PNHP

Gaps in public understanding of Medicare

Gaps in public understanding of Medicare

The Public and the Conflict over Future Medicare Spending

By Robert J. Blendon, Sc.D., and John M. Benson, M.A.
The New England Journal of Medicine, September 12, 2013 Our thesis is that there exists today a wide gap in beliefs between experts on the financial state of Medicare and the public at large. Because of the potential electoral consequences, these differences in perception are likely to have ramifications for policymakers addressing this issue. There are concerns about Medicare today and current cost-containment efforts. Most respondents see Medicare in some cases already withholding treatments and prescription drugs to save money, including 63% who believe this happens very often or somewhat often. Also, the public sees the bigger problem for Medicare beneficiaries as not getting the health care they need (61%) rather than as receiving unnecessary care (21%). Medicare pays about half the total personal health care expenditures for beneficiaries, but many people are confused about what proportion is paid by Medicare, whether it pays for most of recipients’ bills or substantially less. When given a dozen possible causes for rising Medicare costs that have been suggested either by experts or in the media, the majority do not identify any one of them as the most important. However, the three most often cited reasons relate to poor management of Medicare by government, fraud and abuse in the health sector, and excessive charges by hospitals. The lowest ranked reason was the cost of new drugs and treatments being offered to seniors. Although Medicare is popular, it is not seen as better run than private insurance plans, nor is it seen as particularly different from private coverage with respect to quality of care or access to physician care. The one area of clear support for the future is the growing preference for Medicare Advantage–type private health coverage among persons less than 65 years of age. In conclusion, two points are important. It would aid the long-term resolution of these issues if there were a nonpartisan, broad-based public education campaign launched focusing on how Medicare works financially. Second, it would be advantageous if discussions of the financial sustainability of Medicare could be separated from public debates over reducing budget deficits or enacting tax cuts. Until these concerns are better addressed, the gaps in perception are likely to remain. http://www.nejm.org/doi/full/10.1056/NEJMsr1307622?query=TOC

Public Often Clueless About Medicare

By David Pittman
MedPage Today, September 11, 20133 Because of a high level of misunderstanding about Medicare’s financing, lawmakers in Congress are hesitant to enact changes to the program fearing voter backlash, Bob Blendon, ScD, and John Benson, MA, both of Harvard University, wrote in a special report in Wednesday’s New England Journal of Medicine. Ted Marmor, PhD, professor emeritus of public policy at Yale University, said it’s misleading to imply public opinion is a shaper of public policy. He called it more of a protector than a promoter. “The public is almost never well informed about details,” Marmor told MedPage Today in a video interview. “What’s important about public opinion is what its values are and what it would be threatened by, not what it means in terms of shaping public policy in terms of direction on details.” http://www.medpagetoday.com/PublicHealthPolicy/Medicare/41550

Public Attitudes about Medicare

Harvard School of Public Health
Poll – May 13-26, 2013 10. Which do you think is better run, (the federal Medicare program) or (private health insurance plans that people get through their jobs), or do you think they are about equally well run? 15% – The federal Medicare program
41% – Private health insurance plans
39% – About equally well run
5% – Don’t know/ Refused 19. (When you retire,) If you had a choice, would you prefer to get your Medicare health insurance benefits from the current government Medicare program, or from a private health plan, such as a PPO or HMO, offered through Medicare? 34% – From the current government Medicare program
56% – From a private health plan, such as a PPO or HMO, offered through Medicare
10% – Don’t know/ Refused http://www.hsph.harvard.edu/horp/files/2013/06/HSPH-Medicare-Topline.pdf

Comment:

By Don McCanne, M.D. The public is not well informed on the details of Medicare. A plurality believe that private insurance plans are better run than Medicare, and a majority would prefer private plans when they retire., We should think about the political implications of this. Is “Medicare for All” really a good slogan for single payer? Medicare has some very serious defects, like it pays only about half of beneficiaries’ health expenditures. Yet we certainly don’t want a slogan that would suggest that single payer would be like private insurance for everyone. We shouldn’t change course based on the results of a single poll, but we should continue to think about how we can improve our messaging so that people do understand that single payer is what they really want. That’s true when the facts are presented, but too many still don’t understand that. As Ted Marmor implies, perhaps we should be placing more emphasis on values.

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New Census data on the uninsured – still 48 million

Income, Poverty, and Health Insurance Coverage in the United States: 2012

By Carmen DeNavas-Walt, Bernadette D. Proctor, Jessica C. Smith
United States Census Bureau, September 2013 Highlights

• In 2012, the percentage of people without health insurance decreased to 15.4 percent from 15.7 percent in 2011. The number of uninsured people in 2012 was not statistically different from 2011, at 48.0 million. • Both the percentage and number of people with health insurance increased in 2012 to 84.6 percent and 263.2 million, up from 84.3 percent and 260.2 million in 2011. • The percentage of people covered by private health insurance in 2012 was not statistically different from 2011, at 63.9 percent. This is the second consecutive year that the percentage of people covered by private health insurance was not statistically different from the previous year’s estimate. The number of people covered by private health insurance increased in 2012 to 198.8 million, up from 197.3 million in 2011. • The percentage and number of people covered by government health insurance increased to 32.6 percent and 101.5 million in 2012 from 32.2 percent and 99.5 million in 2011. • The percentage and number of people covered by employment-based health insurance in 2012 were not statistically different from 2011, at 54.9 percent and 170.9 million. • The percentage and number of people covered by Medicaid in 2012 were not statistically different from 2011, at 16.4 percent and 50.9 million. The percentage and number of people covered by Medicare increased in 2012 to 15.7 percent and 48.9 million, from 15.2 percent and 46.9 million in 2011. • Since 2009, Medicaid has covered more people than Medicare. • In 2012, the percentage and number of uninsured children under age 18 decreased to 8.9 percent and 6.6 million, down from 9.4 percent and 7.0 million in 2011. In 2012, the uninsured rate for children in poverty, 12.9 percent, was higher than the uninsured rate for children not in poverty, 7.7 percent. • The rate and number of uninsured non-Hispanic Whites in 2012 were not statistically different from 2011, at 11.1 percent and 21.6 million. The rate and the number of uninsured Blacks in 2012 were also not statistically different from 2011, at 19.0 percent and 7.6 million. • The percentage of uninsured Hispanics decreased in 2012 to 29.1 percent, down from 30.1 percent in 2011. The number of uninsured Hispanics in 2012 was not statistically different from 2011, at 15.5 million. http://www.census.gov/prod/2013pubs/p60-245.pdf

Comment:

Don McCanne, M.D.

