PNHP

Time to raise our voices: health justice still not won

Time to raise our voices: health justice still not won

The following remarks by Dr. Claudia Fegan, past president of Physicians for a National Health Program, were delivered to the annual strategy conference of Healthcare-Now! on Jan. 28 in Houston.

By Claudia Fegan, M.D.


Dr. Claudia Fegan

On Jan. 19, Sarah Burke, a Canadian treasure, a pioneer in the sport of freeskiing who was instrumental in getting that sport added to the next Winter Olympics, died at the age of 29.

Sarah, a resident of British Columbia, died from injuries sustained in a fall on Jan.10 at the end of a practice run in Salt Lake City, Utah.

Sarah Burke was a phenomenal skier, immensely talented and tremendously enthusiastic about her sport. If you want to see grace in motion you should search Sarah Burke’s name on YouTube. She soared like an eagle and glided through the air effortlessly.

Immediately following her death her young husband and parents were presented with a bill for $550,000.

While she is Canadian and had cradle-to-grave coverage by Canadian medicare, she did not have coverage for this accident which occurred in the United States. She was covered by her professional skiing organization when she participated in sanctioned events; however, her training run in Salt Lake City was not a part of a sanctioned event.

Now it is true Canadians were stunned by the bill she had racked up during her 10-day ICU stay. However, they were shocked to learn that how much you are billed depends upon your insurance status. They were even more appalled to discover that being uninsured would result in being charged more for health care than if you were insured.

Sarah’s friends took to the Internet and have already raised $294,200 toward her outstanding bills. Unfortunately, most of the 50 million people who are uninsured in the United States today aren’t lucky enough to have a following to raise money to pay their medical bills.

That brings me to why I am here today. I would like to do five things this evening, although my English teacher husband tells me I should never to try to do more than three. So here goes:

1. I want to tell you what I do

2. Tell you why I do what I do

3. Tell you what Barack Obama did

4. Tell you why you must do why you must do what I do

5. Tell you how you can do it

What I do

So I am the Chief Medical Officer for the John H. Stroger Jr. Hospital of Cook County, or as most people outside of Chicago know us, Cook County Hospital. We are unusual among the public hospitals that remain open in the United States today because we still take care of everyone who comes to our door, regardless of their ability to pay.

That means last year 80 percent of the outpatients we saw were uninsured. Fifty-six percent of the patients we admitted were uninsured. The variance is because almost a quarter of those we admitted were able to get insurance once they were in the hospital and we had a chance to apply for coverage on their behalf.

Over the years I have spoken a lot about health care and I usually speak about my patients.

I remember at the Democratic National Convention in 2008 I talked about my patient Nina, who was a hairdresser who had no insurance. When she found a lump in her breast she was afraid to come to the hospital. When her daughter finally brought her in both breasts were rock hard and the tumor had begun to drain from one of the breasts.

Camille had been diagnosed with breast cancer when she was employed and was initially cared for at the University of Chicago where got excellent care. A couple of years later, after she had been laid off, she began to have problems again. Her surgical oncologist wouldn’t return her phone calls and her oncologist told her she couldn’t see her without insurance. So she came to County, where we took care of her.

I have talked about my 63-year-old patient Delois who needed a hip replacement because her joint had been destroyed by arthritis and she had bone grinding on bone. At County we don’t do joint replacements because we can’t afford the prosthetics. All we can do is give those patients pain medication, try to get them disability coverage so they can go somewhere else or wait for them to turn 65.

Then there is my patient Joan, who after a career as a bookkeeper thought she could contribute more to society by teaching music to children. She was frugal with her funds, purchased a small studio and some instruments. She hired instructors, most of them part-time. It means most of the instructors are musicians or schoolteachers whose available time coincides with when there is the most demand for lessons.

For years Joan was able to provide affordable lessons for students and sometimes free instruments for students who couldn’t afford them. She never made much money, but it gives her great joy to bring music to children. Joan does this work because she says it makes us a better society.

In the last three years the number of parents bringing their children for lessons has decreased, the expenses for the studio have increased and Joan has struggled to make ends meet.

For years I have managed Joan’s blood pressure and that has been a cost-saving to her because in the Cook County Health and Hospital System we charge patients based on their ability to pay. So last winter when she fell from her bicycle in Chicago snow and broke her ankle, there was no one to raise money for the surgery she would need to put it back together. With a broken ankle she couldn’t even climb the stairs to her second-floor studio.

Joan did the only thing she knew to do — she dragged herself with her broken ankle to our emergency room, where she knew she would be treated with dignity and respect and where she knew she would not receive a bigger bill because she was uninsured. Surgery went well and Joan has not traded her bike for a car; she has splurged on a three-wheeler instead.

So what I do is advocate for the 50 million uninsured in this country who seek nothing more than Health Care Justice. Yes, I personally take care of the Ninas, Deloises, Camilles and Joans who come to our doors, but in my spare time I fight for social justice.

Why do I do what I do?

Martin Luther King said, “The time is always right to do what’s right.” Well it is not right to punish people who don’t hav
e health insurance. We live in one of the wealthiest, most powerful nations in the world. We have no problems marching all over this world to tell developing nations how they should treat their citizens and yet we don’t have the common decency to provide for our own.

We are an arrogant lot, we Americans. We always think we know what is best for everyone else, but we refuse to look in the mirror and see the indignity and humiliation we impose on those of who do not have health insurance in this country.

We allow the health insurance industry and the pharmaceutical industry to profit tremendously on the misfortunes of many. Most pharmaceutical companies today are multinational entities that sell the same medications in the U.S. as they sell elsewhere in the world, but in the U.S. they are able to sell these medications for twice, three times and sometimes 10 times as much as they sell them elsewhere. That is because the U.S. allows them to sell medications for whatever the market will bear and most of the rest of the world regulates the cost of medications.

Why do I do what I do? Because my parents taught me right from wrong and they taught me to fight for what is right. What we do to people in this country without health insurance is wrong. Single-Payer National Health Insurance would provide our country with health care justice and that is right.

What did Barack Obama do?

Barack Obama pushed for and passed the Patient Protection and Affordable Care Act. Now let’s be clear, I’m a big fan of Barack Obama. His home in Chicago is less than two blocks from mine, he was my state representative before he was my senator and he is a very smart man.

But at the end of the day, he is a politician and I am a physician. I think our values are different, not right or wrong, just different. I think he is the best president we have had in a generation, but it is the job of a politician to compromise and I happen to disagree with where he has chosen to compromise. Passing the Patient Protection and Affordable Care Act was nothing short of miraculous — every single president since Franklin Roosevelt attempted to pass legislation for national health insurance, and not one before Obama had succeeded.

In the book “The Heart of Power,” David Blumenthal chronicles the efforts of presidents from Franklin Roosevelt through George W. Bush to achieve access to health care for the American public. He writes, “Major health reform is virtually impossible: difficult to understand, swarming with interests, powered by money, and resonating with popular anxiety.”

