The Only Way the US Can Ever Get Affordable Health Care
Wednesday, 17 February 2016 00:00 By John Geyman, Speakout | News Analysis
Now that Bernie Sanders has brought forward his progressive agenda, including real health care reform through a single-payer universal Medicare for all program, the knives are out from the Republicans as well as Hillary Clinton to distort and discredit this option with false information.
Going forward, we have three basic alternatives to further reform our health care system: 1.) continue with the Affordable Care Act (ACA) with improvements as needed (which Clinton supports with barely a hint of what those changes might be); 2.) the Republican "plan," including repeal of the ACA and emphasizing market-based "fixes", such as health savings accounts, selling insurance across state lines, and further privatization of both Medicare and Medicaid; and 3.) National Health Insurance (NHI) through a Medicare for all plan, as currently embodied in HR 676, legislation pending in the House of Representatives.
Let's cut through the smoke and mirrors of the debate and compare each alternative in terms of costs, affordability, and what we get in terms of access, quality, and sustainability.
First, looking at costs, we have experience with market approaches to cost containment over the last three-plus decades - none have worked tocontrol either costs or prices. The ACA, with virtually no price controls, has given us, with various government subsidies, six years for private insurers, hospitals, drug companies, and others in the medical-industrial complex to expand their markets with minimal oversight.
Private healthinsurers have bulked up, consolidated, gamed the new "system" for profits and shareholder returns even as they complain of not making enough money and threatening to withdraw from the ACA's exchanges. (1) The CEO of the largest insurer, UnitedHealthcare, Stephen Hemsley, pocketed $66.1 million ($254,328 per day) total compensation in 2014. (2)
Republican policies have accelerated privatization of Medicare and Medicaid, adding higher burdens of administrative overhead and profits at public expense. Their policies are based on the concepts that markets can fix our problems and patients' demands are at the heart of inflatinghealth care costs. Hence their reliance on "consumer directed health care," with its high-deductible, low-value policies which have failed for many years.
You can't believe most of the claims that are being made about the costs of single-payer NHI. Clinton is saying that the middle class will be hit with a big tax increase without mentioning what patients and families will save and get with NHI. She says that Sanders' numbers for savings for typical American families under NHI "don't add up." (3) Some economists are also jumping on the bandwagon to discredit NHI. Paul Krugman, still thinks it is "not politically feasible" because of the political and economic power of the medical-industrial complex, and worries about "disruption for patients" with the ACA, but doesn't acknowledge the huge gains that NHI would bring with far more efficiency than our current multi-payer system. (4) Economist Kenneth Thorpe, an Emory University professor who served in the Clinton administration, claims that NHI would break the bank, and cost $1 trillion more a year than estimated as he grossly underestimated savings on overhead, drug costs, and other government expenses while assuming a grossly exaggerated increase in utilization by patients. (5)
Despite demagoguery on the issue, we have solid information on the costs - and savings - of NHI. The landmark 2013 study by Gerald Friedman, professor of economics at the University of Massachusetts, estimated that implementation of single-payer NHI will save $592 billion annually by cutting administrative waste of private insurers ($476 billion) and reducing pharmaceutical prices to European levels ($116 billion). Those savings would be enough to cover all the uninsured and provide comprehensive coverage for all other Americans, even including dental and long-termcare. Co-payments and deductibles will be eliminated, savings will fund retraining of displaced workers and phasing out investor-owned for-profit delivery systems over a 15-year period. (6)
How will this be paid for? Table 1 proposes a progressive financing plan under which 95 percent of Americans will pay less than they do now for insurance premiums, deductibles, co-payments, and out-of-pocket payments for health care. Only 5 percent of high-income Americans will pay more. The payroll tax will become the main health care tax for people with annual incomes below $225,000 - $1,500 for those with incomes of $50,000, $6,000 for those earning $100,000, and $12,000 for those with incomes of $200,000.
With NHI, all Americans will have full choice of doctors and hospitals, quality of care for the whole population will improve, bureaucracy will be sharply reduced, and we will finally have a more accountable and sustainable system. (7) Employers will be relieved of their burden of providinghealth insurance for their employees and may be able to convert some of their previous contributions to employer-sponsored insurance toemployees' forgone wage increases as they gain a healthier workforce and become more competitive in global markets. Physicians and otherhealth professionals will have a simplified billing system and more time for direct patient care.
