PNHP

From bad to worse: Medicare proposal will surely lead to de facto 'death panels'

From bad to worse: Medicare proposal will surely lead to de facto 'death panels'

By Robert Kiefner
Concord (N.H.) Monitor, May 14, 2011

Say a patient comes to see us with poor appetite, low-grade temperature and progressive right lower quadrant pain, classic symptoms of appendicitis. The cure will be a date with a good local surgeon, during which he will bid farewell to his appendix and be home in a day or two to resume the joy of living. If the appendix is not removed, he will suffer a miserable death from rupture of the appendix and peritonitis.

Let’s imagine that, for political causes or for reasons of institutional greed, the patient cannot avail himself of the cure. The appendectomy cannot be done because he does not have access to the surgeon or he decided to tough it out because he cannot afford the deductible and co-pays if insured, or the stratospheric costs if uninsured.

I’d like to apply that scenario to our current health care system, where we are, collectively, that patient with health care needs, forced to make life and death decisions based on cost. The Affordable Care Act may improve access to private insurance for a relative few, but does nothing to rein in costs. Our premiums will continue to rise unchecked, mirrored by rising co-pays and deductibles which will price many folks out of even using their insurance.

Now the brilliant Rep. Paul Ryan, whose credentials consist of being a political science major in college, wants to take the most medically vulnerable Medicare population and toss them into the for-profit insurance world with a pittance in their pockets to pay for their care. His plan would surely lead us down the path of de facto “death panels” for the elderly, who would be unable to negotiate the insurance nightmare, let alone afford it.

To be certain, Medicare needs to undergo a major overhaul – but it must be more widely applied, not abandoned. The overhead involved in the redundant hierarchies of private insurers amounts to $400 billion per year, enough to cover all of the uninsured for basic health care needs. For some reason (let me see, maybe the campaign contributions, the umpteen lobbyists, profound ignorance, or perhaps just callous disregard for their constituents), our elected officials continue to support the hideously expensive, inefficient and dangerous network of private insurers in this country.

In comparison with other industrialized countries, we spend twice as much per capita on health care, yet we rank 37th in the world relative to standard measures of health. Health care should not be a partisan issue. We need to do better with an informed citizenry and legislators who are willing to turn away from corporate special interest groups and ignore mind numbingly stupid extremist constituents.

So, back to the bedside of our patient. The doctors and nurses making that decision to take out the appendix need to make the decision to save the patient without regard for anyone’s political or financial interests. And for the rest of us, the collective patient, we need to truly reform health care, break the cost curve, and support universal health coverage, a single payer system which places patients ahead of profits. It is the fiscally and morally responsible thing to do.

Robert Kiefner is a family physician in Concord.

http://www.concordmonitor.com/article/257041/from-bad-to-worse

Corporations, Federal ‘Reform’ Keep Shifting Healthcare Costs to Workers

By Roger Bybee
In These Times, May 13, 2011

Despite its $14.2 billion in profits last year untouched by federal income taxes, General Electric is now demanding that its unionized workers accept a new high-deductible “Health Choice” health savings account plan.

GE’s demands are particularly obscene because it is sitting on $25 billion in savings and is threatening to close more U.S. plants, i.e. move more jobs to Mexico, China and elsewhere. And they’re particularly dangerous because GE is modeling bad behavior for other corporations to emulate.

As UE-GE Conference Secretary Steve Tormey has said, “Nobody is more symbolic of the assault on workers than General Electric.” The United Electrical workers union, one of a handful of unions now negotiating with GE, warned its members:

…numerous studies of these high-deductible plans…reveal that employees forced into plans like Health Choice are “significantly more likely to avoid, skip, or delay healthcare because of costs” than those with more comprehensive insurance. …

What GE is really saying with Health Choice is that medical expenses are no longer primarily their responsibility, but that of GE employees.

But GE is only the latest entrant among employers trying to establish a new healthcare normal by thrusting heavy additional costs onto the backs of working families. And the much-trumpeted federal healthcare “reform” legislation may actually exacerbate this race to the bottom.

(Of course, public employers—like the state of Wisconsin, led by labor’s arch enemy Gov. Scott Walker—have also been pushing to make public workers take up even more of the burden of healthcare costs. This despite the fact that, as David Cay Johnston has pointed out without managing to dent mainstream media coverage, public employees have always been paying 100 percent of their benefit costs. When they gained improvements in health and retirement benefits, they had to sacrifice on wage increases.)

How federal healthcare ‘reform’ helps drives the race to the bottom

The race to the bottom is, unfortunately, likely to be intensified as we get closer to fully implementing the Affordable Care Act in 2014. In fact, the ACA may well tend to establish a bare-bones, high-deductible policy as the new norm. The taxation of perversely mis-labeled “Cadillac” benefits has the very real potential of putting the squeeze on union-won healthcare benefits, especially in high-cost states. 

Despite the efforts of AFL-CIO Richard Trumka and others to limit the damage created when the Obama administration suddenly adopted John McCain’s regressive idea of taxing better benefit plans to fund expanded healthcare coverage for the uninsured, it may not take long before fast-rising medical inflation pushes the dollar value of union-won health benefits up to the Cadillac level, as IUE-CWA Local 201 President Jeff Crosby has noted.

As Dr. David Himmelstein and Steffie Woolhandler wrote recently,

The insurance required under the federal ACA is no better than Massachusetts’ bare-bones plans. And as employers emulate this inadequate coverage, the race to the bottom leaves an increasing number of Americans UNDER-insured. Public workers are just the latest group to see their coverage downsized.

What used to be called “health insurance” is now labeled “Cadillac coverage” – and reserved for those who drive Mercedes.