Supporters of the Affordable Care Act (Obamacare) have been touting the improvement in our health care system since the legislation was signed into law three years ago. Well, that improvement does not apply to the numbers remaining uninsured since the minimal gains have been offset by losses, and so we still have 48 million people uninsured. That doesn’t even consider all of the injustices that remain in the maldistribution of coverage. Of course, next year’s numbers should be different. The introduction of state health insurance exchanges with government subsidies to help purchase plans and pay medical bills, plus the expansion in the Medicaid program, will reduce the numbers of uninsured. However, when Obamacare is fully implemented, the CBO estimates that 31 million people will remain uninsured. That’s a reduction of only slightly over one-third of today’s 48 million – hardly a success story for health care reform that was supposed to provide everyone with some form of insurance coverage. If we had a single payer improved-Medicare-for-all program, the number of uninsured would not be 48 million, it would not be 31 million, it would be zero! (The full Census Bureau report also includes unsettling income and poverty data. Although PNHP’s activism is limited to health care, there is so much more that needs to be done. All Americans need to make social justice our leading national priority.) Read PNHP’s press release for a brief analysis of the health insurance implications of today’s Census Bureau report: ‘Stronger medicine than Obamacare needed to end uninsured crisis’: health expert https://www.pnhp.org/news/2013/september/stronger-medicine-than-obamacare-needed-to-end-uninsured-crisis-health-expert

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'Stronger medicine than Obamacare needed to end uninsured crisis': health expert

Citing latest Census count of 48 million uninsured, researcher says Affordable Care Act will cut that figure by only half, leaving tens of millions vulnerable to unnecessary suffering and premature death

FOR IMMEDIATE RELEASE, Sept. 17, 2013
Contact: Mark Almberg, communications director PNHP, (312) 782-6006, mark@pnhp.org.
Local physicians in virtually every state are available for comment. (Also see 4-year historical table of state-by-state uninsured numbers, below.)

The Census Bureau’s official estimate that 48 million Americans lacked health insurance in 2012 means approximately 48,000 people died needlessly last year because they couldn’t get access to timely and appropriate care, a prominent health researcher, Dr. David Himmelstein, said today.

And contrary to many people’s expectations, the number of unprotected Americans will drop by only half when Obamacare is fully implemented – even if all the as yet undecided states were to opt-in to the law’s Medicaid expansion, he said.

The estimate of 48,000 deaths in 2012 is based on a peer-reviewed study by Himmelstein and other Harvard researchers published in the American Journal of Public Health in 2009, widely cited during the health reform debate, which found that for every 1 million persons who were uninsured there were about 1,000 related, preventable deaths.

Himmelstein is professor of public health at the City University of New York, visiting professor of medicine at Harvard Medical School, and a primary care doctor. He said, “The Census Bureau’s latest figure, 48 million uninsured, conjures up a very grim picture: a preventable death every 11 minutes.”

He said studies have shown that uninsured people with chronic illnesses like heart disease delay or forgo care, often leading to serious complications of their medical condition and, in many cases, premature death.

In another study recently published at the Health Affairs blog, Himmelstein and his colleagues found that the Affordable Care Act “will minimally alter the demographic composition of the uninsured, regardless of whether undecided states opt-in or out. While Blacks and Hispanics will continue to be overrepresented among the uninsured, the majority will be non-Hispanic, white, low-income, working-age adults, many of them employed.”

The researchers continue: “The majority … of the uninsured will be U.S. citizens, irrespective of states’ acceptance of Medicaid expansion. More than 4.3 million children and nearly 1 million veterans will remain uninsured under either scenario. … If all currently undecided states opt-in, 29.8 million people will remain uninsured [in 2016], whereas if all opt-out, the number of uninsured will total 31.0 million, 1.2 million above the opt-in scenario.”

Today’s Census Bureau report said in 2012 the percentage of people without health insurance had slightly decreased to 15.4 percent of the population from 15.7 percent in 2011, but that the number of uninsured people in 2012 was not statistically different from 2011, at 48.0 million. The bureau’s figures show the modest gains in coverage were chiefly attributable to an increase in the number of persons covered by Medicare.

While the percentage of persons covered by employment-based insurance, 54.9 percent, was not statistically different than the previous year’s figure, about a half-million fewer workers were covered by such plans in 2012.

The bureau reported that Texas had the highest percentage of uninsured, at 24.6 percent, followed by Nevada, New Mexico, and Florida, each of which exceeded 20 percent. In total numbers, California and Texas had the largest number of uninsured, each exceeding 6.4 million people.

Responding to today’s Census Bureau report, Himmelstein said: “As a physician, I simply cannot accept a situation where tens of thousands of people die every year because they lack insurance coverage. And lest anyone think this problem will be solved by Obamacare, our research and the government’s own Congressional Budget Office projections show that about 30 million people will still be uninsured in 2023. That figure translates into roughly 30,000 excess deaths annually – again, an intolerable prospect.”

Himmelstein said the nation should adopt a “zero-tolerance policy” toward lack of health coverage, and that the Census Bureau report “underscores the urgency of going beyond the Affordable Care Act and swiftly moving to a single-payer, improved-Medicare-for-all program.”

“Such a program would assure truly universal, comprehensive, high-quality coverage for everyone while simultaneously ridding us of the scourge of insurance-company-related waste, bureaucracy and profiteering,” he said. “It would thereby save both lives and money.”

Himmelstein is co-founder of Physicians for a National Health Program, an organization of 18,000 doctors who advocate for single-payer national health insurance. PNHP played no role in funding any of the research work cited above.

Four-year historical state-by-state data on the uninsured, from 2012-2009, compiled by PNHP staff from the annual findings published each fall by the Census Bureau, can be found here.

Physicians for a National Health Program (www.pnhp.org) is an educational and research organization of more than 18,000 doctors who support single-payer national health insurance. To speak with a physician/spokesperson in your area, visit www.pnhp.org/stateactions or call (312) 782-6006.

Exchange plans have sharply limited networks

Insurers limiting doctors, hospitals in health insurance market

By Chad Terhune
Los Angeles Times, September 14, 2013

The doctor can’t see you now.

To hold down premiums, major insurers in California have sharply limited the number of doctors and hospitals available to patients in the state’s new health insurance market opening Oct. 1.

New data reveal the extent of those cuts in California, a crucial test bed for the federal healthcare law.

Consumers could see long wait times, a scarcity of specialists and loss of a longtime doctor.

“These narrow networks won’t work because they cut off access for patients,” said Dr. Richard Baker, executive director of the Urban Health Institute at Charles Drew University of Medicine and Science in Los Angeles.

To see the challenges awaiting some consumers, consider Woodland Hills-based insurer Health Net Inc.

Across Southern California the company has the lowest rates, with monthly premiums as much as $100 cheaper than the closest competitor in some cases. That will make it a popular choice among some of the 1.4 million Californians expected to purchase coverage in the state exchange next year.

But Health Net also has the fewest doctors, less than half what some other companies are offering in Southern California, according to a Times analysis of insurance data.

In Los Angeles County, for instance, Health Net customers in the state exchange would be limited to 2,316 primary-care doctors and specialists. That’s less than a third of the doctors Health Net offers to workers on employer plans.

Other major insurers have pared their list of medical providers too, but not to Health Net’s degree. Statewide, Blue Shield of California says exchange customers will be restricted to about 50% of its regular physician network.

