By Mark Dudzic, National Coordinator of the Labor Campaign for Single Payer
Healthcare-NOW!, May 16, 2011
On the surface, it appears to be a no-brainer. Healthcare costs in the U. S. are twice as high as any other industrialized country. Most large corporations still pay a big chunk of their employees’ health care insurance premiums. Some are obligated by union contracts to pay an even larger percentage and to provide coverage for retirees. Many operate profitably in countries with national health care systems where they pay far less towards healthcare costs than they do in the U.S.
So, from a straight bottom line business perspective, corporations should be leading the fight to replace our dysfunctional, overpriced, for-profit private insurance system with a single-payer, Medicare-for-All model. Yet more than 20 years after the crisis of escalating health insurance premiums first hit the corporate radar screens, not a single major U. S. corporation has come forward to advocate for replacing employment-based health insurance with a comprehensive national healthcare system. What gives?
Well, I can’t claim any deep psychological insights into the corporate mind-set but I did negotiate with a wide array of corporations in my 20-odd years as a union official. In fact, in 2005, my union negotiated a national agreement with the oil industry that established a joint “Health Care Strategic Committee” meant to address the “undue burden” that the “upward spiral of healthcare costs has placed on employees and employers alike.” The purpose of the committee was to, “[E]xamine, explore and seek means, both internal and external, to address this rapid rise in health care costs. Further, the Committee will endeavor to influence the national debate around health care issues through positive participation in public and governmental forums.”
Now many of us were hopeful that this might produce some results. Lots of these companies were based in countries that had national healthcare (British Petroleum, Royal Dutch Shell, etc.). All of them did business in countries where the right to healthcare is a birthright. But it was all in vain. The union practically had to tie them to their chairs to get them to listen to a presentation on single-payer from highly-credentialed experts. After two sessions, the whole thing dissolved into acrimony. They were only interested in one thing: shifting their healthcare costs onto the backs of their employees.
I think there are a number of factors that contribute to this mindset:
It’s about power. Corporations like having healthcare linked to employment. They like having people held captive in jobs they hate for fear they they’ll lose their health coverage. They like it that, when you go on strike, you generally lose your health insurance. They like to control who they will cover, how much they will pay and what benefits are offered. They like the ability to change anything at any time for any reason whatsoever.
They already have a plan to reduce healthcare costs. Thirty years ago, most employees of large corporations were covered by defined benefit pension plans that paid a guaranteed retirement benefit for as long as the person or their spouse lived. Today, the lucky ones have a 401 (k) plan that they pay into that has no guaranteed pay out. In effect, most large corporations have transferred all of the risks of providing retirement coverage onto their employees. This is their same plan for health insurance. All of the talk about “employee-directed health coverage” is about transferring risk from the corporation to the employee, Ultimately, they would like to replace any guarantee of health coverage with a voucher system where workers purchase their own coverage from an unregulated market.
They don’t like slippery slopes. Large corporations almost always religiously resist any attempt to regulate or control their behavior. These people would probably fight a regulation requiring them to help old people cross the street by claiming that it will create a new entitlement mentality that will undermine the free market. Much of the politics of the last 30 years has been about corporations trying to free themselves from any national or social constraints on their mobility or freedom to do just about anything. They’re not going to easily concede that the time has come to establish a new social right in the heartland of capitalism.
They practice class solidarity. Unlike the poor benighted U. S. working class (was it Jay Gould who boasted, “I can hire one half of the working class to kill the other half.”?), large corporations actually believe in class solidarity. Health industry executives serve on other corporate boards and other executives serve on their boards. The banking and financial sectors establish all kinds of interlocking relationships between various large corporations. They belong to the same country clubs and their kids go to school together. They know that the threat to put the voracious health insurance industry out of business is a threat to profiteers everywhere.
They are their own worst enemies. In the darkest days of the depression, President Roosevelt’s New Deal saved the capitalist system from itself by ushering in a new era of regulation and transparency. Almost without exception, corporate interests fought him every inch of the way. In fact, he had to link up with a vast popular movement against the “malefactors of great wealth” in order to create the conditions that stabilized the economy and then allowed corporations to thrive in one of the most prosperous eras in world history. Once we win single-payer, many large corporations will become big supporters. But we’ll have to drag them kicking and screaming to that moment.
This is not to say that we should stop demanding that corporate America add their voice to the fight for healthcare for all. Nor does it mean that all employers will act with the same obstinate resistance that large corporations do. In particular, small businesses are led by flesh and blood human beings with healthcare needs of their own and relationships to their employees and the communities they do business in. They can be a powerful constituency for single payer and there are some successful organizing models out there that we should embrace.
Likewise, public employers should be a natural supporter of single payer. They don’t have the profit-driven reasons to maintain support for a wasteful system of private insurance. They could save trillions if they were relieved of obligations to provide continuing private insurance coverage for retired and active employees. The entire federal budget deficit would disappear if we paid the same amount in per capita healthcare costs as any other industrialized nation where healthcare is a right. You need only to compare the vicious, “low road”, blame-the-workers approach to budget cutting in states like Wisconsin and Ohio (whose current political leaders are financed, I might add, by some of the most despicable corporate interests) with the “high road”, we’re-all-in-this-together, solve healthcare first approach in places like Vermont to see the potential for our movement to have public employers on our side on this issue.
But, in my opinion, the only thing that will move most large corporations is a powerful grassroots anti-corporate movement that will hold their feet to the fire. We’d be better served spending our time building that movement than clinging to a naive hope that somehow corporations are going to come to our rescue out of their own self-interest.
http://www.healthcare-now.org/why-won%E2%80%99t-corporate-america-support-single-payer-medicare-for-all/
Changing physicians' politics
As Physicians’ Jobs Change, So Do Their Politics
By Gardiner Harris
The New York Times, May 30, 2011
Doctors were once overwhelmingly male and usually owned their own practices.
But doctors are changing. They are abandoning their own practices and taking salaried jobs in hospitals, particularly in the North, but increasingly in the South as well. Half of all younger doctors are women, and that share is likely to grow.
There are no national surveys that track doctors’ political leanings, but as more doctors move from business owner to shift worker, their historic alliance with the Republican Party is weakening from Maine as well as South Dakota, Arizona and Oregon, according to doctors’ advocates in those and other states.
Because so many doctors are no longer in business for themselves, many of the issues that were once priorities for doctors’ groups, like insurance reimbursement, have been displaced by public health and safety concerns, including mandatory seat belt use and chemicals in baby products.
