PNHP

Jack Bernard's message for his fellow Republicans

Jack Bernard's message for his fellow Republicans

Head-in-the-sand 'solution' is killing GOP

By Jack Bernard
DesMoinesRegister.com, July 16, 2012

We Republicans have ourselves to blame for the Affordable Care Act, or Obamacare.

Our reaction to the Clinton health reform proposals in the early 1990s was to have conservative think tanks come up with a free competition model based on expansion of private insurance and Medicaid. That idea became Romneycare, which evolved into Obamacare.

It is our baby, ugly or not.

It is the height of hypocrisy for us now to criticize our own idea unless we have something better to replace it. And, the replacement needs to be comprehensive, not just a series of unacceptable statements and proposals based on doing away with traditional Medicare by turning it into a voucher program and gutting Medicaid by making it into a block grant.

Using vouchers for Medicare just dumps the cost problem into the lap of the powerless patient, rather than the federal government that has clout, making the cost escalation problem worse. The block grants for Medicaid idea just shifts the cost issue onto the states rather than the federal government, which once again solves nothing and only makes things worse.

States will just cut services and people from their Medicaid roles, creating more uninsured. Don’t Iowa hospitals serve enough uninsured in their emergency rooms now?

This gets us to what we as Republicans should do: throw out our rule book and be innovative. People my age will remember how we Republicans were 100 percent against recognizing China before Richard Nixon, the anti-communist crusader, came out for it. We must do the same with health care.

There is only one way to control health care costs and insure universal access — and that is by first admitting that the U.S. system has failed and then adopting ideas that have been proven to work elsewhere. We should take a look at how health care is financed and delivered in other developed nations with lower cost and better morbidity and mortality rates.

A Commonwealth Fund study was issued in May 2012 which did just that for 13 countries. The bottom line is that we spend 17.4 percent of our gross national product on health care, far more than other developed nations, which averaged 9.5 percent. Our per-capita spending was $7,960 versus $3,182 for the group as a whole.

Why? One key factor is prices. For example, U.S. pricing on the 30 most commonly prescribed brand name drugs is one-third higher than Canada and double France, both of which have a form of Universal Medicare.

From looking at the international data, if we Republicans really want to dump the Affordable Care Act, the way to go is Medicare for all. Studies show that the nations with universal health care have better overall health care outcomes than we do, not worse.

And, according to the respected Physicians for a National Health Program, www.pnhp.org, yearly savings generated under Medicare for all would be $400 billion. That would go a long way towards paying for universal coverage, versus the Affordable Care Act, which will increase systemic costs because it relies on private insurance.

The canard about waiting times to see doctors is just a tactic to scare the public. If you need a knee replacement for a knee that has been going bad for years, waiting a little longer for an operation should not be a major issue for the patient. Despite the scare tactics, no one who needs immediate care in Canada is ever left to sit in a line. In any case, there should be no waiting lists at all here. Canada spends just $4,363 per capita on health care versus our $7,960.

If we Republicans took the Medicare-for-all approach, it would thrust us into the vanguard of reform. Instead of the Democrats stealing our ideas, we could steal theirs. When it was implemented and turned out to be widely accepted, as was Medicare in the 1960s, we would be the party the public would look to for the future.

Of course, there is an alternative. We can stick our heads in the sand and push for infeasible actions. That approach is killing us regarding immigration and will work just as well for health care.

(JACK BERNARD of Monticello, Ga., is a retired health care executive who worked extensively with Iowa health care providers, including Iowa Health System. He now is a member of the Jasper County (Ga.) Board of Commissioners and Jasper County Board of Health. Contact: bernard_jack@hotmail.com)

http://www.desmoinesregister.com/article/20120716/OPINION01/307160040/

Comment: 

By Don McCanne, MD

This article should be distributed widely. Although it is written by a Republican, targeting his fellow Republicans, if his party can understand this message, then the Democrats and others who bailed on Medicare for all should be able to understand it as well.

Jack Bernard’s message for his fellow Republicans

Head-in-the-sand ‘solution’ is killing GOP

By Jack Bernard
DesMoinesRegister.com, July 16, 2012

We Republicans have ourselves to blame for the Affordable Care Act, or Obamacare.

Our reaction to the Clinton health reform proposals in the early 1990s was to have conservative think tanks come up with a free competition model based on expansion of private insurance and Medicaid. That idea became Romneycare, which evolved into Obamacare.

It is our baby, ugly or not.

It is the height of hypocrisy for us now to criticize our own idea unless we have something better to replace it. And, the replacement needs to be comprehensive, not just a series of unacceptable statements and proposals based on doing away with traditional Medicare by turning it into a voucher program and gutting Medicaid by making it into a block grant.

Using vouchers for Medicare just dumps the cost problem into the lap of the powerless patient, rather than the federal government that has clout, making the cost escalation problem worse. The block grants for Medicaid idea just shifts the cost issue onto the states rather than the federal government, which once again solves nothing and only makes things worse.

States will just cut services and people from their Medicaid roles, creating more uninsured. Don’t Iowa hospitals serve enough uninsured in their emergency rooms now?

This gets us to what we as Republicans should do: throw out our rule book and be innovative. People my age will remember how we Republicans were 100 percent against recognizing China before Richard Nixon, the anti-communist crusader, came out for it. We must do the same with health care.

There is only one way to control health care costs and insure universal access — and that is by first admitting that the U.S. system has failed and then adopting ideas that have been proven to work elsewhere. We should take a look at how health care is financed and delivered in other developed nations with lower cost and better morbidity and mortality rates.

A Commonwealth Fund study was issued in May 2012 which did just that for 13 countries. The bottom line is that we spend 17.4 percent of our gross national product on health care, far more than other developed nations, which averaged 9.5 percent. Our per-capita spending was $7,960 versus $3,182 for the group as a whole.

Why? One key factor is prices. For example, U.S. pricing on the 30 most commonly prescribed brand name drugs is one-third higher than Canada and double France, both of which have a form of Universal Medicare.

From looking at the international data, if we Republicans really want to dump the Affordable Care Act, the way to go is Medicare for all. Studies show that the nations with universal health care have better overall health care outcomes than we do, not worse.

And, according to the respected Physicians for a National Health Program, www.pnhp.org, yearly savings generated under Medicare for all would be $400 billion. That would go a long way towards paying for universal coverage, versus the Affordable Care Act, which will increase systemic costs because it relies on private insurance.

