PNHP

President Obama’s consumer-directed recommendations for Medicare

President Obama’s consumer-directed recommendations for Medicare

Fiscal Year 2016 Budget of the U.S. Government
Office of Management and Budget

Reducing Cost Growth by Encouraging Beneficiaries to Seek High-Value Services.

The Budget includes structural changes that will encourage Medicare beneficiaries to seek high-value health care services. To help improve the financial stability of the Medicare program, the Budget reduces the Federal subsidy of Medicare costs for those beneficiaries who need that subsidy the least. The Budget includes several modifications for new beneficiaries starting in 2019, such as a modified Part B deductible and a modest copayment for certain home health episodes. Research indicates that beneficiaries with Medigap plans that provide first, or near-first-dollar coverage have less incentive to consider the costs of health care services, thus raising Medicare costs and Part B premiums for all beneficiaries. The Budget applies a premium surcharge for new beneficiaries beginning in 2019 if they choose such Medigap coverage. Together, these proposals would save approximately $84 billion over 10 years.

http://www.whitehouse.gov/sites/default/files/omb/budget/fy2016/assets/budget.pdf

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Comment:

By Don McCanne, MD

Using the rhetoric of encouraging Medicare beneficiaries “to seek high-value health care services,” President Obama is recommending in his FY 2016 Budget the application of more consumer-directed, moral hazard suppressing, skin-in-the-game measures that shift more costs away from the government and onto Medicare beneficiaries. Although the recommended measures are not dramatic, they are steps that move away from a position of egalitarian social solidarity (a progressive view), and toward a position of encouraging greater personal responsibility for health care (a conservative view).

Thus, as negotiations begin on the federal budget, instead of taking a position of strongly supporting beneficial progressive policies for Medicare, President Obama has adopted policies supported by conservatives as his opening position in the negotiations. Any union negotiator will tell you that you do not give up anything before you go to the table. Yet President Obama is not only declining to ask for any progressive improvements to Medicare, he is also giving the conservatives policies that they support. That leaves him in the position of starting negotiations only after having moved to the right, into their camp, and then attempting to achieve compromises with the much more highly polarized Republicans who have moved to the extreme far right.

So what specifically is wrong with his relatively benign-looking recommendations?

He would reduce “the Federal subsidy of Medicare costs for those beneficiaries who need that subsidy the least.” That is, he will charge much larger Medicare premiums for those with higher incomes. That will diminish the support of the plutocrats who have the political power to instead drive us closer to the premium support model of private insurance plans advocated for by conservatives such as Paul Ryan (the new Chair of House Ways and Means). Funding for Medicare should be completely separated from the benefits. Instead it should be fully funded through progressive taxes, ensuring full fixed benefits for everyone, with equitable funding based on ability to pay.

He supports “a modified Part B deductible.” That modification, of course, is a higher deductible for Part B (physician) services. It is true that higher deductibles do reduce spending modestly by causing patients to forgo beneficial health care services. But erecting financial barriers to care is exactly the opposite of what we should be doing with a program that should be designed to remove financial barriers, thereby encouraging people to get the care that they should have. Medicare should be a prepaid system for everyone.

He would initiate “a modest copayment for certain home health episodes.” Home health care is a more economical and humane way of providing health care services for many people with advanced illnesses. Individuals in those circumstances may not have enough funds for cost sharing. Introducing copays is a definitive first step in shifting ever more of the costs of home care to patients, and certainly more steps would follow. Bad move.

Conservatives have long targeted Medigap plans because they allegedly create the moral hazard of patients using more health care simply because it is free at the point of care – deductibles and coinsurance being paid by the plan. This theory is based on a misinterpretation of the results of the RAND HIE. Hypochondriasis is very rare. People always have a legitimate medical reason for going to the doctor. 

However, rather than requiring a minimum amount of cost sharing in the Medigap plans, President Obama’s recommendation is to apply a surcharge to the Medigap premiums. Medigap plans are already one of the worst values in health insurance, and jacking the premiums up even more with surcharges is certainly a move in the wrong direction. Perhaps this is an indirect way of intimidating people into forgoing Medigap plans in order to expose them to more out-of-pocket costs, or perhaps to stimulate a market for more spartan Medigap plans with no first dollar coverage. Regardless, it is another push toward the perverse method of reducing spending by making appropriate health care less affordable.

If nothing else, this shows that the conservative, consumer-directed advocates have won the rhetorical debate. It astounds me how many people across the political spectrum have bought the meme that paying medical expenses out-of-pocket gives people pride in exercising their personal responsibility.

Are people in other countries with lower costs and first-dollar coverage ashamed that they abandoned personal responsibility by walking out of their health care facility without making an out-of-pocket payment? If they are ashamed, they have been very effective in hiding it behind the false pride they show in their egalitarianism. Or, could it be? Are they actually egalitarian? Can we try that?

Illinois Universal Health Care Act introduced in 99th General Assembly

By Anne Scheetz, M.D.
Illinois Single Payer Coalition, Feb. 2, 2015

On Jan. 14, 2015, Representative Mary Flowers of Chicago introduced the Illinois Universal Health Care Act in the 99th Illinois General Assembly as House Bill 108.

Flowers first introduced the Illinois single-payer bill on Jan. 18, 2007, in the 95th Assembly, as the Healthy Illinois Act, HB 311. She has reintroduced the bill in each subsequent Assembly.

In 2011 the name was changed to the current one, chosen by vote by Illinois single-payer activists. In the 98th Assembly it was HB 942.

The 2007 bill garnered 30 sponsors. In the summer of 2008, Flowers conducted hearings around the state on the need for single-payer health care, and the 2009 bill gained 36 sponsors. 

Support for the bill declined following the 2010 passage of the Affordable Care Act; the 2011 bill secured 8 sponsors, and the 2013 bill 6.

The bill when enacted would provide coverage for all necessary health care to all residents of the state with no deductibles, co-pays, or other cost sharing. Individuals would not have to search for and try to evaluate insurance policies on the exchanges. No one could lose their health insurance coverage for any reason. Employers would be relieved of the burden of providing health insurance to employees. State and local governments would see their health care spending significantly reduced. In order to create a single-tier system with the same benefits available to everyone, private insurance companies would not be allowed to sell coverage that would duplicate the comprehensive coverage provided by the state program.

Other important provisions of the bill:

  • stress on public health and prevention
  • coverage includes long-term care, mental health care, and dental care
  • complete choice of providers
  • practitioners may be salaried or paid fee for service
  • hospitals, nursing homes, community health centers, non-profit staff model HMOs, and home health agencies receive global budgets for operations; this money may not be used for expansion, profit, excessive executive compensation, marketing, or major capital purchases or leases
  • capital expenditures, including construction of new health facilities and purchase of expensive equipment, budgeted separately and overseen by regional health planning districts
  • negotiated fees and prices
  • no investor ownership of facilities that deliver health care
  • re-education and job placement for people who lose their jobs due to the transition to a single-payer system

The complete text of the bill is available here.

The ISPC Legislative Committee is in the process of contacting all past sponsors of the bill, and new representatives known to support single-payer, to urge their sponsorship in the face of the ACA’s demonstrated inadequacies.

http://www.ilsinglepayer.org/article/illinois-universal-health-care-act-introduced-99th-general-assembly

The financial sinkhole of health insurance complexity

By Jim Kahn, M.D., M.P.H.
KevinMD blog, Feb. 2, 2015

We all know that the U.S. system of paying for health care is tremendously complex and inefficient: a multitude of insurers, thousands of insurance plans, innumerable medical bills, countless incorrect and denied claims.

