PNHP

Single-Payer Solution

Single-Payer Solution

Letter, The New York Times
Published: February 5, 2011

To the Editor:

Re “For Governors of Both Parties, Medicaid Looks Ripe to Slash” (front page, Jan. 29):

It is hard for me to understand why the governors, along with corporate chief executives, aren’t lobbying Congress and President Obama for single-payer health insurance.

It would take the burden of providing health insurance off state and corporate budgets and provide the broadest and least expensive health care solution.

Charles Pack
Red Bank, N.J., Jan. 29, 2011

Health or wealth? What's the mission of our health care system?

Switching to a nonprofit system in Maine would put the focus back on care.

By PHILIP CAPER, JOE LENDVAI and JULIE PEASE
The Portland (Maine) Press Herald
February 6, 2011

There has been a great deal of discussion recently about health care reform in America and in Maine. Many Republicans want to repeal last year’s federal health care reform law, and most Democrats want to implement and improve it.

In the meantime, pending full implementation of the law in 2014, health care costs for individuals, employers and the government continue to soar, and the number of uninsured Americans (including Mainers) continues to grow.

Many Americans believe that the forces of the marketplace can solve our health care problems. They won’t, and they can’t. We have been trying marketplace solutions for more than 30 years.

These “solutions” have led to out-of-control costs, rising numbers of uninsured and under-insured patients, the disappearance of primary care providers, fragmented and duplicative care, and a brutal system dominated by for-profit health insurance companies.

In this system, denial of care is the means to increasing profitability. Marketplace solutions have failed.

America spends about twice as much per-person on health care as the average of all other developed countries, even though those countries are able to provide health care to all of their residents.

Furthermore, by almost every measurement, other developed countries have better health care outcomes than we do, and their health care systems are almost universally popular with their people (including their politicians).

How do they do it?

First, only in America is health care considered a business. The mission of a business is to create wealth for its shareholders.

The mission of a health care system is to prevent disease where that is possible, and to diagnose, treat, cure, heal and comfort patients when they are ill.

Only in America has the business mission been permitted to trump the health care mission.

In all other developed countries, health care is financed by the government or nonprofit funds that are tightly regulated by government and run as public utilities. The for-profit financing of health care is not permitted for basic health care services.

Second, only in America is there such fragmentation of health care systems, with multiple tiers of care provided by Medicare, Medicaid, the VA, Tricare and private insurance.

In most other developed countries, everybody is in the same system. With everybody in the same system, everybody has an interest in seeing that the system is adequately funded and run effectively and efficiently.

Third, all other countries have some way of budgeting for health care for all of their citizens.

In America, the system for the civilian population is totally open-ended. Neither the federal government nor the states has yet shown the political will to control costs.

Some states are beginning to apply the brakes, but only if cost restraint is applied selectively to their most vulnerable and politically disenfranchised populations.

It is time for Mainers to replace our fragmented, expensive and fundamentally unfair health insurance system with a single statewide program of health care financing — everybody in, nobody out.

In recent testimony before the Maine Legislature, professor William Hsiao of Harvard University, one of the world’s leading authorities on the financing of health care, estimated that Mainers could save $1 billion in the first year of such a system, and permanently reduce the rate of health care cost increases by 2 percent per year thereafter.

Some of the savings would come from eliminating excessive insurance company profits and executive compensation.

More would come from standardizing benefits and coverage, eliminating the huge administrative costs that doctors, hospitals and other providers of health care incur in dealing with hundreds of plans.

Still more would come from eliminating the fights about money that are a byproduct of so many different insurance programs — who pays, what for, how much — that now consume so much time and effort, and impede the delivery of quality health care.

Replacing our profit-driven system of financing health care with a mission-driven nonprofit system is the necessary first step in reinventing health care in Maine.

Only then will we be able to address the need to effectively reform the way we pay hospitals and other health care providers to reward efficiency and outcomes, rather than profit and volume.

Maine AllCare proposes nothing less than reforming the culture of health care throughout Maine.

Maine AllCare’s vision is for a system for Maine in which:

• All Mainers have access to affordable and appropriate health care and its supporting social and community services.

