PNHP

Greece's crucial lessons on austerity and health

Greece's crucial lessons on austerity and health

Economic Crisis, Restrictive Policies, and the Population’s Health and Health Care: The Greek Case

By Elias Kondilis, MD, PhD, Stathis Giannakopoulos, MD, PhD, Magda Gavana, MD, PhD, Ioanna Ierodiakonou, MD, PhD, Howard Waitzkin, MD, PhD, and Alexis Benos, MD, PhD
American Journal of Public Health, Published online April 18, 2013

The global economic crisis has affected the Greek economy with unprecedented severity, making Greece an important test of the relationship between socioeconomic determinants and a population’s well-being.
 
Suicide and homicide mortality rates among men increased by 22.7% and 27.6%, respectively, between 2007 and 2009, and mental disorders, substance abuse, and infectious disease morbidity showed deteriorating trends during 2010 and 2011. Utilization of public inpatient and primary care services rose by 6.2% and 21.9%, respectively, between 2010 and 2011, while the Ministry of Health’s total expenditures fell by 23.7% between 2009 and 2011.

What to Learn from the Greek Case

It is tragic that Greece has become an important test regarding the impact of economic and social determinants on a population’s health and well-being. Evidence presented indicates that economic recession and its consequences (unemployment, poverty and social exclusion, homelessness, and insecurity) exert important effects on Greece’s population health and health care services. Several causes of mortality and morbidity related to mental health, substance abuse, and infectious disease already show clear rising trends. Heightened needs and increased demand on public services collide with austerity and privatization policies.

http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2012.301126

And…

More Children in Greece Are Going Hungry

By Liz Alderman
The New York Times, April 17, 2013

Last year, an estimated 10 percent of Greek elementary- and middle-school students suffered from what public health professionals call “food insecurity,” meaning they faced hunger or the risk of it, said Dr. Athena Linos, a professor at the University of Athens Medical School.

(Principal Leonidas) Nikas has taken matters into his own hands and is organizing food drives at (his) school. He is angry at what he sees as broader neglect of Greece’s troubles by Europe.

“I’m not saying we should just wait for others to help us,” he said. “But unless the European Union acts like this school, where families help other families because we’re one big family, we’re done for.”

http://www.nytimes.com/2013/04/18/world/europe/more-children-in-greece-start-to-go-hungry.html?hp&pagewanted=all

And…

Child Well-Being in Rich Countries

UNICEF, April 2013

Rank of child well-being in 29 nations of the industrialized world

25th – Greece
26th – United States

http://www.unicef-irc.org/Report-Card-11/

And…

Growth in a Time of Debt

By Carmen M. Reinhart, Kenneth S. Rogoff
National Bureau of Economic Research (NBER), January 2010

Our main findings are: First, the relationship between government debt and real GDP growth is weak for debt/GDP ratios below a threshold of 90 percent of GDP. Above 90 percent, median growth rates fall by one percent, and average growth falls considerably more.

http://www.nber.org/papers/w15639

And…

Does High Public Debt Consistently Stifle Economic Growth? A Critique of Reinhart and Rogoff

By Thomas Herndon, Michael Ash, Robert Pollin
Political Economy Research Institute, University of Massachusetts Amherst, April 15, 2013

Herndon, Ash and Pollin replicate Reinhart and Rogoff and find that coding errors, selective exclusion of available data, and unconventional weighting of summary statistics lead to serious errors that inaccurately represent the relationship between public debt and GDP growth among 20 advanced economies in the post-war period. They find that when properly calculated, the average real GDP growth rate for countries carrying a public-debt-to-GDP ratio of over 90 percent is actually 2.2 percent, not -0:1 percent as published in Reinhart and Rogo ff. That is, contrary to RR, average GDP growth at public debt/GDP ratios over 90 percent is not dramatically different than when debt/GDP ratios are lower.

Overall, the evidence we review contradicts Reinhart and Rogoff ‘s claim to have identified an important stylized fact, that public debt loads greater than 90 percent of GDP consistently reduce GDP growth.

http://www.peri.umass.edu/236/hash/31e2ff374b6377b2ddec04deaa6388b1/publication/566/

Comment:

By Don McCanne, M.D.

Greece’s austerity program, accompanied with privatization of public health services, is having tragic consequences, reflected in the health of the people. Not only is health care impaired, the children are going hungry! It is particularly tragic when you consider that there are solutions to their economic crisis, other than austerity, that would keep their children fed and in good health.

The world-wide austerity movement received a big boost with the publication three years ago of the paper by Carmen Reinhart and Kenneth Rogoff supposedly showing that public debt to GDP ratios over 90 percent resulted in considerable declines in the growth rate of the economy. The “austerians” were off and running. Paul Ryan even included the concept in the budget passed this year by the Republican-controlled House of Representatives.

The problem with the Reinhart/Rogoff thesis is that it is flat-out wrong. The paper by Thomas Herndon and his colleagues proved to be a bombshell that refuted the R/R doctrine and demonstrated that “average GDP growth at public debt/GDP ratios over 90 percent is not dramatically different than when debt/GDP ratios are lower.” Economists and policy makers are in a frenzy, and let’s hope that it results in a conclusion that transitional resolutions to economic crises require the use of debt to prevent austerity measures that negatively impact the most basic of needs for the people.

So when we look at the UNICEF rankings of child well-being in industrialized nations, we are saddened by the fact that Greece ranks 25th amongst 29 nations. If the European Union had a little heart, they would be helping their sister country pull out of the crisis without extracting a requirement that Greece raises its misery index.

(Excuse the deliberate deception, but it is to make a point. The misery index is a combination of high unemployment and high rates of inflation. Yet inflation is very low, but the austerians are convinced that it should be high even if it isn’t, and so they are acting accordingly – more austerity!)

At least in the United States we are smart enough to not let our budget deficits shift us into an austerity mode. Or are we? President Obama is now negotiating with Republicans to cut back on two of our most successful social programs – Social Security and Medicare, as part of an austerity program.