“We are nervous about these narrow networks,” said Donald Crane, chief executive of the California Assn. of Physician Groups. “It was all about price. But at what cost in terms of quality and access? Is this contrary to the purpose of the Affordable Care Act?”

Insurers and their number of doctors in L.A. County for state health exchange:

2,316  Health Net
3,009  Molina
3,855  Anthem Blue Cross
4,946  L.A. Care
5,705  Kaiser
6,559  Blue Shield PPO
8,839  Anthem EPO

28,181  Number of licensed physicians in L.A. County (MBC)

http://www.latimes.com/business/la-fi-insure-doctor-networks-20130915,0,6433104,full.story

Comment:

By Don McCanne, M.D.

These new data on use of narrow provider networks in state insurance exchanges, using Los Angeles County as an example, are important because they show us the extent to which this concept is being applied. Narrow provider networks reduce health care spending by limiting patient access to low cost providers – taking away choice – and by impairing access though supply-side contractions, that is, rationing care by limiting the supply of covered health care providers.

Another table accompanying the Los Angeles Times article (available at the link above) lists premiums for typical policies issued by these insurers for the benchmark silver plans. When comparing premiums with the numbers of physicians in the network, there are several interesting observations. Health Net, with the fewest number of physicians in their network, has the lowest premiums – no surprise. Blue Shield, California’s nonprofit Blues plan, has premiums on the lower end though it has a much larger number of physicians than does for-profit Anthem Blue Cross, yet their premiums are similar. The nonprofit seems to be more concerned about patient access whereas the for-profit seems to be concerned more about profits. However, Anthem’s EPO (exclusive provider organization) offers a larger choice in providers but extracts a much larger premium for that coverage. Comparing Anthem’s two products, it looks like if you want an accessible doctor, you’re going to have to pay for that right. Considering that Kaiser is a closed, integrated health system, it does have a fairly decent number of physicians, but it also has the highest premiums. It is likely that Kaiser’s premiums are not high because of the number of physicians, but rather they are high to prevent destabilization of their business model by allowing too many new enrollees which might strain their capacity.

Health Net’s silver plan premiums are set far enough below the others such that they will be very attractive for shoppers in the insurance exchange. The bronze plans have even lower premiums and will also be attractive. Most shoppers will be relatively healthy and will select their plans based on the premium – not on the physician networks nor on the out-of-pocket costs they would face if major health problems were to develop. Some of these people will become ill or suffer significant injuries. At that time they will discover that their choices of providers are too limited, that access may be impaired because the physicians are too busy or because they are too far away, and that the out-of-pocket expenses to which they are exposed will cause financial hardships.

Leave policy decisions to private insurers and they will always select policies that will advance their business models as opposed to policies that would provide optimal access, quality and affordability for patients. Having cheap premiums is no solution when you can’t get a doctor when you need one, and, when you finally do, you’re left broke.

Single payer would have avoided all of this, and it still can.

Taxes instead of premiums

By Ellen Oxfeld
Times Argus (Barre & Montpelier, Vt.), Letters, Sept. 16, 2013

The headline of your Sept. 5 article states, “Shumlin to rely on payroll tax hikes” to fund single payer. However, this headline would be equally accurate if it stated, “Gov. Shumlin to implement the largest single premium decrease in U.S. history.” Indeed, as the article itself makes clear, taxes to fund a health care system for all Vermonters (single payer) will replace and not add to premiums, and thus they will not constitute a hike in payments for health care at all.

Further, by replacing private premiums with public financing, we will get much more than we ever could under the current system. Let’s not forget that single payer means guaranteed health care for all Vermonters regardless of employment status. It means no more worries about going bankrupt due to high out-of-pocket costs that even the insured often face. Single payer also means greater simplicity for employers, who will no longer have to waste precious time overseeing the complex paperwork of private health care plans, as well as for providers, who will no longer have to bill many different private plans.

Our current system of patchwork coverage and fragmented financing is expensive, and despite this, we still do not have universal access to health care. Single payer means financing a health care infrastructure in a streamlined way. And it means health care will be there for all of us when we need it. That is why Gov. Shumlin is on the right track in his commitment to implementing a publicly funded health care system for all Vermonters by 2017.

Ellen Oxfeld lives in Middlebury.

http://www.timesargus.com/article/20130916/OPINION02/70916996

Why we need a National Health Plan

By Paul L. Burnley
Fayetteville (N.C.) Observer, Sept. 12, 2013

The objection to a national health plan by many of our lawmakers is similar to the reaction years ago to the Social Security program. It was seen as a tax-imposed on the public by the government. It was thought to be a struggle between the conservatives and liberal factions of government when, in reality, the only people affected by these programs are the poor, those who are at the bottom of the political spectrum.

Many believe a national health program is also a tax imposed on the public by the government. When the Social Security program began, there were those who said, “Why should the government take money from my paycheck to save for my retirement? I can save that money myself. How do I know I will live to retirement?” Today, millions are able to live and maintain themselves because of this program.

As for a national health insurance program, it will affect those who are not able to afford health insurance. If you are in an income bracket where you are able to pay for any and all medical emergencies, I can understand your reluctance about a national health program. But the majority of the residents of North Carolina are not in that income bracket.

Brokering the middle

I am not in favor of the government running the lives of its citizens; however, in some cases there must be an overseer that is fair and reasonable. If some issues that affect the general population were left to individual states, as they were years ago, they would be abused. That’s especially so in some Southern states, where the “good old boy” process was upheld. I can imagine the abuse that would have taken place had certain states been in control of the Social Security program.

Medical bankruptcy

The lack of medical insurance is the cause of many economical disasters, not only for individuals, but for communities. Many lose time from their jobs, because of illnesses that would be treated if medical insurance were available.

The majority of bankruptcies in this country are caused because of medical bills that people are not able to pay, due to the lack of medical insurance. If there were a national health program, many of these problems would not exist.

There are those who say, well, now we have Medicare. That should take care of most of the medical problems. This only covers those over 65 years of age, or those unable to work. This leaves the majority of the public out of the loop. This is why,when there are any free medical services offered by groups trying to address this situation, they are overwhelmed by people needing medical attention.

I am not saying that all elements of our lives should be controlled by the government, but when it comes to a large segment of the population, the decision should not be left to local or state authorities. In many cases opinions are governed by political, racial and social attitudes and choices. Had Social Security been administered by the states, millions of people whose income is derived from Social Security would not have received it.

Paul L. Burnley is a retired newspaper writer and editor and a former member of the Observer’s Community Advisory Board.

http://www.fayobserver.com/articles/2013/09/13/1282406?sac=fo.opinion

Sen. Bernie Sanders on single payer

A single-payer system makes economic sense

By Sen. Bernie Sanders (I-Vt.)
The Hill, September 10, 2013

Americans spend about twice as much per capita on healthcare as almost any other developed nation, but our outcomes are not as good as others that spend much less. We can do better. We must do better.

