PNHP

Medicine and Money

Medicine and Money

On Medicine and Money

By Eli Y. Adashi, MD, MS
JAMA Forum, April 30, 2014

As might have been anticipated, much of the media coverage of the release of the CMS data focused attention on health care professionals dubbed “Medicare millionaires” and their practice patterns. Tantalizing as such details might be, more profound issues were being sidestepped. In particular, little has been said with respect to the uncomfortable relationship between medicine and money.

This is an unfortunate state of affairs, because the ethical and moral challenges associated with the juxtaposition of medicine and money are highly deserving of our attention.

Many see the pairing of money and medicine as a nonissue, and instead view it as capitalism at its best, with medicine being just another market in which competition reigns supreme. For proponents of this point of view, health care professionals might be seen as operatives in a retail business, wherein the volume of sales (of health services) carries the day, creating a vibrant health care market that sparks the scientific innovations upon which we have all come to depend. They see the business model of medicine as no different than that of any other field of pursuit, naturally rooted in foundational libertarian principles. Viewed in this light, the intersection of medicine and money is as American as apple pie. Exemplified by the time-honored “private practice” of medicine, this all-out embrace of the business principles of a market economy remains undiminished—if increasingly untenable.

But there’s a potential flaw in this line of reasoning: the presumption of a fail-safe firewall between financial considerations and clinical decision making. Sadly, that may not always be the case.

Clearly, opinions vary widely as to the ethical and moral wisdom of mixing medicine with money. Some would favor a lightly regulated, self-policing field, wherein unfettered entrepreneurship and Medicare millionaires are bound to thrive. According to this outlook, infractions perpetrated by a select few do not warrant the imposition of blanket, heavy-handed oversight.

But those who consider medicine and money to constitute a volatile mix may express preference for another model, such as a national health care system buttressed by a single governmental payer, in which value rather than volume of services determine provider compensation. Under this system, Medicare millionaires are unlikely to flourish.

http://newsatjama.jama.com/2014/04/30/jama-forum-on-medicine-and-money/

****

Comment:

By Don McCanne, MD

Physician. Seeing that word, what comes into your mind? Do you think of a person who is dedicated to promotion of health and healing of the sick? Or do you think of an occupation that is as American as apple pie in its dedication to retail business within the entrepreneurial health care marketplace?

Medicine is different. Those favoring unfettered entrepreneurship with the chance to become a Medicare millionaire really do not belong in the field. Most physicians find the imposition of money considerations into the relationship between the physician and the patient to be a great nuisance, if not outright repulsive.

Dr. Adashi reminds us that there is another model that would be preferred by most physicians who would rather be healers than entrepreneurial businessmen. That preferred model is “a national health care system buttressed by a single governmental payer.”

Isn’t it time for us to change our model?

Medicine and Money

On Medicine and Money

By Eli Y. Adashi, MD, MS
JAMA Forum, April 30, 2014

As might have been anticipated, much of the media coverage of the release of the CMS data focused attention on health care professionals dubbed “Medicare millionaires” and their practice patterns. Tantalizing as such details might be, more profound issues were being sidestepped. In particular, little has been said with respect to the uncomfortable relationship between medicine and money.

This is an unfortunate state of affairs, because the ethical and moral challenges associated with the juxtaposition of medicine and money are highly deserving of our attention.

Many see the pairing of money and medicine as a nonissue, and instead view it as capitalism at its best, with medicine being just another market in which competition reigns supreme. For proponents of this point of view, health care professionals might be seen as operatives in a retail business, wherein the volume of sales (of health services) carries the day, creating a vibrant health care market that sparks the scientific innovations upon which we have all come to depend. They see the business model of medicine as no different than that of any other field of pursuit, naturally rooted in foundational libertarian principles. Viewed in this light, the intersection of medicine and money is as American as apple pie. Exemplified by the time-honored “private practice” of medicine, this all-out embrace of the business principles of a market economy remains undiminished—if increasingly untenable.

But there’s a potential flaw in this line of reasoning: the presumption of a fail-safe firewall between financial considerations and clinical decision making. Sadly, that may not always be the case.

Clearly, opinions vary widely as to the ethical and moral wisdom of mixing medicine with money. Some would favor a lightly regulated, self-policing field, wherein unfettered entrepreneurship and Medicare millionaires are bound to thrive. According to this outlook, infractions perpetrated by a select few do not warrant the imposition of blanket, heavy-handed oversight.

But those who consider medicine and money to constitute a volatile mix may express preference for another model, such as a national health care system buttressed by a single governmental payer, in which value rather than volume of services determine provider compensation. Under this system, Medicare millionaires are unlikely to flourish.

http://newsatjama.jama.com/2014/04/30/jama-forum-on-medicine-and-money/

Physician. Seeing that word, what comes into your mind? Do you think of a person who is dedicated to promotion of health and healing of the sick? Or do you think of an occupation that is as American as apple pie in its dedication to retail business within the entrepreneurial health care marketplace?

Medicine is different. Those favoring unfettered entrepreneurship with the chance to become a Medicare millionaire really do not belong in the field. Most physicians find the imposition of money considerations into the relationship between the physician and the patient to be a great nuisance, if not outright repulsive.

Dr. Adashi reminds us that there is another model that would be preferred by most physicians who would rather be healers than entrepreneurial businessmen. That preferred model is “a national health care system buttressed by a single governmental payer.”

Isn’t it time for us to change our model?

P4P harms poor patients

Health law’s pay policy is skewed, panel finds

By Robert Pear
The New York Times, April 28, 2014

Federal policies to reward high-quality health care are unfairly penalizing doctors and hospitals that treat large numbers of poor people, according to a new report commissioned by the Obama administration that recommends sweeping changes in payment policy.

Medicare and private insurers are increasingly paying health care providers according to their performance as measured by the quality of the care they provide. But, the draft report by an expert panel says, the measures of quality are fundamentally flawed because they do not recognize that it is often harder to achieve success when treating people who do not have much income or education.

Low-income people may be unable to afford needed medications or transportation to doctor’s offices and clinics, the panel said. If they have low levels of formal education or literacy, they may have difficulty understanding or following written instructions for home care and the use of medications. In addition, the clinics and hospitals they use may lack the resources and high tech equipment needed to diagnose and treat illnesses.

The panel found that existing payment policies unintentionally worsen disparities between rich and poor by shifting money away from doctors and hospitals that care for “disadvantaged patients.”

Measures of health care quality and performance — widely used by Medicare and private insurers in calculating financial rewards and penalties — should be adjusted for various “sociodemographic factors,” the expert panel said. The panel was created by the National Quality Forum, an influential nonprofit, nonpartisan organization that endorses health care standards.

….The Obama administration commissioned the study, but is not entirely comfortable with the recommendations, officials acknowledged. The existing policies of the National Quality Forum and the government say performance scores should generally not be adjusted or corrected to reflect differences in the income, race or socioeconomic status of patients.

