PNHP

Universal health care would cost U.S. less

Universal health care would cost U.S. less

Letter to the Editor
Portsmouth (N.H.) Herald
March 04, 2010

Like Sen. Judd Gregg, I also believe Congress needs to start over with its health care efforts — but for very different reasons.

The current Senate bill has many good features, including the elimination of pre-existing conditions as an excuse for denying insurance and the prohibition of denial of existing coverage when a patient becomes ill. But, as a member of the Physicians for a National Health Program, I feel the current reform efforts falls far short of the goals of PNHP — namely, providing universal health coverage for all Americans and eliminating the excessive waste of health insurance premiums. At present, more than 30 percent of health insurance premiums goes toward administrative expenses and profits. In contrast, administrative expenses under Medicare amount to 3 to 4 percent of expenses.

H.R. 676, which has been suppressed in the House of Representatives for several years, and was not even included in the discussions on health care reform, would provide universal coverage for all Americans under a single-payer health care system for less than what is currently being spent for health care in the United States.

It is a disgrace that the United States is the only developed country in the world that does not provide universal health care coverage, even though we currently spend 17 percent of our gross national product for health care. That is up to twice what other developed countries spend on health care, and they cover all of their citizens.

I would urge everyone to read T.R. Reid’s book, “The Healing of America.” In his book he describes how numerous developed countries provide high quality universal health care coverage. Mr. Reid describes a variety of systems, including single payer and private insurance-based systems.

All of these systems share these basic characteristics: Everyone is included in the health care system; they are all nonprofit; and they all have low administrative expenses.

After reviewing the facts (and ignoring the hyperbole), I urge everyone to contact their senators and representatives to push for true health care reform that provides universal coverage.

P.S. For more information, please visit www.pnhp.org.

H. Dixon Turner, M.D.
Portsmouth, N.H.

http://www.seacoastonline.com/articles/20100304-OPINION-3040392

The single-payer failure

By Rick Alterbaum
The Brandeis Hoot (Brandeis University’s Community Newspaper)
March 5, 2010

Last Thursday, President Obama and leaders from both parties deliberated for seven hours to espouse their talking points and delve into the intricacies of health care policy.  They discussed a multitude of topics, ranging from health savings accounts to medical malpractice reform to the “Cornhusker Kickback.”  What they did not mention, however, was the possibility of establishing a single-payer health care system.  This failure of Congress to consider the plausibility of this policy has been the underlying tragedy of the health care debate.

Several months into the Obama presidency, the Democrats took on the challenge of fixing the broken and convoluted structure in which the American people acquire health insurance.  Believing they possessed a mandate for change after their gigantic 2008 victory, the Democrats yearned for a major legislative victory.  And, more importantly, they ultimately wished to make history where presidents from Theodore Roosevelt to Bill Clinton could not.

But right from the start of this initiative, the Democrats did not even entertain the thought of a single-payer option.  They dismissed it as too radical and politically infeasible, viewing it as a fringe issue and a pet project of the far left.

This is foolhardy. The creation of a single-payer health care system would only extend Medicare coverage to every hard-working, tax-paying American citizen.  Medicare is not a perfect institution.  Indeed, the program contains its fair share of fraud, abuse and waste.  However, its administrative costs are generally far lower than those associated with private health insurance companies, and seniors who are recipients of Medicare’s federally-mandated benefits overwhelmingly approve of the quality and treatment associated with the care they receive.  This program is familiar, a household name from the political lexicon and popular.

So why can’t people younger than 65 be so fortunate?  According to conservatives, single-payer is socialism, government takeover and communism, to name a few.

Despite the conservative histrionics, advocates of these views are at least partially right.  Under a single-payer system, every person would receive coverage that is funded by the federal government.  Consequently, the market for private health insurance would, if not dissipate, erode significantly.

But that shouldn’t be counted against the single-payer system.  People like their doctors and the care they receive and don’t like   the intermediaries they need to deal with as the beneficiaries of this care.  This is especially the case when said-intermediaries escalate premiums by up to 39 percent, as Anthem Blue Cross in California did recently, when said-intermediaries deny people coverage based on previous medical conditions and preexisting conditions; when said-intermediaries haggle and squabble over nearly every single medical claim they get.

As long as for-profit insurers are dominant, the American people will suffer.  Even if the current health care reform bill passes, this will still be the case.  These companies will presumably find loopholes that they can exploit in order to elude the prospect of truly abiding by new regulations.  At the same time, due to an individual mandate, millions of more Americans will be forced into the greedy clutches of these insurers via a virtual marketplace, or exchange.  There will not even be an alternative for these individuals—no public option, no Medicare buy-in, no health care cooperatives, nothing besides a Medicaid expansion for the poor.

While the current proposal is better than nothing, the American people shouldn’t have to settle.

It is a shame that the Democrats did not take the single-payer, Medicare-for-all route.  Quite simply, they do not have the guts to defend significantly expanding government, even when doing so is manifestly in the public interest.  The irrational, paranoid stigma attached to big government looms over their every move.

http://thebrandeishoot.com/articles/7486

A Fresh Approach to Health Care Reform

By MARK E. WILSON
Birmingham News
March 7, 2010

Recently in clinic at Cooper Green Mercy Hospital, I saw a man in his 50s who had a good relationship with his doctor until three years ago, when he lost his job and his health insurance. Before long, he could no longer afford health care from his doctor. He had a history of “borderline diabetes,” but he felt reasonably well, until last month, when his big toe turned black. He came to our emergency room and was admitted with uncontrolled diabetes, kidney disease and gangrene of his toe, which required an amputation.

This man was at least fortunate enough to live in Jefferson County, where an unusual law requires that a portion of the local sales tax revenue goes toward indigent care. But consider a patient I saw at a volunteer clinic in Shelby County, who injured his shoulder through no fault of his own and became unable work at his regular labor job which did not offer health insurance. He received emergency care, but he was unable to pay the money required upfront to see an orthopedic surgeon or have the operation required to restore his shoulder to a level of function necessary to resume his work.

I consider myself fortunate to be a physician who works at a public hospital dedicated to providing quality health care regardless of a person’s ability to pay. I get to be what I’ve wanted to be since I was a kid: a medical doctor who helps people in need, especially those who cannot find help elsewhere.

