Tuesday, December 31, 2013

Fwd: qotd: 4,832,000 of the most vulnerable remain in the coverage gap

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: 4,832,000 of the most vulnerable remain in the coverage gap
Date: Tue, 31 Dec 2013 06:55:41 -0800
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>

Kaiser Family Foundation
December 17, 2013
The Impact of the Coverage Gap in States not Expanding Medicaid by Race
and Ethnicity

Medicaid eligibility for adults is very limited. Many states limit
Medicaid eligibility for parents to below poverty, and adults without
dependent children have historically been excluded from the program. The
ACA's Medicaid expansion to adults with incomes at or below 138% FPL
would significantly increase eligibility for parents in many states and
end the exclusion of adults without dependent children from the program.
The expansion was intended to occur nationwide as of January 2014 and
serve as the base of coverage for low-income individuals, with premium
tax credits available to moderate-income individuals above Medicaid
limits to purchase Marketplace coverage. However, as a result of the
Supreme Court decision on the ACA, implementation of the Medicaid
expansion is now effectively a state choice. As of December 11, 2013, 26
states, including DC, are moving forward with the Medicaid expansion in
2014, while 25 states are not moving forward at this time.

In states that do not expand Medicaid, nearly five million poor
uninsured adults will fall into a "coverage gap." These individuals
would have been eligible for Medicaid if their state had chosen to
expand coverage. In the absence of the expansion, they remain ineligible
for Medicaid and do not earn enough to qualify for premium tax credits
to purchase Marketplace coverage, which begin at 100% FPL. Most of these
individuals have very limited coverage options and are likely to remain

These continued coverage gaps will likely lead to widening racial and
ethnic as well as geographic disparities in coverage and access.

Table 1: Nonelderly Poor Uninsured Adults in the Coverage Gap in States
Not Expanding Medicaid by Race/Ethnicity

Total, United States

4,832,000 - All races/Ethnicities
2,248,000 - White
1,327,000 - Black
992,000 - Hispanic
265,000 - Other
2,584,000 - People of Color


Comment: Since it was decided to reject reform that would have been
truly universal, you would think that at least we would be covering the
most vulnerable segments of our population. But no, half of our states
rejected federal funding for Medicaid expansion, leaving almost 5
million otherwise qualified individuals out of the Medicaid program,
even though their incomes ironically are too low to qualify them for
subsidies to purchase plans in the state insurance exchanges.

Over half of these people left out are people of color, resulting in a
widening of the unjust disparities in care already plaguing our nation.

What a terrible way to start the first year of what is essentially the
full implementation of the Affordable Care Act. It seems pretty obvious
what our New Year's resolution should be: Let's bring health care to
everyone through an improved and expanded Medicare for all.

Monday, December 30, 2013

Fwd: qotd: Mayo Clinic’s Eric Matteson endorses tax-supported universal healthcare

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: Mayo Clinic's Eric Matteson endorses tax-supported
universal healthcare
Date: Mon, 30 Dec 2013 07:41:49 -0800
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>

MedPage Today
December 27, 2013
10 Questions: Eric Matteson, MD
By Nancy Walsh

Eric L. Matteson, MD, of the Mayo Clinic, is the chair of rheumatology
and professor of medicine.

1. What's the biggest barrier to your practicing medicine today?

Without a doubt, it is lack of access for many patients, especially the
un- and underinsured.

2. What is your most vivid memory involving a patient who could not
afford to pay for healthcare (or meds, tests, etc.) and how did you respond?

I have a young woman with severe erosive RA who has limited mental
ability who works 20 hours a week in a rural recycling center at a
minimum wage job sorting recyclables. I see her in another state at a
small clinic that's 80 miles away. She has only Medicaid. She is able to
afford methotrexate and hydroxychloroquine. We accept losses with the
cost of monitoring, and also for the orthopedic surgeries she has
required and she cannot afford. I have sought drug and assistance from
every company with biologics on the market, some on more than one
occasion, and to date have been turned down by all of them. She is not
able to even afford gas, or the time off, to come to our center to
participate in drug studies.

4. If you could change or eliminate something about the healthcare
system, what would it be?

I would have a tax-supported universal healthcare for at least minimum


Comment: Mayo Clinic's Eric Matteson is yet another prominent physician
who supports "tax-supported universal healthcare," though he qualifies
that with "for at least minimum services." From his example, it seems
that he would include most of his field of rheumatology as "minimal
services," though others might say "all essential services."
Nevertheless, there continues to be an increase in those who now are
willing to speak out on the need for a publicly-financed health care
system that covers everyone. There is a growing consensus that financial
barriers to care need to be removed.

Thursday, December 26, 2013

Fwd: qotd: Don’t forget New York

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: Don't forget New York
Date: Thu, 26 Dec 2013 10:44:46 -0800
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>

The New York Times
December 23, 2013
Single Payer for New York

To the Editor:

Re "Under Health Law, Independent Practitioners in City Face Canceled
Policies" (news article, Dec. 14):

The Affordable Care Act makes important repairs to our broken health
care system. The problem is that it leaves insurance companies in charge
— with high premiums, high deductibles and co-pays; too much control
over which doctors or hospitals we can go to and what care they can
provide; and high administrative costs.

The exchanges are complicated because the system requires means-testing
to see who is eligible for Medicaid or subsidies, and then requires
people to select from multiple plans.

We could cover everyone, provide better coverage and save billions
through publicly sponsored, single-payer health coverage, like an
improved version of Medicare for everyone — and no insurance companies.

Washington might not be ready to act, but individual states have long
been the "laboratories of democracy." New York can do better.

Richard N. Gottfried
New York, Dec. 14, 2013

(The writer, chairman of the New York State Assembly Health Committee,
is the author of a bill in the New York Legislature to establish a state
single-payer health plan.)


