Wednesday, July 31, 2013

Fwd: qotd: Friedman analysis of HR 676: Medicare for All would save billions

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-------- Original Message --------
Subject: qotd: Friedman analysis of HR 676: Medicare for All would save
Date: Wed, 31 Jul 2013 08:29:36 -0700
From: Don McCanne <>
To: Quote-of-the-Day <>

Physicians for a National Health Program
July 31, 2013
'Medicare for All' would cover everyone, save billions in first year:
new study

Upgrading the nation's Medicare program and expanding it to cover people
of all ages would yield over a half-trillion dollars in efficiency
savings in its first year of operation, enough to pay for high-quality,
comprehensive health benefits for all residents of the United States at
a lower cost to most individuals, families and businesses.

That's the chief finding of a new fiscal study by Gerald Friedman, a
professor of economics at the University of Massachusetts, Amherst.
There would even be money left over to help pay down the national debt,
he said.

Friedman says his analysis shows that a nonprofit single-payer system
based on the principles of the Expanded and Improved Medicare for All
Act, H.R. 676, introduced by Rep. John Conyers Jr., D-Mich., and
co-sponsored by 44 other lawmakers, would save an estimated $592 billion
in 2014. That would be more than enough to cover all 44 million people
the government estimates will be uninsured in that year and to upgrade
benefits for everyone else.

"No other plan can achieve this magnitude of savings on health care,"
Friedman said.

His findings were released this morning [Wednesday, July 31] at a
congressional briefing in the Cannon House Office Building hosted by
Public Citizen and Physicians for a National Health Program, followed by
a 1 p.m. news conference with Rep. Conyers and others in observance of
Medicare's 48th anniversary at the House Triangle near the Capitol steps.'medicare-for-all'-would-cover-everyone-save-billions-in-first-year-new-study

July 31, 2013
Funding HR 676: The Expanded and Improved Medicare for All Act
How we can afford a national single-payer health plan
By Gerald Friedman, Ph.D.

Executive Summary

The Expanded and Improved Medicare for All Act, HR 676, introduced into
the 113th Congress by Rep. John Conyers Jr. and 37 co-sponsors, would
establish a single authority responsible for paying for medically
necessary health care for all residents of the United States.

Under the single-payer system created by HR 676, the U.S. could save an
estimated $592 billion annually by slashing the administrative waste
associated with the private insurance industry ($476 billion) and
reducing pharmaceutical prices to European levels ($116 billion). In
2014, the savings would be enough to cover all 44 million uninsured and
upgrade benefits for everyone else. No other plan can achieve this
magnitude of savings on health care.

Specifically, the savings from a single-payer plan would be more than
enough to fund $343 billion in improvements to the health system such as
expanded coverage, improved benefits, enhanced reimbursement of
providers serving indigent patients, and the elimination of co-payments
and deductibles in 2014. The savings would also fund $51 billion in
transition costs such as retraining displaced workers and phasing out
investor- owned, for-profit delivery systems.

Health care financing in the U.S. is regressive, weighing heaviest on
the poor, the working class, and the sick. With the progressive
financing plan outlined for HR 676 (below), 95% of all U.S. households
would save money.

HR 676 (Section 211, Appendix 2) specifies a financing plan for
single-payer that includes
• Maintaining current federal financing for health care
• Increasing personal income taxes on the top 5% of income earners
• Instituting a modest tax on unearned income
• Instituting a modest and progressive tax on payroll, self-employment
• Instituting a small tax on stock and bond transactions

The following progressive financing plan would meet the specifications
of HR 676:
• Existing sources of federal revenues for health care
• Tax of 0.5% on stock trades and 0.01% tax per year to maturity on
transactions in bonds, swaps, and trades
• 6% high-income surtax (applies to households with incomes > $225,000)
• 6% tax on unearned income from capital gains, dividends, interest,
profits, and rents
• 6% payroll tax on top 60% of income earners (applies to incomes over
$53,000, tax paid by employers)
• 3% payroll tax on the bottom 40% of income earners (applies to incomes
under $53,000, tax paid by employers)

HR 676 would also establish a system for future cost control using
proven-effective methods such as negotiated fees, global budgets, and
capital planning. Over time, reduced health cost inflation over the next
decade ("bending the cost curve") would save $1.8 trillion, making
comprehensive health benefits sustainable for future generations.

Comment: This is the report that single payer advocates have been
waiting for. Economics Professor Gerald Friedman of the University of
Massachusetts at Amherst has provided us with an analysis of the
financing of John Conyers' HR 676: The Expanded and Improved Medicare
for All Act. The results are quite impressive, especially considering
the comprehensiveness of the HR 676 reforms. Dr. Friedman's report will
be invaluable in our advocacy for a single pager national health program.

The analysis shows that we really can provide everyone with
comprehensive health care without causing a financial hardship for
anyone. This is made possible by depending on progressive tax policies.
Since it is likely that the opposition will become apoplectic when they
see the proposed taxes, we should be prepared to explain why progressive
tax policies to fund health care are a good thing rather than a bad thing.

Let's begin with two fundamental principles: 1) All of us should have
the health care that we need, and 2) Obtaining health care should not
ever result in financial hardship. Having health problems is enough
without adding the financial penalties of paying for health care simply
because of having the misfortune of being sick or injured.

Our audience is not those who disagree with these principles. We will
never be able to satisfy them. Rather we need to address those who agree
but cringe and withdraw when they see a recommendation for TAXES!

We need to keep in mind that we are not working with the spending
baseline that we had when we began to advocate for single payer a couple
decades ago. (They should have listened to us then!) Health costs are
now a much larger percentage of our economy. Health care costs for the
average working family of four are now over $22,000, when median
household income is about $50,000. It is now impossible to meet the goal
of providing affordable health care for everyone without making the
wealthy pay more than the rest of us. Financing must be progressive it
we are to meet our goals.

The Affordable Care Act (ACA) has included several policies that do
increase the progressivity of financing, but it depends on an
administratively wasteful, fragmented system that is the source of many
of the problems in health care today. Many who cannot afford their
allocated share will still pay too much, and many more will not even
receive the care that they should have merely because of the
dysfunctional financing method perpetuated by ACA. In contrast, the
administrative simplicity of progressive taxes ensures an equitable
method of financing care, making it affordable for everyone.

For those who say that we can't afford the taxes, remind them that the
taxes displace much of our current spending for health care. Because of
the efficiencies of the single payer model of financing, the amount that
we would spend in increased taxes for health care is less than the
amount we would save in recovering the administrative and clinical waste
of our current system. Not only will we be paying less in taxes than the
excessive amount that we are currently paying for our dysfunctional
system, the payment will become much more transparent so that we finally
would know what health care really costs us. Much of the costs are
hidden today.

People often think that health care costs are what they or their
employers pay in private insurance premiums, plus out-of-pocket
expenses. In fact, in 2012 we paid only about $884 billion in private
insurance premiums, though our total national health expediters were
about $2,831 billion. It is that other $1,947 billion of relatively
hidden health care costs that we are already paying that will be more
transparent under a public tax system. When you think of these numbers,
you can better understand why the proposed taxes seem to be so high.

Rather than fixating on just the taxes proposed in HR 676, it is much
more important to look at the change in income that each person faces as
a result of these tax policies. Use the link above to access Professor
Friedman's report and go to Figure 2. The bar graph and its explanation
in the note below should be studied carefully to understand the changes.

The four bars on the left represent the bottom four quintiles of
household income - 80 percent of the population. The four bars on the
right represent the top 20 percent. The fifth bar, representing those
with incomes from the 80th to the 95th percentile have an average
household income of $216,922. Yet they and also those with incomes below
them - 95 percent of all households - will see an INCREASE in their net
income in spite of what they may perceive to be onerous taxes. It is
only the top 5 percent that will be paying more in taxes than they will
be receiving in health care benefits.

Okay. That's fair for most of us, but is it really fair for those with
incomes of a half million dollars or more - especially for those with
average incomes of $3 million or even $166 million? Remember that wealth
has moved upwards with high income individuals benefiting from the
increased productivity of the workers, while workers' incomes have
remained flat. This massive, unfair upward shift of income and wealth
screams out for justice. Progressive tax policies are precisely what we
need to correct this injustice. HR 676 does exactly that - not only
ensuring health care for everyone, but finally making it affordable for
everyone while establishing public policies to slow the financial drain
that the wealthy have placed upon the rest of us.

