Congressman Alan Grayson
Press Release
March 9, 2010

Congressman Alan Grayson, D-Fla., today introduced a bill (H.R. 4789) which would give the option to buy into Medicare to every citizen of the United States.  The “Public Option Act,” also known as the “Medicare You Can Buy Into Act,” would open up the Medicare network to anyone who can pay for it.

Congressman Grayson said, “Obviously, America wants and needs more competition in health coverage, and a public option offers that.  But it’s just as important that we offer people not just another choice, but another kind of choice.   A lot of people don’t want to be at the mercy of greedy insurance companies that will make money by denying them the care that they need to stay healthy, or to stay alive.  We deserve to have a real alternative.”

The bill would require the Secretary of Health and Human Services to establish enrollment periods, coverage guidelines, and premiums for the program.  Because premiums would be equal to cost, the program would pay for itself.

“The government spent billions of dollars creating a Medicare network of providers that is only open to one-eighth of the population.  That’s like saying, ‘Only people 65 and over can use federal highways.’  It is a waste of a very valuable resource and it is not fair.  This idea is simple, it makes sense, and it deserves an up-or-down vote,” Congressman Grayson said.

http://grayson.house.gov/News/DocumentSingle.aspx?DocumentID=175363

H.R. 4789 – “Public Option Act” or “Medicare You Can Buy Into Act”:
http://thomas.loc.gov/  Click Bill Number. Enter H.R. 4789. Click Search. From there you can access the text of the legislation (very short bill), cosponsors, and other information.

Video of Grayson’s introduction of H.R. 4789 to House (5 minutes):
http://www.huffingtonpost.com/2010/03/10/grayson-offers-medicare-b_n_492831.html

Article XVIII, Sec. 1818
http://www.ssa.gov/OP_Home/ssact/title18/1818.htm

Article XVIII, Sec. 1818A
http://www.ssa.gov/OP_Home/ssact/title18/1818A.htm

Medicare premiums for 2010
http://questions.medicare.gov/cgi-bin/medicare.cfg/php/enduser/std_adp.php?p_faqid=2260

Comment: 

By Don McCanne, MD

Throughout the reform process members of Congress have been fighting over whether or not the reform legislation should include the option of purchasing a government-sponsored plan through the proposed insurance exchanges – the so-called “public option.” Since Congressman Alan Grayson introduced the “Public Option Act” or “Medicare You Can Buy Into Act” three days ago, a wave of enthusiastic support has been generated based on the perception that this is the perfect solution. Today’s comment briefly discusses this legislation, and it will sound really great at first blush, but do not draw any firm conclusions until you read through to the end.

Okay. What does this bill do? It simply allows any legal resident of the United States under age 65 to buy into Medicare. The program will be paid for by the premiums to be collected from the individuals purchasing the coverage. Six age brackets are established for purposes of pooling funds. This reduces the financial burden on younger, healthier individuals by requiring older individuals to pay the higher premiums that would be required to fully fund their less healthy risk pool.

Many are not aware of this, but Medicare already has a buy-in program. Under Title XVIII, Sec. 1818, individuals over 65 who have fewer than 40 quarters of Medicare-covered employment who would otherwise not be eligible for Medicare can still participate by paying a full premium for Part A coverage (hospital) or a reduced premium if they have 30 to 39 quarters of Medicare-covered employment. Likewise, under Sec. 1818A, disabled individuals whose entitlement ends due to having earnings that exceed the qualification level can also purchase Medicare Part A. Grayson’s bill adds a new Sec. 1818B to Title XVIII to expand the buy-in option to anyone under 65.

For 2010, the premium under Sec. 1818 and Sec. 1818A to buy into Medicare Part A is $461 per month. The premium for Part B (supplemental medical) is the same as for qualified retirees – $110.50 and up, based on income (ignoring the hold harmless exception). Thus the buy-in is about $571 per month, or more for those with higher incomes.

Although Medicare beneficiaries have a high rate of chronic disease plus the costs of end-of-life care, the risk pool is diluted with a very large number of healthy seniors, thus the premiums are not as high as one might think. On the other hand, it is likely that the risk pools for the older but still under 65 age groups in the Grayson proposal would be subject to adverse selection. Since the premiums must pay all costs, they may be higher, perhaps much higher, than the diluted post 65 risk pool. Grayson has not included any risk adjustment mechanism to compensate for this.

At any rate, the Grayson proposal seems to be the true public option, run by the government, that progressives have been fighting for. So what could be wrong with it?

The greatest concern of all is that it still does not fix our outrageously expensive, administratively wasteful, highly inequitable, fragmented method of financing health care. It merely provides another expensive option in our very sick system of paying for health care. Providing yet one more option that people can’t afford really hasn’t moved the process.

Although Medicare is a very popular program, it is highly flawed. It has an oppressive central bureaucracy. It fails to use more efficient financing systems such as global budgeting for hospitals and negotiation to obtain greater value in health care purchasing. There are serious questions about whether Medicare funds are being distributed equitably and in a manner to promote greater efficiency. Its benefit package is relatively poor, covering only about half of health care costs for our seniors. Most Medicare beneficiaries feel that they essentially are forced either to purchase Medigap plans, which provide the worst value of all private health plans, or to enroll in Medicare Advantage plans, which waste too many tax and premium dollars. It would be both much less expensive for all of us and better for Medicare beneficiaries if the extra benefits of these private plans were rolled into the traditional Medicare program. Part D should be stripped of its private market administrative and profit excesses and also be rolled into the traditional program. Medicare also has failed to introduce beneficial innovative programs such as the British NICE system, which would improve both quality and value in our health care.

