Democrats shouldn’t impose litmus tests on health care
by Henry Waxman - The Washington Post - April 8, 3028
Conor Lamb’s stunning victory in last month’s special election for Pennsylvania’s 18th Congressional District makes clear that health care is a winner for Democrats in 2018. More than half of all voters ranked it as a top issue, according to exit polls, and Lamb won the votes of 64 percent of those who named it their No. 1 priority.
Republicans’ attempt last year to repeal the Affordable Care Act and send 32 million Americans into the ranks of the uninsured remains an albatross. Voters in the 18th District, where Donald Trump won by 20 percent, disapproved of the ACA repeal by 53 percent to 39 percent.
Lamb campaigned as a fierce supporter of the ACA, Medicare and Medicaid — something every Democrat should do. We should remind voters again and again that Democrats are committed to universal coverage while Republicans try to take people’s health insurance away.
But what Democrats cannot do is turn this winning issue into a loser by imposing litmus tests — in particular, by demanding that all Democratic candidates support a single-payer bill, such as Medicare for all.
I say this as someone who co-sponsored single-payer legislation with Sen. Edward M. Kennedy (D-Mass.) when I served in Congress, but who also sought to seize any and every opportunity to bring our nation closer to the goal of universal coverage. That’s why I authored laws expanding Medicaid to cover more low-income children in the 1980s and 1990s, why I sponsored the 1997 Children’s Health Insurance Program, and why I led the fight to enact the ACA.
These bills passed, expanding coverage to tens of millions of Americans, while single-payer never mustered majority support in Congress. If Democrats recapture Congress this fall, we should take a similar approach: working in the realm of the possible and building on what works, rather than trying to blow it up.
One priority must be to fix the ACA’s problems — most of which are the result of deliberate sabotage by the Trump administration and the Republican Congress — while also strengthening and expanding the law.
For starters, we need to restore cost-sharing reduction payments and pass other key provisions in Sen. Lamar Alexander’s (R-Tenn.) and Sen. Patty Murray’s (D-Wash.) bipartisan market stabilization bill — urgently needed legislation that was left out of March’s federal spending bill.
We should expand subsidies so they don’t cut off for those earning more than 400 percent of the poverty level, by changing the formula so that no family’s health care premiums exceed 10 percent of their income. This would be a relatively low-cost way of making health care affordable to all and broadening the insurance pool to keep premiums down.
We should explore expanding Medicare, especially for long-term care so senior citizens and people with disabilities don’t have to impoverish themselves to qualify for Medicaid in order to afford extended stays in a rehabilitation center or nursing home.
We should also take steps to lower costs, such as allowing Medicare to negotiate lower drug prices with the pharmaceutical industry and accelerating the move away from traditional fee-for-service models toward accountable-care organizations and other innovative approaches that reward good outcomes rather than more services.
And more broadly, we must work to make the U.S. health-care system more seamless. There is no good reason for the level of disruption people encounter when they change plans today. That means making the benefits covered, degree of cost-sharing and other provisions the same whether your coverage is through Medicare, Medicaid or private insurance.
Much as I respect the passion of Medicare-for-all advocates and share their broader goals, single-payer is no panacea. We couldn’t muster the votes for single-payer nine years ago when we had a filibuster-proof 60 votes in the Senate and a 255-179 majority in the House. Even if we recapture control of Congress in 2018, our margins will be smaller. And of course, the Republican in the White House would veto any such legislation.
Just as important, single-payer is no policy panacea. Medicare is hugely successful and popular, but most beneficiaries purchase private supplemental insurance to reduce the burden of large out-of-pocket costs. The most prominent single-payer bill would eliminate all out-of-pocket costs for Medicare, a move whose astronomical costs would require tax increases at politically suicidal levels.
Moreover, most countries with universal coverage, including Germany, France, Switzerland and the Netherlands, do not have what we would define as single-payer, instead relying on private insurance as part of the mix.
Democrats can embrace a boundless vision for our health-care future without being trapped by a rigid model for how to get there. Instead, we should focus on increasing the number of Americans with comprehensive health insurance and lowering costs. Let’s be united on the goal of universal coverage, pragmatic on tactics and focused most of all on making a positive difference in as many people’s lives as possible.