The Koch brothers and the Walton family may not like this proposal, but
it's not like we're taking away their mansions or their personal jets.
They'll never miss the money that HR 676 would divert to taxes. Even
those with a current $500,000 after tax income will see their net income
reduced to about $460,000. They may whine, but if they are honest with
themselves, they would have to agree that they really won't see any
significant differences in their lifestyles either. Some of them will
even think that it is worth it if it ensures that absolutely everyone
finally has the right to affordable health care.

We can have an Expanded and Improved Medicare for All if we simply
dispense with our irrational tax phobia.

Tuesday, July 30, 2013

Fwd: qotd: Montana government clinic: Maybe single payer is aiming too low

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-------- Original Message --------
Subject: qotd: Montana government clinic: Maybe single payer is aiming
too low
Date: Tue, 30 Jul 2013 09:34:18 -0700
From: Don McCanne <>
To: Quote-of-the-Day <>

July 30,2013
Montana's State-Run Free Clinic Sees Early Success
By Dan Boyce

A year ago, Montana opened the nation's first clinic for free primary
healthcare services to its state government employees. The Helena,
Mont., clinic was pitched as a way to improve overall employee health.

A year later, the state says the clinic is already saving money.

(Government employees still have their) normal health insurance provided
by the state. But at the clinic, (there are) no co-pays, no deductibles.
It's free.

That's the case for the Helena area's 11,000 state workers and their
dependents. With an appointment, patients wait just a couple minutes to
see a doctor.

"For goodness sakes, of course the employees and the retirees like it,
it's free," says Republican State Sen. Dave Lewis.

He and others faulted then-Gov. Brian Schweitzer for moving ahead with
the clinic last year without approval of the state legislature, although
it was not needed.

Now, Lewis is a retired state employee himself. He says, personally, he
does like going there, too.

The state contracts with a private company to run the facility and pays
for everything — wages of the staff, total costs of all the visits.
Those are all new expenses, and they all come from the budget for state
employee healthcare.

Even so, division manager Russ Hill says it's actually costing the state
$1,500,000 less for healthcare than before the clinic opened.

"Because there's no markup, our cost per visit is lower than in a
private fee-for-service environment," Hill says.

Physicians are paid by the hour, not by the number of procedures they
prescribe like many in the private sector. The state is able to buy
supplies at lower prices.

Bottom line: a patient's visit to the employee health clinic costs the
state about half what it would cost if that patient went to a private
doctor. And because it's free to patients, hundreds of people have come
in who had not seen a doctor for at least two years.

Montana recently opened a second state employee health clinic in
Billings, the state's largest city. Others are in the works.

Comment: Let's see. This Montana state-run free clinic is government
owned, the physicians are salaried, there are no deductibles or co-pays,
employees and retirees including Republicans like it, and it costs the
state "about half what it would cost if that patient went to a private
doctor." Wow!

The single payer model of social insurance usually calls for a
government-run insurance program that pays for our largely private
health care delivery system, with all of its inefficiencies and
inequities. But what if it paid for a government owned and financed
health care delivery system similar to this Montana clinic, but with
government ownership expanded throughout the entire delivery system.

Instead of just aiming for the goal of a single payer social insurance
program, we could have a program of socialized medicine - government
ownership of the delivery system. Considering that it is a much lower
cost system with which everyone is happy, is that such a bad idea?

Monday, July 29, 2013

Fwd: qotd: WellPoint/employer conspiracy on reference pricing

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: WellPoint/employer conspiracy on reference pricing
Date: Mon, 29 Jul 2013 11:18:08 -0700
From: Don McCanne <>
To: Quote-of-the-Day <>

American Medical News
July 29, 2013
WellPoint program lets employers name their price for doctors
By Sue Ter Maat

Physicians collecting from WellPoint-insured patients who haven't met
their deductible or have a co-pay might have one more reason to send
them a bill — to collect the difference between the price the insurer
has negotiated with the doctor, and what the employer is willing to pay.

WellPoint plans to launch a program in 2014 in which self-insured
companies can determine what they will pay for certain procedures.
WellPoint would present a price range to the employer based on what has
been negotiated with doctors. Then the company would determine the
maximum price it's willing to pay.

Patients insured through a participating employer would have access to a
website that shows, in as much detail as possible, physician price and
quality information, including what they would expect to pay out of
pocket. Physicians would still be able to charge based on the rate
WellPoint negotiated, but any difference between that rate and what a
company is willing to pay would have to be collected from the patient,
not the insurer.

Companies examine cost distributions for procedure midpoints to
determine reference prices, said George Lenko, program director of
national networks for WellPoint. So, for instance, hip surgery can range
between $20,000 and $100,000. In that case, an employer may set what's
called a reference price at any point in between, Lenko said. If a
physician's contract with WellPoint calls for less than that amount, the
doctor would be paid at that previously negotiated rate. But if a
doctor's negotiated charge was higher than the desired price, he or she
would have to bill the remainder to the patient.

Reference-based benefits are becoming popular as it becomes easier to
compare costs for the same service, Lenko said.

He said when employees know how much services cost, and they are sharing
in that cost, they become more engaged with their health care. "The
patient becomes a better consumer," Lenko said. "The more they shop for
their own health care, the more efficient they will be."

Comment: WellPoint has been a leader in private insurance innovations.
These innovations have worked very well for WellPoint, but for the
patients, providers, and purchasers? Well, let's see how this new
innovation in reference pricing for self-insured employers seems to be

For employers who want to insure their own losses in their health
benefit programs but who need help in the administration of these
programs, private insurers offer health plan administrative services
without assuming any of the risks of medical losses (health care bills).
As part of their services, they provide employers with lists of network
providers - physicians and hospitals who have agreed to contracted rates
for their services.

However, those contracted rates may be higher than the employer would be
willing to spend, that is, the employer's reference price. So what
happens when the providers bill for their services? If the charges are
higher than rates contracted with WellPoint, then WellPoint, using the
self-insured employer's funds after the deductibles are paid by the
patient, pays the contracted rate and the rest is adjusted off - just as
is done today with in-network services in the typical PPO plan. If the
charges are higher than the reference price that the employer is willing
to pay, even though at or lower than the WellPoint contracted rate, then
WellPoint pays only that reference price on behalf of the employer. Yet
the provider's contract allows the full negotiated fee. So who pays the
difference? The patient!

What is going on here? Well, a few things. First, insurers have not been
as effective as public programs such as Medicare in obtaining optimal
lower pricing for their contracted networks. Also, some economists have
suggested that employers should be playing a more active role in slowing
the escalation of health care costs. Introducing reference pricing
allows them to do just that. They find the lowest prices for which the
services can be realistically provided, and then they set their allowed
rates at that level. In addition, those who believe that patients should
be financially involved in their utilization of health care services
(consumer-driven health care) support reference pricing because it
requires patients to either shop prices more effectively, or to be
personally responsible for prices that are higher than the reference prices.

Who wins? Employers with self-insured plans experience a reduction in
their health benefit payments. Insurers who are providing only
administrative services are able to market these less expensive models
to employers, while selling them yet more administrative services,
increasing insurer revenues without any exposure to risk. Providers who
reduce their rates to the level of reference pricing will receive fewer
revenues per unit of their services, but they will increase their market
share if the patients actually do end up choosing providers who will
cost them less out-of-pocket. Providers who are unable to match
reference prices will lose market share.

Who loses the most? The patients. They cannot always shop prices, and
even when they can, they may find that the providers offering reference
prices may be their least preferred choices, or they may find that they
are simply not accessible due to distances or scheduling difficulties.
Not only do patients lose their choices of their preferred providers,
they are once more the victims of the current trend in shifting the
costs of health care from insurers and employers to the patients
themselves. This insurer/employer conspiracy is yet one more
manifestation of The Great Risk Shift (Hacker) - moving funds from the
workers to the uber-wealthy.

Single payer would jettison this nefarious conspiracy.

Tuesday, July 23, 2013

Fwd: qotd: The Motley Fool on Medicare for All

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: The Motley Fool on Medicare for All
Date: Tue, 23 Jul 2013 09:40:39 -0700
From: Don McCanne <>
To: Quote-of-the-Day <>

The Motley Fool
July 21, 2013
How Much Could Medicare for All Save You?
By Rich Smith

But could it be that the ACA isn't really needed at all? Could an
alternative idea -- "Medicare for all" -- actually do a better job of
controlling medical costs, and making health care affordable for Americans?

