PNHP

Canada’s Dr. Danielle Martin educates Sen. Richard Burr on single payer

Canada’s Dr. Danielle Martin educates Sen. Richard Burr on single payer

Health Care: U.S. vs. Canada

YouTube, March 12, 2014

On March 11, 2014, several authorities on single payer health care systems of other nations testified before a committee of the United States Senate, chaired by Sen. Bernie Sanders. The hearing was not only the topic of a recent Quote of the Day (March 12), it also has been covered extensively in the media and on the Internet throughout the United States and Canada.

It was the responses of Dr. Danielle Martin of Canada to the questions from Committee Ranking Member Sen. Richard Burr, that caused this story to go viral. For those who missed it, the 7 minute segment that includes the exchange between Dr. Martin and Sen. Burr can be viewed at this YouTube link: http://www.youtube.com/watch?v=iYOf6hXGx6M

You can read more about this exchange by Googling “Danielle Martin.” Some of the other coverage:

National Post: “Toronto doctor smacks down U.S. Senate question on Canadian waitlist deaths”: http://news.nationalpost.com/2014/03/12/toronto-doctor-smacks-down-u-s-senate-question-on-canadian-waitlist-deaths/
Los Angeles Times: “Watch an expert teach a smug U.S. senator about Canadian healthcare”:http://www.latimes.com/business/hiltzik/la-fi-mh-watch-a-canadian-20140312,0,2995139.story
Huffington Post: “Watch This Doctor Totally School An Anti-Obamacare Senator On Health Care”: http://www.huffingtonpost.com/2014/03/13/danielle-martin-richard-burr_n_4958164.html
Huffington Post Canada: “Canadian Doctor Gives U.S. Senator A Clinic On Public Health Care”: http://www.huffingtonpost.ca/2014/03/13/canadian-doctor-us-senator-health-care_n_4956468.html
CBC.ca (audio): “Canadian doctor schools U.S. Senator on public health care”:http://www.cbc.ca/asithappens/features/2014/03/12/canadian-doctor-schools-us-senator-on-public-health-care/
MSNBC: The Rachel Maddow Show (3/14/14, Ari Melber, guest host):http://www.msnbc.com/rachel-maddow-show
The Maddow Blog: “Martin 1, Burr 0″: http://www.msnbc.com/rachel-maddow-show/martin-1-burr-0#break
Salon: “Canadian doctor makes anti-Obamacare senator look like a buffoon”:http://www.salon.com/2014/03/13/canadian_doctor_makes_anti_obamacare_senator_look_like_a_buffoon/
Toronto Star: “Toronto doctor smacks down U.S. senators’ myths about Canadian health care”:http://www.thestar.com/life/health_wellness/2014/03/13/toronto_doctor_smacks_down_us_senators_myths_about_canadian_health_care.html
Canada.com: “Watch: Canadian doctor schools American senator on health care”:http://o.canada.com/health/danielle-martin-richard-burr-health-care-410599/
Huffington Post Canada: “Republicans Ruin Health Care By Ignoring Jesus (And Canada)”:http://www.huffingtonpost.ca/michael-bolen/canada-america-health-care-christian-nation_b_4957509.html

Well, you get the point.

For those interested in viewing the entire hearing (1 hour, 45 minutes), or wish to download witness statements: http://www.help.senate.gov/hearings/hearing/?id=8acab996-5056-a032-522e-e39ca45fcfbe

Half will have change of eligibility for Medicaid or subsidies within one year

Medicaid And Marketplace Eligibility Changes Will Occur Often In All States; Policy Options Can Ease Impact

By Benjamin D. Sommers, John A. Graves, Katherine Swartz and Sara Rosenbaum

Health Affairs, April 2014 (online March 12, 2014)

Beginning January 1, 2014, the Affordable Care Act (ACA) established two pathways to health insurance for nonelderly US citizens and legal residents. The first was an expansion of Medicaid coverage for people with annual incomes of up to 138 percent of the federal poverty level in states that elected to expand their programs. The second pathway was subsidizing private coverage purchased via health insurance Marketplaces for people with incomes of 138–400 percent of poverty who do not have an offer of affordable coverage through an employer. The pathways are designed to work in tandem, but a major challenge is how to promote continuity of coverage and health care for people when their incomes and life circumstances cause them to transition between Medicaid and subsidized private coverage.

In states that opt out of the ACA’s Medicaid expansion, changes in income or family circumstance will lead many people to lose coverage entirely unless they qualify for coverage under one of the traditional categories of Medicaid eligibility: pregnancy, disability, or being the impoverished parent of a minor child. A less stark problem that presents a different set of challenges will occur in states that do expand Medicaid: the potential for moving between Medicaid and Marketplace coverage.

Both of these types of “churning”—loss of coverage and frequent transitions in the source of coverage—can cause difficulties. The total loss of coverage raises the most serious problems in terms of access to care, but frequent transitions across coverage pathways also raise important issues for beneficiaries, health plans, providers, and policy makers. From one year to the next or during any given year, many individuals and families will experience changes in eligibility either for Medicaid or for Marketplace coverage. These eligibility changes could lead to both gaps in coverage and disruptions in the continuity of care, because people might have to find new providers or change their existing health treatments if their new insurance plan uses a different provider network or covers different services than their old plan did.

Previous research has estimated that approximately half of low-income adults might experience a change in income or family circumstances leading them to transition from Medicaid to Marketplace coverage (or vice versa) each year.

