GOP Attorney General Suing Over Obamacare Supports Single-Payer: ‘I Trust The Government More’

By Scott Keyes
Think Progress, March 30, 2012
According to one Republican attorney general in the lawsuit against the health care individual mandate, the problem with Obamacare is that it’s not a government takeover of health care.
ThinkProgress spoke with Louisiana Attorney General Buddy Caldwell outside the Supreme Court on Wednesday. Caldwell opposes Obamacare and the individual mandate, but for a different reason than most of his fellow litigants: it props up the private health insurance industry. “Insurance companies are the absolute worst people to handle this kind of business,” he declared. “I trust the government more than insurance companies.” Caldwell went on to endorse the idea of a single-payer health care system, saying it’d “be a whole lot better” than Obamacare:
KEYES: You don’t think the subsidies for low-income people are going to be helpful?
CALDWELL: No, no. The worst thing you can do is give it to an insurance company. I want to make my point. All insurance companies are controlled in their particular state. If you have a hurricane come up the east coast, the first one that’s going to leave you when they gotta pay too many claims is an insurance company. Insurance companies are the absolute worst people to handle this kind of business. I trust the government more than insurance companies. If the government wants to put forth a policy where they will pay for everything and you won’t have to go through an insurance policy, that’d be a whole lot better.
http://thinkprogress.org/health/2012/03/30/454261/buddy-caldwell-private-insurance/

Louisiana Attorney General Buddy Caldwell, a Republican, who has joined the lawsuit against the Affordable Care Act, certainly understands the greatest flaw in the legislation. “The worst thing you can do is give it to an insurance company.” Leading to his conclusion, “If the government wants to put forth a policy where they will pay for everything and you won’t have to go through an insurance policy, that’d be a whole lot better.”

NOTE: Wait! Don’t go away! You are not expected to read today’s message in its entirety. This is merely a sampling of the plethora of new articles that suggest that single payer may be the answer to the constitutionally-challenged Affordable Care Act. They represent the views of enthusiastic liberals, reluctant conservatives, and everyone in between. If you read only one entry, I would suggest the very last one, which is my response to today’s New York Times Economix blog by Uwe Reinhardt. Although at times it seems like we single payer activists are hollering in the wind, the profusion of responses demonstrates that single payer is now widely recognized as a model that would work for all of us. Keep hollering!

On The Individual Mandate: Towards A Single-Payer System Or Public Option?

By Renée Landers
Health Affairs Blog, March 29, 2012
Early in the arguments, in an exchange with the Solicitor General, Justice Kennedy raised the idea that one alternative available to Congress may be to “use the tax power to raise revenue and to just have a national health service, single payer.”
Toward the end of the day’s arguments, Justice Sotomayor pressed Mr. Carvin on the same point:  “I want to understand the choices you’re saying Congress has.  Congress can tax everybody and set up a public health care system.”
These discussions leave the Court, conservatives, and the public with a curious dilemma.  Through the Affordable Care Act, Congress has tried to regulate private insurance markets to solve the market problem of making health insurance affordable for the uninsured, whatever their individual health status.  If that market-based approach does not survive a Commerce Clause challenge, what alternatives are left to Congress?  One alternative is to do nothing, which does not seem to be economically responsible given accelerating health care costs and certainly leaves tens of millions of Americans in a precarious and untenable situation.
The other option would be for the government, as the last resort, to create the “public option” that was so controversial during the debates over the Affordable Care Act, or to move entirely to a single-payer system, eschewing markets.
http://healthaffairs.org/blog/2012/03/29/renee-landers-on-the-individual-mandate-towards-a-single-payer-system-or-public-option/
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A stronger prescription for what ails health care

By Eugene Robinson
The Washington Post, March 29, 2012
Our only choice is to try to hold the costs down. President Obama tried to make a start with a modest approach that works through the current system. If this doesn’t pass constitutional muster, the obvious alternative is to emulate other industrialized nations that deliver equal or better health care outcomes for half the cost.
I’m talking about a single-payer health care system. If the Supreme Court strikes down ObamaCare, a single-payer system will go from being politically impossible to being, in the long run, fiscally inevitable.
http://news.investors.com/article/606069/201203291839/single-payer-next-if-obamacare-struck-down.htm
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Judicial activists in the Supreme Court

