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8 facts that explain what’s wrong with American health care

8 facts that explain what’s wrong with American health care

By Sarah Kliff
Vox, September 2, 2014

1) Americans pay way, way, way more for health care than anyone else

Health care in the United States is expensive. Insanely, outlandishly expensive.

We spend $2.8 trillion on healthcare annually. That works out to about one-sixth of the total economy and more than $8,500 per person — and way more than any other country.

If the health-care system were to break off from the United States and become its own economy, it would be the fifth-largest in the world. “It would be bigger than the United Kingdom or France and only behind the United States, China, Japan and Germany,” says David Blumenthal, executive director of the non-profit Commonwealth Fund.

Or here’s another way to put it in its (insane) perspective: The US, which has a mostly private health-care system, manages to spend more on its public health-care system than countries where the health-care system is almost entirely public. America’s government spends more, as a percentage of the economy, on public health care than Canada, the United Kingdom, Japan or Australia. And then it spends even more than that on private health care.

The reason that we spend so much money isn’t because we go to the doctor a ton. On average, Americans actually see the doctor less than people in other countries.

The reason that American health care is expensive is all about the price: when we go to the doctor, it costs more than when, say, someone in Canada goes to the doctor.

Part of this is about the price per unit of health care in the United States. From prescription drugs to imaging scans, nearly everything costs more when it’s prescribed in America. Take the heartburn medication Nexium: the exact same medication costs $215 here and $23 in the Netherlands.

Most other countries have some form of price controls; the government negotiates with drug companies and device makers for lower prices, and the government has the power to win those negotiations. The United States doesn’t do that. It leaves the negotiations up to individual insurers. And they tend to lose.

Defenders of the American system argue that price controls stifle innovation. Many say that our higher spending creates financial incentives for drug companies to come up with wonderful new drugs. And they’re probably right. But that means we’re paying higher prices to subsidize drugs for the rest of the world.

There are more nuanced ways that our health-care prices are more expensive, too. Harvard University’s David Cutler points out that we have much higher administrative costs than most other countries — and those costs get tacked onto the bill when we go to the doctor. The average American doctor spends All those extra billing specialists’ salaries have to get paid somehow — and that gets worked into our prices.

Lastly, American hospitals tend to throw more technology at health problems — a heart attack, for example, is treated with more scans and tests in America than elsewhere, and that also drives up the price of going to the doctor in the United States.

The net price of a heart attack in the United States, then, is more expensive because of the unit price of each service delivered, the more intense treatment and the additional administrative costs of processing the ultimate insurance claim.

2) We pay doctors when they provide lots of health care, not when they provide good health care

The best way for a doctor to make money in the United States right now is simple: prescribe treatments.

The American health-care system by and large runs on what experts describe as a “fee-for-service” system. For every service a doctor provides — whether that’s a primary care physician conducting an annual physical or an orthopedic surgeon replacing a knee — they typically get a lump sum of money.

That’s how most businesses work. Apple gets more money when it sells more iPads and the Ford gets more money when it sells more cars. But health care isn’t like iPads or cars. Or, at least, it’s not supposed to be.

When patients buy knee replacements, for example, what they’re buying isn’t really knee surgery itself. What they’re trying to buy is an improvement in their health.

But here’s the thing: most American doctors aren’t paid on whether they deliver that improved health. Their income largely depends on whether or not they performed the surgery, regardless of patient outcomes. Their patient’s knee could be good as new or busted as always at the end — but, in most cases, that doesn’t factor into their surgeon’s ultimate pay.

There are certainly many non-financial incentives for doctors to help their patients get better; it’s hopefully a big part of why they got into medicine in the first place. But those intrinsic motivations are often in tension with most doctors’ financial interests.

There is a growing movement in health care to change this and tether payments to patients’ outcomes. The non-profit Catalyst for Payment Reform estimates that 10.6 percent of all health care dollars paid are paid in some type of value-based arrangement, where the patient’s outcome factors into how much the health care provider earns.

Obamacare is running dozens of little experiments in the Medicare program that also try to pay doctors more when they provide higher quality care. There are now penalties, for example, if a patient returns to the hospital after something was screwed up the first time. Those seem like they might be working; the number of preventable readmissions has steadily dropped since late 2010.

But all these experiments are on the margins of the American healthcare system. For most doctors, the bargain is as it’s always been: do more stuff, get more money.

3) Half of all healthcare spending goes towards 5 percent of the population

Americans are not equal health care spenders. There’s a handful of patients who use lots of medical services — and tens of millions of people who barely go to the doctor at all.

The National Institute for Health Care Management estimates that, in 2009, about half of health spending ($623 billion) went towards 5 percent of the population. On average, these are people who use $40,000 of health care annually.

The lower-spending half of the population, meanwhile, spent a paltry $236 per person during that same year.

High health-care spenders aren’t richer Americans buying up lots of health care. Instead, these tend to be the sickest patients. They are older and living with multiple chronic conditions, like diabetes and high blood pressure. These are people who take multiple trips to the hospital per year and many prescription drugs every day.

For health-care experts, this spending pattern suggests that the real space to save money is focusing on these high spenders. “What it says to me,” Commonwealth Fund’s Blumenthal says, “is we have a huge opportunity to do something that’s humane and practical by focusing extra attention these parts of the population.”

This is the approach that Atul Gawande described in his influential New Yorker article, “The Hot Spotters.” There, Gawande looked at a New Jersey practice that put extra resources towards a handful of patients who kept turning up in the emergency room. It would have nurses check up on patients to make sure they took their medications — and it worked. Patients got better, and their spending went down.

Whether that type of hands-on, labor-intensive intervention can scale up in a big way remains to be seen. But the spending patterns of the health-care system suggest that the biggest gains are to be made by focusing on the sickest patients.

4) Our health insurance system is the product of random WWII-era tax provisions

If you want to understand why we are the only developed country with an employer-based health insurance — really, the only one — then you had better get familiar with the 1954 Internal Revenue Service Tax Code.

The 1954 Internal Revenue Service Tax Code is the document in which the federal government codified into law that companies can provide health insurance benefits to workers tax-free. This affirmed a 1943 IRS Tax Court ruling that had also decreed health benefits to be non-taxable.

The early decisions were made in the context of a wartime tax code. There were overwhelming taxes meant to stop wartime profiteering and keep unions from shutting down production to extract wage gains. But when health care was protected from these taxes, it immediately became incredibly valuable to workers, and companies were able to keep it tax-free even after the war. The result is that a dollar in health benefits is worth more to a worker than a dollar in wages, because the dollar in health benefits is untaxed and the dollar in wages is taxed.

“That’s a huge discount off the price of health insurance,” says Melissa Thomasson, an economist at Miami University who has written extensively on the history of health insurance. “And it happened very quietly. I looked a few years ago to find out the name of who made the decision, and it’s been lost to history.”

Flash forward about 80 years or so, and the health insurance tax break is the biggest in the federal budget; the government loses out on $260 billion annually by not taxing health benefits. The majority of non-elderly Americans get their health insurance at work, and with good reason: the tax-free dollar can buy a lot more medical care.

But economists on both sides of the political spectrum hate this tax break.