From the Discussion

We estimated that approximately half (plus or minus 5 percentage points) of adults likely to be eligible for Medicaid or subsidized Marketplace coverage will experience an eligibility change within twelve months.

It is important to recognize that the eligibility changes we have analyzed are the result of an effort to expand pathways to affordable coverage for all Americans. Churning has often been used to describe the negative outcome of moving into and out of insurance coverage and becoming uninsured. In contrast, we are discussing changes that are a by-product of a system that allows for transitions among insurance pathways. These transitions increase the risks of disrupting care continuity and of having short gaps in coverage. But they represent a different (and less problematic) form of churning than that between having Medicaid or Marketplace coverage and being uninsured.

However, when low-income adults in states that opt not to expand their Medicaid programs experience a loss of income that drops them below 100 percent of poverty, most will not be eligible for subsidized coverage in the Marketplace or for Medicaid. Most nonexpansion states restrict Medicaid eligibility for adults to pregnant women, certain low-income adults with disabilities, and parents of minor children with incomes of no more than 35 percent of poverty on average. In other words, most adults who lose Marketplace subsidies in nonexpanding states will become uninsured, as has traditionally happened to adults who lose Medicaid eligibility.

Policy Implications

A number of policies have recently been proposed to mitigate the effects of churning between Medicaid and Marketplace coverage, and state policy makers should consider them in the light of our findings.

One option is for states to adopt twelve-month continuous eligibility periods in Medicaid as a means of overcoming the churning effects of periodic income fluctuations

A second, more incremental option offered in CMS’s 2012 regulations allows states to assess people’s ongoing eligibility for Medicaid using projected annual income instead of current monthly income.

A third option for states is to use Medicaid funds to purchase coverage in qualified health plans in the Marketplace for people with incomes below 138 percent of poverty.

A fourth approach is the Basic Health Program, an option under the ACA that enables states to combine their Medicaid expansions with Marketplace subsidies into a single program for individuals and families with incomes of up to 200 percent of poverty.

A fifth option relates to how and when income changes are verified.

Finally, a state option that combines enrollment and marketing strategies is to encourage certified Medicaid managed care plans to enter state Marketplaces.

http://content.healthaffairs.org/content/early/2014/03/10/hlthaff.2013.1023.abstract

Comment:

By Don McCanne

The Affordable Care Act (ACA) compounded and locked into place our highly fragmented, multi-payer method of financing health care. It is a system that makes churning inevitable – moving in and out of various plans or having no coverage at all, simply because program eligibility varies depending on each individual’s circumstances which often are in an intermittent state of flux.

As if there was not already enough instability with employer-sponsored and individual market plans, this study shows that under the two major expansions of ACA, “approximately half of adults likely to be eligible for Medicaid or subsidized Marketplace coverage will experience an eligibility change within twelve months.” Half in just the first year alone. What after that?

Eligibility change is highly disruptive to care. It changes the amounts that the individual or family will have to pay for premiums, cost sharing, and non-covered services. It changes the provider networks that vary under different plans. It can disrupt treatment programs. It can result in gaps in coverage or no coverage at all. As is typical with Medicaid, it can even change the willingness of physicians to accept the individual or family as patients.

And that line about keeping the coverage you have if you want it? Within one year, half will have a change in their eligibility. And the recommendations of the authors will only tweak the instability, but the fundamental problem will not be corrected. It is the ACA model that is irreparably flawed.

Unless we change our model of financing, instability and disruption will be the norm, not only because of shifting eligibility but also because plans obtained through employment or in the market are undergoing dramatic changes – even if less transparent – that will impact all of us with greater cost sharing, narrower networks, and other changes that none of us want. Do Americans really accept this mess as our preferred option for health care financing?

Change to a single payer national health program and this all goes away.

Half will have change of eligibility for Medicaid or subsidies within one year

Medicaid And Marketplace Eligibility Changes Will Occur Often In All States; Policy Options Can Ease Impact

By Benjamin D. Sommers, John A. Graves, Katherine Swartz and Sara Rosenbaum

Health Affairs, April 2014 (online March 12, 2014)

Beginning January 1, 2014, the Affordable Care Act (ACA) established two pathways to health insurance for nonelderly US citizens and legal residents. The first was an expansion of Medicaid coverage for people with annual incomes of up to 138 percent of the federal poverty level in states that elected to expand their programs. The second pathway was subsidizing private coverage purchased via health insurance Marketplaces for people with incomes of 138–400 percent of poverty who do not have an offer of affordable coverage through an employer. The pathways are designed to work in tandem, but a major challenge is how to promote continuity of coverage and health care for people when their incomes and life circumstances cause them to transition between Medicaid and subsidized private coverage.

In states that opt out of the ACA’s Medicaid expansion, changes in income or family circumstance will lead many people to lose coverage entirely unless they qualify for coverage under one of the traditional categories of Medicaid eligibility: pregnancy, disability, or being the impoverished parent of a minor child. A less stark problem that presents a different set of challenges will occur in states that do expand Medicaid: the potential for moving between Medicaid and Marketplace coverage.