Blumenthal quotes congressional veteran and co-chair of the 9/11 Commission, Lee Hamilton: “Health care is so difficult because Congress is an incremental body and health care is a non-incremental issue.”

PPACA, or the Affordable Care Act as it is commonly called today¸ is badly flawed. It has no cost containment and will not address the issues of cost, access and quality. Single payer will.

Why must you do what I do?

The Affordable Care Act, once fully implemented, will leave 23 million people uninsured. About 45,000 people die each year as a result of not having health insurance, which means 180,000 more people will die before full implementation of the Affordable Care Act.

Single payer will cover everyone.

Barack Obama worked hard and maneuvered a massive piece of legislation through an intellectually constipated Congress, but he did not get us what we need. We need health care justice for this country.

He and others might argue that we did not make him fight for single payer. We weren’t marching up the front lawn of Congress or the White House shouting for it, or not shouting loudly enough, so there was no incentive for those on the inside to fight for it.

We didn’t lose the war to gain access to health care for all Americans. We got battered in an ugly skirmish, but we’re not done.

It is time to change our tactics

The opportunity for change is still ahead of us. The Affordable Care Act has not made health care a right.

Access to care in this country a profit center controlled by the insurance industry. We pay them to limit access to care. We spend more per capita on health care than any country in the world more than $7,500 per person and yet we are ranked only 37th in the world by the World Health Organization for the care we provide.

What we have done now is required everyone to purchase insurance. For those who can’t afford it, we’ve required states to either cover them under Medicaid or we’ve provided federal subsidies so they can purchase private insurance.

This is an industry that has a history of profiteering by retroactively denying coverage to people with illnesses. So now we are requiring everyone to buy coverage and, yes, we have told the insurance companies they can’t deny coverage to those with illnesses.

My question is this: Why can’t we just pay for care without having to go through the insurance industry?

We spend enough money on health care in this country. We just let too many people who aren’t involved in providing care take profit from it.

This is about justice. Health care should be a right to which everyone is entitled.

Remember we live in the wealthiest country in the world. We spend more on health care than any other country; it is time we got our money’s worth. It is time we got the health care we deserve, not the care the insurance industry is willing to let us have. It is time we made health care a right and not a privilege.

How can you do it?

You have to speak up. You have to speak loudly. You have to make your voices heard. The Affordable Care Act is an opportunity. It is not going to work!

You have to remind the people that there is still a simpler, easier solution. People want to know, they have questions. They will ask, is the new health law the answer? Will this work? Will this solve the problem? The answer is NO, the answer is NO!

The Affordable Care Act didn’t go too far, it didn’t go far enough and we can’t be afraid to say that. You have to tell the truth, you have to fight for what is right. You can’t be afraid to tell our representatives who are under attack from the right that what they have done in not enough and there are important points on which they cannot compromise. They need us to demand single payer, they need us to make them do it.

Being right is not enough; you have to fight and you have to fight hard to win the hearts and minds of th
e American public.

I keep reminding you that this is an issue of social justice and issues of social justice require struggle and tenacity because there are always reactionary forces ready and willing to push back against change. There are always people who benefit from the status quo. They will resist the change that will provide more for the many and instead want to retain the most for a few. We have to fight that.

My father was a labor union organizer, but he loved literature. He taught me a poem by Langston Hughes that I think applies to our current struggle. It is called “Mother to Son.”

Mother to Son

Well, son, I’ll tell you:
Life for me ain’t been no crystal stair.
It’s had tacks in it,
And splinters,
And boards torn up,
And places with no carpet on the floor —
Bare.
But all the time
I’se been a-climbin’ on,
And reachin’ landin’s,
And turnin’ corners,
And sometimes goin’ in the dark
Where there ain’t been no light.
So, boy, don’t you turn back.
Don’t you set down on the steps.
‘Cause you finds it’s kinder hard.
Don’t you fall now —
For I’se still goin’, honey,
I’se still climbin’,
And life for me ain’t been no crystal stair.

You are going to spend some time tonight and tomorrow discussing strategy, it is important that strategy be about getting the politicians to do what is right and not about compromising on the basic principle of single payer: Everybody in and nobody out! Everybody in and nobody out!

Calif. single-payer campaign to begin new push

Special to The Union
The Union (Grass Valley, Calif.), Feb. 1, 2012

The Campaign for a Healthy California on Wednesday denounced the failure of the California Senate to pass SB 810, the California Universal Care Act. The bill died when it remained two votes short of passage.

Democrats fell short of previous levels of support, which successfully passed similar bills through the legislature twice before, only to be vetoed by then Gov. Arnold Schwarzenegger. This year 19 voted in favor of the bill, two against, and four abstaining in spite of intensive efforts at persuasion by grassroots proponents. The bill received no support from Republicans.

The California Universal Care Act would have created a single public health insurance program for all Californians, much like an improved Medicare-for-All plan that has been proposed at the federal level.

CHC member organizations spoke out against the disappointing vote, “Nurses will not give up on winning guaranteed universal healthcare, like SB 810” stated DeAnn McEwen, RN, co-president of the California Nurses Association, “because we will not abandon our patients who need this vital reform.”

Nan Brasmer, president of the California Alliance for Retired Americans, stated: “This is a very sad day for seniors and all Californians. With millions of us uninsured or underinsured, SB 810 offered the only solution to our skyrocketing health care costs while covering everyone. And the added bonus is that it would save the State billions of dollars once implemented, at a time when essential programs for seniors are being slashed and out of pocket costs for health care have gone through the roof. We will continue to fight for single payer in the legislature and at the ballot box.”

SB 810 would create a new California Healthcare System to provide health insurance for all Californians, replacing the private insurance providers. Critics claim that such as system, often referred to as “single payer,” would be too costly. “Not true,” said Dr. Henry L. Abrons, president of PNHP California. “Currently the U.S. spends twice as much as any other country on health care. We have plenty of money in the system, enough to insure 100% of us; we just need to spend it more wisely.” He continued, “The best way to save money is to take the private insurers out of the system. They are responsible for 30% of each healthcare dollar being lost to pay for exorbitant CEO salaries, lobbyists, sales and marketing, administration and shareholder profit. Medicare’s overhead by contrast is only 3%. Californians would still be free to seek services from any medical provider in the private sector — only the financing would change. The difference is that that everyone in California would be fully covered.”

Joseph Foy, spokesman for the California Health Professional Student Alliance said, “Grassroots activists are not deterred by this setback in the Senate. The movement for single-payer health insurance is growing stronger every day among students who are the doctors, nurses, and other caregivers of the future.”

“Healthcare is a human right,” Progressive Democrats of America’s California state coordinator and emergency physician Dr. Bill Honigman stated, “It is immoral for businesses to profit from the illness of others, just as we would not expect them to profit from other public services such as police, fire, or education.”