We already pay much more in taxes each year for health care than we realize. In their just-published article in the American Journal of PublicHealth, Drs. Woolhandler and Himmelstein report that the US government, at taxpayer expense, is now paying 65 percent of the total annual tab for health care - $2.1 trillion last year, $6,560 per person, more per capita than people pay in taxes in any other advanced country with universalhealth insurance. As they report, much of this taxation is invisible to us, such as government spending to buy private health coverage for public employees and tax subsidies for private employer-sponsored insurance and other privately paid care. (8)
We have to recognize renewal of opposition to NHI for what it is - Clinton's conflicts of interest and involvement with Wall Street, despite her denials (e.g. $2.8 million in speaker fees from the health care industry between 2013 and 2015) (9); corporate media beholden to Wall Street; and a Republican consensus to block whatever President Obama does at every turn, without giving us any assurance that they will govern in the public interest.
This really is a perilous moment in the history of US health care. The ACA is fundamentally flawed - a bailout to a failing private health insurance industry and other corporate stakeholders in the medical-industrial complex. Tweaks around the edges of the ACA will never bring us cost containment in a sustainable way. If Republicans gain more control of Congress, and even the presidency in 2017, health care for much of our population will get much worse in terms of access, affordability, and quality. Research over many years has shown that the majority of Americans want NHI.
We have to come to grips that we cannot afford our present multi-payer financing system. There is more than enough money in the system to pay for it, but its waste and profiteering prevent us from getting what we are already paying for. We have to get the politics right to get the system we need - single-payer financing that we all can afford.
http://www.truth-out.org/speakout/item/34871-the-only-way-the-us-can-ever-get-affordable-health-care
Why privatizing the VA health care system is a bad idea
The Veteran’s Health Administration must fix major problems, but its integrated care system should be a model to learn from.
by Suzanne Gordon
Obamacare isn’t the only program at stake in the next election. The
future of the nation’s largest health care system — the Veterans Health
Administration — is also up for grabs. Republican candidates for
president, some with support from the Koch brothers-funded group
Concerned Veterans for America, are waging a campaign to demonize,
remake, and perhaps ultimately privatize the VHA. Marco Rubio wants to
“jolt the VA back to life,” by forcing it to compete with the private
sector. Donald Trump insists we should “empower our veterans to vote
with their feet,” which, he seems sure, will take them far away from the
nearest VA hospital.
Critics of the VHA have done a good job of erasing any memory of its successes from public consciousness. This is particularly ironic today, 70 years after the head of the Veterans Administration signed a memorandum affiliating veterans’ hospitals with academic medical centers. Since that time, the VHA has become “the largest single provider of medical training in the country,” according to the Association of American Medical Colleges, helping prepare over 70 percent of the nation’s physicians as well as members of more than 40 other health care professions. VHA researchers have helped pioneer innovations — the shingles vaccine, the implantable cardiac pacemaker, the first liver transplant — that benefit all Americans.
Of course, the VHA today has serious problems that can and must be
fixed, including a suicide prevention hotline that sent some callers to
voicemail, according to a recent report. An independent assessment
of the VHA conducted by MITRE Corporation, the Rand Corporation, and
others and released last year highlighted problems with top-heavy
management, cumbersome hiring processes, and delays in access to care in
some regions.
On the whole, however, the assessment also reported that the VHA’s 288,000 employees, including 20,000 physicians, are able to deliver high-quality care to the more than 6 million veterans who receive its services. “VA wait times,” RAND reported, “do not seem to be substantially worse than non-VA waits.” VA patients get care that is often higher quality than that in the private sector — with performance variation “lower than that observed in private sector health plans.” A study published recently in JAMA reported that men with heart failure, heart attacks, or pneumonia were less likely to die if treated at a VHA hospital rather than non-VHA hospital.
These successes are because the VHA has developed into the only nationwide fully integrated health care system in the United States. As such, it provides a model for other systems — one policy makers should be trying to learn from, not dismantle.
