PNHP

Affordable Care Act's Achilles Heel? Blaming Patients, Not Profiteering

Affordable Care Act's Achilles Heel? Blaming Patients, Not Profiteering

By Karen Higgins, R.N.
Common Dreams, June 12, 2013

With the one-year anniversary of the Supreme Court ruling upholding the Affordable Care Act near, it’s time to ask if the decision to put the burden of cutting costs on patients, not corporate healthcare profiteering, is the fatal flaw in the plan.

The law’s tepid cost control measures targeted at healthcare spending that is gobbling up an increasing percentage of the economy and pricing more people than ever out of access to care have been widely viewed as the ACA’s biggest pitfall.

But from the outset, the Obama administration dismissed the most effective means to reduce costs by:

  • refusing to consider a single payer alternative that combines genuine universal coverage not based on ability to pay with global budgeting
  • rejecting a proposal to authorize the federal government to negotiate bulk purchasing (a concession to the drug companies), and
  • failing to regulate price gouging by hospitals, drug companies, insurers and other healthcare corporations.

Those fateful decisions left only one option for significant reduction of overall health expenditures – saving money in the delivery of care by shifting costs to those who use health services and discouraging them from getting care even if they have insurance.

Perhaps that’s not surprising given the decision to craft the ACA in concert with pharmaceutical, insurance, hospital, and Chamber of Commerce lobbyists, and, as recently reported, top Wall Street investment firms and hedge fund executives.

Here are several ways the ACA shifts the hardship of cost cutting to those who need care, and promotes delivery models that result in limiting care, even among those with health insurance.

1. What they’re not telling us about the exchanges

The ACA health exchanges are marketplaces set up to enable the uninsured who the law requires to buy private insurance or pay a financial penalty to choose among competing private insurance and qualify for a federal subsidy to cover some of the costs.

But premiums, deductibles, co-pays and other fees can run to thousands of dollars. Even in the cheapest plans buyers are expected to pay 40 percent of the cost. Subsides may not make these plans “affordable.”

Many younger, healthier people are likely to select the cheapest plan, one outside the exchange with fewer covered services, or just go without coverage entirely and pay the fine.

Further, small businesses can buy coverage for employees through the exchanges, but the premium and co-pay subsidies will not cover family dependents, a huge hole that will leave many uncovered.

Insurers offering lower rates the first year in hopes of acquiring many new customers are likely to raise rates later, as has occurred in Massachusetts, the model for the ACA. A recent study in the journal Health Affairs found that 38 percent of families buying plans through the Massachusetts exchange reported a financial burden and 45 percent said costs were higher than they had expected.

2. The high cost of taxing health benefits

For the first time, the law will tax health benefits beginning in 2018 through the misnamed “Cadillac tax” a 40 percent excise tax on comprehensive health plans. The inevitable result will be fewer employers offering good health benefits, and far more people pushed into skeletal, high deductible plans with far less coverage and much higher out-of-pocket costs. The New York Times just reported that 17 percent of employers this year are stepping up cost shifting five years before the tax goes into effect.

3. An incentive to employers to cut coverage or full-time jobs

Under the ACA employers with 50 workers or more must offer coverage to full time employees or pay a fine, but not to part-timers. Nurses and other workers are increasingly in battles with employers who are demanding elimination of coverage for part time employees, citing the ACA as their pretext. Regal Entertainment, Papa John’s and other companies are reducing workers’ hours to under 30 per week.

4. The wellness scam

“Wellness” programs that enable businesses to transfer more healthcare costs to workers with “unhealthy” factors like smoking or high blood pressure or cholesterol levels are rapidly spreading, actively encouraged by the ACA which offers premium discounts to participating employees. However, health disorders are as likely to derive from chronic or genetic conditions as “life style choices” and economic factors which have a disproportionate impact on the poor.

The cost reductions also fall far short of the hype. The federal government apparently buried a report it mandated for the ACA from the Rand Corporation on wellness programs which showed the overall savings are, at best, modest.

The programs make insurance unaffordable for some workers, and “keep the sickest workers from affording the care they need,” said Alan Balch, vice president of the Preventive Health Partnership, an alliance of the American Cancer Society, the American Diabetes Association, and the American Heart Association.

5. Self-rationing on the rise

With its weak controls on pricing practices by the insurers and hospitals, and encouraging cost shifting and high deductible plans, the ACA provides no relief for those who postpone needed care because of the high price tag.

A survey by the Centers for Disease Control and Prevention just released in early June found that 20 percent of Americans, or 54.2 million people in 2011 said their families had difficulty paying for health care services including physician visits, hospital procedures and medications within the prior 12 months.

Among the effects, people delay getting care include less containment for the spread of infectious diseases and more people ending up in emergency rooms. ER visits as the point of entry for patients to needed healthcare have been on a big upswing, a worrisome trend for the increased pain and suffering for patients and the overall health expenditures.

6. New barriers to care

If Massachusetts is the political model of the ACA, the industry model is Kaiser Permanente by combining the roles of insurance company and medical provider with its network of hospitals and clinics.

As ACA implementation nears, Kaiser has stepped up practices once associated with the worst abuses of HMOs. These include delaying medical appointments, restricting hospital admissions, and rapid discharge of patients from the hospital care to other settings.

These include sending people home where the care burden is placed entirely on family members, or to outpatient facilities or nursing homes that have fewer regulations and f
ewer, typically lesser skilled, lesser paid staff where the patients receive less care than in hospitals.

Other industry giants hope to follow this path, enrolling new members who are required to buy insurance, while they are more directly able to control their expenditures for care and can more easily slash spending. The ACA encourages care cutting practices through several mechanisms, including financial penalties for hospital re-admissions, an incentive to keep people out of the hospital, and rewarding providers who divert patients to outpatient clinics.

7. A tale of the 31 million

More than 48 million people are currently uninsured. A new study in Health Affairs estimates that even after full ACA implementation up to 31 million of those will still be without coverage.

That starts with the 14 states and counting who have rejected the expansion of Medicaid, the single most important provision in the ACA for expanding healthcare access, (with the help of the Supreme Court ruling gutting the federal sanction for opting out).  Others will lose their employer-sponsored coverage due to the ACA taxes on employers, the provision excluding dependent coverage for small businesses that enter the health exchanges, and all of those who will still find insurance far too costly to buy, especially in a recession that has never ended for millions of people.

Political posturing by those on the right opposed to any reform of our broken healthcare system and the bunker mentality of liberal allies of the Obama administration who for their own partisan reasons tend to gloss over serious flaws in the “legacy” law of the Obama years have obscured the reality that our healthcare crisis is far from over and in desperate need of more systemic overhaul.

Studies this year alone show the U.S. ranks last among 17 major industrial nations in life expectancy,  but is ahead of the others in first-day infant mortality rates. That will not end with the ACA.

Nurses will continue to make the case for joining the community of nations with a genuinely universal national or single payer healthcare system based on individual patient need, not corporate profits.

Karen Higgins is a registered nurse and co-president of National Nurses United.