Both of these types of “churning”—loss of coverage and frequent transitions in the source of coverage—can cause difficulties. The total loss of coverage raises the most serious problems in terms of access to care, but frequent transitions across coverage pathways also raise important issues for beneficiaries, health plans, providers, and policy makers. From one year to the next or during any given year, many individuals and families will experience changes in eligibility either for Medicaid or for Marketplace coverage. These eligibility changes could lead to both gaps in coverage and disruptions in the continuity of care, because people might have to find new providers or change their existing health treatments if their new insurance plan uses a different provider network or covers different services than their old plan did.

Previous research has estimated that approximately half of low-income adults might experience a change in income or family circumstances leading them to transition from Medicaid to Marketplace coverage (or vice versa) each year.

From the Discussion

We estimated that approximately half (plus or minus 5 percentage points) of adults likely to be eligible for Medicaid or subsidized Marketplace coverage will experience an eligibility change within twelve months.

It is important to recognize that the eligibility changes we have analyzed are the result of an effort to expand pathways to affordable coverage for all Americans. Churning has often been used to describe the negative outcome of moving into and out of insurance coverage and becoming uninsured. In contrast, we are discussing changes that are a by-product of a system that allows for transitions among insurance pathways. These transitions increase the risks of disrupting care continuity and of having short gaps in coverage. But they represent a different (and less problematic) form of churning than that between having Medicaid or Marketplace coverage and being uninsured.

However, when low-income adults in states that opt not to expand their Medicaid programs experience a loss of income that drops them below 100 percent of poverty, most will not be eligible for subsidized coverage in the Marketplace or for Medicaid. Most nonexpansion states restrict Medicaid eligibility for adults to pregnant women, certain low-income adults with disabilities, and parents of minor children with incomes of no more than 35 percent of poverty on average. In other words, most adults who lose Marketplace subsidies in nonexpanding states will become uninsured, as has traditionally happened to adults who lose Medicaid eligibility.

Policy Implications

A number of policies have recently been proposed to mitigate the effects of churning between Medicaid and Marketplace coverage, and state policy makers should consider them in the light of our findings.

One option is for states to adopt twelve-month continuous eligibility periods in Medicaid as a means of overcoming the churning effects of periodic income fluctuations

A second, more incremental option offered in CMS’s 2012 regulations allows states to assess people’s ongoing eligibility for Medicaid using projected annual income instead of current monthly income.

A third option for states is to use Medicaid funds to purchase coverage in qualified health plans in the Marketplace for people with incomes below 138 percent of poverty.

A fourth approach is the Basic Health Program, an option under the ACA that enables states to combine their Medicaid expansions with Marketplace subsidies into a single program for individuals and families with incomes of up to 200 percent of poverty.

A fifth option relates to how and when income changes are verified.

Finally, a state option that combines enrollment and marketing strategies is to encourage certified Medicaid managed care plans to enter state Marketplaces.

http://content.healthaffairs.org/content/early/2014/03/10/hlthaff.2013.1…

The Affordable Care Act (ACA) compounded and locked into place our highly fragmented, multi-payer method of financing health care. It is a system that makes churning inevitable – moving in and out of various plans or having no coverage at all, simply because program eligibility varies depending on each individual’s circumstances which often are in an intermittent state of flux.

As if there was not already enough instability with employer-sponsored and individual market plans, this study shows that under the two major expansions of ACA, “approximately half of adults likely to be eligible for Medicaid or subsidized Marketplace coverage will experience an eligibility change within twelve months.” Half in just the first year alone. What after that?

Eligibility change is highly disruptive to care. It changes the amounts that the individual or family will have to pay for premiums, cost sharing, and non-covered services. It changes the provider networks that vary under different plans. It can disrupt treatment programs. It can result in gaps in coverage or no coverage at all. As is typical with Medicaid, it can even change the willingness of physicians to accept the individual or family as patients.

And that line about keeping the coverage you have if you want it? Within one year, half will have a change in their eligibility. And the recommendations of the authors will only tweak the instability, but the fundamental problem will not be corrected. It is the ACA model that is irreparably flawed.

Unless we change our model of financing, instability and disruption will be the norm, not only because of shifting eligibility but also because plans obtained through employment or in the market are undergoing dramatic changes – even if less transparent – that will impact all of us with greater cost sharing, narrower networks, and other changes that none of us want. Do Americans really accept this mess as our preferred option for health care financing?

Change to a single payer national health program and this all goes away.

Senate hearing: Learning from other nations’ health systems

Hearing convened by Sen. Bernie Sanders

On March 11, Sen. Bernie Sanders of Vermont chaired a Senate subcommittee hearing on what the health care system in the United States can learn from other countries, particularly Canada, Taiwan, Denmark and France. The following 6-minute video features the testimony of Dr. Danielle Martin, comparing the U.S. and Canadian systems while dispelling myths about health care in Canada.

For a detailed account of the proceedings, including direct links to the full video and to the individual, written statements presented there, see this Quote of the Day post by Dr. Don McCanne, PNHP’s senior health policy fellow.

A four-minute highlight video of the hearing, including all of the panelists from this extraordinary (and to our knowledge, historically unprecedented) session, is available here.

For how the testimony of the Canadian physician, Dr. Danielle Martin, has been received in Canada, click here.

Senate panel examines health systems in Canada, Taiwan, Denmark and France

By Deborah Schumann, M.D.

WASHINGTON – Sen. Bernie Sanders, I-Vt., chairman of the Senate Subcommittee on Primary Health and Aging of the Health, Education, Labor and Pensions Committee, held a hearing Tuesday to gain insight into the health care systems of four other countries, all of which view health care as a human right and have achieved near-universal coverage and access to care for their citizens. 

