Author: cmh

Achieving a High-Performance Health Care System with Universal Access: What the United States Can Learn from Other Countries — American College of Physicians, — Annals of Internal Medicine

Achieving a High-Performance Health Care System with Universal Access: What the United States Can Learn from Other Countries — American College of Physicians,:

When we were talking last week about the lack of single payer advocates at last week’s summit, I didn’t realize that ACP was there. The President of the ACP was there, though I don’t know his persoanl feelings about reform, I did go back and look at the recommendations published by ACP last year.

“Paying for Health Care

“Recommendation 1a: Provide universal health insurance coverage to assure that all people within the United States have equitable access to appropriate health care without unreasonable financial barriers. Health insurance coverage and benefits should be continuous and not dependent on place of residence or employment status. The ACP further recommends that the federal and state governments consider adopting one or the other of the following pathways to achieving universal coverage:

“1. Single-payer financing models, in which one government entity is the sole third-party payer of health care costs, can achieve universal access to health care without barriers based on ability to pay. Single-payer systems generally have the advantage of being more equitable, with lower administrative costs than systems using private health insurance, lower per capita health care expenditures, high levels of consumer and patient satisfaction, and high performance on measures of quality and access. They may require a higher tax burden to support and maintain such systems, particularly as demographic changes reduce the number of younger workers paying into the system. Such systems typically rely on global budgets and price negotiation to help restrain health care expenditures, which may result in shortages of services and delays in obtaining elective procedures and limit individuals’ freedom to make their own health care choices. [CMHMD Note: I guess it shows how complicated this all is. ACP considers Japan single payer and France a hybrid sytem, but most consider both single payer. In any case, neither have significant problems with waiting times.]

“2. Pluralistic systems, which involve government entities as well as multiple for-profit or not-for-profit private organizations, can assure universal access, while allowing individuals the freedom to purchase private supplemental coverage, but are more likely to result in inequities in coverage and higher administrative costs (Australia and New Zealand). Pluralistic financing models must provide 1) a legal guarantee that all individuals have access to coverage and 2) sufficient government subsidies and funded coverage for those who cannot afford to purchase coverage through the private sector. (See the ACP’s proposal for expanding access to health insurance as an example of how a pluralistic system can achieve universal coverage [69].)

“Recommendation 1b: Provide everyone access to affordable coverage—whether provided through a single-payer or pluralistic financing model—that includes coverage for a core package of benefits, including preventive services, primary care services—including but not limited to chronic illness management—and protection from catastrophic health care expenses.

“Recommendation 1c: Until there is political consensus for achieving universal coverage at a federal level, Congress should encourage state innovation by providing dedicated federal funds to support state-based programs with an explicit goal of covering all uninsured persons within the state. (See the ACP position paper, “State Experimentation with Reforms to Expand Access to Health Care” [70].)

“[ACP]Comment: Universal health care insurance is necessary to ensure that everyone within the United States has access to needed health care services of high quality. The federal government should assure that all persons within the borders of the United States also have access to health care services without undue financial barriers and that health care services provided are adequately reimbursed. The ACP recommends 2 alternatives: a system funded solely or principally by government (federal and state), commonly known as a single-payer system, or a pluralistic system that incorporates existing public and private programs with additional guarantees of coverage and with sufficient subsidies and other protections to assure that coverage is available and affordable for all. The ACP has proposed a step-by-step plan that would achieve universal coverage while maintaining a pluralistic system of mixed public and private sector funding.”

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SO, ACP advocates either a single payer model, or a social health insurance model (i.e., a hybrid system) as the path to paying for universal health care. This is where I come down as well. I think it would be very useful if we could get a majority of physicians to accept this either/or approach with the caveat that we vigorously campaign to allow NOTHING LESS than this to be our line in the sand.

