PNHP

When Cost Deters Care

When Cost Deters Care

By Ida Hellander, M.D.
The New York Times, May 9, 2014

H. Gilbert Welch is right to be concerned that patients will forgo diagnostic mammograms, colonoscopies and other kinds of care for serious conditions if they aren’t free, as “prevention” is under the Affordable Care Act (“The Problem With Free Health Care,” Op-Ed, May 1).

Studies show that even patients who need emergency care for a potentially serious problem will go without it if they are in a high-deductible health plan (although this increases their risk of subsequent hospitalization). And therein lies the problem. While cost sharing discourages overuse of medical care, it worsens a greater problem, that of underuse.

In an 11-nation survey by the Commonwealth Fund, more than a third (37 percent) of Americans reported not going to the doctor when sick or not filling a prescription because of cost, compared with a small percentage of people in Britain, Sweden and Norway. The difference: They have single-payer systems in which care is generally free at the point of service.

IDA HELLANDER

Chicago, May 2, 2014

The writer is director of health policy and programs for Physicians for a National Health Program.

A version of this letter appears in print on May 9, 2014, on page A26 of the New York edition with the headline: When Cost Deters Care

Should we pay for screening tests?

The Problem With Free Health Care

By H. Gilbert Welch
The New York Times, April 30, 2014

The Affordable Care Act does have its flaws. Here’s a big one: It favors screening over diagnosis.

While the distinction may seem arcane, it has real-world implications. Screening is what we offer to the well; it’s the effort to find abnormalities in those who do not have signs or symptoms of disease. Because screening is considered part of preventive care under the Affordable Care Act, it is provided at no charge.

Diagnosis is what we offer to those who do have signs or symptoms of disease. Because diagnosis is not preventive care, it is subject to deductibles and co-payments.

I wish money wasn’t such a powerful incentive in medical care. But the economists are right: Incentives matter. Right now they favor lower risk patients (those being screened) over higher risk ones (those with signs and symptoms).

They also encourage a feeding frenzy among providers to recategorize diagnostic testing as screening. Free screenings were seen as a way to get people through the door and ideally to find and address problems before they become more dangerous and expensive.

But in practice, it may not work this way. Some hospitals offer free screening knowing full well that the costs will be more than made up for by all the subsequent services required. More testing, false alarms and overdiagnosis are all part of screening. And if you make it free, patients are less likely to give proper consideration to these potential harms — not to mention the potential for a lot of out-of-pocket costs down the line.

Here’s the fix: Eliminate the incentive mismatch between screening and diagnosis. Treat them equally.

We need people to consider medical care carefully, and that’s what cost sharing is all about.

http://www.nytimes.com/2014/05/01/opinion/the-problem-with-free-health-c…

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When Cost Deters Care

Letters, The New York Times, May 8, 2014

To the Editor:

H. Gilbert Welch is right to be concerned that patients will forgo diagnostic mammograms, colonoscopies and other kinds of care for serious conditions if they aren’t free, as “prevention” is under the Affordable Care Act (“The Problem With Free Health Care,” Op-Ed, May 1).

Studies show that even patients who need emergency care for a potentially serious problem will go without it if they are in a high-deductible health plan (although this increases their risk of subsequent hospitalization). And therein lies the problem. While cost sharing discourages overuse of medical care, it worsens a greater problem, that of underuse.

In an 11-nation survey by the Commonwealth Fund, more than a third (37 percent) of Americans reported not going to the doctor when sick or not filling a prescription because of cost, compared with a small percentage of people in Britain, Sweden and Norway. The difference: They have single-payer systems in which care is generally free at the point of service.

Ida Hellander

Chicago, May 2, 2014

The writer is director of health policy and programs for Physicians for a National Health Program.

http://www.nytimes.com/2014/05/09/opinion/when-cost-deters-care.html?ref…

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Access, Affordability, and Insurance Complexity Are Often Worse in the United States Compared to 10 Other Countries

By Cathy Schoen, Robin Osborn, David Squires, and Michelle M. Doty 
The Commonwealth Fund, November 13, 2013

Synopsis

A 2013 survey conducted in 11 countries finds that U.S. adults are significantly more likely than their counterparts to forgo health care because of the cost, to have difficulty paying for care even when they have insurance, and to deal with time-consuming insurance issues.

http://www.commonwealthfund.org/Publications/In-the-Literature/2013/Nov/…

USPSTF A and B Recommendations:http://www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm

H. Gilbert Welch has been a leading voice in warning us about the costs and adverse consequences of overdiagnosis. When there is little benefit but greater potential harm and expense for a given diagnosis, it usually would be better if that diagnosis had never been made. This is especially true when a screening test is done on a healthy individual if it leads to a diagnosis that will be of no help but could result in harm to the patient.

When should screening tests be done? The decisions should be made by patients after their health care professionals provide them with adequate information regarding the potential benefits and adverse consequences of the screening procedures. That advice should reflect the latest information available from sources such as the U.S. Preventive Services Task Force (USPSTF). In fact, the Affordable Care Act specifically covers, without charge, level A and B preventive service recommendations of the USPSTF. (Link above – USPSTF recommendations are updated as new information becomes available.)

Dr. Welch would add one other consideration. He would require patients to pay a portion of the costs for the screening tests just as they would for diagnostic testing used to evaluate specific symptoms or signs. It is well known that if people have to pay for screening tests that they should have, many will decline them simply because of the expense. This can result in adverse health outcomes or even death. If a screening test warrants an A or B USPSTF rating, its benefits do outweigh the potential harm, and it should be offered to the patient without placing it behind a “paywall” (deductible, coinsurance or copayment).

Dr. Welch has it backwards. We should eliminate the incentive mismatch between screening and diagnosis, but we should do that by removing the paywalls for diagnostic and therapeutic services rather than creating new ones for preventive screening.

PNHP’s director of health policy, Ida Hellander, has it exactly right. Rather than overuse, we have a much greater problem with underuse of beneficial health care services, and cost-sharing paywalls worsen that problem.

The Commonwealth Fund study that Dr. Hellander cites shows that the United States has a much greater cost-related access problem than do the other ten wealthy nations studied, yet those nations spend far less on total health care than we do, without the necessity of erecting these paywall financial barriers to care.

We can thank Dr. Welch for his great work in explaining to us the potential negative consequences of screening tests. With this information we can better inform the patient who has to make the decision on undergoing screening. But we can also thank Dr. Hellander for her great work on explaining to us why health care should be based on patient need rather than on the patient’s ability to pay.

Quite simply, patients should have the care that medical science dictates they should have, if they want it, but not denied that care because they feel they cannot afford it.