Himmelstein and Woolhandler remind us that the Democrats’ ACA plan was based on the Massachusetts model passed in 2006 with Gov. Mitt Romeny’s signature, and whose “achievements” are much less than splendid. Bankruptcies caused by catastrophic medical costs, which account for over half of all bankruptcies, are still rising in Massachusetts, they state:

While only 4 percent of the state’s residents remain uninsured, much of the new coverage is so skimpy that serious illness leaves families with crushing medical bills.

For instance, the cheapest (and most commonly purchased) coverage available to a 56-year-old Bostonian through the state’s health insurance exchange costs $5,616. Yet, if you’re sick, the policy doesn’t start paying bills until you’ve paid a $2,000 deductible. And even after that you’re responsible for 20 percent of the next $15,000 in medical expenses.

Insurers try blackmail

By basing itself on the Massachusetts plan which keeps for-profit insurers as the parasitic middlemen at the core of the healthcare system, the ACA sacrificed the potential for comprehensive, high-quality benefits covered from the first dollar.

This potential has been underscored in the fight over retaining ACA’s requirement that 80 percent of premium revenue be used by insurers to provide healthcare and improve quality, freeing up 20 percent for profit, bureaucratic overhead, and sales and promotion.

No less than nine states are seeking waivers from the 80 percent requirement, falling prey to insurers’ blackmail demands. Insurers are threatening to stop selling individual coverage in a number of states unless they can spend, in several cases, just 65 percent on paying for healthcare and quality improvements.

Both the states and the Obama administration are petrified by this coercive technique. The Obama administration’s timid mentality was revealed in this statement by Robert Laszewski, a consultant to the health care industry and a former insurance executive. “The last thing the Obama administration wants is the Des Moines Register writing about 500 people who lost their health insurance in Iowa because of the Obama health plan,” he chortled.

Singe-payer destiny?

The emerging situation is not pretty. Major corporations and right-wing state governments are fighting furiously to shift more costs onto workers and their families. Instead of setting a new, higher standard, ACA effectively serves to reinforce a new lower standard of “acceptable” coverage. Given this, the limitations of the ACA may become very obvious very quickly both to the public and Congress.

There may even be a possibility that that the essential need for maximum-strength single-payer or “Medicare for all” healthcare system—unburdened by for-profit insurers—will become evident much faster than most have imagined. (Sens. Bernie Sanders (I-Vt.) and Rep. Jim McDermott (D-Wash.) introduced  single-payer bills in Congress this week; Vermont has now passed its own single-payer system into law.)

Himmelstein and Woolhandler make the case concisely:

While the ACA can’t live up to its “affordable care” moniker, a single-payer reform could save $400 billion annually on administrative costs, enough to offer every American first-dollar, comprehensive coverage. While U.S. insurers fight tooth and nail against the 20 percent limit on overhead, Canada’s single-payer program runs for 1 percent.

http://inthesetimes.com/working/entry/7298/ge_other_employers_fight_to_set_lower_new_normal_on_healthcare_benefit/

Funding for primary care panel blocked

Partisan fights in Congress stall panel on primary-health-care shortage

By Amy Goldstein
The Washington Post, May 13, 2011

When the government set out to help 32 million more Americans gain health insurance, Congress and the Obama administration acknowledged that steering more people into coverage had a dark underside: If it works, it will aggravate a shortage of family doctors, internists and other kinds of primary care.

So Page 519 of the sprawling 2010 law to overhaul the health-care system creates an influential commission to guide the country in matching the supply of health-care workers with the need. But in the eight months since its members were named, the commission has been unable to start any work.

The group cannot convene, converse or hire staff because $3 million that it needs for its initial year has been blocked by two partisan wars on Capitol Hill — strife over the federal budget and Republicans’ disdain for the health-care changes that Democrats muscled into law 14 months ago.

“We’ve been sort of hamstrung,” said Fitzhugh Mullan, a professor of medicine and health policy at George Washington University who is one of the 15 commission members appointed by the Government Accountability Office. The panel’s only activity so far, Mullan said, was a single conference call during which members were told they could not lobby members of Congress for funds or accept money to operate from foundations or anywhere else.

The National Health Care Workforce Commission is intended as an ongoing brain trust to focus new energy on solving an old problem that will become increasingly severe. The law says the new commission will analyze primary-care shortages and propose innovations for the government — and medical schools — to help produce the doctors and other health workers the nation needs.

Proponents of the workforce commission say they were surprised that Republicans have balked, because there has, in the past, been little ideological schism over the need to bolster the supply of primary care — doctors, nurses, physicians assistants and others.

http://www.washingtonpost.com/national/health/partisan-fights-in-congress-stall-panel-on-primary-health-care-shortage/2011/05/09/AFCKBW2G_story.html

Republicans and Democrats agree with the health policy community that we desperately need to reinforce our primary care infrastructure. The National Health Care Workforce Commission that would propose innovations to help build primary care requires a mere $3 million to establish operations, but the Republicans have blocked this authorization. Do they expect us to simply rely on the private sector to meet this need? How is that working for us so far?

AFL-CIO, NNU Back New Universal Health Care Bill

By Mike Hall
AFL-CIO blog, May 10, 2011

Last year, when Congress passed the Affordable Care Act, it was a “historic milestone on our path toward a more just society,” says AFL-CIO Executive Vice President Arlene Holt Baker. “But we also know that much work is left to be done.”
 
That work includes moving to a single-payer, universal health care model as called for by the AFL-CIO Convention in 2009 and today in the America Health Security Act, introduced by Sen. Bernie Sanders (I-Vt.) and Rep. Jim McDermott (D-Wash.).
 