…. “We do not want to hold hospitals to different standards of care simply because they treat a large number of low-socioeconomic-status patients,” said Dr. Kate Goodrich, the director of quality measurement programs at the federal Centers for Medicare and Medicaid Services. “Our position has always been not to risk-adjust for socioeconomic status within our measures because of concern about masking disparities, and potentially rewarding providers who provide a lower level of care for minorities or poor patients.”

Comment:

By Kip Sullivan

The notion that doctors and hospitals are screwing up and will behave if they are subjected to punishment and reward by third parties is not new. The Code of Hammurabi (1750 BC) subjected Mesopotamian doctors to a combination of reward (more shekels) and punishment (cutting off of doctors’ hands)  http://economix.blogs.nytimes.com/2013/04/26/hammurabis-code-and-u-s-health-care/.  But even Hammurabi didn’t recommend punishing the patients.

But that is effectively the position taken by the National Quality Forum (NQF), the Obama administration, and the numerous private-sector firms and groups that peddle pay-for-performance (P4P) as a solution to the health care crisis. By refusing to adjust scores on report cards to reflect patient socioeconomic status (SES), P4P proponents are guaranteeing that the P4P fad will punish clinics and hospitals that serve poorer patients.

It is widely known that report cards on clinics and hospitals that are used in P4P schemes are, with rare exceptions, poorly adjusted to reflect differences in patient health. It is also widely known that report cards are almost never adjusted for income, insurance status and other SES indicators. But what was not widely known until Monday’s report in the New York Times was that the NQF and the Obama administration have actually endorsed a policy of prohibiting the use of SES data to adjust scores on report cards.

Why would the NQF go to the trouble of explicitly outlawing the use of SES adjusters and thus draw attention to a serious defect in virtually all P4P schemes in use in America today?

As is always the case with managed care propositions, finding a well-documented argument for the NQF’s position is impossible. All we have is this tiny remark in footnote 15 in an NQF document:

“Risk models should not obscure disparities in care for populations by including factors that are associated with differences/inequalities in care, such as race, socioeconomic status, or gender (e.g., poorer treatment outcomes of African American men with prostate cancer or inequalities in treatment for CVD risk factors between men and women).” http://www.qualityforum.org/docs/measure_evaluation_criteria.aspx

Like most report-card proponents, the NQF gives at least lip service to the necessity of adjusting scores to reflect differences in patient health because (a) these differences affect quality measures and (b) they are beyond provider control. Why, then, wouldn’t the NQF treat SES factors the same way? Patients’ low income, their lack of health insurance, their illiteracy and other factors subsumed under the concept of low SES status affect the outcome of medical care, and they are all way beyond the control of providers.

The basic premise of the NQF and the Obama administration is that the only way for policy makers to know if medical care has worse outcomes in poor people is via report cards. This premise is so foolish its mere statement constitutes a rebuttal.

The NQF “argument” then goes on to claim that the benefits of revealing disparities in health care outcomes via report cards outweighs the damage done to providers who treat poor people and to poor people themselves. Or at least that’s what we have to imagine went through the minds of the folks at NQF. As I said, the proponents of this bizarre policy apparently did not feel compelled to leave a paper trail that would help the rest of us comprehend their thinking.

It was the existence of this strange policy that led to the convening of the expert panel described in the Times article. http://www.qualityforum.org/Risk_Adjustment_SES.aspx The panel rejected the NQF-administration rationale by huge margins. According to the panel’s report:

“There is a clear and expanding body of evidence to suggest that providers serving ‘low-socio-demographic’ populations and communities are more likely to be identified as ‘poor performers’ and either be less likely to receive financial rewards, or be more likely to face financial penalties, in pay-for-performance programs.”

“The net effect,” said the panel, “could worsen rather than ameliorate healthcare disparities.”  To avoid this outcome, said the panel, the NQF should “reconsider” its policy. If the NQF remains concerned that lawmakers may remain in the dark about disparities in health outcomes, it should seek evidence for such disparities through other, more traditional means. In the future, the panel concluded, “purchasers, policymakers and other users of performance measures should assess the potential impact on disadvantaged patient populations …. (p. 10)” before imposing P4P schemes.

How did it come to this? Why do our country’s top health policy makers have to be told to honor the fundamental principles of science and medicine, namely, make sure whatever you recommend is safe and effective before administering it?

There are some big obstacles to achieving universal coverage in the US under a single-payer system. None is more serious than the sloppiness of managed care think – the refusal of the health policy elite to honor the equivalent of evidence-based medicine and the equivalent of the Hippocratic Oath. It encourages lawmakers to buy cheap, snake oil health policy in place of real medicine. All of us who care about an efficient and humane health care system in the US must redouble our efforts to shine a light on the establishment’s cavalier attitude toward science and ethics in health policy.

The Canadian health care system I disparaged

Single-payer regime up north represents a better way

By Wendell Potter
The Center for Public Integrity, April 28, 2014

When I returned home after a two-week speaking tour of Canada and began catching up on news about Obamacare, I was angry and upset, and not just at politicians and special interests that benefit from deception-based PR tactics. I was — and still am — mostly angry and upset with myself. And I know I always will be.

Over the course of a two-decade career as a health insurance executive, I spent hours and hours implementing my industry’s ongoing propaganda campaign to mislead people about the Canadian health care system. We spread horror stories about “rationed care” and long waiting times for medically necessary care. Our anecdotes were not at all representative of most Canadians’ experiences, but we spent millions of dollars to persuade Americans that they were.

At every stop between Halifax and Vancouver this month, I explained how the United States had achieved the dubious distinction of having both the most expensive health care system on the planet and also one of the most inequitable. While Canadian lawmakers in the 1960s were implementing a partnership between the federal and provincial governments to create the country’s publicly funded universal health insurance system — known as Medicare — our lawmakers in Washington were establishing America’s own single-payer Medicare program, but only for folks 65 and older and some younger disabled people. Congress also created the federal and state-administered Medicaid program for the nation’s poor.

Ever since, most of the rest of us have had to deal with private insurance companies and pay whatever they felt like charging us for coverage. Canadians are also paying more for coverage these days because of medical inflation and an aging population, but not nearly as much more as we in the U.S. are paying. Just about everybody in every audience I stood before gasped when I told them that health insurance premiums in the U.S. increased 131 percent between 1999 and 2009 — the main reason why 50 million of us were uninsured at the end of the last decade — and that by 2013 the average employer-based family policy cost $16,351.

At one stop in Toronto, I was asked if there was anything about the U.S. system that Canadians should consider adopting. I was stumped. I noted that while we had some of the world’s best doctors and hospitals, they were in many cases off-limits to millions of Americans, many of whom were uninsured because of preexisting conditions that made them “uninsurable” in the eyes of private insurance companies.

Later, on reflection, I realized I should have mentioned some aspects of our Medicare system and our other single-payer program — the Veterans Health Administration — both of which consistently out-perform private insurers in customer satisfaction surveys.

