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Misleading reports on ACO savings

Misleading reports on ACO savings

ACOs saving some money, but Medicare is short on details

By Jenny Gold

Kaiser Health News, January 31, 2014

The Centers for Medicare and Medicaid Services [CMS] announced Thursday that, overall, provider groups involved in Medicare ACO programs saved a total of $380 million in the first year. Sounds like a lot of money, but CMS declined to explain which hospitals were winners and which were losers, how it compared to expectations and how much the participants invested in coordinating care. Also missing is the scale of the savings; CMS did not provide the context of total spending by the ACOs…. It’s also unclear whether the savings figures factored in any losses from some of the ACOs that did not do well. And the agency did not release information about which ACOs saved money and which did not….

http://capsules.kaiserhealthnews.org/index.php/2014/01/acos-saving-some-…

Comment:

By Kip Sullivan, JD

Congress has instructed CMS to conduct several experiments with Medicare ACOs. The first began in 2005, the year before the “accountable care organization” label was invented, and ran through 2010. The participating hospital-clinic chains were called “physician group practices” (PGPs), but within a few years ACO advocates and skeptics alike were asserting that these PGPs were indeed the equivalent of ACOs. The second and third ACO experiments began in 2012. CMS called one program the Pioneer ACO program and the other the Medicare Shared Savings program.

CMS’s reports on all three ACO experiments have been extremely misleading. Here are the headlines and dates of CMS’s last three reports on its ACO experiments:

July 2011:  Physicians Groups Continue to Improve Quality and Generate Savings

Under Medicare Physician Pay-for-Performance Demonstrationhttp://www.cms.gov/Medicare/Demonstration-Projects/DemoProjectsEvalRpts/…,

July 2013: Pioneer Accountable Care Organizations succeed in improving care, lowering costs http://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-Releases/2013-Pre…,

January 2014: Medicare’s delivery system reform initiatives achieve significant savings and quality improvements – off to a strong start.http://www.hhs.gov/news/press/2014pres/01/20140130a.html.

Note the pattern: “Costs” are always going down, “quality” is always going up.

These reports suffer from numerous defects. The worst defects are:

•  CMS fails to report how much it costs the ACOs to participate ;

•  CMS usually fails to give us enough information to determine the relative size of the savings or increased costs; and

•  CMS offers only the vaguest descriptions of what the ACOs are doing and yet, on the basis of a few quality measures, reports that quality is improving for all patients assigned to the ACOs.

Reports in both the general media and the professional literature rarely note these defects (for a typical example, see this article in Businessweekhttp://www.businessweek.com/articles/2014-01-30/obamacares-medicare-expe…). The article from Kaiser Health News quoted above (it appeared simultaneously in the Washington Post) is an exception to the rule. KHN reporter Jenny Gold criticizes CMS’s latest report – a press release issued last Thursday on the first-year (2012) results for both the Pioneer and the Shared Savings programs – for the first two defects. She notes CMS reports only on whether Medicare saved money and says not a word about whether the hospital-clinic chains that CMS certified as ACOs saved money after taking their ACO-related costs into account. And she comments on CMS’s failure to put the alleged $380-million first-year savings in context, that is, to help the reader understand whether $380 is a relatively large or small savings.

Gold goes on to quote an expert who did his own back-of-the-envelope calculation and concluded that, if CMS’s reported savings are accurate, CMS’s ACOs are cutting costs for Medicare (not Medicare plus the ACOs) by just $80 per beneficiary per year. (Gold offers a confusing explanation of his methodology, so I can’t vouch for it.) In 2012, Medicare spent $11,325 per beneficiary. Eighty dollars comes to seven-tenths of one percent of $11,325. (You can calculate 2012 per capita Medicare spending for yourself by going to page 6 of the 2013 Medicare trustees report. There you’ll find total spending in 2012 was $574.2 billion and total enrollment was 50.7 million. http://downloads.cms.gov/files/TR2013.pdf)

That estimate of seven-tenths of a percent is close to the half-percent savings (for Medicare only) that CMS reported in its July press release on Pioneer ACOs.

But if you want to know what effect CMS’s ACOs are having on the entire health care system (Medicare plus the ACOs), the only information we have that is remotely useful is the testimony to the Medicare Payment Advisory Commission I quoted here last December 9.https://pnhp.org/blog/2013/12/09/medpac-conflicted-between-fiscal-neutral… Katelyn Smalley stated at Medpac’s November 2013 meeting: “CMS reported [ACO Pioneer] program savings of about 0.5 percent…. The ACOs we spoke with confirmed that the cost of running the ACO was about one to two percent….” In other words, ACOs are driving costs up by a percent or two. Until CMS is more forthcoming, Ms. Smalley’s testimony must remain our most reliable estimate of whether ACOs are saving money.

My main quarrel with Gold’s article is that she or, more likely, one of her editors, inserted a misleading phrase in the headline of her article – “Medicare saving some money….” When the Washington Post published Gold’s article on their Wong Blog on January 31, their editor changed the headline to read, “Medicare won’t give a straight answer on Obamacare cost savings” http://www.washingtonpost.com/blogs/wonkblog/wp/2014/01/31/medicare-wont…. Now that’s more like it.

I have a modest request for the entire media: Please don’t insert the word “savings” in any future articles or broadcasts about Medicare ACOs until CMS reports on the cost incurred by the ACOs. There would still be other reasons to suspect there were no savings (the games ACOs play with risk-adjustment being one of them). But if my wish were granted, the media would no longer be an accomplice to the promulgation of CMS’s strange theory that ACO costs are non-existent or so trivial they don’t deserve mention, much less study.

GOP intransigence accelerates health care crisis

By Andrew D. Coates, M.D., F.A.C.P.
WAMC Northeast Public Radio, Jan. 31, 2014

The Affordable Care Act, President Obama’s health care law, will reduce the number of uninsured through an expansion of both private health insurance and Medicaid. When fully implemented five years from now, it is estimated the law will leave about 30 million people without any form of health insurance, a number that would have been lower had 25 states not “opted out” of Medicaid expansion.

In the meantime Republican lawmakers have continued to call for repeal of the Affordable Care Act.

The Republican majority in the House of Representatives has symbolically voted to repeal the law dozens of times — 14 times over the last year and 35 times during the previous Congress. The irony of voting to repeal a law that was initially a Republican and Heritage Foundation idea — the compulsory purchase of private health insurance —has been highlighted by the fact that Republicans have not seemed to have a counter-proposal, something with which to replace the Affordable Care Act.

This week, evidently in an effort to show they have an alternative, but implicitly acknowledging the ongoing health care crisis, three Republican senators put forward a legislative proposal they call the Patient Choice, Affordability, Responsibility, and Empowerment Act. The Republican senators’ proposal would still use taxpayer money to subsidize the purchase of private health insurance for those can’t afford it, but to a lesser extent than the Affordable Care Act now does.

Oddly, from the party where Grover Norquist’s “no new taxes” pledge is so popular, the Republican senators propose to tax health insurance benefits as income.  The income tax would be levied upon employees, not employers.  This stems from the erroneous theory that health care costs might be reduced if workers are compelled to choose plans with lower premiums, but higher out-of-pocket costs, like co-pays, co-insurance, deductibles.

Under the current law, Medicaid expansion was intended to help millions of people living at or near the poverty level obtain health coverage.  Yet Republican lawmakers in 25 states “opted out” of the expansion of Medicaid that the Affordable Care Act proposed. Had these 25 states implemented the law, nearly 8 million people, presently uninsured, would have gained coverage. The Republican senators would like to see even fewer people covered by Medicaid than their counterparts have allowed state-by-state.

Yesterday, a third-year Harvard medical student, Samuel Dickman, together with senior researchers from Harvard Medical School and the City University of New York, published a study that highlights the human toll of these political decisions.

If all states had “opted in” to the expansion of Medicaid coverage as the law was designed, 7,780,000 more uninsured would have gained coverage. Dickman and colleagues found that if these millions of people gained Medicaid coverage, at least 7,115 and perhaps as many as 17,100 deaths might be prevented.

It is important to state that Medicaid coverage is often inadequate. Medical specialty visits can be impossible to obtain and many states have very restricted access to prescription medications under Medicaid, for two examples. However, having Medicaid remains better than being uninsured.

