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Friday, January 29, 2016

Health Care Reform Articles - January 29, 2016

Study: Bernie Sanders'sSingle-Payer Plan Is Almost Twice As Expensive As He Says
By First Amendment  
Thursday Jan 28, 2016
There is now an actual study out and completed by Emory University health care expert Kenneth Thorpe, on Sanders health care plan. 
Thorpe actually authored Vermont’s single-payer proposal, that ended up being shelved because it was going to cost Vermont taxpayers big time:
The numbers were stunning. To implement single-payer, the analysis showed, it would cost $4.3 billion in 2017, with Vermont taxpayers picking up $2.6 billion and the federal government covering the rest. To put the figures into perspective, Vermont’s entire fiscal 2015 budget, including both state and federal funds, is about $4.9 billion.
Shumlin’s office estimated the state would need to impose new personal income taxes of up to 9.5 percent, on top of current rates that range from 3.55 to 8.95 percent. Businesses would be hit with an 11.5 percent payroll tax, on top of 7.65 percent payroll taxes employer pay for Social Security and Medicare.
What’s most interesting about the Vox article is, the Sanders campaign engages Thorpe in a back and forth about the details via e-mail.
The Sanders campaign predictably calls the Thorpe study a "hatchet job” and yet they kept changing their own numbers during the e-mail discussion and that led Thorpe to say this:
"They are just throwing things against the wall to see what sticks,"
There’s a link in the article to Thorpe’s study.
I can confidently say we all want a better health care system. We want more people covered, but promising pie in the sky and fudging the numbers to win votes seems a bit disingenuous.
Just a warning to Mr. Thorpe, shut you e-mail down now, Facebook, Twitter and all other forms of being contacted. Save yourself now!

On Kenneth Thorpe's Analysis of Senator Sanders' Single-Payer Reform Plan

 01/29/2016
by David Himmelstein and Stephanie Woolhandler
Professor Kenneth Thorpe recently issued an analysis of Senator Bernie Sanders' single-payer national health insurance proposal. Thorpe, an Emory University professor who served in the Clinton administration, claims the single-payer plan would break the bank.
Thorpe's analysis rests on several incorrect, and occasionally outlandish, assumptions. Moreover, it is at odds with analyses of the costs of single-payer programs that he produced in the past, which projected large savings from such reform (see this study, for example, or this one).
We outline below the incorrect assumptions behind Thorpe's current analysis:
1. He incorrectly assumes administrative savings of only 4.7 percent of expenditures, based on projections of administrative savings under Vermont's proposed reform.
However, the Vermont reform did not contemplate a fully single-payer system. It would have allowed large employers to continue offering private coverage, and the continuation of the FEHBP and Medicare programs. Hence, hospitals, physicians' offices, and nursing homes would still have had to contend with multiple payers, forcing them to maintain the complex cost-tracking and billing apparatus that drives up providers' administrative costs. Vermont's plan proposed continuing to pay hospitals and other institutional providers on a per-patient basis, rather than through global budgets, perpetuating the expensive hospital billing apparatus that siphons funds from care.
The correct way to estimate administrative savings is to use actual data from real world experience with single-payer systems such as that in Canada or Scotland, rather than using projections of costs in Vermont's non-single-payer plan. In our study published in the New England Journal of Medicine we found that the administrative costs of insurers and providers accounted for 16.7 percent of total health care expenditures in Canada, versus. 31.0 percent in the U.S. - a difference of 14.3 percent. In subsequent studies, we have found that U.S. hospital administrative costs have continued to rise, while Canada's have not. Moreover, hospital administrative costs in Scotland's single-payer system were virtually identical those in Canada.
In sum, Thorpe's assumptions understate the administrative savings of single-payer by 9.6 percent of total health spending. Hence he overestimates the program's cost by 9.6 percent of health spending -- $327 billion in 2016, and $3.742 trillion between 2016 and 2024. Notably, Thorpe's earlier analyses projected much larger administrative savings from single-payer reform -- closely in line with our estimates.
2. Thorpe assumes huge increases in the utilization of care, increases far beyond those that were seen when national health insurance was implemented in Canada, and much larger than is possible given the supply of doctors and hospital beds.
When Canada implemented universal coverage and abolished copayments and deductibles there was no change in the total number of doctor visits; doctors worked the same number of hours after the reform as before, and saw the same number of patients. However, they saw their healthy and wealthier patients slightly less often, and sicker and poorer patients somewhat more frequently. Moreover, the limited supply of hospital beds precluded the kind of big surge in hospitalizations that Thorpe predicts. In health policy parlance, "capacity constraints" precluded a big increase in system-wide utilization.
Thorpe bases his estimates on what has happened when a small percentage of people in a community have had copayments eliminated or added. But in those cases there are no capacity constraints, so it tells us little about what would happen under a system-wide reform like single-payer.
Thorpe does not give actual figures for how many additional doctor visits and hospital stays he predicts. However, his estimates that persons with private insurance would increase their utilization of care by 10 percent and that those with Medicare-only coverage would increase utilization by 10 to 25 percent suggest that he projects about 100 million additional doctor visits and several million more hospitalizations each year - something that's impossible given real-world capacity constraints. There just aren't enough doctors and hospital beds to deliver that much care.
Instead of a huge surge in utilization, more realistic projections would assume that doctors and hospitals would reduce the amount of unnecessary care they're now delivering in order to deliver needed care to those who are currently not getting what they need. That's what happened in Canada.
3. Thorpe assumes that the program would be a huge bonanza for state governments, projecting that the federal government would relieve them of 10 percent of their current spending for Medicaid and CHIP -- equivalent to about $20 billion annually.
No one has suggested that a single-payer reform would or should do this.
4. Thorpe's analysis also ignores the large savings that would accrue to state and local governments -- and hence taxpayers -- because they would be relieved of the costs of private coverage for public employees.
State and local government spent $177 billion last year on employee health benefits - about $120 billion more than state and local government would pay under the 6.2 percent payroll tax that Senator Sanders has proposed. The federal government could simply allow state and local governments to keep this windfall, but it seems far more likely that it would reduce other funding streams to compensate.
5. Thorpe's analysis also apparently ignores the huge tax subsidies that currently support private insurance, which are listed as "Tax Expenditures" in the federal government's official budget documents.
These subsidies totaled $326.2 billion last year, and are expected to increase to $538.9 billion in 2024. Shifting these current tax expenditures from subsidizing private coverage to funding for a single-payer program would greatly lessen the amount of new revenues that would be required. Thorpe's analysis makes no mention of these current subsidies.
6. Thorpe assumes zero cost savings under single-payer on prescription drugs and devices.
Nations with single-payer systems have in every case used their clout as a huge purchaser to lower drug prices by about 50 percent. In fact, the U.S. Defense Department and VA system have also been able to realize such savings.
In summary, professor Thorpe grossly underestimates the administrative savings under single-payer; posits increases in the number of doctor visits and hospitalizations that exceed the capacity of doctors and hospitals to provide this added care; assumes that the federal government would provide state and local governments with huge windfalls rather than requiring full maintenance of effort; makes no mention of the vast current tax subsidies for private coverage whose elimination would provide hundreds of billions annually to fund a single-payer program; and ignores savings on drugs and medical equipment that every other single-payer program has reaped.
In the past, Thorpe estimated that single-payer reform would lower health spending while covering all of the uninsured and upgrading coverage for the tens of millions who are currently underinsured. The facts on which those conclusions were based have not changed.


