PNHP

Canadian businessmen perplexed by U.S. health care

Canadian businessmen perplexed by U.S. health care

Canadians don’t understand Ted Cruz’s health care battle

By Matt Miller
The Washington Post, September 25, 2013

When you’re being forced to endure another rabid Sen. Ted Cruz (R-Tex.) soliloquy on Obamacare’s threat to human freedom, it’s easy to forget how absurd our health-care debate seems to the rest of the civilized world. That’s why it’s bracing to check in with red-blooded, high testosterone capitalists north of the border in Canada — business leaders who love Canada’s single-payer system (a regime far to the “left” of Obamacare) and see it as perfectly consistent with free market capitalism.

Take David Beatty, a 70-year-old Toronto native who ran food processing giant Weston Foods and a holding company called the Gardiner Group during a career that has included service on more than 30 corporate boards and a recent appointment to the Order of Canada, one of the nation’s highest honors. By temperament and demeanor, Beatty is the kind of tough-minded, suffer-no-fools wealth creator who conservatives typically cheer.

Yet over breakfast in Toronto not long ago, Beatty told me how baffled he and Canadian business colleagues are when they listen to the U.S. health-care debate. He cherishes Canada’s single-payer system for its quality and cost-effectiveness (Canada boasts much lower costs per person than the United States). And don’t get him started on the system’s administrative simplicity — you just show your card at the point of service, and that’s it. Though he’s a well-to-do man who can pay for whatever care he wants, Beatty told me he’s relied on the system just as ordinary Canadians do, including for a recent knee replacement operation. The one time he went outside the system was to pay extra for a physical therapist closer to his home than the one to which he’d been assigned.

It’s just “common sense” in Beatty’s view that government takes the lead in assuring basic health security for its citizens. He’s amazed at the contortions of the debate in the United States, and wonders why big U.S. companies “want to be in the business of providing health care anyway” (“that’s a government function,” he says simply). Beatty also marvels at the way the U.S. regime’s dysfunction comes to dominate everyday conversation. He shakes his head recalling how much time and passion American friends devoted one evening to comparing notes on their various supplemental Medicare plans. Talk about your sparkling dinner conversation.

Roger Martin, another Toronto native and avowed capitalist, spent years as a senior partner at the consulting firm Monitor before becoming dean of the Rotman School of Management at the University of Toronto, where he recently completed a 15-year stint. He advises U.S. corporate icons like Proctor & Gamble and Steelcase. He lived in the United States for years and has experienced both systems first hand.

Martin told me that Canada’s lower spending, better outcomes and universal coverage make it superior by definition. Plus, it’s “incredibly hassle-free.” In the United States every time he took his kids in for an earache his wife spent hours fighting with the health plan or filling out reams of paperwork. In Canada, he says, “the entire administrative cost is pulling your card out of your pocket, giving it to them and putting it back.”

There’s more. Canadian divisions of multinational firms love Canada’s system because when they bid on projects they have no health costs to load in. Also, there’s no crazy “job lock” as with the employer-based system in the United States — where people with (say) a sick child cling to their job for fear of being pronounced uninsurable. His peers, he says, view the U.S. debate as “ideological and not based on economics.”

“The whole single payer thing just makes sense,” Martin adds. “You don’t spend time trying to shift costs.” It’s hardly perfect: a few folks go to the United States to jump the line on certain elective procedures, and Canada, like others, free rides on American’s investment in pharmaceutical innovation (funded by higher U.S. drug prices). But, he adds, “I literally have a hard time thinking of what would be better than a single-payer system.”

The moral of the story? Don’t let the rants of cynical demagogues like Cruz confuse you — it is entirely possible to be a freedom loving capitalist and also believe in a strong government role in health care. Remember, Obamacare features a much smaller such role than does Canada’s approach — or England’s, where Margaret Thatcher would have been chased from office for proposing anything as radically conservative as the Affordable Care Act.

One well-known billionaire told me a few years back that the right answer for the United States was single payer for basic coverage, with the ability for folks to buy additional private supplements atop that. But he won’t say this in public; the gang at the club just wouldn’t understand. Maybe when U.S. business leaders muster the common sense of their Canadian counterparts, they’ll deliver the message the Ted Cruzes of the world need to hear: sit down and shut up. 

Matt Miller writes a weekly column on economic and other domestic policy issues. He is a senior fellow at the Center for American Progress, the voice of the political “center” on public radio’s “Left, Right & Center,” the host of the new podcast “This…Is Interesting.” 

http://www.washingtonpost.com/opinions/matt-miller-canadians-dont-understand-ted-cruzs-health-care-battle/2013/09/25/ee2d6e6e-25d9-11e3-b75d-5b7f66349852_story.html

Comment:

By Don McCanne, M.D.

Businessmen in the United States need to listen to their colleagues in Canada.  They see single payer as being “perfectly consistent with free market capitalism.” “The whole single payer thing just makes sense.”

It should be noted that this Washington Post article was written by a “voice of the political center” – Matt Miller. That single payer is appropriately a centrist concept is demonstrated by the fact that it fulfills the fundamental business principles of being efficient (lower costs per person), effective (everyone is included), and of high quality (better health outcomes).

(As an aside, regarding the well-known billionaire who recommended single payer for basic coverage with private supplementary coverage for other care, I should say that I wrote such a proposal right after the failure of the Clinton reform effort. I submitted it to Claudia Fegan, then president of PNHP, and she returned it smothered in red ink. That is when I learned that I knew very little about health policy, so I have studied it on a daily basis since. Simply stated, single payer needs to be comprehensive enough such that no supplemental coverage would be necessary.)

Incidentally, the hotlinks in the article on “Canada’s single payer system” and “lower costs per person” lead to two great articles on these topics. If the links are not live in this email, they can be acc essed in the original article at the link above.