But just how much do we waste on this administrative morass?

I led a research team that recently reviewed all the available evidence and published our findings. The resulting numbers are staggering.

Compared with countries that have a single health insurer (i.e., the government), we waste more than $375 billion per year in excess paperwork to pay medical bills.

That’s $1 billion per day. That’s more than $1 trillion every three years. That’s 15 percent of all health spending — 1 in every 7 dollars spent on health care — on excess paperwork.

Let me put these big numbers into perspective. This waste equals $1,200 per year for each and every person in the United States. It represents 89 percent of total state and federal spending for Medicaid, our health insurance for the poor. It amounts to 2.3 percent of the U.S. economy.

And this striking toll doesn’t even count the effort expended by employers for their employees’ health insurance or time spent by patients and families dealing with insurance and bills.

What does this third of a trillion dollars each year pay for? It funds the endless detailed steps required in the “multi-payer” insurance system:  designing health plans, contracting between insurers and providers, marketing health insurance, signing up subscribers, checking insurance status at each medical visit, collecting copayments, creating bills, sending out bills, processing incoming payments, disputing insurance claims, collecting unpaid bills.

We call this “billing and insurance-related” administrative waste, or BIR. In the dead of our current winter, I pronounce it “brrr” because it reflects a frightfully chilling reality.

Imagine what we could do, as a nation, with more than $375 billion.

We could pay for everyone to have high-quality health care. The massive savings from lower paperwork would be enough to cover all Americans with minimal or no deductibles or copays.

Are we speculating? No, we’re summarizing solid empirical evidence, something sorely missing from most health care reform discussions.

What’s the evidence? The U.S. is part of the OECD — Organization for Economic Cooperation and Development — the wealthy democracies. All of those countries have either a single-payer, or a single absolutely standard comprehensive health plan, with coverage of 98 percent of individuals or higher (compared to 87 percent in the U.S.).

All of them avoid BIR administrative waste. They also use the single payer to get lower prices on medications and durable medical goods like CT scanners, wheelchairs, and hearing aids.

So the $1 trillion over three years isn’t an abstract number. It’s a real savings we can achieve if we finally make the same decision that all of our counterpart countries have.

That should be our New Year’s resolution.

Jim Kahn is a professor of health policy, epidemiology, and global health, University of California, San Francisco. 

http://www.kevinmd.com/blog/2015/02/financial-sinkhole-health-insurance-complexity.html

Blue Cross of California sifts markets

Insurance Choices Dwindle In Rural California As Blue Shield Pulls Back

By Pauline Bartolone, Capital Public Radio
Kaiser Health News, January 30, 2015

Blue Shield of California used to sell policies to individuals in every county in the state, according to the Department of Managed Health Care, one of California’s two teams of health insurance regulators. But by 2014’s open enrollment period, Blue Shield had pulled out of 250 zip codes throughout the state, including four entire counties: Alpine, Monterey, Sutter, and Yuba.

The gaps are particularly felt in the top third of the state, where thousands of residents now have only one choice of insurer if they want to buy a health plan on the exchange.

Blue Shield of California declined an interview with NPR. But in a written statement, the company reported that it’s not selling in certain areas of California because it could not find enough health providers willing to accept a level of payment that would keep premiums low. According to the statement, the company also is not selling in areas where there is no contracted hospital within 15 miles.

Because of the broad changes in the individual health insurance market under the Affordable Care Act, “there is no accurate apples-to-apples comparison between the individual market in 2013 and the individual market in 2014 and beyond,” Blue Shield said, adding that “coverage areas were designed to meet regulatory guidance and with patient access to care in mind.”

Blue Shield of California is acting within the law, says Shana Alex Charles, director of health insurance studies at UCLA’s Center for Health Policy Research. She says Blue Shield could have offered to pay health care providers more. But, at the same time, she adds, insurance companies can’t be forced to operate at a loss.

“There’s no public charge that says they have to be in those zip codes,” she says. “If they determine that it’s not within their company’s best interests to remain there and sell their product there, then they won’t be there.”

http://www.capradio.org/articles/2014/12/17/after-blue-shield-pulls-out-of-zip-codes,-consumers-see-limited-insurance-options/

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Comment:

By Don McCanne, MD

Blue Shield of California has pulled out of 250 California zip codes in the Covered California program (California’s insurance exchange under the Affordable Care Act), citing inability to negotiate low prices with the local health care providers.

Nonprofit Blue Shield of California and for-profit Anthem Blue Cross were the only Covered California insurers in many zip codes in the state. It is ironic that the for-profit Blues plan – Anthem Blue Cross – has continued to serve areas where coverage is more difficult, whereas the nonprofit Blues plan – Blue Shield – has pulled out. So much for the theory that nonprofit Blues plans are public service models while for-profit Blues are primarily profit-making business models. They have become the same animal, with the for-profits leading the way.

Blue Shield blames regulatory guidelines requiring that patients have access to care. By refusing to contract with the local providers, patients would have been required to travel long distances for care – a violation of the Affordable Care Act.

Some might blame Blue Shield for demanding rates that were too low to adequately cover costs, whereas others might blame the providers for demanding rates that provided excessive profits, but the primary blame does not lie with either party. It is the model that uses private insurers as financial intermediaries that is defective and should be blamed.

Contrast that with Medicare, which is a public insurer that administers the rates to be paid. Medicare is not setting rates to ensure that the government is profiting off of the program. Rather it is setting rates to be sure that the health care delivery system is adequately funded so that it will be there when patients need it.

It is true that Medicare rates are not always optimal, but that is because it is only one payer in a dysfunctional, multi-payer system which makes rate setting much more difficult. If Medicare were the only payer for the entire nation, it could set rates with much greater precision, paying legitimate costs and fair margins.

Although the Blues had their day as health insurers serving in the public interest, those days are long gone. It is time for a single payer, improved Medicare for all.

What It’s Like When You’re An American Using Britain’s NHS

By Jim Edwards
Business Insider, Jan. 29, 2015

I’ve spent half my life in the US and half of it in the UK, so I’m used to both countries’ healthcare systems. I recently returned to London after 20 years in America, and after a few doctors’ appointments I’ve come to see the NHS through American eyes.

The National Health Service is, as all Americans know and fear, a completely public “socialized medicine” system. It’s dramatically different from the US’s patchwork system of private providers and insurance companies.

My story isn’t representative, of course. Healthcare delivery is different in the UK depending on where you live and which doctors and hospitals you use — just as it is in the US. But I’ve now used both systems for about two decades each, so I feel I have a pretty good handle on the main contrasts.

‘This Rolls Royce isn’t moving fast enough!’

The context here is that the NHS just released its most recent stats on accident and emergency room waiting times. The headline number is that 84% of patients are seen within four hours. In the UK, this is regarded as a huge failure — the standard the NHS is supposed to meet is 95% of patients in four hours. The UK media went into a fury about it, and some hospitals have begun postponing and rescheduling some non-emergency procedures in order to get those waiting times down.

In the US, having sat in many an ER waiting room for hours at a stretch, the idea of a hospital seeing nearly 9 out of 10 patients in four hours would be regarded as a miracle. Bear in mind that within that four-hour period the NHS doctors are triaging patients: If you get hit by a bus, you’re going to see someone instantly. If you broke a finger because you fell over while drunk at the pub, you’re probably going to wait at the back of the line. It’s not like people are literally bleeding to death while they wait for attention (although the British media loves it when it finds individual cases where that has happened).