Colorado leaders launch campaign against single-payer health proposal

Opponents call it a risky plan that would double state budget

The campaign to defeat a proposal for a single-payer health insurance system in Colorado is kicking off Thursday with some high-profile leaders.
Walker Stapleton, the Republican state treasurer, and former governor Bill Ritter, a Democrat, will co-chair what is being billed as a bipartisan campaign to oppose Amendment 69.
The opposition strategy will be outlined during a morning news conference at the Denver Metro Chamber of Commerce, which also is contributing campaign leaders.
One prominent target: the cost.
In a news release, opponents call the initiative "a risky and untested state-run health insurance system" that would raise taxes by $25 billion in its first year.
Advocates propose a 10 percent payroll tax, with two-thirds of the money coming from employers and one-third from employees, to finance a Colorado health care system. They contend state control could save money by slashing administrative costs for private insurance providers and buying pharmaceuticals at bulk prices.
Other countries have government-run health care systems, but neither the United States nor any individual states have followed that approach.
In Denver, chamber of commerce president Kelly Brough said Colorado should not risk becoming the first state.
"Regardless of where you live in our state, regardless of your party affiliation and even regardless of whether or not you philosophically believe in a national single payer health care system — we can all agree that this proposal is bad for Colorado," she said.
Stapleton said the health care proposal "would literally double the state budget" and impose a new tax on working families.
Ritter said the budget "is already burdened with too many constitutional measures — let alone one of this cost and magnitude."
The opposition group, Coloradans for Coloradans, describes itself as backed by state business, civic and community leaders and state and local elected officials.