The senator opened the session with a comparison of the U.S. system with those of other industrialized nations. He noted the U.S. system is characterized by: 

* Double per-capita spending

* Third-world-like access for many in the U.S.

* Financial barriers and bankruptcy consequences related to health care

* 45,000 deaths/year linked to lack of insurance

* Poor efficiency: U.S. ranked 46th out of 48 countries

* Poor outcomes, e.g. of 34 OECD countries, U.S. is 26th in life expectancy

* Drugs are so expensive that many patients forgo treatment

Ranking subcommittee member Sen. Richard Burr, R-N.C., then weighed in, saying that Obamacare is going in the “wrong direction” and that Americans view it unfavorably. He stated that Medicaid is “unsustainable” and is not accepted by 40 percent of physicians. Furthermore, he stated that premiums in the individual market have risen by 41 percent since Obamacare passed. His proposal for improving the system is to increase “individual choice.”

Then the invited witnesses delivered their testimony. 

Tsung-Mei Cheng, L.L.B., M.A., health policy analyst at the Woodrow Wilson School of Public and International Affairs at Princeton University, summarized the features of a single-payer health care system: 

* Single payer does not equal socialized medicine

* Equity of access; access not based on ability to pay

* Equity of payment to providers

* Financing based on ability to pay

* Competition based on quality, not price

* Patients have choice of providers

* No job-lock; not based on employment

* Total spending is easy to control

* Electronic billing leads to substantial savings

* Data capture is facilitated

* Public satisfaction is generally high as demonstrated in other countries

* Medicare (the U.S. single-payer program) is popular

France 

Victor Rodwin, Ph.D., M.P.H., professor of health policy and management at the Robert F. Wagner School of Public Service at New York University, spoke about the French system. It is not a socialized medicine system like Cuba or the U.K., but rather a publicly financed, privately delivered system with supplementary private insurance to cover co-pays. Patients have free choice of providers whether in public or private hospitals. The French people are proud of their system which is based on liberté, égalité and fraternité. There are no gatekeepers or networks and everyone has access to care. The French rate of “avoidable mortality” [e.g. infant and maternal mortality is 55-60 percent that of the U.S., according to The Commonwealth Fund, 2012] France controls its costs through bulk purchasing, price controls and low administration costs. 

Taiwan

Ching-Chuan Yeh, M.D., former Taiwanese minister of health and currently professor at Tzu-Chi University in Taiwan, said that “having a single-payer system is the main reason for our efficient services and also controls prices.” With a national fee schedule, providers compete on the basis of quality. Like France, Taiwan has public financing and private delivery of care which includes both not-for-profit as well as for-profit centers. All payments are made electronically keeping administrative costs down. Dr. Yeh stated that they have achieved 99.6 percent coverage and that there is not much of a problem of waiting lines for services. The country has seen improvements in both longevity and infant mortality since implementing the system in 1995, and they are on the road to a universal, individualized electronic medical record. 

Denmark

Jakob Kjellberg, M.Sc., professor and program director at the KORA-Danish Institute for Local and Regional Government Research in Copenhagen, described the Danish system as “comprehensive and universal.” Danes choose a GP and get referrals from her or him for specialty care. They have full choice of providers including hospitals. If wait-lines are too long, they have the option of going to private hospitals or out of the country. Overall administrative costs are 4.3 percent [i.e. far less than the U.S. system as a whole, which is 15-30 percent by various estimates, but similar to U.S. Medicare’s percentage].

Canada

Danielle Martin, M.D., M.P.P. , vice president for medical affairs and health system solutions at Women’s College Hospital, Toronto, spoke about Canada’s single-payer system. She emphasized that in spite of some shortcomings (wait-times for elective services), the Canadian people are firmly in favor of Canada’s Medicare. There is zero political will in Canada to move to a market-based, for-profit, fragmented system like we have here. She said even conservative politicians don’t oppose Canada’s Medicare, for fear of committing political suicide. The Canadian system is centrally financed but administered by the provinces. It is based on:

* Equity and medical need

* Central oversight for issues e.g. more primary care training

* Low administrative overhead

Canada achieves better outcomes than the U.S. at two-thirds the per capita cost of the U.S. market system. Urgent care is always available.

Speakers for ‘market-based health care’ 

Sally C. Pipes, CEO of the Pacific Research Institute in San Francisco, and David Hogberg, David Hogberg, Ph.D., health care policy analyst at the National Center for Public Policy Research in Washington, had been invited by Sen. Burr to speak in favor of a market-based health care system such as we have in the U.S. Ms. Pipes testified that she had emigrated from Canada to San Francisco. She told the story of her mother who waited several months in a queue, was finally taken care of but died two weeks later. Her opinion was that the Canadian system “would not be suitable for the U.S.” because she thinks that waiting weeks to see a specialist won’t work here. Her punchlines were that 42,000 Canadians come to the U.S. for care every year and that one Canadian top official came to the U.S. for cardiac surgery. Ms. Pipes made clear that waiting too long is bad for your health. 

Mr. Hogberg spoke in favor of “removing the health care system from control of politicians.” He pointed out that the sick are few in number and not political. In his opinion, “patients overuse health care.” He worried about the fact that “France doesn’t pay for pharmaceuticals that are incrementally better.” He reiterated that French co-insurance picks up out-of-pocket expenses for patients while the government controls 77 percent of health care expenditures. His opinion is that the U.S. should look at other countries’ systems in order to discover what policies to avoid and study other competitive markets like auto insurance, food and clothing.

