PNHP

Konczal and Krugman on the policies and politics of single payer

Konczal and Krugman on the policies and politics of single payer

What Kind of Problem is the ACA Rollout for Liberalism?

By Mike Konczal
Next New Deal, The blog of the Roosevelt Institute, October 23, 2013 Healthcare.gov looks to be having a disastrous launch. Conservatives in particular think this website has broad implications for liberalism as a philosophical and political project. I think it does, but for the exact opposite reasons: it highlights the problems inherent in the move to a neoliberal form of governance and social insurance, while demonstrating the superiorities in the older, New Deal form of liberalism. The general problem is that “More than 30 states refused to set up their own exchanges, requiring the federal government to vastly expand its project in unexpected ways.” Category A Social Insurance 1. is heavily means-tested 2. is provided by private agents to individuals 3. leaves open the possibility of adverse selection because of market segmentation 4. gives discretion to the states to either help or undermine the process 5. is designed to ensure choice and competition Category B Social Insurance 1. is a program that is universal to all who qualify for it 2. has the government running the system itself 3. uses compulsion to default people into social insurance to prevent adverse selection 4. situates the program at the federal level, to avoid states undermining it 5. does all this to ensure better provisioning outcomes, using government’s scale and efficiency What we often refer to as Category A can be viewed as a “neoliberal” approach to social insurance, heavy on private provisioning and means-testing. This term often obscures more than it helps, but think of it as a plan for reworking the entire logic of government to simply act as an enabler to market activities, with perhaps some coordinated charity to individuals most in need. This contrasts with the Category B grouping, which we associate with the New Deal and the Great Society. This approach creates a universal floor so that individuals don’t experience basic welfare goods as commodities to buy and sell themselves. This is a continuum rather than a hard line, of course, but readers will note that Social Security and Medicare are more in Category B category rather than Category A. My man Franklin Delano Roosevelt may not have known about JavaScript and agile programming, but he knew a few things about the public provisioning of social insurance, and he realized the second category, while conceptually more work for the government, can eliminate a lot of unnecessary administrative problems. The choice between Category A and B above will characterize much of the political debate in the next decade. It’s important we get more sophisticated analysis of what has gone wrong with the ACA rollout to better appreciate how utilizing “the market” can be far more cumbersome and inefficient than the government just doing things itself. http://www.nextnewdeal.net/rortybomb/what-kind-problem-aca-rollout-liberalism

Why Is Obamacare Complicated?

By Paul Krugman
The New York Times, October 26, 2013 Mike Konczal says most of what needs to be said about the underlying sources of Obamacare’s complexity, which in turn set the stage for the current tech problems. Basically, Obamacare isn’t complicated because government social insurance programs have to be complicated: neither Social Security nor Medicare are complex in structure. It’s complicated because political constraints made a straightforward single-payer system unachievable. It’s been clear all along that the Affordable Care Act sets up a sort of Rube Goldberg device, a complicated system that in the end is supposed to more or less simulate the results of single-payer, but keeping private insurance companies in the mix and holding down the headline amount of government outlays through means-testing. This doesn’t make it unworkable: state exchanges are working, and healthcare.gov will probably get fixed before the whole thing kicks in. But it did make a botched rollout much more likely. So Konczal is right to say that the implementation problems aren’t revealing problems with the idea of social insurance; they’re revealing the price we pay for insisting on keeping insurance companies in the mix, when they serve little useful purpose. So does this mean that liberals should have insisted on single-payer or nothing? No. Single-payer wasn’t going to happen — partly because of the insurance lobby’s power, partly because voters wouldn’t have gone for a system that took away their existing coverage and replaced it with the unknown. Yes, Obamacare is a somewhat awkward kludge, but if that’s what it took to cover the uninsured, so be it. http://krugman.blogs.nytimes.com/2013/10/26/why-is-obamacare-complicated/?_r=0 Krugman elaborates further on the Obamacare kludge: http://www.nytimes.com/2013/10/28/opinion/krugman-the-big-kludge.html?ref=opinion

One Nation Uninsured

By Paul Krugman
The New York Times. June 13, 2005 The intellectually serious debate is between those who believe that the government should simply provide basic health insurance for everyone and those proposing a more complex, indirect approach that preserves a central role for private health insurance companies. A system in which the government provides universal health insurance is often referred to as “single payer,” but I like Ted Kennedy’s slogan “Medicare for all.” It reminds voters that America already has a highly successful, popular single-payer program, albeit only for the elderly. It shows that we’re talking about government insurance, not government-provided health care. And it makes it clear that like Medicare (but unlike Canada’s system), a U.S. national health insurance system would allow individuals with the means and inclination to buy their own medical care. The great advantage of universal, government-provided health insurance is lower costs. Canada’s government-run insurance system has much less bureaucracy and much lower administrative costs than our largely private system. Medicare has much lower administrative costs than private insurance. The reason is that single-payer systems don’t devote large resources to screening out high-risk clients or charging them higher fees. The savings from a single-payer system would probably exceed $200 billion a year, far more than the cost of covering all of those now uninsured. Nonetheless, most reform proposals out there – even proposals from liberal groups like the Century Foundation and the Center for American Progress – reject a simple single-payer approach. Instead, they call for some combination of mandates and subsidies to help everyone buy insurance from private insurers. Some people, not all of them right-wingers, fear that a single-payer system would hurt innovation. But the main reason these proposals give private insurers a big role is the belief that the insurers must be appeased. That belief is rooted in recent history. Bill Clinton’s health care plan failed in large part because of a dishonest but devastating lobbying and advertising campaign financed by the health insurance industry – remember Harry and Louise? And the lesson many people took from that defeat is that any future health care proposal must buy off the insurance lobby. But I think that’s the wrong lesson. The Clinton plan actually preserved a big role for private insurers; the industry attacked it all the same. And the plan’s complexity, which was largely a result of attempts to placate interest groups, made it hard to sell to the public. So I would argue that good economics is also good politics: reformers will do best with a straightforward single-payer plan, which offers maximum savings and, unlike the Clinton plan, can easily be explained. We need to do this one right. If reform fails again, we’ll be on the way to a radically unequal society, in which all but the most affluent Americans face the constant risk of financial ruin and even premature death because they can’t pay their medical bills. http://www.nytimes.com/2005/06/13/opinion/13krugman.html?hp