Speaking at a Capitol Hill press conference, Holt Baker said: “We in the labor movement have long insisted that health care is a fundamental human right and an important measure of social justice. And for more than 100 years, we have fought for universal health care coverage based on a social insurance model, an approach that has proven to be cost-effective and efficient in countries across the globe and in this country to provide health security for seniors.”
 
Jean Ross, R.N., and co-president of National Nurses United (NNU), says the bill will “create a more just health care system.”
 
Providing a single standard of high-quality care for all is a priority for registered nurses who have seen their abilities to act as patient advocates made more difficult as for-profit interests control more patient care decisions.
 
Sanders says the fight for universal health care “is the civil rights battle of our time.”
 
The legislation establishes a national health care program that requires each participating state to set up and administer comprehensive health care services as an entitlement for all through a progressively financed, single-payer system, as administered by the states. Benefits emphasize primary and preventive care, and free choice of providers. Private health insurance sold by for-profit companies continues in the form of supplemental coverage only.
 
Says McDermott: “If an insurance company’s objective is to make a profit rather than deliver health care, a patient’s best interests may not always be in the forefront of their thinking. Decisions are made by accountants and actuaries, not necessarily on the basis of what’s best for the patient.”
 
The program will be progressively financed, including a surcharge on high-income individuals and a tax on securities and other financial transactions.
 
“Let’s face it,” says Sanders in a guest column in the Guardian, “until we put patients over profits, our system will not work for ordinary Americans.”
 
http://blog.aflcio.org/2011/05/10/afl-cio-nnu-back-new-universal-health-care-bill/

Bucking the pushback against federal health care law, Vermont looks to go far beyond it

By The Associated Press
The Washington Post, May 11, 2011

The Census Bureau reported that, in 2007, Vermont ranked sixth in the country in physicians per capita, with 374 per 100,000, versus a national average of 271 per 100,000. And about 90 percent of Vermonters have some form of health insurance already.

But some of those with insurance say it falls far short of what they need.

Heather Loughlin, 42, was working as a vice president at the Sugarbush ski resort when she was diagnosed 2 1/2 years ago with multiple sclerosis. Before long, she found herself no longer able to work and buying insurance with a subsidy from the state under a current program, but with a private insurer.

A thick stack of coverage denial letters later, Loughlin said, she was back living with her parents in Ludlow, who were going into debt in their retirement to help her meet her medical costs.

“It doesn’t matter if you’re paying $300 or $400 a month for insurance,” Loughlin said. “It’s a mirage.” She called the repeated coverage denial letters “mind-boggling and enraging. They just try to wear you down.”

Advocates for changing the system brought hundreds of people with stories like that to hearings and rallies at the Statehouse last year and again this spring.

James Haslam of the Vermont Workers Center, which spearheaded a campaign under the banner “Health Care Is A Human Right,” said the legislation wouldn’t have passed without the grass-roots support.

“If other people want this in their states, they have to start organizing their neighbors,” he said.

The bill indicates that the state would “maximize the receipt of federal funds” to help pay for the new health care system. But Vermont’s prospects of receiving federal money are uncertain amid efforts by Republicans in Congress to chip away at the federal overhaul.

“The big hole in Vermont’s plan has always been its failure to specify a funding source,” said Shawn Shouldice of the National Federation of Independent Business, which opposes the legislation. “The only clearly defined funding element was the federal grant money … and now that could vanish, as well.”

William Hsiao, a Harvard health care economist and consultant to the drafters of Vermont’s legislation, has called for a payroll tax shared by employers and workers. But lawmakers put off a decision on that, some saying they wanted a way to tax non-wage income to support the program as well.

There are also doubts the bill really will move Vermont toward a genuine single-payer system. It leaves room for people to buy supplemental insurance, and among the big questions is whether workers at IBM and some of the major employers in the state, whose self-insurance systems are regulated under federal law, will be allowed to be absorbed into Vermont’s system.

In a move crucial to the project’s success, backers say, the board will design and administer new cost-control measures, including “global budgeting” for hospitals and other health care providers. Instead of the traditional “fee-for-service” system in which doctors are paid by the patient visit or procedure performed, the new system will be designed to pay for providing necessary health care to a given population.

A senior health researcher at the conservative Heritage Foundation in Washington warned, though, that Vermont may want to be careful in playing with the financial incentives that can influence how health care systems develop over time.

In some other countries, Ed Haislmaier of Heritage said, the sort of “global budgeting” Vermont envisions ends up with less acutely ill patients with longer hospital stays. “Hospitals turn into nursing homes,” he said.

The bill calls for maintaining and expanding the state’s Blueprint for Health program, which is designed to streamline and provide better preventive care to people with chronic conditions like heart disease and diabetes.

Rep. Mark Larson, chairman of the Health Care Committee in the Vermont House and a key architect of the legislation, acknowledged that the bill is really a planning document and that its supporters have much left to prove.

After the House gave the bill final approval 94-49 Thursday, he said, “I think today’s vote reflects people saying, ‘OK, you’ve made your case. Now show me.’”

http://www.washingtonpost.com/world/bucking-the-pushback-against-federal-health-care-law-vermont-looks-to-go-far-beyond-it/2011/05/11/AFqnE0qG_story_1.html

Uwe Reinhardt explains the Milliman Medical Index

Would Privatizing Medicare Lead to Better Cost Controls?

By Uwe E. Reinhardt
The New York Times, May 13, 2011

The annual Milliman Medical Index, released earlier this week by Milliman Inc., the Seattle-based employee-benefit consulting and actuarial company, is illuminating, and I highly recommend it. The index is particularly timely as the nation considers proposals to reduce sharply the role of the federal government in financing health care, along the lines proposed by Paul D. Ryan, Republican of Wisconsin and chairman of the House Budget Committee.