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Mine workers are fighting for our health care and basic human rights

By Ed Weisbart, M.D. The following text represents the prepared remarks of Dr. Ed Weisbart for his speech delivered to a rally sponsored by the United Mine Workers of America in St. Louis on Sept. 24. The event was a protest against Peabody Coal, which is refusing to pay for health care benefits promised to retired miners, their widows and dependents. To see a video of Dr. Weisbart’s speech, please click here. Some of my colleagues have asked me why a physician organization would be participating in a labor rally. Let me explain this. I am here today because of a 57-year-old woman having what she knew to be her second heart attack. Instead of going to the emergency room as most people would, she went home to die rather than risk a $50,000 hospital bill. She knew that a huge medical bill would mean bankruptcy and eviction, but that if she just died at home her mortgage insurance would pay the house off and her son would have a place to live. I am here today because of my 32-year-old diabetic patient who can only afford to take his insulin three days a week. Without his insulin he’ll need dialysis in two to three years. Only at that point, when his illness becomes a catastrophe, will our system start to pay for his care, including his dialysis, at $70,000 per year. And, by the way, his insulin. This is like seeing a small leak in your roof and waiting for it to cave in before doing anything about it. I’ll bet there are even more striking parallels in coal mining. I am here today because of the 64-year-old grandmother whose blood pressure had been well controlled for many years but now it’s 180/115. I asked her what had changed, and she told me she was on her final eviction notice and could no longer pay her rent, buy food for the three grandchildren living with her, and also continue to buy her medications. She said she cannot permit her grandchildren to be homeless. She asked me, “So, Dr. Weisbart, how long can I live without taking my medications?” I never want to hear that question again. Every year, 1 out of 3 Americans goes without medical care because of the high cost. Most of them have medical insurance. Every day, over 100 Americans die because of not having insurance. No one in the rest of the modern world dies from this. Every American is one illness away from bankruptcy. You have a job, you have insurance, you get sick, you’re unable to work so you lose your job, you lose your insurance, with no way to pay your medical bills you declare bankruptcy, and the rest of us are on the hook for these outstanding debts. 62 percent of bankruptcies are triggered by medical expenses, and 78 percent of them had insurance at the beginning of the illness. These problems make a mockery of the notion of “American exceptionalism.” We are now the exception in the modern world, in the worst possible way. We are the only place where a diabetic can’t afford his life-saving insulin, where a working mother would choose to die rather than burden her family with a hospital bill, and where a grandmother would need to trade her health for her grandchildren’s roof. This is not the United States of America that I believe in. This is not the American Dream. And this is not the United States of America that labor built. You have built a nation where child labor is nearly unthinkable, where decent working conditions are the law of the land, and where workers expect – and demand – a living wage. You have joined the 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. You have joined the struggle for single-payer health care. My organization, Physicians for a National Health Program, believes the solution to our crisis is right before us: Medicare. It’s not perfect today, but almost every senior would fight long and hard to keep it. Let’s improve Medicare and provide that to each and every American, no matter their age or background. There’s a bill in Congress, Rep. John Conyers’ H.R. 676, the “Expanded and Improved Medicare for All Act,” that would do exactly this. It’s got 48 co-sponsors and growing. We need such law – urgently. Please, ask your U.S. congressional representative to co-sponsor H.R. 676. With everybody in, and with nobody out, health care would finally become the human right we know it to be. Thank you for your struggle. You are fighting for your right to health care, you are fighting for my right to health care, and you are fighting for every single American’s basic human rights. Physicians for a National Health Program is honored to walk beside you.

[Photo credit: Gary Otten]

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Canadians don't understand Ted Cruz's health care battle

By Matt Miller
The Washington Post, Sept. 25, 2013

When you’re being forced to endure another rabid Sen. Ted Cruz (R-Tex.) soliloquy on Obamacare’s threat to human freedom, it’s easy to forget how absurd our health-care debate seems to the rest of the civilized world. That’s why it’s bracing to check in with red-blooded, high testosterone capitalists north of the border in Canada — business leaders who love Canada’s single-payer system (a regime far to the “left” of Obamacare) and see it as perfectly consistent with free market capitalism.

Take David Beatty, a 70-year-old Toronto native who ran food processing giant Weston Foods and a holding company called the Gardiner Group during a career that has included service on more than 30 corporate boards and a recent appointment to the Order of Canada, one of the nation’s highest honors. By temperament and demeanor, Beatty is the kind of tough-minded, suffer-no-fools wealth creator who conservatives typically cheer.

Yet over breakfast in Toronto not long ago, Beatty told me how baffled he and Canadian business colleagues are when they listen to the U.S. health-care debate. He cherishes Canada’s single-payer system for its quality and cost-effectiveness (Canada boasts much lower costs per person than the United States). And don’t get him started on the system’s administrative simplicity — you just show your card at the point of service, and that’s it. Though he’s a well-to-do man who can pay for whatever care he wants, Beatty told me he’s relied on the system just as ordinary Canadians do, including for a recent knee replacement operation. The one time he went outside the system was to pay extra for a physical therapist closer to his home than the one to which he’d been assigned.

It’s just “common sense” in Beatty’s view that government takes the lead in assuring basic health security for its citizens. He’s amazed at the contortions of the debate in the United States, and wonders why big U.S. companies “want to be in the business of providing health care anyway” (“that’s a government function,” he says simply). Beatty also marvels at the way the U.S. regime’s dysfunction comes to dominate everyday conversation. He shakes his head recalling how much time and passion American friends devoted one evening to comparing notes on their various supplemental Medicare plans. Talk about your sparkling dinner conversation.

Roger Martin, another Toronto native and avowed capitalist, spent years as a senior partner at the consulting firm Monitor before becoming dean of the Rotman School of Management at the University of Toronto, where he recently completed a 15-year stint. He advises U.S. corporate icons like Proctor & Gamble and Steelcase. He lived in the United States for years and has experienced both systems first hand.

Martin told me that Canada’s lower spending, better outcomes and universal coverage make it superior by definition. Plus, it’s “incredibly hassle-free.” In the United States every time he took his kids in for an earache his wife spent hours fighting with the health plan or filling out reams of paperwork. In Canada, he says, “the entire administrative cost is pulling your card out of your pocket, giving it to them and putting it back.”

