The following text is an open letter to the single-payer community from Rep. Dennis Kucinich of Ohio, Rep. John Conyers Jr. of Michigan and Sen. Bernie Sanders of Vermont. It was released on the eve of Medicare’s 45th anniversary.

Congress of the United States
July 29, 2010

Dear friends of health care for all,

Now that a new health care bill has been signed into law, it has never been more important to have a strong movement behind Medicare for All.

Many health care experts have expressed concern that the Patient Protection and Affordable Care Act does not adequately contain costs for American families and businesses. If they are correct, and we believe they are, additional legislative cost containment measures will be necessary in the future.

When it is time for Congress to try to control health care costs again, the demand for Medicare for All must be undeniable. There is substantial support for a federal Medicare for All solution, embodied by H.R. 676, the National Health Care Act, and S. 703, the American Health Security Act, in the Congress and around the country. We believe that this support can and will continue to grow.

The truth is not enough. We already know that such a health care system has repeatedly proven to control costs more effectively, cover everyone or almost everyone, and deliver care of significantly higher quality than health care systems that tolerate the presence of private health insurance companies. Now we must make it so that the truth can no longer be ignored.

During the health care debate, the movement created significant momentum on which to build. Its voice was heard in multiple Congressional hearings – it won historic victories in a House vote to grant an ERISA waiver to a state that passes a Medicare for All-like plan and in a Senate provision allowing a waiver from the Exchanges for states to innovate with health coverage such as a state-based Medicare for All-like system that was included in the new law.

The latter victory created a new opening. Though the effective date for the Exchange waiver was pushed back to 2017 by the Congressional Budget Office to avoid driving up the estimated cost of the bill, the waiver’s presence sent a clear message: if a state thinks it can do better, Congress wants to see it.

We are encouraged by the progress already garnered in multiple states toward guaranteed health care and we will continue to work hard in Congress to clear any obstacles in the way. The 2017 date can be changed at the same time Congress considers all of the other waivers from federal laws that will be required for the state to move forward. That can happen either before or after a state passes a Medicare for All-like bill.

Regardless of the legislative path, we vow to continue to fight alongside you for health care justice at the both the federal and state levels. We believe that Medicare for All is inevitable in the United States. It is up to all of us to determine when the inevitable becomes the reality.

Sincerely,

Rep. Dennis J. Kucinich

Rep. John Conyers Jr.

Sen. Bernie Sanders

http://www.pnhp.org/news/2010/july/lawmakers-vow-to-continue-fight-for-medicare-for-all

On the 45th anniversary of Medicare it is reassuring to know that the vision of President Lyndon Johnson and the 89th Congress for an America that ensures health care for everyone, through a comprehensive Medicare for all, not only still lives, but is an inevitability.

Giving Our Kids the Care they Need

By Nancy-Ann DeParle
The White House
July 28, 2010

One important change in the new law is a provision that prevents insurance companies from discriminating against children with pre-existing conditions.

Some state insurance commissioners expressed concern that, without an open enrollment period that was widely communicated, people might wait until their children got sick to enroll them in coverage, causing plans’ costs to increase. And we were concerned when last week, some indicated that insurance companies would choose to stop offering policies for children rather than cover kids with pre-existing conditions.

Today, the Administration is releasing new guidance to health insurance plans to help ensure children get the high-quality care they need. The new FAQ document notes that insurance companies may establish an open enrollment period for children with pre-existing conditions.

http://www.whitehouse.gov/blog/2010/07/28/giving-our-kids-care-they-need

And…

Questions and Answers on Enrollment of Children Under 19 Under the New Policy That Prohibits Pre-Existing Condition Exclusions

U.S. Department of Health & Human Services
July 27, 2010

Question #2: Do these interim final rules require issuers in the individual health insurance market to offer children under 19 non-grandfathered family and individual coverage at all times during the year?

A: No.  To address concerns over adverse selection, issuers in the individual market may restrict enrollment of children under 19, whether in family or individual coverage, to specific open enrollment periods if allowed under State law.  This is not precluded by the new regulations.

http://www.hhs.gov/ociio/regulations/children19/factsheet.html

And…

Insurers back down on child-coverage stance

By Julian Pecquet
The Hill
July 29, 2010

Health insurance plans across the country on Wednesday began to backtrack on their decision to pull out of the child-only coverage market after the Obama administration addressed their concerns about the potential damage to their bottom lines.

The Department of Health and Human Services (HHS) on Tuesday clarified regulations mandating that insurance plans agree to cover sick children. HHS made it clear that plans are free to set up specific enrollment periods for their insurance plans if allowed under state laws.

“We think this policy will ensure that children get the comprehensive coverage they need while avoiding this unintended consequence,” Scott P. Serota, president and CEO of the Blue Cross and Blue Shield Association, said in a statement. “This is consistent with other public and private health insurance programs.”

Karen Ignagni, president and CEO of America’s Health Insurance Plans, followed suit.

“Today’s announcement will help ensure millions of children have access to affordable healthcare coverage,” she said. “For years, structured enrollment periods have been used in the Federal Employees Health Benefits Program, Medicare and in employer-based coverage to minimize disruption for families, seniors and small businesses. Health plans are committed to working with federal and state officials to ensure consumers are aware of all of their coverage options, including how and when they are able to sign up for coverage.”

http://thehill.com/business-a-lobbying/111535-insurers-backing-down-on-child-coverage-stance

A Quote of the Day message earlier this week described how private insurers were getting around the requirement to provide coverage to children with preexisting disorders. The insurers intended to avoid this obligation simply by closing enrollment to new applicants. It is important to understand the counter-response of the Obama administration because it exemplifies just how dysfunctional the private insurance model is that President Obama and Congress chose for us.