The index measures the total cost of health care for a typical American family of four covered by a preferred provider plan, widely known as a P.P.O. The index’s great virtue is that it includes not only the employer’s and employee’s contributions to the premium for P.P.O. coverage but also the out-of-pocket expenses the family has under the plan.

Employers can control the growth of health insurance premiums by shifting more and more of the cost from the insurance policy to the family’s budget, through higher deductibles and coinsurance or by excluding benefits from coverage that had previously been covered.

Thus, the index provides a more accurate picture of the actual burden of health spending for a typical American family than does just the premium for P.P.O. coverage.

The estimated average cost of health spending from all sources for a typical privately insured American family more than doubled in the last decade, to $19,393 in 2011 from $8,414 in 2001. Over the decade, the index exhibited an average compound annual growth rate — widely known in the trade as C.A.G.R. — of 8.8 percent, although, in recent years, that rate has ranged between 7 and 8 percent.

Despite that recent abatement, the growth rate is still more than twice the rate at which total average employee compensation has grown, for all but the top executives among private employers. In recent years, the growth in employee compensation has hovered beneath 3 percent.

In other words, health care is chewing up employees’ paychecks like Pac-Man in the famous arcade game. And there is considerable empirical evidence that the employer’s ostensible contribution to the employee’s health-insurance premiums actually comes out of the employee’s take-home pay.

As noted above, it is not a stretch to argue that the Milliman Medical Index bears directly on the hypothesis that private health insurers are able to control the growth in per-capita health spending better than Medicare can.

At the theoretical level, one might be persuaded to subscribe to that theory, because private nonprofit and commercial health-insurance plans have at their disposal cost-control mechanisms that traditional Medicare has been denied by statute — for example, selective contracting with preferred providers that offer the insurer lower prices, or various direct interventions to control the volume of health services.

In addition, private nonprofit or commercial health insurers can offer other advantages that traditional Medicare has not, like disease management, wellness programs and better coordinated care — advantages that, in principle, are empirically demonstrable if they exist.

But the Milliman data do not suggest that superior control over total health spending — as opposed to controlling premium growth through cost-shifting to private household budgets — is among the industry’s strengths. To argue that the industry can do so is, at this point, faith-based analysis.

It is widely assumed, among both health insurers and the hospital industry, that the more rapidly rising prices paid by private insurers reflect a cost shift from government to the private sector. The theory is that private insurers must compensate with higher prices for the shortfall from actual cost imposed on providers of care by unduly low Medicaid and Medicare payment rates.

With a few exceptions, economists remain skeptical on the validity of the cost-shift theory, although it may operate in some market environments.

But suppose one accepted the cost-shift theory at face value. It implies that in many markets with highly consolidated hospital systems and large physicians’ groups, private insurers simply lack the market power to resist price increases from the more powerful providers of health care for whatever reason — cost shift or otherwise.

For the full article:
http://economix.blogs.nytimes.com/2011/05/13/would-privatizing-medicare-lead-to-better-cost-controls/

Milliman Medical Index:
http://publications.milliman.com/periodicals/mmi/pdfs/milliman-medical-index-2011.pdf

Readers’ Comments:

9. Don McCanne
San Juan Capistrano, CA
May 13th, 2011

Each year we look at the Milliman Medical Index and realize that our current system is still not working. The Affordable Care Act (ACA) provides no realistic hope of slowing costs in the privately insured sector. ACA’s only effective mechanism is the establishment of the Independent Payment Advisory Board, but that would leave private plans alone while risking converting Medicare into an underfunded welfare program.

Looking at the Milliman numbers, it seems so obvious. Instead of privatizing Medicare, we should improve it and then provide it as a public program that covers everyone. Cost escalation would be slowed to sustainable levels while preserving free choice of physicians and hospitals (which would be lost in a privatized Medicare program).

Single payer legislation has already been introduced that would allow us to take a serious look at this concept. In the House, Rep. John Conyers has introduced The Expanded and Improved Medicare for All Act (H.R.676), and Rep. Jim McDermott has introduced the American Health Security Act of 2011 (H.R.1200), which also has been introduced in the Senate by Sen. Bernie Sanders as S.915.

It is no wonder that conservatives often say that if we don’t adopt their less regulated privatization schemes we are going to end up with single payer. They understand the numbers, and they realize that single payer would actually work. It’s time that we look at single payer not as a threat, but as a hope – a hope that we could finally provide affordable health care for everyone.

http://community.nytimes.com/comments/economix.blogs.nytimes.com/2011/05/13/would-privatizing-medicare-lead-to-better-cost-controls/?permid=9#comment9

Uwe Reinhardt explains the Milliman Medical Index

Would Privatizing Medicare Lead to Better Cost Controls?

By Uwe E. Reinhardt
The New York Times, May 13, 2011

The annual Milliman Medical Index, released earlier this week by Milliman Inc., the Seattle-based employee-benefit consulting and actuarial company, is illuminating, and I highly recommend it. The index is particularly timely as the nation considers proposals to reduce sharply the role of the federal government in financing health care, along the lines proposed by Paul D. Ryan, Republican of Wisconsin and chairman of the House Budget Committee.

The index measures the total cost of health care for a typical American family of four covered by a preferred provider plan, widely known as a P.P.O. The index’s great virtue is that it includes not only the employer’s and employee’s contributions to the premium for P.P.O. coverage but also the out-of-pocket expenses the family has under the plan.