• No Mainer is in danger of financial ruin because of health care costs or is locked into a job solely because it provides health insurance.

• No Maine employer is faced with health care costs spiraling out of control.

• No Maine worker is faced with stagnant or declining wages or the inability to bargain for better working conditions because of the rising cost of health care.

• Maine patients will no longer have to wonder whether their doctor’s treatment decisions are driven by their health needs or their insurance coverage.

• Maine doctors will no longer have their clinical judgment second-guessed by insurance companies. Medical practice will be decided by health care providers and patients, and will return to being driven by mission, not money.

• Maine hospital executives will be free to offer services determined by the needs of their community, not their need or desire to generate revenue.

• The Legislature will not have to stand by and watch rising MaineCare and state and local government employee costs steadily erode its ability to address other critical priorities.

Can it be done? Absolutely. There are plenty of examples from around the world. All other industrialized countries, many less wealthy than ours, are already doing it.

Can we do it? That depends upon the people of Maine.

The authors serve on the board of directors of Maine AllCare, a nonpartisan, nonprofit group committed to educating the public and policymakers about how to improve on the Patient Protection and Affordable Care Act to make health care in Maine universal, accessible and affordable for all.

http://www.pressherald.com/opinion/health-or-wealth_-whats-the-mission-of-our-health-care-system__2011-02-06.html

Individual mandate falls short in Massachusetts

Lack Of Access Due To Costs Remains A Problem For Some In Massachusetts Despite The State’s Health Reforms

By Cheryl R. Clark, Jane Soukup, Usha Govindarajulu, Heather E. Riden, Dora A. Tovar and Paula A. Johnson
Health Affairs
February 2011

Did the Massachusetts health reforms, which provided near-universal insurance coverage, also address problems of unmet need resulting from the cost of care and of inadequate preventive care for diverse patient groups? We found that nearly a quarter of adults who were in fair or poor health reported being unable to see a doctor because of cost during the implementation of the reforms. We also found that state residents earning less than $25,000 per year were much less likely than higher earners to receive screening for cardiovascular disease and cancer.

http://content.healthaffairs.org/content/30/2/247#aff-6

And…

More get waivers of health insurance

By Kay Lazar
The Boston Globe
February 7, 2011

Massachusetts regulators granted more exemptions last year to residents who said they could not afford the health insurance required by the state, waiving the tax penalty for more than half of those who appealed, according to state data.

That is prompting regulators to take a fresh look at how Massachusetts defines affordable when it comes to mandatory health insurance.

Massachusetts residents with the lowest family incomes, less than $33,075 for a family of four, make up the largest share — 43 percent — of the uninsured, according to state data.

“We may want to let them in [to government subsidized health insurance], but it would cost money, and we would have to decide if the state wants to spend money that way,” said committee member Jonathan Gruber, an economics professor at the Massachusetts Institute of Technology.

http://www.boston.com/news/local/massachusetts/articles/2011/02/07/more_get_waivers_of_health_insurance/?page=full

Comment: 

By Don McCanne, MD

Does an individual mandate to purchase private insurance with cost-sharing requirements ensure that citizens will have health care access and be able to afford it? It hasn’t in Massachusetts, and it will not throughout the United States because it is an irreparably flawed mechanism of financing health care.

The literature is replete with policies that would nudge us a little bit closer to the goals of affordability and expanded coverage, but, as Jonathan Gruber, an advocate of the private insurance mandate model, says, “we would have to decide if the state wants to spend money that way.”

But it’s the model, stupid! Dump it and replace it with an improved Medicare for all and then health care will be affordable for everyone. Why does Gruber and the others insist on separating state money from personal money, as if state money is sacred and personal money isn’t? It all belongs to us anyway.