There’s more. Canadian divisions of multinational firms love Canada’s system because when they bid on projects they have no health costs to load in. Also, there’s no crazy “job lock” as with the employer-based system in the United States — where people with (say) a sick child cling to their job for fear of being pronounced uninsurable. His peers, he says, view the U.S. debate as “ideological and not based on economics.”

“The whole single payer thing just makes sense,” Martin adds. “You don’t spend time trying to shift costs.” It’s hardly perfect: a few folks go to the United States to jump the line on certain elective procedures, and Canada, like others, free rides on American’s investment in pharmaceutical innovation (funded by higher U.S. drug prices). But, he adds, “I literally have a hard time thinking of what would be better than a single-payer system.”

The moral of the story? Don’t let the rants of cynical demagogues like Cruz confuse you — it is entirely possible to be a freedom loving capitalist and also believe in a strong government role in health care. Remember, Obamacare features a much smaller such role than does Canada’s approach — or England’s, where Margaret Thatcher would have been chased from office for proposing anything as radically conservative as the Affordable Care Act.

One well-known billionaire told me a few years back that the right answer for the United States was single payer for basic coverage, with the ability for folks to buy additional private supplements atop that. But he won’t say this in public; the gang at the club just wouldn’t understand. Maybe when U.S. business leaders muster the common sense of their Canadian counterparts, they’ll deliver the message the Ted Cruzes of the world need to hear: sit down and shut up. 

Matt Miller writes a weekly column on economic and other domestic policy issues. He is a senior fellow at the Center for American Progress, the voice of the political “center” on public radio’s “Left, Right & Center,” the host of the new podcast “This…Is Interesting.” Miller served as a senior adviser at the White House Office of Management and Budget from 1993 to 1995.

http://www.washingtonpost.com/opinions/matt-miller-canadians-dont-understand-ted-cruzs-health-care-battle/2013/09/25/ee2d6e6e-25d9-11e3-b75d-5b7f66349852_story.html

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Benefits consulting firms move in for their cut of the action

Analysis: Benefit firms create tremors for insurers in U.S. healthcare shakeup

By Caroline Humer and Lewis Krauskopf
Reuters, September 20, 2013 American companies are sending shockwaves through the healthcare industry by moving a rapidly growing number of employees onto privately run online exchanges for their medical coverage. In a business already bracing for major change because of President Barack Obama’s healthcare reforms, the decisions are threatening to shift more power in the market to the benefit consulting firms opening many of the exchanges. “It’s important to the insurance companies to sell through the private exchanges to maintain their biggest customers,” said Mike Nugent, managing director of the healthcare practice at business consulting firm Navigant Consulting. The exchanges received their biggest boost yet when Aon Plc insurance broker said on Wednesday it signed up 18 companies to participate in its Aon Hewitt Corporate Health Exchange, including the country’s largest drug store operator Walgreen Co, resulting in coverage for an estimated 600,000 people next year. The announcement drove up the shares of Aon and other benefits consulting firms, such as Towers Watson and Marsh & McLennan, which owns Mercer, one of the largest consulting firms in the world. All three have easily outpaced the broader market in the past year, with Towers Watson shares up 79 percent and Aon up 42 percent. Corporations are hoping the move to the private exchanges will keep healthcare spending in check and force employees to manage more of their own healthcare costs. Companies still directly pay a portion of the premium and deduct premium payments from employee wages for the difference between the employer contribution and the cost of a plan, but employees can choose a plan from a menu of low to high cost offerings. Insurers have been preparing for this possible shift to private exchanges. In some cases they are investors and in other cases, like Aetna Inc, they are building their own. But plans offered by large, household name insurers such as UnitedHealth Group, Aetna and WellPoint Inc are likely to be among the most prominent choices for consumers selecting a plan on a private exchange, Windley said. Some experts say moving to an exchange prevents companies from “over-buying” insurance. Alan Cohen, chief strategy officer of private exchange company Liazon, said that based on the 200,000 transactions processed at his companies, employees spent on average 25-30 percent less when they chose the plan compared with what the company would have spent. On the other hand, the Aon exchange and others shift the risk associated with providing health insurance to the insurers from the large companies that have traditionally being bearing the risk, or self-insuring, which can be more profitable. Self-insured members generate $4 of pre-tax profit monthly, compared to $18 in pre-tax profit for each fully insured member, according to Credit Suisse analyst Ralph Giacobbe. The coming year is the first time in which a significant number of larger employers will use private exchanges for their workers’ benefits. Companies, which start unveiling benefit plans this month, are sending at least 1 million employees to private exchanges in 2014 versus a few hundred thousand now. More growth is expected in 2015 with nearly 1 in 3 large companies saying they were considering a move. By 2015, 6.5 million people could be on these exchanges for active employees, according to forecasts by analysts at William Blair. The possible market is much larger. About 170 million people received employer-based health insurance in 2012, 156 million of whom were under 65. Aon, Towers Watson and Mercer already dominate the market for consulting for the top 1,000 U.S. companies about benefits, putting them in a position to promote their exchanges. The expansion of private exchanges is expected to add significantly to revenues of the benefit companies. Rates from exchange contracts bring in more revenue per employee than current administrative ones, according to William Blair analysts. Also, once the exchanges are established with a fixed cost base, new corporate clients become highly profitable, according to William Blair. http://www.reuters.com/article/2013/09/21/us-usa-healthcare-exchanges-analysis-idUSBRE98J0W620130921

Comment:

By Don McCanne, M.D. Although these private insurance exchanges which resemble Obamacare’s state insurance exchanges are just getting off the ground, they seem to be providing an out for employers who are tired of managing their employee health benefit programs and who want relief from the seemingly uncontrollable increases in health care costs. What an opportunity this provides for the benefits consulting firms. These consulting firms are not replacing the insurers, but they are inserting themselves as another layer of administration in our system already greatly overburdened with administrative waste. Their administrative costs are not counted in the 15 to 20 percent allowed for the insurers under Obamacare. No, these costs are in addition to the administrative waste of the insurers and the waste of the administrative burden that insurers place on physicians, hospitals and other health care providers. It is part of our uniquely American health care system that is designed to finance administrative services while seeming to pay for health care services only as an aside – an exaggeration but it does emphasize the priorities of these administrative corporations. Since health care policies should be designed to take care of patients, in this case employees who are moved from employer benefit plans to these private exchanges, we should look at the impact that this will have on the employees. *  Since employee health benefits and the costs to administer them are paid by employees in the form of forgone wage increases, this additional layer of administrative costs will be borne by employees with no commensurate increase in health care services. *  This shift from defined benefit health plans to defined contributions is one more example of our current trend of shifting risk and costs onto the backs of employees. *  When employees select their own plans, they will buy the plans with the lowest premiums since most of them and their families are healthy. That means plans with high deductibles and spartan health benefits. For those who develop serious medical problems, financial hardship will be an inevitability because of excessive out-of-pocket costs, and impaired access is very likely because of the shift to narrow networks of providers. *  The private exchanges will not be eligible for the subsidies provided for plans in the state-run Obamacare exchanges, so low and moderate income individuals will not be receiving the same help that those who enroll through the state exchanges will have. Those employers now selecting the private exchange option will be contributing to the employees’ premiums, though, unlike the state exchanges, that contribution will not be equitable since it is not based on income. *  For employers who currently self insure and thus have lower administrative costs, the administrative costs will be much greater in the private exchanges, but those extra costs will be borne by the employees, either directly of indirectly. *  The benefit consulting firms are entering these ventures with visions of great profits. This is one more sad saga of the American approach of scooping up profits from patient care dollars while designing health coverage to maximize business goals and minimize health care services. *  These business intermediaries seek even more profits by catering to Wall Street investors, pushing up the price of their shares while appeasing Wall Street by demonstrating that they will limit as much as possible the diversion of revenues to patient care. Not only do we need to remove private insurers from their nefarious role in all of this, it appears that it is time to remove the employers and their benefit managers as well. By switching to a single payer financing system and funding it through equitable taxes, we can be sure that everyone would be paying their fair share, including members of the business community, while nobody is wasting funds on the middleman money managers.

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New York Times exposes the injustices of private insurers' narrow networks

Lower Health Insurance Premiums to Come at Cost of Fewer Choices

By Robert Pear
The New York Times, September 22, 2013 Federal officials often say that health insurance will cost consumers less than expected under President Obama’s health care law. But they rarely mention one big reason: many insurers are significantly limiting the choices of doctors and hospitals available to consumers. From California to Illinois to New Hampshire, and in many states in between, insurers are driving down premiums by restricting the number of providers who will treat patients in their new health plans. Some consumer advocates and health care providers are increasingly concerned. Decades of experience with Medicaid, the program for low-income people, show that having an insurance card does not guarantee access to specialists or other providers. Consumers should be prepared for “much tighter, narrower networks” of doctors and hospitals, said Adam M. Linker, a health policy analyst at the North Carolina Justice Center, a statewide advocacy group. Insurers say that with a smaller array of doctors and hospitals, they can offer lower-cost policies and have more control over the quality of health care providers. They also say that having insurance with a limited network of providers is better than having no coverage at all. In a new study, the Health Research Institute of PricewaterhouseCoopers, the consulting company, says that “insurers passed over major medical centers” when selecting providers in California, Illinois, Indiana, Kentucky and Tennessee, among other states. “Doing so enables health plans to offer lower premiums,” the study said. “But the use of narrow networks may also lead to higher out-of-pocket expenses, especially if a patient has a complex medical problem that’s being treated at a hospital that has been excluded from their health plan.” In California, the statewide Blue Shield plan has developed a network specifically for consumers shopping in the insurance exchange. Juan Carlos Davila, an executive vice president of Blue Shield of California… said the new network did not include the five medical centers of the University of California or the Cedars-Sinai Medical Center near Beverly Hills. Daniel R. Hawkins Jr., a senior vice president of the National Association of Community Health Centers, which represents 9,000 clinics around the country, said: “We serve the very population that will gain coverage — low-income, working class uninsured people. But insurers have shown little interest in including us in their provider networks.” Dr. Bruce Siegel, the president of America’s Essential Hospitals, formerly known as the National Association of Public Hospitals and Health Systems, said insurers were telling his members: “We don’t want you in our network. We are worried about having your patients, who are sick and have complicated conditions.” “If a health plan has a narrow network that excludes many doctors, that may shoo away patients with expensive pre-existing conditions who have established relationships with doctors,” said Mark E. Rust, the chairman of the national health care practice at Barnes & Thornburg, a law firm. “Some insurers do not want those patients who, for medical reasons, require a broad network of providers.” NYT reader response: Don McCanne
San Juan Capistrano, CA By designing reform that leaves the private insurers in charge, it was inevitable that their business model would be directed to selling their own insurance product by trying to keep their premiums competitive. Instead of controlling health care costs, they are shifting the costs to people who actually need health care – defeating the purpose of insurance. Private insurers will continue to search for innovative ways to keep their premiums competitive, such as narrow networks, high deductibles, and selling in only healthy, profitable markets. Their waste of our health care dollars can be demonstrated by last week’s report from the Office of the Actuary of CMS that projects that, in 2022, government administrative costs for health care (Medicare, Medicaid, CHIP, VA, IHS, Department of Defense, etc.) will be $70 billion, whereas the administrative costs of the private insurers will be $313 billion! (That doesn’t even include the cost of the tremendous administrative burden placed on the health care delivery system.) What a waste! We need to throw out the outrageously priced and administratively burdensome private insurance industry that merely screws up our health care and replace it with an improved version of Medicare that covers everyone. http://www.nytimes.com/2013/09/23/health/lower-health-insurance-premiums-to-come-at-cost-of-fewer-choices.html?hp&pagewanted=all

Comment:

By Don McCanne, M.D. This article featured prominently in The New York Times explains the adverse consequences of the private insurers’ decisions to restrict access to narrow networks of physicians and hospitals. When you look at the very large number of responses to this article, it is somewhat reassuring that the responses endorsed by the readers acknowledge that we need to replace the private insurers with a single payer system. Use the link above to read the full article, and then clink on “Reader Picks.” We need to translate this into citizen action.