So my overall impression is that currently, the Brits’ complaints that the NHS isn’t hitting that 95% mark is akin to saying, “This Rolls Royce isn’t moving fast enough!”

Show up when you’re told to — or else

The first major difference from the patient’s point of view is what happens when you call your doctor for a routine appointment. My specific health issue was that I thought I was going slightly deaf, and wanted it checked out.

I’m a dual US/UK citizen, so I qualify for NHS treatment. Here’s what happened to me.

In America, you call your doctor and request an appointment when it’s convenient for you. They might ask you what’s wrong with you, presumably to make sure it’s not something that requires immediate treatment. But basically, it’s first come, first served, regardless of how important it is. Usually, you can pick an appointment time that’s convenient for you if it is not an emergency.

In the UK, I was given an appointment whether I liked it or not. I called and leave a message. Within an hour or two a nurse practitioner called me back and asked me a few questions about my problem over the phone. (You’ve got to take the call in a private place if you don’t want your office mates to hear.) Then they said: Come in at 9am on Thursday. There was no choice over appointment times — the assumption is that if you’re ill, you’re going to come to the doctor when they say.

At first I found this jarring. In America, I get to choose when I see the doctor! In Britain, I better show up when I’m told. But the appointment came quickly, as the local health authority in London has targets it needs to meet. Ultimately, I saw the logic of it: This is a public health system. It needs to manage its costs and services. If you’re really sick, you’ll show up. If you only want to show up when it’s convenient for your schedule, then how sick are you, really?

America is worse at on-the-day care

In America, I’ve always had a long wait to see my doctor. I have read many a back issue of Newsweek in my primary care / general practitioner (GP) doctor’s office. I’ve sat there for an hour playing with my phone while the doc sees patients in the order they were booked.

In the UK, I showed up at 9am and was seen instantly, at the Waterloo Health Centre. For an American, this was bizarre: My butt barely touched the seat in the waiting room before my name was called. Turns out my doc and her staff are serious about patient scheduling.

This was one reason I became convinced that the NHS way of scheduling is superior: You might not get the time or date that you want, but once you’re in, you get seen super-quick.

The NHS actively discourages some patients — for good reason

The NHS actively discourages some types of patients: Interestingly, NHS offices and hospitals have posters up all over the place warning you not to show up at the emergency room if you have a cold or the flu. They’re actively discouraging patients with minor ailments from seeking emergency treatment, and trying to get them to see their regular doctors instead. It’s sensible — everyone knows that a vast amount of hospital time and money is wasted treating people who are not an emergency. And hospitals and doctor’s surgery waiting rooms are a hotbed of germs. But still, it’s a culture shock to see a medical institution put up signs that basically say, “go home, you idiot!” in every waiting room.

The US never discourages patients from doing anything. I’ve never seen any kind of public campaign to persuade patients to apply some common sense before dropping themselves off at an emergency room. The entire US pharmaceutical industry is also dedicated to running ads encouraging people to “go see your doctor” for even the most trivial of conditions.

The treatment from my primary care GP was the same in the UK as it was in the US. I’ve had great care from 95% of doctors I’ve ever seen in both the US and the UK. Doctors are doctors. They’re mostly really nice and good at what they do. The system that pays them doesn’t seem to make them better or worse.

There is basically no paperwork with the NHS

There is a load of paperwork for patients in the US. This is easily the worst aspect of US healthcare — the billing paperwork. If you’ve ever had any health issue that required more than a simple doctor visit, you will know that it precipitates a seemingly never-ending series of forms, bills, and letters. You can be paying bills months, years later. And it’s almost impossible to correct a billing error. It’s stressful. I developed an intense hatred for health insurance companies in the US because of this.

There was close to zero paperwork in the NHS. I filled in a form telling my doc who I was and where I lived, and that was pretty much it. The only other paperwork I got was a letter in the mail reminding me of my next appointment. They sent me a text reminder, too, which no American doc has ever done. It was incredibly refreshing.

The standard of care is the same

So, was I going deaf? Maybe. Maybe not. I’d lost my sense of balance in summer 2014, which an American doctor had diagnosed as Benign Paroxysmal Positional Vertigo. It’s a condition of the inner ear. It made my body feel slightly drunk and clumsy even though I am completely sober.

The US doc told me there is no treatment and it goes away on its own, mostly. A lot of people get it, apparently. I was managing fine and it doesn’t bother me, anyway.

The UK doc told me the same thing, but also suggested I might have Meniere’s Disease, and wanted to send me to a specialist to get it checked out. Meniere’s isn’t really a disease, it’s just a collection of symptoms: dizziness, hearing loss and a ringing in the ears. Again, there is no treatment. But it’s rare.

This freaked me out a little bit. I was used to the US system which is heavily “defensive.” Doctors tend to over-treat patients because they get sued if they miss something. They also get paid more money for doing more work. Yet it was the NHS doctor that suggested extra treatment.

It was going to be free — so I said yes!

A long wait for NHS treatment …

I then made an appointment with a specialist at the Guy’s and St Thomas’ Hospital in London.

In the US, I’ve always been able to see a specialist within a few days. Score one for America.

In the UK, they said “we’ll see you in January.” It was late November, six weeks or more away. This was a shock. I was going deaf now — not in six weeks! What the hell?!

NHS waiting times are a real thing, it turns out. I comforted myself with the assumption that the staff had made a decision that my condition was likely not life- or health-threatening, and had moved me to the back of the line. It was frustrating. Ultimately, I also needed to change my appointment because I had to leave the country on business, and this was quite difficult to do. I had to call a few times, basically to catch the hospital booking staff at the right time of day, in order to do it. I wished Guy’s and St. Thomas’ had an online system for this, but they don’t — just a bunch of people answering phones, most of whom don’t have access to the right appointment schedule.

It was that appointment system again: You’re booked in according to their priority, not yours. The big lesson with the NHS is, it’s a lot easier to just show up when you’re told.

Old people in Britain are really rude

In the US, I expect to wait up to an hour in the specialist’s waiting room on the day of my appointment. I often wonder if Time and Newsweek were such big magazines in the US because they’re needed for bored patients in American doctors’ waiting rooms. Nothing ever happens promptly on the day in US healthcare, as far as I can tell.

In the NHS, again, I waited only a couple of minutes. Credit to the staff at St. Thomas, they are cranking through their patients.

On two occasions I noticed old people complaining angrily (and rudely) to the office staff that they had been made to wait 15 or 20 minutes to see their doctor. As an American, I almost laughed out loud. Fifteen minutes to see a free doctor! This Rolls Royce isn’t moving fast enough! I asked a British friend — someone who has ongoing health issues and sees a lot of doctors — if old people complaining like this was common. Turns out, it is. Old British people love to complain to NHS staff if they wait more than 1o minutes. Everyone just expects their appointments to be exactly on time.

Again, the NHS care was great. I saw two different doctors within an hour, one for testing and one for diagnosing. A third admin staffer was coordinating the lists so there was no doctor downtime. It was like being in a highly efficient factory. It looked like hard work. I could tell that one of my doctors was not interested in chatting. She treated me, and wanted me out the door. There was a bunch of patients behind me, after all. In America, docs seem to be happy to chat as long as you want — and you can tell that extra couple of minutes with each patient creates long delays as the day wears on.

The good news: I am not going deaf! I have great hearing, it turns out. They even showed me a chart of it. But the tinnitus — ringing in my ears that started years ago because I used to go to a lot of punk rock gigs in my youth — has gotten worse, making me feel more deaf.