Where do we stand now? The UNICEF ranking of child well-being has placed the United States in the 26th position, below Greece! More austerity is the very last thing we need!

For those who have been feeling so smug as we look at Greece’s tragic circumstance, think again! Then fire the austerians! It’s a matter of social justice.

Study reveals austerity’s harmful impact on health in Greece

FOR IMMEDIATE RELEASE
April 18, 2013

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

Findings are ‘much worse than we imagined,’ researcher says

In one of the most detailed studies of its kind, a team of Greek and U.S. researchers have vividly chronicled the harmful public health impacts of the economic austerity measures imposed on Greece’s population in the wake of the global economic crisis.

Writing in today’s American Journal of Public Health, the researchers cite data showing the economic recession and subsequent austerity policies in Greece have led to a sharp deterioration of health services and health outcomes.

Researchers at the Aristotle University of Thessaloniki in Greece and the University of New Mexico in the United States studied current data on economic and social conditions, utilization of health services, and health outcomes.

They found that key public health indicators declined in tandem with the recession and austerity policies that reduced public services.

For example, between 2007 and 2009, suicide and homicide mortality rates among men increased by 22.7 percent and 27.6 percent, respectively. Mental disorders, substance abuse, and infectious diseases showed worsening trends.

Despite deteriorating health conditions, cutbacks occurred in government financing of public services, as the Ministry of Health’s total expenditures fell by 23.7 percent between 2009 and 2011.

Meanwhile, due to unemployment and loss of personal income, patients decreased their use of private medical facilities, and utilization of already-stressed public inpatient and primary care services rose by 6.2 percent and 21.9 percent, respectively, over a two-year period.

Dr. Elias Kondilis, lead author of the study and a researcher at Aristotle University, commented from London, “We were expecting that these austerity policies would negatively affect health services and health outcomes, but the results were much worse than we imagined.”

Based on their findings, the authors criticize austerity policies that are likely to cause deteriorating health conditions in other European countries and in the United States.

The U.S.-based researcher on the team, Dr. Howard Waitzkin, distinguished professor emeritus of sociology and medicine at the University of New Mexico, said: “The policies of cutbacks currently proposed in the United States for Medicare and Social Security will lead to similar devastating effects on health services and outcomes. Instead of austerity policies, we need increased public sector spending to stimulate our failing economy and to protect the health of our people.”

In contrast to the Greek experience, the authors point to several Latin American countries that have resisted demands to reduce public investments in health services. Such policies, they argue, have led to improved economic and health indicators.

The senior researchers of the study were Dr. Howard Waitzkin on the U.S. side and Dr. Alexis Benos in Greece. Both are readily available for comment.

*****

“Economic crisis, restrictive policies, and the population’s health and health care: The Greek case,” Elias Kondilis, M.D., Ph.D., Stathis Giannakopoulos, M.D., Ph.D., Magda Gavana, M.D., Ph.D., Ioanna Ierodiakonou, M.D., Ph.D., Howard Waitzkin, M.D., Ph.D., and Alexis Benos, M.D., Ph.D., American Journal of Public Health, April 18, 2013 (online ahead of print). For AJPH reprint and subscription information, visit www.ajph.org.

A copy of the study is available at www.pnhp.org/kondilis.

*****

Physicians for a National Health Program (www.pnhp.org) is a nonprofit research and education organization of more than 18,000 doctors who advocate for single-payer national health insurance, an improved Medicare for all. Dr. Howard Waitzkin is a founding member of PNHP; Dr. Alexis Benos spoke to PNHP’s Annual Meeting in San Francisco in October. PNHP had no role in funding or otherwise supporting the study described above. To speak with a physician/spokesperson in your area, visit www.pnhp.org/stateactions or call (312) 782-6006.

Greed, fear and other barriers to health care as a human right

By Philip Caper, M.D.
Bangor Daily News, April 18, 2013

Of all the wealthy countries, only the United States has so far failed to treat health care as a human right. A human right to health care means that everybody receives the same health care whatever their age, gender, health or employment status, racial or religious background, sexual orientation, or wealth and income level.

One reason I often hear cited for our failure to join all other wealthy nations in making health care a human right is that we can’t afford it. Some argue, “We’re already spending too much on health care and cannot afford to expand coverage to everybody.”

They have it backwards. Our failure to expand health care to everybody is a major cause for our high costs, not a reason for not doing more. Slicing and dicing our population into “risk categories” (the fundamental business of the commercial insurance industry), having thousands of different insurance companies (all with their own rules), then arguing about who pays what is very expensive.

The Institute of Medicine recently reported that around 25 percent of the approximately $3 trillion we spend as a nation annually on health care is wasted. Much of this waste is traceable back to the way we pay for that care, segmenting the population into categories and paying for them separately: the elderly, the poor or near-poor, the employed, the unemployed, young people, sick people, well people, veterans, Native Americans, and so on.

Each category and its attached financing pool receives its own treatment — range of benefits, prices, utilization review programs, amounts of co-pays and deductibles and more. This complexity is very costly, not only for the private insurers and public programs, but also for doctors, hospitals and health care systems to administer.

I recently heard the CEO of a large Medicare Advantage plan in Maine say that he could cut his overhead by 50 to 60 percent if we reduced the number of payment plans he had to deal with to one. He then went on for the first time publicly to endorse a universal plan for Maine — everybody in, nobody out of the same plan.

Our system of financing health care in the U.S. leaves many people without coverage (about 35 million in the case of Obamacare, even in the unlikely event everything works perfectly), leading to high rates of avoidable human suffering and personal bankruptcy. Obamacare is far too complicated, as was Maine’s ill-fated Dirigo program. Both made the mistake of trying to build on our current, badly flawed employment-based health insurance system.