A.5389/S.2078, New York Health - an act to establish a single payer
health program:


Comment: As the Affordable Care Act unfolds it becomes all too obvious
that the repairs in our system of financing health care are falling far
too short of the goals of universality, affordability, administrative
simplicity, and accessibility with free choice of hospitals and health
care professionals. Clearly we need a single payer system that would
easily achieve these goals. New York, with the leadership of Assemblyman
Richard Gottfried, has joined other states in attempting to enact a
state-based single payer system.

What we desperately need is a federal government that partners with
states - all states - in enacting legislation that will bring single
payer to all of us. With the surge in a renewed interest in single
payer, we need grassroots and coalition efforts to be sure that people
understand the single payer approach and then will demand it when they
go to vote. Let's pull out all stops between now and next November.

Tuesday, December 24, 2013

Fwd: qotd: Commodification harms not only our health care

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: Commodification harms not only our health care
Date: Tue, 24 Dec 2013 11:08:32 -0800
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>

The Washington Post
December 23, 2013
Do bigger governments lead to happier people?
An interview by Dylan Matthews

Benjamin Radcliff is a professor of political science at the University
of Notre Dame. His current research focuses on how public policy affects
human happiness.

Dylan Matthews: You argue that social democratic or left-leaning
policies are more conducive to happiness. What sorts of things are you
talking about? Government spending? Regulations? Both?

Benjamin Radcliff: I have organized my research around two dimensions
of policy. The first is the size of government, i.e. of what it is
government does, from the tax burden to the generosity of the welfare
state to the total impact of the government in terms of its overall
consumption on GDP. The second involve institutions that protect people
in labor markets, which means labor unions and economic regulations (the
minimum wage, mandated vacation time, etc.), which provide a degree of
sovereignty and power for workers in their employment relationships. Two
sides of the coin: the general scope of what government does to make
life more secure for people and the stuff that works specifically in
terms of peoples' work conditions.

Both types of policies contribute to what social theorists call
"decommodification," meaning limiting the degree to which in a
capitalist economy people have to act as commodities in order to
survive. You have to sell your labor power on the market.
Decommodification measures how much people can opt out of the labor
market, whatever the reason, and provides a way of judging to what
extent have we made them free of market commodification.

More decommodification makes people happier, and it does so for rich and
poor people, men and women, and controlling for just about any other
thing. Similar empirical results obtain when considering total social
spending on education, health care, total government consumption, the
tax burden, a well-known OECD measure of employee protection
legislation, even indices on the size of government and labor market
regulation from the conservative Fraser Institute. The smaller the
government, the less happy people are.

Another variable I find of interest is labor union membership and
density, i.e. do you belong, and the percentage of all workers who
belong the unions. People who belong to unions are happier, and, more
importantly, union density is strongly related to levels of happiness
for union members and non-members.

Dylan Matthews: How does that compare to the effects on happiness of
non-policy things like, say, the effect of being married or unemployed?

Benjamin Radcliff: The literature would tell you that being married has
a huge positive impact on wellbeing, while unemployment has an equally
powerful negative effect. They thus make nice benchmarks for comparing
the effect of other variables. My results suggest that the effect of the
political variables is much larger by orders of magnitude.

Dylan Matthews: Can you talk a bit more about what you mean by
"decommodification"? Do you mean not being reliant on work to live — not
being a commodity yourself — or the carving out of certain things (human
organs, say) that just aren't commodities you can buy and sell?

Benjamin Radcliff: A society is decommodified to the degree to which
people are not entirely dependent on labor market participation in order
to survive — principally because they are aged, because they are ill, or
simply because jobs are scarce, but also, potentially, so that they can
take time to care for a new child or an ailing family member, etc. My
research suggests people lead better lives in those societies that are
the most decommodified. The reasons are easy enough to understand:
There's a famous quotation observing that a capitalist economy, whatever
its many positive aspects, creates a situation in which people have to
behave as commodities in order to survive. It doesn't take great insight
to realize that people do not enjoy being reduced to commodities, so a
society that limits that necessity is likely to be a better one in which
to live.

Now, to be sure, the market economy absolutely contributes to human
well-being in other ways — no one can deny that — but we have a macro-
vs. micro-problem. At the macro level, capitalism works well. I would
agree that the market society is one of humanity's greatest
achievements. But at the micro level it depends at the very core of its
logic, as even Adam Smith was at pains to point out, on the idea of
using other people (employees) as a means to making profits for oneself.
The people we hire to do work are just mere commodities in the
profit-loss calculations, no more worthy of special concern than barrels
of oil or bushels of grain. The last chapter of my book ("The Political
Economy of Human Happiness") discusses these moral tensions that
capitalism creates. My conclusion is that the social safety net, labor
market regulations and labor unions all limit the degree to which people
become mere commodities, and thus are more likely to lead fulfilling lives.


Comment: On a positive note just in time for the Holiday Season, we can
be assured that we have it within our power to increase happiness
throughout the nation by joining together, as a government, in
decommodifying ourselves within our own society, but that means that we
cannot leave power in the hands of those who would commodify us.


Monday, December 23, 2013

Fwd: qotd: Uwe Reindardt on the U.S. path to three-tiered health care

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: Uwe Reindardt on the U.S. path to three-tiered health care
Date: Mon, 23 Dec 2013 10:09:37 -0800
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>

The New York Times
December 20, 2013
The Economics of Being Kinder and Gentler in Health Care
By Uwe E. Reinhardt

In the late 1980s, about 35 million respondents to large nationwide
surveys declared that they lacked health insurance of any kind. The
comparable number now is close to 50 million.