When we advocate for an improved Medicare for all, we really aren’t advocating for Medicare with a few tweaks. We are advocating for replacing Medicare with a single payer national health program that covers everyone, which we can still call Medicare, just as the Canadians do. Adding another buy-in program to the two buy-in programs that already exist in our highly dysfunctional system will do virtually nothing to fix these flaws we now have. It does nothing to slow the growth in our national health expenditures, and the high premiums for a package of mediocre benefits will do little to reduce the numbers of uninsured.

For those who say that a Medic
are buy-in is an incremental step towards health care utopia, explain precisely how that is going to work. Explain each problem that it solves. Explain how it is going to morph into a universal or near universal system in which each individual is paying the full actuarial value of the coverage. It won’t happen.

Playing with a Medicare buy-in is an unnecessary diversion at a time that we need to get serious about reform. We need to fix Medicare and expand it to cover everyone.  Nothing less will do.

Grayson Introduces Public Option Act

Congressman Alan Grayson
Press Release
March 9, 2010

Congressman Alan Grayson, D-Fla., today introduced a bill (H.R. 4789) which would give the option to buy into Medicare to every citizen of the United States.  The “Public Option Act,” also known as the “Medicare You Can Buy Into Act,” would open up the Medicare network to anyone who can pay for it.

Congressman Grayson said, “Obviously, America wants and needs more competition in health coverage, and a public option offers that.  But it’s just as important that we offer people not just another choice, but another kind of choice.   A lot of people don’t want to be at the mercy of greedy insurance companies that will make money by denying them the care that they need to stay healthy, or to stay alive.  We deserve to have a real alternative.”

The bill would require the Secretary of Health and Human Services to establish enrollment periods, coverage guidelines, and premiums for the program.  Because premiums would be equal to cost, the program would pay for itself.

“The government spent billions of dollars creating a Medicare network of providers that is only open to one-eighth of the population.  That’s like saying, ‘Only people 65 and over can use federal highways.’  It is a waste of a very valuable resource and it is not fair.  This idea is simple, it makes sense, and it deserves an up-or-down vote,” Congressman Grayson said.

http://grayson.house.gov/News/DocumentSingle.aspx?DocumentID=175363

H.R. 4789 – “Public Option Act” or “Medicare You Can Buy Into Act”:
http://thomas.loc.gov/  Click Bill Number. Enter H.R. 4789. Click Search. From there you can access the text of the legislation (very short bill), cosponsors, and other information.

Video of Grayson’s introduction of H.R. 4789 to House (5 minutes):
http://www.huffingtonpost.com/2010/03/10/grayson-offers-medicare-b_n_492831.html

Article XVIII, Sec. 1818
http://www.ssa.gov/OP_Home/ssact/title18/1818.htm

Article XVIII, Sec. 1818A
http://www.ssa.gov/OP_Home/ssact/title18/1818A.htm

Medicare premiums for 2010
http://questions.medicare.gov/cgi-bin/medicare.cfg/php/enduser/std_adp.php?p_faqid=2260

Comment: 

By Don McCanne, MD

Throughout the reform process members of Congress have been fighting over whether or not the reform legislation should include the option of purchasing a government-sponsored plan through the proposed insurance exchanges – the so-called “public option.” Since Congressman Alan Grayson introduced the “Public Option Act” or “Medicare You Can Buy Into Act” three days ago, a wave of enthusiastic support has been generated based on the perception that this is the perfect solution. Today’s comment briefly discusses this legislation, and it will sound really great at first blush, but do not draw any firm conclusions until you read through to the end.

Okay. What does this bill do? It simply allows any legal resident of the United States under age 65 to buy into Medicare. The program will be paid for by the premiums to be collected from the individuals purchasing the coverage. Six age brackets are established for purposes of pooling funds. This reduces the financial burden on younger, healthier individuals by requiring older individuals to pay the higher premiums that would be required to fully fund their less healthy risk pool.

Many are not aware of this, but Medicare already has a buy-in program. Under Title XVIII, Sec. 1818, individuals over 65 who have fewer than 40 quarters of Medicare-covered employment who would otherwise not be eligible for Medicare can still participate by paying a full premium for Part A coverage (hospital) or a reduced premium if they have 30 to 39 quarters of Medicare-covered employment. Likewise, under Sec. 1818A, disabled individuals whose entitlement ends due to having earnings that exceed the qualification level can also purchase Medicare Part A. Grayson’s bill adds a new Sec. 1818B to Title XVIII to expand the buy-in option to anyone under 65.

For 2010, the premium under Sec. 1818 and Sec. 1818A to buy into Medicare Part A is $461 per month. The premium for Part B (supplemental medical) is the same as for qualified retirees – $110.50 and up, based on income (ignoring the hold harmless exception). Thus the buy-in is about $571 per month, or more for those with higher incomes.

Although Medicare beneficiaries have a high rate of chronic disease plus the costs of end-of-life care, the risk pool is diluted with a very large number of healthy seniors, thus the premiums are not as high as one might think. On the other hand, it is likely that the risk pools for the older but still under 65 age groups in the Grayson proposal would be subject to adverse selection. Since the premiums must pay all costs, they may be higher, perhaps much higher, than the diluted post 65 risk pool. Grayson has not included any risk adjustment mechanism to compensate for this.

At any rate, the Grayson proposal seems to be the true public option, run by the government, that progressives have been fighting for. So what could be wrong with it?

The greatest concern of all is that it still does not fix our outrageously expensive, administratively wasteful, highly inequitable, fragmented method of financing health care. It merely provides another expensive option in our very sick system of paying for health care. Providing yet one more option that people can’t afford really hasn’t moved the process.

