PNHP

Open letter to Gov. Haslam: Don’t abandon the vulnerable

Open letter to Gov. Haslam: Don’t abandon the vulnerable

By Diana Reed, M.D.

The following letter was sent to Gov. Bill Haslam of Tennessee on May 10.

Dear Governor Haslam:

I am a concerned citizen, a retired disabled doctor, a Tennessee resident and a woman who has devoted her life to health care as a neurologist in Columbia and at Vanderbilt before a work related injury left me disabled and uninsured.

What a slap in the face! Eventually I was able to get on Medicare and my husband who had a heart attack in 2005 was also uninsurable until the Preexisting Condition Insurance Plan became available. When that program ends, if you do not participate in the Medicaid expansion or the health exchanges, he may end up uninsured again, and if he has an illness or injury, we may end up in bankruptcy for a second time due to medical bills.

My husband’s best friend just died in January because he stayed home during his heart attack, rather than burden his family with medical bills he couldn’t afford because although he worked full time, he had no health insurance. The last three weeks of his life spent in Intensive Care Unit, cost his children what little inheritance they would have received from his estate.
 
Since my career in medicine was cut short, I wrote a book, “The Other End of the Stethoscope The Physicians’ Perspective on the Health Care Crisis.” The book explains why we are losing so many physicians in practice today, and how the health care crisis affects physician’s morale and bottom line. It explains where the money really goes as we spend twice as much as other countries and leave 46 million out, and why we rank 37th in over all health quality.

With the recent release of information on hospital charges, it is interesting to note that hospitals, like doctors almost never get paid what they charge, and due to antitrust laws, are not able to compare or discuss charges with their colleagues in similar practice situations or regions.

It really doesn’t matter what any of them charge, and of the uninsured, very few will pay anything toward their hospital bills. CMS and private insurers dictate what they will pay, and the only choice hospitals and doctors have is whether to be a provider.

As a physician, I had hundreds of thousands in unpaid accounts receivable that were never collected, yet, unlike hospitals I was not allowed to deduct that from my taxable income. I did provide health insurance to my three employees, but after they had some health issues, my rates tripled, along with the medical malpractice insurance.

With no control over my income or overhead, private practice in Tennessee became unsustainable and I, like most doctors today, was forced out of small business and into employment. The three jobs of my office manager, receptionist and nurse I supported were lost, along with my independence and love of medicine.
 
If someone collapsed on your doorstep, would you let them die there because they have no health insurance? Because as governor, that is exactly what you are doing. The poor and disabled, the most vulnerable of the people you represent, are being let down by the policies you espouse.

Contrary to what you might believe, it is tough out there, and hard working people are suffering while you seem to be most concerned with protecting the richest Tennesseans and their pocketbooks.

You seem to believe that the poor will make wasted trips to their doctors and drive up costs if they don’t have skin in the game by paying co-pays and deductibles they can’t afford, by definition of being poor. Isn’t their life skin enough?

The real cost savings will come when the poor can get to primary care, preventative health screening, medications for high blood pressure and diabetes, mental health care and health education rather than showing up in the ER with end stage catastrophic and chronic conditions that leave them disabled or dead, and costing us all much more in the long run.

Economically, the PPACA and the Medicaid expansion are a win-win for Tennessee, and I urge you to reconsider your political posturing and work to the benefit of all Tennesseans. You and your Republican colleagues are not hurting President Obama, whose agenda and health care plan was overwhelmingly approved as evidenced in the last election. You are not helping to make America strong, you are really hurting the Republican party and it will show in the next elections. People are sick of obstructionism.

Mainstream Americans are not a selfish, money-worshipping group that have no compassion for the poor or disabled. They know that we are all one people on one earth; that the Bible tells us we must help our brothers, especially the least of us, if we are to live by God’s word and we will all benefit. You need to come out of your ivory tower, and see how the majority of people in Tennessee are struggling, starving, and dying.
 
I would like to meet with you face to face, if possible, to discuss the health care crisis further, and as a Tennessee Volunteer, I would be happy to work with you toward a goal of compassionate care for all Tennesseans. Thank you for your consideration.

Dr. Diana Reed resides in Spring Hill, Tenn.

Keep people out of Medicaid to avoid fraud?

Healthcare puts Jerry Brown, Capitol Democrats on different sides

By Anthony York and Chris Megerian
Los Angeles Times, May 10, 2013

With California’s deficit wiped out and its economy starting to hum, this was to be a year when Gov. Jerry Brown was free of the budget logjams that have paralyzed the Capitol.

But instead, the governor has a fight on his hands — with his fellow Democrats. He is on a collision course with them over how to reshape the state’s sprawling, complicated healthcare system to conform with President Obama’s national overhaul.

The sticking points in extending public healthcare to more Californians include how many to add to state insurance rolls, how much to pay doctors and hospitals, and how much money to give counties for their care of the indigent.

The Democrats who control the Legislature — with a veto-proof supermajority — want to make it easier to obtain public insurance than Brown does and send more money to the doctors, hospitals and counties than the governor wants to part with.

The major bill that would expand public insurance under Medi-Cal is from Assembly Speaker John A. Pérez (D-Los Angeles). The measure would make it easier for Californians to enroll in the program by allowing people to sign up online and eliminating requirements that recipients file semiannual financial reports to prove they are still eligible.

Administration officials have said the governor opposes those changes out of concern that the easier enrollment process could lead to fraud.

http://www.latimes.com/health/la-me-brown-healthcare-20130511,0,6700749.story

Comment:

By Don McCanne, M.D.

Isn’t the idea of the Affordable Care Act to get as many people covered as is possible, considering the administrative complexities of this highly flawed model of reform? So what does California Governor Jerry Brown recommend? Do not make enrollment easier since it might lead to fraud!