Individual mandate falls short in Massachusetts

Lack Of Access Due To Costs Remains A Problem For Some In Massachusetts Despite The State’s Health Reforms

By Cheryl R. Clark, Jane Soukup, Usha Govindarajulu, Heather E. Riden, Dora A. Tovar and Paula A. Johnson
Health Affairs
February 2011

Did the Massachusetts health reforms, which provided near-universal insurance coverage, also address problems of unmet need resulting from the cost of care and of inadequate preventive care for diverse patient groups? We found that nearly a quarter of adults who were in fair or poor health reported being unable to see a doctor because of cost during the implementation of the reforms. We also found that state residents earning less than $25,000 per year were much less likely than higher earners to receive screening for cardiovascular disease and cancer.

http://content.healthaffairs.org/content/30/2/247#aff-6

And…

More get waivers of health insurance

By Kay Lazar
The Boston Globe
February 7, 2011

Massachusetts regulators granted more exemptions last year to residents who said they could not afford the health insurance required by the state, waiving the tax penalty for more than half of those who appealed, according to state data.

That is prompting regulators to take a fresh look at how Massachusetts defines affordable when it comes to mandatory health insurance.

Massachusetts residents with the lowest family incomes, less than $33,075 for a family of four, make up the largest share — 43 percent — of the uninsured, according to state data.

“We may want to let them in [to government subsidized health insurance], but it would cost money, and we would have to decide if the state wants to spend money that way,” said committee member Jonathan Gruber, an economics professor at the Massachusetts Institute of Technology.

http://www.boston.com/news/local/massachusetts/articles/2011/02/07/more_get_waivers_of_health_insurance/?page=full

Does an individual mandate to purchase private insurance with cost-sharing requirements ensure that citizens will have health care access and be able to afford it? It hasn’t in Massachusetts, and it will not throughout the United States because it is an irreparably flawed mechanism of financing health care.

The literature is replete with policies that would nudge us a little bit closer to the goals of affordability and expanded coverage, but, as Jonathan Gruber, an advocate of the private insurance mandate model, says, “we would have to decide if the state wants to spend money that way.”

But it’s the model, stupid! Dump it and replace it with an improved Medicare for all and then health care will be affordable for everyone. Why does Gruber and the others insist on separating state money from personal money, as if state money is sacred and personal money isn’t? It all belongs to us anyway.

Here's why a key part of Obamacare will get struck down

By Robert Reich
The Business Insider, Feb. 4, 2011

The Republican-led house vote to repeal the new health care law is purely symbolic. But there’s one provision of the law that Republicans are likely to try to defund, and they may have the public with them on this. It’s the so-called “individual mandate” – the requirement that everyone purchase health insurance, or pay a fine. According to a recent poll, 60 percent of the public opposes it. They just don’t like the idea of  government telling them they have to buy something.

The mandate is also particularly vulnerable to legal challenge. So far, two federal judges, one in Virginia and another in Florida, have struck it down. They say the federal government has no more constitutional authority requiring citizens to buy insurance than requiring them to buy and consume broccoli, or asparagus.  The Florida judge referred to broccoli; the Virginia judge to asparagus.

Yet the new system can’t work without the individual mandate.  Only if everyone buys insurance can insurers afford to cover people with preexisting conditions, or pay the costs of catastrophic diseases.

The curious thing is Americans don’t mind individual mandates when they come in the form of payroll taxes to buy mandatory public insurance. In fact, that’s the system we call Social Security and Medicare, and both are so popular politicians dare not touch them.

And no federal judge has struck down Social Security or Medicare as being unconstitutional requirements that Americans buy something.

Social Security and Medicare aren’t broccoli or asparagus. They’re as American as hot dogs and apple pie.

So if the individual mandate to buy private health insurance gets struck down by the Supreme Court or killed off by Congress, I’d recommend President Obama immediately propose what he should have proposed in the beginning — universal health care based on Medicare for all, financed by payroll taxes.

Read more: http://www.businessinsider.com/the-individual-mandate-in-the-health-care-bill-lets-trade-the-broccoli-and-asparagus-for-hot-dogs-and-apple-pie-2011-2#ixzz1DHmZ3KH3

In Vermont, historic opportunity is now

By Deborah Richter
Burlington Free Press, Feb. 1, 2011

Praise has been heaped on the 120-some page report issued by the Harvard health economist, William Hsiao, and his working group. Words like historic, ground-breaking, and masterful are used, and since I entirely agree I will put them to use as well.

