PNHP

Does the nation support health care as a right?

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.

Message to Congress: Immigrants Pay More Than Their 'Fair Share' of Medicare

By Steffie Woolhander and David U. Himmelstein
Roll Call, June 6, 2013

Immigrants don’t just pick our fruit, deliver our take-out food and design our computers — they pay for our medical care.

As Congress debates immigration reform, some would have us believe that immigrants are draining the Treasury. But it turns out that closing the borders would deplete Medicare’s trust fund.

We, along with colleagues at Harvard Medical School, studied who pays into the Medicare trust fund vs. who uses Medicare coverage. As we report in the current issue of the journal Health Affairs, over a seven-year period, immigrants paid in $115.2 billion more than they took out. Meanwhile, native-born Americans drained $28.1 billion from Medicare. In other words, immigrants are keeping Medicare afloat. And it’s non-citizen immigrants who make the biggest contribution. On average, each one subsidizes Medicare by $466 annually.

It’s not just Medicare that profits from immigrants. Social Security’s chief actuary estimated that undocumented immigrants contributed a net surplus of $12 billion to the Social Security retirement trust fund in 2007 alone.

In essence, without immigrants’ contributions, the financial pressure on Medicare and Social Security would be far greater, and threatened cuts for the elderly far more severe.

Why do immigrants generate surpluses for Medicare and Social Security? Most of them are young, working adults, who pay the payroll taxes that feed the trust funds. Immigrants with legal status pay these taxes under valid Social Security numbers. Many undocumented immigrants also pay these taxes, under invalid or borrowed Social Security numbers (under federal law, employers must report, but needn’t verify, a Social Security number for each employee). Meanwhile, most immigrants are too young to draw Medicare benefits. Even once they pass 65, many don’t qualify for benefits because they lack legal status or proof of their payroll tax contributions. And others retire to their country of origin.

While immigrants heavily subsidize Medicare, millions of them are denied care. Our research has found that foreign-born children get shockingly little care, often skipping routine well-child visits. And immigrant adults with mild conditions such as hypertension often don’t get the care they need to prevent serious (and expensive) complications such as strokes and heart attacks.

But dry statistics don’t tell the story. We’ve cared for a young immigrant mother who died of tuberculosis shortly after giving birth; out of fear, she had avoided earlier lifesaving care. Another of our patients, a 47-year-old immigrant truck driver, stayed home for two days with heart attack symptoms and died because he never got the clot-busting drugs that could have saved him. Some patients work two, even three, jobs but remain uninsured and unable to afford care.

What should Congress and the president do? In the short term, cuts to Medicare Disproportionate Share funding for safety net hospitals (Sections 2551 and 3133 of the Affordable Care Act) should be reversed; support for community and migrant health centers needs to be amped up; and restrictions on immigrants’ enrollment in public programs such as Medicare and Medicaid should be lifted. In the longer term, only a truly universal, single-payer program will do.

And Obamacare won’t do much to help. Even many legal immigrants won’t be eligible for Medicaid and will be prohibited from buying coverage through the new insurance exchanges. Meanwhile, Obamacare will sharply cut funding for safety net hospitals, threatening the solvency of institutions that will care for the 31 million (including 8 million immigrants) who will remain uninsured. The effect will be especially severe in places such as New York City and Los Angeles, where nearly 2 of every 5 residents were born outside the U.S.

Scare-mongering about the cost of immigration has become a staple of political debate. We started our research on immigrants’ health because as doctors we believe that health care is a human right, a right that we too often saw violated even in liberal Massachusetts. But our findings indicate that economic fairness, not just morality, argues for immigrants’ rights to care.

Steffie Woolhander and David U. Himmelstein are internists, professors at the City University School of Public Health at Hunter College and visiting professors of medicine at Harvard Medical School.

http://www.rollcall.com/news/message_to_congress_immigrants_pay_more_than_their_fair_share_of_medicare-225395-1.html

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.”

Acknowledging Medicare’s greater success at controlling costs than private insurance plans, Goldman and Leive raise the specter of “underprovision of services” and doctors leaving the system if Medicare were universal.  But Medicare patients are significantly less likely to have problems with access to care and medical bills than non-elderly adults with private insurance, according to a recent study by The Commonwealth Fund. The same study found that Medicare beneficiaries are also more satisfied with their coverage than people with private insurance. Only 6 percent of beneficiaries in traditional Medicare rated their coverage as fair or poor in 2010, compared with 20 percent with employer-sponsored private insurance.

Among physicians who treat Medicare patients, 90 percent of all physicians and 96 percent of specialists are accepting new Medicare patients according to the Medicare Payment Advisory Commission.  In contrast to the limited networks of doctors available to the privately insured, and the appalling “underprovision of services” to those left uninsured and underinsured by today’s for-profit, market driven system, a Medicare-for-All system would expand choice and access.