Obamacare’s rollout is already over budget and behind schedule, mostly because of its complexity. Maine’s Dirigo program is on life support and slated to be phased out. I’m afraid their problems are only going to get worse.

Other countries figured out long ago that simplicity works and as a result have health care systems that cover everybody, get better results than we do for most health outcomes, are far more popular with both their publics and politicians, and cost about half of what ours does.

As a physician, I have always thought that health care should be a human right. I believe there is a strong moral argument for health care systems that cover everybody. There is now a strong economic argument as well. Overwhelming evidence exists from all other wealthy countries that a simpler and therefore more efficient system is much less expensive and more humane than ours.

So why don’t we just go ahead and simplify our system by expanding Medicare, a program that is overwhelmingly popular with the U.S. public, to everybody?

When I’m asked this question, I think of “A-FIG:”

— Apathy on the part of the protected classes. Those of us employed by large businesses, highly paid executives and some union workers who enjoy good (and heavily tax-subsidized) health insurance. “I’ve got mine.”

— Fear of losing what we already have, if we are consumers of health care, and of losing our (sometimes excessively high) incomes, if we are individual or corporate providers of health care.

— Ignorance on the part of most Americans about how our health care system now works, that other nations have better health care systems than ours by almost all measurable outcome criteria, and that our health care system could be much better here, if we had the political will to change it.

— Greed on the part of lots of people (most of them corporate “people”) who are enjoying windfall profits and would like to continue doing so from our present disorganized, poorly regulated and opaque system.

We could do much better. As more of us question the status quo and understand how health care as a human right can become a reality, reasons for not doing so will dwindle to nothing.

Physician Philip Caper of Brooklin is a founding board member of Maine AllCare, a nonpartisan, nonprofit group committed to making health care in Maine universal, accessible and affordable for all. He can be reached at pcpcaper21@gmail.com.

http://bangordailynews.com/2013/04/18/health/greed-fear-and-other-barriers-to-health-care-as-a-human-right/

Public and private payment of hospital complications

Relationship Between Occurrence of Surgical Complications and Hospital Finances

By Sunil Eappen, MD; Bennett H. Lane, MS; Barry Rosenberg, MD, MBA; Stuart A. Lipsitz, ScD; David Sadoff, BA; Dave Matheson, JD, MBA; William R. Berry, MD, MPA, MPH; Mark Lester, MD, MBA; Atul A. Gawande, MD, MPH
JAMA, April 17, 2013

We found that under private insurance and Medicare, which cover the majority of US patients, the occurrence of surgical complications was associated with higher hospital contribution margins. Depending on payer mix, efforts to reduce surgical complications may result in worsened near-term financial performance.

The financial effects of surgical complications varied considerably by payer type. Complications were associated with more than $30 000 greater contribution margin per privately insured patient ($16 936 vs $55 953) compared with less than $2000 per Medicare patient ($1880 vs $3629). In contrast, for Medicaid and self-pay procedures, those with complications were associated with significantly lower contribution margins than those without complications.

http://jama.jamanetwork.com/article.aspx?articleid=1679400

And…

Making Surgical Complications Pay

By Uwe E. Reinhardt, PhD
Editorial, April 17, 2013, JAMA

In this issue of JAMA, Eappen et al reach the troublesome but not surprising conclusion that hospitals in the United States can profit handsomely from postsurgical complications, even if the hospitals could avoid them.

Under the federal Medicare program, payment for all of the services involved in hospital inpatient treatment has been bundled since the mid-1980s into 1 payment per inpatient case categorized into 1 of 745 distinct diagnosis related groups (DRGs) of cases, which are categorized by adjustments for complications and comorbidities. This approach has made Medicare a pioneer in payment reform that has since been copied worldwide.

According to the authors’ propensity-adjusted estimates, a patient with 1 or more complications results in a $39 017 (95% CI, $20 069-$50 394) greater contribution margin than a patient without complications if the care is reimbursed by a private payer. In contrast, for Medicare, the gain in complication-related contribution margins is only $1749 (95% CI, $976-$3287). This observation contradicts the prevailing perspective that private insurers are axiomatically assumed to be smarter payers than government-run Medicare. However, if, as the authors imply, many of the observed postsurgical complications were avoidable, then perhaps Medicare should more appropriately be considered a smarter payer than private insurers. By having moved to the bundled DRG payments for inpatient care as early as the mid-1980s, Medicare appears to have largely avoided rewarding hospitals financially for avoidable mistakes.

However, the data reported by the authors appear different for the state-run Medicaid programs. Essentially, Medicaid did not even cover the hospital’s variable costs of treating Medicaid patients. Suggesting to the public that fellow citizens receiving Medicaid have adequate health insurance but then not covering even the clinicians’ and hospitals’ variable costs of treating those patients might warrant the label of “government-initiated Medicaid fraud.”

http://jama.jamanetwork.com/article.aspx?articleid=1679384

Comment:

By Don McCanne, M.D.

In reporting this JAMA article on surgical complications and hospital finances, headlines throughout the nation are stating that hospitals profit from surgical errors. The story that should be reported is that private insurers have been richly rewarding hospitals for surgical complications, whereas Medicare has largely avoided paying these rewards.

Specifically, private insurers pay an average of $39,000 more for surgical complications whereas Medicare pays only $1,700 extra. Obviously the government has done a much better job than the private sector in ensuring value in our health care purchasing, not to mention providing incentives to improve performance.

The government isn’t always right, as the Medicaid program demonstrates. Being chronically underfunded, Uwe Reinhardt suggests that the resulting underpayments “might warrant the label of ‘government-initiated Medicaid fraud.'”

Medicare’s prospective payment system using DRGs (745 diagnosis-related groups) has improved payment levels, but it still provides an incentive for the provision of excess care. There is a better way. Hospitals should receive global budgets based on legitimate costs, just as our fire and police departments are budgeted. Periodic re-budgeting will compensate for changing medical and community requirements. Of course, incentives catering to passive investors should be removed by converting all hospitals to nonprofit status.