The report is called “Act 128 Health System Reform Design: Achieving Affordable Universal Health Care in Vermont” but will forever be known as the Hsiao Report.

It does exactly what is was asked by the Legislature. It outlines the designs for three health care systems and offers the rationale behind the thinking for each, including facts, figures and the probable economic consequences. For Vermont, this is ground breaking.

Two of the three look good. One of them (the second, which is called the public option) is hardly in the running because effectively it will not achieve universal coverage.

The favored system designs have numbers. Option No. 1 is a single-payer system. Option No. 3 is a single-payer system. What is the difference? Not a lot. Operationally there are differences. But at this stage, far more important is what they share. It is something of overriding importance that we overlook at our peril, and in fact have overlooked at our peril for years. That peril can be described as unsustainable rises in costs.

Here is the Hsiao Report: “Vermont will need to reorganize existing systems and develop new administrative capacities to manage an integrated, single-payer health system. In addition, the state will need to institute a regulatory apparatus to oversee the functioning of the system.”

This admonition appears about nine-tenths of the way through the report, but it is the key to everything.

Our Legislature and new administration are called on to create an integrated health care system. System is not an idle idea. Without a system the costs of health care in our state cannot be managed, contained, controlled, budgeted and will in fact remain unmanaged, uncontained, uncontrolled, unbudgeted.

The Hsiao Report is a masterful piece of work. It is specific to Vermont, to our health care, to our economy, to our political landscape and to Vermont’s intersection with federal laws, regulations and, by implication, politics. It is not a template for other states. It is not a one-size fits all. It is particular to our state.

Vermont has never before had anything close to this to work with. It maps out routes to a goal that can be abbreviated as “high-quality health care for all Vermonters,” and by affordable is meant affordable to Vermont as a whole as well as to individuals.

Comments after its release Jan. 19 no doubt are pouring in. Because they are by post or e-mail we can’t know what they are. But the usual pattern is reservations, objections, gloomy prognostications, alternative theories, quarrels over details, complaints from idealists, self-interested criticisms from the what-about-me crowd, some valuable, some a deplorable waste of time, but all more or less beside the main point.

As the Hsiao Report implies in its gentle way, if we don’t move to an integrated health care system that is uniform and regulated we are done. The costs are going to bury us. That is the essential point.

A system oversees and coordinates. It integrates. At some basic level it abolishes the what-about-me chorus in favor of what-about-all-of-us. A system takes the fundamentally necessary step of grounding health care, and all of its elements, solidly in the realm of the public interest.

The Hsiao Report is a report, not a bill. It hands the Legislature and the new administration an historic opportunity.

The draft, or redraft, will be subject to the usual practice in committees and hearings — the standard back and forth of legislation — of picking away at the details (“the devil is in the details”). Not this time. This time the devil will be found in our failure to create and implement a system.

Dr. Deborah Richter of Montpelier is president of Vermont Health Care for All, which is campaigning for a single-payer health care system for Vermont.

http://www.burlingtonfreepress.com/article/20110201/OPINION05/102010308/Comment-Debate-Historic-opportunity-is-now

Health care's federal future, brought to you by the GOP

By Matt Miller
The Washington Post, Thursday, February 3, 2011

“Good afternoon, I’m Brian Williams reporting from Washington, where it looks like October 26, 2017, will be a day that truly goes down in history. In a few moments, at a table not far from where I now stand, President Hillary Clinton will sign into law the universal health-care legislation – “Medicare for All,” as she calls it – that completes a journey Mrs. Clinton began nearly 25 years ago. Back then, as first lady, her attempt to reform the health-care system proved a fiasco that cost Democrats their hold on power. Who would have thought then – or later, when President Barack Obama’s big health reform was overturned by the Supreme Court in a controversial 5 to 4 ruling in 2012 – that today’s bipartisan bill would be the result? For some perspective on the twists and turns of history, we’re joined by NBC’s David Gregory. David, health reform seemed dead in the water in 2012. How did we get from that Supreme Court ruling to today?”