Enrollment fraud could not possibly occur under a single payer system since it automatically enrolls everyone. We need a change in attitude. A single payer system would start us thinking in the right way about how to cover everyone and still pay for it.

Caregiving As Humankind's Shared Project

By Andrew D. Coates, M.D., F.A.C.P.  
WAMC Northeast Public Radio, May 13, 2013

In two recent essays Dr. Arthur Kleinman, the eminent Harvard anthropologist and psychiatrist, writes in the world’s leading medical journals about caregiving as a moral experience.

One essay appeared last November in The Lancet. A few weeks ago The New England Journal of Medicine published another article by Dr. Kleinman with a similar theme but a slightly different emphasis.

“Consider how central caregiving is to what it means to be human,” Dr. Kleinman writes. “Caregiving is an indelible part of relations between partners, the raising of children, and response to the infirmities of aged parents and grandparents. It is, of course, the very definition of how families and friendship networks cope with sickness or disability among their own.”

He goes on to say there’s “an ancient lineage to caregiving across historical periods and societies,” and in today’s world “[n]ursing, medicine, and the allied health disciplines justify their status as healing professions by underlining their professional commitment to caregiving.”

Dr. Kleinman’s words in these essays have delivered for me, a physician, the kind of a jolt you get if you pull off your clothes on a hot June day and jump into a Catskill mountain pond. A systemic shock, then the deep breaths that bring a liberating awareness of the world around us.

Kleinman has drawn a bright line around the sphere of caregiving. He reminds us that our relationships with those we care for give our lives meaning. He then extends this truth to the caregiving professions.

The shock and awareness come refreshingly thanks to Kleinman’s gentle assertion that market forces and money interests — profit-seeking — serve only to poison and undermine the very relationships that are most defining of our humanity and our profession.

Kleinman writes: “Everyone who has been in love or built a family knows that there are things, essential things, that money can’t buy.

“Patients with serious illness and their network of caregivers know this too, because those things that really matter to us are threatened and must be defended.”

He then says many clinicians “reflecting on what is at stake in health care not only for patients but for themselves, know the same thing: the market has an important role in health-care financing and health systems reform, but it should not reach into those quintessentials of caregiving that speak to what is most deeply human in medicine and in living.”

To briefly digress, I so admire Dr. Kleinman’s courage. It is not easy to explain the experience of becoming a physician, let alone the ongoing work we do to be the best we can be for our patients and our fellow caregivers. Kleinman locates our profession within a continuity of sharing, self-sacrifice and humanity — a profession with profound rewards on the most basic and human level, rewards not measurable with money.

He introduces, courageously, a deeply personal element. He offers reflections on the personal role of caregiving for his wife, who developed early Alzheimer’s disease.

Dr. Kleinman alludes to the corrosive, corrupting external pressures of what he calls “the market model” and “the clarion call of efficiency” weighing upon doctors and nurses and family members. Yet, from the standpoint of personal responsibility, he doesn’t let any of us off the hook. He challenges all of us to insist that health policies and programs place caregiving at their core.

If we don’t demand this, Kleinman writes, “all of us are demeaned and the profession of medicine and the processes of health care are transmuted into something that is hollowed of its humanity and moral value.”

Dr. Kleinman’s honesty brings a liberating awareness. He invites us to face our contemporary crisis in health care with sober senses. Every effort to turn caregiving into a marketplace transaction does indeed demean us – not just we doctors and our patients, but all of us.

As distressing as the idea is that money interests threaten to steal humanity from our professional efforts at caregiving, Kleinman encouragingly notes that among many clinicians the passion for caregiving is still very much alive. This is true in my experience too. The urgent task, however, is to elevate that passion – through medical education and other means – to a new level in the face of challenging, market-oriented headwinds.

In my view, the first step toward protecting the sphere of caregiving from the corrupting influence of money would be to enact a national health program, publicly financed, truly universal, and stripped of the corporate profiteering that afflicts us today. It’s an achievable goal, as other nations have shown us. And it will bring us closer to what Dr. Kleinman calls “enact[ing] care as humankind’s shared project.”

Dr. Andrew Coates practices internal medicine in upstate New York. He is president of Physicians for a National Health Program.

You can listen to Dr. Coates’ radio broadcast here: http://www.wamc.org/post/andrew-coates-caregiving-humankinds-shared-project

Private insurers' Medicare Advantage plans cost Medicare an extra $34.1 billion in 2012

Instead of being more efficient, private insurers have cost Medicare almost $300 billion more over the life of the program

FOR IMMEDIATE RELEASE, May 10, 2013

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

A study published online today finds that the private insurance companies that participate in Medicare under the Medicare Advantage program and its predecessors have cost the publicly funded program for the elderly and disabled an extra $282.6 billion since 1985, most of it over the past eight years. In 2012 alone, private insurers were overpaid $34.1 billion.

That’s wasted money that should have been spent on improving patient care, shoring up Medicare’s trust fund or reducing the federal deficit, the researchers say.

The findings appear in an article published in the International Journal of Health Services by Drs. Ida Hellander, Steffie Woolhandler and David Himmelstein titled “Medicare overpayments to private plans, 1985-2012: Shifting seniors to private plans has already cost Medicare US$282.6 billion.”

Hellander is policy director at Physicians for a National Health Program (PNHP), a nonprofit research and advocacy group. Woolhandler and Himmelstein are professors at the City University of New York School of Public Health, visiting professors at Harvard Medical School and co-founders of PNHP.