The canard about waiting times to see doctors is just a tactic to scare the public. If you need a knee replacement for a knee that has been going bad for years, waiting a little longer for an operation should not be a major issue for the patient. Despite the scare tactics, no one who needs immediate care in Canada is ever left to sit in a line. In any case, there should be no waiting lists at all here. Canada spends just $4,363 per capita on health care versus our $7,960.

If we Republicans took the Medicare-for-all approach, it would thrust us into the vanguard of reform. Instead of the Democrats stealing our ideas, we could steal theirs. When it was implemented and turned out to be widely accepted, as was Medicare in the 1960s, we would be the party the public would look to for the future.

Of course, there is an alternative. We can stick our heads in the sand and push for infeasible actions. That approach is killing us regarding immigration and will work just as well for health care.

(JACK BERNARD of Monticello, Ga., is a retired health care executive who worked extensively with Iowa health care providers, including Iowa Health System. He now is a member of the Jasper County (Ga.) Board of Commissioners and Jasper County Board of Health. Contact: bernard_jack@hotmail.com)

http://www.desmoinesregister.com/article/20120716/OPINION01/307160040/

Comment: 

By Don McCanne, MD

This article should be distributed widely. Although it is written by a Republican, targeting his fellow Republicans, if his party can understand this message, then the Democrats and others who bailed on Medicare for all should be able to understand it as well.

Head-in-the-sand 'solution' is killing GOP

By Jack Bernard
Des Moines Register, July 16, 2012

We Republicans have ourselves to blame for the Affordable Care Act, or Obamacare.

Our reaction to the Clinton health reform proposals in the early 1990s was to have conservative think tanks come up with a free competition model based on expansion of private insurance and Medicaid. That idea became Romneycare, which evolved into Obamacare.

It is our baby, ugly or not.

It is the height of hypocrisy for us now to criticize our own idea unless we have something better to replace it. And, the replacement needs to be comprehensive, not just a series of unacceptable statements and proposals based on doing away with traditional Medicare by turning it into a voucher program and gutting Medicaid by making it into a block grant.

Using vouchers for Medicare just dumps the cost problem into the lap of the powerless patient, rather than the federal government that has clout, making the cost escalation problem worse. The block grants for Medicaid idea just shifts the cost issue onto the states rather than the federal government, which once again solves nothing and only makes things worse.

States will just cut services and people from their Medicaid roles, creating more uninsured. Don’t Iowa hospitals serve enough uninsured in their emergency rooms now?

This gets us to what we as Republicans should do: throw out our rule book and be innovative. People my age will remember how we Republicans were 100 percent against recognizing China before Richard Nixon, the anti-communist crusader, came out for it. We must do the same with health care.

There is only one way to control health care costs and insure universal access — and that is by first admitting that the U.S. system has failed and then adopting ideas that have been proven to work elsewhere. We should take a look at how health care is financed and delivered in other developed nations with lower cost and better morbidity and mortality rates.

A Commonwealth Fund study was issued in May 2012 which did just that for 13 countries. The bottom line is that we spend 17.4 percent of our gross national product on health care, far more than other developed nations, which averaged 9.5 percent. Our per-capita spending was $7,960 versus $3,182 for the group as a whole.

Why? One key factor is prices. For example, U.S. pricing on the 30 most commonly prescribed brand name drugs is one-third higher than Canada and double France, both of which have a form of Universal Medicare.

From looking at the international data, if we Republicans really want to dump the Affordable Care Act, the way to go is Medicare for all. Studies show that the nations with universal health care have better overall health care outcomes than we do, not worse.

And, according to the respected Physicians for a National Health Program, www.pnhp.org, yearly savings generated under Medicare for all would be $400 billion. That would go a long way towards paying for universal coverage, versus the Affordable Care Act, which will increase systemic costs because it relies on private insurance.

The canard about waiting times to see doctors is just a tactic to scare the public. If you need a knee replacement for a knee that has been going bad for years, waiting a little longer for an operation should not be a major issue for the patient. Despite the scare tactics, no one who needs immediate care in Canada is ever left to sit in a line. In any case, there should be no waiting lists at all here. Canada spends just $4,363 per capita on health care versus our $7,960.

If we Republicans took the Medicare-for-all approach, it would thrust us into the vanguard of reform. Instead of the Democrats stealing our ideas, we could steal theirs. When it was implemented and turned out to be widely accepted, as was Medicare in the 1960s, we would be the party the public would look to for the future.

Of course, there is an alternative. We can stick our heads in the sand and push for infeasible actions. That approach is killing us regarding immigration and will work just as well for health care.

Jack Bernard of Monticello, Ga., is a retired health care executive who worked extensively with Iowa health care providers, including Iowa Health System. He now is a member of the Jasper County (Ga.) Board of Commissioners and Jasper County Board of Health. Contact: bernard_jack@hotmail.com

http://www.desmoinesregister.com/article/20120716/OPINION01/307160040/

Head-in-the-sand ‘solution’ is killing GOP

By Jack Bernard
Des Moines Register, July 16, 2012

We Republicans have ourselves to blame for the Affordable Care Act, or Obamacare.

Our reaction to the Clinton health reform proposals in the early 1990s was to have conservative think tanks come up with a free competition model based on expansion of private insurance and Medicaid. That idea became Romneycare, which evolved into Obamacare.

It is our baby, ugly or not.

It is the height of hypocrisy for us now to criticize our own idea unless we have something better to replace it. And, the replacement needs to be comprehensive, not just a series of unacceptable statements and proposals based on doing away with traditional Medicare by turning it into a voucher program and gutting Medicaid by making it into a block grant.

Using vouchers for Medicare just dumps the cost problem into the lap of the powerless patient, rather than the federal government that has clout, making the cost escalation problem worse. The block grants for Medicaid idea just shifts the cost issue onto the states rather than the federal government, which once again solves nothing and only makes things worse.

States will just cut services and people from their Medicaid roles, creating more uninsured. Don’t Iowa hospitals serve enough uninsured in their emergency rooms now?

This gets us to what we as Republicans should do: throw out our rule book and be innovative. People my age will remember how we Republicans were 100 percent against recognizing China before Richard Nixon, the anti-communist crusader, came out for it. We must do the same with health care.

There is only one way to control health care costs and insure universal access — and that is by first admitting that the U.S. system has failed and then adopting ideas that have been proven to work elsewhere. We should take a look at how health care is financed and delivered in other developed nations with lower cost and better morbidity and mortality rates.