Dickman also reports because 25 states “opted out” of the Affordable Care Act Medicaid expansion, more than 240,000 people will face catastrophic medical expenses, over 400,000 diabetics will lack access to medications, nearly 200,000 women will forgo mammograms and over 400,000 women will forgo pap smears.

It is not only that Republican intransigence against the Affordable Care Act does nothing to advance the national debate about health care in a direction that would improve quality, increase access or reduce disparities. Nor would Republican proposals offer any means of cost saving, for both out-of-pocket costs and aggregate spending would continue to soar.  It is also important to recognize that the decision to “opt out” of Medicaid expansion has a human toll. As Samuel Dickman said of his research findings, these “political decisions have consequences, some of them lethal.”

Unfortunately, because the Affordable Care Act will not extend coverage to all of the uninsured, is powerless to rein in costs, and keeps profit-seeking in the driver’s seat of the U.S. health system, it too allows an unacceptable situation to persist. Medicaid expansion would lessen preventable death in the United States, for example, yet tens of thousands would still die from lack of health insurance annually, even if all 25 states had “opted in.”

Our nation must move beyond a debate in which neither side will boldly state the obvious goal:  every person in the United States deserves equal access to all necessary health care.

Dr. Andrew Coates practices internal medicine in Upstate New York. He is president of Physicians for a National Health Program.
 
You can find an archive of Dr. Coates’ WAMC radio broadcasts here: http://wamc.org/term/andrew-coates

Was the ACA ‘politically feasible’?

The group that got health care passed is packing up and going home

By Harold Pollack
The Washington Post, January 5, 2014

Harold Pollack: [S]ingle-payer folks … might ask: “Wouldn’t we have a better system if we had a single payer? Why didn’t HCAN [Health Care for America Now] and its friends push for that?”

Richard Kirsch [chief executive of HCAN]: What’s the expression: “If wishes were horses, beggars would ride?”

Yes — if we could wave a magic wand and design a rational health-care system that would control costs while providing much better access, we wouldn’t design our current one. The ACA was the best that we could get through the American political system. The fact that we failed in every previous instance in the past 100 years reflects the reality that there hadn’t been a reform designed to deal with the realities of American politics….

http://www.washingtonpost.com/blogs/wonkblog/wp/2014/01/05/the-group-that-got-health-reform-passed-is-declaring-victory-and-going-home/

****

Implementing health reform: Four years later

By Timothy Jost
Health Affairs, January 2014

How did things go so wrong [for the Affordable Care Act]? Why is there so much bad news?….

More devastating for the future of the ACA, however, were the 2010 midterm elections. Republicans picked up sixty-three seats in the House, swinging control of the chamber from the Democrats to the Republicans. Before the 2010 elections, Democrats controlled fifty-two state legislative houses and the Republicans thirty-three; after the elections, Republicans controlled fifty-three and the Democrats thirty-two. Before the 2010 election there were twenty-six Democratic and twenty-four Republican governors, and after there were twenty Democrat and twenty-nine Republican. Many saw the election as a referendum on the ACA.

http://content.healthaffairs.org/content/33/1/7.full

Comment:

By Kip Sullivan, J.D.

Was the Affordable Care Act politically feasible? Was it “the best” America could do in 2009 and 2010? Was single-payer legislation more or less feasible than the ACA? It is still too early to pronounce on the fate of the ACA, but it is not too early to discuss the political feasibility question. We have much to learn from looking back at the muffled debate about that issue among universal coverage advocates prior to the enactment of the ACA.

Since the modern American single-payer movement was formed in the late 1980s, many supporters of universal coverage have claimed that single-payer is not politically feasible. Those who made this argument (Bernstein and Marmor refer to them as “political yes buts” http://healthaffairs.org/blog/2008/08/28/medicare-for-all-why-we-should-say-yes-not-yes-but) never explained why multiple-payer “solutions” would be more feasible than single-payer. In the worldview of the “yes buts,” only single-payer proponents had to answer that question. If, on any given day, single-payer proponents could not point to 60 votes in the US senate or majority votes in the US House or in state legislative chambers, the conversation was over: Single-payer was not politically feasible and had to be taken off the table to make room for more “realistic” legislation.

This simple counting-noses definition of “political feasibility” avoided two issues that many observers inside and outside the single-payer movement consider paramount: Any legislation that proposes to achieve universal coverage, or even to cut the uninsured rate substantially, is not politically feasible, or at minimum is no more feasible than single-payer legislation, if

(1) it doesn’t simultaneously reduce health care spending or
(2) is so complex it cannot be implemented within a reasonable period of time.

This definition of feasibility asks not merely whether a given legislative body can be pushed into enacting a given bill. This definition asks as well, once the bill is enacted, is it politically sustainable? By this more realistic definition of political feasibility, a bill might have enough votes to pass a given legislative body, but if the bill can’t contain costs or can’t be implemented within a reasonable period of time, it shouldn’t be assumed to be politically sustainable and therefore should not be assumed to be more politically feasible than other approaches.

Sustainability depends ultimately on how the public perceives legislation after it is enacted. If the public punishes lawmakers who voted for the putative “universal coverage” legislation and rewards legislators who are hostile to government doing anything to help the uninsured and to lower health care costs, the legislation may die on the vine or be repealed.

One would think that this definition of political feasibility would have appealed naturally to the Democrats and their supporters who pushed the ACA because it asks them to take into account the impact of the ACA on voters’ perceptions of Democrats. In other words, it asks Democrats to consult their own self-interest in the course of picking a solution to a problem. It is a noble thing to suffer retribution at the polls for a bill that does good things for people when you know it’s going to work. But it is foolish to suffer retribution for a bill you suspect, or should suspect, will fail, or at minimum, will perform far below the expectations your rhetoric about the bill has created.

When in June 2009, congressional Democrats unveiled the health care “reform” bills that would become the ACA, I and many others were filled with apprehension. Our concern was not that some version of these bills might not pass. To the contrary, our concern was that it might pass (and thereby demonstrate it was “politically feasible” in the narrow sense of the phrase) but not be politically sustainable. In a June 2009 comment on this blog entitled, “Democrats’ hype about health care reform will hurt them,” I said:

“President Obama and Democratic congressional leaders are playing a dangerous game with health care reform. They are raising the public’s expectations sky high before figuring out how to meet those expectations. They are promising to give us the moon – significant cuts in health care costs and universal coverage or something close to it – but even at this late hour they have failed to publish anything resembling a detailed plan to do that. And the hints they have given us about the ‘reforms’ they are likely to endorse indicate they haven’t got a clue how to cut costs.”
https://pnhp.org/blog/2009/06/04/democrats%E2%80%99-hype-about-health-care-reform-will-hurt-them/.

I wanted a real debate about the political feasibility of the Democrats’ multiple-payer solution versus our single-payer proposal, and I thought the most effective way to make my argument was to appeal to Democrats’ self-interest, not just their altruism. Although I doubted the altruism of some members of Congress, I didn’t doubt the altruism of the vast majority of ACA supporters — I knew their desire to minimize the suffering inflicted on this country by our health care system was real. What I questioned was their understanding of how expensive and complex the ACA was going to be. If they didn’t understand that, how could they grasp what a political liability the ACA would be for Democrats? How could they intelligently evaluate the risk that future Congresses might not have enough Democrats in them to protect the ACA from underfunding or outright repeal?

But the debate about political feasibility that I and many others hoped for never came to pass. The single-payer and multiple-payer wings of the American universal coverage movement never discussed whether the ACA would be more feasible — that is, be more likely to pass AND be more sustainable — than a single-payer. We never debated whether the simplicity and efficiency of a single-payer made it more feasible, or at least no less feasible, than the costly and insanely complicated ACA. ACA proponents simply pronounced single-payer “off the table” on the ground that powerful opponents would have made a majority vote in Congress impossible. And that was that.

Four years have now passed since the enactment of the ACA. The sky is clotted with chickens coming home to roost. Evidence that the ACA was never as sustainable as its proponents implied is all around us. This evidence includes evidence of the damage the ACA has inflicted on Democrats. Timothy Jost’s article in the January 2014 Health Affairs contains an excellent summary of the unhappy history of the ACA. One of the most important paragraphs in his paper is the one quoted above in which he notes the damage Democrats suffered during the 2010 elections and that many believe this damage was due in part to the enactment of the ACA in March of 2010. Jost also predicts more bad news for the ACA as a substantial portion of the people insured through exchanges discover their choice of provider has been restricted and their out-of-pocket payments are very high. We are going to see more heartwarming stories about sick people finally getting the medical care they deserve, thanks to the ACA, but it will not be enough to forestall more damage to Democrats (especially if Republicans manage to nominate candidates who can refrain from discussing “legitimate rape” and similar subjects).