Global budgeting for hospitals is just one of the features of the single payer model of reform as advocated by Physicians for a National Health Program, all of which together would result in an affordable system of high-quality care for everyone. We should go for it.

Rep. Kowalko reintroduces single-payer health care bill

By James Dawson
WDDE Public Radio (Dover, Del.), April 12, 2013

In a legislative season marked by hot-button issues, one Delaware lawmaker is adding another to that list. Rep. John Kowalko (D-Newark South) introduced a bill this week that would transform the state’s health care system into a single-payer option.

Kowalko introduced a similar bill late last session, but it failed to gain traction. He says the new system would pay for Delawareans’ health care through new taxes instead of private insurance.

“To be honest and frank and blunt, yes, they’re new taxes,” said Kowalko. “But to be honest and frank and blunt, they are supplanting a probably higher rate of revenue that is leaving the pockets of the employers and the employees at this time.”

Kowalko adds the move would eliminate administrative overhead and duplicative costs associated with insurance companies, although he is concerned about those who could face layoffs if the bill passes. He says that’s an unfortunate possibility, but single payer would ultimately reduce costs for everyone.

“We have got to get off the fact that health care available availability and health care insurance is a job placement service when it’s at the expense of the rate payers, because it’s becoming unmanageable,” said Kowalko.

Part of the money collected through taxes would go toward retraining displaced workers for up to three years after becoming law.

The new taxes would be levied through the payroll tax, personal income tax and an additional surcharge on high-income earners.

Senate Minority Whip Greg Lavelle (R-4th District) says this bill would reduce consumer choices and would not support it.

“This does nothing to strengthen the economy. Right now, we’ve got a hobbled economy with a sprained ankle. It doesn’t make sense to come in and whack it with an axe to make it better.

He says he doesn’t believe that it would actually lower costs to Delawareans. “These things never go as suggested. Just look at the Affordable Care Act. This is just such an inopportune time to introduce something like this.”

http://www.wdde.org/42444-kowalko-single-payer-bill

Fox News: Obamacare takes food off the table

Nation's biggest movie theater chain cuts workweek, blaming ObamaCare

By Perry Chiaramonte
FoxNews.com, April 15, 2013

The nation’s largest movie theater chain has cut the hours of thousands of employees, saying in a company memo that ObamaCare requirements are to blame.

Regal Entertainment Group, which operates more than 500 theaters in 38 states, last month rolled back shifts for non-salaried workers to 30 hours per week, putting them under the threshold at which employers are required to provide health insurance. The Nashville-based company said in a letter to managers that the move was a direct result of ObamaCare.

One Regal theater manager told FoxNews.com the move has sparked a wave of resignations from full-time managers who have seen their hours cut by 25 percent or more.

The manager told FoxNews.com ObamaCare has had the unintended consequence of taking food off his table.

“Mandating businesses to offer health care under threat of debilitating fines does not fix a problem, it creates one,” he said. “It fosters a new business culture where 30 hours is now considered the maximum in order to avoid paying the high costs associated with this law.

Regal, which operates cinemas under the names Regal Cinemas, Edwards Theatres and United Artists Theaters and recently purchased Oregon-based Hollywood Theaters for $191 million, did not respond to repeated requests for comment from FoxNews.com. The publicly-traded company’s stock has risen nearly 30 percent over the last year.

http://www.foxnews.com/us/2013/04/15/nation-biggest-movie-theater-chain-cuts-workweek-blaming-obamacare/

Comment:

By Don McCanne, M.D.

It is no surprise that Fox News would frame the 30 hour work week requirement under the Affordable Care Act as “ObamaCare has had the unintended consequence of taking food off (the) table.”

Regal Entertainment Group is only one of many employers who have decided to limit part time workers to 30 hours to avoid the requirement of providing them with health insurance. That does create financial hardships for lower-income employees. They must either find more part time work, in which case they still wouldn’t be eligible for employer-sponsored health plans, or they must find a new, full-time job at a time in which unemployment rates are quite high.

Fox’s framing indicates that the problem is the requirement in “ObamaCare” for larger employers to provide health insurance for their employees, or face a penalty for not doing so. Fox is right when you consider that legislation designed to expand health care coverage instead has the result of causing low-income workers to lose one-fourth of their work week hours, and still remain uninsured. But is this really the prime issue?

The problem that needs to be framed properly is the tens of millions in our nation who have no insurance. How do we cover those people? Obviously a single payer national health program financed equitably through progressive taxes would solve the problem, without taking food off of anyone’s table.

Instead, if we look only at the coverage provisions of the Affordable Care Act, we see an administratively complex, wasteful, fragmented system of a multitude of varying eligibilities and coverage requirements that can never ensure that everyone has stable coverage indefinitely. In fact, it is estimated that after the provisions are in full force, there will still be 30 million people without any coverage at all (CBO). What is worse, we will be paying much more than we would have if we were instead to adopt a single payer, improved Medicare for all.

Until we start doing a better job of framing the problems, we are not going to come up with the right solutions.

Oregon lawmaker pitches universal health care study

Funding for the study to provide health care financing for all Oregonians would come from private sources, and the study would consider several options, including single-payer, a public option and hybrid model to provide care from cradle-to-grave. A Pennsylvania study found a state single-payer government health insurance system would cut health care costs 15 percent

By Christopher David Gray
The Lund Report (Portland, Ore.), April 12, 2013

The Affordable Care Act will roll out next year, and Oregon has instituted its own pioneering health care delivery reforms through coordinated care organizations.

But Rep. Michael Dembrow, D-Portland, believes these reforms will not go nearly far enough to drive down the health care costs and make health care affordable for everyone.

He and other liberal Democrats would like to go beyond the federal health insurance reforms and get rid of private health insurance once and for all, replacing it with a single-payer government health insurance similar to Medicare that would provide coverage to everyone from cradle-to-grave.