“We’re disappointed today, but this is just the beginning of our efforts to win quality, comprehensive health care for all,” said Pilar Schiavo, the CHC campaign coordinator. “We will continue to build on the momentum we have created through our recent actions and statewide activism, and build an even broader and more powerful grass roots movement to ensure we win universal healthcare in California.”

The Campaign for a Healthy California represents over 1.4 million Californians and includes: California Alliance for Retired Americans, Physicians for a National Health Program – California, California Health Professional Student Alliance, Communication Workers of America – District 9 (California & Nevada), Health Care For All, Single Payer Now, California Nurses Association, California OneCare, California School Employee Association, Democracy For America, The Progressive Caucus of California, and Progressive Democrats of America.

http://www.theunion.com/article/20120201/BREAKINGNEWS/120209999/1001&parentprofile=1053

More bad news about "essential health benefits"

HHS Essential Benefits ‘Bulletin’ Draws Tide Of Comments

Kaiser Health News
February 2, 2012
As the official window of time allowed for groups to react to the Department of Health and Human Services essential benefits proposal closed, a variety of objections, concerns and common themes became clear.
CQ HealthBeat: State ‘Flexibility’ For Essential Benefits Gets Cool Reception
A tide of objections and worries rolled in just before Tuesday’s deadline for health groups to react to a Department of Health and Human Services proposal on essential health benefits. Input from health interests and consumers on the benefits “bulletin” is not being made public by the Obama administration, which asked that comments be sent to an email address rather than posted on a government website as would be the practice with a proposed regulation (Norman, 2/1).
Politico Pro: EHB Comments Show Some Common Themes
Believe it or not, businesses, insurers and consumers do see eye to eye on essential health benefits — well, on some parts, anyway. They’re at odds on some of the bigger issues, which doesn’t exactly come as a surprise. The comments submitted to HHS on its essential health benefits approach shows a wide divide between consumers … and businesses and insurers, who don’t see enough safeguards to keep the essential health benefits package affordable (Millman, 2/2).
http://www.kaiserhealthnews.org/Daily-Reports/2012/February/02/essential-benefits.aspx

Yesterday we reported that some of the most politically powerful organizations in the nation have joined together in a coalition to try to weaken the package of “essential health benefits” that will be required of health plans under the Affordable Care Act.  Excerpts from two new articles covered in the Kaiser Daily Health Policy Report should have us even more concerned.
In Politico Pro, it is reported that businesses and insurers “don’t see enough safeguards to keep the essential health benefits package affordable.” The proposal already has reduced the required benefits down to the relatively austere level of small group plans offered in the various states. These plans leave patients facing financial hardship when they must access health care.
Yet the powerful businesses and insurers want an even lower standard of benefits in order to keep the health benefits package affordable. The insurers want to protect their markets by keeping the insurance premiums affordable, and businesses also want the lowest premiums they can negotiate. Low premiums equate with higher out-of-pocket expenses for those with medical needs. In trying to make the health insurance plans more affordable, actual health care for the patients will be even less affordable.
As we have seen, the process has always been about powerful interests, with only a passive concern for patients.
In CQ HealthBeat, we see that comments on the proposal are being “sent to an email address rather than posted on a government website as would be the practice with a proposed regulation,” and are “not being made public by the Obama administration.”
The White House gave these special interests carte blanche with secretive access during the reform process. Secrecy continues. Should we be surprised when the final rule on “essential health benefits” pleases business and insurance interests, at a cost of exposing those with health care needs to greater financial hardship? No, not surprised. Outraged is more like it!

Beware the Essential Health Benefits Coalition

Essential Health Benefits Coalition

January 31, 2012
Letter
To: HHS Secretary Kathleen Sebelius
From: Neil Trautwein, National Retail Federation

Re: Request for Information on the Essential Health Benefits Bulletin

The Essential Health Benefits Coalition (“EHBC”) appreciates the opportunity to provide comments in response to the “Essential Health Benefits Bulletin” as issued by Department of Health and Human Services’ (HHS’s) Center for Consumer Information and Insurance Oversight (CCIIO) on December 16, 2011.

As you finalize the definition of the Essential Health Benefits (EHB) package, we want to emphasize our concerns regarding the affordability of coverage for small employers and individuals under the Affordable Care Act (ACA). HHS seeks to give states flexibility to structure their own EHB package using private market coverage options in use today to serve as benchmarks.  Yet these benchmark options are subject to the same state mandates that today keep coverage unaffordable and out of reach for many small employers and individuals. We urge HHS to consider an approach that balances reasonably comprehensive benefits with affordability for employers and individuals. A definition that does otherwise will make health coverage more expensive for employers and individuals to purchase and make jobs more difficult for employers to create.

Excerpt from recommendations:

Specifically, we urge the Department to reiterate that the Bulletin reflects the statutory requirements that:

* The EHB package does not dictate cost sharing requirements.

* Use of benefit limits included within benchmark plans is not barred.

* Future state mandates will not be added to the benchmark plan.

* Use the benchmark plan only to define the 10 categories of EHBs required by the ACA, and not any additional benefits that the benchmark may cover.

Members of the Essential Health Benefits Coalition Steering Committee:
 
American Osteopathic Association
America’s Health Insurance Plans
Blue Cross Blue Shield Association
Express Scripts Inc.
National Association of Health Underwriters
National Association of Manufacturers
National Association of Wholesaler-Distributors
National Federation of Independent Business
National Retail Federation
Pharmaceutical Care Management Association
Prime Therapeutics
Retail Industry Leaders Association 
U.S. Chamber of Commerce 

http://ehbcoalition.org/wp-content/uploads/2012/02/EHBC-Comments.pdf

Comment: 

By Don McCanne, MD

HHS has proposed that “essential health benefits” for plans under the Affordable Care Act need meet only the minimal standard of state regulated plans in the small group market. Now a coalition of the usual suspects which push self-serving reforms is proposing to further weaken the “essential health benefits” standard.

The details of their recommendations are not nearly as important as the fact that this maneuver represents what has been wrong with the reform process all along. The vested interests have been in the front seat while the guileless  patients have had to accept their work product – a mandate to purchase unaffordable under-insurance, amongst many other flawed policies.

Instead of fighting over the definition of minimal essential benefits in a highly flawed health financing program, we should be joining with the nation’s patients in demanding that our elected leaders quit listening to these self-serving interests and instead enact a program that puts patients in the front seat – an improved Medicare for all.

Addendum:  Members of the American Osteopathic Association (AOA) may want to advise their leadership that, as a patient-oriented organization, AOA should immediately withdraw from this dastardly coalition.