None of us have a crystal ball. I don’t claim that if Democrats and groups supporting the ACA had used the opportunity presented to us in 2009-2010 to promote HR 676 instead of the ACA that HR 676 would have passed by March 2010 or even by now. I’m reasonably sure something good would have been enacted — for example, an expansion of traditional Medicare and Medicaid to more people (Bob Kuttner makes a similar argument here http://www.huffingtonpost.com/robert-kuttner/obamacare-republicans_b_4293314.html).

I am, however, absolutely certain about one thing: The universal coverage movement in America would be in a much better position to bring the long fight for universal coverage to a successful conclusion than we are now. There are several reasons why I’m so sure about that.

First, whether we had won big or won some incremental improvements in 2010, the public would have been exposed to a debate about a real solution to the health care crisis as opposed to a debate about make-believe cost containment schemes such as exchanges, “accountable care organizations” and punishing hospitals for “excess” readmissions.

Second, the health insurance industry would be receiving less money from the taxpayer and would be, therefore, less powerful than they are now. The insurance industry has been driving away private-sector customers in droves over the last few decades. If public purchasers — state and federal governments — had long ago stopped throwing money at Aetna et al. with legislation like the ACA, schemes to overpay Medicare Advantage plans, and legislation privatizing state Medicaid programs, the industry would by now be a shadow of its former self and a much less potent opponent of universal coverage.

Third, the political environment for health care reform would be less toxic than it is today, not because conservatives wouldn’t be leveling the same extreme charges they level at all forms of health care reform no matter how innocuous, but because the public would be less vulnerable to extremism and ultimately less cynical about real reform.

ACA proponents may disagree with my assessment of where we might be today if they had joined ranks with the single-payer movement and had fought for HR 676. What they can’t deny is they refused to engage in a real debate about the political feasibility (narrowly defined) AND sustainability of the ACA versus single-payer. They might have learned something if they had.

Vicco, Ky., stays in spotlight, endorses single payer

By Kentuckians for Single Payer Healthcare

VICCO,  Ky. — This little Appalachian community that made national news a year ago by passing a Fairness Ordinance did it again Monday night. It voted to endorse single-payer health care, H.R. 676, joining 54 other American cities, including Chicago, San Francisco, Seattle, Philadelphia, Detroit and Baltimore.

The struggling coal town of 334 people unanimously endorsed Expanded and Improved Medicare for All, H.R. 676, national single-payer legislation sponsored by Congressman John Conyers Jr. (D-Mich.).

Vicco — established by the Virginia Iron Coal and Coke Company — is now the fourth Kentucky local government to favor single-payer health care.  The others are Metro Louisville, Boyle County, and the city of Morehead. In 2007, the Kentucky House legislators also endorsed the bill.

Vicco was put on the map early last year when The New York Times, USA Today, the Los Angeles Times and other national media covered the passage of the town’s new law prohibiting discrimination based on sexual orientation or gender identity. It was the smallest city in America to pass such a law.

Vicco gained further fame last August when Mayor Johnny Cummings and city commissioners were featured on “The Colbert Report” on cable television. The Colbert segment went viral, with almost three-quarters of a million views.

Since then, Vicco Mayor Johnny Cummings and the city commissioners have won further state and national praise.  At an event that featured Supreme Court Justice Elena Kagan last September, University of Kentucky President Eli Capilouto referred to Vicco when he described Kentucky as a place “deep in values that show up in unexpected ways and in unexpected places.”

Vicco’s newfound reputation as a progressive and humane community led to a presentation Monday night on health care by Dr. Garrett Adams, past president of Physicians for a National Health Program, and three Louisville colleagues, all representing Kentuckians for Single Payer Healthcare (KSPH).

The KSPH members pointed out that every person in Vicco — and everywhere else in the United States — would be covered by a plan similar to but better than the Medicare system that now serves those over 65 years of age.  The H.R. 676 bill would expand Medicare to all ages and would improve it to include dental, vision, mental health — all medically necessary care.  Patients would choose their own doctors and hospitals and there would be no co-pays or deductibles.  H.R. 676 would annually save over $400 billion by ending the profits and waste caused by private insurance companies.  The savings would then be used to expand an improved care to everyone in the country.

Kay Tillow, chair of KSPH, said, “It’s a moral issue. We believe that health care should not depend on ability to pay. We invite other cities to join our grassroots movement.”

The Vicco city commissioners decided to throw the weight of the town government behind this movement. Their resolution appears below.

Text of the Resolution under the seal of the City of Vicco, Kentucky

Whereas:  Barriers to quality medical care infringe on the right to life, liberty and the pursuit of happiness, and access to health care is a fundamental human right, and;

Whereas a bill has been introduced in Congress, H.R. 676, aka The Expanded and Improved Medicare for All Act, that will provide all medically necessary care, including dental and prescription drugs, to everyone in the country from birth to death.  There will be no co-pays nor deductibles so that inability to pay will be removed as an impediment to care.

Whereas with H.R. 676 each person will choose their own physicians, hospitals, and other providers.

Therefore be it resolved that the City of Vicco wholeheartedly endorses H.R. 676, the Expanded and Improved Medicare for All Act; and

Be it further resolved that we call on our representative in Congress, Representative Harold Rogers, to formally co-sponsor H.R. 676 so that the people of our city, our state, and our nation can  move forward toward the excellent health care we deserve.

Signatories:
Mayor Johnny Cummings
Claude Branson, Commissioner
Lula Gibson, Commissioner
Jimmy Slone, Commissioner

An electronic copy of the resolution available upon request from Kay Tillow, nursenpo@aol.com. Kentuckians for Single Payer Healthcare, www.kyhealthcare.org, (502) 636-1551.

A ‘Pause’ to reflect: Chicagoan Quentin Young tells his story

By Rick Kogan
The Chicago Tribune, January 31, 2014

It seems impossible that the life and times and accomplishments of Dr. Quentin Young might be able to fit into fewer than 250 pages, but there it is, colorful and passionate, between the covers of “Everybody In, Nobody Out: Memoirs of a Rebel Without a Pause.”

As Young, in collaboration with Steve Fiffer, writes, “When you get to be my age, there’s no shortage of stories to tell about things you’ve done, people you’ve met, and places you’ve been. Whether those stories are interesting enough to fill a book is for you, the reader, to decide.”

Well, I have read and I have decided, and the answer is a resounding “Yes.”

Young was born in 1923 and raised on the South Side, where he still lives. He enrolled in the University of Chicago at 16, volunteered for the U.S. Army, went to war and served in the medical corps, came back, earned his medical degree at Northwestern University, went to work at Cook County Hospital, where he eventually rose to chairman of the Department of Medicine from 1972 to 1982. He spent more than 60 years in private practice in Hyde Park.

Though on one level this book is about health care and the decades Young has been an articulate and indefatigable advocate for a single-payer national health care system, Young’s passions and interests extend beyond his life’s work. He attended his first protest as a teenager in support of steelworkers’ efforts to unionize. He helped organize the Freedom Summers in Mississippi. Through the decades Young could be found front and center of so many good causes, social justice matters and civil rights issues.

For instance, when Dr. Martin Luther King Jr. brought his fight for open housing and an end to segregation in the public school system to Chicago in 1966, Young was there. After King was hit in the head with a rock during the horrific open-housing march in Marquette Park, Young tended that wound. “We stopped the blood loss and transported him to the hospital,” Young writes. “The event had the capacity to kill him. He was my medical responsibility. In that moment, I was his doctor.”

And he was the doctor for many others, including columnist Mike Royko, the Beatles when the band was making concert visits here, and his lifelong friend and fellow activist Studs Terkel. “I was fortunate to be kind of Zelig to a number of accomplished and well-known Chicagoans and outsiders,” Young writes.

Politicians pepper these pages: the powerful Daleys on the fifth floor of City Hall, neighbor/friend Harold Washington, legendary 5th Ward Alderman Leon Despres, but not Gov. Pat Quinn, who last year nominated Young to the board of the Illinois Sports Facilities Authority. The current occupant of the White House? “I’ll get into my relationship with President Obama and my profound disappointment in Obamacare shortly,” he writes — and he does, very frankly.