Distinguishing current Medicare from Medicare for All.  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), and imply that negotiating fee schedules with doctors is the only way a single-payer system controls costs.  On the contrary, other proven-effective cost-control methods, such as globally budgeting hospitals, negotiating drug prices, and planning capital investment are made possible by expanding the program to everyone and eliminating the private insurance middlemen.  Canada’s spending on the elderly under its single-payer program has grown much more slowly than U.S. spending on the elderly since 1980, despite a 1984 law in Canada banning co-payments and deductibles.

Goldman and Leive make note of single payer’s greater administrative efficiency (e.g., traditional Medicare’s overhead was recently pegged at 1.4 percent), but criticize Medicare for not doing more to reduce fraud. But they offer no figure for how much fraud the insurance industry suffers from, or how much of the extra 16 percent of premiums devoted to private insurance overhead is spent on fraud detection as opposed to expenditures on marketing, underwriting, CEO salaries, profits, and utilization review aimed at denying care to their enrollees.

Furthermore, private insurers are not the scrupulous conservers of scarce resources that Goldman and Leive imply. Practices like “upcoding” (making patients appear sicker on paper so insurers can collect higher premiums) and “cherry picking” by private Medicare Advantage plans raise the cost of caring for their enrollees 14 percent higher than under the traditional Medicare program, according to MedPAC.

The poor US performance on preventable mortality.  The United States ranks last out of 16 countries in deaths that might have been prevented with timely and effective medical care, leading to an estimated 91,000 excess deaths annually. In this context, Goldman and Leive’s claim that high U.S. health spending is buying more effective treatment of breast and prostate cancer compared to other countries is of questionable significance as well as accuracy. Earlier diagnosis from greater screening improves survival times for cancers, especially at five years, but has very little impact on mortality.  At any rate, Medicare for All would not reduce spending on cancer treatment. The whole point of single payer is to shift resources we are squandering on bureaucracy (including the administrative burden on physicians and hospitals) into clinical care, increasing the amount available to care for patients by about $380 billion annually, according to the authors of a landmark New England Journal of Medicine study.

As it currently stands, Medicare needs to be improved to eliminate cost-sharing, and cover medications and long-term care as part of the basic program. A properly designed single-payer system would also have these attributes.

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.

Who will remain uninsured after ACA implemented?

The Uninsured After Implementation Of The Affordable Care Act: A Demographic And Geographic Analysis

By Rachel Nardin, Leah Zallman, Danny McCormick, Steffie Woolhandler, and David Himmelstein
Health Affairs Blog, June 6, 2013

The Affordable Care Act (ACA) proposed expanding health insurance coverage by: 1) requiring states to offer Medicaid to people with incomes up to 138 percent (133 percent plus a 5 percent income disregard) of the federal poverty level (FPL), with most of this expansion funded federally; and 2) offering subsidies to help those with incomes up to 400 percent FPL purchase private insurance through newly created insurance exchanges.

In June 2012, however, the Supreme Court ruled that states may opt-out of Medicaid expansion. Since then, the governors of 14 states have announced their intention to opt-out, 6 are undecided, 3 are leaning against, and 2 toward the expansion. Opt-outs will likely leave several million more uninsured, but little is known about who is likely to remain uninsured under the ACA.

To estimate the number and characteristics of US residents who will remain uninsured in 2016, we analyzed data from the Census Bureau’s 2012 Current Population Survey, a nationally representative survey of the non-institutionalized US population.

Results

We found that if all currently undecided states opt-in, 29.8 million people will remain uninsured, whereas if all opt-out, the number of uninsured will total 31.0 million, 1.2 million above the opt-in scenario.

For states that are opting out, this choice will lead to a decrease in the number of uninsured of only approximately 17 percent, rather than the approximately 50 percent decrease had they opted in.

Overall, the ACA will minimally alter the demographic composition of the uninsured, regardless of whether undecided states opt-in or out. While Blacks and Hispanics will continue to be overrepresented among the uninsured, the majority will be non-Hispanic, white, low-income, working-age adults, many of them employed. The majority (around 80 percent) of the uninsured will be US citizens, irrespective of states’ acceptance of Medicaid expansion. More than 4.3 million children and nearly 1.0 million veterans will remain uninsured under either scenario.

Implications

The Supreme Court’s decision to allow states to opt-out of Medicaid expansion weakens the ACA’s impact. Because the ACA also reduces funding to safety-net hospitals, states’ refusal to expand Medicaid will likely result in both medical and financial hardship for vulnerable Americans.

Our finding that, following the ACA, only 20 percent of the uninsured will be non-citizens (some of whom reside here legally) runs counter to the common perception that the ACA will cover virtually all legal residents.

The ACA will leave tens of millions uncovered. It will do little to alter racial disparities in coverage. It will also perpetuate disparities in access based on state of residence. The ACA, whatever its merits, will fall well short of its stated goal of providing affordable care for all Americans.

http://healthaffairs.org/blog/2013/06/06/the-uninsured-after-implementation-of-the-affordable-care-act-a-demographic-and-geographic-analysis/

Comment:

By Don McCanne, M.D.

Who will remain uninsured after the Affordable Care Act is fully implemented? Roughly 30 million individuals, mostly U.S. citizens, predominately non-Hispanic, white, low-income, working-age adults, with many of them employed. Blacks and Hispanics will continue to be over-represented among the uninsured.