The two aspects of our Medicare system worth emulating are: (1) the fact that it’s a federal arrangement, meaning that benefits and services do not vary from state to state, and (2) the prescription drug benefit (Medicare Part D) that Congress added a few years ago. The Canadian Medicare program is akin to our Medicaid program in that the provinces have broad latitude in administering benefits and services. As a consequence, Albertans’ experience with Medicare can be quite different from that of Newfoundlanders. And the Canadian Medicare program still does not cover medications. Canadians have to buy private insurance for their prescriptions. Consumer advocates there continue to push for the adoption of a nationwide drug benefit.

As for the Veterans Health Administration, which owns and operates its own hospitals, it not only gets higher customer-service scores than private hospitals, it is frequently cited for better health outcomes. For example, the RAND Corporation found in a 2004 study published in the Annals of Internal Medicine that the VHA outperformed all other sectors of the U.S. health care system in 294 measures of quality.

In other words, Canadians should consider making their system even more public than it is, rather than more private.

I usually began my remarks in Canada with an apology — for all the misinformation I helped spread in the U.S. about their system, which, by the way, continues to have overwhelming support. I didn’t encounter a single Canadian who didn’t talk about their Medicare program with pride.

Back in the states, among the distressing pieces I read was a New York Times story last Monday based on interviews with Americans who said they had decided to remain uninsured either because they couldn’t afford to pay the premiums or had just decided to gamble with their health and personal finances.

Those are decisions completely unknown and unnecessary in Canada, where the per capita spending on health care is far lower than it is here and where people live longer.

Former CIGNA executive-turned-whistleblower Wendell Potter writes about the health care industry and the ongoing battle for health reform.

http://www.publicintegrity.org/2014/04/28/14674/canadian-health-care-system-i-disparaged

P4P harms poor patients

Health law’s pay policy is skewed, panel finds

By Robert Pear
The New York Times, April 28, 2014

Federal policies to reward high-quality health care are unfairly penalizing doctors and hospitals that treat large numbers of poor people, according to a new report commissioned by the Obama administration that recommends sweeping changes in payment policy.

Medicare and private insurers are increasingly paying health care providers according to their performance as measured by the quality of the care they provide. But, the draft report by an expert panel says, the measures of quality are fundamentally flawed because they do not recognize that it is often harder to achieve success when treating people who do not have much income or education.

Low-income people may be unable to afford needed medications or transportation to doctor’s offices and clinics, the panel said. If they have low levels of formal education or literacy, they may have difficulty understanding or following written instructions for home care and the use of medications. In addition, the clinics and hospitals they use may lack the resources and high tech equipment needed to diagnose and treat illnesses.

The panel found that existing payment policies unintentionally worsen disparities between rich and poor by shifting money away from doctors and hospitals that care for “disadvantaged patients.”

Measures of health care quality and performance — widely used by Medicare and private insurers in calculating financial rewards and penalties — should be adjusted for various “sociodemographic factors,” the expert panel said. The panel was created by the National Quality Forum, an influential nonprofit, nonpartisan organization that endorses health care standards.

….The Obama administration commissioned the study, but is not entirely comfortable with the recommendations, officials acknowledged. The existing policies of the National Quality Forum and the government say performance scores should generally not be adjusted or corrected to reflect differences in the income, race or socioeconomic status of patients.

…. “We do not want to hold hospitals to different standards of care simply because they treat a large number of low-socioeconomic-status patients,” said Dr. Kate Goodrich, the director of quality measurement programs at the federal Centers for Medicare and Medicaid Services. “Our position has always been not to risk-adjust for socioeconomic status within our measures because of concern about masking disparities, and potentially rewarding providers who provide a lower level of care for minorities or poor patients.”

http://www.nytimes.com/2014/04/28/us/politics/health-laws-pay-policy-is-…

The notion that doctors and hospitals are screwing up and will behave if they are subjected to punishment and reward by third parties is not new. The Code of Hammurabi (1750 BC) subjected Mesopotamian doctors to a combination of reward (more shekels) and punishment (cutting off of doctors’ hands)  http://economix.blogs.nytimes.com/2013/04/26/hammurabis-code-and-u-s-health-care/.  But even Hammurabi didn’t recommend punishing the patients.

But that is effectively the position taken by the National Quality Forum (NQF), the Obama administration, and the numerous private-sector firms and groups that peddle pay-for-performance (P4P) as a solution to the health care crisis. By refusing to adjust scores on report cards to reflect patient socioeconomic status (SES), P4P proponents are guaranteeing that the P4P fad will punish clinics and hospitals that serve poorer patients.

It is widely known that report cards on clinics and hospitals that are used in P4P schemes are, with rare exceptions, poorly adjusted to reflect differences in patient health. It is also widely known that report cards are almost never adjusted for income, insurance status and other SES indicators. But what was not widely known until Monday’s report in the New York Times was that the NQF and the Obama administration have actually endorsed a policy of prohibiting the use of SES data to adjust scores on report cards.

Why would the NQF go to the trouble of explicitly outlawing the use of SES adjusters and thus draw attention to a serious defect in virtually all P4P schemes in use in America today?

As is always the case with managed care propositions, finding a well-documented argument for the NQF’s position is impossible. All we have is this tiny remark in footnote 15 in an NQF document:

“Risk models should not obscure disparities in care for populations by including factors that are associated with differences/inequalities in care, such as race, socioeconomic status, or gender (e.g., poorer treatment outcomes of African American men with prostate cancer or inequalities in treatment for CVD risk factors between men and women).”http://www.qualityforum.org/docs/measure_evaluation_criteria.aspx

Like most report-card proponents, the NQF gives at least lip service to the necessity of adjusting scores to reflect differences in patient health because (a) these differences affect quality measures and (b) they are beyond provider control. Why, then, wouldn’t the NQF treat SES factors the same way? Patients’ low income, their lack of health insurance, their illiteracy and other factors subsumed under the concept of low SES status affect the outcome of medical care, and they are all way beyond the control of providers.

The basic premise of the NQF and the Obama administration is that the only way for policy makers to know if medical care has worse outcomes in poor people is via report cards. This premise is so foolish its mere statement constitutes a rebuttal.

The NQF “argument” then goes on to claim that the benefits of revealing disparities in health care outcomes via report cards outweighs the damage done to providers who treat poor people and to poor people themselves. Or at least that’s what we have to imagine went through the minds of the folks at NQF. As I said, the proponents of this bizarre policy apparently did not feel compelled to leave a paper trail that would help the rest of us comprehend their thinking.

It was the existence of this strange policy that led to the convening of the expert panel described in the Times article. http://www.qualityforum.org/Risk_Adjustment_SES.aspxThe panel rejected the NQF-administration rationale by huge margins. According to the panel’s report:

“There is a clear and expanding body of evidence to suggest that providers serving ‘low-socio-demographic’ populations and communities are more likely to be identified as ‘poor performers’ and either be less likely to receive financial rewards, or be more likely to face financial penalties, in pay-for-performance programs.”