Sen. Sanders asked Mr. Hogberg if we should get rid of Medicare. He did not answer yes or no, but said it is a “moot point.”

Sen. Sanders asked Dr. Rodwin why U.S. health care spending is so high, especially in light of relatively poor outcomes. The answer is that prices are “much higher because we have no price control.” He added, “The free market system doesn’t exist anywhere in health care.”

Sen. Burr asked Dr. Martin why doctors are exiting the public system in Canada. She replied that he had misunderstood her remarks and “that there are no doctors exiting the public system in Canada.” With regard to excessive wait times in Canada, she said that the country has a commission to address the issue and that “the solution is not to move away from our single-payer system toward a multi-payer system.” She said that having a single payer allows the wait-time commission to appropriately address the issue. “Sometimes it is not about the amount of resources, but on how you organize people,” adding, “And this organization should be based on criteria that benefit everyone, not just those who can afford to pay.”

Several other subcommittee members made comments or asked questions.

Sen. Mike Enzi, R-Wy., opined that “the Affordable Care Act was designed to fail so that we would go to single-payer health care.” But he feels that the debacle of the exchanges has convinced Americans that government can’t succeed in universal health care. He didn’t ask any questions.

Sen. Pat Roberts, R-Kan., asked Dr. Martin about how the Canadian system makes changes, e.g. Can the prime minister make changes? She replied that “the public commitment to our single-payer Medicare system is so strong that for a prime minister of any stripe to try and alter that or undermine it in any way would be political suicide.” Sen. Roberts replied, “I got your message.”

Sen. Sanders followed up by saying, “Canadians understand that a system that guarantees health care for all their people in a cost effective way is the way that they want to stay.”

Sen. Chris Murphy, D-Conn., followed up on the wait-time/convenience discussion with the opinion that convenience does not necessarily equal quality. He said that the other two important aspects of quality are outcomes and cost control. 

There was quite a bit of discussion about pharmaceuticals:

* France, Taiwan and Denmark provide drug coverage in their national health care financing systems

* Canada, according to Dr. Martin, has realized that they made a mistake in not including drug coverage in Canadian Medicare. She said that Canada has an estimated 10 percent non-compliance. [the comparable figure in the U.S. is 25 percent]

* Dr. Cheng believes that high drug costs, partially fueled by R&D of new products, is “pricing people out of the system”

* Both Taiwan and Denmark have out-of-pocket limits on drug spending ($1,000/yr. and $600/yr., respectively.

Dr. Cheng concluded the hearing following up on Sen. Murphy’s remarks and responding to a question from Sen. Burr by saying: “Yes, the United States does fund a whole lot of R&D in pharmaceutical and other device innovations. But in so doing we are helping to make the American health care system that much more expensive; in fact so expensive that we are pricing people out of the health care altogether . … In single-payer systems, the government can set aside money for R&D.” He added: “A very serious issue in U.S. health care is overuse. An Institute of Medicine book states that about one-third of U.S. health care is waste. Unnecessary services are about one-third of that waste.”

A video of the hearing and links to statements of all participants can be found here: http://www.help.senate.gov//hearings/hearing/?id=8acab996-5056-a032-522e… 

A 4-minute YouTube video of clips from the hearing can be viewed here: https://www.youtube.com/watch?v=9WdqtPLRc1A 

Dr. Deborah Schumann practiced ophthalmology for 25 years in a variety of clinical settings. Since retiring from practice she has been an active advocate for reform of the U.S. health care system. She is active in Healthcare-NOW of Maryland as well as Physicians for a National Health Program. She resides in Bethesda, Md.

Resolved: The United States should switch to a single payer health care system

The Great Debate – Single Payer or Private Insurance

By Katie Britton

WAMC, March 13, 2014

Students for a National Health Program at Albany Medical College presented The Great Debate at WAMC’s The Linda on the evening of February 21st.  Moderated by Dr. Kimberly Kilby, the debate featured Dr. Paul Song of the Physicians for a National Health Program (PNHP) from California and Dr. Mitchell Heller of the Benjamin Rush Society from New York City as they argued for and against single payer vs. private insurance.

For an audio of the debate (55 minutes): http://wamc.org/post/great-debate-single-payer-or-private-insurance

Comment:

By Don McCanne, M.D.

The debate:

Resolved: The United States should switch to a single payer health care system

Speaking in favor is Paul Song, MD, representing Physicians for a National Health Program – an organization of physicians and others who advocate for “a universal, comprehensive single-payer national health program.”

Speaking in opposition is Mitchell Heller, MD, representing the Benjamin Rush Society – an organization of physicians and others “who believe that the profession of medicine calls its practitioners to serve their patients, rather than the government.”

“We as a society are defined by how we take care of the least amongst us.” – Dr. Song

“It’s hard to understand how command and control models like single payer still gain intellectual traction at all.” – Dr. Heller

Although you should listen to the debate before hearing the results, many of you do not have the extra 55 minutes. So here is the vote:

Before the debate:

66% – For
 5% – Against
29% – Undecided

After the debate:

80% – For
 2% – Against
18% – Undecided

Doctor who schooled U.S. senator ‘thrilled’ by Canadian support

By Carmen Chai
Global News (Canada), March 13, 2014

TORONTO – Dr. Danielle Martin knows Canadians are proud of the country’s universal health care. She is too.

