PNHP

Child health care and the class divide

Child health care and the class divide

By W.T. Whitney Jr., M.D.
CounterPunch, Jan. 29, 2015

The U.S. split between a wealthy elite and the majority poor is old news. Yet as revelations surface as to who siphons off money for themselves and what happens to the impoverished many, the story continues. It gets into how governments deal with health care. In that regard, health care for children may serve as a marker for when government programs leave off serving the common good. The state of children’s health is like the proverbial “yellow canary” in a mine shaft whose death warned of toxic gas accumulation.

Children are vulnerable, and when problems emerge, they are readily apparent. That’s the case in Florida now. On Dec. 31, 2014, U.S. Circuit Judge Adalberto Jordan announced a decision involving Florida’s Medicaid program and its role in serving child health. Jordan was responding to a 2005 legal action brought by pediatricians, dentists, and nine children on behalf of children enrolled in Florida’s Medicaid program. The lawyer arguing their case insisted that $200 million was needed to fix the program.

As reported by the Miami Herald, Jordan stated that “lawmakers had for years set the state’s Medicaid budget at an artificially low level, causing pediatricians and other specialists for children to opt out of the insurance program for the needy.” Jordan’s ruling declared that to force physicians caring for poor children to accept payments “far below what private insurers would spend — and well below what doctors were paid in the Medicare program for a more powerful group, elders — amounted to rationing of care.”

Judge Jordan cited adverse effects: physicians refusing to care for children served by Medicaid, children going without preventative care, dental care, and screening for lead intoxication. To secure specialty care, children had to travel to other states or to distant cities in Florida. Every year Florida’s Medicaid program removes thousands of recipient children from its rolls.

Jordon’s ruling applies to large numbers of children. In 2013, 24 percent of Florida children were classified as poor, presumably making them Medicaid-eligible. More specifically, 40 percent of black children and 15 percent of white children were poor. The year before, 11.4 percent of Florida children had no health insurance at all.

Child death figures for Florida’s children suggest health services for low-income children and families are fundamentally flawed. For example, mortality for African American children, whose families are much more likely to be poor than those of white children, is high. In 2011, out of 1,000 babies born, 11.5 African American babies died in their first year of life; the comparable figure for white babies was 4.8. Similarly, out of 100,000 children from 1 to 14 years of age, 35 black children and 27 white children died in 2011.

Yet well-to-do Floridians, and their children, are far removed from grim realities like these. It appears that, “Florida ranked third (in the nation) in 2011 in a study measuring the gap between the income of the top 1 percent of Floridians and the bottom 99 percent. In Florida, the top 1 percent earned on average 32.2 times as much as the bottom 99 percent.”

Governor Rick Scott and colleagues drawn from Florida’s wealthy minority have operated Florida’s Medicaid program since 2011. A basic assumption would be that as a program serving the public’s health, Florida Medicaid should prioritize thriving and survival for all children. Judge Jordan’s findings suggest that goals for the program are otherwise, or that its administration is incompetent. Gov. Scott is an experienced health care administrator, but what about his priorities?

During Scott’s tenure as CEO of the massive Columbia/HCA health care corporation, the U.S. government convicted 14 of his underlings on charges of fraud. His corporation paid a $1.7 billion fine. The Tampa Bay Times reported that, to avoid incriminating himself, Scott pleaded the Fifth Amendment 75 times during the course of depositions related to the case. He resigned in 1997, spent a few years as a “venture capitalist,” and then turned to politics.

In a financial disclosure statement released at the end of his successful 2014 gubernatorial campaign – his second – Scott reported a 2013 net worth of $132.7 million. Additionally, “three members of the state cabinet … reported a net worth of $10.95 million.” With Scott and his team attending to their personal wealth, the suspicion is that children’s health was never their foremost concern.

Pondering on who is in charge of public health programs for children and how such programs operate has its limitations, however. A larger, more basic, question remains: why are some population groups of children in trouble and others not? A recent United Nations statement epitomizes worldwide epidemiologic analyses over many years. “Children born into poverty,” it said, “are almost twice as likely to die before the age of 5 as those from wealthier families.”

In this sense, Judge Jordon’s epoch ruling on the Florida Medicaid program evokes an oil and water difference between the interests of two social classes. If that is so, then remediation of problems with Florida Medicaid – the cure – rests ultimately on achieving big changes within U.S. society such that all children survive and live in dignity. The health care part of that agenda would entail a universalized health care endeavor or a national health service.

Such ambitious thinking rests on unified struggle by the many, which is not presently in the cards. In the meantime, however, what is to keep health care activists buoyed up by Judge Jordan’s decision from taking incremental, consciousness-raising steps as they look toward health care for us all?

W.T. Whitney Jr. is a retired pediatrician and political journalist living in Maine.

http://www.counterpunch.org/2015/01/29/child-health-and-the-class-divide/

Purchasing insurance across state lines doesn’t work and causes more problems than it can possibly solve

By James Fieseher, M.D.
Concord (N.H.) Monitor, Jan. 29, 2015

In American politics, ideology often supersedes reason. We don’t have to look any further than in the New Hampshire state Legislature.

State Sen. Andy Sanborn, a Bedford Republican, is sponsoring a bill that would allow New Hampshire residents to purchase health insurance across state lines. He argues that giving New Hampshire citizens out-of-state options will increase competition and lower the cost of health insurance. This works for purchasing automobile and life insurance, so why wouldn’t it work for health insurance?

On the surface, this sounds reasonable, but in fact it is an expression of ideology.

When submitting a claim for auto or life insurance, the insurance company writes a check and the consumer (usually) has the option of choosing where to go to consummate the deal. But with health insurance, the insurance company builds the network and determines which hospitals and which providers are available to the consumer. In other words, a New Hampshire citizen may be able to purchase a cheaper health insurance plan in Alabama, but he might have to travel to Alabama to see a doctor or obtain emergency room benefits.