A Commonwealth Fund study was issued in May 2012 which did just that for 13 countries. The bottom line is that we spend 17.4 percent of our gross national product on health care, far more than other developed nations, which averaged 9.5 percent. Our per-capita spending was $7,960 versus $3,182 for the group as a whole.

Why? One key factor is prices. For example, U.S. pricing on the 30 most commonly prescribed brand name drugs is one-third higher than Canada and double France, both of which have a form of Universal Medicare.

From looking at the international data, if we Republicans really want to dump the Affordable Care Act, the way to go is Medicare for all. Studies show that the nations with universal health care have better overall health care outcomes than we do, not worse.

And, according to the respected Physicians for a National Health Program, www.pnhp.org, yearly savings generated under Medicare for all would be $400 billion. That would go a long way towards paying for universal coverage, versus the Affordable Care Act, which will increase systemic costs because it relies on private insurance.

The canard about waiting times to see doctors is just a tactic to scare the public. If you need a knee replacement for a knee that has been going bad for years, waiting a little longer for an operation should not be a major issue for the patient. Despite the scare tactics, no one who needs immediate care in Canada is ever left to sit in a line. In any case, there should be no waiting lists at all here. Canada spends just $4,363 per capita on health care versus our $7,960.

If we Republicans took the Medicare-for-all approach, it would thrust us into the vanguard of reform. Instead of the Democrats stealing our ideas, we could steal theirs. When it was implemented and turned out to be widely accepted, as was Medicare in the 1960s, we would be the party the public would look to for the future.

Of course, there is an alternative. We can stick our heads in the sand and push for infeasible actions. That approach is killing us regarding immigration and will work just as well for health care.

Jack Bernard of Monticello, Ga., is a retired health care executive who worked extensively with Iowa health care providers, including Iowa Health System. He now is a member of the Jasper County (Ga.) Board of Commissioners and Jasper County Board of Health. Contact: bernard_jack@hotmail.com

http://www.desmoinesregister.com/article/20120716/OPINION01/307160040/

Fee-For-Service is Not the Problem

By Stephen Kemble, M.D.
OpEd News, July 14, 2012

There is a widespread assumption among health policy experts that the key problem with runaway health care costs is unnecessary care driven by the incentive to over-treat that is inherent in fee-for-service payment of doctors. Therefore, the argument goes, we need to improve financial incentives for care coordination and reorganize doctors into “Accountable Care Organizations,” forcing primary care, specialist physicians, and hospitals into shared financial arrangements that shift at least some insurance risks onto providers, countering the fee-for-service incentive to over-treat.

While there are certainly some doctors providing unnecessary procedures due to fee-for-service financial incentives, it is extremely unlikely that this is the root of our health care cost problem. The argument that fee-for-service incentives are the driver of excess health care cost is based on a fundamental misdiagnosis of the reasons for unsustainable cost escalation in U.S. health care.

If one attempts to quantify the sources of excess U.S. health spending by looking at actual evidence, it is apparent that exorbitant and unnecessary administrative costs are the biggest driver (around 20-25 percent of National Health Expenditures[1,2]), followed by unnecessary care due to over-treatment[3,4](perhaps 10 percent of NHE, of which only a fraction is attributable to fee-for-service incentives), and expensive complications of under-treatment due to lack of access (perhaps 5-10 percent of NHE, plus a lot of suffering and death that does not show up in health spending figures). About half of over-treatment is due to unreasonable demands for care by patients, most of which is actually driven by providers (direct-to-consumer advertising for drugs, ads by hospitals, and by the recommendations of doctors.) Malpractice costs and defensive medicine are only a few percent at most.[5]

There is a problem with lack of coordination of care for certain patients, but the far bigger problem is inadequate access to necessary care. There is a nation-wide shortage of doctors in primary care and also in many specialties. This is compounded by the problems of un-insurance and under-insurance, and the refusal of many doctors to accept patients with insurance plans that are onerous, pay low fees, or both. Care coordination is meaningless without access.

According to a recent CBO report[6], all 34 pilot care coordination projects funded by CMS either failed to save any Medicare spending at all, or if they did save on health care spending, they cost more in administrative expenses than they saved, for a net increase in total cost for all of them. Three of four payment reform demonstration projects that relied on pay-for-quality incentives failed to save money, and the only successful one negotiated a discounted, bundled fee for coronary bypass surgeries and did not use pay-for-performance incentives. After three years, the PROMETHEUS project on bundled payments for episodes of care has failed to implement any actual contracts due to the complexities of defining a “bundle.”[7] Just about all the “cost saving” initiatives in the Affordable Care Act (ACA) are along the same lines and will fail for the same reasons.

There are only a few U.S. health reform programs that have actually achieved significant cost savings without relying on “cherry picking” healthier populations and avoiding sicker ones. Major examples are Community Care of North Carolina[8] and Rocky Mountain Health Plans in Colorado[9]. The common denominator is not elimination of fee-for-service, which both still employ; it is physician leadership, high levels of physician participation and buy-in, significantly improved access to outpatient care for sicker high-risk patients, and a shared commitment to quality improvement.

Part of the problem is indeed the imbalance in pay between certain specialties and primary care, rooted in the flawed Medicare SGR physician fee schedule, and we do need to re-think how the money is distributed between “cognitive services” and procedures. Increased payment for primary care and care-coordination is part of the solution, but does not require shifting insurance risk onto doctors via HMOs or ACOs.

Administrative costs

If we want to “bend the cost curve,” we should focus first and foremost on administrative simplification. The drivers of excess administrative costs are primarily due to use of competing insurance plans to finance health care. Insurance works fine for expensive, infrequent, and unpredictable risks like house fires. However, when insuring health care for a population, a large percentage of whom have known risks (pre-existing conditions and risk factors), then the overriding incentive for competing plans is not to offer a better plan; it is to identify higher risk (sicker) individuals and groups and avoid insuring them or avoid paying for their care if they get sick. The attempts in the ACA to counter the perverse incentives due to competition among insurance plans have been watered down and will fail to achieve adequate control of the problem, and are adding even more administrative costs. The only definitive way around these perverse incentives would be to establish a social insurance model with a single risk pool covering an entire population. This means eliminating competing private health insurance plans, at least for medically necessary health care. Competing private health plans also carry approximately six times the administrative cost of a social insurance system.