Should hospitals become the insurers?

Hospitals plot the end of insurance companies

By Rob Garver
The Fiscal Times, March 27, 2014

At The Atlantic’s Health Care Forum in Washington on Thursday [March 27], health care and business professionals said that there’s an increasing trend in the industry toward cutting insurance companies out of the process entirely, as large, regional hospital systems move into the insurance business. 

Dr. Kenneth L. Davis, CEO and president of Mount Sinai Health System, the largest health care provider in the state of New York, said that starting next year, Mt. Sinai will begin offering its own Medicare Advantage plan. It will look for other opportunities to bring premium payments directly into the hospital system, rather than filtering them through insurance companies.

Davis said he expects organizations similar to his to move in the same direction. “Inevitably the large systems are going to move to take part of the premium dollar,” he said.

For both non-profit systems like Mt. Sinai and for-profit systems, he said, retaining more and more of the health care premiums paid by consumers is essential to providing a full spectrum of care. He said that his system’s St. Luke’s Hospital in New York runs a psychiatric program that loses $14 million per year. It’s “not sustainable,” he said, so the system needs to cross-subsidize the money-losing services that it nonetheless must continue to provide, with income from more profitable services, such as orthopedic surgery.

http://www.thefiscaltimes.com/Articles/2014/03/27/Hospitals-Plot-End-Insurance-Companies

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Comment:

By Kip Sullivan, JD

The media is doing a good job of telling the public that consolidation within the hospital industry accelerated dramatically after the Affordable Care Act was enacted. The media is doing a terrible job of explaining why. 

The flabbiness of managed-care speak is part of the problem. So too is the tendency of merger partners in all sectors of the economy to feign disinterest in market power and to claim their merger was motivated only by a desire for greater efficiency. These problems were on display during a recent interview of Dr. Kenneth Davis, CEO of Mount Sinai Health System (an enormous hospital-clinic chain), by Corby Kummer, a senior editor for the Atlantic. http://www.theatlantic.com/live/events/health-care-forum/2014/ 

The Fiscal Times summary of that interview, quoted above, accurately portrays what Davis said. He mentioned two motives for his recent acquisition of other hospitals: (1) to ensure that services that lose money for Mt. Sinai, such as pediatrics, psychiatry, and obstetrics, are cross-subsidized by money-making services such as orthopedics; and (2) to create an entity large enough to bear insurance risk. But Dr. Davis failed to explain why Mt. Sinai should have to cross-subsidize anything or bear any insurance risk, and Mr. Kummer’s vague questions failed to clarify Dr. Davis’s opaque remarks. 

Dr. Davis was one of several experts convened on March 27 by The Atlantic for a forum on “fundamental questions underlying” the Affordable Care Act. Mr. Kummer began the interview with this gentle question: “How should people be viewing… the size of these health care systems?”

Dr. Davis first replied with his cross-subsidization argument. He claimed cross-subsidization was possible only “in an integrated health care system” that can create “efficiencies both in clinical care and corporate infrastructure.” He said the Roosevelt Hospital was going to become a “real mecca for orthopedics,” and that in turn would make adequate financing of underfunded services possible. 

Note the unspoken, undocumented assumptions lurking under these statements, including: 

  • Control of numerous hospitals and clinics by a single corporation results in “efficiencies;” 
  • Mt. Sinai’s management, not society through its government, should decide how much doctors should be paid, and
  • Mt. Sinai should seize the power to do that by gobbling up other providers.

Some version of the second question did enter Mr. Kummer’s mind, but he couldn’t figure out how to pose it. “Is one way of bending the cost curve trying to equalize that hierarchy of reimbursement, or is that just too much to hope for?” he finally blurted out. Davis dodged the question (see Davis’s answer at 5:30 into the interview).

Rather than rephrase his question, Kummer raised another subject. He asked Davis if Mt. Sinai intended to start its own insurance company. Davis said it wasn’t clear yet whether Mt. Sinai would create an insurance company in partnership with an existing insurer or “with our own license,” but he had no doubt Mt. Sinai would become an insurance company. 

Rather than question why hospitals should be branching into the insurance business, Kummer asked: “Does the Affordable Care Act make it easier for you to think in terms of offering this product?”

“No, it’s the macroeconomics of health care that is forcing this,” Davis replied. “It’s large systems coming together that are large enough to take actuarial risk…. You need a certain size and scale to be able to take risk.”

Can you imagine a more abstract answer? Some force majeure was making Davis build an empire so he could “take actuarial risk.” Kummer bought it.

A good interview would have helped listeners understand the policies that have triggered periodic spasms of merger fever in our health care system, and the arguments for and against letting those policies persist. The most important cause of the rapid consolidation of our health care system is the 40-year-old campaign waged by the powerful managed care movement to blame the fee-for-service method for overuse of health care, and to replace that method with capitation and other methods of forcing doctors and hospitals to bear insurance risk. The zenith of this campaign was reached in March 2010 with the enactment of the Affordable Care Act. This campaign conveniently ignores the role of high administrative costs inflicted on the system by our multiple-payer system and by managed care itself.

The media occasionally drops a hint that the attack on fee-for-service is the original cause in the chain of causes leading to merger fever. For example, the New York Times article on Mt. Sinai’s merger with Continuum Health Partners last year quoted Richard Ravitch, a member of Mt. Sinai’s board, saying: “‘The fee-for-service system is going to be history shortly,” it will be replaced with a system of “bundled payments” that shift insurance risk to hospitals, and to handle that new system hospitals will “need a population that’s larger than what any one [hospital] has … today.” http://www.nytimes.com/2013/07/17/nyregion/2-hospital-networks-agree-to-merge-raising-specter-of-costlier-care.html 

But the article made no effort to explain why the fee-for-service method should be terminated, why a system of “bundled payments” would be better, and who is promoting these notions. The nation badly needs the mainstream media to connect the dots between the demonization of fee-for-service and the latest merger spasm in our health care system.

The dots could be connected quite simply, as follows: 

  • Managed care advocates, including leaders of both political parties, think overuse is the cause of our health care crisis, and that overuse is caused by the fee-for-service method; 
  • The managed care movement’s demonization of fee-for-service and its lionization of shifting risk onto hospitals and doctors means providers must consolidate in order to bear insurance risk. 

Once the dots are connected, society can then ask, Is it true that overuse is our main problem and fee-for-service causes it, and if not, is there a better way to solve the health care crisis? 

For single-payer advocates, the answer is clear. It makes utterly no sense to replace the existing insurance industry with a hospital-based insurance industry. The existence of multiple, privately controlled insurers is the problem. Shifting control over those insurers from the traditional insurance industry to the hospital industry does not solve that problem. We need one publicly controlled insurer.

