Thursday, December 27, 2012

Fwd: qotd: GAO report on USPS Retiree Health Benefits Fund

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: GAO report on USPS Retiree Health Benefits Fund
Date: Thu, 27 Dec 2012 13:35:03 -0800
From: Don McCanne <>
To: Quote-of-the-Day <>

GAO (U.S. Government Accountability Office)
December 4, 2012
Status, Financial Outlook, and Alternative Approaches to Fund Retiree
Health Benefits

The Postal Service Retiree Health Benefits Fund (PSRHBF) covered about
49 percent of the U.S. Postal Service's (USPS) $94 billion retiree
health benefit liability at fiscal year-end 2012. USPS's deteriorating
financial outlook, however, will make it difficult to continue the
current prefunding schedule in the short term, and possibly to fully
fund the remaining $48 billion unfunded liability over the remaining 44
years of the schedule on which the 2006 Postal Accountability and
Enhancement Act (PAEA) was based.

USPS is intended to be a self-sustaining entity funded almost entirely
by postal ratepayers, but its financial losses are challenging its
sustainability. GAO has testified that USPS should prefund its retiree
health benefit liabilities to the maximum extent that its finances
permit, but none of the funding approaches may be viable unless USPS has
the ability to make the payments. USPS's default on its last two
required PSRHBF payments and its inability to borrow further make the
need for a comprehensive package of actions to achieve sustainable
financial viability even more urgent.

USPS agreed that comprehensive reform is necessary to achieve financial
sustainability. It also recognized its obligation to provide effective,
affordable health benefits to its employees and retirees, but said that
it does not have the financial resources to make prefunding payments
required by current law.

Comment: Linking health insurance to employment has contributed greatly
to the dysfunction of health care financing within the United States. If
it were a good method, you would think that the United States Postal
Service would provide an exemplary model for such financing.

This GAO report confirms that none of the proposed funding approaches
for the Postal Service Retiree Health Benefits Fund may be viable unless
USPS has the ability to make the payments. The USPS has responded in
writing that "it does not have the financial resources to make
prefunding payments required by current law."

It is long past time to take the employer out of health care coverage
and financing decisions. Instead, we should establish our own single
universal risk pool funded equitably through the tax system. Employers
could get on with the task of managing their own businesses, while our
public stewards would take charge of managing more efficiently and more
assuredly health care financing for all of us.

Wednesday, December 26, 2012

Fwd: qotd: New America Foundation implicitly endorses single payer

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-------- Original Message --------
Subject: qotd: New America Foundation implicitly endorses single payer
Date: Wed, 26 Dec 2012 09:03:40 -0800
From: Don McCanne <>
To: Quote-of-the-Day <>

New America Foundation
December 2012
Social Contract Budgeting: Prescriptions from Economics and History
By Peter H. Lindert, Distinguished Research Professor of Economics,
University of California – Davis

America has yet to accept the insurance solution that has worked
relatively well in other countries: let the government serve as a
dominant payer, with mandatory universal coverage and mandated pure
community rating. (Note that international experience recommends
single-payer insurance, but is indifferent to government provision of
health care.) Instead, American state and federal insurance systems
embody an unavoidably messy political compromise, one in which the
public is forced to buy coverage choosing from a menu of private
insurers. As it stands, the government will act as single regulator, not
as single payer. This has the political advantage of keeping government
budgets from raising taxes to cover insurance, but the disadvantage of
perpetuating, and still subsidizing, a costly private insurance industry.


New America Foundation
About New America

The New America Foundation is a nonprofit, nonpartisan public policy
institute that invests in new thinkers and new ideas to address the next
generation of challenges facing the United States.

With an emphasis on big ideas, impartial analysis and pragmatic
solutions, New America invests in outstanding individuals whose ability
to communicate to wide and influential audiences can change the
country's policy discourse in critical areas, bringing promising new
ideas and debates to the fore.

Comment: This statement implicitly supporting single payer is of great
importance because of its source. The New America Foundation was
established to move beyond partisan politics. "The foundation's mission
is animated by the American ideal that each generation will live better
than the last."

In his article, "Social Contract Budgeting," UC Davis Professor Peter
Lindert discusses four fronts: education, health insurance, pensions,
and broad taxes. Although he attempts to move beyond politics, most of
us will still reflect on his concepts under the cloud of our own biases.
As an example, although some of us are uncomfortable with the concept of
a VAT (value added tax, a consumption tax), he discusses a variation in
which the VAT can be progressively redistributive.

For those of us who have campaigned so long and so hard for health care
justice, Lindert states what we perceive to be the obvious: we need to
move beyond politics and "accept the insurance solution that has worked
relatively well in other countries," noting that "international
experience recommends single-payer insurance."

Tuesday, December 25, 2012

Fwd: qotd: Bruce Bartlett's Christmas gift to all of us

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: Bruce Bartlett's Christmas gift to all of us
Date: Tue, 25 Dec 2012 09:35:06 -0800
From: Don McCanne <>
To: Quote-of-the-Day <>

Though it is not our policy to distribute a Quote of the Day message on
Christmas Day, we have to make an exception this year and thank Bruce
Bartlett for his Christmas present to PNHP and to all of us who dream of
a future with health care justice throughout the nation.

The New York Times
December 25, 2012
A Conservative Case for the Welfare State
By Bruce Bartlett

(Bruce Bartlett held senior policy roles in the Reagan and George H.W.
Bush administrations and served on the staffs of Representatives Jack
Kemp and Ron Paul.)

At the root of much of the dispute between Democrats and Republicans
over the so-called fiscal cliff is a deep disagreement over the welfare
state. Republicans continue to fight a long-running war against Social
Security, Medicare, Medicaid and many other social-welfare programs that
most Americans support overwhelmingly and oppose cutting.

Republicans in Congress opposed the New Deal and the Great Society, but
Republican presidents from Dwight D. Eisenhower through George H.W. Bush
accepted the legitimacy of the welfare state and sought to manage it
properly and fund it adequately. When Republicans regained control of
Congress in 1994 they nevertheless sought to repeal the New Deal and
Great Society programs they had always opposed.

Republicans are now using the fiscal impasse to try to raise the age for
Medicare and reduce Social Security benefits by changing the index used
to adjust them for inflation. They know that such programs will be
easier to abolish in the future if the number of people who qualify can
be reduced and benefits are cut so that privatization becomes more

This is foolish and reactionary. Moreover, there are sound reasons why a
conservative would support a welfare state.

One problem with this conservative view is its lack of an empirical
foundation. Research by Peter H. Lindert of the University of
California, Davis, shows clearly that the welfare state is not
incompatible with growth while providing a superior quality of life to
many of those left to sink or swim in America.

In a new paper for the New America Foundation, Professor Lindert
summarizes his findings. He points out that there are huge efficiencies
in providing pensions and health care publicly rather than privately. A
main reason is that in a properly run welfare state, benefits are nearly
universal, which eliminates vast amounts of administrative overhead
necessary to decide who is entitled to benefits and who isn't, as is the
case in America, and eliminates the disincentives to work resulting from
benefit phase-outs.

A 2003 study in the New England Journal of Medicine found that Canada's
single-payer health system had less than a third of the per-capita
administrative cost of the United States system, with its many private
insurance companies and overlapping government programs.

Americans believe that their health system is the best in the world, but
in fact it is not.

The one area where the United States tops all other countries in terms
of health is cost. According to the Organization for Economic
Cooperation and Development, the United States spent more than any other
country – 17.4 percent of gross domestic product on health in 2009. By
contrast, Britain spent only 9.8 percent of G.D.P. on health.

Thus, for no more than the United States already spends through
government, we could have a national health-insurance system equal to
that in Britain. The 7.6 percent of G.D.P. difference between American
and British total health spending is about equal to the revenue raised
by the Social Security tax. So, in effect, having a single-payer health
system like Britain's could theoretically give Americans 7.6 percent of
G.D.P. to spend on something else – equivalent to abolishing the payroll

This is a powerful conservative argument for national health insurance.