Since the insurance industry does not want to be pushed out of health care, they have a strong incentive to blame providers and patients for rising health care costs, hence the focus on fee-for-service and unnecessary care, and on increasing cost sharing for patients to deter care. The result is ever rising administrative costs and ever decreasing access to care for sick people.

Over-treatment and fee-for-service

Perhaps 10 percent of national health expenditures is attributable to unnecessary care (over-treatment). Some of this is not due to financial incentives at all, but rather to lack of effort or skill on the part of doctors to persuade patients that further care or the requested treatment is ineffective or would only prolong suffering. Major examples are futile end of life care and antibiotics for colds. Some unnecessary care is also driven by direct to consumer ads for drugs and specialized hospital services, which don’t involve financial incentives for doctors. Only a fraction is attributable to fee-for-service incentives.

Fee-for-service physician payment cannot be a root cause of high U.S. health care costs. Other countries with much less expensive health care systems pay doctors with fee-for-service and seem to have fewer problems with unnecessary care, and in studies of regional variation in Medicare spending, high and low cost areas use fee-for-service equally. It takes a combination of fee-for-service and other factors to generate a lot of unnecessary care, such as for-profit hospitals pushing doctors to do unnecessary procedures, and doctors who start for-profit facilities and therefore have incentives beyond getting paid for professional services.

There are pros and cons to paying physicians with either fee-for-service or salaried arrangements that need to be clearly understood in health care planning. Fee-for-service motivates doctors to work harder than they do under salaried arrangements, but can be an incentive to unnecessary care. Salaried arrangements have no incentive to over-treat, but do introduce an incentive to under-treat and may skimp on necessary care. Salaried doctors also tend to work less hard and have to be pushed to maintain high productivity. Where there is a shortage of doctors, fee-for-service can encourage higher productivity. In urban areas where there is an over-supply of doctors,
salaried arrangements may be better. For patients with straightforward chronic diseases, integrated systems that can enforce protocols for best practice are probably superior. For “complex” patients (around 25 percent of a primary care doctor’s practice[10]) with unclear diagnoses, unusual or complex problems, or poor compliance, fee-for-service is probably superior because doctors will be more motivated to put in the extra time required if they can get paid more for it.

Integrated, capitated health plans such as Kaiser pay doctors on salary, so they have no financial incentive to over-treat. Kaiser does a good job of treating patients with established chronic diseases, but their system can be quite unfriendly to patients with unclear diagnoses, complex interacting problems, or complicating psychosocial problems. Kaiser in Hawaii limits their exposure to Medicare and Medicaid. They accept some Medicaid patients under General Assistance and Aid For Dependent Children, but they declined to bid on a plan for the higher risk Aged, Blind, Disabled population. Their ads are entirely targeted to healthy people. In other words, a good portion of their “success” in delivering cost-effective care is actually attributable to cherry picking healthier populations and avoiding sicker ones.

What does motivate doctors?

Doctors are indeed motivated by financial incentives, and they do expect to achieve an income commensurate with the rigors and expense of the training necessary to do what they do. However, they are also motivated by professionalism: putting the needs of their patients first, quality improvement, and individualizing care for complex and difficult patients.

There are two broad ethical paradigms in the world of economics: commercial ethics and “guardian” ethics.[11] The commercial paradigm assumes a seller and buyer of goods or services, whose power and interests are balanced through the marketplace and the laws of supply and demand, with financial incentives as a primary motivator. Guardian ethics are applicable to socially necessary services that require specialized training not available or achievable by the general public, so that there is an inherent imbalance of power between the provider and recipient of services. Classic examples are the military, medicine, and other specialized professions. In these cases, the interests of the public are protected by a tradition of professionalism and concern for the welfare of the public, or patient, or client, which is held to be a higher ethical value than financial considerations.

There has been a movement in this country for the past 50 years to de-professionalize medicine, with an underlying assumption that commercial ethics are the only valid and trustworthy ethics. This justifies increasing interference in health care decisions by insurance plans and government, and a reliance on financial incentives to “fix” problems in health care, and especially its high cost. However, if doctors are stripped of their professional autonomy and treated as if financial considerations are paramount, they actually do start to abandon professional ethics for commercial ones. They start responding to financial considerations above patient needs; they select patients according to their insurance status; and they look for ways to game the system and make more money from things other than professional services. They begin to try to maximize income by any available means, helping drive the cost of health care higher. Sometimes this leads to outright fraud.

My opinion is that the real cause of much of the physician-controlled unnecessary care in the U.S. is abandonment of traditional professional ethics for commercial ethics — “medicine as a business, patients as consumers” — that when combined with fee-for-service leads to excessive and unnecessary care. If my diagnosis is correct, then the further commercialization of medical practices into competing corporate entities will only make the problem worse.

On the other hand, promotion of professionalism among doctors and harnessing it to make care more cost effective through quality improvement programs is the antidote to both the incentive to over-treat under fee-for-service and to under-treat under salaried arrangements.

Quality Improvement

Payment reform initiatives that rely on financial incentives tied to individual quality and performance ratings of doctors and hospitals carry a serious risk of unintended adverse consequences. Much of health care is too complex to be amenable to valid quality ratings anyhow. Rating individual providers will quickly induce them to game the ratings by up-coding diagnoses or avoiding sicker, atypical, and more complex patients, or it will drive them to refuse plans that impose such ratings. Attempts to correct for these problems require complex information from computerized health records and are fraught with problems. Many older, less tech-savvy physicians are likely to retire rather than accept enforced computerization, and with our nation-wide physician shortage we cannot afford to drive a large number of physicians out of practice.

Instead of rating individual doctors for pay-for-performance, quality improvement efforts should be based on the Continuous Quality Improvement (CQI) model, as exemplified by Intermountain Healthcare in Utah.[12] This model defines problems as systems problems, not problems with individual doctors, and engages all doctors cooperatively in improving care. It means focusing on processes of care and transitions between care settings. It encourages reduced variation in practice patterns without punishing doctors for deviating from guidelines when there are good clinical reasons to do so. It means health IT is not focused on measuring for selection, but on measuring for relative improvement. It does not require all doctors to have an EHR, and it requires less disruption in physician workflow. CQI harnesses physician professionalism to improve care and make it more cost effective, rather than relying primarily on financial incentives.

