PNHP

Shocking injustice in health care

Shocking injustice in health care

By Thomas Clairmont, M.D.
Letters, Portsmouth (N.H.) Herald, Jan. 27, 2012

Celebrating Martin Luther King Jr. Day should lead us to review some of what this great man said. Let’s review three of his quotes:

“Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” With 65,000 Maine citizens about to be ejected from their Medicaid insurance, and 3,500 New Hampshire citizens with Medicaid eliminated from practices at Lakes Region Hospital, the time is long past to solve injustice in health care. You wouldn’t know it from the recent primary, where the only “plan” to help you with health care was to repeal President Obama’s Affordable Care Act and replace it with … nothing.

“The time is always right to do the right thing.”

Dr. Wennberg at Dartmouth has shown a way to “cut costs by 40 percent, enough to cover every uninsured person in the United States.” Dr. Himmelstein of Physicians for a National Health Program has shown that “if we cut our bureaucratic costs to Canadian levels, we’d save nearly $400 billion annually — more than enough to cover the uninsured and to eliminate co-payments and deductibles for all Americans.” Harvard Economics Professor Hsaio demonstrates “our research and analysis shows that a single-payer system can immediately reduce health care costs in Vermont by 8 percent to 12 percent and reduce health care costs by an additional 12 percent to 14 percent over time.” Why isn’t saving money, covering you and your family and covering your neighbors the right thing to do?

“The ultimate measure of a man is not where he stands in moments of comfort and convenience, but where he stands at times of challenge and controversy.”

Our group says that health care is a human right and every citizen should be fully covered. How about you?

Thomas Clairmont, M.D., is a member of Physicians for a National Health Program. He practices internal medicine in Portsmouth.

http://www.seacoastonline.com/apps/pbcs.dll/article?AID=/20120127/OPINION/201270389/-1/NEWSMAP

GAO report on Medicare Advantage risk adjustment

Medicare Advantage: CMS Should Improve the Accuracy of Risk Score Adjustments for Diagnostic Coding Practices

GAO
January 2012

We found that diagnostic coding differences exist between MA plans and Medicare FFS and that these differences had a substantial effect on payment to MA plans. We estimated that risk score growth due to coding differences over the previous 3 years was equivalent to $3.9 billion to $5.8 billion in payments to MA plans in 2010 before CMS’s adjustment for coding differences. Before CMS reduced 2010 MA beneficiary risk scores, we found that these scores were at least 4.8 percent, and perhaps as much as 7.1 percent, higher than the risk scores likely would have been as a result of diagnostic coding differences, that is, if the same beneficiaries had been continuously enrolled in FFS. Our estimates suggest that, after accounting for CMS’s 3.4 percent reduction to MA risk scores in 2010, MA risk scores were too high by at least 1.4 percent, and perhaps as much as 3.7 percent, equivalent to $1.2 billion and $3.1 billion in payments to MA plans.

http://democrats.waysandmeans.house.gov/media/pdf/112/gao_macodesfinal.pdf

Comment: 

By Don McCanne, MD

One of the greatest abuses of the private insurance industry is taking advantage of favorable selection. Through deceptive practices such as selective marketing, they enroll healthier individuals while receiving higher premiums appropriate for a less healthy population.

To correct for this, payment is modified through risk adjustment (RA) – reducing payments for healthier populations and increasing payments for less healthy populations. If health care spending is to be equitable, risk adjustment is mandatory in a multi-payer system such as that of the Affordable Care Act.

We now have considerable experience with risk adjustment between the private Medicare Advantage plans and the public fee-for-service Medicare program. The experience is not good. As Medicare has refined the risk adjustment tools, the private Medicare Advantage plans have found new ways to game the system which have resulted in even greater overpayments for their patients who are healthier than the data submitted by the insurers would indicate.

This GAO report recommends that Medicare needs to increase its data collection and revise its application of risk adjustment in an attempt to recover some of the overpayments that would be made in the future. However, the experience to date indicates that the private insurers will use the greater complexity to further game the system to their own advantage.

PNHP co-founders Steffie Woolhandler and David Himmelstein state it well in this comment on risk adjustment:

“RA (risk adjustment) folks have been making this claim for decades; great improvement is just around the corner. To us, the most interesting part of the 2004 enhancement of Medicare Advantage RA is not that plans beat it, but that the gaming was actually much more lucrative AFTER the enhancement than before. Static analyses of RA schemes can virtually always come up with schemes that explain far more of the variance than existing schemes – ie. they’re better. But once incentives are based on a particular RA scheme, the gaming is on. There is absolutely no evidence that RA works or can work in the dynamic reality of profit-seeking health care insurers/providers.”

Private insurers operate on market principles. They will always place business interests first. They chase the money.

A universal public insurance program operates in the interests of patients. Gaming risk adjustment is a totally foreign concept to administrators of a single payer system.

Why would we ever want to have private plans involved at all? Dump them and we’ll get rid of the problems of adverse selection and favorable selection. Keep them and they’ll always game the system. They win, and we lose.

How the Health and Social Care Bill 2011 would end entitlement to comprehensive health care in England

By Allyson M. Pollock, et al.
The Lancet, Jan. 26, 2012

The National Health Service (NHS) in England has been a leading international model of tax-financed, universal health care. Legal analysis shows that the Health and Social Care Bill currently making its way through the UK Parliament[1] would abolish that model[2] and pave the way for the introduction of a US-style health system by eroding entitlement to equality of healthcare provision. The Bill severs the duty of the Secretary of State for Health to secure comprehensive health care throughout England and introduces competitive markets and structures consistent with greater inequality of provision, mixed funding, and widespread provision by private health corporations. The Bill has had a turbulent passage. Unusually, the legislative process was suspended for more than 2 months in 2011 because of the weight of public concern.[3] It was recommitted to Parliament largely unaltered after a “listening exercise”. These and more recent amendments to the Bill do not sufficiently address major concerns that continue to be raised by Peers and a Constitution Committee of the House of Lords,[4,5] where the Bill now faces one of its last parliamentary hurdles before becoming law.

Fundamental to the Bill are provisions that transform a mandatory system into a discretionary one with structures that permit the introduction of charging for services that are currently free under the NHS, as well as a system in which much delivery would be privatised. Under the current statutory framework the Government has a legal duty to secure comprehensive health care, whereas, under the new system, substantial discretionary powers will instead be extended to commissioners and providers of care. These measures will increase inequalities of provision.

Panel: Red lines to protect the NHS

1. The Secretary of State must have the duty to secure provision of comprehensive and equitable health care for the whole of the population of England, taking action whenever there are problems.

2. CCGs, operating on behalf of the Secretary of State, must make sure that comprehensive and equitable health care is available for everyone and be responsible for all residents living in single geographically defined areas that are contiguous, without being able to pick and choose patients.