Unraveling the Crisis in American Healthcare

By Joie Meissner, N.D.
Vital News (Seattle), Spring 2013

As N.D.s most of us are sole proprietors or in small group practices where we may feel cut off from the larger healthcare system. Yet what happens in the reform of our larger healthcare system will have an enormous impact not only on our practices and our patients, but also on our friends, families and on our own lives.

Ours is the most expensive healthcare system on earth. We spend billions more on healthcare than other industrialized nations yet we are the only industrialized country in the world that does not provide some type of universal health coverage to its people. No one dies due to lack of healthcare access in other industrialized countries, and yet a study done by Harvard Medical School and Cambridge Health Alliance found that nearly 45,000 deaths occur annually in our country due to lack of healthcare access. According to this study, there is a 40% increased risk of death in uninsured American adults.[1]

We spent $2.8 trillion in 2012 on healthcare. This is $750 billion or 27% more than the per capita costs of healthcare in other developed countries, yet WHO ranks our healthcare system’s performance 37th in the world.[2,3]

Despite its high cost, 50.7 million Americans do not have adequate access to healthcare.[4] Public outcry over the state of healthcare has already led to the attempt at nationwide healthcare reform known as Obamacare. The high cost of the multi-payer system is at the heart of our unsustainable healthcare costs, costs that can be predicted to lead to even more dramatic changes in the healthcare system in the years following full implementation of Obamacare.

The anticipated healthcare changes will affect all sectors, including naturopathic physicians, their patients and the treatments they often recommend. Understanding the shape that future reforms will likely take and our potential role in these reforms can help our profession and our patients have greater control over our destiny.

In order to understand the reforms necessary to solve our healthcare crisis, we first need to understand that unsustainable costs are occurring due to the lack of governmental and industry price controls and due to the expanded number of insurance plans and carriers, which respectively lead to skyrocketing hospital charges, and pharmaceutical prices as well as and excessive administrative costs in our current system.

Obscene Overpricing

Steven Brill, writing in Time magazine, uncovered the fact that hospitals set their fees for goods and services based on hugely inflated “chargemaster” pricing schemes that bear no relationship to costs, but which allow “non-profit” and for-profit hospitals to maintain plush surplus revenue and astronomical executive salaries.

Brill found that drug prices are so inflated under the current healthcare system that if pharmaceutical prices were controlled to the same degree that they are in other developed countries, we would save more than $90 billion annually and $25 billion/year in Medicare/tax payer savings.[5]

The Private Insurance System Jacks Up the Price of Healthcare

Between 25-30% of all US healthcare dollars go to pay for administration.[6] Because of the substantially higher administrative cost of the private insurance carriers as compared to non-privatized counterparts like Medicare or Medicaid and because of the logistical inefficiency inherent in having thousands of insurance plans and carriers, the private insurance system inevitably jacks up the price of healthcare.

According to healthcare economist Gerald Friedman, Ph.D., the inefficiencies in our healthcare system which lead to its unsustainable price tag are allowed to exist because the prevailing economic view sees the free-market as the remedy to healthcare overspending. He explains that the for-profit system economic framework that views healthcare spending as waste is why we have problems ensuring that all our citizens have access to healthcare.[8]

The For-Profit System; Cherry Picking and Lemon Dropping

Despite the fact that other economists like Paul Krugman, Ph.D., Nobel Prize-winning economist Kenneth Arrow, Ph.D., and Friedman himself would strongly disagree, Friedman asserts that the prevailing economic viewpoint holds that governmental health insurance promotes over-utilization of healthcare which, in turn, promotes wasted spending. He further asserts that this viewpoint leads the insurance carriers to engage in practices that results in lack of coverage for all Americans. He explains that profit in health insurance comes from a practice called ‘cherry picking’ and ‘lemon dropping’ in which insurance providers discourage the sickest patients, who incur 70% of healthcare costs, from being able to obtain insurance while providing membership incentives to the healthiest patients who incur only 10% of these costs.[9] The profit motive behind the mainstream practice of lemon dropping is the impetus for many of the rules and clauses in insurance policies such as the pre-existing condition clauses that denied many Americans medical insurance coverage.

Sixty-two percent of all American bankruptcies are due to unpaid medical bills; 78% of these were insured at the time.[10] Obamacare’s injunction against coverage caps was designed to prevent the growing number of medical bankruptcies. However, Obamacare does not prevent coverage caps from causing health insurance premiums to rise, thus allowing the high numbers of medical bankruptcies to continue.

Obamacare’s Exchange Benefit Plans Are Underinsurance Plans

Insurance policies sold on the exchanges created by Obamacare are only required to have actuarial values (AVs) of 60% (Bronze plan), 70% (Silver plan), 80% (Gold plan), and 90% (Platinum plan). This means that the actual health care expenses that a policy pays, on average, will be 60%, 70% and 80% respectively.[11] For example, the purchaser of a bronze level plan can expect to pay 40% of actual medical bills even after paying the premiums. Due to their lower cost, AVs of 60% and 70% are likely to be the predominant plans chosen and these plans are highly inadequate coverage for any serious illness such as cancer.

Not everyone who needs healthcare will qualify for healthcare subsidies under Obamacare. Although Obamacare enacts laws to address the problem of lack of healthcare access, the Congressional Budget Office and Joint Committee on Taxation estimate that at least through 2022, 30 million of the 50.7 million Americans who currently have no insurance will still have no insurance after Obamacare has been implemented. Sources project an increased number of Americans will have very inadequate insurance, leaving them bankrupt should they become seriously ill.[12,13]

Based on the need to maintain profits, the cost of insuring those who need it most will lead insurer’s to inflate overall premiums and cost sharing expenses. Even those who qualify for Obamacare’s expanded Medicaid coverage will still have some cost sharing expenses that for them may pose a financial hardship and the increased cost sharing expenses for those who do not qualify for subsidies especially for those with serious illnesses (the lemons) may lead to bankruptcies and/or avoidance of medical care they simply cannot afford.[14]

Sadly, these sorts of policies allowed under Obamacare will continue to result in extensive numbers of American medical bankruptcies and will not prevent insurers from shifting the costs of covering the sickest patients onto enrollees in the form of markedly increased premiums and cost sharing expenses (deductibles, coinsurance and co-pays).

Obamacare Isn’t Enough

The reasons why additional reforms beyond Obamacare are necessary is because Obamacare fails to ensure that
everyone is adequately covered, that those who are covered can actually afford to use healthcare services, and because Obamacare does not end the epidemic of medical bankruptcies or control the bloated costs that are bankrupting the American healthcare system.

To a large extent, Obamacare fails to control the unsustainable cost of American healthcare because it fails to use the government’s substantial purchasing power to bargain down prices for drugs and other medical goods and services and it fails to streamline excess administrative cost inherent in the private insurance system but instead it increases both the patient pool and the tax subsidies to the multi-payer system, the system that the prevailing economic paradigm lauds as the free-market solution.[15] This is because it does not address the basic precept held by prevailing healthcare economists and policy makers, namely the idea that the free-market can remedy all the nation’s healthcare woes.

Healthcare as Commodity or a Right?