Children’s Hospital resolves tiff with Aetna

By  GLOBE STAFF  

Boston Children’s Hospital and Aetna Inc. said Thursday that they have resolved a dispute over reimbursement rates, avoiding what could have been a disruptive change for thousands of people.
“We look forward to our continued relationship with Boston Children’s,” Aetna spokesman Walt Cherniak said.
The state’s dominant pediatric hospital and the country’s third-largest insurer had planned to end their contract in February, meaning Aetna would largely stop paying for medical care its members received at Children’s Hospital.
The disagreement was over rates for a large New York-based doctors group that Children’s Hospital acquired last year. Aetna said Children’s was demanding unacceptably high payments, while Children’s said it wanted to raise the pay of its New York doctors to “reduce the gap” between them and their competitors.
Hartford-based Aetna insures about 200,000 people in Massachusetts, or about 5 percent of the commercial health insurance market. 
“Boston Children’s Hospital is pleased that we’ve reached agreement with Aetna assuring no patient will have care from their preferred caregiver interrupted,” hospital spokesman Rob Graham said.



As Population Ages, Where Are the Geriatricians?

By KATIE HAFNER
JANUARY 25, 2016
PORTLAND, Ore. — Ruth Miles, 83, sat in a wheelchair in a small exam room, clutching a water bottle, looking frightened and uncomfortable.
She was submitting to the tender scrutiny of Dr. Elizabeth Eckstrom, who scooted her stool so close that she was knee to knee with her patient.
Ms. Miles had broken her pelvis after tripping on an electric cord in her apartment. The weeks since then had been hellish, she told her doctor. At the rehab center, incapacitated and humiliated, she had cried for help from the bathroom. Her hands were covered with bruises from the blood thinners she was on. She winced as Dr. Eckstrom tugged slightly at a bandage that adhered stubbornly to her left elbow. “We’ll have to get that changed,” Dr. Eckstrom said softly.
Dr. Eckstrom, 51, who spends her days focused on the complex medical needs of older patients, is, like the Central African okapi, a species that is revered, rare and endangered. She is a geriatrician.
Geriatrics is one of the few medical specialties in the United States that is contracting even as the need increases, ranking at the bottom of the list of specialties that internal medicine residents choose to pursue.
“One of the greatest stories of the 20th century was that we doubled the life expectancy of adults,” said Terry Fulmer, president of the John A. Hartford Foundation, which funds programs to improve the care of older adults. “Now we need to make sure we have all the supports in place to assure not just a long life but a high quality of that long life.”
Here in Oregon, there is approximately one geriatrician for every 3,000 people over 75. The shortage will grow more acute as the state’s population continues to age.
Oregon’s problem is mirrored across the United States. According to projections based on census data, by the year 2030, roughly 31 million Americans will be older than 75, the largest such population in American history. There are about 7,000 geriatricians in practice today in the United States. The American Geriatrics Society estimates that to meet the demand, medical schools would have to train at least 6,250 additional geriatricians between now and 2030, or about 450 more a year than the current rate.
Yet, the field is becoming even less popular among physicians in training. Oregon Health and Science University, where Dr. Eckstrom practices, had five slots open for geriatrics fellows for 2016 and filled only three.
Last year, Dr. Elizabeth White-Chu, who directs the university’s geriatrics fellowship program, said she had resorted to cold-calling residency programs throughout the Pacific Northwest in search of candidates. This year, there were so many unfilled slots around the country that Dr. White-Chu did not even bother to call. “It would have been a total waste of time.”
A geriatrician is a physician already certified in internal or family medicine who has completed additional training in the care of older adults. In addition to providing clinical care, geriatricians are skilled in navigating the labyrinth of psychological and social problems that often arise in the aging population.
“Part of the reason aging has such a negative connotation is this sense that you can’t cure older people’s problems,” said Dr. Kenneth Brummel-Smith, a professor of geriatrics at Florida State University College of Medicine in Tallahassee, Fla., a state with a particularly severe geriatrician shortage. “And yet a good geriatrician can bring someone back to functional status.”
People avoid the field for understandable reasons. Geriatrics is among the lowest-paying specialties in medicine. According to the Medical Group Management Association, in 2014, the median yearly salary of a geriatrician in private practice was $220,000, less than half a cardiologist’s income. Although geriatrics requires an extra year or two of training beyond that of a general internist, the salary for geriatricians is nearly $20,000 less.
Since the health care of older patients is covered mostly by Medicare, the federal insurance program’s low reimbursement rates make sustaining a geriatric practice difficult, many in the field say.
“Medicare disadvantages geriatricians at every turn, paying whatever is asked for medications and procedures, but a pittance for tough care-planning,” said Dr. Joanne Lynn, a geriatrician and the director of the Center for Elder Care and Advanced Illness at Altarum Institute, a nonprofit health systems research organization based in Ann Arbor, Mich.