“It was a comfortable fit 30 years ago representing physicians and being an active Republican,” said Gordon H. Smith, executive vice president of the Maine Medical Association. “The fit is considerably less comfortable today.”
But doctors in Maine have abandoned the ownership of practices en masse, and their politics and points of view have shifted dramatically. The Maine doctors’ group once opposed health insurance mandates because they increase costs to employers, but it now supports them, despite Republican opposition, because they help patients.
Dr. Nancy Cummings, a 51-year-old orthopedic surgeon in Farmington… went to work for a hospital, sees health care as a universal right and believes profit-making businesses should have no role in either insuring people or providing their care. She said she was involved with the Maine Medical Association, for the most part, to increase patients’ access to care.
Dr. Lee Thibodeau, 59, a neurosurgeon from Portland, still calls himself a conservative but says he has changed, too. He used to pay nearly $85,000 a year for malpractice insurance and was among the most politically active doctors in the state on the issue of liability. Then, in 2006, he sold his practice, took a job with a local health care system, stopped paying the insurance premiums and ended his advocacy on the issue.
“It’s not my priority anymore,” Dr. Thibodeau said. “I think Gordon and I are now fighting for all of the same things, and that’s to optimize the patient experience.”
Dr. Cecil B. Wilson, the president of the A.M.A., said that changes in doctors’ practice-ownership status do not necessarily lead to changes in their politics. And some leaders of state medical associations predicted that the changes would be fleeting.
Dr. Kevin S. Flanigan, a former president of the Maine Medical Association, described himself as “very conservative” and said he was fighting to bring the group “back to where I think it belongs.” Dr. Flanigan was recently forced to close his own practice, and he now works for a company with hundreds of urgent-care centers. He said that in his experience, conservatives prefer owning their own businesses.
“People who are conservative by nature are not going to go into the profession,” he said, “because medicine is not about running your own shop anymore.”
http://www.nytimes.com/2011/05/30/health/policy/30docs.html?_r=1&emc=eta1&pagewanted=all
Comment:
By Don McCanne, MD
Anecdotes and hearsay are not the same as scientifically conducted surveys, but most of us who have been around for a while have seen the trends described in this article. Many physicians seem to be less concerned about personal involvement in the business of medicine and are seeking out approaches that “optimize the patient experience,” and in so doing are optimizing their own professional practice experiences.
Dr. Kevin Flanigan, a former president of the Maine Medical Association, represents the old guard. He says that conservatives prefer owning their own businesses and “are not going to go into the profession because medicine is not about running your own shop anymore.”
AMA President Cecil Wilson doesn’t believe that physicians will change their politics simply because of a change in practice ownership status. That view may be held by the old guard, but those now entering the profession who care more about patients than they do about running a business may well align themselves politically with those who believe in health care justice.
This reminds me of another personal anecdote. When I was interviewed for my application to UCSF by revered pediatrician Moses Grossman, he asked me what I would do if I wasn’t accepted into medical school. I told him that I was confident that I would be accepted somewhere, but, if not, I would most likely become a school teacher. He asked me why I thought he asked that question. I said that I assumed that he wanted to be sure that I had the practical sense to consider other options since realistically many did not make it into medical school. He then said something I’ve never forgotten. He said, “Suppose you told me that instead you would take over your uncle’s fur business… “
The old guard can have their fur business equivalencies, and hopefully they eventually will go the way of that heartless industry. Let’s welcome the new guard who have decided that they would prefer to join our growing ranks of compassionate, humanitarian stewards of the healing arts.
"The Republican vision of Medicare’s future" by David Horsey
Changing physicians’ politics
As Physicians’ Jobs Change, So Do Their Politics
By Gardiner Harris
The New York Times, May 30, 2011Doctors were once overwhelmingly male and usually owned their own practices.
But doctors are changing. They are abandoning their own practices and taking salaried jobs in hospitals, particularly in the North, but increasingly in the South as well. Half of all younger doctors are women, and that share is likely to grow.
There are no national surveys that track doctors’ political leanings, but as more doctors move from business owner to shift worker, their historic alliance with the Republican Party is weakening from Maine as well as South Dakota, Arizona and Oregon, according to doctors’ advocates in those and other states.
Because so many doctors are no longer in business for themselves, many of the issues that were once priorities for doctors’ groups, like insurance reimbursement, have been displaced by public health and safety concerns, including mandatory seat belt use and chemicals in baby products.
“It was a comfortable fit 30 years ago representing physicians and being an active Republican,” said Gordon H. Smith, executive vice president of the Maine Medical Association. “The fit is considerably less comfortable today.”
But doctors in Maine have abandoned the ownership of practices en masse, and their politics and points of view have shifted dramatically. The Maine doctors’ group once opposed health insurance mandates because they increase costs to employers, but it now supports them, despite Republican opposition, because they help patients.
Dr. Nancy Cummings, a 51-year-old orthopedic surgeon in Farmington… went to work for a hospital, sees health care as a universal right and believes profit-making businesses should have no role in either insuring people or providing their care. She said she was involved with the Maine Medical Association, for the most part, to increase patients’ access to care.
Dr. Lee Thibodeau, 59, a neurosurgeon from Portland, still calls himself a conservative but says he has changed, too. He used to pay nearly $85,000 a year for malpractice insurance and was among the most politically active doctors in the state on the issue of liability. Then, in 2006, he sold his practice, took a job with a local health care system, stopped paying the insurance premiums and ended his advocacy on the issue.
“It’s not my priority anymore,” Dr. Thibodeau said. “I think Gordon and I are now fighting for all of the same things, and that’s to optimize the patient experience.”
Dr. Cecil B. Wilson, the president of the A.M.A., said that changes in doctors’ practice-ownership status do not necessarily lead to changes in their politics. And some leaders of state medical associations predicted that the changes would be fleeting.
Dr. Kevin S. Flanigan, a former president of the Maine Medical Association, described himself as “very conservative” and said he was fighting to bring the group “back to where I think it belongs.” Dr. Flanigan was recently forced to close his own practice, and he now works for a company with hundreds of urgent-care centers. He said that in his experience, conservatives prefer owning their own businesses.