The UK NHS specialist said she was 99% sure there was nothing wrong with me, or at least nothing that could be treated, but she recommended an MRI to see what the condition of my inner ears is like. This was reassuring. In no way was my treatment rationed or denied, the way Americans fear. It was just the same as in the US, with the same number of docs and the same level of high-tech equipment.

The cost to the patient is much cheaper in the UK, obviously

So how much did all this NHS care cost me? £0. Nothing. Zero. I paid not a penny for some top-notch healthcare. There is no such thing as a “free,” of course, but the per-capita cost of healthcare in the UK (paid by the government via tax collections) is generally lower than the US, according to the World Health Organization. Americans spend $8,362  per capita on healthcare annually, the Brits spend $3,480. Here is a breakdown:

NHS prices

    Doctor visit: £0
    Specialist: £0
    Diagnostic test: £0
    MRI: £0
    Total: £0 

Typical US prices*

    Doctor visit: $100
    Specialist: $150
    Hearing test: $72
    MRI: $1,000
    Total: $1,372 (Total payable by the patient in cash, or typically 90% from insurance and 10% as a patient copay. Prices taken from Healthcare Bluebook.) 

Sorry America, but NHS treatment really is better over all

The bottom line: I prefer the NHS to the American private system. It’s a little more inconvenient in terms of appointment times, but due to the fact that it is free, has no paperwork, and the treatment on the day is super-fast, the NHS wins. That Rolls Royce is moving at a pretty decent clip.

And, of course, there is the small matter of the fact that the NHS covers everyone equally, whereas Americans get care based on their ability to pay, leaving tens of millions with only minimal access to care. (Obamacare is changing that, but it’s leagues behind the NHS if you’re comparing them by the standard of universal full-service coverage.)

Americans think they have the best healthcare in the world. Take it from me, a fellow American: They don’t.

http://www.businessinsider.com/an-american-uses-britain-nhs-2015-1

Dr. Rob Stone on Indiana’s substitute Medicaid expansion

By Alycin Bektesh
WFHB 91.3 Radio (Bloomington, Ind.), Jan. 28, 2015

PNHP note: The following text is an unofficial transcript of excerpts from a radio interview given by Dr. Rob Stone, director of Hoosiers for a Commonsense Health Plan, on Indiana Gov. Mike Pence’s recently announced Medicaid expansion alternative. The interview was conducted by WFHB’s news director, Alycin Bektesh. To listen to the full 7-minute segment, click here. It was originally posted under the headline “H.I.P. 2.0 Accepted as Medicaid Substitute for Indiana.” In Indiana’s newly approved program, enrollees will be required to pay premiums of 2 percent of their incomes for coverage. People earning less than  poverty are not required to pay premiums, but if they don’t, they will be required to pay co-pays for care, such as $4 for a doctor’s visit and $75 for hospitalization, and will lose their dental and vision benefits. Additionally, people above the poverty line will lose their coverage entirely for 6 months if they miss a payment — a penalty never before applied to Medicaid patients — unless they are deemed “medically frail.” Even small premiums and co-pays have been found to discourage care, and the cost to administer the program’s changes will be more than it raises in premiums. Immediately following this transcript is an article about the settlement in the Herald Times of Bloomington on Jan. 30.

Alycin Bektesh: In his announcement yesterday, [Gov.] Pence called the updated Healthy Indiana plan a model for Medicaid reform across the nation. Dr. Rob Stone, director of Hoosiers for a Commonsense Health Plan, agreed that other states might try to emulate Indiana’s model, but said that in the end it would not be a victory for those seeking coverage.

Dr. Rob Stone: In all these other states they don’t have to deal with these premiums and lockouts and all this stuff. Everybody else has taken a much easier path, and we in Indiana have chosen to take this much more bureaucratic path, more complicated path, all in the name of somehow, supposedly, when people make these small payments then they’re supposedly better health care consumers. There’s really no evidence to prove that, and I think it’s just unnecessarily bureaucratic, which I think is a little bit of an irony since the Republicans are always the ones who are saying, you know, that government bureaucracy needs to be cut and avoided, but they’ve set up this really bureaucratic system.

Apparently Indiana is the only state that has that, and now I’m sure other states will ask for that, because there are a number of other states that are basically politically controlled by the Republicans who, up to now, haven’t completed their application for waivers. Many, of course, are not doing it at all. But there are a number of others that are looking for waivers and they may follow this path. That seems to have been the final point where HHS [the U.S. Department of Health and Human Services] gave up something, set a precedent. You know, maybe, I wish they hadn’t done that.

Alycin Bektesh: Pence is using the term “reform” to refer to HIP 2.0 coverage, but he’s not acknowledging the funds he turned away over the last two years that would help with low-income health insurance coverage, or that HIP 2.0 is essentially a higher-burden version of Medicaid.

Dr. Rob Stone: I still regret that we went 13 months without Medicaid expansion which we could have had a year ago January. It could already be in place. Hundreds of lives would have been saved, thousands of people would be getting treatment now for illnesses that were untreated. We’d be in a better place if we hadn’t gotten all this messing around, political posturing, over the last year or more.

Alycin Bektesh: Stone said consumer-driven health care is more of a showmanship term than a signal that something new has been created.

Dr. Rob Stone: So “consumer-driven” means that patients are supposed to be motivated to be good consumers, to make wise choices about whether they go to the emergency room or whether they get preventative care. And it all kind of sounds good when you listen to their rhetoric, but there’s actually no evidence – zero published, credible evidence – that these kinds of “consumer-driven” features really accomplish any of the things they claim to do. But they are politically important to the governor because he’s on record against the government, he’s on record as being vehemently opposed to the Affordable Care Act. But of course he’s also a smart enough guy to know that $1.7 billion a year of federal money coming into the state is only going to help the state. So he’s made a decision to move forward on this thing, and he wants to couch this thing as some kind of radical, new Medicaid change. There are a few changes to traditional Medicaid which I think are actually changes for the worse – like I said before, too much bureaucracy – but he’s got to kind of couch it politically and I think that really it’s not that big a change and I think it’s going to on balance help people. But in the larger picture I do worry that I don’t want to see Medicaid to continue to be privatized, bureaucratized, and made worse. It’s already a difficult enough program.

http://wfhb.org/news/h-i-p-2-0-accepted-as-medicaid-substitute-for-indiana/

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Feds forced changes in Pence’s HIP 2.0 plan

By Lauren Slavin
Herald Times (Bloomington, Ind.), Jan. 30, 2015

In a rare moment of agreement, the state government and health care advocates have both praised the federal approval of a waiver to extend state Medicaid through the Healthy Indiana Plan, now called HIP 2.0.

But after reviewing the plan, those who worked to push the process to bring health care to low-income Hoosiers have two lingering questions: What took so long, and why?

“On many different levels, I think this is a wonderful thing. It doesn’t change the fact we could’ve had this all 13 months ago,” said Rob Stone, director of Hoosiers for a Commonsense Health Plan. “I remain skeptical that this plan is any improvement on traditional Medicaid.”

HIP 2.0, which opened for enrollment Tuesday, is estimated to offer health care coverage to 350,000 currently uninsured citizens starting Feb. 1.

For months, Gov. Mike Pence’s administration and the U.S. Centers for Medicare and Medicaid Services negotiated a Medicaid expansion to be paid for by the federal government until 2017, when that funding will decrease to 90 percent of costs. The state estimates it will pay $1.5 billion from 2015 to 2020 without imposing new taxes. HIP 2.0 will be paid for through new hospital assessment fees and Indiana’s cigarette tax.