Medicare has contracted with private insurance plans – previously referred to as Medicare HMOs and now called Medicare Advantage plans – since 1985. Such plans, most of them for-profit, currently cover about 27 percent of Medicare enrollees and have been growing at a fast clip. UnitedHealth and Humana are among the largest players in this market, and together operate about one-third of such plans.

Medicare pays these privately run plans a set “premium” per enrollee for hospital and physician services (averaging $10,123 in 2012) based on a prediction of how costly the enrollee’s care will be.

The authors find that private insurers have four strategies that make them more costly than the traditional Medicare program.

1.    Private plans cherry-pick healthier beneficiaries who cost less to care for, guaranteeing large profits. Although private plans must accept all seniors who choose to enroll, they cherry-pick by selectively recruiting the healthiest seniors through advertising, office location, etc. They also induce sicker ones to disenroll by making expensive care inconvenient.
2.    They recruit otherwise healthy seniors with very mild (and inexpensive) cases of sometimes serious conditions – automatically triggering higher premiums for these beneficiaries from the risk-adjustment scheme implemented in 2004, but escaping payments for expensive care. For instance, many seniors have very mild cases of arthritis, heart failure and bronchitis that require little or no treatment.
3.    They enroll patients who get most of their care free at the Veteran’s Administration.
4.    They heavily lobby Congress to raise their reimbursement. The insurance industry successfully induced Congress and the Bush administration to add bonus payments to Medicare Advantage premiums beginning in 2003.

Since the study was completed, the industry has again successfully lobbied the administration to raise payments to Medicare Advantage plans, reversing a planned cut of 2.2 percent in reimbursement rates and instead obtaining a 3.3 percent increase. Stock prices of private insurers soared over the announcement.

“We’ve long known that Medicare has been paying private insurers more than if their enrollees had stayed in traditional fee-for-service Medicare, but no one had added up the total extra cost to the taxpayer since contracting with private insurers began 27 years ago,” said Dr. Ida Hellander, lead author of the study. “Nor has anyone systematically examined the many ways that private insurers have gamed the system to maximize their bottom line at taxpayers’ expense.”

“In 2012 alone, private insurers are being overpaid $34.1 billion, or $2,526 per Medicare Advantage enrollee,” Hellander said.

Co-author Dr. Steffie Woolhandler said: “It’s clear that having Medicare Advantage programs compete with Medicare doesn’t save us money. In fact the opposite is the case. The private plans only add waste, and the aggregate waste is staggering – enough to be a significant drag on the economy.

“It’s time we look to proven, cost-effective ways of providing high-quality care to Medicare’s beneficiaries and to the entire population,” Woolhandler said. “That means taking a fresh look at the single-payer model of reform.”

###

“Medicare overpayments to private plans, 1985-2012: Shifting seniors to private plans has already cost Medicare US$282.6 billion.” Ida Hellander, M.D., Steffie Woolhandler, M.D., M.P.H., David U. Himmelstein, M.D. International Journal of Health Services, May 10, 2013 (online first), Vol. 43, No. 2. DOI: 10.2190/HS.43.2.g

Physicians for a National Health Program (https://pnhp.org) is a nonprofit educational and research organization of more than 18,000 doctors who advocate for single-payer national health insurance.

Medicare private plans overpaid $282 billion

Medicare Overpayments to Private Plans, 1985-2012: Shifting Seniors to Private Plans has Already Cost Medicare $282.6 Billion

By Ida Hellander, David U. Himmelstein, Steffie Woolhandler
International Journal of Health Services, Volume 43, Number 2 / 2013, Posted online May 10, 2013

Abstract:

Previous research has documented Medicare overpayments to the private Medicare Advantage (MA) plans that compete with traditional fee-for-service Medicare. This research has assessed individual categories of overpayment for, at most, a few years. However, no study has calculated the total overpayments to private plans since the program’s inception. Prior to 2004, selective enrollment of healthier seniors was the major source of excess payments. We estimate this has added US$41 billion to Medicare’s costs since 1985. Medicare adopted a risk-adjustment scheme in 2004, but this has not curbed private plans’ ability to game the payment system. This has added US$122.5 billion to Medicare’s costs since 2004. Congress mandated increased payment to private plans in the 2003 Medicare Modernization Act, which was mitigated, to a degree, by the subsequent Affordable Care Act. In total, we find that Medicare has overpaid private insurers by US$282.6 billion since 1985. Risk adjustment does not work in for-profit MA plans, which have a financial incentive, the data, and the ingenuity to game whatever system Medicare devises.

How Does Medicare Overpay Private Plans?

1. The selective enrollment of healthier beneficiaries before 2004, or what we will call “old cherry-picking.” Under the payment formula in effect until 2004, Medicare paid private plans a premium that was risk-adjusted only for a few demographic factors, such as age, gender, disability, whether an enrollee resided in a nursing home, and Medicaid eligibility (a proxy for poverty). Hence a healthy 70-year-old man would bring the same premium as his sicker, 70-year-old neighbor. Private plans used marketing, benefit design, enrollment office location, and other techniques to recruit the healthy and discourage sicker seniors from enrolling.

2. Gaming of Medicare’s more complex risk-adjustment scheme, known as Hierarchical Condition Categories (HCCs). Since 2004, private plans have been selectively enrolling beneficiaries with very mild cases
of the medical conditions included in the HCC risk-adjustment formula; such patients have, on average, substantially lower costs than the risk-adjusted premium payment that Medicare pays the private plan on their behalf. We refer to this as “new cherry-picking.”

3. Congressionally-mandated overpayments included in the 2003 Medicare Prescription Drug, Improvement, and Modernization Act (MMA), including duplicate payments for indirect medical education. The provisions that generated this overpayment were tacked onto the MMA after heavy lobbying by the private insurance industry.