Today, some 50 million Americans lack health insurance. Many others delay going to the doctor because of high deductibles and unaffordable copayments. While the number of uninsured Americans will go down with the implementation of the Affordable Care Act, widely known as ObamaCare, tens of millions of Americans will remain uninsured.

The goal of an effective healthcare system is to do everything possible to enable people to live long and healthy lives. Sadly, the American system fails to do that and falls behind many other countries. While we devote 18 percent of our gross domestic product to healthcare, we rank 33rd in life expectancy and 34th in infant mortality, and trail in many other health outcomes. A Harvard University study indicated that, incredibly, some 45,000 Americans die needlessly each year because they do not get to a doctor in time.
 
I start my approach to healthcare from a very basic premise: healthcare is a right, not a privilege. Unfortunately, uniquely among major nations, that statement is not true for the United States, where access to healthcare depends on how much money you have and what your employer is willing to provide.

It is simply unconscionable that the most advanced nation in the world has so many people who lack health insurance. It makes no sense that millions more are one diagnosis or car accident away from financial disaster. And, despite the trillions of dollars we spend on healthcare, the disparity in the quality of care between the rich and everyone else grows wider.

Our system doesn’t make economic sense, and it certainly doesn’t make moral sense. In a civilized, democratic society, every man, woman and child must be able to get the medical care they need regardless of income.

It is incomprehensible that drug companies still get away with charging Americans twice as much — or more — than citizens of Canada or Europe for the exact same drugs manufactured by the exact same companies. It is an outrage that insurers still want to hike premiums by as much as 60 percent a year on individual policyholders.

It boggles the mind that approximately 30 percent of every healthcare dollar spent in the United States goes to administrative costs rather than to delivering care. Taiwan, for example, spends only a little over 6 percent of its GDP on healthcare, while achieving better health outcomes on some key indicators than we do. The reason, of course, is that they spend a fraction of what we do on administrative costs.

If our goal is to provide high-quality healthcare in a cost-effective way, what should we be doing?

Clearly, we must move toward a single-payer system.

The health insurance lobby and other opponents of single-payer care make it sound scary. It’s not. In fact, a large-scale single-payer system already exists in the United States. It’s called Medicare. People enrolled in the system give it high marks. More importantly, it has succeeded in providing near-universal coverage to Americans over the age of 65.

Establishing a single-payer system will mean peace of mind for all Americans. When health insurance is no longer tied to employment, people will not fear losing both their job and their family’s access to healthcare. Millions of Americans won’t have to stay in jobs they don’t like because their family needs healthcare. Entrepreneurs and small businesses will be free to develop their business plans without worrying about the cost and complexity of providing healthcare for themselves and their employees.

For these reasons and more, Rep. Jim McDermott (D-Wash.) and I have introduced the American Health Security Act, which would guarantee healthcare as a human right and provide every U.S. citizen and permanent resident with healthcare coverage and services through a state-administered, single-payer program.

I am very proud that my home state of Vermont is now taking big steps to lead the nation in healthcare by moving forward on a plan to establish a single-payer healthcare system that puts the interests of patients over corporate profits. The American Health Security Act would make sure every state does the same.

The goal of real healthcare reform must be high-quality, universal coverage in a cost-effective way. We must ensure, to as great a degree as possible, that the money we put into health coverage goes to the delivery of healthcare, not to paper-pushing, astronomical profits and lining CEOs’ pockets.

http://thehill.com/special-reports-archive/1549-healthcare-september-2013-/321477-a-single-payer-system-makes-economic-sense

Comment:

By Don McCanne, M.D.

Although the nation is distracted with the implementation of the Affordable Care Act, the single payer concept is not going to go away. Soon the nation will understand why.

AFL-CIO reaffirms support of single payer

2013 Convention

AFL-CIO

September 11, 2013
Adopted Resolutions

Resolution 54: AFL-CIO Convention Resolution on the Affordable Care Act

WHEREAS, in 2009, the AFL-CIO Convention passed two health care resolutions—Health Care Reform Now and the Social Insurance Model for Health Care Reform—which reaffirmed the labor movement’s commitment to health care for all, ultimately through a single-payer system. In 2010, Congress passed the Affordable Care Act (ACA);

(23 more WHEREASs)

NOW, THEREFORE, BE IT RESOLVED, that the AFL-CIO reaffirms the health care resolutions adopted by the 2009 convention, including the commitment to pursue health care for all ultimately through a single-payer system;

(8 more BE-IT-FURTHER-RESOLVEDs)

http://www.aflcio.org/About/Exec-Council/Conventions/2013/Resolutions-and-Amendments/Resolution-54-AFL-CIO-Convention-Resolution-on-the-Affordable-Care-Act

Comment:

By Don McCanne, M.D.

There are two important health care reform issues before us today. The most important by far is that this nation desperately needs a single payer system. The other is that the Affordable Care Act is well on its way to being fully implemented, with all of its intolerable flaws. Yesterday, AFL-CIO passed a resolution dealing with both of these.

The first WHEREAS and the first BE-IT-RESOLVED reaffirmed organized labor’s support of single payer reform. It is an imperative.

The other twenty-three WHEREASs and eight BE-IT-FURTHER-RESOLVEDs can be accessed at the link above. They concern very serious flaws in the Affordable Care Act, especially applicable to union members, which will be very difficult to correct. They are important to understand because flaws such as these permeate the entire Act.

Maintaining and expanding our highly dysfunctional health care financing system while adding administrative complexity is precisely what we did not need. All of this could have been avoided by moving directly to a single payer system. We can still do that, even if we have already wasted much time and money, while prolonging hardship and suffering.

Although organized labor’s targeted attack on the Affordable Care Act is making headlines today, they passed another resolution that is also very important:

Resolution 15: Protecting and Expanding Medicare Benefits

Excerpts:

Instead of cuts and cost shifting, we call for improvements to Medicare. Doing so is an essential prerequisite to establishing it as a model for a universal, single-payer system.

Instead of looking for ways to destroy Medicare, which has been a leader in improving our dysfunctional health care system, we must build on its experience as a single-payer program, demonstrating that single payer is the most cost-effective and equitable way to provide quality health care.

http://www.aflcio.org/About/Exec-Council/Conventions/2013/Resolutions-and-Amendments/Resolution-15-Protecting-and-Expanding-Medicare-Benefits

AFL-CIO reaffirms commitment to single payer, demands fixes to ACA

By Kay Tillow
Single Payer News, Sept. 12, 2013              

The just-concluded AFL-CIO convention in Los Angeles reaffirmed its commitment to a single-payer health care system while demanding that the Affordable Care Act (ACA) be fixed to protect Taft-Hartley (multi-employer) plans, to end the excise tax, to make employers cover workers who average 20 hours a week, to require construction companies with five or more employees to provide health care, to penalize companies who dump their workers onto Medicaid, plus more.