From a business perspective, the insurers’ complaint was quite valid. If a child was guaranteed insurance no matter the circumstances, it would be a wise decision to save money by forgoing insurance while healthy, but then purchasing the coverage only when needed. Adverse selection (concentrating high-cost patients within a plan) results in the death spiral of insurance premiums (shutting down the plan because it is no longer economically viable).

The insurers said that they could provide coverage for children with preexisting disorders only if open enrollment periods were established. As an example, December could be set aside as the one month in which a child could enroll for the following year. If the parents decided not to enroll the child that month, they could not change their minds during the next twelve months. If something serious came up, that’s too bad. They should have known better than to gamble with their child’s health.

Whoa! Wasn’t the original intention of the reform effort to be sure that each and everyone of us could have the health care that we need without having to face financial hardship? But now the Obama administration is giving its stamp of approval to a policy that will make access worse, not better.

“Open enrollment” is a business concept that serves the insurance industry well, but it is a very deceptive term. Instead of having open enrollment throughout the year, the insurers have really established the concept of “closed enrollment” for most of the year. From the patient’s perspective, instead of improving access to insurance products, it greatly impairs access – the opposite of what reform was supposed to bring us. We should change the rhetoric to “closed enrollment,” because that’s really what they are promoting.

As expected from the industry, the statements of Scott Serota of the Blue Cross and Blue Shield Association and Karen Ignagni of America’s Health Insurance plans are very supportive of closed enrollment. Of course, it’s in their business interests, even if not in the interests of patients who are shut out.

Suppose we had a single payer national health program – an improved Medicare for all. The concept of closed enrollment totally vanishes since everyone is automatically enrolled.

Imagine a couple of generations from now explaining to someone that there was a time in America that private companies prohibited you from having the insurance you needed because of a quirky rule that closed enrollment for most of the year. Isn’t that weird? I mean… like… enrollment is only once… for life!

Astorians for Peace and Justice and the West Queens Greens present  A Forum on Health Care Reform
Health Care for All:Are We Almost There?
Thursday, July 29th at 7:30pm  Location: Bohemian Hall, 29-19 24th Avenue between 31st and 29th Streets in Astoria. Take the N or Q train to Astoria Blvd.  When you leave the train station,   walk north to 24th Avenue and turn left.   The building will be on your right.   Dr Mary O'Brien is a primary care physician at Columbia University who has been practicing medicine in NYC for the past 30 years and has been  a strong advocate for single payer health care through her work with  NY Metro Physicians for a National Health Program.
Ajamu Sankofa, Esq. is a co-founder and chair of the Private Health Insurance Must Go! Coalition, a NYC-based grassroots organization demanding a national single-payer healthcare system. He also coordinates the Urban Leadership Program at the Murphy Institute for Worker Education and Labor Studies/CUNY and is a graduate instructor in urban affairs at Queens College. Mr. Sankofa is a former trial lawyer with the ACLU National Prison Project where he wrote the first model HIV Prevention Policy in the nation for incarcerated youth while representing prisoners throughout the United States on their conditions of confinement.
Mark Hannay is Director of the Metro New York Health Care for All Campaign, a citywide coalition of community groups and labor unions founded in 1993 that advocates for fundamental health care reform leading to a universal health care program. Mark began his health activist career in the early 1990s as a member of the Insurance and Health Care Access Committee of ACT UP/New York.  Since 2002, Mark has also co-hosted the weekly “Health Action” program broadcast over WBAI/Pacifica radio.  He is also a member of the Steering Committee of “Health Care for All New York”, a consortium of groups across New York State working for state-based health care reform.  He serves on the Board of Directors of the New York Metro Chapter of Physicians for a National Health Program.
Contact:  maryannlewis@earthlink.net for more information

Hijacked: Stolen Health Care Reform V

By John Geyman
The Huffington Post
July 27, 2010

On the positive side of the ledger, the PPACA (Patient Protection and Affordable Care Act) brings some welcome changes.

On the negative side of the ledger, however, these are some of the reasons that the PPACA will fall so far short of needed health care reform that it is not much better than nothing:

• Surging health care costs will not be contained as cost-sharing increases for patients and their families.
• Uncontrolled costs of health care and insurance will make them unaffordable for a large and growing part of the population.
• At least 23 million Americans will still be uninsured in 2019, with tens of millions more underinsured.
• Quality of care for the U. S. population is not likely to improve.
• Insurance “reforms” are so incomplete that the industry can easily continue to game the system.
• New layers of waste and bureaucracy, without added value, will further fragment the system.
• With its lack of price controls, the PPACA will prove to be a bonanza for corporate stakeholders in the medical-industrial complex.
• Perverse incentives within a minimally-regulated market-based system will still lead to overtreatment with inappropriate and unnecessary care even as millions of Americans forego necessary care because of cost.
• The “reformed” system is not sustainable and will require more fundamental reform sooner than later to rein in the excesses of the market.

(Adapted from “Hijacked: The Road to Single Payer in the Aftermath of Stolen Health Care Reform,” 2010, with permission of the publisher Common Courage Press. John Geyman is Professor Emeritus of Family Medicine at the University of Washington School of Medicine.)

http://www.huffingtonpost.com/john-geyman/hijacked-stolen-health-ca_b_660904.html

Hijacked: The Road to Single Payer in the Aftermath of Stolen Health Care Reform

by John Geyman
http://www.commoncouragepress.com/index.cfm?action=book&bookid=402
(Hijacked can be ordered now, at discount, for delivery in September.)

“A trenchant and highly readable account of how the special interests sabotaged health reform, leading to a law that won’t provide universal care nor control escalating costs. Geyman shows us the way to real reform when the current law implodes. An eye-opening book.”

