surmount these barriers.

A single-payer system would also offer economic benefits. A federally-run financing system would have far lower administrative costs than private insurance, as the Medicare program consistently demonstrates. A universal public model would lift a significant financial burden from businesses that currently fund health insurance for their employees. Finally, a single-payer program would largely eliminate the financial burden of illness, a leading cause of bankruptcy and debts sent to collection.

Perhaps most importantly, a single-payer system would make a clear statement that health care is a human right. This framework recognizes health care as a universal necessity, not a commodity reserved for those lucky enough to have won the economic lottery, and most definitely not a scheme for denial and discrimination. While implementing a single-payer insurance program will not solve all of our nation’s health, racial or social inequities, it is clearly a step in that direction.

http://harvardpublichealthreview.org/single-payer-health-reform-a-step-toward-reducing-structural-racism-in-health-care/

Hospital mergers show need for Medicare for all

By Marc H. Lavietes, M.D.
Asbury Park (N.J.) Press, Letters, July 17, 2015

Mergers of large health care facilities such as that proposed by Barnabas and Robert Wood Johnson are occurring across the country. They are facilitated by the Affordable Care Act (ACA) but are ruinous to the delivery of affordable quality health care.

Mergers are the antithesis of a “free market” delivery system, establishing networks that limit the choices for both physicians and patients. Administrators rather than physicians may dictate length of visits, fees and often choices of therapy.

For the patient, mergers mean less face time with their physicians, more costly and often unnecessary testing, occasional denials of costly but indicated procedures or treatments and in general higher costs. There are winners in this equation: mergers predictably bring about industry profit and higher CEO salaries.

We should not forget that major portions of the ACA were crafted by industry consultants while medical expertise was largely ignored. All other industrialized countries minimize these shortcomings a with regulated delivery system accompanied by single-payer financing, similar to Medicare. Medicare has served for 50 years to provide high quality health care to our seniors while controlling costs. Medicare should be for all.

Dr. Marc H. Lavietes resides in Bradley Beach.

http://www.app.com/story/opinion/readers/2015/07/17/hospital-mergers/30299379/

Medicare turns 50 this month

By Ray Bellamy, M.D.
Tallahassee Democrat, July 18, 2015

In 1963 or so, a group of us UF second year medical students tramped upstairs to listen to some of a spirited discussion among Gainesville-area physicians along with UF faculty regarding providing nearly universal health coverage to seniors. I remember little of the discussion other than some inflammatory rhetoric about “government overreach and what it would do to or for Granny.”

Most folks now are not aware that in those days, the AMA had only recently come off its traditional opposition to group medical practice. (Yes, they felt all physicians should be working solo.) So now, on July 30, we will herald arguably one of this country’s most successful social programs ever — the establishment of Medicare. We should also acknowledge the role Medicare played in speeding the integration of hospitals.

There is much one can complain about Medicare — that it will begin running a deficit in 17 years, that some providers are not reimbursed adequately to cover expenses, that the first day of inpatient care costs a thousand dollars out of pocket. However, with a strong approval among seniors — 92-percent satisfaction, a low overhead of about 2.5-percent, and the benefit of safety net coverage for a part of the population which is stressed to pay bills (elderly women average a third of their income for medical expenses), the goal of sharing risk broadly over a large population has been been met. Note that the sickest 20 percent of this group accounts for 80 percent of the cost.

Presidential candidate Vermont Senator Bernie Sanders is advocating for an improved Medicare for All, properly funded, as he has for decades. Since the simplicity of everyone having the same comprehensive plan and a Smart Card to swipe at the physician’s office or pharmacy would save several hundred billion dollars a year in reduced overhead, it is easy to understand how most developed nations use some version of a single payer system. Because prevention is often less expensive than treatment, but the payoff may take years to realize, enrollees in private insurance who tend to stay with one plan for only a short time are unlikely to see this cost reduction passed to them.

But we muddle on, and costs in health care keep rising, inflammatory opposition rhetoric about “death panels” and “socialized medicine” gets bandied about, and our overall healthcare non-system struggles from day to day.

So here we are with Medicare at 50, struggling with proposals for vouchers, the higher costs of Advantage plans, the need to more adequately fund the trust fund. The latest assault comes from a “bribe” to help passage of the TPP Fast Track international deal. It would take $700 million from Medicare and use those funds to support job retraining and assistance for workers who lose their jobs due to offshoring, etc.

And with our political paralysis, along with suspicion of all things government does, even when government has demonstrated it can do many tasks better than the private sector, stay tuned.

Ray Bellamy, MD, is a long time Tallahassee physician.

http://www.tallahassee.com/story/opinion/2015/07/18/medicare-turns-month/30322447/