The only state to actually pass legislation that would allow the purchase of out-of-state health insurance, Georgia, found the experiment to be a total failure. No out-of-state company wanted to participate because it didn’t have the network of doctors and hospitals and couldn’t afford to pay out-of-network fees.

But that’s just the tip of the iceberg. Anyone who has ever had to work with a health insurance company is aware of problems that seem to crop up on a regular basis: prior approvals, pre-existing conditions, out-of-network providers and so on. The Affordable Care Act has helped to reduce some of these, but not all and not well. When that happens, the state insurance officials step in to sort things out.

New Hampshire doesn’t have the budget to oversee out-of-state health insurance companies, which means that New Hampshire residents would have to rely on insurance regulators from other states (where they are not taxpayers and have no electoral voice) to address out-of-state health insurance problems. This would eventually result in greater federal involvement in our health care.

All of this overlooks the fact that the cost of insurance premiums is based upon the overall health of the risk pool – those folks who are enrolled in the policy. As the number of members in the risk pool gets larger, premiums decrease as the cost of care for the less healthy is spread out over a greater number of policyholders. Mr. Sanborn may not like to purchase a plan that covers maternity care, but by doing so, his risk pool is larger and the cost of his health premium is reduced.

The problem is that the reverse is also true. If Mr. Sanborn’s bill were to become law and New Hampshire residents were willing to travel out of state for their health care, then the price of health insurance in New Hampshire would increase as the risk pools diminish. Since we are a state with a relatively small population, then even the loss of a few thousand health insurance members would cause a large rise in the cost of insurance premiums – the opposite effect that Mr. Sanborn intended.

During the New Hampshire primary campaign in 1999, George W. Bush proposed the exact same concept Mr. Sanborn is sponsoring. Yet, despite having a Republican Congress for six years, President Bush never carried through with the idea – because he realized it wouldn’t work.

Mr. Sanborn’s bill makes sense only in the abstract world of ideology. In practice, it has been shown to be costly and unworkable in the only place that has ever tried it.

Ironically, there is a much better way of reducing health care costs and simultaneously increasing outcomes and the quality of care that has been successfully “field-tested” over 100 times: a single-payer system. The United States is the only major industrial nation that does not have a single-payer system of health care. We pay three times as much per person for our care, and we don’t even cover all of our tax-paying citizens.

In a recent report published in the online journal BMC Health Services Research, it was calculated that “the U.S. spent a total of $471 billion in medical billing paperwork and insurance-related red tape.” Switching to a single-payer system would save the United States more than $1 trillion every three years! That cost savings includes: longer life expectancy, more preventative care and total coverage for all citizens. Single-payer is not ideology, it is a system that works in Canada, France, the United Kingdom, Japan, Germany, Sweden, Norway, Switzerland, etc. – you get the idea.

Up until now, when our legislators start to think about health care, they begin by talking with health insurance companies. Maybe it’s time to start with the needs of New Hampshire citizens and then look at various health care systems to decide which system of care best fits our needs. We need to put ideology and special interests aside if we’re going to find a health care solution that is affordable and works.

Dr. James Fieseher is a primary care physician and lives in Dover.

http://www.concordmonitor.com/home/15417979-95/my-turn

Barriers to More Healthcare Reform Are Numerous

Apathy and fear are among the biggest stumbling blocks, experts say

By Joyce Frieden
MedPage Today, Jan. 28, 2015

WASHINGTON — The lack of greater movement toward universal healthcare coverage — especially a single-payer system — in the U.S. can be boiled down to four letters: AFIG, according to Philip Caper, MD.

The “A” stands for Apathy, Caper said Wednesday during a briefing on barriers to healthcare reform sponsored by the National Academy of Social Insurance (NASI). Caper is with Maine AllCare, an organization devoted to getting universal healthcare in Maine.

The attitude of many people is “‘I’ve got mine; why should I worry about anyone else?'” said Caper, a founding member of NASI, whose mission is to increase public understanding of how social insurance contributes to economic security.

“Or think of young invincibles, who think it’s worth the risk to go uncovered,” continued Caper, who was speaking by phone from Maine. “Perhaps apathy is the result of our emphasis on personal liberty and personal responsibility.”

The “F” stands for fear, Caper continued — “fear of change; the fear of losing coverage they already have; or the fear of loss of income or profitability” on the part of those working in the healthcare industry.

“I” is for ignorance, he said, making it clear that he was not equating ignorance with stupidity, rather a lack of information and understanding. “Most Americans don’t understand the healthcare system and don’t understand there are better ways of financing this,” Caper said.

“I definitely include doctors in this group,” he added. “I can tell you from personal experience that it’s almost impossible to get health policy into the medical school curriculum, where the focus is rightly on clinical medicine.”

And finally, there is the “G” — for greed. “This may seem harsh [but] the widely accepted view of healthcare as just another business is uniquely American, at least in degree,” he said. “I have heard some people say the healthcare system is becoming a wealth extraction machine. This view is reinforced by news stories of opportunistic pricing of drugs for chronic diseases such as hepatitis.”

Satisfied With the Status Quo

Another barrier to changing the way health insurance is delivered comes from the fact that many people are satisfied with their employer-provided health insurance, said Laurence Seidman, PhD, professor of economics at the University of Delaware in Newark.

“But they don’t seem to realize two things,” he continued. “First, what would happen if they lose their job? And second, [they don’t realize] that the rising premiums for medical care that their employers are paying is a key reason why their wage and salary growth has been so low.”