Then, as now, the endless "national conversation" went on and on,
pondering ways to achieve truly universal health insurance coverage, a
feat most other developed nations accomplished long ago.

Then, as now, news organizations and the health services research
community reported on the financial and physical hardship that many
low-income, uninsured Americans face when they fall ill.

And then, as now, the prices for identical health care goods and
services were more than twice as high in the United States as they were
– and still are – in the member nations of the Organization for Economic
Cooperation and Development.

For all the wonderful things the United States health system has done
for the American people, then, as now, it has also helped price some
degree of kindness out of our souls, a side effect of their treatments
that the leaders of American health care at some point must begin to

My interpretation is that opposition to the Affordable Care Act largely
reflects the age-old reluctance among many of the nation's haves and the
healthy to help purchase for America's lower-income families and the
chronically ill the super-expensive health care that the haves enjoy
themselves. That attitude is all the more striking because of the
generous federal indirect subsidies enjoyed by many of the haves,
especially high-income Americans. (I am thinking specifically of the
generous tax preference accorded employment-based health insurance, the
largest tax expenditure in the federal budget.)

Some people on both the extreme left and right seem to believe that the
current travails of implementing the Affordable Care Act and the
possibility of a so-called "death spiral" in the market for individual
health insurance may usher in single-payer health insurance in the
United States – say, Medicare for all.

I do not find that a likely prospect. Rather than embracing a
single-payer system, the United States is more likely to stumble, in
fits and starts, toward something resembling officially sanctioned
tiering of the American health care experience by income class, as follows:

system of public hospitals and public clinics. It would allow
politicians to ration health care (through tight budgets) without ever
having to acknowledge that they were doing so. In other words, it would
reduce the price of being kind.

FOR THE EMPLOYED MIDDLE CLASS, a mixed system with defined contributions
by employers, private health insurance exchanges and reference pricing
by insurers. Under a restructured Medicare program also based on a
defined contribution model, reference pricing would be likely to apply
to Medicare beneficiaries as well. Depending on how it is operated –
e.g., if it were solely based on cost, in abstraction of quality –
reference pricing also permits tiering of the health care experience by
income class, without anyone having to say so openly.

FOR THE UPPER-INCOME GROUPS, boutique medicine, which is already growing
in the United States. Here the sky will be the limit.

And what do readers think?


Comment: Uwe Reinhardt, an astute observer of the U.S. health care
system, does not see single payer in our future, but rather sees an
"officially sanctioned tiering of the American health care experience by
income class." We already have the three tiers that he describes, but
the middle tier is rapidly evolving in a way that may provoke a renewed
and more intense interest in single payer.

The lowest tier - Medicaid beneficiaries and the uninsured - have never
had much of a political voice. Nevertheless, even the most heartless of
politicians recognize that we must provide care for indigent pregnant
women and children. Thus we have the chronically underfunded Medicaid
program plus safety net hospitals and community health centers. Some
states also have included other low-income adults, though they still
make up the largest percentage of the uninsured. Except for the most
basic of primary care services and care for events that threaten life or
limb, access to health care for this sector is limited, especially for
specialized services. As Professor Reinhardt indicates, politicians are
able to ration health care for Medicaid beneficiaries and the uninsured
without admitting that they are doing it, merely by placing restraints
on the budget. Since it is unAmerican to ration health care, they would
never do that, but rather they merely refuse to budget spending that we
can't afford. (Of course, inadequate funding of health care is
rationing, and we actually can afford to pay for health care for all,
though we do need more efficiency in our financing system.)

The highest tier - the upper-income groups - have never had problems
with gaining access to the best care available. That is true now, and
will be true no matter what health care financing system we will have.
Some have expressed concerns that in a truly egalitarian system, such as
a single payer system, the wealthy would have to give up some of the
finer amenities of health care and stand in line with the rest of us,
but that will never happen. The wealthy are not hampered by noblesse
oblige when it comes to moving to the front of the line for health care.
Besides, a well designed system should not have an excessive queue anyway.

The middle tier - the employed middle class - will see greater changes
in health care access and affordability, changes that have already
begun. Although the plans to be offered in the state exchanges will
include many of these changes, employers are already following by
modifying their plans to reduce their own exposure to costs. Higher
deductibles and other forms of cost sharing are shifting more costs to
the pockets of those who need health care. Although ten categories of
benefits will be required under the plans, the insurers have
considerable flexibility in the composition of benefits within each
category and will leave out selected benefits that some individuals will
need, especially some of the more expensive benefits. Insurers are
reducing their networks of physicians and hospitals, further limiting
patient choice of their health care providers, unlike the traditional
Medicare program, which allows free choice. Patents may still face
catastrophic losses since the maximum out-of-pocket expenditures apply
only to covered benefits provided within the networks. Care unavoidably
obtained out of network and health care services not included as a plan
benefit can result in costs that threaten personal bankruptcy. Even the
allowed maximums would create a hardship for many. Employers are
beginning to switch to defined benefit contributions to health plans
that would be selected from private (not state) health exchanges. This
voucher approach allows employers to shift the future increases in
health care costs disproportionately to the employees. Reference pricing
is the process of setting a low price for given health care services and
requiring the patient to pay the full difference in prices if the
patient selects a more expensive provider. This is another method of
shifting more costs to the patient, not to mention that it further
limits choice of providers since these extra costs may be truly
unaffordable. A shift in control of Congress and the White House to
conservatives may well result in premium support of Medicare (vouchers -
a defined contribution), thereby allowing Medicare to adopt some of
these same policies that shift more costs to patients in need.