This book is the story of a life well and courageously lived. It is an essential for any Chicago book collection. His recall is solid and his style (with Fiffer) compelling.

He is grateful for being able to mine the many newspaper stories that charted his life and career, and the recall of his family members (including his five grown children, two stepchildren and their families) and colleagues, “the thousands I have worked with.” He slyly tips his hat to “(a)nother organization (that) also kept an almost daily diary of my activities during the 1960s and 1970s, the Federal Bureau of Investigation.”

Near the end of this fine, fine book, he writes, “As you’ve no doubt noticed in the preceding pages, my views and actions have also propelled me into sharp conflict with institutions and persons who would perpetuate injustice. That was true yesterday; it remains true today. My work is unfinished.”

Ever busy, Young might take a moment to be proud — of his work, his life, this book.

Rick Kogan is a Tribune senior writer and columnist.

“Everybody In, Nobody Out”
By Quentin Young, Copernicus Healthcare, 254 pages, $18.95

http://www.chicagotribune.com/site/chi-everybody-in-nobody-out-quentin-young-20140131,0,7501065.story

State opt-outs from Medicaid expansion to result in thousands of deaths

Republican state lawmakers’ refusal to expand Medicaid will result in thousands of deaths

Dr. Steffie Woolhandler: 8 million Americans will be excluded from the Affordable Care Act’s Medicaid expansion

By Jessica Desvarieux
The Real News Network, Jan. 31, 2014

PNHP note: The following is a transcript. You can watch the video of this interview here.

JESSICA DESVARIEUX, TRNN PRODUCER: Welcome to The Real News Network. I’m Jessica Desvarieux in Baltimore.

Since the U.S. Supreme Court’s 2012 ruling that states can opt out of Medicaid expansion and the Affordable Care Act, 21 states have done so, and (not surprising) they’re all under Republican control. What is new to this Obamacare saga is a new Harvard University and CUNY study. It found that the lack of Medicaid expansion in these opt-out states will result in about 7,000 to 17,000 deaths a year.

Now joining us to go over the study is coauthor of the report Dr. Steffie Woolhandler. Dr. Woolhandler is the cofounder of Physicians for a National Health Program and professor of public health and medicine at City University of New York.

Thank you for joining us, doctor.

DR. STEFFIE WOOLHANDLER, COFOUNDER, PHYSICIANS FOR A NATIONAL HEALTH PROGRAM: My pleasure.

DESVARIEUX: So, according to your study, nearly 8 million people will not be able to access health insurance because their states opted out. Can you give us a rundown of the health consequences for these 8 million people?

WOOLHANDLER: Yes. Well, we’ll expect between 7,000 and 17,000 of those people to die. We’ll expect about three-quarters of a million, 750,000 people to experience depression that they would have been spared had they had access to health care. We’ll also see that many diabetics will not have access to medications to treat their condition and that women who need pap smears and mammograms will not get the pap smears and mammograms that they need. So we’re going to see a lot of adverse health consequences from what is essentially a political refusal by the red state governors to accept the Medicaid expansion.

DESVARIEUX: And these red state governors, they really have been coming out saying that they cannot afford to expand Medicaid. What’s your response to that?

WOOLHANDLER: Well, that’s completely ridiculous. The first three years of the Medicaid expansion are 100 percent funded by the federal government, and thereafter the expansion is 90 percent funded by the federal government. And, you remember, these billions are going to go into–if they accepted the money, billions would have gone into the state to pay for the hospitals, to pay for hospital workers, doctors, supplies. So it would have been money that would have gone to their states’ economies. So there’s absolutely no economic argument for turning down the Medicaid expansion. The decision by the red state governors to turn down that expansion is purely political.

DESVARIEUX: All right. But they also say, though, that because the federal government is not going to be funding this beyond that three-year mark, they’re concerned that they’ll have to pick up the tab. What do you make of that?

WOOLHANDLER: Well, over the very long run, the federal share is going to fall. But in the next three, four, five years, the federal government’s going to be picking up most of this. And generally when states do their fiscal planning, they only plan for a few years. They don’t usually make fiscal plans 20 or 30 years in advance. So I think these fiscal arguments are really a ruse. I think the real arguments are political.

You know, I want to say Medicaid is not perfect. You know, Medicaid reimburses doctors at such a low rate that often folks with Medicaid find they can’t see a specialist, they can’t get people to take care of them. Nonetheless, Medicaid is really a lot better than being uninsured. And if you have the opportunity to cover uninsured people with Medicaid, you ought to be taking that opportunity.

DESVARIEUX: All right. Dr. Woolhandler, I want to talk also about the 24 million people who would still lack health insurance even if their states expanded Medicaid. Who are these remaining 24 million people? And why are they not covered by the Affordable Care Act?

WOOLHANDLER: Well, the Affordable Care Act, as passed, as signed, was only going to cover about half of America’s uninsured. It was going to leave 23, 24 million people uninsured. Most of those people, as it turns out, will be U.S. citizens. Many of them will earn just a little bit too much to be Medicaid-eligible. They may be eligible for subsidies. But a lot of people find they still can’t afford the health insurance, despite the subsidies. You know, particularly as you get up into the 250 percent of poverty range, still pretty low-income, but not really poor, the subsidies are not very good and people have to take a lot of money out of their pocket to pay their premiums. And then, when they get sick, they find that they have these big deductibles and copayments. So, many folks may look at the insurance that they’re offered under the exchanges and say, I just can’t afford it, this is not worth it, I’m going to remain uninsured.

So what we saw in Massachusetts was, when we did the Massachusetts reform–which, as you know, was the model of the national reform–is only about half of the uninsured ended up getting insurance through the reform. The other half remained uninsured. And, of course, that’s one of the biggest problems with the Obamacare reform: even if it had been implemented as passed, if the Supreme Court had said the whole thing is constitutional, it has to be implemented, we were still going to have 23, 24, 25 million Americans with no health insurance.

DESVARIEUX: All right. Dr. Steffie Woolhandler, thank you so much for joining us.

WOOLHANDLER: My pleasure.

DESVARIEUX: And thank you for joining us on The Real News Network.

Short bio of Dr. Woolhandler:

Dr. Steffie Woolhandler is professor at the CUNY School of Public Health at Hunter College and visiting professor of medicine at Harvard Medical School, where she co-directed the general internal medicine fellowship program and practiced primary care internal medicine at Cambridge Hospital.

Dr. Woolhandler earned her bachelor’s degree from Stanford University,  a medical degree from Louisiana State University, and a master’s degree from the University of California. She worked in 1990-1991 as a Robert Wood Johnson Foundation health policy fellow at the Institute of Medicine and the U.S. Congress.

Dr. Woolhandler is a frequent speaker and has written extensively on health policy, administrative overhead and the uninsured. She has authored more than 50 research articles on health care access and financing. A co-founder and board member of Physicians for a National Health Program, Dr. Woolhandler co-edits PNHP’s newsletter and is a principal author of PNHP articles published in the JAMA and the New England Journal of Medicine in conjunction with Dr. David Himmelstein.

http://therealnews.com/t2/index.php?option=com_content&task=view&id=767&Itemid=74&jumival=11415

Was the ACA ‘politically feasible’?

The group that got health care passed is packing up and going home

By Harold Pollack
The Washington Post, January 5, 2014

Harold Pollack: [S]ingle-payer folks … might ask: “Wouldn’t we have a better system if we had a single payer? Why didn’t HCAN [Health Care for America Now] and its friends push for that?”

Richard Kirsch [chief executive of HCAN]: What’s the expression: “If wishes were horses, beggars would ride?”

Yes — if we could wave a magic wand and design a rational health-care system that would control costs while providing much better access, we wouldn’t design our current one. The ACA was the best that we could get through the American political system. The fact that we failed in every previous instance in the past 100 years reflects the reality that there hadn’t been a reform designed to deal with the realities of American politics….

http://www.washingtonpost.com/blogs/wonkblog/wp/2014/01/05/the-group-tha…

****

Implementing health reform: Four years later

By Timothy Jost
Health Affairs, January 2014

How did things go so wrong [for the Affordable Care Act]? Why is there so much bad news?….