McCain’s hero Teddy Roosevelt was more socialist than Obama. – By Timothy Noah – Slate Magazine

McCain’s hero Teddy Roosevelt was more socialist than Obama. – By Timothy Noah – Slate Magazine:

All from Tim Noah’s Slate.com post from before the election. I got an email from a local restauranteur decrying “villifying the rich” and complaining about complaining about excessive corporaatte entertaining.

T.R., of course, was no socialist. Indeed, his purpose was largely to prevent socialists from coming to power. But the trust buster got called a socialist a lot more often than Obama ever will. He writes in his autobiography:

Because of things I have done on behalf of justice to the workingman, I have often been called a Socialist. Usually I have not taken the trouble even to notice the epithet. … Moreover, I know that many American Socialists are high-minded and honorable citizens, who in reality are merely radical social reformers. They are opposed to the brutalities and industrial injustices which we see everywhere about us.

T.R. then goes on to outline his strong differences ‘with the Marxian Socialists’ and their belief in class warfare and the inevitable demise of capitalism. Later, he returns to his earlier theme:

Many of the men who call themselves socialists today are in reality merely radical social reformers, with whom on many points good citizens can and ought to work in hearty general agreement, and whom in many practical matters of government good citizens can well afford to follow.

There were, however, limits to T.R.’s tolerance. ‘I have always maintained,’ he concluded, ‘that our worst revolutionaries today are those reactionaries who do not see and will not admit there is any need for change.'”

Updated:Action Alert: Call The White House: Let Single Payer In | Physicians for a National Health Program

Action Alert: Call The White House: Let Single Payer In Physicians for a National Health Program:

***Update***

The White House has reversed itself and extended invitations for two single payer supporters to attend Thursday’s Healthcare Summit.
Congressman John Conyers, author of HR 676 single payer legislation in the House, and Dr. Oliver Fine, who currently heads Physicians for a National Health Program (PNHP), received invitations on Wednesday.

“On Thursday, March 5, 2009, the White House will host a summit on how to reform the healthcare system.

“The 120 invited guests include lobbyists for various interest groups including the private-for-profit insurance industry (AHIP), some members of Congress including Senate Finance Chairman Max Baucus who has already ruled single payer “off the table,” and various others concerned with healthcare.

“No single payer advocates have been invited to attend.”

A disappointing turn of events. My letter to the White House and Senator Casey (my Senator, who is now on the HELP Committee.)

RE: March 5th Health Care Summit

I am disappointed that Single-Payer Health Care advocates are not going to be represented at the Summitt. If this is because Single-Paye is “off the table,” then I suggest you disinvite all those representing the status quo, as I understand that that option is also off the table.

I personally favor transitioning to Universal Health Care via the Swiss or German Societal health Insurance model, but by not having Single Payer advocates at the table, a vast swath of serious intellectual and scientific thought is cut out of the discussion. This is NOT acceptable if we are to have a serious debate about the faith of Health Care in the US.

Thank you, etc.

To Senator Casey:

Dear Senator Casey,

I was very pleased to see that you have joined the HELP Committee. It represents a very important opportunity to do “to the least among us,” what we would want for ourselves and our children.

I hope you will push for a very strong intellectual debate on health care reform, in particular.

I was very disappointed in a recent decision by President Obama to exclude those who advocate for a Single Payer system in the US from his upcoming Health Care Summit.

If this is because Single-Payer is “off the table,” then I suggest disinviting all those representing the status quo, as I understand that that option is also off the table.

I personally favor transitioning to Universal Health Care via the Swiss or German Societal Health Insurance model, but by not having Single Payer advocates at the table, a vast swath of serious intellectual and scientific thought is cut out of the discussion. This is NOT acceptable if we are to have a serious debate about the faith of Health Care in the US.

Although I do not expect you to be able to change what will happen on March 5th, I hope you will use your position on the HELP Committee to ensure a robust, inclusive debate on health care reform.

Thank you etc.

You can get more details at the PNHP site, including that Rep. Conyers, the sponsor of HR 676 asked to be invited and was not at the PNHP site. And the WH phone numbers.