–Marcia Angell, M.D., Senior Lecturer in
Social Medicine, Harvard Medical School,
former editor-in-chief, New England Journal of Medicine

“By reading John Geyman’s very timely Hijacked, those who are uncomfortable with the reform process that took place will be able to understand more precisely what went wrong. He explains why our concerns are fully warranted, but, instead of abandoning hope, he provides us with a road map for reform that will ensure that all of us will have the health care that we need.”

–Don McCanne, M.D., family physician, Senior Health Policy Fellow,
Physicians for a National Health Program (PNHP)

Insurers to Comply With Rules on Children

By Robert Pear
The New York Times
March 30, 2010

Under pressure from the White House, health insurance companies said Tuesday (March 30) that they would comply with rules to be issued soon by the Obama administration requiring them to cover children with pre-existing medical problems.

“Health plans recognize the significant hardship that a family faces when they are unable to obtain coverage for a child with a pre-existing condition,” said Karen M. Ignagni, president of America’s Health Insurance Plans, a trade group. Accordingly, she said, “we await and will fully comply with” the rules.

The White House immediately claimed victory.

In a Twitter message, Robert Gibbs, the White House press secretary, scored the tug of war as “Kids 1, insurance 0.”

http://www.nytimes.com/2010/03/31/health/policy/31health.html?_r=1

And…

Some insurers stop writing new coverage for kids

By Ricardo Alsonso-Zaldivar
Philly.com
July 27, 2010

Starting later this year, the health care overhaul law requires insurers to accept children regardless of medical problems – a major early benefit of the complex legislation. Insurers are worried that parents will wait until kids get sick to sign them up, saddling the companies with unpredictable costs.

The major types of coverage for children – employer plans and government programs – are not affected by the disruption. But a subset of policies – those that cover children as individuals – may run into problems. Even so, insurers are not canceling children’s coverage already issued, but refusing to write new policies.

In Florida, Blue Cross and Blue Shield , Aetna, and Golden Rule – a subsidiary of UnitedHealthcare – notified with the insurance commissioner that they will stop issuing individual policies for children, said Jack McDermott, a spokesman for McCarty.

(Blue Cross and Blue Shield of Florida) vice president Randy Kammer said the company’s experts calculated that guaranteeing coverage for children could raise premiums for other individual policy holders by as much as 20 percent.

“We believe that the majority of people who would buy this policy were going to use it immediately, probably for high cost claims,” said Kammer. “Guaranteed issue means you could technically buy it on the way to the hospital.”

Kammer said the company did not make the decision lightly. “We were looking at all our other individual policy holders who pay a lot for coverage, and we didn’t think it was fair to give them that kind of an increase to benefit a small population that receives a greater advantage than they do,” she said.

http://www.philly.com/philly/business/personal_finance/072710_no_new_kid_coverage.html

In several speeches about the Patient Protection and Affordable Care Act, President Obama extolled the immediate end of insurers denying coverage to children with preexisting conditions. He was wrong. His miscalculation stems from the fact that he seemed to trust the insurers to do the right thing for patients instead of continuing to place their own business interests first.

Although the insurers can no longer reject a child with preexisting disorders, they can close the plan to new enrollees. As a business decision, that is what many are doing. A social good is not part of their business model.

Although White House press secretary Robert Gibbs scored this as “Kids 1, Insurance 0,” it’s really “Insurance 1, Kids disqualified.”

That the insurers placed business first should come as no surprise to anyone. AHIP’s lobbyist Karen Ignagni continued with the “await and comply” position on the regulations that former WellPoint vice president Liz Fowler is helping to write. Compliance is easy for them when the rules are written to support the insurers’ business model.

Proving that the private insurers have learned nothing, Blue Cross and Blue Shield of Florida vice president Randy Kammer repeats the long held position of private insurers that they didn’t think that it was fair to increase premiums for all of the policy holders merely “to benefit a small population that receives a greater advantage” than the rest of the policy holders. Because it interferes with their business model, they refute the fundamental principle that the primary purpose of health insurance is to transfer funds from the many willing who are healthy to the few who have greater health care needs.

The exchanges won’t be in effect until 2014, and yet we’re already seeing this sterile, perverse behavior on the part of the insurers. Denying children with health care needs the right to buy insurance is only the bare beginning. There is absolutely no way that the regulators can preempt the negative impact of the unlimited innovations that insurers will introduce, especially after the insurance exchange infrastructures are solidly in place.

Businesses do what businesses have to do. Voters need to do what voters have to do. We have to eliminate the private business intermediaries and establish our own public insurance program that has a social mission of patient service.

Implementing Medical Loss Ratio (MLR) Requirements to Improve Quality, Promote Choice, and Avoid Disruptions in Coverage

America’s Health Insurance Plans (AHIP)
July, 2010

The “Patient Protection and Affordable Care Act” (PPACA) requires health plans, beginning in 2011, to meet a medical loss ratio (MLR) requirement of 80 percent in the individual and small group markets and 85 percent in the large group market. This means that plans must spend a specified percentage of premium revenue on either reimbursement for clinical services provided to enrollees or “activities that improve health care quality.”

Goal #1

Ensure That Existing Efforts to Improve Quality are Allowed to Continue and New Initiatives to Support the Goals of PPACA are Not Discouraged

(Examples: nurse care managers, maternity managed care programs, and imaging managed care programs, as programs that improve quality)

Goal #2

Recognize That Quality Improvement Efforts Will Be Advanced By ICD-10 Implementation

The startup costs associated with implementing the International Classification of Diseases 10 classification system (ICD-10) by 2013 should be defined as an “activity that improves health care quality.”

ICD-10 is a quality, not a claims payment, initiative.

Goal #3

Include Fraud Prevention and Detection Activities that Improve Quality

The definition of “activities that improve health care quality” should include the expenses health plans are required to make for fraud prevention activities.