“People who are conservative by nature are not going to go into the profession,” he said, “because medicine is not about running your own shop anymore.”
http://www.nytimes.com/2011/05/30/health/policy/30docs.html?_r=1&emc=eta1&pagewanted=all
Anecdotes and hearsay are not the same as scientifically conducted surveys, but most of us who have been around for a while have seen the trends described in this article. Many physicians seem to be less concerned about personal involvement in the business of medicine and are seeking out approaches that “optimize the patient experience,” and in so doing are optimizing their own professional practice experiences.
Dr. Kevin Flanigan, a former president of the Maine Medical Association, represents the old guard. He says that conservatives prefer owning their own businesses and “are not going to go into the profession because medicine is not about running your own shop anymore.”
AMA President Cecil Wilson doesn’t believe that physicians will change their politics simply because of a change in practice ownership status. That view may be held by the old guard, but those now entering the profession who care more about patients than they do about running a business may well align themselves politically with those who believe in health care justice.
This reminds me of another personal anecdote. When I was interviewed for my application to UCSF by revered pediatrician Moses Grossman, he asked me what I would do if I wasn’t accepted into medical school. I told him that I was confident that I would be accepted somewhere, but, if not, I would most likely become a school teacher. He asked me why I thought he asked that question. I said that I assumed that he wanted to be sure that I had the practical sense to consider other options since realistically many did not make it into medical school. He then said something I’ve never forgotten. He said, “Suppose you told me that instead you would take over your uncle’s fur business… ”
The old guard can have their fur business equivalencies, and hopefully they eventually will go the way of that heartless industry. Let’s welcome the new guard who have decided that they would prefer to join our growing ranks of compassionate, humanitarian stewards of the healing arts.
Vermont Lays Out a Path to Single-Payer, But It's a Long Journey
By Jane Norman, CQ HealthBeat Associate Editor
The Commonwealth Fund, May 26, 2011
Last Thursday was a day of celebration for advocates of single-payer health care when Vermont Gov. Peter Shumlin signed into law a measure that’s intended to pave the way for government-run health care in the Green Mountain State.
But it’s a case of delayed gratification. Numerous questions and uncertainties surround implementation, the costs have not been determined, and the law is unlikely to go into effect until sometime six years or more down the road.
In remarks at the Statehouse in Montpelier, Shumlin, a Democrat, acknowledged that Vermont has a way to go before its proposed system can achieve the cost efficiencies and quality dreamed of by those who advocate a single-payer health care system.
“I realize that people have legitimate questions about how a single-payer will be financed and operated, and we will answer those questions before the legislature takes the next step,” Shumlin said. “We’ll be getting input from all Vermonters moving forward, which is essential to the success of this effort.”
He said that 47,000 state residents are uninsured and another 150,000 have inadequate coverage. The objective is to provide them and the rest of the state’s residents with better health care.
While single-payer advocates were happy with the bill signing and its significance, they said the details of implementation are problematic.
The leaders of Physicians for a National Health Program, a prominent single-payer group, praised the Vermont measure and said it’s providing inspiration for the rest of the country. But Garrett Adams, president of the organization, said in a statement that “the actual provisions of the law fall considerably short of the single-payer reform needed to realize those goals.”
One problem is that multiple private insurers would still be allowed to operate in Vermont, denying residents the savings they would see under a true single-payer plan, he said.
Meanwhile, the liberal Web site Firedoglake mounted a petition effort asking the federal Department of Health and Human Services to grant the waivers the state would need from Medicaid, the Children’s Health Insurance Program, Medicare, worker’s compensation laws and more.
The three-part Vermont measure, which its House approved earlier this month, will establish a paid Green Mountain Care Board whose five members — all state employees — will be appointed and in place by October, according to Shumlin’s office. It’s supposed to work with providers to reduce their reliance on fee-for-service payments. The board will also have approval over insurance rate requests and eventually will review hospital budgets.
In addition, the bill authorizes the creation of a health exchange, which is required for the state to set up under the federal health care law by 2014 or the federal government would step in. “The intent of the general assembly is to establish the Vermont health benefit exchange in a manner such that it may become the foundation for Green Mountain Care,” the bill says.
Green Mountain Care is the third element: the single-payer system that would begin in 2017, the earliest date at which current federal health care law (PL 111-148, PL 111-152) allows states to ask for waivers from the overhaul measure to set up their own systems. The Vermont congressional delegation is pushing to move that date to up 2014.
Vermont’s system would not go into effect until its legislature approves a budget and means of financing for it, yet to be determined though new taxes are thought to be likely. A benefits package would have to be approved by the Care Board.
Supporters of the federal health care law saw Vermont’s move as proof that the law has plenty of flexibility to allow states to make their own decisions about how to run their health care systems. “We hope that other states across the country take inspiration from Vermont to implement their own unique pathways to improving health coverage, costs, and quality of care,” said Ron Pollack, head of the advocacy group Families USA.
http://www.commonwealthfund.org/Content/Newsletters/Washington-Health-Policy-in-Review/2011/May/May-31-2011/Vermont-Lays-Out-a-Path-to-Single-Payer.aspx
Vermont has a plan for single-payer health care
Health blog
Consumer Reports, May 26, 2011
Vermont made history today when Governor Peter Shumlin, a Democrat, signed into law a plan to create the nation’s first state-run “single-payer” health system. If fully implemented, every Vermont resident, including those on Medicare and Medicaid, would be entitled to enroll in the state’s own insurance plan, Green Mountain Care. Private insurers would still be allowed to operate in the state.
The goal is to establish a system in which “health care is a right and not a privilege,” Governor Shumlin told National Public Radio. But the new law doesn’t establish the system right away. Instead, it creates a five-member board that is charged with coming up with options to pay for the system, which are to be presented to the legislature for approval by Jan. 15, 2013.
In addition, there’s the hurdle of getting federal approval to allow Vermonters who have coverage through Medicaid or Medicare to enroll in Green Mountain Care. While the federal government has previously allowed states to experiment with their Medicaid programs, which is a joint federal-state initiative, is hasn’t for Medicare, the nation’s health program for seniors and the disabled.
The Vermont law seeks to comply with—and initially build on—the national reform law. That law was passed in March 2010 but its major elements don’t go into effect until January 2014. For example, the Vermont law creates a web-based insurance “exchange” where residents could compare insurance plans and choose among them. The federal reform law requires that such exchanges be set up in all 50 states. In Vermont, though, one of the options in its exchange would be Green Mountain Care.
The Vermont law seeks eventually to supplant other parts of the federal law as well. For example, it envisions that doctors and hospitals will be paid fixed rates set by the new board and lawmakers, similar to how health systems in Canada and Europe work.