Reducing Preventable Harm in Hospitals

By 
 

Each year, in the United States, millions of patients are harmed while receiving care in hospitals. They get infections, experience adverse reactions to drugs, develop dangerous bed sores, or come down with pneumonia from the very ventilators meant to help them breathe.
The estimates of the number of people who die each year as a result of hospital errors have ranged from as many as 98,000 in a landmark Institute of Medicine report from 1999 to as many as 440,000 in a 2013 study.
It’s believed that most of these deaths could be prevented if health care providers always adhered to evidence-informed practices. In recent years, the Centers for Medicare and Medicaid Services, an arm of the Department of Health and Human Services, has sought to drive improvements by linking payments to hospital performance, including patient safety.
But hospital care is astonishingly complex. In the United States each year, there are over 35 million hospital admissions and 136 million visits to emergency rooms. Doctors, nurses and technicians conduct so many procedures and dispense so much medication that even seemingly tiny error rates can translate to tens of thousands of patients harmed.
Amid the complexity, the chaotic pace, and the increasing need for coordination, how can hospitals do better to improve patient safety? How can they ensure, for example, that every single time a patient receives a medication, precautions are taken to reduce the risks of an adverse drug reaction?
Or that every time medical practitioners insert a central line catheter into a major artery or vein, they wash their hands, use sterile drapes, and remove it as soon as it’s no longer needed?
Or that every patient confined to a bed is regularly watched to prevent pressure sores, which can cause life-threatening infections?
The answer is systems with safeguards. One way to understand the problem is the “Swiss cheese model,” which was proposed by James Reason, an expert in the psychology of human error. In a good system, there are multiple layers of defense, each compensating for weaknesses in other layers. System failures occur when layers share the same vulnerabilities — and the holes go all the way through the cheese. That’s when mistakes harm patients.
The big challenge isn’t just designing systems with better defenses; it’s gaining acceptance for them, and properly implementing them. Over the past decade, for example, many hospitals have adopted a key feature of aviation safety — checklists — to improve safety in areas where standard protocols can save many lives, such as inserting central line catheters, using ventilators, and while performing surgery and assisting childbirth.
When well implemented, the results have been stunning. In the groundbreaking Michigan Keystone project, a collaborative safety-driven endeavor by numerous hospitals that began in 2003 and was led by Peter Pronovost, a five-step checklist led to a 66 percent drop in central line infections. (Over the past 20 years, the rates of central line infections in the United States have dropped substantially.)
However, as checklists have proliferated, the results have been inconsistent, often because front-line practitioners rejected them or adopted them halfheartedly. The devotion to protocol that pilots see as integral to their professionalism is derided by some doctors as ‘cookbook medicine.’ Atul Gawande, a surgeon and contributor to The New Yorker, has said that the high value that physicians place on autonomy and independence makes them reluctant to submit to checklists. (Watch his TED Talk.)
So the big question is: How can health systems be made safer when success means changing the attitudes and habits of health care professionals at a time when many are overwhelmed and deeply frustrated by all of the demands being made on them? What does it take to get them to embrace, with urgency, new ways of working?

Is Medicaid Expansion Near a Tipping Point?


  • January 26, 2016
    •  
  • By Christine Vestal
  • Louisiana this month became the first state in the Deep South to make the politically charged decision to expand Medicaid health insurance to low-income adults under the Affordable Care Act.
    At least one other state — South Dakota — is expected to extend Medicaid coverage this year. But in the lead up to the November presidential election, supporters of the ACA aren’t holding out much hope that more states will join in extending Medicaid coverage to more people — although the governors of Alabama, Virginia and Wyoming say they want to, as do key legislators in Maine and Nebraska.
    Meanwhile, newly elected Republican Gov. Matt Bevin in Kentucky and Republican lawmakers in Arkansas are threatening to roll back or modify their states’ existing expansion programs. 
    After a new president is elected, the situation could change and more states could join in expanding coverage, predicted Joan Alker, executive director of Georgetown University’s Center for Children and Families, which advocates for greater health care coverage for the poor. 
    Ever since the Supreme Court’s 2012 decision making Medicaid expansion a state option, the issue has been more political than practical. Many Republican governors and lawmakers have rejected the deal, fearing they would lose their jobs if they were seen cooperating with President Barack Obama on a law most conservatives abhor.
    With Obama out of office, that could change. “The ideological opposition to the president will have to start fading when he’s out of office,” Alker said. “At that point, the facts and the evidence will start to matter more.”  
    Matt Salo, executive director of the National Association of Medicaid Directors, agrees. If a Democrat is elected president, the new administration could be expected to continue the Obama administration’s approach of approving proposals from Republican-governed states to shape expanded Medicaid programs to fit their individual state needs and politics.
    Even greater flexibility could come if a Republican is elected president, Salo said. In that case, the GOP-led states that have so far shunned expansion would likely seek authority to revamp their programs more radically than the Obama administration has allowed. Until then, Salo said, “Governors are probably thinking, ‘Maybe I’ll just keep my powder dry.’ ” 
    Congress voted 60 times on repealing the ACA before successfully passing legislation earlier this month to undermine the law and phase out Medicaid expansion. Obama vetoed it. Would a newly elected Republican president instead sign it and eliminate health coverage now extended to millions more poor people? Most analysts doubt it and predict expansion will endure, even if other parts of the ACA are changed.