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Forum asks: Is single-payer the future of Ohio health care?

By Michael O’Brien
The Athens (Ohio) News, Sept. 22, 2013 At a recent public forum, community members had the opportunity to learn more about single-payer health-care systems. The forum was hosted by the Single Payer Action Network, Ohio (SPAN), a statewide coalition of organizations and individuals who say they’re working to enact fundamental health-care reform that guarantees full and comprehensive access to a full range of medical services. Insurance exchanges under the Patient Protection and Affordable Care Act (PPACA) are set to open Oct. 1 nationwide, making access to affordable health care a primary concern for many Ohioans. Whether referred to as single-payer or Medicare for all, SPAN believes the current market-driven system is not sustainable. Under a single-payer health-care system like Medicare, medical service providers would be paid directly by the federal government. During an opening presentation, SPAN Ohio Director Debbie Silverstein stressed that the issue of health care and the Patient Protection and Affordable Care Act evokes very strong emotions. “We want health care to be there when we need it but what if resources aren’t there? Obamacare is a good start but we’re not done yet,” Silverstein said. “Health care is a basic human need.” Proponents of single-payer systems cite reduced administrative costs in Medicare compared to those of for-profit medical insurance companies. Silverstein noted that since 1970, the health-insurance industry has seen a 2,500 percent rise in the number of administrative jobs compared to a roughly 100 percent increase in jobs for direct health-care providers. Opponents to single-payer systems argue that Americans without health insurance are not denied access to care, citing federal law that requires hospitals to treat people without insurance. Speaking in Cleveland in 2007, then-President George W. Bush addressed an effort in Congress to expand eligibility to State Children’s Health Insurance Program (SCHIP), cited a common argument against government having a larger role in access to health care. “I mean, people have access to health care in America. After all, you just go to an emergency room,” Bush said. “I mean, think of it this way: They’re going to increase the number of folks eligible through SCHIP; some want to lower the age for Medicare… to get more people to be a part of a federalization of health care. In my judgment, it would lead to not better medicine, but worse medicine. It would lead to not more innovation, but less innovation.” Silverstein used her own experiences to illustrate the difference between medical services in the U.S. and France, which provides universal health care. While visiting a sister in France, Silverstein said she suffered a severe foot injury, the result of tripping on a curb. Despite her concern over the cost, Silverstein went to an emergency room at a Paris hospital. “I was afraid I had broken my left foot,” she recalled. “After some deliberation due to concern for cost, I did go to the emergency room. When I explained that I had fallen, the first question asked was ‘Madame, when you fell, did you hit your head?’ They then proceeded to evaluate my problem and get me checked in. My bill for the emergency room visit was zero.” Silverstein explained that her experience at an Ohio hospital was very different and illustrative of what many Americans experience when seeking medical care. Suffering from severe headaches, Silverstein sought care at a Cleveland hospital. “I suffered a very bad headache that was unrelenting unless I was flat on my back,” she said. “After six weeks, a friend suggested I try the Headache Clinic at the Cleveland Clinic. I called to make an appointment and started to explain my symptoms. I was interrupted and was asked if I had insurance. I had to go through the insurance verification before they were concerned about my condition.” The event’s panel discussion included Silverstein, Ohio University professor of sociology Deborah Thorne and local health-care advocate Warren Hayden. All agreed that the negative economic impacts of medical debt are widespread even for people with insurance. Thorne stressed that even the rich are not immune to the consequences of getting sick in American. In 2008, Thorne coauthored a book with now Massachusetts Sen. Elizabeth Warren titled  “Get Sick, Go Broke. Health at Risk: America’s Ailing Health System-and How to Heal It.” Thorne said her research into medical bankruptcies shows 62 percent of all personal bankruptcies nationally result from medical debt, and 78 percent of the people involved had insurance at the onset of their illness. A follow-up study, focused on Massachusetts, which has a system similar to the ACA, showed little difference in the percentage of medical bankruptcies. “Medical debt is a leading factor in 49 percent of home foreclosures, and medical debt is one of the leading reasons middle- and lower-income Americans cannot get financing to purchase a home,” Thorne said. “The PPACA will not necessarily lower incidence of medical bankruptcy. Unless you’re Bill Gates, you are not immune to medical bankruptcy.” As for the future of health care going forward, beginning in 2017, provisions in the PPACA would grant exemptions to states that develop plans similar to those in the health-care law including single-payer or Medicaid for all systems. SPAN sees this as an opportunity to enact a single-payer system in Ohio. “Over 60 percent of all health-care costs in the U.S. are paid for by taxes,” said Hayden. “When you look at Medicare, Medicaid, veterans, anyone who works for the government and a number of non-profits funded by the government, there are huge amounts of tax dollars already going into the system. We would not need a whole lot more because of the savings that would come about from a single-payer system.” SPAN supports on effort by Healthy Ohioans Work to place an initiative on the 2014 ballot that would force the state to expand Medicaid in Ohio and would put the state on the road to a single-payer system. Ohio is one of several states that have opted not to expand Medicaid coverage despite a guarantee of federal funding. Gov. John Kasich has pressed the Republican-controlled Legislature to act but the House and Senate have so far resisted the expansion. At the close of the forum Silverstein expressed surprise that the audience did not raise the issue of individuals having to pay for someone else’s health care. “We are all in this together. We are a society, a community, and Americans have always cared about each other and have always cared for one another,” Silverstein said. http://www.athensnews.com/ohio/article-40672-forum-asks-is-single.html