Some of the debate on the resolution can be seen here:

http://www.youtube.com/watch?v=vpVOf9Qsmno

Full text of the resolution can be found here:

http://www.aflcio.org/About/Exec-Council/Conventions/2013/Resolutions-and-Amendments/Resolution-54-AFL-CIO-Convention-Resolution-on-the-Affordable-Care-Act

Distributed by 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. http://unionsforsinglepayer.org

Other media coverage:

AFL-CIO heads off health care fight by criticizing, not dumping, Affordable Care Act

By Mark Gruenberg
Press Associates Union News Service, Sept. 11, 2013

LOS ANGELES – Leaders of the AFL-CIO headed off a knock-down drag-out fight over the Affordable Care Act – the Obama administration’s signature 2010 health care law that organized labor strongly supported – with a compromise resolution that specifies the act’s ills and puts the administration on notice they must be fixed.

But if they aren’t fixed, Laborers President Terry O’Sullivan said, the ACA should be dumped.

The health care fight was the most open controversy at the four-day convention. A compromise headed off another battle, where the building trades unions questioned the role and power of nonunion groups – particularly environmentalists – in labor’s councils. Complaints about lack of protection against inter-union raiding were diverted to the federation’s executive council, with a February 2014 reporting deadline.

But the health care fight couldn’t be headed off.

The resolution and several union leaders said administration’s interpretation of the ACA would virtually trash multi-employer health care plans, which cover 20 million people – workers, retirees and their families – nationwide.

Those plans, prevalent in construction, but present in other industries – such as food processing and seafaring – let joint union-management boards run health care plans that cover workers who frequently shift from job site to job site in an industry.

“If the ACA is not fixed, if it destroys the health and welfare funds we fought for, it needs to be repealed!” O’Sullivan roared. “The proud men and women we represent cannot be collateral damage” of the health care law.

“The ACA as it currently stands is not meeting its promise,” added IBEW President Ed Hill, whose union and five others openly wrote congressional leaders saying they must fix the health care law.

“This is make-or-break for a lot of unions, not just the building trades,” warned Sheet Metal Workers President Joe Nigro. “A resolution is a piece of paper and may offend a lot of politicians, but a labor movement is run by leaders who represent working men and women. …You let the ACA bill go through like this and you won’t need a room a quarter of this size” for the next federation convention four years from now, he added.

“We have to follow this with action,” declared Unite Here President D. Taylor, after reminding delegates of ACA’s benefits – and of exceptions Obama already illegally granted to businesses, congressional staffers and to some religious-run enterprises.

Dissent also came from those who want to go further. Though both federation President Richard Trumka and Professional and Technical Engineers President Greg Junemann said the eventual goal of the resolution is single-payer government-run national health care, the compromise downplays that goal.

The other dissenter was Kathryn Donahue, board member of the California Nurses Association/ National Nurses Organizing Committee. Her union stayed away from the convention until its final session due to, among other issues, disagreement about the ACA. CNA/ NNOC, part of National Nurses United, has been one of labor’s most ardent advocates of single payer, which 21 unions endorsed before the AFL-CIO’s 2009 convention.

“The ACA does not solve the health care crisis facing all of the people, not just union people,” Donahue declared. “It will not improve access to health care” and “will not remove health care from collective bargaining,” she said. Her union provided the scattered “no” votes in the crowd when delegates approved the health care resolution by voice vote. The resolution specifies, among other things, that:

• The AFL-CIO backs single payer – along with other alternatives it OK’d in 2009.

• Demands Congress amend the ACA unless the act is “administered in a manner that preserves the high-quality coverage” of multi-employer plans.

• Says the multi-employer plans “should have access to the ACA’s premium tax credits and cost-sharing reductions … just as for-profit insurance companies will.” The difference between the two has been the big problem in private talks Trumka and other union leaders have had with White House staffers. The White House has stonewalled.

• Says workers toiling more than 20 hours a week must be covered by ACA’s employer responsibility rules. The ACA now sets the lower limit at 30 hours per week. Several speakers at the convention said private firms – and some state and local governments – are racing to cut full-timers to 29 hours, to get out from under the act.

• Declares the employer responsibility rules should extend to construction companies with at least five employees, not 50. The 50-worker rule would exempt the overwhelming majority of construction firms, building trades leaders say.

• Reiterates unions’ strong opposition to taxing health care benefits. Obama strong-armed the AFL-CIO, at the end of the 2010 health care fight, into accepting such a tax on so-called “Cadillac” plans, in 2018.

Mark Gruenberg is editor of Press Associates Union News Service, 2605A P Street NW, Washington DC 20007. Phone: (202) 898-4825. E-mail: paiunionnews@yahoo.com. www.paiunionnews.com

AFL-CIO Convention Calls for Fixes in Affordable Care Act

By Mike Hall
AFL-CIO NOW blog, Sept. 11, 2013

Delegates to the AFL-CIO Convention this afternoon passed a resolution expressing support for the goals of the Affordable Care Act (ACA) but also addressing a number of issues about the ACA’s implementation, including the way the ACA treats multi-employer health care plans. The resolution reiterates that the labor movement’s ultimate health care goal is health care for everyone under a single-payer model.

The resolution calls for preservation of high-quality coverage under multi-employer plans. It also calls for greater employer responsibility, especially in regards to part-time workers. Sean McGarvey, president of the AFL-CIO Building and Construction Trades Department (BCTD), said the resolution, “Points out the key facts that must be addressed by the administration and if needed, by Congress.”

AFL-CIO President Richard Trumka called the issues raised by the resolution ones of “fundamental fairness,” including if low- and moderate-income union members and their collectively bargained health care plans will
be able to benefit from the same premium support that big insurance companies will receive and if they will have to pay fees to subsidize big insurance companies. There also are concerns that smaller employers will be able to get away with taking health care away from workers while paying no penalty. 

Laborers (LIUNA) President Terry O’Sullivan, who endorsed the resolution, told the convention delegates that without changes to the way the ACA is implemented, there are likely to be “unintended consequences” that will hurt workers’ health care coverage.

It needs to be changed and fixed now….We will work with the president to do everything we can to fix the Affordable Care Act….We want it fixed, fixed, fixed.

AFT Secretary-Treasurer Lorretta Johnson called the resolution “a road map to making the Affordable Care Act a success” and called the ACA, especially in the way it is being implemented by the federal agencies involved, “a work in progress.” She also said many AFT members, including para-professionals, adjunct college professors, nurses and public employees, have had their hours cut to under the 30-hour week threshold they must work before ACA requires employers to provide affordable, comprehensive health care coverage or pay a penalty.

Trumka did tell the delegates that “the labor movement is engaged in ongoing dialogue with a number of government agencies regarding implementation of the Affordable Care Act — especially the way it treats collectively bargained multi-employer funds.”

http://www.aflcio.org/Blog/Political-Action-Legislation/AFL-CIO-Convention-Calls-for-Fixes-in-Affordable-Care-Act

AFL-CIO steps up criticism of health care law

By Sam Hananel
The Associated Press, Sept. 11, 2013

WASHINGTON (AP) — The AFL-CIO on Wednesday approved a resolution critical of parts of President Barack Obama’s health care law in spite of efforts by White House officials to discourage the labor federation from making its concerns so prominent.