At a U.S. Senate subcommittee earlier this week, the Toronto family doctor laid the smack down on American officials who alleged that doctors and patients were fleeing Canada for greener pastures in the U.S.

Martin knew she had to stand her ground. But she didn’t expect the overwhelming response from Canadians who are now applauding how she handled the heated exchange.

So far, she’s been hailed as a national hero for “schooling” the U.S. Senate.

“I think it taps into a really deep pride that Canadians have about single payer health care. I don’t think it’s about me. The basic value that Canadians hold that access to health care should be based on need and not ability to pay is very fundamental to how people view themselves as Canadians,” Martin told Global News on Thursday morning.

“We see our health care system get misrepresented and trashed in the American media as part of their debate quite a lot and that’s a source of real frustration for Canadians,” she said.

The Women’s College Hospital doctor was invited by senators to Washington for a panel on what the U.S. can learn from other countries that function on a single payer health care system. Martin joined a panel of international experts on single payer health care models – doctors from Denmark, France, and Taiwan also shed light on the system.

It was during the question-and-answer period when Martin and Republican Senator Richard Burr began their verbal sparring.

“On average, how many Canadian patients on a waiting list die each year? Do you know?” Burr asked.

“I don’t, sir, but I know that there are 45,000 in American who die waiting because they don’t have insurance at all,” she said.

“What do you say to an elected official who goes to Florida and not the Canadian system to have a heart valve replacement?” Burr asked. He was referring to Newfoundland Premier Danny Williams’ decision to head to Miami for heart surgery in 2010.

“It’s actually interesting because, in fact, the people who are the pioneers of that particular surgery…are in Toronto, at the Peter Munk Cardiac Centre, just down the street from where I work,” Martin quipped back.

Finally, when Burr asked why Canadian doctors are leaving the public system, Martin shot down his claim: “In fact, we see a net influx of physicians from the United States into the Canadian system over the last number of years,” she said.

But Martin wants Canadians to know: as much as it might look like it, the meeting was respectful and the senators graciously welcomed the panelists.

“People have strong opinions about this so it was clear there were clashing views but I certainly didn’t find the tone disrespectful,” Martin told Global News.

She knows a single committee meeting wouldn’t suddenly sway U.S. health officials into considering the Canadian health care model, but Martin said she’s “thrilled” that the exchange has people talking.

“It means this kind of hearing isn’t just political theatre. It serves a social function to get a conversation going and that’s really important,” she said.

So far, she’s received emails and phone calls about her appearance at the Senate meeting. Some people have even written to her to say that they ended up watching the entire 90-minute meeting because they were so enthralled.

Doctor who schooled U.S. senator ‘thrilled’ by Canadian support

PNHP note: For additional Canadian coverage of Dr. Danielle Martin’s testimony, see this story by CBC News:
http://www.cbc.ca/news/world/dr-danielle-martin-gives-washington-a-lesson-on-canadian-health-care-1.2570872

Resolved: The United States should switch to a single payer health care system

The Great Debate – Single Payer or Private Insurance

By Katie Britton

WAMC, March 13, 2014

Students for a National Health Program at Albany Medical College presented The Great Debate at WAMC’s The Linda on the evening of February 21st.  Moderated by Dr. Kimberly Kilby, the debate featured Dr. Paul Song of the Physicians for a National Health Program (PNHP) from California and Dr. Mitchell Heller of the Benjamin Rush Society from New York City as they argued for and against single payer vs. private insurance.

For an audio of the debate (55 minutes): http://wamc.org/post/great-debate-single-payer-or-private-insurance

The debate:

Resolved: The United States should switch to a single payer health care system

Speaking in favor is Paul Song, MD, representing Physicians for a National Health Program – an organization of physicians and others who advocate for “a universal, comprehensive single-payer national health program.”

Speaking in opposition is Mitchell Heller, MD, representing the Benjamin Rush Society – an organization of physicians and others “who believe that the profession of medicine calls its practitioners to serve their patients, rather than the government.”

“We as a society are defined by how we take care of the least amongst us.” – Dr. Song

“It’s hard to understand how command and control models like single payer still gain intellectual traction at all.” – Dr. Heller

Although you should listen to the debate before hearing the results, many of you do not have the extra 55 minutes. So here is the vote:

Before the debate:

66% – For
5% – Against
29% – Undecided

After the debate:

80% – For
2% – Against
18% – Undecided

As ACA deadline looms, Maine doctors show support for single-payer health care

By Jackie Farwell    
Bangor (Maine) Daily News, March 12, 2014

With March 31 fast approaching as the deadline to buy health insurance under the Affordable Care act, the state’s largest physicians group has released new survey results showing Maine doctors favor a very different kind of health reform.

The survey of Maine Medical Association members shows nearly two-thirds of doctors prefer a single-payer health care system.

Conducted in January and completed by more than 450 respondents, the survey asked:

“When considering the topic of health care reform, would you prefer to make improvements to the current public/private system or a single-payer system such as a “Medicare for all” approach?

Nearly 65 percent of doctors preferred the single-payer option, a jump from about 52 percent in a 2008 MMA survey asking the same question.

Single-payer health systems cover everyone under a publicly funded insurance plan run by a single entity, often the government. All hospitals, doctors, and other health providers bill that entity for their services.