3. Nothing must be done that undermines the ability of the Secretary of State to fulfil the duty to secure provision of comprehensive and equitable health care, by bringing more of the NHS within the scope of EU competition law so that, in particular:

• There must be no increase in the commercial contracting of health services;

• The current authorisation system for central regulation of Foundation Trusts must be retained;

• Statutory functions of CCGs must be carried out by NHS staff, with CCG finances being used solely for the benefit of patients;

• Statutory and enforceable codes of conduct must be laid down for all NHS bodies, underpinned by sanctions that are rigorously policed;

• Information about commercial contracting, including the planning, procurement, financing, and monitoring, must be available as a matter of course.

CCGs=Clinical Commissioning Groups.

Clauses 1 and 12 of the Bill will dismantle key sections of the 1946 founding legislation of the NHS by repealing the unifying duty from which all other legislative powers and functions flow.[6] This unifying duty is currently laid down in Sections 1 and 3 of the National Health Service Act 2006. It requires the Government to promote a comprehensive health service by providing or securing the provision throughout England of a list of specified NHS services and hospital accommodation in ways that meet all reasonable requirements. Accordingly, since 1948, most NHS hospital and community-based provision has its own facilities and NHS staff. The whole system has been publicly administered and funded on the basis of contiguous geographical areas by bodies, now called primary care trusts (PCTs), that act on behalf of the Secretary of State and have responsibility for the health-care needs of everyone in their area. Experiments with internal and external markets since 1990 have taken place within this overarching geographical framework.

The Bill creates two new bodies with responsibility for managing care: an NHS Commissioning Board and Clinical Commissioning Groups (CCGs), the number of which remain unclear. PCTs will be abolished and not replaced. Powers currently exercised by the Secretary of State for Health will be transferred to each CCG, which, in contrast to PCTs, will act in place of, and not on behalf of, the minister. The NHS Commissioning Board will exercise its functions at a distance from the Secretary of State and have oversight of CCGs. These changes will repeal the minister’s core duty to provide or secure provision of specified health services.

Clause 12 of the Health and Social Care Bill repeals the Secretary of State’s “duty to provide” specific services. Instead, a “duty to arrange” provision is imposed on each of the many CCGs that will also have transferred to them the power to determine what care is necessary to meet all reasonable requirements. However, CCGs will not have the duty to promote a comprehensive free health service. Amendments suggested by the Government in a letter to Peers from the responsible minister dated Jan 12, 2012, do not restore the duty.[7] Thus, the link between the duty to promote comprehensive care and the duty to provide would be severed.

Although the Government has said that its intention is to “reinforce” the overarching duty to promote a comprehensive health service,[8] the creation of bodies that are independent of the Secretary of State for Health to support a lesser duty fundamentally affects the minister’s duty. This is because the test of whether the Secretary of State is discharging his or her duty to promote a comprehensive health service will no longer depend on whether a comprehensive service is actually provided.

As well as transferring powers from the Secretary of State to other bodies, the Bill leaves each CCG free to choose the patients for whom they have responsibility. Unlike PCTs, CCGs will not be responsible for all residents within contiguous geographical areas. CCGs select patients, initially assembling their patient populations on the basis of general practitioners’ (GPs) lists; they will not have to cover everyone in a geographical area but only “persons for whom it [the CCG] has responsibility”. Nor will they be required to arrange for the provision of all the services that are currently part of the comprehensive health system. For example, accident and emergency services are not an explicit CCG responsibility under these proposals. Only a new category “of services or facilities for emergency care” will have to be provided for people in a CCG’s area, which need not consist of adjoining or indeed whole electoral districts, as is the case with PCTs.

Another organisation, known as Monitor and with the functions of a regulator, is independent of the Secretary of State for Health, and will have oversight of providers (public and private) in the new system. However, it will not have a duty to promote a comprehensive service—a crucial consideration given that its decisions about the extent of competition will affect the financial viability of local services. In a parallel move, NHS hospitals that currently get most of their funding from NHS sources will be free to obtain almost half their income from private patients.

Although there are provisions in the Bill giving the Secretary of State for Health power to regulate the new system through secondary rather than primary legislation, that power is limited by a new clause (Clause 4), under which the minister has a duty to observe the autonomy of commissioners and providers. The autonomy clause means that commercial providers can bring legal challenges against a minister who chooses to curtail their discretion. Furthermore, the adoption of compulsory market competition will bring more NHS activity under the jurisdiction of EU competition law. Competition law is designed to limit government powers of intervention and will provide a further check on secondary regulation.

These changes will have substantial legal consequences. First, the duty to provide a national health service throughout England would be lost if the Bill became law.[9] It would be replaced by a duty on an unknown number of CCGs, not GPs, to arrange provision as they see fit for various sections of the population for which they are separately responsible. Second, CCGs would not be bound by the “duty to continue to promote a comprehensive free health service” when exercising their functions. Under present law, according to a judgment of the Court of Appeal, the Secretary of State “has the duty to continue to promote a comprehensive free health service and he must never, in making a decision [about services provided], disregard that duty”.[10] Third, the Secretary of State’s accountability to Parliament for the provision of services to patients in the new NHS will be diminished.[4,11]

At the same time, a new parallel system of public health services will be established at the local level. Under this system, the provision of a range of public health services will be assigned to local authorities, including immunisation, screening, mental health, dental health, children’s services, sexual health, drug and alcohol services, and health protection programmes. However, neither services nor funding have been defined.[12] Moreover, in this new system local authorities will have considerable discretion to define and decide what services are provided and how. As with the social services they provide, these services may be chargeable.

All these factors will increase inequality in service access, provision, and uptake. The abolition of PCTs and loss of overall political control will impair, or take away altogether, current information systems used to monitor inequalities at area level. The new structures for CCGs and public health create such a multiplicity of denominators, resource flows, populations, and fragmented responsibilities for care and data that systematic inequalities will cease to be identifiable and no body will have overall responsibility for an area. Furthermore, the loss of area-based population responsibilities has serious implications for the stability and accuracy of measurement of needs and equity of resource allocation and service provision. Loss of geographical population data and area-based structures and responsibilities will impair, or take away altogether, the capacity to plan health services by monitoring needs, access, service use, and health outcomes.

The Government has not disclosed the radical nature of this reform. The Leader of the House of Lords, Earl Howe, told the Lords that the Bill reinforces and does not “dilute the Secretary of State’s overarching duty…Let me be clear: the Bill’s provisions would in no way dilute the Secretary of State’s overarching duty. Indeed, they are intended further to reinforce the promotion of a comprehensive health service rather than to undermine it.”[7] Legal analysis of the Bill shows this is not the case. Recent amendments raised for consideration in a letter of Jan 12, 2012, from Earl Howe to Peers do not substantially change the situation.[7]

In the USA, opposition to health reforms under both the Clinton and Obama administrations is articulated as erosion of personal freedom by increasing government powers.[13] Conversely, pro-market reforms of universal health systems in Europe are often justified on the grounds that they increase personal freedom by transferring powers from government to nongovernmental or commercial bodies and by increasing choice. Citizens’ rights in democracies are underpinned not just by limitations on government powers but also by legal duties imposed on governments, such as those that guarantee citizens access to health care. The Bill would withdraw this legal underpinning.[14] As the Bill enters its final critical stages it is crucial that Peers observe three red lines for the NHS (panel below)[15] and are fully aware of the key parts of the legislation that would abolish core NHS functions, if they are to safeguard the NHS for future generations.