In order to receive government approval and funding, the state had to make adjustments to HIP 2.0, as well as discontinue several aspects of the original Healthy Indiana Plan. HIP 2.0 includes the same essential health benefits guaranteed under the Affordable Care Act, such as preventive care and hospitalization.

Unlike HIP, HIP 2.0 does not have capped enrollment. Any proposal with capped enrollment would not have been approved by the Centers for Medicare and Medicaid Services, nor receive matching federal funds, according to the U.S. Department of Health and Human Services.

Stone participated in a conference call with representatives from the Centers for Medicare and Medicaid Services on Tuesday after Pence announced that the HIP 2.0 waiver had been approved by the federal government.

“It sounds like really most of the compromises, most of the changes between the original HIP and HIP 2.0, happened during the negotiations in March, April, May of last year,” Stone said. “It took a little while to kind of work out this thing about the six-month lockout, which has been a 12-month lockout in the original HIP.”

The HIP “lockout” required all enrollees to pay premiums through their Personal Wellness and Responsibility, or POWER, accounts, which the state compares to a health savings account, or HSA. Those who did not pay into their POWER accounts became ineligible for health care.

Now, HIP 2.0 enrollees who are below the federal poverty level and cannot make payments into their POWER accounts cannot be locked out of coverage. The state also contributes $2,500 to POWER accounts, and a portion of any remaining account funds rolls over every year.

“(They) want to make sure those under 100 percent of the federal poverty level are a category of especially protected people under federal Medicaid,” said Kosali Simon, a professor in Indiana University’s School of Public and Environmental Affairs, and an affiliated scholar at the Urban Institute, which examines social and economic policy through research. “That way it looks like Indiana Medicaid has a plan for them, regardless if they pay any monthly fee.”

Those who are above 100 percent of the federal poverty level and do not pay into their POWER accounts can only be locked out of coverage for six months, with several exceptions, including those who are medically frail.

“That lockout threat gives the incentive for people to keep paying in and stay in,” Simon said.

HIP 2.0 enrollees who do not make payments into their POWER accounts because their incomes are below the federal poverty level are automatically enrolled in the HIP Basic plan after a 60-day grace period. Unlike HIP Plus, HIP Basic does not include vision or dental services, and requires copays for doctor’s visits and hospitalizations. The HIP 2.0 website warns that this plan can be more expensive than HIP Plus.

“I still think it’s silly to lock those people out,” Stone said. “I hate to see dental be lost by those people, because they need dental more than anybody. But at least they’ll have full coverage if they can’t make these small payments.”

Stone and Simon also wonder if the POWER payment will be worth the government hassle. While Pence has said using POWER accounts and having “skin in the game” has contributed to the high percentage of HIP enrollees satisfied with their health care, Stone says there is no peer-reviewed data to back that claim.

“Think about the administrative burden of thinking out how to write a check, get a stamp, make a credit card payment with a processing fee for $3 a month,” Simon said. “How many letters will it take to remind people, to keep track of the 60-day grace period? All of that is a lot of work.”

Indiana’s HIP 2.0 proposal to CMS also included a mandatory work requirement called Gateway to Work, which was not approved. This program would have made referral to workforce training programs a requirement in order to receive health care unless enrollees were also in college or technical school.

Gateway to Work is now a voluntary referral work assistance program.

“I think job programs are always great, and they always sound better than they turn out to be in reality,” Stone said. “I just don’t want to put more bureaucratic requirements and impingements on access to health care. Republicans always claim they want less government regulation, and this is a government-instituted plan that has lot more bureaucracy and regulations and overhead cost.”

How to apply:  Hoosiers can apply for HIP 2.0 online at www.HIP.IN.gov, by mail, fax or calling 1-877-GET-HIP-9, or by visiting a local Family and Social Services Administration Division of Family Resources office. The Monroe County FSSA office is at 1711 N. College Ave., Suite 101, in Bloomington. 

http://www.heraldtimesonline.com/news/local/feds-forced-changes-in-pence-s-hip-plan/article_062f175b-06aa-57cd-8b07-ff41c0021085.html

Don’t Trade Away Our Health

By Joseph E. Stiglitz
The New York Times, Jan. 30, 2015

A secretive group met behind closed doors in New York this week. What they decided may lead to higher drug prices for you and hundreds of millions around the world.

Representatives from the United States and 11 other Pacific Rim countries convened to decide the future of their trade relations in the so-called Trans-Pacific Partnership (T.P.P.). Powerful companies appear to have been given influence over the proceedings, even as full access is withheld from many government officials from the partnership countries.

Among the topics negotiators have considered are some of the most contentious T.P.P. provisions — those relating to intellectual property rights. And we’re not talking just about music downloads and pirated DVDs. These rules could help big pharmaceutical companies maintain or increase their monopoly profits on brand-name drugs.

The secrecy of the T.P.P. negotiations makes them maddeningly opaque and hard to discuss. But we can get a pretty good idea of what’s happening, based on documents obtained by WikiLeaks from past meetings (they began in 2010), what we know of American influence in other trade agreements, and what others and myself have gleaned from talking to negotiators.

Trade agreements are negotiated by the office of the United States Trade Representative, supposedly on behalf of the American people. Historically, though, the trade representative’s office has aligned itself with corporate interests. If big pharmaceutical companies hold sway — as the leaked documents indicate they do — the T.P.P. could block cheaper generic drugs from the market. Big Pharma’s profits would rise, at the expense of the health of patients and the budgets of consumers and governments.

There are two ways the office of the trade representative can use the T.P.P. to maintain or raise drug prices and profits.

The first is to restrict competition from generics. It’s axiomatic that more competition means lower prices. When companies have to fight for customers, they end up cutting their prices. When a patent expires, any company can enter the market with a generic version of a drug. The differences in prices between brand-name and generic drugs are mind- and budget-blowing. Just the availability of generics drives prices down: In generics-friendly India, for example, Gilead Sciences, which makes an effective hepatitis-C drug, recently announced that it would sell the drug for a little more than 1 percent of the $84,000 it charges here.

That’s why, since the United States opened up its domestic market to generics in 1984, they have grown from 19 percent of prescriptions to 86 percent, by some accounts saving the United States government, consumers and employers more than $100 billion a year. Drug companies stand to gain handsomely if the T.P.P. limits the sale of generics.

The second strategy is to undermine government regulation of drug prices. More competition is not the only way to keep down the prices of essential goods and services. Governments can also directly restrain prices through law, or effectively restrain them by denying reimbursement to patients for “overpriced” drugs — thus encouraging companies to bring down their prices to approved levels. These regulatory approaches are especially important in markets where competition is limited, as it is in the drug market. If the United States Trade Representative gets its way, the T.P.P. will limit the ability of partner countries to restrict prices. And the pharmaceutical companies surely hope the “standard” they help set in this agreement will become global — for example, by becoming the starting point for United States negotiations with the European Union over the same issues.

Americans might shrug at the prospect of soaring drug prices around the world. After all, the United States already allows drug companies to charge what they want. But that doesn’t mean we might not want to change things someday. Here again, the T.P.P. has us cornered: Trade agreements, and in particular individual provisions within them, are typically far more difficult to alter or repeal than domestic laws.

We can’t be sure which of these features have made it through this week’s negotiations. What’s clear is that the overall thrust of the intellectual property section of the T.P.P. is for less competition and higher drug prices. The effects will go beyond the 12 T.P.P. countries. Barriers to generics in the Pacific will put pressure on producers of such drugs in other countries, like India, as well.