Many people also believe that using the private sector to provide services is better than using the public sector, “but it’s not better for things like national defense or health insurance,” he continued. “Many people also believe prices should be set without interference by government. I agree that’s true for most goods and services, but medical care is different [because] consumers can’t shop around; the best mechanism is for the government to represent consumers and negotiate prices for medical care with doctors, hospitals, and drug companies.”

Merton Bernstein, emeritus professor of law at Washington University in St. Louis, pointed out that most of the crowd at the meeting consisted of older people. “Millennials are not here, and that’s the problem,” he said. “How do we reach them to make them understand their stake in universal healthcare that’s affordable and comprehensive?”

Mischaracterization of the issues is another barrier to reform, Bernstein said. “One [mischaracterization] is that Medicare is not adaptable to the entire population because one size doesn’t fit all. People have to be told what in fact Medicare does — it is a massive program that’s the basis of the well-being of tens of millions of people, and it’s enormously popular, and yet it’s treated by many as if it’s an impediment to appropriate care.”

Suspicion of Government

Marcia Angell, MD, of Harvard Medical School in Boston, noted that “We distribute healthcare like a market economy, according to ability to pay, and not like a social service, which would be distributed according to medical need. But the people who most need healthcare are precisely those least able to pay.”

In terms of barriers, “much of the public often opposes the health reform law and [people] claim it expresses their antipathy toward big government. I believe that’s largely a canard promulgated by [the healthcare industry] and much of the media,” said Angell, who is also a past editor of the New England Journal of Medicine. “The issue for the public, I suspect, is not the size of government but the feeling that it doesn’t often work for their benefit and instead serves special interests.”

“Americans have no problems with programs [they consider beneficial] but are very suspicious of the private healthcare industry, which has the largest lobby in Washington,” she added. “So the major barrier … is the ‘medical industrial complex,’ as my late husband, Arnold Relman, pointed out in the New England Journal of Medicine 35 years ago.”

Joseph White, PhD, director of the Center for Policy Studies at Case Western Reserve University in Cleveland, said that three things needed for a policy to work were “technical capacity, institutional capacity, and political capacity … Most of the barriers to [single-payer] are political barriers; most barriers to other kinds of reform are technical barriers.”

The only way to overcome the political barriers would be to get businesses on board and make them realize that single-payer healthcare would be advantageous to them because they wouldn’t have to provide health benefits any more, “but business finds it easier to cut benefits,” White said. “I think it’s fair to say that the people who would be most necessary to cooperate, to overcome the power of the medical industrial complex, are much more interested right now in cutting benefits.”

Joe Antos, PhD, scholar in healthcare and retirement policy at the American Enterprise Institute, a right-leaning think tank here, said it is not clear what kind of reform people want, “for lots of reasons. One of the reasons is, not everybody’s going to agree to everything, so you have to decide who you want to listen to. So I think it is a good question … what is it that people prefer? The partial answer is, they just want something that works.”

Donald Berwick, MD, former administrator of the Centers for Medicare and Medicaid Services (CMS) in the Obama administration, said that after he left the agency and decided to run for governor of Massachusetts, “I did not enter the race as single-payer advocate, but my mind got changed very early” as he looked at the state’s budget and saw the increasing amounts of money going to healthcare. During his tenure at CMS, Berwick was criticized by Republicans for stating his admiration of the British healthcare system, which they said indicated support of rationing healthcare.

When he was campaigning, Berwick said he encountered a lot of confusion about the issue. “The first was confusion between the consolidation of payment in single-payer, and socialized medicine, where the government takes over delivery of care. People thought single-payer meant that the government becomes the provider of healthcare.”

In addition, the rising cost of healthcare was kind of buried, Berwick said. “People sort of know their own contributions to healthcare are going up, but when they actually do the subjective math, they can see the problem.”

Joyce Frieden is news editor at MedPage Today.

http://www.medpagetoday.com/Washington-Watch/Reform/49764

Government supports rotten teeth for patients in poverty

Indiana Will Allow Entry to Medicaid for a Price

By Abby Goodnough
The New York Times, January 27, 2015

After a lengthy back-and-forth, the Obama administration has agreed to let Gov. Mike Pence of Indiana, a Republican, expand Medicaid on his own terms, including some that have not been allowed before under federal rules.

The plan will extend coverage to an additional 350,000 Indiana residents with incomes of up to 138 percent of the federal poverty level — about $16,100 for a single person and $27,310 for a family of three — starting next month.

Mr. Pence, like several Republican governors before him, insisted on adding a conservative twist to the expansion, mostly by requiring beneficiaries to pay something toward their coverage. Under his plan, most people will have to pay monthly premiums equaling 2 percent of their household income — between about $3 and $25 a month for a single childless adult — for coverage that includes dental and vision benefits.

At the Obama administration’s insistence, people who earn less than the poverty level will not have to pay premiums. But if they do not, their coverage will be downgraded to exclude dental and vision benefits. And they will owe co-payments for medical care, including $4 for a doctor’s visit and $75 for a hospitalization.

In another unusual concession, the Obama administration will let Indiana lock some people out of coverage for six months if they stop paying monthly premiums.

Joan Alker, executive director of the Georgetown University Center for Children and Families, called the Indiana plan “enormously complicated” and questioned the fairness of withholding dental and vision coverage from those who cannot come up with premium payments.

“It’s just common sense that when people take greater ownership of their health care,” Mr. Pence said, “they make better choices.”

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Gov. Pence gets federal OK for Medicaid alternative

By Shari Rudavsky and Maureen Groppe
Indystar, January 27, 2015

Those who are eligible for the plan already live at the poverty level, said Timothy Jost, a law professor at Washington and Lee University and a healthcare reform expert. People who by definition are already having trouble covering basic costs such as food and rent will struggle to make an addition payment. Instead, they may opt not to participate in the program or avoid getting care.