Comment:

By Don McCanne, M.D. Mike Konczal’s article makes important distinctions between social insurance along the lines of private market provisioning (neoliberal), as with the Affordable Care Act, and social insurance along the lines of public provisioning (New Deal liberal), as with single payer, and why “utilizing ‘the market’ can be far more cumbersome and inefficient than the government just doing things itself.” Paul Krugman reinforces Konczal’s thesis by saying that the implementation problems are “revealing the price we pay for insisting on keeping insurance companies in the mix, when they serve little useful purpose.” Yet Krugman says liberals were correct in not insisting on single payer, because Obamacare, a kludge, was “what it took to cover the uninsured.” He remains silent on the fact that 31 million will still remain uninsured. Krugman’s statement is a far cry from what he wrote in 2005. He rejected the so-called lesson of the Clinton fiasco – that any reform must buy off the private insurance industry – writing then, “good economics is also good politics: reformers will do best with a straightforward single-payer plan.” Konczal’s astute framing of private social insurance versus government social insurance can be useful in our advocacy work since it makes it very clear why it is imperative that we first get policy right, and then conform the politics to match the policy. The great tragedy of Obamacare is that we strangled the policies in order to protect our terribly flawed politics.

]]>

Vermont eyes 2017 launch of single-payer health plan

By Dave Gram
Modern Healthcare, Oct. 26, 2013 (AP) As states open insurance marketplaces amid uncertainty about whether they’re a solution for healthcare, Vermont is eyeing a bigger goal, one that more fully embraces a government-funded model. The state has a planned 2017 launch of the nation’s first universal healthcare system, a sort of modified Medicare-for-all that has long been a dream for many liberals. The plan is especially ambitious in the current atmosphere surrounding healthcare in the United States. Republicans in Congress balk at the federal health overhaul years after it was signed into law. States are still negotiating their terms for implementing it. And some major employers have begun to drastically limit their offerings of employee health insurance, raising questions about the future of the industry altogether. In such a setting, Vermont’s plan looks more and more like an anomaly. It combines universal coverage with new cost controls in an effort to move away from a system in which the more procedures doctors and hospitals perform, the more they get paid, to one in which providers have a set budget to care for a set number of patients. The result will be healthcare that’s “a right and not a privilege,” Gov. Peter Shumlin said. Where some governors have backed off the politically charged topic of healthcare, Shumlin recently surprised many by digging more deeply into it. In an interview with a newspaper’s editorial board, he reversed himself somewhat on earlier comments that Vermont would wait to figure out how to pay for the new system. He said he expects a payroll tax to be a main source of funding, giving for the first time a look at how he expects the plan to be paid for. The reasons tiny Vermont may be ripe for one of the costliest and most closely watched social experiments of its time? It’s the most liberal state in the country, according to Election Day exit polls. Democrats hold the governor’s office and big majorities in both houses of the Legislature. It has a tradition of activism. Several times in recent years, hundreds of people have rallied in Montpelier for a campaign advocating that healthcare is a human right. It’s small. With a population of about 626,000 and just 15 hospitals, all nonprofits, Vermont is seen by policy experts as a manageable place to launch a universal healthcare project. “Within a state like Vermont, it should be much more possible to actually get all of the stakeholders at the table,” said Shana Lavarreda, director of health insurance studies at the University of California at Los Angeles’ Center for Health Policy Research. Vermont’s small size also is often credited with helping preserve its communitarian spirit. People in its towns know one another and are willing to help in times of need. “The key is demography,” said University of Vermont political scientist Garrison Nelson. Discussions about health policy “can be handled on a relative face-to-face basis,” he said. And, for better or worse, Vermont has little racial or income diversity, Nelson pointed out. Then there’s the fact that Vermont is close to universal healthcare already. Lavarreda noted that the state became a leader in insuring children in the 1990s. Now 96 percent of Vermont children have coverage, and 91 percent of the overall population does, second only to Massachusetts. At this stage, no one knows whether state-level universal healthcare will succeed, and it’s an open question as to whether Vermont can work as a model for other states. “Developing a single-payer system for Vermont is a lot easier than in California or Texas or New York state,” said U.S. Sen. Bernie Sanders. The independent, frequently described as the only socialist in the Senate, has been pushing for some form of socialized medicine since he was mayor of Burlington 30 years ago. Vermont’s efforts have largely gone unnoticed as the nation focuses on the rollout of the state-based health insurance marketplaces and the disastrous unveiling of healthcare.gov, said Chapin White, a researcher with the Washington-based Center for Studying Health System Change. “Vermont’s thinking about 2017, and the rest of the country is just struggling with 2014 right now,” White said. Even with years to go before Vermont’s single-payer plan will be in place, several obstacles remain. The largest national health insurance industry lobbying group, America’s Health Insurance Plans, has warned that the law could limit options for consumers and might not be sustainable. “The plan could disrupt coverage consumers and employers like and rely on today, limit patients’ access to the vital support and assistance health plans provide, and put Vermont taxpayers on the hook for the costs of an unsustainable healthcare system,” said AHIP spokesman Robert Zirkelbach. And questions have also arisen about the expected cost savings of eliminating multiple insurance companies and their different coverage levels and billing styles. Much of a hospital’s billing process is coding to ensure that the right patient is billed the right amount for the right procedure, said Jill Olson, vice president of the Vermont Association of Hospitals and Health Systems. That would continue in a single-payer system. Vermont also has yet to answer how it will cover everyone. The post-2017 system is not envisioned to include federal employees or those with self-insured employers that assume the risk of their own coverage and are governed by federal law, including IBM, one of the state’s largest private employers. It also may not include residents who work for and get insurance through companies headquartered out of state, Olson said. At least one resident, 73-year-old Gerry Kilcourse, has little patience for the naysayers. Kilcourse said that when he and wife Kathy bought a hardware store in Plainfield in the early 1980s, they struggled for years to find good, affordable health insurance coverage. In retirement, Kilcourse has schooled himself on health policy and advocates for universal coverage. He sees healthcare as a public good and likens the current campaign to the 19th-century push in the United States for public schools. “It should be similar to education, which is publicly funded,” Kilcourse said of healthcare. “If we did the same thing for education (as in healthcare), you’d have a number of people being excluded” from public schools. Shumlin has made it clear the status quo can’t hold. As a part owner himself of a small business — a student travel service based in Putney — he has spoken often of the burden that employee health coverage is to such business owners. At a Chamber of Commerce forum in September, he called the federal health overhaul “a great improvement over the past” but added it “is not the silver bullet that will … provide universal access and quality healthcare for all Vermonters.” That, he appears to hope, will come in 2017. http://www.modernhealthcare.com/article/20131026/INFO/310269893/vermont-eyes-2017-launch-of-single-payer-health-plan