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A Man Who Worked Too Hard

By Andrew D. Coates, M.D., F.A.C.P.
WAMC Northeast Public Radio, Sept. 20, 2013 Influenza rocked our community hospital for weeks last winter just as the first snowstorms came. Our hospital medicine service was swamped with patients. I was working the night shift. One emergency physician dramatically recounted how a queue of ambulances had clogged the parking lot. Once all of the emergency department beds, hallway spaces, and waiting room seats were taken, patients waited outside in ambulances. With the usual triage system in gridlock, he had climbed into ambulances one by one to help triage or stabilize patients. Such are the undignified consequences of a system that encourages hospitals to run themselves like factories or just-in-time warehouses. One patient’s admission stood out. A young-looking man in his early 40s had keeled over while shoveling snow. As I admitted him to the hospital, National Weather Service advisories that mention the dangers of snow shoveling and warn persons at risk for ischemic heart disease to be cautious (mostly those who are past our chance at preventive medicine) flashed through my mind. Yet, this person had not been merely shoveling some snow. He had been running a snowblower, as well as manually shoveling, from shortly after 3:00 a.m. until a quarter past 6:00 p.m. – just over 15 hours straight, without a break. I asked what he had eaten. Nothing. He had consumed only about a half gallon of liquids all day. The previous day he had tried to eat a chicken salad sandwich but managed to down only about one third of it because a sore tooth prevented him from eating. In fact, he had not had much solid food for more than a week. The patient had an untreated breaking, decayed molar with an adjacent gum abscess. He had no health insurance. Seeing a dentist meant an outlay of cash that he didn’t have. Our patient, able to find steady work only in summer months, had jumped at the chance to earn money during the snowstorm. He concluded his explanation with a stoic shrug, saying that his tooth was beginning to feel better now that part of it had broken off. I finished taking the patient’s history, performed a full examination, and retreated to review his data in full. His test results were normal. Apart from his dental abscess, he seemed rather healthy. He received no medicines and had no chronic illnesses. Assessment: He had worked himself into the ground – and this wasn’t his fault. He had done what he could to help himself. Unfortunately, he also needed to pay attention to taking enough fluids and food to sustain his exertion. Like an increasing number of our patients, this man was living at the very edge. From a physiologic point of view, our patient had just had a big all-day-long stress test. His outlook and insight; history of good health; normal vital signs; and normal results on his physical examination, EKG, laboratory values, and head CT all spoke of someone who had passed the test with flying colors. A sick person might have collapsed before dawn, not after sunset, on such a day of work. As we discussed these findings, I sought to reassure him. When I suggested that perhaps he really didn’t need more tests, he seemed shocked. “We need to get to the bottom of this!” he exclaimed. In spite of his meager means, he wanted admission to the hospital and the full work-up promised. He mused that he might apply for Medicaid but recognized that if he didn’t qualify, the ambulance and hospitalization might cost thousands of dollars, with bills for years to come. Once admitted on observation status, our patient found one of the only available beds – in the intensive care unit. He was released the next day after receiving more normal laboratory results. On reflection, the experience left me feeling less like a doctor and more like a hapless worker bee in a buzzing but somehow misguided hive, fraught with unnecessary and avoidable endeavors. Moreover, if the patient had access to dental care, he would have been able to take adequate fluids and calories and perhaps never would have collapsed in the first place. Lastly, here was a glimpse of the health consequences of an economy increasingly reliant upon temporary, part-time, and seasonal jobs. It was redeeming to recognize that I had helped him by initiating treatment for his dental infection. Yet, the experience also reaffirmed my strong belief that our nation needs, at minimum, a public, single-payer program that will provide care – and system planning – for every patient. What good we could do if we mustered, rather than squandered, our resources. This case of a man who worked too hard illuminated how feeble, even irrelevant, our profession may seem when it comes to basic requirements of personal health in the 21st-century United States. We have earned great scientific and human insight into the lives of our patients. To practice the art and science of medicine, to fulfill the calling of our profession, we must ultimately learn to articulate our insights to guide social resources toward the health of each and all. If we continue to embrace the role of worker bees, focused upon chart checklists and testing algorithms and petty incentives to generate revenue, we will place ourselves in a role unworthy of our profession. To eliminate unnecessary tests and treatments – and to prevent so many avoidable illnesses – our profession will need to heal itself. Dr. Andrew Coates practices internal medicine in upstate New York. You can listen to Dr. Coates’ radio broadcast here: http://wamc.org/post/man-who-worked-too-hard

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Single-payer system would succeed

By Michael C. Huntington, M.D.
Register-Guard (Corvallis, Ore.), Letters, Sept. 9, 2013 In response to a July 31 column about single-payer health care, Reginald Jensen, a retired insurance underwriter, strayed from credibility as he dismissed the ability of single-payer systems to lower costs (“Single-payer system is just too costly to work”). In doing so he ignored the success of 22 wealthy countries and our own Department of Veterans Affairs, which use single-payer systems to provide better care for more people at far less cost than does the U.S. market-based health care system. Single-payer can be defined as a type of financing system for health care such that one entity — on behalf of and directed by the public through government or a public/private agency — collects all health care fees and pays out all health care costs. Under such a financing system, health care can be delivered through both private and public providers just as it is now, but with the public setting standards of care and negotiating prices. Jensen didn’t mention that the United States pays, per capita, twice as much for health care as other countries do and has poorer outcomes by many criteria, according to the Organization for Economic Cooperation and Development and the World Health Organization. His claims — that European health care costs could surpass U.S. costs, that Europe’s humane health care systems somehow cause economic crises, that we can solve our health care crisis through more jogging or personal discipline, that taking care of all of us means indenturing some of us — are baseless. Dr. Michael C. Huntington resides in Corvallis. http://registerguard.com/rg/opinion/30407489-78/care-health-system-quality-eugene.html.csp

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What if Medicare covered everybody’s medical care?