Harvard Medical School visiting professors David Himmelstein and Steffie
Woolhandler recently noted on the pages of The New York Times that a
Medicare-for-all health care system -- known commonly as "single-payer"
-- is an incredibly efficient operation, in terms of costs.

On average, only 2% of the revenues that flow through Medicare are
needed to cover overhead costs. In contrast, patients who subscribe to
private health insurance spend 14% of their money -- seven times as much
-- just paying for the overhead costs doctors incur from juggling the
multitude of insurance procedures required for different patients
subscribing to insurance plans.

In contrast, the U.S. government itself agrees that the ACA -- the
system we've settled upon instead of offering Medicare for all -- costs
more than a move to a cheaper, more efficient, and better single-payer
system. The U.S. Government Accountability Office calculates that a
switch to single-payer would shave $400 billion a year off the national
health-care bill.

Little wonder, then, that a 2008 survey published in the Annals of
Internal Medicine found that 59% of physicians polled support Medicare
for all.

If an individual consumers think they're better off with a private
health insurance plan from WellPoint -- or from UnitedHealth Group,
Aetna, or Cigna -- then fine. They could still sign up for one of those,
either as a supplement to Medicare-for-all or, if they prefer, as an
exclusive plan, and choose not to participate in Medicare at all. For
that matter, there should be no need to require anyone to buy any
insurance whatsoever.

Excerpts from representative Comments:

"Well, of course! But isn't the ACA a step in the right direction?"

"Medicare for all would be far superior to any other plan, which was why
it was killed before it could get out of committee."

"ahh, if only the Republicans had not fought the entire idea so hard,
that would have been the ideal solution."

"A big concern, that not a lot of people know about-more and more
doctors are refusing to take on new Medicare patients."

"Medicare is an existing program that could simply be expanded and fixed
a bit where necessary. This seem like a much much more common sense
approach than a whole new bureaucracy."

"Authors often site Medicare's discount rate and admin cost. Both are a
mirage. The Medicare discount rate is so low that it does not pay lights
on costs."

"It's true that Medicare is already set up very well and that a minor
legislative action could make it available to all...ObamaCare puts more
power into the hands of private insurance companies and BigPharma, and
how do you think those will use it?"

"Of course "single payer" would be better, but was not proposed in
anticipation of Republican opposition to "socialized medicine" and their
insistence on the primacy of a role for the private health insurance
companies. As to Medicare for all on a voluntary basis, it still does
not answer what to do about the uninsured who get sick. Who pays for them?"

"DUH! How soon could America deal Rich Smith and "Medicare for All" for
Ovomit and OvomitCare?"

"Of course Medicare for all makes sense."

"Regarding hospital charges vs. what insurers pay ($24,000 vs. $4000). .
.that is a HUGE problem in healthcare that in a way, single payer WOULD

"You are dreaming in theory. The Complete Lives System that withholds
medical care from infants, special needs children and reduces the amount
of medical care available each year by a dollar amount to anyone over 50."

"the money saving answer is to repeal the ACA and start over with
insurance pools and letting those who could afford insurance and don't
have it suffer for their sin"

"PS: don't forget that Obamacare expands IRS and gives IRS much control
over your healthcare"

"Physicians often limit total Medicare patients, and broadening the
program will just further stratify medical care from those who have the
money to pay and those who do not."

"Medicare for all would work but only if the discounts were renegotiated."

"Obamacare will be the destruction of America !! Obama wouldn't have it
any other way !!! Hail to ol RACE BAITER IN CHIEF !!!"

"More and more doctors are refusing new Medicare patients since the pay
is too low and it takes too long to get reimbursed. If we moved to a
Medicare-based system, what would happen? We would all have insurance,
but it would be next to impossible to find a doctor that accepts the
insurance. Yeah, that's smart. Real smart."

"You don't have the right to infringe on someone else's liberties and
that is exactly what happens when the government taxes one person to
give it to another. Freedom is the answer. God Bless America."

"This is exactly what Dr. Ben Carson has been proposing the past two
years. EACH and every American citizen would have a medicare spending
plan and credits to that fund would start immediately upon birth."

"i think eveyone knows that single-payer is the only efficient answer,
but the scum in washington d.c. won't allow it - they their souls to big

"Great article. This is so straightforward anyone could understand it.
Maybe even congresspeople?"

"Of course this is a step in the right direction, and someday a single
payer system will prevail."

About The Motley Fool

The Motley Fool is a multimedia financial-services company dedicated to
building the world's greatest investment community. Reaching millions of
people each month through its website, books, newspaper column,
television appearances, and subscription newsletter services, The Motley
Fool champions shareholder values and advocates tirelessly for the
individual investor. The company's name was taken from Shakespeare,
whose wise fools both instructed and amused, and could speak the truth
to the king -- without getting their heads lopped off.

Comment: This article is truly remarkable because of its source. The
Motley Fool "champions shareholder values and advocates tirelessly for
the individual investor." Although they didn't get everything right
(they would include private insurance options and would have no
requirement to even be insured), nevertheless this is a particularly
strong statement for Medicare for All from a Wall Street source that is
just now joining the parade.

Perhaps even more remarkable are the comments posted in response to this
article. Considering that these comments are from the investment
community, there is strong support for Medicare for All. Inevitably, as
with most comment sections, there is a representation of ill-informed,
ideologically-driven and sometimes belligerent comments, but those can
be ignored.

We should take home from this the lesson that many in the investment
community understand that Medicare for All really does make sense from
the business perspective. We should tailor our message accordingly.

Monday, July 22, 2013

Fwd: qotd: Kuttner on Medicare shifting costs to patients

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: Kuttner on Medicare shifting costs to patients
Date: Mon, 22 Jul 2013 08:13:37 -0700
From: Don McCanne <>
To: Quote-of-the-Day <>

The Boston Globe
July 18, 2013
Medicare 'cost-savings' rules pushing costs onto patients
By Robert Kuttner

The cost of Medicare, the top driver of runaway entitlement outlays,
seems to be stabilizing at last. For the past three years, Medicare
inflation has moderated to an annual average of 3.9 percent. But if you
look more deeply, a lot of these supposed savings are actually a shift
in costs to patients. As Congress and the administration devise new ways
to restrain Medicare, this disguised form of rationing is likely to worsen.

In order to cut costs — actually shift them, partly to hospitals and
partly to patients — Medicare applies extreme financial pressure on
hospitals to book admissions as outpatients whenever possible. This
shifts them from Medicare Part A (the hospital program) to Medicare Part
B, which is designed to cover only doctor bills. The hospital gets paid
a lot less and the patient gets stuck for a lot more.

Medicare does this through outside, for-profit vendors known as
"recovery audit contractors," who are paid based on how much they save
Medicare. They achieve savings by punishing hospitals after the fact if
a patient who might have been booked as an outpatient is classified by
the admitting doctor as an inpatient. The contractor only gets paid when
it overturns a medical decision — which sure seems like a gross conflict
of interest. The hospital not only doesn't paid at the inpatient rate,
it doesn't get reimbursed at all.

The big players in the system — hospitals, doctors, insurers — spend a
small fortune working to game it, while patients remain in the dark.
Thirty years of cost containment efforts using market incentives,
beginning with the creation of health maintenance organizations in the
Nixon era, have not altered the fundamental inefficiencies in the
system. The more complications the forces of cost containment add, the
more money the big players spend working the rules.

The latest fad in the ideology of using commercial incentives and
intermediaries to contain costs goes under the name of consumer-directed
care. The idea is to combine tax-favored "health savings accounts" with
high-deductible health insurance plans and to rely on the consumer's
capacity to shop around for the most suitable plan. But as the system
becomes ever-more convoluted, the idea of consumers having the knowledge
or market power to intelligently navigate it is laughable.

Medicare has been one of the crown jewels of American social policy.
Historically, it has been far more cost effective than the commercial
parts of the system because it has far fewer middlemen. Today, however,
instead of being a model of a comprehensive national system that
provides Medicare for all, Medicare is at risk of being pushed into the
commercialized model that has made the rest of America's health system
such a costly and inefficient mess.

