By Ralph Nader
Counterpunch, Sept. 27, 2013
Freshman Senator Ted Cruz (R-Texas), who somehow got through Princeton and Harvard Law School, is the best news the defaulting Democratic Party has had in years.
As the Texas bull in the Senate china shop, he has been making a majority of his Republican colleagues cringe with his bare-knuckle antics and language. His 21 hour talkathon on the Senate floor demanding the defunding of Obamacare made his Republican colleagues gasp. His Nazi appeasement analogies, and threats to shut down were especially embarrassing.
After listening to his lengthy rant on the Senate Floor on Tuesday and Wednesday, one comes away with two distinct impressions. Ted Cruz cannot resist inserting himself here, there and everywhere. And nothing is too trivial for Senator Talkathon. He likes White Castle hamburgers, he loves pancakes; he talked about what he liked to read as a little boy, where he’s travelled, what clothes he wears and other trivia.
You’d think he would have used his time to talk specifically about the suffering that uninsured people and their children are going through, especially in the Lone Star State. Or about what could replace Obamacare other than his repeated “free market” solution, which is to say the “pay or die” profiteering, tax-subsidized corporate system.
It was puzzling why he never mentioned that during his two days of talking, over two hundred Americans died, on average, because they couldn’t afford health insurance to get diagnoses and timely treatment. (A peer reviewed study by Harvard Medical School researchers estimated about 45,000 die annually for lack of affordable health insurance every year.)
The other reaction to Senator Cruz was that many of his more specific objections to Obamacare – its mind-numbing complexity, opposition by formerly supportive labor unions, and employers reacting by reducing worker hours below 30 hours a week to escape some of the law’s requirements – are well-taken and completely correctible by single-payer health insurance, as provided in Canada. Single-payer, or full Medicare for all, with free choice of physician and hospital has been the majority choice of Americans for decades. Even a majority of doctors and nurses favor it.
Single-payer’s advantage is that everybody is in, nobody is out. It is far more efficient, allows for better outcomes, saves lives, prevents injuries and illnesses, relieves people of severe anxieties and wasted time spent figuring out often fraud-ridden, inscrutable computerized bills and allows for the collection of pattern-detecting data to spot harmful trends.
For example, in Canada, full Medicare covers everyone at half the per capita cost that Americans pay even though 50 million Americans are still not covered. The U.S. per capita figure is almost $9,000 a year and over 17% of our total GDP. In Canada, administrative costs are much lower.
Symbolically, the single-payer legislation that passed in Canada over four decades ago was 13 pages long, compared to over two thousand pages for Obamacare.
Critics of Canada’s system charge it with delays for patients. For some elective procedures, provinces that were under-investing have experienced some delays until Ottawa raised its contributions. Canada spends just over 10% of its GDP on healthcare, by comparison.
But in the U.S. not being able to pay for treatment is the biggest problem. And in the U.S., who hasn’t heard of delays in various areas of the country due to lack of primary care physicians or other specialties? I have many friends and relatives in Canada who have not complained of delays for routine, essential or emergency treatments.
For those who prefer to believe hard-bitten businesspeople, Matt Miller, writing yesterday in The Washington Post, interviewed big business executives – David Beatty who ran the giant Weston Foods and Roger Martin long-time consultant to large U.S. companies in Canada. They were highly approving of the Canadian system and are baffled at the way the U.S. has twisted itself in such a wasteful, harmful and discriminatory system.
Mr. Beatty wondered why U.S. companies “‘want to be in the business of providing health care anyway’ (‘that’s a government function,’ he says simply).”
Mr. Martin, an avowed capitalist, who has experienced healthcare in the U.S. and Canada, according to Mr. Miller, called Canadian Medicare “incredibly hassle-free,” by comparison. (In Canada, single-payer means government insurance and private delivery of healthcare under cost controls). Now Dean of the business school at the University of Toronto, Mr. Martin told reporter Miller: “I literally have a hard time thinking of what would be better than a single-payer system.”
So why the U.S. is the only Western country without some version of a single-payer system?
Most concessionary Democrats, including Barack Obama and Hillary Clinton, have said in the past that they prefer single-payer, but that the corporate forces against it cannot be overcome. (They use phrases like “single-payer is not practical.”)
But with the Cruz crew in Congress going berserk against Obamacare, now is the time to press again for the far superior single-payer model. Or at least get single-payer into the public discussion. Unfortunately, even some of the major citizen groups organized for single-payer, behind H.R. 676, are keeping quiet, not wanting to undercut Obama and the Congressional Democrats.
Go to Single Payer Action and connect with the movement that does not play debilitating politics and seeks your engagement.
Ralph Nader is a consumer advocate, lawyer and author of “Only the Super-Rich Can Save Us!”
http://www.counterpunch.org/2013/09/27/people-want-full-medicare-for-all/
Where are our professional boundaries?
Crossing Boundaries—Violation or Obligation?
By Gordon D. Schiff, MD
JAMA, September 25, 2013
It is 5 pm on Friday afternoon. After 2 hours on the telephone trying (and failing) to get her insurance plan to pay for her medication refill, I reached into my pocket and handed the patient $30 so she could fill the prescription. It seemed both kinder and more honest than sending her away saying, “I’m sorry I can’t help you.” While I hardly expected a commendation for such a simple act of kindness, I was completely surprised to find myself being reprimanded for my “unprofessional boundary-crossing behavior” after the resident I was supervising shared this incident with the clinic directors. This allegation of an ethics violation was not only personally painful; it also raised important, controversial, and timely questions about appropriate professional roles.
Physicians must indeed respect certain boundaries. A growing literature and guidelines have admonished physicians and other health professionals to strictly respect boundaries to avoid improper expectations, dependency, legal liabilities, and confusion of personal and professional relationships. Most concerning were data documenting sexual relationships between physicians (often psychiatrists) and their patients.