“The net effect,” said the panel, “could worsen rather than ameliorate healthcare disparities.”  To avoid this outcome, said the panel, the NQF should “reconsider” its policy. If the NQF remains concerned that lawmakers may remain in the dark about disparities in health outcomes, it should seek evidence for such disparities through other, more traditional means. In the future, the panel concluded, “purchasers, policymakers and other users of performance measures should assess the potential impact on disadvantaged patient populations …. (p. 10)” before imposing P4P schemes.

How did it come to this? Why do our country’s top health policy makers have to be told to honor the fundamental principles of science and medicine, namely, make sure whatever you recommend is safe and effective before administering it?

There are some big obstacles to achieving universal coverage in the US under a single-payer system. None is more serious than the sloppiness of managed care think – the refusal of the health policy elite to honor the equivalent of evidence-based medicine and the equivalent of the Hippocratic Oath. It encourages lawmakers to buy cheap, snake oil health policy in place of real medicine. All of us who care about an efficient and humane health care system in the US must redouble our efforts to shine a light on the establishment’s cavalier attitude toward science and ethics in health policy.

Ezekiel Emanuel: “Reinventing American Health Care”

Reinventing American Health Care: How the Affordable Care Act Will Improve our Terribly Complex, Blatantly Unjust, Outrageously Expensive, Grossly Inefficient, Error Prone System

By Ezekiel J. Emanuel
PublicAffairs

There are 4 things the average physician can do. One is to begin the process of transformation to more efficient practice, knowing that payment changes that move away from fee for service are inevitably coming.

Second, part of this transformation means that physicians will need to change their business model to increasing efficiency in their delivery of the services.

Third, physicians should engage insurers to try to modify contracts so that they have a financial reward for being more efficient.

Finally, these impending changes confront many physicians with the major existential question of whether to sell their practice to a hospital system or remain independent.

==

Six megatrends

* End of insurance companies as we know them

Insurance companies will either become purveyors of management analytics, and actuarial services, or integrated delivery systems actually employing (or contracting with) hospitals, physicians, and other providers to render patient care.

* VIP care for the chronically and mentally ill

Physicians and hospitals will focus on keeping patients with chronic illnesses healthy and out of the emergency room and hospital, thereby decreasing the frequency of avoidable complications and rate of hospitalization. Then they will begin routinely screening for depression and other mental health problems and develop standardized rapid interventions.

* The emergence of digital medicine and closure of hospitals

Over 1,000 acute-care hospitals will close. We will see a slew of new technologies for remote monitoring, testing, and treating patients in real time outside of the hospital and physicians’ offices.

* End of employer-sponsored health insurance

Fewer than 20% of workers in the private sector will receive traditional employer-sponsored health insurance.

* End of health care inflation

Health care inflation will be GDP+0%.

* Transformation of medical education

Medical education will be transformed in 4 fundamental ways: (1) three-year medical schools and shorter residencies; (2) half of medical school clinical training will be outside of hospitals; (3) integration of nurses, pharmacists, social workers with medical students in multi-professional team training; and (4) formal incorporation of population health and management skills in training.

==

Regardless of the short-term political costs, in the longer sweep of history, beginning in 2020 or so, the ACA will increasingly be seen as a world historical achievement, even more important for the United States than Social Security and Medicare had been. And Barack Obama will be viewed more like Harry Truman – judged with increasing respect over time.

http://www.publicaffairsbooks.com/book/hardcover/reinventing-american-health-care/9781610393454

Ezekiel J. Emanuel, speaking about his book, “Reinventing American Health Care: How the Affordable Care Act Will Improve Our Terribly Complex, Blatantly Unjust, Outrageously Expensive, Grossly Inefficient, Error Prone System”

Politics and Prose, April 16, 2014

Q&A

At 39:30

Harvey Fernbach:  I’m a member of Physicians for a National Health Program. We believe in single payer simplicity, Medicare for all. As you know the president was for single payer, he said it, he’s for Medicare for all. Nancy Pelosi has come out for it. Harry Reid has. John Podesta when he signed up for Medicare said, “Hey, I signed up for Medicare in five minutes; how about single payer?” At a recent discussion at the Center for American Progress, Sen Daschle said very vigorously he was for single payer, if it was not for the politics. Do you have any philosophical problems with single payer, aside from the politics?

Ezekiel Emanuel:  Well, first of all, I think someone once said, “It’s not going to happen so I’m not wasting any time on it.” I think that was Jonathan Gruber, economist at MIT. It isn’t going to happen, so let’s just get clear. It ain’t gonna happen! We barely got the Affordable Care Act through. Single payer, zero chance! Okay, so let’s just be clear on that.

Dr. Fernbach:  No, I don’t think that’s clear. You can go twenty-five years back, and I’m not saying we’d do in six months, or by the end of this talk, but to say that sixty percent of the American people who are for it can’t have what they want…

Dr. Emanuel:  Let me repeat myself.

Dr. Fernbach:  Please.

Dr. Emanuel:  Certainly in my lifetime, not happening. Okay, so I’m not wasting any of my time on it. Okay? Let me just say philosophically I also do have some disagreements with it. Okay? It depends what you mean by “single payer.” You need.. you don’t want to have one system determining payments like Medicare does for 310 million people. I don’t think that’s an efficient system. There are many things Medicare does that aren’t efficient, that they can’t do, and they have to do slowly because they’re affecting so much of medical practice and so many people. Second, you do get a lot of political gridlock; a lot of what Medicare does is a response to political pressures rather than to top quality policy pressures or policy ideas. Second, you do want to have a lot of experimentation. We don’t know the best way to care for someone who’s got chronic conditions or mental illness. We just don’t. We need to experiment a lot, and I think if you have single payer it gets hard to experiment on those things. So, for those reasons, I’m not a wildly big advocate of it because I think it would slow down the ability to make changes. Having said that, you know, I also don’t think it’s politically gonna happen, so.. We couldn’t even, look, we couldn’t even get the public option. Okay? I mean… and we barely got this bill through! It has failed a hundred years worth! Okay?

http://www.politics-prose.com/video/reinventing-american-health-care

Comment:

By Don McCanne, MD

Ezekiel Emanuel’s “Reinventing American Health Care” is largely a history of reform efforts and a description of the enactment and early implementation of the Affordable Care Act. The last section is his view of the future of American health care – the source of the excerpts above.

Some of his suggestions are mere platitudes. Others are “it-sounds-like-a-good-idea” abstractions, but have little solid policy support as to how they would be accomplished. Other recommendations are basic functions physicians already provide. Several of his ideas have already been suggested by others and hold little promise of benefit, and still other ideas are simply sort of weird.