Although Medicare is a very popular program, it is highly flawed. It has an oppressive central bureaucracy. It fails to use more efficient financing systems such as global budgeting for hospitals and negotiation to obtain greater value in health care purchasing. There are serious questions about whether Medicare funds are being distributed equitably and in a manner to promote greater efficiency. Its benefit package is relatively poor, covering only about half of health care costs for our seniors. Most Medicare beneficiaries feel that they essentially are forced either to purchase Medigap plans, which provide the worst value of all private health plans, or to enroll in Medicare Advantage plans, which waste too many tax and premium dollars. It would be both much less expensive for all of us and better for Medicare beneficiaries if the extra benefits of these private plans were rolled into the traditional Medicare program. Part D should be stripped of its private market administrative and profit excesses and also be rolled into the traditional program. Medicare also has failed to introduce beneficial innovative programs such as the British NICE system, which would improve both quality and value in our health care.

When we advocate for an improved Medicare for all, we really aren’t advocating for Medicare with a few tweaks. We are advocating for replacing Medicare with a single payer national health program that covers everyone, which we can still call Medicare, just as the Canadians do. Adding another buy-in program to the two buy-in programs that already exist in our highly dysfunctional system will do virtually nothing to fix these flaws we now have. It does nothing to slow the growth in our national health expenditures, and the high premiums for a package of mediocre benefits will do little to reduce the numbers of uninsured.

For those who say that a Medicare buy-in is an incremental step towards health care utopia, explain precisely how that is going to work. Explain each problem that it solves. Explain how it is going to morph into a universal or near universal system in which each individual is paying the full actuarial value of the coverage. It won’t happen.

Playing with a Medicare buy-in is an unnecessary diversion at a time that we need to get serious about reform. We need to fix Medicare and expand it to cover everyone.  Nothing less will do.

Grayson Introduces Public Option Act

Congressman Alan Grayson
Press Release
March 9, 2010
Congressman Alan Grayson, D-Fla., today introduced a bill (H.R. 4789) which would give the option to buy into Medicare to every citizen of the United States.  The “Public Option Act,” also known as the “Medicare You Can Buy Into Act,” would open up the Medicare network to anyone who can pay for it.
Congressman Grayson said, “Obviously, America wants and needs more competition in health coverage, and a public option offers that.  But it’s just as important that we offer people not just another choice, but another kind of choice.   A lot of people don’t want to be at the mercy of greedy insurance companies that will make money by denying them the care that they need to stay healthy, or to stay alive.  We deserve to have a real alternative.”
The bill would require the Secretary of Health and Human Services to establish enrollment periods, coverage guidelines, and premiums for the program.  Because premiums would be equal to cost, the program would pay for itself.
“The government spent billions of dollars creating a Medicare network of providers that is only open to one-eighth of the population.  That’s like saying, ‘Only people 65 and over can use federal highways.’  It is a waste of a very valuable resource and it is not fair.  This idea is simple, it makes sense, and it deserves an up-or-down vote,” Congressman Grayson said.
http://grayson.house.gov/News/DocumentSingle.aspx?DocumentID=175363
H.R. 4789 – “Public Option Act” or “Medicare You Can Buy Into Act”:
http://thomas.loc.gov/ Click Bill Number. Enter H.R. 4789. Click Search. From there you can access the text of the legislation (very short bill), cosponsors, and other information.
Video of Grayson’s introduction of H.R. 4789 to House (5 minutes):
http://www.huffingtonpost.com/2010/03/10/grayson-offers-medicare-b_n_492831.html
Article XVIII, Sec. 1818
http://www.ssa.gov/OP_Home/ssact/title18/1818.htm
Article XVIII, Sec. 1818A
http://www.ssa.gov/OP_Home/ssact/title18/1818A.htm
Medicare premiums for 2010
http://questions.medicare.gov/cgi-bin/medicare.cfg/php/enduser/std_adp.php?p_faqid=2260

Throughout the reform process members of Congress have been fighting over whether or not the reform legislation should include the option of purchasing a government-sponsored plan through the proposed insurance exchanges – the so-called “public option.” Since Congressman Alan Grayson introduced the “Public Option Act” or “Medicare You Can Buy Into Act” three days ago, a wave of enthusiastic support has been generated based on the perception that this is the perfect solution. Today’s comment briefly discusses this legislation, and it will sound really great at first blush, but do not draw any firm conclusions until you read through to the end.
Okay. What does this bill do? It simply allows any legal resident of the United States under age 65 to buy into Medicare. The program will be paid for by the premiums to be collected from the individuals purchasing the coverage. Six age brackets are established for purposes of pooling funds. This reduces the financial burden on younger, healthier individuals by requiring older individuals to pay the higher premiums that would be required to fully fund their less healthy risk pool.
Many are not aware of this, but Medicare already has a buy-in program. Under Title XVIII, Sec. 1818, individuals over 65 who have fewer than 40 quarters of Medicare-covered employment who would otherwise not be eligible for Medicare can still participate by paying a full premium for Part A coverage (hospital) or a reduced premium if they have 30 to 39 quarters of Medicare-covered employment. Likewise, under Sec. 1818A, disabled individuals whose entitlement ends due to having earnings that exceed the qualification level can also purchase Medicare Part A. Grayson’s bill adds a new Sec. 1818B to Title XVIII to expand the buy-in option to anyone under 65.
For 2010, the premium under Sec. 1818 and Sec. 1818A to buy into Medicare Part A is $461 per month. The premium for Part B (supplemental medical) is the same as for qualified retirees – $110.50 and up, based on income (ignoring the hold harmless exception). Thus the buy-in is about $571 per month, or more for those with higher incomes.
Although Medicare beneficiaries have a high rate of chronic disease plus the costs of end-of-life care, the risk pool is diluted with a very large number of healthy seniors, thus the premiums are not as high as one might think. On the other hand, it is likely that the risk pools for the older but still under 65 age groups in the Grayson proposal would be subject to adverse selection. Since the premiums must pay all costs, they may be higher, perhaps much higher, than the diluted post 65 risk pool. Grayson has not included any risk adjustment mechanism to compensate for this.
At any rate, the Grayson proposal seems to be the true public option, run by the government, that progressives have been fighting for. So what could be wrong with it?
The greatest concern of all is that it still does not fix our outrageously expensive, administratively wasteful, highly inequitable, fragmented method of financing health care. It merely provides another expensive option in our very sick system of paying for health care. Providing yet one more option that people can’t afford really hasn’t moved the process.
Although Medicare is a very popular program, it is highly flawed. It has an oppressive central bureaucracy. It fails to use more efficient financing systems such as global budgeting for hospitals and negotiation to obtain greater value in health care purchasing. There are serious questions about whether Medicare funds are being distributed equitably and in a manner to promote greater efficiency. Its benefit package is relatively poor, covering only about half of health care costs for our seniors. Most Medicare beneficiaries feel that they essentially are forced either to purchase Medigap plans, which provide the worst value of all private health plans, or to enroll in Medicare Advantage plans, which waste too many tax and premium dollars. It would be both much less expensive for all of us and better for Medicare beneficiaries if the extra benefits of these private plans were rolled into the traditional Medicare program. Part D should be stripped of its private market administrative and profit excesses and also be rolled into the traditional program. Medicare also has failed to introduce beneficial innovative programs such as the British NICE system, which would improve both quality and value in our health care.
When we advocate for an improved Medicare for all, we really aren’t advocating for Medicare with a few tweaks. We are advocating for replacing Medicare with a single payer national health program that covers everyone, which we can still call Medicare, just as the Canadians do. Adding another buy-in program to the two buy-in programs that already exist in our highly dysfunctional system will do virtually nothing to fix these flaws we now have. It does nothing to slow the growth in our national health expenditures, and the high premiums for a package of mediocre benefits will do little to reduce the numbers of uninsured.
For those who say that a Medicare buy-in is an incremental step towards health care utopia, explain precisely how that is going to work. Explain each problem that it solves. Explain how it is going to morph into a universal or near universal system in which each individual is paying the full actuarial value of the coverage. It won’t happen.
Playing with a Medicare buy-in is an unnecessary diversion at a time that we need to get serious about reform. We need to fix Medicare and expand it to cover everyone.  Nothing less will do.