By E.J. Dionne Jr.
The Washington Post, March 28, 2012
The irony is that if the court’s conservatives overthrow the mandate, they will hasten the arrival of a more government-heavy system. Justice Anthony Kennedy even hinted that it might be more “honest” if government simply used “the tax power to raise revenue and to just have a national health service, single-payer.” Remember those words.
http://www.washingtonpost.com/opinions/activist-judges-on-trial/2012/03/28/gIQAKdE2gS_story.html
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My Mom, the Supreme Court, and the Affordable Care Act

By Emil Guillermo
San Francisco Chronicle, March 28, 2012
My mom died before the Clintons attempted their push for reform, and before Obama came up with his intricate compromise. Before then, Mom’s old fashioned Medicare plan worked just fine.
So I know this crazy Supreme Court debate to overturn the Affordable Care Act would have surely given her chest pains.
She’d ask, “Why can’t the government just extend Medicare to all?” (Seniors have a way of getting to the point. Unlike lawyers.) Medicare is a single payer system that doesn’t have people crying “Socialism!” It doesn’t get conservatives’ dander up about individual liberty and the broad powers of the federal government.
And it works. Everyone gets the care they need.
Done.
If only mom were alive and in charge.
http://blog.sfgate.com/eguillermo/2012/03/28/my-mom-the-supreme-court-and-the-affordable-care-act/
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If Obamacare is overturned, will that lead to single payer? And would that be a good thing?

By Ezra Klein
The Washington Post, March 29, 2012
Eventually, we end up with something close to a single-payer system, as a majority of Americans — and particularly a majority of Americans who have significant health risks — are covered by the government.
http://www.washingtonpost.com/blogs/ezra-klein/post/if-obamacare-is-overturned-will-that-lead-to-single-payer-and-would-that-be-a-good-thing/2012/03/29/gIQAQwypiS_blog.html
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Single-Payer or Bust

By Steve Erickson
The American Prospect, March 30, 2012
Striking down the individual mandate leaves only one of two options: adopt a system in which government pays for health care, or do nothing.
http://prospect.org/article/single-payer-or-bust
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RedBlueAmerica: Will ‘Obamacare’ survive?

Scripps Howard News Service, March 29, 2012
Joel Mathis:  The insurance mandate was a half-step toward that goal. Let’s take the full step: Single-payer health insurance, run and administered by the government, with no private-sector middlemen to add costs and reap profits from taxpayers.
Ben Boychuk:  The problem with the single-payer fantasy is it makes promises the government cannot keep. The health-care budget is not unlimited. Government would make choices about your health care based not on what you need, but how much a procedure costs. In truth, that’s becoming the case more and more under our existing system, which is why reform remains essential.
http://www.scrippsnews.com/node/68356
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What if Supreme Court strikes down Obama healthcare act?

By Mark Mardell
BBC News, March 29, 2012
(A Democrat strategist I’ve spoken to) adds that defeat might make Democrats more radical and argue that what is called here a “single payer system” – a tax-funded national health system as we have in the UK – is the only real answer, rather than President Obama’s market-sensitive half-way house.
http://www.bbc.co.uk/news/world-us-canada-17540685
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Obamacare health-insurance exchanges are set up to fail

By Paul Mulshine
The Star Ledger, March 25, 2012
The real threat is not that Obamacare will take over Medicare. It’s the other way around, says Mike Cannon, a health-care expert with the free-market Cato Institute in Washington.
“These exchanges are built to fail,” said Cannon. “They’ll drive private insurance companies out of the market. When they do, the whole thing will collapse.”
At that point, some sort of single-payer system would be needed to cover the people the private insurers don’t want. Those who’ve been arguing Medicare should be extended to everyone would probably win at the polls.
http://blog.nj.com/njv_paul_mulshine/2012/03/obamacare_health-insurance_exc.html
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If Health Law Is Overturned, What Will Liberals Do?