For one thing, it’s regressive. As a rule, people who have jobs that offer healthcare benefits are paid more than people who don’t have jobs that offer healthcare benefits — or who don’t have jobs at all. And remember that someone is ultimately paying for this tax break. In short, we’ve created a tax system where the people with good jobs are getting their health care subsidized by the people with worse jobs or even no jobs.

The tax exclusion also drives up demand for expensive health insurance. Partly, this is because of the subsidy. But partly, it’s because employees usually don’t know the real prices of their health benefits. Though ultimately economists believe that the money employers spend on health benefits comes from the money they would have spent on wages, workers don’t feel the direct cost of their health-insurance choices, and so they have little reason to try to keep spending low.

Doing away with the tax exclusion might seem like a no-brainer, but it’s very politically difficult. It would mean a huge price increase on employer-sponsored insurance, which is not a popular platform to run on (John McCain got nailed for suggesting capping, not eliminating, this particular tax exclusion).

Obamacare did manage to make some inroads. It includes a 40 percent tax on the most expensive insurance plans that starts in 2018. Know as the “Cadillac tax,” this fine will hit any insurance plans that cost more than $10,200 for an individual or $27,500 for a family. That tax is meant to push back against the too-generous plans that the tax exclusion encourages.

What the Cadillac tax does not do is eliminate the tax-exclusion for employer-sponsored coverage. Instead, it puts a dent in a 60-year-old policy — one that was set up with little forethought and is pretty much universally derided by health economists on both ends of the political spectrum.

5) Insurance companies have small profit margins

Health insurance companies are an incredibly easy target for any antipathy towards the American health care system. They’re the ones that deny claims for the care that we want, but still charge an always rising premium for their coverage.

But here’s one fact about insurers that often gets lost in the debate over health care: their profit margins tend to be relatively small. Yahoo Business estimates that the health-care sector as a whole runs a 15.4 percent profit margin. Health plans, meanwhile, have an average profit margin of 3.2 percent.

“I’ve asked an audience of doctors what share of the money that goes to insurance companies gets kept there, and most audiences will guess the company keeps about 50 percent of it,” Harvard’s Cutler says. “The truth is, they keep about 10 to 15 percent of it, and most of that goes towards claims processing and administration.”

As to who makes the most money, it’s mostly drug companies and device manufacturers — the people who make the things that insurance companies buy. They typically run profit margins around 20 percent.

One reason the cost of American health care is so high is that insurers are so weak. Having hundreds of different carriers, for example, means no one insurer has lots of negotiating power — hence those high prices drug and device makers can charge.

This suggests that tamping down on insurers’ profits won’t do much to tamp down on overall healthcare costs. They’re not pocketing a large amount of premiums; instead, they’re spending those premiums on a really expensive medical products.

“Only a nickel of your premium dollar stays with the insurance company,” says Uwe Reinhardt, a health economist at Princeton University. “The profits of insurance companies are truly a trivial part of national health spending.”

Video break!

We have covered a lot of territory — and still have a little ways to go. So now’s as good of a time as any to take a short breather and be thankful for how well the airline industry works.

Or, at least grateful for the fact air travel isn’t like health care. Even with the lengthy delays, terrible food and undignified battles over reclining chairs, just imagine how much worse your flights would be if a hospital called a shots. That, as this video underscores, would be utterly horrifying.

6) Getting health care in the United States is dangerous

We don’t know exactly how many Americans are killed in hospitals each year, but we do know that it is a lot.

In 1999, the Institute of Medicine published a seminal report titled To Err is Human, which estimated that at least 44,000 patients — and as many as 98,000 — die in hospitals each year as results of medical errors.

Even using the lower-bound figure, that would mean medical errors in hospitals kill more people annually than “such feared threats as motor-vehicle wrecks, breast cancer, and AIDS.”

A follow-up study published in 2013 argued that the IOM numbers were a vast underestimate, and that medical errors contribute to the deaths of between 210,000 and 440,000 patients. At the lower bound, that’s the equivalent of nearly 10 jumbo jets crashing every week — or the entire population of Birmingham, Alabama dying every year.

“It’s a big problem,” says Commonwealth Fund’s Blumenthal. “There has not been anything like the progress we should have expected or could have had since the To Err is Human report.”

He argues that the problem with hospital errors has much to do with medical culture, in which doctors rarely discuss their mistakes. Blumenthal remembers, shortly after the landmark IOM report came out, trying to start up a consulting business that would teach hospitals how to reduce errors.

“I thought it was this great little consulting opportunity,” he says. “But there was just no interest. It was sobering, and it made clear that abstract data was not going to change the behavior of complicated health care institutions.”

And on their own, patient deaths are small events that often happen with little notice or fanfare, making them less noticeable than other events.

“Even here in Houston, if a small plane crashes by the airport, that makes the evening news,” says John T. James, founder of Patient Safety America, who authored the 2013 report. “But people dying in hospitals are happening one at a time and in insolation, and we pay less attention.”

James has argued that the United States should have something akin to the National Transportation Safety Board, which investigates every plane crash in the United States, except for patient deaths from medical errors. Even if it couldn’t get to each and every case (there are thousands more patient deaths than airplane accidents), it would create some federal oversight that, right now, does not exist.

7) One third of healthcare spending isn’t helping

The United States spends $765 billion annually (about one third of our overall health care dollars) on things that do not make Americans any healthier.

“I’m always amazed at these conversations I have with physicians,” says Amitabh Chandra, a health economist at Harvard. “They’ll openly say that about 50 percent of what happens in medicine is waste, but it’s hard to always know which care was wasteful and which wasn’t.”

Much of the waste in our system has to do with the fact that we run an inefficient health-care system, in which hundreds of health insurance plans all charge different prices for the same surgeries and scans. That requires lots of billing staff: for every three doctors in the United States, there are two administrative staff to handle all the paperwork. That’s unique to the US system.

In addition, there’s unnecessary care: of the $765 billion wasted each year, the Institute of Medicine estimates that $210 billion is spent on medicine we don’t need.

Aside from being a waste of money, this extra medicine can be harmful.

Take the example of prescribing antibiotics for acute bronchitis. Researchers have known for decades this isn’t an effective treatment, but nearly three-quarters of doctors do so anyway. Those prescriptions are actively harmful, as overuse of antibiotics can speed up the creation of deadly, antibiotic-resistant superbugs. Wasteful spending doesn’t just mean extra dollars put towards health care — in cases like this, it also means worse care.

Unfortunately, most situations of waste aren’t as easy to recognize as the overprescribing of antibiotics. At many appointments, doctors have difficulty knowing when treatment is needed — and when it won’t provide help at all.

The medical community tries to address these issues with comparative effectiveness research. As the name suggests, these studies compare the effectiveness of one treatment against another for a given patient population. Many national health insurance programs use comparative effectiveness research, for example, to decide which drugs they will cover, aiming to pick the medication that gives the best results at the most affordable price.

But comparative-effectiveness research doesn’t always offer clear directions. Study methods can be faulty and results contradictory; one drug might work great for certain patients but terribly for others. These studies can also be controversial and met with outcry over rationing.

When the government, for example, recommended lowering the frequency of breast cancer screenings — more screenings, decades of research had found, didn’t save any more lives — there was public outcry.

And that’s one of the really tough issues with cutting down on waste in medicine: there are lots of healthcare treatments that we want, even when it might not actually be health-care treatment that we need.