Achieving cost-effective, sustainable health care

We must abandon the idea that competition among health plans can make care more cost-effective. Competition adds administrative complexity and cost for both plans and providers, and interferes with efficient delivery of health care. It does not reduce total health care costs, but does push plans to try to exclude the sick from coverage, reduce benefits, and increase administrative burdens, all of which are destructive to health care. Fragmentation in health care financing also impairs quality improvement efforts, which work best in a universal system. We need consolidation of health plans under an administrative structure that is accountable to effective delivery of health care.

Universal access to care is crucial to ensuring that health care is delivered in the most cost effective setting, minimizing use of emergency rooms and hospitals. Significant savings from administrative simplification depend on universal access, and quality improvement is much more effective when everyone in a community is included.

Solving our physician workforce problems will require improved pay for care coordination and cognitive services, and correcting the imbalance in pay between procedural specialties and primary care. With a universal system, CPT procedure codes could be replaced with a simplified time-based system, with multipliers for training and overhead costs needed to practice a given specialty. An expanded program like the National Health Service, with government subsidies for medical education in exchange for a commitment to practice in under-served specialties and under-served areas, could remove medical education debt as a deterrent to entering less lucrative specialties such as primary care, psychiatry, and general surgery.

We need to promote professionalism among doctors. I am in favor of requiring all physicians
to be members of a professional organization, tied to licensure, to ensure their participation in system-wide quality improvement, peer review, and continuing education. Physician professionalism, not pay-for-performance, should be the primary driver of quality improvement and cost containment efforts. It is more effective and costs less than managed care administered by an insurance plan.[8,9,12]

Cost-effective, sustainable health care will require a much simpler administrative structure, universal access to necessary care, and organization of doctors to promote quality improvement. Accountability must always be to the health care needs of the population served.

References
1.      Woolhandler S, Campbell T, Himmelstein D. Costs of Health Care Administration in the United States and Canada. N Engl J Med 2003;349:768-75.
2.      Morra D, Nicholson S, Levinson W, Gans DN, Hammons T, Casalino LP. US Physician Practices vs. Canadians: Spending Nearly Four Times as Much Money Interacting With Payers. Health Affairs 30 , No. 8 (2011): doi: 10.1377/hlthaff.2010.0893.
3.      Fisher ES, Bynum JP, Skinner JS. Slowing the Growth of Health Care Costs — Lessons From Regional Variation. N Engl J Med. 2009 Feb 26;360(9):849-52.
4.      White C. Health Status and Hospital Prices Key to Regional Variation in Private Health Care Spending. National Institute for Health Care Reform. Research Brief No. 7 (February 2012).
5.      Mello MM, Chandra A, Gawande AA, Studdert DM. National Costs Of The Medical Liability System. Health Affairs 29, No. 9 (2010): 1569–1577.
6.      Congressional Budget Office. Lessons from Medicare’s Demonstration Projects on Disease Management, Care Coordination, and Value-Based Payment. January 18, 2012 http://www.cbo.gov/ftpdocs/126xx/doc12663/01-18-12-MedicareDemoBrief.pdf .
7.      Hussey PS, Ridgely MS, and Rosenthal MB. The PROMETHEUS Bundled Payment Experiment: Slow Start Shows Problems In Implementing New Payment Models. Health Affairs 30, No. 11 (2011): 2116–2124.
8.      Community Care of North Carolina: Putting Health Reform Ideas into Practice in Medicaid. The Kaiser Family Foundation Publication #7899, May 2009. ( http://www.kff.org/medicaid/7899.cfm )
9.      Bodenheimer, T, West D. Low-Cost Lessons from Grand Junction, Colorado. N Eng J Med 2010; DOI:10.1056/NEJMp1008450.
10.   Grant, RW, Ashburner, JM, Hong, CC, Chang Y, Barry MJ, Atlas, SJ. Defining Patient Complexity From the Primary Care Physician’s Perspective. Ann Int Med 155, No 12 (2011): 797-804.
11.   Jacobs J. Systems of Survival: A Dialogue on the Moral Foundations of Commerce and Politics. New York: Random House; 1992
12.   James BC and Savitzdoi LA. How Intermountain Trimmed Health Care Costs Through Robust Quality Improvement Efforts. Health Affairs 30, no. 6 (2011); DOI:10.1377/hlthaff.2011.0358.

http://www.opednews.com/articles/1/Fee-For-Service-is-Not-the-by-Stephen-Kemble-120706-547.html

Primary care a primary concern: Thousands of new patients will stress already burdened health care system

By Charles McMahon
Portsmouth (N.H.) Herald, July 15, 2012

When more than 100,000 state residents are thrust into the health care system on Jan. 1, 2014 — the date the Affordable Care Act will go into full effect — local primary care physician Dr. Thomas Clairmont said he has only one piece of advice.

Be prepared.

Clairmont, who specializes in geriatric care and is the New Hampshire chairman of Physicians for a National Health Program, said the expected addition of approximately 134,000 uninsured residents into the system will likely be burdensome on a system already struggling to meet patients’ needs.

“Adding that many more patients will be a real problem,” Clairmont said, adding his office in Portsmouth has few openings for new patients.

With his specialty focused around elderly care, Clairmont said he believes there are several things that will need to happen before the floodgates open.

“We need more people doing geriatrics and primary care,” he said.

Clairmont said perhaps the biggest challenge to attracting more people into his line of work is the amount of debt tomorrow’s doctors carry when graduating from medical school.

Having paid $375 a semester when he was in school, Clairmont said he knows of some who are borrowing $75,000 just for the first year of their education. When it’s all said and done, Clairmont said it seems graduates end up with so much debt that most of them only consider high-paying areas of the medical field.

“It’s not because primary care isn’t fun or challenging,” he said. “It’s a matter of income.”

Clairmont said he believes one way the health care law can be improved is by including mandates for raises in salaries for primary care physicians.

This is where someone like Jeanne Ryer comes into play.

As a member of the state’s Primary Care Workforce Commission, Ryer is on the front lines of helping develop strategies to address expected shortages in the field of primary care.

Ryer, who is also director of the New Hampshire Citizens Health Initiative, said she was focused on the issue long before the Affordable Care Act came into play.

Having been in the field for some time now, Ryer said New Hampshire has struggled with shortages in the primary care workforce for years.

“New Hampshire has gone through spasms where it has had problems with primary care and provider shortages in the past,” she said.

Those shortages occurred in the 1990s and in the middle of the last decade, according to Ryer.