]]>

Group marches for health care for all

Participants rally to promote single-payer system

By Andrea K Walker
Baltimore Sun, October 26, 2013 The federal Affordable Care Act is expected to provide access to medical coverage to hundreds of thousands of Maryland’s uninsured, but one group said that doesn’t go far enough. The group, Healthcare is a Human Right-Maryland, led a rally Saturday in Baltimore to push for single-payer coverage similar to that in countries such as Canada and Sweden, where the government runs most of the health system and there are no insurance companies. The health reforms widely known as Obamacare require most people to get insurance. The uninsured will be able to buy from private insurers on a state exchange. Low-income people will qualify for plans under expanded Medicaid. Healthcare is a Human Right-Maryland said that while health reform will expand coverage to many of Maryland’s 800,000 uninsured, many people still won’t qualify, including immigrants in the country illegally who can’t get insurance under the law. Others still won’t be able to afford adequate coverage or coverage at all, members of the group say. Health reform creates a tiered system where people who have more money can buy better plans, the group said. For example, people who buy insurance on a state exchange in Maryland can choose between bronze, silver and gold plans. The bronze plans have less costly premiums but higher deductibles. “Although the Affordable Care Act has helped some people get insurance, it doesn’t solve the problem,” said Roxanna Harlow, a member of the organization’s Carroll County chapter. Maryland Health Secretary Dr. Joshua M. Sharfstein said he agrees that the ultimate goal is for everyone to be insured. But he said the access Marylanders will have to insurance under reform shouldn’t be underestimated. Obamacare will also create a system that focuses on preventive care and keeping people out of the hospital. This will help create a healthier population and curb health care costs, he said. “I think we’re engaged in the task at hand right now, which is making progress in the areas that we can,” he said. “We can help a lot of people through what we’re working on now,” he said. Harlow was one of many who shared their experiences of living without insurance during Saturday’s rally. When she left a full-time job to start an education nonprofit, Harlow said, she didn’t make enough to pay for insurance. Under Obamacare, she will qualify for Medicaid. But she said that is only because Maryland chose to expand Medicaid under reform. The law gives states the choice to opt out of Medicaid expansion, which many states chose to do. Because of this, many people will remain uninsured. In addition to Medicaid expansion, federal subsidies will also be offered to help people who fall under certain incomes pay for insurance. That won’t help everyone, those at the rally said. They believe that under health reform, deductibles, co-pays and other out-of-pocket medical expenses will continue to keep health coverage out of reach for some. They also say people will still be in danger of falling into debt or medical bankruptcy because of health costs they can’t afford.
Raquel Rojas Rojas knows what it’s like to incur exorbitant medical fees. She didn’t have health insurance when she recently contracted pneumonia and landed in the hospital for two days. It cost her $12,000, and she said she feels that she’ll be paying that off for the rest of her life. Rojas now has a job as a cook at a restaurant that provides health benefits, but she said she knows many others who don’t have insurance and have gotten stuck with hefty medical bills. “As someone who has been uninsured, I really understand the importance of fighting for this,” she said. Rojas and a large group marched from Highlandtown to the Canton waterfront and the offices of CareFirst BlueCross BlueShield. Healthcare is a Human Right-Maryland believes that insurance companies such as CareFirst cause many of the problems with access to coverage. CareFirst officials could not be reached for comment Saturday. Margaret Flowers was a pediatrician until 2007, when she said she became fed up with the insurance industry. She said insurers don’t pay for much-needed tests and drugs. She also had a hard time getting paid for services, she said. “The system is not about health,” she said. “It is about profit. I decided I would quit and fight for health care.” Sergio Espana, the statewide organizer for Healthcare is a Human Right-Maryland, said he hopes the rally brings more attention to the need for a better health care system. “What we have now is not enough,” he said. http://articles.baltimoresun.com/2013-10-26/health/bs-md-health-care-march-20131026_1_health-reform-medicaid-expansion-health-coverage