More devastating for the future of the ACA, however, were the 2010 midterm elections. Republicans picked up sixty-three seats in the House, swinging control of the chamber from the Democrats to the Republicans. Before the 2010 elections, Democrats controlled fifty-two state legislative houses and the Republicans thirty-three; after the elections, Republicans controlled fifty-three and the Democrats thirty-two. Before the 2010 election there were twenty-six Democratic and twenty-four Republican governors, and after there were twenty Democrat and twenty-nine Republican. Many saw the election as a referendum on the ACA.

http://content.healthaffairs.org/content/33/1/7.full

By Kip Sullivan, J.D.

Was the Affordable Care Act politically feasible? Was it “the best” America could do in 2009 and 2010? Was single-payer legislation more or less feasible than the ACA? It is still too early to pronounce on the fate of the ACA, but it is not too early to discuss the political feasibility question. We have much to learn from looking back at the muffled debate about that issue among universal coverage advocates prior to the enactment of the ACA.

Since the modern American single-payer movement was formed in the late 1980s, many supporters of universal coverage have claimed that single-payer is not politically feasible. Those who made this argument (Bernstein and Marmor refer to them as “political yes buts” http://healthaffairs.org/blog/2008/08/28/medicare-for-all-why-we-should-…) never explained why multiple-payer “solutions” would be more feasible than single-payer. In the worldview of the “yes buts,” only single-payer proponents had to answer that question. If, on any given day, single-payer proponents could not point to 60 votes in the US senate or majority votes in the US House or in state legislative chambers, the conversation was over: Single-payer was not politically feasible and had to be taken off the table to make room for more “realistic” legislation.

This simple counting-noses definition of “political feasibility” avoided two issues that many observers inside and outside the single-payer movement consider paramount: Any legislation that proposes to achieve universal coverage, or even to cut the uninsured rate substantially, is not politically feasible, or at minimum is no more feasible than single-payer legislation, if

(1) it doesn’t simultaneously reduce health care spending or
(2) is so complex it cannot be implemented within a reasonable period of time.

This definition of feasibility asks not merely whether a given legislative body can be pushed into enacting a given bill. This definition asks as well, once the bill is enacted, is it politically sustainable? By this more realistic definition of political feasibility, a bill might have enough votes to pass a given legislative body, but if the bill can’t contain costs or can’t be implemented within a reasonable period of time, it shouldn’t be assumed to be politically sustainable and therefore should not be assumed to be more politically feasible than other approaches.

Sustainability depends ultimately on how the public perceives legislation after it is enacted. If the public punishes lawmakers who voted for the putative “universal coverage” legislation and rewards legislators who are hostile to government doing anything to help the uninsured and to lower health care costs, the legislation may die on the vine or be repealed.

One would think that this definition of political feasibility would have appealed naturally to the Democrats and their supporters who pushed the ACA because it asks them to take into account the impact of the ACA on voters’ perceptions of Democrats. In other words, it asks Democrats to consult their own self-interest in the course of picking a solution to a problem. It is a noble thing to suffer retribution at the polls for a bill that does good things for people when you know it’s going to work. But it is foolish to suffer retribution for a bill you suspect, or should suspect, will fail, or at minimum, will perform far below the expectations your rhetoric about the bill has created.

When in June 2009, congressional Democrats unveiled the health care “reform” bills that would become the ACA, I and many others were filled with apprehension. Our concern was not that some version of these bills might not pass. To the contrary, our concern was that it might pass (and thereby demonstrate it was “politically feasible” in the narrow sense of the phrase) but not be politically sustainable. In a June 2009 comment on this blog entitled, “Democrats’ hype about health care reform will hurt them,” I said:

“President Obama and Democratic congressional leaders are playing a dangerous game with health care reform. They are raising the public’s expectations sky high before figuring out how to meet those expectations. They are promising to give us the moon – significant cuts in health care costs and universal coverage or something close to it – but even at this late hour they have failed to publish anything resembling a detailed plan to do that. And the hints they have given us about the ‘reforms’ they are likely to endorse indicate they haven’t got a clue how to cut costs.”
https://pnhp.org/blog/2009/06/04/democrats%E2%80%99-hype-about-health-car….

I wanted a real debate about the political feasibility of the Democrats’ multiple-payer solution versus our single-payer proposal, and I thought the most effective way to make my argument was to appeal to Democrats’ self-interest, not just their altruism. Although I doubted the altruism of some members of Congress, I didn’t doubt the altruism of the vast majority of ACA supporters — I knew their desire to minimize the suffering inflicted on this country by our health care system was real. What I questioned was their understanding of how expensive and complex the ACA was going to be. If they didn’t understand that, how could they grasp what a political liability the ACA would be for Democrats? How could they intelligently evaluate the risk that future Congresses might not have enough Democrats in them to protect the ACA from underfunding or outright repeal?

But the debate about political feasibility that I and many others hoped for never came to pass. The single-payer and multiple-payer wings of the American universal coverage movement never discussed whether the ACA would be more feasible — that is, be more likely to pass AND be more sustainable — than a single-payer. We never debated whether the simplicity and efficiency of a single-payer made it more feasible, or at least no less feasible, than the costly and insanely complicated ACA. ACA proponents simply pronounced single-payer “off the table” on the ground that powerful opponents would have made a majority vote in Congress impossible. And that was that.

Four years have now passed since the enactment of the ACA. The sky is clotted with chickens coming home to roost. Evidence that the ACA was never as sustainable as its proponents implied is all around us. This evidence includes evidence of the damage the ACA has inflicted on Democrats. Timothy Jost’s article in the January 2014 Health Affairs contains an excellent summary of the unhappy history of the ACA. One of the most important paragraphs in his paper is the one quoted above in which he notes the damage Democrats suffered during the 2010 elections and that many believe this damage was due in part to the enactment of the ACA in March of 2010. Jost also predicts more bad news for the ACA as a substantial portion of the people insured through exchanges discover their choice of provider has been restricted and their out-of-pocket payments are very high. We are going to see more heartwarming stories about sick people finally getting the medical care they deserve, thanks to the ACA, but it will not be enough to forestall more damage to Democrats (especially if Republicans manage to nominate candidates who can refrain from discussing “legitimate rape” and similar subjects).

None of us have a crystal ball. I don’t claim that if Democrats and groups supporting the ACA had used the opportunity presented to us in 2009-2010 to promote HR 676 instead of the ACA that HR 676 would have passed by March 2010 or even by now. I’m reasonably sure something good would have been enacted — for example, an expansion of traditional Medicare and Medicaid to more people (Bob Kuttner makes a similar argument here http://www.huffingtonpost.com/robert-kuttner/obamacare-republicans_b_429…).

I am, however, absolutely certain about one thing: The universal coverage movement in America would be in a much better position to bring the long fight for universal coverage to a successful conclusion than we are now. There are several reasons why I’m so sure about that.

First, whether we had won big or won some incremental improvements in 2010, the public would have been exposed to a debate about a real solution to the health care crisis as opposed to a debate about make-believe cost containment schemes such as exchanges, “accountable care organizations” and punishing hospitals for “excess” readmissions.

Second, the health insurance industry would be receiving less money from the taxpayer and would be, therefore, less powerful than they are now. The insurance industry has been driving away private-sector customers in droves over the last few decades. If public purchasers — state and federal governments — had long ago stopped throwing money at Aetna et al. with legislation like the ACA, schemes to overpay Medicare Advantage plans, and legislation privatizing state Medicaid programs, the industry would by now be a shadow of its former self and a much less potent opponent of universal coverage.

Third, the political environment for health care reform would be less toxic than it is today, not because conservatives wouldn’t be leveling the same extreme charges they level at all forms of health care reform no matter how innocuous, but because the public would be less vulnerable to extremism and ultimately less cynical about real reform.

ACA proponents may disagree with my assessment of where we might be today if they had joined ranks with the single-payer movement and had fought for HR 676. What they can’t deny is they refused to engage in a real debate about the political feasibility (narrowly defined) AND sustainability of the ACA versus single-payer. They might have learned something if they had.

Med students lobby for New Yorkers’ health

Medical students lobby lawmakers to advance health care proposals

By Claire Hughes
Times Union (Albany, N.Y.), Jan. 28, 2014

ALBANY, N.Y. — Doctors must advocate for their patients’ health — with supervisors who approve procedures, for instance, or insurance companies that pay for services.