However, some interpretations of these restrictions risk constructing a misguided model—one that discourages physicians from humanly caring for and about their patients. This new paradigm risks encouraging detached, arms-length, uncaring relationships. When do “boundaries” become barriers to meaningful caring relationships? And will such bounded thinking serve to rationalize abdication of our professional and personal responsibilities to humanely respond to patient suffering and underlying injustices?
While I had rarely paid for a patient’s medication as I did on that Friday afternoon, in this situation it seemed reasonable and appropriate. Various ethics and conflict of interest rules prohibiting physicians from having “financial relationships” with patients may be appropriate when it comes to physicians taking or soliciting money from patients. But what about the propriety of giving money to a needy patient in this particular situation? While other alternatives such as using a special fund might be preferable, when I found that no such fund existed at my hospital (and the drug insurance plan denied coverage due to a technical glitch in the patient’s enrollment), was it wrong to personally help a patient in such a moment of need?
Everything we do in medicine has risks. Whether prescribing a medication or performing surgery, we, in consultation with the patient and family, must weigh potential benefits and risks. When considering reaching out to help patients in need, possible adverse effects should be weighed against the benefits in that particular context and situation.
In weighing such risks, however, we need to be clear whose risks we are considering. Many of these risks are actually more risks to physicians, rather than to patients. Thus, those insisting on stricter boundaries need to rethink what they mean by “limits.” Who are those limits designed to protect? Are “limits” protecting the patient, or are they protecting us—protecting our time or even protecting our consciences, allowing us to avoid painful questions of inequality or taking needed moral action? While there is nothing inherently wrong with protecting caregivers against overwhelming time demands or burnout, let’s not pretend we are imposing limits for patients rather than our own best interests.
The American Medical Association’s Code of Medical Ethics states: “The practice of medicine … is fundamentally a moral activity that arises from the imperative to care for patients and to alleviate suffering. … The relationship between patient and physician is based on trust and gives rise to physicians’ ethical obligations to place patients’ welfare above their own self-interest … and to advocate for their patients’ welfare.” The type of caring relationships embodied in this statement, and the kindness I believe most patients and physicians yearn for, has been pejoratively dubbed “nostalgic professionalism.” This outmoded model of professionalism, it is argued, needs to be replaced by a more dispassionate business-like model where limitations and boundaries are more circumscribed and it is clear that we are not our patients’ friends, neighbors, or personal advocates for issues beyond their medical problems. Short of avoiding caring for poor patients entirely or not being part of the community in which our patients live and work (both unfortunately not rare), personal engagement with patients as people, not just as “clients” or “consumers,” is inevitable, and even desirable. For many of us (particularly primary care physicians), more than any P4P (pay-for-performance) financial incentives, our most fulfilling rewards and professional satisfactions come from having meaningful relationships with our patients, as well as our ability to broadly ameliorate their problems and suffering. Of course we have to make daily compromises with reality, especially the realities of suffering and hardships poor and underserved patients face—problems we obviously can’t personally cure. Nonetheless, we should try within the limitations of our time, resources, and abilities to help where we can.
The real danger of personal engagement is not that we further complicate already complicated relationships with our patients by doing too much. Rather it is that of tokenism—of doing too little and feeling satisfied and excused from addressing the social and economic injustices that underlie poor patients’ suffering. It is here we have to be mindful of the fundamental distinction between charity and solidarity. Yes, we need to be charitable in every way possible, but we also need to stand alongside our patients in striving for a fairer, more caring world. If physicians want to stand aloof, addressing only the biomedical problems, ignoring and seemingly indifferent to the social circumstances of our patients, then patient/relation-centered medical homes are likely to feel more like gated communities than places where people live and work together. Fortunately, the two strands of genuine “caring DNA” are closely intertwined. Collective advocacy for societal change and personal advocacy and helping of individual patients cross-fertilize and nourish each other. Minimizing barriers for professionals and patients working together for this shared agenda represents true patient-centered medical care.
http://jama.jamanetwork.com/article.aspx?articleid=1741827
Comment:
By Don McCanne, M.D. For my home office that I use for my health reform advocacy work, I had put away all of my credentials and hung on the wall only one item: The Oath of Hippocrates. Regarding today’s message, one sentence stands out: “Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and, further, from the seduction of females or males, of freemen and slaves.” Boundaries are as old as the profession. But what has happened with boundaries now that we seem to have transitioned from the profession of medicine to the business of medicine? “Care providers” are to turn to the clinic directors or whatever entity is representing the business to learn about redefined boundaries that are best for… the business? What about establishing boundaries between the healing arts professions and the financial accounting functions for health care that should be relegated to the virtual back office? How about allowing the health care professionals to revert to the traditional Hippocratic concepts of boundaries? In fact, instead of limiting boundary considerations strictly to the one-o n-one interaction between patients and professionals, shouldn’t we be exploring the boundaries that Gordon Schiff implies when he refers to “collective advocacy for societal change and personal advocacy and helping of individual patients”? If we were to use that collective advocacy for societal change to establish a single payer system, we could break down barriers, allowing us to come closer to achieving optimal care for all patients. As Schiff says, “Minimizing barriers for professionals and patients working together for this shared agenda represents true patient-centered medical care.” After reading Gordy Schiff’s commentary and seeing that his moral compass is set on the primacy of the patient, it should come as no surprise to readers that he has been very active in Physicians for a National Health Program, having served as its president. Thank goodness he understands as much as anyone where our professional boundaries should be. Sadly, the stewards of the new business world of medicine will never understand.
]]>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.”
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.
]]>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]
]]>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.
]]>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.
]]>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.
]]>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
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
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
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
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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