Employers can control the growth of health insurance premiums by shifting more and more of the cost from the insurance policy to the family’s budget, through higher deductibles and coinsurance or by excluding benefits from coverage that had previously been covered.

Thus, the index provides a more accurate picture of the actual burden of health spending for a typical American family than does just the premium for P.P.O. coverage.

The estimated average cost of health spending from all sources for a typical privately insured American family more than doubled in the last decade, to $19,393 in 2011 from $8,414 in 2001. Over the decade, the index exhibited an average compound annual growth rate — widely known in the trade as C.A.G.R. — of 8.8 percent, although, in recent years, that rate has ranged between 7 and 8 percent.

Despite that recent abatement, the growth rate is still more than twice the rate at which total average employee compensation has grown, for all but the top executives among private employers. In recent years, the growth in employee compensation has hovered beneath 3 percent.

In other words, health care is chewing up employees’ paychecks like Pac-Man in the famous arcade game. And there is considerable empirical evidence that the employer’s ostensible contribution to the employee’s health-insurance premiums actually comes out of the employee’s take-home pay.

As noted above, it is not a stretch to argue that the Milliman Medical Index bears directly on the hypothesis that private health insurers are able to control the growth in per-capita health spending better than Medicare can.

At the theoretical level, one might be persuaded to subscribe to that theory, because private nonprofit and commercial health-insurance plans have at their disposal cost-control mechanisms that traditional Medicare has been denied by statute — for example, selective contracting with preferred providers that offer the insurer lower prices, or various direct interventions to control the volume of health services.

In addition, private nonprofit or commercial health insurers can offer other advantages that traditional Medicare has not, like disease management, wellness programs and better coordinated care — advantages that, in principle, are empirically demonstrable if they exist.

But the Milliman data do not suggest that superior control over total health spending — as opposed to controlling premium growth through cost-shifting to private household budgets — is among the industry’s strengths. To argue that the industry can do so is, at this point, faith-based analysis.

It is widely assumed, among both health insurers and the hospital industry, that the more rapidly rising prices paid by private insurers reflect a cost shift from government to the private sector. The theory is that private insurers must compensate with higher prices for the shortfall from actual cost imposed on providers of care by unduly low Medicaid and Medicare payment rates.

With a few exceptions, economists remain skeptical on the validity of the cost-shift theory, although it may operate in some market environments.

But suppose one accepted the cost-shift theory at face value. It implies that in many markets with highly consolidated hospital systems and large physicians’ groups, private insurers simply lack the market power to resist price increases from the more powerful providers of health care for whatever reason — cost shift or otherwise.

For the full article:
http://economix.blogs.nytimes.com/2011/05/13/would-privatizing-medicare-lead-to-better-cost-controls/

Milliman Medical Index:
http://publications.milliman.com/periodicals/mmi/pdfs/milliman-medical-index-2011.pdf

Each year we look at the Milliman Medical Index and realize that our current system is still not working. The Affordable Care Act (ACA) provides no realistic hope of slowing costs in the privately insured sector. ACA’s only effective mechanism is the establishment of the Independent Payment Advisory Board, but that would leave private plans alone while risking converting Medicare into an underfunded welfare program.

Looking at the Milliman numbers, it seems so obvious. Instead of privatizing Medicare, we should improve it and then provide it as a public program that covers everyone. Cost escalation would be slowed to sustainable levels while preserving free choice of physicians and hospitals (which would be lost in a privatized Medicare program).

Single payer legislation has already been introduced that would allow us to take a serious look at this concept. In the House, Rep. John Conyers has introduced The Expanded and Improved Medicare for All Act (H.R.676), and Rep. Jim McDermott has introduced the American Health Security Act of 2011 (H.R.1200), which also has been introduced in the Senate by Sen. Bernie Sanders as S.915.

It is no wonder that conservatives often say that if we don’t adopt their less regulated privatization schemes we are going to end up with single payer. They understand the numbers, and they realize that single payer would actually work. It’s time that we look at single payer not as a threat, but as a hope – a hope that we could finally provide affordable health care for everyone.


Comment originally published on The New York Times website.

Reforms Prod Insurers to Diversify

By AVERY JOHNSON
Wall Street Journal, May 12, 2011

Major U.S. health insurers, including Aetna Inc., Humana Inc. and WellPoint Inc., are retooling to become more than just health plans, in the wake of the federal health-care overhaul that is changing the rules for the industry’s core business.

Diversification plans, touted in meetings with investors this year, include stepped up acquisitions and partnerships that will allow the companies to employ doctors directly, deliver health-information technologies, and participate in new hospital-doctor groups known as accountable-care organizations.

Managed-care companies have been on buying sprees before, mostly to gobble up competing insurers and expand their networks and membership. But with the health law stripping thick profit margins from the business of providing health-care benefits, that isn’t such a popular strategy anymore.

Insurance profit margins have historically averaged 7% to 8%, said Carl McDonald of Citigroup Investment Research, but the health overhaul—which requires insurers to spend more on medical care instead of profits—is expected to reduce that to between 3% and 5%.

Meanwhile, health IT, especially, is growing briskly, and can command fat margins because of relatively low overhead. UnitedHealth Group Inc., which until recently has been largely alone in its quest to supplement core insurance operations, is expected to earn margins of about 14% this year on its health IT business, and has earned margins higher than 20% in years past, according to Goldman Sachs.

Since 2010, about 20% of deals by managed-care companies involved health IT firms, up from 7% in 2007, while insurers buying other insurers dropped to 27% of the deals from 39% over the same period, according to FactSet Research Systems, a company that ran an analysis on the market.

At Aetna, new Chief Executive Mark Bertolini is implementing a strategy that will see the Hartford, Conn., insurer get more deeply into health-information technology and run the back-end operations of the new accountable-care organizations, or ACOs.

