PNHP

Medicare fix needs fixing

Medicare fix needs fixing

By Theodore R. Marmor
Philadelphia Inquirer (Philly.com), April 13, 2015

In recent weeks, reform legislation that proposes to change how Medicare pays physicians drew much attention. The prod to action was the imminent expiring of the present fee schedule.

For many years, Congress had failed to reach agreement about the rate of increase in physician payments under Medicare. This, in turn, prompted annual, ad hoc “fixes” while postponing decisions on how Medicare should operate as a “purchaser” of medical care.

The surprise of 2015 is that the House of Representatives did agree, in bipartisan fashion, on a remedy. After five years of persistent and contentious debate over the Obama health reform we now know as Obamacare, the sight of Speaker John Boehner (R., Ohio) embracing Minority Leader Nancy Pelosi (D., Calif.) over a health-care bill is indeed newsworthy.

But here, as in other instances, the problem is faulty reasoning from misleading assumptions.

Take the definition of what’s wrong with our current payment arrangements. Many lawmakers say that Medicare should reject the fee-for-service method, the mode Medicare has used since its inception – and the way many industrial nations pay their doctors.

Instead, these lawmakers argue, Medicare should reward doctors for the “quality” rather than the “quantity” of their work, and reward “value” over “volume.” Sylvia Burwell, secretary of Health and Human Services, has fervently embraced “value-based payment.”

This seeming agreement on the need to do away with fee-for-service has prompted much discussion of alternative payment models, such as “capitation,” “bundled payments,” and monetary incentives for exemplary physician behavior.

Sounds plausible, doesn’t it? But the problem is – as all other industrial democracies have learned in the last three decades – there is no single payment panacea. Each method of compensating doctors has the vice of its virtue.

If you pay physicians per capita – known as capitation, an annual or monthly amount for each patient signed up with a practice – the hope is that the doctors will care more about the health of their patients and less about the number of procedures they perform.

But there is little or no evidence to back up this hope. Many other countries use fee-for-service payments, but spend far less on health care than we do, and yet get decent results, without alarming problems of excess procedures.

Under Britain’s National Health Service, physicians were once paid almost exclusively by capitation, and it generally served them well. Now general practitioners get paid partly per capita, partly by meeting targeted actions, and partly by the equivalent of a “salary” for being available on weekends and evenings. They are experimenting with a mix of payment methods.

So the international evidence shows there is no one obvious way to pay doctors. How to manage sensibly the mix of methods is the important challenge.

The celebration of paying for “value over quantity” assumes we know how to identify value and pay for it. Yet, there is considerable disagreement in modern medicine about how much one way of working is better than another.

For example, an attempt to establish a standardized cost-benefit analysis of treatments for Medicaid patients in Oregon in the late 1990s fell apart upon implementation. There was no agreed-upon list of what treatments were more valuable on grounds of both cost and quality, and physicians were rightfully indignant when their professional knowledge about what was best for their individual patients was upended by a rulebook.

In reading the bill that the Senate will soon vote on, I can’t help but notice how the new prescriptions for physician behavior represent marketing jargon more than considered thought. For decades, one has seen prepaid group practice redefined as “managed care,” while actually what was going on were mostly efforts to reduce the costs of care.

We have now seen a whole series of reforms celebrated for giving the patient financial “skin in the game,” based on a vision of a medical-care marketplace where large deductibles force patients to make choices among goods and services that earlier forms of health insurance did not do.

As if these issues weren’t enough to abandon this bill and start over, there are a couple of specific provisions that represent a Trojan horse for the further undermining of traditional Medicare. One is the imposition of deductibles on Medigap plans that the majority of Medicare beneficiaries buy to help with cost-sharing, a reform that will discourage seniors from seeking needed care. The other is a measure that would require wealthier people to pay higher Medicare premiums – a measure that could further erode universal political support for the program.

The Senate should take this legislation back to the drawing board.

Ted Marmor is a professor emeritus of political science and public policy at Yale University and a coauthor, with Rudolf Klein, of “Politics, Health and Health Care.” He can be reached at theodore.marmor@yale.edu.

www.philly.com/philly/opinion/20150413_Medicare_fix_needs_fixing.html

An Effective Prescription for Our Failing Health-Care System

By Samuel Metz
Truthout, April 10, 2015

How Obamacare is Unsustainable: Why We Need a Single-Payer Solution for All Americans
By John Geyman, M.D.
Copernicus Healthcare, January 2015

The Affordable Care Act is a sitting duck. Working with private insurance companies, hospital chains and Big Pharma, Congress superimposed arcane regulations on an already Byzantine system of financing health care.

Dr. John Geyman cannot resist this target. His new book, How Obamacare is Unsustainable, confirms that the Affordable Care Act (ACA) is not the pathway to a better health-care system. It is one of the biggest impediments.

The structure of this critique reflects Geyman’s organized mind. The first of three parts reviews the unhappy history of American health-care reform. The second assesses our health-care landscape five years into the ACA. The last presents a solution: a national single-payer health plan.

History first. Geyman notes that President Obama, from whom the ACA derives its nickname, doomed the reform from its inception.

By inviting the insurance industry, hospital chains and pharmaceutical companies to set the agenda, Obama adopted a strategy similar to his unsuccessful predecessor, President Clinton, in the early 1990s.

This time, these key components of the “medical-industrial complex” fought first with outside industries, then with patient interest groups, and finally with each other. Organized medicine joined the fray. It was not pretty.

“Health-care ‘reform’ through the ACA,” says Geyman, “was framed and hijacked by corporate stakeholders, themselves in large part responsible for system problems of health care and dedicated to perpetuating their self-interests in an unfettered health-care marketplace.”

Not surprisingly, the needs of this privileged complex were addressed by the resulting legislation. The needs of patients were not.

Geyman refines the definition of patient interests. He mentions, with some contempt, the four “pillars of patients’ rights” promoted by Florida’s governor, Rick Scott: Choice, competition, accountability and personal responsibility. These “pillars,” notes Geyman, support a political, not a health-care, agenda.

Geyman even refines the “Triple Aim” of Dr. Donald Berwick. He replaces “improving the experience of care, improving the health of populations, and reducing per capita costs of health care” with “access, cost and quality.”

Note the key addition of “access.” The best care is immaterial without access. And the biggest impediment to access is lack of money, even for the insured, given rising copays and deductibles.

By Geyman’s criteria, the ACA fails. Governor Scott and Dr. Berwick would agree.

What next? “It is futile to embark on unproven or disproven incremental tweaks to our present system while ignoring health policy and experience around the world,” warns Geyman. Every other industrialized country provides better care to more people for less money. What can they teach us?

Geyman answers: A national health-care plan, with single-payer financing and not-for-profit delivery. This suggestion is not new; Geyman and others have advocated this alternative for decades. Evidence validates this: In every population, single payer provides better care to more people for less money than private insurance.