Goal #4

Implement a Transition Plan to Maximize Consumer Choice

PPACA provides for the implementation of comprehensive insurance market reforms in 2014, including the creation of state health insurance exchanges. Until that time, consumers in the individual market will rely on brokers to review their insurance options and consider which ones best suit their needs. For health plans, four-fifths of the individual market will remain medically underwritten, guided by the rules and regulations in each state. A transition policy is needed to move from the current system to the new system that will be created in 2014 and to allow individuals to maintain their coverage.

The NAIC (National Association of Insurance Commissioners) is charged with the responsibility to develop MLR methodologies that take into account special circumstances. This means that Congress intended for the NAIC to exercise its expertise to make adjustments to the MLR to ensure that consumers are not harmed and that competition is not decreased.

http://americanhealthsolution.org/assets/Uploads/Blog/AHIP-MLR-Paper.pdf

In what might be perceived as private insurer chicanery, the industry’s lobby organization, AHIP, is capitalizing on phrasing in the Patient Protection and Affordable Care Act that defines the minimum percent of benefits that the insurers must pay out (medical loss ratio or MLR) as including not only reimbursement for clinical services but also for “activities that improve health care quality.”

Thus any of their administrative functions that they can pass off as improvements in quality will not apply to the 15 percent (large group) or 20 percent (individual or small group) caps on administrative spending. That allows the industry to perpetuate its pattern of profound administrative excesses and very high profits (outrageously high when considered as a percentage of their actual product – the administrative services that they are selling us).

In this report, what are they trying to pass off as quality? 1) Intrusive care managers who are employed to save money. 2) Implementation of diagnostic codes used for claims payments. 3) Administrative functions to detect fraud. 4) Perpetuating medical underwriting during the transition to cover “special circumstances” to ensure that “consumers are not harmed and that competition is not decreased.” That’s code for perpetuating the perversities of adverse selection.

The impact of this relabeling of administrative services as quality improvements is to allow the insurers to retain a greater percentage of the premium dollars for their own intrinsic purposes. The consumer pays for this either through higher premiums or decreased health care benefits.

An extremely important unintended consequence of fixed medical loss ratios has been mentioned here before, but seems to have escaped the mainstream media, so it is being repeated: Once the MLR rules are established, the primary method by which insurers can increase the services they sell us, while increasing their profits, is by increasing gross revenues, since they are guaranteed a fixed percentage of those revenues. The most effective way to increase gross revenues is to increase the amount of health care services authorized and paid for.

If the insurers change provider incentives to double the amount of health care that is being delivered, they can double their own total revenues, keeping even more as profit because of the smaller marginal administrative costs of paying for more care. This incentive of the insurers to increase total health care spending is the exact opposite of the reform goal of slowing future health care cost increases

All of this is good business. But that’s the problem. Our elected representatives chose a business model to finance health care when what we desperately need is a service model.

“Medical loss ratio” is a term that needs to be moved into the history books of failed policy concepts. Instead, we need our own public service model – an improved Medicare for everyone.

Medicare's 45th birthday is July 30!
Friday, July 30, 12:30 pm 
In
 commemoration of this special day, the Healthcare-NOW! NYC Chapter is officially launching with an action aimed at not only celebrating
 Medicare but also coordinating against the pending attack on Medicare 
by the federal Deficit Commission.  
Healthcare NOW! is doing a "Flash Mob" -- a choreographed dance number to celebrate Medicare's 45th birthday. 
We'd love as many of you to join the dance as possible, but you do not HAVE
 to dance to participate. Supporters are welcome and expected!
If you're interested in participating either as a performer (we need performers!) or as a supporter, please contact us ASAP.  RSVP to Jean Fox at jeanmaryfox@yahoo.com, 917-280-7279. 











 DANCE REHEARSAL WEDNESDAY, JULY 28, 6:30 PM at 55 Bethune St. apt. 1108 (corner of Bethune and Washington, one block south of West 12th Street and one block east of the West Side Highway.  RSVP to bagarson@yahoo.com  Wondering why we're doing a dance mob? 'Cause it's fun and gets the message across. Get inspired by --
- This action in San Francisco AND
- This action in Antwerp
and discover how fun this is going to be!

Astorians for Peace and Justice and the West Queens Greens present  A Forum on Health Care Reform
Health Care for AllAre We Almost There?
Thursday, July 29th at 7:30pm  Location: Bohemian Hall, 29-19 24th Avenue between 31st and 29th Streets in Astoria. Take the N or Q train to Astoria Blvd.  When you leave the train station,   walk north to 24th Avenue and turn left.   The building will be on your right.   Dr Mary O'Brien is a primary care physician at Columbia University who has been practicing medicine in NYC for the past 30 years and has been  a strong advocate for single payer health care through her work with  NY Metro Physicians for a National Health Program.
Ajamu Sankofa, Esq. is a co-founder and chair of the Private Health Insurance Must Go! Coalition, a NYC-based grassroots organization demanding a national single-payer healthcare system. He also coordinates the Urban Leadership Program at the Murphy Institute for Worker Education and Labor Studies/CUNY and is a graduate instructor in urban affairs at Queens College. Mr. Sankofa is a former trial lawyer with the ACLU National Prison Project where he wrote the first model HIV Prevention Policy in the nation for incarcerated youth while representing prisoners throughout the United States on their conditions of confinement.
Mark Hannay is Director of the Metro New York Health Care for All Campaign, a citywide coalition of community groups and labor unions founded in 1993 that advocates for fundamental health care reform leading to a universal health care program. Mark began his health activist career in the early 1990s as a member of the Insurance and Health Care Access Committee of ACT UP/New York.  Since 2002, Mark has also co-hosted the weekly “Health Action” program broadcast over WBAI/Pacifica radio.  He is also a member of the Steering Committee of “Health Care for All New York”, a consortium of groups across New York State working for state-based health care reform.  He serves on the Board of Directors of the New York Metro Chapter of Physicians for a National Health Program.
Contact:  maryannlewis@earthlink.net for more information

Ever get stuck when asked a question about Single Payer? Ever hear a talk that makes everything clear and then couldn't explain the idea?