The strongly worded resolution says the Affordable Care Act will drive up the costs of union-sponsored health plans to the point that workers and employers are forced to abandon them. Labor unions still support the law’s overall goals of reducing health costs and bringing coverage to all Americans, the resolution says, but adds that the law is being implemented in a way that is “highly disruptive” to union health care plans.

Some individual unions have complained about the law’s impact for months. The resolution marks the first time the nation’s largest labor federation has gone on record embracing that view. Unions were among the most enthusiastic backers of the law when it passed in 2010.

A labor official told The Associated Press that White House officials had been calling labor leaders for days to urge them not to voice their concerns in the form of a resolution. The official, who wasn’t authorized to discuss the conversations publicly and requested anonymity, said many union leaders insisted that they wanted to highlight their concerns.

Asked about any efforts to discourage unions from passing the resolution, the White House said in a statement Wednesday night that officials “are in regular contact with a variety of stakeholders, including unions, as part of our efforts to ensure smooth implementation and to improve the law.”

The AFL-CIO, one of the president’s major boosters, approved the resolution just as the administration began rolling out a multimillion-dollar advertising campaign to encourage Americans to sign up for health care exchanges starting Oct. 1.

Harold Schaitberger, president of the International Association of Firefighters, said the intent of the resolution is to “point out the criticisms without being overly caustic.”

“There have to be some changes made in the area that are giving a number of our unions great concern,” said Schaitberger, who chaired the committee that hammered out the resolution’s language.

The resolution was approved at the AFL-CIO’s quadrennial convention in Los Angeles. It claims the new law will increase costs for health plans that are jointly administered by unions and smaller employers in the construction, retail and transportation industries. That could encourage employers to hire fewer union workers or abandon the health plans altogether and force union members to seek lower-quality coverage on the new health exchanges.

Union officials are seeking rule changes that would make their low-income workers eligible for the same types of federal subsidies they could get in the exchanges. They have also suggested rules that would treat their multi-employer plans as qualified exchange plans under the new law.

But the Congressional Research Service issued a memo earlier this year finding that neither change is allowed through rulemaking. The AFL-CIO resolution calls for the law to be amended by Congress if new rules cannot satisfy their concerns.

AFL-CIO President Richard Trumka held meetings at the White House last month in which he and other union leaders pressed the administration to make changes. Trumka has said he is encouraged that the White House is listening, but that no firm proposals have been made.

In a statement issued earlier Wednesday, the White House said there is nothing in the Affordable Care Act that changes the law for union plans. The statement said the White House would continue to work with unions and other stakeholders on ways to ensure smooth implementation of the law.

The AFL-CIO resolution was toned down from a draft originally offered by Sean McGarvey, head of the AFL-CIO’s Building and Construction Trades Department. The early draft said the AFL-CIO could no longer support the health care law and called for its repeal unless changes were made to protect union multi-employer plans.

Republican critics of the health care law have seized on the union complaints to fuel their push to repeal the law. At the same time, GOP leaders have warned the White House against carving out any special deal for unions.

“We will do whatever is within our power to ensure that the administration does not once again provide a special exemption to unions at the expense of American taxpayers,” Michigan Rep. Dave Camp and Utah Sen. Orrin Hatch wrote in a letter this week to Treasury Secretary Jack Lew. Camp is chairman of the House Ways and Means Committee and Hatch is top Republican on the Senate Finance Committee.

http://www.usnews.com/news/politics/articles/2013/09/11/afl-cio-steps-up-pressure-for-health-law-changes

Michael Hiltzik: To fix health law, go single-payer

Health law's ailments can be cured by single-payer system

By Michael Hiltzik
Los Angeles Times, September 10, 2013

All the shortcomings of the healthcare restructuring result from the decision to leave it in the hands of private insurers.

With the Oct. 1 rollout of a major facet of the Affordable Care Act on the horizon, you’ll be hearing a lot about the glitches, loopholes and shortcomings of this most important restructuring of America’s healthcare system in our lifetimes. Here are a couple of things to keep in mind:

First, the vast majority of these issues result from one crucial compromise made in the drafting of the 2010 law, ostensibly to ease its passage through Congress. That was to leave the system in the hands of private health insurance companies.

Second, there’s an obvious way to correct this flaw: The country should progress on to a single-payer system.

The idea that the ACA is a logical precursor to single-payer, in which the government would be the source of all medical reimbursement, has been gaining traction as key thresholds for healthcare reform approach. The biggest milestone is the Oct. 1 launch of open enrollment for the health insurance exchanges that will offer individual insurance starting Jan. 1.

Last month, Senate Majority Leader Harry Reid made that point in a Nevada news broadcast, calling the ACA “a step in the right direction” but adding that the U.S. would have to “work our way past” private insurance-based healthcare. “We’re far from having something that’s going to work forever,” he said.

“There isn’t a popular groundswell yet” for a single-payer plan “because most people haven’t seen the ACA at work in detail yet,” says David Himmelstein, a professor of public health at the City University of New York and co-founder of Physicians for a National Health Program, the leading advocacy group for single-payer healthcare. But he anticipates that discontent will start in October “and accelerate through the winter.”

Among the law’s shortcomings, he says, are the lack of effective provisions to control healthcare costs and insurance premiums. Premium regulation remains in the hands of the states, and many don’t have strong regulatory oversight of health insurance. In California, health insurance premiums are exempt from prior approval by the insurance commissioner, unlike home and auto insurance. (An initiative to remove the exemption will appear on the November 2014 ballot.)

That’s not to say that the ACA won’t make health insurance more affordable and accessible to millions of Americans now excluded from the market. Published exchange premiums in 18 states have generally come in below expectations, and the federal subsidies available to most buyers will make them cheaper still.

In some cases the premiums may be higher than those of plans on the market now. But because of exclusions for preexisting conditions — which will no longer be legal — they’re actually unavailable at any price to people who will have no trouble qualifying for the exchange plans.

The ACA’s critics observe that a plurality of Americans still view the ACA unfavorably (43%, according to an opinion poll released in June by the Kaiser Family Foundation). They rarely acknowledge, however, that nearly 1 in 5 of those critics think the law doesn’t go far enough — that is, further toward single-payer.

In its earliest incarnation, the Affordable Care Act included a prototype government single-payer provision — the “public option,” a government-sponsored plan to compete with commercial insurers in the exchanges. The public option was deleted at the insurance industry’s insistence.

But the U.S. does offer a healthcare program that resembles single-payer. It’s Medicare, the broadly popular health plan that covers all Americans over 65. Medicare’s administrative costs are only about 2%, and its size gives it the clout to extract large discounts from doctors and hospitals. That’s why one oft-proposed version of single-payer is “Medicare for all” — simply expand its coverage beyond the 65-plus.