8) Obamacare is not universal health care

The United States does have a very recent, very large expansion of health insurance coverage — that’s the program we all call Obamacare. It’s expected to cover an additional 26 million people by 2024.

What the United States does not have, however, is universal coverage.

Obamacare doesn’t eliminate uninsurance in America; instead, it cuts the number of people lacking coverage about in half. Even after Obamacare is fully implemented, budget forecasters still expect that 31 million Americans will lack insurance coverage — a bigger group than the people buying coverage on the exchanges. Our uninsured rate will still be in the double digits, hovering around 11 percent.

This group includes people who are locked out of the insurance expansion and those who do have access but decide not to participate.

Among the groups left out of the healthcare law are undocumented workers, who are not eligible to purchase any healthcare plans from the new insurance exchanges, and people who live in states that are not expanding Medicaid. For a sense of how big a population that is, the 10 largest states not expanding Medicaid are leaving out an estimated 3.6 million low-income residents.

There will also be millions of people who do have access to health insurance, maybe at work or through the new exchanges, but decide not to enroll. Maybe they think its too expensive — lots of shoppers felt that way during Healthcare.gov’s open enrollment — or maybe they don’t think health insurance will help them. Many of these people will face a penalty for not purchasing insurance coverage.

This will continue to set the United States apart from most other industrialized nations, in which universal coverage is the standard. And it means there will still, in decades to come, be people who can’t afford health insurance. That means there will be millions who rely on free clinics for medical care.

http://www.vox.com/2014/9/2/6089693/health-care-facts-whats-wrong-american-insurance

Instruction sheets for completing ACA tax forms – a proxy for ACA complexity

Implementing Health Reform: Tax Form Instructions

By Timothy Jost
Health Affairs Blog, August 29, 2014

On August 28, 2014, the Internal Revenue Service re-released the draft forms that will be used by employer, insurers, and exchanges for reporting Affordable Care Act tax information to individuals and to the IRS for 2014 and 2015, as well as the instructions for completing those forms.  The IRS also released in the Federal Register requests for public comments on three of those forms – the 1094-B, the 1094-C, and the 1095-C – under the Paperwork Reduction Act.  This post reports on these forms and instructions and on a guidance released by the Centers for Medicare and Medicaid Services.

The tax forms had been published earlier and are described in an earlier post.  The instructions for the forms, however, had not been available and had been eagerly awaited by employers, insurers, exchanges, and tax professionals. Forms 1094-C and 1095-C will be used by large employers with more than 50 full-time or full-time-equivalent employees to determine whether the employer is responsible for penalties under the employer shared responsibility requirements of the ACA.  They will also be used to determine whether employees have received an affordable and adequate offer of coverage, rendering them ineligible for premium tax credits.  Employers are required to provide each full-time employee with a form 1095-C and to file each of these together with a transmittal form 1095-B form with the IRS.

The instructions for the 1094-C and 1095-C are by far the most complex of the instructions released on August 28, filling 13 pages with dense, two column, print.  Most of the complexity derives from the options for complying with the employer mandate and the transition exceptions to that mandate that the administration has created…

Implementing Health Reform: Tax Form Instructions, by Timothy Jost: http://healthaffairs.org/blog/2014/08/29/implementing-health-reform-tax-form-instructions/

IRS – 2014 Instructions for Forms 1094-C and 1095-C (Draft): http://www.irs.gov/pub/irs-dft/i109495c–dft.pdf

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Comment:

By Don McCanne, MD

If you enjoy minutia, click on the links to the full blog post and the draft instructions and read away.

Although today’s message deals with only one minor provision of the Affordable Care Act –  the instructions for tax forms used to report ACA tax information to individuals and to the IRS – the administrative detail required is mind-boggling. Extrapolate that to all aspects of ACA and it becomes obvious that, instead of gaining administrative simplicity, ACA greatly increased administrative complexity – on top of the most administratively complex health financing system in the world. What a waste!

Timothy Jost’s comment from yesterday’s message can be repeated again today: “We are doomed to continue to struggle with this complexity as long as we stubbornly cling to a private health insurance-based health care financing system.”

Single payer.

Timothy Jost analyzes Avik Roy’s “Transcending Obamacare”

Transcending Obamacare: A Patient-Centered Plan for Near-Universal Coverage and Permanent Fiscal Solvency

By Avik Roy
Manhattan Institute for Policy Research, August 2014

The proposal contained herein — dubbed the Universal Exchange Plan (“the Plan”) — seeks to substantially repair both sets of health-policy problems: those caused by the ACA and those that predate it.

The Universal Exchange Plan would introduce major changes to the broad set of federal health care entitlements: Obamacare, Medicare, and Medicaid. The Plan uses a reformed version of the ACA’s health insurance exchanges as the basis for far-reaching entitlement reform.

The Plan would repeal many of the ACA’s cost-increasing insurance mandates, including the individual mandate. But it would preserve the ACA’s guarantee that every American can purchase coverage regardless of preexisting conditions. And it would utilize the concept of using federal premium support subsidies, on a means-tested basis, to defray the cost of private health coverage.

It would gradually migrate most Medicaid recipients, along with future retirees (N.B.: Medicare), onto these reformed exchanges.

The plan has its roots in real-world examples of market-oriented, cost-effective health reform. Notably, two wealthy nations — Switzerland and Singapore — spend a fraction of what the United States spends on health care subsidies; yet they have achieved universal coverage with high levels of access and quality.

http://www.manhattan-institute.org/pdf/mpr_17.pdf

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Following is a posted response by Don McCanne to an August 13, 2014 Forbes article in which Avik Roy introduced his reform proposal:

“A 2011 OECD & WHO report of the Swiss health system revealed that it is highly inefficient with profound administrative waste. It is inequitably funded using regressive financing. It has excessive out-of-pocket costs that can create financial hardships. And it has an increasing prevalence of managed care intrusions through a private insurance industry that has learned how to game risk selection. The problems are severe enough that current polls indicate that a majority of the Swiss support their upcoming ballot measure (September 28) that would convert Swiss health care financing to a single payer system. Obviously the current failed Swiss system should not serve as a model for U.S. reform.”

http://www.forbes.com/sites/theapothecary/2014/08/13/transcending-obamacare-an-introduction-to-patient-centered-consumer-driven-health-reform/

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Transcending Obamacare? Analyzing Avik Roy’s ACA Replacement Plan

By Timothy Jost
Health Affairs Blog, September 2, 2014

Avik Roy’s proposal, “Transcending Obamacare,” is the latest and most thoroughly developed conservative alternative for reforming the American health care system in the wake of the Affordable Care Act.

Roy’s proposal is a curious combination of conservative nostrums (limiting recoveries for victims of malpractice), progressive goals (eliminating health status underwriting, providing subsidies for low-income Americans), and common sense proposals (enacting a uniform annual deductible for Medicare).

Most importantly, however, Roy proposes that conservatives move on from a single-minded focus on repealing the ACA toward building upon the ACA to accomplish their policy goals. He supports repealing certain features of the ACA—including the individual and employer mandate—but would retain others, such as community rating and exchanges. As polling repeatedly shows that many Americans are not happy with the ACA, but that a strong majority would rather amend than repeal it, and as it is very possible that we will have a Congress next year less supportive of the ACA than the current one, Roy’s proposal is important.