Should hospitals become the insurers?

Hospitals plot the end of insurance companies

By Rob Garver
The Fiscal Times, March 27, 2014

At The Atlantic’s Health Care Forum in Washington on Thursday [March 27], health care and business professionals said that there’s an increasing trend in the industry toward cutting insurance companies out of the process entirely, as large, regional hospital systems move into the insurance business.

Dr. Kenneth L. Davis, CEO and president of Mount Sinai Health System, the largest health care provider in the state of New York, said that starting next year, Mt. Sinai will begin offering its own Medicare Advantage plan. It will look for other opportunities to bring premium payments directly into the hospital system, rather than filtering them through insurance companies.

Davis said he expects organizations similar to his to move in the same direction. “Inevitably the large systems are going to move to take part of the premium dollar,” he said.

For both non-profit systems like Mt. Sinai and for-profit systems, he said, retaining more and more of the health care premiums paid by consumers is essential to providing a full spectrum of care. He said that his system’s St. Luke’s Hospital in New York runs a psychiatric program that loses $14 million per year. It’s “not sustainable,” he said, so the system needs to cross-subsidize the money-losing services that it nonetheless must continue to provide, with income from more profitable services, such as orthopedic surgery.

http://www.thefiscaltimes.com/Articles/2014/03/27/Hospitals-Plot-End-Ins…

The media is doing a good job of telling the public that consolidation within the hospital industry accelerated dramatically after the Affordable Care Act was enacted. The media is doing a terrible job of explaining why.

The flabbiness of managed-care speak is part of the problem. So too is the tendency of merger partners in all sectors of the economy to feign disinterest in market power and to claim their merger was motivated only by a desire for greater efficiency. These problems were on display during a recent interview of Dr. Kenneth Davis, CEO of Mount Sinai Health System (an enormous hospital-clinic chain), by Corby Kummer, a senior editor for the Atlantic. http://www.theatlantic.com/live/events/health-care-forum/2014/ 

The Fiscal Times summary of that interview, quoted above, accurately portrays what Davis said. He mentioned two motives for his recent acquisition of other hospitals: (1) to ensure that services that lose money for Mt. Sinai, such as pediatrics, psychiatry, and obstetrics, are cross-subsidized by money-making services such as orthopedics; and (2) to create an entity large enough to bear insurance risk. But Dr. Davis failed to explain why Mt. Sinai should have to cross-subsidize anything or bear any insurance risk, and Mr. Kummer’s vague questions failed to clarify Dr. Davis’s opaque remarks.

Dr. Davis was one of several experts convened on March 27 by The Atlantic for a forum on “fundamental questions underlying” the Affordable Care Act. Mr. Kummer began the interview with this gentle question: “How should people be viewing… the size of these health care systems?”

Dr. Davis first replied with his cross-subsidization argument. He claimed cross-subsidization was possible only “in an integrated health care system” that can create “efficiencies both in clinical care and corporate infrastructure.” He said the Roosevelt Hospital was going to become a “real mecca for orthopedics,” and that in turn would make adequate financing of underfunded services possible.

Note the unspoken, undocumented assumptions lurking under these statements, including:

  • Control of numerous hospitals and clinics by a single corporation results in “efficiencies;”
  • Mt. Sinai’s management, not society through its government, should decide how much doctors should be paid, and
  • Mt. Sinai should seize the power to do that by gobbling up other providers.

Some version of the second question did enter Mr. Kummer’s mind, but he couldn’t figure out how to pose it. “Is one way of bending the cost curve trying to equalize that hierarchy of reimbursement, or is that just too much to hope for?” he finally blurted out. Davis dodged the question (see Davis’s answer at 5:30 into the interview).

Rather than rephrase his question, Kummer raised another subject. He asked Davis if Mt. Sinai intended to start its own insurance company. Davis said it wasn’t clear yet whether Mt. Sinai would create an insurance company in partnership with an existing insurer or “with our own license,” but he had no doubt Mt. Sinai would become an insurance company.

Rather than question why hospitals should be branching into the insurance business, Kummer asked: “Does the Affordable Care Act make it easier for you to think in terms of offering this product?”

“No, it’s the macroeconomics of health care that is forcing this,” Davis replied. “It’s large systems coming together that are large enough to take actuarial risk…. You need a certain size and scale to be able to take risk.”

Can you imagine a more abstract answer? Some force majeure was making Davis build an empire so he could “take actuarial risk.” Kummer bought it.

A good interview would have helped listeners understand the policies that have triggered periodic spasms of merger fever in our health care system, and the arguments for and against letting those policies persist. The most important cause of the rapid consolidation of our health care system is the 40-year-old campaign waged by the powerful managed care movement to blame the fee-for-service method for overuse of health care, and to replace that method with capitation and other methods of forcing doctors and hospitals to bear insurance risk. The zenith of this campaign was reached in March 2010 with the enactment of the Affordable Care Act. This campaign conveniently ignores the role of high administrative costs inflicted on the system by our multiple-payer system and by managed care itself.

The media occasionally drops a hint that the attack on fee-for-service is the original cause in the chain of causes leading to merger fever. For example, the New York Times article on Mt. Sinai’s merger with Continuum Health Partners last year quoted Richard Ravitch, a member of Mt. Sinai’s board, saying: “‘The fee-for-service system is going to be history shortly,” it will be replaced with a system of “bundled payments” that shift insurance risk to hospitals, and to handle that new system hospitals will “need a population that’s larger than what any one [hospital] has … today.” http://www.nytimes.com/2013/07/17/nyregion/2-hospital-networks-agree-to-…

But the article made no effort to explain why the fee-for-service method should be terminated, why a system of “bundled payments” would be better, and who is promoting these notions. The nation badly needs the mainstream media to connect the dots between the demonization of fee-for-service and the latest merger spasm in our health care system.

The dots could be connected quite simply, as follows:

  • Managed care advocates, including leaders of both political parties, think overuse is the cause of our health care crisis, and that overuse is caused by the fee-for-service method;
  • The managed care movement’s demonization of fee-for-service and its lionization of shifting risk onto hospitals and doctors means providers must consolidate in order to bear insurance risk.

Once the dots are connected, society can then ask, Is it true that overuse is our main problem and fee-for-service causes it, and if not, is there a better way to solve the health care crisis?

For single-payer advocates, the answer is clear. It makes utterly no sense to replace the existing insurance industry with a hospital-based insurance industry. The existence of multiple, privately controlled insurers is the problem. Shifting control over those insurers from the traditional insurance industry to the hospital industry does not solve that problem. We need one publicly controlled insurer.