The obvious point is that the exchange plans and now even
employer-sponsored plans will cause the employed middle class to become
quite dissatisfied with our health care financing system. Once they or
their families and friends have enough negative experiences with our
health care financing, and once they understand single payer - an
improved Medicare for all - it will be the middle class workers that
will be the loudest in demanding change.

In the meantime, under our present three-tiered system, we will be able
to obtain a basic level of care for Tiny Tim, just not the specialized
services that he really needs. And Ebenezer Scrooge will be able to
access his boutique providers, with the sky as the limit. But what about
the people of the village? Once Scrooge gains control of the insurance
industry, will he further advance the current agenda of making health
care more expensive to increase profits, and less accessible to reduce
costs? Will another visit from the Ghost Of Christmas Yet To Come be
adequate? Or will he be hardened enough to carry on, as Reinhardt
writes, "the age-old reluctance among many of the nation's haves and the
healthy to help purchase for America's lower-income families and the
chronically ill the super-expensive health care that the haves enjoy

Though should we really expect a different outcome? We now have a
society that when Bob Cratchit pulls himself up by his bootstraps and
runs for mayor, we elect Ebenezer Scrooge instead.

Sunday, December 22, 2013

Fwd: qotd: Urgent Request: Take one minute NOW to support single payer

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: Urgent Request: Take one minute NOW to support single payer
Date: Sun, 22 Dec 2013 10:39:20 -0800
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>

Elizabeth Rosenthal of The New York Times has been writing a series on
the outrageous health care costs in the United States. In today's
opinion pages she wrote an article, "Health Care's Road to Ruin."

Her closing comment:

"But after a year spent hearing from hundreds of patients… I know, too,
that reforming the nation's $2.9 trillion health system is urgent, and
will not be accomplished with delicate maneuvers at the margins. There
are many further interventions that we know will help contain costs and
rein in prices. And we'd better start making choices fast."



(His comment begins, "As a 40 year practicing family physician and
member of Physicians for a National Health Program, I believe the best
and only answer is improved "Medicare for all.")

The readers and the editorial staff of The New York Times need to
understand how much support there is for single payer.

Friday, December 20, 2013

Fwd: qotd: Expanding eligibility for catastrophic plans

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: Expanding eligibility for catastrophic plans
Date: Fri, 20 Dec 2013 11:26:20 -0800
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>

Accessed December 20, 2013
What if my individual health insurance plan is changing or being cancelled?

If your insurance company cancels your plan, you have several options:

* Buy one of the plans the company offers in its place.
* Buy a new plan in the Marketplace.
* Buy a plan outside the Marketplace.

Additional option if your plan is cancelled: A catastrophic plan

If your plan has been cancelled and you can't afford a Marketplace plan
to replace it, you can apply for a hardship exemption. This will allow
you to buy a catastrophic plan. A catastrophic plan generally requires
you to pay all of your medical costs up to a certain amount, usually
several thousand dollars. These policies usually have lower premiums
than a comprehensive plan, but cover you only if you need a lot of care.
They basically protect you from worst-case scenarios.


Comment: As the numerous reports in the media indicate, the insurance
industry is not particularly pleased with the prospect of a large influx
of older and sicker individuals enrolling in the catastrophic plans
designed and priced for healthy individuals under age 30. Instability is
an inherent characteristic of such a dysfunctional financing system.

This rule modification is simply one more reason why we need to enact a
simplified, more affordable, and more effective health care financing
system - an improved Medicare for all.

Wednesday, December 18, 2013

Fwd: qotd: Does your estate belong to Medicaid?

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: Does your estate belong to Medicaid?
Date: Wed, 18 Dec 2013 13:32:54 -0800
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>

Mediciad.gov (CMS)
Estate Recovery and Liens

State Medicaid programs must recover certain Medicaid benefits paid on
behalf of a Medicaid enrollee. For individuals age 55 or older, states
are required to seek recovery of payments from the individual's estate
for nursing facility services, home and community-based services, and
related hospital and prescription drug services. States have the option
to recover payments for all other Medicaid services provided to these
individuals, except Medicare cost-sharing paid on behalf of Medicare
Savings Program beneficiaries.


The Seattle Times
December 15, 2013
Expanded Medicaid's fine print holds surprise: 'payback' from estate
after death
By Carol M. Ostrom

With an estimated 223,000 adults seeking health insurance headed toward
Washington's expanded Medicaid program over the next three years, the
state's estate-recovery rules, which allow collection of nearly all
medical expenses, have come under fire.

Medicaid, in keeping with federal policy, has long tapped into estates.
But because most low-income adults without disabilities could not
qualify for typical medical coverage through Medicaid, recovery
primarily involved expenses for nursing homes and other long-term care.

The federal Affordable Care Act (ACA) changed that. Now many more
low-income residents will qualify for Medicaid, called Apple Health in
Washington state.

But if they qualify for Medicaid, they're not eligible for tax credits
to subsidize a private health plan under the ACA, which requires all
adults to have health insurance by March 31.

Some 55- to 64-year-olds, who may have taken early retirement or who
were laid off during the recession, have found themselves plunged into a
low-income bracket. Unlike Medicaid recipients in the past — who were
required to reduce their assets to qualify — they're more likely to have
a home or other assets.

For health coverage through Medicaid, income is now the only financial

Around the country, the issue has sizzled away in blogs and commentaries
from both right and left.


California Advocates for Nursing Home Reform (a nonprofit 501(c)(3)
advocacy organization)
Medi-Cal Recovery Frequently Asked Questions (FAQ)

California's Medi-Cal applicants and beneficiaries are often confused
about their rights regarding Medi-Cal and are particularly concerned
that the state will "take" their homes after they die if they received
Medi-Cal benefits.