“The question is how far is CMS willing to go in accommodating governors or states that want to work their own policy agenda into the Medicaid program,” Jost said. “This is pretty much pushing the limits of how far they should go if it’s not beyond it.”

Throughout the months of back and forth with federal health officials, Pence had said he was not willing to compromise on the personal responsibility piece.

http://www.indystar.com/story/news/politics/2015/01/27/gov-pence-gets-federal-ok-medicaid-alternative/22396503/

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Comment:

By Don McCanne, MD

This is insane! In an age when we are supposed to be a society that cares enough to see that all of us receive the health care that we need, we still have amongst us those who insist that people with no assets, often homeless, frequently missing meals, are supposed to exercise “personal responsibility” by paying funds that they don’t have as a condition for receiving much needed medical care.

And, oh, if they don’t come up with those funds, let their teeth rot out. That will show them! And sentence some of them to six months without any medical care at all.

We have covered extensively the irrationality and inhumanity of the consumer-directed, moral hazard-based policies that erect financial barriers to care for the four-fifths of us with minimal or modest resources. But this exposes the colors of these “skin in the game “ advocates. What kind go people are we that we elect individuals like this to take charge of our federal and state governments. What is government all about? This!? It can’t be. Tell me it isn’t.

Single payer plan can aid tax cut

By Darius Shahinfar
Times Union (Albany, N.Y.), Jan. 28, 2015

As city treasurer in Albany, I am constantly reminded by our taxpayers that our property taxes need to be cut.

Mayor Kathy Sheehan is doing her part by budgeting responsibly, improving operations and actually cutting taxes.

But taxpayers need a lot more help. Legislative hearings have been held across the state regarding the New York Health Care Act, a variation of the federal “Medicare for All” bill (HR 676), which would bring Medicare-style, single-payer health care funding to the state. There is no stronger measure New York could take to cut our property taxes than to pass this bill into law. Hidden health care costs are present in every product, good or service in our economy. For example, health care adds an estimated $2,000 to $4,000 to the price of every car built in the United States.

For taxpayers, we have an enormous hidden health care “tax” in our property taxes. And the truth is this hidden tax is bleeding property taxpayers dry. In Albany, 96 percent of our tax bills are composed of three, separate bills from the city, the county and the school district. Astonishingly, health care costs are nearly half of our city tax bill, a quarter of our school district’s tax bill and more than the entire amount in a county tax bill.

This means that Albany homeowners are paying 38 percent of our combined property tax bills on health care costs. For the owner of a $150,000 home, this is a hidden health care tax of $2,100 within the property tax bills.

Using the models of the pending state and federal legislation, and accounting for local variables, it is my estimate that city taxpayers would conservatively save 28 percent of their entire tax bills in property taxes with a single-payer system. That same homeowner of a $150,000 home would save about $1,600 per year.

And, just to be clear, every taxpayer in every municipality in New York would see similar, massive savings. In fact, our wealthier suburbs would receive the greatest savings, because the more valuable the taxpayer’s property, the more his or her taxes are cut. Additionally, businesses that provide health care would also see dramatic cost savings, leading to opportunities for lower prices and greater profits.

Furthermore, savings for Albany city taxpayers would be two to three times larger if the state repaired revenue deficits caused by: The outdated AIM formula that provides one-half to one-sixth the per capita aid to Albany that it provides to Buffalo, Rochester, Syracuse, Yonkers and Utica; the outdated School Aid formulas; and the 60 percent of our entire property value that is tax-exempt, 33 percent of which is owned by the state.

No matter where you live in New York, if you want to see dramatically lower property taxes, tell our state and federal representatives to pass single-payer health care into law. Now.

The author is Albany city treasurer. He recently testified at state hearings in support of the New York Health Care Act.

http://www.timesunion.com/tuplus-opinion/article/Single-payer-plan-can-aid-tax-cut-6043890.php

Panel describes pros and cons of health care system

By Rohma Siddiqui
WFFT TV (Fox affiliate, Fort Wayne, Ind.), Jan. 26, 2015

Open enrollment for Obamacare comes to an end February 15 and a panel of local experts with Theater for Ideas weighed in on the pros and cons of our healthcare system. 

There were strong opinions on both sides but the experts stressed the importance of healthcare, and consumers educating themselves on Obamacare before choosing their plans.

“We are the only western democracy that does not have some form of government sponsored healthcare system for its citizens. We are the only one,” says Edith Kenna who is a social worker with Hoosiers for Common Sense Health Plan.

Kenna feels that there are pros to Obamacare and considers it a start towards the right direction.

“I think it’s a good start at change of healthcare but we’re not there yet until we get a single-payer system. A single-payer system would be private doctors, physicians. The government would administer the funds. It is not the government owning my practice, the doctor’s practice, but it is the management of the fee.”

Kenna says it’s good that people now have something instead of nothing but thinks regardless of its pros, it is in fact very complicated even for someone of her background. She mentions that Obamacare is over 1,500 pages long.

“One of my real concerns about Obamacare is that [people] are under-insured. They’re forced to pay premiums, some of the $500 – $600 a month for inadequate insurance. It doesn’t cover their need. The co-pays are too high and the premiums are too high.”

Dr. Jon Walker is a local physician who spoke at the panel. He says one of the best things about Obamacare is the ability to be accepted regardless of pre-existing conditions, but there are still improvements to be made. Especially since profits for insurance companies have been going higher and higher since Obamacare.

“I think there’s one really big option that’s been kept off the table and that is expanding Medicare, raising everybody’s taxes a little bit starting off with some basic Medicare coverage,” Walker said. “I think there’s a lot of evidence from around the world that it’s something we should at least be able to talk about but we don’t seem to be able to do that.”