In the national health care reform debate, I’ve heard other doctors object to any system in which the government plays a major role in financing care. They say they don’t want government getting between them and their patients. These doctors do have some legitimate concerns, but part of me is perplexed. Several times a day, I see patients who had something come between them and their doctor, but it wasn’t the government. It was the loss of a job, loss of private insurance, new restrictions imposed by a private insurer or just a simple lack of money.

I see patients like these again and again, often with some really sad stories. They run out of medicines and get sick. Some end up with strokes, heart attacks, amputations, incurable cancers or premature death, all of which may have been prevented if their care had not been interrupted. Some may get to us before they get sick, but only after unnecessary anxiety, disruption and waste of resources, such as emergency room visits or unnecessary duplication of medical tests.

I have no trouble believing the study in the September 2009 American Journal of Public Health estimating that 45,000 people die in the United States each year due to lack of health insurance. That’s one death every 12 minutes. An American Journal of Medicine study published last year showed 62 percent of bankruptcies in 2007 were linked to medical bills. Three-quarters of these medical bankruptcies were for people who had health insurance when they first got sick. A report by Families USA showed that 73.6 percent of the medically uninsured in Alabama are members of working families.

The human tragedies buried in these grim statistics occur because our society has not found the will to ensure everyone has lifelong access to health care. The legislation currently being considered in Washington is not going to provide this or do much to control runaway costs.

Before Medicare was passed in 1965, millions of our nation’s elderly were without adequate health care and driven into poverty by high medical bills. Once signed into law, our seniors’ plights changed overnight. Medicare, even with its imperfections, has served this population relatively well ever since, and with relatively low administrative costs.

Physicians for a National Health Program, using research done by Steffie Woolhandler, M.D., and David Himmelstein, M.D., of Harvard Medical School, estimates that a publicly funded, single-payer system can save about $400 billion annually by eliminating the enormous administrative costs associated with a multi-payer system that includes for-profit, private insurance companies. This would be enough money to cover all of those who are currently uninsured. Additional savings could be attained through bulk purchasing of medicines. I suggest that we start with an overhaul of the Medicare program, which already has an infrastructure in place, and offer it to all citizens.

With this kind of true health care reform, I would be able to say to any patient in Alabama, “Welcome. We’re going to do our best to provide you with the care that you need.” Wouldn’t every doctor like to be able to say that?

Mark Wilson, M.D., practices general internal medicine and is chief of staff at Cooper Green Mercy Hospital. E-mail: wilsonm@jccal.org.

http://blog.al.com/birmingham-news-commentary/2010/03/viewpoints_a_fresh_approach_to.html

Massachusetts Senate election: A call to start over on healthcare reform

Dr. James C. Mitchiner
Ann Arbor (Mich.) News
March 7, 2010

Count me among those who were not terribly disappointed at the outcome of the recent Senate race in Massachusetts to fill the un-expired term of the late Sen. Edward Kennedy.

The election of Scott Brown, a conservative Republican who until recently was an obscure state senator, in a state well known for its liberal politics, should be construed as nothing less than a revealing denouement of the Democratic health reform agenda. Nor should the outcome of this election be seen as an unanticipated surprise; well before the historic Jan. 19 vote, there was indeed a sense that the Massachusetts voters were collectively acting as the nation’s proverbial “canary in the coal mine” for the Democrats’ ambitious social agenda.

Exit polls suggested that voters’ concerns over the scope and speed of health care reform provided the primary motivator for their electoral decision. Whether the reforms proposed by the Democratic congressional leadership were too radical, too costly, too confusing or too partisan for the taste of the average independent voter, one conclusion is certain: health care reform, in its current iteration, made people uncomfortable. Clearly, the proposed health bills are unnecessarily convoluted, bureaucratic and controversial. And if Brown’s election provides the 41st vote needed to scuttle health care reform in the Senate, perhaps he has done the country – and the Democrats – a big favor. It’s not that I want to wait the next 16 years for yet another attempt at overhauling our deplorable, inept and inequitable health care system. Rather, I join the chorus of those, particularly the Republican congressional leadership, who are demanding that we start over on health care reform. We can begin by recognizing what works: Medicare. Yes, Medicare has its faults. It underpays doctors and hospitals, is going broke, is subject to fraud (although perhaps not to the extent that some claim), and has its own bureaucracy. But it also has an established infrastructure, provides universal coverage and is highly popular among senior citizens.

In terms of reimbursement, its apparent pecuniary stinginess stems from doctors’ need to pay their office overhead, which of course can be traced to the extra costs and time spent dealing with our rapacious for-profit health insurance industry. And the way to “save” Medicare from its impending bankruptcy is to expand its risk pool by incorporating younger – and healthier (read: less costly) – beneficiaries, and pay for it through a more progressive tax structure than what now exists.

In other words, we need to extend the benefits of Medicare to all Americans by creating a universal, equitable, portable and more cost-effective single-payer Medicare-for-All health care system.

Single-payer’s mischaracterization as “socialized medicine” can be remedied by educating citizens to understand that a single-payer system will permit them to go to the physician and hospital of their choice, an option they lack now because they are limited to a provider within their health plan’s network.

Single-payer will permit them to have health insurance coverage independent of their job, and even if they are unemployed. Single-payer will stay with them as they switch jobs or move from state to state. A single-payer system will simplify billing, capture administrative economies of scale, and provide uniform benefits, including coverage for pre-existing conditions. And single-payer will reduce racial, gender, financial and geographic disparities of care.

In his State of the Union address last month, President Barack Obama asked rhetorically, “But if anyone from either party has a better approach that will bring down premiums, bring down the deficit, cover the uninsured, strengthen Medicare for seniors, and stop insurance company abuses, let me know…. I’m eager to see it.”

Well, Mr. President, I know of a solution that will meet all those goals: a universal, single-payer, Medicare-for-All program. I’m eager to see it, too.

Dr. James C. Mitchiner is an Ann Arbor emergency physician and the former president of the Washtenaw County Medical Society.

http://www.annarbor.com/news/opinion/massachusetts-senate-election-a-call-to-start-over-on-healthcare-reform/

AMA and Goldman Sachs on insurer market concentration and decline in price competition

Health plans extend their market dominance

By Emily Berry
American Medical News
March 8, 2010

Members of Congress and state lawmakers have called health insurance executives on the carpet to make them explain why their companies are hiking individual insurance rates so steeply across the country. A recently released American Medical Association study of health insurance markets gives one answer: Because they can.