4. Bonus payments from the $8.35 billion CMS Medicare Advantage Quality Bonus Payment Demonstration, an expansion of the $3 billion in quality bonuses contained in the ACA. This demonstration will award bonuses to plans covering more than 90 percent of MA beneficiaries and offset more than one-third of the cuts to MA overpayments mandated by the ACA between 2012 and 2014. According to the General Accountability Office (GAO), the demonstration is so poorly designed that it will generate almost no useful findings to improve quality.

5. Duplicate payments for private plan members who receive all or part of their care at Veterans Health Administration (VA) facilities. Medicare pays the private plan a full premium payment, no matter how much of the patient’s care is delivered (and paid for) by the VA. In an extreme case, a senior might receive all care at the VA, making the premium given to the private plan pure profit. In 2009, 8.3 percent of all MA enrollees were enrolled in the VA.

Conclusions

Advocates of market-based Medicare reforms suggest that competition among private plans will induce greater efficiency and result in cost savings. Our findings indicate that the opposite is true. Private plans have drained more than $280 billion from Medicare since 1985, most of it in the last eight years. Increasing private enrollment through voucher-type Medicare reform (as suggested by Republicans) or through quality bonuses and financial incentives to plans to enroll dual-eligible beneficiaries (as enacted by President Barack Obama’s administration) will almost certainly raise Medicare’s costs, not lower them.

Funds wasted on overpayments to private MA plans could instead have been used to improve benefits for seniors, extend the life of the Medicare Trust Fund by more than a decade, or reduce the federal deficit. Private insurers have enriched themselves at the expense of the taxpayers.

It is time to end Medicare’s long and costly experiment with privatization. The U.S. needs to adopt a single-payer national health insurance program with proven, effective methods for controlling costs.

http://baywood.metapress.com/app/home/contribution.asp?referrer=parent&backto=issue,7,11;journal,1,170;linkingpublicationresults,1:300313,1  (you may have to cut and paste this link)

Comment:

By Don McCanne, M.D.

Now we know that the private Medicare plans have been overpaid $282 billion in taxpayer funds. The Obama administration has continued to add to the overpayments by expanding eligibility for extra quality award payments to which the plans were not entitled, and by using a bookkeeping gimmick for suspended SGR adjustments. Congress and the administration, in using our taxpayer funds to reward this unprincipled industry, should pay a political price for their misdeeds.

The health law and its incentives

By Marc H. Lavietes, M.D.
The New York Times, Letters, May 9, 2013

Re “What Health Insurance Doesn’t Do,” by Ross Douthat (column, May 5):

Ross Douthat’s statement that liberals “remain wedded to the dream of a health care bureaucracy that pays” is disingenuous. Obamacare will provide greater access to health care but will neither diminish health care costs nor provide universal care. Progressive physicians favor a single-payer health plan serving as an insurance fund, leaving physicians free to organize their own practices and patients free to choose their physicians.

“Lump” payments for a given condition (angina, asthma) rather than individual payments for each test ordered would push physicians to minimize testing rather than maximize it, and thus limit cost. A powerful single provider could negotiate reasonable drug prices, thus decreasing the exorbitant cost of prescription drugs.

Countries with a single-payer system show major reductions in their administrative costs. Pharmaceutical industry and medical insurance company profits are unconscionable. It is possible to improve health care while limiting both bureaucracy and cost.

Dr. Marc H. Lavietes, a clinical associate professor of medicine at U.M.D.N.J., is secretary of Physicians for a National Health Program, New York City chapter. He resides in Bradley Beach, N.J.

http://www.nytimes.com/2013/05/10/opinion/the-health-law-and-its-incentives.html?_r=0

CMS pushes price transparency

Administration Offers Consumers an Unprecedented Look at Hospital Charges

Centers for Medicare and Medicaid Services, May 8, 2013

New data released today show significant variation across the country and within communities in what hospitals charge for common inpatient services.

“Currently, consumers don’t know what a hospital is charging them or their insurance company for a given procedure, like a knee replacement, or how much of a price difference there is at different hospitals, even within the same city,” Secretary Sebelius said.

These amounts can vary widely.  For example, average inpatient charges for services a hospital may provide in connection with a joint replacement range from a low of $5,300 at a hospital in Ada, Okla., to a high of $223,000 at a hospital in Monterey Park, Calif.

“Transformation of the health care delivery system cannot occur without greater price transparency,” said Risa Lavizzo-Mourey, M.D., RWJF president and CEO.

http://www.cms.gov/apps/media/press/release.asp?Counter=4596

Medicare Provider Charge Data: http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/index.html

Comment:

By Don McCanne, M.D.

So now we have access to hospital chargemaster prices – meaningless numbers that nobody pays. And that is going to make us better health care shoppers?

What matters are payments, not prices. Actual payments are negotiated prospectively by private insurers, and even more effectively by Medicare. Cash paying patients usually feebly attempt to conduct negotiations retroactively, if they pay at all.

This CMS effort on hospital price transparency will have almost no impact on controlling total health care spending since chargemaster prices are a fabrication.

There is a far better way to control spending without forcing patients to make unwise health care decisions in their efforts to avoid the financial burdens of health care. Each hospital should be placed on a global budget, just as we do with our police and fire departments. That way, services are rendered simply when needed, without having an associated price tag.

Requiring price shopping as a prerequisite to health care access is anathema to health care justice.

Oregon needs single-payer health care

By Bill Whitaker
Wallowa County Chieftain (Enterprise, Ore.), May 8, 2013

Many Wallowa County families and businesses are facing financial catastrophe because of the increasing cost of health insurance and medical care. They hope that the Affordable Care Act (“Obamacare”) will cure their problems. Unfortunately it will not.