Insurance works, but not for the 36,000 who will die

Changes in Mortality After Massachusetts Health Care Reform: A Quasi-experimental Study

By Benjamin D. Sommers, MD, PhD; Sharon K. Long, PhD; and Katherine Baicker, PhD
Annals of Internal Medicine, May 6, 2014

Abstract

Background: The Massachusetts 2006 health care reform has been called a model for the Affordable Care Act. The law attained near-universal insurance coverage and increased access to care. Its effect on population health is less clear.

Objective: To determine whether the Massachusetts reform was associated with changes in all-cause mortality and mortality from causes amenable to health care.

Design: Comparison of mortality rates before and after reform in Massachusetts versus a control group with similar demographics and economic conditions.

Setting: Changes in mortality rates for adults in Massachusetts counties from 2001 to 2005 (prereform) and 2007 to 2010 (postreform) were compared with changes in a propensity score–defined control group of counties in other states.

Participants: Adults aged 20 to 64 years in Massachusetts and control group counties.

Measurements: Annual county-level all-cause mortality in age-, sex-, and race-specific cells (n = 146 825) from the Centers for Disease Control and Prevention’s Compressed Mortality File. Secondary outcomes were deaths from causes amenable to health care, insurance coverage, access to care, and self-reported health.

Results: Reform in Massachusetts was associated with a significant decrease in all-cause mortality compared with the control group (−2.9%; P = 0.003, or an absolute decrease of 8.2 deaths per 100 000 adults). Deaths from causes amenable to health care also significantly decreased (−4.5%; P < 0.001). Changes were larger in counties with lower household incomes and higher prereform uninsured rates. Secondary analyses showed significant gains in coverage, access to care, and self-reported health. The number needed to treat was approximately 830 adults gaining health insurance to prevent 1 death per year.

Limitations: Nonrandomized design subject to unmeasured confounders. Massachusetts results may not generalize to other states.

Conclusion: Health reform in Massachusetts was associated with significant reductions in all-cause mortality and deaths from causes amenable to health care.

From the Discussion

Although we cannot rule out unmeasured confounders, it is challenging to identify factors other than health care reform that might have produced this pattern of results: a declining mortality rate in Massachusetts since 2007 not present in similar counties elsewhere in the country, primarily for health care–amenable causes of death in adults aged 20 to 64 years (but not elderly adults), concentrated among poor and uninsured areas and not explained by changes in poverty or unemployment rates.

http://annals.org/article.aspx?articleid=1867050

***

Could Obamacare save 24,000 lives a year?

By Harold Pollack
healthinsurancee.org, May 5, 2014

It is a pleasure to read beautifully conducted studies on important subjects. Annals of Internal Medicine published one such study today by Benjamin Sommers, Sharon Long, and Katherine Baicker, three of the most prominent people researching health reform.

Using ten years of mortality data over the period 2000-2010, these authors compare trends in Massachusetts counties to those observed in similar counties in states that did not expand insurance coverage.

Some details are complicated. The final results are admirably clear. Deaths from causes amenable to health care declined by about 4.5 percent in Massachusetts compared with comparison counties. The annual number of deaths declined by an additional 8.2 per 100,000 non-elderly adults in Massachusetts, with larger results for counties with low average incomes and ones that began with lower rates of insurance coverage.

Sommers, Long, and Baicker then perform an intriguing calculation. They estimate that 830 adults would need to gain health insurance coverage to prevent one death per year.

The absolute numbers are also striking. The Congressional Budget Office estimates that ACA will reduce the ranks of uninsured adults by something like 20 million people. I rather heroically extrapolated the authors’ 1/830 estimate to the entire uninsured population across the U.S. This back-of-the-envelope calculation implies that ACA will prevent something like 24,000 deaths every year. That’s almost the number of Americans who die in auto crashes. It’s more than the number who die of AIDS or the number who are murdered every year.

That’s a crude calculation, of course. The authors understandably avoided such a calculation in their paper. One study of Massachusetts can hardly pin down the mortality reduction we can expect from a huge national policy. Still, the findings allow us to glimpse an order of magnitude, which is pretty impressive.

http://www.healthinsurance.org/blog/2014/05/05/could-obamacare-save-24000-lives-a-year/

Comment:

By Don McCanne, MD

This highly credible study of the changes in mortality before and after health care reform was implemented in Massachusetts indicates that one death was prevented for each 830 adults under age 65 gaining health insurance. The deaths that were prevented were concentrated in conditions most likely to be amenable to health care. Health insurance does save lives.

Prior international studies of deaths due to conditions that a well functioning health care system should prevent have shown that the United States has one of the worst rates of preventable mortality. Using the results of this study, it would be easy to conclude that the fact that we have the lowest rate of insurance coverage of all wealthy nations is a major contributor to our high rate of preventable mortality. 

Although the authors of this paper state that other confounders cannot be excluded as causes, nevertheless, they write, “it is challenging to identify factors other than health care reform that might have produced this pattern of results.” Conservative critics are already discrediting this study, yet they certainly are not providing any other reasonable explanation for the improved mortality.

Professor Harold Pollack of The University of Chicago has extrapolated the ratio of one life saved for each 830 insured and applied that to the estimated 20 million additional people who will be insured when the Affordable Care Act (ACA) is fully implemented. He estimates that 24,000 lives will be saved.

Using the same extrapolation for the roughly 30 million people who will remain uninsured after full implementation of ACA, we can estimate that about 36,000 people will die each year who would not have had they been insured. Do we really have the gall to passively accept these 36,000 deaths each year just because a few audacious individuals keep telling us that an improved Medicare for all is not politically feasible? Come on! It’s an imperative!

New push for state-funded health care

By Kelly Fay
The Legislative Gazette (Albany, N.Y.), May 6, 2014

Lawmakers, patients and health providers are urging the Legislature to pass a bill they say would provide every New Yorker with the basic human right to health care. Advocates rallied outside the Capitol Tuesday demanding the state adopt a single-payer system of health insurance and put “patients before profits.”

The universal health insurance bill, also known as New York Health, would streamline coverage for New Yorkers by replacing existing private and state health care programs with one universal program paid for by the federal and state governments. In order to do so, the state will need a waiver so that federal funding streams for specific programs can be pooled and applied toward statewide health coverage.

The concept for the bill (A.5389-a/S.2078-a) was initially introduced 23 years ago, and passed in the Assembly in 1992. However, it has not been brought to the floor for a vote since. Currently, New York Health has received the official support of 72 assembly members, but activists are confident it would pass if a vote is allowed.