Of course, pharmaceutical companies claim they need to charge high prices to fund their research and development. This just isn’t so. For one thing, drug companies spend more on marketing and advertising than on new ideas. Overly restrictive intellectual property rights actually slow new discoveries, by making it more difficult for scientists to build on the research of others and by choking off the exchange of ideas that is critical to innovation. As it is, most of the important innovations come out of our universities and research centers, like the National Institutes of Health, funded by government and foundations.

The efforts to raise drug prices in the T.P.P. take us in the wrong direction. The whole world may come to pay a price in the form of worse health and unnecessary deaths.

Joseph E. Stiglitz, a Nobel laureate in economics, a professor at Columbia and a former chairman of the Council of Economic Advisers, is the author of “The Price of Inequality.” 

U.S. Trade Deal Will Devastate Poor Peoples’ Access to Medicines

By Medicins Sans Frontieres (MSF) /Doctors Without Borders
Medicins Sans Frontieres, Jan. 26, 2015

Many countries and treatment providers like MSF rely on affordable quality generic medicines to treat life-threatening diseases. But the U.S.-led Trans-Pacific Partnership Agreement (TPP) would make it much harder for generic companies to produce cheaper drugs that are vital to people’s health. The TPP would give pharmaceutical companies longer monopolies over brand name drugs and the ability to charge high prices for critical drugs for longer periods of time.

The United States government continues to demand intellectual property provisions in the Trans-Pacific Partnership Agreement (TPP) that will limit access to medicines for at least half a billion people, said the international medical humanitarian organization Doctors Without Borders/Médecins Sans Frontières (MSF) on Monday as negotiators continued another round of secret meetings in New York.

“MSF and many others have repeatedly voiced concerns that the TPP is a looming disaster for people who rely on access to affordable generic medicines, both internationally and in the United States,” said Rohit Malpani, director of policy and analysis at the MSF Access Campaign. “Despite this outcry, the US continues to work behind closed doors, without any input from the public, experts, or elected officials, to aggressively push for intellectual property provisions that put the profits of pharmaceutical companies ahead of people’s health.”

If signed in its current form, the TPP—a far-reaching trade agreement involving the US and 11 other Pacific-Rim countries—would force all countries to  grant additional drug patents, extending monopolies on medicines beyond 20 years, a practice called patent “evergreening.”

The agreement would also impose an unprecedented extended period of exclusivity for clinical data required to prove the safety and efficacy of drugs and vaccines that are “biologic” products, extending monopolies in TPP countries, which will delay lower-cost versions of these medicines from entering the market.

“The intellectual property provisions of the TPP completely undermine the Administration’s stated public health goals, including its own goal to achieve an AIDS-free generation,” said Malpani. “While President Obama speaks of expanding health care and tackling issues of income inequality at home, he is actively promoting a trade agreement that will exacerbate economic disparities and endanger people’s health care worldwide.”

MSF has relied on leaks of the TPP text for information because the negotiations have been held in secret. While MSF and other civil society groups have been excluded from official negotiations on the TPP, industry groups representing various multinational corporations have had the opportunity to read the text and suggest revisions.

In the coming weeks, the US Congress could vote to renew “fast-track” authority on the TPP, which would allow the agreement to be put to an “up or down” vote without revision.

Renewal of fast-track authority without public health safeguards that mandate major revisions of the intellectual property chapter will all but ensure that these damaging provisions remain in the text.

“The TPP is the most damaging trade agreement we have ever seen in terms of access to medicines for poor people,” said Malpani. “With USTR [Office of the United States Trade Representative] publicly stating that these negotiations are winding down, it is now more urgent than ever that concerns about access to medicines be addressed.”

[Read MSF’s Open Letter to President Obama.]

http://www.doctorswithoutborders.org/article/tpp-trade-deal-will-be-devastating-access-affordable-medicines

A night at the free clinic shows limits of health-care reform

By Marina Bolotnikova
The Toledo Blade, February 1, 2015

TOLEDO, Ohio — Every Thursday night, CedarCreek Church in South Toledo becomes a bustling health clinic that serves the region’s uninsured population. Medical students in white coats take each patient’s vital signs, hear their complaints, and refer them to one of the clinic’s doctors.

Patients can get consultations, medications, and simple tests for free. Most have no access to regular, preventive care. Many attend the clinic regularly to manage their health.

A crowd of patients often lines up long before the clinic opens, said Chris Marino, a second-year medical student at the University of Toledo college of medicine and life sciences — formerly the Medical College of Ohio — and executive director of UT’s CommunityCare Clinics. Many of the patients need insulin, which is in short supply and sometimes runs out early.

Guadalupe Peña, 40, recently lost his job and health insurance, and comes to the clinic to manage his diabetes. “If it wasn’t for this place, I wouldn’t have my medication,” he said. Mr. Peña is waiting to hear about his application for Medicaid coverage.

He said he doesn’t mind the often hours-long wait to see a doctor. Other patients echoed his attitude: They may have to wait three hours to talk to a doctor, but they appreciate the volunteers’ dedication and quality of care.

And they don’t have much choice. Even as the number of insured Americans climbs to unprecedented levels thanks to Obamacare and Medicaid expansion, countless people like the clinic patients struggle with prohibitively difficult applications, long wait times, and appeals processes to get health care. Estimates vary, but patients like these likely number in the millions.

Dr. Johnathon Ross, an internist at Mercy St. Vincent Medical Center and a weekly clinic volunteer, invited me to shadow his patient consultations. One woman got a prescription to treat dangerously high blood pressure. Without health insurance, there was no guarantee she’d have a follow-up consultation.

The patients I saw with Dr. Ross did not know they were eligible for Medicaid based on their income. Others said they had tried and failed to get insurance, or were waiting to hear from state agencies.

Karen Burnsworth, 50, said she earns about $7,000 a year, well below the poverty line. But when she tried to apply for Medicaid last year, she was denied.

Out of the woodwork

Many of the clinic’s patients fall into Ohio’s “woodwork” population: people who are eligible for Medicaid based on their income or disability, but haven’t enrolled. The Ohio Department of Medicaid estimated that 231,000 eligible Ohioans would come out of the woodwork and enroll in the program last year, because Americans without health insurance now face tax penalties under the Affordable Care Act. But Sam Rossi, a department spokesman, said that the actual number of woodwork patients to enroll has been much lower.

Part of that is because of the perceived difficulty of applying. Ohio Medicaid has streamlined its processes and introduced an online application to make it easier to apply, Mr. Rossi said.

Even so, many uninsured patients like Ms. Burnsworth say they find the application process arduous, and don’t have the knowledge or time to appeal unfavorable decisions. Free, no-questions-asked clinics such as the one at CedarCreek offer an alternative to the psychological barrier of applying, waiting for approval, and being denied coverage.

Donald Stout, 52, comes to the clinic for treatment of his high blood pressure. He was approved for Medicaid, but he didn’t like the coverage because of its limited network of doctors.

“They’re too pushy — they pick what doctors you can go to,” he said. “I like these doctors [at the clinic]. They’re all good people.”

Network inadequacy has always been one of Medicaid’s biggest shortcomings. Because doctors are reimbursed at a fraction of their regular rates to treat Medicaid patients, few physicians are willing to see them at all. So patients struggle with a small selection of doctors and long wait times.

Medicaid expansion has expanded the pool of eligible Ohioans to include childless adults who earn as much as 138 percent of the federal poverty level — about $16,100 a year for an individual. That change has helped 450,000 more Ohioans get coverage, bringing the state’s Medicaid enrollment to 2.9 million people.

But the expansion also threatens to make network inadequacy worse. To accommodate the influx of Medicaid patients, the federal government mandated an increase in Medicaid reimbursement rates for primary-care physicians to the same rates it pays doctors who treat Medicare patients. In Ohio, that was a pay bump of about 69 percent.