The risk is that as Congress seeks Medicare savings, it will require the
Centers for Medicare and Medicaid Services to come up with more such
self-defeating cost-containment tricks. Gimmicks that take money out of
Medicare are the wrong means to address the federal deficit. The reform
of Medicare is properly part of the larger project of getting a
comprehensive and universal health coverage system.

If you have time, you should read the full article:

Comment: A prevailing meme is that patients are going to have to bear
more of the costs of health care if we ever expect to bring costs under
control. Although there are far more equitable and effective methods of
controlling costs, this dangerous concept of the need of the patient to
become financially engaged is now pervasive.

The private insurance industry has been quite innovative in developing
both direct and indirect methods of shifting more health care costs to
patients, thereby slowing the increases in premiums, which in turn keeps
their insurance products more competitive. This places the health and
the finances of patients at risk.

Employers are now adopting changes to their benefit programs with the
same goal of shifting more costs to patients. Employers, of course, are
interested in controlling the costs of their health benefit programs.
This also places the health and the finances of patients at risk.

What is revolting is that this alarming trend has now extended to
Medicare, presumably with the intent of shifting costs from the
government to the patients. This too places the health and finances of
patients at risk. This is totally unnecessary since the government has
the power to pay the right amount for the right care - a power that
insurers, employers and individual patients do not have.

Is health policy in the United States to be driven by a highly flawed
meme?A meme that harms patients' health and finances? As Robert Kuttner
says, "the reform of Medicare is properly part of the larger project of
getting a comprehensive and universal health coverage system." Patients
should really care about this. Your health should not depend on how much
green stuff you have in your pockets.

Friday, July 19, 2013

Fwd: qotd: Forty Hours Is Full Time Act of 2013

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: Forty Hours Is Full Time Act of 2013
Date: Fri, 19 Jul 2013 12:19:17 -0700
From: Don McCanne <>
To: Quote-of-the-Day <>

The Library of Congress
113th Congress, First Session

S.1188 -- Forty Hours Is Full Time Act of 2013

To amend the Internal Revenue Code of 1986 to modify the definition of
full-time employee for purposes of the individual mandate in the Patient
Protection and Affordable Care Act.

June 19, 2013

Ms. COLLINS (for herself and Mr. DONNELLY) introduced the following
bill; which was read twice and referred to the Committee on Finance

To amend the Internal Revenue Code of 1986 to modify the definition of
full-time employee for purposes of the individual mandate in the Patient
Protection and Affordable Care Act.

Be it enacted by the Senate and House of Representatives of the United
States of America in Congress assembled,

This Act may be cited as the `Forty Hours Is Full Time Act of 2013'.

Section 4980H(c) of the Internal Revenue Code of 1986 is amended--
(1) in paragraph (2)(E), by striking `by 120' and inserting `by 174'; and
(2) in paragraph (4)(A) by striking `30 hours' and inserting `40 hours'.


The Wall Street Journal
July 18, 2013
ObamaCare's Definition of a Full-Time Job Needs Revising
By Sen. Joe Donnelly (D-Indiana) and Sen. Susan Collins (R-Maine)

In Lafayette, Ind., a school district cut the hours of 200 support staff
to no more than 29 per week. In Bangor, Maine, the school system is
preparing to track and cap the number of hours worked by substitute
teachers to ensure that they don't work more than 29 hours a week.
Elsewhere, in Portland, Maine, a small business reduced a part-time
employee's hours from 35 to 29.

We are hearing reports like this from across the country. Why is this

It's happening because under the Affordable Care Act a "full-time
employee" is defined as anyone working an average of 30 hours a week,
rather than the traditionally accepted 40-hour work week. Employers with
more than 50 full-time employees or full-time equivalents will be
required to provide their employees with health insurance or potentially
face a financial penalty, essentially a fine.

This rule is causing a growing number of employers to cut the hours of
their workers, and according to one study by the UC Berkeley Labor
Center, at least 2.3 million workers are at risk. This provision of the
health law is not in the best interests of the country, and it needs to

As the economy shows modest signs of recovery, we should be working with
employers to encourage additional job growth. Yet we are hearing from
small businesses, public school systems and nonprofit organizations,
that they are cutting employee hours and forgoing additional hiring in
an effort to ensure that they are in compliance with the law.

To address this problem, we have introduced the "Forty Hours is Full
Time Act of 2013." It defines a full-time employee for the purposes of
complying with the Affordable Care Act as someone who works an average
of 40 hours per week, or 174 hours per month for full-time equivalents.

Comment: Many employers are in the process of reducing employees' hours
to under 30 per week in order to avoid the requirement to either provide
health insurance for their workers or pay a penalty. Not only do these
employees end up with no health insurance, they also have their
paychecks reduced by about 25 percent. Since most already have modest
incomes, this reduction in pay can create severe financial hardship.
What can be done?

Senators Collins and Donnelly seem to define the primary problem as the
reduction in income that these employees face. By changing the
definition of full time work to 40 hours per week for purposes of the
Affordable Care Act (ACA), employers will be able to preserve most of
their workers' incomes by employing them for 39 hours, while being
relieved of the responsibility of providing health insurance. The
employees will still be able to have health insurance since they can
then purchase individual plans in the state insurance exchanges. Little
does it matter that these are low-actuarial value plans with
high-deductibles, and inadequate subsidies to protect family budgets.
Oh. Maybe that won't work so well.

It is not simply the definition of a work week that is wrong. It is the
fundamental ACA financing model that is terribly flawed. Trying to fix
it with patches such as redefining the work week will never get us where
we need to be. We have to change the financing model. (Yes, we need
single payer.)

Thursday, July 18, 2013

Fwd: qotd: Union leaders: Taft-Hartley plans at risk under ACA

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: Union leaders: Taft-Hartley plans at risk under ACA
Date: Thu, 18 Jul 2013 09:19:16 -0700
From: Don McCanne <>
To: Quote-of-the-Day <>

The Wall Street Journal
July 12, 2013
Union Letter: Obamacare Will 'Destroy The Very Health and Wellbeing' of
By Tom Gara

The leaders of three major U.S. unions, including the highly influential
Teamsters, have sent a scathing letter to Democratic leaders in
Congress, warning that unless changes are made, President Obama's health
care reform plan will "destroy the foundation of the 40 hour work week
that is the backbone of the American middle class."

The full letter, below:


Dear Leader Reid and Leader Pelosi:

When you and the President sought our support for the Affordable Care
Act (ACA), you pledged that if we liked the health plans we have now, we
could keep them. Sadly, that promise is under threat. Right now, unless
you and the Obama Administration enact an equitable fix, the ACA will
shatter not only our hard-earned health benefits, but destroy the
foundation of the 40 hour work week that is the backbone of the American
middle class.

Like millions of other Americans, our members are front-line workers in
the American economy. We have been strong supporters of the notion that
all Americans should have access to quality, affordable health care. We
have also been strong supporters of you. In campaign after campaign we
have put boots on the ground, gone door-to-door to get out the vote, run
phone banks and raised money to secure this vision.

Now this vision has come back to haunt us.

Since the ACA was enacted, we have been bringing our deep concerns to
the Administration, seeking reasonable regulatory interpretations to the
statute that would help prevent the destruction of non-profit health
plans. As you both know first-hand, our persuasive arguments have been
disregarded and met with a stone wall by the White House and the
pertinent agencies. This is especially stinging because other
stakeholders have repeatedly received successful interpretations for
their respective grievances. Most disconcerting of course is last week's
huge accommodation for the employer community—extending the statutorily
mandated "December 31, 2013" deadline for the employer mandate and

Time is running out: Congress wrote this law; we voted for you. We have
a problem; you need to fix it. The unintended consequences of the ACA
are severe. Perverse incentives are already creating nightmare scenarios:

First, the law creates an incentive for employers to keep employees'
work hours below 30 hours a week. Numerous employers have begun to cut
workers' hours to avoid this obligation, and many of them are doing so
openly. The impact is two-fold: fewer hours means less pay while also
losing our current health benefits.

Second, millions of Americans are covered by non-profit health insurance
plans like the ones in which most of our members participate. These
non-profit plans are governed jointly by unions and companies under the
Taft-Hartley Act. Our health plans have been built over decades by
working men and women. Under the ACA as interpreted by the
Administration, our employees will treated differently and not be
eligible for subsidies afforded other citizens. As such, many employees
will be relegated to second-class status and shut out of the help the
law offers to for-profit insurance plans.