The Oregon legislature has the opportunity to pull Oregon back from the health care brink. HB 2922, The Affordable Health Care for All Oregon Plan Act, would establish a universal single-payer health care system for all of Oregon. Passing this bill would allow every family in Oregon to get the health care they need when they need it. Oregonians would spend no more on health care than they do now, probably less.

Objections to HB 2922 are not financial: at this moment single-payer systems throughout the U.S. and in Oregon provide better care to more people for less money than our private insurance industry. Almost every large business in Oregon uses its own private single-payer system (also known as “self-funded”) to finance health care for its employees. All our armed forces and veterans get their health care through single-payer systems.

Single-payer is not experimental. It provides access when needed. It costs less than private health insurance. And people who receive single-payer care are healthier than they would be with private insurance.

Oddly, the biggest objections to creating a single-payer system in Oregon are not financial. They are based on the erroneous assumption that the Affordable Care Act (“Obamacare”) will solve all our problems.

Here’s why Obamacare takes us closer to the brink of catastrophe.

Obamacare will not improve access to health care. The Congressional Budget Office (CBO) estimates the ACA will leave 60 million Americans under-insured (at risk for bankruptcy if a family member gets the wrong disease at the wrong time) or uninsured (with no access to care whatsoever). We do not yet have a study in Oregon, but we can expect 700,000 Oregonians to be left at risk for medical bankruptcy or death from a treatable disease – if the ACA works perfectly.

Obamacare will increase, not decrease, health care costs. Although government spending goes down, expenses for patients go up; the CBO estimates a $100 billion annual increase. We can expect annual costs in Oregon to increase by over $1 billion – if the ACA works perfectly.

The ACA will not improve public health. We know this because of the experience in Massachusetts. Since implementing its own version of Obamacare in 2006 (now known as “RomneyCare”), nearly 100 percent of Massachusetts residents own a health insurance policy. However, measures of public health have not improved; medical bankruptcies have increased 30 percent; and health care costs in Massachusetts are rising faster than any region in the country. (Massachusetts began with the highest health care costs in the country and still leads all other states).

What does all this mean for Oregon? After we fully implement Obamacare, we can expect health care to remain dangerously inaccessible, our health care costs and medical bankruptcies to increase, and our public health to continue to deteriorate – if the ACA works perfectly.

Obamacare is not the answer. The consequences of Obamacare will make health care reform in Oregon more urgent than ever. Oregon must act decisively now to protect our health care in the future.

Oregon needs and deserves single-payer health care. A public hearing on HB 2922 will be held in Salem on May13. Every resident of Wallowa County and eastern Oregon should ask Rep. Bob Jenson and Sen. Bill Hansell about HB 2922 and what it can do for you and your family’s health care.

For further information about how you can help bring health care to every person in Oregon, contact: Oregon Rural Action Health Care Reform Action Team, bill@oregonrural.org, 541-663-1358. See our website at oregonrural.org. You can help ensure every Oregonian gets the health care they need. Everybody in, nobody out!

Bill Whitaker is co-chair of the Oregon Rural Action Health Care Reform Action Team.

http://wallowa.com/opinion/regional_opinions/commentary-oregon-needs-single-payer-health-care/article_e4a4d1d2-b772-11e2-b173-0019bb2963f4.html

Bernie Sanders on primary care

Primary physician shortage calls for intervention

By Sen. Bernie Sanders
Politico, May 7, 2013

The American approach to primary health care is one of the more glaring failures of a dysfunctional health care system that costs almost twice as much per capita as that of any other major country — often with worse results.

Instituting major reforms in primary care and enabling people to see a doctor when they need one will save lives, ease suffering and save billions of dollars in wasteful health care costs. What should we do?

First, we need to substantially increase the number of primary-care practitioners. In most countries, about 70 percent of doctors practice primary care while 30 percent are specialists. We have it backward. Only 30 percent of doctors in America practice primary care.

Second, we must implement a major change in the culture of our medical schools. Some medical schools do an excellent job educating primary-care physicians, but too many do too little and some — believe it or not — do nothing at all. In 2011, about 17,000 doctors graduated from American medical schools. Only 7 percent of those graduates chose a primary-care career.

Third, we need to greatly expand the Federally Qualified Health Center program which today provides high quality and affordable health care, dental care, mental health treatment and low-cost prescription drugs to 22 million Americans, regardless of income. This is a program that provides some of the most cost-effective health care in the country and serves as a medical home for millions with nowhere else to go.

Finally, we should greatly expand the National Health Service Corps, which provides loan-forgiveness and scholarships to students who are prepared to provide medical, dental and mental health care in underserved areas. Like the community health center program, the health service corps has expanded in recent years. In 2012, the corps provided financial help to nearly 10,000 clinicians, nearly three times more than in 2008. That’s a good step forward, but nowhere near enough.

The bottom line is that we need a revolution in primary health care services and accessibility.

(Sen. Bernie Sanders (I-Vt.) is chairman of the Subcommittee on Primary Health Care and Aging of the Senate Health, Education, Labor and Pensions Committee.)

http://www.politico.com/story/2013/05/doctors-physician-shortage-calls-for-intervention-91024.html

Comment:

By Don McCanne, M.D.

Every expert understands the pressing need to reinforce our primary care infrastructure – a need that grows more urgent with the implementation of the Affordable Care Act. The inevitable transformation into a single payer system will be much smoother if we already have a high-performance primary care infrastructure in place.

Sen. Bernie Sanders provides us with a framework for expanding that system. It’s too bad that we don’t have a Congress that is willing to support the reforms that we need. We need to keep Sen. Sanders and his allies and replace the rest of them.