The Globalist | Global Health — What Obama Can Learn from European Health Care (Part I)

The Globalist Global Health — What Obama Can Learn from European Health Care (Part I):

“Imagine a place where doctors still do house calls. When I was visiting my friend Meredith, living in the small rural town of Lautrec about an hour’s drive outside Toulouse, France, one day she was stung badly by a wasp, causing a sizable and painful swelling on her hand.

“She called her doctor, and to my great surprise within 15 minutes he had shown up at her door — the famous French doctor’s house call. I couldn’t get over it. “House calls in the United States went out when Eisenhower was president,” I told her, shaking my head.”

Part Two of this article is here.

“The first overriding difference between U.S. and European healthcare systems is one of philosophy. The various European healthcare systems put people and their health before profits — la santé d’abord, “health comes first,” as the French are fond of saying.

“It is the difference between health care run mostly as a non-profit venture with the goal of keeping people healthy and productive — or running it as a for-profit commercial enterprise. “

And this section is well said:

Unlike single-payer Britain or Sweden, other nations like France, Germany, Switzerland and Belgium have figured out a third way, a hybrid with private insurance companies, short waiting lists for treatment and individual choice of doctors (most of whom are in private practice).

This third-way hybrid is based on the principle of “shared responsibility” between workers, employers and the government, all contributing their fair share to guarantee universal coverage.

Participation for individuals is mandatory, not optional, just as it is mandatory to have a driver’s license to drive a car.

These healthcare plans are similar to what Massachusetts recently enacted — but with two essential differences. First, in France and Germany, the private insurance companies are non-profits. Doctors, nurses and healthcare professionals are paid well, but you don’t have corporate healthcare CEOs making hundreds of millions of dollars. Generally speaking, the profit motive has been wrung out of the system.

The second key difference is in the area of cost controls. In France and Germany, fees for services are negotiated between representatives of the healthcare professions, the government, patient consumer representatives and the private non-profit insurance companies.

These are a nice pair of articles to send to people who need a basic primer on what “socialized medicine” really is, rather than what the Right wants you to think it is.

Cheers,

Poll: Obama Gets Strong Support -Health care nugget.

Poll: Obama Gets Strong Support – WSJ.com:

“On health care, the poll flashed warning signs for the administration.

“Forty-nine percent said they were willing to pay higher taxes so that everyone can have health insurance, compared with 66% who said the same in March 1993, when President Bill Clinton was embarking on his ultimately unsuccessful health-reform effort. That underscores why the administration is focused on cutting costs, not covering the uninsured.”

My take is twofold. First, Americans are paying such a large percentage of household income on health care now, 17% according to Len Nichols at New America, that perhaps they can’t imagine paying more than 17%. I often wonder how people think about this question: Do they think, “Hmm, would I be willing to pay my 17% AND more in taxes” and answer “No,” or do they think, “Hmm, the 17% of my income that goes to health care and my taxes go up some uncertain amount,” and answer “Yes?” (Or maybe they answer “no,” too.)

Or, perhaps they are picking up on the conversations we are having in the health care reform debate and take us at our word. That is, many of us routinely point out that if we truly reform health care, we should eventually be able to spend less overall. If we are right, perhaps consumers are beginning to catch on and realize we might actually end up spending less in the long run and they shouldn’t be expected to pay more of our GDP on health care.

But that would require a lot of average people paying quite a bit of attention…

I can dream, can’t I?

A national healthcare reform primer – Los Angeles Times

A national healthcare reform primer – Los Angeles Times

The cost of covering the uninsured ultimately will depend on the number of people included, the specific benefits they receive, and the amount of financial help the taxpayers would provide. The only agreement among economists who study the issue is that the tab would be a big one:* $200 billion to $250 billion a year, says Joe Antos of the conservative American Enterprise Institute.* $150 billion to $175 billion a year, says Len M. Nichols of the liberal New America Foundation.