Grayson Introduces Public Option Act

Congressman Alan Grayson
Press Release
March 9, 2010

Congressman Alan Grayson, D-Fla., today introduced a bill (H.R. 4789) which would give the option to buy into Medicare to every citizen of the United States.  The “Public Option Act,” also known as the “Medicare You Can Buy Into Act,” would open up the Medicare network to anyone who can pay for it.

Congressman Grayson said, “Obviously, America wants and needs more competition in health coverage, and a public option offers that.  But it’s just as important that we offer people not just another choice, but another kind of choice.   A lot of people don’t want to be at the mercy of greedy insurance companies that will make money by denying them the care that they need to stay healthy, or to stay alive.  We deserve to have a real alternative.”

The bill would require the Secretary of Health and Human Services to establish enrollment periods, coverage guidelines, and premiums for the program.  Because premiums would be equal to cost, the program would pay for itself.

“The government spent billions of dollars creating a Medicare network of providers that is only open to one-eighth of the population.  That’s like saying, ‘Only people 65 and over can use federal highways.’  It is a waste of a very valuable resource and it is not fair.  This idea is simple, it makes sense, and it deserves an up-or-down vote,” Congressman Grayson said.

http://grayson.house.gov/News/DocumentSingle.aspx?DocumentID=175363

H.R. 4789 – “Public Option Act” or “Medicare You Can Buy Into Act”:
http://thomas.loc.gov/ Click Bill Number. Enter H.R. 4789. Click Search. From there you can access the text of the legislation (very short bill), cosponsors, and other information.

Video of Grayson’s introduction of H.R. 4789 to House (5 minutes):
http://www.huffingtonpost.com/2010/03/10/grayson-offers-medicare-b_n_492831.html

Article XVIII, Sec. 1818
http://www.ssa.gov/OP_Home/ssact/title18/1818.htm

Article XVIII, Sec. 1818A
http://www.ssa.gov/OP_Home/ssact/title18/1818A.htm

Medicare premiums for 2010
http://questions.medicare.gov/cgi-bin/medicare.cfg/php/enduser/std_adp.php?p_faqid=2260

Throughout the reform process members of Congress have been fighting over whether or not the reform legislation should include the option of purchasing a government-sponsored plan through the proposed insurance exchanges – the so-called “public option.” Since Congressman Alan Grayson introduced the “Public Option Act” or “Medicare You Can Buy Into Act” three days ago, a wave of enthusiastic support has been generated based on the perception that this is the perfect solution. Today’s comment briefly discusses this legislation, and it will sound really great at first blush, but do not draw any firm conclusions until you read through to the end.

Okay. What does this bill do? It simply allows any legal resident of the United States under age 65 to buy into Medicare. The program will be paid for by the premiums to be collected from the individuals purchasing the coverage. Six age brackets are established for purposes of pooling funds. This reduces the financial burden on younger, healthier individuals by requiring older individuals to pay the higher premiums that would be required to fully fund their less healthy risk pool.

Many are not aware of this, but Medicare already has a buy-in program. Under Title XVIII, Sec. 1818, individuals over 65 who have fewer than 40 quarters of Medicare-covered employment who would otherwise not be eligible for Medicare can still participate by paying a full premium for Part A coverage (hospital) or a reduced premium if they have 30 to 39 quarters of Medicare-covered employment. Likewise, under Sec. 1818A, disabled individuals whose entitlement ends due to having earnings that exceed the qualification level can also purchase Medicare Part A. Grayson’s bill adds a new Sec. 1818B to Title XVIII to expand the buy-in option to anyone under 65.

For 2010, the premium under Sec. 1818 and Sec. 1818A to buy into Medicare Part A is $461 per month. The premium for Part B (supplemental medical) is the same as for qualified retirees – $110.50 and up, based on income (ignoring the hold harmless exception). Thus the buy-in is about $571 per month, or more for those with higher incomes.