Despite the historical trends, Ryer said she believes the fear of a shortage may be exaggerated. She said the more than 100,000 chronically uninsured people in New Hampshire pales in comparison to other states.

“I don’t think we’ll see these floodgates open up,” she said.

The reason being, according to Ryer, is that those who are uninsured will likely fall back on the community health centers, rather than on primary care practitioners.

Ryer said that is the reason why if the state wants to prepare itself, it will invest in community health centers.

“We should be better supporting the community health centers now so they can recruit and retain people now,” she said.

Ryer said another important issue that must be addressed is the creation of more preceptor sites to train nurse practitioners and physician assistants.

“There needs to be places for people to train and practice,” she said. “Where people train is where people stay.”

All in all, Ryer said it’s clear that the state needs to do more.

Ned Helms, director of the Institute for Health Policy and Practice at the University of New Hampshire, said if the state wants to prepare itself it should look to Massachusetts.

Helms, who is also a presidential appointee to the National Prevention Strategy Advisory Group, which is part of the Affordable Care Act, said what happened in Massachusetts was that more and more people ended up filtering into the system than anticipated. When that happened, Helms said it became harder and harder for people to find a primary care practitioner.

With more than 30 years of experience in New Hampshire health policy and politics, Helms said he agrees there aren’t enough primary care physicians because of the compensation.

“We do not pay for and focus on primary care,” he said. “Historically our system is more specialty focused.”

Helms said despite there being uncertainty, the Affordable Care Act is loaded with incentives for people to go into primary care, including grants and incentives for loan repayment if a prospective doctor chooses to go into that field.

“There’s a lot of reform taking place at the local level, in that people are realizing that we have to put a heck of a lot more emphasis on primary care and that we need to start getting folks into the doctor’s office instead of the emergency rooms,” Helms said.

Dr. James Fieseher, a board-certified family practitioner who works with Clairmont, said over the last two years there has been an uptick of medical students going into primary care. However, even if a slight uptick continues, Fieseher said New Hampshire still won’t be nearly prepared enough to meet the demand in 2014. Fieseher said he imagines his office will likely need to add more physicians, but agrees with Ryer that some patients will continue to rely on health centers rather than primary care doctors.

“I already know a number of people that aren’t my patients, who want to be, but don’t have the money to come into the office,” he said.

Looking toward 2014, Fieseher said he believes the uninsured will be a tad “skittish” about how to use the new health care law, meaning the immediate influx of new patients won’t be as bad as most anticipate.

“I think 2014 will be a little bit of a shock,” he said. “But in 2015 and 2016, we won’t be able to churn out primary care physicians fast enough.”

http://www.seacoastonline.com/articles/20120715-NEWS-207150338

Health care reform: Much still to do

By Rob Stone, M.D.
Herald Times (Bloomington, Ind.), July 15, 2012

The Supreme surprise June 28 upholding the constitutionality of President Obama’s health reform still leaves much to be done before the American people will have a health care system worthy of a civilized nation. The Affordable Care Act (ACA) will never live up to its name as it contains insufficient cost controls to make care affordable. Hospitals will still charge $265 for a $2.25 tetanus shot. Insurance companies will continue to drive up premiums.

It was never designed to cover all the uninsured. The Congressional Budget Office had previously estimated that the bill would leave 26 million of the nation’s 50 million uninsured still uncovered, even when fully implemented. We await new projections, but preliminary data suggest that the Medicaid expansion ruled unconstitutional by the court will cut perhaps 8 million from the number who could otherwise expect to have been covered, leaving 34 million, or 11 percent of Americans uninsured. In the developed world, there is no other country with more than 3 percent of its population uncovered.

Too many of those insured under the ACA will have coverage so skimpy it has been described as “unaffordable underinsurance.” Millions will still be one job loss or illness away from bankruptcy.

Although the law is often referred to as “Obamacare,” it should better be called “Romneycare,” since the idea was originated by the Heritage Foundation, a conservative think tank, and famously passed by Gov. Romney in Massachusetts. Many have argued, myself included, that “Romneycare” doesn’t go far enough. Is it a step in the right direction?

What we really need is an improved Medicare for all — everybody in, nobody out. That solution is clearly constitutional. If we replaced our dysfunctional, profit-seeking, private insurance industry with a streamlined, single-payer system, we could save over $400 billion squandered annually on administrative overhead, enough to cover all of the uninsured and eliminate co-pays and deductibles for everyone else. Only a single-payer system can control costs and reduce our nation’s deficit over the long term.

In his weekly column in the Herald-Times, July 11, 2010, conservative commentator George Will wrote, “The new health care legislation is a step toward elimination, by slow strangulation, of private health insurance and establishment of government as the ‘single payer.’” May his prediction come true.

The American people need a universal health system that delivers comprehensive, equitable, compassionate and high-quality care, with free choice of provider and no financial barriers to access.

My dream is that Americans will one day join the citizens of other industrialized, capitalist democracies, from Canada to Germany, in being able to see a doctor without fear of personal debt or national deficit.

Dr. Rob Stone of Bloomington is director of Hoosiers for a Commonsense Health Plan.

http://www.heraldtimesonline.com/stories/2012/07/15/digitalcity.health-care-reform-much-to-do.sto?1342367352

Why not a single-payer system?

By Ivan Moore
Anchorage Press, July 12, 2012

To be honest with you, I’m not much of a fan of the “individual mandate.”  I don’t think it’s much of a solution, given the soaring costs of health care and health insurance, to say “You must have it!” and fine people if they don’t. I’d much prefer a single-payer system.

Single-payer is the jargon that refers to a system whereby the health insurance companies are replaced by government funding of health care. The single-payer option didn’t get much traction back when the overhaul of the health care system was being considered, which is why we ended up with the mandate.

I wonder why not?

A single-payer option would work something like this. As I pointed out last week, more money gets spent per capita on health care in the U.S. from government funding than most other countries spend in total expenditures. These government-funded programs, for better or worse, would provide the care they currently provide … Medicare, Medicaid, the VA, health insurance programs for public employees, plus those lavish Congressman and Senator benefits. The rest, the portion that is currently financed through private health insurance, would be made public.

The tax structure most often discussed would entail a personal tax on income of about 2 percent, plus a payroll tax on businesses of about 6-7 percent. This would raise a sufficient amount of revenue to entirely replace the private portion of health care expenditures, and render every single person in the country covered.