But first, Dembrow said, the state needs to find a way to get from here to there.

“We need to do more than back-of-the-napkin figures,” Dembrow said. “We need a high-level study.”

House Bill 3260 would require that the universal health care study take into account 17 different metrics, including cost controls, a fair and sustainable funding stream, a respect for primary-care provider choice, and the ability to provide all health care services — including dental, optical, mental, and long-term care as well as traditional physical health care, hospitalization and ambulance coverage.

“Our health system is one of the most expensive, inequitable, inefficient and unsustainable in the world,” said Chunhei Chi, a health policy scholar at Oregon State University. “I think it is vital that we conduct research so we can run our policy decisions on sound data.”

The ACA’s health care financing reforms will still allow insurers to collect 20 percent of health care costs for administrative purposes, and the ACA requires people in the middle class to pay a higher percentage of their income for health care than those in the upper class. In 2016, even with the reforms, 170,000 Oregonians are still projected to lack health insurance, according to the Oregon Health Authority.

A single-payer health care system seeks to eliminate deductibles and eliminate or reduce copayments. These costs, according to supporters, often leave people reluctant to seek care when they need it, and by delaying going to a physician early on, people may need more expensive care as their health care condition worsens.

The Affordable Care Act prevents states from enacting single-payer health insurance even it’s approved by voters or state legislatures until at least 2017. Dembrow said that preclusion is not a deterrent but is a way of giving Oregon time both to build grassroots support for universal health care and conduct a comprehensive academic study to show the state how to get there.

Such a study would look closely at several options, including a single-payer government insurance system such as the one pushed by Dembrow in House Bill 2922. The Affordable Care Act reforms will be used as the control. Other options include a public option insurance plan and a sales tax driven plan, such as pitched previously by business lobbyist John DiLorenzo.

HB 3260 would call for the Oregon Health Authority to solicit funds for the study, which Dembrow said could be retrieved from private, philanthropic sources.

“I think this is something that can be passed this session, and this will get us ready for 2017,” Dembrow told The Lund Report.

The study bill has won critical support from the Oregon Medical Association, the president of the Oregon Health & Science University and Rep. Jim Thompson of Dallas, the ranking Republican on the House Health Committee.

“I’m probably going to vote in favor. I’m not afraid of a study. It’s a conversation that’s going to move ahead. At the end of the study, at least we’ll have something to evaluate,” Thompson told The Lund Report. “In no way does this mean I support universal health care. I honestly have no idea what we might find.”

Thompson said Oregon lacks enough primary care providers to provide services to everyone, even if all Oregonians had insurance coverage, and has repeatedly expressed this concern with nearly 400,000 Oregonians expected to gain access to coverage next year, according to the Oregon Health Authority.

Rep. Mitch Greenlick, D-Portland, has scheduled a vote in the House Health Committee for Friday on HB 3260, expecting to pass it onto the full House.

Pennsylvania Study Shows 15 Percent Cut in Costs

Pennsylvania just completed a similar study, conducted by health economist Gerald Friedman of the University of Massachusetts, which recommended that Pennsylvania choose a single-payer healthcare plan and estimated it would cut health care spending by 15 percent and save an estimated $17 billion a year in annual health care costs — including $4 billion in state and local government spending, with the rest in savings to employers and individuals.

Chuck Pennacchio, the director of Health Care for All Pennsylvania, said it would be funded by a 3 percent individual income tax and a 10 percent tax on employer payroll. Employers currently spend 20 percent of labor costs on private health insurance, which would no longer be needed.

“We’re actually talking about cutting the cost in half for employees in Pennsylvania,” Pennacchio told The Lund Report.

The savings are a result of drastically reducing the high percentage of health care costs that result from non-medical administrative costs as well as the profits and executive pay of private insurers.

Pennacchio said contrary to making primary care providers scarce, the injection of resources would make the state a magnet for such providers. Single-payer would also cause malpractice rates and claims to drop, increasing the attraction to providers.

“You don’t have to sue for the cost of medical treatment, because that’s already covered,” he said. Reimbursement rates would be set regionally based on the rates in the six bordering states.

The Pennsylvania plan would cover a full spectrum of health care needs, including mental, dental, optical and long-term care — and there would still be enough money to give severance pay to people whose administrative or insurance jobs become obsolete, and provide them with training. Its plan would eliminate 65,000 jobs but create 140,000 new jobs, primarily in health care.

Pennsylvania is unique in America as the only state that has Republican co-sponsors for single-payer legislation. “There’s resistance to the idea of health care as a human right,” Pennacchio said. “[But] Economically, it makes the most sense to cover everybody.”

Unique to Oregon

Dembrow said he couldn’t say for sure that the study would actually recommend a single-payer system which happened in Pennsylvania. Vermont, the
first state to approve a government health insurance system, approved a hybrid model that exempted self-insured companies like IBM as well as federal employees.

Oregon has its own unique elements, such as Kaiser Permanente, which provides an integrated model of care that includes insurance and delivery not found in the East.

Funding the system will also be an uneasy question that the study could help resolve. Oregon already has one of the nation’s highest income taxes, but Dembrow said finding support for a sales tax would be “a long shot” from Oregon voters, which have been reluctant to move in this direction.

“We need this study to figure out what’s right for Oregon,” Dembrow said. Whatever the study ends up showing, Dembrow indicated he’d be supportive as long as the study was done correctly.

Oregon also has a greater challenge than Vermont, which was able to pass its universal health care system through its Legislature with a Democratic governor’s support.

“We have to assume that whatever plan will have to stand up to the scrutiny of the voters,” said Dembrow, who expects a single-payer initiative to require voter approval. Such an initiative is not allowed in Vermont or most eastern states, like Pennsylvania.

Lou Sinninger of Health Care for All Oregon said the Oregon universal health care study will give grassroots organizers who favor universal healthcare a chance to come up with hard data on the advantages of single-payer health insurance.