The AMA’s most recent look at the health insurance market — “Competition in health insurance: A comprehensive study of U.S. markets,” released Feb. 23 and based on 2009 data — finds that 99% of 313 metropolitan areas tracked would be considered to have “highly concentrated” insurance markets under guidelines used by the U.S. Dept. of Justice and the Federal Trade Commission. In its 2009 version of the study, the AMA found that 94% of metropolitan areas were ranked “highly concentrated.”

One insurer held 70% or more of the health plan market share in 24 of 43 states measured, up from 18 in 42 states in the previous year’s study. In 92% of the 313 markets in the report, one insurer held at least a 30% share.

In past releases of its survey, the AMA has noted that insurer market dominance has allowed health plans to force physicians into take-it-or-leave-it contracts. But this year the AMA — echoing other experts — noted that market dominance has allowed plans to give patients take-it-or-leave-it pricing.

http://www.ama-assn.org/amednews/2010/03/08/bil20308.htm

And…

A front-line perspective on 2010 commercial price & product trends

Transcript of conference call with Willis
Goldman Sachs
March 3, 2010

Matt Borsch, Goldman Sachs:  Let me jump right in here with, perhaps, the most important question from the standpoint of institutional investors looking at the sector, and that is, what are you seeing in terms of competition between the carriers, specifically relative to last year or two years ago or whatever you want to use as the baseline, has price competition increased or decreased?

Steve Lewis, regional leader for the employee benefits practice of Willis, the third largest insurance broker in the world:  As a specific answer to that, we would say, price competition is down from year ago. An overall theme that we would characterize this year, meaning, when I say this year, the just completed January 1 renewals, and continuing up and through today. We feel this is the most challenging environment for us and our clients in my 20 years in the business.

Not only is price competition down from year ago (when we had characterized last year’s price competition as being down from the prior year), but trend or (healthcare) inflation is also up and appears to be rising. The incumbent carriers seem more willing than ever to walk away from existing business resulting in some carrier changes.

And that’s a significant adjustment from last year where we saw aggressive pricing on the renewal front but not so much on the new business front.

http://graphics8.nytimes.com/packages/pdf/health/20100307_GOLDMAN.pdf

Comment: 

By Don McCanne, MD

So 99 percent of metropolitan areas have “highly concentrated” private insurance markets, and price competition of private insurers continues to decrease as private insurers are “more willing than ever to walk away from existing business.” Competitive pricing has almost disappeared from the private insurance market, so insurance has become a “take it or leave it” proposition.

And precisely what does the legislation before Congress do to ensure a competitive market of private insurance plans? Look at the Senate bill which forms the basis of the Obama proposal. When you read “Part II – Consumer Choices and Insurance Competition through Health Benefit Exchanges,” you will see that this legislation does virtually nothing to expand insurer competition in these concentrated markets.

President Obama and the members of Congress need to give up on the idea that they can legislate a thriving, competitive market of private health plans that will bring affordable health care to all of us. The changes that would be required are not in this bill, and, besides, they would be more complex, more expensive, and less effective than merely replacing the private insurers with a single payer national health program – an improved Medicare for all.

Once again today, in a pep talk at Arcadia University near Philadelphia, President Obama said that they put all ideas on the table, but they didn’t. They left single payer off. He did mention that people on the left wanted single payer, and judging by the cheers, apparently the audience wants single payer as well. Too bad he doesn’t listen.

AMA and Goldman Sachs on insurer market concentration and decline in price competition

Health plans extend their market dominance

By Emily Berry
American Medical News
March 8, 2010
Members of Congress and state lawmakers have called health insurance executives on the carpet to make them explain why their companies are hiking individual insurance rates so steeply across the country. A recently released American Medical Association study of health insurance markets gives one answer: Because they can.
The AMA’s most recent look at the health insurance market — “Competition in health insurance: A comprehensive study of U.S. markets,” released Feb. 23 and based on 2009 data — finds that 99% of 313 metropolitan areas tracked would be considered to have “highly concentrated” insurance markets under guidelines used by the U.S. Dept. of Justice and the Federal Trade Commission. In its 2009 version of the study, the AMA found that 94% of metropolitan areas were ranked “highly concentrated.”
One insurer held 70% or more of the health plan market share in 24 of 43 states measured, up from 18 in 42 states in the previous year’s study. In 92% of the 313 markets in the report, one insurer held at least a 30% share.
In past releases of its survey, the AMA has noted that insurer market dominance has allowed health plans to force physicians into take-it-or-leave-it contracts. But this year the AMA — echoing other experts — noted that market dominance has allowed plans to give patients take-it-or-leave-it pricing.
http://www.ama-assn.org/amednews/2010/03/08/bil20308.htm

And…

A front-line perspective on 2010 commercial price & product trends

Transcript of conference call with Willis
Goldman Sachs
March 3, 2010
Matt Borsch, Goldman Sachs:  Let me jump right in here with, perhaps, the most important question from the standpoint of institutional investors looking at the sector, and that is, what are you seeing in terms of competition between the carriers, specifically relative to last year or two years ago or whatever you want to use as the baseline, has price competition increased or decreased?
Steve Lewis, regional leader for the employee benefits practice of Willis, the third largest insurance broker in the world:  As a specific answer to that, we would say, price competition is down from year ago. An overall theme that we would characterize this year, meaning, when I say this year, the just completed January 1 renewals, and continuing up and through today. We feel this is the most challenging environment for us and our clients in my 20 years in the business.
Not only is price competition down from year ago (when we had characterized last year’s price competition as being down from the prior year), but trend or (healthcare) inflation is also up and appears to be rising. The incumbent carriers seem more willing than ever to walk away from existing business resulting in some carrier changes.
And that’s a significant adjustment from last year where we saw aggressive pricing on the renewal front but not so much on the new business front.
http://graphics8.nytimes.com/packages/pdf/health/20100307_GOLDMAN.pdf