Maine Voices: Conditions now favorable for expansion of Medicaid coverage in Maine


  • Addressing the scourge of opioid addiction and lower spending on incarceration are just two likely benefits.
    by Trish Riley
    Enacting a bipartisan bill to provide Medicaid coverage to all low-income people in Maine is a challenge not unlike that faced – and overcome – by other states.
    Times have changed since Maine’s last unsuccessful effort to expand Medicaid. Six states where the expansion controversy was as intense as the debate in Maine are administering “private option” Medicaid programs. Those programs buy private insurance, require premiums and cost sharing and, in one state, disenroll those who fail to meet their premium payments after a grace period.
    Some programs penalize excessive, inappropriate use of emergency departments. Others have included voluntary initiatives connecting unemployed enrollees to job training and job banks. And they encourage healthy behaviors by waiving payments for those who commit to work on improving their health and participating in disease management and related programs.
    Most of these states have provisions to end the expansion if the federal government does not maintain its level of funding. The federal government remains committed to funding for the program and has shown its willingness to meet the states halfway, approving these unique state proposals among the 31 states that have now expanded Medicaid.
    Medicaid expansion must cover individuals sometimes referred to as the “working poor” – those with an annual income under $15,654 for an individual or, for a family of four, those earning less than $32,253.
    Those below poverty level who are medically fragile – that is, they require medical intervention for everyday living – are covered by traditional Medicaid. But all the others can be covered by commercial insurance.
    And who are they? Keep in mind that these are people with some income. They work. In fact, according to the Kaiser Family Foundation, among the states that have not expanded Medicaid, Maine leads in the number of uninsured low-income people attached to the workforce; 88 percent live in families with a worker.
    Yet those jobs often do not pay enough to afford coverage. They are part-time positions, and they are in fields like agriculture and service industries where coverage is not offered or is often not affordable – even with the subsidies provided through the federal health insurance marketplace.
    But there are too many people in Maine who have trouble getting or holding down a job, often because they struggle with illness or substance abuse. They are caught in a vise – unable to work and unable to afford the treatment that would help them recover and gain employment.
    With Medicaid expansion, adults could seek and receive that needed treatment – and that may be especially important for those with substance use addictions. For Maine’s criminal justice system, the toll of these addictions is evidenced by repeated criminal behavior and incarceration.

Enrollment growth in Obamacare health insurance slower than expected

by Noam Levey - LA Times

Reflecting slower than anticipated enrollment growth in health insurance purchased through the Affordable Care Act, the nonpartisan Congressional Budget Office has lowered its estimate of how many people will get coverage through the law in 2016.
In any given month this year, about 13 million people on average are now expected to be enrolled in a health plan purchased on a marketplace created by the law, often called Obamacare.
That is down from 21 million people previously estimated by the budget office, whose projections about the impact of legislation are closely watched by both parties in Washington.
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The lower enrollment number brings the budget office closer in line with the Obama administration, which scaled back its own enrollment targets for 2016, citing the difficulty of reaching new consumers who have not so far taken advantage of the marketplaces.
The insurance marketplaces, a key pillar of the health law, allow people who do not get coverage through an employer to shop among plans that must meet basic standards and cannot turn away customers with preexisting medical conditions.
Those making less than four times the federal poverty level — about $47,000 for a single adult or about $97,000 for a family of four — qualify for federal aid to offset their insurance premiums.
The lower enrollment numbers have fueled some criticism from Republicans, who continue to argue that the heathcare law should be repealed.
http://www.latimes.com/nation/la-na-obamacare-estimate-20150125-story.html