One example is he says that we should replace fee-for-service with bundled payments. Yet Medicare representatives objected for three reasons. There was too much uncertainty without extended testing; the computer infrastructure would have to be very complex to pay based on bundles; and the delivery system is not organized to handle bundles. Although Medicare was adamantly opposed, they were able to slip into ACA ten demonstration projects with the proviso that the administration could then mandate bundled payments throughout Medicare without the need to return to Congress.

In several interviews while promoting his book he has been asked if he sees the changes he predicts as steps toward single payer. He is quite emphatic in rejecting any such possibility. His response to Harvey Fernbach, transcribed above, is typical.

His opposition to single payer dates back to his previous efforts to sell the concept of vouchers for private insurance, paid for by a value-added tax, as the ideal model for reform – a proposal he shared with Victor Fuchs. Although he did not get that, tax credits for the purchase of individual “marketplace” plans seem to be close enough for him.

In his previous book, “Healthcare, Guaranteed,” he devotes an entire chapter to single payer. He concludes, “In their zeal, single-payer advocates seem to forget how American institutions and governmental agencies actually operate. They envision superbly efficient, incorruptible bureaucracies capable of rational policy choices. Unfortunately, American governmental agencies do not spontaneously operate this way.” Thus he dismisses single payer with the trite “incompetent government” meme.

The good news is that you do not have to put “Reinventing American Health Care” on your “must read” list, though some may find it of value as escape literature. But be forewarned that it is not humorous.

Single-payer advocate makes pitch to doctor executives

By Andis Robeznieks
Modern Healthcare, Vital Signs blog, April 28, 2014

CHICAGO — The American College of Physician Executives annual meeting drew a record 830 attendees, including one doctor whose presentation on the merits of a national single-payer system may have been something of a surprise.

Dr. Ed Weisbart described himself as a long-time ACPE member who is also a member of Physicians for a National Health Program and now serves as chairman of the single-payer advocacy group’s Missouri chapter.

Weisbart, a family physician, had a table full of PNHP literature and a poster indicating that salaries for Canadian physicians are comparable or better than those earned by U.S. doctors. The poster also said that Canadian physicians pay lower malpractice insurance premiums.

His intent, Weisbart said, was to build bridges between the two organizations, and he left with “several pages” of new names to add to the PNHP mailing list. “I think it was time well-spent.”

One visitor to his table questioned whether the government could be trusted to run the nation’s healthcare system. Weisbart replied that he agrees. PNHP’s goal, he said, is to have a publicly funded, privately operated system.

“I think many people wouldn’t want to see a government-delivered healthcare system with physicians employed by the federal government,” he said.

http://www.modernhealthcare.com/article/20140428/BLOG/304289995

Ezekiel Emanuel: “Reinventing American Health Care”

Reinventing American Health Care: How the Affordable Care Act Will Improve our Terribly Complex, Blatantly Unjust, Outrageously Expensive, Grossly Inefficient, Error Prone System

By Ezekiel J. Emanuel
PublicAffairs

There are 4 things the average physician can do. One is to begin the process of transformation to more efficient practice, knowing that payment changes that move away from fee for service are inevitably coming.

Second, part of this transformation means that physicians will need to change their business model to increasing efficiency in their delivery of the services.

Third, physicians should engage insurers to try to modify contracts so that they have a financial reward for being more efficient.

Finally, these impending changes confront many physicians with the major existential question of whether to sell their practice to a hospital system or remain independent.

==

Six megatrends

* End of insurance companies as we know them

Insurance companies will either become purveyors of management analytics, and actuarial services, or integrated delivery systems actually employing (or contracting with) hospitals, physicians, and other providers to render patient care.

* VIP care for the chronically and mentally ill

Physicians and hospitals will focus on keeping patients with chronic illnesses healthy and out of the emergency room and hospital, thereby decreasing the frequency of avoidable complications and rate of hospitalization. Then they will begin routinely screening for depression and other mental health problems and develop standardized rapid interventions.

* The emergence of digital medicine and closure of hospitals

Over 1,000 acute-care hospitals will close. We will see a slew of new technologies for remote monitoring, testing, and treating patients in real time outside of the hospital and physicians’ offices.

* End of employer-sponsored health insurance

Fewer than 20% of workers in the private sector will receive traditional employer-sponsored health insurance.

* End of health care inflation

Health care inflation will be GDP+0%.

* Transformation of medical education

Medical education will be transformed in 4 fundamental ways: (1) three-year medical schools and shorter residencies; (2) half of medical school clinical training will be outside of hospitals; (3) integration of nurses, pharmacists, social workers with medical students in multi-professional team training; and (4) formal incorporation of population health and management skills in training.

==

Regardless of the short-term political costs, in the longer sweep of history, beginning in 2020 or so, the ACA will increasingly be seen as a world historical achievement, even more important for the United States than Social Security and Medicare had been. And Barack Obama will be viewed more like Harry Truman – judged with increasing respect over time.

http://www.publicaffairsbooks.com/book/hardcover/reinventing-american-he…

Ezekiel J. Emanuel, speaking about his book, “Reinventing American Health Care: How the Affordable Care Act Will Improve Our Terribly Complex, Blatantly Unjust, Outrageously Expensive, Grossly Inefficient, Error Prone System”

Politics and Prose, April 16, 2014

Q&A

At 39:30

Harvey Fernbach:  I’m a member of Physicians for a National Health Program. We believe in single payer simplicity, Medicare for all. As you know the president was for single payer, he said it, he’s for Medicare for all. Nancy Pelosi has come out for it. Harry Reid has. John Podesta when he signed up for Medicare said, “Hey, I signed up for Medicare in five minutes; how about single payer?” At a recent discussion at the Center for American Progress, Sen Daschle said very vigorously he was for single payer, if it was not for the politics. Do you have any philosophical problems with single payer, aside from the politics?

Ezekiel Emanuel:  Well, first of all, I think someone once said, “It’s not going to happen so I’m not wasting any time on it.” I think that was Jonathan Gruber, economist at MIT. It isn’t going to happen, so let’s just get clear. It ain’t gonna happen! We barely got the Affordable Care Act through. Single payer, zero chance! Okay, so let’s just be clear on that.

Dr. Fernbach:  No, I don’t think that’s clear. You can go twenty-five years back, and I’m not saying we’d do in six months, or by the end of this talk, but to say that sixty percent of the American people who are for it can’t have what they want…

Dr. Emanuel:  Let me repeat myself.

Dr. Fernbach:  Please.