So 99 percent of metropolitan areas have “highly concentrated” private insurance markets, and price competition of private insurers continues to decrease as private insurers are “more willing than ever to walk away from existing business.” Competitive pricing has almost disappeared from the private insurance market, so insurance has become a “take it or leave it” proposition.
And precisely what does the legislation before Congress do to ensure a competitive market of private insurance plans? Look at the Senate bill which forms the basis of the Obama proposal. When you read “Part II – Consumer Choices and Insurance Competition through Health Benefit Exchanges,” you will see that this legislation does virtually nothing to expand insurer competition in these concentrated markets.
President Obama and the members of Congress need to give up on the idea that they can legislate a thriving, competitive market of private health plans that will bring affordable health care to all of us. The changes that would be required are not in this bill, and, besides, they would be more complex, more expensive, and less effective than merely replacing the private insurers with a single payer national health program – an improved Medicare for all.
Once again today, in a pep talk at Arcadia University near Philadelphia, President Obama said that they put all ideas on the table, but they didn’t. They left single payer off. He did mention that people on the left wanted single payer, and judging by the cheers, apparently the audience wants single payer as well. Too bad he doesn’t listen.

Obama’s Reprehensible Rhetoric Against Single-Payer

By Matthew Rothschild
The Progressive, March 3, 2010

When Barack Obama gave his “this is it” speech on health care reform on March 3, he once again swerved out of his way to hit advocates of a single-payer system.

He said: “On one end of the spectrum, there are some who have suggested scrapping our system of private insurance and replacing it with government-run health care. Though many other countries have such a system, in America it would be neither practical nor realistic.”

You can argue about whether it is realistic politically but there should be no question whatsoever that it’s practical in the sense of being functional. It works well in other countries, including Canada, and there is no reason it can’t work well here. Canada’s health outcomes, and the health outcomes of every other advanced industrial country with government-run systems, are superior to ours.

Maybe Obama was using the “neither, nor” construction to try to strengthen his weak and illogical opposition to single-payer and even to a robust public option like Medicare for all who want it—and 65 percent of the American people do want that kind of a public option.

There is not that much difference between “practical” and “realistic” if by both he meant to say politically possible. I suppose he could have really stretched the sentence out by saying “government-run health care . . . would be neither practical nor realistic nor feasible nor possible nor doable nor achievable nor viable.” But it would all mean the same thing. At bottom, he didn’t want to expend any political capital for it, or even for the robust public option.

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Instead, he exploited advocates of a single-payer system as a foil to say, in not so many words, “I’m not an extremist like they are.”

He juxtaposed them with Republicans who want to “loosen regulations on the insurances companies.” And he did so in order to try to claim the middle ground, on the false and facile assumption that the middle ground is always the best ground.

Here’s how he put it: “I don’t believe we should give government bureaucrats or insurance company bureaucrats more control over health care in America.”

By damning “government bureaucrats,” Obama played right into the hands of the anti-government crowd and made any durable expansion of health care coverage all the more difficult. He also insulted every single federal employee in the Medicare and Medicaid and VA and Indian health programs.

This was reprehensible rhetoric.

Matthew Rothschild is the editor of The Progressive magazine.

http://progressive.org/wx0303b10.html

Why Is Barack Obama Writing GOP Talking Points?

By John Nichols
The Nation, The Beat Blog
03/05/2010

If you want to know where conservatives in Congress get all their ridiculous talking points about how dysfunctional the federal government is, how incapable the public sector is when it comes to doing anything right and, above all, how worthless federal employees are, we’ve tracked down the source.

It’s not Rush Limbaugh.

It’s not Michael Steele.

It’s Barack Obama.

The president, who was once an ardent advocate for repairing are broken health care system by developing a single-payer “Medicare for All” program, now rejects the wisdom he expressed before moving to Washington.

As recently as 2003, Obama told an AFL-CIO gathering in Illinois: “I happen to be a proponent of a single payer universal health care program. I see no reason why the United States of America, the wealthiest country in the history of the world, spending 14 percent of its Gross National Product on health care cannot provide basic health insurance to everybody. And that’s what (another speaker) is talking about when he says everybody in, nobody out — single payer health care plan, a universal health care plan.”

Yet, after excluding single-payer advocates from his health care summit, the president explicitly rejected the option when he delivered a March 3 speech pressing for final action to enact some sort of health care reform.

Just as his speech dismissed “Party of No” Republicans who want to “loosen regulations on the insurance companies,” Obama took a swipe at the real reformers with whom he once stood in solidarity.

“On one end of the spectrum, there are some who have suggested scrapping our system of private insurance and replacing it with government-run health care,” the president declared. “Though many other countries have such a system, in America it would be neither practical nor realistic.”

The president is wrong about what is practical or realistic.

Those “other countries” he mentions are industrialized democracies that budget analysts and physicians have long argued that, by expanding access to care while cutting costs, a “Medicare for All” plan would improve the competitive position of U.S. industries in global markets.

But the president is even more wrong to dismiss a single-payer response as unworkable because of some supposed flaw in the DNA of the public employees who would implement real reform.

“I don’t believe we should give government bureaucrats or insurance company bureaucrats more control over health care in America,” declared Obama.

So the president is equating career civil servants – like the folks who organize the military’s health care, services for veterans, the existing Medicare and Medicaid programs, the Indian Health Services and the care provided for the president and his family – with insurance company profiteers who refuse coverage to people with preexisting conditions, discriminate against women and the elderly in establishing pricing structures and connive to deny care to Americans when they need it most.

My friend Matt Rothschild, the able editor of The Progressive magazine, describes Obama’s statement as “reprehensible rhetoric.” It is difficult to disagree.

But what Obama’s flawed calculus does is even more damaging than his word choice.

By suggesting that “government bureaucrats” are no better than “insurance company bureaucrats,” the president reinforces everything his Republican critics are saying. Republicans in the House and Senate argue that a “government takeover of health care” would not do a thing to expand quality of care or to reduce costs.

With his inept comparison, Obama says pretty much the same thing.

In effect, he is writing the GOP’s talking points.

The U.S. needs a new health care system, to be sure.