Chair of the Assembly Health Committee and sponsor of the legislation Richard Gottfried said great strides were made with the passage of the federal Affordable Care Act, but more needs to be done.

“What is now crystal clear to everyone is that while you can patch it up, the system still does not work,” said Gottfried, D-Manhattan. “We do not need health insurance companies. We need to recognize that health care is a human right, not a commodity.”

Similar measures have been introduced in 26 states, but only one — Vermont — has passed legislation instituting a single-payer program. Vermont is expected to launch the program in 2017 once it has received the proper federal waivers. In California, the Legislature has passed universal health care bills twice, but the legislation did not receive the support of Gov. Arnold Schwarzenegger.

According to a 2009 study by the Urban Institute and funded by the New York state Legislature, the state could cut health care expenses — whether agency, employer or individual — by $20 billion if a single payer program were adopted.

According to Laurie Wen, executive director of the NY-Metro chapter of Physicians for a National Health Program, under a single payer system, some people, primarily wealthier individuals, may see an increase in taxes. However, she explained, other costs such as deductibles, premiums, out-of-network charges and co-pays would no longer be an issue.

More importantly, she said, the system would save the lives of six people a day who die because they do not have health coverage, and provide everyone with the same freedom of choice when choosing a physician.

“This is the most momentum we have had for this campaign in the last 22 years,” Wen said. “What we really need right now is for Speaker Silver to do the right thing. We had the majority last year for 6 months but speaker has not allowed it to come for a vote.”

Dr. Daniel Lugassy, a member of Physicians for a National Health Program, pointed out that medical bills are the leading cause of personal bankruptcy in the nation and said he encounters first-hand the problems presented by the current, profit-driven health insurance system at his job in the emergency room.

He shared a story of a woman who was experiencing a heart attack, but tried to refuse care because she was concerned she did not have adequate coverage and said many under-insured and uninsured New Yorkers face the same dilemma daily.

“I never went to medical school to practice business — I went to school to practice medicine,” Lugassy said. “A single payer system is the only way I’ll be able to do the job I was meant to do.”

New York Health is endorsed by more than 75 physician, labor and social justice groups as well as Green Party candidate for governor Howie Hawkins. It is sponsored in the Assembly by Health Committee Chair Richard Gottfried, D-Manhattan, and in the Senate by Bill Perkins, D-Harlem.

The New York State Black, Puerto Rican, Hispanic and Asian Legislative Caucus is scheduled to endorse the legislation during an event in the Capitol on Wednesday.

http://www.legislativegazette.com/Articles-Top-Stories-c-2014-05-06-87812.113122-New-push-for-statefunded-health-care.html

PNHP note: The May 6 Lobby Day was endorsed by Single Payer New York, 1199SEIU United Healthcare Workers East, American Academy of Pediatrics-District II, Capital District Alliance for Universal Healthcare, Central Labor Council – Albany, NY, Capital District Area Labor Federation, Citizen Action of New York, Committee of Interns and Residents/SEIU, Communications Workers of America District 1, Doctors Council/SEIU, Doctors for America—New York, Downtown Manhattan HCV Support Group, Finger Lakes for New York Health – Ithaca, NY, Granny Peace Brigade, Gray Panthers NYC Network, Green Party New York, Green Party of Onondaga, Labor-Religion Coalition New York State, New York HCV & HBV Support Group at O’Connor Hospital, Healthcare-NOW! NYC, Hunger Action Network of New York State, IATSE—Local 1, Interfaith Health Care Coalition of Rochester, Interfaith Impact of New York State, League of Women Voters of New York State, Metro Justice of Rochester, Move On, National Physicians Alliance—New York, New York State Academy of Family Physicians, New York State Labor Religion Coalition, New York State Nurses Association, New York State AFL-CIO, Metro New York Health Care for All Campaign, New York Lawyers for the Public Interest, Physicians for a National Health Program – Finger Lakes Chapter, Physicians for a National Health Program – NY Metro Chapter, Rekindling Reform, Single Payer New York, Statewide Senior Action Council, Sullivan County Legislature, Troy Area Labor Council, UAW Regions 9 and 9A, United University Professions, Upstate Hepatitis Awareness Project, VOCAL-NY, Westchester for Change, Working Families Party.

Single-payer health care seems to be inevitable

By Pat Barcas
Fox Valley Labor News, April 5, 2014

CHICAGO — Single-payer health care, or universal health care, is care paid for by the government through taxation. The United States does not offer this, falling woefully behind other industrialized nations in health care, and advocates want to change that through legislation.

“I think single payer is inevitable in America,” said Anne Scheetz, M.D., of the Illinois Single Payer Coalition. “Health care right now in America isn’t sustainable. It’s a terrible system and it’s going to fall apart.”

The Labor News sat down with Scheetz, and another advocate, Hale Landes of IBEW Local 134. Landes said even though many unions offer privatized health care, single payer would still benefit them.

“Health care is a huge bargaining chip in union negotiations. Take that away and we have more power. No one likes negotiating, but the thing is, the health insurance company doesn’t care, because they always win,” said Landes.

Single payer would allow for older people only working for insurance coverage to retire and open up the market, and workers comp insurance industry would vanish, because everyone would be covered.

“It really eliminates a lot of problems,” he said.

People who don’t want to pay the increased tax for covering strangers may not know they are already covering the cost. The existing system is operating extremely inefficiently, and hospitals have to raise prices for those uninsured who get treated at the emergency room.

“The vast majority of people would pay less in taxes than they pay now in premiums, co-pays, and services,” said Sheetz, who added the system we have now only serves those at the top, and snubs those at the bottom.

“Low-wage workers pay the same now as high wage-workers. It’s a huge disparity. And no one has the responsibility now of putting health care where it’s needed, so low income and rural areas have either one choice or no choice at all in an emergency,” she said.

Landes cited the efficiency of the VA in delivering quality care to those who say the government is too sloppy to handle single payer.

“The Obamacare rollout was done with private companies. It’s not always the most efficient way,” he said.

The points for single payer are staggering — a 2013 study alone showed massive savings during the first year alone if the United States switches to single payer.

Gerald Friedman, a professor of economics at the University of Massachusetts, Amherst, found that upgrading the nation’s Medicare program and expanding it to cover people of all ages would yield more than a half-trillion dollars in efficiency savings in its first year of operation, enough to pay for high-quality, comprehensive health benefits for all residents of the United States at a lower cost to most individuals, families and businesses.

Friedman said the savings would come from slashing the administrative waste associated with today’s private health insurance industry ($476 billion) and using the new, public system’s bargaining muscle to negotiate pharmaceutical drug prices down to European levels ($116 billion).