Editor's Note:
The following personal message was sent by Kenneth Dolkart to Dr. Tom Clairmont of Portsmouth, N.H., in response to (ex-) Congressman Henry Waxman's Washington Post op-ed posted above. I agree with his point, that the challenge is in re-framing the current debate around universal health care, not just to simply react to the current framing.
-SPC
Hi Tom - I read this original article by Henry Waxman, and he takes the perspective of someone who doesn’t believe single payer will happen in his lifetime - I met with Valerie Jarett, (Obama’s campaign aide) early on when he was running in the NH primary, and she made it clear that they would NOT introduce single payer approaches back then, since they believed it would never pass (they were right about that at the time.)
- I agree with all your comments below:"And more broadly, we must work to make the U.S. health-care system more seamless. There is no good reason for the level of disruption people encounter when they change plans today. That means making the benefits covered, degree of cost-sharing and other provisions the same whether your coverage is through Medicare, Medicaid or private insurance.”
What that means is a more uniform benefit package, and value/efficiency requires more uniform billing forms, formularies, coverage policies, etc, (presumably based on Medicare) which will never be accepted by for-profit publicly traded insurance companies. As you point out, private insurers which collaborate with the Netherlands or Germany are restricted in profit. I would personally not have any objection to incorporating current American insurers if they adopted uniform forms and policies, eliminated their banks of utilization review administrators, and accepted taking no profit! (What am I smoking, you ask…) You are right, he yearns for expanded Medicare for all, but believes passage of HR676 or Sander’s Senate proposal is a lost cause. I think Waxman was invested in the ACA, and he wants to see it persist, and being burned in the past he cannot move beyond that to the next logical steps.
- Does the possibiity of instituting Expanded Medicare for All require a radical change in our corrupted system first? I don’t think so - Given building public sentiment, if a dramatic change in the composition of Congress occurs in the midterms, I think incremental expansion of Medicare is feasible in the near future. This might be either as a “public option” (not our preference) or a phased-in expansion to younger age groups. PNHP, of course, should continue to push for the appropriate national solution, knowing it is unlikely to pass soon.
-But times do change, sometimes as a reaction to extreme corruption, as we are seeing in recent decades and certainly now (see Mulvaney’s recent comments) To eliminate our current American Oligarchy, we ultimately need a 2nd American Revolution to create legislation to eliminate unbridled corporate financing of elected officials, overturn Citizens United, institute European style-public funding of limited campaigns, etc. A truely efficient, high value, non-profit national single payer system might require diminishing the power of the for profit health insurance industry in Congress, no matter what the public will might be. Perhaps we need to introduce national legislation, based on precedent during the crisis of war, to specifically restrict financing of elected officials by corporations which profit on “essential” health services.
-Keep up the good fight, Tom!
Ken
Let’s make medicines a public good again
by Diane Archer - Jus+Care - April 25, 2018
Fran Quigley writes for The Other 98 percent that it is time to make medicines a public good again. He explains that it is only recently that we began treating medicines as a commodity that could be priced at any level and kept from people who needed it. Throughout most of history it would have been “immoral and illegal” to impede access to medicines by making them unaffordable.
How is it that we now assume that medicines should be developed, distributed and marketed by profit-driven corporations and that these corporations should have monopolies to charge what they will for them? We have created a system in which people suffer and die because they can’t afford their medicines. Are we prepared to let these people die?
Patents are the problem, along with the pharmaceutical corporations that own them. It was only in the second half of the 20th century that a large number of countries began giving individuals and corporations patent protections. These patent protections combined with people’s critical need for life-saving and life-improving medicines have delivered larger profits to pharmaceutical companies than any other industry in the world.
Today, thousands of lobbyists spend tens of millions of dollars telling policymakers and the public that they need to make huge profits to develop new medicines. They want to ensure that policymakers do not once again insist that medicines are a public good. And, they are winning, internationally and domestically, nationally and at the state level.
What is particularly galling is that taxpayer dollars are paying for a big chunk of the discoveries. Indeed, in the six years between 2010 and 2016, all 210 new drugs approved by the FDA were developed with taxpayer dollars. Drug companies spend more on marketing than on research. And, a big chunk of our taxpayer dollars is going to CEO salaries, lobbying and campaign contributions, not to drug development.