But, even more urgently, Obama needs a new speechwriter.

http://www.thenation.com/blogs/thebeat/537639/why_is_barack_obama_writing_gop_talking_points

State single payer waiver provisions in the Senate healthcare bill – legislative language and fact sheet from Vermont Sen. Bernie Sanders

Why the 1332 Waiver in the Senate Health Reform Bill is the Only Opportunity for State Single Payer Systems Under the Bill

The health care reform bill passed by the Senate requires that all states set up Exchanges through which private insurance companies could sell their plans.  Because federal laws preempt state laws, the federal health care reform bill would supplant any state attempt to set up a single payer system in lieu of an Exchange, which by its nature calls for multiple payers to compete.  If the Senate bill is enacted, the only opportunity for states to move toward a single payer system is found in Section 1332.  This section would allow a state with a plan that meets certain coverage and affordability requirements to waive out of the requirement to set up an Exchange for private insurance companies.  Only with such a waiver could a state move in the direction of a single payer system.

The requirements of the Senate bill

Section 1311(b) of the Senate healthcare reform bill requires that “each state shall, not later than January 1, 2014, establish an American Health Benefit Exchange” through which a variety of health insurance plans could compete for buyers.  Additionally, states would have to create “Small Business Health Options Program Exchanges” through which small businesses could purchase insurance.  The bill allows regional or interstate Exchanges if the States agree to and the Secretary approves them. 

State governments would have to run the Exchanges according to guidelines and minimum criteria established by the federal government.  State insurance commissioners would continue to provide oversight regarding consumer protections, rate review, and solvency.  States would also be allowed to create additional requirements for offering insurance to their residents and employers through the Exchanges, provided that they defrayed any related additional cost.  

In each Exchange, traditional insurance companies would be allowed to compete for customers provided they met the federal requirements and any additional state requirements.  Exchanges would include web portals and a toll-free hotline and insurance companies would use standardized formats and definitions to allow easy comparison of the prices, benefits, and performance of health plans, as well as standardized health insurance enrollment applications and standardized marketing requirements.

Under Section 1321(c), if the Secretary of Health and Human Services determined before 2013 that a State would not have an Exchange operational by 2014, or would not implement the standards, the Secretary would be required to establish and operate an Exchange in the State and to implement the standards.

Federal Pre-emption

From a legal perspective, it is quite clear that the federal requirements of the Senate bill would prevent a single payer system that excludes such an Exchange.  Under Article VI of the U.S. Constitution, federal law is “the supreme law of the land, … anything in the laws of any State to the contrary notwithstanding.”  For that reason, courts have held for hundreds of years that when a federal law conflicts with a state law, the federal law trumps, and the state law is “preempted,” or void.  The most obvious type of preemption, known as conflict preemption, occurs when it is impossible to comply with both the federal law and the state law at the same time, or where the state law stands as an obstacle to the full purposes and objectives of Congress.  In these cases, courts will quickly find preemption and strike down the state legislation.

This is exactly the type of preemption that is in play here.  If the Senate bill were enacted into law, state agencies would have to set up Exchanges and allow private insurance companies to sell plans through them.  It would be impossible for states to do this while at the same time operating a single payer system, which by definition would prohibit or prevent private competition through the Exchanges. Such a state law would therefore be effectively preempted by the federal bill.

Waivers from the federal Exchange requirements

If the Senate bill is passed, the only opportunity that states would have to move towards a single payer system would be to get a waiver from the Exchange requirements through Section 1332.[1] 

Section 1332 enables a state to apply for and receive a waiver (beginning in 2017) from the requirement to operate an Exchange.  In order to get such a waiver, the state would have to present an alternative plan that would provide coverage at least as comprehensive and affordable, to at least a comparable number of residents, as the federal legislation would achieve.  The state plan could not increase the federal deficit.

States could apply for Section 1332 waivers for up to 5 years at a time. To do so, they would have to comply with transparency regulations in the development of the state plan and enact a law providing for state action under the plan.  If the state waivers were approved, the federal government would provide the State the aggregate amount of any tax credits and cost-sharing reductions that would have been paid to residents of the State in the absence of a waiver, which may only be used for providing health insurance coverage under the state plan.

Section 1332 does not expand existing waiver authority under any existing federal health program (e.g., Medicaid, Medicare, CHIP), but it would require the Secretary to create a coordinated waiver process so that a state could submit a single application for waivers under Sec. 1332 and under any other federal health law for which waiver authority already exists.

In order for states to try a different approach without first having to set up an Exchange, the date the waivers are currently available under Section 1332 of the Senate bill would have to be changed from 2017 to 2014.  Otherwise, a state seeking to innovate using a different model – including something approaching a single payer system at the state level – would first have to go through all the trouble and expense of establishing and operating an Exchange before having the opportunity to receive a waiver.