On Tuesday, dozens of doctors-to-be tried different advocacy skills — lobbying state lawmakers to advance proposals they believe will improve New Yorkers’ health.

“If we are not going to fight for our patients, who will?” Albany Medical College student Xin Guan asked a few dozen young adults in white coats who had stopped in the basement of the Legislative Office Building for coffee, bagels and a press briefing between their morning and afternoon visits to lawmakers.

It was the first Medical Student Advocacy Day, organized by Guan, originally from California, and two other second-year students from Albany Med, Ajay Major of Indiana and Phyllis Ying of Seattle.

Some 60 to 70 students from around the state joined them. A glance at the coats suggested most were from Albany Med, but some had traveled from several downstate schools, including Albert Einstein College of Medicine, SUNY Downstate Medical Center and Mt. Sinai Medical Center.

Guan, Major and Ying had prepped them with some activist training before the event. Lobbying representatives was a new activity for about half the students, they said.

While the group shared a concern for health issues, they spoke with legislators about proposals that interested them as individuals. Small groups organized around a few popular issues, including bills to provide universal health coverage for all New Yorkers, allow marijuana for medical use, and prohibit doctors from participating in the torture and improper treatment of prisoners.

Anti-hunger advocate Mark Dunlea gave the students a pep talk before they headed back out to meet their afternoon slate of legislators. Dunlea’s group, Hunger Action Network of New York State, works with a coalition of organizations that provide aid to low-income people who struggle with the costs of health care.

He told the students that their future profession would carry some weight with legislators. And he reminded them that legislators are public servants.

“Remember, these guys work for you,” he said. 

http://www.timesunion.com/local/article/Med-students-lobby-for-New-Yorkers-health-5183446.php

Canadian Health Care: Separating Opinion From Fact

By Trudy Lieberman
The Huffington Post Canada, Jan. 29, 2014

One thing Americans and Canadians can agree on is that we don’t want each other’s health care systems. In truth, most Americans don’t know how Canada’s system works and Canadians don’t know much about the U.S. system.

What Americans know has come mainly from the negative talking points of politicians and others who have argued for years against national health insurance. Two decades ago, The New York Times reported that Canadian women had to wait for Pap smears, a point vigorously refuted by the Canadian ambassador who shot back in a letter to the Times editor: “You, and Americans generally, are free to decide whatever health care system to choose, avoid or adapt, but the choice is not assisted by opinions unrelated to fact.”

Yes, there are waiting lists for some services — but, no, Canadians are not coming across the border in droves to get American care.

There’s misinformation among Canadians, too. Wherever I went, Canadians told me they thought, mostly based on what they said they heard on CNN and Fox, that Obamacare meant America was getting universal health coverage like their country has.

When I explained the law was simply another patch on a patchwork quilt of coverage, and the Congressional Budget Office had estimated last year there would still be some 30 million people without insurance, the reaction was “the news media didn’t tell us that.” A former deputy health minister in New Brunswick said to me, “After all that, you will still have 30 million people without coverage!”

Separating fact from opinion as the Canadian ambassador long ago urged was something I tried to do as I made my way across Canada while visiting there recently. In some ways, the Canadian system is very different from U.S. health care. In other ways, it’s very much the same and faces similar challenges in the years ahead.

What we don’t share

Although the Affordable Care Act in the U.S. calls for more people to have health insurance by offering subsidies and mandating all Americans have it or face penalties, the concept of universality is still a far distant goal. The Canada Health Act, on the other hand, calls for universality — all residents must be covered by the public insurance plan run by their province on uniform terms and conditions. They have coverage wherever they are treated in their home province, and there’s none of this stuff about limiting the doctors and hospitals that patients can use as a condition of getting full benefits. In Canada, there are no financial barriers to care at the point of service as there are and will continue to be in the U.S.

Canadians don’t pay coinsurance of 30 percent or 50 percent if they have an outpatient procedure or go to an urgent care clinic, charges that are becoming increasingly common here. They don’t worry about paying a gigantic bill if they happen to use an out-of-network doctor or hospital. The publicly-funded system north of the border bases patients’ access to medical services on need, not on the ability to pay. To use the word “ration,” Canadians ration by need; Americans ration by price and will continue to do so as the ACA is implemented.

Because it’s publicly funded, Canadian health care is more equitable. There’s no such thing as buying a platinum plan and getting first-rate coverage or a cheapo bronze policy and paying 60 per cent of the bill yourself. The tiered policies available in the state exchanges further bake inequality into the U.S. system. People have wildly varying benefits depending on where they live, how old they are, where they work, and how much they can afford to spend on health insurance.

That’s not the case in Canada, except when it comes to prescription drug coverage. Drug benefits are quite unequal in Canada, and the lack of them is a pretty big hole for about 10 percent of the population. There is no universal drug benefit, although two provinces have mandatory drug insurance — you can get it from an employer or buy it from a public plan. About 40 per cent of the population gets coverage from their employers. If you can’t afford the premium, there are subsidies. In that sense, Canadian drug coverage in those provinces resembles Obamacare. Still, having drug benefits does not necessarily mean adequate coverage, says Globe and Mail health columnist, André Picard: “The big difference from the rest of Canada’s system is there is very little first-dollar coverage of prescription drugs.”

On this trip I heard much more about the social determinants of health than I hear in the U.S. Almost everyone I interviewed mentioned the dismal health stats for aboriginal populations and the need to improve access and quality of care. I tried to remember the last time I heard anyone discuss the medical problems of Native Americans or quality of care provided by the Indian Health Service.

I asked Michael Decter, a health policy expert and a former deputy health minister in Ontario, what was his wish list for Canadian health care. Topping his list was not more money for the health system; it was more for education aimed at improving the lives of aboriginal peoples. Better education correlates with better health. The second was drug coverage. Canada’s infamous waiting times were not high on his list of priorities. In fact, he didn’t even mention them as a problem.

Trudy Lieberman, a former president of Association of Health Care Journalists, is a contributing editor to the Columbia Journalism Review. She is a fellow at the Center for Advancing Health where she blogs about paying for health care. This article is published with permission of the AHCJ. 

http://www.huffingtonpost.ca/trudy-lieberman/canadian-health-care_b_4683089.html

Oncologists Call for Single-Payer System

By Charles Bankhead
MedPage Today, Jan. 29, 2014

Oncologists have a “moral and ethical obligation” to their patients to advocate for a single-payer universal health insurance program, according to two oncologists who stated their case in an editorial.

A single-payer system would simplify healthcare delivery for patients and providers without sacrificing quality of care, said Ray Drasga, MD, and Lawrence Einhorn, MD, in an editorial published online in the Journal of Oncology Practice, a journal of the American Society of Clinical Oncology.

The switch to such a national system would face huge and innumerable challenges, but gradual implementation, perhaps even on a state-by-state basis, would reduce the administrative burdens, they wrote.

“Because the [Affordable Care Act or ACA] will fail to remedy the problems of the uninsured, the underinsured, rising costs, and growing corporate control over care giving, we cannot in good conscience stand by and remain silent,” said Drasga, a retired oncologist in Chicago, and Einhorn, of Indiana University in Indianapolis.

“Life is short, especially for some patients with cancer; they need help now.”

Making Their Case

Drasga and Einhorn state their case for a single-payer system by delineating problems that such a system could address:

  • Reduced administrative costs, which currently account for almost a third of healthcare expenditures
  • Eliminating many bankruptcies attributable to healthcare costs, which accounted for more than 60% of family bankruptcies identified in a 2009 report
  • Improved health, as indicated by evidence that being uninsured increases the mortality hazard by 40%
  • Building on an existing structure, noting that about 60% of all healthcare in the U.S. is publicly funded
  • Implementation of proven cost-containment strategies, which are absent from the ACA
  • Improving quality of care and outcomes by increasing access to care
  • Reverse the trend toward for-profit, investor-owned healthcare plans
  • Preserve physician’s income potential, as judged by experience with the Canadian healthcare system

The authors devoted special attention to the cost of drugs and devices. They cited a study showing that pharmaceutical companies charge 50% more in the U.S. than in Europe for the same drugs. Much of the difference can be traced to large outlays for marketing and for a 20% profit margin, they said. By comparison, research and development (R&D) accounts for about 13% of drug costs.