*Allyson M Pollock (a.pollock@qmul.ac.uk), David Price, Peter Roderick, Tim Treuherz, David McCoy, Martin McKee, Lucy Reynolds

Centre for Primary Care and Public Health, Queen Mary, University of London, London E1 4NS, UK (AMP, DP); 101 Weavers Way, London, UK (PR); 5 Hobson Road, Oxford, UK (TT); Inner North West London Primary Care Trusts, London, UK (DM); and European Centre on Health of Societies in Transition, London School of Hygiene and Tropical Med
icine, London, UK (MM, LR)

PR is a London-based public interest lawyer who has supported 38 Degrees on an unpaid basis. TT is a non-practising barrister and formerly Head of Legal Services, Vale of White Horse District Council. The other authors declare that they have no conflicts of interest.

1. House of Lords. Health and Social Care Bill 2011. HL Bill 92. http://www. publications.parliament.uk/pa/bills/lbill/2010-2012/0119/2012119.pdf (accessed Jan 20, 2012).

2. Pollock AM, Price D. How the Secretary of State for Health proposes to abolish the NHS in England. BMJ 2011; 342: 800–03.

3. NHS Futures Forum. Summary Report on proposed changes to the NHS. London: London School of Hygiene and Tropical Medicine, 2011.

4. House of Lords Select Committee on the Constitution. Health and Social Care Bill. HL Paper 197, Sept 30, 2011. London: The Stationery Office Ltd, 2011. http://www.publications.parliament.uk/pa/ld201012/ldselect/ ldconst/197/197.pdf (accessed Jan 20, 2012).

5. House of Lords Select Committee on the Constitution. Health and Social Care Bill: Follow-up. HL Paper 240, Dec 20, 2011. London: The Stationery Office Ltd, 2011. http://www.publications.parliament.uk/pa/ld201012/ ldselect/ldconst/240/24002.htm (accessed Jan 20, 2012).

6. Pollock AM, Price D, Roderick P, Treuherz T. Health and Social Care Bill, Briefing on Clause 1. 2011. http://www.allysonpollock.co.uk/administrator/ components/com_article/attach/2011-10-26/AP_2011_Pollock_ HouseOfLordsBriefingC1__22Oct11.pdf (accessed Jan 17, 2012).

7. Pollock AM, Price D, Roderick P, Treuherz T. Health and Social Care Bill, Briefing note 12, Earl Howe’s response to the Constitution Committee’s follow-up report and his letter dated Jan 12, 2012. http://www. allysonpollock.co.uk/administrator/components/com_article/ attach/2012-01-17/Pollock_HouseOfLords_HSCB_Briefing12_ HoweLetter_17Jan12.pdf (accessed Jan 17, 2012).

8. House of Lords Debate. Nov 14, 2011 column 494. Hansard. http://www. publications.parliament.uk/pa/ld201011/ldhansrd/text/111114-0002.htm (accessed Jan 20, 2011).

9. 38 Degrees. NHS expert legal advice. http://www.38degrees.org.uk/page/ content/NHS-legal-advice (accessed Jan 20, 2012).

10. Coughlan & Ors, R (on the application of) v North & East Devon Health Authority [1999] EWCA Civ 1871 (July 16, 1999). http://www.bailii.org/ ew/cases/EWCA/Civ/1999/1871.html (accessed Jan 20, 2012).

11. Pollock AM, Price D, Roderick P, Treuherz T. Health and Social Care Bill 2011, House of Lords Committee Stage, Briefing Note 2, on Clause 1 for day 1 Oct 25, 2011 in the light of evidence from Professor Malcolm Grant. http:// www.allysonpollock.co.uk/administrator/components/com_article/ attach/2011-10-26/AP_2011_Pollock_HouseOfLordsBriefing2C2_24Oct11. pdf (accessed Jan 24, 2012).

12. Pollock AM, Price D, Roderick P, Treuherz T. Health and Social Care Bill 2011, House of Lords Committee stage, Briefing Note 7, Clause 8 (Amendments 60B–75A) for Monday Nov 14, 2011. http://www.allysonpollock.co.uk/ administrator/components/com_article/attach/2011-11-21/AP_2011_ Pollock_HouseOfLordsBriefing7C8-9.pdf (accessed Jan 20, 2012).

13. Starfield B. The Obama presidency: what may happen, what needs to happen in health policies in the USA. J Epidemiol Community Health 2009; 63: 265–66.

14. Pollock AM, Price D, Roderick P, Treuherz T. Health and Social Care Bill 2011, House of Lords Committee stage, Briefing Note 6 Clause 10. http://www. allysonpollock.co.uk/administrator/components/com_article/attach/ 2011-11-11/AP_2011_Pollock_HouseOfLordsBriefing6C10_11Nov11.pdf (accessed Jan 20, 2012).

15. Health and Social Care Bill 2011. House of Lords Report Stage. Briefing Note 10: Red Lines for Peers on the NHS Bill. Jan 9, 2011. http://www. allysonpollock.co.uk/administrator/components/com_article/attach/2012- 01-09/20120109-AP_2012_Pollock_HouseOfLordsBriefing10_ C1412_09Jan12.pdf (accessed Jan 20, 2012).

Published Online
January 26, 2012
DOI:10.1016/S0140-6736(12)60119-6

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60119-6/fulltext

GAO report on Medicare Advantage risk adjustment

Medicare Advantage: CMS Should Improve the Accuracy of Risk Score Adjustments for Diagnostic Coding Practices

GAO
January 2012
We found that diagnostic coding differences exist between MA plans and Medicare FFS and that these differences had a substantial effect on payment to MA plans. We estimated that risk score growth due to coding differences over the previous 3 years was equivalent to $3.9 billion to $5.8 billion in payments to MA plans in 2010 before CMS’s adjustment for coding differences. Before CMS reduced 2010 MA beneficiary risk scores, we found that these scores were at least 4.8 percent, and perhaps as much as 7.1 percent, higher than the risk scores likely would have been as a result of diagnostic coding differences, that is, if the same beneficiaries had been continuously enrolled in FFS. Our estimates suggest that, after accounting for CMS’s 3.4 percent reduction to MA risk scores in 2010, MA risk scores were too high by at least 1.4 percent, and perhaps as much as 3.7 percent, equivalent to $1.2 billion and $3.1 billion in payments to MA plans.
http://democrats.waysandmeans.house.gov/media/pdf/112/gao_macodesfinal.pdf