“Brian, when historians look back on this period, they’ll see it as a classic case of shortsighted politics – of Republicans winning the battle but losing the war. It really dates to the fight to overturn Barack Obama’s health reform. There’s no question the GOP got a boost from that ‘victory’ – it galvanized their base, and, combined with high unemployment and the dollar crisis right before the 2012 election, denied President Obama a second term.

“But some Republicans now say the trouble was that their party never acknowledged that health care wasn’t just about politics – it was a major policy problem that needed real solutions. President Mitch Daniels, of course, had to spend virtually all of his term in office getting America’s fiscal house in order, what with the International Monetary Fund and the rating agencies telling Washington the jig was up. The new carbon and value-added taxes he enacted, and the spending cuts he muscled through, left Daniels respected but hardly popular.

“Meanwhile, as you know, Brian, health costs kept soaring, employers kept dropping coverage they could no longer afford, and by the 2016 campaign, with 70 million Americans uninsured, something had to give. It was Hillary Clinton’s moment, Brian.”

“David, it seems hard to recall now, but back in the fight over Obamacare, Republicans only offered plans to insure 3 million of the 50 million who were uninsured back then. Today, most Republicans have signed on to Mrs. Clinton’s plan to have government provide every American with basic coverage, with a much more modest role for private insurance as a supplement. What accounts for the change?”

“Well, Brian, a cynic might say that when you get to 70 million uninsured, some of them are actually Republican voters! But the key difference was the way business and labor came together behind Mrs. Clinton’s approach. Top chief executives agreed companies shouldn’t be expected to bear these costs anymore and backed the modest taxes needed to move health costs from private payrolls to public budgets, as happens in every other wealthy nation. The unions finally took a larger view, too. Instead of moaning about the ‘loss’ of a benefit they’d bargained for, labor leaders accepted that most workers had gone years without real wage increases, because health costs were devouring every penny available for compensation. Having government fund health care was the only way to give Americans a raise.”

“What seems so ironic, David, is that Republicans now endorse a much more ‘liberal’ solution than they would have had if they’d supported Barack Obama’s approach years ago.”

“That’s right, Brian. Obama modeled his reform on Mitt Romney’s in Massachusetts. It had an individual mandate because of something Republicans privately understood: The only way to reach universal coverage through private health plans that cover folks regardless of health status is to require everyone to be in the insurance pool. If people are free to wait until they’re sick to buy in, premiums soar and coverage erodes. Republicans who knew better assailed the mandate not because they really cared about some constitutional defect – after all, that could have been fixed easily by structuring incentives to buy coverage as opposed to a mandate. They did it because it was a way to take a bite out of Obama. In the near term, it worked. In the long term, they lost the chance to preserve the private-sector role they claimed to cherish in health care.”

“Ironic indeed. We’re getting word that President Clinton is about to speak. We join her now in the Rose Garden.”

“Thank you all for being here. It’s hard to imagine a better 70th birthday present for a president than the law I am about to sign. . . .”

Matt Miller, a senior fellow at the Center for American Progress and co-host of public radio’s “Left, Right & Center,” writes a weekly column for The Post. He can be reached at mattino2@gmail.com. Follow him on Twitter at @mattmillernow.

http://www.washingtonpost.com/wp-dyn/content/article/2011/02/02/AR2011020203149.html

Blue Shield Delays Rate Hike After Nurses' Protest

By Mike Hall
AFL-CIO Blog, Feb. 2, 2011

How’s this for a demonstration of cause and effect?

Cause—Yesterday, some 200 activists, led by the California Nurses Association/National Nurses United (CNA/NNU) rallied outside Blue Shield’s San Francisco corporate headquarters to protest the health insurance giant’s premium hikes of as much as 59 percent for California consumers.

Effect—Blue Shield announced a 60-day delay in the massive increase. Says CNA/NNU Executive Director Rose Ann DeMoro:

It’s not hard to connect the dots here between nurses and patients turning up the heat on Blue Shield’s barricaded doorstep the same day it agrees to a brief reprieve in its egregious rate increase.

Kerry Abukhalaf, who brought her son to the rally, says, “Our insurance is completely not worth the price. We pay almost half what we pay for rent.”