According to CMS, we spent $2.1 Trillion on all of health care with costs rising rapidly. So even using AEI’s numbers, this only represents a 10% increase to cover all Americans.

Regardless of what happens, will I be able to keep the insurance I have now?

LA Times answers: “Almost certainly” and “Further, most people get their coverage at work, and this would continue.”

Which is too bad. Given the choice between keeping my $15 K a year policy and buying into a public policy (Medicare – like, if not Medicare) at lower cost, with less red tape, no pre-approvals, fighting for benefits and on and on, I believe most would choose the public option after it has shown its stuff. But if a public option is put out there, it allows the transition to begin away from bloated private insurers as they will have to compete with public policies.


If I don’t have health insurance, would I have to buy it if an agreement on reform is reached?

This is the tricky mandate issue. Advocates say you can’t cover everyone unless you make everyone buy a policy.Although nobody from the administration is using the “M” word these days — a mandate would represent a big expansion of government authority — many believe it is the logical way to go. So do Democratic leaders in Congress.Before such a mandate could become law, however, Congress would have to decide the amount of financial subsidies to help people pay for their coverage. Most people without health insurance work full-time and earn less than $30,000 a year. Meanwhile, the average policy for a family of four under job-based coverage cost $12,680 last year, with the employer paying $9,325, according to figures compiled by the Kaiser Family Foundation. Coverage for an individual through work cost $4,704, with the employer paying $3,983.A decision on a mandate would also involve intense negotiations between the government and the insurance industry over the terms and details of coverage.

The industry has indicated it’s willing to deliver “guaranteed issue” (nobody gets turned down) in return for a law requiring mandatory purchase of insurance.The National Assn of Insurance Commissioners has proposed a model act for the states as a way to control costs. It says that the highest rates for any age group should be no more than 400% of the lowest rate charged to any group.

This would be reduced to 300% two years after the law is passed, then to 200% after five years. That would mean a 63-year-old living in San Diego, for example, could not be charged more than double the rate paid by a 25-year-old in Santa Monica.Price differences and subsidies are crucial. It would be meaningless to have the guaranteed right to buy health insurance if you make $30,000 a year, have high blood pressure and diabetes, and a policy would cost you $10,000.

Well explained. I don’t think it is “tricky,” as there must be guaranteed insurance for all and none can be left out or much savings gained by easy access to primary care is lost.

If I have a business, would I have to buy coverage for my workers?

The answer to this question may determine the success or failure of health reform efforts.

I’m a de-linker in the sense I don’t think insurance should be linked to income and, if you like the deep economics of it, ALL benefits are from wages anyway, so if you want to do like Germny and others,you could use a payroll tax specifically for this purpose. This will cause lots of sturm and drang, however.

Would there be some help for older workers who don’t have coverage on the job and can’t afford an individual policy?

Perhaps.

Again, if we don’t get everyone in, it is not very “universal”, is it? I don’t know enough about the mind set of Congress to make a prediction, but how would the people who are just beginnning to enter their health care using years not be central to the solution?

Might there be a public health insurance plan?

This idea, backed by the president, would create for the first time a public insurance plan to compete with the myriad plans offered by private-industry insurers. The plan would be designed to provide a benchmark for quality coverage, with a basic package of comprehensive benefits. The Obama health plan issued during the presidential election campaign envisioned that millions of the 47 million uninsured would move into a public plan.

To quote Helen Hunt in, “As Good As It Gets,” “I hope, I hope, I hope, I hope.”

How can the country pay for a reworking of its health insurance system?

A nice discussion of some potential savings. This will cause a lots of discussion, but I would go back to the top of the article and point out that even the AEI’s estimates (which I admittedly have not read) which I expect are all worst case scenarios, estimates only a 10% or so increase in costs. I happen to be one who believes that the waste in our system is at least 30% and that in perhaps 5 years we will begin to see those savings. But, even if it costs more, it is the right thing to do.