One of the greatest abuses of the private insurance industry is taking advantage of favorable selection. Through deceptive practices such as selective marketing, they enroll healthier individuals while receiving higher premiums appropriate for a less healthy population.
To correct for this, payment is modified through risk adjustment (RA) – reducing payments for healthier populations and increasing payments for less healthy populations. If health care spending is to be equitable, risk adjustment is mandatory in a multi-payer system such as that of the Affordable Care Act.
We now have considerable experience with risk adjustment between the private Medicare Advantage plans and the public fee-for-service Medicare program. The experience is not good. As Medicare has refined the risk adjustment tools, the private Medicare Advantage plans have found new ways to game the system which have resulted in even greater overpayments for their patients who are healthier than the data submitted by the insurers would indicate.
This GAO report recommends that Medicare needs to increase its data collection and revise its application of risk adjustment in an attempt to recover some of the overpayments that would be made in the future. However, the experience to date indicates that the private insurers will use the greater complexity to further game the system to their own advantage.
PNHP co-founders Steffie Woolhandler and David Himmelstein state it well in this comment on risk adjustment:
“RA (risk adjustment) folks have been making this claim for decades; great improvement is just around the corner. To us, the most interesting part of the 2004 enhancement of Medicare Advantage RA is not that plans beat it, but that the gaming was actually much more lucrative AFTER the enhancement than before. Static analyses of RA schemes can virtually always come up with schemes that explain far more of the variance than existing schemes – ie. they’re better. But once incentives are based on a particular RA scheme, the gaming is on. There is absolutely no evidence that RA works or can work in the dynamic reality of profit-seeking health care insurers/providers.”
Private insurers operate on market principles. They will always place business interests first. They chase the money.
A universal public insurance program operates in the interests of patients. Gaming risk adjustment is a totally foreign concept to administrators of a single payer system.
Why would we ever want to have private plans involved at all? Dump them and we’ll get rid of the problems of adverse selection and favorable selection. Keep them and they’ll always game the system. They win, and we lose.

Destroying England's National Health Service (as we know it)

How the Health and Social Care Bill 2011 would end entitlement to comprehensive health care in England

By Allyson M Pollock, David Price, Peter Roderick, Tim Treuherz, David McCoy, Martin McKee, Lucy Reynolds
The Lancet, January 26, 2012

(Excerpts)

The National Health Service (NHS) in England has been a leading international model of tax-financed, universal health care. Legal analysis shows that the Health and Social Care Bill currently making its way through the UK Parliament would abolish that model and pave the way for the introduction of a US-style health system by eroding entitlement to equality of health-care provision. The Bill severs the duty of the Secretary of State for Health to secure comprehensive health care throughout England and introduces competitive markets and structures consistent with greater inequality of provision, mixed funding, and widespread provision by private health corporations. The Bill has had a turbulent passage. Unusually, the legislative process was suspended for more than 2 months in 2011 because of the weight of public concern. It was recommitted to Parliament largely unaltered after a “listening exercise”. These and more recent amendments to the Bill do not sufficiently address major concerns that continue to be raised by Peers and a Constitution Committee of the House of Lords, where the Bill now faces one of its last parliamentary hurdles before becoming law.

Fundamental to the Bill are provisions that transform a mandatory system into a discretionary one with structures that permit the introduction of charging for services that are currently free under the NHS, as well as a system in which much delivery would be privatised. Under the current statutory framework the Government has a legal duty to secure comprehensive health care, whereas, under the new system, substantial discretionary powers will instead be extended to commissioners and providers of care. These measures will increase inequalities of provision.

The whole system has been publicly administered and funded on the basis of contiguous geographical areas by bodies, now called primary care trusts (PCTs), that act on behalf of the Secretary of State and have responsibility for the health-care needs of everyone in their area.

The Bill creates two new bodies with responsibility for managing care: an NHS Commissioning Board and Clinical Commissioning Groups (CCGs), the number of which remain unclear. PCTs will be abolished and not replaced.

Clause 12 of the Health and Social Care Bill repeals the Secretary of State’s “duty to provide” specific services. Instead, a “duty to arrange” provision is imposed on each of the many CCGs that will also have transferred to them the power to determine what care is necessary to meet all reasonable requirements. However, CCGs will not have the duty to promote a comprehensive free health service.

As well as transferring powers from the Secretary of State to other bodies, the Bill leaves each CCG free to choose the patients for whom they have responsibility. Unlike PCTs, CCGs will not be responsible for all residents within contiguous geographical areas. CCGs select patients, initially assembling their patient populations on the basis of general practitioners’ (GPs) lists; they will not have to cover everyone in a geographical area but only “persons for whom it [the CCG] has responsibility”. Nor will they be required to arrange for the provision of all the services that are currently part of the comprehensive health system.

These changes will have substantial legal consequences. First, the duty to provide a national health service throughout England would be lost if the Bill became law. It would be replaced by a duty on an unknown number of CCGs, not GPs, to arrange provision as they see fit for various sections of the population for which they are separately responsible. Second, CCGs would not be bound by the “duty to continue to promote a comprehensive free health service” when exercising their functions. Under present law, according to a judgment of the Court of Appeal, the Secretary of State “has the duty to continue to promote a comprehensive free health service and he must never, in making a decision [about services provided], disregard that duty”. Third, the Secretary of State’s accountability to Parliament for the provision of services to patients in the new NHS will be diminished.

The Government has not disclosed the radical nature of this reform.

In the USA, opposition to health reforms under both the Clinton and Obama administrations is articulated as erosion of personal freedom by increasing government powers. Conversely, pro-market reforms of universal health systems in Europe are often justified on the grounds that they increase personal freedom by transferring powers from government to non-governmental or commercial bodies and by increasing choice. Citizens’ rights in democracies are underpinned not just by limitations on government powers but also by legal duties imposed on governments, such as those that guarantee citizens access to health care. The Bill would withdraw this legal underpinning. As the Bill enters its final critical stages it is crucial that Peers observe three red lines for the NHS (below) and are fully aware of the key parts of the legislation that would abolish core NHS functions, if they are to safeguard the NHS for future generations.

****

Red lines to protect the NHS

# The Secretary of State must have the duty to secure provision of comprehensive and equitable health care for the whole of the population of England, taking action whenever there are problems.

# CCGs (Clinical Commissioning Groups), operating on behalf of the Secretary of State, must make sure that comprehensive and equitable health care is available for everyone and be responsible for all residents living in single geographically defined areas that are contiguous, without being able to pick and choose patients.

# Nothing must be done that undermines the ability of the Secretary of State to fulfil the duty to secure provision of comprehensive and equitable health care, by bringing more of the NHS within the scope of EU competition law so that, in particular:

* There must be no increase in the commercial contracting of health services;
* The current authorisation system for central regulation of Foundation Trusts must be retained;
* Statutory functions of CCGs must be carried out by NHS staff, with CCG finances being used solely for the benefit of patients;
* Statutory and enforceable codes of conduct must be laid down for all NHS bodies, underpinned by sanctions that are rigorously policed;
* Information about commercial contracting, including the planning, procurement, financing, and monitoring, must be available as a matter of course.

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60119-6/fulltext (The Lancet is offering access to this important article for free, but they do require registration.)

Comment:

By Don McCanne, MD

The Conservative government of David Cameron is about to destroy England’s National Health Service, as we know it. While we are struggling in our attempt to ensure health care for everyone (and are still not receiving it under the Affordable Care Act), the British government is severing its responsibility to secure comprehensive health care throughout England.