Beware the Essential Health Benefits Coalition

Essential Health Benefits Coalition

January 31, 2012
Letter
To: HHS Secretary Kathleen Sebelius
From: Neil Trautwein, National Retail Federation
Re: Request for Information on the Essential Health Benefits Bulletin
The Essential Health Benefits Coalition (“EHBC”) appreciates the opportunity to provide comments in response to the “Essential Health Benefits Bulletin” as issued by Department of Health and Human Services’ (HHS’s) Center for Consumer Information and Insurance Oversight (CCIIO) on December 16, 2011.
As you finalize the definition of the Essential Health Benefits (EHB) package, we want to emphasize our concerns regarding the affordability of coverage for small employers and individuals under the Affordable Care Act (ACA). HHS seeks to give states flexibility to structure their own EHB package using private market coverage options in use today to serve as benchmarks.  Yet these benchmark options are subject to the same state mandates that today keep coverage unaffordable and out of reach for many small employers and individuals. We urge HHS to consider an approach that balances reasonably comprehensive benefits with affordability for employers and individuals. A definition that does otherwise will make health coverage more expensive for employers and individuals to purchase and make jobs more difficult for employers to create.
Excerpt from recommendations:
Specifically, we urge the Department to reiterate that the Bulletin reflects the statutory requirements that:
* The EHB package does not dictate cost sharing requirements.
* Use of benefit limits included within benchmark plans is not barred.
* Future state mandates will not be added to the benchmark plan.
* Use the benchmark plan only to define the 10 categories of EHBs required by the ACA, and not any additional benefits that the benchmark may cover.
Members of the Essential Health Benefits Coalition Steering Committee:
American Osteopathic Association
America’s Health Insurance Plans
Blue Cross Blue Shield Association
Express Scripts Inc.
National Association of Health Underwriters
National Association of Manufacturers
National Association of Wholesaler-Distributors
National Federation of Independent Business
National Retail Federation
Pharmaceutical Care Management Association
Prime Therapeutics
Retail Industry Leaders Association
U.S. Chamber of Commerce
http://ehbcoalition.org/wp-content/uploads/2012/02/EHBC-Comments.pdf

HHS has proposed that “essential health benefits” for plans under the Affordable Care Act need meet only the minimal standard of state regulated plans in the small group market. Now a coalition of the usual suspects which push self-serving reforms is proposing to further weaken the “essential health benefits” standard.
The details of their recommendations are not nearly as important as the fact that this maneuver represents what has been wrong with the reform process all along. The vested interests have been in the front seat while the guileless  patients have had to accept their work product – a mandate to purchase unaffordable under-insurance, amongst many other flawed policies.
Instead of fighting over the definition of minimal essential benefits in a highly flawed health financing program, we should be joining with the nation’s patients in demanding that our elected leaders quit listening to these self-serving interests and instead enact a program that puts patients in the front seat – an improved Medicare for all.
Addendum:  Members of the American Osteopathic Association (AOA) may want to advise their leadership that, as a patient-oriented organization, AOA should immediately withdraw from this dastardly coalition.

Emanuel and Liebman predict the end of private insurance

The End of Health Insurance Companies

By Ezekiel J. Emanuel and Jeffrey B. Liebman
The New York Times, January 30, 2012

Here’s a bold prediction for the new year. By 2020, the American health insurance industry will be extinct. Insurance companies will be replaced by accountable care organizations — groups of doctors, hospitals and other health care providers who come together to provide the full range of medical care for patients.

… thanks to the accountable care organizations provided for by the health care reform act, a new system is on its way, one that will make insurance companies unnecessary. Accountable care organizations will increase coordination of patient’s care and shift the focus of medicine away from treating sickness and toward keeping people healthy.

… accountable care organizations will typically be paid a fixed amount per patient, along with bonuses for achieving quality targets. The organizations will make money by keeping their patients healthy and out of the hospital and by avoiding unnecessary tests, drugs and procedures. Thus, they will actually have a financial incentive to hire that nurse for follow-ups.

In addition to providing better and more efficient care, A.C.O.’s will also make health insurers superfluous. Because they will each be responsible for a large group of patients (typically more than 15,000), they will pool the risk of patients who have higher-than-average costs with those with lower costs. And with the end of fee-for-service payments, insurance companies will no longer be needed to handle complicated billing and claims processing, nor will they need to be paid a fee for doing so. Payments can flow directly from an employer, Medicare or Medicaid to the accountable care organizations. A.C.O.’s will require enhanced information systems to track patients and figure out how to deliver more effective care, but this analytic capacity will be directed at improving health outcomes, not at imposing barriers to those seeking treatment.

A.C.O.’s are not simply a return to the health maintenance organizations of the 1990s. Although in both models patients are members of a provider network with a specific group of doctors and hospitals, and both are paid primarily per member rather than per procedure or test, there are big differences between them. H.M.O.’s were often large national corporations far removed from their members. In contrast, A.C.O.’s will consist of local health care providers working as a team to take care of patients who are likely to be members for years at a time.

A few health insurers see this asteroid coming. Wellpoint, for example, bought the clinic operator CareMore for $800 million last summer to make the transition into the A.C.O. business. Others, like the Optum unit of UnitedHealth Group, are developing data analysis services to provide to future A.C.O.’s. If they don’t want to go the way of the dinosaurs, insurance companies will have to find a new business to be in, one that is useful in the new world of coordinated care.

http://opinionator.blogs.nytimes.com/2012/01/30/the-end-of-health-insurance-companies/

Comment:

NYT Pick

Don McCanne
San Juan Capistrano, CA

The policy community, as represented by Ezekiel Emanuel and Jeffrey Liebman, speaks in glowing terms about idealistic, altruistic accountable care organizations (ACOs) in which health care professionals and institutions join together to improve quality and lower costs. Yet the specifics of the Medicare Shared Savings program that would establish ACOs through the Affordable Care Act (ACA), has only a superficial resemblance to these idealistic models.

The fact that the two largest for-profit insurers in the nation – WellPoint and UnitedHealth – are going after the ACO business is proof that we are in for more of the same. Eliminating private insurers by merely setting up ACOs is a pipe dream. The state insurance exchanges mandated by ACA are exchanges of private insurance plans, not ACOs.

We need to improve Medicare, dump the private insurers including the Medicare Advantage plans, and provide Medicare for everyone. Medicare has been far more effective than the private insurers in controlling costs, and would be even more so if it were our own publicly-financed single payer system.

http://opinionator.blogs.nytimes.com/2012/01/30/the-end-of-health-insurance-companies/?comments#permid=7

Market reforms will not result in health care for all in Maine

Federal and state programs will not achieve the savings promised by a single-payer system

By Julie Pease, M.D.
Portland Press Herald (Maine), Jan. 30, 2012

For two years, while great effort has been spent debating health care reforms, costs for health insurance have continued to spiral out of control. Contrary to the assertions of Sen. Deborah Sanderson in a Dec. 30 column (“Legislature is tackling the causes of Maine’s high health care costs”), there is simply no evidence to suggest that increasing competition in the for-profit insurance market will control health care costs, just as there is no evidence to suggest that federal reforms will be able to bring costs under control.