Poll after poll show that most people see a big difference between TVs and other commodities, which are patented, and medicines. Unlike medicines, we can go without those products without risk to our health and well-being. We should be treating medicines as a public good not as a commodity.
It does not have to be this way. If Congress stepped in and allowed negotiated drug pricing, the money we saved would more than pay for all the research currently undertaken and allow us to target research money on needed medicines. Pharmaceutical companies dedicate a lot of their research dollars to me-too prescription drugs and spinoffs of branded products that do not contribute in any meaningful way to the public good. Rather, these drugs may extend the patent life of a prescription drug or prevent the development of generic alternatives and increase Pharma profits.
Taking a step back to the past in order to move forward and treating prescription drugs as a public good is not unheard of. We did it with the AIDs drugs. It is time we do it for all prescription drugs.
Universal health care, worldwide, is within reach
The case for it is a powerful one—including in poor countries
by The Economist - April 26, 2018
Yet the gap between this progress and the still greater potential that medicine offers
has perhaps never been wider. At least half the world is without access to what the
World Health Organisation deems essential, including antenatal care, insecticide-
treated bednets, screening for cervical cancer and vaccinations against diphtheria,
tetanus and whooping cough. Safe, basic surgery is out of reach for 5bn people.
Those who can get to see a doctor often pay a crippling price. More than 800m people spend over 10% of their annual household income on medical expenses; nearly 180m spend over 25%. The quality of what they get in return is often woeful. In studies of consultations in rural Indian and Chinese clinics, just 12-26% of patients received a correct diagnosis.
That is a terrible waste. As this week’s special report shows, the goal of universal basic health care is sensible, affordable and practical, even in poor countries. Without it, the potential of modern medicine will be squandered.
The evidence for the feasibility of universal health care goes beyond theories jotted
on the back of prescription pads. It is supported by several pioneering examples.
Small amounts of spending can go a long way. Research led by Dean Jamison, a
health economist, has identified over 200 effective interventions, including
immunisations and neglected procedures such as basic surgery. In total, these
would cost poor countries about an extra $1 per week per person and cut the
number of premature deaths there by more than a quarter. Around half that
funding would go to primary health centres, not city hospitals, which today receive
more than their fair share of the money.
Europeans have long wondered why the United States shuns the efficiencies and
health gains from universal care, but its potential in developing countries is less
understood. So long as half the world goes without essential treatment, the fruits of
centuries of medical science will be wasted. Universal basic health care can help
realise its promise.
https://www.economist.com/news/leaders/21741138-case-it-powerful-oneincluding-poor-countries-universal-health-care-worldwide
The case for it is a powerful one—including in poor countries
by The Economist - April 26, 2018
BY MANY measures the world has never been in better health. Since 2000 the
number of children who die before they are five has fallen by almost half, to 5.6m.
Life expectancy has reached 71, a gain of five years. More children than ever are
vaccinated. Malaria, TB and HIV/AIDS are in retreat.
Those who can get to see a doctor often pay a crippling price. More than 800m people spend over 10% of their annual household income on medical expenses; nearly 180m spend over 25%. The quality of what they get in return is often woeful. In studies of consultations in rural Indian and Chinese clinics, just 12-26% of patients received a correct diagnosis.
That is a terrible waste. As this week’s special report shows, the goal of universal basic health care is sensible, affordable and practical, even in poor countries. Without it, the potential of modern medicine will be squandered.
Universal basic health care is sensible in the way that, say, universal basic
education is sensible—because it yields benefits to society as well as to individuals.
In some quarters the very idea leads to a dangerous elevation of the blood pressure,
because it suggests paternalism, coercion or worse. There is no hiding that public
health-insurance schemes require the rich to subsidise the poor, the young to
subsidise the old and the healthy to underwrite the sick. And universal schemes
must have a way of forcing people to pay, through taxes, say, or by mandating that
they buy insurance.
But there is a principled, liberal case for universal health care. Good health is something everyone can reasonably be assumed to want in order to realise their full individual potential. Universal care is a way of providing it that is pro-growth. The costs of inaccessible, expensive and abject treatment are enormous. The sick struggle to get an education or to be productive at work. Land cannot be developed if it is full of disease-carrying parasites. According to several studies, confidence about health makes people more likely to set up their own businesses.