Health care justice is an international cause. We should partner with our colleagues in England to support their cause in this moment of crisis, as they later partner with us to see that health care justice becomes a reality in the United States… and throughout the world.

Destroying England’s National Health Service (as we know it)

How the Health and Social Care Bill 2011 would end entitlement to comprehensive health care in England

By Allyson M Pollock, David Price, Peter Roderick, Tim Treuherz, David McCoy, Martin McKee, Lucy Reynolds
The Lancet, January 26, 2012

(Excerpts)

The National Health Service (NHS) in England has been a leading international model of tax-financed, universal health care. Legal analysis shows that the Health and Social Care Bill currently making its way through the UK Parliament would abolish that model and pave the way for the introduction of a US-style health system by eroding entitlement to equality of health-care provision. The Bill severs the duty of the Secretary of State for Health to secure comprehensive health care throughout England and introduces competitive markets and structures consistent with greater inequality of provision, mixed funding, and widespread provision by private health corporations. The Bill has had a turbulent passage. Unusually, the legislative process was suspended for more than 2 months in 2011 because of the weight of public concern. It was recommitted to Parliament largely unaltered after a “listening exercise”. These and more recent amendments to the Bill do not sufficiently address major concerns that continue to be raised by Peers and a Constitution Committee of the House of Lords, where the Bill now faces one of its last parliamentary hurdles before becoming law.

Fundamental to the Bill are provisions that transform a mandatory system into a discretionary one with structures that permit the introduction of charging for services that are currently free under the NHS, as well as a system in which much delivery would be privatised. Under the current statutory framework the Government has a legal duty to secure comprehensive health care, whereas, under the new system, substantial discretionary powers will instead be extended to commissioners and providers of care. These measures will increase inequalities of provision.

The whole system has been publicly administered and funded on the basis of contiguous geographical areas by bodies, now called primary care trusts (PCTs), that act on behalf of the Secretary of State and have responsibility for the health-care needs of everyone in their area.

The Bill creates two new bodies with responsibility for managing care: an NHS Commissioning Board and Clinical Commissioning Groups (CCGs), the number of which remain unclear. PCTs will be abolished and not replaced.

Clause 12 of the Health and Social Care Bill repeals the Secretary of State’s “duty to provide” specific services. Instead, a “duty to arrange” provision is imposed on each of the many CCGs that will also have transferred to them the power to determine what care is necessary to meet all reasonable requirements. However, CCGs will not have the duty to promote a comprehensive free health service.

As well as transferring powers from the Secretary of State to other bodies, the Bill leaves each CCG free to choose the patients for whom they have responsibility. Unlike PCTs, CCGs will not be responsible for all residents within contiguous geographical areas. CCGs select patients, initially assembling their patient populations on the basis of general practitioners’ (GPs) lists; they will not have to cover everyone in a geographical area but only “persons for whom it [the CCG] has responsibility”. Nor will they be required to arrange for the provision of all the services that are currently part of the comprehensive health system.

These changes will have substantial legal consequences. First, the duty to provide a national health service throughout England would be lost if the Bill became law. It would be replaced by a duty on an unknown number of CCGs, not GPs, to arrange provision as they see fit for various sections of the population for which they are separately responsible. Second, CCGs would not be bound by the “duty to continue to promote a comprehensive free health service” when exercising their functions. Under present law, according to a judgment of the Court of Appeal, the Secretary of State “has the duty to continue to promote a comprehensive free health service and he must never, in making a decision [about services provided], disregard that duty”. Third, the Secretary of State’s accountability to Parliament for the provision of services to patients in the new NHS will be diminished.

The Government has not disclosed the radical nature of this reform.

In the USA, opposition to health reforms under both the Clinton and Obama administrations is articulated as erosion of personal freedom by increasing government powers. Conversely, pro-market reforms of universal health systems in Europe are often justified on the grounds that they increase personal freedom by transferring powers from government to non-governmental or commercial bodies and by increasing choice. Citizens’ rights in democracies are underpinned not just by limitations on government powers but also by legal duties imposed on governments, such as those that guarantee citizens access to health care. The Bill would withdraw this legal underpinning. As the Bill enters its final critical stages it is crucial that Peers observe three red lines for the NHS (below) and are fully aware of the key parts of the legislation that would abolish core NHS functions, if they are to safeguard the NHS for future generations.

****

Red lines to protect the NHS

# The Secretary of State must have the duty to secure provision of comprehensive and equitable health care for the whole of the population of England, taking action whenever there are problems.

# CCGs (Clinical Commissioning Groups), operating on behalf of the Secretary of State, must make sure that comprehensive and equitable health care is available for everyone and be responsible for all residents living in single geographically defined areas that are contiguous, without being able to pick and choose patients.

# Nothing must be done that undermines the ability of the Secretary of State to fulfil the duty to secure provision of comprehensive and equitable health care, by bringing more of the NHS within the scope of EU competition law so that, in particular:

* There must be no increase in the commercial contracting of health services;
* The current authorisation system for central regulation of Foundation Trusts must be retained;
* Statutory functions of CCGs must be carried out by NHS staff, with CCG finances being used solely for the benefit of patients;
* Statutory and enforceable codes of conduct must be laid down for all NHS bodies, underpinned by sanctions that are rigorously policed;
* Information about commercial contracting, including the planning, procurement, financing, and monitoring, must be available as a matter of course.

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60119-6/fulltext (The Lancet is offering access to this important article for free, but they do require registration.)

Comment:

By Don McCanne, MD

The Conservative government of David Cameron is about to destroy England’s National Health Service, as we know it. While we are struggling in our attempt to ensure health care for everyone (and are still not receiving it under the Affordable Care Act), the British government is severing its responsibility to secure comprehensive health care throughout England.

Health care justice is an international cause. We should partner with our colleagues in England to support their cause in this moment of crisis, as they later partner with us to see that health care justice becomes a reality in the United States… and throughout the world.