“We want people to know they can do something about this,” said Scheetz, who said representatives from the Illinois Single Payer Coalition are available for educational speaking engagements.

“Learn about single payer, contact your state senator or representative. This will help a lot of people,” Scheetz stressed.

Visit the Illinois Single Payer Coalition website to join, to obtain more information or to schedule a speaking engagement.

http://foxvalleylabornews.com/

Insurance works, but not for the 36,000 who will die

Changes in Mortality After Massachusetts Health Care Reform: A Quasi-experimental Study

By Benjamin D. Sommers, MD, PhD; Sharon K. Long, PhD; and Katherine Baicker, PhD
Annals of Internal Medicine, May 6, 2014

Abstract

Background: The Massachusetts 2006 health care reform has been called a model for the Affordable Care Act. The law attained near-universal insurance coverage and increased access to care. Its effect on population health is less clear.

Objective: To determine whether the Massachusetts reform was associated with changes in all-cause mortality and mortality from causes amenable to health care.

Design: Comparison of mortality rates before and after reform in Massachusetts versus a control group with similar demographics and economic conditions.

Setting: Changes in mortality rates for adults in Massachusetts counties from 2001 to 2005 (prereform) and 2007 to 2010 (postreform) were compared with changes in a propensity score–defined control group of counties in other states.

Participants: Adults aged 20 to 64 years in Massachusetts and control group counties.

Measurements: Annual county-level all-cause mortality in age-, sex-, and race-specific cells (n = 146 825) from the Centers for Disease Control and Prevention’s Compressed Mortality File. Secondary outcomes were deaths from causes amenable to health care, insurance coverage, access to care, and self-reported health.

Results: Reform in Massachusetts was associated with a significant decrease in all-cause mortality compared with the control group (−2.9%; P = 0.003, or an absolute decrease of 8.2 deaths per 100 000 adults). Deaths from causes amenable to health care also significantly decreased (−4.5%; P < 0.001). Changes were larger in counties with lower household incomes and higher prereform uninsured rates. Secondary analyses showed significant gains in coverage, access to care, and self-reported health. The number needed to treat was approximately 830 adults gaining health insurance to prevent 1 death per year.

Limitations: Nonrandomized design subject to unmeasured confounders. Massachusetts results may not generalize to other states.

Conclusion: Health reform in Massachusetts was associated with significant reductions in all-cause mortality and deaths from causes amenable to health care.

From the Discussion

Although we cannot rule out unmeasured confounders, it is challenging to identify factors other than health care reform that might have produced this pattern of results: a declining mortality rate in Massachusetts since 2007 not present in similar counties elsewhere in the country, primarily for health care–amenable causes of death in adults aged 20 to 64 years (but not elderly adults), concentrated among poor and uninsured areas and not explained by changes in poverty or unemployment rates.

http://annals.org/article.aspx?articleid=1867050

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Could Obamacare save 24,000 lives a year?

By Harold Pollack
healthinsurancee.org, May 5, 2014

It is a pleasure to read beautifully conducted studies on important subjects. Annals of Internal Medicine published one such study today by Benjamin Sommers, Sharon Long, and Katherine Baicker, three of the most prominent people researching health reform.

Using ten years of mortality data over the period 2000-2010, these authors compare trends in Massachusetts counties to those observed in similar counties in states that did not expand insurance coverage.

Some details are complicated. The final results are admirably clear. Deaths from causes amenable to health care declined by about 4.5 percent in Massachusetts compared with comparison counties. The annual number of deaths declined by an additional 8.2 per 100,000 non-elderly adults in Massachusetts, with larger results for counties with low average incomes and ones that began with lower rates of insurance coverage.

Sommers, Long, and Baicker then perform an intriguing calculation. They estimate that 830 adults would need to gain health insurance coverage to prevent one death per year.

The absolute numbers are also striking. The Congressional Budget Office estimates that ACA will reduce the ranks of uninsured adults by something like 20 million people. I rather heroically extrapolated the authors’ 1/830 estimate to the entire uninsured population across the U.S. This back-of-the-envelope calculation implies that ACA will prevent something like 24,000 deaths every year. That’s almost the number of Americans who die in auto crashes. It’s more than the number who die of AIDS or the number who are murdered every year.

That’s a crude calculation, of course. The authors understandably avoided such a calculation in their paper. One study of Massachusetts can hardly pin down the mortality reduction we can expect from a huge national policy. Still, the findings allow us to glimpse an order of magnitude, which is pretty impressive.

http://www.healthinsurance.org/blog/2014/05/05/could-obamacare-save-2400…

This highly credible study of the changes in mortality before and after health care reform was implemented in Massachusetts indicates that one death was prevented for each 830 adults under age 65 gaining health insurance. The deaths that were prevented were concentrated in conditions most likely to be amenable to health care. Health insurance does save lives.

Prior international studies of deaths due to conditions that a well functioning health care system should prevent have shown that the United States has one of the worst rates of preventable mortality. Using the results of this study, it would be easy to conclude that the fact that we have the lowest rate of insurance coverage of all wealthy nations is a major contributor to our high rate of preventable mortality.

Although the authors of this paper state that other confounders cannot be excluded as causes, nevertheless, they write, “it is challenging to identify factors other than health care reform that might have produced this pattern of results.” Conservative critics are already discrediting this study, yet they certainly are not providing any other reasonable explanation for the improved mortality.

Professor Harold Pollack of The University of Chicago has extrapolated the ratio of one life saved for each 830 insured and applied that to the estimated 20 million additional people who will be insured when the Affordable Care Act (ACA) is fully implemented. He estimates that 24,000 lives will be saved.

Using the same extrapolation for the roughly 30 million people who will remain uninsured after full implementation of ACA, we can estimate that about 36,000 people will die each year who would not have had they been insured. Do we really have the gall to passively accept these 36,000 deaths each year just because a few audacious individuals keep telling us that an improved Medicare for all is not politically feasible? Come on! It’s an imperative!

Health insurance CEO pay skyrockets in 2013

Some see their compensation double

Healthcare-NOW!, May 5, 2014

Chief executive officers at Fortune 500 health insurance companies, who have opposed new regulations under the Affordable Care Act, emerged this month as one of the ACA’s greatest beneficiaries. Recently filed financial reports show that average compensation for these top nine health insurance CEOs rose by more than 19 percent in 2013, while several of the nation’s largest insurers more than doubled CEO pay.