By Michael D. Shear
The New York Times, March 28, 2012
If Democrats make little progress on alternatives, some purists might decide it’s best to just renew the case for a single-payer system in which all Americans receive health care paid for by the government.
Sidney M. Wolfe, the director of the Health Research Group at Public Citizen, an advocacy group, has been pushing for government-run health care for decades.

http://thecaucus.blogs.nytimes.com/2012/03/28/if-health-law-is-overturned-what-will-liberals-do/?hp
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Overturning health care law could lead to a single-payer system

By Peter Morici
SunSentinel, March 26, 2012
Conservatives, by persuading a majority of Justices to overturn the individual mandate, could reverse Washington’s relentless push to over regulate individual and business behavior, but they could ultimately instigate their worst nightmare — a single payer system akin to the British system.
http://articles.sun-sentinel.com/2012-03-26/news/fl-morici-single-payer-health-0326-20120326_1_individual-mandate-health-insurance-affordable-care-act-requirement
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After the Ruling

By Maggie Fox
National Journal, March 29, 2012
There is one easy solution to the issue—a single-payer health system that strictly controls costs and administrative fees, using evidence-based science to determine which interventions, drugs, and diagnostic tests are worth the money and effort.
http://www.nationaljournal.com/daily/after-the-ruling-20120328?mrefid=freehplead_3
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ACA Alternatives Waiting in the Wings

By Emily P. Walker
MedPage Today, March 29, 2012
While Republicans are crafting limited-government alternatives to the Affordable Care Act (ACA), some on the other side of the political spectrum are trumpeting a single-payer, government-run system as the preferred alternative to the ACA.
The irony is that while the public option wasn’t popular enough to pass, no one disputes the Supreme Court wouldn’t be considering the case if a single-payer plan had passed, because expanding Medicare and taxing everyone more would have been well within the powers of Congress.
http://www.medpagetoday.com/Washington-Watch/Reform/31930
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Experts: Medicaid Expansion Will Stand; Mandate’s Fate Unclear

By George Lauer
California Healthline, March 29, 2012
Some see the potential for a quicker move toward single payer solutions if all or part of the ACA is ruled unconstitutional.
While he didn’t go so far as to call for provisions of the ACA to be struck down, Bill Skeen, executive director of the California chapter of Physicians for a National Health Program, did see potential for progress in such a scenario.
“If the ACA is dismantled, I don’t predict there will be an easy road for single payer, but there is the sort of last-man-standing feeling that — OK, the plan Congress put together isn’t holding up. Single payer is the last best option.”
http://www.californiahealthline.org/features/2012/experts-medicaid-expansion-will-stand-mandates-fate-unclear.aspx
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Chris Matthews, Ezra Klein Identify Strategy To Impose ‘De Facto Single Payer System’

By Noah Rothman
Mediaite, March 29, 2012
On Wednesday, Hardball host Chris Matthews and Washington Post columnist Ezra Klein discussed the potential for all or part of President Obama’s health care reform law to be ruled unconstitutional in the Supreme Court and the ways in which progressives could move forward with health care reform in a post-Affordable Care Act world. Klein confirmed conservative’s latest fear: striking down the health care law could pave the way for a single payer system that could be implemented over time through the budget reconciliation process in the Senate.
http://www.mediaite.com/tv/chris-matthews-ezra-klein-identify-strategy-to-impose-de-facto-single-payer-system/
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Growth & Justice lays out its case for Minnesota single-payer health care

By Beth Hawkins
MinnPost, March 29, 2012
What if single-payer were feasible?
On Wednesday, the St. Paul-based progressive-leaning think tank Growth & Justice made its case, releasing a first-of-its-kind analysis showing that a unified system of health care could provide all Minnesotans with guaranteed cradle-to-grave care at a projected savings of about $190 billion over 10 years. By 2023, overall savings could be 12 percent to 33 percent per year, it said.
During his gubernatorial campaign, Mark Dayton supported a single-payer system for Minnesota, Smith added. The advent of ACA presents a good opening to put the topic back in the public discourse.
“This option needs to stay on the table,” he said. “It is an attempt to change the conversation. … This is one of the last big hurdles for a fair and just society. You can’t just check out of the social contract.”
http://www.minnpost.com/health/2012/03/growth-justice-lays-out-its-case-minnesota-single-payer-health-care
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The Wall Street Journal: Unwitting Advocates of Single-Payer

By David Frum
The Daily Beast, March 29, 2012
The crazy thing about the litigation over the Affordable Care Act is this… nobody disputes that Congress has full authority to set in motion a national healthcare program. Congress could tax all American at any rate — or any schedule of rates, no matter how confiscatory for those at the top — and then use the money to fund a British-style National Health Service.