Some dismiss single payer as “Un-American.” Geyman disagrees. Single payer “is completely in step with traditional American values, including efficiency, choice, value, equity and integrity. These values . . . are echoed by both major political parties.” Single payer is as American as . . . well, Medicare, America’s largest single-payer-like system.

A note on style. Geyman, professor emeritus at the University of Washington School of Medicine, clearly suffered greatly listening to tedious monologues from academics exploiting captive audiences. In contrast, Geyman’s readers get respect. Each chapter begins with intended points, then offers colorful and immaculately documented examples, and concludes with a conclusion. Refreshing.

By the final chapter, few readers will remain unconvinced, fewer still will lack comprehension, and none will have lost interest. Given a topic renowned for incomprehensible diatribes (i.e. health-care reform), this is a respectable achievement.

One deficiency. Every other industrialized country provides universal care at less cost than we do. But Geyman fails to note that only a handful use the single-payer financing, not-for-profit delivery format that he advocates. This does not invalidate his thesis, but some readers may miss learning other options.

Nonetheless, Geyman’s national health plan is credible. America’s need for reform received validation from a surprising source. Mark Bertolini, CEO of Aetna, said of his industry, “The system doesn’t work; it’s broke today. The end of insurance companies, the way we’ve run the business in the past, is here.”

How Obamacare is Unsustainable confirms not only Mr. Bertolini’s despair of the pre-ACA health-care system, but the despair of patients who learn the ACA leaves our system just as broken.

Dr. Geyman’s text is a blueprint for repair.

Samuel Metz is a private practice anesthesiologist who lives and works in Portland, Oregon. He is a member of Physicians for a National Health Program and a founding member of Mad As Hell Doctors. Both organizations advocate for universal health care.

Copyright, Truthout.org. Reprinted with permission. 

http://www.truth-out.org/opinion/item/30051-an-effective-rx-for-our-failing-health-care-system

Ted Marmor’s urgent message on the pending ‘SGR fix’

Medicare fix needs fixing

By Theodore R. Marmor
philly.com, April 13, 2015

In recent weeks, reform legislation that proposes to change how Medicare pays physicians drew much attention. The prod to action was the imminent expiring of the present fee schedule.

For many years, Congress had failed to reach agreement about the rate of increase in physician payments under Medicare. This, in turn, prompted annual, ad hoc “fixes” while postponing decisions on how Medicare should operate as a “purchaser” of medical care.

The surprise of 2015 is that the House of Representatives did agree, in bipartisan fashion, on a remedy. After five years of persistent and contentious debate over the Obama health reform we now know as Obamacare, the sight of Speaker John Boehner (R., Ohio) embracing Minority Leader Nancy Pelosi (D., Calif.) over a health-care bill is indeed newsworthy.

But here, as in other instances, the problem is faulty reasoning from misleading assumptions.

Take the definition of what’s wrong with our current payment arrangements. Many lawmakers say that Medicare should reject the fee-for-service method, the mode Medicare has used since its inception — and the way many industrial nations pay their doctors.

Instead, these lawmakers argue, Medicare should reward doctors for the “quality” rather than the “quantity” of their work, and reward “value” over “volume.” Sylvia Burwell, secretary of Health and Human Services, has fervently embraced “value-based payment.”

This seeming agreement over the need to do away with fee for service has prompted much discussion of alternative payment models, such as “capitation,” “bundled payments,” and monetary incentives for exemplary physician behavior.

Sounds plausible, doesn’t it? But the problem is — as all other industrial democracies have learned in the last three decades — there is no single payment panacea. Each method of compensating doctors has the vice of its virtue.

If you pay physicians per capita — known as capitation, an annual or monthly amount for each patient signed up with a practice — the hope is that the doctors will care more about the health of their patients and less about the number of procedures they perform.

But there is little or no evidence to back up this hope. Many other countries use fee-for-service payments, but spend far less on health care than we do, and yet get decent results, without alarming problems of excess procedures.

Under Britain’s National Health Service, physicians were once paid almost exclusively by capitation, and it generally served them well. Now general practitioners get paid partly per capita, partly by meeting targeted actions, and partly by the equivalent of a “salary” for being available on weekends and evenings. They are experimenting with a mix of payment methods.

So the international evidence shows there is no one obvious way to pay doctors. How to manage sensibly the mix of methods is the important challenge.

The celebration of paying for “value over quantity” assumes we know how to identify value and pay for it. Yet, there is considerable disagreement in modern medicine about how much one way of working is better than another.

For example, an attempt to establish a standardized cost-benefit analysis of treatments for Medicaid patients in Oregon in the late 1990s fell apart upon implementation. There was no agreed-upon list of what treatments were more valuable on grounds of both cost and quality, and physicians were rightfully indignant when their professional knowledge about what was best for their individual patients was upended by a rulebook.

In reading the bill that the Senate will soon vote on, I can’t help but notice how the new prescriptions for physician behavior represent marketing jargon more than considered thought. For decades, one has seen prepaid group practice redefined as “managed care,” while actually what was going on were mostly efforts to reduce the costs of care.

We have now seen a whole series of reforms celebrated for giving the patient financial “skin in the game,” based on a vision of a medical-care marketplace where large deductibles force patients to make choices among goods and services that earlier forms of health insurance did not do.

As if these issues weren’t enough to abandon this bill and start over, there are a couple of specific provisions that represent a Trojan horse for the further undermining of traditional Medicare. One is the imposition of deductibles on Medigap plans that the majority of Medicare beneficiaries buy to help with cost-sharing, a reform that will discourage seniors from seeking needed care. The other is a measure that would require wealthier people to pay higher Medicare premiums — a measure that could further erode universal political support for the program.

The Senate should take this legislation back to the drawing board.

Ted Marmor is a professor emeritus of political science and public policy at Yale University and co-author, with Rudolf Klein, of “Politics, Health and Health Care.”

http://www.philly.com/philly/opinion/20150413_Medicare_fix_needs_fixing.html

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Comment:

By Don McCanne, MD

The Senate is back in session this week and is expected to rush through H.R.2 – the House approved “SGR fix.” SGR has got to go and CHIP needs to be funded, but the unproven and administratively burdensome replacement for SGR, along with the Medicare tweaks, are worse than the current fee-for-service method of financing health care. 

It is wrong to replace bad legislation with bad legislation. As an interim measure, we should get rid of the existing bad legislation by repealing SGR, since Congress has made it an emergency. Ted Marmor, in this important article, explains why this legislation then needs to be taken back to the drawing board so we can keep the good (funding CHIP) and get rid of the bad.

Ted Marmor is an icon in the academic world of the politics of Medicare. It is urgent that we take heed of his advice.

Krugman: Government does health insurance better

Where Government Excels

By Paul Krugman
The New York Times, April 10, 2015

Like all advanced nations, America mainly relies on private markets and private initiatives to provide its citizens with the things they want and need, and hardly anyone in our political discourse would propose changing that. The days when it sounded like a good idea to have the government directly run large parts of the economy are long past.