]]>

Amid tangle of Obamacare, consider single-payer health care

By Jack Bernard
The Augusta (Ga.) Chronicle, Oct. 26, 2013 With private insurance covering most of the employed and 48 million uninsured, the United States has seen health care costs skyrocket for many decades. Something had to be done, so Congress passed the Affordable Care Act (Obamacare) in 2010. Apparently, the House suddenly awakened to that fact and wanted to shut down the government to reverse history to when George W. Bush was president. Contrary to the social media hysteria being sent out, the ACA is not a left-wing socialist program. It is built on a flawed conservative Heritage Foundation proposal that was the basis for Romneycare in Massachusetts. As opposed to what the demagogues spout, the ACA simply expands the private insurance system to cover everyone, a right-of-center concept. Until relatively recently, that was exactly what the Republican Party was advocating, per Bob Dole when he ran for president. Regardless of the hypocrisy, the pundits are correct that the ACA will increase total costs; fail to cover tens of millions of people (partly because of the refusal of many red states to expand Medicaid because of party politics); and perpetuate the self-interested stranglehold that private insurance companies have on our health care system. And the delays in implementation, many because of politics, should tell all of us how hard it will be to install. So what is the best alternative? Medicare is a well-established program beloved by most Americans – Republican, Democrat or independent. It is easy to understand why that support is so strong. Go back and look at what existed before it was enacted: the free market, with older Americans thrown to the wolves. The Darwinian notion that we simply can return to the bad old days is out of touch with modern society. The radical philosophy of Ayn Rand, formed as a reaction to the communist threat nearly a century ago, is behind the Paul Ryan/GOP health care proposals of today. In the 1960 presidential debates, Richard Nixon called national health insurance for the elderly “socialism.” Right or wrong, even our right-leaning seniors now love it. Remember the Tea Party placards in 2009 at town hall meetings – “Keep the government out of my Medicare”? There is tremendous voter resistance to cutting entitlements (earned benefits, say some) via a Ryanesque Medicare voucher program that takes away the government guarantee of health insurance for the elderly. Having an inevitably decreasing federal ‘‘premium support,” which will
be tied to Washington partisan budget politics, should give few citizens younger than 55 little comfort. I am a capitalist and a former Republican elected official, but we are going in the wrong direction with the simplistic Ryan approach. Health care is different than other economic markets. The “rational economic man” theory, wherein the buyer can evaluate quality and costs in a perfect world of readily available data, is just not applicable. We should be setting up regulatory mechanisms to control costs, as other developed countries with more effective national health care systems do. That includes universal budget-setting with control of payments to providers, ensuring that compensation is equitable but not excessive. The most efficient way to accomplish this goal is single-payer Medicare for all, funded primarily via payroll tax shared by employers and employees. The best place to find out more about single payer is from the Physicians for a National Healthcare Program: • Private insurance companies have 31 percent administrative and marketing costs vs. 3 percent for Medicare; • Medical bills are a major cause of bankruptcies in the United States, although most folks going broke had health insurance; • The current breakdown of payers is not what you might think – 60 percent government; 20 percent private; and 20 percent out of pocket; • We currently pay more per capita in taxes for government health care (Medicare/Medicaid/Veterans Administration and so forth) than most nations, but we still have tens of millions uninsured. Let’s ask our politicians to finally put their ideologies aside and do what works for many other developed nations: single payer, universal Medicare. The writer is a retired senior health care executive with several national for-profit firms, and was the state of Georgia’s first director of health planning. He lives in Monticello, Ga. http://chronicle.augusta.com/opinion/opinion-columns/2013-10-26/amid-tangle-obamacare-consider-single-payer-health-care

]]>

New Mexico is 44th state AFL-CIO to back H.R. 676

By Kay Tillow
Single Payer News, Oct. 24, 2013
 
On October 17, 2013, the Executive Council of the New Mexico Federation of Labor, AFL-CIO, endorsed H.R. 676, national single-payer health care legislation sponsored by Congressman John Conyers (D-Mich.), reports Jon Hendry, president.
 
New Mexico is the 44th state AFL-CIO federation to take such action.
 
President Hendry stated, “We are huge believers in single payer here. There is absolutely no dissent from this unanimous support.” He said he was surprised to learn that formal action to support H.R. 676 had not been taken earlier. “We are not late,” he said, because “we have been big proponents of single payer for a long time.” He noted that his union, IATSE, is a leader in single-payer efforts nationally and that commitment was reaffirmed at their recent national convention.
 
The New Mexico Federation of Labor, AFL-CIO, is the state federation of labor representing over 170,000 members counting the families, retirees, and community affiliates throughout New Mexico, said Hendry.
 
Prior to the endorsement, James Besante, a third-year student at the University of New Mexico School of Medicine, spoke to the council about H.R. 676 and single-payer health care. In 2012 Besante received the Nicholas Skala Student Activist Award from Physicians for a National Health Program (PNHP), the 18,000-member organization of doctors that leads in research and advocacy for single payer.
 
In most states PNHP is able to provide speakers to union organizations that are interested in learning how single payer works. info@pnhp.org (312) 782-6006.

** H.R. 676 would institute a single-payer health care system by expanding a greatly improved Medicare to everyone residing in the U.S.
 
H.R. 676 would cover every person for all necessary medical care including prescription drugs, hospital, surgical, outpatient services, primary and preventive care, emergency services, dental (including oral surgery, periodontics, endodontics), mental health, home health, physical therapy, rehabilitation (including for substance abuse), vision care and correction, hearing services including hearing aids, chiropractic, durable medical equipment, palliative care, podiatric care, and long-term care.
 
H.R. 676 ends deductibles and co-payments. H.R. 676 would save hundreds of billions annually by eliminating the high overhead and profits of the private health insurance industry and HMOs.
 
In the current Congress, H.R. 676 has 51 co-sponsors in addition to Conyers.
 
H.R. 676 has been endorsed by 609 union organizations including 146 Central Labor Councils/Area Labor Federations and 44 state AFL-CIO’s (KY, PA, CT, OH, DE, ND, WA, SC, WY, VT, FL, WI, WV, SD, NC, MO, MN, ME, AR, MD-DC, TX, IA, AZ, TN, OR, GA, OK, KS, CO, IN, AL, CA, AK, MI, MT, NE, NJ, NY, NV, MA, RI, NH, ID & NM).
 