How much longer must we wait before we can agree that our health care system is irretrievably broken and recent incremental “reforms” are ineffective? How many families will go bankrupt due to medical expenses? How many people will die due to delaying care or being unable to access care at all?

The best way to control health care costs and to bring quality comprehensive health care to all Maine people is through a universal single-payer health care system. Under a universal system, everybody would be equally affected by changes in benefits and eligibility would become a moot point. The conversation in Augusta would be much different if Gov. LePage were proposing health care cuts for all Mainers rather than our most impoverished and vulnerable citizens.

Eliminating administrative waste would save a great deal of money. In testimony before the Maine Legislature, Harvard Professor William Hsiao estimated potential savings in the first year under single-payer to be $1 billion in Maine alone!

Maine could use these savings to provide real health care benefits instead of wasting money on administrative overhead or insurance company profits. Shifting from a for-profit to a not-for-profit financing mechanism would place the focus of health care on healing and health rather than profitability.

It is time to follow the lead of our neighbors in Vermont who have taken steps toward universal health care. We can’t afford to wait.

Julie Pease, M.D., is president of the board of directors of Maine AllCare. She lives in Brunswick.

http://www.pressherald.com/opinion/market-reforms-will-not-result-in-health-care-for-all-in-maine_2012-01-30.html

To rein in health costs, look to single payer

Letters, The New York Times, January 29, 2012

To the Editor:

Ezekiel J. Emanuel chooses to assign liberals with controlling costs in health care, when he should be waving his finger at the health care sector. When “skyrocketed” health care costs come up, profit never makes it into the discussion or calculations.

Dr. Emanuel should remember, too, that many liberals wanted the cost-saving, improved Medicare-for-all system to be included in Senator Max Baucus’s committee hearings. Sadly, the cabal made sure that its proponents got no seat at the table.

H.R. 676, the Expanded and Improved Medicare for All Act, would have cut out unnecessary administrative costs, given Americans real choice in their health care, and dissolved the employment-benefits contract that keeps us an indentured labor force. These are factors that both liberals and conservatives should be able to support.

BARBARA COMMINS
San Francisco, Jan. 22, 2012

The writer is a registered nurse.

To the Editor:

Ezekiel J. Emanuel suggests that liberals “ignore costs.” He doesn’t seem to recognize that many conservatives oppose the payment reform proposals in the Affordable Care Act. Remember the outcry about “death panels”?

Moreover, it should not be a given that insurers should continue to consume a large fraction of the health care dollar.

There are many good options for payment reform not included in the health care law. We need a wider discussion on how care is paid for, and how everyone can have access to care in a way that is more efficient, safer and better.

Our government should not write off the possibility of single-payer (which it has so far, largely because of conservative opposition). Those are liberal ideas, and they do not mean that costs should be ignored.

BRUCE L. WILDER
Pittsburgh, Jan. 22, 2012

The writer is a neurosurgeon and a lawyer.

http://www.nytimes.com/2012/01/30/opinion/health-costs-regardless-of-your-politics.html

Emanuel and Liebman predict the end of private insurance

The End of Health Insurance Companies

By Ezekiel J. Emanuel and Jeffrey B. Liebman
The New York Times, January 30, 2012
Here’s a bold prediction for the new year. By 2020, the American health insurance industry will be extinct. Insurance companies will be replaced by accountable care organizations — groups of doctors, hospitals and other health care providers who come together to provide the full range of medical care for patients.
… thanks to the accountable care organizations provided for by the health care reform act, a new system is on its way, one that will make insurance companies unnecessary. Accountable care organizations will increase coordination of patient’s care and shift the focus of medicine away from treating sickness and toward keeping people healthy.
… accountable care organizations will typically be paid a fixed amount per patient, along with bonuses for achieving quality targets. The organizations will make money by keeping their patients healthy and out of the hospital and by avoiding unnecessary tests, drugs and procedures. Thus, they will actually have a financial incentive to hire that nurse for follow-ups.
In addition to providing better and more efficient care, A.C.O.’s will also make health insurers superfluous. Because they will each be responsible for a large group of patients (typically more than 15,000), they will pool the risk of patients who have higher-than-average costs with those with lower costs. And with the end of fee-for-service payments, insurance companies will no longer be needed to handle complicated billing and claims processing, nor will they need to be paid a fee for doing so. Payments can flow directly from an employer, Medicare or Medicaid to the accountable care organizations. A.C.O.’s will require enhanced information systems to track patients and figure out how to deliver more effective care, but this analytic capacity will be directed at improving health outcomes, not at imposing barriers to those seeking treatment.
A.C.O.’s are not simply a return to the health maintenance organizations of the 1990s. Although in both models patients are members of a provider network with a specific group of doctors and hospitals, and both are paid primarily per member rather than per procedure or test, there are big differences between them. H.M.O.’s were often large national corporations far removed from their members. In contrast, A.C.O.’s will consist of local health care providers working as a team to take care of patients who are likely to be members for years at a time.
A few health insurers see this asteroid coming. Wellpoint, for example, bought the clinic operator CareMore for $800 million last summer to make the transition into the A.C.O. business. Others, like the Optum unit of UnitedHealth Group, are developing data analysis services to provide to future A.C.O.’s. If they don’t want to go the way of the dinosaurs, insurance companies will have to find a new business to be in, one that is useful in the new world of coordinated care.
http://opinionator.blogs.nytimes.com/2012/01/30/the-end-of-health-insurance-companies/

Comment originally posted on the New York Times’ website.
NYT Pick
Don McCanne
San Juan Capistrano, CA
The policy community, as represented by Ezekiel Emanuel and Jeffrey Liebman, speaks in glowing terms about idealistic, altruistic accountable care organizations (ACOs) in which health care professionals and institutions join together to improve quality and lower costs. Yet the specifics of the Medicare Shared Savings program that would establish ACOs through the Affordable Care Act (ACA), has only a superficial resemblance to these idealistic models.
The fact that the two largest for-profit insurers in the nation – WellPoint and UnitedHealth – are going after the ACO business is proof that we are in for more of the same. Eliminating private insurers by merely setting up ACOs is a pipe dream. The state insurance exchanges mandated by ACA are exchanges of private insurance plans, not ACOs.
We need to improve Medicare, dump the private insurers including the Medicare Advantage plans, and provide Medicare for everyone. Medicare has been far more effective than the private insurers in controlling costs, and would be even more so if it were our own publicly-financed single payer system.

Paying for a free screening colonoscopy

'Free' preventive care can cost patients big money: Is procedure a screening or therapeutic?

By Tom Kisken
Ventura County Star, January 28, 2012

Patients are getting charged as much as $3,000 for screenings they thought would be free under a federal health care reform mandate that promises free preventive care.

Most of the problems revolve around colonoscopies — screenings designed to detect colon and rectal cancers that kill about 52,000 Americans a year.