Yet we also know that some things more or less must be done by government. Every economics textbooks talks about “public goods” like national defense and air traffic control that can’t be made available to anyone without being made available to everyone, and which profit-seeking firms, therefore, have no incentive to provide. But are public goods the only area where the government outperforms the private sector? By no means.

One classic example of government doing it better is health insurance. Yes, conservatives constantly agitate for more privatization — in particular, they want to convert Medicare into nothing more than vouchers for the purchase of private insurance — but all the evidence says this would move us in precisely the wrong direction. Medicare and Medicaid are substantially cheaper and more efficient than private insurance; they even involve less bureaucracy. Internationally, the American health system is unique in the extent to which it relies on the private sector, and it’s also unique in its incredible inefficiency and high costs.

****

Comment:

By Don McCanne, MD

Next week, when the Senate returns from its break, they will likely approve House-passed H.R.2 – the “SGR fix” – a bill that is being used as a vehicle to move Medicare closer to privatization by taking small incremental steps in increasing Medicare premiums and deductibles – features that are more characteristic of private individual plans than public social insurance programs.

Paul Krugman reminds us that governments are better at providing health insurance. So we should reject the current bipartisan efforts that are moving us further in the direction of converting Medicare from a public insurance program into a premium support model (defined contribution vouchers) of a market of private health plans.

This week’s taxpayer boost given by the Obama administration to the private Medicare Advantage plans – the fourth such devious boost in the past four years – enhances the private plans to set them up as a model for privatized Medicare. Is there no stopping this?

Why the Private Health Insurance Industry Has to Go

By John Geyman, M.D.
The Huffington Post, April 10, 2015

The private health insurance industry in the U.S. has had a long run since shifting to medical underwriting and a for-profit status in the early 1960s. It finds itself increasingly dependent on the government as the costs and prices of health care have continued upward since the 1980s. Its many perks from government include tax exemptions for employer-sponsored insurance (ESI), privatized Medicare and Medicaid programs, and longstanding over-payments to Medicare Advantage programs. The Affordable Care Act (ACA) has added to these perks since 2010 with subsidized premiums through the exchanges, a “risk corridor system” to protect insurers from losses, and allowing automatic self-renewal for 2015 plans.1

Incremental attempts to contain health care costs and reform the system since the 1990s have built upon our current multi-payer financing system. After five years’ experience with the ACA, we now know that insurers themselves are a major barrier to achieving the kind of access to affordable care that our population so desperately needs.

Here are some of the major reasons why private health insurers warrant no further bailout by government and taxpayers.

1. Continued discrimination against the sick.

Despite the supposed consumer protections in the ACA, a 2014 letter from more than 300 patient advocacy groups to the Secretary of Health and Human Services described continuing ways that insurers still discriminate against the sick, including benefit designs that limit access, high cost-sharing, restrictive drug formularies, inadequate provider networks, and deceptive marketing practices.2

A recent study by Kaiser Family Foundation found that only one-third of households with incomes between 100 percent and 250 percent of poverty have enough liquid assets to pay their deductibles, while only about one-half can meet out-of-pocket limits.3 As other examples, Wellpoint developed an algorithm to search its database for patients with breast cancer with an intent to cancel their policies4, while many insurers place all drugs used to treat such complex diseases as cancer, multiple sclerosis and HIV in the highest drug formulary cost-sharing tiers, thereby reducing insurers’ costs but making the drugs unaffordable for many patients.5

2. Fragmentation, inefficiency, and exorbitant administrative overhead.

There are some 1,300 private insurers still trying to maximize their income by avoiding the costs of sicker patients. Their administrative overhead is more than five times higher than that of the single-payer program in two Canadian provinces6; the overhead of private Medicare Advantage plans averages 19 percent vs. the 1.5 percent for traditional Medicare.7 Although the ACA set limits of 20 percent for overhead in the individual market and 15 percent in large-group markets, a recent study has found that those requirements had no effect on insurers’ overhead spending over the first three years of the ACA.8

3. Increasing costs for less coverage

The ACA provided insurers with four levels of coverage — the so-called “metals” — with actuarial values (what insurers pay vs. what patients pay) ranging from 60 percent (bronze) 70 percent (silver) to 80 percent (gold) and 90 percent (platinum). Not content with those levels of coverage, the industry through its trade group, America’s Health Insurance Programs (AHIP), has been lobbying hard for copper plans with only 50 percent actuarial value.9

Silver plans have been the most popular on the exchanges, so that patients are left with almost one-third of their costs, plus the cost-sharing that was required to get and maintain their policies. All this has led to an epidemic of underinsurance, whether the plans are purchased through the ACA exchanges or through the private insurance markets. The ACA has made the mistake of focusing on raising the numbers of Americans with “insurance”, but has not been effective in containing prices or costs of health care, with the result that an increasing proportion of these costs are shifted to patients and families. One-half of bronze plans in seven large U.S. cities requireenrollees to pay the deductible (often $5,000) before covering a doctor’s visit.10

4. Gaming the ACA for profits more than service to patients

There are many examples of this, starting with Medicare Advantage. Many insurers have been cited by the Centers for Medicare & Medicaid Services (CMS) for serious violations of Medicare’s patient protection requirements, including inappropriate denial of coverage and failure to consider physicians’ clinical information.11 Humana, one of the largest Medicare Advantage insurers in the country, is facing scrutiny from the U.S. Department of Justice for its risk-adjustment practices, which “upcode” the severity of patients’ illnesses in order to gain increased reimbursement, even as they lobby Congress for continued high over-payments.12 Meanwhile, some insurers are marketing short-term plans that last less than 12 months, evading any of the ACA’s requirements.13

5. Private insurance has priced itself out of the market.

Premiums keep going up at rates much higher than the cost of living, with little or no containment by regulators. As examples, MetroPlus, a popular new entrant on the New York exchange in 2014, has requested rate hikes of up to 28 percent in 2015 for some of its enrollees14, while Florida Blue, the state’s largest insurer, has announced an average rate increase of 17.8 percent for 2015.15

One can argue that the private insurance industry should be regarded as obsolete and not worth saving. However, the ACA has extended its life, including almost $2 trillion in federal subsidies over the next ten years16 (if these subsidies survive a U.S. Supreme Court ruling on their legality in coming months). Insurers have focused on attracting enrollees with low premiums, high cost-sharing, and low levels of actual coverage. Large insurers such as Wellpoint (Anthem) and Humana expect to receive $5.5 billion in 2015 through the ACA’s “risk corridor” provision that protects them from “losses.”17

6. As their business plan dictates, insurers are leaving unprofitable markets without regard for patients’ needs.

Private health insurers are all about making money, so they leave unprofitable markets regardless of the public’s needs. A recent example is Blue Shield of California (which just lost its state tax-exempt status with a surplus of more than $4 billion), which withdrew from 250 zip codes in California throughout the state in 2014.18,19.