Although Medicare beneficiaries have a high rate of chronic disease plus the costs of end-of-life care, the risk pool is diluted with a very large number of healthy seniors, thus the premiums are not as high as one might think. On the other hand, it is likely that the risk pools for the older but still under 65 age groups in the Grayson proposal would be subject to adverse selection. Since the premiums must pay all costs, they may be higher, perhaps much higher, than the diluted post 65 risk pool. Grayson has not included any risk adjustment mechanism to compensate for this.

At any rate, the Grayson proposal seems to be the true public option, run by the government, that progressives have been fighting for. So what could be wrong with it?

The greatest concern of all is that it still does not fix our outrageously expensive, administratively wasteful, highly inequitable, fragmented method of financing health care. It merely provides another expensive option in our very sick system of paying for health care. Providing yet one more option that people can’t afford really hasn’t moved the process.

Although Medicare is a very popular program, it is highly flawed. It has an oppressive central bureaucracy. It fails to use more efficient financing systems such as global budgeting for hospitals and negotiation to obtain greater value in health care purchasing. There are serious questions about whether Medicare funds are being distributed equitably and in a manner to promote greater efficiency. Its benefit package is relatively poor, covering only about half of health care costs for our seniors. Most Medicare beneficiaries feel that they essentially are forced either to purchase Medigap plans, which provide the worst value of all private health plans, or to enroll in Medicare Advantage plans, which waste too many tax and premium dollars. It would be both much less expensive for all of us and better for Medicare beneficiaries if the extra benefits of these private plans were rolled into the traditional Medicare program. Part D should be stripped of its private market administrative and profit excesses and also be rolled into the traditional program. Medicare also has failed to introduce beneficial innovative programs such as the British NICE system, which would improve both quality and value in our health care.

When we advocate for an improved Medicare for all, we really aren’t advocating for Medicare with a few tweaks. We are advocating for replacing Medicare with a single payer national health program that covers everyone, which we can still call Medicare, just as the Canadians do. Adding another buy-in program to the two buy-in programs that already exist in our highly dysfunctional system will do virtually nothing to fix these flaws we now have. It does nothing to slow the growth in our national health expenditures, and the high premiums for a package of mediocre benefits will do little to reduce the numbers of uninsured.

For those who say that a Medicare buy-in is an incremental step towards health care utopia, explain precisely how that is going to work. Explain each problem that it solves. Explain how it is going to morph into a universal or near universal system in which each individual is paying the full actuarial value of the coverage. It won’t happen.

Playing with a Medicare buy-in is an unnecessary diversion at a time that we need to get serious about reform. We need to fix Medicare and expand it to cover everyone.  Nothing less will do.

By Tara Sussman Oakman, Robert J. Blendon, Andrea L. Campbell, Alan M. Zaslavsky and John M. Benson
Health Affairs
March 11, 2010

Abstract

The partisan split in Congress over health reform may reflect a broader divide among the public in attitudes toward the uninsured. Despite expert consensus over the harms suffered by the uninsured as a group, Americans disagree over whether the uninsured get the care they need and whether reform legislation providing universal coverage is necessary. We examined public perceptions of health care access and quality for the uninsured over time, and we found that Democrats are far more likely than Republicans to believe that the uninsured have difficulty gaining access to care. Senior citizens are less aware than others of the problems faced by the uninsured. Even among those Americans who perceive that the uninsured have poor access to care, Republicans are significantly less likely than Democrats to support reform. Thus, our findings indicate that even if political obstacles are overcome and health reform is enacted, future political support for ongoing financing to cover the uninsured could be uncertain.

Attitudes Toward Universal Coverage

Creating a national health insurance system to pay for most forms of health care was significantly more popular among people who perceived that the uninsured are unable to get care (72 percent) or able to get care with great difficulty (75 percent) than it was among those who perceived that it is not too difficult (38 percent) or not at all difficult (31 percent) for the uninsured to get care. Similarly, 63 percent of respondents who perceived that the uninsured do not get the same quality of care as the average insured person also favored national health insurance, as compared to a minority (43 percent) of respondents who said that there is no difference in the care obtained by uninsured and insured people.

These associations persisted even after political party and demographic characteristics were controlled for in multivariate analysis. As expected from prior literature, political party is still a significant predictor of support for reform. The effect of partisanship does not appear to be mediated by the perceptions of how difficult or not it is to obtain care. Republicans are less favorable toward national health insurance than Democrats, even after perceptions of care access or quality for the uninsured are controlled for.

http://content.healthaffairs.org/cgi/content/full/hlthaff.2009.1019v1

Comment: 

By Don McCanne, MD

Since the failure of the Clinton effort at reform there has been an intense campaign by innumerable entities to educate the nation on the problems with our health care system and the potential impact of the various solutions. The results of the surveys reported in this Health Affairs article are sobering, if not depressing.

A proliferation of studies has demonstrated beyond all doubt that uninsured individuals have difficulty gaining access to health care, and the results of those studies have been widely disseminated. Yet these surveys show that far too many individuals do not believe this is true in spite of the overwhelming evidence presented to them through the years.

This study demonstrated that those less likely to believe the facts about impaired access for the uninsured included Republicans, males, seniors, and the wealthy. What is perhaps most disconcerting of all is that even Republicans who do understand that lack of insurance impairs access still are opposed to creating a national health insurance system. They simply don’t care about the fate of those who must do without adequate health care.

Those supporting the current proposal before Congress should take note of this quotation from the article:

“Even among those who perceive that the uninsured have poor access to care, Republicans are significantly less likely than Democrats to support reform. Further, the elderly, who are a politically influential group because of their high political participation rates, are not cognizant of the problems faced by the uninsured. Thus, our findings indicate that even if President Barack Obama signs health reform into law, its future political support could be uncertain. A shift from Democratic to Republican control of either congressional body could mean the reduction or elimination of funding for insurance subsidies. Subsidies are essential to a coverage expansion that these critical constituencies ultimately deem unnecessary.”