Comment: Thank you, Bruce Bartlett, for perhaps the greatest Christmas
gift of all - a rationale for why we all have to join together to
provide health care for everyone.

(The 2003 NEJM article cited is that of PNHP co-founders Steffie
Woolhandler and David Himmelstein, plus Terry Campbell of the Canadian
Institute for Health Information.)

Monday, December 24, 2012

Fwd: qotd: Rasmussen survey shows split on single payer

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: Rasmussen survey shows split on single payer
Date: Mon, 24 Dec 2012 11:29:41 -0800
From: Don McCanne <>
To: Quote-of-the-Day <>

Rasmussen Reports
December 17, 2012
40% Favor Single-Payer Health Care System, 44% Oppose

Forty percent (40%) of Likely U.S. Voters favor a single-payer system,
according to a new Rasmussen Reports national telephone survey.
Forty-four percent (44%) oppose the creation of such a system. Sixteen
percent (16%) are undecided.

The question asked:

Do you favor or oppose a single-payer health care system where the
federal government provides coverage for everyone?

(Conducted December 10-11, 2012. Margin of Sampling Error, +/- 3
percentage points with a 95% level of confidence.)

Comment: Rasmussen telephone surveys are noted for results
demonstrating right-wing bias. Understanding that, it is interesting
that the results of this poll demonstrated a near even split in public
support for single payer.

Several surveys from other sources have demonstrated closer to sixty
percent support for single payer. Considering the likely bias in this
poll, there does not seem to be any significant decline in support for
single payer even though the Affordable Care Act is already being

As people observe how many will be left uninsured and how ineffective
the plans will be in protecting personal finances, it can be anticipated
that support for single payer will continue to grow until it reaches a
threshold where it finally becomes a political imperative.

Sunday, December 23, 2012

Fwd: qotd: A message of hope from our economists

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: A message of hope from our economists
Date: Sun, 23 Dec 2012 11:30:24 -0800
From: Don McCanne <>
To: Quote-of-the-Day <>

December 2012
Statement on Healthcare


We are economists who think that the economy should serve people, the
planet and the future.

We oppose treating health care as a commodity to be rationed on the
basis of purchasing power or a privilege to be rationed on the basis of
political power.

We call for a national health insurance system that provides universal
access to essential health care.

We call for insurance for all Americans in a single risk pool - the
efficient model already used by Medicare and the Veterans Administration
- a system that can save billions of dollars while improving health and

We extend our support to all who are working to build an effective and
accountable health care system that puts public health before private
profit and secure health care for all regardless of income, age, or
pre-existing conditions.

(Signed by over 100 economists)

Comment: Against a background of depressing news during this Holiday
Season, this group of social-minded economists is sending us a message
of hope for a better health care system for all of us.

The link above will lead you to a ten minute video featuring four of the
over 100 economists that signed onto this message. It is a video that
you likely will want to share with others.

Friday, December 21, 2012

Fwd: qotd: Guns and health

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: Guns and health
Date: Fri, 21 Dec 2012 09:33:46 -0800
From: Don McCanne <>
To: Quote-of-the-Day <>

NRA (National Rifle Association)
December 21, 2012
Press Conference
Wayne Lapierre, CEO & Executive Vice President

The ONLY thing that stops a BAD guy with a gun is a GOOD guy with a gun.

Comment: BANG! BANG!

(There is a not-so-subtle message here about the health of the nation.)

Thursday, December 20, 2012

Fwd: qotd: Ron Pollack and Celinda Lake: carnival hawkers for big insurance

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: Ron Pollack and Celinda Lake: carnival hawkers for big
Date: Thu, 20 Dec 2012 13:42:07 -0800
From: Don McCanne <>
To: Quote-of-the-Day <>

The New York Times
December 19, 2012
Next Challenge for the Health Law: Getting the Public to Buy In
By Abby Goodnough

On its face, the low-key discussion around a conference table in Miami
last month did not appear to have national implications. Eight men and
women, including a diner owner, a chef and a real estate agent, answered
questions about why they had no health insurance and what might persuade
them to buy it.

But this focus group, along with nine others held around the country in
November, was an important tool for advocates coming up with a campaign
to educate Americans about the new health care law.

The sessions confirmed a daunting reality: Many of those the law is
supposed to help have no idea what it could do for them.

There lies the challenge for Enroll America, a nonprofit group formed
last year to get the word out to the uninsured and encourage them get
coverage, providing help along the way. With the election over and the
law almost certain to survive, the group is honing its fund-raising and
testing strategies for persuading people to sign up for health insurance
— a process that will begin in less than a year.

The group has raised only about $6 million so far — but financial
backers include some major players in the medical industry: insurers
like Aetna and Blue Cross Blue Shield, associations representing both
brand name and generic drug manufacturers, hospitals and the Catholic
Health Association.

Over the next two years, the group hopes to raise as much as $100
million for advertising, social media and other outreach efforts. "There
are so many different groups that can play some role in this: hospitals,
community health centers, pharmacies, tax preparers," said Ron Pollack,
chairman of Enroll America's board. "Our job has got to be to try to
galvanize each of those sectors, so there is a wide variety of ways
people potentially can hear about this."

In addition to holding focus groups in Miami, Philadelphia, San Antonio
and Columbus, Ohio, Enroll America commissioned a nationwide survey to
help hone its message. The survey, conducted in September and October by
Lake Research Partners, a Democratic polling group, found that the vast
majority of uninsured people are unaware of the new coverage options
provided by the law.

They are also skeptical. Many who participated in the focus groups or
survey reported bad experiences trying to get health insurance, and
doubted that the law would provide coverage that was both affordable and

"It's two major mountains that need to be climbed," Mr. Pollack said.
"People are unaware of the benefits that could be provided to them, and
they have to overcome skepticism, based on their past experiences with
trying to obtain insurance."

But the survey found that even with federal subsidies, many uninsured
people may balk at the cost of coverage. Only about a third of
respondents leaned toward thinking monthly premiums of $210 for a single
person earning $30,000 a year, for example, were affordable.

Those amounts became more acceptable when respondents were told it would
"protect you from thousands of dollars of medical debt if you got sick"
or "cover all of the basic care you need."

In the end, Lake Research Partners recommended that Enroll America not
cite specific dollar amounts at all when they talk to the uninsured
about new coverage options. "Talking about 'free or low cost' plans may
be more motivating," the survey authors wrote in a report.

Comment: From the days of the Clinton effort to reform health care, Ron
Pollack of Families USA has opposed single payer reform as not being
politically feasible, supporting instead reform based on private
insurance plans. Likewise, Celinda Lake of Lake Research Partners has
actively rejected single payer while using her polling and focus group
activities to push the rhetoric of "Choice" to promote private insurers,
glossing over the fact that private insurers take away choice of health
care professionals and institutions. Both Pollack and Lake have had
considerable influence in Democratic administrations.

Now that they got their wish and we have reform based on private
insurance plans, they have a new hurdle and that is to try to sell the
program to the public. They have formed a new organization, "Enroll
America," to do just that, and the private insurance industry is front
and center in financing the organization.

Just as they concocted the "Choice" campaign to sell the legislation,
they are now concocting the "Free or Low Cost" campaign to sell the
uninsured on the new coverage options. When the survey found that many
people may balk at the cost of coverage even with the subsidies, Lake
recommended that Enroll America not cite specific dollar amounts at all
when they talk to the uninsured about new coverage options.

Can you imagine? Just as they sold the nation on legislation using
"Choice" for a program that takes away choice, they now are selling the
nation on "Free or Low Cost" plans that the uninsured cannot afford to
pay for. What chutzpah!

Where is the Occupy movement? Maybe we should occupy Enroll America and
use it instead to enroll everyone in a single payer national health
program - an Improved Medicare for All.