Much of Roy’s proposal is taken up with traditional conservative talking points on health care reform. It is tempting to respond to these point by point. For example, Roy trots out the health systems of Switzerland and Singapore as models for the United States because they depend heavily on consumer-funded health financing. The bottom line, however, is that we are not Switzerland and we are certainly not Singapore, and we cannot have their health care systems.

Roy also has his own hobby horses. He claims that people are better off being uninsured than on Medicaid and trots out a long list of studies that he claims show negative effects from Medicaid coverage.

Roy’s Universal Exchange Plan

Rather than respond to Roy point by point, however, this review will focus on the heart of Roy’s proposal; his universal exchange plan. (To access Jost’s critique of Roy’s universal exchange plan, use the link below.)

Projecting The Benefits And Costs Of Roy’s Proposal

In sum, higher cost-sharing should result in lower premiums for health plans — a 40 percent actuarial value plan should cost less than a 60 percent plan. Skinnier benefits could also reduce premiums. Reduced premiums should in turn draw more uninsured into the market and reduce federal subsidy costs. But higher cost-sharing would reduce access to care, decrease treatment adherence, and increase provider bad debt. The savings Roy touts come at a high cost.

The Stubborn Problem Of Complexity

Another important point about the Roy plan must be noted: It does not reduce the complexity of the ACA. Indeed, it might increase it.

The ACA has been woven inextricably into the fabric of our health care system, and even ignoring, if that were possible, the millions of Americans who are now covered under the ACA, it is simply not possible to return to status quo ante through repeal. Roy reasonably recognizes this and proposes instead to build on the ACA to move toward a system that he finds more sympathetic.

But “transcending Obamacare” will not be easy. One of the greatest defects of the ACA is its complexity. That complexity has required the Obama administration to exercise considerable creativity in implementing the law.  But the law’s complexity simply follows from the fact that the drafters of the ACA attempted to build on, rather than to radically change, our current, impossibly complex, health care system.

Much of Roy’s proposal is still a broad conceptual framework. Even that framework is complicated, but were the proposal reduced to actual legislation, much less regulation, it would become far more convoluted and politically contested. We are doomed to  continue to struggle with this complexity as long as we stubbornly cling to a private health insurance-based health care financing system.

http://healthaffairs.org/blog/2014/09/02/transcending-obamacare-analyzing-avik-roys-aca-replacement-plan/

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Comment:

By Don McCanne, MD

Avik Roy presents his model of health care reform as a plan that does not require the repeal of the Affordable Care Act, but rather represents a reform of the ACA insurance exchanges along with the eventual elimination of Medicaid and Medicare. His proposed system is not yet fleshed out, but to achieve his stated ends, tremendous administrative complexity would have to be introduced.

There is much to criticize about Roy’s conservative, consumer-directed approach to health care financing – the worst flaw being the great financial burden that would be placed on those requiring health care. Should his proposal ever be seriously considered by Congress, a detailed response should be effective in countering it.

But for now, Timothy Jost summarizes the fatal flaw of his approach in two sentences:

“But the law’s complexity simply follows from the fact that the drafters of the ACA attempted to build on, rather than to radically change, our current, impossibly complex, health care system.”

and

“We are doomed to  continue to struggle with this complexity as long as we stubbornly cling to a private health insurance-based health care financing system.”

Avik Roy has contributed to the cause by showing us a proposal that makes it ever more clear why we must change to a single payer national health program. And we can thank Timothy Jost for clarifying that for us.

Single payer will simplify

By Ellen Oxfeld
Rutland (Vt.) Herald, Aug. 28, 2014

In his Aug. 24 column, Middlebury’s outgoing state Rep. Paul Ralston raises some questions about the state’s road map to single payer. However, his conclusions are based on assumptions that need more probing. Here are a few of the issues raised that need more careful examination:

1) The column asserts that the state has performed poorly in its “first attempt at health care reform” and that therefore people must now be cautious. However, it is important to make clear that the health care exchanges were federally mandated and not a state idea. Furthermore, single payer is a simpler concept than the health care exchange, as it does not involve different levels of coverage for different people, changing subsidies as your life situation changes, restricted enrollment periods that can leave you in the lurch, and all the rest of the exchange complexity, including a long and less than dependable application process. Rather, with single payer we are all enrolled automatically by virtue of our Vermont residence, and then our coverage is guaranteed. As Act 48 states, Green Mountain Care will cover all Vermonters regardless of any other coverage they may also hold (such as Medicare, for which it will act as a wraparound).

2) As stated above, single payer detaches payment from coverage. We are covered regardless of whether we lose a job, get a job, get a divorce, or undergo any other change in our life circumstance, so long as we are a Vermont resident. As far as payment, we have figured out how to pay for other state services equitably, and we can do so for single payer as well.

3) The column states that the program for Green Mountain Care, the proposed single-payer plan has no “clear definition.” That is incorrect. Act 48 specifies the minimum cost sharing and coverage for Green Mountain Care, the state’s future single-payer plan. The benefit package, by law, must include primary and specialty care, mental health and substance abuse, hospitals and prescription drugs. Under Green Mountain Care everyone will be eligible for these broad benefits, and out of pockets must be kept to a minimum because the “actuarial value,” or the amount that the plan pays, must be kept high. What is still undecided are the categories of adult dental and vision, and this is something on which citizens will need to weigh in about as the Legislature considers the financing package in the next session.

4) So what about the financing parameters? In fact, we already know them. Every professional study has estimated a cost of between $1.6 billion and $2.1 billion for the tax package to fund single payer. That is less than Vermonters already pay in private premiums and out of pockets ($2.6 billion in 2012), and most importantly, it will replace them. Of course, how the tax package is crafted, how progressive it is, what portion will be payroll and what portion income, etc., are important questions. They will be carefully thought about and debated once the administration presents its proposal, the Legislature considers and weighs it, and revisions are suggested based on citizen input.

5) Of course, as Ralston’s column indicates, voters do not want their representatives to act like “lemmings” marching into the sea. We expect them to consider carefully how to craft a single-payer health care tax package (which will replace premiums) that is as comprehensive and equitable as possible. But since Act 48 has been passed and is the law, we should insist that our legislators complete the road map it laid out. If anything, the problems with the exchange demonstrate how complicated things get when health care remains tethered to the private insurance system.

To insure seamless coverage for all Vermonters we will need the guaranteed inclusion that is part of a universal publicly financed health care system. That is the goal of the road map laid out in Act 48.

Ellen Oxfeld is a resident of Middlebury.

http://rutlandherald.com/article/20140828/OPINION04/708289999

Health care can be affordable and accessible

By Gordon D. Fiedler Jr.
The Salina (Kan.) Journal, Aug. 26, 2014

Affordable, accessible health care for all is not a dream but can be a reality, according to David Kingsley, who represents Physicians for a National Health Plan.

Kingsley, of Kansas City, Mo., who has a doctorate in public policy, addressed about 40 people who attended the Salina League of Women Voters Fall Issues Forum Monday night at the Salina Public Library.

He had little good to say about American medical care.

Ours, he said, “is the most complicated health care system ever devised on the face of the Earth.”

And it’s not producing the desired results.

The United States is 51st among nations in life expectancy, yet spends $8,950 per capita on medical care. This is more than twice that of Canada and nearly three times that of Japan. The Japanese average 12 doctor visits per capita per year, whereas in the United States, visits per capita per year are less than four.