“It’s kind of like going to the store and that store taking every single currency in the world and have the value of that currency change every minute and trying to figure out what you’re going to buy.”

Walker says the system definitely needs more transparencies and that it would be nice to know prices to be able to compare and shop for. Not just insurance but procedures and medication as well, which is currently not possible for the consumer.

Now for those who choose to opt out of Obamacare, will face a penalty fee. Currently, that fee is 2 percent of your annual income. Only those who earn more than $10,000 annually are responsible for paying the fee.

http://www.fortwaynehomepage.net/story/d/story/open-enrollment-for-obamacare-ends-february-15th/23330/H8OoKqdBUEWh0eA8CkK5AA

PNHP note: This article was originally published under the headline, “Open Enrollment for Obamacare Ends February 15th.” The version of the story at the link contains video footage of Ms. Kenna and Dr. Walker, among others.

HHS creating policy out of rhetoric devoid of science

Setting Value-Based Payment Goals — HHS Efforts to Improve U.S. Health Care

By Sylvia M. Burwell, U.S. Secretary of Health and Human Services
The New England Journal of Medicine, January 26, 2015

Now that the Affordable Care Act (ACA) has expanded health care coverage and made it affordable to many more Americans, we have the opportunity to shape the way care is delivered and improve the quality of care systemwide, while helping to reduce the growth of health care costs. Many efforts have already been initiated on these fronts, leveraging the ACA’s new tools. The Department of Health and Human Services (HHS) now intends to focus its energies on augmenting reform in three important and interdependent ways: using incentives to motivate higher-value care, by increasingly tying payment to value through alternative payment models; changing the way care is delivered through greater teamwork and integration, more effective coordination of providers across settings, and greater attention by providers to population health; and harnessing the power of information to improve care for patients.

As we work to build a health care system that delivers better care, that is smarter about how dollars are spent, and that makes people healthier, we are identifying metrics for managing and tracking our progress. A majority of Medicare fee-for-service payments already have a link to quality or value. Our goal is to have 85% of all Medicare fee-for-service payments tied to quality or value by 2016, and 90% by 2018. Perhaps even more important, our target is to have 30% of Medicare payments tied to quality or value through alternative payment models by the end of 2016, and 50% of payments by the end of 2018. Alternative payment models include accountable care organizations (ACOs) and bundled-payment arrangements under which health care providers are accountable for the quality and cost of the care they deliver to patients. This is the first time in the history of the program that explicit goals for alternative payment models and value-based payments have been set for Medicare. Changes assessed by these metrics will mark our progress in the near term, and we are engaging state Medicaid programs and private payers in efforts to make further progress toward value-based payment throughout the health care system.

Although we have much to celebrate regarding increased access and quality and reduced cost growth, much of the hard work of improving our health care system lies ahead of us.

http://www.nejm.org/doi/full/10.1056/NEJMp1500445

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Early Evidence On Medicare ACOs And Next Steps For The Medicare ACO Program (Updated)

By Mark McClellan, S. Lawrence Kocot, and Ross White
Health Affairs Blog, January 22, 2015

On December 1, CMS released a Notice of Proposed Rulemaking (NPRM) for the Medicare Shared Savings Program (MSSP), which requests feedback for changes CMS is considering for the Medicare accountable care organization (ACO) programs in 2016 and beyond. The proposal suggests significant potential alterations to the program, many of which we recently reviewed, that would address major issues that ACOs and others have raised: uncertainty and inexperience at transitioning to increasing levels of risk, lack of timely and accurate data, changes in attributed patient populations from year-to-year, and financial benchmarks that fail to account for regional variations and continue to reward high ACO performance over time.

Ideally, big changes in key features in a major program like the MSSP would be based on extensive empirical evidence on what determines success in the program. Unfortunately, only limited evidence, including case studies and some comparative data, is available on the determinants of success for Medicare ACOs, and thus on the MSSP.

http://healthaffairs.org/blog/2015/01/22/early-evidence-on-medicare-acos-and-next-steps-for-the-medicare-aco-program/

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Unpacking The Medicare Shared Savings Proposed Rule: Geography And Policy

By Scott Heiser, Carrie Colla, and Elliott Fisher
Health Affairs Blog, January 22, 2015

The Centers for Medicare and Medicaid Services (CMS) recently announced a Notice of Proposed Rulemaking (NPRM) for Medicare Shared Savings Program (MSSP) Accountable Care Organizations (ACOs).

Of the 220 ACOs in the program that participated in the first performance year, 53 earned shared savings, 52 saved money but not enough to meet the required “minimum savings rates,” and the other 115 did not accrue savings (spending on patients assigned to the ACO was greater than projected).

Depending on one’s perspective, the early results of the MSSP are either promising or disappointing. On the one hand, nearly a quarter of qualifying ACOs achieved shared savings in the first year of performance; on the other, three-quarters either did not lower spending or did so but failed to exceed the minimum savings rate.

Improvements in the benchmarking formula, the risk adjustment methodology, and perhaps additional incentives to sustain high performance over a longer period are worth exploring.

http://healthaffairs.org/blog/2015/01/22/unpacking-the-medicare-shared-savings-proposed-rule-geography-and-policy/

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Measuring Success in Health Care Value-Based Purchasing Programs

By Cheryl L. Damberg, Melony E. Sorbero, Susan L. Lovejoy Grant Martsolf, Laura Raaen, Daniel Mandel
RAND Corporation

Value-based purchasing (VBP) refers to a broad set of performance-based payment strategies that link financial incentives to providers’ performance on a set of defined measures in an effort to achieve better value by driving improvements in quality and slowing the growth in health care spending. Policymakers are grappling with many policy decisions about how best to design and implement VBP programs so that they are successful in achieving stated goals.