“Our core business is necessary but not sufficient,” said Mr. Bertolini. He pledged to transform Aetna into “more than an insurance company.”

Earlier this year, Aetna spent $500 million on technology company Medicity, which sells software to securely transmit health data so health-care providers with many different systems can share patient information. Besides commanding higher margins, health IT businesses are expanding due to some $27 billion in federal funding available for hospitals and doctors to computerize their records.

In March, Aetna announced plans to partner with Carilion Clinic in Virginia to build an ACO—a concept outlined in the health law to make the health-care system more interconnected and hold costs down. In late April, Aetna said it was buying Prodigy Health Holdings for $600 million to get more deeply into the business of providing midsized companies with a self-funded insurance option—which Mr. Bertolini pointed to as evidence of further diversification.

In the accountable-care organizations, the hospitals or doctor groups would take on some of the financial risk of caring for patients—the role traditionally played by insurers. Aetna hopes to provide ACOs with the know-how. And even if the law is ultimately repealed, health insurers see opportunities to sell services to help improve how the health system works, which was a major focus of the debate on the overhaul.

“Health-care reform was an action-forcing event: Everyone’s antenna is up and saying, ‘We’ve got to change,”‘ said Mr. Bertolini.Further into the future are plans for a health-care app store. By the end of the year, the insurer hopes consumers will be able to download mobile applications, such as a program that could help patients find doctors much like opentable.com helps diners find restaurants. Already, doctors can install CareSuite, a workflow tool for physician offices. The tools will be available to users regardless of whether Aetna is their insurer.

Reinventing the health-insurance industry has its challenges. Diversification “may take away management focus from the core business and also [runs] the risk that they may not do well in some of these newer areas,” said Matthew Borsch, a Goldman Sachs analyst who follows health insurers.

But industry executives point out that newer areas are growing a lot faster than the traditional core business. For instance, specialty businesses, such as stand-alone dental or vision coverage, command margins over 10%, said Mr. McDonald of Citigroup.

He also pointed to the new frontiers that health plans are exploring to export their model overseas, which can bring margins in the teens.
Michael McCallister, chief executive of Humana, is getting into the business of employing doctors and is eyeing home health care because, he said, “these areas are growing faster than the core and will continue to do so.” Home health, for instance, commands margins in the midteens, said Sheryl Skolnick, an analyst at CRT Capital Group LLC, and also has the benefit for an insurer of keeping patients at home instead of at costly nursing facilities.

Humana in December spent nearly $800 million to buy Concentra, which runs urgent- and occupational-care clinics in about 40 states. Last month, the company reorganized its business units to better reflect its new diversified structure.

Concentra employs about 1,000 primary-care doctors who are near to where three million Humana members live, the insurer said. Humana hopes the centers can provide an alternative to costly emergency-room care for its members: A typical visit to a Concentra urgent-care clinic costs $190 to $200, including an X-ray, according to the company, while a comparable ER visit would range from $350 to $650 or more, with additional services for X-rays.
The Concentra deal is also a way to capitalize on the looming shortage of primary-care doctors when an estimated 32 million additional people gain coverage in 2014 due to the health law.

Meanwhile, WellPoint earlier this year said it is diversifying more heavily into consumer-oriented and health IT businesses. At an investor conference, the company outlined plans to create a “portfolio of new noncore growth businesses.” Chief Financial Officer Wayne DeVeydt said, “WellPoint is actively engaged in a range of partnership discussions with leading technology and consumer companies to redefine health IT.”

Write to Avery Johnson at avery.johnson@WSJ.com

Bernie Sanders introduces single-payer bill in Senate

May 12, 2011

Dear PNHP colleagues,

On Tuesday at a news conference in Washington, Senator Bernie Sanders, I-Vt., announced the introduction of his national single-payer bill, the American Health Security Act of 2011, S. 915, with characteristic flourish.

Sanders’ legislation is a revised version of the bill he introduced last year. It has a companion bill in the House, H.R. 1200, sponsored by Rep. Jim McDermott, D-Wash.

McDermott was also present for the announcement. Speakers in support of the measure included Arlene Holt Baker, executive vice-president of the AFL-CIO, and Jean Ross, R.N., co-president of National Nurses United.

In a Tuesday news release, PNHP welcomed the Sanders and McDermott bills, even though we expressed concerns about some of their provisions (see below).

In many respects, H.R. 676, the Expanded and Improved Medicare for All Act, sponsored by Rep. John Conyers Jr., D-Mich., has stronger provisions. Conyers’ bill also currently enjoys greater congressional sponsorship and wider organizational backing than the Sanders-McDermott legislation.

But having the public’s attention drawn to the benefits of a national single-payer system is a very good thing, particularly at a time when federal health programs are under assault and people are seeking more fundamental remedies to our persistent health care crisis. PNHP also remains supportive of state-based movements for single-payer too, of course.

PNHP chapters and activists are urged to visit or otherwise contact their congressional representatives to urge them to support single-payer legislation in the House (especially H.R. 676) and in the Senate (Sanders’ S. 915).

Finally, these bills, along with the current debate over the future of Medicare and the federal deficit, offer us opportunities to get our single-payer viewpoint published in letters to the editor or opinion pieces in our local newspapers. We encourage you to write one and send it in! (If you need assistance, contact Mark Almberg at mark@pnhp.org.)

Our news release about the Sanders bill appears below, as does an opinion piece by Sen. Sanders that appeared Tuesday in The Guardian (U.K.).

Thanks for all that you do in support of single payer!