Budget Office Lowers Its Forecast for Obamacare Enrollment

by Margot Sanger-Katz - NYT
When the Affordable Care Act was drafted, the Congressional Budget Office expected people to sign up quickly for new health insurance.
Now, two years into the law, it’s clear that progress is going to be slower. The Obama administration acknowledged as much in late 2014, and again in October, when it presented its own modest predictions. Monday, the budget office also agreed, slashing its 2016 estimate by close to 40 percent.
The Obamacare marketplaces have helped millions of Americans get health insurance, but they have not caused the kind of immediate and drastic plunge in the ranks of the uninsured that analysts had hoped for before the law was passed. It has proved harder to spread the word about new health insurance, and harder yet to persuade people to shell out money for new health insurance they hadn’t had in their household budgets.
The new budget and economic outlook now predicts that about 13 million people will get their health insurance through the Obamacare marketplaces this year, down from an earlier estimate of 21 million. The budget office’s estimates for future years won’t be released until March, but it seems reasonable to assume they will also come down. Currently, the 2017 estimate is 24 million.
The revisions to early estimates show how it’s possible to say both that the Affordable Care Act has created a “path to universal coverage” — as Hillary Clinton did at the last Democratic presidential debate — and that it has left nearly 29 million uninsured, as Bernie Sanders responded.
The slower growth of enrollment in the new marketplace plans is not a sign that the health law is failing. Another part of the report shows that sign-ups for Medicaid, expanded in many states because of the health law, have been extraordinarily popular. Sign-ups last year were 20 percent higher than the budget office had expected. And enrollment in employer health plans has basically held steady, despite expectations that employers might drop coverage once their workers had other ways to get insurance. Surveys show that the number of Americans without health insurance is lower than ever before.
Some analysts have said that the slower-than-expected growth in health insurance is just that, and they predict that people will eventually sign up for Obamacare plans, as they become better informed and they become more aware of the law’s tax penalties for failing to sign up. Others are concerned that the slow initial enrollment means expectations should be permanently scaled down.
The open enrollment period for 2016 plans wraps up next week.


Our View: Time to halt baseless campaign against Planned Parenthood

Portland Press Herald Editorial Board

The backfiring of anti-abortion 'sting' videos should defuse efforts to defund the nonprofit.
The anti-abortion activists whose notorious videos accused Planned Parenthood of illegal for-profit fetal tissue sales are now facing criminal charges themselves. But the indictment doesn’t undo the damage the “sting” tapes have done to Planned Parenthood’s reputation and funding – at the expense of the women it serves.
The charges follow a Houston grand jury’s investigation into undercover footage shot by David Deleiden and Sandra Merritt of the Center for Medical Progress. No wrongdoing by Planned Parenthood was discovered. However, Deleiden and Merritt each face a felony count of governmental record-tampering for allegedly making and presenting fake driver’s licenses for their April meeting with Planned Parenthood officials.
The release of the covert recordings last summer fueled a controversy that has yet to simmer down. Maine has so far been spared the most dire fallout, including a fatal shooting at a Colorado Springs Planned Parenthood and arsons and a spate of attacks elsewhere.
However, those who take part in the weekly protests outside Planned Parenthood’s Portland clinic have been energized, resulting in an unprecedented state effort to permanently ban one high-volume demonstrator from coming within 50 feet of the facility. And even Attorney General Janet Mills’ lawsuit against the protester hasn’t quelled tensions: The crowds at subsequent demonstrations reportedly have been loud enough to be heard inside the building.
Citing both the rhetoric and recent events, local Planned Parenthood officials announced last week that they’re temporarily replacing volunteer patient greeters with clinic employees and a Portland police officer hired by the nonprofit.
We hope that by the time the volunteer greeter program is reinstated, discussion will be underway about how the city can ensure peaceful access to the health center.
Portland repealed a 39-foot protest-free zone in 2014, after a similar buffer was deemed unconstitutional by the U.S. Supreme Court. A more workable option for our city could be a 15-foot buffer.

Finding a Cure for Bernie Sanders’ and Hillary Clinton’s Health Care Plans

By Margaret Flowers and Jill Stein
Hillary Clinton’s recent attack on Sen. Bernie Sanders for his advocacy of single-payer health plan has brought the health care crisis into the spotlight.
We are both physicians who have a long history of working on health policy. While the two Democratic candidates offer proposals that are very different from each other, we see that neither is calling out health care privatization as the fatal flaw in the Affordable Care Act (ACA).
Clinton argues we can simply expand the Affordable Care Act to achieve universal coverage, which we view as impossible. Sanders is on target with his new Medicare-for-all proposal. However, by preserving the illusion that the ACA is a “step in the right direction,” Sanders misses the point that the current U.S. health care system under the ACA is unique among industrialized nations because it treats health care as a commodity rather than a public good.
Health care should be a central issue in the presidential campaigns. A Reuters/IPSOS poll in December showed that the cost of health care is a bipartisan concern, with 62 percent of Republicans and 67 percent of Democrats surveyed saying they would want to know about a presidential candidate’s plan for reducing health care costs. This is not surprising, since the ACA has produced high premiums and unaffordable out-of-pocket costs. The status quo is not working.
We have both been clear about our long-term support for a national improved Medicare-for-all health system based on a strong public health foundation and human rights principles. We offer a critique of the current health care debate and our prescription for the solution to the crisis.
Clinton’s Attack on Sanders, and Her Plan
Clinton attacked Sanders on the health legislation he has introduced in Congress nine times. There are reasons to criticize his bill, but they are not the disingenuous reasons Clinton uses.
The claim that she, her daughter and her campaign made, that Sanders would do away with Medicaid, Medicare, the Veterans Administration, the Children’s Health Insurance Plan and the Affordable Care Act, while technically true, didn’t tell the full story. In truth, all these programs would become part of a national health care plan that would provide comprehensive benefits while saving money and allowing free choice of doctors, hospitals and health services. This would be an improved and expanded Medicare-for-all.
Clinton took this half-truth/half-lie approach because she knows better than to openly criticize single-payer, which is popular in the U.S. In December, a Kaiser Family Foundation poll found nearly 58 percent of all people in the U.S. favor the idea of Medicare-for-all, including 34 percent who say they strongly favor it. The poll also found that 81 percent of Democrats support this single-payer program. These results are deeply held, being consistent with polling before the 2009 debate on the ACA. Clinton avoided using the terms “single payer” or “Medicare-for-all” because Democrats support this approach—by a landslide.
The other criticism Clinton made of the Sanders plan was that each state would administer its own plan. This is a valid critique, because there is a wide variation in ideology from state to state. Under the ACA, some governors refused to expand Medicaid, leaving 3 million people without coverage. Without a clear federal standard, states can prevent universal coverage.
Again, however, Clinton did not tell the whole truth. She left out that Sanders’ bill included national oversight. If governors did not meet national standards, the federal government would take over.