http://www.thedailybeast.com/articles/2012/03/29/wall-street-journal-single-payer.html
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If Health Care Reform Falls, Look in the Mirror

By Karen Dolan
The Huffington Post, March 29, 2012
Candidate Barack Obama campaigned on universal coverage. He told would-be supporters that, if he were “starting from scratch,” single-payer would be ideal. Indeed, he even understood that the only true reform, that would sufficiently control costs and actually achieve universal coverage, was a single payer, government-sponsored health care system. The evidence is overwhelming that only such a system can achieve those goals.
Isn’t it time to fight for Medicare for all?
http://www.huffingtonpost.com/karen-dolan/health-care-reform_b_1388082.html
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How Obamacare’s Rejection Would Lead to Single Payer

By Josh Barro
Forbes, March 28, 2012
Strike down Obamacare, and single payer instantly becomes the number one organizing cause for liberals in America. This Congress won’t pass a single payer insurance law, but you can bet Democrats would the next time they control both the legislative and executive branches.
http://www.forbes.com/sites/joshbarro/2012/03/28/how-obamacares-rejection-would-lead-to-single-payer/
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Single-Payer Briar Patch

By Timothy Noah
The New Republic, March 28, 2012
The professional Obama-hater Dick Morris said today on Fox News that if President Obama is elected to a second term after the Supreme Court strikes down Obamacare (as is looking more likely) then “he’ll move to a single payer system.”
http://www.tnr.com/blog/timothy-noah/102125/single-payer-briar-patch
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Take It From Me: Defending Obamacare is Super-Hard

By Reid Cherlin
GQ, March 27, 2012
It would have been easy for Verrilli—or any of us—to explain single-payer health care. “Look,” we could have said, “the government is paying for everyone to have coverage.” End of story. But single-payer is not what our brilliant, world-leading political system gave us.

http://www.gq.com/news-politics/blogs/death-race/2012/03/take-it-from-me-defending-obamacare-is-super-hard.html
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Lawmakers Propose Single-Payer System For Mass.

By Meghna Chakrabarti
WBUR, March 28, 2012
A major national story is playing out in the halls of Beacon Hill: this week’s Supreme Court hearings on the national Affordable Health Care Act.
Some lawmakers want the state to push health care reform to the next level. They’ve introduced a bill that would bring a “single-payer” system to the Bay State.

http://radioboston.wbur.org/2012/03/28/single-payer-proposal
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What’s really wrong with Obamacare

By Cathy Young
Newsday, March 29, 2012
If the Affordable Care Act is struck down, the eventual outcome may be better health care reform — or it may be a more socialistic road, such as a single-payer system.
Libertarian and conservative voices are essential to the health care debate. But they should be careful not to lapse into a defense of freeloading or unconstrained spending on expensive (and not always beneficial) medical procedures. Freedom is a key conservative and libertarian principle; so is responsibility.

http://www.newsday.com/opinion/oped/young-what-s-really-wrong-with-obamacare-1.3632152
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If the Mandate Fails, Single Payer Awaits

By George Zornick
The Nation, March 27, 2012
One obvious option, besides just doing nothing and allowing health care costs to continue their exponential growth while more people lose coverage, is a single-payer health insurance plan. There is no doubt about the constitutionality here — the government is clearly allowed to levy taxes to fund public benefits.
So if health care reform goes down, the next logical step may well be just extending Medicare to everyone.
http://www.thenation.com/blog/167071/if-mandate-fails-single-payer-awaits
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Kucinich: Single-payer healthcare on its way regardless of how Supreme Court rules

By Julian Pecquet
The Hill, March 26, 2012
The Supreme Court’s review of President Obama’s healthcare reform law is just another step on the inevitable path toward a single-payer medical system, Rep. Dennis Kucinich (D-Ohio) said Monday.
http://thehill.com/blogs/healthwatch/legal-challenges/218185-kucinich-single-payer-healthcare-on-its-way-regardless-of-how-supreme-court-rules
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Health Care Jujitsu

By Robert Reich
The Huffington Post, March 26, 2012
But with a bit of political jujitsu, the president could turn any such defeat into a victory for a single-payer healthcare system — Medicare for all.
http://www.huffingtonpost.com/robert-reich/single-payer-health-care_b_1381382.html
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Individual Mandate Is Ryan Tax Credit by Other Name