Dr. Emanuel:  Certainly in my lifetime, not happening. Okay, so I’m not wasting any of my time on it. Okay? Let me just say philosophically I also do have some disagreements with it. Okay? It depends what you mean by “single payer.” You need.. you don’t want to have one system determining payments like Medicare does for 310 million people. I don’t think that’s an efficient system. There are many things Medicare does that aren’t efficient, that they can’t do, and they have to do slowly because they’re affecting so much of medical practice and so many people. Second, you do get a lot of political gridlock; a lot of what Medicare does is a response to political pressures rather than to top quality policy pressures or policy ideas. Second, you do want to have a lot of experimentation. We don’t know the best way to care for someone who’s got chronic conditions or mental illness. We just don’t. We need to experiment a lot, and I think if you have single payer it gets hard to experiment on those things. So, for those reasons, I’m not a wildly big advocate of it because I think it would slow down the ability to make changes. Having said that, you know, I also don’t think it’s politically gonna happen, so.. We couldn’t even, look, we couldn’t even get the public option. Okay? I mean… and we barely got this bill through! It has failed a hundred years worth! Okay?

http://www.politics-prose.com/video/reinventing-american-health-care

Ezekiel Emanuel’s “Reinventing American Health Care” is largely a history of reform efforts and a description of the enactment and early implementation of the Affordable Care Act. The last section is his view of the future of American health care – the source of the excerpts above.

Some of his suggestions are mere platitudes. Others are “it-sounds-like-a-good-idea” abstractions, but have little solid policy support as to how they would be accomplished. Other recommendations are basic functions physicians already provide. Several of his ideas have already been suggested by others and hold little promise of benefit, and still other ideas are simply sort of weird.

One example is he says that we should replace fee-for-service with bundled payments. Yet Medicare representatives objected for three reasons. There was too much uncertainty without extended testing; the computer infrastructure would have to be very complex to pay based on bundles; and the delivery system is not organized to handle bundles. Although Medicare was adamantly opposed, they were able to slip into ACA ten demonstration projects with the proviso that the administration could then mandate bundled payments throughout Medicare without the need to return to Congress.

In several interviews while promoting his book he has been asked if he sees the changes he predicts as steps toward single payer. He is quite emphatic in rejecting any such possibility. His response to Harvey Fernbach, transcribed above, is typical.

His opposition to single payer dates back to his previous efforts to sell the concept of vouchers for private insurance, paid for by a value-added tax, as the ideal model for reform – a proposal he shared with Victor Fuchs. Although he did not get that, tax credits for the purchase of individual “marketplace” plans seem to be close enough for him.

In his previous book, “Healthcare, Guaranteed,” he devotes an entire chapter to single payer. He concludes, “In their zeal, single-payer advocates seem to forget how American institutions and governmental agencies actually operate. They envision superbly efficient, incorruptible bureaucracies capable of rational policy choices. Unfortunately, American governmental agencies do not spontaneously operate this way.” Thus he dismisses single payer with the trite “incompetent government” meme.

The good news is that you do not have to put “Reinventing American Health Care” on your “must read” list, though some may find it of value as escape literature. But be forewarned that it is not humorous.

Important AAP policy statement on high-deductible health plans

Policy Statement: High-Deductible Health Plans

American Academy of Pediatrics
PEDIATRICS, April 28, 2014

Abstract

High-deductible health plans (HDHPs) are insurance policies with higher deductibles than conventional plans. The Medicare Prescription Drug Improvement and Modernization Act of 2003 linked many HDHPs with tax-advantaged spending accounts. The 2010 Patient Protection and Affordable Care Act continues to provide for HDHPs in its lower-level plans on the health insurance marketplace and provides for them in employer-offered plans. HDHPs decrease the premium cost of insurance policies for purchasers and shift the risk of further payments to the individual subscriber. HDHPs reduce utilization and total medical costs, at least in the short term. Because HDHPs require out-of-pocket payment in the initial stages of care, primary care and other outpatient services as well as elective procedures are the services most affected, whereas higher-cost services in the health care system, incurred after the deductible is met, are unaffected. HDHPs promote adverse selection because healthier and wealthier patients tend to opt out of conventional plans in favor of HDHPs. Because the ill pay more than the healthy under HDHPs, families with children with special health care needs bear an increased cost burden in this model. HDHPs discourage use of nonpreventive primary care and thus are at odds with most recommendations for improving the organization of health care, which focus on strengthening primary care.

This policy statement provides background information on HDHPs, discusses the implications for families and pediatric care providers, and suggests courses of action.

http://pediatrics.aappublications.org/content/early/2014/04/22/peds.2014-0555.full.pdf

Comment:

By Don McCanne, MD

Although this policy statement from the American Academy of Pediatrics is on High-Deductible Health Plans, its reach is well beyond that. It describes some of the consequences of the way that we pay for health care today, not only for children but for everyone.

The abstract above touches on some of these fundamental flaws, but the full statement should be read in its entirety. The last two pages of the text provide a list of recommendations that greatly increase administrative complexity while falling far short of what needs to be done to correct these injustices in health care financing. Single payer advocates will immediately recognize that the financing system needs to be replaced with a single payer system that provides first dollar coverage.

This important policy statement should be downloaded to share with others as we continue with our efforts to provide health care justice for all.

Cross-border checkup: Dr. Danielle Martin defends Canada’s single-payer system

Health-care advocate alumna takes fight to Washington

By Adela Talbot
Western (University) News, London, Ont., April 24, 2014

Danielle Martin sure can stand her ground.

Last month, the 2003 Schulich School of Medicine & Dentistry graduate spoke as part of an international panel presenting to the U.S. Senate’s Subcommittee on Primary Health and Aging. Invited alongside health-care professionals from Taiwan, France and Denmark to present a defense of a single-payer health-care system, Martin did just that.

And when conversation veered toward an attack of Canada’s health-care system, and its long wait times for certain procedures, Martin delivered a defense that has garnered much applause from fellow Canadians and national media.

“On average, how many Canadian patients on a waiting list die each year? Do you know?” asked U.S. Sen. Richard Burr, R-N.C., in Washington, D.C., last month.

“I don’t, sir, but I know there are 45,000 in America who die waiting because they don’t have insurance at all,” replied Martin, a family physician and vice-president of medical affairs and health systems solutions at Women’s College Hospital in Toronto.

And that’s just one snippet of her Senate exchange with the anti-Obamacare Republican.

After completing her undergraduate degree at McGill University, Martin first worked in health-care policy and politics. She applied to Schulich for medical school and arrived at Western in 1999. Having done her residency in family medicine in Toronto, she stayed put. She took on a Master’s of Public Policy at the University of Toronto and has since enjoyed a professional life as a doctor who gets things done – with and without her white coat.

“My area of interest has always been health-care systems and how can we construct health-care systems to best serve the needs of the population; that’s what drew me to medical school in the first place,” Martin said.

In 2006, along with colleagues across the country, she helped establish Canadian Doctors for Medicare, a national physician organization that does advocacy work around evidence relating to equity and access to health-care services.

“Unlike many other medical leaders who sort of start from a clinical interest and move into policy issues later in their careers, I started out with a policy interest and then developed a love of family medicine during my medical training at Western,” Martin continued.

“But my interest has really been in health-care systems, and my primary concern, until recently, has been around the preservation and enhancement of publically funded health care in Canada – trying to make sure that we construct an insurance model that makes sure that access to health care is based on need, rather than ability to pay.”