Based on the above, the time has come for us to replace private health insurers with a more efficient, not-for-profit single-payer financing system–national health insurance (NHI)–which could be enacted by passage of H. R. 676, Expanded and Improved Medicare for All.

Dr. John Geyman is professor emeritus of family medicine at the University of Washington School of Medicine in Seattle, a member of the Institute of Medicine, and past president of Physicians for a National Health Program. He is the author of more than 160 scholarly articles and twelve books. 

Read more at http://www.johngeymanmd.org.

References: 

  1. Geyman, JP. How Obamacare Is Unsustainable: Why We Need a Single Payer Solution for All Americans. Friday Harbor, WA, Copernicus Healthcare, 2015, p. 170.
  2. Patient advocacy groups. Letter to Sylvia Burwell, Secretary of Health and Human Services, July 28, 2014.
  3. Claxton, G, Rae, M, Panchal, N. Consumer assets and patient cost sharing. Kaiser Family Foundation, March 11, 2015.
  4. Tillow, K. Health care law did not end discrimination against those with pre-existing conditions. Firedoglake, MyFDL, March 6, 2015.
  5. Pearson, C. Exchange benefit designs increasingly place all medications for some conditions on specialty drug tier. Avalere, February 11, 2015.
  6. Woolhandler, S, Campbell, T, Himmelstein, DU. Costs of health care administration in the United States and Canada. N Engl J Med 349: 768-775, 2003.
  7. Healthcare-NOW! Single-Payer Activist Guide to the Affordable Care Act, 2013. p. 22. Available at www.healthcare-now.org
  8. Day, B, Himmelstein, DU, Broder, M et al. The Affordable Care Act and medical loss ratios: No impact in first three years. Intl J Health Services 45 (1), 2015.
  9. Andrews, M. Proposal to add skimpier “copper” plans to marketplace raises concerns. Kaiser Health News, July 1, 2014.
  10. Appleby, J. Consumers beware: Not all health plans cover a doctor’s visit before the deductible is met. Kaiser Health News, December 23, 2013.
  11. Pear, R. U.S. finds many failures in Medicare health plans. New York Times, October 12, 2014.
  12. Herman, B. CMS pitches 1.1 % boost to Medicare Advantage payments. Modern Healthcare, February 20, 2015.
  13. Andrews, M. Short-term plans can skirt health law requirements. Kaiser Health News, October 28, 2013.
  14. Hartocollis, A. Insurers on New York State’s exchange seek significant rate increases. New York Times, July 2, 2014.
  15. Galewitz, P. Florida’s largest insurer is raising exchange rates average of 17.6 percent. Kaiser Health News, August 1, 2014.
  16. Pear, R. Health law turns Obama and insurers into allies. New York Times, November 17, 2014.
  17. Wayne, A. Insurers’ Obamacare losses may reach $5.5 billion in 2015. Bloomberg News Businessweek, March 4, 2014.
  18. Terhune, C. With billions in the bank, Blue Shield of California loses its tax-exempt status. Los Angeles Times, March 18, 2015.
  19. Bartolone, P., Capital Public Radio. Insurance choices dwindle in rural California as Blue Shield pulls back. Kaiser Health News, January 30, 2015.

Adapted in part from my recently released book, How Obamacare Is Unsustainable: Why We Need a Single Payer Solution for All Americans.

http://www.huffingtonpost.com/john-geyman/why-the-private-health-in_b_7029594.html

Taming high healthcare bills

By Jessica Schorr Saxe, M.D.
The Charlotte Observer, April 9, 2015

“Skin in the game.” The phrase pops up frequently in health insurance discussions, as it did twice in the recent Charlotte Observer article about high deductible policies (“A Growing Risk: High Deductible Health Plans Can Ruin Finances,” April 9).

In finance, the phrase refers to high-level executives investing their own money in stock in their company, so that they have a stake in its performance.

In health care, it refers to “consumers” having financial responsibility – in the form of high deductibles and co-pays in their insurance plans – for their health care so that they will be “smarter shoppers.” This raises a number of questions.

What problem is it solving?

The call for skin in the game implies that Americans are profligate over-users of health care. In fact, we have fewer doctors, see them less frequently, and spend less time in the hospital than residents of most other developed countries.

According to the Commonwealth Fund, more than one-third of Americans missed medical care because of cost in 2014. And more than one-third of non-elderly adults have a problem with paying their medical bills or debt. It seems we already have plenty of skin in the game.

Does it promote smarter choices?

Cost-sharing does decrease medical expenditures in the short term. But, according to the Robert Wood Johnson Foundation, “patients do not accurately discriminate between essential and nonessential services when responding to changes in cost-sharing.”

Avoiding a doctor visit to check your high blood pressure or skimping on a recommended medication because you have a high deductible might not turn out to be such a smart decision.

Does it save money? And, if so, for whom?

It certainly saves money for private health insurance companies: if patients don’t get care, insurers don’t have to pay for it. Healthy families who manage to avoid seeking medical care might see savings. But most people who have the misfortune to get sick are likely to find deductibles of thousands of dollars hard to pay. Such families have other losses in income, such as missed days of work for the patient and the caretaker, exacerbating their financial hardship.

With regard to national health care expenses, almost half are incurred by the 5 percent of people who are seriously ill. These people will not save money by putting skin in the game – they are likely already down to the bone. Robert Wood Johnson notes that increased cost-sharing will likely have no impact on national health spending.

Are patients the major drivers of excessive procedures?

Almost everyone knows someone who had an unnecessary MRI. But does that impetus come strictly from the patient? Medical device makers and pharmaceutical companies invest a lot of money in making us think we need more procedures and drugs. As a practicing physician, I noted that it was faster to order a test or lab than to do a meticulous exam. Our fee-for-service system has provided many people (other than patients) incentives for excessive spending.

Is this how we want medical decisions made?

A recent Medical Economics article about dealing with high-deductible plans tells doctors that they need to adjust their care by discussing costs and options as defined by the patient’s insurance plan. As a patient, I would like my doctor to let me know what recommendations are optional. Even if fully covered by insurance, I might prefer to spend my afternoon somewhere other than in a radiology waiting room or in a lab. Shouldn’t doctors be advising everyone on what is medically indicated – and not spending precious, limited time with patients discussing cost?

Whom is insurance supposed to protect, anyway?

Do we evaluate the value of fire insurance by whether people who don’t have fires feel secure in having it? Or by whether it protects those who actually have house fires?

Maybe health insurance is the wrong model after all. It differs from other insurance programs. Everyone needs health care, whereas not everyone needs fire care. Insuring against only catastrophic events (which high deductibles do) will ensure more catastrophic events, because of the resulting avoidance of primary and preventive care.