Brill and others including healthcare economists like Kenneth Arrow, Paul Krugman and Gerald Friedman maintain that the very nature of healthcare being essential to life itself abrogates its ability to exist as a free-market commodity. They hold that because healthcare itself cannot obey the laws of supply and demand, it cannot be treated like a for-profit commodity. Common sense tells us that when we are having a heart attack, we are not going to be in any position to bargain over the cost of lab tests. Because of this, Brill insists that the healthcare market will always be a ‘seller’s’ market’ with the seller setting the price as far into orbit as our US promissory notes will stretch.[16]

The effects that the traditional “free”-market paradigm will continue to have on our ailing healthcare system are anticipated to lead to another public outcry for more healthcare reform. We are realizing that healthcare is too essential and too expensive to be treated like a commodity. The next outcry will be for something that goes beyond the for-profit-mindset: It will herald that healthcare is a human right, best supported by the implementation of a single-payer healthcare system.

We are the only industrialized country in the world that does not provide some type of universal health coverage to its people. A universal healthcare system such as single-payer is our long awaited reform that most other developed countries have already implemented.

Movement in the direction of a single-payer healthcare system has begun in our country. Vermont’s version of single-payer legislation was already passed by both houses, and that state is currently applying for a waiver allowable under Obamacare so that it can implement a state single-payer system. Most states have single-payer bills and there is a national bill called H.R. 676 that currently has 41 cosponsors.[17] The effects of the single-payer reform regarding how we practice medicine and how we are reimbursed will be substantial. As physicians we need to understand how we will be affected and also how we can be a part of the single-payer system that is in the future of American healthcare.

Special Thanks to Sherry Weinberg, MD, Don Bunger, Don Mitchell, MD, Jim Squire, MD, Marti Schmidt, JD, David McLanahan, MD, Kathleen Myers, DDS, Kathleen Randall, MA, and Helen Thorsen CDP.

Click here for references. This is the first of a three-part series.

Dr. Meissner is a member of the Washington Association of Naturopathic Physicians and a primary care physician in Seattle’s Capital Hill area. Currently on the board of directors Physicians for a National Healthcare Program of Western Washington, her personal interests include food safety, securing a universal healthcare system and clinical research on multiple sclerosis at Bastyr University.

http://www.wanpnews.com/2013/04/16/unraveling-the-crisis-in-american-healthcare-part-1-of-a-3-part-series/

Are physicians driven by profits or fear?

Appropriate Use of Myocardial Perfusion Imaging in a Veteran Population: Profit Motives and Professional Liability Concerns

By David E. Winchester, MD, MS; Ryan Meral, BA; Scott Ryals, MD; Rebecca J. Beyth, MD, MSc; Leslee J. Shaw, PhD
JAMA Internal Medicine, June 10, 2013

Myocardial perfusion imaging (MPI) is performed millions of times annually in the United States to assess patients for coronary ischemia. Some have expressed concern that MPI is being used inappropriately, possibly because of self-referral profit motives and professional liability fears. To inform clinicians about situations in which patients are likely to benefit from MPI testing, appropriate use criteria (AUCs) for MPI were developed, last revised in 2009. Prior investigations have applied AUCs to describe the magnitude and patterns of inappropriate testing. Rates of inappropriate testing have ranged from 7% to 24%. We hypothesized that the single-payer environment of the Veterans Affairs (VA) health system, which eliminates self-referral profit motive and limits liability concern, will result in less inappropriate use of MPI.

Results

For all but 4 patients (1%), an indication from the 2009 AUCs could be identified. Study indications were 78% (n = 259) appropriate, 13% (n = 42) inappropriate, and 8% (n = 27) uncertain. The most common inappropriate MPI indications included testing of patients with low pretest probability who could have undergone treadmill electrocardiogram testing (7 patients [16.7% of total inappropriate MPI]) and asymptomatic patients with low coronary heart disease risk (7 patients [16.7% of total inappropriate MPI]).

Discussion

In this retrospective cross-sectional investigation regarding the appropriate use of MPI in a VA health care setting, we observed that a substantial portion of MPI tests were ordered for inappropriate indications. The findings are in contrast to our initial hypothesis but are similar to those of another VA-based investigation, the results of which were published during our investigation.

Our hypothesis was based on unique characteristics of the VA patient care environment. First, no self-referral or profit motives exist. Second, whereas the Federal Tort Claims Act permits medical malpractice lawsuits against federally employed physicians, the substantial majority of claims are resolved through administrative processes.

We did not detect a significant reduction in inappropriate testing in the VA environment, which suggests a lesser role of defensive medicine and self-referral in the inappropriate use of MPI.

Reasons for the observed patterns of ordering MPI are unclear. Conceivably, commonalities in medical training, independent of postgraduate practice environment, could contribute to an exaggerated perception of benefit of MPI in asymptomatic patients and those at low risk of coronary heart disease.

http://archinte.jamanetwork.com/article.aspx?articleid=1696189

Comment:

By Don McCanne, M.D.

This study has two important lessons for health reform advocates – one obvious and the other not so obvious.

The obvious lesson is that “excessive” medical interventions occur even in the absence of greed or fear. In this study, since VA physicians receive no additional income with an increased volume of services – in this case the ordering of myocardial perfusion imaging – the tests that were inappropriate were not done to increase personal income. Also, since most VA malpractice claims are resolved administratively, there is a much lower fear factor that would cause physicians to order tests to reduce the risk of liability lawsuits.

This is good news in the respect that we can dismiss any nefarious motives on the part of most physicians who are recommending interventions that seem to be excessive. Policy corrections should be directed instead to the more important causes of excessive medical interventions.

This leads to the more subtle lesson of this study. What retrospectively is considered to be inappropriate medical management was done by physicians who, at the time, thought that they were doing the right thing for the patient. The policy recommendation that should follow is that we should continue to identify best practices and continue to educate our health professionals on just what those best practices are.

We are already doing this in the form of medical research and continuing medical education. The process can be enhanced by greater reliance on organizations such NICE, Cochrane, and several others. If we want to reduce unnecessary care, our resources should be directed to these efforts rather than being wasted on administrative excesses such as accountable care organizations that rely on feeble measurements that are used to distribute nominal rewards and punishments – not really much of a motivator but more of an insult for dedicated physicians.

Physicians appreciate receiving good information and will use that in their practices. Let’s make better use our public agencies, such as the NIH, that are dedicated to the health of patients, rather than private agencies that jerk our health care dollars around to conform to their business models.

Single payer really would shift the motive from “money first” to “patients and their health first.”

The Affordable Care Act and single payer

By Alec Pruchnicki, M.D.
WestView News (New York City), June 2013

Part 1: How Does the Affordable Care Act Affect Us?

The Affordable Care Act (ACA), sometimes referred to as Obamacare, will affect us. It is a complex area of law with many pieces. In 2010, it passed Congress with many compromises, and mostly survived a Supreme Court challenge. Here are a few of its major provisions.

From the start, insurers can no longer cancel coverage if you become sick; there will be no lifetime limits on total cost of coverage, and more preventive care will be covered. Young adults (up to 26 years of age) can usually stay on their parents plan, and denials for pre-existing conditions will start to decrease. Drug costs under Medicare will start to decrease in addition to reimbursements for Medicare Advantage plans (Medicare MOs). A significant new provision requires insurance companies to spend at least 85 percent of their budgets on medical care. If they do not, they must send a refund to their enrollees.