But that parity expired at the end of last year. According to the Ohio State Medical Association, 40 percent of doctors who were treating Medicaid patients said they would see fewer or none of those patients once the higher reimbursement ended. A bill sponsored by Sen. Sherrod Brown (D., Ohio) that would extend the pay increase through 2016 hasn’t budged in Congress.

Long way to go

Through a combination of Medicaid expansion and insurance subsidies for low and middle-income households, the Affordable Care Act has reduced the percentage of uninsured Americans from 17.1 percent to 12.9 percent. That’s an impressive drop, but it leaves more than 30 million Americans, including 1.2 million Ohioans, still uninsured.

For Dr. Ross, a vocal advocate of health reform, the need for free clinics illustrates the injustices and inefficiencies of American health care.

“The complexity of trying to figure out who’s supposed to pay and how in the private system generates billions of dollars of waste,” he said. “Here, we try to cobble together care for patients who fall through the cracks.”

Dr. Ross, a former president of Physicians for a National Health Program, advocates a single-payer system funded by tax dollars. The government, not insurance companies, would pay for health-care. Every American would be covered from birth. No confusing applications, networks, or payment schedules.

The Congressional Budget Office has consistently found that a single-payer system could cover every American and still cost less than what we pay for health care now, because of the enormous administrative costs of managing private insurers.

It’s hard not to see the appeal of a single-payer system. Obamacare has extended coverage to millions of people, but it hasn’t eliminated the basic problems of our health-care system: the link between health care and employment and the chaos of competing insurers. It hasn’t spared poor Americans the indignities of being denied care, or waiting for hours to see a doctor at a free clinic.

For now, though, single-payer health care in the United States is a pipe dream. As health reform moves at a glacial pace, patients will continue to depend on the goodwill of groups such as CommunityCare.

If free health clinics remind us of the indignities of American health care, they also show us the generosity of providers who are willing to work long, unpaid hours to fill the gaps in a broken system. I was reminded of that when I asked Mr. Marino of UT how working with uninsured patients has affected him.

“The people who come here are really struggling,” he said. “They’re giving us a lot of trust by letting us play a role in their care, because we’re students and we’re still learning.

“Another volunteer put it really nicely: ‘We’re not just here to volunteer. This is a privilege.’ ”

Marina Bolotnikova is an editorial writer and columnist for The Blade.

http://www.toledoblade.com/Marina-Bolotnikova/2015/02/01/A-night-at-the-free-clinic-shows-limits-of-health-care-reform.html#Ll5pbF92k2xUvWWd.99

Martin Luther King Jr. — Health Care as a Moral Crisis

By John Geyman, M.D.
The Huffington Post, Jan. 30, 2015

On this occasion honoring the anniversary of the birthday of Martin Luther King 86-years-ago, coinciding with the release of the movie Selma, it is fitting to recall his leadership on moral principles toward equity of health care in this country. Among his many classic quotes about health care, he had this to say in 1966 in a speech to the Medical Committee for Human Rights:

Of all the forms of inequality, injustice in health care is the most shocking and inhumane.

Were he here today, Martin Luther King, Jr. would be appalled to see what Americans are facing, even five years after the passage of the Affordable Care Act.

Here’s one patient vignette that puts a human face on the outcomes facing patients unfortunate enough to live in states that opted out of Medicaid expansion, as more than twenty states have done.

Charlene Dill was a 32-year-old mother of three who earned $11,000 a year cleaning houses and babysitting in Florida. That was too much to qualify for Medicaid, and too little to afford health insurance. The ACA would have provided subsidies for health insurance if her income was more than $23,550. When she developed a heart condition, and later, abscess on her legs, she did go to emergency rooms, but couldn’t afford those bills or any other care.

This is not an isolated anecdote, but more the rule for many millions of Americans. Access to care has improved for some, especially in states that expanded Medicaid, but there are still more than 30 million uninsured and tens of millions underinsured. Lacking any mechanisms to rein in markets and contain costs or prices, the ACA has unleashed increasing consolidation and control by hospital systems and insurers.

Wall Street is happy, and health care stocks are soaring. Yet one-third of insured Americans cannot afford to pay their medical bills, often leading to bankruptcy. Meanwhile, our safety net continues to deteriorate. We can expect that to worsen in the months and years ahead if Republican governors impose more restrictions on Medicaid, and if the Republican-controlled Congress cuts spending for critical programs.

As Martin Luther King knew full well, health care is a moral issue. Virtually all advanced countries around the world recognized long ago that health care is a human right, not a privilege based on ability to pay. Dr. Edmund Pellegrino, leading medical ethicist for many years at Georgetown University’s Center for Clinical Bioethics, summed up the issue this way at the Annual Meeting of Academic Health Centers in 2000:

Access to health care is a moral obligation of a good society.

Yet, as a society, we still seem to have a moral blind spot when it comes to health care. As the income gap widens between rich and poor in America, and as the middle class falls into increasingly dire straits in affording health care, our sense of social solidarity continues to erode. The political process toward reform has been corrupted by money, especially in the wake of Citizens United and the McCutcheon rulings of the U.S. Supreme Court.

We can expect that Martin Luther King would see our present health care “system,” despite limited progress from the Affordable Care Act, as a political failure and a moral crisis unnecessarily harming a large and growing part of our population. He would be a leader toward the concept of health care as a human right, not just a commodity for sale on a largely for-profit market. He would speak truth to power and be a beacon of hope if he were on the scene today. He was never one to give up in a fight, and has left us with this perspective:

We must accept finite disappointment, but never lose infinite hope.

We need to carry on his spirit to best honor his legacy. This would address his strong belief that injustice in health care is a major expression of inequality and inhumanity. An answer to health care reform is in plain sight if we just take off our blinders — single payer national health insurance along the lines of H.R. 676 Improved Medicare for All, the Conyers bill in the House of Representatives. That will assure all Americans full access to necessary care, with full choice of physician and hospital care anywhere in the country. It includes public financing, coupled with a private delivery system, at a cost far less than we are paying today.

John Geyman, M.D. is professor emeritus of family medicine at the University of Washington School of Medicine in Seattle and past president of Physicians for a National Health Program 2005-2007. Adapted in part from his just released book “How Obamacare Is Unsustainable: Why We Need a Single Payer Solution for All Americans,” Copernicus Healthcare, 2015.

http://www.huffingtonpost.com/john-geyman/martin-luther-king-jr-hea_b_6526410.html

MLK’s Vision and the Right to Healthcare

By James Besante, MS4
Common Dreams, Jan. 25, 2015

This past week the world celebrated the life of Dr. Martin Luther King Jr.

Marches of remembrance also served as painful reminders of unhealed wounds along the lines of race in America, particularly the failure to realize equal access to health care for all.

In 1966, while addressing the second convention of the Medical Committee for Human Rights, King declared, “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”

The true magnitude of race-based health inequality is staggering: In his seminal paper “What If We Were Equal,” former Surgeon General David Satcher calculated approximately 83,000 excess deaths per year among African Americans, also known as the “black-white mortality gap.”

Despite progress in civil rights, housing, education, and employment from 1960 to 2000, this gap has remained. Shockingly, it has widened for infants and African American men over the age of 35.

The King holiday was a sobering day of reflection, but it was also the crescendo to the very audible justice movement loosely organized under the banner Black Lives Matter.