Health care in America: best of all possible worlds?

By Elena Rumiantseva
Examiner, May 6, 2013

SEATTLE – The Western Washington chapter of Physicians for a National Health Program (PNHP) held its annual public meeting on May 4 at the University of Washington’s Kane Hall. The theme was “Health care is a human right.” PNHP adheres to this philosophy and pushes for universal health coverage in the United States.

The meeting was opened by Dr. Jim Squire, president of the Western Washington chapter of PNHP, who argued that health care should be organized as a fire department. People who had fires before don’t pay a larger premium if their house sets on fire again (read, no pre-existing condition). Everybody gets the same protection in case they need the services of the fire crew. It should be this way for health care needs. When a person has to go to the doctor, he should be able to do it without thinking twice about the cost.

Dr. Andy Coates, national president of PNHP, stated that health care is tied to caregiving. It is continuous: today your neighbor needs it, and tomorrow you might need it. That is why it has to be available to everybody. Coates said, “Social solidarity is the only foundation for quality health care.” Right now our country lacks this foundation. Incomes have shrunk in real dollars since the recession began, and some families face a choice whether to buy food or necessary medications. Income inequality exacerbates the problem, creating “second class” citizens with low expectations of their basic rights of health and well-being.

Corporate ownership of health care services is also stunning. There are for-profit hospices and ambulances; private equity firms own the majority of nursing homes. Single-payer is the first step of stopping this madness. Then we need transformation of caregiving, Coates reiterated in the end of his presentation.

While Coates and Squire talked about health care from a philosophical point of view, there was an economist on the panel, who crunched the numbers for the audience. Gerald Friedman is the professor of economics at the University of Massachusetts, Amherst, and he researches questions about labor history and the economics of health care. He was the keynote speaker at PNHP’s annual meeting last October.

Statistics that Friedman offered to the people’s attention supported the general message of the meeting that health care is a human right. On average, a person pays $6,000 for health care per year and lives to 80 years old. If this number is compared to numbers of other developed nations, it turns out that for this money a person should live until 84 years. That is significant if we think in terms of the whole population in the U.S. For data from OECD, click here.

According to statistics presented by Friedman, in 1960, 7 percent of total wages went to cover medical costs. In 1970 it went up to 11 percent, in 1980 to 17 percent, in 1990 to 26 percent. In 2010 the share of wages that went to cover health care costs was 39 percent. Unfortunately, the Affordable Care Act (also known as “ObamaCare”) will not fix the problem of rising costs. The number of uninsured is also expected to rise. In 2017 it will be 29 million people, in 2023 – 30 million.

Of course, the ACA deserves some kind words. It will ultimately remove the words “pre-existing condition” from use by insurance companies and more people will receive coverage through expanded Medicaid if the states choose to have it. However, the underlying problems of inequality and high costs with ever-shrinking benefits will not go away. “Shared risk,” “consumer-directed health care” and “pay for quality” are euphemisms that mean more costs will be shifted to the consumer.

To fix these problems, this country needs to cover everybody and remove the profit motive from the equation. It can and will be done, as all the speakers at the program stressed. So, the question is, do we live in the best of all possible worlds, as Leibniz quipped, or can we improve ours to be more just, fair and equal?

http://www.examiner.com/article/health-care-america-best-of-all-possible-worlds?cid=rss

Health Affairs articles on Medicare reform options

Tackling the Cost Conundrum

Health Affairs, May 2013

Medicare Essential: An Option To Promote Better Care And Curb Spending Growth

By Karen Davis, Cathy Schoen and Stuart Guterman

We describe a new option we call Medicare Essential, which would combine Medicare’s hospital, physician, and prescription drug coverage into an integrated benefit with an annual limit on out-of-pocket expenses for covered benefits. Cost sharing would be reduced for enrollees who seek care from high-quality low-cost providers. Out-of-pocket savings from lower premiums and health care costs for a Medicare Essential enrollee could be $173 per month, compared to what an enrollee would pay with traditional Medicare, prescription drug and private supplemental coverage. Financed by a budget-neutral premium, we estimate that this new plan choice could reduce total health spending relative to current projections by $180 billion and reduce employer retiree spending by $90 billion during 2014–23. Given its potential, such an alternative should be a part of the debate over the future of Medicare.

http://content.healthaffairs.org/content/32/5/900.abstract

Supplemental Coverage Associated With More Rapid Spending Growth For Medicare Beneficiaries

By Ezra Golberstein, Kayo Walsh, Yulei He and Michael E. Chernew

Supplemental coverage makes health care more affordable for beneficiaries but also makes beneficiaries insensitive to the cost of their care, thereby increasing the demand for care. We found that supplemental insurance coverage was associated with significantly higher rates of overall spending growth. Specifically, employer-sponsored and self-purchased supplemental coverage were associated with annual total spending growth rates of 7.17 percent and 7.18 percent, respectively, compared to 6.08 percent annual growth for beneficiaries without supplemental coverage. Results for Medicare program spending were more equivocal, however. Our results are consistent with the belief that current trends away from generous employer-sponsored supplemental coverage and efforts to restrict the generosity of supplemental coverage may slow spending growth.

http://content.healthaffairs.org/content/32/5/873.abstract

Public Financing Of The Medicare Program Will Make Its Uniform Structure Increasingly Costly To Sustain

By Katherine Baicker, Mark Shepard and Jonathan Skinner

In this article we describe a model incorporating the benefits of public programs and the cost of tax financing. The model implies that the “one-size-fits-all” Medicare program, with everyone covered by the same insurance policy, will be increasingly difficult to sustain. We show that a Medicare program with guaranteed basic benefits and the option to purchase additional coverage could lead to more unequal health spending but slower growth in taxation, greater overall well-being, and more rapid growth of gross domestic product.