By Ezra Klein
Bloomberg, March 28, 2012
The real fight is over whether the Affordable Care Act should exist at all. Republicans lost that battle in Congress, where they lacked a majority in 2010. Now they hope to win it in the Supreme Court, where they hold a one-vote advantage. The argument against the individual mandate is a pretext to overturn Obamacare. But it’s a pretext that could set a very peculiar precedent.
If the mandate falls, future politicians, who will still need to fix the health-care system and address the free-rider problem, will be left with the option to move toward a single payer system or offer incredibly large, expensive tax credits in order to persuade people to do things they don’t otherwise want to do. That is to say, in the name of liberty, Republicans and their allies on the Supreme Court will have guaranteed a future with much more government intrusion in the health-care marketplace.
http://www.bloomberg.com/news/2012-03-28/individual-mandate-is-ryan-tax-credit-by-other-name.html
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The Supreme Court and the National Conversation on Health Care Reform

By Uwe E. Reinhardt
The New York Times, Economix, March 30, 2012
Once again America is having one of its “national conversations” on health care reform. This time the buzz is over arguments before the Supreme Court on the constitutionality of certain provisions in the Affordable Care Act. The justices’ rulings will be landmark decisions, because they will indirectly go much beyond the act itself to our entire system of governance.
The two major substantive decisions the Supreme Court has to make are:
1. Whether Congress has the constitutional authority to mandate every legal resident in the United States to have insurance coverage for a specified package of health benefits (hereafter the “mandate”) or whether that is an issue for the states to decide.
2. Whether Congress has the constitutional authority to expand eligibility for Medicaid benefits from the highly varied income thresholds that currently define eligibility to anyone under 133 percent of the federal poverty level.

Reader Comment:

By Don McCanne
San Juan Capistrano, CA
The intense attention being given to the constitutionality of the individual mandate and the severability of guaranteed issue and community rating and to the constitutionality of the Medicaid expansion superficially seems to have detracted from the fundamental issue of whether or not the Affordable Care Act itself should serve as a durable model for health care reform.
With the best possible outcome of the Supreme Court deliberations, we’ll still be faced with uninsurance (at least 26 million uninsured), underinsurance (low actuarial value plans with spartan essential benefits) and unaffordability (lack of effective systemic cost containment).
Right now we are seeing a surge in commentaries declaring that we will end up with single payer (Medicare for all) if the mandate and guaranteed issue and community rating are struck down by the Supreme Court, simply because that’s the only rational financing option left for us.
We will, in fact, end up with single payer, but not because of the pending Supreme Court decision. We will adopt a single payer system simply because we will not be able to continue to tolerate uninsurance, underinsurance and unaffordability.
http://economix.blogs.nytimes.com/2012/03/30/the-supreme-court-and-the-national-conversation-on-health-care-reform/

By Ashish K. Jha, M.D., M.P.H., Karen E. Joynt, M.D., M.P.H., E. John Orav, Ph.D., and Arnold M. Epstein, M.D.
The New England Journal of Medicine, March 28, 2012

Tying financial incentives to performance, often referred to as pay for performance, has gained broad acceptance as an approach to improving the quality of health care. The Centers for Medicare and Medicaid Services (CMS) recently completed a 6-year demonstration of pay for performance for hospitals through the Premier Hospital Quality Incentive Demonstration (HQID), and the Affordable Care Act calls for CMS to expand this program to nearly all U.S. hospitals in 2012. The policy of tying financial incentives to the quality of performance has strong face validity — that is, paying for better care should promote improvements in quality and, ideally, lead to better patient outcomes. Whether pay for performance will lead to better patient outcomes, however, is unclear.

Although there is evidence from the Premier HQID that pay for performance is associated with modest improvements in the processes of care, much less is known about its effect on patient outcomes.

We found little evidence that participation in the Premier HQID program was associated with declines in mortality above and beyond those reported for hospitals that participated in public reporting alone, even when we examined care over a period of 6 years after the program’s inception. Furthermore, we found no differences in trends in mortality between conditions for which outcomes were explicitly linked to incentives and conditions for which outcomes were not linked to incentives.