Destroying England's National Health Service (as we know it)

How the Health and Social Care Bill 2011 would end entitlement to comprehensive health care in England

By Allyson M Pollock, David Price, Peter Roderick, Tim Treuherz, David McCoy, Martin McKee, Lucy Reynolds
The Lancet, January 26, 2012
(Excerpts)
The National Health Service (NHS) in England has been a leading international model of tax-financed, universal health care. Legal analysis shows that the Health and Social Care Bill currently making its way through the UK Parliament would abolish that model and pave the way for the introduction of a US-style health system by eroding entitlement to equality of health-care provision. The Bill severs the duty of the Secretary of State for Health to secure comprehensive health care throughout England and introduces competitive markets and structures consistent with greater inequality of provision, mixed funding, and widespread provision by private health corporations. The Bill has had a turbulent passage. Unusually, the legislative process was suspended for more than 2 months in 2011 because of the weight of public concern. It was recommitted to Parliament largely unaltered after a “listening exercise”. These and more recent amendments to the Bill do not sufficiently address major concerns that continue to be raised by Peers and a Constitution Committee of the House of Lords, where the Bill now faces one of its last parliamentary hurdles before becoming law.
Fundamental to the Bill are provisions that transform a mandatory system into a discretionary one with structures that permit the introduction of charging for services that are currently free under the NHS, as well as a system in which much delivery would be privatised. Under the current statutory framework the Government has a legal duty to secure comprehensive health care, whereas, under the new system, substantial discretionary powers will instead be extended to commissioners and providers of care. These measures will increase inequalities of provision.
The whole system has been publicly administered and funded on the basis of contiguous geographical areas by bodies, now called primary care trusts (PCTs), that act on behalf of the Secretary of State and have responsibility for the health-care needs of everyone in their area.
The Bill creates two new bodies with responsibility for managing care: an NHS Commissioning Board and Clinical Commissioning Groups (CCGs), the number of which remain unclear. PCTs will be abolished and not replaced.
Clause 12 of the Health and Social Care Bill repeals the Secretary of State’s “duty to provide” specific services. Instead, a “duty to arrange” provision is imposed on each of the many CCGs that will also have transferred to them the power to determine what care is necessary to meet all reasonable requirements. However, CCGs will not have the duty to promote a comprehensive free health service.
As well as transferring powers from the Secretary of State to other bodies, the Bill leaves each CCG free to choose the patients for whom they have responsibility. Unlike PCTs, CCGs will not be responsible for all residents within contiguous geographical areas. CCGs select patients, initially assembling their patient populations on the basis of general practitioners’ (GPs) lists; they will not have to cover everyone in a geographical area but only “persons for whom it [the CCG] has responsibility”. Nor will they be required to arrange for the provision of all the services that are currently part of the comprehensive health system.
These changes will have substantial legal consequences. First, the duty to provide a national health service throughout England would be lost if the Bill became law. It would be replaced by a duty on an unknown number of CCGs, not GPs, to arrange provision as they see fit for various sections of the population for which they are separately responsible. Second, CCGs would not be bound by the “duty to continue to promote a comprehensive free health service” when exercising their functions. Under present law, according to a judgment of the Court of Appeal, the Secretary of State “has the duty to continue to promote a comprehensive free health service and he must never, in making a decision [about services provided], disregard that duty”. Third, the Secretary of State’s accountability to Parliament for the provision of services to patients in the new NHS will be diminished.
The Government has not disclosed the radical nature of this reform.
In the USA, opposition to health reforms under both the Clinton and Obama administrations is articulated as erosion of personal freedom by increasing government powers. Conversely, pro-market reforms of universal health systems in Europe are often justified on the grounds that they increase personal freedom by transferring powers from government to non-governmental or commercial bodies and by increasing choice. Citizens’ rights in democracies are underpinned not just by limitations on government powers but also by legal duties imposed on governments, such as those that guarantee citizens access to health care. The Bill would withdraw this legal underpinning. As the Bill enters its final critical stages it is crucial that Peers observe three red lines for the NHS (below) and are fully aware of the key parts of the legislation that would abolish core NHS functions, if they are to safeguard the NHS for future generations.
****
Red lines to protect the NHS
# The Secretary of State must have the duty to secure provision of comprehensive and equitable health care for the whole of the population of England, taking action whenever there are problems.
# CCGs (Clinical Commissioning Groups), operating on behalf of the Secretary of State, must make sure that comprehensive and equitable health care is available for everyone and be responsible for all residents living in single geographically defined areas that are contiguous, without being able to pick and choose patients.
# Nothing must be done that undermines the ability of the Secretary of State to fulfil the duty to secure provision of comprehensive and equitable health care, by bringing more of the NHS within the scope of EU competition law so that, in particular:
* There must be no increase in the commercial contracting of health services;
* The current authorisation system for central regulation of Foundation Trusts must be retained;
* Statutory functions of CCGs must be carried out by NHS staff, with CCG finances being used solely for the benefit of patients;
* Statutory and enforceable codes of conduct must be laid down for all NHS bodies, underpinned by sanctions that are rigorously policed;
* Information about commercial contracting, including the planning, procurement, financing, and monitoring, must be available as a matter of course.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60119-6/fulltext (The Lancet is offering access to this important article for free, but they do require registration.)

The Conservative government of David Cameron is about to destroy England’s National Health Service, as we know it. While we are struggling in our attempt to ensure health care for everyone (and are still not receiving it under the Affordable Care Act), the British government is severing its responsibility to secure comprehensive health care throughout England.
Health care justice is an international cause. We should partner with our colleagues in England to support their cause in this moment of crisis, as they later partner with us to see that health care justice becomes a reality in the United States… and throughout the world.

Ontario should move carefully on medicare reforms

By Thomas Walkom
The Guelph Mercury (Canada), Jan. 24, 2012

Don Drummond, the Ontario government’s adviser-on-everything, is still a few days away from officially revealing details of his proposed spending cutbacks. But critics are already weighing in.

Chief among these are the health care unions, who suspect from Drummond’s musings that the former bank economist will propose sweeping measures designed to make Ontario’s non-profit hospitals operate more like profit-maximizing private corporations.

The unions obviously have a monetary interest in this. Private corporations are under tremendous shareholder pressure to reduce costs by whatever means — including the contracting out of good jobs to cheaper, non-union shops.

But the Ontario Council of Hospital Unions, which bargains for 30,000 hospital, long-term care and ambulance workers, also argues that the kinds of free-market measures Drummond has been hinting at won’t save money for taxpayers.

The union analysis rests to a large extent on research done in the U.S. and Britain, where private corporations are far more involved in the delivery of publicly funded health services than in Canada.

So this week I called one of those experts, physician and public health professor Steffie Woolhandler, to see what she had to say.

Woolhandler, a former Harvard professor who now teaches at the City University of New York, has spent some time researching U.S. Medicare — a program that covers only those 65 and over.

Like Canada’s much more comprehensive health-care system, U.S. Medicare is publicly funded. Government pays not the whole tab, but most of it.

However, private, profit-making corporations play a far bigger role in delivering these publicly-funded health services than they do here.

Here’s what Woolhandler says research by her and others has shown.

First, for-profit hospitals don’t provide higher quality care. In fact, research shows that patients do marginally worse in the average U.S. private hospital.

In for-profit dialysis clinics, one investigation found that patients were 21 per cent more likely to die.

Second, and perhaps more important to Ontario Premier Dalton McGuinty, market reforms to U.S. Medicare haven’t saved money. Perversely, they have cost taxpayers more.

Eight separate empirical studies compared for-profit to non-profit hospitals, Woolhandler says. All showed that for-profit hospitals cost the government treasury more — by about 18 per cent.

“The evidence of higher cost is simply irrefutable,” she says.

Why would this be? Woolhandler’s explanation is that, in the realm of health care, for-profit institutions have an overwhelming incentive to game the system in order to squeeze as much as possible from their public paymaster.

In some cases, they encourage the use of unnecessary tests or services operated by their own subsidiaries. In others, they “upcode” the patients — present them as sicker than they are in order to reap higher payments.