Think about what a 2 percent tax on your income would be, what it would come to dollar-wise. If you haven’t currently got health insurance, you just got a screamer of a bargain. If you do have health insurance, the 2 percent is very likely to be less than the amount you currently have to pay each year to cover deductibles, co-pays and those procedures your insurance company says they won’t cover.

Now think about the 6-7 percent payroll tax on employers. If the employer currently provides health insurance to their employees through a private plan, the payroll tax amount is very likely to be less than what they currently pay. The only employers who lose out are the ones who don’t currently provide insurance benefits to their employees.  Oh dear, so sad.

(This raises the side question of why, in a country where the vast majority of health insurance is employer-provided, we aren’t talking about an employer health insurance mandate. Shouldn’t companies who hire people and put them to work be mandated to provide health insurance to those employees? You could argue that a company that provides health insurance to their employees puts themselves, at least in respect to labor costs, at a competitive disadvantage over those that don’t. Great incentive, that.)

A single-payer system is one where everyone is covered. Where everyone receives access to the same standard of care. Where there are no longer any out-of-pocket expenses that you have to fork over. Where insurance companies don’t refuse to cover something that goes wrong with you. Where they don’t jack your premiums up or cut you off if you get too expensive.

The thing that people opposed to a system like this don’t get is that the health care itself remains pretty much unchanged. The doctors aren’t suddenly working for the government. They have their private clinics just like they do now. You would be able to choose your doctor freely, instead of being restricted to a roster chosen by your insurance company. Health care decisions wouldn’t suddenly be made by government bureaucrat death panels, they’d still be made by you and your doctor, just like now.

The bill just gets paid by the government, out of one big pool. The single payer.

It’s so simple. So bleeding obvious. Bleeding obvious… that’s a good Englishism for you. The American equivalent is “Duh!!!”

So why didn’t it happen? Well, the health insurance companies and their army of lobbyists on Capitol Hill, the ones with an iron grip on the wherewithal of every single Congressman and Senator, made sure it didn’t happen.

It’s quite a cash cow, the health insurance racket. Makes them lots of money. Your money. And they’re not letting go of it without a fight. So they dole out enough campaign contributions to keep their elected representatives quiet, no doubt in good Abramoff style, whisk them off on junkets, on holidays and to sporting events, and the end result is that single-payer doesn’t even get off the ground.

God forbid, they’d have to switch to peddling other forms of insurance, because health insurance essentially wouldn’t exist any more.

Think about all that expense for a minute. Not only the insurance company lobbyists, but the CEO salaries and the bonuses, the staggering administrative costs, the advertising costs so they can all compete against each other, and so on… all passed on to YOU in your premiums. The overhead cost for a government program like Medicare is about 3 percent, your average HMO spends 20 percent. Think about it, all of that would be gone.

So yes, I know what you’re thinking… a single-payer system really would be cheaper.  Once everyone’s covered, what would be the point of having these government programs targeted towards the more needy populations, the Medicares and Medicaids and VA programs? They’re all safety net programs that only exist because our health care is not universal. So yes, gradually, bureaucracy would decrease. And costs would go down.

And yet, people still rail against the idea. Rail against something that is categorically in their interest to support.

Funny how that happens, hey?

Ivan Moore is a public opinion pollster who lives in Anchorage.

http://www.anchoragepress.com/opinion/moore-report-why-not-a-single-payer-system/article_a9779bdc-cc98-11e1-9f91-0019bb2963f4.html

Jack Bernard's message for his fellow Republicans

Head-in-the-sand ‘solution’ is killing GOP

By Jack Bernard
DesMoinesRegister.com, July 16, 2012
We Republicans have ourselves to blame for the Affordable Care Act, or Obamacare.
Our reaction to the Clinton health reform proposals in the early 1990s was to have conservative think tanks come up with a free competition model based on expansion of private insurance and Medicaid. That idea became Romneycare, which evolved into Obamacare.
It is our baby, ugly or not.
It is the height of hypocrisy for us now to criticize our own idea unless we have something better to replace it. And, the replacement needs to be comprehensive, not just a series of unacceptable statements and proposals based on doing away with traditional Medicare by turning it into a voucher program and gutting Medicaid by making it into a block grant.
Using vouchers for Medicare just dumps the cost problem into the lap of the powerless patient, rather than the federal government that has clout, making the cost escalation problem worse. The block grants for Medicaid idea just shifts the cost issue onto the states rather than the federal government, which once again solves nothing and only makes things worse.
States will just cut services and people from their Medicaid roles, creating more uninsured. Don’t Iowa hospitals serve enough uninsured in their emergency rooms now?
This gets us to what we as Republicans should do: throw out our rule book and be innovative. People my age will remember how we Republicans were 100 percent against recognizing China before Richard Nixon, the anti-communist crusader, came out for it. We must do the same with health care.
There is only one way to control health care costs and insure universal access — and that is by first admitting that the U.S. system has failed and then adopting ideas that have been proven to work elsewhere. We should take a look at how health care is financed and delivered in other developed nations with lower cost and better morbidity and mortality rates.
A Commonwealth Fund study was issued in May 2012 which did just that for 13 countries. The bottom line is that we spend 17.4 percent of our gross national product on health care, far more than other developed nations, which averaged 9.5 percent. Our per-capita spending was $7,960 versus $3,182 for the group as a whole.
Why? One key factor is prices. For example, U.S. pricing on the 30 most commonly prescribed brand name drugs is one-third higher than Canada and double France, both of which have a form of Universal Medicare.
From looking at the international data, if we Republicans really want to dump the Affordable Care Act, the way to go is Medicare for all. Studies show that the nations with universal health care have better overall health care outcomes than we do, not worse.
And, according to the respected Physicians for a National Health Program, www.pnhp.org, yearly savings generated under Medicare for all would be $400 billion. That would go a long way towards paying for universal coverage, versus the Affordable Care Act, which will increase systemic costs because it relies on private insurance.
The canard about waiting times to see doctors is just a tactic to scare the public. If you need a knee replacement for a knee that has been going bad for years, waiting a little longer for an operation should not be a major issue for the patient. Despite the scare tactics, no one who needs immediate care in Canada is ever left to sit in a line. In any case, there should be no waiting lists at all here. Canada spends just $4,363 per capita on health care versus our $7,960.
If we Republicans took the Medicare-for-all approach, it would thrust us into the vanguard of reform. Instead of the Democrats stealing our ideas, we could steal theirs. When it was implemented and turned out to be widely accepted, as was Medicare in the 1960s, we would be the party the public would look to for the future.
Of course, there is an alternative. We can stick our heads in the sand and push for infeasible actions. That approach is killing us regarding immigration and will work just as well for health care.
(JACK BERNARD of Monticello, Ga., is a retired health care executive who worked extensively with Iowa health care providers, including Iowa Health System. He now is a member of the Jasper County (Ga.) Board of Commissioners and Jasper County Board of Health. Contact: bernard_jack@hotmail.com)
http://www.desmoinesregister.com/article/20120716/OPINION01/307160040/

This article should be distributed widely. Although it is written by a Republican, targeting his fellow Republicans, if his party can understand this message, then the Democrats and others who bailed on Medicare for all should be able to understand it as well.