Although the past decade has witnessed a fair amount of experimentation with performance- based payment models, primarily P4P programs, we still know very little about how best to design and implement VBP programs to achieve stated goals and what constitutes a successful program.

http://www.rand.org/content/dam/rand/pubs/research_reports/RR300/RR306/RAND_RR306.pdf

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Medicare’s payment reform push draws praise and fears

By Melanie Evans and Paul Demko
Modern Healthcare, January 26, 2015

“I think we can all agree that moving away from fee-for-service and moving toward more value-based payment is a really good idea,” said Dr. Ashish Jha, a health policy professor at Harvard University who studies healthcare quality. “The challenge is, how do you measure value? If you don’t do that well, then these models can end up being not only not all that helpful, but even hurtful.”

With weak incentives, Medicare’s shift to alternative contracts could amount to little actual change, said Mark Pauly, an economist and health policy professor at the University of Pennsylvania. “It’s not a sledgehammer. If the penalty or reward is relatively modest, then a cynic could say what’s the big deal?”

http://www.modernhealthcare.com/article/20150126/NEWS/301269813/medicares-payment-reform-push-draws-praise-and-fears

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Comment:

By Don McCanne, MD

Since the beginning of the reform process we have been inundated with rhetoric about how health reform is going to improve quality and slow spending, but the mechanisms proposed were more “wish lists” than being proven mechanisms based on sound policy science. Now we have an announcement from HHS Secretary Sylvia Burwell that, even though we have not progressed much beyond the rhetoric, these mechanisms will be put into place by the end of 2018.

An extensive RAND report confirms that we still don’t know how to do this. Advocates such as Elliott Fisher and Mark McClellan report that, although we need extensive empirical evidence, only limited evidence is available. Harvard policy professor Ashish Jha says that “these models can end up being not only not all that helpful, but even hurtful.” And University of Pennsylvania policy professor Mark Pauly, of “moral hazard” fame, even says “what’s the big deal?”

Primum non nocere…

… and, second, let’s put into place policies that really would benefit everyone – a single payer national health program, aka an improved Medicare for all.

Prescribing an epiphany for Ron Pollack and Henry Aaron

Costs derail Vermont’s dream of a single-payer health plan

By Jay Fitzgerald
The Boston Globe, January 25, 2015

For decades, liberal activists yearned for a European-style, single-payer health system that they argued would lead to more affordable, efficient, and comprehensive medical coverage for all citizens. When Vermont four years ago enacted a landmark bill to establish the nation’s first single-payer health care system, they saw their long-sought dream about to be fulfilled.

But reality hit last month.

(Henry Aaron)

“The idea of single-payer, or a Medicare-for-all type program, has always been a cherished dream for many in the Democratic Party,” said Henry J. Aaron, a senior fellow at the Brookings Institution, a liberal-leaning Washington think tank. “In truth, there had never been a hard, developed plan to implement such a dream. In Vermont, they finally developed a plan, and look what happened.”

In Europe, many countries built their universal health care systems from scratch, with some starting early last century when most citizens had no medical coverage and any services provided by governments were welcome, the Brooking Institution’s Aaron said. That allowed those countries to slowly build and expand health care systems over decades.

But in the United States private insurance arrangements between employees and employers have expanded and matured over the decades, with many people with insurance expecting a high level of medical service. So, switching to a single-payer system would need to meet those higher expectations — and higher costs — all at once, Aaron said.

“It’s easier to build from scratch than when a system is already up and running,” he said. “We could have maybe created a single-payer system 60 or so years ago, when insurance wasn’t as complete and widespread. But it would be very disruptive and costly today.”

(Ron Pollack)

Ron Pollack, executive director of Families USA, a national organization representing health care consumers, said he has long believed in the benefits of a single-payer system. But he also remembered his talks with Kennedy. The late senator, Pollack said, expressed regrets he didn’t earlier embrace insurance-based universal care, rather than holding out for a single-payer system that never materialized.

Pollack said activists might be better off pushing to improve provisions of the Affordable Care Act. “It may change in time and single-payer might become reality,” Pollack said. “But the political reality and the fiscal realities make it a very tough sell.”

http://www.bostonglobe.com/business/2015/01/25/costs-derail-vermont-single-payer-health-plan/VTAEZFGpWvTen0QFahW0pO/story.html

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Comment:

By Don McCanne, MD

I have greatly admired Ron Pollack and Henry Aaron through the decades. They share with us our desire to expand health care justice to all. So why do I feel tormented when I hear comments from them?

Perhaps it’s because we chose different paths at the intersection of policy and politics. Ron Pollack says that he has long believed in the benefits of a single-payer system. Henry Aaron says that we could have created a single payer system sixty or so years ago. Yet Pollack says, “the political reality and the fiscal realities make it a very tough sell.” And Aaron says, “it would be very disruptive and costly today.”

Early on, Pollack decided to join forces with the neoliberal Democrats in supporting reform that would gain the support of the insurance and pharmaceutical industries – a political path with realistic potential. Aaron’s views have been more perplexing, such as when he attempted to refute a meticulous landmark study on the profound administrative waste in health care by using back-of-the-envelope numbers. We were not alone in our amazement when another very prominent health care economist said that he didn’t understand why Aaron did that.

At any rate, they both clearly understand the policy superiority of single payer. More importantly, they understand what that means when it comes to reducing suffering and financial hardship – fundamental principles in health care justice.

It wasn’t the policies that needed to be changed. It was the politics. Maybe someday Aaron and Pollack, and the multitude of others who bailed on single payer, will have an epiphany and join the effort to change the politics. How much more suffering and hardship do they have to witness before they are ready? We cannot change the errors of the past, but we can do the right thing going forward.