By 2014, all denials for pre-existing conditions are to be eliminated. Medicaid coverage will be expanded for millions of individuals and essential benefits will define minimal coverage for policies. Individuals will be required to have coverage which could be purchased through newly established health care exchanges, with subsidies for those with low income. Persons who do not purchase or have their own insurance will pay a penalty that will eventually rise to $695 for individuals and $2,085 for families, or 2.5 percent of income. Employers with 50 or more workers will be required to provide coverage, or face a tax penalty. Employers with less than 50 workers will not be required to provide coverage, but subsidies will exist to encourage them to do so.

Although the ACA establishes many reforms in the area of health care and is one of the major pieces of legislation in this field since the 1960s when Medicare and Medicaid were established, there are significant weaknesses. Progressive politicians tried to include a “public option” in the bill, or at least a possible buy-in to Medicare or Medicaid. However, these were never included and now much of the increased coverage will be channeled through private plans, both profit and non-profit, rather than any government program. This will expand, and sometimes subsidize, the private sector often with government enforcement or government funds.

The exchanges set up within the states are still being established and their goal of significantly decreasing costs and widening consumer options has yet to be determined. Furthermore, since the Medicaid reforms were not supported by the Supreme Court decision, many states have refused to implement them. Whether or not these refusals persist and states continue to reject substantial federal funds also remains to be seen.

Possibly the greatest problem with the ACA is that only half of those without medical insurance will be covered by the provisions of the act, even if more states agree to participate in Medicaid reform, and as many as 31 million people will still not have coverage. Supporters of the act point to Massachusetts where a similar plan led to more coverage than projected, while critics of the act also point to Massachusetts for failure to adequately control costs, either on a state-wide or individual basis, and the coverage that does exist is often insufficient and leads to under-insurance.

As this complex act is implemented, its strengths and weaknesses will become more apparent and the need for further health care reform may arise at some time in the future, possibly very soon.

http://westviewnews.org/2013/06/how-does-the-affordable-care-act-affect-us/

Part 2: What Is Single-Payer Health Care?

Single-payer national health insurance is a system in which one entity (usually a government agency) organizes the financing of health care, leaving the delivery of care mostly in private hands.

All residents would be automatically enrolled in the program at birth and be covered for life. Everyone would have equal access to comprehensive, high- quality health care, with no premiums, co-pays or deductibles.

Financed by a system of progressive taxation, the program would pay for all necessary medical expenses, including doctor, hospital, preventive, long-term care, mental health, reproductive health care, dental, vision, prescription drug, and medical supply costs. Patients would have free choice of doctor and hospital. People would no longer be afraid of unaffordable medical bills and would never be bankrupted by medical expenses.

In some single-payer systems, such as in Canada, hospitals receive lump-sum government payments rather than depend on piecemeal billing and negotiations with insurance companies. Had we such a system, it’s likely we would have prevented the closing of St. Vincent’s Hospital and many other hospitals around New York City.

There is a bill in Congress, the Expanded and Improved Medicare for All Act, H.R.676, that would establish such a program. Polls show that its principles have solid majority support, including among physicians and nurses. The bill has been endorsed by many unions, civic, and faith based organizations.

Why do we need it?

We already spend twice as much as other industrialized countries on health care but we receive mediocre results. Some Americans benefit from very good health care but millions do not. Fifty-four percent of Americans report delaying needed care in 2010, while 25 percent report having trouble paying medical bills. Many must choose between paying for medicine and paying for food or rent.

Approximately 45,000 deaths each year in the U.S. are associated with a lack of health insurance. Sixty-two percent of personal bankruptcies are a result of illness and medical bills.

We spend 17.7 percent of our GDP on health care and this is a terrible drain on our economy. Our reliance on private, for profit health insurance companies wastes billions of dollars every year on administrative costs. This money could be going towards providing health care if we eliminated this expensive middleman who adds cost but no value to the system.

How do we know it would work?

We already have a single-payer-like system in this country and it has been working well for nearly 50 years: Medicare. We also have publicly financed nonprofit health care for the military, veterans, and the poor. They all could be improved but they work and pay half of our country’s health care bill.

A single-payer system would bring health care justice to our country. It would be transparent, publicly accountable, fair, and efficient. It is time to end the immorality of our unequal, chaotic, inefficient health care “non-system” and join the rest of the industrialized world in providing equal access to high-quality health care for all our people.

Dr. Alec Pruchnicki practices internal and geriatric medicine and serves on the board of the N.Y. Metro chapter of Physicians for a National Health Program (pnhpnymetro.org). He resides in the West Village.

http://westviewnews.org/2013/06/what-is-single-payer-health-care/

Central labor councils to AFL-CIO: Strengthen Social Security & pass Improved Medicare for All

By Kay Tillow
Single Payer News, June 2, 2013

Four central labor councils have passed an identical resolution calling upon the September AFL-CIO convention to organize an offensive campaign for expanding Social Security financing and passing improved “Medicare For All” legislation.

The resolution, which was initiated by the Troy Area Labor Council, has also been passed by the Greater Louisville Central Labor Council, the Greater Green Bay Central Labor Council and the Capital District Area Labor Federation in Albany, N.Y.

The resolution calls upon the AFL-CIO to organize a Solidarity Day march on Washington and on the West Coast “to demand an expansion of Medicare to cover everyone and to defend Social Security by removing the cap on income and tax all income in a similar fashion.”

The resolution calls for taxing all income for the purpose of Social Security including dividends, interest, capital gains, and rental income as well as removing the cap on wages and salaries now set at $113,700. Currently, those who earn up to $113,700 pay 6.2 percent in Social Security taxes on every dollar. Those who earn over that amount do not pay taxes on their earnings above that level even if they make millions. Currently the income of the wealthy in dividends, interest, capital gains, etc. is not taxed at all for Social Security.

On Medicare the resolution calls for “implementing a single Payer Medicare for All system as outlined in H.R. 676,” Congressman John Conyers’ single-payer legislation which has 43 House co-sponsors. The legislation would cover everyone for all medically necessary care without co-pays, deductibles or premiums. The removal of the private health insurance industry would bring costs under control while expanding care.

In Minnesota, the Machinists’ State Retirees’ Council (IAM) is sending the resolution to all central labor councils in that state. In Pittsburgh, the president of a steelworkers local (USW) is submitting it to the Allegheny County Labor Council.

The AFL-CIO convention opens Sept. 8 in Los Angeles, Calif. Central Labor Councils, Area Labor Federations, and State AFL-CIO Federations as well as international unions may submit resolutions. Resolutions can be sent to Elizabeth Shuler, Sec.-Treas. AFL-CIO, 815 16th St. NW, Washington, DC 20006.

The resolutions can be found here: http://unionsforsinglepayer.org/tools/clc_resolutions

Text of resolution:

Resolution for Action in Defense of Social Security and Medicare

Whereas: Both Social Security and Medicare are hard fought fundamental gains for all working people.