The Department of Veterans Affairs gets a 40% discount on medication by buying in bulk. Medicare is legally forbidden to negotiate drug prices.

“Lower drug prices would not jeopardize drug innovation,” Drasga and Einhorn stated. “Most true innovations in therapeutics (as opposed to me-too drugs that are slightly different versions of existing drugs) stem from publicly financed research.”

The issue of drug pricing is especially relevant to oncology, they added, where the median cost of a new drug has risen to $10,000 a month since 2010.

The authors called on ASCO to lead the way in advocating for a single-payer system, which would orient healthcare “toward care giving, not toward maximizing investors’ profits.”

ASCO has taken no position on a single-payer or other type of healthcare system, said ASCO chief executive officer Allen Lichter, MD.

“We have long advocated that every American deserves to have insurance coverage,” Lichter told MedPage Today. “We have advocated that those patients who receive a new cancer diagnosis and don’t have insurance should be placed into Medicare because facing a cancer diagnosis without insurance lowers your risk of survival, as Dr. Drasga and Dr. Einhorn pointed out in their paper.”

Payment Reform

Coinciding with the Drasga-Einhorn editorial, ASCO and the Community Oncology Alliance (COA) jointly issued principles for achieving payment reform in oncology.

The six principles focus on:

  • Oncologists taking a leadership role in payment reform
  • The inadequacy of current reimbursement models
  • The need for new models for delivering oncology services to ensure high quality and value
  • Retaining choices in payment models at the local level
  • Improved measurement of quality
  • The inadequacy and inequity of reimbursement for oncology drugs under Medicare Part B

The editorial provides “a good look at Nirvana,” but most community-based oncologists would find it difficult to embrace, said Mark Thompson, MD, president of the COA, which represents community oncology practices and centers.

“You can’t dispute a lot of the facts that they lay out in the article,” said Thompson, who practices at the Mark H. Zangmeister Center in Columbus, Ohio. “We do spend a huge amount of money in administering healthcare in the U.S.

“The difficulty that most of us who have spent any time in Washington — and I’ve spent a lot of time there — is the idea of making this public, which to me translates into government. I don’t think we have a government or a Medicare program that can handle all of the wonderful suggestions that they talk about.”

To the arguments against government-run programs, Drasga and Einhorn countered that “years of private-sector solutions have failed. There needs to be a major paradigm shift in our approach to funding healthcare in the U.S.”

Strong opposition to a single-payer system is to be expected because a lot of money is at stake, Drasga told MedPage Today. Several academic oncologists turned down Drasga’s offer of co-authorship before Einhorn accepted.

“I think they were afraid that it might hurt their relationship with pharma,” he said. “A lot of research is funded by the pharmaceutical industry. There are a lot of powerful forces that do not want to see something like socialized insurance come along.”

Nirvana or not, the single-payer approach is coming, Drasga continued. Vermont has set the process in motion by starting implementation of a state-run single-payer system. Total implementation is anticipated by 2017.

“Once one or two states get programs in place and see that they can save millions and millions of dollars, plus insure everybody, I think we could see a snowball effect,” he said.

The Vermont program is envisioned as “kind of a Medicare for all, but at the state level,” said Deb Richter, MD, a primary care physician from Montpelier who also is on the board of directors of Green Mountain Healthcare, the organization coordinating implementation of the state’s single-payer plan.

Program leaders still have to jump through a lot of legislative and bureaucratic hoops (including waivers from the ACA and Medicare), but they remain optimistic the plan will be fully operational by 2017. The waivers could provide a portion of the funding for system, but the state still has to come up with extra revenue, currently estimated at $1.6 to $2 billion.

The Green Mountain board will submit revenue options to the state legislature in March.

When fully implemented, the plan will leave little business for private insurers, Richter said. The state plans to accept bids for administration of the system, but the market for private insurers will be limited to Vermonters who opt out of the state-run plan.

Whether support for a single-payer system catches fire remains to be seen, but reaction to the Drasga-Einhorn editorial has been limited thus far in the week-plus since the online article appeared, said journal editor John Cox, DO, of Texas Oncology in Dallas.

“The intention was to stir the pot the little, and I suspect we will because this is an issue that has a lot of strong feelings on both sides,” Cox told MedPage Today.

Charles Bankhead is a staff writer at MedPage Today.

http://www.medpagetoday.com/HematologyOncology/OtherCancers/44034

OncoBlog: Single-Payer, the Authors Respond

By Charles Bankhead
MedPage Today, February 6, 2014

When two oncologists wrote an editorial to make a case for a single-payer healthcare system, the response was immediate, abundant, and passionate — on both sides of the issue. One reader, Gary Jones, AA-C, of Case Western Reserve in Cleveland, wrote apoint-by-point rebuttal of the editorial, which set off another round of verbal jousting among MedPage Today readers. In response to the rebuttal by Jones, the two oncologists, Ray E. Drasga, MD, of Chicago, and Lawrence Einhorn, MD, of Indiana University in Indianapolis, submitted their own point-by-point response, published here as a guest blog.

“We read the rebuttal by Mr. Jones and appreciate his time and effort to comment upon our article in Journal of Oncology Practice (JOP). Medical oncologists are particularly data-driven and make clinical decisions based upon evidence-based medicine. Initially, data becomes information which can then lead to a change in standard practice. However, sometimes data simply permits us to form opinions and write commentaries.

“We did not expect complete congruence among the readers of the JOP paper. We realized the conclusions we reached would be contentious with a certain segment of the intended audience. H.L. Mencken once opined, ‘For every complex problem there is an answer that is clear, simple, and wrong.’ However, that does not mean we should avoid solutions for difficult issues, nor accept that the current status quo in healthcare is immutable. With these points in mind, we would like to respond to the points [in boldface below] that were raised by Mr. Jones.”

1. Overhead costs for Medicare and Medicaid are higher than those in the private sector. Calculating the overhead costs based on the Medicare trustees’ report rather than using Zycher’s methodology dramatically changes per-capita spending. For example in 2005, Medicare’s per-capita spending was $144 compared with $680 in the private sector. Medicare’s overhead of 1.4% includes all types of nonmedical spending by the Centers for Medicare and Medicaid Services, as well as other federal agencies, such as the IRS, and is based on data contained in the latest report of the Medicare trustees. Alternative estimates aren’t credible and have been refuted elsewhere. Under the Affordable Care Act, insurers are allowed overhead and profits of 15% of premiums, or 10-fold Medicare’s.

2. Data on bankruptcies related to healthcare costs are inaccurate or misleading. The high proportion (three-fourths) of people with coverage at the onset of illness or injury demonstrates how widespread the problem of under-insurance is. This is particularly the case for cancer patients, who face high deductibles, copays, and high medication costs even with coverage. When you add the under-insured to the uninsured, about 80 million Americans would be financially devastated by a serious illness. In a recent study from the CDC, one-fourth of Americans reported having problems paying medical bills. We have a national problem and need a national solution. Medical bankruptcies in Canada are unheard of.

3. Outcomes with Medicare and Medicaid should be compared with those of private-sector payers, not with the underinsured or uninsured. Medicare is better than private insurance at controlling costs, and beneficiaries are more satisfied with their coverage. Furthermore, studies show that the private Medicare Advantage plans that participate in the Medicare program raise Medicare’s costs by 14% per beneficiary — over $34 billion annually.

4. Using the existing publicly funded system as the foundation for a single-payer system makes little sense. Instead of building on the existing system run by private insurers, who consider every dollar spent on healthcare to be a “loss,” we propose the U.S. adopt a nonprofit national health insurance program, like an improved Medicare for all. We propose to stop using public funds to enrich the drug and insurance companies. We are already paying for comprehensive coverage for everyone, but we aren’t getting it.

5. Government-mandated cost-containment strategies will not work. Effective cost-containment strategies are well known and include implementing global budgets for hospitals, negotiated fees with providers, and bulk-purchasing of drugs and medical supplies. Although it’s better at controlling costs than private insurers, if the U.S. Medicare program was as good at controlling costs as Canada’s is for care of the elderly, the U.S. would have saved over $2 trillion since 1980, when our health systems diverged.

6. Increased access to care does not assure improved quality of care or outcomes. The U.S. ranks 19th out of 19 high-income countries in preventing deaths amenable to medical care, and while we are improving slightly, other countries are improving faster, so we are falling further behind.