Canada’s single-payer system is another model. It’s popular and efficient and costs about one-third of America’s system to administer. Don’t believe the myths purveyed about Canada’s healthcare by the U.S. insurance industry’s minions.

As health economist Aaron Carroll has documented, Canadian patients and doctors are satisfied with the program. As for the contention that it “rations” care, he points out that care in the U.S. is rationed by cost: one-third of adult Americans surveyed by the Commonwealth Fund in 2010 said they had put off important treatment because of the cost. In Canada, the figure was 15%.

There’s little question that taking private insurers out of the American healthcare system would save hundreds of billions of dollars a year. Dozens of studies of federal and state single-payer proposals have found that single-payer plans could provide universal coverage — not even the ACA does that — and still save money.

Estimates of the administrative costs of commercial health insurers exceed 10%. That doesn’t include the costs to doctors and hospitals of maintaining billing staffs to deal with insurers and keep all their rules and peculiarities straight, or the time lost to individuals and their employers of navigating this unnecessarily byzantine system.

Add those, and the overall administrative costs embedded in the U.S. healthcare system come to 31% of all spending, according to a 2003 article co-written by Himmelstein for the New England Journal of Medicine. Administrative and clerical workers accounted for nearly 44% of all employees in doctors’ offices, they calculated.

What do Americans receive in return for all this overhead? Practically nothing. The insurance industry says its role is to hold down costs by negotiating for preferential fees from doctors and hospitals and trolling for abuses, but the truth is they’re totally ineffective at cost control.

Just last year I reported on an admission by Aetna and United Healthcare, two of our biggest insurers, that they had been snookered to the tune of $60 million by one chain of small surgical clinics in Northern California. That happened because the insurers didn’t hire enough staff to give the claims from those clinics decent scrutiny — in other words, their administrative costs, high as they were, didn’t buy adequate oversight.

The result, to cite just one example, was that United paid the chain more than $97,000 for a kidney stone operation that it usually covers for $6,851.

“Private insurance is a parasite in the system,” says Arnold S. Relman, the former editor of the New England Journal of Medicine and an advocate of healthcare reform. “It adds nothing of value commensurate with its cost.”

Relman believes that fixing the healthcare system will require more than single-payer. The delivery of care needs to be reorganized by promoting the formation of more “accountable care organizations” — medium- and large-scale group practices with hospital affiliates whose physicians would be salaried to discourage the overuse fostered by the fee-for-service system.

What’s really needed is political will. It would help if big companies, which grouse incessantly about the rising costs of covering their employees, would throw their weight behind a system that would relieve them of that burden.

The forces of opposition won’t l
ie down; the insurance industry won’t give up its central role in the healthcare system without a costly and bruising fight, as it showed in Congress and in numerous states, including California, where single-payer plans were on the table.

“It’s going to be a slow and painful process,” Relman says. “But sooner or later we’ll have to turn to single-payer. It’s the only logical solution.”

http://www.latimes.com/business/la-fi-hiltzik-20130911,0,2211922.column

Comment:

By Don McCanne, M.D.

This is an article that you should share with your friends and others who may not have an adequate understanding of single payer. If this kindles an interest in them, which it certainly should, then let them know that they can learn more by accessing the website of Physicians for a National Health Program at www.pnhp.org.

My gosh, who wouldn’t want a lifetime of guaranteed, affordable health care, free of the intrusions and inherent waste of the private insurance industry?

A single-payer system makes economic sense

By Sen. Bernie Sanders
The Hill, Sept. 10, 2013

Americans spend about twice as much per capita on healthcare as almost any other developed nation, but our outcomes are not as good as others that spend much less. We can do better. We must do better.

Today, some 50 million Americans lack health insurance. Many others delay going to the doctor because of high deductibles and unaffordable copayments. While the number of uninsured Americans will go down with the implementation of the Affordable Care Act, widely known as ObamaCare, tens of millions of Americans will remain uninsured.

The goal of an effective healthcare system is to do everything possible to enable people to live long and healthy lives. Sadly, the American system fails to do that and falls behind many other countries. While we devote 18 percent of our gross domestic product to healthcare, we rank 33rd in life expectancy and 34th in infant mortality, and trail in many other health outcomes. A Harvard University study indicated that, incredibly, some 45,000 Americans die needlessly each year because they do not get to a doctor in time.

I start my approach to healthcare from a very basic premise: healthcare is a right, not a privilege. Unfortunately, uniquely among major nations, that statement is not true for the United States, where access to healthcare depends on how much money you have and what your employer is willing to provide.

It is simply unconscionable that the most advanced nation in the world has so many people who lack health insurance. It makes no sense that millions more are one diagnosis or car accident away from financial disaster. And, despite the trillions of dollars we spend on healthcare, the disparity in the quality of care between the rich and everyone else grows wider.

Our system doesn’t make economic sense, and it certainly doesn’t make moral sense. In a civilized, democratic society, every man, woman and child must be able to get the medical care they need regardless of income.

It is incomprehensible that drug companies still get away with charging Americans twice as much — or more — than citizens of Canada or Europe for the exact same drugs manufactured by the exact same companies. It is an outrage that insurers still want to hike premiums by as much as 60 percent a year on individual policyholders.

It boggles the mind that approximately 30 percent of every healthcare dollar spent in the United States goes to administrative costs rather than to delivering care. Taiwan, for example, spends only a little over 6 percent of its GDP on healthcare, while achieving better health outcomes on some key indicators than we do. The reason, of course, is that they spend a fraction of what we do on administrative costs.

If our goal is to provide high-quality healthcare in a cost-effective way, what should we be doing?

Clearly, we must move toward a single-payer system.

The health insurance lobby and other opponents of single-payer care make it sound scary. It’s not. In fact, a large-scale single-payer system already exists in the United States. It’s called Medicare. People enrolled in the system give it high marks. More importantly, it has succeeded in providing near-universal coverage to Americans over the age of 65.

Establishing a single-payer system will mean peace of mind for all Americans. When health insurance is no longer tied to employment, people will not fear losing both their job and their family’s access to healthcare. Millions of Americans won’t have to stay in jobs they don’t like because their family needs healthcare. Entrepreneurs and small businesses will be free to develop their business plans without worrying about the cost and complexity of providing healthcare for themselves and their employees.

For these reasons and more, Rep. Jim McDermott (D-Wash.) and I have introduced the American Health Security Act, which would guarantee healthcare as a human right and provide every U.S. citizen and permanent resident with healthcare coverage and services through a state-administered, single-payer program.

I am very proud that my home state of Vermont is now taking big steps to lead the nation in healthcare by moving forward on a plan to establish a single-payer healthcare system that puts the interests of patients over corporate profits. The American Health Security Act would make sure every state does the same.

The goal of real healthcare reform must be high-quality, universal coverage in a cost-effective way. We must ensure, to as great a degree as possible, that the money we put into health coverage goes to the delivery of healthcare, not to paper-pushing, astronomical profits and lining CEOs’ pockets.