And Whereas: Cutting Social Security and Medicare benefits would mean destitution for millions of workers and their families.

And Whereas: The social insurance Social Security and Medicare provide is now under sustained attack by Wall Street interests which seek to direct these funds into private hands for private profit.

And Whereas: Removing the cap on income taxed for Social Security would both solve any financial issues the fund might have and end the unfair advantage of those making over the current capped level.

And Whereas: Implementing a Single Payer Medicare for All system as outlined in HR 676 would both cover everyone and save billions of dollars over the current private health insurance industry.

Therefore: The Troy Area Labor Council AFL-CIO urges that the AFL-CIO, within this calendar year, organize a Solidarity Day of Action in Washington and on the West Coast which calls all affiliates and labor allies to mobilize their members to demand an expansion of Medicare to cover everyone and to defend Social Security by removing the cap on income and tax all income in a similar fashion.

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

Does the nation support health care as a right?

Summary Memo on National Poll Findings of Public Opinion on U.S. Healthcare System

The Morning Consult, June 11, 2013

This bipartisan poll included a national sample of 1,000 likely voters and was conducted May 22 to May 26, 2013 by Republican pollster John McLaughlin of McLaughlin & Associates and Democratic pollster Margie Omero of Momentum Analysis.

Q6:  In general, do you view health care as a right guaranteed to all citizens or is it something that citizens should be primarily responsible for providing for themselves?

44% – Guaranteed right
47% – Citizens responsibility
 9% – DK/Refused

Q8:  In your own personal opinion, which of the following do you see as the  biggest problem facing health care today?

58% – Too expensive
11% – Too many uninsured
17% – Not worth the price
 5% – Accessing quality doctors
 9% – DK/Refused

Q10:  And who do you believe is most responsible for the cost of health care coverage?

44% – Insurance companies
10% – Hospitals
 4% – Doctors
12% – Drug companies
 1% – Medical device companies
 9% – Individuals
19% – DK/Refused

Q40:  Currently, health care benefits provided by an employer are tax-free for both employers and employees. On the other hand, health insurance benefits are not tax-free for people who either buy insurance themselves or do not receive benefits from their employers. Knowing this, do you favor or oppose changing the law so health insurance benefits provided by employers are taxed?

 9% – Strongly favor
15% – Somewhat favor
20% – Somewhat oppose
43% – Strongly oppose
13% – Neither

http://themorningconsult.com/summary-memo-on-national-poll-findings-of-public-opinion-on-u-s-healthcare-system/

Comment:

By Don McCanne, M.D.

Three-fourths of likely voters believe that the biggest problem in health care today is that it is too expensive or not worth the price. When allowed to select only one option as to who is responsible for the costs, close to half blame the insurance companies, with far less blame placed on others. It seems like the voters would want something done about costs, but there is no voters’ revolt in sight. Maybe we have a problem with framing.

Although most outspoken supporters of a truly universal health program claim that health care should be a right, just as many believe that it should be an individual responsibility. The social justice argument is not going to sway those who have views opposed. Shoving a “Health Care Is a Right” placard in their faces only turns them off even more. Framing health care as a right is too polarizing.

Regarding employer-sponsored health plans, only about one-fourth favor ending the income tax exemption of the benefits, whereas about two-thirds would oppose taxing these benefits. Just as with their views on high health care costs, voters are also concerned about preserving an existing government tax policy that helps give limited relief of their costs – their own personal costs, that is.

When individuals have to buy their own insurance, they are very concerned about unaffordable premiums, and they blame the insurers for that. When they access health care, they are concerned about high out-of-pocket expenses, especially the deductibles. Even when they receive insurance through work, many realize that this insurance was paid for by forgoing wage increases. The high costs of health care are a personal matter for them, and they want relief.

Rather than talking about abstract health care rights, we should be framing the problem as an intolerable personal financial burden – one that is perpetuated through our reliance on expensive but ineffective private insurance plans. We need to explain that they can get relief from this burden on two fronts: 1) Free access to health care by curtailing out-of-pocket expenses, and 2) Replacing unaffordable premiums with equitable public funding.

The first point was covered yesterday with the brief from EPI titled, “Increased health care cost sharing works as intended – It burdens patients who need care the most.” We can get rid of this burden. People need to understand that many other nations provide care that is free at the time of service – no deductibles, no copays. That’s what they want to hear, though for those who are dubious that this is possible, we can explain that we can do this by replacing the private insurers with an efficient Medicare-like program.

For the second point, we can explain that, under an equitable tax system, individuals pay no more than they can afford, based on their income, and for most individuals that would be less than they are currently paying in both direct and hidden costs of health care.

So the framing needs to appeal to the individuals’ concerns about their personal high health care costs: Are you spending too much out-of-pocket for your health care and for your insurance? Would like like to be able to get rid of your private insurance and have health care free at the time you need it? We can do this if we make some modest improvements in Medicare and then provide it for everyone, paying for it through fair taxes.

You can work on the rhetoric. Just be sure that they hear that they will not have their health care threatened simply because they cannot afford to pay for it. Some may feel that it is their right, and some may not. But they all want to hear that in the future they finally can have relief from their own personal financial burdens of health care.

Single payer is needed cure

By Jack Bernard
Charlotte (N.C.) Observer, June 10, 2013

After spending 25 years in the health care field, most of it related to making hospitals more efficient and effective, I have become skeptical of many of Washington’s reform efforts, especially by my party, the GOP.

One of the biggest problems with health care is escalating, uncontrolled expenditures, taking a larger and larger proportion of our GNP. However, what Rep. Paul Ryan and the GOP want to talk about is the federal budget and cost-shifting via Medicare and Medicaid.

Experts in health care economics differ on many things. But one thing they all agree on is that raising the age for Medicare will do virtually nothing to reduce the overall cost of health care in this nation.

Under the Affordable Care Act, everyone must have insurance or be taxed. Medicare has a 3 percent administrative overhead while the private sector has run 28 percent, coming down to 20 percent as required by the ACA. Raising the Medicare age simply shifts the insurer from the government to less efficient private providers. This dumps the extra cost into the lap of the senior, who at 65 is probably unemployed and unemployable. There are no overall cost savings via efficiencies with Ryan’s Medicare “voucher” proposal.

Dr. Gerald Friedman, professor of economics at the University of Massachusetts, was in Charlotte recently for the launching of a physician advocacy group, Health Care Justice. Friedman indicated that U.S. per capita health care cost is $7,920. That compares with $3,323 in Sweden, $2,984 in Finland and only $2,686 in Italy. He points out that people in these countries are healthier than in our country and things are getting worse here. In 2001 among the non-elderly, 14 percent did not see a doctor for needed medical care. The figure rose to 26 percent in less than a decade.

Friedman pointed out that the most basic financial problem with U.S. health care is the for-profit insurance system. Insurance company profits have increased 250 percent in the last decade, Friedman said. The head of Cigna made a whopping $29 million in 2009 while health care premiums and increased deductibles are eating up more and more of workers’ wages.

He further pointed out that the administrative cost of health care insurance is one of the major drivers of escalating health care costs from 1980 to 2005. According to Friedman, the administrative cost of private insurance will be $200 billion in 2013. In the U.S. billing costs run $83,975 per doctor per year versus only $22,205 in Ontario.