U.S. women face higher health care costs

Oceans Apart: The Higher Health Costs of Women in the U.S. Compared to Other Nations, and How Reform Is Helping

By Ruth Robertson, David Squires, Tracy Garber, Sara R. Collins, and Michelle M. Doty
The Commonwealth Fund, July 2012

Abstract

An estimated 18.7 million U.S. women ages 19 to 64 were uninsured in 2010, up from 12.8 million in 2000. An additional 16.7 million women had health insurance but had such high out-of-pocket costs relative to their income that they were effectively underinsured in 2010. This issue brief examines the implications of poor coverage for women in the United States by comparing their experiences to those of women in 10 other industrialized nations, all of which have universal health insurance systems. The analysis finds that women in the United States — both with and without health insurance — are more likely to go without needed health care because of cost and have greater difficulty paying their medical bills than women in the 10 other countries. In 2014, the Affordable Care Act will substantially reduce health care cost exposure for all U.S. women by significantly expanding and improving health insurance coverage.

From the Conclusion

When fully implemented, the Affordable Care Act will correct much of the inequity in the U.S. system. A substantial expansion of affordable health insurance options is expected to reduce the percentage of uninsured working-age women from 20 percent to 8 percent.

http://www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/2012/Jul/1606_Robertson_oceans_apart_reform_brief.pdf

Comment: 

By Don McCanne, MD

Over 35 million working-age women in the United States potentially face financial hardship should they need health care either because they are uninsured or because their insurance exposes them to excessive out-of-pocket expenses. That’s not acceptable.

The authors of this Commonwealth Fund report note how the Affordable Care Act “will correct much of the inequity in the U.S. system.” But not enough. Not only will underinsurance remain a problem, 8 percent of working-age women will have no insurance at all. That’s not acceptable either, especially since we already know how to fix our system and can afford to do so. We simply have to do it.

U.S. women face higher health care costs

Oceans Apart: The Higher Health Costs of Women in the U.S. Compared to Other Nations, and How Reform Is Helping

By Ruth Robertson, David Squires, Tracy Garber, Sara R. Collins, and Michelle M. Doty
The Commonwealth Fund, July 2012
Abstract
An estimated 18.7 million U.S. women ages 19 to 64 were uninsured in 2010, up from 12.8 million in 2000. An additional 16.7 million women had health insurance but had such high out-of-pocket costs relative to their income that they were effectively underinsured in 2010. This issue brief examines the implications of poor coverage for women in the United States by comparing their experiences to those of women in 10 other industrialized nations, all of which have universal health insurance systems. The analysis finds that women in the United States — both with and without health insurance — are more likely to go without needed health care because of cost and have greater difficulty paying their medical bills than women in the 10 other countries. In 2014, the Affordable Care Act will substantially reduce health care cost exposure for all U.S. women by significantly expanding and improving health insurance coverage.
From the Conclusion
When fully implemented, the Affordable Care Act will correct much of the inequity in the U.S. system. A substantial expansion of affordable health insurance options is expected to reduce the percentage of uninsured working-age women from 20 percent to 8 percent.
http://www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/2012/Jul/1606_Robertson_oceans_apart_reform_brief.pdf

Over 35 million working-age women in the United States potentially face financial hardship should they need health care either because they are uninsured or because their insurance exposes them to excessive out-of-pocket expenses. That’s not acceptable.
The authors of this Commonwealth Fund report note how the Affordable Care Act “will correct much of the inequity in the U.S. system.” But not enough. Not only will underinsurance remain a problem, 8 percent of working-age women will have no insurance at all. That’s not acceptable either, especially since we already know how to fix our system and can afford to do so. We simply have to do it.

WP's Richard Cohen on Obama and single payer

Terror among the rich

By Richard Cohen
The Washington Post, July 9, 2012

I wrote last year that Obama had lost the Hamptons. Nothing has changed. He is roundly denounced for not doing a Heimlich on the economy, for his allegedly socialist ways, for Obamacare, for low employment, for high unemployment, for not returning phone calls, for not asking advice — for being cold, distant and, increasingly, just for being president of the United States. The man, it seems, has to go.

I share some of these sentiments. The economy remains in the doldrums, the occasional good month followed by two or three bad ones. Obama is something of a cold fish, which may be something he cannot help, but he is also a lazy politician, unwilling — not unable — to do the telephoning and backslapping that his job requires.

As for Obamacare, it is both a legal and programmatic mess not because it is even modestly socialist but because it is not socialist enough. A government-run health-care system such as the ones used in virtually all the industrialized world — the so-called single-payer system — would have been the way to go. Instead, we have a system in which private insurance companies will abuse doctors and patients alike in the cause of profit. This, alas, truly is the American Way.

http://www.washingtonpost.com/opinions/richard-cohen-obama-the-ineffable/2012/07/09/gJQA3mcCZW_story.html

Comment: 

By Don McCanne, MD

Obviously, this quote is being distributed because of the strong endorsement of single payer, a vastly superior model of financing health care when compared to the current “American Way” of using private insurance companies.

Although, in this opinion article, Richard Cohen blasts President Obama for his, shall we say, inaction, he doesn’t include here the difficulties Obama faced from the obstructionism by the opposition party, nor from the inaction of the electorate which suffers from a combination of being uninformed and misinformed, thus unable to advocate effectively for policies that would benefit us all. Of course, the candidate of the opposition party spent the weekend in the Hamptons hauling in millions in campaign donations from the “terrified rich,” thus offering little hope that the November elections would bring us any relief from our political quagmire.

Political leaders do not lead; they follow. We will have to lead by promoting education, coalitions, and grassroots efforts. It will be not be easy, but there is no substitute for massive citizen activism.