The proposed private insurance subsidies are already so modest that RAND predicts that 25 million people will remain uninsured. When Republicans take control, under the proposed model of reform they wouldn’t even have to repeal the program. All they would have to do is slash the premium subsidies to wipe out the effectiveness of this legislation. Then the next step would be to reduce the actuarial value of the plans supported, thereby requiring sick and injured individuals to pay even more out of pocket than these plans already require.

Try that with a single publicly-financed and publicly-administered program that belongs to the people. The Republicans have already tried that with Medicare, and though they caused some damage, the program barely budged.

We desperately need a single program built on a solid foundation, a program that belongs to all of us – an improved Medicare for all.

A Partisan Divide On The Uninsured

By Tara Sussman Oakman, Robert J. Blendon, Andrea L. Campbell, Alan M. Zaslavsky and John M. Benson
Health Affairs
March 11, 2010

Abstract

The partisan split in Congress over health reform may reflect a broader divide among the public in attitudes toward the uninsured. Despite expert consensus over the harms suffered by the uninsured as a group, Americans disagree over whether the uninsured get the care they need and whether reform legislation providing universal coverage is necessary. We examined public perceptions of health care access and quality for the uninsured over time, and we found that Democrats are far more likely than Republicans to believe that the uninsured have difficulty gaining access to care. Senior citizens are less aware than others of the problems faced by the uninsured. Even among those Americans who perceive that the uninsured have poor access to care, Republicans are significantly less likely than Democrats to support reform. Thus, our findings indicate that even if political obstacles are overcome and health reform is enacted, future political support for ongoing financing to cover the uninsured could be uncertain.

Attitudes Toward Universal Coverage

Creating a national health insurance system to pay for most forms of health care was significantly more popular among people who perceived that the uninsured are unable to get care (72 percent) or able to get care with great difficulty (75 percent) than it was among those who perceived that it is not too difficult (38 percent) or not at all difficult (31 percent) for the uninsured to get care. Similarly, 63 percent of respondents who perceived that the uninsured do not get the same quality of care as the average insured person also favored national health insurance, as compared to a minority (43 percent) of respondents who said that there is no difference in the care obtained by uninsured and insured people.

These associations persisted even after political party and demographic characteristics were controlled for in multivariate analysis. As expected from prior literature, political party is still a significant predictor of support for reform. The effect of partisanship does not appear to be mediated by the perceptions of how difficult or not it is to obtain care. Republicans are less favorable toward national health insurance than Democrats, even after perceptions of care access or quality for the uninsured are controlled for.

http://content.healthaffairs.org/cgi/content/full/hlthaff.2009.1019v1

Comment: 

By Don McCanne, MD

Since the failure of the Clinton effort at reform there has been an intense campaign by innumerable entities to educate the nation on the problems with our health care system and the potential impact of the various solutions. The results of the surveys reported in this Health Affairs article are sobering, if not depressing.

A proliferation of studies has demonstrated beyond all doubt that uninsured individuals have difficulty gaining access to health care, and the results of those studies have been widely disseminated. Yet these surveys show that far too many individuals do not believe this is true in spite of the overwhelming evidence presented to them through the years.

This study demonstrated that those less likely to believe the facts about impaired access for the uninsured included Republicans, males, seniors, and the wealthy. What is perhaps most disconcerting of all is that even Republicans who do understand that lack of insurance impairs access still are opposed to creating a national health insurance system. They simply don’t care about the fate of those who must do without adequate health care.

Those supporting the current proposal before Congress should take note of this quotation from the article:

“Even among those who perceive that the uninsured have poor access to care, Republicans are significantly less likely than Democrats to support reform. Further, the elderly, who are a politically influential group because of their high political participation rates, are not cognizant of the problems faced by the uninsured. Thus, our findings indicate that even if President Barack Obama signs health reform into law, its future political support could be uncertain. A shift from Democratic to Republican control of either congressional body could mean the reduction or elimination of funding for insurance subsidies. Subsidies are essential to a coverage expansion that these critical constituencies ultimately deem unnecessary.”

The proposed private insurance subsidies are already so modest that RAND predicts that 25 million people will remain uninsured. When Republicans take control, under the proposed model of reform they wouldn’t even have to repeal the program. All they would have to do is slash the premium subsidies to wipe out the effectiveness of this legislation. Then the next step would be to reduce the actuarial value of the plans supported, thereby requiring sick and injured individuals to pay even more out of pocket than these plans already require.

Try that with a single publicly-financed and publicly-administered program that belongs to the people. The Republicans have already tried that with Medicare, and though they caused some damage, the program barely budged.

We desperately need a single program built on a solid foundation, a program that belongs to all of us – an improved Medicare for all.