“The citizens of Oregon, including the Legislature, can make an informed decision to provide health care in Oregon,” Sinninger said. “I would guess that single-payer would come out in the lead.”

Sinninger said single-payer could reform the financial side of health care to complement the delivery reforms that Gov. John Kitzhaber has implemented through coordinated care organizations.

The full Pennsylvania study can be viewed here.

http://www.thelundreport.org/resource/dembrow_pitches_oregon_universal_healthcare_study

To solve health care, Medicare for all

By Kevin Twine
The Times Record (Brunswick, Maine), Letters, March 21, 2013

Thanks to Gordon Weil for his cogent explanation of the cost problem our health care system faces (“The problem with health care is cost, page A10, March 15). “Problem” is a charitable term. “Disaster” would be far more appropriate.

In a nutshell, in comparison with other developed nations, the U.S. health care system has much more unfettered free enterprise, much higher cost, far fewer people covered and quite mediocre results.

More free enterprise is not the solution. We are in this mess because there’s too much free enterprise, and it’s out of control. Hospitals can charge whatever they want in a totally seller’s market. That’s why we get $1.50 Tylenol tablets.

Medicare, because of its size and market clout, limits these abuses — but only for our senior citizens.

I have yet to hear any “free enterprise” health care plans that make sense. All we hear is that Medicare and Medicaid are the problems. The truth is that they are part of our overall health care system and should not be singled out simply because they are big targets. The problem is systemic, and must be dealt with that way.

In fact, Medicare for everyone is an entirely reasonable alternative. It would be relatively easy to implement because it is well-understood, and a sound cost control structure is already in place. It would immediately cut costs because its administrative expenses are low compared with the insurance industry: about 4 percent for Medicare versus more than 25 percent for the insurance companies.

We must cease the ideological arguments and focus instead on solutions that make sense and are attainable. “Medicare For All” fits these criteria quite well.

Kevin Twine resides in Brunswick.

Passing the plate on critical health care

By William D. Clark, M.D.
The Times Record (Brunswick, Maine), Letters, April 9, 2013

Reading your article about the 6-year-old Harpswell girl with severe injuries from a skiing accident (“Harpswell girl, 6, hurt while skiing,” April 1, Page A1) makes me sad.

Reading about local fundraising to cover her medical costs makes me mad.

Imagining that her family might join others bankrupted by health care costs makes me distressed, with 1,830 estimated Maine health care bankruptcies in 2012.

Maine AllCare thinks every Mainer should have comprehensive health insurance. The year we vote it in, the families of 130,000 citizens with no insurance will be spared from bankruptcy when an accident or leukemia strikes from nowhere.

When we do that, Maine will save $1 billion by not paying insurance-industry profits and salaries, eliminating wasteful billing practices and so on.

Maine AllCare supports an improved Medicare for all. Mainers can and should care for each other this way.

How many bake sales does it take to cover treatment costs for “serious head injuries?”

Tell your legislators. The choice is yours. Act. And please join me in wishing the youngster a full and speedy recovery.

Dr. William D. Clark resides in Woolwich.

U.S. cancer drug policy is scandalous

Compared To US Practice, Evidence-Based Reviews In Europe Appear To Lead To Lower Prices For Some Drugs

By Joshua Cohen, Ashley Malins and Zainab Shahpurwala
Health Affairs, April 2013

Abstract

In Europe drug reimbursement decisions often weigh how new drugs perform relative to those already on the market and how cost-effective they are relative to certain metrics. In the United States such comparative-effectiveness and cost-effectiveness evidence is rarely considered. Which approach allows patients greater access to drugs? In 2000–11 forty-one oncology drugs were approved for use in the United States and thirty-one were approved in Europe. We compared patients’ access to the twenty-nine cancer drugs introduced into the health care systems of the United States and four European countries (England and Wales, France, Germany, and the Netherlands). Relative to the approach used in the US Medicare program in particular, the European evidence-based approach appears to have led to reduced prices for those drugs deemed worthy of approval and reimbursement. The result is improved affordability for payers and increased access for patients to those drugs that were available. The United States lacks a systematic approach to assessing such evidence in the coverage decision-making process, which may prove inadequate for controlling costs, improving outcomes, and reducing inequities in access to care.

From the Discussion

The current method in the US Medicare program of seemingly “muddling through elegantly” appears incapable of striking a fiscally sustainable balance between cost and access, particularly with respect to cancer drugs. Spending on cancer treatments continues to grow at double-digit rates annually, which in turn has led to much higher cost sharing for patients. This has an impact on the kind of treatment that Medicare beneficiaries get because patients with better insurance, or those who are able to pay higher out-of-pocket costs, have better access to care.

Conclusion

Medicare policy makers might do well to draw lessons cautiously from the experiences of health care systems that have integrated clinical and economic evaluations into decision making. Should the US Medicare program decide to move toward more systematic use of comparative effectiveness findings, there are formidable challenges inherent in the US system that will need to be addressed.

One challenge is payer fragmentation. The diffuse system of payers would probably make the uptake of comparative effectiveness evidence segmented and uneven.

A second challenge is the view of many oncologists that resources are unlimited. In a US-based survey conducted in 2009, nearly 80 percent of oncologist respondents said that patients should have access to “effective” care regardless of costs. An implied cost-effectiveness threshold was calculated at $300,000 per quality-adjusted life-year. Needless to say, having Medicare pay for every cancer treatment that cost up to that amount would not be feasible in the long run.

There is room in the US Medicare program for more systematic and coordinated methods and a process for developing and implementing evidence relative to cost and cost-effectiveness. The immediate goal should be to encourage a more evidence-based process of decision making by closing the gap between what providers, payers, and policy makers know in pharmaceutical care and what they do.

http://content.healthaffairs.org/content/32/4/762.abstract

Comment:

By Don McCanne, M.D.