The procedure has been covered by federal health care reform for men and women 50 and older since September 2010, although many older insurance policies are exempt from the new provision.

Some patients are still receiving bills for deductibles or co-pays when the procedures show an abnormal growth called a polyp that can develop into cancer.

Insurance companies may charge for screenings or tests if patients show symptoms of cancer or are going through a colonoscopy as a follow-up to an earlier diagnosis, said Robert Zirkelbach, spokesman for the trade group. But many insurers consider colonoscopies to be preventive care — and covered — regardless of whether polyps are present, he said. Bills are sent when they aren’t told the nature of the procedure.

“One of the challenges is: How are those procedures being coded by physicians?” he said. “Is it clear that it’s a preventive service?”

Some doctors, however, insist the issue isn’t coding, but rather money and the insurers’ desire for it.

“That is subterfuge,” said Dr. Paul Sanders, a Thousand Oaks gastroenterologist, contending insurers are shifting blame from themselves to physicians. “It’s utter baloney. The insurance companies have quite intentionally blocked any way that anybody could understand what they’re going to, and not going to, pay for.”

Charles Rosen, a Simi Valley insurance broker and president-elect of the California Association of Health Underwriters, tells clients to minimize chances of any billing confusion by not talking to a doctor about any health concerns during a screening exam.

“If you have a pending issue, make another appointment,” he said.

http://www.vcstar.com/news/2012/jan/28/free-preventive-care-can-cost-patients-big-money/

Comment: 

By Don McCanne, MD

Colonoscopy is one of several cancer screening tests that are covered 100 percent – no deductibles nor coinsurance are required. What separates out colonoscopy from the other screening tests is that it is frequently converted, on the spot, to a therapeutic procedure when polyps are detected and removed.

Somewhere between the billing office for the physician or outpatient department and the processing of the claim by the insurer, the diagnostic and procedure coding is changed from the free screening test to the therapeutic procedure, subject to cost sharing. The physician blames the insurer, and the insurer blames the physician. But it is the patient who is harmed by being required to pay the out-of-pocket costs of a therapeutic procedure after having been promised a free screening test.

As is typical in our health care financing system that turns decisions over to private insurers (even if only private administrators of Medicare), the president-elect of the California Association of Health Underwriters advises patients to withhold medical information until after they have received their free screening. Only then should they inform their physician about the rectal bleeding or the tenesmus that they have been experiencing. What’s a little fraud if it is only the patient that is committing it?

There are two policy lessons here.

One is that deductibles, co-payments and coinsurance should be eliminated for all appropriate care. Payment issues should not interfere with health care decisions made by the patient with the best advice of the physician. The harm dome by erecting financial barriers to care is potentially far greater than the almost negligible decrease in our national health expenditures that would result from cost sharing (most of which is merely shifted from the insurer to the patient). Obtaining appropriate health care should not result in the assessment of cost sharing penalties or fines.

The second policy lesson is that we need to throw the middleman crooks out. Only that industry would come up with a solution that patients should be instructed to lie to their health care professionals. Not a lie to withhold information? Isn’t the oath for swearing in, “The truth, the whole truth, and nothing but…”? Maybe the whole truth is confidential proprietary information. At least that’s what the insurers keep telling us when we ask for transparency.

Free-Market Medicine: A Personal Account

By Michael Parenti
CommonDreams, Jan. 27, 2012

When I recently went to Alta Bates hospital for surgery, I discovered that legal procedures take precedence over medical ones. I had to sign intimidating statements about financial counseling, indemnity, patient responsibilities, consent to treatment, use of electronic technologies, and the like.

One of these documents committed me to the following: “The hospital pathologist is hereby authorized to use his/her discretion in disposing of any member, organ, or other tissue removed from my person during the procedure.” Any member? Any organ?

The next day I returned for the actual operation. While playing Frank Sinatra recordings, the surgeon went to work cutting open several layers of my abdomen in order to secure my intestines with a permanent mesh implant. Afterward I spent two hours in the recovery room. “I feel like I’ve been in a knife fight,” I told one nurse. “It’s called surgery,” she explained.

Then, while still pumped up with anesthetics and medications, I was rolled out into the street. The street? Yes, some few hours after surgery they send you home. In countries that have socialized medicine (there I said it), a van might be waiting with trained personnel to help you to your abode.

Not so in free-market America. Your presurgery agreement specifies in boldface that you must have “a responsible adult acquaintance” (as opposed to an irresponsible teenage stranger) take you home in a private vehicle. I kept thinking, what happens to those unfortunates who have no one to bundle them away? Do they languish endlessly in the hospital driveway until the nasty weather finishes them off?

You are not allowed to call a taxi. Were a taxi driver to cause you any harm, you could hold the hospital legally responsible. Again it’s a matter of liability and lawyers, not health and doctors.

One of the two friends who helped me up the steps to my house then went off to Walgreen’s to buy the powerful antibiotics I had to take every four hours for two days. I dislike how antibiotics destroy the “good bacteria” that our bodies produce, and how they help create dangerous strains of super-resistant bacteria. I kept thinking of a recent finding: excessive reliance on medical drugs kills more Americans than all illegal narcotics combined.

So why did I have to take antibiotics? Because, as everyone kept telling me, hospitals are seriously unsafe places overrun with Staph infections and other super bugs. It’s a matter of self-protection.

Two days after surgery I noticed a dark red discoloration on my lower abdomen indicating internal bleeding. I was supposed to get a follow-up call from a nurse who would check on how I was doing. But the call might never come because the staff was planning a walkout. “We have no contract,” one of them had told me when I was in the recovery room. So now the nurses are on strike — and I’m left on my own to divine what my internal bleeding is all about. What fun.

Fortunately, it didn’t turn out that way. A nurse did call me despite the walkout. Yes, she said, it was internal bleeding, but it was to be expected. My surgeon called later in the day to confirm this opinion. Death was not yet knocking.

A few days later, there were massive nurses strikes on both coasts. Among other things, the nurses were complaining about “being disrespected by a corporate hospital culture that demands sacrifices from patients and those who provide their care, but pays executives millions of dollars.” (New York Times, 16 December 2011). One cold-blooded management negotiator was quoted as saying, “We have the money. We just don’t have the will to give it to you” (ibid.).

As for the doctors, both my surgeon and my general practitioner (GP) are among the victims, not the perpetrators, of today’s corporate medical system. My GP explained that it is an endless fight to get insurance companies to pay for services they supposedly cover. Feeling less like a doctor and more like a bill collector, my GP found he could no longer engage in endless telephone struggles with insurance companies.

There are 1,500 medical insurance companies in America, all madly dedicated to maximizing profits by increasing premiums and withholding payments. The medical industry in toto is the nation’s largest and most profitable business, with an annual health bill of about $1 trillion.

Along with the giant insurance and giant pharmaceutical companies, the greatest profiteers are the Health Maintenance Organizations (HMOs), notorious for charging steep monthly payments while underpaying their staffs and requiring their doctors to spend less time with each patient, sometimes even withholding necessary treatment.