Sanders, I-Vt., is the junior senator from Vermont, serving since 2007. He sits on the Environment and Public Works; the Energy and Natural Resources, the Health, Education, Labor and Pensions; and the Budget; and the Veterans’ Affairs committees, as well as the Joint Economic Committee.

http://thehill.com/special-reports-archive/1549-healthcare-september-2013-/321477-a-single-payer-system-makes-economic-sense#ixzz2ebEei2sQ

PNHP note: see also Sen. Sanders’ op-ed in Sept. 30 edition of The Guardian (U.K.) titled “A single-payer system, like Medicare, is the cure for America’s ailing healthcare.”

Health law's ailments can be cured by single-payer system

All the shortcomings of the healthcare restructuring result from the decision to leave it in the hands of private insurers

By Michael Hiltzik
Los Angeles Times, Sept. 10, 2013

With the Oct. 1 rollout of a major facet of the Affordable Care Act on the horizon, you’ll be hearing a lot about the glitches, loopholes and shortcomings of this most important restructuring of America’s healthcare system in our lifetimes. Here are a couple of things to keep in mind:

First, the vast majority of these issues result from one crucial compromise made in the drafting of the 2010 law, ostensibly to ease its passage through Congress. That was to leave the system in the hands of private health insurance companies.

Second, there’s an obvious way to correct this flaw: The country should progress on to a single-payer system.

The idea that the ACA is a logical precursor to single-payer, in which the government would be the source of all medical reimbursement, has been gaining traction as key thresholds for healthcare reform approach. The biggest milestone is the Oct. 1 launch of open enrollment for the health insurance exchanges that will offer individual insurance starting Jan. 1.

Last month, Senate Majority Leader Harry Reid made that point in a Nevada news broadcast, calling the ACA “a step in the right direction” but adding that the U.S. would have to “work our way past” private insurance-based healthcare. “We’re far from having something that’s going to work forever,” he said.

“There isn’t a popular groundswell yet” for a single-payer plan “because most people haven’t seen the ACA at work in detail yet,” says David Himmelstein, a professor of public health at the City University of New York and co-founder of Physicians for a National Health Program, the leading advocacy group for single-payer healthcare. But he anticipates that discontent will start in October “and accelerate through the winter.”

Among the law’s shortcomings, he says, are the lack of effective provisions to control healthcare costs and insurance premiums. Premium regulation remains in the hands of the states, and many don’t have strong regulatory oversight of health insurance. In California, health insurance premiums are exempt from prior approval by the insurance commissioner, unlike home and auto insurance. (An initiative to remove the exemption will appear on the November 2014 ballot.)

That’s not to say that the ACA won’t make health insurance more affordable and accessible to millions of Americans now excluded from the market. Published exchange premiums in 18 states have generally come in below expectations, and the federal subsidies available to most buyers will make them cheaper still.

In some cases the premiums may be higher than those of plans on the market now. But because of exclusions for preexisting conditions — which will no longer be legal — they’re actually unavailable at any price to people who will have no trouble qualifying for the exchange plans.

The ACA’s critics observe that a plurality of Americans still view the ACA unfavorably (43%, according to an opinion poll released in June by the Kaiser Family Foundation). They rarely acknowledge, however, that nearly 1 in 5 of those critics think the law doesn’t go far enough — that is, further toward single-payer.

In its earliest incarnation, the Affordable Care Act included a prototype government single-payer provision — the “public option,” a government-sponsored plan to compete with commercial insurers in the exchanges. The public option was deleted at the insurance industry’s insistence.

But the U.S. does offer a healthcare program that resembles single-payer. It’s Medicare, the broadly popular health plan that covers all Americans over 65. Medicare’s administrative costs are only about 2%, and its size gives it the clout to extract large discounts from doctors and hospitals. That’s why one oft-proposed version of single-payer is “Medicare for all” — simply expand its coverage beyond the 65-plus.

Canada’s single-payer system is another model. It’s popular and efficient and costs about one-third of America’s system to administer. Don’t believe the myths purveyed about Canada’s healthcare by the U.S. insurance industry’s minions.

As health economist Aaron Carroll has documented, Canadian patients and doctors are satisfied with the program. As for the contention that it “rations” care, he points out that care in the U.S. is rationed by cost: one-third of adult Americans surveyed by the Commonwealth Fund in 2010 said they had put off important treatment because of the cost. In Canada, the figure was 15%.

There’s little question that taking private insurers out of the American healthcare system would save hundreds of billions of dollars a year. Dozens of studies of federal and state single-payer proposals have found that single-payer plans could provide universal coverage — not even the ACA does that — and still save money.

Estimates of the administrative costs of commercial health insurers exceed 10%. That doesn’t include the costs to doctors and hospitals of maintaining billing staffs to deal with insurers and keep all their rules and peculiarities straight, or the time lost to individuals and their employers of navigating this unnecessarily byzantine system.

Add those, and the overall administrative costs embedded in the U.S. healthcare system come to 31% of all spending, according to a 2003 article co-written by Himmelstein for the New England Journal of Medicine. Administrative and clerical workers accounted for nearly 44% of all employees in doctors’ offices, they calculated.

What do Americans receive in return for all this overhead? Practically nothing. The insurance industry says its role is to hold down costs by negotiating for preferential fees from doctors and hospitals and trolling for abuses, but the truth is they’re totally ineffective at cost control.

Just last year I reported on an admission by Aetna and United Healthcare, two of our biggest insurers, that they had been snookered to the tune of $60 million by one chain of small surgical clinics in Northern California. That happened because the insurers didn’t hire enough staff to give the claims from those clinics decent scrutiny — in other words, their administrative costs, high as they were, didn’t buy adequate oversight.

The result, to cite just one example, was that United paid the chain more than $97,000 for a kidney stone operation that it usually covers for $6,851.

“Private insurance is a parasite in the system,” says Arnold S. Relman, the former editor of the New England Journal of Medicine and an advocate of healthcare reform. “It adds nothing of value commensurate with its cost.”

Relman believes that fixing the healthcare system will require more than single-payer. The delivery of care needs to be reorganized by promoting the formation of more “accountable care organizations” — medium- and large-scale group practices with hospital affiliates whose physicians would be salaried to discourage the overuse fostered by the fee-for-service system.

What’s really needed is political will. It would help if big companies, which grouse incessantly about the rising costs of covering their employees, would throw their weight behind a system that would relieve them of that burden.

The forces of opposition won’t lie down; the in
surance industry won’t give up its central role in the healthcare system without a costly and bruising fight, as it showed in Congress and in numerous states, including California, where single-payer plans were on the table.

“It’s going to be a slow and painful process,” Relman says. “But sooner or later we’ll have to turn to single-payer. It’s the only logical solution.”

Michael Hiltzik’s column appears Sundays and Wednesdays. Reach him at mhiltzik@latimes.com.

http://www.latimes.com/business/la-fi-hiltzik-20130911,0,2211922.column