This is waste, pure and simple. Although the Affordable Care Act pushed through by the Democrats does not do enough to solve the issue, the current GOP proposals totally ignore it.

A related area is prescription drugs. We pay 60 percent more than other countries. Our nation is in effect providing a subsidy to all the others. Why should we pay more to develop drugs that are used elsewhere, not just here?

What is the best course of action to provide better health care and reduce the growth of national health care expenditures? Dr. Friedman’s cure is to move to single payer.

Single payer would drive down costs because Medicare (or a utility-like private single payer insurer) would have leverage to keep costs down. With no other game in town, providers would be forced to operate more efficiently. Drug companies would be pressured to give Americans the same drug pricing that is found elsewhere.

Friedman pointed out that in multiple state studies (independently done by several groups), single payer turns out to save money. In his own studies, he has shown savings of around 20 percent for North Carolina, Pennsylvania and Massachusetts, and even more in Colorado and Maryland.

According to Friedman, a North Carolina single payer system would produce enormous savings, $18.7 billion per year. Surely, at a time when wage earners are being faced with ever increasing premiums and higher deductibles, we should at least consider Medicare for all or a similar single payer system.

The real question is whether either party is willing to stand up to the drug and insurance lobbies and do what is best for America.

Jack Bernard is a retired health care executive, former Jasper County, Ga., commission chairman and former chairman of the Jasper County Republican Party.

http://www.charlotteobserver.com/2013/06/10/4097735/single-payer-is-needed-cure.html##storylink=cpy

Medicaid expansion good thing, for now

By Brandon Sandine
Rockford Register Star, Letters, June 9, 2013

The Illinois General Assembly agreed to accept federal monies to expand Medicaid in our state beginning in 2014.

That’s good news for the residents of our state who are disabled or have an income at or below 133 percent the federal poverty level, or $15,281 a year.

Effective Jan. 1, 2014, some of the most vulnerable sections of our population will less frequently have to choose between paying food bills and seeking medical care. Much human suffering will be alleviated and many lives will be saved. An estimated 342,000 people are expected to benefit.

Medicaid is a federally and state-funded program. However, the financial risk that our state is taking on with the expansion of Medicaid is small. This expansion is almost completely funded by the federal government, and should the federal source of funding ever drop beneath 90 percent, the law will automatically cease.

While the financial pressures on the Illinois economy are very real, expanding Medicaid should not prove to be one of them. When it comes to the state’s pension funds, for example, the law certifies that its impact is null.

Illinois’ decision to support the provisions of the Affordable Care Act, President Obama’s landmark health law, is great news for our nation’s health. Yet even if the ACA takes full effect, an estimated 1.7 million residents of our state will still be left uninsured or underinsured.

In many ways the new health law is merely a Band-Aid fix. I believe single-payer health insurance is the only way to repair our broken, fragmented system, which currently wastes so much money on private insurance company paperwork and bureaucracy. What we really need is an improved Medicare for all.

Brandon Sandine of Machesney Park is a Master of Public Health candidate at the University of Illinois at Chicago.

http://www.rrstar.com/updates/x1466762604/My-View-Medicaid-expansion-good-thing-for-now#ixzz2Vp63AWzJ

Ball of confusion

Description fits both the Affordable Care Act and most of the GOP opposition to it

By Jack Bernard
Ledger-Enquirer (Columbus, Ga.), June 8, 2013

In my rural county, the Tea Party was started by, and is still headed by, a Republican blue-collar trade union worker from New Jersey who looks and sounds like someone you would see on “The Sopranos.”

He has not worked for years, is under 65, and gets health insurance through his trade union. He constantly and loudly complains about Obamacare, which when implemented will help older unemployed people like him (but not in a trade union) to get coverage. Influenced by extremist propaganda, I doubt he realizes that uninsured older workers currently either: (a) cannot get insurance at all, or (b) cannot afford the excessive age-adjusted and health-adjusted premiums charged by for-profit insurance companies.

Remember the contradictory signs carried in 2009 by Tea Party senior citizens saying “Stop Obamacare; keep the government out of my Medicare”? In 2010, Dr. Paul Broun, my own Tea Party-endorsed congressman (now running to succeed Senator Saxby Chambliss), declared that under Obamacare, “the elderly are gonna be denied the care to keep them living.” His weak rationale was that he bought the misleading and factually incorrect Sarah Palin “death panel” ruse.

Unfortunately, these are the confused folks at all levels who are still heavily influencing my party, the GOP, and its policy positions on health reform. Thus, we see the recent highly partisan 37th vote for repeal of Omamacare by our out-of-touch House of Representatives.

Am I a dyed-in-the-wool supporter of Obamacare? No, I am not. There is a much better alternative that I outline below. (The main thing I support about Obamacare is that at least it will help in providing coverage to some of the 50 million Americans who are currently without insurance.) But that does not mean that I endorse the misguided direction that my own party has taken on health care.

The GOP currently has two big new ideas regarding health reform, both doing away with so called “entitlements” that are very popular with taxpayers. Neither initiative makes any sense in the broader context of systemic cost reduction and quality improvement.

First, the GOP wants to change Medicare into a voucher program. Let’s be clear as to the underlying aim of this “premium support” proposal: A voucher system would cap expenditures by the federal government, period. It does nothing to make the health care system more effective, quality-wise or cost efficiency-wise. By providing vouchers, you just shift the burden of ever-increasing hospital, physician and pharma costs onto powerless, sick patients. Over time, this means that the elderly will not get the care they need … or they will go broke trying to pay for it. Is this an appropriate GOP national goal?

Second, the Republican Party proposes making Medicaid, the safety net for the poor for the last 50 years, into a block grant program. Again, costs to the federal and state government are capped. But that simply means that Medicaid beneficiaries, all very low-income people, will suffer tremendously and fail to receive needed care. Plus, most Americans are unaware that the largest payer for nursing homes is Medicaid. Do you really want a sick, frail, elderly person who has worked all his or her life to be out on the streets just because there is no government funding to put them into a nursing home?

The best solution is starring us in the face: Expand Medicare and make it the sole payer for all health care. It is one the few areas where government has proven to be more efficient than the private sector. Medicare administrative costs are 3% versus 20%-30% for private insurance companies, which have lots of administrative and marketing overhead.

When we look at European countries and Canada with similar systems, we find that statistically their quality of care is as good as or better than ours, and costs are much less. For example, the per capita cost of care in Canada is $4,205 versus $7,910 in the United States. France, with possibly the best health system in the world, costs only $3,835 per capita.

More on this topic can be found on the web site of Physicians for a National Health Program, PNHP. Go to www.pnhp.org for more regarding how a Medicare For All system would work and the clear benefits it would bring to all Americans.