Assuming the date in section 1332 is changed, however, this provision will facilitate state efforts to set up single payer systems.  If a state plan to cover everyone through an alternative model is approved, they will not be required to set up an Exchange through which private companies compete.  In other words, after receiving such a waiver, states would no longer be preempted from setting up their own systems in lieu of an Exchange.

~~~~~

[1] Another section of the bill, section 1331 creates a separate, relatively narrow waiver opportunity, allowing State flexibility to establish a “basic” health program for low-income individuals who are not eligible for Medicaid, but only those up to 200% of the Federal Poverty Level.  It requires the Secretary to transfer to such states 95 percent of the tax credits and cost-sharing reductions that would have been provided to individuals covered by the “basic” plan if they were instead enrolled in qualified health plans in the Exchanges.  However, it does not enable a state to avoid creating the Exchanges required by the bill – rather, it simply allows them to create one additional plan for a limited percentage of the population – those between 133% and 200% of the FPL.

WAIVERS FOR STATE INNOVATION – SEC. 1332 OF THE SENATE BILL

  • We need to change the date the waivers under Sec 1332 of the Senate bill are available from 2017 to 2014 because making them unavailable until 3 years after states have to start the exchanges all but renders the provision meaningless. 

WHAT THIS PROVISION DOES:

  • This provision would allow states to propose to HHS an alternative system for delivering affordable, quality health care insurance to state residents. 
  • Before submitting a plan, the state must go through a thorough notice and comment process to ensure that its citizens supported the plan, and its legislature would have to pass a law authorizing the plan.
  • This provision would allow states to receive waivers from certain components of the new law (exchange-related requirements only), only if the HHS Secretary finds that the under the state’s alternative plan:
    • at least as many state residents would get health insurance coverage;
    • the coverage would be at least as comprehensive as the Essential Health Benefits under Sec 1302 – to be certified by the CMS Actuary; and
    • the coverage would be at least as affordable – in terms of both premiums and cost-sharing.

WHAT THIS PROVISION DOES NOT DO:

  • It would NOT allow states to offer lower quality or less affordable coverage to its residents than would be available in the exchange – and it would NOT allow states to cover fewer people than would be covered.
  • This provision does NOT amend or address ERISA.  
  • This provision does NOT allow waivers of the insurance market reforms in the bill, such as the bans on pre-existing condition discrimination.
  • It does NOT expand existing waiver authority under any existing federal health program (Medicaid, Medicare, CHIP, etc.), but it would require the Secretary to create a coordinated waiver process so that a state could submit a single application for waivers under this section and under any other federal health law for which waiver authority already exists.

Uwe Reinhardt on fraud and abuse

How Much Fraud and Abuse Is There in U.S. Health Care?

By Uwe E. Reinhardt
The New York Times
March 5, 2010

One of the more remarkable proposals put on the table at last week’s bipartisan summit on health care reform was an idea from Senator Tom Coburn, an Oklahoma Republican, to deploy undercover agents posing as patients in an effort to ferret out fraud and abuse by doctors and hospitals.

It subsequently became one of the ideas from Republicans that President Obama offered to incorporate in a revised health reform bill. One wonders whether the president was sincere or just being a bit naughty.

After all, the idea to legislate the infiltration of undercover agents into private medical practices and hospitals in America does not exactly square with the loudly voiced opposition of Republicans to government intrusion into American health care. Can one imagine anything more intrusive?

Senator Coburn is a physician and may have reasons to put forth such a controversial idea. As someone outside of the profession, I would not be in a position to second-guess him on that issue.

…

If the president and Congress wish to constrain the growth of the administrative cost of American health care, they should look not only to the private health insurance industry. They might commission a study exploring how government-run health systems in other nations manage to pay hospitals and doctors without imposing on them the huge administrative burden borne by American providers of health care. Perhaps Congress can learn from such a study.

A proper slogan here might be “evidence-based administration” (E.B.A.), meaning that just as the use of clinical procedures should be based on solid empirical evidence that they work and are worth their cost, the ever-new administrative burdens that government imposes on health-care providers should meet the same evidence-based test.

A second problem faced by hospital executives is that they have only partial control over the costs they must book and for which they seek to get paid. The bulk of these costs are driven by the clinical decisions of physicians who are affiliated with hospitals and can use the hospital as a free workshop, so to speak.

http://economix.blogs.nytimes.com/2010/03/05/how-much-fraud-and-abuse-is-there-in-u-s-health-care/

Posted response of Don McCanne, San Juan Capistrano, CA (# 1):

Instances of blatant fraud in health care provide great fodder for the media. The identification and prosecution of criminals in Florida becomes national news.

Those who claim that fraud and abuse are a primary reason for high health care costs use such stories to say that the government is not doing its job in identifying and prosecuting these crooks, when the stories are about the government doing its job in identifying and prosecuting these crooks.

Thieves will always be with us and need to be ferreted out, and the government will continue to do that.

The far greater problem, as Dr. Reinhardt explains, is in physician practice patterns. The great variability in use of resources is not so much a matter of abuse as it is simply a variation in individual and regional concepts of “that’s the way its done.”

Much of the high use is in imaging, or consultations, or referral for high-tech procedures for which the primary physician receives no additional compensation. That is not fraud.

Nor is it defensive medicine. A test or consultation allegedly ordered to prevent a malpractice lawsuit is not ordered out of an intellectual void. It is ordered because the patient has a real risk, even if small, of having a problem that may require intervention.

Most physicians want to practice high quality, efficient medicine. They welcome information such as that generated by the British NICE program – a program designed to identify best practices. The opponents of reform dismiss even these efforts with nonsense accusations of “rationing.”

Not spending money on medical services that are not helpful or even harmful is not rationing. Rather it exemplifies a fundamental concept characteristic of free markets – providing more transparency in order to obtain greater value in our health care purchasing.

Single-Payer Healthcare Coming to Minnesota and Maryland

By David Swanson
OpEdNews.com, March 3, 2010

California keeps passing bills for state single-payer healthcare, but Ahhhnold won’t sign em, and Jerry Brown who wants to be governor doesn’t seem to want it badly enough to make a commitment on healthcare. Meanwhile, Pennsylvania is encouraged that their current governor has said he probably will sign a single-payer healthcare bill, and the legislature just might pass one. But Minnesota has an angle neither of these other states can claim: a serious candidate for governor who is the state’s leading advocate for single-payer.

State Senator John Marty was the Democratic nominee for governor of Minnesota 16 years ago and is making another run for it. My friend Vin Gopal, who’s working on Marty’s campaign, tells me “Senator John Marty is the real deal. If he gets elected Governor this year, which he has a good shot at, it’s a whole new ballgame for the single-payer movement. No other statewide candidate in the country is as committed to the movement as he is.”