And finally, even though non-profit plans like ours won't receive the
same subsidies as for-profit plans, they'll be taxed to pay for those
subsidies. Taken together, these restrictions will make non-profit plans
like ours unsustainable, and will undermine the health-care market of
viable alternatives to the big health insurance companies.

On behalf of the millions of working men and women we represent and the
families they support, we can no longer stand silent in the face of
elements of the Affordable Care Act that will destroy the very health
and wellbeing of our members along with millions of other hardworking

We believe that there are common-sense corrections that can be made
within the existing statute that will allow our members to continue to
keep their current health plans and benefits just as you and the
President pledged. Unless changes are made, however, that promise is hollow.

We continue to stand behind real health care reform, but the law as it
stands will hurt millions of Americans including the members of our
respective unions.

We are looking to you to make sure these changes are made.

James P. Hoffa
General President
International Brotherhood of Teamsters

Joseph Hansen
International President

D. Taylor

Comment: The Affordable Care Act (ACA) was intended to keep insurance
obtained through employment intact, while adding coverage for the
uninsured through new state insurance exchanges and through an expansion
of Medicaid. Among the programs to be protected were the multi-employer
Taft-Hartley plans that were collectively bargained between unions and
employers. Yet an unintended consequence of ACA seems to have put these
plans at risk.

Why? The provision of ACA that exempts employers from a requirement of
providing coverage for part-time workers - those working less than 30
hours per week - has provided an opportunity for employers to escape the
burden of their health benefit programs by merely rearranging the work
schedules of their employees. It is already happening even though the
employer requirement does not go into effect for another one and a half

Employers can assuage their guilt to some extent since they know that
the government will subsidize the plans when their newly part-time
employees switch to the insurance exchanges. These subsidies are not
available for the Taft-Hartley plans (though employers are able to
deduct from taxable revenues the cost of these plans - a tax expenditure).

Another motivation for employers to attempt to reduce the Taft-Hartley
plans is that ACA includes a tax to be assessed against so-called
Cadillac plans. Little does it matter that these are not plans with some
kind of gilded benefits. These are merely standard health plans that
have not had benefits stripped out nor have they shifted excessive costs
to patients through higher deductibles and other forms of cost sharing.
Yet health care costs are now so high that the cost of the standard
benefits offered exceed the Cadillac threshold.

Union members gave up major wage increases in order to have secure
health care coverage. If they lose their Taft-Hartley plans, it is
unlikely that employers would grant the wage increases that they would
have received had they not had to spend so much on the health plans,
even though economists consider these plans to be paid for by forgone
wage increases. The reality is that the economic model we have today
transfers much of the productivity of the workers to the wealthiest one
percent of our society.

Taft-Hartley was designed as anti-union legislation, though allowing
collectively-bargained health benefit programs. Now even those programs
are at risk. The anti-union one-percenters are winning the war.

We should remove responsibility of providing health benefits from the
employers, but not in a way that shafts their employees. We need to
replace our current dysfunctional health care financing system with one
that works for everyone, while sharing the costs equitably - a single
payer national health program. The solution is so obvious. Why isn't it
catching on?

Wednesday, July 17, 2013

Fwd: qotd: Pioneer Accountable Care Organizations disappoint

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-------- Original Message --------
Subject: qotd: Pioneer Accountable Care Organizations disappoint
Date: Wed, 17 Jul 2013 08:41:14 -0700
From: Don McCanne <>
To: Quote-of-the-Day <>

Centers for Medicare and Medicaid Services
July 16, 2013
Pioneer Accountable Care Organizations succeed in improving care,
lowering costs

Today, the Centers for Medicare & Medicaid Services (CMS) announced
positive and promising results from the first performance year of the
Pioneer Accountable Care Organization (ACO) Model, including both higher
quality care and lower Medicare expenditures. Made possible by the
Affordable Care Act, the Pioneer ACO Model encourages providers and
caregivers to deliver more coordinated care for Medicare beneficiaries.
This model, launched by the CMS Innovation Center, is part of the
Affordable Care Act's efforts to realign payment incentives, promoting
high quality, efficient care for Medicare beneficiaries. ACOs,
including the Pioneer ACO Model and the Medicare Shared Savings Program,
are one way CMS is providing options to providers looking to better
coordinate care for patients and use health care dollars more wisely.

"These results show that successful Pioneer ACOs have reduced costs for
Medicare and improved the quality of care for their patients," said CMS
Administrator Marilyn Tavenner. "The Affordable Care Act has given us a
wide range of tools to realign payment incentives in Medicare and
Medicaid, and these efforts are already paying off."


Bloomberg Businessweek
July 16, 2013
A Pillar of Obamacare's Cost-Saving Effort Falls Short
By Devin Leonard

It's no secret that the Obama administration's effort to roll out
health-insurance exchanges in every state is turning out to be more
challenging than expected. Its campaign to lower health costs isn't
faring any better. On Tuesday, the Centers for Medicare and Medicare
Services announced middling first-year results for the administration's
highest profile cost-control effort: the Pioneer Accountable Care
Organization Model.

Obamacare supporters have long promised that Accountable Care
Organizations — groups of hospitals and doctors that tend to large
flocks of Medicare patients, with an eye toward keeping them out of the
hospital — would be integral to bringing down the nation's health-care
costs. ACOs are supposed to come up with innovative ways of keeping
patients in better shape by focusing on preventive measures while saving
money in the process. Under the plan, the ACOs themselves are to be
rewarded with the share of the savings they generate.

Thirty-two health care provider groups signed up for the pioneer program
intended to promote the new model, but the Centers for Medicare and
Medicare Services said Tuesday that only 13 of them generated enough
savings to qualify for a cut. Two participants actually lost money instead.

The news wasn't all bad. The pioneers produced better-than-average
results on cholesterol control for diabetes patients. "Overall, we are
very excited about the results," Patrick Conway, chief medical officer
for the Centers for Medicare and Medicare Services, told the Wall Street
Journal. But a significant percentage of the pioneers weren't so
thrilled, and nine are slated to exit the program.

It's much too soon to call the pioneer program a failure. It's also
premature to say the ACO model is one that will save vast amounts sums
of money. That hasn't stopped some of the law's staunchest supporters,
who might want to temper their rhetoric after Tuesday's report.


Health Affairs Blog
July 17, 2013
Pioneer ACOs Year One: On The Path To A Learning Health Care System
By Douglas Hastings

The Pioneer Model should be seen as part of a crucial phase of testing
alternative payment and delivery models in an effort to achieve greater
value in health care. One year's results should not be seen as a
definitive outcome or leading to a dispositive conclusion, but rather as
a valuable source for learning.

The participating providers are required to be both financially and
clinically integrated. The ACOs must, among other core attributes, have
an effective governance and leadership structure, have the ability to
apply evidence-based medicine and care coordination processes, meet
quality measures, have a savings distribution formula, develop a robust
electronic health record infrastructure, and, importantly, be able to
effectively engage patients in their care and their health.

ACO skeptics clearly remain. Among the doubts and cautions that have
been raised are that ACOs will drive insufficient change in physician
behavior and patient engagement, result in insufficient savings, create
a specialist (and thus patient) backlash, suffer from lack of agreement
over measures and metrics, and drive up prices due to consolidation.
These are legitimate concerns. But such concerns should not mean that
the testing should slow down. Rather, in my view, it should accelerate,
given some early positive results and the ongoing cost and quality
challenges faced by our health care system.

Comment: The Pioneer Accountable Care Organizations (ACOs) were already
existing health care organizations that were selected as potentially
exemplary models that could show the rest of the nation how well ACOs
can work to achieve higher quality at lower costs. We now have a report
from CMS of the initial "successes" of this model. Although the rhetoric
from CMS is quite rosy, most reporters were not impressed, as the
Bloomberg Businessweek response demonstrates.

Considering the added administrative hassle, the savings were
negligible, with only 13 of the 32 organizations saving enough to
receive "shared savings" from CMS, and 2 actually lost money.

Even the supposed quality gains were unimpressive since they represented
only 15 measurements which the organizations were told in advance would
be used to determine whether or not they met quality standards. These
teach-to-the-test gains can hardly represent the overall quality status
of each organization.