It’s just a big rip-off. We may just throw our chances to the wind and find insurance for our son and pay out of pocket for my husband and myself.

Along with condemning the rate hike, protestors pointed to a recent report that shows major California health insurers reject about a quarter of all health care claims.

Joining the nurses were members of the San Francisco Labor Council (SFLC), Courage Campaign, Healthcare Now and Physicians for a National Health Program as well as seniors and community and health care activists.

For more on the rally, including more photos, click here to read CNA/NNU’s diary on Daily Kos.

http://blog.aflcio.org/2011/02/02/blue-shield-delays-rate-hike-after-nurses-protest/

Maine single-payer feasibility study requested

By Stephan Burklin
MaineWatchdog.org, Feb. 3, 2011

A resolve requiring the Legislature to update a single-payer feasibility study is headed for the Insurance and Financial Services Committee on Wednesday.

The resolve’s sponsor, Rep. Paulette Beaudoin, D-Biddeford, said she introduced LD 57 to assess the viability of single-payer health care in Maine.

The legislation, which is contingent on $60,000 in outside funding, would update a study conducted by Mathematica Policy Research in 2002.

“It’s a study,” Rep. Beaudoin said “to find out how much it would cost for all the people in Maine to have health insurance at a good price.  And I have to find out how much it would cost before we can go any further.  Otherwise, it would be like putting the cart before the horse.”

She said that LD 57 represents her third attempt to commission a study with newer data.

Single-payer denotes a health care funding mechanism in which a single entity acts as administrator.  Under a single-payer system, all hospitals, doctors, and other health care providers bill the administrator for services rendered.

Single-payer health care bills have surfaced in the Legislature, but none have been enacted in both chambers.  In 2001, LD 1277, “An Act to Establish a Single-payor Health Care System” was passed by the House but withered on the Senate Appropriations Table where it died on adjournment at the end of the 120th session.  Two iterations in subsequent sessions failed to receive favorable committee reports.

“It means a lot to me,” Beaudoin said.  “All I want is for everyone to be insured.”

“They found money for the rich,” she said, referring to the Bush-era tax cut extensions for all income brackets signed into law in December, “but they can’t find the money for the people to get insurance.  That’s pretty sad.”

Deb Richter, MD, Chair of Vermont Health Care for All, said that enacting a single-payer health care system in Maine would depend on local political will.

“It’s been proven throughout the industrialized world that a single-payer system is the most cost-effective way to cover every Vermonter, and every American.  We know from numerous studies that you can cover an entire population without wasting it on administrative functions.”

“We could give everyone a comprehensive benefit package for less money than we’re spending now.  This is not ideological – it just makes sense.”

Vermont Gov. Peter Shumlin is scheduled to submit a single-payer health care bill to the Legislature next Tuesday.

Richter said the conditions for achieving single-payer health care in Vermont have never been better: “Our congressional delegation is completely behind it, we have Democratic majorities in both the House and Senate, the majority of doctors are behind it, and the sole insurance company operating in Vermont has said they are behind it.  We have everything we need.”

LD 57 was scheduled to appear before the Joint Standing Committee on Insurance and Financial Services yesterday, but it was postponed due to inclement weather.  The non-partisan Office of Policy and Legal Analysis said a public hearing will likely be held next Wednesday.

http://maine.watchdog.org/2011/02/03/single-payer-feasibility-study-requested/

qotd weekend special: The Super Bowl and a Crystal Stair

By Don McCanne, MD

Well here we are. Super Bowl weekend! Hurrah! What could be more American than this? Billions of dollars and the nation’s full attention directed to a couple dozen men playing a game. And this is no sandlot game. No. This is our nation at its finest – honoring in unparalleled splendor those great Americans who prevail and are declared winners of this historic rough-and-tumble fracas. And what more could our nation be than about winners?

Let me digress for a moment. I have a little story to tell.

I was still in practice during the Clinton effort to reform health care. Although practicing in an affluent community, I was experiencing great frustrations in trying to obtain specialized health care services for not only our indigent patients, but also for our insured patients who were facing increasing managed-care barriers to care.