A Partisan Divide On The Uninsured

By Tara Sussman Oakman, Robert J. Blendon, Andrea L. Campbell, Alan M. Zaslavsky and John M. Benson
Health Affairs
March 11, 2010
Abstract
The partisan split in Congress over health reform may reflect a broader divide among the public in attitudes toward the uninsured. Despite expert consensus over the harms suffered by the uninsured as a group, Americans disagree over whether the uninsured get the care they need and whether reform legislation providing universal coverage is necessary. We examined public perceptions of health care access and quality for the uninsured over time, and we found that Democrats are far more likely than Republicans to believe that the uninsured have difficulty gaining access to care. Senior citizens are less aware than others of the problems faced by the uninsured. Even among those Americans who perceive that the uninsured have poor access to care, Republicans are significantly less likely than Democrats to support reform. Thus, our findings indicate that even if political obstacles are overcome and health reform is enacted, future political support for ongoing financing to cover the uninsured could be uncertain.
Attitudes Toward Universal Coverage
Creating a national health insurance system to pay for most forms of health care was significantly more popular among people who perceived that the uninsured are unable to get care (72 percent) or able to get care with great difficulty (75 percent) than it was among those who perceived that it is not too difficult (38 percent) or not at all difficult (31 percent) for the uninsured to get care. Similarly, 63 percent of respondents who perceived that the uninsured do not get the same quality of care as the average insured person also favored national health insurance, as compared to a minority (43 percent) of respondents who said that there is no difference in the care obtained by uninsured and insured people.
These associations persisted even after political party and demographic characteristics were controlled for in multivariate analysis. As expected from prior literature, political party is still a significant predictor of support for reform. The effect of partisanship does not appear to be mediated by the perceptions of how difficult or not it is to obtain care. Republicans are less favorable toward national health insurance than Democrats, even after perceptions of care access or quality for the uninsured are controlled for.
http://content.healthaffairs.org/cgi/content/full/hlthaff.2009.1019v1

Since the failure of the Clinton effort at reform there has been an intense campaign by innumerable entities to educate the nation on the problems with our health care system and the potential impact of the various solutions. The results of the surveys reported in this Health Affairs article are sobering, if not depressing.
A proliferation of studies has demonstrated beyond all doubt that uninsured individuals have difficulty gaining access to health care, and the results of those studies have been widely disseminated. Yet these surveys show that far too many individuals do not believe this is true in spite of the overwhelming evidence presented to them through the years.
This study demonstrated that those less likely to believe the facts about impaired access for the uninsured included Republicans, males, seniors, and the wealthy. What is perhaps most disconcerting of all is that even Republicans who do understand that lack of insurance impairs access still are opposed to creating a national health insurance system. They simply don’t care about the fate of those who must do without adequate health care.
Those supporting the current proposal before Congress should take note of this quotation from the article:
“Even among those who perceive that the uninsured have poor access to care, Republicans are significantly less likely than Democrats to support reform. Further, the elderly, who are a politically influential group because of their high political participation rates, are not cognizant of the problems faced by the uninsured. Thus, our findings indicate that even if President Barack Obama signs health reform into law, its future political support could be uncertain. A shift from Democratic to Republican control of either congressional body could mean the reduction or elimination of funding for insurance subsidies. Subsidies are essential to a coverage expansion that these critical constituencies ultimately deem unnecessary.”
The proposed private insurance subsidies are already so modest that RAND predicts that 25 million people will remain uninsured. When Republicans take control, under the proposed model of reform they wouldn’t even have to repeal the program. All they would have to do is slash the premium subsidies to wipe out the effectiveness of this legislation. Then the next step would be to reduce the actuarial value of the plans supported, thereby requiring sick and injured individuals to pay even more out of pocket than these plans already require.
Try that with a single publicly-financed and publicly-administered program that belongs to the people. The Republicans have already tried that with Medicare, and though they caused some damage, the program barely budged.
We desperately need a single program built on a solid foundation, a program that belongs to all of us – an improved Medicare for all.

A Partisan Divide On The Uninsured

By Tara Sussman Oakman, Robert J. Blendon, Andrea L. Campbell, Alan M. Zaslavsky and John M. Benson
Health Affairs
March 11, 2010

Abstract

The partisan split in Congress over health reform may reflect a broader divide among the public in attitudes toward the uninsured. Despite expert consensus over the harms suffered by the uninsured as a group, Americans disagree over whether the uninsured get the care they need and whether reform legislation providing universal coverage is necessary. We examined public perceptions of health care access and quality for the uninsured over time, and we found that Democrats are far more likely than Republicans to believe that the uninsured have difficulty gaining access to care. Senior citizens are less aware than others of the problems faced by the uninsured. Even among those Americans who perceive that the uninsured have poor access to care, Republicans are significantly less likely than Democrats to support reform. Thus, our findings indicate that even if political obstacles are overcome and health reform is enacted, future political support for ongoing financing to cover the uninsured could be uncertain.

Attitudes Toward Universal Coverage

Creating a national health insurance system to pay for most forms of health care was significantly more popular among people who perceived that the uninsured are unable to get care (72 percent) or able to get care with great difficulty (75 percent) than it was among those who perceived that it is not too difficult (38 percent) or not at all difficult (31 percent) for the uninsured to get care. Similarly, 63 percent of respondents who perceived that the uninsured do not get the same quality of care as the average insured person also favored national health insurance, as compared to a minority (43 percent) of respondents who said that there is no difference in the care obtained by uninsured and insured people.

These associations persisted even after political party and demographic characteristics were controlled for in multivariate analysis. As expected from prior literature, political party is still a significant predictor of support for reform. The effect of partisanship does not appear to be mediated by the perceptions of how difficult or not it is to obtain care. Republicans are less favorable toward national health insurance than Democrats, even after perceptions of care access or quality for the uninsured are controlled for.

http://content.healthaffairs.org/cgi/content/full/hlthaff.2009.1019v1

Since the failure of the Clinton effort at reform there has been an intense campaign by innumerable entities to educate the nation on the problems with our health care system and the potential impact of the various solutions. The results of the surveys reported in this Health Affairs article are sobering, if not depressing.

A proliferation of studies has demonstrated beyond all doubt that uninsured individuals have difficulty gaining access to health care, and the results of those studies have been widely disseminated. Yet these surveys show that far too many individuals do not believe this is true in spite of the overwhelming evidence presented to them through the years.

This study demonstrated that those less likely to believe the facts about impaired access for the uninsured included Republicans, males, seniors, and the wealthy. What is perhaps most disconcerting of all is that even Republicans who do understand that lack of insurance impairs access still are opposed to creating a national health insurance system. They simply don’t care about the fate of those who must do without adequate health care.