Americans need health care, but not private health insurance. We need accessible, affordable care without high deductibles or other barriers. Let’s drop the “skin in the game” cliche like a hot potato and use constructive language and thought to move toward a single-payer health care system – with real savings in administrative and drug costs – that would provide care for all.

The writer is a Charlotte physician and chair of Health Care Justice-NC, a group of health professionals and non-medical providers pursuing a single-payer, universal healthcare system.

http://www.charlotteobserver.com/opinion/op-ed/article17978219.html

Private insurance exchange enrollment doubles

Private Health Insurance Exchange Enrollment Doubled from 2014 to 2015

By Richard Birhanzel, Scott Brown, Joshua Tauber
Accenture, April 3, 2015

An estimated 6 million1 members enrolled in their benefits on a private health insurance exchange for the 2015 plan year, continuing a remarkable adoption trend in excess of 100 percent annual growth since 2013.

The mid-size employer segment of 100 to 2,500 employees is driving initial growth, as evidenced by the expansion of the consultant-led exchanges servicing this market.

Accenture forecasts enrollment of employees under 65 years old and dependents will grow to 12 million in 2016 and 22 million in 2017.

Accenture projects growth will remain on track to reach 40 million enrollees by 2018.

Two Early Growth Limiters Will Dissipate

Two key factors limiting private health insurance exchange growth in the initial years will dissolve in the near term: capacity constraints by a lack of mature solution providers and adoption delays among large employers.

Accelerators Are Emerging To Further Catalyze Growth

  • Increasing administrative requirements: Employers face increasing administrative requirements each year under the Patient Protection & Affordable Care Act (PPACA), such as new minimum essential coverage reports due to the IRS (section 6055). These requirements add to an already substantial compliance workload (e.g., ERISA, HIPAA, COBRA). Private health insurance exchanges can significantly reduce these requirements with robust reporting and compliance services.
  • Employer Mandate: The Employer Shared Responsibility Provision, more popularly known as the Employer Mandate, will compel employers to revisit their benefits strategy. Coupled with lower than expected SHOP enrollment, smaller firms in particular may increasingly consider the merits of private exchanges to deliver a simpler path to comprehensive coverage in a compliant fashion.
  • Employers maintaining coverage: Many employers have not dropped coverage altogether, as some initially forecasted. In fact, most employees view health insurance as a critical employer-provided benefit, limiting some employers’ ability to drop or defund health coverage. Accenture’s 2015 Private Health Insurance Exchange Consumer Research shows that 76 percent of consumers see health insurance as the primary or an important factor for continuing to work at their current employer. As employers seek a compelling alternative, the private exchange model of reducing costs and administrative burden emerges as a clear favorite.
  • Cadillac Tax: Finally, the 40 percent excise tax on high-cost plans, often termed the Cadillac Tax, will go into effect in 2018. This could affect as many as 38 percent of large employers and 17 percent of all American businesses3 if insufficient action is taken. Private health insurance exchanges will provide an ideal alternative to simultaneously migrate away from these legacy high-cost plans, and provide employees with new options to manage their health. Accenture expects private exchange enrollment to spike in 2017 as employers look to avoid these looming penalties.

Latent Demand Will Ensure Growth

Consumers’ latent demand for choice and flexibility in a retail-like shopping environment, paired with notable early successes, are increasingly overwhelming capacity constraints and employer inhibitions. Employers’ drive to meet consumer expectations, spurred on by key accelerators, will lead to 40 million members on private exchanges by 2018.

http://www.accenture.com/us-en/Pages/insight-private-health-insurance-exchange-annual-enrollment.aspx

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Comment:

By Don McCanne, MD

Employers have discovered that they can relieve themselves of much of the burden and costs of administering their employee health benefit programs, while using defined contributions to shift more costs to their employees, simply by referring them to private insurance exchanges. This is really catching on now with over 100 percent annual growth in the past three years, and an anticipated enrollment of 40 million by 2018.

These are not the insurance exchanges established by the Affordable Care Act, but they are private programs established by insurers and other industry consulting organizations. As more costs are passed on to the employees, the adequacy of the plans will certainly deteriorate further. Most employees will find that their increasing contribution requirements for the insurance premiums plus their out-of-pocket costs will become less and less affordable.

We continue to hear from politicians and the policy community that we do not need comprehensive reform such as the single payer model since the implementation of the Affordable Care Act is working so well with large numbers of new enrollments in the various sectors of health care coverage. What is being ignored is that the insurance products are deteriorating rapidly, especially with the very large increases in deductibles and the further narrowing of networks of health care providers. That some lower-income individuals are receiving subsidies (often inadequate) will provide little solace for the majority who find that their costs are becoming ever less manageable.

This explosion in the growth of private insurance exchanges further advances the ideology of those who wish to place patients in charge of their own spending by making them bear an ever increasing share of health care costs. This shift from solidarity to individual responsibility will be devastating for individuals with future health care needs. And now the venerated employer-sponsored coverage is becoming a major part of the problem.

Changing to a single payer national health program would remove control of health care financing from external players such as employers and place it in our hands through our own elected public stewards. The three trillion dollars that we are already spending is more than enough to provide quality care for everyone. We just have to make sure it is being spent on patients rather than on a glut of administrators and insurers who are eroding the protection provided by private insurance.

A Cadillac tax for Chevy health care

‘Cadillac tax’ the next big Obamacare battle

By Brian Faler
Politico, April 6, 2015

A mix of business groups and labor unions are pushing to tee up the next big Obamacare fight: killing its so-called Cadillac tax.

Though the nickname suggests it will apply to a select few, experts say a majority of employers could eventually face the prospect of imposing what will be the first-ever tax on health care benefits.

At issue is a 40 percent excise tax on the health benefits companies provide their workers above a certain threshold. In 2018, the tax will hit insurance and related perks valued at more than $10,200 for singles and $27,500 for families. So for family benefits worth $30,000, the tax would apply to the $2,500 that’s above the limit.

Unions, which often have generous health benefits and have opposed the tax since the law’s inception, say the looming levy is already becoming a factor in their contract negotiations.

“Employers are coming to the table asking for cuts in benefits based on their preliminary projections around the tax,” said Shaun O’Brien, assistant policy director for health and retirement at the AFL-CIO, which backs repeal.

The National Education Association, which is also demanding the tax be rescinded, issued a report Thursday complaining it would disproportionately hit women and older workers.

Congress pegged the tax threshold to a relatively slow measure of inflation. It’s linked to the consumer price index plus 1 percent, even though medical costs typically grow much faster. Private health care spending per enrollee will grow by an average of 5.6 percent annually over the next decade, according to the Congressional Budget Office, while inflation will increase by 2 percent per year.

About one-third of employers will be hit by the tax in 2018 if they do nothing to change their plans, according to a March survey by Mercer, a benefits consulting firm. By 2022, almost 60 percent will be facing the levy.