Practice answering questions about Single Payer. See how others respond to questions. Then, go to Bryant Park, only a block away, and practice on the public.

Light refreshments.

Sunday, August 8, 2010

25 West 43rd Street, 18th floor

Manhattan

Any questions, you can call Paul: 347-278-4267

Otherwise, just show up, bring friends, bring doubters. 

Democrats spar over health care claim

WCAX.com
July 21, 2010

The gloves are off in the fight for the Democratic nomination for governor (Vermont). Former State Senator Matt Dunne is calling out Senator Peter Shumlin for what he says is a troubling misstatement.

Peter Shumlin first said it two weeks ago in an online questionnaire, then again this week in a mailing to voters: “I am the only candidate who sponsored a single-payer health care bill.” Dunne says that is simply not true.

“The facts are that I also sponsored a single-payer health care bill,” Dunne told reporters outside the Statehouse Wednesday.

He did. During the 1993-1994 legislative session when Dunne was serving as a State Representative he co-sponsored a bill that would have created a single-payer system. He wants a public retraction of Shumlin’s claim and is requesting that Shumlin send out another mailer with the correction.

“It is critically important that Peter Shumlin take action and take action quickly to correct the record, to be clear in public that he was factually wrong,” says Dunne.

http://www.wcax.com/Global/story.asp?S=12850303

When two candidates for governor are engaged in a political skirmish as to which one is the bona fide single payer supporter, then we know that single payer is back on the table (at least in Vermont).

Our last four posts have examined the PPACA from the perspectives of the four main goals of health care reform — cost containment, affordability, improved access and quality of care. Here we draw these goals together in asking whether this legislation delivers enough to be worth the $1 trillion investment over the next 10 years, and whether it will really work.

On the positive side of the ledger, the PPACA brings some welcome changes:

• Will extend health insurance to 32 million more people by 2019.
• Provides subsidies to help many lower-income Americans afford health insurance.
• Starting in 2014, expands Medicaid to cover 16 million more lower-income people.
• Provides new funding for community health centers that could enable them to double their current capacity.
• Eliminates cost-sharing for many preventive services.
• Phases out the “doughnut hole” coverage gap for the Medicare prescription drug benefit.
• Will create a new national insurance plan for long-term services: Community Living Assistance Services and Supports (CLASS) program.
• Will establish a nonprofit Patient-Centered Outcomes Research Institute to assess the relative outcomes, effectiveness and appropriateness of different treatments.
• Initiates some limited reforms of the insurance industry, such as prohibiting exclusions based on pre-existing conditions and banning of annual and lifetime limits.
• Contains some provisions to improve reimbursement for primary care physicians and expand the primary care workforce.

On the negative side of the ledger, however, these are some of the reasons that the PPACA will fall so far short of needed health care reform that it is not much better than nothing:

• Surging health care costs will not be contained as cost-sharing increases for patients and their families.
• Uncontrolled costs of health care and insurance will make them unaffordable for a large and growing part of the population.
• At least 23 million Americans will still be uninsured in 2019, with tens of millions more underinsured.
• Quality of care for the U. S. population is not likely to improve.
• Insurance “reforms” are so incomplete that the industry can easily continue to game the system.
• New layers of waste and bureaucracy, without added value, will further fragment the system.
• With its lack of price controls, the PPACA will prove to be a bonanza for corporate stakeholders in the medical-industrial complex.
• Perverse incentives within a minimally-regulated market-based system will still lead to overtreatment with inappropriate and unnecessary care even as millions of Americans forego necessary care because of cost.
• The “reformed” system is not sustainable and will require more fundamental reform sooner than later to rein in the excesses of the market.

How did this latest reform effort get so far off track? Here are three of the major reasons:

• The issues and policy options were framed as the political process was hijacked by the very interests that are largely responsible for today’s cost, access and quality problems in health care. As examples, the drug industry lobbied successfully to avoid any price controls of drugs, as the VA does so well; the insurance industry avoided real rate controls over their premiums and ended up with other loopholes to game the new system; and all of the corporate stakeholders will gain subsidized new markets without significant regulation of the market.
• The quest for bipartisanship was futile as reform got run over in the middle of the road. The big questions cannot be answered in the political center, such as whether health care should be a right or a privilege, or whether health care resources should be allocated based on ability to pay or medical need.
• Market failure was not recognized as the wellspring of our system problems. When it was agreed to “build on the strengths of the present system” instead of more fundamental reform, corporate stakeholders and their lobbyists found willing legislators to craft centrist “remedies” which could be sold to the public as  reform. But the various incremental tweaks of our existing system, such as employer and individual mandates, have failed over the last 20 or 30 years to remedy cost, access and quality problems.  In the absence of real health care reform, we can now expect these kinds of unfavorable outcomes in coming years:

• soaring costs without effective price controls throughout the system.
• managed care fails to control costs or improve quality.
• persistent financial and other access barriers for many millions of Americans.
• growing backlash by physicians and consumers.
• gaming of private plans and adverse selection in public plans.
• consolidation among hospitals sustaining high prices.
• increased cost-sharing for employees as employers cut back benefits.
• continued high levels of inappropriate and unnecessary care.
• added bureaucracy and waste in an even more fragmented and dysfunctional system.