The biggest winner was Aetna CEO Mark Bertolini, who received a staggering $30.7 million compensation package in 2013. This marks the largest payout to any health insurance executive since passage of the ACA and exceeded the compensation of the next two highest paid health insurer CEOs combined. The Bertolini pay package, which included a large “special one-time performance-based retention award,” represented a 131 percent increase over his $13.3 million compensation in 2012. (See table below.)

Molina Healthcare and Centene, both Fortune 500 insurers that specialize in privately managed Medicaid plans, roughly doubled CEO compensation in 2013. J. Mario Molina received $11.9 million, up from $5 million in 2012, while Centene’s CEO Michael Neidorff made $14.5 million, up from $8.5 million. Overall, average CEO pay across Fortune 500 health insurers rose from $11.6 million in 2012 to $13.9 million in 2013.

The disclosures of higher CEO pay coincided with several of the same companies announcing better-than-expected earnings in the first quarter of 2014, even as they signaled that patients and businesses should prepare for increased insurance premiums in 2015.

“For far too long, private health insurance executives have received outsized compensation packages – subsidized by the ever-increasing premiums of hardworking Americans – while millions of low-income individuals and those with pre-existing conditions went uninsured,” says Representative John Conyers, Jr. (D-Mich.). “The United States’ healthcare sector has been in need of repair for decades, and over the top executive compensation is emblematic of the failure of our private health insurance system. While the Affordable Care Act is a good first step, truly universal coverage and meaningful reform to our healthcare system can be provided only through a single-payer system. I have introduced H.R. 676 – the Expanded and Improved Medicare for All Act – since 2003 to live up to this aim of universal care and establish health insurance as a basic right rather than a for-profit industry,” he continued.

“Families and patients are being asked to tighten their belts in the face of rising healthcare costs, while our premiums are being used to subsidize even more astronomical compensation for the already wealthy,” said Benjamin Day, director of organizing at Healthcare-NOW!, a nonprofit group that advocates for a single-payer system, sometimes called “an improved Medicare for all.”

“In contrast, the top administrator of Medicare – our public, universal health plan for all seniors, which is more efficient, provides better financial protection, and receives higher marks from patients than private health insurers – is paid less than $200,000 per year. The culture of excess at these for-profit corporations is incompatible with the goals of an efficient, ethical health care system, where every dollar diverted from patient care represents a loss of access for real families.”

Day continued: “We face the highest healthcare costs and have among the worst health outcomes of any country in the developed world because we allow private health insurers and dozens of other intermediaries to act as for-profit middlemen in the health care system. Although many backers of the Affordable Care Act said it would rein in insurance company excesses, the law clearly hasn’t curtailed top executive pay.”

“Thirty-million-dollar CEO paychecks – millions that should be spent on saving lives, not making the rich richer – should be a stark reminder that a single-payer, Medicare-for-All program would lower costs by spending every available dollar on patient care, and making access to care an inalienable right for everyone in the United States,” Day said.

Graphics:

Chart: 2012 and 2013 Health Insurance CEO and Average Worker Compensation

https://salsa.wiredforchange.com/o/6055/images/2013CEOPayChart1.jpg

Bar Graph: 2013 Health Insurance CEO, CMS Administrator, and Average Worker Compensation

https://salsa.wiredforchange.com/o/6055/images/2013CEOWages1.jpg

Sources:

  1. Securities and Exchange Commission, 10-K Annual Reports
  2. Securities and Exchange Commission, DEF 14A Proxy Statements

(Both available at https://www.sec.gov/edgar/searchedgar/companysearch.html)

Embracing Fee-For-Non-Service – Again!

Report of The National Commission on Physician Payment Reform

Society of General Internal Medicine, March 2013

Recognizing that the level of spending on health care in the United States is unsustainable, the return on investment is generally poor, and the way that physicians are paid contributes substantially to the high cost of health care, The Society of General Internal Medicine (SGIM) convened The National Commission on Physician Payment Reform in March 2012 to recommend new ways to pay physicians that will ultimately improve patient outcomes but also rein in health care costs.

The commission’s recommendations focus on the near-term, calling for drastic changes to the current fee-for-service payment system and a five-year transition to a physician- payment system that rewards quality and value-based care. The recommendations pertain to the way physicians are paid throughout the health care system — both public and private payers.

http://physicianpaymentcommission.org/wp-content/uploads/2013/03/physician_payment_report.pdf

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Do We Get What We Pay For? Transitioning Physician Payments Towards Value and Efficiency

By Malathi Srinivasan and Mark D. Schwartz
Editorial, Journal of General Internal Medicine, May 2014

In March 2013… the National Commission on Physician Payment Reform (NCPPR), released a report with twelve recommendations to reform how physicians are paid, linking incentives to quality in patient care to curtail rising health care costs.

In this issue, SGIM ad hoc Committee members offer three Comments addressing the Commission’s recommendations. First, Selker and colleagues review the first three recommendations, which argue for phasing out the current volume-based, fee-for service (FFS) reimbursement model over 5 years, to be replaced by a system emphasizing value and efficiency, with incentives that promote high quality, coordinated, and cost-effective, patient-centered care. Then Siddiqui et al., addressing Commission recommendations four through nine, contend that while transitioning away from FFS, the US must strengthen the primary care foundation of high performing healthcare systems, notably evaluation, management and preventive services. Finally, Patel and Nadel examine the Commission’s last three recommendations, arguing that Medicare’s Sustainable Growth Rate (SGR) formula be repealed and replaced with policy that rewards value rather than volume, and that is based on a valuation of physician work that rectifies the current relative value unit (RVU) bias in favor of procedural compared with cognitive-based services.

http://link.springer.com/article/10.1007/s11606-014-2818-9/fulltext.html

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Global Amnesia: Embracing Fee-For-Non-Service — Again

By David U. Himmelstein, MD and Steffie Woolhandler, MD, MPH
Editorial and Comment, Journal of General Internal Medicine, May 2014

Now SGIM’s Commission has joined the growing policy bandwagon to reanimate the HMO strategy. There are semantic changes — ACO has replaced HMO, and when insurers drop expensive doctors (e.g. the 1,000-member Yale Medical Group5), it’s called “network optimization” not “delisting”. In a new twist on gag clauses, today’s ACO patients (e.g. seniors in Medicare’s Pioneer ACOs) aren’t told they’re enrolled. But the diagnosis and prescription are unchanged.

As in 1971, fee-for-service is the culprit. A shift to “bundled payment, capitation, and increased financial risk sharing” is the solution, with “risk adjustment… to avoid physicians and other providers cherry-picking the healthiest patients”; and “quality measures… to assure that evidence- based care is not denied as a cost-saving mechanism.”