Activists marched in cities across the nation to bring attention to numerous highly publicized incidents of police violence. More broadly, organizers sought to underline the subversive elements of racism still deeply etched in our nation’s subconscious, and no doubt represented in unequal health outcomes for African Americans.

As a nation, we do not provide universal access to even the most basic medical services. This is not likely to change anytime soon since the Congressional Budget Office estimates that 27 million people will remain uninsured after the full implementation of Obamacare.

The absence of universal health care coverage sets the U.S. apart from all other developed countries. It is the only member of the elite G7—a group of nations accounting for 66 percent of net global wealth—without universal health insurance for its citizens.

Dr. Satcher proposed national health insurance as the evidenced-based remedy to finally close the racial mortality gap and address persistent health injustice in America.

Polls show most Americans also support universal health care. In fact, the majority of physicians agree the private health insurance industry should be replaced with a streamlined, publicly accountable system, like “single-payer,” also known as “improved Medicare for all.”

What is single-payer? It simply means the government pays for health care costs without routing money through private insurers who manufacture paperwork, billing complexity and profits. This is how traditional Medicare insurance is able to operate with overhead costs of 2 percent, which is far more efficient than private health insurance plans, with overhead costs of 15 to 25 percent.

Harvard researchers recently calculated the administrative savings of single-payer’s simplified financing structure to be $375 billion annually, nearly 15 percent of total health spending. This would help to lower the sky-high cost of our current system, which is approaching 18 percent of the gross domestic product.

Single-payer would free patients from out-of-pocket expenses, like co-payments and deductibles—proven barriers to care that are administratively unwieldy and unnecessary for cost containment.

National health insurance would also give patients free choice of providers without the narrow networks that are commonly encountered by insured Americans.

The comprehensive, high-quality care that is equitably accessible in a single-payer national health program stands in stark contrast to our current market-based system in which health care is rationed based on an individual’s ability to pay.

The implications of ensuring a right to health care go well beyond medicine, because “health” is of fundamental importance for the exercise and enjoyment of all other civil, political and economic rights. Dr. King envisioned a world of justice for all. In spite of this, preventable or treatable illnesses continue to needlessly compromise the liberty and dignity of countless Americans.

A right to health care is therefore instrumental for effective citizenship and promotes active participation by the greatest number of citizens in a more robust democratic process.

Equality—whether in health care or any other sphere—is not a “dream deferred,” to quote Langston Hughes, but is attainable. We simply need the political will.

James Besante is a fourth-year medical student at the University of New Mexico School of Medicine and a board member of the Chicago-based Physicians for a National Health Program.

This work is licensed under a Creative Commons Attribution-Share Alike 3.0 License

http://www.commondreams.org/views/2015/01/25/mlks-vision-and-right-healthcare

Pew: The Precarious State of Family Balance Sheets

The Precarious State of Family Balance Sheets

The Pew Charitable Trusts, January 29, 2015

  • The majority of American households (55 percent) are savings-limited, meaning they can replace less than one month of their income through liquid savings.
  • Most families face financial strain across all balance sheet elements: income, expenditures, and wealth. In addition to being savings-limited, households face other financial challenges; just under half of families are “income-constrained,” reporting household spending greater than or equal to their income; and 8 percent are “debt-challenged,” with payments equal to 41 percent or more of their gross monthly income. Fully 70 percent of households face at least one of these problems, with many confronting two or even all three.

Conclusion

Previous Pew research has shown that family finances are a critical component of future economic mobility, not just for individuals but also for their children. However many families, even those with relatively high incomes, are walking a financial tightrope, and have little, if any, cushion to absorb an unexpected financial emergency. What’s more, this is not a new phenomenon. While the most recent recession shined a spotlight on the fragility of family balance sheets, the downturn alone did not cause households’ financial insecurity; many of the indicators explored here have been stable for the past 30 years.

No single solution exists for stabilizing family balance sheets. Putting families on solid financial footing and the road to upward economic mobility will require a selection of thoughtful and strategic policy interventions. As policymakers strive to increase opportunity for all Americans, policies and programs that support asset accumulation will be key. These efforts will also require careful design and rigorous evaluation to ensure that they are effective in helping families improve all elements of their balance sheets.

http://www.pewtrusts.org/en/research-and-analysis/reports/2015/01/the-precarious-state-of-family-balance-sheets

****

Comment:

By Don McCanne, MD

Far too many American families simply do not have the income or assets to meet unexpected expenses such as health care, especially now that insurers are shifting more of the costs to patients. This Pew report recommends “thoughtful and strategic policy interventions,” carefully designed and rigorously evaluated to be sure they are effective. We already have a carefully designed and rigorously evaluated proposal for health care – a single payer national health program, aka an improved and expanded Medicare for all. We merely have to enact and implement it.

A Canadian physician responds to Gov. Pence’s Medicaid program

Yesterday’s Quote of the Day (“Government supports rotten teeth for patients in poverty”) discussed the Medicaid waivers obtained by Indiana Governor Mike Pence. Today’s post continues on that topic.

The Goal Was Simplicity; Instead, There’s a Many-Headed Medicaid

By Margot Sanger-Katz
The New York Times, January 28, 2015

Indiana has become the latest Republican-led state to expand its Medicaid program as part of the Affordable Care Act. As has become the pattern, it was done with a series of waivers from particular federal requirements.

When the state’s governor, Mike Pence, announced the news on Tuesday, the focus of his speech was less about his state’s decision to embrace this part of Obamacare than about the special concessions he’d been able to extract from the Obama administration.

Newly eligible Medicaid recipients will have to pay monthly premiums or be locked out of certain services, he announced, and higher-earning beneficiaries who fail to pay will be shut out of the program for six months. People who use the emergency room frequently will need to pay higher co-payments than the federal government has ever allowed.

The provisions, designed to encourage residents to take more responsibility for the costs of their health care, break new ground in what the Obama administration will allow in exchange for expansion.

NYT Readers’ Comments:

By Bob Solomon, MD
Edmonton, Canada

You live in “Cloud-Cuckoo Land” in the fantasy you have the best medical care system on earth. Baloney. Check it out.

Canada is right next door. Come see how a sane federal health plan works, covering all and ensuring that (1) we live longer, (2) we have fewer chronic ills, (3) we have lower cost drugs, (4) we have lower cost hospitals, (5) we have lower cost operations, (6) we have lower accounting costs for all parties, and (7) we have no medical bankruptcies and impoverishment anywhere, for any income, for the unemployed, for the elderly. Long waits for ER? I waited 4 minutes for an asthma attack to be dealt with, 2.4 hours for a minor ear problem — wax. In Philly, I waited 2.4 for a back injury. Twice. So no difference.

We get free (tax-paid) care in Alberta. No out of pocket, no minimum, no exclusions, no co-pays, no nothin’.

Premiums exist in certain provinces: $35 a month per person or about that, and some people purchase extended coverage. I also pay approx. $1200 a year for added features: free or nearly free drugs, and a large subsidy for glasses, hearing aids, private rooms, canes, and things like that.

Americans live in a “exceptional” med world — a medical services madhouse. It was not created by ACA, of course. And because of the med and drug and hospital corporations, I mean “people”, and the know-little-or-nothing GOP, it was ensured to endure after ACA. Medical madness is still a disease you need to cure.

And…

By Don McCanne, MD

Denying poor people dental care simply because they cannot pay the premium, as Pence’s program does, defies logic. Does sentencing poor people to rotten teeth truly motivate them to find money that they don’t have in order to provide them with the “dignity to pay for their own health insurance”?

Does Pence propose that we change the rhetoric from “skin in the game” to “rotten teeth in the mouth”?