Cordially,

Quentin D. Young, M.D.
National Coordinator


Mark Almberg
Communications Director

FOR IMMEDIATE RELEASE
May 10, 2011

Contact:
Garrett Adams, M.D., president PNHP
Margaret Flowers, M.D., congressional fellow PNHP, margaret@pnhp.org
Mark Almberg, communications director PNHP, (312) 782-6006, mark@pnhp.org

Doctors’ group greets single-payer health bill in Senate

Physicians for a National Health Program says Sen. Bernie Sanders’ American Health Security Act would go far beyond federal health law, slash bureaucracy and lay the basis for universal, high-quality care

A national doctors’ group welcomed the introduction in the Senate today of a single-payer health reform bill that it said moves in the direction of providing comprehensive care to everyone, reducing wasteful paperwork, reining in health costs, and delivering better medical outcomes.

This morning Sen. Bernie Sanders, I-Vt., announced the introduction of the American Health Security Act of 2011, S. 915, in the U.S. Senate. Significantly, at Sanders’ side for the announcement was Arlene Holt Baker, executive vice president of the AFL-CIO, among others.

“At a time when the airwaves are filled with talk about cutting or even ending Medicare,” said Dr. Garrett Adams, president of Physicians for a National Health Program, “Sen. Sanders has boldly stepped forward with the seemingly paradoxical proposition that the best way to financially strengthen the Medicare program is to upgrade it and expand it to cover everyone.”

Adams said that the improved-Medicare-for-all approach embodied in Sanders’ bill goes considerably beyond the Obama administration’s health law, which keeps the for-profit private health insurance industry at the center of the U.S. health system. This sacrifices universal coverage, efficiency and cost containment, he said.

“In contrast, Sanders’ legislation would cover nearly all 51 million people who currently lack coverage and improve benefits for everyone by eliminating co-pays and deductibles and restoring free choice of physician,” Adams said. “By slashing private insurance overhead and bureaucracy in doctors’ offices and hospitals, S. 915 would recapture about $400 billion annually that is currently wasted on unnecessary paperwork. That money, in turn, would be channeled back into high-quality clinical care.”

“Further, by using a single-payer system’s bargaining power, we would be able to negotiate lower prices for pharmaceuticals and other goods and services, allowing us to rein in rising health care costs,” he said.

Adams, a pediatric infectious disease specialist in Louisville, Ky., continued: “We are confident that Sen. Sanders’ bill will spur the drive for the only national reform that the evidence shows will work and that poll after poll shows the public supports.”

“To be sure, the bill can still be improved upon,” he said. “For example, the program should cover all residents of the United States, including undocumented immigrants. That’s the right thing to do and it’s also good medicine. Similarly, the bill should exclude for-profit hospitals and other investor-owned providers such as dialysis clinics from the new system. Research has shown for-profit institutions deliver inferior care at inflated prices.”

“That being said, the introduction of this bill is good news for the nation’s health,” he said. “We salute Sen. Sanders for his consistently outstanding leadership on this issue.”

Sanders, who serves on the Senate Committee on Health, Education, Labor and Pensions, is a longtime advocate of fundamental health reform. His bill draws heavily on single-payer legislation introduced by the late Sen. Paul Wellstone, D-Minn., in the early 1990s, and closely parallels similar legislation pending in the House, H.R. 1200, introduced by Rep. Jim McDermott, D-Wash. The program would be federally funded, but administered by the states.

Sanders is also working to get expedited waivers from the federal health law permitting states, including his home state of Vermont, to experiment with their own models of health reform.

A single-payer bill introduced by Rep. John Conyers Jr., D-Mich., H.R. 676, obtained 87 co-sponsors in the House during the last session. It has been reintroduced in the 112th Congress as the Expanded and Improved Medicare for All Act with the same bill number.

******

Physicians for a National Health Program (www.pnhp.org) is an organization of 18,000 doctors who support single-payer national health insurance, an improved
Medicare for all. To speak with a physician/spokesperson in your area, visit www.pnhp.org/stateactions or call (312) 782-6006.

Single payer health: it’s only fair

U.S. health care is grossly distorted by waste and profit, while millions go uninsured. Americans deserve full universal coverage

By Bernie Sanders
Guardian, May 10, 2011

The United States is the only major nation in the industrialized world that does not guarantee health care as a right to its people. Meanwhile, we spend about twice as much per capita on health care and, in a wide number of instances, our outcomes are not as good as others that spend far less.

It is time that we bring about a fundamental transformation of the American health care system. It is time for us to end private, for-profit participation in delivering basic coverage. It is time for the United States to provide a Medicare-for-all, single payer health coverage program.

Under our dysfunctional system, 45,000 Americans a year die because they delay seeking care they cannot afford. We spent 17.6 percent of our GDP on health care in 2009, which is projected to go up to 20 percent by 2020, yet we still rank 26th among major, developed nations on life expectancy, and 31st on infant mortality. We must demand a better model of health coverage that emphasizes preventive and primary care for every single person without regard for their ability to pay.

It is certainly a step forward that the new health reform law is projected to cover 32 million additional Americans, out of the more than 50 million uninsured today. Yet projections suggest that roughly 23 million will still be without insurance in 2019, while health care costs will continue to skyrocket.

Twenty-three million Americans still without health insurance after health reform is implemented? This is unacceptable. And that is why, this week, Representative Jim McDermott and I are announcing the re-introduction of the American Health Security Act, recognizing health care as a human right and providing every U.S. citizen and permanent resident with health care coverage and services through a state-administered, single payer program.

Let’s face it: until we put patients over profits, our system will not work for ordinary Americans.