“‘Cadillac tax’ is really a misnomer,” said Beth Umland, Mercer’s director of research for health and benefits. “Potentially any employer could be hit by this tax.”

Former Obamacare adviser Jonathan Gruber, in one of the now-infamous videos that emerged late last year, said rising medical costs ensure the Cadillac tax will eventually all but eliminate the break companies get for providing health insurance.

Economists in both parties have been pushing the idea for decades as a way to slow health care costs, because it amounts to a cap on benefits.

That’s a good thing, many say, because overly generous insurance shields beneficiaries from costs, which encourages them to use more services, driving up prices for everyone else. It’s also a matter of fairness, some say, because forgoing taxes on health care benefits amounts to a major break for those with jobs offering coverage.

“Capping the tax benefit for employer-sponsored health insurance, I think, is a great idea,” said Len Burman, head of the nonpartisan Tax Policy Center. “Providing an open-ended subsidy for health insurance, which encourages people to get plans that do less to restrain spending, contributes to rising health care costs. Most economists who’ve looked at health care spending have concluded that.”

Congress’ independent budget scorekeepers have said Obamacare won’t add to the deficit, and why the tax will be tough to repeal. The levy, which is projected to generate $87 billion over a decade, ramps up slowly, but is estimated to eventually produce so much money that it alone will cover the cost of providing insurance subsidies through the program’s exchanges.

http://www.politico.com/story/2015/04/obamacare-health-care-cadillac-tax-116659.html

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“What Does the ACA’s Excise Tax on High-Cost Plans Actually Tax?”: An NEA-Commissioned Report by Milliman

National Education Association (NEA), March 13, 2015

Why Did NEA Commission an Actuarial Firm to Assess the Excise Tax on High-Cost Plans?

Always suspecting the term “Cadillac Tax” to be highly misleading, NEA hired the actuarial firm Milliman to determine whether the excise tax on high-cost plans is really a tax on overly generous health plans. In addition, NEA has a much higher percentage of older and female workers than the national workforce, so we asked Milliman whether the tax corrects for the impact of age and sex on premiums.

What Does the Excise Tax Really Tax?

The actuaries found that “although the excise tax is often referred to as a tax on overgenerous health benefits, it is likely to be a tax based on factors other than benefit richness and beyond the control of health plan members.”

For example, Milliman tested the relative impact on premiums of plan benefits and other factors. The actuaries concluded that, compared to their benchmark, geography had a potential 69.3 percent impact on premiums, meaning that area-specific health care costs alone could boost a $9,189 premium in 2018 to $15,556. Among their other findings: Premiums could increase by as much as 15.7 percent for plans with provider networks that have low negotiated discounts for doctors, hospitals, and others. In contrast, plan benefits in the study only increased premiums by as much as 6.2 percent.

The excise tax was designed to push employers to cut employees’ health benefits, but with factors other than health plan generosity driving tax liabilities, the resulting benefit reductions will be arbitrarily damaging to millions of employees and their families.

What Role Does Geography Play in Generating Tax Liabilities?

Milliman concluded that geography-related premium differences will “lead to much higher premiums and substantial taxable costs in many parts of the country.” When the actuaries tested benefits typical of gold- level health insurance exchange plans, they found that plan members’ location alone would trigger the excise tax in many places, even when the same gold-level benefits in other places would not.

They found, for example, that the premium for a gold-level plan in San Francisco, California, would be 37 percent higher than the exact same plan’s premium if it were in Huntington, West Virginia. In fact, they found striking disparities all over the country.

Does the “Age and Gender Adjustment” Correct for the Impact of Age and Sex on Premiums?

Congress knew that the excise tax on high-cost plans could be unfair to women and older workers, but Milliman concluded that the tax’s attempt to fix the problem “fails to compensate for the impact on premiums of age and sex in many parts of the country.” As a result, health plan members’ age and sex could contribute to excise tax liabilities. It also means that women and older workers could be disproportionately hurt by tax-spurred benefit cuts.

http://www.nea.org/assets/docs/Actuarial_Study_on_Excise_Tax–In_Brief–March_13_2015.pdf

Milliman – Full report: http://www.nea.org/assets/docs/Milliman–What_Does_the_Excise_Tax_Actually_Tax.pdf

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Comment:

By Don McCanne, MD

The Affordable Care Act’s “Cadillac tax” is a 40 percent excise tax on spending on employer-sponsored plans that falls above a given threshold. It has three primary purposes:

  1. As the revenues from this excise tax increase through the years, they will eventually pay much of the costs of the subsidies provided through the exchange plans, 
  2. The tax should eventually displace much of the current regressive tax expenditures that subsidize employer-sponsored plans, and 
  3. The tax should incentivize employers to reduce health benefits offered to their employees, thereby making employees better health care shoppers by increasing their exposure to out-of-pocket costs when accessing health care.

“Cadillac tax” is a label that creates the impression that the excise tax is applied primarily to plans with exceedingly generous benefits that only the wealthiest amongst us would purchase – a sector that could easily afford the excise tax. That is not true. According to the Milliman study commissioned by the NEA, the tax may apply to the baseline Blue Cross and Blue Shield standard benefit option offered through the Federal Employees Health Benefit Program.

What we have traditionally considered to be standard health plans – “Chevy plans” – are now considered to be “Cadillac plans.” These are plans that union members have paid for through forgone wage increases – wage concessions merely to maintain standard health care coverage, not “Cadillac” coverage.

This attitude that standard coverage is somehow a “Cadillac” plan shows how much the definition of standard coverage has deteriorated. Under the Affordable Care Act, the benchmark plans in the exchanges are silver plans with an actuarial value of 70 percent (patient pays 30 percent of costs) whereas standard employer-sponsored plans formerly had an actuarial value closer to 90 percent (patient pays 10 percent of costs).

What is particularly alarming about the Milliman study is that they show the tax will be applied inequitably based not only on the generosity of the benefits, but also based on factors over which employees have very little control such as age, sex, geographical location, the size of the risk pool, and the industry in which they work. Lower-income individuals with lower actuarial value plans under these circumstances could still be assessed the excise tax. That is really unfair. It is also possible that these factors could allow high-income individuals with very generous plans to escape the excise tax.

So let’s look again at the three purposes of this excise tax:

  1. An unfair tax is being used to fund administratively-complex subsidies in exchanges that were designed to revitalize the private insurance industry. Instead, the dysfunctional, inequitable, multi-payer system should have been replaced with an equitably-financed, efficient, publicly-administered single payer system.
  2. The regressive tax expenditures that subsidize employer-sponsored plans do need to be eliminated, but they need to be replaced with equitable progressive financing – the type of financing that characterizes a well designed single payer system.
  3. Requiring individuals to assume control of health care spending as a means of controlling costs has become a pathological obsession within the policy and political communities. Requiring patients to spend money that they do not have is a blunt instrument that prevents patients from receiving beneficial services that they should have. Costs can be controlled more effectively through an administratively efficient single payer system that provides prepaid health care with first dollar coverage.