Whether the federal government will grant the waivers could depend on politics. The federal reform law allows states to launch alternative systems starting in 2017. And in February, President Obama endorsed legislation that would move that date up to 2014—a concession to states clamoring for more “flexibility” or to opt out of the law altogether. But states would have to meet stringent conditions, such as covering as many as or more people as the federal law and providing as generous a package of benefits. To date, there’s been no movement on the proposal. Rather, in the House, lawmakers have voted to repeal the entire law or restrict its funding.
Most business groups in Vermont have either opposed the law or been non-committal. Under the law, employers can continue providing workers with benefits through private insurers but will be expected to help finance the new system through a tax, as yet unspecified. Many employers nationwide have been looking for ways to lower their rising health care costs.
Long time single-payer advocates praised passage of the Vermont law but were dismayed that it allowed private insurers to continue operating in the state. “Allowing multiple insurers…will deny Vermonters the enormous administrative savings they would otherwise get under a true single payer plan,” Garrett Adams, M.D., president of Physicians for a National Health Program, said in a statement.
AMA supports Medicare balance billing
Medicare Patient Empowerment Act
American Medical Association
Rep. Tom Price, MD (R-GA) introduced H.R. 1700, the Medicare Patient Empowerment Act, on May 3, 2011. This bill, in line with AMA policy, would allow Medicare patients and their physicians to enter into private contracts without penalty to either party. It would enable beneficiaries to use their Medicare benefits to see physicians who do not accept Medicare, as opposed to paying for the entire cost of their care out-of-pocket as required under current law. On May 22, Sen. Lisa Murkowski (R-AK) introduced S. 1042, the Medicare Patient Empowerment Act, in the Senate.
AMA letters expressing “strong support for this legislation”:
To Rep. Tom Price:
http://www.ama-assn.org/resources/doc/washington/hr1700-ama-letter-of-support.pdf
To Sen. Lisa Murkowski:
http://www.ama-assn.org/resources/doc/washington/s1042-ama-letter-of-support.pdf
Medical organizations supporting this legislation:
http://www.ama-assn.org/resources/doc/washington/medicare-patient-empowerment-sign-on-letter.pdf
And…
Existing law (excerpts):
Sec. 1802.
Use of Private Contracts by Medicare Beneficiaries.—
(1) In general.—Subject to the provisions of this subsection, nothing in this title shall prohibit a physician or practitioner from entering into a private contract with a medicare beneficiary for any item or service—
A) for which no claim for payment is to be submitted under this title, and
(B) for which the physician or practitioner receives—
(i) no reimbursement under this title directly or on a capitated basis, and
(ii) receives no amount for such item or service from an organization which receives reimbursement for such item or service under this title directly or on a capitated basis.
(B) Items required to be included in contract.—Any contract to provide items and services to which paragraph (1) applies shall clearly indicate to the medicare beneficiary that by signing such contract the beneficiary—
(i) agrees not to submit a claim (or to request that the physician or practitioner submit a claim) under this title for such items or services even if such items or services are otherwise covered by this title;
(ii) agrees to be responsible, whether through insurance or otherwise, for payment of such items or services and understands that no reimbursement will be provided under this title for such items or services;
(iii) acknowledges that no limits under this title (including the limits under section 1848(g)) apply to amounts that may be charged for such items or services;
(iv) acknowledges that Medigap plans under section 1882do not, and other supplemental insurance plans may elect not to, make payments for such items and services because payment is not made under this title; and
(v) acknowledges that the medicare beneficiary has the right to have such items or services provided by other physicians or practitioners for whom payment would be made under this title.
(B) Affidavit.
(ii) the affidavit provides that the physician or practitioner will not submit any claim under this title for any item or service provided to any medicare beneficiary (and will not receive any reimbursement or amount described in paragraph (1)(B) for any such item or service) during the 2–year period beginning on the date the affidavit is signed
http://www.ssa.gov/OP_Home/ssact/title18/1802.htm
And…
Proposed law
H.R. 1700 and S. 1042 (excerpts):
Section 1802 of the Social Security Act is amended to read as follows:
(b) Freedom To Contract by Medicare Beneficiaries-
`(1) IN GENERAL- Subject to the provisions of this subsection, nothing in this title shall prohibit a Medicare beneficiary from entering into a contract with a participating or non-participating physician or practitioner for any item or service covered under this title.
(B) ITEMS REQUIRED TO BE INCLUDED IN CONTRACT- Any contract to provide items and services to which paragraph (1) applies shall clearly indicate to the Medicare beneficiary that by signing such contract the beneficiary–
`(i) agrees to be responsible for payment to such physician or practitioner for such items or services under the terms of and amounts established under the contract;
`(ii) agrees to be responsible for submitting claims under this title to the Secretary, and to any other supplemental insurance plan that may provide supplemental insurance, for such items or services furnished under the contract if such items or services are covered by this title, unless otherwise provided in the contract under subparagraph (C)(i); and
`(iii) acknowledges that no limits or other payment incentives that may otherwise apply under this title (such as the limits under subsection (g) of section 1848 or incentives under subsection (a)(5), (m), (q), and (p) of such section) shall apply to amounts that may be charged, or paid to a beneficiary for, such items or services.
SEC. 3. PREEMPTION OF STATE LAWS LIMITING CHARGES FOR PHYSICIAN AND PRACTITIONER SERVICES.
(a) In General- No State may impose a limit on the amount of charges for services, furnished by a physician or practitioner, for which payment is made under section 1848 of the Social Security Act (42 U.S.C. 1395w-4), and any such limit is hereby preempted.
http://thomas.loc.gov (enter either H.R.1700 or S.1042)
Comment:
By Don McCanne, MD
Sadly, the American Medical Association is showing once again whom they really represent – physicians, but not their patients. This legislation would greatly enhance physician revenues at a considerable cost to their Medicare patients. It would allow physicians to require their patients to pay the full balance of their unrestricted fees, even if far in excess of Medicare allowable charges.
Current law prohibits physicians from billing the patient for any charges other than deductibles and coinsurance that are applied to allowable charges only. All fees beyond the allowable amount must be adjusted off. The only exception is that a physician may enter into a private contract with a patient who agrees to pay the full amount, but only if the physician and patient agree to not bill Medicare for even the allowed charges, and the physician agrees to not bill Medicare for any other patient for a minimum of two years.