Twentieth century risk adjustment and quality monitoring were overmatched by HMOs’ gaming and deception. Despite additional decades of work to devise bullet-proof risk adjustment, gaming remains so powerful and pervasive that cost and quality rankings are often distorted, or even inverted. No solution is on the horizon.

Conclusion

Like the SGIM Commission, we rue the toxic incentives of the current fee-for-service system. But in the profit-maximizing milieu of American medicine, capitation risks making things even worse. “Risk-sharing” too often means that physicians earn bonuses for denying care — a danger perceived by patients, who take a dim view of capitation. Risk-sharing is not simply the inverse of fee-for-service, but of fee splitting, the illegal practice of kickbacks for referrals.

There are many bad ways to pay doctors, and no particularly good ones. Other nations have achieved better outcomes, lower costs and fairer compensation of physicians using a variety of methods: fee-for-service, capitation, and salary; none is clearly best. The common theme isn’t mode of payment, but a universal system with regulations that restrain costs and minimize the opportunities for profit and the risk of loss.

Payment reform should focus not on manipulating greed, but on dampening it. Then the real motivations for good doctoring — altruism, social duty, and the glow we feel when we help our patients — can flourish.

Use the following link to read the entire article or to download the PDF: http://link.springer.com/article/10.1007/s11606-013-2745-1

Comment:

By Don McCanne, MD

Regarding controlling health care spending, the meme of this decade seems to be that we must start paying based on value and not volume, as if the greatest value would be realized by reducing the volume of health care to as close to zero as possible.

There are plenty of articles on how this might be accomplished, many of them centering on concepts such as accountable care organizations and bundling of payments. What seems to be missing are comprehensive discussions of how unrealistic and misdirected these proposals are.

That is why it is important that you download the article by Himmelstein and Woolhandler. It should be used in your advocacy work to move us away from the empty managed-care promise of supposedly replacing volume with value, so that we can move forward with reform that actually will improve value – a single payer national health program.

Is The Commonwealth Fund serious about searching for disruptive breakthroughs?

Searching for the Next Breakthrough in Health Care

By Anne-Marie J. Audet, M.D, M.Sc., S.M.
The Commonwealth Fund, May 5, 2014

It is well documented that health care in the United States is not just expensive; it’s world-class expensive, and unsustainably so. And although many would like to believe that all that spending buys us the safest, most effective care to be found anywhere on the planet, it is equally well documented that our health care system, on many levels, doesn’t measure up on a global scale. We’re simply not getting what we pay for.

Clearly, it’s going to take more than minor tweaks or adjustments to change our course. It’s going to take a real breakthrough.

What do we mean by a breakthrough? Though incremental change is valuable, and The Commonwealth Fund pursues this in many of its other programs, that’s not what we’re looking for here. We mean an idea, a paradigm, a strategy that positively and profoundly disrupts the status quo.

The Commonwealth Fund’s new Breakthrough Health Care Opportunities program aims to discover and vet transformative ideas that have the potential to expand access to care, dramatically simplify the delivery of care, decrease costs, and improve health outcomes.

We’ve set the bar high. Here are our working criteria for a breakthrough:

  • How much does it disrupt the status quo? We’re looking for major disruption—a whole new approach that represents a break with what we do now.
  • How big a difference will it make? Broad societal impact is the goal, with large numbers of people benefiting nationwide. To gauge impact, we’re using a 20/20 rule for screening breakthroughs: the potential must be at least a 20 percent improvement in health care quality and/or a 20 percent reduction in costs nationally.
  • How quickly can it become a reality? The timeframe we envision is up to 10 years to achieve impact.

Our work in exploring breakthrough opportunities is just beginning. We will seek ideas from a broad network of colleagues, and communicating what we find along the way. Please share your thoughts with us here or Tweet them with the hashtag #hcbreakthrus.

http://www.commonwealthfund.org/Blog/2014/May/Searching-for-the-Next-Bre…

Breakthrough Health Care Opportunities: http://www.commonwealthfund.org/Program-Areas/Breakthrough-Health-Care-O…

The Commonwealth Fund’s new Breakthrough Health Care Opportunities program is looking for “major disruption – a whole new approach that represents a break with what we do now.” They aim to “discover and vet transformative ideas that have the potential to expand access to care, dramatically simplify the delivery of care, decrease costs, and improve health outcomes.”

Uh, there is a great idea already out there that would seem to be just what they are looking for – a well designed single payer system. It is highly unlikely that anyone will come up with any other idea that does not yet exist which is a truly disruptive, transformative breakthrough that will achieve their goals. It is much more likely that proposals will be for incremental tweaks or adjustments which they say they are not looking for.

But are they serious? As one example of “the scale and ambition we believe are needed to achieve dramatic improvements in U.S. health care” they suggest “the massive and widespread implementation of financial risk-sharing arrangements to encourage more careful allocation of resources and create incentives to keep patients healthy.” Yikes! We already have introduced that with accountable care organizations and their predecessors, and the results to date indicate that improvements are negligible or worse. A special form of risk sharing – requiring patients to pay more of the costs of the care they obtain – might slow spending very modestly but at a cost of increasing financial hardship and impairing health care access.

Although single payer is not a new concept, it would certainly be a beneficial, disruptive breakthrough for the United States. It will be interesting to see if they are really serious about considering all ideas, or if this will be yet another ABSP proposal. (ABSP – Anything But Single Payer).

Singular solution

By Ana Malinow, M.D.
Pittsburgh Post-Gazette, Letters, May 4, 2014

Kudos to Bill Toland for his April 27 piece “How Did America End Up With This Health Care System?” To briefly summarize 100 years of our patchwork, dysfunctional health care system is almost as remarkable as finding a real solution for it. Mr. Toland gets all the particulars right, but the solution will not be found in the Affordable Care Act, no matter how long we wait for it to change.

As Americans gain more experience with the ACA, they will become disappointed when they realize that plans in the marketplace have low actuarial value and high deductibles. Narrow provider networks will prevent Americans from having choices in physicians and hospitals. Those previously satisfied with their employer-sponsored coverage will find they, too, have fewer options at greater cost. This incremental step will put billions in the pockets of insurance companies, entrenching them further in our system.

The solution today as in 1915, when the first national health insurance bill was introduced in Congress, is a health care system that is truly universal, affordable, accountable, accessible, sustainable and just.

Only with a single-payer system or improved and expanded Medicare for all will we ever have a health care system worth $2.8 trillion — something that cannot be said for what we have today or what we are getting under the ACA.

Dr. Ana Malinow resides in Shadyside.

Read more: http://www.post-gazette.com/opinion/letters/2014/05/04/Singular-solution/stories/201405040080#ixzz30lTqtxS7