For further information, a list of union endorsers, or a sample endorsement resolution, contact: Kay Tillow, All Unions Committee for Single Payer Health Care–HR 676, c/o Nurses Professional Organization (NPO), 1169 Eastern Parkway, Suite 2218, Louisville, KY 40217. Phone: (502) 636-1551. E-mail: nursenpo@aol.com. Website: http://unionsforsinglepayer.org

]]>

UnitedHealth’s Simon Stevens to head NHS England

UNISON responds to appointment of Simon Stevens as NHS chief executive

UNISON, October 24, 2013 Responding to the announcement that the president of Global Health and group executive vice-president at UnitedHealth, Simon Stevens, will take on the role of chief executive of NHS England in April next year, UNISON Head of Health Christina McAnea said: “The NHS is facing its first serious crisis for the best part of the decade, and it is critical that Simon Stevens respects and shares the values of our NHS – universal healthcare that is free at the point of need. “It is surprising that no one within the NHS has been found to take on this position. We sincerely hope this is not a sign that the government wants to import America-type values into the NHS and look at ways of developing healthcare through an insurance model. If this is the intention there will be massive opposition. “Mr Stevens will have his work cut out for him right from the start. Far from being protected from government cuts, the NHS is being starved of the funds it needs. Thousands of jobs are under threat and accident and emergency departments are creaking under the pressure of cuts, privatisation and upheaval.” (UNISON is a UK trade union of public employees) http://www.unison.org.uk/news/unison-responds-to-appointment-of-simon-stevens-as-nhs-chief-executive

Simon Stevens, new head of NHS England, is in for a rude awakening

Under Labour, Stevens began the culture of competition in health. He will now find out just how perverse this has become

By Polly Toynbee
The Guardian, October 24, 2013
As he sowed, so shall he reap. Simon Stevens will get his just deserts as he takes up the reins of NHS England, only to find this horse has no bridle or bit, galloping out of anyone’s control. That was, of course, precisely the explosive “creative destruction” Andrew Lansley intended. Stevens returns from the biggest US health company to an NHS whose current path he designed as Tony Blair’s adviser. Now he must piece together some coherence from the fragments of what Sarah Wollaston, MP and GP, called “a grenade” tossed into the NHS. As Lansley outlined his scheme in 2010, Stevens wrote a paean of praise in the Financial Times. It reads as a touchingly optimistic vision, where choice and competition in a perfect market deliver everything a patient or GP could desire. When he sees what he’s inherited, he may get a rude awakening. But he shares the blame, claiming authorship: “What makes the coalition’s proposals so radical is not that they tear up (our) earlier plan,” but “move decisively towards fulfilling it – in a way that Mr Blair was blocked from doing by internal opposition”. He lists the plan’s glories: in “the new model NHS, patients are rightly being promised that ‘no decision will be made about me, without me'”. No sign yet of that. He praises “the severing of day-to-day political control of the NHS”, but now he’ll find his own control severed. How will he marry his vouchers for pregnant women with wildly unpopular maternity closures? His hope that “patient power will become real, GP commissioners will fire on all cylinders and hospitals will be liberated to innovate” is a world away from today’s NHS. But his greatest regret may be his praise for “the decision to extend competition law across the health sector and treat the NHS as a regulated utility, with an economic regulator – Monitor”. Faith in competition fills his writings – but reality is biting back. Monitor, engine of NHS competition, has only just understood its destructive force: its chief executive, David Bennett, recently recoiled, saying Monitor would be “mad” to enforce the Lansley competition rules leaving commissioners to “spend all their time running competitive processes because they’re terrified they’re going to get in trouble if they don’t”. Too late now. So far, 63% of contracts have been put out to tender by clinical commissioning groups (CCGs), now run by just a few GPs. The 211 CCGs are widely regarded as no match for the private sector in writing complex contracts. Section 75 of the Health and Social Care Act forces them to put all but a few services out or risk any putative bidder challenging them in court. Bringing competition law into the NHS means no one can control these unleashed forces. Watch Stevens demand more changes to the law if he’s to control the unfolding chaos. Half of NHS trusts have announced a deficit for this year – that’s unprecedented – yet by 2017 the NHS must “save” £30bn. The Care Quality Commission says one in four hospitals are a safety risk, but their inspections aren’t allowed to count numbers of staff: the NHS has haemorrhaged 6,000 nurses since 2010. Many CCGs that control NHS funds are chaotic, with services falling between gaps, no one paying for them. Privatisation rushes on, at least £11bn so far, but private providers escape the NHS duty of openness or freedom for whistleblowers. Waiting times are rising, ambulance and A&E times growing, as the social care crisis blocks NHS beds with winter approaching. Stevens will find many perversities in the competition culturre. He said top-down control was a disaster – but he may find fragmentation and lack of strategic control far worse. Can he make his perfect market work – or admit he might have been wrong? http://www.theguardian.com/commentisfree/2013/oct/25/simon-stevens-nhs-england-rude-awakening

Comment:

By Don McCanne, M.D. The National Health Service in England currently exemplifies the greatest problem with publicly-administered and publicly-financed national health programs: They become subject to privatization efforts whenever conservatives gain control of the government. Selecting UnitedHealth’s Simon Stevens as chief executive of NHS England surely advances Conservative Prime Minister David Cameron’s privatization scheme. When do you suppose UnitedHealth will put in a bid to purchase the NHS? It would be great for Cameron’s budget, though the people would lose out.

]]>

Glitches

By Andrew D. Coates, M.D., F.A.C.P.
WAMC Northeast Public Radio, Oct. 25, 2013 When I was young I worked as a carpenter’s helper here in rural upstate New York. The man I worked for, a treasure of local lore, is someone who possesses generous good humor and a gift for analogy. On ladders and roofs, in the back-road truck journeys to our jobs, and at the sawhorses we would debate the big questions of life and also share the most pedestrian observations about farm and family life.
 
One day, trying to describe how someone had taken a narrow view of a much larger question, he took a dime out of his pocket and held it at arms length. “Imagine that dime is a hole and all you can see of the world is what you can see through that hole,” he said. “If that’s all you can see, you’ll miss out.”
 
This week “glitches” in signing up for private health insurance through the Affordable Care Act website conquered the news cycle. The gathering storm of weekend talking heads prompted President Obama to summon a Rose Garden press conference on Monday.
 
In turn the talking heads grew even louder all week long, although the amount of the world their debate illuminated now seems smaller than that dime-sized hole.
 
On “The Daily Show,” Jon Stewart lanced the President’s Rose Garden performance, calling it a deal-closing speech from “Glengarry Glen Ross,” David Mamet’s award-winning play and film about failing real estate salesmen who are driven to desperate indignity by their corporate bosses.
 
On Wednesday the House of Representatives Energy and Commerce Committee took testimony about the website “glitches.” As the information technology subcontractors — ironically the two major firms involved are owned by a Canadian firm and a major U.S. insurance company — passed the buck and pointed fingers at public servants, the Republicans’ talking points seemed absurdly hypocritical.
 