We have yet to learn that an unfettered health care marketplace can only perpetuate our problems, not fix them. Most industrialized nations have learned this many years ago, and are able to achieve better quality of care with improved outcomes for their populations even as they spend much less on health care than we do. We have to conclude that a larger role of government will be required to assure real and sustainable health care reform.

There is a fix in plain sight for our problems — single-payer financing coupled with a private delivery system. The private insurance industry has outlived its usefulness, and is only being kept alive by government subsidies, whether by overpayments of private Medicare plans or this latest provision in the PPACA to pay out nearly half of a trillion dollars in subsidized premiums for their inadequate coverage.

When will we have the political will to face up to our real problems in health care and show that the democratic process can still work?

Adapted from “Hijacked: The Road to Single Payer in the Aftermath of Stolen Health Care Reform,” 2010, with permission of the publisher Common Courage Press. http://commoncouragepress.com/index.cfm?action=book&bookid=402

In our last three posts, we examined how the Patient Protection and Affordable Care Act of 2010 (PPACA) stacks up against the goals of reform for cost containment, affordability and access to care. Here we consider what its likely impact will be on the quality of care, the fourth major goal of the reform effort.

For starters, quality of care in the U.S. is highly variable, and is unsatisfactory for many millions of Americans, as these cross-national comparisons against other nations with one or another form of universal access clearly show:

• The U.S. ranks last among 19 industrialized countries in “amenable mortality rates,” deaths that could have been prevented by timely and effective health care; that translates to about 101,000 excessive deaths per year in this country. (Nolte, E, McKee, CM. U.S. has most preventable deaths among 19 nations. Health Affairs 27 (1):58-71, 2008)

• The U.S. ranks last among 23 industrialized nations on infant mortality, with rates double those of Iceland, Japan and France. (Schoen, C, Davis, K, How, SKH, Schoenbaum SC. U.S. health system performance: A national scorecard. Health Affairs Web Exclusive, W457-475, 2006) http://www.commonwealthfund.org/Content/Publications/In-the-Literature/2006/Sep/U-S–Health-System-Performance–A-National-Scorecard.aspx

• Lower-income people in this country receive worse care than their higher- income counterparts on 21 of 30 primary care quality measures, four to five times higher rates of disparity compared to Australia and Canada. (Huynh, P, et al. The U.S. health care divide. Commonwealth Fund, April 2006)

On the plus side, the PPACA does make some attempts to improve the quality of care through such provisions as these: expanded access to care; elimination of cost-sharing for preventive services; establishing a comparative effectiveness research initiative; expansion of health information technology (HIT); and modification of payment mechanisms (e.g. accountable care organizations, or ACOs, and “value modifiers” for physician reimbursement).

But these are important ways that will largely cancel out the impact of these efforts to improve the quality of care:

• We can expect an increase in cost-sharing (with reduced affordability) as employers downgrade the actuarial value of their coverage and as insurers market their underinsurance products in the individual market and through exchanges. A recent study of Medicare Advantage plans found that increased co-payments resulted in fewer outpatient visits, more hospital admissions and longer hospital stays for patients with hypertension, diabetes and a history of acute myocardial infarction. (Trivedi, AN, Moloo, H, Mor, V. Increased ambulatory care copayments and hospitalizations among the elderly. N Engl J Med 363 (4):320-8, 2010)

• The critical shortage of primary care physicians and an underfunded primary care infrastructure persist as our specialist-dominated workforce continues to provide more care than is appropriate or necessary, with less coordination and worse outcomes. For optimal quality of care, patients need both primary care and appropriate specialist care. (Parchman, M, Culter, S. Primary care physicians and avoidable hospitalization. J Fam Pract 39: 123-6, 1994) (Beal, AC, Doty, MM, Hernandez, SE, Shea, KK, Davis, K. Closing the divide: How medical homes promote equality in health care: results from the Commonwealth Fund 2006 Health Care Quality Survey)

• The new Patient-Centered Outcomes Research Institute lacks the authority to mandate or even endorse coverage and reimbursement rules for any particular test or treatment. (Kaiser Health News staff. True or false: Seven concerns about the new health care law. March 31, 2010)

• Perverse incentives will still permeate the system because of largely unchanged reimbursement policies (mostly fee-for-service) and coverage decisions influenced more by politics and lobbying by industry than hard scientific evidence of efficacy and cost-effectiveness. Procedures will continue to be over-reimbursed, primary and cognitive care services will remain under-reimbursed, and there will be little restraint over excess volume of services in most practice settings. These are examples of how big this problem is:

• One-third of U.S. births today are by Caesarian section (compared to a national average of just 5 percent in the 1960s). (Neergaard, L. Overtreated: More medical care isn’t always better. Associated Press, June 7, 2010)

• About one-third of tests and treatments are inappropriate or unnecessary and often harmful. (Wennberg, JB, Fisher, ES, Skinner, JS. Geography and the debate over Medicare reform. Health Affairs Web Exclusive W-103, February 13, 2001)

• Investor-owned hospitals, HMOs, nursing homes and mental health centers provide more expensive care of lower quality than not-for-profit facilities. (Geyman, JP. The Corrosion of Medicine: Can the Profession Reclaim its Moral Legacy? Monroe, ME. Common Courage Press, 2008, p 37)

• Well-reimbursed imaging procedures are greatly overused, thereby increasing risk of cancer; as an example, a recent report found that Illinois hospitals are using twice as many double CT scans (one with dye, the other without) than the national average, believed by many experts to be unwarranted. (Graham, J. New government report raised questions about CT scans at Illinois hospitals. Chicago Tribune, July 12, 2010)

• Wider adoption of health information technology has not been demonstrated to improve outcomes of care in most non-integrated parts of our health care “system”; most of the increase in medical computing has been driven by financial and billing reasons, not quality of care. And most quality improvement efforts have been based on process measures, such as use of beta blockers after a heart attack or use of hemoglobin A1C in diabetes, without good correlation with actual outcomes. (Chaudhry, B, Wang, J, Wu, S, Maglione, M, Mojica, W, et al. Systematic review: Impact of health information technology on quality, efficiency and costs of medical care. Ann Int Med 144 (10):742-52, 2006) (Himmelstein, DU, Wright, A, Woolhandler, S. Hospital computing and the costs and quality of care: A national study. Amer J Med 123 (1):40-6, 2010)

• The long-delayed experiments with accountable care organizations and bundled payments are likely to be ineffective in improving quality of care in non-integrated practice settings which involve non-salaried physicians. So despite what we are being asked to believe by supporters of PPACA, we cannot really expect much, if any, improvement in the quality of care for the U.S. population as a result of this legislation.