I. Can the State Take my Home If I Go on Medi-Cal?

The State of California does not take away anyone's home per se. Your
home can, however, be subject to an estate claim after your death. For
example, your home may be an exempt asset while you are alive and is not
counted for Medi-Cal eligibility purposes. However, if the home is still
in your name when you die, the State can make a claim against your
estate for the amount of the Medi-Cal benefits paid or the value of the
estate, whichever is less. Thus, if your home or any part of it is still
in your name when you die, it is part of your "estate" and can be
subject to an estate claim.

III. What Happens After I Die If I Received Medi-Cal?

After the Medi-Cal beneficiary's death, the State can make a claim
against the estate of an individual who was 55 years of age or older at
the time he or she received Medi-Cal benefits or who (at any age)
received benefits in a nursing home, unless there is a surviving spouse
or a minor, blind or disabled child. Thus, if there are any assets left
in the estate of the deceased beneficiary, Medi-Cal will seek to be
reimbursed for benefits paid. It is important to note that, even if you
received Medi-Cal at home, any benefits paid while you were 55 years of
age or older will be subject to Medi-Cal recovery.

IV. How Much Can the State Recover?

Managed Care: Estate claims can be much higher if the beneficiary is
enrolled in managed care. When a managed care beneficiary dies, the
estate will receive a claim for the total amount paid by Medi-Cal to the
managed care plan, regardless of how much the actual services cost the
managed care plan.

IX. How Do I Avoid an Estate Claim?

The best way to avoid an estate claim is to leave nothing in the estate.
Most Medi-Cal beneficiaries leave nothing but a home. If the property is
transferred out of the beneficiary's name during life, the state cannot
place a claim. Any transfer of real property can have tax consequences
that may outweigh a Medi-Cal estate claim. Currently, there are a number
of legal options (irrevocable life estates, occupancy agreements,
certain types of trusts) available to avoid probate, avoid tax
consequences and avoid estate claims. Anyone considering a transfer of
real property should consult an attorney experienced in the Medi-Cal
rules and regulations.


Comment: States are required to recover the costs of certain benefits
from the estates of Medicaid beneficiaries who received them. That is
not new. What is new is that the Affordable Care Act requires everyone
to be insured (with exemptions for hardship, immigration status, etc.),
and, if individuals are eligible for Medicaid based on income, they are
not allowed to use subsidies to purchase plans in the exchanges. Since
plans outside of the exchanges are unaffordable for individuals with low
incomes that qualify them for Medicaid, they are pretty much stuck with
enrolling in Medicaid.

Since Medicaid eligibility is determined by income and not by assets,
those who were able to purchase a home and build other assets, but have
retired at 55 or reduced their incomes for other reasons, are now
becoming part of a large pool that states can tap to recover Medicaid
expenditures. The states will be taking over estates that the deceased
had intended would go to their heirs.

The rules are complicated enough such that individuals concerned about
this potential transference to the state are advised to consult with an
attorney. Just what we need. More excessive administrative costs tacked
onto our wasteful system of health care financing.

Another annoyance is that many states are now forcing their Medicaid
patients into managed care organizations. Even though the individuals
may not have utilized much health care, the rules require that the
entire capitated payments made to the managed care organizations be
recovered from the estate. How ironic. The individual doesn't want
managed care but is forced into it, doesn't use it, and then his heirs
must pay through reduced vale of the estate the full managed care
premiums of a program the deceased would have avoided by remaining in
the fee-for-service Medicaid program.

As with so much in the Affordable Care Act, these issues are not simple.
Let's look just at how we finance health care, and how we tax estates.

If we had a single payer national health program, it would be financed
equitably based on ability to pay. You would not have the situation we
have now in which Medicaid spending is reimbursed by the estate whereas
Medicare spending is not. Everyone would contribute through progressive
financing of the universal risk pool, and everyone would receive
benefits based on medical need.

With the highly inequitable distribution of income and wealth that has
taken place within the past few decades, we have an imperative to
establish fairness in providing the government with the necessary
revenues to fulfill its functions. We have largely agreed that income
taxes need to be progressive, though many believe that we need tax
policies that would have very high income individuals contribute more
than is their current obligation.

But the issue of the Medicaid Estate Recovery Program should make us
look at how we tax wealth. Although most believe that very wealthy
individuals should pay higher estate taxes, we have here a situation in
which individuals with very small estates are having to pay what is, in
essence, an estate tax in the form of recovered Medicaid expenses. How
is that fair?

This is one more example of why we need to totally separate the funding
of our health care system from the delivery of health care services. A
single payer national health program - an improved Medicare for all -
would do precisely that.

Monday, December 16, 2013

Fwd: qotd: U.S. ranks near bottom on efficiency of health care spending

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: U.S. ranks near bottom on efficiency of health care spending
Date: Mon, 16 Dec 2013 11:39:40 -0800
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>

UCLA Fielding School of Public Health
December 12, 2013
U.S. ranks near bottom among industrialized nations in efficiency of
health care spending

A new study by researchers at the UCLA Fielding School of Public Health
and McGill University in Montreal reveals that the United States health
care system ranks 22nd out of 27 high-income nations when analyzed for
its efficiency of turning dollars spent into extending lives.

The study, which appears online Dec. 12 in the "First Look" section of
the American Journal of Public Health, illuminates stark differences in
countries' efficiency of spending on health care, and the U.S.'s
inferior ranking reflects a high price paid and a low return on investment.

For example, every additional hundred dollars spent on health care by
the United States translated into a gain of less than half a month of
life expectancy. In Germany, every additional hundred dollars spent
translated into more than four months of increased life expectancy.

The researchers also discovered significant gender disparities within

"Out of the 27 high-income nations we studied, the United States ranks
25th when it comes to reducing women's deaths," said Dr. Jody Heymann,
senior author of the study and dean of the UCLA Fielding School of
Public Health. "The country's efficiency of investments in reducing
men's deaths is only slightly better, ranking 18th."