Then there is so-called cherry picking. For-profit hospitals prefer to avoid seriously ill patients since these cost more to treat. Even hospices for the terminally ill are affected. Research shows that many try to fill their beds with dying heart patients in order to avoid end-of-life cancer victims, who require more costly treatment.

From time to time, the U.S. government tries to close these Medicare loopholes. But, says Woolhandler, the corporations just find new ways to game the system. (She refers to a 2011 study by the National Bureau of Economic Research that makes just that point.)

The lesson for McGuinty? Governments interested in reducing health care costs shouldn’t rely on free-market reforms to do the trick. Health care isn’t a commodity like, say, soap where the normal laws of supply and demand operate.

It is a human necessity where one side — the provider — has all the information and power, while the other — the patient — is far too often acting out of desperation.

Thomas Walkom is a columnist with Record News Services and national affairs columnist for the Toronto Star.

http://www.guelphmercury.com/opinion/columns/article/660049–ontario-should-move-carefully-on-medicare-reforms

Wyden-Ryan plan won't improve health care system

By Chris Goeser, M.D., and Samuel Metz, M.D.
Statesman Journal (Salem, Ore.), Jan. 24, 2012

“Health care is a human right” is what the people of Vermont told their legislators and governor, a view shared by the majority of Americans according to the 2009 Kaiser Health Tracking Poll.

On May 26, 2011, Vermont Gov. Peter Shumlin signed our country’s first statewide publicly financed health care law providing universal health care to all Vermonters. We should have a similar law in Oregon.

On Dec. 15, 2011, Sen. Ron Wyden, D-Ore., and Rep. Paul Ryan, R-Wis., co-authored “Guaranteed Choices to Strengthen Medicare and Health Security for All: Bipartisan Options for the Future.” It seems Sen. Wyden wants to further entrench private health insurance for those employed, and to let private plans compete with Medicare.

This is not in the best interest of Oregonians. What they propose is the not so new idea of “defined contribution” health care plans. Simply put, these are vouchers. Employers provide a fixed sum to employees who then purchase whatever insurance they can afford. Because employer contributions stay fixed while health care costs increase, basic benefits quickly become unaffordable.

Without reform, American businesses can survive only by shifting escalating health care costs to someone else. A “defined contribution” plan allows just that — it moves increasing costs away from businesses and onto employees. These plans do nothing, of course, for those without benefits or without a job.

No successful health care system uses “defined contribution” plans (or vouchers of any kind, for that matter). Nor do they discourage patients from seeking care with high co-pays and deductibles. In fact, we are the only industrialized country to do so.

Consequently, our health costs are double the amount of an average industrialized country, our public health is near the bottom of the industrialized world and the social consequences are devastating; no other industrialized country allows citizens to lose limbs, homes or lives if they get a treatable disease.

Health care financing in successful systems has three common properties:

1. Every citizen maintains health care access no matter how sick, poor, old or unemployed they become.

2. There are no financial impediments to receiving health care.

3. Financing is provided by publicly accountable, transparent, not-for-profit agencies.

“Defined contribution” plans have none of these properties. For the record, financing with all three properties but using one publicly accountable, transparent, not-for-profit agency is called “single-payer” health care. All of America’s successful health care systems (e.g., Veterans Affairs medical centers and multi-employer health care plans) use single-payer financing.

The most significant bipartisan agreement that Sen. Wyden and Rep. Ryan could make is to recognize that health care is not a privilege but a human right. Instead, their plan continues employer-based private insurance to finance health care, which will accelerate the destruction of American’s families, America’s health and America’s future as a civilized nation.

The Wyden-Ryan proposal is misleading and distracts from the best solution. Instead of “defined contribution” plans, let’s define for Sen. Wyden what this country needs to save health care: single-payer, universal coverage. “Everybody in, nobody out.”

Chris Goeser, D.C., M.D., is a radiologist practicing in Salem, Silverton, Woodburn and Albany, and a member of both Physicians for a National Health Program and Mad As Hell Doctors. He can be reached at cdgoeser@diaradiology.org.Samuel Metz, M.D., is an anesthesiologist, member of Physicians for a National Health Program and founding member of Mad As Hell Doctors. He can be reached at SamuelMetz@SamuelMetz.com.

http://www.statesmanjournal.com/article/20120125/OPINION/201250381/Wyden-Ryan-plan-won-t-improve-health-care-system

Wyden-Ryan plan won’t improve health care system

By Chris Goeser, M.D., and Samuel Metz, M.D.
Statesman Journal (Salem, Ore.), Jan. 24, 2012

“Health care is a human right” is what the people of Vermont told their legislators and governor, a view shared by the majority of Americans according to the 2009 Kaiser Health Tracking Poll.

On May 26, 2011, Vermont Gov. Peter Shumlin signed our country’s first statewide publicly financed health care law providing universal health care to all Vermonters. We should have a similar law in Oregon.

On Dec. 15, 2011, Sen. Ron Wyden, D-Ore., and Rep. Paul Ryan, R-Wis., co-authored “Guaranteed Choices to Strengthen Medicare and Health Security for All: Bipartisan Options for the Future.” It seems Sen. Wyden wants to further entrench private health insurance for those employed, and to let private plans compete with Medicare.

This is not in the best interest of Oregonians. What they propose is the not so new idea of “defined contribution” health care plans. Simply put, these are vouchers. Employers provide a fixed sum to employees who then purchase whatever insurance they can afford. Because employer contributions stay fixed while health care costs increase, basic benefits quickly become unaffordable.

Without reform, American businesses can survive only by shifting escalating health care costs to someone else. A “defined contribution” plan allows just that — it moves increasing costs away from businesses and onto employees. These plans do nothing, of course, for those without benefits or without a job.

No successful health care system uses “defined contribution” plans (or vouchers of any kind, for that matter). Nor do they discourage patients from seeking care with high co-pays and deductibles. In fact, we are the only industrialized country to do so.

Consequently, our health costs are double the amount of an average industrialized country, our public health is near the bottom of the industrialized world and the social consequences are devastating; no other industrialized country allows citizens to lose limbs, homes or lives if they get a treatable disease.

Health care financing in successful systems has three common properties:

1. Every citizen maintains health care access no matter how sick, poor, old or unemployed they become.

2. There are no financial impediments to receiving health care.

3. Financing is provided by publicly accountable, transparent, not-for-profit agencies.

“Defined contribution” plans have none of these properties. For the record, financing with all three properties but using one publicly accountable, transparent, not-for-profit agency is called “single-payer” health care. All of America’s successful health care systems (e.g., Veterans Affairs medical centers and multi-employer health care plans) use single-payer financing.

The most significant bipartisan agreement that Sen. Wyden and Rep. Ryan could make is to recognize that health care is not a privilege but a human right. Instead, their plan continues employer-based private insurance to finance health care, which will accelerate the destruction of American’s families, America’s health and America’s future as a civilized nation.