Supporters of the “Medicare for all” approach advocate expanding that government program to cover all Americans, not just those over age 65 and people with disabilities.

For the full story, visit:

http://vitalsigns.bangordailynews.com/2014/03/12/affordable-care-act/as-aca-deadline-looms-maine-doctors-show-support-for-single-payer-health-care/

Watch an expert teach a smug U.S. senator about Canadian healthcare

By Michael Hiltzik
The Los Angeles Times, March 12, 2014

A U.S. politician’s I-don’t-need-no-stinkin’-facts approach to health policy ran smack into some of those troublesome facts Tuesday at a Senate hearing on single-payer healthcare, as it’s practiced in Canada and several other countries.

The countries in question have successful and popular government-sponsored single-payer systems, provide universal coverage and match or outdo the United States on numerous measures of medical outcomes — for far less money than the U.S. spends. To explain this, Sen. Bernie Sanders (I-Vt.) asked seven experts to testify before his subcommittee on primary health and aging.

Those interested in how the U.S. matches up should watch the whole 90-minute session. (The official subcommittee hearing record is available.)

By far the high point of the morning was an exchange between Sen. Richard Burr (R-N.C.) and Danielle Martin, a physician and health policy professor from Toronto. The exchange, in which Martin bats down the myths and misunderstandings about the Canadian system that Burr throws at her, starts at about the 1:08:15 mark.

(The reference to “Premier Williams” is to Newfoundland Premier Danny Williams, whose decision to have a heart valve procedure in Miami, near where he owns a condo, rather than Canada, is widely viewed in Canada as a rich man’s failure to investigate the care available to him closer to home.)

Here’s a lightly edited transcript of the key moments, which start with Burr asking Martin about the observation in her written testimony that wait times for elective surgery in single-payer systems will lengthen as doctors move out of the public system:

BURR: Why are doctors exiting the public system in Canada?

MARTIN: Thank you for your question, Senator. If I didn’t express myself in a way to make myself understood, I apologize. There are no doctors exiting the public system in Canada, and in fact we see a net influx of physicians from the United States into the Canadian system over the last number of years.

What I did say was that the solution to the wait time challenge that we have in Canada — we do have a difficult time with waits for elective medical procedures — does not lie in moving away from our single-payer system toward a multipayer system. And that’s borne out by the experience of Australia. So Australia used to have a single-tier system and did in the 1990s move toward a multiple-payer system where private insurance was permitted. And a very well-known study by Duckett, et al., tracked what took place in terms of wait times in Australia as the multipayer system was put in place.

And what they found was in those areas of Australia where private insurance was being taken up and utilized, waits in the public system became longer. 

BURR: What do you say to an elected official who goes to Florida and not the Canadian system to have a heart valve replacement?

MARTIN: It’s actually interesting, because in fact the people who are the pioneers of that particular surgery, which Premier Williams had, and have the best health outcomes in the world for that surgery, are in Toronto, at the Peter Munk Cardiac Center, just down the street from where I work.

So what I say is that sometimes people have a perception, and I believe that actually this is fueled in part by media discourse, that going to where you pay more for something, that that necessarily makes it better, but it’s not actually borne out by the evidence on outcomes from that cardiac surgery or any other.

(The ultimate zinger came at the end of the exchange, when Burr thought he had Martin down for the count about wait times in Canada, and she neatly put the difference between the Canadian and U.S. systems in perspective.)

BURR: On average, how many Canadian patients on a waiting list die each year? Do you know?

MARTIN: I don’t, sir, but I know that there are 45,000 in America who die waiting because they don’t have insurance at all.

http://www.latimes.com/business/hiltzik/la-fi-mh-watch-a-canadian-20140312,0,2995139.story#ixzz2vmQDiy2b

Tickets written to ‘Truthful Tuesday’ protesters calling for Medicaid expansion

By Jamie Self
The State (Columbia, S.C.), March 11, 2014

COLUMBIA, S.C. — Protesters calling on lawmakers to expand Medicaid under the federal Affordable Care Act — and to stop trying to impede the law in South Carolina — blocked a driveway into the State House parking garage for the second week in a row.

This time, the 11 protesters standing in the street were asked to step aside and await tickets — a different outcome than last week, when Columbia Police hauled protesters off in patrol cars. Another protester today was written a ticket after attempting to block traffic with his vehicle.

Lexington resident Daniel Deweese, 26, only got a verbal warning last Tuesday when he blocked the entrance to the State House parking garage, long enough to allow a group of protesters to block traffic. Today, Deweese was among the protesters ticketed for standing in the road.

Their message today was the same as last week.

Deweese cited a study that says 1,000 people in South Carolina will die without access to Medicaid.

“This is not ethical, and there are people who will not stand for this and will risk arrest” to make the point, he said.

“I’m about as law-abiding a citizen as they come,” said David Ball, who represents a group called Healthcare for All South Carolina, the state chapter of Physicians for a National Health Program.

A nurse for 25 years and U.S. Air Force reservist, Ball said he was willing to participate in civil disobedience, even with risk of arrest or a ticket, to raise awareness about the broken healthcare system.

Ball, who says Medicare should be available for everyone from “cradle to grave,” also said the United States is one of the richest countries, but spends a lot more than other countries on healthcare — a problem he attributed to powerful healthcare and pharmaceutical lobbyists.