The notion that government intervention is always a bad thing seems a bit silly if the point is made while grilling private subcontractors.
 
Tea Party criticizing the White House for website “glitches” seems even more silly, if we recall that the health care proposal put forward by Wisconsin Republican Paul Ryan would dismantle Medicare and set up a “Medicare Exchange” where seniors would log into websites to purchase their Medicare benefits from private insurance companies.
 
The day the House Committee deliberated the White House hosted a meeting with over a dozen top leaders of private insurers. The stated purpose of the meeting was to establish ways of working even more closely with the lucrative corporations to implement the Affordable Care Act. With a parade of insurance company CEOs at the White House against the background of Republican calls to dismantle all public programs in favor of a health care finance system even more dominated by private interests, should we laugh or cry?
 
Finally, by the end of the week Democratic Party supporters of the Affordable Care Act recalled that the Medicare Part D rollout — in which seniors and the disabled were enrolled in private prescription drug plans — was also characterized by a period of “glitches.” But comparing the problems with the president’s program to a bad public policy also seemed a strange talking point.
 
Stunningly, throughout the week, those who keep a keen eye on health policy and politics began to hear that the solution is single payer. While some of the far-right imagine a conspiracy led by the president, most people in the United States know that it doesn’t have to be this way in our wealthy country. Medicare was rolled out in 1965 with typewriters and telephones, not websites. Enrolling everyone over age 65 in one program offered simplicity.
 
The “glitches” in purchasing private health insurance arise from the complexity and bureaucracy of our private insurance system — with hundreds of insurers, thousands of plans, state-by-state as well as federal regulation and the need to mine new databases in order for the federal government to subsidize premium payments for Americans who have incomes below 400 percent of poverty.
 
In reviewing this week’s events in Washington, I am reminded of a view through a hole the size of a dime held at arms length, instead of the world around us.
 
Every day in the hospital I meet patients who can’t afford prescription drugs. Every day in the hospital I work with patients who can’t get timely specialty care, who are on waiting lists. Every day in the hospital we learn about new bottlenecks that deny or delay necessary care, problems caused by private insurance.
 
It is true that it is better to be insured than uninsured and we know this intimately, for every day at the hospital we help uninsured patients find out how to enroll in insurance and apply for charity care. Yet in the big picture private insurance has already failed us, individually and as a nation. It is beyond repair.
 
We stand on one side of a chasm. We stand amid a dysfunctional health system that fails to serve tens of millions of people. On the other side of the chasm, in this wealthy country, another world is waiting.
 
Signing people up for private insurance incrementally will not get us across that chasm. If we relax our focus from the narrow, dime-sized view and look around us, we will realize that we can’t leap that chasm in several jumps. We need fundamental change.
 
Dr. Andrew Coates practices internal medicine in Upstate New York. He is president of Physicians for a National Health Program.
 
You can listen to Dr. Coates’ radio broadcast here: http://wamc.org/post/andrew-coates-glitches

]]>

Obamacare: not enough

By Bill Knight
Pekin (Ill.) Times, Oct. 24, 2013 Americans for years have been annoyed and angered by escalating health-care costs, declining insurance coverage and millions of neighbors who haven’t been able to get health insurance, and the Affordable Care Act has started to cope with the latter problem. But it does too little about controlling medical costs, pharmaceutical prices, and the driving force behind much health-care inflation: escalating medical costs and profit-driven insurers. Amid the Tea Party tantrums about the new law being government taking over the health care too much, the opposite is true: Government hasn’t taken over enough of the U.S. health care system. So it’s too little. But it’s not too late. There’s a practical approach — a single-payer health-care system. House Resolution 676: Expanded and Improved Medicare for All, is sponsored by U.S. Rep. John Conyers (D-Mich.) and 50 co-sponsors. The nation has remained a republic with a free-market economy although the federal government for decades has ensured health care for citizens 65 and older. Won’t the country remain strong and free if government ensures health care for citizens younger than 65? HR 676 would institute a single-payer health care system simply by expanding Medicare to everyone. It would cover everyone for all necessary medical care, including prescriptions, hospital, surgical, outpatient services, primary and preventive care, emergency services, dental (including oral surgery), mental health, home health, physical therapy, rehabilitation (including substance abuse), vision care, hearing, chiropractic, medical equipment, palliative care, podiatric care, and long-term care. It would end the big speed bump that the newly insured are discovering: co-payments and deductibles. And HR 676 would save hundreds of billions annually by eliminating the high overhead and profits of the private health insurance industry. “[It’s a] struggle to build a nation where health care is a human right, where this right is not on the negotiating table to be traded against a decent living wage, and where the rich can’t get richer by blocking your ability to get your medicine, to see your doctor, and to have your life saved in a hospital,” said Dr. Ed Weisbart, an M.D. and chair of the Missouri chapter of Physicians for a National Health Program. For employers and unions, “Medicare for All” would remove from negotiations a huge compensation problem: health care costs, which have been part of bargaining since World War II, when that benefit was a way to reward workers during a wartime wage freeze. Eliminating health care from labor relations would let companies and unions concentrate on bargaining over real wages, hours and working conditions, and pay could rise economically for management, and for employees faster than the cost of living and any taxes needed to support Medicare for All. Medicare has not been the threat the right-wing says it’s been. It’s popular and effective. However, for people not in Medicare, the threat has been the ridiculous and relentless increase in medical costs including drugs, and insurance premiums, deductibles and co-pays. Americans pay far more than people in other countries, says the International Federation of Health Plans – the United States spends twice as much per capita as other developed nations. So, insurers pass these ever-rising medical expenses on to employers through more expensive premiums. Employers pass the costs to workers through diminished benefits. The cycle must stop. The buck “starts there,” with consumers, and we cannot continue. Personally, my adult son broke his nose playing basketball a week before his new job’s benefits started. Anesthesia to deal with a hematoma alone cost him $600; his final bill for the outpatient procedure will be more than $3,000. I was hospitalized for an infection requiring an antibiotic IV for a couple of days. My bill is $5,600. My Dad needed a stent in one leg, an outpatient procedure that took about an hour. His bill is $50,000, but covered by Medicare. In an open letter to Congress and President Obama, the AARP said, “It is clear that older Americans want the focus of the debate to be on reducing overall health costs.” Despite the gridlock on Capitol Hill, there are precedents for more and better government involvement than the Affordable Care Act. The concept of controlling costs exists in Medicare reimbursement rates, based on a “sustainable growth rate” (SGR), set up to connect doctors’ pay to growth in the U.S. economy. Further, Medicare already negotiates with drug companies for prescription rebates — but ONLY in Medicare. Organizing and action are required, and it’s beginning in some quarters. This fall, an Illinois Jobs with Justice chapter endorsed HR 676, according to retired union carpenter David Johnson, a delegate to the chapter from the Illinois Single Payer Coalition. Again, the Affordable Care Act is too little, but it’s not too late. Bill Knight is opinion columnist at the Pekin Times. He can be reached at Bill.Knight@hotmail.com. http://www.pekintimes.com/article/20131024/OPINION/131029746/0/NEWS#ixzz2ikEtqB00