Even though we often hear threats that physicians will stop seeing Medicare patients, most really can’t afford to give up their Medicare revenues, and, besides, too many Medicare beneficiaries do not have adequate resources to pay large medical bills in full. The current law provides leverage to ensure that physicians will be there when Medicare patients need them.
The Price/Murkowski legislation would no longer require physicians to exit the Medicare program entirely should they enter agreements to independently bill the patients for the balance of their fees. Also Medicare would still have to pay the allowed charges. As a further insult, the physician can require the patient to do their own Medicar
e billing. The physician gets the full fee, in cash, including the disallowed charges, and the patient has to do the paperwork. Nice guys, AMA!
If physicians were allowed to bill for the balance of the charges, Medicare as we know it would be destroyed. It is a more direct and more powerful method of shifting payment from the government to individual patients – far worse than the cost shift that would occur with the Ryan premium support proposal for Medicare. Since the greatest contributor to our excessive health care spending is our high prices, the Price/Murkowski legislation would cause health care spending to skyrocket because there would be no limits on physician pricing.
If you check the list of endorsing medical organizations at the link above, it is an embarrassment to those of us who have always thought that the patient comes first, but there is one consolation. Conspicuously absent from the list are the American Academy of Family Physicians and the American College of Physicians. Thankfully, our nation’s primary care physicians still believe that our patients really do come first.
AMA supports Medicare balance billing
Medicare Patient Empowerment Act
American Medical Association
Rep. Tom Price, MD (R-GA) introduced H.R. 1700, the Medicare Patient Empowerment Act, on May 3, 2011. This bill, in line with AMA policy, would allow Medicare patients and their physicians to enter into private contracts without penalty to either party. It would enable beneficiaries to use their Medicare benefits to see physicians who do not accept Medicare, as opposed to paying for the entire cost of their care out-of-pocket as required under current law. On May 22, Sen. Lisa Murkowski (R-AK) introduced S. 1042, the Medicare Patient Empowerment Act, in the Senate.
AMA letters expressing “strong support for this legislation”:
To Rep. Tom Price:
http://www.ama-assn.org/resources/doc/washington/hr1700-ama-letter-of-support.pdfTo Sen. Lisa Murkowski:
http://www.ama-assn.org/resources/doc/washington/s1042-ama-letter-of-support.pdfMedical organizations supporting this legislation:
http://www.ama-assn.org/resources/doc/washington/medicare-patient-empowerment-sign-on-letter.pdf
And…
Existing law (excerpts):
Sec. 1802.
Use of Private Contracts by Medicare Beneficiaries.—
(1) In general.—Subject to the provisions of this subsection, nothing in this title shall prohibit a physician or practitioner from entering into a private contract with a medicare beneficiary for any item or service—
A) for which no claim for payment is to be submitted under this title, and
(B) for which the physician or practitioner receives—
(i) no reimbursement under this title directly or on a capitated basis, and
(ii) receives no amount for such item or service from an organization which receives reimbursement for such item or service under this title directly or on a capitated basis.(B) Items required to be included in contract.—Any contract to provide items and services to which paragraph (1) applies shall clearly indicate to the medicare beneficiary that by signing such contract the beneficiary—
(i) agrees not to submit a claim (or to request that the physician or practitioner submit a claim) under this title for such items or services even if such items or services are otherwise covered by this title;
(ii) agrees to be responsible, whether through insurance or otherwise, for payment of such items or services and understands that no reimbursement will be provided under this title for such items or services;
(iii) acknowledges that no limits under this title (including the limits under section 1848(g)) apply to amounts that may be charged for such items or services;
(iv) acknowledges that Medigap plans under section 1882do not, and other supplemental insurance plans may elect not to, make payments for such items and services because payment is not made under this title; and
(v) acknowledges that the medicare beneficiary has the right to have such items or services provided by other physicians or practitioners for whom payment would be made under this title.(B) Affidavit.
(ii) the affidavit provides that the physician or practitioner will not submit any claim under this title for any item or service provided to any medicare beneficiary (and will not receive any reimbursement or amount described in paragraph (1)(B) for any such item or service) during the 2–year period beginning on the date the affidavit is signed
And…
Proposed law
H.R. 1700 and S. 1042 (excerpts):
Section 1802 of the Social Security Act is amended to read as follows:
(b) Freedom To Contract by Medicare Beneficiaries-
`(1) IN GENERAL- Subject to the provisions of this subsection, nothing in this title shall prohibit a Medicare beneficiary from entering into a contract with a participating or non-participating physician or practitioner for any item or service covered under this title.(B) ITEMS REQUIRED TO BE INCLUDED IN CONTRACT- Any contract to provide items and services to which paragraph (1) applies shall clearly indicate to the Medicare beneficiary that by signing such contract the beneficiary–
`(i) agrees to be responsible for payment to such physician or practitioner for such items or services under the terms of and amounts established under the contract;
`(ii) agrees to be responsible for submitting claims under this title to the Secretary, and to any other supplemental insurance plan that may provide supplemental insurance, for such items or services furnished under the contract if such items or services are covered by this title, unless otherwise provided in the contract under subparagraph (C)(i); and
`(iii) acknowledges that no limits or other payment incentives that may otherwise apply under this title (such as the limits under subsection (g) of section 1848 or incentives under subsection (a)(5), (m), (q), and (p) of such section) shall apply to amounts that may be charged, or paid to a beneficiary for, such items or services.SEC. 3. PREEMPTION OF STATE LAWS LIMITING CHARGES FOR PHYSICIAN AND PRACTITIONER SERVICES.
(a) In General- No State may impose a limit on the amount of charges for services, furnished by a physician or practitioner, for which payment is made under section 1848 of the Social Security Act (42 U.S.C. 1395w-4), and any such limit is hereby preempted.
http://thomas.loc.gov (enter either H.R.1700 or S.1042)
Sadly, the American Medical Association is showing once again whom they really represent – physicians, but not their patients. This legislation would greatly enhance physician revenues at a considerable cost to their Medicare patients. It would allow physicians to require their patients to pay the full balance of their unrestricted fees, even if far in excess of Medicare allowable charges.
Current law prohibits physicians from billing the patient for any charges other than deductibles and coinsurance that are applied to allowable charges only. All fees beyond the allowable amount must be adjusted off. The only exception is that a physician may enter into a private contract with a patient who agrees to pay the full amount, but only if the physician and patient agree to not bill Medicare for even the allowed charges, and the physician agrees to not bill Medicare for any other patient for a minimum of two years.