The Senate hearing had more elements of political theatre than a substantive policy discussion.

Martin was invited to testify by the committee chairman, U.S. Sen. Bernie Sanders, an independent Vermont senator and self-described socialist who has advocated for the United States to adopt a single-payer system like in Canada.

Burr, however, is no fan of the single-payer system.

According to the Center for Responsive Politics, health professionals, insurance companies and pharmaceuticals/health products companies ranked second, third and fifth, respectively, among his top donors. Combined, these industries, which led the fight against Obamacare, have given the senator more than a million dollars toward his campaign. Elected in 2004, and then again in 2010, Burr ranked second among 100 senators in receiving donations from health insurers and topped the list of those receiving money from pharmaceuticals/health products companies.

But in response to Burr, and other critics of single-payer health-care systems, Martin has a message: There is no evidence to support a claim that the structure of the system is to blame for lengthy wait times.

“On the international panel that day, there was a representative from Taiwan, which is a true single-payer system that has no wait times at all. The U.K. model, which is a two-tier health-care model, has struggled a lot with wait times. There’s no causality there,” she explained.

At the same time, Canada can be better, Martin continued. But saying that is not a critique of the Canadian Medicare system.

“The Canadian system’s not perfect, but what we need to be doing is protecting the public insurance plan and doing everything we can to fix the delivery system so that it will meet people’s needs better into the future. We call that ‘better Medicare’ – building a better version of the public health-care system that we have,” she explained.

“Supporting Medicare doesn’t mean making excuses for areas in which the system is underperforming. Supporting it means remaining committed to the values and principles that underpin it, and working very hard, every day, to do all we can to make it better for patients.”

Addressing long patient wait times – which largely affect non-urgent cases, Martin noted – includes considering options like a central intake assessment in which there is a single common queue that would ensure patients are seen by the next available specialist or surgeon. Another option is primary-care reform that would connect patients with a hub of health-care specialists that includes doctors, nurse practitioners and pharmacists working together, ensuring patients have same day or next-day access to primary care.

“Obviously, nobody wants to see patients waiting too long for care. The question is, how do you go about fixing the problem? Those of us who are working in the system are looking at trying to make better utilization of the resources that we have. There’s lots of good work being done in the country,” she explained, noting she was thrilled to see so much support of her defense in the U.S. Senate.

“An explicit articulation of our values is important. The reaction I’ve had has been overwhelming and I think that speaks to the profound values of Medicare Canadians hold, and that’s terrific and heartening,” Martin said.

Pharmacare is the next big challenge she sees coming for Canada’s health-care system.

“It really is an accident of history that we’ve ended up with publicly funded health-care system that provides us insurance for doctor and hospital care not for their medially essential medications,” she said.

“We really need to do everything we can to advocate as physicians for our patients to get access to the medically necessary pharmaceuticals they require. They are not optional; in many cases, they are life saving medications and it ends up costing the system more when we have people being admitted and readmitted to the hospital because their chronic illnesses aren’t controlled because they can’t afford their medicine.”

While she has encountered some political courtship as a result of her advocacy, it’s a career Martin won’t be pursuing.

“I feel really lucky to be able to be in a job where I have this opportunity to both do patient care and think about these big picture issues. I can’t really imagine anything better at this stage of my career,” she said.

http://communications.uwo.ca/western_news/stories/2014/April/crossborder_checkup_healthcare_advocate_alumna_takes_fight_to_washington.html

Important AAP policy statement on high-deductible health plans

Policy Statement: High-Deductible Health Plans

American Academy of Pediatrics
PEDIATRICS, April 28, 2014

Abstract

High-deductible health plans (HDHPs) are insurance policies with higher deductibles than conventional plans. The Medicare Prescription Drug Improvement and Modernization Act of 2003 linked many HDHPs with tax-advantaged spending accounts. The 2010 Patient Protection and Affordable Care Act continues to provide for HDHPs in its lower-level plans on the health insurance marketplace and provides for them in employer-offered plans. HDHPs decrease the premium cost of insurance policies for purchasers and shift the risk of further payments to the individual subscriber. HDHPs reduce utilization and total medical costs, at least in the short term. Because HDHPs require out-of-pocket payment in the initial stages of care, primary care and other outpatient services as well as elective procedures are the services most affected, whereas higher-cost services in the health care system, incurred after the deductible is met, are unaffected. HDHPs promote adverse selection because healthier and wealthier patients tend to opt out of conventional plans in favor of HDHPs. Because the ill pay more than the healthy under HDHPs, families with children with special health care needs bear an increased cost burden in this model. HDHPs discourage use of nonpreventive primary care and thus are at odds with most recommendations for improving the organization of health care, which focus on strengthening primary care.

This policy statement provides background information on HDHPs, discusses the implications for families and pediatric care providers, and suggests courses of action.

http://pediatrics.aappublications.org/content/early/2014/04/22/peds.2014…

Although this policy statement from the American Academy of Pediatrics is on High-Deductible Health Plans, its reach is well beyond that. It describes some of the consequences of the way that we pay for health care today, not only for children but for everyone.

The abstract above touches on some of these fundamental flaws, but the full statement should be read in its entirety. The last two pages of the text provide a list of recommendations that greatly increase administrative complexity while falling far short of what needs to be done to correct these injustices in health care financing. Single payer advocates will immediately recognize that the financing system needs to be replaced with a single payer system that provides first dollar coverage.

This important policy statement should be downloaded to share with others as we continue with our efforts to provide health care justice for all.

Single payer in the next presidential term?

Fox News Poll, April 13-15, 2014

14. I’m going to read a list of potential candidates for the 2016 Democratic nomination. Please tell me which one you would like to see as the Democratic presidential nominee.

69%  Hillary Clinton

14%  Joe Biden

 6%  Elizabeth Warren

 2%  Andrew Cuomo

 1%  Martin O’Malley

 –   (Other)

 4%  (None of the above)

 3%  (Don’t know)

15. I’m going to read a list of potential candidates for the 2016 Republican nomination. Please tell me which one you would like to see as the Republican presidential nominee.

15%  Chris Christie

14%  Jeb Bush

14%  Rand Paul

 9%  Paul Ryan

 8%  Marco Rubio

 7%  Ted Cruz

 5%  Scott Walker

 5%  Rick Santorum

 5%  Rick Perry

 2%  Bobby Jindal

 1%  (Other)

 6%  (None of the above)

 9%  (Don’t know)

http://www.foxnews.com/politics/interactive/2014/04/21/fox-news-poll-independents-more-likely-to-back-anti-obamacare-candidates/

****

Clinton urges move away from fee-for-service payment model; says current system is not serving physicians, or patients, well

California Medical Association, April 21, 2014

Former Secretary of State Hillary Rodham Clinton addressed 700 physicians, practice managers, medical students and others at the Western Health Care Leadership Academy in San Diego. Delivering the keynote address live via satellite, Secretary Clinton urged the California Medical Association to work with other like-minded organizations to help advance meaningful health care delivery and payment reform, instead of continuing to “rejigger” a broken system.