Their bottom line:

If Obama can figure out a way to persuade Congress to expand coverage to millions of uninsured people, while keeping those with coverage happy, it will be a feat of political magic that has eluded presidents for decades.

I agree. It is up to us to make not doing the right thing a very unattractive option.

Cheers,

A Public Health Insurance Plan | OurFuture.org

A Public Health Insurance Plan OurFuture.org:

As the ball rolls along in our debate, one thing that keeps coming up is the idea that everyone must have insurance. Being forced to buy insurance from a private insurer ($15K a year at our house – from a “not-for-profit” !) is obviously not an option for most, especially considering the median family income is only about $60K. Medicare spends anywhere from $6K to $14K per enrollee (65 and over, mind you). So can a public option be the solution?

Here are the key findings of the report, but you can click the link above to get the full report, an executive summary and a PowerPoint show.

The report contains these findings:
• Medicare has controlled health care costs much better than have private health insurers over the last 25 years.
• The private insurance market is highly consolidated and needs competition from a public health insurance plan to lower skyrocketing premiums.
• Administrative costs are dramatically lower under public health insurance plans,
resulting in enormous savings to the system.
• The bargaining power of public health insurance plans significantly reduces provider costs.
• In a head-to-head competition, the public Medicare plan is much better at containing costs than private Medicare Advantage plans.
• Independent analyses show substantial savings can be achieved from a public health insurance plan that competes with private insurance plans.
• Quality and effectiveness innovations occurring under the public Medicare plan show that public health insurance plans have greater potential to drive the quality revolution than do private plans.
• Public health insurance plans increase choice, competition and accountability.

Dartmouth Atlas of Health Care: Regional Disparity in Medicare Spending – Interactives – Quality/Equality newsroom – Quality/Equality – RWJF

Dartmouth Atlas of Health Care: Regional Disparity in Medicare Spending – Interactives – Quality/Equality newsroom – Quality/Equality – RWJF

The above link takes youto the interactive map that is kind of cool to look at and comare a few regions to see where yours falls.

The actual NEJM article is here. And here is the substantive part of the article (for me, anyway):

What’s going on? It is highly unlikely that these differences in growth could be explained by differences in health. Marked regional differences in spending remain after careful adjustment for health, and there is no evidence that health is decaying more rapidly in Miami than in Salem.

The variations allow us to rule out two overly simplistic explanations for spending growth. First, “technology” is clearly an insufficient explanation: residents of all U.S. regions have access to the same technology, and it is implausible that physicians in the regions with slower spending growth are consciously denying their patients needed care. Indeed, evidence suggests that the quality of care and health outcomes are better in lower-spending regions and that there have been no greater gains in survival in regions with greater spending growth.1 Second, it is difficult to blame regional differences entirely on the current payment system, since all our evidence on regional growth comes from populations in the fee-for-service system. Other research has emphasized the role of managed care in moderating the growth of costs,2 but this story cannot explain the rapid growth in Miami, where roughly half of Medicare enrollees are covered by Medicare Advantage plans.

The causes must therefore lie in how physicians and others respond to the vailability of technology, capital, and other resources in the context of the fee-for-service payment system. A recent study by researchers in our group provides further insight.3 Using clinical vignettes to present standardized patient care scenarios to physicians throughout the country, the researchers found that physicians in high- and low-spending regions were about equally likely to recommend specific clinical
interventions when the supporting evidence was strong. Those in higher-spending
regions, however, were much more likely than those in lower-spending regions to
recommend discretionary services, such as referral to a subspecialist for typical gastroesophageal reflux or stable angina or, in another vignette, hospital admission for an 85-year-old patient with an exacerbation of end-stage congestive heart failure. And they were three times as likely to admit the latter patient directly to an intensive care unit and 30% less likely to discuss palliative care with the patient and family. Differences in the propensity to intervene in such gray areas of decision making were highly correlated with regional differences in per capita spending.