Prior studies of the Premier HQID showed that the early gains in process quality had mostly dissipated after 5 years under the program. Werner et al. found that the modest benefits in adherence to process measures were most perceptible for hospitals that were eligible for larger bonuses, that were well financed, or that operated in less competitive markets. We failed to find that these factors were associated with a significantly greater effect on outcomes.

In summary, we found little evidence that participation in the Premier HQID program led to lower 30-day mortality rates, suggesting that we still have not identified the right mix of incentives and targets to ensure that pay for performance will drive improvements in patient outcomes. Even though Congress has required that the CMS adopt pay for performance for hospitals, expectations with regard to programs modeled after Premier HQID should remain modest.

http://www.nejm.org/doi/full/10.1056/NEJMsa1112351?query=TOC#t=abstract

Comment:

By Don McCanne, MD

Pay for performance (P4P) is one of the measures in the Affordable Care Act (Sec. 3001) that supposedly is designed to improve quality and reduce costs. The recommendation was based on data such as this Medicare Hospital Quality Incentive Demonstration (HQID) which had shown that providing financial bonuses and penalties improves processes of care. But does it improve outcomes?

This large study of hospital performance had already shown early but non-sustained improvement in processes, but it turns out that paying for this performance did not improve patient outcomes. P4P did not improve 30 day nor 6 year mortality for the conditions studied – three medical conditions (acute myocardial infarction, congestive heart failure, and pneumonia) and two surgical procedures (coronary-artery bypass grafting [CABG] and total knee or total hip replacement). Yet the Affordable Care Act requires that all hospitals participate in the value-based purchasing (VBP) program, which provides financial incentives for both high achievement and improvement in performance – an approach closely modeled after the Medicare HQID.

This “teach to the test” P4P experiment did, in fact, result in rewards and penalties for hospitals based solely on process measures, though having no impact on outcomes. Such programs seem to promote gamesmanship much more than they promote actual improvements in quality – appealing to hospitals that were “eligible for larger bonuses, that were well financed, or that operated in less competitive markets.” It is yet another example of the multitude of unproven or minimally effective quality and cost measures in the Affordable Care Act.

The tragedy is that Congress and the President rejected the proven model of reform that would have achieved these goals – a single payer national health program. One benefit of the Supreme Court hearings this week is that there has been a resounding response that single payer is the answer. If only we could convert that perception into action. If only…

The Long-Term Effect of Premier Pay for Performance on Patient Outcomes

By Ashish K. Jha, M.D., M.P.H., Karen E. Joynt, M.D., M.P.H., E. John Orav, Ph.D., and Arnold M. Epstein, M.D.
The New England Journal of Medicine, March 28, 2012
Tying financial incentives to performance, often referred to as pay for performance, has gained broad acceptance as an approach to improving the quality of health care. The Centers for Medicare and Medicaid Services (CMS) recently completed a 6-year demonstration of pay for performance for hospitals through the Premier Hospital Quality Incentive Demonstration (HQID), and the Affordable Care Act calls for CMS to expand this program to nearly all U.S. hospitals in 2012. The policy of tying financial incentives to the quality of performance has strong face validity — that is, paying for better care should promote improvements in quality and, ideally, lead to better patient outcomes. Whether pay for performance will lead to better patient outcomes, however, is unclear.
Although there is evidence from the Premier HQID that pay for performance is associated with modest improvements in the processes of care, much less is known about its effect on patient outcomes.
We found little evidence that participation in the Premier HQID program was associated with declines in mortality above and beyond those reported for hospitals that participated in public reporting alone, even when we examined care over a period of 6 years after the program’s inception. Furthermore, we found no differences in trends in mortality between conditions for which outcomes were explicitly linked to incentives and conditions for which outcomes were not linked to incentives.
Prior studies of the Premier HQID showed that the early gains in process quality had mostly dissipated after 5 years under the program. Werner et al. found that the modest benefits in adherence to process measures were most perceptible for hospitals that were eligible for larger bonuses, that were well financed, or that operated in less competitive markets. We failed to find that these factors were associated with a significantly greater effect on outcomes.
In summary, we found little evidence that participation in the Premier HQID program led to lower 30-day mortality rates, suggesting that we still have not identified the right mix of incentives and targets to ensure that pay for performance will drive improvements in patient outcomes. Even though Congress has required that the CMS adopt pay for performance for hospitals, expectations with regard to programs modeled after Premier HQID should remain modest.
http://www.nejm.org/doi/full/10.1056/NEJMsa1112351?query=TOC#t=abstract