Adapted from Hijacked: The Road to Single Payer in the Aftermath of Stolen Health Care Reform, 2010, with permission of the publisher Common Courage Press. www.commoncouragepress.com

H.R. 5808 – To amend the Patient Protection and Affordable Care Act to establish a public health insurance option.

Introduced July 21, 2010 by Rep. Lynn C. Woolsey, with 128 cosponsors
The Library of Congress

SEC. 1325. PUBLIC HEALTH INSURANCE OPTION.
(a) (1)  ESTABLISHMENT- For years beginning with 2014, the Secretary of Health and Human Services (in this subtitle referred to as the `Secretary’) shall provide for the offering through Exchanges established under this title of a health benefits plan (in this Act referred to as the `public health insurance option’) that ensures choice, competition, and stability of affordable, high-quality coverage throughout the United States in accordance with this section. In designing the option, the Secretary’s primary responsibility is to create a low-cost plan without compromising quality or access to care.

http://thomas.loc.gov/

And…

Letter from Douglas W. Elmendorf, Director

To: Honorable Fortney Pete Stark, Chairman, Subcommittee on Health, Committee on Ways and Means
Congressional Budget Office
July 22, 2010

Under the proposal (H.R. 5808), a public health insurance plan would be established and administered by the Secretary of Health and Human Services (HHS), and it would have to charge premiums that fully cover its costs for benefit payments and administrative expenses.

The Congressional Budget Office (CBO) estimates that the public plan’s premiums would be 5 percent to 7 percent lower, on average, than the premiums of private plans offered in the exchanges.

In deciding whether to enroll in the public plan, potential subscribers would consider those premium differences along with various other factors, including the number of providers who chose to participate in that plan. CBO expects that some providers would decline to participate in the public plan because its payment rates would be lower, on average, than private plans’ payment rates. Even so, many providers would be likely to participate, in part because they would expect a plan administered by HHS to attract a substantial number of enrollees.

Taking into account all of the relevant factors, CBO estimates that roughly one-third of the people obtaining coverage through the insurance exchanges would enroll in the public plan. CBO estimates that about 25 million people would purchase coverage individually through the exchanges in the 2017–2019 period under the proposal; in addition, about 13 million people would be expected to obtain employment-based coverage through the exchanges — so total enrollment in exchange plans would be about 38 million. Total enrollment in the public plan would thus be roughly 13 million.

Compared with projections of enrollment under current law for the 2017–2019 period, CBO estimates that about three-quarters of a million more people would obtain individually purchased coverage and about three-quarters of a million fewer would have employment-based coverage. The proposal would have minimal effects on the number of people with other sources of coverage and on the number of people who would be uninsured.

CBO and the staff of the Joint Committee on Taxation (JCT) estimate that the proposal would reduce federal budget deficits through 2019 by about $53 billion. That estimate includes a $37 billion reduction in exchange subsidies and a $27 billion increase in tax revenues that would result from changes in employment-based coverage, partly offset by an $11 billion increase in costs for providing tax credits to small employers.

http://www.cbo.gov/ftpdocs/116xx/doc11689/Stark_Letter-HR_5808-07-22.pdf

So here is the stand-alone bill for the public insurance option that created so much controversy during the reform process. As we look closer at this option, we can see that the great tragedy of the public option debate was that this almost worthless proposal diverted our attention away from the debate that we should have been having – a debate over whether or not we should enact a single, universal public insurance program.

Let’s look first at the very narrow impact of the features of the public option, and then we’ll look at the very broad and crucial implications of returning to this debate instead of the one that we should be having.

First of all, what impact would this have on the numbers of insured? The additional three-quarters of a million individuals net who would obtain individually purchased coverage would be offset by approximately the same number who would no longer have employer-sponsored coverage. Enacting the public option will produce no net gain in the numbers of individuals insured.

CBO estimates that premiums for the public option will be 5 to 7 percent lower than the premiums for the private plans offered in the exchanges. This savings is from a combination of lower administrative costs for the public option, and the ability of the government to extract greater price and fee concessions from the providers of health care. Paying a slightly lower premium may not be wise if the providers start bailing out of the system.

Also, the supporters of this measure shouldn’t pretend that the very modest reduction in administrative costs of these public plans somehow addresses the profound administrative waste throughout our system. The single payer model would be effective in reducing this waste by hundreds of billions of dollars, whereas H.R. 5808  merely takes a paring knife to plans that would cover only about 4 percent of us, while neglecting the profound administrative waste of the other insurers and the administrative burden that they place on the health care delivery system. The public option is merely another plan in the insurance exchange markets, and, as such, fails to provide the fundamental structural financing reform that we need.

Further, the 5 to 7 percent difference could easily be lost in the fog of comparing the government subsidies for the exchange plans with the employers’ contributions to the premiums of employer-sponsored plans. A policy that has a very modest benefit for 13 million people is unimpressive when we are trying to fix a system so that it takes care of all 310 million of us.