Wednesday, December 19, 2012

Fwd: qotd: Cleveland Clinic CEO Cosgrove on single payer

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: Cleveland Clinic CEO Cosgrove on single payer
Date: Wed, 19 Dec 2012 09:33:48 -0800
From: Don McCanne <>
To: Quote-of-the-Day <>

The Wall Street Journal
December 18, 2012
Cleveland Clinic Diagnoses Health-Care Act
By Anna Wilde Mathews

Just over a year from now, the Affordable Care Act is set to unleash
enormous change in the health-care sector, and Cleveland Clinic Chief
Executive Delos "Toby" Cosgrove is preparing his institution by
expanding its reach and striving to make caregivers more cost-conscious.

WSJ: Do you think employers will stop providing health insurance, even
though they can pay a penalty under the health overhaul law?

Dr. Cosgrove: The first ones will be the small companies... Every CEO
I've talked to knows how much he'd save between insuring his people and
paying the federal penalty.

WSJ: What does that tell you?

Dr. Cosgrove: The first time some big player does that, it's going to
fall like dominoes. What that does is drive everybody to the exchanges.

WSJ: What does that mean to you?

Dr. Cosgrove: It's going to be a faster move towards one payer.
Increasingly, people think that in 10 years you're going to have 75% of
the health-care costs paid by the federal government.

WSJ: You think we're moving toward a single-payer system?

Dr. Cosgrove: Well, the question is how long...I don't think in the next
10 years, but I think it probably is going to head in that direction.

Comment: Cleveland Clinic President and CEO Delos "Toby" Cosgrove
confirms what Physicians for a National Health Program has been saying
all along. It's not whether we'll ever have single payer, it's how long.

It's our job to expedite it.

Tuesday, December 18, 2012

Fwd: qotd: PacifiCare's massive Medicare Advantage fraud

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: PacifiCare's massive Medicare Advantage fraud
Date: Tue, 18 Dec 2012 12:33:44 -0800
From: Don McCanne <>
To: Quote-of-the-Day <>

Department of Health and Human Services
Office of Inspector General
November 2012
Risk Adjustment Data Validation of Payments Made to PacifiCare of
California for Calendar Year 2007

Under the Medicare Advantage (MA) program, the Centers for Medicare &
Medicaid Services(CMS) makes monthly capitated payments to MA
organizations for beneficiaries enrolled in the organizations' health
care plans. Subsections 1853(a)(1)(C) and (a)(3) of the Social Security
Act require that these payments be adjusted based on the health status
of each beneficiary. CMS uses the Hierarchical Condition Category (HCC)
model (the CMS model) to calculate these risk-adjusted payments.

The diagnoses that PacifiCare submitted to CMS for use in CMS's risk
score calculations did not always comply with Federal requirements. For
55 of the 100 beneficiaries in our sample, the risk scores calculated
using the diagnoses that PacifiCare submitted were valid. The risk
scores for the remaining 45 beneficiaries were invalid because the
diagnoses were not supported by the documentation that PacifiCare provided.

As a result of these unsupported diagnoses, PacifiCare received $224,388
in overpayments from CMS. Based on our sample results, we estimated that
PacifiCare was overpaid approximately $423,709,068 in CY 2007. The
confidence interval for this estimate has a lower limit of $288 million
and an upper limit of $559 million.

The following are examples of HCCs that were not supported by the
documentation that PacifiCare submitted to us for medical review:

* For one beneficiary, PacifiCare submitted the diagnosis code for
"spinocerebellar disease, other cerebellar ataxia." CMS used the HCC
associated with this diagnosis in calculating the beneficiary's risk
score. However, the documentation that PacifiCare provided described an
evaluation for fever and cough. The documentation did not mention
cerebellar ataxia or indicate that cerebellar ataxia had affected the
care, treatment, or management provided during the encounter.

* For a second beneficiary, PacifiCare submitted the diagnosis code for
"malignant neoplasm of the prostate." CMS used the HCC associated with
this diagnosis in calculating the beneficiary's risk score. However, the
documentation that PacifiCare provided appeared to describe suture
removal and left shoulder bursitis/tendonitis. The documentation did not
mention prostate cancer or indicate that prostate cancer had affected
the care, treatment, or management provided during the encounter.

* For a third beneficiary, PacifiCare submitted the diagnosis code for
"unspecified septicemia" (commonly referred to as "blood poisoning").
CMS used the HCC associated with this diagnosis in calculating the
beneficiary's risk score. However, the documentation that PacifiCare
provided noted that the patient was admitted for a "left total knee
revision arthroplasty." The documentation did not mention blood
poisoning or indicate that blood poisoning had affected the care,
treatment, or management provided during the encounter.

Comment: It has long been recognized that the private Medicare
Advantage plans (offered as an option to the traditional Medicare
program) have been cheating the taxpayers, initially by selectively
enrolling the healthy while being paid at rates that include a mix of
the sick, and, more recently, by gaming the process of risk adjustment
(which seeks to correct for the health status of the beneficiaries
actually enrolled by the private plans). This new report from the HHS
Office of Inspector General is helpful because it provides a perspective
of the enormity of the problem.

In one year alone (2007), one California insurer - PacifiCare (acquired
by UnitedHealth Group in 2005) - used their Medicare Advantage program
to cheat taxpayers out of almost half a billion dollars! Extrapolate
that to all Medicare Advantage plans in all states for all years, and
think of the impact this must have had on our Medicare budget.

The private insurers pride themselves on their innovations. Based on
their past behavior, we can be assured that they will continue to
innovate in opaque ways that cheat not only the taxpayers, but also the
health professionals and institutions, and, most importantly, the
patients. Without transparency, they will get away with it for extended
periods of time, with new innovations introduced as they get tripped up
on the old.

Although the Affordable Care Act calls for a reduction in overpayments
to these plans, the legislation leaves them in place. That is a terrible

We need to shut down the Medicare Advantage plans, and, while we're at
it, shut down all private insurers and replace them with an improved
Medicare for everyone. We may not be able to do that before we reach
"The Cliff," but we should start working on it immediately.

Monday, December 17, 2012

Fwd: qotd: Enough specialists for Medicare, but not Medicaid

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: Enough specialists for Medicare, but not Medicaid
Date: Mon, 17 Dec 2012 12:04:16 -0800
From: Don McCanne <>
To: Quote-of-the-Day <>

Los Angeles Times
December 15, 2012
Healthcare crisis: not enough specialists for the poor
By Anna Gorman

By the end of the decade, the nation will be short more than 46,000
surgeons and specialists, a nearly tenfold increase from 2010, according
to the Assn. of American Medical Colleges. Healthcare reform is expected
to worsen the problem as more patients — many with complex and deferred
health needs — become insured and seek specialized treatment.

Many of the newly insured will receive Medi-Cal, the government plan for
the needy as administered through the state of California. Clinics
already struggle to get private specialists to see Medicaid patients
because of the low payments to doctors. Last week, an appellate court
decision that authorized the state to move forward with 10% cuts in
Medi-Cal reimbursement, which could make finding doctors for those
patients even more difficult.

"Specialists are paid so poorly that they don't want to take Medi-Cal
patients," said Mark Dressner, a Long Beach clinic doctor and
president-elect of the California Academy of Family Physicians. "We're
really disappointed and concerned what it's going to do for patient access."

In Los Angeles County, the sheer volume of poor or uninsured patients
needing specialist services has long overwhelmed the public health
system, creating costly inefficiencies and appointment delays that can
stretch as long as a year and half.

Patients' conditions often must be dire for them to see a neurologist,
cardiologist or other specialist quickly. Community clinics try to
bypass the backed-up formal government referral system by pleading,
cajoling and negotiating to get less critically ill patients moved up on
waiting lists.

At times, clinic staff members are forced to work against one of their
key missions by sending patients to emergency rooms to increase the odds
of their seeing a specialist more quickly.,0,5422442,full.story

Comment: My career in private practice began with the introduction of
Medicare and Medi-Cal (Medicaid). At that time, I had no problems
referring Medicare and privately insured patients to specialists, but
the majority of them refused to see my Medi-Cal patients. The stigma of
"welfare patient" was there right from the beginning.

Quite a few years later, my Medicare patients continued to be accepted
without question, but some of the managed care patients were rejected,
and, of course, Medi-Cal patients continued to be rejected, except by a
few very dedicated specialists. Eventually with EMTALA, at least I could
force unwanted referrals for patients requiring specialized emergency
services by sending them directly to the Emergency Department. What a
terrible way to practice medicine.