Pay for performance (P4P) is one of the measures in the Affordable Care Act (Sec. 3001) that supposedly is designed to improve quality and reduce costs. The recommendation was based on data such as this Medicare Hospital Quality Incentive Demonstration (HQID) which had shown that providing financial bonuses and penalties improves processes of care. But does it improve outcomes?
This large study of hospital performance had already shown early but non-sustained improvement in processes, but it turns out that paying for this performance did not improve patient outcomes. P4P did not improve 30 day nor 6 year mortality for the conditions studied – three medical conditions (acute myocardial infarction, congestive heart failure, and pneumonia) and two surgical procedures (coronary-artery bypass grafting [CABG] and total knee or total hip replacement). Yet the Affordable Care Act requires that all hospitals participate in the value-based purchasing (VBP) program, which provides financial incentives for both high achievement and improvement in performance – an approach closely modeled after the Medicare HQID.
This “teach to the test” P4P experiment did, in fact, result in rewards and penalties for hospitals based solely on process measures, though having no impact on outcomes. Such programs seem to promote gamesmanship much more than they promote actual improvements in quality – appealing to hospitals that were “eligible for larger bonuses, that were well financed, or that operated in less competitive markets.” It is yet another example of the multitude of unproven or minimally effective quality and cost measures in the Affordable Care Act.
The tragedy is that Congress and the President rejected the proven model of reform that would have achieved these goals – a single payer national health program. One benefit of the Supreme Court hearings this week is that there has been a resounding response that single payer is the answer. If only we could convert that perception into action. If only…

MSNBC, March 27, 2012

Chris Matthews:  Professor Gruber, I’ve got a curve ball for you, from the left field, all right? I’m mixing my metaphors here. If the Supreme Court strikes down the individual mandate today, which is the most conservative way to have national health for everybody, requiring people to take responsibility as individuals. If that fails, and the progressive left of the Democratic Party says, no, now’s our chance to go for single payer, or what’s called the public option – I guess they’ll wind up being the same thing because there won’t be another option really. Is that a better economic proposition? That the government simply provides health insurance for the country? Single payer. Is that a better economic deal with no profit motive?

Jonathan Gruber:  I think that single payer, if you could start over, I think that single payer has a lot to recommend it, but we can’t, and I think the bottom line is…

Chris Matthews:  But we might have to start over after tonight.

Jonathan Gruber:  No. I agree, but if we start over, the problem with failing, if this ruling goes against… this law fails, we’ll see the same pattern we’ve seen for the past century, which when we start over again which will on average be about seventeen years from now, because it’s about every seventeen years we start over, it’s going to be further to the right of where we are.  Every seventeen years… Remember Richard Nixon proposed something to the left of the Affordable Care Act. Every seventeen years we move to the right. If this fails, the next round is not going to be single payer. It’s going to be even more conservative than what we have now.

http://www.msnbc.msn.com/id/3036697/#46873470

Comment:

By Don McCanne, MD

What is the basis for this conversation about starting over if the Affordable Care Act (ACA) is struck down by the Supreme Court? Implicit is the concept that the Affordable Care Act actually accomplished the reform that we need. Of course, it didn’t. So, regardless of the decision, we wouldn’t be starting over since no iteration of ACA would hardly even begin to complete the process of reform.

For those who believe that ACA is the most feasible path to reform, there are some issues in this debate that would have the appearance of a make-or-break outcome (even though ACA itself isn’t a make-or-break model).

Based on the first two days of deliberation before the Supreme Court, it appears that the individual mandate to purchase private insurance may well be struck down. If it is, then both sides (plus an amicus from America’s Health Insurance Plans) agree that guaranteed issue and community rating should be declared inseverable and struck along with the individual mandate.

Though an intact ACA falls intolerably short on reducing uninsurance, underinsurance, and unaffordability, a decision eliminating guaranteed issue (eliminates pre-existing condition exclusions) and community rating (prevents insurers from gouging those with greater health care needs) would leave yet many more uninsured, especially those with greater health care needs plus the healthy invincibles whose funds are needed for the insurance risk pools. That should be enough to cause ACA supporters to take another look at single payer, though the mess we have with an intact ACA should make them reconsider anyway. ACA did not turn out to be the affordable-care-for-everyone model that supporters had hoped for at the beginning.