I am without private insurance. And my Medicare goes just so far. Like many other doctors, my GP no longer accepts Medicare. For a number of years now, Medicare payments to physicians have remained relatively unchanged while costs of running a practice (staff, office space, insurance) have steadily increased. So now my GP’s patients have to pay in full upon every visit — which is not always easy to do.

Our health system mirrors our class system. At the base of the pyramid are the very poor. Many of them suffer through long hours in emergency rooms only to be turned away with a useless or harmful prescription. No wonder “the United States has the worst record among industrialized nations in treating preventable deaths” (Healthcare-NOW! 1 December 2011).

Too often the very poor get no care at all. They simply die of whatever illness assails them because they cannot afford treatment. An acquaintance of mine told me how her mother died of AIDS because she could not afford the medications that might have kept her alive.

In Houston I once got talking with a limousine driver, a young African-American man, who remarked that both his parents had died of cancer without ever receiving any treatment. “They just died,” he said with a pain in his voice that I can still hear. 

Living just above the poor in the class pyramid are the embattled middle class. They watch medical coverage disappear while paying out costly amounts to the profit-driven insurance companies. I was able to get surgery at Alta Bates only because I am old enough to have Medicare and have enough disposable income to meet the co-payment.

For my out-patient operation, the hospital charged Medicare $19,466. Of this, Medicare paid $2,527. And I was billed $644. The hospital then writes off the unpaid balance thus saving considerable sums in taxes (amounting to an indirect subsidy from the rest of us taxpayers). Had I no Medicare coverage, I would have had to pay the entire $19,466.

I was informed by the hospital that the $19,466 charge covers only hospital costs for equipment, technicians, supplies, and room. So besides the $644, I will have to pay for any pathologists, surgical assistants, and anesthesiologists who performed additional services. I am waiting for the other shoe to drop.

How much does my surgeon earn? Not much at all. He gets about $400 to $500 for everything, including my pre-op and post-op visits and the surgery itself, an exacting undertaking that requires skills of the highest sort. He also has to maintain insurance, an office, an assistant, and an increasing load of paperwork.

My surgeon pointed out to me, “If you ask people how much I make on an operation like yours, they will say $4000 to $5000, and be wrong by a factor of ten.” He noted that in a recent speech President Obama criticized a surgeon for charging $30,000 to replace a knee cap. “The surgeon gets a minute fraction of that amount,” my doctor pointed out. 

To make matters worse, there is talk about cutting Medicare payments to physicians by 27 percent. If this happens, it is going to be in
creasingly difficult to find a surgeon who will take Medicare. Still worse, the private insurance companies will join in squeezing the physicians for still more profits.

I was able to meet my payment ($644) not only because my operation was heavily subsidized by Medicare but because it was a one-day “ambulatory surgery.” I don’t know how I would fare if I had to undergo prolonged and extremely costly treatment.

So much for life in the middle class. At the very top of the class pyramid are the 1%, those who don’t have to worry about any of this, the superrich who have money enough for all kinds of state-of-the-art treatments at the very finest therapeutic centers around the world, complete with luxury suites with gourmet menus.

Among the medically privileged are members of Congress and the U.S. president. They pay nothing. They are treated at top-grade facilities. They enjoy, how shall we put it, socialized medicine. No conservative lawmakers have held fast to their free-market principles by refusing to accept this publicly funded, medical treatment.

John Mackey, CEO of Whole Foods, cheerfully announced that medical care is not a human right; it should be “market determined just like food and shelter.” Nobody has a higher opinion of John Mackey than I, and I think he is a greed-driven, union-busting bloodsucker. Nevertheless I will give him credit for candidly admitting his dedication to a dehumanized profit pathology.

The U.S. medical system costs many times more than what is spent in socialized systems, but it delivers much less in the way of quality care and cure. That’s the way it is intended to be. The goal of any free-market service — be it utilities, housing, transportation, education, or health care — is not to maximize performance but to maximize profits often at the expense of performance.

If profits are high, then the system is working just fine — for the 1%. But for us 99%, the profit lust is itself the heart of the problem.

Michael Parenti’s recent books include God and His Demons (Prometheus), Contrary Notions: The Michael Parenti Reader (City Lights); Democracy for the Few, 9th ed. (Wadsworth); The Assassination of Julius Caesar (New Press); Superpatriotism (City Lights); and The Culture Struggle (Seven Stories Press). For further information, visit his website: www.michaelparenti.org.

http://www.commondreams.org/view/2012/01/27-0

Lawmakers press Green Mountain Care Board on work plan

By Alan Panebaker
Vtdigger.org, Jan. 20, 2012

The Shumlin administration and the Green Mountain Care Board introduced road maps Thursday for how they plan to implement health care reform.

The board’s annual report and the administration’s Strategic Plan for Vermont Health Reform shed light on the specifics of how the state will maneuver to a health benefits exchange in 2014 and into a single-payer system in 2017.

Download the GMCB Annual Report

Last week the board approved its work plan, identifying high priorities for 2012. Anya Rader Wallack, chair of the Green Mountain Care Board, fielded questions from legislators Thursday that have become somewhat of the norm: How will the board maintain its independence from the Shumlin administration and how is a reformed system going to control costs?

Sen. Kevin Mullin, R-Rutland, pushed both Wallack and Director of Health Care Reform Robin Lunge on the issue of containing costs through tort reform. A report by Harvard economics professor Dr. William Hsiao last February recommended moving to a no-fault medical malpractice system similar to New Zealand. Act 48, last year’s health care reform law, requires a report to the legislature on the costs of reform. It was due this week, but the administration requested an extension until Jan. 30.

Mullin, who is vice chair of the Senate Committee on Health and Welfare, told Wallack that he thinks analysis is the most important issue for the board as it designs what will be a new health care system for the state.

“We should be looking at the best results from all different health care systems in world,” Mullin said. “We need to see if they work.”

Mullin said the board’s analysis should address what impacts other systems have on factors like patient safety and quality of care then make a decision based on all available information.

“What I’m afraid we’re going to hear is it’s a political compromise rather than a reasoned analysis,” Mullin said.

Wallack, who has been working on health care reform efforts since the 1990s, assured Mullin that the board is working to make sure it does the necessary research.

“In terms of having analytic capability moving forward, that’s absolutely what we’re moving toward,” Wallack said.

Currently, the board has 13 staff members, and it is in the process of hiring three more full-time.

The board’s work plan includes a plethora of tasks for analyzing data for evaluating quality and performance in the health care system, implementing pilot payment programs, and dealing with a host of issues involving insurance rate review and hospital budget oversight. The board has also submitted a grant application to the Robert Wood Johnson foundation for a payment reform project. Vermont was one of 15 sites invited to submit a proposal for the $500,000 grant out of 120 applicants.