]]>

Rural areas not benefitting from exchange plan competition

Health Care Law Fails to Lower Prices for Rural Areas

By Reed Abelson, Katie Thomas and Jo Craven McGinty
The New York Times, October 23, 2013 As technical failures bedevil the rollout of President Obama’s health care law, evidence is emerging that one of the program’s loftiest goals — to encourage competition among insurers in an effort to keep costs low — is falling short for many rural Americans. While competition is intense in many populous regions, rural areas and small towns have far fewer carriers offering plans in the law’s online exchanges. Those places, many of them poor, are being asked to choose from some of the highest-priced plans in the 34 states where the federal government is running the health insurance marketplaces, a review by The New York Times has found. Of the roughly 2,500 counties served by the federal exchanges, more than half, or 58 percent, have plans offered by just one or two insurance carriers, according to an analysis by The Times of county-level data provided by the Department of Health and Human Services. In about 530 counties, only a single insurer is participating. The Obama administration, while not disputing the findings, responded to the analysis in a statement that the marketplaces “allow insurers to compete for customers based on price and quality.” Observers cautioned against drawing too many conclusions from the current landscape, noting that several major insurers were waiting to see what happens next. http://www.nytimes.com/2013/10/24/business/health-law-fails-to-keep-prices-low-in-rural-areas.html?hp&pagewanted=all

Polis fights sky-high rates as ski town signups stall

By Katie Kerwin McCrimmon
Solutions, October 23, 2013 Health insurance rates are so high in Colorado’s mountain resort areas that U.S. Rep. Jared Polis plans to seek waivers from the federal government so people who skip buying insurance in 2014 won’t face financial penalties. Health coverage guides working to enroll Summit County residents in new health plans through Colorado’s health exchange have been deeply disappointed. They have not enrolled a single new client since Colorado’s health exchange launched on Oct. 1. http://www.healthpolicysolutions.org/2013/10/23/congressman-fights-sky-high-rates-as-ski-town-signups-stall/

Comment:

By Don McCanne, M.D. Another flaw in Obamacare is the failure in rural areas to make premiums affordable through health plan competition, primarily because the markets are too small to attract enough insurers to promote competition. An example is found in the Colorado mountain resort areas such as Summit County where not one person has been enrolled through the exchange. How many times do we have to say it? The Affordable Care Act was the wrong model for reform. It leaves in place our profoundly expensive, administratively inefficient, fragmented, dysfunctional health care financing system. Compared to what needed to be done, the improvements were only marginal, and some of the problems actually increased, such as underinsurance – plans that provide less health security and less financial security than many of us had before. Besides, even in areas with greater plan competition, health care costs are still out of control. A publicly-administered single payer program is far more effective in getting health spending right than is health insurer competition.

]]>

Ed Kilgore: The Restive Single Payer Tribe

The Restive Single Payer Tribe

By Ed Kilgore
Washington Monthly, Political Animal, October 21, 2013 But if I were in the White House, I’d keep an eye on one issue they might not have thought much about in quite some time: the revival of progressive hostility to Obamacare on grounds that the law reflected a “sell-out” of the obvious single-payer solution to the problems of the health care system. I’m not going to relitigate the whole single-payer-versus-managed-competition debate that’s been going on for decades, or even the argument that a managed competition model requires a “public option” to function properly. But whatever else it is, a single-payer system is a whole lot simpler and more predictable than anything that not only accepts but insists upon a publicly regulated and subsidized private health insurance marketplace. Single-payer fans (or those strongly favoring a public option in a hybrid system) are never going to have much in common with conservatives who don’t believe in universal access to affordable health care and want to disable or repeal the public programs we already have. But if the one thing they do have in common — disdain for the messy hydraulics of any hybrid system — becomes the center of attention and stays there, watch out! Ed Kilgore is a contributing writer to the Washington Monthly. He is managing editor for The Democratic Strategist and a senior fellow at the Progressive Policy Institute. http://www.washingtonmonthly.com/political-animal-a/2013_10/the_restive_single_payer_tribe047438.php

Comment:

By Don McCanne, M.D. It is fair to say that Ed Kilgore represents the views of neoliberals who have taken control of the Democratic Party and moved it to the right: that is, he represents centrist views. What is striking about his message is that the intensive political attacks on Obamacare by the conservatives are assisting single payer advocates who are busy exposing its profound policy deficiencies. With their noise, and our reasoned policy prescriptions, middle America may be ready to move to single payer much sooner than expected.