Even though we often hear threats that physicians will stop seeing Medicare patients, most really can’t afford to give up their Medicare revenues, and, besides, too many Medicare beneficiaries do not have adequate resources to pay large medical bills in full. The current law provides leverage to ensure that physicians will be there when Medicare patients need them.
The Price/Murkowski legislation would no longer require physicians to exit the Medicare program entirely should they enter agreements to independently bill the patients for the balance of their fees. Also Medicare would still have to pay the allowed charges. As a further insult, the physician can require the patient to do their own Medicare billing. The physician gets the full fee, in cash, including the disallowed charges, and the patient has to do the paperwork. Nice guys, AMA!
If physicians were allowed to bill for the balance of the charges, Medicare as we know it would be destroyed. It is a more direct and more powerful method of shifting payment from the government to individual patients – far worse than the cost shift that would occur with the Ryan premium support proposal for Medicare. Since the greatest contributor to our excessive health care spending is our high prices, the Price/Murkowski legislation would cause health care spending to skyrocket because there would be no limits on physician pricing.
If you check the list of endorsing medical organizations at the link above, it is an embarrassment to those of us who have always thought that the patient comes first, but there is one consolation. Conspicuously absent from the list are the American Academy of Family Physicians and the American College of Physicians. Thankfully, our nation’s primary care physicians still believe that our patients really do come first.
Vermont Poised to Become 1st State to Enact Single-Payer Healthcare
Democracy Now!
May 26, 2011
Today Vermont is set to make history by becoming the first state in the nation to offer universal, single-payer healthcare when Gov. Peter Shumlin signs its healthcare reform bill into law. The Vermont plan, called the Patient Protection and Affordable Care Act, will attempt to stem rising medical care prices and provide universal coverage. We speak with Dr. Deb Richter, president of Vermont Health Care for All. She moved from Buffalo, New York, to Vermont in 1999 to advocate for a universal, single-payer healthcare system in the state. Gov. Shumlin calls her the “backbone” of the grassroots effort that helped persuade the Democratic-led state legislature to pass the bill this spring.
JUAN GONZALEZ: Today, Vermont is set to become the first state in the nation to offer single-payer healthcare when Governor Peter Shumlin signs its healthcare reform bill into law.
The cost of healthcare has risen sharply in Vermont in recent years, as it has everywhere in the country. The Vermont plan, called the Patient Protection and Affordable Care Act, will attempt to stem that rise and also provide universal coverage. Every Vermont resident will be eligible for coverage under the state-run health plan.
Earlier this year, Governor Shumlin explained to Democracy Now! why the state needs the change.
GOV. PETER SHUMLIN: Here’s our challenge. Our premiums go up 10, 15, 20 percent a year. This is true in the rest of the country, as well. They are killing small business. They’re killing middle-class Americans, who have been kicked in the teeth over the last several years. What our plan will do is create a single pool, get the insurance company profits, the pharmaceutical company profits, the other folks that are mining the system to make a lot of money on the backs of our illnesses, and ensure that we’re using those dollars to make Vermonters healthy.
JUAN GONZALEZ: Governor Shumlin has appointed a five-member board to determine payment rates for doctors and what benefits to cover. Given all the details that need to be worked out, the plan may not go into effect until 2017.
AMY GOODMAN: To discuss the signing of the bill into law and the details of the plan, we’re going to the capital of Vermont, Montpelier, where we’re joined by Dr. Deb Richter. She’s the president of Vermont Health Care for All. Dr. Richter moved from Buffalo, New York, to Vermont 12 years ago to advocate for universal, single-payer healthcare in Vermont. Governor Shumlin calls her the “backbone” of the grassroots effort that helped persuade the Democratic legislature to pass the bill this spring.
Dr. Richter, welcome to Democracy Now! This is an enormous day for you. You’re going from your house to the Capitol for the signing. Can you explain what this bill actually does?
DR. DEB RICHTER: Well, this bill really establishes a framework for a true healthcare system, which is lacking anywhere in the United States. And what it will do is put in place a board that will oversee the healthcare system, and the board will be nominated in July. And we’ll start working in October to look at how we can reduce cost in our system. And that will be sort of the first phase. And most Vermonters won’t feel too much then, except probable a slowing of the rate of increase of their premiums.
And then the second phase, if we can’t get a change in federal law, is we will build the exchange according to federal law. But we will heavily regulate the insurance companies within that exchange and try to also streamline the payments to providers by making them uniform, calling them “all payer rates.” So that’s sort of the second phase.
And then the third phase, if we get the waivers that we need in 2017, we hope to have a publicly financed single-payer healthcare—as close to a single-payer healthcare system as we can get.
JUAN GONZALEZ: And why the long wait, Dr. Richter, until 2017 for a full implementation? Is there any concern on your part that a change in the political climate, new people elected in Vermont, might attempt to roll that back in that period of time?
DR. DEB RICHTER: Well, we are not—we are not naive enough to think that we are not going to have significant challenges trying to get this bill in place. Our problem is really the federal law put restrictions on states that they couldn’t apply for waivers until 2017. What we’re hoping is that we can roll that back to 2014 and get our system in place before then.
And we’ve had—look, we’ve had struggles up ’til this point, and no one said we could get this far, and people were basically naysayers saying that you’ll never get this far. And we’ve gotten this far. And I think the same energy that got us this far—we have a congressional delegation that is superb. We have a wonderful legislature; at this point, they’re all in—most of—the majority are in favor of single payer. And, of course, we have our governor, who campaigned on this issue, and a strong grassroots movement in the state of Vermont. And all of those together are really going to be needed to get us to where we need to go in 2017, or hopefully 2014.
AMY GOODMAN: Dr. Richter, did you actually move from Buffalo, New York, to Vermont for this purpose, to get one state in the nation to pass single payer? And why did you choose Vermont?
DR. DEB RICHTER: It was one of the major factors as to why we moved here. It’s also an absolutely beautiful state, wonderful schools, great place to raise children. We had two teenage kids at the time, and it seemed like the right thing to do at the time.