As stated in my last message, there will be about 10,000,000 Medi-Cal
patients in California, once the Affordable Care Act is fully
implemented. Can you imagine the specialists suddenly opening their
doors and welcoming these patients into their practices?

I'll say it once again. If we had an improved Medicare single payer
system that treated everyone equitably, we would not have this problem.

Friday, December 14, 2012

Fwd: qotd: Medi-Cal could implode

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: Medi-Cal could implode
Date: Fri, 14 Dec 2012 10:31:40 -0800
From: Don McCanne <>
To: Quote-of-the-Day <>

Los Angeles Times
December 13, 2012
Court ruling could cut California spending on Medi-Cal
By Maura Dolan and Chris Megerian

A federal appeals court decided unanimously Thursday that California may
cut reimbursements to doctors, pharmacies and others who serve the poor
under Medi-Cal.

A three-judge panel of the 9th Circuit U.S. Court of Appeals overturned
injunctions blocking the state from implementing a 2011 law that slashed
Medi-Cal reimbursements by 10%. Medi-Cal, a version of Medicaid, serves
low-income Californians.

The ruling could make it harder to find doctors for as many as 2 million
new patients who could become eligible for Medi-Cal under President
Obama's healthcare law — a possible 25% expansion of the program.
California already provides one of the lowest rates of reimbursement in
the nation for medical services to the poor, and there is a shortage of
doctors to serve those patients.

According to the California HealthCare Foundation, Medi-Cal patients
already have difficulty finding doctors.

A foundation study published in July 2010 said 25% of physicians
provided care to 80% of Medi-Cal patients.

Although 90% of physicians told the foundation they were accepting new
patients, only 57% said they were taking on new Medi-Cal patients.,0,4784104,full.story

Comment: One of the major defects in the Affordable Care Act is that it
perpetuates and expands the Medicaid program - a welfare program for
low-income individuals. Because of political anti-welfare bias, it is
vulnerable to budget cuts that would not be tolerated in a program like
Medicare that benefits all of us.

California's Medicaid program, Medi-Cal, exemplifies this problem. It
has one of the lowest payment rates in the nation, not even meeting the
expenses of many of the physicians still willing to see these patients.

There are already over 7 million Californians on the program, and there
will be almost a million children added as California shuts down its
CHIP program (Medi-Cal pays less than CHIP). There will be about 2
million more individuals added in 2014 under the provisions of the
Affordable Care Act. Further, low-income Medicare patients also eligible
for Medi-Cal are being transferred into Medicaid managed care plans.

In spite of California being at the bottom in Medicaid payment rates,
this 9th Circuit Court of Appeals decision upholds the additional 10
percent cut enacted because of California's budget crisis. The reduction
was challenged based on the fact that federal law requires that the
state ensure that Medicaid patients have access to adequate health care
services, and underpayment reduces the number of willing providers. That
argument was rejected by the court, though it is difficult to see how
California's physicians will be able to care for over 10 million
Medi-Cal patients when they are effectively donating their services plus
subsidizing their losses resulting from overhead expenses that are
greater than reimbursement rates. As more physicians turn them away, the
crowd out of privately insured patients will threaten the solvency of
the few remaining dedicated physicians.

This underpayment has real consequences. Access to primary care is
impaired, and specialized services are especially difficult to obtain
since most specialists are particularly resistant to allowing these
patients in their practices, no matter how great the need. Outcomes for
Medicaid patients are not as favorable as for those who have Medicare or
private insurance. In some studies, the outcomes are as bad as the
outcomes for the uninsured.

What good is a Medi-Cal card if it won't provide access to health care?

If we had a single improved Medicare that covered everyone, this problem
wouldn't exist. Everyone would have the level of care that we should
expect from a high-performance health care system. Are there too many
politicians who still believe that we should offer only inferior health
care to the poor because that is all they deserve? The rhetoric of the
recent elections doesn't bode well for a more egalitarian approach.

Thursday, December 13, 2012

Fwd: qotd: United Nations passes resolution supporting universal coverage

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: United Nations passes resolution supporting universal
Date: Thu, 13 Dec 2012 06:05:05 -0800
From: Don McCanne <>
To: Quote-of-the-Day <>

The Hill
December 12, 2012
US backs United Nations measure in favor of universal health coverage
By Elise Viebeck

The United States has backed a United Nations draft resolution favoring
universal healthcare coverage.

The nonbinding measure calls on U.N. member states to ensure citizens'
access to health insurance, and was approved by the U.N. General
Assembly on Wednesday.


United Nations
General Assembly
December 12, 2012
Adopting Consensus Text, General Assembly Encourages Member States to
Plan, Pursue Transition of National Health Care Systems Towards
Universal Coverage

Recognizing the intrinsic role of health in achieving international
development goals, the General Assembly today – through the unanimous
adoption of a resolution on global health and foreign policy –
encouraged Governments to plan or pursue the transition towards
universal access to affordable and quality health-care services.

By that text, the Assembly, calling for more attention to health as an
important cross-cutting policy issue, urged Member States, civil society
and international organizations to incorporate universal health coverage
in the international development agenda and in the implementation of the
internationally agreed development goals, including the Millennium
Development Goals.

The Assembly also recognized that improving social protection towards
universal coverage "is an investment in people that empowers them to
adjust to changes in the economy and the labour market and helps support
a transition to a more sustainable, inclusive and equitable economy".
As such, while planning or pursuing the transition towards universal
coverage, Member States were encouraged to continue investing in
health-delivery systems to increase and safeguard the range and quality
of services and meet the health needs of their populations.

Further, Member States were encouraged to recognize the links between
the promotion of universal health coverage and other foreign policy
issues, such as the social dimension of globalization, inclusive and
equitable growth and sustainable development.


United Nations
General Assembly
Sixty-seventh session
Agenda item 123

Global Health and Foreign Policy

IV. Universal health coverage

56. Universal health coverage captures the aspiration that everyone will
be able to obtain the high-quality health services they need without the
risk of suffering severe financial hardship when using them. The goal of
achieving universal health coverage has two important and interrelated
components: coverage for everyone who needs health services (including
prevention, promotion, treatment and rehabilitation) and coverage with
financial risk protection.

57. Both components are critical to the fulfilment of the highest
attainable level of health, a fundamental human right embedded in the
WHO constitution of 1948 and in the Universal Declaration of Human
Rights. At the same time, people value them for their own sake. They
sleep securely at night knowing that the health services they might
require are available and of good quality and that they can afford to
use them.

Population figures by country

Comment: It is terrific that the United States has voted for a United
Nations resolution in support of universal health coverage for all
Member States. But what about the United States? The Affordable Care Act
will leave about 30,000,000 uninsured, more than the entire population
of each of 183 countries and territories. Oh, of course... the U.N.
resolution is nonbinding.

Wednesday, December 12, 2012

Fwd: qotd: Rising costs and eroding protection

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: Rising costs and eroding protection
Date: Wed, 12 Dec 2012 12:57:46 -0800
From: Don McCanne <>
To: Quote-of-the-Day <>

The Commonwealth Fund
December 2012
State Trends in Premiums and Deductibles, 2003–2011: Eroding Protection
and Rising Costs Underscore Need for Action
By Cathy Schoen, Jacob Lippa, Sara Collins, and David Radley

Across states, the total average premium reached $15,022 per year in
2011 for family coverage, an increase of 62 percent since 2003.

Although premiums are rising more slowly than they were before enactment
of the recent reforms, private insurance spending per person is
projected to continue to grow more rapidly than incomes over the next

By 2011, there were 35 states in which the annual premium equaled 20
percent or more of income, compared with just one state in 2003. And
there are now no states where premiums amount to less than 14 percent of
median incomes, compared with 13 such states in 2003.