There is growing bipartisan support to eliminate this unfair tax, but then what would happen? Both parties would search for new revenues to replace the tax while leaving in place this overpriced system that serves us so poorly that was perpetuated and expanded by the Affordable Care Act. What we really need instead is a single payer national health program.

Expand Medicare’s benefits

By David Ray, M.D.
Times Union (Albany, N.Y.), April 8, 2015

As we approach the 50th anniversary of the Medicare program, and the third year of the Affordable Care Act, what can we say about the state of America’s health care? For one thing, this: While the United States has centers which offer some of the most sophisticated medical treatments in the world, there is unequal access both geographically and economically to that care.

The Johns Hopkins School of Public Health published a paper in 2014 comparing health care in the 11 most developed countries in the world. The U.S. ranked at or near the bottom in access, cost, efficiency, safety and overall population health. Yet per capita cost in this country, at $8,500 per year, is nearly double that in every one of the other countries.

Those who oppose change continue to insist that our system offers choice, yet insurance company physician networks continue to contract, and for a large number of people, the dominant choice is between paying enormous out-of-pocket expenses or forgoing care.

Many people believe our system is primarily privately financed, but taxpayers already support much of this costly system (including Congress’ health care) with huge subsidies in the form of tax breaks to private employers for providing health coverage to their employees. Why are costs so high in our country?

There are many reasons, some of which the Affordable Care Act attempted to address, such as limiting the administrative costs of large private insurance companies to less than 15 percent of total premiums. But the fact is, after three years, careful maneuvering by these companies has kept their administrative and profit margins at nearly 17 percent, unchanged from 2012. For comparison, this is six times the administrative cost of the traditional Medicare program.

A great many people continue to believe that universal, single-payer health care is a pipe dream that could never be implemented in our country. Apologists for the status quo are now pointing at the recent attempt by Vermont to create “Green Mountain Care.” However, this was a hybrid of single payer and the many government and privately funded insurance programs that already existed in the state, and not a true single-payer system for the entire population of the state.

While the Affordable Care Act improves health care access for many, its provisions actually make it more difficult for an individual state to enact a true single-payer system. Furthermore, even the most pessimistic projections for this complex compromise would have resulted, by expert estimates, in $500 million in annual cost savings — not a trivial amount in a small state with an annual health care budget approaching $2 billion.

We need to stand up for Medicare, and the huge social benefit our society has reaped from the program, especially for the vulnerable elderly. Moving forward, we need to expand that social benefit to other vulnerable populations, and to each other, to keep our nation healthy and economically competitive.

Dr. David Ray is chairman of the Capital Region chapter of Physicians for a National Health Program. The chapter is sponsoring a talk on the idea of a single-payer health care system at 7 p.m. April 20 at the SUNY School of Public Health at the University at Albany. The speaker will be Dr. David Himmelstein, a professor at the City University of New York School of Public Health, and an expert on the economics and practicality of national single-payer health care.

http://www.timesunion.com/tuplus-opinion/article/Expand-Medicare-s-benefits-6184538.php

CMS gives another boost to Medicare Advantage plans

Fact Sheet: Moving Medicare Advantage and Part D Forward

Centers for Medicare and Medicaid Services (CMS), April 6, 2015

On April 6, CMS released final updates to the Medicare Advantage and Part D programs through the 2016 Rate Announcement and Call Letter. The finalized policies will continue to strengthen the growing Medicare Advantage program, and continue the successful implementation of the Affordable Care Act’s reforms that improve quality and provide greater protections for beneficiaries and value for taxpayers. 

Recent Trends in Medicare Advantage and Part D

  • Enrollment continues to grow – MA enrollment has increased by 42 percent since passage of the Affordable Care Act in 2010 to an all-time high of more than 16 million beneficiaries, with nearly 30 percent of Medicare beneficiaries enrolled in an MA plan.
  • Plan quality continues to improve – In 2015, 60 percent of MA enrollees will be enrolled in a 4 or 5 star plan, compared to an estimated 17 percent back in 2009.
  • Premiums remain affordable – Average premiums today are lower than before the Affordable Care Act went into effect, dropping 6 percent between 2010 and 2015.

2016 Rate Announcement

Expected Average Change in Revenue
  1.05% – 2016 Advance Notice
  3.25% – 2016 Rate Announcement

Effective Growth Rate
  1.7% – 2016 Advance Notice
  4.2% – 2016 Rate Announcement

Updated Growth Rate

The 2016 rate announcement reflects an underlying per capita growth of 1.9 percentage points of additional FFS spending for 2014 and 2015 and 0.6 percent for 2016, and 0.1 percent for the assumption that Congress will enact the pending legislation to permanently fix the SGR. The updated growth rates reflect the Office of the Actuaries’ best estimate of Medicare spending and are not the product of discretionary CMS policy. The underlying per capita FFS costs continue to demonstrate a historically slow health care growth rate and that growth rate remains below the per capita gross domestic product growth rate. Initial information from Medicare actuaries suggests that contributing factors behind the change from the preliminary growth rate include higher than expected spending on inpatient hospitalizations and some intermediary services such as therapy, rural health clinics and federally qualified health centers.  As always, when changes occur, we’ll continue to watch developments closely and work to understand these factors in greater detail.

Value-Based Contracting

In January 2015, the Secretary announced the Administration’s vision for moving the health care system toward paying providers based on quality rather than the quantity of care they provide. In the Call Letter, CMS continues to signal an intention to begin working with plans participating in Medicare Advantage to better understand, through a voluntary effort, the extent to which they use value-based payment models to compensate providers offering services to their enrollees.

http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-04-06.html

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Seniors Love Their Medicare (Advantage)

By Meghan McCarthy
Morning Consult, March 30, 2015

Whether enrolled in traditional Medicare or Medicare Advantage, Morning Consult polling shows Americans aged 65 and older expressing high levels of satisfaction with their federal health benefits. But when asked about individual pieces of their insurance—like prescription drug coverage, the benefits that are covered, and preventive care—seniors using Medicare Advantage reported higher satisfaction rates, sometimes by double-digits.

The poll of 3,975 seniors found that 85 percent of seniors on traditional Medicare said they were satisfied with their plan, compared to 88 percent of seniors on Medicare Advantage.

Despite registering nearly identical satisfaction levels for the overall programs, 80 percent of seniors on Medicare Advantage said they were satisfied with the overall cost of their plans, compared to 68 percent of traditional Medicare seniors. The gap in satisfaction appeared in every individual measure, with Medicare Advantage proving more popular every time.

Robert Berenson, a Medicare expert at the Urban Institute who previously served on the Medicare Payment Advisory Commission, said seniors on Medicare Advantage often get more benefits and have to pay less out of pocket, because the federal government ends up paying more per beneficiary when compared to traditional Medicare.