Steve Compton, a social worker from Greenville who also received a ticket, said he’s seen the impact of poverty on healthcare and came out to protest as a way of increasing “the attention that we can bring to the problem. Not enough information has been given to citizens” about the Affordable Care Act or what the state’s rejecting of expanding Medicaid would do.

The protest was one of several that activists, organized under the umbrella of Truthful Tuesday, have planned at the State House.

The protesters all have the same March 28 court date as those arrested last week, Columbia Police officials said Tuesday.

http://www.thestate.com/2014/03/11/3318943/buzz-12-more-tickets-written-to.html#storylink=cpy

Senate committee on single payer lessons for the U.S.

Subcommittee Hearing – Access and Cost: What the US Health Care System Can Learn from Other Countries

Committee on Health, Education, Labor and Pensions (HELP) , Subcommittee on Primary Health and Aging
United States Senate, March 11, 2014

Statement by:
Tsung-Mei Cheng, LL.B., M.A.
Health Policy Research Analyst
Woodrow Wilson School of Public and International Affairs, Princeton University

Today’s hearing is focused on “international single payer health system models that provide universal coverage of health care.” I will tailor my remarks according to the three sub-themes the Committee wishes to explore, namely:

*  Primary care access in single payer systems

*  Health care costs in single payer systems, and

*  Cross-country comparisons of health outcomes

Before proceeding with the Committee’s agenda in more detail, however, I would like to provide the Committee with a summary of my main points:

1. If equity and social solidarity in access to health care and financing health care were fundamental goals of a health care system, the single payer system provides an ideal platform for achieving these goals.

2. Single-payer systems typically are financed by general- or payroll taxes in a way that tailors the individual’s or family’s contribution to health-care financing to their ability to pay, rather than to their health status, which until this year has long been the practice in the individual health insurance market in the U.S.

3. These systems protect individual households from financial ruin due to medical bills.

4. Single-payer health systems typically afford patients free choice of health-care provider, albeit at the expense of not having a freedom of choice among different health insurers. Remarkably, in the U.S. households have some freedom of choice of health insurers – to the extent their employer offers them choice – but most Americans are confined to networks of providers for their insurance policy. In other words, Americans appear to have traded freedom of choice among providers for the sake of choice among insurers.

5. In single-payer systems “money follows the patient.” Therefore providers of health care must and do compete for patients on the basis of quality and patient satisfaction, but not price.

6. In a single payer health insurance system, health insurance is fully portable from job to job and into unemployment status and retirement. The “job-lock” phenomenon prevalent in the US is unknown in those systems, contributing to labor-market efficiency.

7. Because all funds to providers of health care in a single-payer system flow from one payer, it is relatively easy to control total health spending in such systems. Indeed, total national health spending as a percent of GDP in countries with single-payer systems is lower than it tends to be in non-single-payer health systems. This does not mean providers are left without a voice. Provider inputs are part of the formal negotiations over health-care budgets.

8. For the most part, single-payer systems achieve their cost control by virtue of the monopsonistic market power they enjoy vis a vis providers of health care. It is a countervailing power that the highly fragmented U.S. health-insurance system lacks vis a vis providers.

9. As part of their effort to control total health spending, however, and to avoid the waste of excess capacity that easily develops in health care, some single-payer systems (the UK and Canada) put constraints on the physical capacity of their health system (number of inpatients beds, MRI scanners, etc). That approach can lead to rationing by the queue. The alternative to rationing by such administrative devices, of course, is rationing by price and ability to pay, an approach used by design or by default in the United States. Rationing by price or by non-price mechanism are just alternative forms of rationing.

10. A single-payer system is an ideal platform for a uniform electronic health information system of the sort, for example, used by our Veterans Administration health system (a single-payer system in its own right). There is a common nomenclature which enables 100% electronic billing and claims processing, thus yielding significant savings in administrative costs.

11. Because they conveniently capture information on all health-care transactions, single-payer systems provide a data base that can be used for quality measurement, monitoring and improvement, and also for more basic research on what drives health spending and what clinical treatments works and does not work in health care. It enables evidence based medicine and the tracking of efficacy and safety of new drugs and devices once they are introduced after approval by government based on results of clinical trials.

Statement of Tsung-Mei Cheng (28 pages): http://www.help.senate.gov/imo/media/doc/Cheng.pdf

Video of the hearing and links to statements of all participants: http://www.help.senate.gov//hearings/hearing/?id=8acab996-5056-a032-522e-e39ca45fcfbe

Comment:

By Don McCanne, M.D.

Sen. Bernie Sanders chaired a Senate committee hearing on what the health care system in the United States can learn from other countries. Tsung-Mei Cheng provided an excellent overview of single payer and of the sharp contrasts between the United States and other nations. Her 28 page statement is well worth downloading to use as an information resource in educating others about single payer.

Other informative presentations included those of Victor Rodwin on France, Ching-Chuan Yeh on Taiwan, Danielle Martin on Canada, and Jakob Kjellberg on Denmark. Even the presentations from the other side by Sally Pipes and David Hogberg were helpful in that they showed how silly (sadly) their views were when contrasted with a group of experts who understand well how systems based on solidarity work. If you can find the time, viewing the entire video (1 hour & 46 minutes) and reading the statements would be well worth the effort (link above).

If you don’t have the time, at least view this 4 minute YouTube video of clips from the hearing: https://www.youtube.com/watch?v=9WdqtPLRc1A