Although workers are paying more for insurance, their premiums are
buying them less financial protection because of the rapid increase in
deductibles from 2003 to 2011. The resulting shift of medical care costs
onto workers and their families has led to higher out- of-pocket costs
for medical bills — on top of higher premium costs. By 2011, 78 percent
of workers faced a deductible, compared with about half (52 percent) in

With the recent recession, millions of workers lost their jobs or were
otherwise unable to afford coverage and, as a result, joined the ranks
of the uninsured. From 2008 to 2010, the percentage of people with
employment-based insurance fell from 58.9 percent to 55.3 percent. An
estimated 9 million adults ages 19 to 64 lost a job with health benefits
and became uninsured during this period.

Along with rising numbers of uninsured, the nation has seen a rapid
increase in the number of underinsured, those at risk of high
out-of-pocket costs for medical care although insured all year. As of
2010, estimates indicate 81 million adults under age 65 (44% of all
adults) were either uninsured during the year or underinsured, up from
61 million in 2003.

From 2003 to 2010, median family incomes increased by only 10 percent,
on average, not enough to keep up with an inflation rate that has
increased by 18.5 percent over these seven years.
To date, with highly concentrated insurance markets, the path of least
resistance for insurers has been to simply pass on the rising costs of
medical care and higher prices, while adding insurance administrative
costs and profit margins. In fact, the major national private insurance
companies have done well throughout the recession years, with strong
pretax profit margins and administrative costs that have largely kept
pace with increases in medical care costs.
The national debate on health care costs often centers on the federal
deficit and on Medicare's future. Less attention is focused on the costs
of private insurance spending per person, which have been rising faster
than Medicare spending per person and are projected to continue to do so
over the next decade. The mounting stresses on businesses and families
underscore the need for action on behalf of the private sector as well.
Absent a significant change in the way private insurance and health care
markets function, cost pressures will continue to push up private
insurance costs and out-of-pocket medical expenses, if the past two
decades are any guide.
The Affordable Care Act's effectiveness in tackling costs, however, will
require collaboration among public and private stakeholders to ensure
that markets operate in the broad national interest of better health,
more positive health care experiences, and lower future costs.

For full report, click "Issue Brief" at this link:

Comment: It just gets worse. Family insurance premiums are now over
$15,000 - more than 20 percent of income in a majority of states. Family
deductibles now average over $2000. Family incomes have not kept up with
inflation, much less with the cost of health care. Yet private insurers
are thriving.

Many are hoping that the Affordable Care Act will provide some relief.
The PNHP website ( <>) has a plethora of
reports and studies indicating that there is no hope that that we will
have truly substantial reform under this Act - only
administratively-complex tweaks.

The authors of this report state that the Affordable Care Act's
effectiveness "will require collaboration among public and private
stakeholders." This is the fundamental reason that there is no hope.
Under our current dysfunctional financing system, which was left in
place by this legislation, that collaboration must be voluntary - an
impossibility since each vested interest is jockeying for the most
advantageous position.

Under a properly designed single payer system, the publicly-administered
policies are designed to ensure collaboration of all parties. What works
in the interests of the patients also works in the interests of the
collaborators. Until the nation is ready to demand structural reform
that benefits us all, we are going to continue to see the numbers in
this report grow even worse.

Tuesday, December 11, 2012

Fwd: qotd: Means testing Medicare

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: Means testing Medicare
Date: Tue, 11 Dec 2012 12:20:28 -0800
From: Don McCanne <>
To: Quote-of-the-Day <>

The Hill
December 8, 2012
Democrats warm to Medicare change that late Sen. Edward Kennedy opposed
By Elise Viebeck

Democrats in Congress are changing their tune on means testing in
Medicare, an idea the late Sen. Edward Kennedy (D-Mass.) resisted for

Leading Democratic lawmakers have suggested that raising premiums for
wealthy Medicare beneficiaries could be a matter of common ground with
Republicans in the ongoing deficit-reduction talks.

"I think that is reasonable and certainly consistent with the Democratic
message that those who are better off in our country should be willing
to pay a little more," Senate Majority Whip Dick Durbin (D-Ill.) said

The idea of affluence testing is not new — wealthy Medicare recipients
already pay higher premiums for doctor visits and prescription drug

But negotiations to avoid the so-called "fiscal cliff" open the door to
new measures that would make Medicare costs more progressive based on

Last week, Senate Finance Committee Chairman Max Baucus (D-Mont.) called
the idea "somewhat attractive" as a bargaining chip for talks on the
so-called fiscal cliff.

Sen. Claire McCaskill (D-Mo.) remarked that "Donald Trump may need
medication, but he certainly doesn't need the government to pay for it."

And Congressional Black Caucus Chairman Emanuel Cleaver (D-Mo.) called
means testing a good way to bolster Medicare's budget without cutting

"We already have a substantial amount of means-testing in the Medicare
program — most significantly, there is no cap on the income subject to
the Medicare tax," said (Rep. Henry) Waxman in a statement to The Hill.

"That is the right way to ask the better-off to pay more. And in fact,
we also have means testing now of the Part B and Part D premiums. It is
a mistake to go further."

Comment: Now that health care costs are unbearably high, Medicare must
be progressively financed since moderate- and low-income individuals can
no longer bear the full costs. A major step forward was the removal of
the cap on wages subject to Medicare taxes, so higher income individuals
pay more. The Affordable Care Act also added a new 0.9% Medicare tax for
incomes over $200,000/$250,000.

In addition, in order to help cover Medicaid expansion and subsidies for
the exchange plans, the Affordable Care Act also added a 3.8% tax on
investment income, again for those with incomes over $200,000/$250,000.
So we have already embarked on policies that make health care financing
progressive, though we need to do more, but only on the financing end.

Medicare benefits should be the same for everyone. We should eliminate
premiums and cost sharing, and we should expand benefits so that
administratively wasteful Medigap and retiree health benefit programs
are no longer necessary. Low income individuals should receive the same
standard of care as the wealthy, just as was the intent in enacting the
traditional Medicare program.

Introducing means testing, which we have already begun with Part B and
Part D premiums, reduces support of wealthier beneficiaries who are
annoyed by these additional charges. Once the principle of means testing
is established, the budget hawks ratchet it up, driving wealthier
individuals to look for private options, currently available as the
Medicare Advantage plans. It is only one small additional step to
introduce premium support - vouchers - where the wealthy will take their
money and run. Once you lose support of wealthier individuals who have a
strong political voice, then Medicare will descend down the path toward
becoming a welfare program, like Medicaid.

We cannot allow this bipartisan attack on Medicare to proceed. Mobilize
the forces!

Monday, December 10, 2012

Fwd: qotd: John Goodman says the problem is the anti-capitalist mentality

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: John Goodman says the problem is the anti-capitalist
Date: Mon, 10 Dec 2012 11:49:20 -0800
From: Don McCanne <>
To: Quote-of-the-Day <>

National Center for Policy Analysis
John Goodman's Health Policy Blog
December 10, 2012
The Anti-Capitalist Mentality
By John Goodman


Have you ever noticed that people who worry about inequality seem to be
focused only on certain kinds of inequality? When they obsess about the
income and wealth of the top 1%, they seem to be bothered by only some
of those at the top, and not others.

For example, have you ever seen Robert Reich or Paul Krugman or any
like-minded complainer bemoan the huge salaries of professional athletes?

Even more puzzling, when is the last time you saw any of them assailing
worthless heirs?

Something else is odd about the sociology of the anti-inequality crowd.
They seem to be unfazed by inequality created by government.

Take the recent Powerball outcome. At $588 million, it was the largest
lottery prize in history ― to be shared by two ticketholders.

Then there is the entire structure of elderly entitlements. They mainly
take from people who have less and give to people who have more.

Think about that last finding for a moment. Throughout the country,
families who are struggling to get by and who cannot afford to buy their
own health insurance are paying 15% of their income to fund hip and knee
replacements for our true leisure class, so they can get back out on the
golf course.

But when Paul Krugman writes about the top 1%, this is not who he has in
mind. He is complaining about the incomes of people who run large
companies. He wants their tax rate to be 91%!