The annual report also outlines the board’s estimated expenditures, which total around $2.1 million for 2012 and nearly $2.5 million for 2013.

Legislators also pressed Wallack on the recently-withdrawn request for proposal for a communications consultant. The issue became a political hot potato when Gov. Peter Shumlin expressed dismay that the the board was trying to hire what appeared to be a public relations firm.

Rep. Patti Komline, R-Dorset, asked Wallack why the board decided to back off so quickly amid criticism.

Wallack emphasized that the decision to withdraw the RFP was not in response to the governor and that the board will likely go back to the drawing board and make more clear what it is looking for.

“It’s not about PR,” Wallack said. “It’s about communicating with the public and engaging the public.”

With somewhat of an overlap between the administration’s mandate to implement a health benefits exchange dovetailing with the Green Mountain Care Board’s mandate to lay the groundwork for a universal health care system, Rep. Chris Pearson, P-Burlington, said he was concerned people are becoming confused and losing sight of the ultimate goal of single payer.

“We’ve really got to keep our eye on the prize,” Pearson said.

The focus on a health benefits exchange, which is a federal mandate, has become a point of frustration, he said.

“People are deeply interested in seeing a real health care system that is effective, and there’s a lot of anxiety about that,” Pearson said. “It’s all geared to this goal, but we can’t talk about it in a way the public understands if we’re not talking about the goal. Nobody is mentioning Green Mountain Care.”

The exchange is a step toward single payer, however, and transforming health care involves lots of moving parts.

“Just focusing on single payer and saying that’s going to be the silver bullet would be very naïve,” Wallack said.

Rep. George Till, D-Jericho, commended Wallack and the rest of the Green Mountain Care Board for their efforts.

“I’m impressed with the work they’re doing,” Till said.

He echoed Wallack’s point that health care reform involves more than the single payer concept where one government-run organization accepts all the health care fees and pays out all the health care costs.

“It’s really about the clinical and payment reforms that will control the health care costs which is the real aim in addition to providing health care to everybody,” Till said.

Despite his commendation, Till said he thought the board missed a tremendous opportunity to establish its independence from the governor when it decided to withdraw the request for proposal for a communications specialist.

He emphasized, also, the importance of moving to a no-fault medical malpractice system where patients who are injured would receive government-funded compensation rather than suing physicians for negligence. This type of system, which the Hsiao report recommended, reduces defensive medicine, which can really contain costs, according to the report.

http://vtdigger.org/2012/01/20/lawmakers-press-green-mountain-care-board-on-work-plan/

State releases report on single-payer plan

By CHRIS GAROFOLO / Reformer St
aff
The Brattleboro Reformer, Jan. 24, 2012

BRATTLEBORO, Vt. — Officials in the process of overhauling Vermont’s “unsustainable” health care system released a 21-page report on how the state will implement a single-payer plan within the next three to five years.

Anya Rader Wallack, chairwoman of the Green Mountain Care Board, said the report relates to Vermont’s health care delivery system and reform aimed at controlling rising costs in the state.

“One of the things I tell audiences when I go around the state and talk about our goals on cost containment is; you take current trends, which is about 6 or 7 percent increase per year in health care costs, trend it out to about 2020, if you reduce that by two percentage points, you save about $3 billion dollars between 2014 and 2019,” she said.

The Green Mountain Care Board and governor’s administration released its Strategic Plan for Vermont Health Reform last week. It proposes a guide for the state to implement the plan of Gov. Peter Shumlin, a first-term Democrat, to expand and improve health insurance coverage in Vermont.

“I think there is an important distinction to be made between what is proposed in Vermont and, for example, the Canadian system or United Kingdom where the government owns the delivery system,” Rader Wallack said.

“The financing would be public so the government would run the financing and have responsibility for raising funds that are now privately taken into the system,” she said. “The health care delivery system in Vermont is private and will remain private even under this plan.”

With the help from the state Legislature, the governor pushed through an ambitious measure to reduce health care costs while assuring Vermonters have access to coverage.

Lawmakers created the five-member care board within its bill to craft a cost containment system and design a plan on how to deliver health care to all Vermonters.

“It’s not a matter of spending new dollars on health care, it’s a question of where the dollars come from, and the main impact will be on people who pay premiums, because we’ll have to raise that money some other way,” said Commissioner Stephen W. Kimbell with the Department of Banking, Insurance, Securities & Health Care Administration.

Kimbell and Rader Wallack met with the Reformer Monday morning.

According to Kimbell, the state spends about $5 billion annually on health care. Vermont’s higher insurance costs and aging population are the major factors in the skyrocketing health care figures.

“We’re not talking about reducing overall expenditures, we’re talking about reducing the rate of growth. We’ve got a system of $5 billion now and we’re talking about growing it 2 or 3 percent instead of 6 or 7,” Kimbell said. “The most hopeful thing we’ve seen is that the provider community, hospitals and doctors, they sense the unsustainability on the path we’re on. They are working with us very closely.”

Said Rader Wallack: “Our whole thrust is how to change the whole framework for how we pay [providers], how we measure quality of care, but really we need health care providers to figure out what’s the best way to be more efficient.”

The strategic plan lists the responsibilities moving forward, specifying tasks and deadlines for different Vermont agencies.

Currently, the Green Mountain Care Board is working with BISHCA and the Department of Vermont Health Access to develop a health care budget that reflects the principles embodied in the legislation.

The health access department will implement simplifications to reduce administrative costs by 2014, two years after the board reviews payment and benefit design to encourage providers to drop expenses in care.

But the largely unanswered question of how the state finances such a health care system ultimately falls into the office of Vermont’s administration secretary, Rader Wallack said.

“They are supposed to come back with a more detailed plan around the single-payer financing and for how it would operate,” she said. “The question is, the portion that is now paid for through employment, can we divorce that from employment and have a system of financing where people don’t have to worry if their income changes, if their job changes, if they don’t have coverage … and also to relief employers, especially small employers of the burden of having to deal with choosing health insurance.”

Both the health access department and GMC board have the ongoing task of reducing cost-shifting between the public and private sectors by incorporating the effect on hospital budget processes, the state funding and rate-setting by insurance companies. All the payment reforms the state is currently reviewing have strong quality measurements.

“It’s really important to have a public-private conversation about, ‘We’re designing this new financing system and we intend to make sure the rate of growth in it is sustainable relative to our economic capability, how can we work with you private providers to make sure that’s not just a false promise,'” Rader Wallack said. “We are working with them to design a payment system and support delivery system changes that will actually lead to some efficiency and allow us to say something’s different in Vermont.”

The board will measure success over the next three years by checking enrollment numbers, the percentage of Vermonters underinsured and the rate of growth in health care expenditures.

Chris Garofolo can be reached at cgarofolo@reformer.com or 802-254-2311 ext. 275.

http://www.reformer.com/ci_19803543?IADID=Search-www.reformer.com-www.reformer.com