Marty tells me he’s optimistic about bringing single-payer healthcare to Minnesota, and that he has a third of the legislature on board with it at this point. Marty’s election campaign can be supported here http://johnmarty.org and the campaign for single-payer in Minnesota can be found here http://muhcc.org and here http://mnhealthplan.org

The legislation currently moving forward is somewhat unusual. Like any single-payer plan, it would eliminate the for-profit health insurance companies and all of their bureaucracy. It would cover all medical needs of all Minnesota residents. There would be no co-pays, deductibles, or out-of-pocket expenses. All bills would be paid by the single plan. Those who now have no coverage would be covered. Those who do have coverage would, in most or all cases, save money in the new system which would be far more efficient, purchase drugs in bulk, etc. All of that should be familiar to supporters of single-payer or visitors to civilized nations. What’s different is that the word “premium” would still be around.

Most single-payer healthcare plans raise funding through taxes. The Minnesota plan would ask the same Department of Revenue that collects taxes to collect premiums from both individuals and businesses, but the premiums would go into a separate fund for healthcare that could never be tapped for anything else. Premiums would be based on each person’s ability to pay, but they would not be optional. However, they would fund a public system developed by elected representatives, unlike the legislation being considered in Congress which would require people to fund for-profit corporations that come with the built-in motivation to provide as little healthcare as possible.

Will Minnesota be our Saskatchewan, the Canadian province that led the way on healthcare? Not if Maryland can help it. I asked Eric Naumburg, a doctor with the Maryland chapter of Physicians for a National Health Program, where things stood in his state, and he told me:

“We have bills in both the Maryland Senate (SB-682) and House of Delegates (HB-767). The Senate Bill has 12 co-sponsors and the House Bill 38; that’s approximately 1/4 of each chamber. So far we have only Democrats on board. The leadership has not taken serious notice yet but there are some good signs and we are really just getting started. Also, between the state’s budget problems, the upcoming election and the health insurance reform mess in Washington, we hear lots of excuses for why not this year.

“The reality is that our bill, which is modeled after the one that has passed twice in California, has only general language about funding. We are raising money for an economic impact study on the effects of single payer. Key areas would include the effect on the state budget and economic growth within Maryland. This will help us with the best ways to fund the system. We continue to build our grassroots movement. This summer we are planning a concerted effort to talk to as many legislators as possible.

“As you have probably heard we have been collaborating on a weekly basis with groups from California and Pennsylvania; learning from each other’s experiences. California and Pennsylvania are further along in this process than we are; but we’re working to catch up. Also, the knowledge that there are several states working on state level single-payer healthcare reform has had a positive effect on some of our legislators. Down the road there is the possibility that a region could develop single payer reform, e.g. two or more adjoining states.”

Maryland and Pennsylvania? The Mason Dixon line crossed by a humane healthcare region? Why not. And who knows, maybe the nation someday!

The Maryland Senate bill is scheduled for a hearing March 10th at 1:00 p.m. in the Finance Committee.

David Swanson is the author of “Daybreak: Undoing the Imperial Presidency and Forming a More Perfect Union” by Seven Stories Press.

http://www.opednews.com/articles/Single-Payer-Healthcare-Co-by-David-Swanson-100303-463.html

Single payer, here we come

Public option still on table in California’s health-care debate

By Amy Yannello
Sacramento News and Review
March 4, 2010

For more than 7 million working Californians who currently don’t have health insurance, Congress and President Barack Obama’s attempt to reform health care has been an exercise in frustration. The public option was almost immediately taken off the table, despite the fact that most independent experts agree reform won’t work without it, and after a year of negotiations, no bill is in sight. If the politicians in Washington, D.C., don’t get their act together soon, California just might beat the feds to the punch with a single-payer system of its own.

Senate Bill 810 (Mark Leno, D-San Francisco) would establish the “California Healthcare System”—a single-payer health-care system open to all residents. Currently in the Assembly, S.B. 810 is the third incarnation of a bill previously carried—and passed—by former state Sen. Sheila Kuehl (D-Santa Monica). Both bills, Senate Bill 921 and Senate Bill 840, were passed by the Legislature and vetoed by Republican Gov. Arnold Schwarzenegger.

Leno doesn’t expect the bill to pass this year, but said it lays the groundwork for two things: first, possible approval of the bill should a governor friendly to the concept be elected this November; and, in lieu of that, placing the bill on the ballot as an initiative and letting the people decide.

“We’ll either wait until we get a vote from a different governor—a Democrat—that believes in what we’re trying to do,” Leno said, “in which case the health insurers will challenge us at the ballot box. Or we won’t get a different vote, and we’ll take it to the voters ourselves. Either way, the voters will get their say.”

Leno and other health-care watchers say the initiative could land on the ballot as soon as 2012 and no later than 2014.

“It’s not socialized medicine,” Leno said. “It is a public/private partnership—publicly funded, privately managed. Your doctor does not change, your clinic, your hospital does not change. What changes is who pays, and rather than waste a third of our health-care dollars on administrative waste—current system—with single-payer, as with Medicare, we will have a 5 percent administrative cost.”

As with all government programs, taxpayers will be on the hook for the cost. But Leno and other experts claim that by pooling all the money together, including the federal dollars the state receives for public health-care programs such as Medicare, Medi-Cal and the Healthy Families Program, most individuals, families and employers will pay less than private insurance plans, which will be supplanted by the public system.

“That’s where the word tax takes on a negative connotation, and we need to educate people,” Leno said. “It’s important for people to know that this replaces the current premiums, co-pays and deductibles that they now pay to insurance companies.”

The fee structure was set out in 2005-06, when the bill was originally introduced. Leno maintains that voters would have to approve a premium structure based on true health-care costs once the measure is approved. The bill mandates that premiums must save the “average” resident and employer money.

If it should pass, the California Healthcare System would levy a tax on all working Californians, say, 4 percent, the amount agreed upon in the 2006 bill. This tax, combined with all public moneys currently spent on health care—including Medicare, Medi-Cal and Healthy Families—would be combined to form the funding mechanism for the CHS.

The bill places these public entities under one administrative umbrella. As the single payer, CHS will negotiate with providers to set fees for health-care services and reimburse claims for those services.

Should S.B. 810 pass, private health insurers, like Anthem Blue Cross, would be prohibited from practicing in California, except to do so for coverage of benefits not covered by the CHS—in other words, under very limited circumstances. The CHS will be administered by the California Healthcare Agency under the control of a health-care commissioner appointed by the governor and confirmed by the Senate.