Universal basic health care is also affordable. A country need not wait to be rich before it can have comprehensive, if rudimentary, treatment. Health care is a labour-intensive industry, and community health workers, paid relatively little compared with doctors and nurses, can make a big difference in poor countries. There is also already a lot of spending on health in poor countries, but it is often inefficient. In India and Nigeria, for example, more than 60% of health spending is through out-of-pocket payments. More services could be provided if that money— and the risk of falling ill—were pooled.
But there is a principled, liberal case for universal health care. Good health is something everyone can reasonably be assumed to want in order to realise their full individual potential. Universal care is a way of providing it that is pro-growth. The costs of inaccessible, expensive and abject treatment are enormous. The sick struggle to get an education or to be productive at work. Land cannot be developed if it is full of disease-carrying parasites. According to several studies, confidence about health makes people more likely to set up their own businesses.
Universal basic health care is also affordable. A country need not wait to be rich before it can have comprehensive, if rudimentary, treatment. Health care is a labour-intensive industry, and community health workers, paid relatively little compared with doctors and nurses, can make a big difference in poor countries. There is also already a lot of spending on health in poor countries, but it is often inefficient. In India and Nigeria, for example, more than 60% of health spending is through out-of-pocket payments. More services could be provided if that money— and the risk of falling ill—were pooled.
Chile and Costa Rica spend about an eighth of what America does per person on
health and have similar life expectancies. Thailand spends $220 per person a year
on health, and yet has outcomes nearly as good as in the OECD. Its rate of deaths
related to pregnancy, for example, is just over half that of African-American
mothers. Rwanda has introduced ultrabasic health insurance for more than 90% of
its people; infant mortality has fallen from 120 per 1,000 live births in 2000 to
under 30 last year.
And universal health care is practical. It is a way to prevent free-riders from passing on the costs of not being covered to others, for example by clogging up emergency rooms or by spreading contagious diseases. It does not have to mean big government. Private insurers and providers can still play an important role.
Indeed such a practical approach is just what the low-cost revolution needs. Take, for instance, the design of health-insurance schemes. Many countries start by making a small group of people eligible for a large number of benefits, in the expectation that other groups will be added later. (Civil servants are, mysteriously, common beneficiaries.) This is not only unfair and inefficient, but also risks creating a constituency opposed to extending insurance to others. The better option is to cover as many people as possible, even if the services available are sparse, as under Mexico’s Seguro Popular scheme.
And universal health care is practical. It is a way to prevent free-riders from passing on the costs of not being covered to others, for example by clogging up emergency rooms or by spreading contagious diseases. It does not have to mean big government. Private insurers and providers can still play an important role.
Indeed such a practical approach is just what the low-cost revolution needs. Take, for instance, the design of health-insurance schemes. Many countries start by making a small group of people eligible for a large number of benefits, in the expectation that other groups will be added later. (Civil servants are, mysteriously, common beneficiaries.) This is not only unfair and inefficient, but also risks creating a constituency opposed to extending insurance to others. The better option is to cover as many people as possible, even if the services available are sparse, as under Mexico’s Seguro Popular scheme.
The health of nations
Consider, too, the $37bn spent each year on health aid. Since 2000, this has helped save millions from infectious diseases. But international health organisations can distort domestic institutions, for example by setting up parallel programmes or by diverting health workers into pet projects. A better approach, seen in Rwanda, is when programmes targeting a particular disease bring broader benefits. One example is the way that the Global Fund to Fight AIDS, Tuberculosis and Malaria finances community health workers who treat patients with HIV but also those with other diseases.
Consider, too, the $37bn spent each year on health aid. Since 2000, this has helped save millions from infectious diseases. But international health organisations can distort domestic institutions, for example by setting up parallel programmes or by diverting health workers into pet projects. A better approach, seen in Rwanda, is when programmes targeting a particular disease bring broader benefits. One example is the way that the Global Fund to Fight AIDS, Tuberculosis and Malaria finances community health workers who treat patients with HIV but also those with other diseases.
https://www.economist.com/news/leaders/21741138-case-it-powerful-oneincluding-poor-countries-universal-health-care-worldwide
Canada: global leadership on health
Executive Summary
The Lancet’s Series on Canada, the first-ever for the journal, examines the country’s system of universal health coverage and its global role in health, including Canada’s legacy, challenges, and future path on issues such as access to health care, gender equality, global health diplomacy, and Indigenous peoples’ health. Led by authors from across the country’s diverse ethnocultural, linguistic, and geographic landscape, the Series sets the stage for accelerated Canadian leadership on health at home and abroad, as Canada marks 150 years since confederation and assumes the G7 presidency for 2018. Commentaries by leaders in Indigenous health and foreign aid assistance, and by Prime Minister Justin Trudeau and Minister Jane Philpott, show Canada to be poised for more action, more financial investment, and bolder leadership on health for the world.