CBO estimates that the measure would reduce the federal budget deficits through 2019 by about $53 billion, partly by decreasing subsidies in the exchanges and increasing income and payroll taxes for those losing employer-sponsored coverage. This reduction in government spending results in increased costs to individuals – a trend that already is having a negative impact on affordable access to health care. Nevertheless, 53 billion dollars is hardly a blip when you consider that we’ll be spending about 30,000 billion dollars on health care through 2019. Besides, though CBO is required to estimate the impact on the federal budget, what we really care about is our total national health expenditures (NHE) and not the portion that passes through a government budget.

So the narrow impact is that the public option fails to meet the goals of reform since it does nothing to increase the net numbers of individuals with insurance, and it doesn’t even provide a blip in our NHE.

The broader impact of H.R. 5808 is much more consequential. Considerable political capital will be consumed in efforts to enact it. The managers of the bill would understand that any consideration of a single payer national health program would have to be left off of the table since that model actually would accomplish the goals of reform. To go through another process that alienates so many colleagues in the health care justice camp risks creating an impasse to real reform that could last many years or perhaps even a decade or two.

The financing infrastructure of the Patient Protection and Affordable Health Care Act cannot work to achieve equitable health care financing for everyone. We can’t afford to waste political capital on a legislative amendment that merely appeases those who lost the public option debate, but does nothing to build the solid financial infrastructure that we need.

Let’s spend all of our political capital on real reform: a single payer national health program – an improved Medicare for everyone.

Cigna Medical Group Announces Grand Opening of CMG CareToday Clinic in South Chandler, Ariz.

Cigna Medical Group
July 19, 2010

Cigna Medical Group has announced the opening of its newest CMG CareToday convenience care medical clinic in South Chandler, Ariz. This brings the total number of clinics to 10 since CMG CareToday’s launch in 2007.

Staffed by board-certified nurse practitioners and physician assistants, the clinics offer walk-in medical care for unscheduled patients with low acuity conditions such as colds, flu, sore throat, lower back pain, ear aches, bladder infections and pink eye. In addition, the clinics offer pregnancy tests and child and adult immunizations, including flu shots. School, sports and camp physicals are also available.

“CMG CareToday is a convenient alternative that can accommodate local residents who may be unable to see their primary care physician because of time or other issues,” said Corinne Bell, DO, MBA, medical director of CMG CareToday. “Expanding the number of clinics Valleywide gives residents a place to go for non-emergency care and provides quick relief for common illnesses.”

First time visits to any CMG CareToday location are $29 retail; subsequent visits are $59. Lab services range from $10 to $15 and a select number of generic prescription medications are available for $10 or $15. CIGNA customers, and individuals covered under other accepted health plans, pay only their office visit co-pay or co-insurance. Additionally, Cigna Medical Group patients who visit CMG CareToday will have their medical records transferred seamlessly through an electronic health record directly to their primary care physician for future follow-up.

About Cigna Medical Group

Cigna Medical Group, the multi-specialty group practice division of CIGNA HealthCare of Arizona, Inc., is one of the Valley’s largest group practices with more than 30 offices located throughout Metropolitan Phoenix, including three Urgent Care centers and 10 CMG CareToday convenience care clinics. To learn more about Cigna Medical Group and the services they provide, please visit www.CignaMedicalGroup.com.

About CIGNA Corporation

CIGNA (NYSE: CI), a global health service company, is dedicated to helping people improve their health, well being and sense of security. CIGNA Corporation’s operating subsidiaries provide an integrated suite of medical, dental, behavioral health, pharmacy and vision care benefits, as well as group life, accident and disability insurance, to approximately 46 million people throughout the United States and around the world. To learn more about CIGNA, visit www.cigna.com.

http://www.prnewswire.com/news-releases/cigna-medical-group-announces-grand-opening-of-cmg-caretoday-clinic-in-south-chandler-ariz-98780589.html

Cigna is no longer simply one of the largest, for-profit, private insurance corporations in the nation, it is now a component of the health care delivery system. From the Cigna Medical Group website: “CIGNA is the only managed care organization in Arizona that operates multi-specialty centers designed to help you conveniently receive care and move on with your busy day.”

With tighter regulation under the Patient Protection and Affordable Care Act, the private insurers are looking for innovative solutions that will ensure a bright future for their executives and shareholders. What better opportunity is there than to expand their intrusion into health care delivery? Imagine the expansion of a chain of nurse practitioner- and physician assistant-staffed convenience care clinics with CIGNA branding in bright neon lights.

What next? Accountable care organizations (ACOs) with full control of physicians and hospitals? Imagine each hospital in your community with a building-top mounted branding neon sign – WELLPOINT, UNITEDHEALTH, AETNA, CIGNA, HEALTH NET, HUMANA, though further consolidation could leave us with maybe just three market choices: WellPoint, UnitedHealth, and Kaiser Permanente. Maybe we could end up with only one: UnitedWellPoint.

Though this seems farcical, instead of simply controlling the puppet strings of health care – the insurance function – these national corporations would like to take over the puppets as well.

You say that’s impossible? I remember telling my colleagues what we could expect when the legislation passed that enabled the managed care revolution. They said that the scenario I described was impossible, and, besides, they would never sign the contracts anyway. It didn’t take long.

How could we end up with one or more UnitedWellPoints? The steamrollers for ACOs are fired up and beginning to roll. Physicians will have almost no say in this transformation. The fight for control will be between the hospitals and the major private insurers. What kind of a contest will that be with thousands of local hospitals competing for control with a few large national insurance companies that already hold the money?

Wouldn’t it be much safer to give entire control of the purse strings to an improved Medicare? At least then any redesign of the health care delivery system would benefit patients rather than shareholders.