But the other reason was, I was trying to do advocacy to get a single-payer healthcare system in New York—very naive of me, I think—and realized I was spinning my wheels in New York. And I really, at that point, felt that it needed to happen in one state or several states, and I figured Vermont was a wonderful place. We have a citizen legislature. Within six months of moving here, I met the governor at the time, was Howard Dean. I met the speaker of the House, who called me up, after writing a letter to the editor. I met all of my key legislators, the heads of committees. They’re very—it’s a very open process. They don’t even have offices. In fact, all of the lobbying and education goes on in the cafeteria. So it’s very accessible. And there’s only 300,000 voters in Vermont. So it seemed like, why not? It seemed like the right thing to do.
JUAN GONZALEZ: And in terms of being able to win support among the public and among the politicians in Vermont, you often talked about your own experiences, the problems that you have dealing with all of the different insurance companies that a medical practice has to deal with. Could you talk about that and how that was able—you were able to use those arguments to convince people of the need for single payer?
DR. DEB RICHTER: Right. I mean, that’s what originally had sort of inspired me to look into how could we fix the healthcare system. I had, in Buffalo, 40 percent of my patients had no insurance, and many of them died young as a result of preventable illnesses, as a result of having been on and off insurance. And I had dozens of examples that—from my own practice, just me—if you multiply that times 700,000, you get an idea of how widespread this problem was.
And in addition, the amount of administrative burden and all of the bureaucracy that was—I’m a primary care physician, and all of the bureaucracy that we had—the hoops we had to jump through just to get patients the care they needed was ridiculous. And we know that 31 percent of the healthcare dollar is spent on administrative costs, transaction costs and paperwork. And just ask any primary care doctor, and they can tell you that they actually live that every single day.
So those are the things that I think resonated with people. I think people who had gone to the doctor 30 years ago and didn’t see all those people behind the counter just pushing paper, it’s something that they all felt. And we’re seeing this. More and more in the middle class is now experiencing what the poorer folks used to experience in terms of access. And I think that now that we have probably a majority of the population experiencing problems, this is something that’s resonating. And I do believe that that’s one of the major reasons that we got this legislation passed this year.
AMY GOODMAN: Dr. Richter, can you explain more who exactly is going to pay for this? Of course, that’s the argument that’s used all over the country. This is what we most understand as Medicare, but you just drop the age of eligibility to zero, to when—the day you’re born.
DR. DEB RICHTER: Well, I’d like to point out that we always ask this question: how are we going to pay for it? I think we should remind people that they’re paying—every penny of the healthcare dollar is coming from Americans. Right now we’re paying—60 percent of it is financed through taxes, 20 percent out of pocket, and 20 percent for private insurance premiums. That’s all coming from us. We either give up higher wages, or we pay higher prices for goods, or we give up paving our roads. All of those things go into financing the healthcare system now.
What this bill will do—and we do not have a financing mechanism set up yet. We did have Dr. William Hsiao, who suggested an 11 percent payroll tax on employers and a three percent payroll tax on the employees could finance a very robust benefit package for all Vermonters. At the time, the Governor felt that we really needed to look into whether that was the best way. But it is—we have committed to broad-based taxes to finance the healthcare system, much like you described, a Medicare for all, which would be—you’d get it at birth rather than waiting ’til you’re 65. More than likely, this will be some combination of a payroll tax, perhaps some income tax, perhaps some other taxes, but that will then be in place of premiums and out-of-pocket payments. So, we should keep in mind that what this does is it dedicates financing for the healthcare that we expect to be there for us.
AMY GOODMAN: I should just clarify something. When you said Dr. Hsiao, this very interesting Harvard economist who Vermont hired, who addressed a rare session, a joint session, of the Vermont legislature, with all three—the whole delegation from Congress, the two senators and the Congress member there, as well as the Governor, to lay out what the proposals are. Juan?
JUAN GONZALEZ: Yeah, I’d like to ask you about the response of the doctors of the state. And there’s obviously public support for it, but what about the medical community? What’s been their response to your efforts and to the new plan?
DR. DEB RICHTER: Well, we’ve had some opposition, but there was a public hearing for providers. This was—included hospitals. And what we found was, two to one were in favor of single payer. And that’s particularly true in the primary care specialty. Eighty percent, roughly 80 percent nationally and in other state polls have shown that primary care, 80 percent of them are in favor. And we—our American Academy of Family Physicians Vermont chapter endorsed it. Our Vermont Psychiatric Association endorsed it.
What we find is that there is opposition. Most of it is in the sub-specialties, and these are physicians that are very worried about their income. And that’s what they specified as one of their bigger concerns. And I would try to—you know, I tried to explain to them that if they read the bill, actually, the bill states that the payments for providers will be adequate to sustain their medical practices. And Dr. Hsiao specifically stated that doctors would see no net loss in income under the financing plan that he had worked out. So, I think, as physicians, we—it’s going to take time. They need to be educated. I think they need to get more comfortable with this. And we also want their input. I think if we can get the input of providers and patients, we can build a system that’s unique for Vermont.
AMY GOODMAN: Now, this is very interesting that this is going to happen today in Vermont. If you look at the example of Canada, it was Tommy Douglas, the premier of Saskatchewan, who—what—the poll was taken, calling him the greatest Canadian, who got it in Saskatchewan in the early ’60s, when we were having our debate on Medicare in this country. And then it rapidly was adopted throughout Canada. And that’s how they got what they call Medicare there, single payer for all there. Interestingly, his grandson is the actor Kiefer Sutherland. Are you thinking that Vermont will be the beginning, just the beginning?
DR. DEB RICHTER: Absolutely. I think Vermont tends to be first. We were the first to abolish slavery. We have many firsts in our state. And the attitude is, is we see a problem and we try to fix it. The idea of negative thinking is not so much a part of our DNA. So, I am very confident that we will certainly embark on this, and I do believe that we will see single payer in 2017.
AMY GOODMAN: And Bernie Sanders, the senator, and Congressman McDermott from Washington state have introduced the legislation for single-payer healthcare into Congress once again.
DR. DEB RICHTER: Right. And I think it’s important to point out also that being—the ultimate goal is a national single-payer, Medicare-for-all system. This is really—what our feeling is is that this is going to be the best way for us to show the rest of the nation that we actually can cover people for less money, but you need a single-payer system to do it.
JUAN GONZALEZ: And how do you respond to those who might say that Vermont is not representative of the rest of the country, it’s sort of the Berkeley of the East, the eastern part of the United States, and that the state is a small state of 600,000 that—without the disparities in wealth and income, without the extreme poverty that you might find in other parts of the country, that what’s workable there might not be workable in the rest of the country?