The Wyden-Ryan proposal is misleading and distracts from the best solution. Instead of “defined contribution” plans, let’s define for Sen. Wyden what this country needs to save health care: single-payer, universal coverage. “Everybody in, nobody out.”

Chris Goeser, D.C., M.D., is a radiologist practicing in Salem, Silverton, Woodburn and Albany, and a member of both Physicians for a National Health Program and Mad As Hell Doctors. He can be reached at cdgoeser@diaradiology.org.Samuel Metz, M.D., is an anesthesiologist, member of Physicians for a National Health Program and founding member of Mad As Hell Doctors. He can be reached at SamuelMetz@SamuelMetz.com.

http://www.statesmanjournal.com/article/20120125/OPINION/201250381/Wyden-Ryan-plan-won-t-improve-health-care-system

Even With Insurance, Unemployed Have Worse Health Outcomes

Report finds that high co-pays, deductibles can still make medical care unaffordable

By Steven Reinberg, HealthDay Reporter
U.S. News and World Report, Jan. 24, 2012

People without jobs who have health insurance are less likely to get medical care or prescription drugs than people with jobs who have such coverage, U.S. health officials reported Tuesday.

During the depths of the recent recession, unemployment reached 9.6 percent, a level not seen since 1983. Because health insurance affects access to care and most people rely on getting insured through their employer, researchers wanted to look at the effect of unemployment and lower income on access to health care, according to the U.S. Centers for Disease Control and Prevention.

“Insurance without a job is a difficult position to be in,” said report author Anne Driscoll, a senior fellow at the CDC’s National Center for Health Statistics.

In the study, Driscoll and her colleague, Amy Bernstein, wanted to find out whether having private, public or no insurance mattered if you were employed or unemployed.

They found that private insurance, which experts think is the most comprehensive, was no guarantee of better health care.

“If you had private insurance but weren’t employed, you had worse mental health, worse physical health and were less likely to get prescriptions you needed or care that you needed than if you had a job,” Driscoll said.

Cost of care appears to be the overriding factor why having private insurance and no job was associated with lack of access to care, she said.

“Because you don’t have a job, deductibles and co-payments are the reasons you can’t use your insurance to the fullest. You’re better having insurance than no insurance, but it’s not a panacea. A job and insurance is the most advantageous category to be in, not just being insured,” Driscoll said.

For their study, the authors used data from the 2009 and 2010 U.S. National Health Interview Survey and compared the health insurance status, health and access to health care of employed and unemployed adults aged 18 to 64.

Highlights of the report include:

*  48 percent of unemployed adults had health insurance, compared with 81 percent of employed adults.
*  More of the unemployed had public insurance than those employed.
*  The unemployed had worse physical and mental health than the employed, whether they had insurance or not.
*  The insured unemployed were less likely to get medical care because of cost than the insured employed.
*  The insured unemployed were less likely to get prescription drugs because of cost than the insured employed.
*  The uninsured were less likely to get medical care and prescription drugs because of cost than people with public or private insurance, regardless of whether they had jobs or not.
*  The unemployed were more likely to be black, have less than a high school education and have an income below the poverty level.

Dr. Steffie Woolhandler, a visiting professor of medicine at Harvard Medical School and co-founder of Physicians for a National Health Program, doesn’t hold out hope that health care reform will make things better for the unemployed.

“During the recession, the use of health care plummeted. We had a 19.5 percent drop in primary care in the United States,” she said.

This study shows that even if people lost their jobs and held onto their insurance, they couldn’t afford to use health care, Woolhandler said.

“That’s a uniquely American issue because we have such high co-payments, deductibles and uncovered services that people can’t afford to use care,” she said.

Woolhandler noted that health care reform will help some people because the number of uninsured is expected to be cut by over half.

“While there will still be 23 million uninsured after health reform is fully implemented, it’s a whole lot less than it would be otherwise,” she said.

But, having health insurance will not mean that you can afford care if you lose your job, Woolhandler added.

“It will be a little worse after health reform, because the new policies that will be offered will be quite a bit skimpier than an employer policy is now. And there will be high co-pays, high deductibles. So even if you hang on to your insurance you likely won’t be able to afford care,” she said.

http://health.usnews.com/health-news/managing-your-healthcare/insurance/articles/2012/01/24/even-with-insurance-unemployed-have-worse-health-outcomes?page=2

"Global budgeting" for Children's Hospital Boston

Children’s, Blue Cross deal curbs payments

The Boston Globe
January 24, 2012

Children’s Hospital Boston has agreed to a three-year contract with Blue Cross Blue Shield of Massachusetts…

Perhaps most important, Children’s and its doctors groups will accept global payments for the first time, meaning they will be given a budget for patients’ care rather than billing for each visit and procedure.

“The contract is completely aligned with our aggressive and comprehensive efforts to take costs out of the system, while also improving quality,” said Children’s president Sandra Fenwick.

Until recently, it was thought unlikely that specialty providers such as Children’s, a 395-bed teaching hospital that is a national leader in pediatric research and training, would join the new global payment plans being offered by insurers.

Fenwick said the deal makes Children’s the first pediatric hospital in the nation to take global payments instead of traditional fee-for-service reimbursements. The contract also covers the Children’s Physicians Organization, made up of 959 specialists, and the Pediatric Physician Organization at Children’s, which includes 279 primary care doctors.

http://articles.boston.com/2012-01-24/business/30655411_1_pediatric-care-health-care-providers-specialty-hospitals

Comment: 

By Don McCanne, MD

Under a well designed single payer system, hospitals would be funded through global budgets, much like police and fire departments, libraries and other civic institutions. Single payer eliminates the need to provide complex, itemized billings for each and every patient to any of hundreds of third party payers. The hospitals are simply paid a global fee that covers all of their costs for the year. As Canada and other nations have shown, global budgeting dramatically reduces the high costs of the administrative excesses that U.S. hospitals face.

Blue Cross Blue Shield of Massachusetts has now negotiated the first contract with a pediatric hospital that they say uses global budgeting. So can we use this as an experiment to prove that global budgeting will work in the United States? Unfortunately, no.

This contract has almost nothing in common with global budgeting under a single payer system. A global budget limited to one insurer does not place the entire hospital under a single global budget. Far from it. They still have to interact with all other payers in our fragmented financing system. Further, the products and services provided to Blue Cross Blue Shield patients must be segregated and itemized separately to know the amount of the budget to be negotiated. The uncertainties on how to allocate various hospital costs also can result in inequities amongst the various payers, likely making Blue Cross Blue Shield a winner while other payers lose.

When we are told later on that we do not want hospitals globally budgeted under a single payer system because it did not work for Children’s Hospital Boston, be prepared to answer that this was not global budgeting. This was merely another individual contract between one hospital with its physicians’ organizations and one insurer, under a fragmented financing system in which it was impossible to achieve the efficiencies of globally budgeting of the hospital’s entire costs.

We can even invent a term based on what this process is. It is “segregated budgeting.” We can make that a pejorative term by demonstrating that it is merely another insurer gimmick in our dysfunctional system of financing health care. Let’s keep the definition of “global” clean, and not let the insurers steal it from us.