Access to medical care should be a human right, he said.

“Everybody should get treatment on an equal basis. They could get all the care they need, not all the care they want,” he said.

Kingsley said there is a need for more doctors in the system and fewer administrative staff. Now, there are about 500,000 practicing physicians but more than 2.5 million office support positions.

One of his PowerPoint slides drew chuckles with the quote, “It takes a lot of people to impede access to health care.”

Not a fan of ACA

Lest the audience think he’s a staunch backer of the federal Affordable Care Act, also known as ObamaCare, Kingsley made it clear that for all the good it has done, it has a serious problem.

“The ACA’s biggest flaw is that it preserves the insurance industry,” he said.

The plan that the PNHP proposes would be “Medicare for all” and would offer universal coverage, with no economic barriers to care — meaning no copays, no deductibles — and would be similar to the system in Canada, where hospitals remain private and for profit. That’s different from the system in Great Britain, where the government owns the hospitals and employs the doctors.

The plan, he said, would be fair, fiscally prudent and patriotic.

Plan based on Medicare

It would be based on the Medicare model, which he said is popular among those 65 and older who are on the plan, and he said he would caution any politician who considers tampering with it.

“Most people like Medicare, so why not make it for everybody,” he said.

He has little hope of seeing the ACA get better.

“I hear people say we can improve on it. I’m not a big believer in that idea,” he said.

The question becomes what should be done.

“Do we want to continue spending $9,000 per capita and still have 37 million people (without access to care) who are going to get sicker and that really will cost us more money?” he said.

Questions to ponder

He said people have to get beyond the notion that privatizing services is better.

“A lot of things government does, it does well,” he said.

Kingsley said it’s time to have a conversation and left the audience with some questions to ponder.

“Let’s begin to think about what we’re going to do about these uninsured people, what are we going to do about paying double for drugs, what are we going to do about an ongoing concentration of industry which maybe 30, 40 years ago would have brought an antitrust lawsuit but isn’t happening now,” he said.

Cost is in advancements

To the relief of those of a certain age in the audience, he dispelled the myth that the elderly are largely responsible for increases in health care costs.

“The biggest cost in health care that’s coming down the road is medical advancements,” he said. “This is just the beginning. This is where we have to talk to each other. What are our values? What are our ethics? How are we going to deal with a society that can make a new kidney in the laboratory? It won’t be cheap.”

Already, cancer patients are receiving “designer” chemotherapy, he said.

“What are we going to do? Who’s going to get this? How much can we do?” he said.

–Gordon D. Fiedler Jr. can be reached at 822-1407 or by email at gfiedler@salina.com. This article was distributed by McClatchy-Tribune Information Services. It was originally published under the title of “Health care is topic for speaker.”

http://salina.com/search/health-care2014-08-26T01-09-48

Surgery Prices Surge With Innovation and Consolidation Under Obamacare

By Bill Briggs
NBC News, August 31, 2014

The price to remove a gall bladder or replace a hip has spiked more than 20 percent during the past five years, according to an analysis of data collected for NBC News.

Surgery has bloomed into a $500 billion industry in the United States, where 80 to 100 million procedures are performed annually — a per-capita rate that’s some 50 percent higher than in the European Union, said Dr. John Birkmeyer, a researcher and adjunct professor at the Dartmouth Institute and in the university’s Community & Family Medicine program.

The reason? Expensive yet safer technologies and hospital consolidations that create medical monopolies, according to doctors and researchers.

For hospitals, surgery is the No. 1 revenue source. That encourages medical center administrators to ensure operating suites remain humming — an assembly-line mentality that can lead to unnecessary procedures and spiraling prices, experts say.

“The cost of surgery is growing at a surprising rate,” said Birkmeyer, a leading researcher on healthcare trends. He bases his calculations on national Medicare claims data.

A price check on four of the most common procedures reveals the inflationary trends hitting ORs since 2009:

  • Hernia repair, up 16 percent, with a “total fair price” of $5,056, according to Healthcare Bluebook.
  • Gall bladder removal, up 21 percent, with a “total fair price” of $5,532.
  • Hysterectomy, up 19 percent, with a “total fair price” of $11,780.
  • Hip replacement, up 24 percent, with a “total fair price” of $22,606.

The cost-increase data was generated for NBC News by Healthcare Bluebook, an online guide that helps consumers shop for the best prices in their areas for various medical services. The dollar amounts show the “total fair price” for each surgery as estimated by the website.

Overall, health care inflation has averaged about 4 percent per year during the past five years, Dr. Jeffrey J. Rice, chief executive officer of Healthcare Bluebook, based in Brentwood, Tennessee.

Further causing surgical costs to surge: The U.S. health care economy is built on a tilted foundation. Insurance-company contracts can vastly differ from one hospital to another just blocks away, skewing prices for the same treatments.

“There is almost always a 500 percent — or more — variation for health care services in most cities,” Rice said. “For example, an MRI may cost $500 at one facility and over $3,000 at another facility across the street.”

Surgeons know this, of course. Their fees, dictated by insurance contracts or by Medicare, are included in the overall price of any operation.

“I can take out a gall bladder, and a surgeon in the next room can take out another gall bladder, but he or she may be with a different network of doctors or a different hospital system that negotiated better (insurance) contracts,” said Dr. Paul A. Ruggieri, a general surgeon in Fall River, Massachusetts. “He or she can get paid 20 to 30 percent more than what I get paid regardless of the outcome.”

Those hospital “systems” and doctor “networks” are rooted in a consolidation of care that’s been steadily gobbling up a greater share of the U.S. medical landscape and are a chief driver of the rising surgical prices, according to Birkmeyer, Rice and Ruggieri.

“Hospitals and their pricing systems have, for a very long time, been shielded from competitive market forces,” said Ruggieri, author of “The Cost of Cutting,” out Tuesday. “Hospitals have been allowed to charge whatever they want to charge to third-party payers (insurers). There’s been no transparency to the public in how hospital pricing is determined.”

And as more local hospitals end competitions and merge, the idea of winning new patients through lower prices vanishes, the experts said.

Consider Boston. In 1994, Massachusetts lawmakers allowed Brigham and Women’s Hospital and Massachusetts General Hospital to consolidate into a one system known as Partners HealthCare. According to the New York Times: “Investigations by the state attorney general’s office have documented that the merger gave the hospitals enormous market leverage to drive up health care costs in the Boston area by demanding high reimbursements from insurers that were unrelated to the quality or complexity of care delivered.”

The Affordable Health Care Act — or Obamacare — fueled even more hospital consolidations, Birkmeyer asserts.

The law created Accountable Care Organizations (ACOs) that “incentivize doctors and other providers to work together to provide more coordinated care to their patients,” former Health and Human Services Secretary Kathleen Sebelius wrote in March 2013. These ACOs “agree to take responsibility for the cost and quality of their patients’ care, (and) to improve care coordination and safety.”

They also boost the costs of surgeries, Birkmeyer asserts.

“That drive toward hospitals forming bigger conglomerations of networks and physician practices has reduced competition, and in a non-Medicare population, has enabled hospital systems in many parts of the country to charge far more,” Birkmeyer said.

At the same time, OR innovation — great for patients, tough on wallets — has bumped up surgery prices.