It is time for our policy makers to stop wishing that the ACO model is
the nirvana of health policy and get on with endorsing a proven model of
enhancing quality while controlling costs - a single payer national
health program - a model that would have the additional benefit of
actually covering everyone.

Tuesday, July 16, 2013

Fwd: qotd: Tempering P4P expectations

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: Tempering P4P expectations
Date: Tue, 16 Jul 2013 08:35:35 -0700
From: Don McCanne <>
To: Quote-of-the-Day <>

Health Services Research (HSR)
August 2013

An Examination of Pay-for-Performance in General Practice in Australia
By Jessica Greene Ph.D.

This study examines the impact of Australia's pay-for-performance (P4P)
program for general practitioners (GPs).

There was a short-term increase in diabetes testing and cervical cancer
screens after program implementation. The increase, however, was for all
GPs. Neither signing onto the program nor claiming incentive payments
was associated with increased diabetes testing or cervical cancer screening.


The Effect of Pay-for-Performance in Nursing Homes: Evidence from State
Medicaid Programs
By Rachel M. Werner M.D., Ph.D., R. Tamara Konetzka Ph.D., Daniel Polsky

Medicaid-based P4P in nursing homes did not result in consistent
improvements in nursing home quality. Expectations for improvement in
nursing home care under P4P should be tempered.

Comment: More evidence that pay-for-performance (P4P) does not improve
quality nor reduce costs.

Single payer does.

Monday, July 15, 2013

Fwd: qotd: Insurers will continue to skirt regulations

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: Insurers will continue to skirt regulations
Date: Mon, 15 Jul 2013 10:58:50 -0700
From: Don McCanne <>
To: Quote-of-the-Day <>

The Wall Street Journal
July 14, 2013
Insurers Seek Right Balance of Risk, Reward
By Anna Wilde Mathews

In the insurance business, some customers are more desirable than
others—and insurers will be seeking to woo them in preparation for the
health law's new marketplaces.

Customers not only bring revenue in the form of the premiums they pay.
They also come with costs, since the insurer will be on the hook for
medical expenses. Traditionally, that has made healthier people the best
insurance risk. Insurers often could decline to sell plans to people
with health problems, or charge them more.

Now, the health law is changing the rules of the game. Under its
requirements, insurers must sell plans to all comers, and the rates
can't be tied to customers' health. Less obviously, the law includes
mechanisms that are designed to ensure that individual companies aren't
punished if they draw a mix of sicker consumers.

Young and healthy people will still be needed to help balance out the
costs of sicker customers. But, in addition, some people who weren't
sought after in the past may become profitable because of the law's
payment structure. Among them: people who have chronic conditions such
as diabetes, but who can keep their diseases managed and avoid big costs
such as hospital visits, said Shubham Singhal, a director at consulting
firm McKinsey & Co. That is because insurers can be paid more to cover
consumers based on their diagnoses.

Since insurers can no longer pick and choose their customers, they will
employ a range of subtler tools, including marketing campaigns and
carefully designed plans aimed at the customers the insurers most want.

"They want to attract the right risk," said Siva Namasivayam, chief
executive of SCIO Health Analytics Inc. His firm helps insurers identify
customer types, such as "entry-level singles" and "healthy baby
boomers," each with projections on likely costs. The firm pinpoints, by
ZIP Code, where the different types tend to live, so the insurer can
target its marketing geographically.

Highmark Inc., a Pittsburgh, insurer, said it has around 100 targeted
campaigns aimed at particular types of consumers, including recent
college graduates and retirees not yet eligible for Medicare. It sends
walk-in tractor-trailers to college campuses and sets up booths at
community events such as charity walks. "We have to be more one-to-one
than we were historically," said Steven Nelson, a senior vice president
at Highmark.

Blue Cross & Blue Shield of Rhode Island also plans to aim at certain
populations, including young men. Last year, the insurer promoted one of
its low-cost plans with a campaign that included posters on the walls of
men's bathrooms in bars. "You don't need beer goggles to fall in love
with this health plan," one slogan said.

Comment: One of the great advantages of the Affordable Care Act was
that it would finally bring an end to insurance company chicanery in
which they were able to selectively insure more profitable healthy
individuals while keeping the more costly sick individuals out of their
plans. At least, that's what the new requirements for guaranteed issue
(they must sell the plans to everyone, not only the healthy) and
community rating (they cannot charge higher rates for the sick) were
supposed to do. But insurers have a much larger bag of tricks.

Although insurers can no longer reject applicants who fail medical
underwriting standards, they have learned to selectively market their
plans to healthier populations, and they will continue to do so. They
intensify their targeting to younger, healthier individuals while
avoiding marketing to higher cost individuals. As this article
indicates, an industry has arisen to help insurers select their targets
for marketing, based on the health of selected groups or on the average
health in geographical regions (ZIP Codes). This adds yet more
administrative costs to our system already tremendously overburdened
with administrative waste.

Not only do insurers market selectively to the healthier, they also are
taking advantage of risk adjustment. Since insurers who take on clients
with greater medical problems are paid more through these adjustments,
it is to their advantage to include individuals with unfavorable
diagnoses but whose health care needs are actually quite minimal. An
individual might technically be diagnosed as a diabetic but require very
little care, and yet the insurer can receive adjustments that are
designed for a more severe diabetic with multiple complications. So it
is to their advantage to enroll patients with just a touch of bad
disease. They are already doing this in the private Medicare Advantage

If an insurer misjudges and ends up with higher cost risk pools, they
can no longer dump only those with greater needs, but they can pull
their plans from the regions where they are experiencing high spending.

Insurers are masters at innovation. No matter how many laws and
regulations they face, they will always find other ways to work the
system. That's just plain old good business. And that is the problem. We
don't want our health care defined by what is good for the industry; we
want it defined by what is good for patients. We won't get that until we
establish our own public system dedicated to the primacy of patients.

And about that Blue Cross & Blue Shield of Rhode Island campaign that
included posters on the walls of men's bathrooms in bars with the
slogan, "You don't need beer goggles to fall in love with this health
plan." Although there are ten categories of essential health benefits,
insurers are allowed flexibility within each category. Those young men
would be well advised to read their plans carefully to see if they
exclude sexually transmitted diseases and injuries while intoxicated.
Insurers know no boundaries.

Friday, July 12, 2013

Fwd: qotd: What is best health care coverage for part-time workers?

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: What is best health care coverage for part-time workers?
Date: Fri, 12 Jul 2013 08:33:07 -0700
From: Don McCanne <>
To: Quote-of-the-Day <>

The Buffalo News
July 10, 2013
Wegmans cuts health benefits for part-time workers
By Samantha Maziarz Christmann

Et tu, Wegmans?

The Rochester-based grocer that has been continually lauded for
providing health insurance to its part-time workers will no longer offer
that benefit.

Until recently, the company voluntarily offered health insurance to
employees who worked 20 hours per week or more. Companies are required
by law to offer health insurance only to full-time employees who work 30
hours or more per week.

Wegmans employs roughly 1,433 full-time employees and 4,304 part-time
employees in the Buffalo Niagara region.

Several Wegmans employees confirmed part-time health benefits had been
cut and said the company said the decision was related to changes
brought about by the Affordable Care Act.

However, part-time employees may actually benefit from Wegmans'
decision, according to Brian Murphy, a partner at Lawley Benefits Group,
an insurance brokerage firm in Buffalo.

"If you have an employee that qualifies for subsidized coverage, they
might be better off going with that than a limited part-time benefit,"
Murphy said.

That's because subsidized coverage can have a lower out-of-pocket cost
for the insured employee while also providing better benefits than an
employer-paid plan.

Under the Affordable Care Act, part-time employees are not eligible for
health insurance subsidies if their employer offers insurance.

"It's a win-win. The employee gets subsidized coverage, and the employer
gets to lower costs," Murphy said.

"As a private company, we don't share specifics of our employee benefits
programs. It's a given that health care reform will result in some
changes to our benefits program, but it will not change our commitment
to meeting the needs of our employees," Wegmans said in a statement.

Comment: The best coverage for part-time workers? Well, for part-time
workers and for everyone else, it would be a single payer national
health program. But we don't have that. So, before we can enact an
improved Medicare for everyone, what would be the best way to cover
part-time workers under the Affordable Care Act?

During the reform process, the plight of the part-time worker remained
an important consideration in trying to design a near-universal system
(which it didn't turn out to be). Part-time workers tend to have very
low wages making it impossible to purchase decent insurance on their
own, and yet their family incomes are often just barely high enough that
they do not qualify for Medicaid.