Cancer drug policies in the United States, compared to other nations, result in higher drug costs, intolerable out-of-pocket costs, and inequitable access to the drugs – preventing many people from receiving comparatively effective drugs, while enabling others to have very expensive drugs of little or no value, wasting our healthcare dollars.

We can do far better in establishing drug policies that are evidence-based and cost-effective based on quality-adjusted life-years. First we need to elect leaders who care more about us, as patients, than they care about kowtowing to the pharmaceutical giants and other special interests.

When it comes down to it, it really is our fault when we fall for the government-can’t-do-anything-right malarkey, and elect those who disseminate this false notion.

Beyond Obamacare

How a single-payer system can save health care in the United States

By Dave Dvorak, M.D., M.P.H.
Minnesota Medicine, April 2013

As Minnesota’s physicians, health care leaders and legislators grapple with the complex changes brought by the Affordable Care Act (ACA), many are concerned that even after the law is fully implemented, hundreds of thousands of people will remain uninsured while health care costs continue to spiral.

What if there were a simple, streamlined solution that would guarantee health coverage for every Minnesotan while saving the state billions of dollars? A growing number of Minnesota physicians are endorsing what they consider to be such a solution: single-payer health care. Weary of having to comply with hundreds of different insurance plans’ administrative requirements while their patients are denied needed tests and treatments, these physicians are drawn to the simplicity, cost-effectiveness and truly universal coverage offered by a single-payer system.

Their views were supported by an independent analysis last year demonstrating that with a state-based single-payer system, every Minnesotan could have comprehensive coverage while the state would save billions annually.[1]

A deeply flawed system

The desire for meaningful reform comes in the face of the U.S. health care system’s long-recognized dysfunction. Despite health care accounting for 18 percent of the nation’s economy—twice that of other wealthy democracies—48 million Americans lack health coverage.[2,3] Another 29 million are underinsured, having poor coverage that exposes them to unaffordable out-of-pocket expenses.[4] Health insurance premiums have doubled over the past decade, with the average annual cost for family coverage now exceeding $15,700;[5] and health care costs now account for two-thirds of personal bankruptcy filings in the United States.[6]

At the root of these problems is the fact that we have a fragmented, highly inefficient system. Employed Americans younger than 65 years of age have job- based insurance, if their employer chose to provide it; the elderly and disabled are covered through Medicare; the poor by Medicaid; military veterans through the Veterans Administration; and American Indians through the Indian Health Service. Persons who do not fall into any of those categories must try to purchase individual coverage in the private market, where it is often prohibitively expensive or unobtainable if they have a pre-existing health condition.

Owing largely to this fragmentation and inefficiency, a staggering 31 percent of U.S. health care spending goes toward administrative costs, rather than care itself.[7] Inefficiency exists at both the provider and payer level. To care for their patients and get paid for their work, physicians and hospitals must contend with the intricacies of numerous insurance plans—which tests and procedures they cover, which drugs are on their formularies, which providers are in their network. Meanwhile, private health insurance companies divert a considerable share of the premiums they collect toward advertising and marketing, sales teams, underwriters, lobbyists, executive salaries and shareholder profits. The top five private insurers in the United States paid out $12.2 billion in profits to investors in 2009, a year when nearly 3 million Americans lost their health coverage.[8,9]

The ACA of 2010, known widely as Obamacare, is expected to extend coverage to 32 million more Americans.[10] But it accomplishes this goal primarily by expanding the current fragmented, inefficient system and maintaining the central role of the private insurance industry in providing coverage. As a result, the ACA is expected to do little to rein in health care spending.[11] Furthermore, it will fall far short of achieving universal coverage, as tens of millions of Americans (including 262,000 Minnesotans) will remain uninsured after its full implementation.[1,10]

The solution

The central feature of a single-payer health care system would be one health plan that covers all citizens, regardless of their employment status, age, income or health status. Having a public fund that pays for care would slash administrative inefficiencies and eliminate profit-taking by the private insurance industry.

Under a single-payer system, the way society pays for health care would change, but the market-based health care delivery system would remain. Physicians and hospitals would continue to compete with one another based on service, quality of care and reputation. The chief difference is that they would bill a single entity for their services, rather than numerous insurers.

Individuals would benefit immensely by having continuous coverage that is decoupled from their employment. This would alleviate “job lock,” in which people remain in undesirable employment situations in order to maintain coverage. In a single-payer system, individuals could choose to see any provider, in contrast to the current system in which choice is restricted to those who are in-network. Deductibles and copays would be minimal or eliminated, removing cost as a barrier to obtaining needed care.

A single-payer system would be funded through savings on administrative costs, along with modest taxes that would replace the premiums and out-of-pocket expenses currently paid by individuals and businesses. The cost savings to individuals, businesses and government would be considerable. The nonpartisan U.S. General Accounting Office concluded that single- payer health care would save the United States nearly $400 billion per year, enough to cover all of the uninsured.[7,12,13]

Physician support for a simplified, universal health care system is robust and growing. A 2008 survey published in Annals of Internal Medicine found that 59 percent of physicians supported a national health insurance system—up from 49 percent in 2002.[14] Physicians for a National Health Program, a national organization advocating for single-payer reform, reports a membership of 18,000.[15] In Minnesota, single payer has been formally endorsed by nearly 800 physicians, other providers and medical students.[16]

The Minnesota model

Recognizing the implausibility of achieving single-payer reform at the national level in the current political climate, many single-payer advocates have turned their attention to state-level reform. The ACA provides for “state innovation waivers” to be granted beginning in 2017, allowing states to implement creative plans they believe would work best for them. With this in mind, organized single-payer movements have taken root in states as varied as Colorado, Hawaii, Illinois, New York, California, Oregon and Vermont. Vermont’s governor and Legislature passed a law in 2011 setting the path for the state to move toward single payer.[17]