By Betty Johnson
Gazette-Times (Corvallis, Ore.), Letters, Sept. 19, 2013 Members of Mid-Valley Health Care Advocates posed this question to area residents at the celebration of Medicare’s 48th birthday party at Riverfront Park this summer: How would your life be different if we had Medicare for all? Here are some of the thoughtful answers which area residents wrote on notes which they attached to the writer’s wall: “My granddaughter would not be bankrupt and uninsurable at age 30.” “I would no longer lay awake every night in abject terror of my future.” “I’d feel that things were fairer.” “My husband could take a job that would let him come home every night.” “As a physician, I would stop worrying about all the people I know who are needlessly suffering with untreated illness.” “My wife would be covered, and I could retire.” “My 29-year-old daughter, who is fighting cancer, would not be bankrupt … and I would not, in covering her co-pays, be headed toward bankruptcy.” “I’d start a business.” “My friends, family and I could replace our glasses.” “As a healthcare provider, I could make decisions based on clinical factors, not an individual’s financial (insurance) situation.” “I’d be living in a country that reflects a sense of community and caring and I would no longer be embarrassed to be an American.” And the last response sums it up … for me and, I hope, for you … “Health Care for all is the way it should be. Why is it taking us so long?” Betty Johnson resides in Corvallis. http://www.gazettetimes.com/news/opinion/mailbag/letter-what-if-medicare-covered-everybody-s-medical-care/article_b71dac94-2107-11e3-a31b-0019bb2963f4.html

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Health care coverage for the homeless

Medicaid Expansion: Chronically Homeless Adults Will Need Targeted Enrollment And Access To A Broad Range Of Services

By Jack Tsai, Robert A. Rosenheck, Dennis P. Culhane and Samantha Artiga
Health Affairs, September 2013 Prior to health reform, eligibility for Medicaid was limited to low-income people in certain categories, including children, pregnant women, parents with dependent children, people who qualified as disabled, and elderly adults. The Medicaid expansion in 2014 extends eligibility to low-income, nonelderly, nondisabled adults without dependent children—often called “childless adults”—who were historically excluded from the program. Among other people who could gain coverage under the Affordable Care Act’s Medicaid expansion are the estimated 1.2 million people across the country who are homeless in a given year, including roughly 110,000 chronically homeless adults. Given their low incomes, many currently uninsured or underinsured homeless adults will gain from the Medicaid expansion a new pathway to coverage and new health care opportunities. Conclusion The Medicaid expansion under the Affordable Care Act will likely increase coverage options and provide broader access to care for many chronically homeless adults who are uninsured or rely solely on state or local assistance programs. Moreover, states that expand Medicaid may experience offsetting cost savings, as chronically homeless adults who previously relied on state and local assistance transition to Medicaid. Conversely, in states that do not expand Medicaid coverage, poor uninsured adults will not gain a new coverage option, and many will likely remain uninsured and continue to face barriers to accessing needed care. The findings of this study illustrate the broad and varied health care needs of chronically homeless adults. Ensuring access to preventive and mental health services is particularly important for addressing the needs of this population, and the services available to this group should include case management and other supportive services, such as help with housing. http://content.healthaffairs.org/content/32/9/1552.abstract

Comment:

By Don McCanne, M.D. For those states that expand Medicaid, many of the chronically homeless will have an opportunity to obtain health care coverage – much needed in this vulnerable population. However, these individuals face many hurdles in both initial enrollment and maintaining enrollment in Medicaid. Many will still be without adequate coverage. This is unfortunate since we could have eliminated the coverage problem by establishing a single payer national health program – enroll once and it is for life. We could still do that. For more information on health care for the homeless, see the website of National Health Care for the Homeless Council: http://www.nhchc.org

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The high costs of complexity in health care reform

By Philip Caper, M.D.
Bangor (Maine) Daily News, Sept. 19, 2013

I have great admiration for the political courage of President Barack Obama and the congressional leaders who were willing to take on health care reform, justifiably called the “third rail” of American politics. Our system cries out for reform. But they made a fatal mistake in allowing the law to be drafted by Congress, which is composed of 535 members with vastly varying values, goals and interests.

Consequently, the resulting law is a conglomeration of ideas from across the political spectrum, thrown together and lacking any coherent conceptual framework. (Congress is usually a better editor than author.) This lack of coherence has resulted in a law that is far too complicated and therefore too expensive to manage, full of holes, will be appliedunevenly and unfairly, be full of unintended consequences, and be easily exploited by those looking to make a quick buck.

It has been credibly estimated that administrative costs make up more than 30 percent of our national health care bill, most of it unnecessary. The waste in this area alone isequivalent to around $400 billion annually. That is more than enough to provide health care to every uninsured person living in our country. Some of these costs result from the slicing and dicing of Americans into ever-tinier and more confusing categories, the inevitable result of applying the principles of insurance to health care.

But the costs go beyond dollars to a lack of basic fairness, and of public understanding and support.

A plurality of the public still views the law negatively. Even many experts are confused by it. The law tries to deal with this confusion by providing a host of federally funded“navigators” to help people find their way through the maze it creates. While this provision will provide many well-paying jobs, it uses health care funds but does not pay for any health care — an example of your health care dollars not at work.

The ways in which the costs and benefits of the law are distributed are patently unfair. Even if it is perfectly implemented, it will leave around 30 million Americans without health care coverage. Some of this was intentional, but some wasn’t. The Affordable Care Act’s architects intended the federal government to expand the Medicaid program and make it more uniform to cover the poorest among us on a fairer basis.

But the Supreme Court found that requiring the states to expand their Medicaid programs would be unconstitutional, thereby gutting that provision. About half the states, including Maine, have declined the Medicaid expansion. They have decided to forgo the 100 percent federal funding (dropping to 90 percent after three years). That has created the anomalous situation where some of the poorest Mainers will receive no help, while those who are slightly wealthier will receive federal subsidies to buy insurance.

Similarly, some people who make too much money to qualify for any federal assistance but cannot afford increasingly expensive health insurance on their own will continue to pay state and federal taxes to finance Medicare, Medicaid, the VA and other programs for others. They will also pay higher federal taxes to compensate for the fact that private insurance for union members, corporate executives, and others with employment-based coverage, some of it quite comprehensive, is tax exempt.

The ACA does not go nearly far enough in restraining ballooning health care costs or reforming the way we pay those providing health care products and services. These abuses have been brilliantly and persuasively documented in Steven Brill’s Time Magazine cover story “ Bitter Pill.” Health care prices are completely out of control and the uninsured, many of them the least able to pay, are often the only ones charged full sticker price.