Plain Dealer op-ed on single-payer health plans was inaccurate

By H.J. Bud McTaggart
Plain Dealer (Cleveland), Letters, Jan. 20, 2015

Editors of other publications should proofread Op-Eds for accuracy before they are published in The Plain Dealer.

“Vermont’s example a telling lesson in fate of single-payer health plans” by Megan McArdle (Forum, Dec. 26) has one small problem: Vermont’s legislation was not a single-payer plan.

The Vermont bill would have allowed private insurers to continue to operate in the state alongside many other types of plans – e.g. employer self-insured plans, private Medicare Advantage plans, Medicare, Medicaid, the federal employee private plans, etc. – in short, an array of multiple payers.

By retaining a multi-payer model of financing care, the Vermont plan couldn’t achieve the administrative cost savings of a streamlined single-payer model. It also couldn’t muster the bargaining clout of a would-be sole buyer of medical supplies, for example.

Lawmakers acknowledged this reality when they stripped the words “single payer” from the bill. In the end, the Vermont plan was much closer to the Affordable Care Act than an improved-Medicare-for-All model.

Many nations have shown us single-payer systems provide truly universal access to high-quality, effective care, with no co-pays or deductibles, for much less money that we’re spending now.

Vermont shows us  as long as you retain multiple payers – particularly private insurance companies – you can’t get the savings you need to equitably cover everyone at lower cost.

H.J. Bud McTaggart lives in Olmsted Township.

http://blog.cleveland.com/letters/2015/01/op_eds_inaccurate_letter_to_th.html

Gallup – Health care remains a top financial burden for American families

Americans See Healthcare, Low Wages as Top Financial Problems

By Art Swift
Gallup, January 21, 2015

Healthcare costs and lack of money or low wages rank as the most important financial problems facing American families, each mentioned by 14% of U.S. adults.

Gallup has been asking Americans about the most important financial problem facing their family in an open-ended format for the past 10 years. Healthcare this year has returned to the top of the list for the first time since early 2010, when the Affordable Care Act, or “Obamacare,” was signed into law. Still, Americans viewed it as an even bigger financial problem in 2007, when a range of 16% to 19% said it was most important.

For Americans earning $75,000 or more a year, retirement savings, college expenses and healthcare costs rank as the most important financial problems. Among lower-income Americans, retirement savings and college expenses are less important. Healthcare costs, however, have double-digit-percentage support across the board.

Bottom Line

The American economy continues to recover. With Gallup’s Economic Confidence Index in positive territory for the first time since the Great Recession, and with President Barack Obama stating that the U.S. last year had its best year for job growth since 1999, certain financial problems have receded from the nation’s memory, while others have persisted in the forefront. Americans have consistently cited healthcare, a topic of fierce debate this decade, as one of the most important financial problems, and it remains so.

http://www.gallup.com/poll/181217/americans-healthcare-low-wages-top-financial-problems.aspx

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Comment:

By Don McCanne, MD

The recent slowing in the rate of increases in health care costs has been good news for those supervising budgets of government health programs and for employers providing employee health benefits, but how has it impacted patients? This new Gallup poll shows that health care costs remain one of the most important financial problems facing American families. The Affordable Care Act has not provided the level of financial relief from medical bills that Americans want and need.

Under the current financing model, there is virtually no prospect for future relief. In fact, the trend of placing an ever greater financial burden on “health care consumers” will likely compound medical debt problems for patients. We need a new model. We need a single payer national health program.

Oregon lawmaker promotes public funding for healthcare study

A private study of the best way to provide universal healthcare in Oregon has foundered for lack of funds. The study was sanctioned in 2013 to rely on private funding; with little materializing, legislators such as Sen. Michael Dembrow and Rep. Barbara Smith Warner are asking for an extended deadline and public funding.

By Chris Gray
The Lund Report, Jan. 21, 2015

Two years ago, the Legislature authorized an examination of universal healthcare, but asked the private sector to pick up the tab. That effort foundered when donors — and dollars — failed to materialize.

This year, legislators who want to know the best way to expand healthcare access to everyone in Oregon may be ready to fund a study that would examine the options, Rep. Barbara Smith Warner, D-Portland, told the Portland City Club on Monday night.  

“We got it through last time without funding,” Smith Warner said. “We’re going to attempt to get some public financial assistance.”

In addition to providing a relatively small amount of public funding, House Bill 2828 will extend the deadline to raise funds and complete the work, since the original legislation called for the mothballed study to be finished this past November.

Dr. Sam Metz, who led efforts to raise private funds to pay for the study, told The Lund Report that the desired level of state funding had not been worked out, but proponents were shooting for about $100,000, which is roughly half what the study would cost. If the state doesn’t pay the full amount, Metz said he believed Oregon’s down payment could spur private donations this time.

Sen. Michael Dembrow, D-Portland, authored the 2013 bill that authorized the universal healthcare study, and he crafted the legislation to examine four approaches: single-payer; a full roll out of the Affordable Care Act with the Cover Oregon exchange, including a Basic Health Plan option for low-income families ineligible for Medicaid; a public option sold on the exchange; and a system offering families a private insurance plan with just the essential health benefits.

The study could help solve a hole that has plagued Vermont’s faltered attempt at state-run universal health care, by providing the financing scheme and means of funding such a system.

Metz said he believes that, compared to private insurance, the cost of universal healthcare would likely be cost-neutral or cheaper than what individuals and most businesses are paying now.

“The major obstacle is not moral, it’s not political,” Metz said. “It’s coming up with a financing plan that they believe will work.”