In Minnesota, two advocacy organizations—Health Care for All Minnesota and the Minnesota chapter of Physicians for a National Health Program—are garnering public support for a single-payer system. Gov. Mark Dayton has expressed support for single payer,[18] and Sen. John Marty (DFL-Roseville) has authored legislation to establish such a system in Minnesota. Known as the Minnesota Health Plan, it would replace the current inefficient patchwork of private and public health plans with a single statewide fund that would cover the health needs of all Minnesotans—inpatient and outpatient services, preventive care, prescription drugs, medical equipment and mental health and dental care.[19] A 2012 study by the Lewin Group confirmed the feasibility of single payer in Minnesota. It concluded that adoption of a single-payer system would provide coverage to every Minnesotan, including the 262,000 left uncovered by the ACA, while saving the state $4 billion in the first year alone.[1] The average Minnesota family would save $1,362
annually in health costs, while the average Minnesota employer that currently provides insurance would realize savings of $1,214 per employee per year. The analysis showed these savings came primarily from administrative simplification; provider compensation remained unchanged.

Conclusion

With nearly 50 million uninsured people in the United States and skyrocketing health costs, the need for profound reform of our health system could not be more clear. The ACA is a start, but it will fall far short of achieving universal coverage, and it allows unsustainable spending growth to continue. Single-payer health care would eliminate administrative waste and inefficiency, thereby creating an opportunity to achieve truly universal, cost-effective health care.

Dave Dvorak practices emergency medicine at Fairview Southdale Hospital.

REFERENCES

1. Sheils J, Cole M. Cost and economic impact analysis of a single-payer plan in Minnesota. 2012. Available at: http://growthandjustice.org/ sites/2d9abd3a-10a9-47bf-ba1a-fe315d55be04/ uploads/LEWIN.Final_Report_FINAL_DRAFT.pdf. Accessed February 14, 2013.

2. The World Bank. Health expenditure, total ( percent of GDP). 2012. Available at: http://data.worldbank.org/ indicator/SH.XPD.TOTL.ZS. Accessed February 14, 2013.

3. DeNavas-Walt C, Proctor BD, Smith JC. Income, poverty, and health insurance coverage in the United States: 2011. September 2012. Available at: www. census.gov/prod/2012pubs/p60-243.pdf. Accessed February 14, 2013.

4. Schoen C, Doty MM, Roberston RH, Collins SR. Affordable Care Act reforms could reduce the number of underinsured by 70 percent. Health Aff. 2011; 30(9):1762-71.

5. Kaiser Family Foundation. Employer health benefits 2012 annual survey. Available at: http://ehbs.kff. org/?page=charts&id=1&sn=6&ch=2659. Accessed February 14, 2013.

6. Himmelstein DU, Thorne D, Warren E, et al. Medical bankruptcy in the United States, 2007: results of a national study. Am J Med. 2009. Available at: www.pnhp.org/new_bankruptcy_study/ Bankruptcy-2009.pdf. Accessed February 14, 2013.

7. Woolhandler S, Campbell T, Himmelstein DU. Costs of health care administration in the United States and Canada. N Engl J Med. 2003;349(8): 768-75.

8. U.S. Securities and Exchange Filings. 2010.

9. Health Care for America Now. Health insurers break profit records as 2.7 million Americans lose coverage. 2010. Available at: http://hcfan.3cdn.net/ a9ce29d3038ef8a1e1_dhm6b9q0l.pdf. Accessed February 14, 2013.

10. Congressional Budget Office. Updated estimates for the insurance coverage provisions of the Affordable Care Act. 2012. Available at: www.cbo. gov/system/assets/drupal/cbofiles/attachments/03-13-Coverage%20Estimates.pdf. Accessed February 14, 2013.

11. Keehan SP, Cuckler GA, Sisko AM, et al. National health expenditure projections: modest annual growth until coverage expands and economic growth accelerates. Health Aff. 2012;31(7):1600-12. Available online at: http://content.healthaffairs.org/content/31/7/1600.early. Accessed February 14, 2013.

12. Woolhandler S. Cutting health costs by reducing the bureaucracy. New York Times. November 20, 2011.

13. U.S. General Accounting Office. Canadian health insurance: lessons for the United States. June 1991. Available at: http://archive.gao.gov/d20t9/144039. pdf. Accessed February 14, 2013.

14. Carroll AE, Ackerman RT. Support for national health insurance among US physicians: 5 years later. Ann Intern Med. 2008;148(7):566-7.

15. Physicians for a National Health Program. Available at: www.pnhp.org. Accessed February 14, 2013.

16. Physicians for a National Health Program Minnesota. Available at: www.pnhpminnesota.org/ signers.php. Accessed February 14, 2013.

17. Marcy J. Vermont edges toward single payer health care. Kaiser Health News. October 2, 2011. Available at: http://www.kaiserhealthnews.org/ stories/2011/october/02/vermont-single-payer-health-care.aspx. Accessed February 14, 2013.

18. On the Issues. Mark Dayton on health care. Available at: www.ontheissues.org/governor/ Mark_Dayton_Health_Care.htm. Accessed February 14, 2013.

19. Campaign for the Minnesota Health Plan. Available at: http://mnhealthplan.org/ Accessed February 14, 2013.

http://www.minnesotamedicine.com/Portals/mnmed/April%202013/Beyondobamacare1304.pdf

Economic Crisis, Restrictive Policies, and the Population’s Health and Health Care: The Greek Case

“Economic crisis, restrictive policies, and the population’s health and health care: The Greek case,” Elias Kondilis, M.D., Ph.D., Stathis Giannakopoulos, M.D., Ph.D., Magda Gavana, M.D., Ph.D., Ioanna Ierodiakonou, M.D., Ph.D., Howard Waitzkin, M.D., Ph.D., and Alexis Benos, M.D., Ph.D., American Journal of Public Health, April 18, 2013 (online ahead of print). For AJPH reprint and subscription information, visit www.ajph.org.

Economic Crisis, Restrictive Policies, and the Population’s Health and Health Care: The Greek Case