Our model thus helps explain the rapid growth in US health care expenditures relative to other countries. More important, the model highlights the trade-offs in different approaches to reining in public spending — from the current approach of providing a uniform benefit that increasingly crowds out other programs, to a less egalitarian model that guarantees only a basic benefit and redirects some redistribution toward other programs.

Our analysis suggests that the policy of providing a uniform benefit to all — rather than a basic benefit that higher-income residents can augment — may be increasingly untenable if health care expenditures continue to rise.

Other excerpts:

Why has the United States diverged so dramatically from its counterparts? This divergence is probably not explained by commonly cited factors such as administrative costs — already high by the 1980s — or physician salaries, which have stagnated over the past decade.

The implications of our model are not dissimilar to the idea of voucher-type premium support suggested over the years by Ezekiel Emanuel and Victor Fuchs, Henry Aaron and Robert Reischauer, and Rep. Paul Ryan (R-WI). Indeed, it may appear that this plan most closely resembles a Ryan-style premium support plan.

Our “basic” plan does not correspond so much to a high-deductible or higher-cost-sharing plan, but rather to one that covers a more limited set of treatments or providers. Unlike high-deductible plans, the basic plan need not expose poorer households to the risk of substantial cost sharing. Instead, it is designed to limit coverage to treatments with proven effectiveness at a reasonable cost. Of course, identifying which treatments are of high value — and for which patients — poses substantial challenges.

Perhaps the greatest challenge to offering this kind of plan choice more widely in Medicare is that it would require setting aside the egalitarian goals enshrined in the Medicare legislation of 1965. Publicly providing only basic coverage would implicitly recognize that higher-income households would probably elect to procure more generous coverage — and, ultimately, to obtain more health care and possibly better health outcomes.

http://content.healthaffairs.org/content/32/5/882.abstract

Background paper (40 pages): “Optimal Healthcare Spending with Redistributive Financing”

http://www.dartmouthatlas.org/downloads/papers/ShepardBaickerSkinner_OptimalHealthSpending.pdf

Three Large-Scale Changes To The Medicare Program Could Curb Its Costs But Also Reduce Enrollment

By Christine Eibner, Dana P. Goldman, Jeffrey Sullivan and Alan M. Garber

With Medicare spending projected to increase to 24 percent of all federal spending and to equal 6 percent of the gross domestic product by 2037, policy makers are again considering ways to curb the program’s spending growth. We used a microsimulation approach to estimate three scenarios: imposing a means-tested premium for Part A hospital insurance, introducing a premium support credit to purchase health insurance, and increasing the eligibility age to sixty-seven. We found that the scenarios would lead to reductions in cumulative Medicare spending in 2012–36 of 2.4–24.0 percent. However, the scenarios also would increase out-of-pocket spending for enrollees and, in some cases, cause millions of seniors not to enroll in the program and to be left without coverage.

http://content.healthaffairs.org/content/32/5/891.abstract

Additional Reductions In Medicare Spending Growth Will Likely Require Shifting Costs To Beneficiaries

By Michael E. Chernew

The Affordable Care Act created a projected trajectory for Medicare spending per beneficiary that is lower than historical growth rates. Although opportunities for one-time savings exist, any long-term savings from Medicare, beyond those already forecast, will probably require a shift in spending from taxpayers to beneficiaries via higher beneficiary premium contributions (overall or via means testing), changes in eligibility, or greater cost sharing at the point of service.

http://content.healthaffairs.org/content/32/5/859.abstract

Comment:

By Don McCanne, M.D.

At a time when our politicians have decided to open discussions on reducing government spending in Medicare, it likely is no coincidence that this cluster of articles on ways of reforming the financing of Medicare appears in the leading journal of health policy – Health Affairs. But beware; the thrust of most of the articles should raise our concerns.

The most alarming articles are the pair from Katherine Baicker and her colleagues. They support unlimited care with “better health outcomes” for higher-income households, with only “basic” care for for the rest of us, even though they note that defining basic c
are “poses substantial challenges.” Class division in health care seems to be a uniquely American concept. “It would require setting aside the egalitarian goals enshrined in the Medicare legislation of 1965.”

The article by Ezra Golberstein and his colleagues calls for diminishing the financial protection offered by supplemental Medigap and retiree health benefits “to restrict the generosity of supplemental coverage,” making beneficiaries more sensitive to the cost of their care, even though “results for Medicare program spending were more equivocal.” Feeling the pain of their health care spending seems to be the policy goal even if the total reduction in Medicare spending is only nominal.

Christine Eibner and her colleagues propose, “imposing a means-tested premium for Part A hospital insurance, introducing a premium support credit to purchase health insurance, and increasing the eligibility age to sixty-seven” as three means of reducing overall Medicare spending, even though these measures would shift costs to the beneficiaries and cause perhaps millions of them to withdraw from Medicare and remain uninsured.

Michael Chernew keeps it simple. Lowering the projected trajectory for Medicare spending “will probably require a shift in spending from taxpayers to beneficiaries via higher beneficiary premium contributions (overall or via means testing), changes in eligibility, or greater cost sharing at the point of service.” In other words, reduce the tax transfer by sticking it to the seniors.