So we wouldn’t be starting over again since ACA was merely a misfire that gained us very little. A misfire is not enough to restart the seventeen year clock, not to mention that the clock is only an illusion anyway.

And Gruber’s contention that our next reform efforts will move further to the right because that’s the way history has led us? Really? Was Social Security a move to the right? Was Medicare a move to the right? Was the Civil Rights Act a move to the right?

Does health care really fall at some point along a linear, bipolar, one-dimensional span between right and left? Of course not, though we should tell the ideologues in Congress who believe this that such in-the-box thinking is why we are replacing them in the forthcoming election. We want not just the elderly but everyone in America to be able to say, “Leave my Medicare alone!”

Hardball with Chris Matthews

MSNBC, March 27, 2012
Chris Matthews: Professor Gruber, I’ve got a curve ball for you, from the left field, all right? I’m mixing my metaphors here. If the Supreme Court strikes down the individual mandate today, which is the most conservative way to have national health for everybody, requiring people to take responsibility as individuals. If that fails, and the progressive left of the Democratic Party says, no, now’s our chance to go for single payer, or what’s called the public option – I guess they’ll wind up being the same thing because there won’t be another option really. Is that a better economic proposition? That the government simply provides health insurance for the country? Single payer. Is that a better economic deal with no profit motive?
Jonathan Gruber: I think that single payer, if you could start over, I think that single payer has a lot to recommend it, but we can’t, and I think the bottom line is…
Chris Matthews: But we might have to start over after tonight.
Jonathan Gruber: No. I agree, but if we start over, the problem with failing, if this ruling goes against… this law fails, we’ll see the same pattern we’ve seen for the past century, which when we start over again which will on average be about seventeen years from now, because it’s about every seventeen years we start over, it’s going to be further to the right of where we are. Every seventeen years… Remember Richard Nixon proposed something to the left of the Affordable Care Act. Every seventeen years we move to the right. If this fails, the next round is not going to be single payer. It’s going to be even more conservative than what we have now.
http://www.msnbc.msn.com/id/3036697/#46873470

What is the basis for this conversation about starting over if the Affordable Care Act (ACA) is struck down by the Supreme Court? Implicit is the concept that the Affordable Care Act actually accomplished the reform that we need. Of course, it didn’t. So, regardless of the decision, we wouldn’t be starting over since no iteration of ACA would hardly even begin to complete the process of reform.
For those who believe that ACA is the most feasible path to reform, there are some issues in this debate that would have the appearance of a make-or-break outcome (even though ACA itself isn’t a make-or-break model).
Based on the first two days of deliberation before the Supreme Court, it appears that the individual mandate to purchase private insurance may well be struck down. If it is, then both sides (plus an amicus from America’s Health Insurance Plans) agree that guaranteed issue and community rating should be declared inseverable and struck along with the individual mandate.
Though an intact ACA falls intolerably short on reducing uninsurance, underinsurance, and unaffordability, a decision eliminating guaranteed issue (eliminates pre-existing condition exclusions) and community rating (prevents insurers from gouging those with greater health care needs) would leave yet many more uninsured, especially those with greater health care needs plus the healthy invincibles whose funds are needed for the insurance risk pools. That should be enough to cause ACA supporters to take another look at single payer, though the mess we have with an intact ACA should make them reconsider anyway. ACA did not turn out to be the affordable-care-for-everyone model that supporters had hoped for at the beginning.
So we wouldn’t be starting over again since ACA was merely a misfire that gained us very little. A misfire is not enough to restart the seventeen year clock, not to mention that the clock is only an illusion anyway.
And Gruber’s contention that our next reform efforts will move further to the right because that’s the way history has led us? Really? Was Social Security a move to the right? Was Medicare a move to the right? Was the Civil Rights Act a move to the right?
Does health care really fall at some point along a linear, bipolar, one-dimensional span between right and left? Of course not, though we should tell the ideologues in Congress who believe this that such in-the-box thinking is why we are replacing them in the forthcoming election. We want not just the elderly but everyone in America to be able to say, “Leave my Medicare alone!”