Additionally, S.B. 810 simplifies the eligibility process for Medi-Cal and raises the income threshold to double the federal poverty index. An individual earning $21,000 or less annually, or a family of four earning $44,000 or less annually, would qualify for no-cost or low-cost medical care under Medi-Cal.

No co-pays or deductibles would be charged until the third year of the program’s operation, and then only for seeing a specialist without a referral from a primary care physician. Co-pays and deductibles would not exceed $250 annually per individual and $500 annually per family, except for those on Medi-Cal, who will not be subject to the co-pays or deductibles.

No co-pays or deductibles would be charged for preventive care received from a primary care physician.

Supporters of S.B. 810 out number opponents 3-1, and include the California Nurses Association, League of Women Voters, assorted clergy, labor unions, teachers and senior citizens.

“Why are the nurses supporting this?” asked Geri Jenkins, RN and co-president of the California Nurses Association. “Because we have 7 million uninsured in California and millions more who are underinsured, and they come to us sicker than they need to be because they didn’t have access to preventive care. So we see the pain and suffering that needn’t be there.”

Jenkins also contends that small-business owners are paying too much under the current system and that Leno’s plan would curtail spending substantially.

“Right now, employers are spending 14 percent of payroll to cover their employees. … This would cut that by half!” she said. “So it’s business-friendly. It’s an economic stimulus for the state to do something like this. We can’t compete with countries that have single-payer systems, because it costs us so much to provide health care, so this would give us an economic edge.”

Jenkins added that with health-insurance corporations like Anthem Blue Cross announcing in late February that it was raising its rates by 39 percent for all residents who sought to purchase insurance on the open market, California will cease to be a viable economy if it can’t rein in health-care costs.

“It’s the moral and economic thing to do,” Jenkins said. “We’re doing something fundamentally wrong here, the way things are.”

Anthem Blue Cross, one of the insurance companies signed on in opposition to the bill, did not return repeated calls for comment for this story.

The World Health Organization ranks the United States 37th among nations in quality of care, access to health care, health-care outcomes, life-expectancy rates and infant mortality rates—“and we pay twice per capita for this failed system,” Leno noted.

Check out the statistics: In 1960, the United States spent 5 percent of its gross domestic product on health-care costs. By 2000, health-care costs jumped to 13 percent of GDP, and in 2010, it will spend 17.3 percent. Projections for 2015 show the costs going up to 20 percent, and to 25 percent in 2025.

“This will consume us,” Leno said. “And the president is right—we will not restore our economic position on the world stage until we reform health care. Small business should support this because they can’t keep up with the ever-escalating cost, and we can’t compete in a global market with this system.”

At least two 2010 Republican candidates for governor—Steve Poizner and Meg Whitman—don’t appear to share Leno’s concern with the private system. Health care appears nowhere on either of their Web sites, not under
Poizner’s “Solutions for California” or Whitman’s “A New California” drop-down menus.

Poizner told SN&R he was “strongly against” any universal health-care plan and would, if elected, focus on four cost-containment measures. He believes “we need to accelerate the deployment of privacy-protected electronic medical records.” He would also support allowing health-insurance companies to offer catastrophic health plans, “rather than prepaid health care.”

“A big portion of the people who don’t have insurance right now could afford insurance if we would got rid of these mandates and just allow the health-insurance product to cover catastrophic events that, if they occur, would cause huge financial damage to people. If you had [that] coverage, then more people would be protected.”

Third, Poizner said he would greatly expand the fee-for-service “doc-in-the-box” clinics in Target and Wal-Mart stores “and other places where they actually post their prices and they provide a lot of the routine care that some people now go to the emergency rooms for.”

The final measure in Poizner’s medicine bag is cracking down on health-insurance fraud. As the current state insurance commissioner, Poizner claims he has 300 police officers in his department’s fraud unit who have uncovered “millions in insurance scams that all add to the current price of health insurance.”

Whitman’s campaign failed to return repeated phone calls for this story.

Meanwhile, state Attorney General Jerry Brown, who announced his bid for the Democratic gubernatorial nomination as this was going to press, makes it a point to highlight his health-care accomplishments in office at www.jerrybrown.org, under the heading “Fighting For You.”

“As Attorney General, Brown has sued medical laboratories for massive overcharges, stopped rip-offs in the Medi-Cal Program, cracked down on unlawful abuse of prescription drugs, fought misleading ad campaigns by major drug companies and arrested nursing home operators for forcibly drugging elderly patients,” the section reads.

As attorney general, he’s ordered an investigation into possible illegal practices by some insurers.

“We have been looking at these companies for a number of months and are very concerned that some of them are unjustly raising premiums and denying payment of legitimate claims,” Brown said. “Not only are the rate increases devastating to Californians strapped by the economy, but in some cases, they are possibly illegal. Our best attorneys are going to get to the bottom of this, and where we find violations of California’s unfair business laws, we intend to stop them.”

Brown subpoenaed records from the states seven largest insurers, Aetna, Anthem Blue Cross, Cigna, Health Net, Blue Shield of California, Kaiser Permanente and PacifiCare. The subpoenas cover pay-for-service health plans, which reimburse doctors and hospitals for services performed, unlike the HMO approach. The same seven companies were served subpoenas last month regarding their HMOs.

Brown said the insurance companies have 30 days to hand over their financial and other records. The investigation began in September and was prompted by reports that California’s five largest health-insurance providers were denying claims at rates of up to 39.6 percent.

Meanwhile, business owners appear to be taking a cautious approach to the Leno’s bill.

Daniel Conway, spokesman for the California Restaurant Association and its 23,000 members and 80,000 establishments, said his organization’s been “very focused” on what’s going on at the national level, “trying to find a workable solution.”

“Our stand right now is, they say there’s going to be a $46 billion hole the first year [in the state’s program] and a 12 percent tax imposed on employers and employees. … Who’s going to pay for those costs?” Conway said. “That’s a tough nut to crack.”

“I’m optimistic that we can get some solution at the federal level before we have to go to the voters here,” he added. “I think President Obama has put a lot of energy into this.”

But Leno and others dispute Conway’s figures, saying that the assumption is just a “spin answer” and that “no one can tell you for sure, right now, what premium schedule would be imposed.”

The nonpartisan Legislative Analyst’s Office, in its analysis of both Leno’s bill and of Kuehl’s previous two bills, seems to be saying both camps are correct. First, had S.B. 840 gone into effect and the CHS been enacted for 2010-11, the LAO estimated there would indeed have been a gap in funding of $42 billion. At the same time, the true cost of the initiative is “unknown” and could run into the “hundreds to millions” of dollars, depending on the ongoing role of the health-care commission and CHS.

What’s not in doubt is the dismal.

Whether S.B. 810 can cure California’s ills remains to be seen. What is certain, all agree, is that our health-care system is broken. For more than 7 million uninsured residents, the solution can’t come soon enough.

http://www.newsreview.com/sacramento/content?oid=1380298