No Endorsement Yet, But Plenty of Clues from Sen. Elizabeth Warren

In speech lambasting big money in politics, 'Warren came as close as she has—or perhaps will—come to officially endorsing Sanders.'
by
Deirdre Fulton, staff writer
With days to go before the critical Iowa caucus and New Hampshire primary, pundits are abuzz about one potential endorsement in particular—one they say could actually sway voters: that of progressive luminary Elizabeth Warren.
Many are pointing to an impassioned speech the senator from Massachusetts gave on the U.S. Senate floor last week, in which she offered what Salon described on Tuesday as a "not-so-subtle endorsement of Bernie Sanders."
The speech, which marked the sixth anniversary of the U.S. Supreme Court's Citizens United decision, lambasted the "flood of hidden money that is about to drown our democracy." It called for citizen-funded elections, stronger financial disclosure laws, and a "full-blown" Constitutional amendment to restore authority to Congress, individual states, and the American people to regulate campaign finance.
But "[t]he most revealing part of the speech was the end," wrote Salon staff writer Sean Illing, when "Warren came as close as she has—or perhaps will—come to officially endorsing Sanders."
"A new presidential election is upon us," Warren said. "The first votes will be cast in Iowa in just eleven days. Anyone who shrugs and claims that change is just too hard has crawled into bed with the billionaires who want to run the country like some private club."
As Illing argued: "The subtext here is clear: do not listen to those who say we have to be prudent and accept that fundamental problems like financial corruption or campaign finance can’t be solved in the short or medium term. The knock on Sanders, fair or not, is that he’s too idealistic, too detached from the realities of Washington. Part of Clinton’s appeal to voters is that she’s pragmatic and experienced. She may not be as progressive as Sanders, but she can get more done in Washington."

Bernie Sanders’s fiction-filled campaign
Editorial Board - Washington Post

SEN. BERNIE Sanders (I-Vt.) is leading in New Hampshire and within striking distance in Iowa, in large part because he is playing the role of uncorrupted anti-establishment crusader. But Mr. Sanders is not a brave truth-teller. He is a politician selling his own brand of fiction to a slice of the country that eagerly wants to buy it.
Mr. Sanders’s tale starts with the bad guys: Wall Street and corporate money. The existence of large banks and lax campaign finance laws explains why working Americans are not thriving, he says, and why the progressive agenda has not advanced. Here is a reality check: Wall Street has already undergone a round of reform, significantly reducing the risks big banks pose to the financial system. The evolution and structure of the world economy, not mere corporate deck-stacking, explained many of the big economic challenges the country still faces. And even with radical campaign finance reform, many Americans and their representatives would still oppose the Sanders agenda.
Mr. Sanders’s story continues with fantastical claims about how he would make the European social model work in the United States. He admits that he would have to raise taxes on the middle class in order to pay for his universal, Medicare-for-all health-care plan, and he promises massive savings on health-care costs that would translate into generous benefits for ordinary people, putting them well ahead, on net. But he does not adequately explain where those massive savings would come from. Getting rid of corporate advertising and overhead would only yield so much. Savings would also have to come from slashing payments to doctors and hospitals and denying benefits that people want.
He would be a braver truth-teller if he explained how he would go about rationing health care like European countries do. His program would be more grounded in reality if he addressed the fact of chronic slow growth in Europe and explained how he would update the 20th-century model of social democracy to accomplish its goals more efficiently. Instead, he promises large benefits and few drawbacks.
Meanwhile, when asked how Mr. Sanders would tackle future deficits, as he would already be raising taxes for health-care expansion and the rest of his program, his advisers claimed that more government spending “will result in higher growth, which will improve our fiscal situation.” This resembles Republican arguments that tax cuts will juice the economy and pay for themselves — and is equally fanciful.
Mr. Sanders tops off his narrative with a deus ex machina: He assures Democrats concerned about the political obstacles in the way of his agenda that he will lead a “political revolution” that will help him clear the capital of corruption and influence-peddling. This self-regarding analysis implies a national consensus favoring his agenda when there is none and ignores the many legitimate checks and balances in the political system that he cannot wish away.
Mr. Sanders is a lot like many other politicians. Strong ideological preferences guide his thinking, except when politics does, as it has on gun control. When reality is ideologically or politically inconvenient, he and his campaign talk around it. Mr. Sanders’s success so far does not show that the country is ready for a political revolution. It merely proves that many progressives like being told everything they want to hear.