We really do need a single payer national health program that truly covers everyone. Let’s start that process now.

30 million to remain uninsured under Obamacare: new state-by-state estimates at Health Affairs blog

Harvard and CUNY researchers say 4.9 million Texans and 3.7 million Californians will still be uninsured in 2016

FOR IMMEDIATE RELEASE
June 6, 2013

Contact:
Mark Almberg, PNHP communications director, (312) 782-6006, mark@pnhp.org

A study released today on the Health Affairs blog finds that between 29.8 million and 31.0 million people will remain uninsured after the implementation of the Affordable Care Act in 2016 and breaks down those figures by state.

The research team from Harvard Medical School and the City University of New York School of Public Health projects that the demographic composition of today’s uninsured population will change little under Obamacare.

The share of the uninsured who are U.S. citizens will rise slightly from 80 percent to 81 percent. White persons (of all ethnicities) will continue to constitute 74 percent of all uninsured Americans. About 59 percent of the uninsured will have incomes between 100 percent and 399 percent of poverty, while 27 percent will have incomes below poverty.

The researchers also estimated uninsured figures for each state (see table below).

The study analyzed Census Bureau data on current patterns of uninsurance, and used a coverage prediction model based on the model used by the Congressional Budget Office.

The researchers projected two coverage scenarios for each state. One assumed that the state turns down a Medicaid expansion and the other assumed that the state implements Medicaid expansion despite the Supreme Court ruling that such expansion is optional. The national estimates use the Advisory Board Company’s latest summary of which states are likely to participate in the Medicaid expansion.

Study co-author Dr. Steffie Woolhandler, a professor at CUNY and visiting professor of medicine at Harvard, said: “Many people believe that Obamacare will cover everyone. But the reform is so deeply flawed that 30 million or more will still be uninsured after it’s fully implemented. Even if the Supreme Court hadn’t let states of the hook for Medicaid expansion, 26 million would have been uninsured. We need to replace Obamacare with a simple single-payer system that would cover everyone.”

Lead author Dr. Rachel Nardin, chief of neurology at Cambridge Health Alliance and assistant professor of neurology at Harvard, commented: “Even in Massachusetts, where a reform like Obamacare has been in place since 2006, too many patients still can’t get the care they need. Hundreds of thousands are still uninsured, and many more have such skimpy coverage that they face unaffordable co-payments.”

“The Uninsured After Implementation of the Affordable Care Act: A Demographic and Geographic Analysis,” Rachel Nardin, M.D., Leah Zallman, M.D., M.P.H., Danny McCormick, M.D., M.P.H., Steffie Woolhandler, M.D., M.P.H., David Himmelstein, M.D. Health Affairs blog, June 6, 2013.

Number of Uninsured Persons by State, pre- and post-ACA

Physicians for a National Health Program is a nonprofit research and educational organization of more than 18,000 doctors who support single-payer national health insurance, an improved Medicare for all. PNHP had no role in funding or otherwise supporting the study described above.

Calls for Universal Health Care in Colorado and Nation

By Stephanie Carroll Carson
Public News Service – Colorado, June 3, 2013

DENVER — Efforts toward universal health care in Colorado were highlighted over the weekend at an event in Denver, part of a push to establish a constitutional right to health care in the state.

Appearing at the gathering was Congressman John Conyers of Michigan, who is seeking to build support for his “Medicare for All Act,” which proposes health care coverage for the uninsured, particularly those not covered by policies in the Affordable Care Act.

“Because more and more people are asking about this, what we’re looking for is a good way to get this through as soon as possible,” the veteran lawmaker said.

Also at the Saturday event, a petition drive was launched seeking to put a measure on the Colorado ballot that would establish a state constitutional right to health care.

There are currently 750,000 people in Colorado who do not have health insurance. After the Affordable Care Act is implemented next January, 400,000 will continue to lack coverage. Organizations like Health Care for All Colorado hope the state ballot measure, or the passage of Conyers’ bill, can result in coverage for everyone.

According to Donna Smith, the executive director for Health Care for All Colorado, the Affordable Care Act is necessary, but is largely about insurance reform, rather than universal health coverage. Congressman Conyers’ legislation provides coverage immediately.

“The moment you’re born, you’re in, and the moment you die, you’re out,” she declared. “There’s no question about you being covered; you are covered. It’s a publicly funded, privately and publicly delivered plan.”

The Medicare for All legislation establishes one publicly-owned, nonprofit health insurance plan. It would change the current model of private insurance in the country. Under the new system, private insurance companies would be able to create supplemental policies to cover things like cosmetic procedures not covered by the universal coverage.

Conyers said his legislation is supported by many in the medical field, including the Physicians for a National Health Program.

“The assistance and support and encouragement we get from doctors, health providers, medical scholars and people that work in hospitals is very fundamental to us making this happen as soon as possible,” he said.

The Medicare for All Act is currently under review in a House committee.

http://www.publicnewsservice.org/index.php?/content/article/32744-1