Jack Bernard, a retired senior executive for several national health care corporations, is also the former Director of Health Planning for the state of Georgia and former chairman of the Jasper County Republican Party; Bernard_Jack@hotmail.com.

http://www.ledger-enquirer.com/2013/06/08/2535529/ball-of-confusion.html

Burdening patients who need care the most

Increased health care cost sharing works as intended

It burdens patients who need care the most

By Elise Gould
Economic Policy Institute, May 8, 2013

A number of different health care policy proposals that have emerged in recent years share a common goal: make households directly pay for a larger share of most health expenditures by encouraging higher deductibles, higher copays, or higher co-insurance rates. The rationale of such proposals is that too-generous insurance policies (either those provided by employers or public insurance such as Medicare) distort the prices consumers face, and that removing this distortion would allow patients to choose their health care more wisely, hence slowing health care cost growth.

This brief argues that this is a flawed strategy for health care cost containment. The health care market is unlike other markets; thus, forcing increased cost sharing on American households is a deeply inefficient strategy for trying to contain health care costs. Forcing Americans to pay a higher share of health costs will not induce them to shop around and compare prices when they are experiencing chest pains or their child is suffering from an asthma attack. Further, consumers of health care are in no position to second-guess their doctor when she tells them an MRI is better than an X-ray (and hence worth the higher price) to diagnose a condition. Lastly, unlike other markets, prices of health care services faced by consumers bear very little relation to providers’ cost to supply these services. Hence, these prices provide little to no information for consumers looking to judge the relative efficacy of various health care interventions.

In addition, increased health cost sharing is unlikely to make American health care more affordable to those currently unable to afford it, and will instead likely place the largest burdens on those who need care the most.

Most cost-sharing proposals lead to higher out-of-pocket medical costs, hitting those who require a high degree of medical care especially hard. The short-term cost savings achieved as patients respond to increasing out-of-pocket burdens may be realized by reducing medically necessary health care—a penny-wise, pound-foolish result.

Most cost-sharing proposals are poorly targeted for containing overall system costs. They miss the expensive cost drivers. Any cost containment would be driven by reduced medical care, not reduced prices.

* Not all moral hazard is inefficient

* Cost sharing can lead to medically and economically inefficient decisions

* Cost sharing is a poorly targeted cost-containment device

http://www.epi.org/files/2013/increased-health-care-cost-sharing-works.pdf

Comment:

By Don McCanne, M.D.

A major objective of health care reform was to slow the intolerable escalation in health care spending. Most of the pilot initiatives included in the Affordable Care Act (ACA), such as accountable care organizations and bundled payments, will likely have very little impact on our national health expenditures. But one important policy approach – the subject of this EPI brief – began before ACA was enacted and is probably responsible for most of the slowing in health care spending that was not directly due to the recession.

That policy is placing a financial burden on individuals who need care, especially through higher deductibles, but also through other forms of cost sharing. The impact of this policy is expressed well in the title of the brief: “Increased health care cost sharing works as intended – It burdens patients who need care the most”

Talk about a flawed policy! We are attempting to cover as many people as possible considering the limitations of ACA, and yet, at the same time, we are expanding the use of policies that keep patients away from care that they should have – by erecting these financial barriers. We are increasing the spending on private insurance plans while reducing the spending on health care by preventing insured people from getting the care they need!

How many times do we have to say it? Many other nations provide first dollar coverage – not charging any fees when health care is accessed – yet they have been much more effective in slowing cost escalation. You do not have to expose patients to potential financial hardship to bring costs under control.

This is one of the most important flaws of ACA (and there are many of them). It not only allows, but it actually encourages, through low actuarial value plans, the expansion of these financial disincentives to obtaining health care. If you read the full EPI brief, you will understand better why we must abandon this approach. Unfortunately, the author provides only a couple of feeble suggestions as to alternative approaches, but you will not find in the brief what we really need to do.

It is astounding that when it comes down to the obvious – that we need a well designed single payer national health program – so many knowledgeable people in the policy community choke up. Let’s let them know that it is okay to say it: WE NEED A SINGLE PAYER NATIONAL HEALTH PROGRAM!

I guess we really don’t have to shout. But we should explain to our colleagues and the public at large the reasons contained in this EPI brief explaining why cost sharing is harmful to our health and how it leads to financial insecurity. Then we can explain, in a calm voice, how we can fix this by improving Medicare (partly by including first dollar coverage) and then providing it for everyone. Naw. They’re not listening. We’d better shout.

Obamacare leaves millions uninsured. Here’s who they are.

By Sarah Kliff
Washington Post, June 7, 2013

When we talk about the Affordable Care Act, we mostly focus on the millions of Americans who will gain health insurance coverage. We talk less about the millions who will remain uninsured.

And there are a lot of them: 30 million Americans will not have coverage under Obamacare, according to a new analysis in the journal Health Affairs.

“Even if the law were fully implemented, there would have been 26 million uninsured people,” co-author Steffie Woolhandler said in an interview Thursday. “This isn’t just about the Medicaid expansion. This is the system as originally designed.”

Thirty million is a lot smaller than the 48.6 million Americans who lack insurance coverage right now. It’s also, as Woolhandler points out, not exactly breaking news: The Congressional Budget Office estimated over a year ago that between 26 million and 27 million Americans would not have insurance under the expansion.

Woolhandler and her colleagues have done one of the most in-depth analyses of the uninsured under Obamacare that I’ve seen. They look at who will be uninsured in 2016, a few years after the health law’s insurance expansion takes place. You can expect these numbers to change (likely to shrink) in later years, as budget forecasters expect enrollment in health law programs to grow gradually.

One of the most surprising findings, perhaps, is that the vast majority of the uninsured under Obamacare — 80 percent — will be U.S. citizens. This is true in the two scenarios that the researchers looked at, one in which states on the fence about the Medicaid expansion opt-in and one in which those states opt out. As you can see, there’s not much of a difference.

The uninsured under Obamacare tend to be between between ages 18 and 44, with a few million in younger and older age demographics.

This analysis suggests that the uninsured under Obamacare will be heavily low-income, even though many of those people will have access to subsidized health insurance. Still, some might not find it affordable, and the health care law does allow for an exemption from the individual mandate for those who cannot find affordable coverage (defined as insurance that costs less than 9.5 percent of an individual’s income).

“If people are not eligible for Medicaid, then affordability can be a big deal,” Woolhandler says. “Even with subsidies, you could see some people who either can’t find affordable coverage or decide to pay the mandate.”

The researchers also broke it down by employment status, which shows that most of the uninsured will be employed:

And, last but not least, here is the breakdown by race:

http://www.washingtonpost.com/blogs/wonkblog/wp/2013/06/07/obamacare-leaves-millions-uninsured-heres-who-they-are/

Response to Goldman and Leive's critique of Medicare for All

Why ‘Medicare-For-All’ Is Not The Answer

By Dana Goldman and Adam Leive
Health Affairs Blog, May 14, 2013

The Affordable Care Act survived the Supreme Court and a presidential election, so why does it face such an uncertain future?  One reason is that it was essentially silent on how to control costs.  This has led many pundits — including the likes of Paul Krugman and Robert Reich — to argue that the best approach would be to extend Medicare to everyone.

The idea of universal Medicare is powerful and attractive.

However, the argument that Medicare is superior in terms of cost savings and quality is flawed and ignores key factors that make any conclusion decidedly more nuanced. As the country’s fiscal challenges pressure us to make dramatic health system changes, we should be wary of calls to implement “Medicare-for-All.”