The study, which utilized data from 27 member countries of the
Organization for Economic Cooperation and Development collected over 17
years (1991–2007), is the first-known research to estimate
health-spending efficiency by gender across industrialized nations.

"While there are large differences in the efficiency of health
spending across countries, men have experienced greater life expectancy
gains than women per health dollar spent within nearly every country,"
said Douglas Barthold, the study's first author and a doctoral candidate
in the department of economics at McGill University.

The report's findings bring to light several questions. How is it
possible for the United States to have one of the most advanced
economies yet one of the most inefficient health care systems? And while
the U.S. health care system is performing so poorly for men, why is it
performing even worse for women?

The exact causes of the gender gap are unknown, the researchers said,
thus highlighting the need for additional research on the topic, but the
nation's lack of investment in prevention for both men and women
warrants attention.


American Journal of Public Health: Abstract - "Analyzing Whether
Countries Are Equally Efficient at Improving Longevity for Men and Women":


Comment: To no surprise to those who have been paying attention to the
U.S. health care system, we rank very low amongst OECD nations - 22nd
out of 27 studied - on the efficiency of health care spending when
measured by improvements in life expectancy. Spending on women was even
less efficient than spending on men. As we have long known, we spend
more while getting less.

There are likely many factors that contribute to these differences, but
there is no doubt that we have a very dysfunctional, fragmented,
wasteful, inequitable health care financing system that certainly is an
exemplar of inefficiency. Why should we not expect poor outcomes for our
high level of spending?

Once we have in place a single payer national health program it will be
much easier to identify the deficiencies specifically related to health
care delivery, and then we can correct them. Ladies first, please.

Friday, December 13, 2013

Fwd: qotd: Alan Maynard on rationing in public and private health care systems

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: Alan Maynard on rationing in public and private health
care systems
Date: Fri, 13 Dec 2013 14:30:12 -0800
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>

Journal of Health Politics, Policy and Law
December 2013
Health Care Rationing: Doing It Better in Public and Private Health Care
By Alan Maynard


All public and private health care systems ration patient access to
care. The private sector rations access to consumers who are willing and
able to pay. The poor and disadvantaged have limited access to care and
inadequate income protection. In public health systems, care is provided
on the basis of "need," that is, the comparative cost-effectiveness of
competing treatments. This results in patients being deprived of care if
treatments are clinically effective but not cost-effective. Rationing
health care is ubiquitous. In both types of systems physicians have
discretion to deviate from these rationing principles. This has created
inefficient variations in clinical practice. These are difficult to
resolve because of the lack of transparency of costs and patient
outcomes and perverse incentives. The failure to remove universal
inefficiency in a period of economic austerity sharpens awareness of
rationing. Hopes of greater efficiency are largely faith based.
Competing ideologues from the left and the right continue to offer
evidence for free solutions to long-established problems. Inefficiency
is unethical, as it deprives potential patients of care from which they
could benefit. Reducing inefficiency is essential but difficult. The
universal challenge is to decide who shall live when all will die in a
world of scarce resources.

From the Overview

In all countries there is a reluctance to use the word "rationing."
Policy makers and politicians prefer terms such as "prioritization" and
"resource allocation." Call it what you will, rationing in health care
is ubiquitous in public and private health care systems. The latter
ration by consumers' ability to pay, and "success" is related to
physicians and other providers making a good living. Public health care
systems, in principle, ration in relation to need or comparative
cost-effectiveness; in practice, prioritization is determined by
physicians' providing treatments that most satisfy the physicians.

Productivity variations exist throughout the manufacturing and service
industries. Indeed, these variations drive innovators to act smarter and
capture market share from rivals. Public and private health care markets
are remarkable in that innovation tends to increase costs rather than
reduce them, as has happened in information technology and other
industries. The causes of this difference are debated and include the
power of the medical profession (physicians' monopoly of many areas of
activity where efficient substitutes exist), third-party pays (weak
budget caps), and perverse incentives confronting providers and
consumers (moral hazard). Mitigating problems such as these could ease
rationing constraints but would not remove them.

The failure of health care systems to measure and manage these problems
with greater transparency and improved incentive structures will result
in rationing becoming more explicit. The hope is that the consequent
debate about who will die and who will live in what degree of pain and
discomfort will not be dominated only by emotion (e.g., hysteria about
"death panels") but by evidence of cost-effectiveness produced by robust
HTA programs (health technology assessment) and the transparent
judgments of clinicians using this information. The policy priority, as
efficient HTA and P4P (pay for performance) schemes increasingly
influence rationing choices, will be to ensure that this is seen by the
public as improving patient safety and value for money for insurers and
taxpayers, and not merely seen as depriving patients of care from which
they might benefit marginally but which societies choose not to fund,
either by NHS rationing or US rationing by restrictive benefit packages
and poor access.


Comment: "All public and private health care systems ration patient
access to care." Professor Alan Maynard of the University of York, with
his characteristic academic objectivity, describes the differences in
public and private approaches to health care rationing.

Public health care systems ration access in relation to medical need,
whereas private systems ration access based on willingness and ability
to pay. In public systems, success is measured by the satisfaction of
physicians with their ability to meet the medical needs of their
patients, whereas in private systems, success is measured by the ability
of physicians to make a good living.

Both public and private systems experience inefficiency. Since the
rationing that results from inefficiency deprives some patients of care
that they should have, tolerating inefficiency is unethical. When you
compare the public British system with the largely private system in the
United States, it is clear that our much greater inefficiency results in
an insufferable level of ethical compromise. We do ration far more than
the British; we just don't see it since our victims of rationing are not
even allowed a position in the queue.