7. Reverse the trend toward government-funded healthcare and empower patients by increasing choices. People don’t want to be free to choose between two or three or 300 overpriced, defective insurance products. They want to choose their doctors and know they will receive medically necessary healthcare if they become ill or injured. Private insurance with its “skinny” networks means that people have a limited choice of oncologists and may have to change doctors annually.

8. Physician income will decrease as government-funded healthcare increases. Once you factor in lower malpractice costs in Canada and their much lower overhead to run a practice, the difference in earnings isn’t that great. Besides, with our much greater level of health spending (twice Canada’s) we can afford to continue to pay physicians well.

OncoBlog is a blog by the MedPage Today staff for readers with an interest in oncology. This post comes from guest bloggers Ray Drasga, MD, and Lawrence Einhorn, MD.

More than 7,100 deaths likely from states’ rejection of Medicaid expansion: Health Affairs Blog

Harvard and CUNY researchers say death toll from 25-state ‘opt-out’ may be as high as 17,100 annually; hundreds of thousands more will be harmed by depression, untreated diabetes, and skipping mammograms and pap smears

FOR IMMEDIATE RELEASE, January 30, 2014
Contact: Mark Almberg, communications director, PNHP, (312) 782-6006,  mark@pnhp.org

The decision by 25 states to reject the expansion of Medicaid coverage under the Affordable Care Act will result in between 7,115 and 17,104 more deaths than had all states opted in, according to researchers at Harvard Medical School and the City University of New York.

The study, the first detailed estimate of the health impact of the states’ decision to reject the Medicaid expansion (with state-by-state data as well), is being published today at the Health Affairs Blog.

The researchers found that because of the states’ “opting out” of the Medicaid expansion, 7.78 million people who would have gained coverage will remain uninsured. In addition to the thousands of excess deaths associated with that lack of coverage, the rejection of the Medicaid expansion will have the following likely impacts:

* 712,037 more persons diagnosed with depression
* 240,700 more persons suffering catastrophic medical expenses
* 422,533 fewer diabetics receiving medication
* 195,492 fewer women receiving mammograms and
* 443,677 fewer women receiving pap smears

“We calculated the number and characteristics of people who will remain uninsured as a result of their state’s opting out of the Medicaid expansion, and applied these figures to the known effects of insurance expansion from prior studies,” said Samuel Dickman, a third-year medical student at Harvard Medical School and the study’s lead author. “The results were sobering. Political decisions have consequences, some of them lethal.”

Dickman and his colleagues, longtime health researchers at Harvard Medical School and the City University of New York, drew on demographic data from the Census Bureau’s 2013 Current Population Survey and estimates on Medicaid take-up rates from the Congressional Budget Office and elsewhere to characterize those who would remain uninsured in states opting out of Medicaid expansion.

They developed estimates of the health effects of remaining uninsured based on previous studies that used state-level data on Medicaid expansions and death rates, the National Health and Nutrition Examination Survey Mortality Follow-up, and the Oregon Health Insurance Experiment.

In addition to arriving at national estimates, the researchers were able to break the findings down by state.

For example, in Texas, the largest state opting out of the Medicaid expansion, approximately 2 million people who would otherwise have been insured will remain uninsured as a result of the state’s action.

“Texas’ refusal to accept federal money to expand Medicaid will result in 184,192 more people experiencing depression, 62,610 more people suffering catastrophic medical expenses, and as many as 3,035 avoidable deaths,” said Dr. Steffie Woolhandler, a professor of public health at the City University of New York who is also on the faculty at Harvard Medical School.

The study includes a table showing expected excess deaths and other harms from opting out of the Medicaid expansion on a state-by-state basis.

“Medicaid is far from perfect,” said Dr. David Himmelstein, who also teaches at CUNY and Harvard. “In many parts of the country Medicaid pays so little that patients have trouble finding a doctor who will accept it. A single-payer program like Canada’s that covers all Americans is a far better solution for both the poor and the middle class. But until we get to single payer, Medicaid is the only safety net for many low-income Americans.”

Woolhandler and Himmelstein are also co-founders of Physicians for a National Health Program, a nonprofit research and education organization of more than 18,000 doctors who support single-payer national health insurance. PNHP had no role in funding or otherwise supporting the study.

A link to the study at the Health Affairs Blog is available here.

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“Health and Financial Harms of 25 States’ Decision to Opt Out of Medicaid Expansion.” Samuel L. Dickman, A.B.; David U. Himmelstein, M.D.; Danny McCormick, M.D., M.P.H.; Steffie Woolhandler, M.D., M.P.H. Health Affairs Blog, January 30, 2014.

State Medicaid opt-out will cost over 7,000 lives, maybe 17,000

Opting Out Of Medicaid Expansion: The Health And Financial Impacts

By Sam Dickman, David Himmelstein, Danny McCormick, and Steffie Woolhandler
Health Affairs Blog, January 30, 2014

The Affordable Care Act (ACA) was designed to increase access to health insurance by: 1) requiring states to expand Medicaid eligibility to people with incomes less than 138 percent of the Federal Poverty Level (FPL) ($19,530 for a family of three in 2013), with the cost of expanded eligibility mostly paid by the federal government; 2) establishing online insurance “exchanges” with regulated benefit structures where people can comparison shop for insurance plans; and 3) requiring most uninsured people with incomes above 138 percent FPL to purchase insurance or face financial penalties, while providing premium subsidies for those up to 400 percent of FPL.

Recent studies suggest that Medicaid expansion will result in health and financial gains.  Older studies also found salutary health effects of expanded or improved insurance coverage, particularly for lower income adults.

The Supreme Court ruled in June 2012 that states may opt out of Medicaid expansion, and as of November 2013, 25 states have done so.

The Consequences of Opting Out

The Supreme Court’s decision to allow states to opt out of Medicaid expansion will have adverse health and financial consequences. Based on recent data from the Oregon Health Insurance Experiment, we predict that many low-income women will forego recommended breast and cervical cancer screening; diabetics will forego medications, and all low-income adults will face a greater likelihood of depression, catastrophic medical expenses, and death.

The ACA’s tax subsidy for insurance purchase on the Exchanges is only available to persons with incomes above 100 percent of FPL.  People below this threshold in opt-out states (the so-called low-income “coverage gap”) will see no benefit as the law goes into effect.  They may even see harm because the ACA cuts disproportionate share (DSH) funding to safety net hospitals, reducing the resources available to care for the remaining uninsured.

Examining the numbers

Nationwide, 47,950,687 people were uninsured in 2012; the number of uninsured is expected to decrease by about 16 million after implementation of the ACA, leaving 32,202,633 uninsured.  Nearly 8 million of these remaining uninsured would have gotten coverage had their state opted in.  States opting in to Medicaid expansion will experience a decrease of 48.9 percent in their uninsured population versus an 18.1 percent decrease in opt-out states.

We estimate the number of deaths attributable to the lack of Medicaid expansion in opt-out states at between 7,115 and 17,104.  Medicaid expansion in opt-out states would have resulted in 712,037 fewer persons screening positive for depression and 240,700 fewer individuals suffering catastrophic medical expenditures. Medicaid expansion in these states would have resulted in 422,553 more diabetics receiving medication for their illness, 195,492 more mammograms among women age 50-64 years and 443,677 more pap smears among women age 21-64. Expansion would have resulted in an additional 658,888 women in need of mammograms gaining insurance, as well as 3.1 million women who should receive regular pap smears.

http://healthaffairs.org/blog/2014/01/30/opting-out-of-medicaid-expansion-the-health-and-financial-impacts/

Comment:

By Don McCanne, M.D.

Apparently for no other purpose than to make a political statement, politicians in about half of our states are willing to expose about 8 million poor people to further financial hardship and greater impairment in health care access. More than 7,000 of those people will die as a result. That’s not simply politics; that’s a crime!

In a PNHP press release, Dr. David Himmelstein, co-author of the study and co-founder of PNHP said it well: “Medicaid is far from perfect. In many parts of the country Medicaid pays so little that patients have trouble finding a doctor who will accept it. A single-payer program like Canada’s that covers all Americans is a far better solution for both the poor and the middle class. But until we get to single payer, Medicaid is the only safety net for many low-income Americans.”

PNHP press release: https://www.pnhp.org/news/2014/january/more-than-7100-deaths-likely-from-states-rejection-of-medicaid-expansion-%C2%A0health-a