The only persuasive reason that has been given for our failure to address these glaring problems is that the power of the health care industry (that spends three times as much on lobbying as the defense industry) is too great. Pretty pathetic, and yet another example of your health care dollars at work — this time against you.

It doesn’t have to be this way. It is now well-documented that Medicare, a far simpler program than the ACA, spends much less on administration and is much more effective in controlling prices than private insurance. Apologists for the existing system of private insurance claim that it preserves “choice” of insurers, and that Americans want that choice.

But the choice people really want is a choice of health care providers, not insurance. Medicare beneficiaries can already choose any participating provider they wish. I have never heard a single Medicare patient complain about not having more choice of insurance companies.

Even Sen. Harry Reid, one of the ACA’s architects, now admits that it must be a way-station to a Medicare-like, single-payer plan. He has said he thinks the country has to “work our way past” insurance-based health care.

Fortunately, in Maine we have a couple of ways to do that. Next year, hearings will be held on L.D. 1345, co-sponsored by Rep. Charlie Priest and Sen. Geoff Gratwick. That bill would start us on a path toward a statewide nonprofit, unified and universal health care system, similar to the route recently taken by our neighbors in Vermont.

Failing approval of that measure, Maine (unlike Vermont) has a referendum process, a direct vote of the people for sanity in health care. If we were to follow either path, Maine would once again have the right to say “Dirigo” — I lead — and set a historic example for other states to follow.

Physician Philip Caper of Brooklin is a founding board member of Maine AllCare, a nonpartisan, nonprofit group committed to making health care in Maine universal, accessible and affordable for all. He can be reached at pcpcaper21@gmail.com.

http://bangordailynews.com/2013/09/19/health/the-high-costs-of-complexity-in-health-care-reform/

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CMS Office of the Actuary on growth in health expenditures

National Health Expenditure Projections, 2012–22: Slow Growth Until Coverage Expands And Economy Improves

By Gigi A. Cuckler and colleagues in the Office of the Actuary at the Centers for Medicare and Medicaid Services (CMS)
Health Affairs, October 2013 Health spending growth through 2013 is expected to remain slow because of the sluggish economic recovery, continued increases in cost-sharing requirements for the privately insured, and slow growth for public programs. These factors lead to projected growth rates of near 4 percent through 2013. However, improving economic conditions, combined with the coverage expansions in the Affordable Care Act and the aging of the population, drive faster projected growth in health spending in 2014 and beyond. Expected growth for 2014 is 6.1 percent, with an average projected growth of 6.2 percent per year thereafter. Over the 2012–22 period, national health spending is projected to grow at an average annual rate of 5.8 percent. National Health Expenditures (NHE): 2013  $2.915 trillion
2022  $5.009 trillion NHE per capita: 2013  $9,216
2022  $14,664 NHE as percent of Gross Domestic Product (GDP): 2013  18.0%
2022  19.9% 2014 Growth Rates By Selected Sector, Before And After The Impact Of The Affordable Care Act

SOURCE: Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group. http://content.healthaffairs.org/content/early/2013/09/13/hlthaff.2013.0721.abstract Link to bar graph:
http://content.healthaffairs.org/content/early/2013/09/13/hlthaff.2013.0721/F2.large.jpg

Comment:

By Don McCanne, M.D. Celebrating the slowing of the rate of increase in health care spending is premature, judging by the conclusions of the experts at the Office of the Actuary at CMS. Over the next decade, health care costs will continue to increase at a rate of about 6 percent annually, reaching nearly 20 percent of our GDP by 2022. If the Affordable Care Act (ACA or Obamacare) will not adequately control health care inflation, then what financial impact is it having? Look at the bar graph above. The differences represent only the impact of ACA in 2014 and not the other economic factors that the actuaries took into consideration in this report. Instead of slowing the growth in our national health expenditures, ACA will increase spending. This is expected because of the numbers of individuals who will gain coverage through the expansion of Medicaid and the establishment of the state Marketplaces (exchanges). Had we enacted single payer reform instead, the savings from the efficiencies would have offset the costs of even greater expanded coverage, including everyone. Most of the increases in coverage will be amongst healthier children and younger adults. For that reason hospital care is not expected to increase much due to ACA, but physician and clinical services and prescription drugs will increase significantly now that these individuals will have more affordable access to health care. The net cost of health insurance (premiums earned minus benefits paid) will skyrocket, since, after all, ACA was a gift to the private insurance industry. Obviously much of that represents an increase in the administrative waste that characterizes our dysfunctional financing system. “Net cost of health insurance is calculated as the difference between calendar year incurred premiums earned and benefits paid for private health insurance. This includes administrative costs and, in some cases, additions to reserves; rate credits and dividends; premium taxes; and plan profits or losses. Also included in this category is the difference between premiums earned and benefits paid for the private health insurance companies that insure the enrollees of the following public programs: Medicare, Medicaid, Children’s Health Insurance Program, and workers’ compensation (health portion only).” But look at the growth in government administration directly due to ACA. Think of the administrative costs of Medicare – under 2 percent of benefits paid. Now look at the rate of increase in administrative costs that are attributable to a complex, fragmented, multi-payer system of financing health care – flaws greatly compounded by ACA. Government administration “includes all administrative costs (federal, state, and local employees’ salaries; contracted employees including fiscal intermediaries; rent and building costs; computer systems and programs; other materials and supplies; and other miscellaneous expenses) associated with insuring individuals enrolled in the following public health insurance programs: Medicare, Medicaid, Children’s Health Insurance Program, Department of Defense, Department of Veterans Affairs, Indian Health Service, workers’ compensation, maternal and child health, vocational rehabilitation, Substance Abuse and Mental Health Services Administration, and other federal programs.” Although the dollar amount that will be spent by the government on health care administration (projected $70.4 billion in 2022) is a bargain compared to the cost of administration in the private sector (net cost of private insurance projected to be $313.2 billion in 2022), these increases nevertheless are representative of the profound administrative waste of the ACA model of reform. Haven’t you readers had enough of this? Why don’t you go out and do something about it?

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