I think Ayn Rand may have been right. The left is populated by people
who are not especially bothered by those who become wealthy by virtue of
birth or luck or good fortune. They do not even seem to be bothered by
the winner-take-all feature of professional sports that confers millions
of dollars on some athletes while those who were almost as good languish
in near poverty. No, who they obsess about are the creators, the
builders, the entrepreneurs.

They don't hate the wealthy who don't deserve their wealth. They hate
the wealthy who do deserve it.

(John Goodman understandably wants his comments to be read in full,
which you can do at the following link.)

Reader Comments:

Don McCanne says:
December 10, 2012 at 12:30 pm

Although everyone already understands this, it is still important to
distinguish between equality and equity. Most progressives are not
striving for equality of income and wealth, rather the goal is equity –
introduce an element of fairness in distribution.

Although sometimes expressed as an anti-corporate bias, the objection is
more to policies favoring massive perverse distributions, as from rent
seeking for instance. Rent seeking that provides little net benefit to
society while the rent seekers scoop up the wealth, to many of us
represents an intense sense of unfairness.

The work of Piketty and Saez demonstrates the unfairness that has now
become the norm. In the face of a massive transfer to the wealthy,
median household incomes are no longer enough to bring average families
the American Dream – paying for essential needs while allowing enough
for higher education of their children, adequate retirement accounts,
medical costs for those with greater needs, and perhaps even a modest
improvement in housing and transportation, and even an occasional
well-earned vacation. And keep in mind the obvious that half of all
households fall below the median.

With equitable public policies in a wealthy nation like the United
States, hard working families should be able to realize the American
Dream. That's fair. What isn't fair is for the rent seekers to establish
a plutocracy and use it to break up our unions, clobber our retirement
and health programs, ship jobs out of the country, saddle higher
education with intolerable debt, all of this and similar abuses on top
of filling their coffers with funds they have wrested away from the main
source of our productivity – the workers of America.

Inequality will always be with us, but we do need policies that increase
fairness by reducing inequity in America.

Comment: This blog on "The Anti-Capitalist Mentality" does pertain to
health care reform in that we will never have an equitable health care
system for all until we decide that equity - fairness - must be a
primary goal of public policy.

Friday, December 7, 2012

Fwd: qotd: Decline in general medicine career choices

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: Decline in general medicine career choices
Date: Fri, 7 Dec 2012 11:52:34 -0800
From: Don McCanne <>
To: Quote-of-the-Day <>

December 5, 2012
General Medicine vs Subspecialty Career Plans Among Internal Medicine
By Colin P. West, MD, PhD and Denise M. Dupras, MD, PhD

This study of a large national sample of internal medicine residents
confirms that general medicine remains a less common career plan overall
than subspecialty medicine. Combined with the fact that only a small
minority of medical students express interest in general medicine and
primary care careers, the small number of internal medicine residents
reporting plans for generalist careers means a very limited number of
generalists can be expected to enter practice each year.

Comment: This update confirms that internal medicine residents are
selecting the subspecialties in preference to general medicine and
primary care. In light of the pressing need for improving our primary
care infrastructure, what policies should we support?

Since family medicine residents almost always eventually enter primary
care, should training programs de-emphasize general internal medicine
and place more emphasis on family medicine, while relegating internal
medicine to the subspecialties? That would improve the allocation of
residency slots since you would not be losing general medicine residents
to the subspecialties after their residencies began. This is not to
suggest that subspecialists should skip all training in general
medicine. The purpose would be to stem the loss of generalists from the
training programs.

Also many agree that the role of nurse practitioners in primary care
should be expanded. This would be especially valuable in integrated
health systems and medical homes. If so, the expansion should be
coordinated with the family medicine programs to achieve an optimal
balance of primary care professionals.

Since we aren't getting the numbers right, shouldn't we consider an
alternative approach? If we had a federally funded national health
program, wouldn't we be striving to improve the use of our resources to
be sure that our health care infrastructure is better balanced? Our
current dysfunctional, fragmented method of financing our health care
system doesn't seem to be doing the job very well.

Thursday, December 6, 2012

Fwd: qotd: Greg Scandlen explains the irrationality of the individual mandate

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: Greg Scandlen explains the irrationality of the
individual mandate
Date: Thu, 6 Dec 2012 08:12:46 -0800
From: Don McCanne <>
To: Quote-of-the-Day <>

National Center for Policy Analysis (NCPA)
December 5, 2012
The Crown Jewel of ObamaCare Failures
By Greg Scandlen

Now we get to the biggest failure of them all — the individual mandate.
The premise was simple: If people aren't buying what they should (in
this case, health insurance), pass a law telling them they have to, and
they will. Presto, Change-o problem solved!

Now, to be fair, Congressional Democrats weren't quite that simple
minded. They threw in lots of subsidies and required that insurers
enroll anyone who applied, no questions asked. So, they made it
affordable and available, along with being mandated. So, it should work
like a charm, right?

Well, maybe in a vacuum. But in reality this rule is being inserted into
a very complex and mature system of existing subsidies,
responsibilities, and incentives. In this case, one of the primary
factors is the role of employers in providing and paying for coverage.

Many people, including this writer, believe that placing that
responsibility on employers was a major policy screw-up that created all
the wrong dynamics in health care and virtually eliminated market
functions because the payer and the consumer were not the same person.

Nevertheless, it is a system we have lived with for two-thirds of a
century. Almost everything about health care and employment has been
built around that relationship — prospective employees consider a
company's health benefits when deciding to take a new job; employers
devote a lot of staff time and resources on choosing benefit programs;
laws and regulations are written to ease the problems of interruption of
benefits when people change jobs; courts are concerned that employers
may not always fulfill their obligations to their workers. Not all
employers provide benefits, but all feel an obligation and
responsibility to do so, and the ones who don't offer health benefits
often feel conflicted about it.

Unwinding all this, even if desirable, is extremely complex and should
take a very long transition period as we all learn new ways of doing things.

Enter ObamaCare. This law provides stark incentives for employers to get
out of the business immediately. It even assuages any guilt feelings the
employer might have by, first requiring that they continue to help pay
for it, and next, by offering workers richer subsidies than the employer
typically can. An employer will be able to save many thousands of
dollars per worker by dropping coverage and sending employees to the
Obama Exchange where they will get a choice of benefits plans and
substantial subsidies if they make under 400% of the poverty level.
Instead of paying, say, $10,000 per worker for coverage, now the
employer can pay a simple $2,000 penalty and use the savings to give
each worker a raise. Most employers will be able to save even more by
reducing their HR departments, and they will be freed of complaints
about any problems with the health plan they offer.

In February, 2011 McKinsey & Company did a large (1,329) survey of
employers asking about their intentions with the Affordable Care Act and
found that 30% said their company would "probably" or "definitely" drop
coverage as a result. McKinsey is an extremely credible firm, but that
didn't stop supporters of ObamaCare from lambasting the survey because
it was not consistent with other economic analyses. McKinsey had to
issue a statement explaining it was not intended to be an economic
analysis, it was an opinion survey. I would argue that such a survey is
probably far more accurate than an economic analysis that must rely too
much on assumptions. Indeed, it likely understated the situation. As
employers learn more about the requirements of the new law they are more
likely to run away from it.

We can't know until it happens how many employers will drop coverage,
but the 30% estimated by McKinsey may be the minimum. That could mean 50
million or more people who used to get employer coverage no longer will.
For those employees this means:

* No more automatic enrollment going along with the job. People will
have to take the initiative to find out about the Exchange.
* No more pure community rating of the employee share of premiums. The
Exchange will vary premiums every year based on a person's age.
* No more paycheck deductions of the employee share of premiums. People
will have to make some kind of payment arrangement for their share of
the premium.
* No more convenient and friendly HR Department people to answer
questions. People will have to seek out an "Exchange navigator" to get
their questions answered.