What the scare tactics miss about public health care
by Julia Underwood - BDN - May 2, 2018
In an anguished column, Matthew Gagnon, CEO of The Maine Heritage Policy Center, describes the extraordinary case of Alfie Evans, a British child born with a neurodegenerative disorder who was at the center of a legal and international firestorm until his death early Saturday morning.
At Consumers for Affordable Health Care, we are not physicians, lawyers, judges or bureaucrats. We take no position on the Evans case, but we are disturbed by Gagnon’s use of such an extreme case to disparage the United Kingdom’s publicly funded health system, which serves 58 million people.
In detailing the Evans case, it appears Gagnon’s purpose is to make people afraid of “state-sponsored health care.” What he seems to forget is, here in America, plenty of people already use and appreciate health care sponsored by the government — though they may not think of it that way. In fact, on this side of the Atlantic the public has undertaken medical care for some populations since before the country’s inception.
According to the Department of Veterans Affairs website, the pilgrims passed a law in 1636 providing support to disabled veterans. Over time, public support for veterans evolved into what the VA describes as “the most comprehensive system of assistance for Veterans of any nation of the world.” This publicly funded system provides medical care not only to veterans but to retirees, spouses and children.
We have other publicly funded health care programs in the U.S., including Medicare, which provides health coverage for 55 million people over age 65, and Medicaid, which provides coverage for close to 74 million individuals, including seniors, people with disabilities and low-income families. And thanks to the Affordable Care Act, more than 20 million people, including 75,000 Mainers, have health insurance because of this public-private partnership.
While these programs may not be perfect, private insurance in the U.S. creates numerous problems. According to a 2015 Commonwealth Fund report, the U.S. health care system is the most expensive in the world. This unfortunate status has far-reaching consequences for the U.S. economy, contributing to wage stagnation, personal bankruptcy, budget deficits, and a competitive disadvantage in the global marketplace.
Sure, private insurers take on risk and should be rewarded, but given large private insurers’ rising stock prices, larger than expected profits and increasing investor confidence, everyone should be concerned about the individuals, families and businesses struggling to pay for coverage. Furthermore, it is shocking, if not “horrific,” that many people in the U.S. cannot afford coverage and must choose between basic needs and medicine. Fortunately, if a family in Maine loses private coverage, there is a government-sponsored health care program that can serve as a “safety net” so at least their children can get the health care they need.
Although this patchwork system works for many of us, it leaves too many people to fend for themselves. About 28 million people in the U.S. lack any form of health insurance. Even those who are eligible often face barriers to enrolling. At Consumers for Affordable Health Care, we help people understand, find and use health insurance, whether public or private, and access other programs to meet their medical needs. Every day we hear about obstacles, including exorbitant costs, that Maine people face when trying to access the health care or medicine they need. We would be first in line to advocate for a more streamlined system — and one in which everyone has coverage and access to quality care, regardless of their ability to pay.
In deriding the U.K. health system, Gagnon ignores the fact that the U.K. spends about half of what the U.S. spends on health care, measured as a percent of GDP. What’s more, U.K. health outcomes in many areas are consistently better than in the U.S., including a lower infant mortality rate and longer life expectancy.
Do we argue for a system like the U.K.’s? Not necessarily. We support universal coverage, a concept distinct from single-payer health insurance. But, unlike Gagnon, we look at the big picture in addition to individual outcomes. Millions of Americans have benefitted historically from government-funded health care and continue to do so. Let’s not lose sight of that extraordinary contribution to the health and well-being of our fellow Americans.
Julia M. Underwood is the associate director for Consumers for Affordable Health Care, a Maine-based nonprofit organization with the mission to improve access to quality and affordable health care for all people living in Maine.
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