(In fairness, no attempt is made to edit their explanation of why “Medicare-for-All” is not the answer. Please use the following link to access their reasoning.)
 
http://healthaffairs.org/blog/2013/05/14/why-medicare-for-all-is-not-the-answer/

HA BLOG RESPONSES:

Theodore Marmor Says (May 19):

This critique of Medicare is bafflingly opaque to the difference between single payer systems providing broad, first dollar coverage and the particular features of Medicare US version 2013. The arguments for the former rely on normative appeal of principles like those of the Canada Health Act, on experience with very limited if any patient cost-sharing at the point of service, and decades of comparative financing experience. On that basis, one can compare how Canadian developments differ from those in the US from 1971 – when their system was operational – to now. Not everyone would agree that Canadian experience is superior, but it would be difficult to argue the case that the US experience was superior. So, why are those data not addressed seriously when dealing with “international experience.” One cannot coherently argue against that form of medical care policy by selectively observing features of American medical care and speculative claims about the extent of ‘fraud’ in private and public health insurance. The monopsonist noted in the article is not US Medicare, but Canadian Medicare at the provincial level—or, by extension, the NHS in the UK. There are indeed issues of fraud in the US, but interestingly, there is no serious evidence presented that supports the claim that private health insurance is superior on that front.

Finally, in no OECD nation is health care financing the central explanation for the profile of the population’s health. Health care serves lots of purposes and is important in many ways, but it ought not be evaluated primarily or substantially–in rich countries with basic public health–for major changes in population health profiles.

Dana Goldman Says (May 23):

There is a tone here that somehow the Canadian system is ‘better’ — or at least non-inferior and less expensive. But surely everyone can agree that the Canadian system restricts choice, has greater delays, and is starting to show cracks. Just try getting Erbitux for Stage IV colon cancer ; or an office visit in Yarmouth, Nova Scotia, where they held a lottery to see who would get primary care.
(See http://www.city-journal.org/html/17_3_canadian_healthcare.html or http://www.nationalreviewofmedicine.com/issue/2006/03_15/3_policy_politics03_05.html).

In fact, cancer is a poignant example, as research we published in Health Affairs last year demonstrated that the US has better survival than the EU, and the gap is widening. These better outcomes come at a cost, but a straightforward cost-benefit analysis indicates that the gains are worth it. (See http://content.healthaffairs.org/content/31/4/667.short)

The point is that the US — while wasteful — has a system that on average provides the best access and choice, especially with the ACA. Canada has a lower global budget, but it has restricted choice. If we move to global budgets, we can lower costs, but we shouldn’t fool ourselves that health outcomes will magically improve and access will improve.

Jon Oberlander Says (May 23):

Dana Goldman is concerned about tone in blog responses – I am more concerned by his factual errors and misleading statements. Comparing the United States to Canada, Goldman writes that “the US — while wasteful — has a system that on average provides the best access and choice, especially with the ACA.” It is not clear what “the best” means here – best in the world? Or only in North America? Regardless, it is simply inarguable that Canada provides better health security to its citizens with universal coverage at a much lower cost than the US.

To be sure, Canada has its share of significant problems. But it is a bit much for Goldman to cite issues in primary care shortages and a lottery for care as an indictment of Canada without mentioning America’s own issues with primary care or the now famous Oregon lottery for Medicaid or medical care costs driving Americans (including those with insurance) into bankruptcy and much more. Even when the ACA is fully implemented, over 30 million US residents will lack insurance coverage – we will not match Canada on universality.

Goldman is worried about Canada’s limits on choice but he does not note that the US is itself not free of constraints: many Americans face constraints on choice of medical care options because they do not have any coverage at all, do not have a choice of insurers from their employer, or have restricted choice of doctor because they are in a managed care plan. In short, Goldman’s conviction that the US has the “best access and choice” is strangely divorced from the evidence.

Finally, Goldman’s published work does not, as he claims, demonstrate that higher US spending on cancer produces better results than the EU. That work has serious methodological problems which undercut its conclusions:
see: http://theincidentaleconomist.com/wordpress/health-affairs-authors-respond-to-criticism-maybe-mine/
and http://www.reuters.com/article/2012/04/09/us-cancercare-idUSBRE8380SA20120409

http://healthaffairs.org/blog/2013/05/14/why-medicare-for-all-is-not-the-answer/

Evidence Supports Medicare For All

By Ida Hellander
Health Affairs Blog, June 7, 2013

Dana Goldman and Adam Leive’s effort to discredit the single payer, Medicare-for-All model of financing health care — or as they put it, make “any conclusion decidedly more nuanced” — is sorely lacking in nuance, defined by Merriam-Webster as “made or done with extreme care or accuracy.”

As Goldman and Leive note, the Affordable Care Act will not control rising costs. In addition, the Congressional Budget Office estimated last week that even after it is fully implemented, the ACA will leave 31 million Americans uninsured. The support of Nobel Prize-winning economists like Paul Krugman and Joseph Stiglitz, the former chief economist at the World Bank, along with Professor Robert Reich, the former U.S. secretary of labor, reflects a broad consensus that the only way to provide universal coverage and control costs is a single-payer system.

(In fairness, and because of the length of today’s message, no attempt is made to edit Ida Hellander’s response to Goldman and Leive. Please use the following link to access her response.)

http://healthaffairs.org/blog/2013/06/07/evidence-supports-medicare-for-all/

Comment:

By Don McCanne, M.D.

We rarely respond to criticisms of Medicare for All since most of them are driven by conservative/libertarian ideology devoid of any acknowledgment of health care justice. Single
payer advocates simply cannot have an intelligent discussion with someone who does not believe that society has a moral obligation to ensure that absolutely everyone has affordable access to appropriate health care.

We had to make an exception in this case. Dana Goldman is a Professor and the Leonard D. Schaeffer Director’s Chair at the University of Southern California, and, until 2009, was RAND’s Distinguished Chair in Health Economics. Because he is “a nationally-recognized health economist influential in both academic and policy circles” (HA Bio), a response was obligatory on our part.

The thrust of their discrediting of Medicare for All is that they challenge the lower prices that Medicare pays, the much lower administrative costs of the Medicare program, and they even challenge the mediocrity of our health outcomes. Anyone with a basic knowledge of health policy cannot be but perplexed by their attack of these well established facts.

As an example of the questionable credibility of their statements, Jon Oberlander cites the dubious cancer statistics in his comment above. The link that he provides to The Incidental Economist is to an article that quotes the critique I had of the cancer study Goldman cites – a study of which he is a co-author.

Ida Hellander, in her full article, makes the very important point that Goldman and Leive “confuse today’s Medicare program (not a single payer but just one plan in a marketplace of multiple public and private plans) with Medicare for All (single payer).” Although they were off in what they did criticize, they did not discuss the other very important features of the single payer, improved Medicare for all model advocated for by PNHP.

By providing us with such a flawed critique of Medicare for All, Goldman and Leive have helped to make the case for us by demonstrating that they have to stretch their rhetoric to the breaking point to come up with arguments against it.