These employees are also likely to find at the Exchange:

* A clunky web site run by the state or federal government laying out
the coverage options.
* Overpriced insurance options. (Because insurers can no longer ask
medical questions, they will have no idea what kind of risks they are
enrolling, or the premiums needed to cover those risks. They will err on
the side of caution and charge higher premiums.)
* Confusion about how much they will be charged for their share of the
premium. (They will be subsidized, but the amount of the subsidy will
vary according to their age, income, geographic location, family size,
and choice of plan.)
* Insurance plans that cover a bunch of stuff they don't want or need.
* No reliable source of personalized information. (Ever tried to call
the Medicare helpline?)

Finally, they will realize that they don't need to go through all this.
They can delay making a decision until they really need to get health
care services:

* Exchange coverage is guaranteed to accept them at any time with no
questions asked.
* They can save a whole lot of money by not paying premiums and using
that money for more pressing needs.
* There is no meaningful penalty for failing to enroll. What penalty
there is applies only to people who make enough money to pay income
taxes, and it can be collected only by seizing whatever tax return is
due the taxpayer. This can be easily avoided by upping deductions at the
start of the year.

Most people have very few medical expenses in the course of a year.
According to this chart 50% of the people in the United States consume
only 3.9% of all health care expenses each year, while the top 20%
consume 78.3%. People in the top 20% will certainly want to be covered
but the bottom 50% get no advantage from insurance coverage. They spend
far less on services than they would on insurance premiums.

(Scandlen includes here a slide taken from a presentation on "Medicare
for All" by Paul Y. Song, MD of Physicians for a National Health
Program, graphically demonstrating this distribution of health care

Obviously not everyone will make the choice to go uninsured. People who
are risk-adverse, or who have ongoing medical needs, or who have small
children, will continue to be covered. But every year, every person will
have to decide how best to spend their money. A very large number will
decide they have better things to do with that money than spend it on
insurance coverage they don't want and never use.

The odds are that after all the trauma and expense of enacting and
implementing ObamaCare, we will have fewer people insured than we did
before it was enacted.

Comment: Greg Scandlen is a very well informed and respected member of
the policy community who has been associated with
conservative/libertarian organizations such as the National Center for
Policy Analysis, Cato Institute, Galen Institute and Heartland
Institute. This article for NCPA is presented in its entirety to
demonstrate how much agreement there is with those of us at Physicians
for a National Health Program in defining some of the problems with the
highly flawed Affordable Care Act (Obamacare). This article could have
been written by one of us at PNHP.

He does not offer any solutions in this particular article, though had
he, it would undoubtedly be from his area of expertise and advocacy -
consumer-driven health care, including health savings accounts and
health reimbursement arrangements. That, of course, is quite a contrast
from the single payer solution advanced by PNHP.

When there is so much agreement on what is wrong, why can't we agree on
the solution? Perhaps it's our respective goals. We at PNHP want
everyone to have affordable access to all essential health care
services, as a matter of social justice. The advocates of
consumer-driven health care seem to place the will of the individual
consumer above that of society's collective will for health care
justice. But the divide is not quite that simple.

Supporters of an improved Medicare for all still agree that the patient
(health care consumer) should make the ultimate decisions on his or her
individual health care, after being informed on the options. The role of
the government is to remove the financial barriers to that care.

The consumer-driven advocates would add to the health care consumer
(patient) the responsibility of making spending decisions so that they
would shop for higher quality and greater value. The role of the
government would be to ensure access to basic health care services for
those who lack the financial resources to pay for that care.

The problem with the consumer-driven approach is that is what we have
now, and it isn't working. Except for a marginal tax benefit, it doesn't
matter whether the patient's share of cost comes from a health savings
account or from other personal funds. The system perpetuates uninsurance
and under-insurance which exposes far too many to financial hardship in
the face of medical need.

An improved Medicare for all would eliminate financial hardship for
individual patients while using public policies to reduce the excessive
escalation of our collective health care spending. The latter is a task
that our private insurers cannot master, but is ideally suited to a
single, national, publicly-administered insurance risk pool.

Greg Scandlen understands this. He understands the inadequacies of his
consumer-directed approach. I wish he could explain to us better, in
terms devoid of ideology, just what is wrong with our approach - an
approach that would provide everyone the care that they need in a
progressively-financed system that we can all afford.

Wednesday, December 5, 2012

Fwd: qotd: Will Liz Fowler determine the drugs you can have?

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: Will Liz Fowler determine the drugs you can have?
Date: Wed, 5 Dec 2012 14:04:52 -0800
From: Don McCanne <>
To: Quote-of-the-Day <>

The Hill
December 4, 2012
Analysis finds big state-by-state swings in prescription coverage
By Sam Baker

President Obama's signature healthcare law requires insurance plans to
cover a range of prescription drugs, but the number of drugs covered
will vary widely from state to state, according to a new analysis from
Avalere Health.

Based on its analysis of state benchmark plans, Avalere said some states
cover as little as 45 percent of available drugs, while others cover
more than 99 percent.

"This means that ... linking drug coverage to the benchmark formulary
will result in drastically different coverage requirements
state-to-state," Avalere said.

Map of state variations in number of drugs covered:


The Guardian
December 5, 2012
Obamacare architect leaves White House for pharmaceutical industry job
By Glenn Greenwald

When the legislation that became known as "Obamacare" was first drafted,
the key legislator was the Democratic Chairman of the Senate Finance
Committee, Max Baucus, whose committee took the lead in drafting the
legislation. As Baucus himself repeatedly boasted, the architect of that
legislation was Elizabeth Folwer, his chief health policy counsel;
indeed, as Marcy Wheeler discovered, it was Fowler who actually drafted it.

What was most amazing about all of that was that, before joining Baucus'
office as the point person for the health care bill, Fowler was the Vice
President for Public Policy and External Affairs (i.e. informal
lobbying) at WellPoint, the nation's largest health insurance provider
(before going to WellPoint, as well as after, Folwer had worked as
Baucus' top health care aide).

More amazingly still, when the Obama White House needed someone to
oversee implementation of Obamacare after the bill passed, it chose ...
Liz Fowler.

Now, as Politico's "Influence" column briefly noted on Tuesday, Fowler
is once again passing through the deeply corrupting revolving door as
she leaves the Obama administration to return to the loving and
lucrative arms of the private health care industry: "Elizabeth Fowler is
leaving the White House for a senior-level position leading 'global
health policy' at (pharmaceutical giant) Johnson & Johnson's government
affairs and policy group."

It's difficult to find someone who embodies the sleazy, anti-democratic,
corporatist revolving door that greases Washington as shamelessly and
purely as Liz Fowler.

Comment: A well designed, national, single payer financing system would
ensure that everyone would receive whatever appropriate drugs they might
need. Instead, we have an inefficient, fragmented, costly financing
system that imposes regulatory and financial barriers in the way of many
needed medications, in a manner inconsistent from state to state.

Congress and the President could have consulted with those fine folks at
Physicians for a National Health Program, and then we would have a
system that serves the needs of patients. Instead, they consulted a
"sleazy, anti-democratic, corporatist," Liz Fowler, who orchestrated a
program that instead primarily serves the needs of the insurance and
pharmaceutical industries. She had previously played a key role in the
2003 Medicare Prescription Drug Act (MMA), a program that prohibits
government contracting for drugs under Part D of Medicare. She entered
the revolving door as a pawn of the insurance industry and departs as a
pawn of the pharmaceutical industry - the very industries for which she
wrote the legislation.


We can change it.

Tuesday, December 4, 2012

Fwd: qotd: Physicians find insurer ACO payment models "completely unfavorable"

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: Physicians find insurer ACO payment models "completely
Date: Tue, 4 Dec 2012 10:44:08 -0800
From: Don McCanne <>
To: Quote-of-the-Day <>

American Medical News
December 3, 2012
Medical practices wary of insurer efforts on new payment programs
By Victoria Stagg Elliott

Medical practices have a low opinion of how insurers are operating
emerging payment programs, such as accountable care organizations,
patient-centered medical homes, shared savings and payment bundling,
according to a survey of 800 practices released Nov. 14 by MGMA-ACMPE.

Researchers asked practices to rate the willingness of seven large
payers to engage in innovative models on a scale of one, meaning
completely unwilling, to five, which indicates completely willing.
Medicare Part B scored the highest at 1.95, and United Healthcare was
the highest private payer at 1.82.