Integration affords veterans a level of care unavailable to most Americans, who remain subject to our fragmented private sector health care system. A VHA patient moving from Boston to San Francisco can get uninterrupted care from professionals with access to his or her medical records. The treatment veterans receive at the VHA’s more than 1,500 hospitals, community-based outpatient clinics, and other facilities is highly coordinated. For example, veterans seeing their primary care practitioner to discuss health problems — diabetes, say, or PTSD — can then walk down the hall and talk to a nutritionist about a diet, a pharmacist about how to correctly administer insulin, or a mental health professional. Because the VHA now recognizes that female veterans have special needs, they can often access care from dedicated women’s clinics. A recent study reported that women veterans have higher rates of screening for cervical and breast cancer when they see a specially designated women’s health provider.
You might think that the committees, commissions, and panels assigned to evaluate the VHA would be trying to bolster this system, focusing not only on its problems but also its strengths. Yet some seem intent on picking apart the VHA’s tapestry of comprehensive care thread by thread.
In an October essay in the New England Journal of Medicine,
the two leading members of a blue-ribbon commission charged with
evaluating the MITRE group’s assessment suggested that VHA primary care
could be spun off to the private sector. Gail Wilensky, a former head of
Medicare, and physician Brett Giroir wrote that the VHA’s model of
providing “comprehensive care” to veterans could be shifted to one
focused on specialized care, like treatment of traumatic brain injuries.
Others have suggested shifting audiology or optometry or mental health
to the private sector.
The problem is that veterans with brain injuries may also need a hearing aid or treatment for asthma or diabetes. These overlapping health problems can only be managed in a system in which primary care is, in fact, primary. Which is why improving and strengthening the integrated VHA system is something worth fighting for.
http://www.bostonglobe.com/magazine/2016/02/17/why-privatizing-health-care-system-bad-idea/2PyB5Dz36pdahjwVFr3p3M/story.html?s_campaign=email_BG_TodaysHeadline&s_campaign=
Critics of the VHA have done a good job of erasing any memory of its successes from public consciousness. This is particularly ironic today, 70 years after the head of the Veterans Administration signed a memorandum affiliating veterans’ hospitals with academic medical centers. Since that time, the VHA has become “the largest single provider of medical training in the country,” according to the Association of American Medical Colleges, helping prepare over 70 percent of the nation’s physicians as well as members of more than 40 other health care professions. VHA researchers have helped pioneer innovations — the shingles vaccine, the implantable cardiac pacemaker, the first liver transplant — that benefit all Americans.
On the whole, however, the assessment also reported that the VHA’s 288,000 employees, including 20,000 physicians, are able to deliver high-quality care to the more than 6 million veterans who receive its services. “VA wait times,” RAND reported, “do not seem to be substantially worse than non-VA waits.” VA patients get care that is often higher quality than that in the private sector — with performance variation “lower than that observed in private sector health plans.” A study published recently in JAMA reported that men with heart failure, heart attacks, or pneumonia were less likely to die if treated at a VHA hospital rather than non-VHA hospital.
These successes are because the VHA has developed into the only nationwide fully integrated health care system in the United States. As such, it provides a model for other systems — one policy makers should be trying to learn from, not dismantle.
Integration affords veterans a level of care unavailable to most Americans, who remain subject to our fragmented private sector health care system. A VHA patient moving from Boston to San Francisco can get uninterrupted care from professionals with access to his or her medical records. The treatment veterans receive at the VHA’s more than 1,500 hospitals, community-based outpatient clinics, and other facilities is highly coordinated. For example, veterans seeing their primary care practitioner to discuss health problems — diabetes, say, or PTSD — can then walk down the hall and talk to a nutritionist about a diet, a pharmacist about how to correctly administer insulin, or a mental health professional. Because the VHA now recognizes that female veterans have special needs, they can often access care from dedicated women’s clinics. A recent study reported that women veterans have higher rates of screening for cervical and breast cancer when they see a specially designated women’s health provider.
You might think that the committees, commissions, and panels assigned to evaluate the VHA would be trying to bolster this system, focusing not only on its problems but also its strengths. Yet some seem intent on picking apart the VHA’s tapestry of comprehensive care thread by thread.
The problem is that veterans with brain injuries may also need a hearing aid or treatment for asthma or diabetes. These overlapping health problems can only be managed in a system in which primary care is, in fact, primary. Which is why improving and strengthening the integrated VHA system is something worth fighting for.
http://www.bostonglobe.com/magazine/2016/02/17/why-privatizing-health-care-system-bad-idea/2PyB5Dz36pdahjwVFr3p3M/story.html?s_campaign=email_BG_TodaysHeadline&s_campaign=
Break Up the Insulin Racket
By KASIA LIPSKA
FEBRUARY 20, 2016
ONE of my patients — whom I will call Mrs. B — is a 78-year-old who has had Type 2 diabetes for over 30 years. She takes several injections of insulin each day. Her blood sugars have been running too high, but she doesn’t want to increase the dose of her insulin. She told me she simply can’t afford to.