Bernie Sanders’s ideas are not too bold. They are too facile.
 
‘IF THE Washington Post wants to say that our ideas are bold, I accept that,” Sen. Bernie Sanders (I-Vt.) said Thursday in response to a critical editorial we ran about him. “We’ve got to create an economy that works for the middle class. And whether The Washington Post likes it or not, that’s what I intend to do.”
In fact, we would love that — and we were heartened that Mr. Sanders chose to engage with our editorial. Yet our disagreements with Mr. Sanders are not as he portrayed them; they do not concern the problems he chooses to address or the boldness with which he proposes to address them. The nation could use big measures to take on climate change, advance public health, tackle poverty, shore up entitlement programs, boost education, improve our democracy and do all sorts of other things that Mr. Sanders cares about. We argue for policies such as a carbon tax and public campaign financing, even though they are subject to massive and possibly insurmountable political opposition, because they would lead to large and needed changes.
What concerns us is not that Mr. Sanders’s program to tackle these issues is “radical,” as he put it, but that it is not very well thought out. We are far from the only ones, for example, to point out that his health-care plan rests on unbelievable assumptions about how much he could slash health-care costs without affecting the care ordinary Americans receive. “Their savings numbers are — well, politely said — simply wrong,” Emory University health-care expert Kenneth E. Thorpe told Vox. Mr. Thorpe, who is not hostile to single-payer systems of the type Mr. Sanders favors and has even advanced single-payer plans of his own, released an analysis Wednesday finding that Mr. Sanders’s proposal would cost $1 trillion more than the candidate estimated. That is not over a 10-year budget window. That is every year.
Mr. Sanders’s response to concerns over health-care costs was that other countries, such as Canada and France, spend much less than the United States per person on health care. That is true, but the question is how, specifically, he would make the model work here. The countries he praises ration care in ways that federal health programs in the United States, such as Medicare, do not. While there may be a fair case for a single-payer health-care system, Mr. Sanders does not make it. Instead, he promises comprehensive benefits without seriously discussing the inevitable trade-offs. That is not just bold; it is half-baked.
Health-care policy is only one place where Mr. Sanders makes solving the country’s difficult problems seem easy and obvious when reality is messier. He would use higher taxes on Wall Street and the rich to fund vast new programs, such as free college for all, but has no plausible plan for plugging looming deficits as the population ages. His solution to the complex international crises the United States must manage is to hand them off to others — though there is no such cavalry. This might not distinguish him much from other politicians. And that is part of the point: His campaign isn’t so much based on a new vision as on that old tactic known as overpraising.


Drug Shortages Forcing Hard Decisions on Rationing Treatments


By 

CLEVELAND — In the operating room at the Cleveland Clinic, Dr. Brian Fitzsimons has long relied on a decades-old drug to prevent hemorrhages in patients undergoing open-heart surgery. The drug, aminocaproic acid, is widely used, cheap and safe. “It never hurt,” he said. “It only helps.”
Then manufacturing issues caused a national shortage. “We essentially did military-style triage,” said Dr. Fitzsimons, an anesthesiologist, restricting the limited supply to patients at the highest risk of bleeding complications. Those who do not get the once-standard treatment at the clinic, the nation’s largest cardiac center, are not told. “The patient is asleep,” he said. “The family never knows about it.”
In recent years, shortages of all sorts of drugs — anesthetics, painkillers, antibiotics, cancer treatments — have become the new normal in American medicine. The American Society of Health-System Pharmacists currently lists inadequate supplies of more than 150 drugs and therapeutics, for reasons ranging from manufacturing problems to federal safety crackdowns to drugmakers abandoning low-profit products. But while such shortages have periodically drawn attention, the rationing that results from them has been largely hidden from patients and the public.
At medical institutions across the country, choices about who gets drugs have often been made in ad hoc ways that have resulted in contradictory conclusions, murky ethical reasoning and medically questionable practices, according to interviews with dozens of doctors, hospital officials and government regulators.



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