]]>

State Sen. Eldridge: Single-payer health care saves money

By Lisa Hagen
Lowell Sun, Oct. 23, 2013 BOSTON — While critics complain that Obamacare, and the Massachusetts model for the federal plan involve too much government, a state senator says it is time for more government involvement in paying for health care. On Tuesday, Sen. James Eldridge, D-Acton, again proposed a single-payer system to the Committee on Health Care Financing that would eliminate private health-insurance companies and have the government reimburse doctors, hospitals, and nurses. “As much as Massachusetts has an excellent system, it is the most expensive in the country,” Eldridge said. “When talking to constituents, they still feel the quality of care is largely controlled by companies.” Eldridge said the single-payer system would function similar to Medicare, alleviating the burden small businesses face in providing health-care plans to employees. He said the money saved by eliminating private insurance companies can then be used to hire more nurses and primary care physicians. Benjamin Day, director of organizing at Healthcare-NOW, an advocacy group for single-payer health care, said there is evidence from countries such as Canada, England, and France that this type of system works. “There are measured steps legislators can take to let us learn from other countries that have this,” Day said. “They have much better cost control than we do and we can use (single-payer) as a back-up plan.” Eldridge, a House member when the 2006 universal health-care law was passed, said Obamacare was modeled after the state’s law requiring residents to purchase health insurance. Both laws also provide subsidies to those who cannot pay their full insurance premiums. More than 97 percent of Massachusetts residents now have health insurance, but Eldridge said the system still has a high administrative cost and requires a lot of insurance paperwork for hospitals, doctors, and consumers. “Consumers can go to doctors and hospitals with a (government-issued) health-care card and all costs would be paid for by the government so there would be no bill in the mail,” he said. But Daniel Foley, legislative counsel for Massachusetts Association of Health Underwriters, said the state should continue on the same track, noting the progress in both health-care coverage and cost control. He warned that single-payer systems can delay treatment for some patients. “From a personal standpoint, I don’t want to be in situation where I need special treatment or a special doctor and to have to wait six, eight, nine months down road,” Foley said. “If I have serious situation, I want to see the specialist now.” Even though removing third-party insurers would cut those jobs, Eldridge said that part of the bill would devote money to train these workers to become nursing assistants or other jobs within the health-care field. “I don’t think it would negatively affect the job environment, but these people would have to be retrained for a different profession,” he said. Eldridge is also sponsoring a bill that would enable residents to choose a public option if they were unhappy with health care from an employer. He hopes this would stimulate competition between the government and private insurance companies and encourage cost reduction and increased quality of care. “We need a more efficient system and Massachusetts has the opportunity to remain an innovator in health care and reform,” he said. But some of his legislative colleagues aren’t completely sold on these health-care changes. Sen. Eileen Donoghue, D-Lowell, said in an interview that she wants to further look into the cost of converting to a single-payer system since health-care finances are an issue that impacts both individuals and small businesses. She said cost containment is one of her biggest concerns since passage of a bill aimed at holding down medical charges in 2012. “In theory, direct pay and not having middleman seems to indicate cost savings,” Donoghue said. “Health care is taking a bite out of paychecks and small businesses, and in reality, we need to understand how the (numbers) translate.” Rep. Marc Lombardo, R-Billerica, labeled both single-payer and public option as a “terrible idea” because it would require too much government involvement. He suggested an option that would eliminate state-mandated coverage of certain treatments to accommodate consumers’ different needs as well as allowing residents to purchase health care outside the state as a way to boost competition. “Most people select what’s important to them, and right now they don’t have enough options,” Lombardo said. “With a mandate-light option, they can find the appropriate value they want to spend their dollars, so families who need lesser options can find a lighter plan that fits their cost needs.” Lisa Hagen is Statehouse correspondent. http://www.lowellsun.com/news/ci_24368475/eldridge-single-payer-health-care-saves-money

]]>

Are we ready for ACOs?

Predicting ACO Formation: Two Studies With More In Common Than It Might Seem

By Valerie Lewis, Carrie Colla, and Elliott Fisher
Health Affairs Blog, October 22, 2013 At a time when policy makers, providers and payers are all trying to make high stakes decisions about how respond to the proliferation of Accountable Care Organizations (ACOs), divergent research findings might feel as welcome as rain on the fourth of July. Two recently published studies, one by our group at Dartmouth and one by David Auerbach and coauthors in Health Affairs, both examined predictors of ACO formation.  On the surface, they appear to have some inconsistent findings.  Their core conclusions, however, are similar, and differences in the results are readily explained.  Most importantly, policy implications are well aligned: there is much we can do to help the transition to accountable care succeed. A common set of policy implications The findings in both studies also point to challenges that deserve further attention by policy makers.  How can providers without experience in risk-based contracts or who are in smaller, more fragmented practices get the additional support they may need to become an ACO?  Models like the Medicare Advance Payment model are one move to support these types of providers, but our results here and elsewhere suggest that policymakers should be further developing programs to support the financing of these systems, along with the development of analytic and care coordination capabilities that are likely necessary for ACO success. Another important question How can spending and quality benchmarks be refined to encourage broader participation?  Some (including us) have suggested that paying for improvement rather than absolute performance on quality may encourage underperforming systems to join the ACO model. Careful thinking is necessary from health economists and health care finance experts on how to set cost targets that do not penalize providers already on the low end of the cost spectrum. The imperative of continued learning Perhaps the most important conclusion, however, is to acknowledge the many uncertainties that remain.  The transition to performance-based payment systems has barely begun – and better information on what is working and what isn’t would make successful reform more likely. http://healthaffairs.org/blog/2013/10/22/predicting-aco-formation-two-studies-with-more-in-common-than-it-might-seem/

Comment:

By Don McCanne, M.D. If you are holding your breath to see if accountable care organizations (ACOs) are the answer to our quality and cost issues, I have some life-saving advice for you. Don’t wait, but breathe immediately! Elliott Fisher from the Dartmouth Institute has been credited with coining the term, accountable care organization. Look at what he and his colleagues have to say: The most important conclusion is that many uncertainties remain. One of the more important reasons for the uncertainties is that there remains a conflict between those who support better integration of health care (a noble goal) and those who support a business model that smacks of MBA-driven managed care (an ignoble goal). There are no uncertainties with the single payer model. We should proceed immediately to the enactment of an improved Medicare for all, and then we can afford to take years to study variations of the ACO model to see if we can improve health care delivery.

]]>