Why do we tolerate this? A clue might be found in Alan Maynard's words
in "The Public-Private Mix for Health" (The Nuffield Trust, 2005):

"As societies spend increasing proportions of their rising GDP on
healthcare, more realism about its productivity in terms of improving
the health of the population is needed. But this is not in the interest
of the media, politicians and commerce. Promising miracles increases
their income and power!"

Thursday, December 12, 2013

Fwd: qotd: Conclusive evidence that physicians are not leaving Medicare

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: Conclusive evidence that physicians are not leaving Medicare
Date: Thu, 12 Dec 2013 11:47:40 -0800
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>

Kaiser Family Foundation
December 10, 2013
Medicare Patients' Access to Physicians: A Synthesis of the Evidence
By Cristina Boccuti, Christina Swoope, Anthony Damico and Patricia Neuman

Main findings:

* On a national level, Medicare patients have good access to
physicians. The vast majority (96%) of Medicare beneficiaries report
having a usual source of care, primarily a doctor's office or doctor's

* Most people with Medicare — about 90 percent — are able to schedule
timely appointments for routine and specialty care. Medicare seniors are
more likely than privately insured adults age 50-64 to report "never"
having to wait longer than they want for timely routine care appointments.

* A small share of Medicare beneficiaries say they looked for a new
physician in the past year, and only 2 percent of seniors with Medicare
report problems finding one when needed — comparable to rates reported
by privately insured adults age 50-64.

* Medicare seniors report foregoing medical care at similar or lower
rates than privately insured adults age 50-64. Certain subgroups of the
Medicare population are more likely than others to report not seeing a
doctor when they thought they needed to during the year, particularly
beneficiaries who: are under age 65 and qualify for Medicare because of
a permanent disability; have either Medicaid (dually eligible for
Medicare and Medicaid) or no supplemental coverage; are Black; have
lower incomes; are in fair or poor health, and/or have five or more
chronic conditions. Even within these vulnerable subgroups, however,
the majority do not report foregoing doctor visits when needed.

* According to recently-released physician survey data, the majority
(91%) of non-pediatric physicians accept new Medicare patients — the
same rate that accept new patients with private non-capitated insurance.
This correlation persists generally across states, indicating that
physician acceptance of new Medicare patients may be more related to
local market factors than issues unique to Medicare overall.

* According to new physician data from Medicare, less than 1 percent of
physicians in clinical practice have formally "opted-out" of the
Medicare program, with psychiatrists accounting for the largest share (42%).

These findings show that according to national patient and physician
surveys and other data sources, most Medicare beneficiaries enjoy good
access to physician services, comparable to the experiences of privately
insured patients. Most physicians accept new Medicare patients, and
relatively few have formally opted out of the Medicare program.


Comment: This comprehensive report lays to rest once and for all the
the rumor that physicians are leaving Medicare in droves. Most
physicians accept new Medicare patients, and less than 1 percent have
formally opted-out of the Medicare program.

An improved Medicare would be even more attractive to physicians,
especially if it covered everyone. It would dramatically reduce hassles
with intrusive third party payers so that physicians could spend most of
their time doing what they devoted their lives to - taking care of their

As far as the threat that physicians would quit if we enacted an
improved Medicare for all, first of all, very few would leave - likely
less than 1 percent - and, second, since most of those who would leave
seem to be more interested in money rather than patients (think
concierge), we really don't want them around anyway. It would be a great
way to clean up our profession.

Wednesday, December 11, 2013

Fwd: qotd: Insurers using high drug cost sharing to scare away patients with expensive chronic disorders

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: Insurers using high drug cost sharing to scare away
patients with expensive chronic disorders
Date: Wed, 11 Dec 2013 11:22:17 -0800
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>

The Washington Post
December 9, 2013
AIDS advocates say drug coverage in some marketplace plans is inadequate
By Ariana Eunjung Cha

The nation's new health-care law says insurers can't turn anyone away,
even people who are sick. But some companies, patient advocates say,
have found a way to discourage the chronically ill from enrolling in
their plans: offer drug coverage too skimpy for those with expensive

Some plans sold on the online insurance exchanges, for instance, don't
cover key medications for HIV, or they require patients to pay as much
as 50 percent of the cost per prescription in co-insurance — sometimes
more than $1,000 a month.

"The fear is that they are putting discriminatory plan designs into
place to try to deter certain people from enrolling by not covering the
medications they need, or putting policies in place that make them jump
through hoops to get care," said John Peller, vice president of policy
for the AIDS Foundation of Chicago.

As the details of the benefits offered by the new health-care plans
become clear, patients with cancer, multiple sclerosis, rheumatoid
arthritis and autoimmune diseases also are raising concerns, said Marc
Boutin, executive vice president of the National Health Council, a
coalition of advocacy groups for the chronically ill.

"The easiest way [for insurers] to identify a core group of people that
is going to cost you a lot of money is to look at the medicines they
need and the easiest way to make your plan less appealing is to put
limitations on these products," Boutin said.

Insurers say that such accusations are unfounded, and that the drug
coverage is more than adequate, with many plans exceeding the minimum
levels required by the Affordable Care Act. But they acknowledge that to
keep premiums low, they must restrict the use of some costly drugs if
there are alternatives. And they say that when high-priced medications
must be used, it's reasonable to expect patients to pick up more of the

But people who expected the new plans to provide pharmaceutical coverage
comparable with that of employer-sponsored plans have been disappointed.
In recent years, employers have compelled workers to pick up a growing
share of the costs, especially for brand-name drugs. But insurers
selling policies on the exchanges have pared their drug benefits
significantly more, according to health advocates, patients and industry

Robert Zirkelbach, a spokesman for American's Health Insurance Plans, an
industry group, said the exchange plans are designed "to try to give
consumers better value for their health-care dollars."