Those tech advances include robotic surgeries, now performed hundreds of thousands of times a year for certain procedures, including hysterectomies. A doctor sits near the operating table at a console, where he or she can manipulate robotic arms while watching through a 3-D viewfinder.

“Those have very positive effects in respect to recovery or the risks of complications for patients,” Birkmeyer said.

“But technology is very costly for hospitals and, ultimately, those costs get passed to insurers — and to the rest of us.”

http://www.nbcnews.com/health/health-care/surgery-prices-surge-innovation-consolidation-under-obamacare-n191901

Compensation for health insurance executives

Report: Health Law Ups Taxes On Insurers With Big Pay Packages

By Julie Appleby
Kaiser Health News, August 27, 2014

While average compensation for top health insurance executives hit $5.4 million each last year (up from $5.1 million in 2012), a little-noticed provision in the federal health law sharply reduced insurers’ ability to shield much of that pay from corporate taxes.

As a result, insurers owed at least $72 million more to the U.S. Treasury last year, said the Institute for Policy Studies, a liberal think tank in Washington D.C.

Researchers analyzed the compensation of 57 executives at the 10 largest publicly traded health plans, finding they earned a combined $300 million in 2013. Insurers were able to deduct 27 percent of that from their taxes as a business expense, estimates the report. Before the health law, 96 percent would have been deductible.

UnitedHealth Group, which paid CEO and President Stephen Hemsley about $28 million in pay and stock options in 2013, had the biggest tax bill among the 10 companies, the report found. Hemsley’s compensation accounted for nearly $6 million of the firm’s estimated $19 million in taxes that the report says it owed on  pay packages for five executives under the health law.

“They’re paying more in taxes just to protect these pay packages,” said Sarah Anderson, global economy project director at the institute.

Under the 2010 law, insurers can deduct only the first $500,000 of annual compensation per employee from corporate taxes, down from $1 million allowed before the law’s passage.  The law also requires insurers to include so-called “performance pay,” such as stock options, which often represent a hefty portion of an executive’s pay.

http://capsules.kaiserhealthnews.org/index.php/2014/08/report-health-law-ups-taxes-on-insurers-with-big-pay-packages/

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Covered California’s Peter Lee nets bonus, Obamacare site nets 1.2 million enrollees

By Chris Rauber
San Francisco Business Times, August 22, 2014

Covered California’s executive director, Peter Lee, has won a one-time $52,528 bonus for his role in launching the Obamacare exchange in the Golden State, which apparently netted 1.2 million enrollees all told during its first open enrollment period.

Lee’s one-time bonus is his first pay increase in three years… “excepting general state increases,” and represents a 20 percent “incentive award” based on his annual $262,644 salary.

http://www.bizjournals.com/sanfrancisco/blog/2014/08/covered-californias-peter-lee-nets-bonus.html?page=all

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Comment:

By Don McCanne, MD

There are a great many reasons that health care reform activists believe that private, investor-owned insurers should be eliminated from our health care financing, but one reason that is particularly offensive is the outrageous compensation packages for their executives. For that reason, the Affordable Care Act (ACA) included a provision prohibiting insurers from writing off for tax purposes more than $500,000 per executive, as a means to discourage the excessive executive pay.

Well, it didn’t work. Instead of taking those taxes out of the excessive salaries, executives were given pay increases averaging $300,000, raising their incomes to an average of $5.4 million. Although more corporate taxes were paid, those funds were recovered through higher premiums charged to the purchasers of health plans.

Compare the executive pay of the private insurers to that of Peter Lee, the head of California’s ACA insurance exchange – by far the largest and most successful ACA exchange in the nation. With his performance bonus, his income was only about one-twentieth of the average income of the executives of the largest publicly-traded health plans. In fact, Stephen Hemsley of UnitedHealth Group received almost 100 times as much as Lee.

These differences reflect the priorities of invested-owned corporations as opposed to quasi-public agencies. One is about making the most money possible, and the other is about serving the needs of the people.

Make no mistake. The ACA exchanges are still the wrong model because they contract with these same private insurers that perpetuate their abusive practices, such as overpaying their executives. Under a single payer system, administrators such as Peter Lee would be providing us with much greater value for their services since single payer systems eliminate much of the administrative waste while spending appropriate amounts for health care, and, yes, spending appropriate amounts for our public administrators.

Insurers shoving “advanced illness counselors” on us

Operator? Business, Insurer Take On End-of-Life Issues By Phone

By Elana Gordon, WHYY
Kaiser Health News, August 27, 2014

Kate Schleicher, 27,  is a licensed clinical social worker, who knows almost as little about you as you do about her. Except she knows your phone number, your insurance provider and that you are pretty sick.

Schleicher is one of 50 social workers at a company called Vital Decisions. After sending a letter (people rarely respond) counselors essentially cold-call to offer what they describe as “nondirected” end-of-life counseling.

The hope of this program, she says, is to build a relationship over the phone, so (the patient) might be comfortable discussing his situation and his goals. Then he’ll be empowered to communicate those things with others, including his family and his doctors. He could also choose to allow the counselor to talk to his doctors or family directly. It’s paid for by insurers and federal privacy rules permit this for business purposes.

And when these conversations do happen, there’s can be another byproduct: reduced costs. Research is finding that when patients fully understand aggressive care, many choose less of it.

But some people are wary of the company’s approach. Dr. Lauris Kaldjian, professor of bioethics at the University of Iowa, has concerns about the social worker, patient and family never actually meeting. “Because if you don’t have enough knowledge about what’s actually going on with the patient, it would actually be irresponsible to pretend to have discussion that depends upon such knowledge.” 

http://www.kaiserhealthnews.org/Stories/2014/August/27/insurers-new-business-end-of-life-conversations.aspx

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Vital Decisions

Vital Decisions is an innovative organization that assists patients and families dealing with advanced illness. We help patients clarify their values and preferences and then communicate with their family and care team to actualize those preferences. Our clients include several leading national, regional, and local health care plans which offer our service free of charge to appropriate individuals within their member populations.

We are a privately held company located in the Metropark business complex in Edison, NJ. The Company is profitable, and cash flow-positive, and is a leader in the growing field of advanced illness counseling.

The Company is a portfolio company of MTS Health Investors, the New York-based healthcare private equity firm.

http://www.vitaldecisions.net/careers.asp

HHS.gov: Health Information Privacy: “Business Associates”: http://www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/businessassociates.html

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Comment:

By Don McCanne, MD

When you are faced with advanced illness, perhaps nearing the end of life, where would you want to turn for medical advice on how to get through this difficult time? Your personal physician and health care team? Private health insurers, always looking for more administrative innovations to sell us, are now using high pressure tactics to force “advanced illness counselors” into the management of your care.

Who are these counselors? In the example given, they are employees of Vital Decisions, a private, for-profit corporation that sells its services to private insurance companies. They use your confidential medical diagnoses that have been provided to them by the private insurers to market to you an advisory service on negotiating the health care system. After an introductory letter that is routinely ignored, the counselors cold-call to try to convince you to accept their end-of-life counseling. Of course, this is “at no cost to you” since your insurer pays for this service. The services are provided over the phone from offices in New Jersey – a definition of personal care that only the insurers can understand. The clients of Vital Decisions are the private insurers, not the patients, nor the physicians, nor any other members of the health care team.