It is incomprehensible that drug companies still get away with charging Americans twice as much, or more, than citizens of Canada or Europe for the exact same drugs manufactured by the exact same companies. It is an outrage that insurers still often hike premiums 20 percent, 40 percent and 60 percent a year on individual policy holders; and some insurers still spend 40 cents of every premium dollar on administration and profits while lavishing multimillion-dollar payouts on their CEOs.

It boggles the mind that approximately 30 percent of every health care dollar spent in the United States goes to administrative costs, rather than to delivering care. We must do better. Taiwan, for example, spends only a little over 6 percent of GDP on health care, while achieving better health outcomes on some key indicators than we do; yet they spend a relative pittance on administrative costs.

I am very proud that my home state of Vermont is now taking big steps to lead the nation in health care by moving forward on a plan to establish a single payer health care system that puts the interests of patients over chasing profits. The American Health Security Act would make sure every state does the same – taking profits out of the equation by implementing a single payer system, but letting each state administer its own program, according to strict standards, in a way best suited to its needs.

The goal of real health care reform must be high-quality, universal coverage in a cost-effective way. We must ensure, to as great a degree as possible, that the money we put into health coverage goes to the delivery of health care, not to paper-pushing, astronomical profits and lining CEOs’ pockets.

Bernie Sanders is U.S. senator from the state of Vermont.

http://www.guardian.co.uk/commentisfree/cifamerica/2011/may/10/healthcare-congress

The Milliman Medical Index ($19, 393) in perspective

2011 Milliman Medical Index

Milliman
May 2011

The annual Milliman Medical Index (MMI) measures the total cost of healthcare for a typical family of four covered by a preferred provider plan (PPO).

2011 cost is $19,393 (an increase of $1,319, or 7.3% over 2010)

83.1% – Actuarial value of an employer-sponsored PPO

Relative proportions of medical costs

59% ($11,385) – Employer contribution
24% – ($4,728) – Employee contribution
17% – ($3,280) – Employee out-of-pocket

http://publications.milliman.com/periodicals/mmi/pdfs/milliman-medical-index-2011.pdf

Comment:

By Don McCanne, MD

Under the Affordable Care Act (ACA) the largest sector of health care coverage – employer-sponsored plans – remains relatively unchanged. The Milliman Medical Index is a measure of health care costs in the employer-sponsored plan sector, so it is important to understand what the number – $19,393 – really means.

In 2011, $19,393 is the average amount paid for health care for a family of four insured by an employer-sponsored preferred provider organization (PPO). Keep in mind that this large sector is composed of members of the relatively healthy workforce and their young healthy families. It represents what we are paying for health care in the best of circumstances.

It is important to understand that the $19,393 is only the amount paid for actual health care and does not include the administrative costs of the insurers or the employers. It does not include the 15 or 20 percent of the premium that the insurer would consume under the ACA guidelines. However, the $19,393 does reflect the discounts that the PPO receives by contracting with the various providers, so list prices are not taken into consideration.

Milliman does split the costs into 1) the employer contribution to costs paid through insurance (which is not the same as the premium, as explained above), 2) the employee contribution to costs paid through insurance (ditto), and 3) the employee contribution to costs paid out-of-pocket (including deductibles, coinsurance, and co-payments).

Thus the employees’ average payment for actual health care costs is about $8000 or 40 percent of total average health care spending for a family of four. Yet these plans are better than the gold plans under ACA since they have an actuarial value of 83 percent (the insurance pays an average of 83 percent of the costs). Under ACA, most will purchase plans with actuarial values of 60 or 70 percent, so the patient will be responsible for even more of the costs (albeit with inadequate subsidies).

When you consider that the median household income is $50,221 (2009), $8000 is quite a bite out of the household budget, but most economists don’t buy this number. They calculate the employer contribution as having been paid by the employee in forgone wage increases. So it is the employee who is actually paying the full $19,393 in health care costs, plus the expenses consumed by the insurers that don’t appear in this number. Though an apples to oranges comparison, $20,000 in family health care costs and $50,000 median household income are not a dire prediction for the future. Those are today’s numbers!

In a society in which we have expanded the ongoing transfer of wealth up to the top of the chain, the only way we are going to be able to pay this staggering bill is through progressive financing. Middle-income individuals and families are no longer able to pay for their proportionate share of health care. We can do this simply, equitably, efficiently and transparently through the tax system (a tax-financed single payer system), or we can attempt to do it through a fragmented, inequitable, expensive, opaque, complex maze of private and public plans (ACA), acknowledging that we’ll fall far short of covering everyone while threatening hard working, middle-income Americans with financial hardship should they need health care.

So why isn’t this in the forefront of the national dialogue on health care spending? Do we really want the debate to be over slashing Medicare? That framing of the problem is getting us nowhere. Do we continue to let them control the framing as we stand on the sidelines taking potshots? Or do we finally take over the framing and debate the real issues that concern all of us? It’s our choice.

Clarification

In today’s message on the Milliman Medical Index, I stated, “Though an apples to oranges comparison, $20,000 in family health care costs and $50,000 median household income are not a dire prediction for the future. Those are today’s numbers!”

The “apples to oranges” referred especially to two issues: 1) the family of four with an employer-sponsored PPO is not necessarily the same as a median household, and 2) $11,385 in health care paid by the employer, according to the view of most economists, should be added to the household income, but to the household income of the family of four with an employer-sponsored PPO (a number that I don’t have) and not to the median household with an income of $50,221.

The numbers are still valid.

The average costs of health care, with insurance administrative costs added, is about $20,000 for a four person family in the workforce.

Median household income is about $50,000.

You can adjust these numbers all you want to try to align them better (sort apples from oranges), but you will still end up with the fact that middle-income Americans need more help with their health care costs.