Insulin has been around for almost a century. The World Health Organization considers it an essential medicine, which means it should be available “at a price the individual and the community can afford.” So why is this product increasingly too expensive for many Americans?
In the United States, just three pharmaceutical giants hold patents that allow them to manufacture insulin: Eli Lilly, Sanofi and Novo Nordisk. Put together, the “big three” made more than $12 billion in profits in 2014, with insulin accounting for a large portion.
What makes this so worrisome is that the big three have simultaneously hiked their prices. From 2010 to 2015, the price of Lantus (made by Sanofi) went up by 168 percent; the price of Levemir (made by Novo Nordisk) rose by 169 percent; and the price of Humulin R U-500 (made by Eli Lilly) soared by 325 percent.
To make insulin affordable, we need more competition. Nothing would do this faster than a “generic” form of insulin. (Technically, because insulin is made using bacteria, it should be referred to as a “biosimilar” instead of a “generic.”) Unfortunately, there isn’t one available in the United States.
This is true, in no small part, because the big three have cleverly extended the lives of their patents, making incremental “improvements” to their insulin. It’s not clear whether the newer insulin products are significantly safer or more effective than their predecessors, yet the strategy has been effective: There is no generic insulin, and over 90 percent of privately insured patients with Type 2 diabetes who are prescribed insulin get the newer and more expensive products.
But even a generic version of insulin might not solve all of Mrs. B’s problems. Something else is most likely contributing to the rising price of insulin: a very powerful and largely invisible group of middlemen, known as pharmacy benefit managers, or P.B.M.s.
Benefit managers negotiate with drug companies on behalf of insurers, such as employer plans and government programs like Medicaid and Medicare Part D. In theory, their job is to bargain for lower drug prices.
The hitch is that the biggest P.B.M.s are out to make a buck. They get “rebates” from drug manufacturers — payments based on sales or other criteria, which look suspiciously similar to kickbacks. The rebates are not publicly disclosed, but they are sizable. Industry analysts estimate that those payments, and other back-room deals, amount to as much as 50 percent of the list price of insulin.
HHS failed to heed many warnings that HealthCare.gov was in trouble
During the two years before the disastrous opening of HealthCare.gov, federal officials in charge of creating the online insurance marketplace received 18 written warnings that the mammoth project was mismanaged and off course but never considered postponing its launch, according to government investigators.
The warnings included a series of 11 scathing reviews from an outside consultant — among them a top-10 list of risks drawn up in the spring of 2013 that cited inadequate planning for the website’s capacity and deviations from usual IT standards. A few months before, then-Health and Human Services Secretary Kathleen Sebelius had hired another consultant to review the project and recommend ways to improve its management, but its advice was never shared with the technical staff working on the website.
The long trail of unheeded warnings is among the findings from an exhaustive two-year inquiry by HHS’s Office of Inspector General into the failings of HealthCare.gov, which crashed within two hours of its launch on Oct. 1, 2013. The failings tarnished the start of a central aspect of the Affordable Care Act — new insurance marketplaces for Americans who cannot get affordable coverage through a job — and embarrassed the White House, which championed the law.
The findings are contained in a “case study” to be released Tuesday. It represents the most penetrating look ever into what went wrong with the building of the federal insurance exchange and what was done to fix it. It is based on interviews with 86 employees of HHS, its Centers for Medicare and Medicaid Services (CMS) and companies that worked on the project, as well as on several thousand emails, memos, government contracts and other internal documents.
Many of the basic contours laid out in the 84-page report are, by now, familiar: Federal health officials failed to recognize the enormity of the undertaking, were disorganized and fragmented, were hampered by late and shifting ACA policies, had too little money, used poor contracting practices, and ignored problems until it was too late.
But the inquiry unearthed vivid details that have not been public. And it concludes that the central reason for the problems rested not with the shoddy work of vital IT contractors but with mismanagement by federal health officials carrying out this part of the law.
How a MaineCare expansion plan differs from past 5 failures
Posted Feb. 22, 2016
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