With today’s emphasis on privacy, how could unrelated business entities gain enough information about you to make a contact? In another concession to the private insurers, HHS allows them to share this confidential information with “business associates” – basically any business entity that might interact with the insurer as the insurer carries out its business functions. It is the private insurers that sic on you these end-of-life-care marketeers just at a time that you do not want any more extrinsic intrusions since you are suffering enough already.

Although the insurers say that they are paying for these services, they are actually paid by plan enrollees in the form of higher premiums. What is worse, these services are classified as health care related services and can be included in the insurers’ medical loss ratios. They do not apply to the 15% or 20% limit on administrative costs. In fact, since they are counted as medical losses, it allows the insurers even more leeway in adding on yet more administrative services. Since the percentages are fixed, more medical losses allow more administrative services – the primary product that the private insurers are selling us.

As a portfolio company of MTS Health Investors, the New York-based healthcare private equity firm, Vital Decisions is taking very good care of Wall Street, while intruding in our most difficult time of life and then walking away with our health care dollars.

Regular readers know what a single payer national health program would do with these parasites. They’d be out the door, right now.

Doctor’s prognosis: American-style health care a nightmare

By Inge De Becker, M.D.
The Chronicle Herald (Halifax, Nova Scotia), Aug. 26, 2014

As a Canadian physician who now lives south of the 49th parallel, I’m alarmed that Canada’s publicly financed national health-care system is once again under attack

Nine years ago, we witnessed Dr. Jacques Chaoulli’s legal attack on medicare in Quebec. Then we saw the Harper government’s failure to renegotiate a new Canada Health Accord this past March. And now Dr. Brian Day, owner of the for-profit Cambie Surgery Centre in Vancouver, is unleashing his drive to “profitize” health care in British Columbia.

On Sept. 8, a trial to hear a constitutional challenge to B.C.’s health system that Dr. Day launched in 2008 will begin in Vancouver. Day wants to strike down provincial legislation that limits private payments for medically needed services by claiming that these laws violate the Canadian Charter of Rights and Freedoms.

Should he win, the door will open for an American-style health-care system (consistently ranked lowest in performance among wealthy nations — and the most expensive) with its profit-driven insurance companies, bloated administrative costs, and inequitable access.

Let me tell you about my experience with the U.S. health-care system. I am a pediatric ophthalmologist by training and, like all of us, I am occasionally also a patient. In 2008, for personal reasons — not for a better job — I chose to move across the border from my home in Nova Scotia to Minnesota.

I knew that the health-care system in both countries would be different. But I did not grasp what that meant until I lived the difference.

My learning curve as a patient in the U.S. was brutal: even as a “well-insured” patient, I suddenly was dealing with pre-authorizations, in-network/out-of-network issues, co-pays, co-insurance, deductibles, health savings accounts, and EOBs (Explanation of Benefits) which look like bills but aren’t.

The accounting department of my HMO (Health Maintenance Organization) overbilled me by thousands of dollars. I stalled with the payment.

On a bright Saturday morning, I received an intimidating call from a collection agency for unpaid medical bills. Never mind how that affected my credit rating.

In Canada, I paid taxes, had a Nova Scotia health card that guaranteed access to medically needed care anywhere in the country, used the health-care system if I needed it, got to choose my doctor, and did not have to worry about bills. With private insurance in the U.S., I learned not to take the Canadian experience for granted anymore.

In Canada, I benefited from superb oncology care. In Canada, my son was in a catastrophic car crash. He spent seven days in a state-of-the-art neuro-intensive care unit. Not one bill, not one phone call to or from an insurance company disrupted emotionally charged times.

My learning curve as a physician practising in the U.S. was equally unpleasant. For the first time in my professional life, I had to deal with the intrusion of third parties — health insurance companies — between the patient and me.

I had to keep in mind that a patient’s insurance may not cover the tests and treatments needed, that common procedures needed to be pre-authorized by an insurance clerk, that certain things needed to be done before the insurance ran out, or that some treatments had to be delayed to the next “benefit year.”

I have been an unknowing accomplice in causing great anxiety and financial harm to a patient and his family: a $24,000 bill for services that were not covered because the patient had gone “out-of-network.”

The U.S. is the world’s richest democracy, yet it has decided that health care is a commodity for the privileged who can pay. Its health-care system is an opaque and complex patchwork of competing multiple payers, causing mammoth administrative costs (12 per cent for U.S. private multi-payer insurance overhead vs. 2.1 per cent for Canadian public single payer insurance — i.e. medicare).

Each year, up to 45,000 people die from a treatable condition because they lacked coverage and could not access care. Medical bills cause 56 million adult Americans, more than 20 per cent of adults between the ages of 19 and 64, to struggle financially, and about 650,000 to go bankrupt annually, affecting 2,608,119 individuals.

Other rich and civilized democracies have made the fundamental moral decision that access to health care is a human right and have figured out a way to make it happen. Canada is one of them.

Rather than sliding down the slippery slope toward a U.S.-style system, I ask you to stand on guard for Canadian medicare. Please reject Dr. Day’s bid to undermine it.

Dr. Inge De Becker practised in Nova Scotia for 20 years. She now resides in St. Paul, Minnesota.

http://thechronicleherald.ca/opinion/1232079-doctor-s-prognosis-american-style-health-care-a-nightmare

Jonathan Bernstein: “Public opinion is an incoherent mess”

Loving and Hating Obamacare With One Muddled Mind

By Jonathan Bernstein
Bloomberg View, August 25, 2014

E.J. Dionne has a nice column pointing out that while “Obamacare” remains unpopular, most of the provisions are well-liked, and thus Democrats should run on the issue. As regular readers know, I certainly agree that the individual components of reform are far more popular than reform overall. Actually, support for key provisions of the law, including coverage of pre-existing conditions, health-insurance exchanges offering subsidies to middle-income policy holders and Obamacare’s Medicaid expansion, have always polled well.

Moreover caution is always in order with issue polling. When these kinds of polls show public opinion fractured, it’s tempting to believe that one side or the other represents voters’ “true” support. That’s the wrong way to interpret such polls. Yes, the ACA polls badly while most of its components poll well. But that doesn’t mean that the ACA is genuinely unpopular (as most opponents suggest) or that it’s genuinely popular (as most supporters contend). There is no underlying truth to be excavated from the results; the best we can do is say that public opinion is inconsistent.

Well, that’s the best we observers can do. Campaign operatives, in contrast, can counsel their candidates to stress whatever is popular. What those operatives shouldn’t do is to fall for their own spin, or let their candidates fall for it.

The broader point: We can measure public opinion, but sometimes – actually, quite often – public opinion is an incoherent mess. Voters have plenty of things other than politics going on in their lives; it’s not surprising that they should find the strongest selling points from both sides quite appealing and let it go at that. For those of us who pay close attention, it may seem weird that someone could hate Obamacare while loving almost every part of it. There must be one overriding opinion hidden in there — pro or con — that good research can isolate, no? Well, no. Sometimes, incoherence in the polls simply reflects incoherence among voters. We just have to live with that.

http://www.bloombergview.com/articles/2014-08-25/loving-and-hating-obamacare-with-one-muddled-mind

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Comment:

By Don McCanne, MD

The public reaction to the Affordable Care Act (ACA) is very instructive as far as understanding public attitudes toward single payer reform.