DR. DEB RICHTER: Well, I think the problems of costs are present everywhere, and those are going to worsen. In fact, they’re going to worsen in Vermont before we get this thing fixed. And I think we’re going to see a lot more converts if that starts to happen. And more and more people are giving up coverage and having problems with getting—accessing healthcare as a result. And as a result of that, I think this will become an offer that few of them will be able to refuse.
It probably will start with some of the blue states first, I think. I envision it as something that would probably happen in the New England states in the Northeast first, before we see it in Alabama or Mississippi. I think that’s way down the road. And certainly, a small state—I think the important thing to remember is, a larger state, that’s all the more reason to have simplified billing and administration and a simplified way of paying for healthcare. It actually argues to having that be more the reason why they should be doing this.
AMY GOODMAN: Finally, the insurance industry and the drug lobby in Vermont, what happened with them?
DR. DEB RICHTER: Well, Blue Cross Blue Shield, which is our major insurer, they have the major percentage of the market, I believe 60 percent of the market. They actually were neutral on the bill. They said that they envision themselves as being the single payer—in other words, the single processor of claims—if we got our single-payer system in 2017. So they did not feel threatened by it. There’s another major insurer that has 15 percent of the market, MVP, that actually issued a statement opposing the bill. The others didn’t say a word. And I probably—I think they probably won’t, but they will find subterranean ways of trying to co-opt this by funding ads and campaigns to try to flip the legislature and convince the public that this is a bad thing to do.
AMY GOODMAN: Well, we want to thank you very much for being with us, Dr. Deb Richter. And of course, we’ll cover the signing ceremony today. Vermont is poised today to become the first state to pass single-payer healthcare and will require a waiver from the government to be able to move forward. Interestingly, in Vermont, the governor is elected every two years, so, Juan, your point about changing climate and what will happen is very significant. Dr. Deb Richter, thanks for joining us, president of Vermont Health Care for All. She practices family medicine in Montpelier, Vermont, and is a past president of Physicians for a National Health Program.
When we come back, we’ll be joined by another Vermonter, not just talking about Vermont, but that’s the environmentalist Bill McKibben. The horrible tornadoes, the powerful tornadoes that are killing hundreds, we’ll talk about what their connection is to climate change, to global warming. Stay with us.
http://www.democracynow.org/seo/2011/5/26/vermont_poised_to_become_1st_state
Joe Jarvis and Brent James on Intermountain Healthcare
A recent Quote of the Day (May 19) discussed Intermountain Healthcare as an example of how an integrated health care system can help to control costs by emphasizing quality improvement. A co-author of the Health Affairs article cited, Dr. Brent C. James of Intermountain Healthcare, has discussed this topic with Dr. Joe Jarvis of the Utah Healthcare Initiative. Although their views on single payer differ, their discussion is a welcome addition to this dialogue.
Utah Health Care Initiative
IHC: A Quality Story
By Dr. Joe Jarvis
May 21, 2011
http://www.utahhealthcareinitiative.com/blog/2011/05/21/ihc-quality-story/
Dr. Brent James Responds
By Dr. Joe Jarvis
May 23, 2011
http://www.utahhealthcareinitiative.com/blog/2011/05/23/dr-brent-james-responds/
Brent James: Senate Testimony on quality
April 29, 2009
http://www.utahhealthcareinitiative.com/blog/2009/04/29/brent-james-md-senate-testimony/
Comment:
By Don McCanne, MD
Although Brent James has demonstrated that quality is attainable independently of the financing system for health care, his approach requires a degree of altruism which he posses but which has not permeated the entire health care delivery system.
Quality and financing are two different considerations, but there is a tremendous amount of overlap. A well designed single payer system provides tools and incentives for quality enhancement, just as a high quality system provides efficiencies for the financing system.
Dialogues such as this between Dr. Jarvis and Dr. James move the process forward bringing us closer to the day that we can experience a high quality health care system for all that is truly affordable – a financing system that is universal and equitable, and a high quality delivery system that makes it work.
Vermont health reform signed into law, spurs interest in single-payer reform
May 26, 2011
Dear PNHP colleagues and friends,
Vermont Gov. Peter Shumlin signed into law today “An Act Relating to a Universal and Unified Health System.” We salute the single-payer activists in Vermont and applaud their efforts. Although this is not a single-payer bill, we will continue to support the struggle to achieve health care justice in Vermont and across the nation. PNHP’s full statement on the legislation is here.
One of the many obstacles facing any state seeking to enact a true single-payer system is obtaining necessary waivers from the federal government. Click here to sign our petition urging the granting of waivers to implement single payer.
PNHP has already received press coverage from this event, from PNHP co-founder Dr. David Himmelstein’s comments in Bloomberg News to an interview with PNHP past president Dr. Deb Richter on Democracy-Now! Please help us mark this momentous development by forwarding our viewpoint to your local newspaper and radio stations.
Cordially,
Quentin D. Young, M.D.
National Coordinator
Joe Jarvis and Brent James on Intermountain Healthcare
A recent Quote of the Day (May 19) discussed Intermountain Healthcare as an example of how an integrated health care system can help to control costs by emphasizing quality improvement. A co-author of the Health Affairs article cited, Dr. Brent C. James of Intermountain Healthcare, has discussed this topic with Dr. Joe Jarvis of the Utah Healthcare Initiative. Although their views on single payer differ, their discussion is a welcome addition to this dialogue.
Utah Health Care Initiative
IHC: A Quality Story
By Dr. Joe Jarvis
May 21, 2011
http://www.utahhealthcareinitiative.com/blog/2011/05/21/ihc-quality-story/Dr. Brent James Responds
By Dr. Joe Jarvis
May 23, 2011
http://www.utahhealthcareinitiative.com/blog/2011/05/23/dr-brent-james-responds/Brent James: Senate Testimony on quality
April 29, 2009
http://www.utahhealthcareinitiative.com/blog/2009/04/29/brent-james-md-senate-testimony/
Although Brent James has demonstrated that quality is attainable independently of the financing system for health care, his approach requires a degree of altruism which he posses but which has not permeated the entire health care delivery system.
Quality and financing are two different considerations, but there is a tremendous amount of overlap. A well designed single payer system provides tools and incentives for quality enhancement, just as a high quality system provides efficiencies for the financing system.
Dialogues such as this between Dr. Jarvis and Dr. James move the process forward bringing us closer to the day that we can experience a high quality health care system for all that is truly affordable – a financing system that is universal and equitable, and a high quality delivery system that makes it work.