Congress decided to continue to rely heavily on employer-sponsored
health plans for coverage. The problem with part-time workers is that
most employers either provided them with no coverage at all, or, if they
did, the coverage was often so spartan that it was almost worthless.
Although it was decided to require all but the smallest employers to
provide employee coverage or face financial penalties, legislators
yielded to larger employers who wanted part-time employees to be exempt.
The threshold qualifying as part-time was set at 30 hours.

Think of all of the occupations in which flexible, part-time positions
are ideal. Large retail sellers, supermarket chains, restaurant and fast
food chains, hospitality services, and so forth, serve as examples.
Labor costs are a great concern for these employers, and they have
struggled with the concept of trying to meet the high costs of adequate
health benefit programs.

But look at the opportunity they have with the 30 hour threshold. They
no longer have to feel guilty about providing only worthless plans or no
plans at all. Under the Affordable Care Act, the government is going to
provide part-time employees subsidies inversely related to income,
supposedly allowing these people to buy more comprehensive coverage
through the exchanges. Employers can walk away, and these employees will
get a better deal from the government.

Although it may be a better deal, it's still not such a hot prospect.
Even with subsidies for both premiums and out-of-pocket expenses, these
low income individuals will still not be able to afford their portion of
the costs and will face financial hardship as a result.

So these employers will be relieved of their responsibility of paying
for health care coverage for their part-time employees, and the
taxpayers will pick up the tab. Although there are important reasons for
bringing an end to employer-sponsored coverage, it is unfair to give
these employers special breaks, especially when considering that several
members of the Walton family are near the top of the billionaires list.
We should pay more taxes so that they can collect more billions?

No. This "win-win," wherein "the employee gets subsidized coverage, and
the employer gets to lower costs," is a loser for health care equity and
justice. As said at the start, we need a single payer national health

Thursday, July 11, 2013

Fwd: qotd: The State of US Health: Older but Sicker

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-------- Original Message --------
Subject: qotd: The State of US Health: Older but Sicker
Date: Thu, 11 Jul 2013 11:45:53 -0700
From: Don McCanne <>
To: Quote-of-the-Day <>

July 10, 2013
The State of US Health, 1990-2010
By US Burden of Disease Collaborators


To measure the burden of diseases, injuries, and leading risk factors in
the United States from 1990 to 2010 and to compare these measurements
with those of the 34 countries in the Organisation for Economic
Co-operation and Development (OECD) countries.


We used the systematic analysis of descriptive epidemiology of 291
diseases and injuries, 1160 sequelae of these diseases and injuries, and
67 risk factors or clusters of risk factors from 1990 to 2010 for 187
countries developed for the Global Burden of Disease 2010 Study to
describe the health status of the United States and to compare US health
outcomes with those of 34 OECD countries.


US life expectancy for both sexes combined increased from 75.2 years in
1990 to 78.2 years in 2010; during the same period, HALE (healthy life
expectancy) increased from 65.8 years to 68.1 years. The diseases and
injuries with the largest number of YLLs (years of life lost due to
premature mortality) in 2010 were ischemic heart disease, lung cancer,
stroke, chronic obstructive pulmonary disease, and road injury.
Age-standardized YLL rates increased for Alzheimer disease, drug use
disorders, chronic kidney disease, kidney cancer, and falls. The
diseases with the largest number of YLDs (years lived with disability)
in 2010 were low back pain, major depressive disorder, other
musculoskeletal disorders, neck pain, and anxiety disorders. As the US
population has aged, YLDs have comprised a larger share of DALYs
(disability-adjusted life-years) than have YLLs. The leading risk
factors related to DALYs were dietary risks, tobacco smoking, high body
mass index, high blood pressure, high fasting plasma glucose, physical
inactivity, and alcohol use. Among 34 OECD countries between 1990 and
2010, the US rank for the age-standardized death rate changed from 18th
to 27th, for the age-standardized YLL rate from 23rd to 28th, for the
age-standardized YLD rate from 5th to 6th, for life expectancy at birth
from 20th to 27th, and for HALE from 14th to 26th.

Conclusions and Relevance

From 1990 to 2010, the United States made substantial progress in
improving health. Life expectancy at birth and HALE increased, all-cause
death rates at all ages decreased, and age-specific rates of years lived
with disability remained stable. However, morbidity and chronic
disability now account for nearly half of the US health burden, and
improvements in population health in the United States have not kept
pace with advances in population health in other wealthy nations.

Comment: According to The Washington Post (July 10), Thomas R. Frieden,
director of the Centers for Disease Control and Prevention "noted that
the United States is among the last of its economic peers in offering
universal health care, and it is late in making societal changes to
address the risks that needlessly shorten lives." He said, "The good
news is these are things we can do something about. If you look at the
county-by-county charts, it shows in communities where they took
improvements in health seriously, they were able to see dramatic

With our great wealth, we can do both. We can offer universal health
care, and we can expand public health programs, including fostering
societal changes that address our health risks. But first we need to
elect legislators and administrators who support these goals. It's
really up to us.

Wednesday, July 10, 2013

Fwd: qotd: Public Citizen's roadmap toward state single payer

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: Public Citizen's roadmap toward state single payer
Date: Wed, 10 Jul 2013 07:51:48 -0700
From: Don McCanne <>
To: Quote-of-the-Day <>

Public Citizen
July 10, 2013

How States Can Get Close to a Single-Payer System

Public Citizen Releases Road Map for States to Achieve Unified,
Universal Health Care; Distributes to State Lawmakers Throughout U.S.

WASHINGTON, D.C. – The steps a state would need to take to move toward
creating a single-payer health care system are somewhat complicated but
are doable, according to a new Public Citizen report that provides
states with a road map of how to achieve unified, universal health coverage.

A state could not hope to achieve a pure single-payer system, such as
exists in Canada, because of federal programs, such as Medicare and
Medicaid. But many of the ambitions of a single-payer system can be
realized at the state level, the report explains. A state can accomplish
much that the Affordable Care Act (ACA), or Obamacare, does not: provide
universal care, greatly increase administrative efficiency and control

Public Citizen distributed the report to state lawmakers throughout the
country through the state affiliates of Health Care NOW. The report is
available (at the link below).

"The facts are simple: We pay far more for health care than any
developed country, yet we cover fewer people and get worse results,"
said Dave Sterrett, health care counsel for Public Citizen's Congress
Watch division. "It's time for real change."

Calling for a universal care system in the United States is often
painted as a quixotic pursuit because of incessant fear-mongering by
conservatives about the supposed evils of a "government takeover" of
health care.

But the report, A Road Map to "Single-Payer": How States Can Escape the
Clutches of the Private Health Insurance System, points out that
Americans polled in 2012 were nearly evenly divided when asked if they
favored a single-payer system, and this was amid the relentless drumbeat
of opposition to the ACA. Evidence suggesting support for the
single-payer concept also can be found in Americans' widespread approval
of Medicare, the government-run program that provides nearly universal
care to those over 65 at far less cost than care that is reimbursed by
private insurance companies.

The first step on a state's road to a quasi-single payer system is to
obtain a waiver from the ACA. This is well within reach because the act
includes language that permits a state to receive a waiver from the
ACA's strictures, beginning in 2017. A state can be granted this waiver
if it demonstrates that its alternative would provide coverage at least
as good, for at least as many people, as the ACA would, and not add
costs to the federal budget. For states that receive waivers, the
federal government must provide funds to the state that equal what it
would spend pursuant to the ACA. A state promising to provide
comprehensive, universal care would easily clear this hurdle.

Achieving integration between a state system and Medicare and Medicaid
would be more difficult because the law does not permit a broad waiver
from these programs. But the law does provide ample room for the
administration of these programs within a state to be altered to align
billing systems and prices. This would allow Medicare and Medicaid to
appear to providers and patients to be almost seamlessly integrated with
a state system, although this strategy would require a state to dedicate
resources to reconcile claims with the federal government.

The other major legal hurdle for a state to overcome is posed by the
1974 Employee Retirement Income Security Act (ERISA), which forbids
states from regulating employer benefits plans. But a small body of case
law provides grounds for cautious optimism that the hurdles of ERISA can
be overcome. A state could insulate its system from being struck down on
ERISA grounds by legislating alternative funding options, such as
payroll, income or sales taxes.