Most of the specific policies in ACA have been supported for many years by those who are relatively well informed on the issues – a minority of our population. The negative views of the public have been formed in the hollow echo chamber filled with empty political rhetoric devoid of illuminating explanations – a message chamber that reaches most of our people. The political attack has been aimed at President Obama and the Democratic Party, but not at ACA’s beneficial policies. Thus many in the media have correctly reported that “Obamacare” continues to poll poorly – as a political construct – whereas the specific improvements in health care coverage – the health policies – have support of the majority.

Although the situation with the public attitude towards single payer is similar, it has not had nearly the same intensity of exposure has had ACA. More Americans have now heard the term “single payer,” but the majority still have a poor understanding of what a tremendous improvement it would be over our highly dysfunctional, wasteful, inefficient, and inequitable multi-payer system. That is, the public at large is still very poorly informed on single payer policies.

The hollow echo chamber of empty political rhetoric targeting single payer has been around much longer but has been maintaining a lower profile. As long as single payer reform does not seem to be imminent, the effort of opponents has been directed to building anti-government memes that can be rapidly brought to the front should a single payer reform effort gain traction.

Examples of this latter phenomenon include Proposition 186 in California and Measure 23 in Oregon. Both of these single payer measures polled favorably until close to the elections. In both instances, it took only a couple of weeks of mindless trashing of the measures to result in a tidal wave of opposition. They were defeated by empty rhetoric and not by opposition to beneficial health policies.

In today’s article, Jonathan Bernstein makes the important point that “quite often public opinion is an incoherent mess.” Look how much difficulty the supporters of ACA are having in getting the message out about the genuine benefits of ACA when the listeners are exposed to a background of meaningless cacophony generated in the hollow echo chamber.

When single payer is ready for its day, the cacophony will be almost unbearable. That is why it is so important now to pull all stops in educating the public on single payer benefits. They will need a much better understanding of the concept so that they can sort out the facts from the noise.

Bernstein says, “Sometimes, incoherence in the polls simply reflects incoherence among voters. We just have to live with that.” No, we don’t have to live with that. We simply need to build our own colossal echo chamber spewing out the facts. Education. Education. Education.

Single-payer would provide better health care to more people

By Mimi Signor, R.N.
St. Louis Post-Dispatch, Letters, Aug. 26, 2014

Regarding “Hospitals team up with banks to get patients to pay” followed by “Charity care cut for some who declined coverage” (Aug. 24) exemplifies Missouri’s hospitals’ lean and mean business model. The first article talks about ways to make patients pay for acute care already administered. The second talks about demanding payments prior to non-urgent care.

Missouri hospitals believe mandatory commercial insurance will keep them in the black. However, the majority of people who face bankruptcy due to medical costs are those who have insurance. Commercial insurance companies enforce co-pays, deductibles and other high out-of-pocket costs as a disincentive to seeking care. Insurers often deny payment for care in advance or after care has been provided.

We have the ability to cure, but have lost the capacity to care. Rather than bullying the sick into commercial insurance they cannot afford to buy or use, Missouri hospitals should support passage of HR 676, “Improved Medicare for All,” the most fiscally conservative and fair way to provide better health care to more people. Missouri hospitals would receive guaranteed payment from the single payer, Medicare, for care provided. Missourians would get medical care without fear of bankruptcy, and hospitals would not need to dun patients through collection agencies.

Mimi Signor resides in University City.

http://www.stltoday.com/news/opinion/mailbag/letters-to-the-editor/single-payer-would-provide-better-health-care-to-more-people/article_bfb14297-74d6-58f1-b607-97a2c0ba6097.html

Beware siren song of private-payer care

In the U.S., the doctor is in, but maybe financially unavailable

By Jessica Schorr Saxe, M.D.
Vancouver Sun, Aug. 25, 2014

The middle-aged woman came to my family medicine practice for a routine visit to check her high blood pressure. It was the highest I’ve ever seen in the office: 280/180. I told her to go to the emergency department for probable admission to the hospital.

Her eyes crinkled, and tears fell silently. I thought she was crying because I had frightened her about the urgency of her condition. I was wrong.

“I can’t go to the hospital,” she said, “I can’t afford it.”

I have practised for more than 30 years in a health centre that cares for low-income patients in Charlotte, N.C. As is typical in the United States, our patients rely on a hodgepodge of funding sources. Almost all patients face some financial barriers to care.

A few have private insurance (increasingly with high co-pays and deductibles), many have Medicare (for the elderly) or Medicaid (for some of the poorest of the poor), and many are uninsured. Of the uninsured, some are “self-pay” and some qualify for sliding-scale charges pegged to their income.

While my patient with extreme hypertension is deeply etched into my mind, I could tell you many similar stories.

The typical new patients in my practice have not had health care for months or years. In many cases, they once had employer-based insurance and access to private doctors, then lost their job and thus their coverage and their physicians. Some cry when they talk about the interruption of these long-term relationships with their doctors.

One such patient had been hospitalized with severe congestive heart failure and had lost his full-time job because of his illness. Although he continued to work part-time, he was uninsured and could no longer see his usual doctor.

It took months for him to see me. When he did, I promptly sent him to a cardiologist who prescribed open-heart surgery. He received it, but he could have died waiting for care, as thousands of Americans do every year.

The constant churning of patients in and out of coverage, or in and out of private insurance plans (each with a restrictive network of providers), is cumbersome and costly. Such transitions require patients to seek out new doctors who request and scrutinize old records and sometimes order tests, not realizing they have already been done.

The U.S. system creates other challenges to providing good care. Some patients miss appointments simply because they don’t have enough money for their insurance co-pays.

I approach each patient with an algorithm. This patient has Blue Cross/Blue Shield and has these options, this one has Medicare and another set of options for referrals and medications, this patient is on sliding scale and another set: oops, no options here for certain services. It is even more complicated, because the options change.

Unlike many other places in the U.S., we are fortunate at my health centre to have many services for the uninsured, but there are still many gaps. Elective orthopedic surgery, for example, is not even an option.

I have a patient with a painful hand condition and several patients who need knee or hip replacements. Many of them would be able to work if they could afford the recommended surgery, but instead they live in pain and poverty.

I know some people in Canada decry excessive waiting times for elective procedures. The waiting times for patients on the U.S. side are sometimes infinite or until they reach the age of 65 (decades away for some), when they finally receive our Medicare.

Medical care in the United States costs twice as much per capita as in Canada, yet we have tens of millions who are uninsured, two million people a year who are victims of medical bankruptcy, and some of the worst health statistics in the developed world.

As Canada considers the “Cambie case,” i.e. a constitutional challenge to your single-payer system, I urge you to protect and defend what you have. Allowing private payers to jump the queue, and expanding the role of private insurance and for-profit medicine, will inevitably lead down the road to worsening inequities, greater expense, and poorer quality.

Learn from your neighbour to the south. Don’t follow our disastrous example. Improve your imperfect but fundamentally sound medicare system, and continue to enjoy good care, good health, and the financial savings your system offers.

Jessica Schorr Saxe is a family physician in Charlotte, N.C.

http://www.vancouversun.com/opinion/op-ed/Opinion+Beware+siren+song+private+payer+care/10147696/story.html