Those supporting the current proposal before Congress should take note of this quotation from the article:

“Even among those who perceive that the uninsured have poor access to care, Republicans are significantly less likely than Democrats to support reform. Further, the elderly, who are a politically influential group because of their high political participation rates, are not cognizant of the problems faced by the uninsured. Thus, our findings indicate that even if President Barack Obama signs health reform into law, its future political support could be uncertain. A shift from Democratic to Republican control of either congressional body could mean the reduction or elimination of funding for insurance subsidies. Subsidies are essential to a coverage expansion that these critical constituencies ultimately deem unnecessary.”

The proposed private insurance subsidies are already so modest that RAND predicts that 25 million people will remain uninsured. When Republicans take control, under the proposed model of reform they wouldn’t even have to repeal the program. All they would have to do is slash the premium subsidies to wipe out the effectiveness of this legislation. Then the next step would be to reduce the actuarial value of the plans supported, thereby requiring sick and injured individuals to pay even more out of pocket than these plans already require.

Try that with a single publicly-financed and publicly-administered program that belongs to the people. The Republicans have already tried that with Medicare, and though they caused some damage, the program barely budged.

We desperately need a single program built on a solid foundation, a program that belongs to all of us – an improved Medicare for all.

By Michael Hochman and Danny McCormick
Los Angeles Times
March 10, 2010

Some doctors treat patients with early-stage prostate cancer with radiation. Others favor surgery, while some advocate only close monitoring. Which approach is most successful? No one knows.

When it comes to diabetes management, doctors don’t have answers to key questions: At what point should insulin be started? Is it safe to lower the blood sugar to normal levels? What is the best way to monitor blood sugar control?

Similarly, endocrinologists don’t know what is the best way to treat patients with hyperactive thyroids. Doctors in Europe typically use medications, while those in the U.S. more frequently give radioactive iodine. Only limited evidence is available to guide the decision.

It may seem perplexing that there is so much uncertainty about these relatively simple questions. All of the above treatments have been around for decades. Shouldn’t we have definitive answers by now?

In this week’s issue of the Journal of the American Medical Assn., we report the results of a study that may help explain why we don’t. In the study, we analyzed 328 medication studies recently published in six top medical journals and found that just 32% were aimed at determining which available treatment is best. The rest were either aimed at bringing a new therapy to market or simply compared a medication with a placebo. Whether the therapy was better or worse than other treatments was simply not addressed.

Research involving new therapies is of course crucial for medical progress, but there is also a need for research that compares the effectiveness of the rapidly growing array of existing therapies and approaches.

So why, then, did only a third of medication studies focus on helping doctors use existing therapies more effectively? The answer lies in the fact that pharmaceutical companies fund nearly half of all medication research, including the lion’s share of large clinical trials. For obvious reasons, commercially funded research is primarily geared toward the development of new and marketable medications and technologies. Once these products have won approval for clinical use, companies no longer have incentives to study exactly how and when they should be used.

In support of this claim, we found that 87% of the comparative effectiveness studies we analyzed were funded entirely or in part by non-commercial sources, such as nonprofit foundations or government institutions. In addition, 91% of studies comparing medications with non-pharmacologic therapies (such as surgery or lifestyle changes) received non-commercial funding, as did 94% of studies comparing different medication strategies (such as different blood sugar targets in patients with diabetes) and 90% of studies comparing the safety profiles of medications. Non-commercial sources funded 100% of studies comparing the cost- effectiveness of different treatments, though only 2% of the studies we reviewed included such analysis.

Congress recently appropriated more than $1 billion in the American Recovery and Reinvestment Act to promote comparative effectiveness research. This is a good first step, but the money will need to be spent carefully. We believe studies that address fundamental clinical decisions — such as when to use medications versus surgery or how to use therapies more effectively — should be favored over those that simply compare two alternative medications. There is also clearly a need for more research on the comparative safety and costs of different treatments. And although many researchers are thankful for the new research funds, it may soon become apparent that $1 billion is far from sufficient.

Reform is also necessary to ensure that commercially funded research is designed in a way that is more helpful to doctors. Our study showed that two-thirds of commercially funded randomized trials compared medications with a placebo rather than with another active therapy. Though placebos are appropriate when no alternative therapies are available, in many of the trials we examined, we suspect alternative therapies could have been used instead. For this reason, we believe that regulatory agencies such as the Food and Drug Administration should only approve new therapies that have been shown to be at least as good as existing therapies whenever such alternatives exist. Alternatively, though more controversial, some experts have proposed that pharmaceutical companies should be allowed to fund — but not design — clinical studies.

As medical science advances, clinical decision-making will only become more complex. Only by expanding public funding for comparative effectiveness research can we hope to put existing medical treatments and healthcare services to their best use. Doing so would ensure that national research priorities are determined by patient needs rather than by corporate agendas.

Michael Hochman, MD, is an assistant professor of clinical medicine at USC’s Keck School of Medicine. Danny McCormick, MD, MPH, is an assistant professor of medicine at Harvard Medical School.

http://www.latimes.com/news/opinion/commentary/la-oe-hochman10-2010mar10,0,3812725.story

JAMA – Characteristics of Published Comparative Effectiveness Studies of Medications, by Michael Hochman, MD and Danny McCormick, MD, MPH:
http://jama.ama-assn.org/cgi/content/full/303/10/951

JAMA editorial – Charting a Path From Comparative Effectiveness Funding to Improved Patient-Centered Health Care, by Patrick H. Conway, MD, MSc and Carolyn Clancy, MD:
http://jama.ama-assn.org/cgi/content/full/303/10/985

Comment: 

By Don McCanne, MD

Rather than using excerpts from the JAMA article by Hochman and McCormick as today’s qotd, their op-ed in today’s Los Angeles Times provides an even better summary of their findings along with their astute comments.  Their op-ed obviates the need for me to provide any additional commentary.