The final major hurdle is determining how to pay for a universal care
system. Transitioning from a system largely financed by employer and
employee-paid insurance premiums to one likely financed by some
combination of taxes would be challenging.

But the transition should not hurt employers or residents in the long
run, the report concludes. A proposed system in Vermont, for instance,
would significantly expand both the quality of benefits and the number
of people covered. Yet Vermont's plan would cost slightly less than the
state's current system, according to analysis commissioned by the state.

"Single-payer in the United States has been scorned but never tested,"
said Lisa Gilbert, director of Public Citizen's Congress Watch division.
"We're looking for a few pioneering states with the courage and
fortitude to let common sense prevail over the insanity of our current
patchwork system. Once they succeed, we expect most opposition to
single-payer and our reliance on privately insured health care to become
historical relics."

Report - "A Road Map to 'Single-Payer'" (21 pages):

Comment: This very useful Public Citizen report on steps toward single
payer at the state level serves two important functions:

1) Although the Affordable Care Act is providing a few beneficial
tweaks to the financing of our health care system, by now it is obvious
that, by building on our dysfunctional, fragmented system, intolerable
health care injustices will be perpetuated. Yet Congress itself is
currently so dysfunctional that it is impossible to get them to consider
a vastly superior alternative - a single payer Improved Medicare for All.

For those who cannot wait until we are able to elect a sane
supermajority in Congress, this report provides suggestions on how some
single payer principles could be applied at the state level. Although
that pathway is rugged and cannot lead all the way to single payer, at
least it would provide more improvement than we are seeing with the
Affordable Care Act. There is plenty in this report to keep health
justice activists very busy on the state level.

2) The far more important conclusion to be drawn from this report is
that states acting alone cannot establish a bona fide single payer
system. There are too many major barriers that would prevent states from
totally replacing their fragmented financing infrastructure. Under
current federal laws, limitations imposed on states would not allow them
to capture many of the more effective benefits of the single payer model.

Although states could come much closer to universal coverage, their
systems would still perpetuate many of the inefficiencies and inequities
that exist today. Without the power of a public, single payer monopsony
(a single buyer), improving allocation of our resources would be much
more difficult. Although states could improve billing functions, that
captures only a very small portion of the profound administrative waste
in our system. Any savings on a state level would be very modest and
would not be enough to pay for the elimination of uninsurance and
underinsurance. Total health care costs would increase even more, when
costs are already intolerable.

The lesson? We cannot let up in the least in our efforts to educate the
nation on the imperative of a single payer national health program. To
be unequivocally clear, that's NATIONAL.

We cannot use the example of Saskatchewan and pretend that a state can
set up a single payer system that could serve as an example for the
nation - a model that could be expanded to all states. No. Saskatchewan
began with a tabula rasa. They were able to create a de novo single
payer system. The Public Citizen report shows us that our existing
federal laws create complexities that would prevent states from enacting
a financing model that could be held up to the rest of the nation as an
example of the benefits of single payer, even though that is a noble
intent of the report. In fact, there is a risk that such an effort would
allow opponents to claim, "See, single payer doesn't work."

Vermont is currently implementing legislation that originally was
intended to bring it a single payer financing system. But they found
that a bona fide single payer system is not possible, so they have
abandoned the term, "single payer." That might be wise advice for other
state activists.

We cannot allow enthusiasm for state efforts to diminish in the least
the exhaustive effort that will be required to reach the threshold of
political feasibility that will be a requisite to motivate Congress to
take action.

Tuesday, July 9, 2013

Fwd: qotd: First do no financial harm

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: First do no financial harm
Date: Tue, 9 Jul 2013 11:36:37 -0700
From: Don McCanne <>
To: Quote-of-the-Day <>

July 8, 2013
First, Do No (Financial) Harm
By Christopher Moriates, MD; Neel T. Shah, MD, MPP; Vineet M. Arora, MD,

"First, do no harm" is a well-established mantra of the medical
profession, but it may need to be reconceptualized in an era of
unsustainable health care spending. Medical bills are now a leading
cause of financial harm and physicians decide what goes on the bill. The
possible consequential harm is substantial, often leading to lost homes
and depleted savings. While the Affordable Care Act will ensure expanded
coverage, newly insured Americans will not necessarily be immune from
increased costs of their care. More Americans than ever before are
enrolled in high-deductible insurance plans, meaning that seemingly
simple decisions that physicians make about testing could directly lead
to thousands of dollars in out-of-pocket costs. This strain on household
budgets can cause further erosion of personal health.

Just as physicians play an important role in preventing serious
infections, physicians can also help patients avoid experiencing
financial harm as a result of medical care.


First, physicians can help patients avoid financial harm by screening
each patient to determine financial risk and preferences.


In 2007, the majority of medical debtors had health insurance at the
beginning of their illness, and an estimated 25 million Americans were
underinsured. Hence, it is increasingly difficult to know which patients
will be faced with insurmountable medical bills in the near future.
Since physicians cannot be sure which patients will ultimately have
unaffordable medical bills, they should treat all patients as if they
could be.

This approach applies to both inpatient and outpatient encounters
because patients often face significant financial obligations in both
settings. Although physicians may assume that hospitalizations for
insured patients are automatically covered by health plans, in reality
these patients may still face large co-payments. Thus, in some instances
whether hospitalization can be avoided should be discussed. In addition,
the payer may refute the appropriateness of admission or leave coverage
gaps due to high deductibles, caps, or other cost-sharing mechanisms. In
the ambulatory care setting, patients may pay a percentage of the fees
for services.


Many studies demonstrate that physicians are unaware of the cost of
routinely ordered tests, let alone the potential financial risks for
patients seeking care. To explain potential options and their fiscal
implications to patients, physicians will need to take responsibility
for knowing the financial ramifications of the care they are providing.


Physicians also should learn how to optimize personalized health care
decisions for patients' financial health.


Financial concerns are important to patients and physicians need to be
prepared to address this aspect of their care. Although these financial
discussions may present some challenges, physicians already participate
in difficult discussions with patients about opiate abuse, domestic
violence, and end-of-life decisions. To provide truly patient-centered
care, physicians can live up to the mantra of "First, do no harm" by not
only caring for their patients' health, but also for their financial

For the full JAMA article (free access):

Comment: In these days of outrageous health care costs physicians now
have not only the obligation to provide care as close to optimal as the
circumstances will allow, they also have an obligation to prevent
personal financial harm to the patient that could result from their
medical decisions. But should the latter really be the physicians'

The authors of this JAMA article list steps to be followed during
patient encounters designed to prevent financial harm to patients.
Doesn't the physician already have enough to do without having to become
the keeper of the patients' pocketbooks? Unfortunately, under our
current dysfunctional system of financing health care, too many patients
face significant financial barriers to care. The physician remains the
person in charge of determining the magnitude of those barriers, simply
based on the medical management selected.

The Affordable Care Act will not help much since the new standard for
private insurance is low actuarial value, high-deductible plans. In
fact, the financial barriers will become more commonplace as employers
are now greatly expanding the use of consumer-driven, high-deductible plans.

Patients who previously weren't concerned much about their out-of-pocket
costs are now going to want more information from physicians about what
their own plans will or will not cover, how much they will have to pay
out-of-pocket, whether the specialists or diagnostic facilities are in
or out of their networks, which prescriptions are covered and under what
tier, and many other spending issues for which the physicians frequently
do not have the answers. Yet knowing the answers is now becoming the
responsibility of physicians?

Why do we have a system with so much financial exposure to patients when
other nations have much lower national health expenditures with cost
sharing usually at negligible levels? It is because of the nutty idea
that only patients can control costs when they have to pay out-of-pocket
(consumer-driven health care), when we know that is absolutely untrue.
Other nations have proven that there are far more effective methods of
controlling costs that not only provide financial security for the
patients, but also improve the allocation of health care dollars,
providing higher quality and greater value.

Physicians should be leading the bandwagon in first doing no financial
harm by supporting a system that totally separates financing from the
clinical environment. If they could convince the nation that we need a
single payer national health program then they could proceed with
tending to patients' health care needs while letting our own public
administrators deal with the financing of the system.

Financial barriers harm patients. It is our obligation to first do no
harm by removing those barriers - for everyone. Then we can get on with
simply taking care of the patients.