Previously, in 1989, a life-changing event had occurred for me. It was simply that I read an article in The New England Journal of Medicine titled “A National Health Program for the United States,” written by a team led by David Himmelstein and Steffie Woolhandler, representing a group called Physicians for a National Health Program. I was stoked! I joined PNHP.

Then Bill Clinton was elected, and the nation was ready for a national health program. As masters of health policy science, PNHP was there and ready to help guide the process. But President Clinton decided that they would follow the path of political expediency and build reform based on the existing private insurers/managed care entities. Thus, in a political maneuver, to be repeated years later, PNHP was denied a seat at the table.

I watched the process closely. I listened as the opposition proposed a model almost identical to that of the Patient Protection and Affordable Care Act. I saw the effort go down in flames. I decided that we couldn’t just walk away.

I felt then that a pure single payer program, as much as I wanted it, could never pass. But I thought that there was enough agreement on fundamental principles that almost everyone would be able to support some model of social insurance, if we just had the right one. So I crafted a model. It was brilliant – just the right balance to achieve our goals while pleasing everyone.

I sent it in to PNHP. The task of reviewing it was handed to PNHP’s new president, Claudia Fegan. It required more postage to return it to me, because it was newly laden with red ink.

My lesson? I was passionate about reforming our system so that everyone would have the health care that they need, but I knew nothing about health policy science. I am forever indebted to Claudia for showing me the light, and resetting my course in my advocacy for reform. The principle she taught me is that you change policy recommendations only when policy science has demonstrated that there are better policies available. You do not ever change policy recommendations simply to conform to politics.

Claudia has continued to be a great inspiration to me. And that brings us to a crystal stair. On this glittering Super Bowl weekend, we should take a look at that crystal stair. You will understand what I mean when you read the Claudia’s remarks that she delivered to the Louisville, Kentucky Urban League on January 15, 2011. After reading her comments maybe we can think about what it really takes to make winners in America.

Cladia Fegan’s remarks to the Louisville Urban League:
http://www.spiritualprogressives.org/article.php/2011020212215961

qotd weekend special: The Super Bowl and a Crystal Stair

Well here we are. Super Bowl weekend! Hurrah! What could be more American than this? Billions of dollars and the nation’s full attention directed to a couple dozen men playing a game. And this is no sandlot game. No. This is our nation at its finest – honoring in unparalleled splendor those great Americans who prevail and are declared winners of this historic rough-and-tumble fracas. And what more could our nation be than about winners?

Let me digress for a moment. I have a little story to tell.

I was still in practice during the Clinton effort to reform health care. Although practicing in an affluent community, I was experiencing great frustrations in trying to obtain specialized health care services for not only our indigent patients, but also for our insured patients who were facing increasing managed-care barriers to care.

Previously, in 1989, a life-changing event had occurred for me. It was simply that I read an article in The New England Journal of Medicine titled “A National Health Program for the United States,” written by a team led by David Himmelstein and Steffie Woolhandler, representing a group called Physicians for a National Health Program. I was stoked! I joined PNHP.

Then Bill Clinton was elected, and the nation was ready for a national health program. As masters of health policy science, PNHP was there and ready to help guide the process. But President Clinton decided that they would follow the path of political expediency and build reform based on the existing private insurers/managed care entities. Thus, in a political maneuver, to be repeated years later, PNHP was denied a seat at the table.

I watched the process closely. I listened as the opposition proposed a model almost identical to that of the Patient Protection and Affordable Care Act. I saw the effort go down in flames. I decided that we couldn’t just walk away.

I felt then that a pure single payer program, as much as I wanted it, could never pass. But I thought that there was enough agreement on fundamental principles that almost everyone would be able to support some model of social insurance, if we just had the right one. So I crafted a model. It was brilliant – just the right balance to achieve our goals while pleasing everyone.

I sent it in to PNHP. The task of reviewing it was handed to PNHP’s new president, Claudia Fegan. It required more postage to return it to me, because it was newly laden with red ink.