When asked to rate the favorability of these payment models to the
practice on a scale of one to five, Medicare Part B scored highest at 1.68.

Health industry insiders said the scores on innovative payment models
reflect physicians' frustrations with programs they believe were not
designed for their specialty or size, and that insurers were not
flexible in negotiating terms.

ACOs serve 25 million to 31 million patients, a "remarkable achievement
for a care arrangement that was scarcely on the map at all two years
ago," according to a report released Nov. 26 by management consulting
company Oliver Wyman.

Cigna's collaborative accountable care program includes 42 participating
entities, mostly large, with about 10,000 physicians providing care for
400,000 members. A paper in the November Health Affairs found the plan's
ACO program improved quality and lowered costs.


Practice Perspectives on Payer Performance, 2012

For the fifth year in a row, the Medical Group Management Association
(MGMA) has conducted its poll to determine group practice professionals'
attitudes about payer interactions.

Of the payers who are willing to engage in innovative payment models
(accountable care, shared savings, medical homes or payment bundling),
how favorable or unfavorable do you consider these options to be to your

Rating average / Payer

1.68 Medicare Part B
1.62 United Healthcare
1.62 Aetna
1.58 Cigna
1.57 Anthem
1.55 Humana
1.48 Coventry

(Based upon a 5 point scale where 1 = Completely unfavorable, 2 =
Moderately unfavorable, 3 = Neutral, 4 = Moderately favorable, and 5 =
Completely favorable.)


Health Affairs
November 2012
A Collaborative Accountable Care Model In Three Practices Showed
Promising Early Results On Costs And Quality Of Care
By Richard B. Salmon, Mark I. Sanderson, Barbara A. Walters, Karen
Kennedy, Robert C. Flores and Alan M. Muney

Cigna's Collaborative Accountable Care initiative provides financial
incentives to physician groups and integrated delivery systems to
improve the quality and efficiency of care for patients in commercial
open-access benefit plans.

Although not statistically significant, these early results revealed
favorable trends in total medical costs and quality of care.

Comment: These early results should sound the alarms on our current
efforts to implement accountable care organizations (ACOs). We've barely
begun and already about 30 million patients have been assigned to ACOs.
Yet look at how that is working.

Health care professionals in group practices were polled on how
favorable or unfavorable the insurers' innovative payment models,
primarily ACOs, were to their practices. The average rating for all
insurers was in the 1s - "completely unfavorable"!

Further, we are now seeing the same response from the insurers that we
did with earlier efforts at managed care. They were telling us then that
we were receiving higher quality care at lower cost. As it turned out,
costs continued to rise and quality remained mediocre.

Now Cigna is reporting that the recent Health Affairs article that they
authored showed that their "ACO program improved quality and lowered
costs." Yet the article actually states that these early results were
"not statistically significant."

This turkey has already taken off, and yet it can't fly. The health care
of 30 million patients is already at stake, and they are being cared for
health care professionals who find the arrangement COMPLETELY UNFAVORABLE!

Monday, December 3, 2012

Fwd: qotd: Cash upfront for ED visits?

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: Cash upfront for ED visits?
Date: Mon, 3 Dec 2012 14:08:48 -0800
From: Don McCanne <>
To: Quote-of-the-Day <>

American Medical News
December 3, 2012
New ED drama? Hospitals demand upfront fee for nonemergencies
By Kevin B. O'Reilly

(A small) but growing number of hospitals give patients whose problems
are deemed nonemergent a choice: Pay an initial fee to get the problem
treated in the ED, or seek care elsewhere. The fees range from $100 to
$180 for uninsured patients, or the relevant co-pay or deductible for
insured patients.

Hospitals implementing the pay-first policy say it complies with the
Emergency Medical Treatment and Active Labor Act because all patients
receive the federally required medical screening regardless of ability
to pay. It is only after a patient's condition is deemed nonemergent
that upfront payment for further treatment in the ED is discussed.

Yet many doctors interviewed for this article found the growing trend
alarming. They said it unfairly targets patients with poor access to
primary care and is unlikely to alleviate ED crowding because nonurgent
problems make up less than 10% of visits. Emergency physicians added
that the policy could result in tragedy, because some seemingly
nonemergent conditions quickly worsen, and because some patients with
life-threatening problems may wrongly decide to steer clear of the ED to
avoid pay-first fees.

The pay trend is severely misguided, said Arthur L. Kellermann, MD, MPH,
who served on an Institute of Medicine emergency care panel and now is a
health policy researcher at the RAND Corp., an independent nonprofit
think tank.

"People don't go the ER as a recreational event," he said. "If you tell
me you have an urgent care clinic or walk-in clinic or other places
where these people can go straight to, then OK. But to tell someone to
just go away if you don't have $150, you have to be ignoring the fact
that if they had somewhere to go they wouldn't be there in the first
place. And you have to be damn sure that this patient doesn't have a
more serious problem. This is putting a Band-Aid on a gunshot wound."

"There are truly people who come to the ED with something very benign,
and it ends up being a major medical issue," said Patrick O'Malley, MD,
an emergency physician in a suburb of Columbia, S.C. "Determining who
those patients are right at the front door is difficult."

The pay-first policy appears to be aimed at discouraging uninsured
patients from visiting the ED, said Leora Horwitz, MD, assistant
professor of general internal medicine at Yale University School of
Medicine in Connecticut.

"A much better solution to this kind of problem would be to incentivize
primary care doctors to provide the care that's needed, to have evening
hours, weekend hours, and to have more urgent care centers," Dr. Horwitz
said. "There are many ways to improve access for patients without
barring the door of the ER as your solution."

Comment: Over half of emergency department (ED) visits are truly urgent
or emergent and should be seen within minutes. About 35 percent are
semi-urgent and should be seen within a couple of hours. Only 8 percent
are non-urgent and could be seen the next day. Which of these patients
should never be seen in the ED?

If you assume that patients are fully capable of assessing the urgency
of their own problems and and that triage nurses are fully capable of
never making a judgement error, then perhaps the 8 percent who are
non-urgent should be seen by their primary care professionals at the
next available appointment. But such an assumption is a stretch since
the true urgency often cannot be determined with absolute certainty
until there is a full assessment of the problem.

Maybe that head cold is an acute bacterial sinusitis, which could lead
to meningitis or an abscess with sepsis. Maybe that gastrocnemius strain
is thromboplebitis, which could result in a pulmonary embolism. Maybe
that migraine is a rupturing berry aneurysm, which... well, you know.
Then again, maybe these really are minor, non-urgent problems that do
not need assessment in the ED.

How do you decide that? Do you have the triage nurse make a decision to
turn the patient away at the front desk with no further ED evaluation?
That can be a problem if the nurse's initial screen misses a serious
problem, which is certainly possible, even if infrequent.

The answer is easy. In this age of consumer-directed health care, you do
not turn anyone away. Instead, you require the patient who seems to have
a non-urgent problem to use their health care shopping skills by
requiring a payment up front. Thus the ultimate decision is not left
with the triage nurse but rather is left with the least qualified
individual in the ED - the patient.

Some patients will make the wrong decision - bad policy. This is
overkill, perhaps literally.

If a local ED is truly overburdened with routine medical problems, the
proper management should be to adjust capacity in the health care
system. If primary care services need to be extended to evening and
weekend hours, improve capacity so that can be done. If the void can be
filled with a free-standing urgent care clinic, then establish that. The
ED itself could be expanded to include a wing for less urgent problems,
staffed with a nurse practitioner of primary care physician, if
appropriate for the community. The marginal cost should not be much
different from a free-standing, off-hours clinic, if that.

Under a single payer system, some adjustments in capacity can be made by
administrators of the global budgets for the facilities. More extensive
changes might involve separate budgets established for capital
improvements. But creating financial barriers to care runs the risk of
having the patient decide to forgo beneficial health care that just
might possibly be lifesaving.

If the ED is crowded with the worried well, fix the system. Don't kill
the seriously ill patient hidden amongst them.