Though Smith Warner led Monday’s City Club discussion, she was not actually around when the Legislature initiated the study; she was appointed in late 2013 to fill the Northeast Portland House seat of now-Sen. Dembrow, the Legislature’s champion of single-payer health insurance. Dembrow passed the baton to Smith Warner on the study bill, but with or without the study, he will once again be introducing legislation to bring single-payer to Oregon with a separate bill that stands little chance of passing.

Her landslide election to a seat she was first appointed to fill has seemed to have given Smith Warner a growing confidence on the stump, and she told the friendly crowd at the City Club that she had just won the support that day for the study bill from Rep. Betty Komp, D-Woodburn.

The Komp endorsement could very well be the coup that pushes House Bill 2828 through the Legislature. The Woodburn legislator and retired educator is known as a no-nonsense veteran with considerable behind-the-scenes clout within her caucus. Komp holds a key position on the budget committee and previously served as House Speaker Pro Tempore.

Dembrow’s predecessor bill from 2013 — House Bill 3260 — attracted support from nine Republicans, including Sen. Jeff Kruse, R-Roseburg, partly because Dembrow drafted the bill to allow for an open-ended, comprehensive study that asks researchers to compare multiple possibilities, rather than to simply look into how a single-payer system would work in Oregon.

One member of the audience, Dr. Mike Huntington, said that he wanted that big-tent approach continued, with messages tailored to people of different political persuasions. Single-payer supporters often speak very dismissively of the reforms in the Affordable Care Act, which he said may be unwise. “I think we have to be very careful that we don’t over-emphasize the negatives of the Affordable Care Act,” he said. “You’ve got to know your audience.”

One Democrat who opposed HB 3260, Rep. Brent Barton of Gladstone, told The Lund Report he didn’t like that it was privately funded, which may mean he’ll come on board for the 2015 bill.

Metz noted that while the United States is the only industrialized nation without a guarantee of universal healthcare, each country does it differently, providing many different models for a workable system that the study would analyze.

“It’s not all socialized medicine. They all do it differently,” he said. “Some have private insurance companies, though they little resemble the ones we have here.”

Chris can be reached at chris@thelundreport.org.

https://www.thelundreport.org/content/smith-warner-promotes-public-funding-healthcare-study

PNHP note: This story was originally published with the headline, “Smith Warner Promotes Public Funding for Healthcare Study.”

New poll on single payer and a Medicare buy-in

Poll of Likely 2016 Voters
Progressive Change Institute, Conducted by GBA Strategies, January 9-15, 2015

SINGLE PAYER HEALTHCARE VIA MEDICARE

“Enact a national health plan in which all Americans would get their insurance through an expanded, universal form of Medicare.”

51%  Support
36%  Oppose
12%  Neutral

Percent supporting by party

79%  Democrat
23%  Republican
45%  Independent

MEDICARE BUY-IN FOR ALL

“Give all Americans the choice of buying health insurance through Medicare or private insurers, which would provide competition for insurance companies and more options for consumers.”

71%  Support
13%  Oppose
14%  Neutral

Percent supporting by party

77%  Democrat
63%  Republican
71%  Independent

https://s3.amazonaws.com/s3.boldprogressives.org/images/Big_Ideas-Polling_PDF-1.pdf

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Comment:

By Don McCanne, MD

This poll shows that the nation’s attitude towards single payer remains essentially unchanged. About four-fifths of Democrats support single payer, three-fifths of Republicans are opposed, and Independents remain evenly split. But what about the attitude towards the “public option” – allowing all Americans the choice of purchasing Medicare instead of private insurance?

Support for the option of a Medicare buy-in is strong across the political spectrum. What can we make of this?

The debate in Congress during the reform process was highly partisan, the public option having been defeated by the defection of just one senator – Joseph Lieberman. The support that we now see amongst Republican voters is probably genuine. The opposition of the Republican members of Congress at that time was probably more related to the decision to defeat the Affordable Care Act (ACA) regardless of any benefits in it, just to “make Obama a one-term president.”

If the Republicans in Congress can forget about their prior opposition and decide that they want to move forward with constructive policies, those who want changes in Medicare may decide that placing it in competition with private insurance plans may bring market concepts to the traditional Medicare program. They can conveniently ignore the fact that the current market experiment with private Medicare Advantage plans has been unsuccessful in providing comparable benefits at a lower cost.

The Democrats in Congress are likely to support a renewed effort to enact a public option, especially since many still regret that it was not included in ACA.

We have to keep in mind that the insurance industry was successful in changing the public option from a Medicare plan to a public plan that had most of the unfavorable features of private health plans along with restrictions on how it could compete with private plans. This was to prevent it from having an “unfair advantage” in the marketplace – by giving the private plans an unfair advantage over the public option.

During the implementation of ACA we have seen that the private insurers still control the puppet strings. Should the political environment become more favorable for a public option, we can be sure that the insurance industry will once again write the legislation, creating a flawed public option that will surely invoke the wrath of those enrolling in the program, “proving” once again the meme that “the government can’t do anything right.”

These comments bring back memories of how the reform debate was hijacked by histrionics over the public option, which played into the hands of the insurance industry. The debate should have been over single payer, but remember we were emphatically and ungraciously denied a seat at the table from very early on in the process (back when the Democratic strategists in control wanted us to sell “CHOICE” to the public – choice of private health plans – and single payer was banned from the strategy sessions).

Little attention was given to the fact that adding another option – the public option – would still leave in place our inefficient, costly and highly dysfunctional system. We would have gained virtually none of the other benefits of single payer. And that would still be true if we abandon our quest for single payer and head off towards the Medicare buy-in. We would still have an outrageously expensive system with profound administrative waste, and intolerable inequities in affordability and access.

At least more Democrats favor single payer (79%) than favor the Medicare buy-in (71%). We need to start tailoring our message to appeal to the Republicans and Independents as well.