My lesson? I was passionate about reforming our system so that everyone would have the health care that they need, but I knew nothing about health policy science. I am forever indebted to Claudia for showing me the light, and resetting my course in my advocacy for reform. The principle she taught me is that you change policy recommendations only when policy science has demonstrated that there are better policies available. You do not ever change policy recommendations simply to conform to politics.

Claudia has continued to be a great inspiration to me. And that brings us to a crystal stair. On this glittering Super Bowl weekend, we should take a look at that crystal stair. You will understand what I mean when you read the Claudia’s remarks that she delivered to the Louisville, Kentucky Urban League on January 15, 2011. After reading her comments maybe we can think about what it really takes to make winners in America.

Cladia Fegan’s remarks to the Louisville Urban League:
http://www.spiritualprogressives.org/article.php/2011020212215961

Half of

Issues In Health Reform: How Changes In Eligibility May Move Millions Back And Forth Between Medicaid And Insurance Exchanges

By Benjamin D. Sommers and Sara Rosenbaum
Health Affairs
February 2011

The Affordable Care Act will extend health insurance coverage by both expanding Medicaid eligibility and offering premium subsidies for the purchase of private health insurance through state health insurance exchanges. But by definition, eligibility for these programs is sensitive to income and can change over time with fluctuating income and changes in family composition. The law specifies no minimum enrollment period, and subsidy levels will also change as income rises and falls. Using national survey data, we estimate that within six months, more than 35 percent of all adults with family incomes below 200 percent of the federal poverty level will experience a shift in eligibility from Medicaid to an insurance exchange, or the reverse; within a year, 50 percent, or 28 million, will.

Income fluctuation raises issues for all subsidy-eligible individuals or families up to 400 percent of the federal poverty level, which includes those whose incomes place them squarely within the exchange system. For those purchasing coverage with subsidies through exchanges, income changes may trigger the obligation to repay some or all subsidies received; the amounts subject to repayment were significantly increased recently by Congress. But income fluctuations pose a particular challenge for individuals and families who cross the Medicaid-exchange divide, because this change may trigger a shift between plans and provider networks. In short, for this group, income fluctuation carries both financial and health care consequences.

Our multivariate analyses show that income fluctuations were common even among adults initially with incomes below the poverty level. This is particularly troubling because many of these people will often have incomes low enough to exempt them from the federal insurance mandate, which means that fatigue with frequent coverage changes may lead them to simply stop signing up for insurance over time. This is a problem on two fronts. First, it is uninsured low-income adults who have the most to gain from health reform. Second, this group includes millions of healthy adults whose participation in the exchanges is crucial to robust risk pools. We found that income changes were more common among adults who were younger, more educated, and white—characteristics that correlate with a lower burden of illness. Indeed, these results are consistent with previous findings on changes in Medicaid coverage among adults.

http://content.healthaffairs.org/content/30/2/228.abstract

Comment: 

By Don McCanne, MD

We have previously made the point that fluctuations in eligibility for Medicaid and for the income-related subsidies in the exchange plans create instability in coverage. Impaired outcomes occur because of gaps in coverage, and disruptions in provider networks. This new study puts a number on the degree of instability. Within one year, over 50 percent of adults with a family income under 200 percent of the federal poverty level (FPL) will experience a shift in eligibility from Medicaid to an insurance exchange, or vice versa.

The article discusses some of the implications of this, including problems with shifting eligibility levels for exchange subsidies for those with incomes over 200 percent of the FPL. Though eligible for one program or another, many individuals will have incomes that exempt them from the mandate to purchase insurance, and, assuredly, the healthier ones who are needed to round out the risk pools will go without coverage as a result of fatigue over multiple ejections by one program or another.

The authors offer policy options that might reduce this instability in coverage, but these options can never eliminate it. Our fragmented financing system of various private and public programs will never ensure that everyone is covered at all times, and it will continue to waste funds on administrative excesses such as trying to keep up with eligibility shifts due to income fluctuations.

A policy option that would work, not mentioned by the authors, would be to dump our dysfunctional multi-payer system and enact an improved Medicare that includes everyone. The problem of fluctuating incomes is greatly simplified because it impacts only the contribution through the tax system, without moving the individual in or out of Medicare.