“At some point, we have to move away from fee for service payment for medical care,” said Secretary Clinton. “It is not serving physicians well, or any other health care providers, and I don’t believe it’s serving patients well.”

Secretary Clinton told attendees that she shares physicians’ frustration with Congress’s inability to make any progress on fixing the current broken payment system. She said she would like to see more systemic reform so that physicians are fully reimbursed for everything that goes into the care of patients. “It is deeply bothersome to me that it is still not accepted that a lot of what constitutes wellness—things that a physician can be promoting with his or her patients—should be reimbursed by Medicare,” Clinton said. “When a physician sits down with a patient and says ‘I’m going to give you a nutrition regimen. I’m going to have my nurse or my PA check in on you to make sure that you’re walking every day.’ These are all things that would keep that patient out of the operating room for a bypass or a stent or some other expensive intervention.”

“We’re never going to resolve the injustice, the unpredictability, the unfairness that unfortunately permeates the current system,” she said. “We need to move away from this very narrow approach to reimbursing physicians.”

“At some point, I hope we’re going to be able to take a look at the broad base of funding streams, both public and private, that go into funding health care–particularly physicians’ pay—and look more at who the patient is and what the doctor is providing that patient, instead of what the program is and how we can keep trying to put square pegs in a round hole.”

Secretary Clinton also held up California’s implementation of the Affordable Care Act as a model for the nation. “We’re going to be watching closely what happens in California. Seeing what works, and what doesn’t. States like California, intent on covering more citizens and fostering bold experimentation to improve outcomes and reduce costs, will not only lead the way, but help everyone else find the way.”

Secretary Clinton also urged all stakeholders to work together to keep pushing for improvements to the health care system. “The transparency called for under the Affordable Care act is going to reveal a lot of information. Some of it may be surprising. And some of it may even be quite troubling,” said Clinton. “But for the first time, we’re going to see information. And everyone will be able to look at the same information. We can then try and figure out ‘Is there a problem that needs to be fixed?’”

The data collected under the Affordable Care act will, according to Clinton, will allow us to ask questions that will give us much better insight into how we can move towards a more efficient, quality driven health care system.

“I think this is a great opportunity, if we do it with that kind of open attitude of ‘let’s learn what works, let’s make this better.’ Let’s hear from physicians and nurses and pharmacists, you name it. Everyone come to the table. What do you think needs to be changed?” 

http://www.cmanet.org/cma-alert/archives/april-21-2014/#11

****

Position Statement on the Affordable Care Act (ACA)

PNHP California, April 9, 2014

Excerpt:

Recognizing that we share core principles with those who worked hard to implement the ACA, including the desire for a healthcare system that is truly universal, affordable and provides comprehensive benefits with one standard of high quality care, we resolve to:

• Build bridges to ACA supporters to forge strong alliances for continued reform.

• Work with our partners towards the successful implementation of ACA and to find solutions for the 3-4 million Californians who are still left out of the system, including the undocumented.

• Support efforts to provide healthcare as a basic human right rather than a commodity available only to those who can afford it.

http://pnhpcalifornia.org/2014/04/news-article-pnhp-california-aca-position-paper/

Comment:

By Don McCanne, MD

Considering the difficulty that President Obama has experienced in passing and then implementing the Affordable Care Act (ACA), it is clear that he is in no position to advocate for single payer reform before he leaves office. Thus it seems reasonable to consider the prospects of enacting single payer reform during the term of our next president. What are the prospects?

As people gain more experience with the ACA reforms, it is likely that many will be disappointed. The marketplace (exchange) plans that most people are selecting have relatively low actuarial values with high deductibles, thus many will experience financial hardship should they have significant health care needs. Also many will be disappointed with the narrow provider networks which will often prevent patients from having their choice of physicians and hospitals. Since employers are now adopting some of these same insurance innovations, many who previously were satisfied with their employer-sponsored coverage may also become much less content with their coverage.

It is thought that, by 2017, enough people will have become dissatisfied with our high-cost, administratively inefficient, dysfunctional system that many of them will be ready for an improved Medicare for all. That happens to be the year that our next president will take office. Will we have a president who is willing to support a vastly superior alternative – a single payer national health program?

Obviously we cannot predict the results of a presidential election this far in advance, but we can take a look at the political climate – a climate which is unlikely to change dramatically in the next few years.

Looking at the Fox poll and other recent polls, the clear front runner is Hillary Clinton. Although it is possible that the Republican Party could rally around a candidate that would be a serious challenge to Clinton, currently she outpolls each of the Republicans under consideration.

Suppose Hillary Clinton were elected president, what could single payer advocates expect? The report on her speech to physicians in California is reproduced above in its entirety, mainly to show what was left out of her message. There is certainly no mention of single payer nor expanding Medicare. She does mention moving away from fee-for-service payments, and expanding payments for “wellness-things,” while holding up California’s implementation of ACA as a “model for the nation.” She also touted information transparency. In her last run for the presidential nomination she had displaced her previous failed proposal with the current ACA model. Based on her comments, it is highly likely that her efforts at reform would be limited refinement of the ACA model, if she can get past the crippling partisan divide in Congress.

Should a Republican be elected, it is likely that efforts would be directed to replacing some elements of ACA with policies supporting less regulation of insurance products, limitation of mandates, and ability of individuals to purchase insurance products in less regulated states. No serious potential Republican candidate supports single payer.

So, no single payer will be coming from the top. Then what can we do? We should intensify our efforts to educate the public at large – so they understand why ACA does not seem to be working well for them, while showing them how single payer is precisely the model we need. We need to create a critical threshold of support coming from the general public. If the demand is intense enough, the politicians will follow.

But a caveat. The single payer message must be loud and clear. People must understand that the ACA model is fundamentally flawed and must be superseded by a single payer system. Many single payer supporters abandoned the cause and chose to support the “progressive” alternative – Obamacare. They continue to be involved in the implementation of this highly flawed model (better than nothing but still highly flawed). Fortunately, there are still organizations, such as PNHP, that are not willing to compromise and dilute the single payer message. Doing so would merely continue us down the incremental path of reform, when there are no incremental steps that bridge the gap between a fragmented system of private and public payers and a single payer system.

PNHP California has adopted a position statement calling for “work(ing) with our partners towards the successful implementation of ACA.” Most of the progressive community is already engaged in supporting ACA, and they really do not need more help. Muddling the message of the single payer purists that remain can only perpetuate inertia in the single payer movement. Some sincerely believe that helping the ACA supporters will result in reciprocal support for our efforts on single payer. Really? They are going to help us disassemble a system that they worked so hard on to build?

Let’s not adulterate our single payer message.