“Medicare Advantage plans provide better benefits, and overall costs are less, but plans get paid more—with favorable selection—to be able to do that,” Berenson said in an interview. A March MedPAC report found that Medicare Advantage plans would be paid 2 percentage points more than traditional Medicare in 2015.

Berenson also noted that traditional Medicare often covers the sickest and poorest seniors, and they might have a more negative view of their insurance, and health care in general.

With more seniors signing up for the program, insurers are getting more help from Congress to pressure the Obama administration to protect payment rates from any reductions.

http://morningconsult.com/2015/03/seniors-love-their-medicare-advantage/

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Comment:

By Don McCanne, MD

CMS has done it again. For the fourth year in a row, CMS has used innovative methods to boost the payment rates for Medicare Advantage plans, more than compensating for the required reductions in overpayments mandated by the Affordable Care Act.

Although this year’s Advance Notice called for a 1.05% increase in Medicare Advantage revenue, CMS has responded to an intensive campaign orchestrated by AHIP – the insurance lobby organization – by increasing revenue by 3.25% instead. Members of both parties in Congress were involved in this lobbying function – 239 from the House and 53 from the Senate.

Although many factors are considered when determining payment increases for Medicare Advantage plans, this year’s surprise discovery of new funds was predominantly in the updated effective growth rate of fee-for-service (FFS) Medicare – a rate of 4.2% as opposed to their Advanced Notice estimate of 1.7%. They explain that this is their “best estimate” of FFS Medicare spending and “not the product of discretionary CMS policy,” though they say, “the underlying per capita FFS costs continue to demonstrate a historically slow health care growth rate.”

This continued overpayment to private Medicare Advantage plans has allowed the insurers to offer greater benefits with lower out-of-pocket costs, and that is what has made the plans popular – demonstrated by a 40 percent increase in enrollment between 2010 and 2015. Little is said about the fact that the majority of the overpayments are retained by the insurers for administrative costs and profits. Robert Berenson confirms how these overpayments have made the plans more popular in polls such as that from Morning Consult, whereas “traditional Medicare often covers the sickest and poorest seniors, and they might have a more negative view of their insurance, and health care in general.” The Happy Healthy are in the private plans, and the Sad Sick are in traditional Medicare.

The march to Medicare privatization moves forward, aided and abetted by both Democrats and Republicans in Congress and in the Administration. Enabling better benefits and lower beneficiary costs for private Medicare Advantage plans, while leaving those in the traditional, less expensive FFS Medicare program devoid of these additional benefits, continues to incentivize the shift to private plans. Next week another step forward will occur with the enactment of the “SGR fix” which will expand somewhat the use of premiums and deductibles in the traditional Medicare program, but not in the Medicare Advantage plans.

Where is citizen action on all of this? Are we headed to “Medicare for None” with “Private Plans for All.” Keep in mind that the purpose of privatization is to shift the costs of health care from the government (collectivism) to individuals (freedom). That surely cannot be what Martin Luther King Jr meant when he dreamed of being “free at last.” What are we doing to his dream?

Health: The Right Diagnosis and the Wrong Treatment

By Marcia Angell, M.D.
The New York Review of Books, April 23, 2015

America’s Bitter Pill: Money, Politics, Backroom Deals, and the Fight to Fix Our Broken Healthcare System
By Steven Brill
Random House, 512 pp., $28.00

Steven Brill has achieved the seemingly impossible—written an exciting book about the American health system. In his account of the passage of the Affordable Care Act (now known as Obamacare), he manages to transform a subject that usually befuddles and bores into a political thriller. There was reason to think he might pull it off; his lengthy 2013 Time magazine exposé of the impact of medical bills on ordinary people was engrossing. But his success also owes much to the Bob Woodward method of writing best sellers about government policy: interviews with hundreds of insiders, many anonymous, some evidently willing to talk to him to increase their chances of being shown in a favorable light.

For example, one of Brill’s principal sources and a great favorite is Liz Fowler, chief health counsel to Senator Max Baucus, chairman of the Senate Finance Committee, which oversaw the legislation. Brill credits her with being “more personally responsible than anyone for the drafting of what became Obamacare.” He is unbothered by the fact that she was vice-president for public policy at WellPoint, the country’s second-largest private insurance company, before taking her job with Senator Baucus, or by the fact that shortly after passage of the law (and a brief stint with the administration), she became head of global health policy at the drug company Johnson & Johnson—even though both of these industries benefited greatly from Obamacare.

By contrast, Brill is appropriately critical of others who used the revolving door between industry and government, such as Billy Tauzin, the congressman who pushed through the industry-friendly Medicare drug benefit in 2003 and then became head of the pharmaceutical industry’s trade association. The excuse he gives for Fowler is that she was not a lobbyist, but that is hardly the point.

In view of his method, it’s not surprising that there is as much political gossip and score-settling in Brill’s book as analysis. Nevertheless, his description of our dysfunctional health system is dead-on. He shows in all its horror how the way we distribute health care like a market commodity instead of a social good has produced the most expensive, inequitable, and wasteful health system in the world. (The US now spends per capita two and a half times as much on health care as the average for the other OECD countries, while still leaving tens of millions of Americans uninsured.) Brill makes it clear that the problems are unlikely to be fixed by Obamacare. For that alone, his book deserves to be widely read.

full:
http://www.nybooks.com/articles/archives/2015/apr/23/health-right-diagnosis-and-wrong-treatment/

Health care system unjust

By John Sytsma
Lewiston (Maine) Sun Journal, Letters, April 7, 2015

Once again, a bill to study the benefits of a publicly funded, not-for-profit, universal health care system has been brought before the Legislature’s Insurance and Financial Services Committee.

On March 25, 32 people from all walks of life urged the committee to approve that bill. Well known facts were again presented. According to Sen. Geoff Gratwick, M.D., Maine is spending 22 percent of its gross domestic product on health care, while it, along with the rest of the country, ranks between 17th and 35th in worldwide measures of health care quality.

According to Dr. Julie Pease of Physicians for a National Health Plan and president of Maine All Care, per capita spending in Maine is $8,500, while in New Zealand — which has universal health care — per capita spending is approximately $3,000. She estimates there were 130 needless deaths in Maine for lack of health coverage and 1,400 bankruptcies.

The editor of Maine All Care, in the monthly publication stated that there were 147,000 Mainers without health insurance in 2013; after “Obamacare,” that figure was 130,000.

The present health care system is appallingly unjust and immoral. The U.S. wastes billions of dollars on profit-driven insurance companies, overpriced services, drugs and medical equipment. Meanwhile, the public is getting third-rate care.

A not-for-profit, universal health care system could not only improve the national health, but cost half as much and help prevent unnecessary deaths and bankruptcies.

This nation needs to look seriously at that option and move in that direction.

John Sytsma resides in Farmington.

http://www.sunjournal.com/news/letters/2015/04/07/j-sytsma-health-care-system-unjust/1679897