We can thank Karen Davis, Cathy Schoen and Stuart Guterman for not causing us to lose all hope. Their proposal – “Medicare Essential” – is designed to increase the coverage and efficiency of Medicare. They would combine the hospital Part A, physician Part B, and drug Part D programs into a single program with less administrative complexity. They would also add much needed catastrophic coverage by placing a maximum on out-of-pocket expenses. They would also fold in the benefits of supplemental plans eliminating the need for wasteful, superfluous Medigap and retiree health plans. Their proposal would actually reduce spending for most Medicare beneficiaries while enhancing the benefits.

They would leave in place the flawed Medicare Advantage plans, although competing with a truly superior public plan could make them obsolete – the goal of “the public option.” They would have the deductible apply to Part A, opening the treacherous territory of a path for more cost shifting to beneficiaries. Also they do not mention that Medicare Essential could eventually be expanded to include everyone, becoming an improved Medicare for all. There are many other important features of the PNHP version of the single payer model that they do not address, and that we won’t mention here. Suffice it to say, that Medicare Essential is only a tiny though important step in the direction in which we should be headed.

For incrementalists, Medicare Essential should captivate you. For those of us who are impassioned single payer supporters, we should continue to advocate for moving the political process forward toward achieving an Improved Medicare for All single payer program as soon as possible.

PNHP leader honored for ‘extraordinary commitment’ by peers

Dr. Oliver Fein receives prestigious David R. Calkins Award at SGIM meeting

PNHP note: The following text consists of two parts: (1) a news release from the Society of General Internal Medicine, and (2) the remarks of Dr. Oliver Fein, past president of Physicians for a National Health Program, upon receiving the award.
Dr. Oliver Fein
Calkins Award Announcement

Oliver Fein, M.D., professor of clinical medicine and clinical public health at the Weill Cornell Medical College, received the David R. Calkins Award in Health Policy Advocacy at the 36th Annual Meeting of the Society of General Internal Medicine (SGIM) on April 26 in Denver.

Dr. Fein was honored for his “extraordinary commitment in health policy advocacy.”

During the 1990s, Dr. Fein founded the Health Reform Cluster of SGIM’s Health Policy Committee, which he subsequently chaired. In 1993-94, he served as a Robert Wood Johnson Health Policy fellow in the congressional office of Senate Majority Leader George Mitchell, where he championed issues related to primary care training. In 2008, he received the Robert Wood Johnson Health Policy Fellowship Alumni Award for Excellence in Promoting and Advancing Health Policy, a Lifetime Achievement Award.

In 2009, as president of Physicians for a National Health Program (PNHP), Dr. Fein attended the White House Health Care Summit, where he advocated for single-payer national health care reform.

At Weill Cornell, he is co-director of the David Rogers Health Policy Colloquium, a weekly forum for the discussion of health policy issues and directs a two-week course for internal medicine residents titled “Perspectives on the Changing Health Care System.”

At the SGIM meeting, Dr. Fein’s acceptance speech was followed by a standing ovation.

*****

Remarks upon receiving the Calkins Award

By Oliver Fein, M.D., F.A.C.P.

Wow, this is so exciting and completely unexpected.

Exciting, because it is a thrill to be recognized for doing valuable work by one’s peers.

Unexpected, because I thought some members of SGIM might not agree with aspects of my advocacy. For example:

• My passing out leaflets at the 2008 SGIM Annual meeting questioning the keynote invitation to Gail Wilensky, an economist who favors Paul Ryan’s premium support proposal to privatize Medicare by converting it into a defined contribution program.

• My efforts at the 2011 SGIM Annual meeting to organize a “white coat” demonstration attended by over 300 SGIMers at the Arizona Statehouse to protest Arizona’s anti-immigrant legislation.

• My persistent attempt to get SGIM to support single-payer national health care reform.

In 1992, anticipating the Clinton presidency, SGIM’s Health Policy Committee distributed a questionnaire on health care reform. Fifty-eight percent of SGIMers responded and over 80 percent supported universal access to health care.

In 2003-4, we repeated the questionnaire, but only got a 26 percent response rate, still with overwhelming support for universal access.

Finally, in 2009, with the election of Barack Obama, the SGIM Council adopted a statement favoring “access to affordable, comprehensive, equitable health care for all residents of the United States.” But it still didn’t include a call for single payer.

And here we are, in 2013, SGIM honors me with the David Calkins Award for health policy advocacy … in part because of my advocacy for single-payer health care reform.

What are the lessons I hope you take away from this experience:

• SGIM is a dynamic organization. SGIM not only tolerates dissent within its ranks, it rewards it!

• Advocacy for social justice issues generates respect from your peers.

• Don’t give up on single-payer Medicare-for-All. It places a priority on access to health care, can be financed fairly, and has the greatest potential to control costs. Keep the vision alive!

I have so many people to thank for this honor: First my four brothers and our immigrant parents, who in spite of being small-business Republicans, taught me social justice – to respect and value every human being equally.

Second, I thank my partner and wife of 49 years, Charlotte Phillips, and our two daughters, Kim and Jess and granddaughter Clara, for their ongoing support.

And third, I want to thank all those people, some of whom are in this room, who have supported me throughout my career: during residency at Lincoln Hospital in the South Bronx; at Columbia-Presbyterian where we tried to make the academic health center socially accountable to the community; and at Cornell, where we have tried to diversify the clinical education of our students by getting them off the island of Manhattan (particularly the Upper East Side) into the Bronx, Queens and Brooklyn, and subsequently off the continent of North America to Africa, Asia, Latin America, and Europe. Special thanks to SGIM members who served and still serve on the Health Policy Committee. I could not have done all these things without all of you. This award is your award.

I love this quote from Martin Luther King: “The arc of the moral universe is long, but it bends toward justice.”

And I love this paraphrase: “The arc of history is long, but it bends toward universal access to single-payer health care.”

Perhaps access to health care will become the civil rights movement of the 21st century.