Comment: It is no surprise that private insurers would use every
devious trick to try to limit their payments for expensive drugs,
including requiring the patient to pay more through higher cost sharing,
or by omitting expensive drugs from their formulary altogether. From the
insurers' perspective, that's just good business. What is really
nefarious is that they are now using this to discourage patients with
expensive disorders from even enrolling in their plans.

Patients with HIV/AIDS, multiple sclerosis, rheumatoid arthritis, lupus,
cancer, hepatitis C, and other disorders who are on long term therapy
with expensive drugs will go elsewhere for their coverage when they find
that their current drug regimens would leave them with intolerable costs
under these plans.

A provision of the Affordable Care Act - guaranteed issue - requires
that insurers accept all applicants, no matter how expensive their care
is anticipated to be. But Obamacare did not change the nature of the
private insurance beast. Insurers will always find more ways to
circumvent requirements such as guaranteed issue.

Insurers boast to their shareholders about innovation in insurance
product design. The problem for us is that the innovations are not
designed to improve access and affordability for the insured. The
innovations are to improve the bottom line of the insurers.

Just think of the innovations we are already seeing - higher
deductibles, more limited provider choice through narrower networks,
limited benefits within each of the ten categories of required benefits,
and greater financial barriers to care such as these outrageous cost
sharing requirements for drugs.

The insurers are not through. When the insurance lobbyists are saying
that they are trying to "give consumers better value for their
health-care dollars," they really mean keeping insurance premiums low
enough to compete in the marketplace. They do that by paying as little
as possible for health care, shifting ever more of the costs to
patients. The sky is the limit on innovations when they are driven by greed.

We have the wrong people in charge - the insurers. We need our own
public financing system that is designed to help patients get care by
removing financial barriers. That's what an improved Medicare that
covered everyone would do for us.

Enough of this, "Boy, do we have a plan for you, and it's cheap, but if
you have anything wrong, study this plan carefully since you'll find
that it won't cover what you need (and then go away kid, you bother me)."

Monday, December 9, 2013

Fwd: qotd: MedPAC conflicted between fiscal neutrality and paying private programs more

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: MedPAC conflicted between fiscal neutrality and paying
private programs more
Date: Mon, 9 Dec 2013 11:03:34 -0800
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>

Medicare Payment Advisory Commission (Medpac)
Public Meeting
November 7, 2013

From the transcript:
Okay. It is time to begin….
Our first topic today is synchronizing Medicare policy across the
options that Medicare beneficiaries will face in the future….[Medpac
staff] Julie [Lee] is going to lead the way on this topic. Julie, it is
all yours.
DR. LEE: Good morning. In recent months, the Commission has been
thinking about the relationship between … ACOs, Medicare Advantage
plans, and traditional fee-for-service….
In the past, the Commission has expressed a general desire to "move away
from fee-for-service." In today's presentation, we want to clarify what
you mean by "moving away" and by "synchronizing" Medicare policy across
delivery systems…. [pp 3-4]
The title of this presentation says, "Synchronizing Medicare policy
across delivery systems," but we haven't defined what we mean by
"synchronizing." Does it mean payment neutrality across delivery
systems? In other words, would Medicare pay the same amount for the same
beneficiary whether she gets her Medicare through fee-for-service, ACO,
or MA? …. Alternatively, if not neutrality, does synchronizing mean
moving toward one system over another? For instance, would Medicare
policy create incentives to move away from traditional fee-for-service?
If so, what would that entail? ….[pp 13-14]
DR. [MICHAEL] CHERNEW [VICE CHAIR]: My view is that we have to start
with fiscal neutrality…. [p 62]
DR. CHERNEW: I've heard … broad consensus [from other commission
members] around the notion of some type of fiscal neutrality…. [p 72]
program savings of about 0.5 percent…. The ACOs we spoke with confirmed
that the cost of running the ACO was about one to two percent….[p 164]
MR. HACKBARTH: If your ultimate goal is to try to move everybody
or a high percentage of care delivery into this new [ACO] model,
then I think … you've got to have a clear, explicit strategy for how
you're going to make fee-for-service increasingly uncomfortable. [p 222]

Comment by Kip Sullivan:

The Medicare Payment Advisory Commission (Medpac) has set an impossible
task for itself. Even though the traditional fee-for-service (FFS)
Medicare program is indisputably less expensive than the Medicare
Advantage (MA) program and probably less expensive than the new ACO
pilot programs, the commission wants to move doctors and patients out of
the FFS program and into the MA and ACO programs while still maintaining
"fiscal neutrality," that is, while paying the same amount per
beneficiary regardless of whether the beneficiary is enrolled in the
FFS, MA, or ACO program.
Medpac has been weaving the intellectual trap it now finds itself in for
many years. On the one hand, Medpac has been urging Congress for decades
to honor the rule of fiscal neutrality in deciding how much to pay MA
plans vis a vis the FFS program and, specifically, to stop paying MA
plans more per beneficiary than it pays for FFS beneficiaries. As the
excerpts above indicate, there appears to be a consensus among
commission members to make fiscal neutrality a fundamental criterion in
deciding how much to pay ACOs as well.
On the other hand, over the last decade Medpac has taken the position
that Medicare's FFS program encourages unnecessary services and must
either be shrunk ("moved away from") or transformed from a
"volume-based" program to a "value-based" program by somehow subjecting
doctors to the managed care methods – the financial incentives, report
cards and third-party oversight – used by MA insurers and ACOs.
The statements by commissioners Chernew and Hackbarth, quoted above,
capture the tension created by Medpac's conflicting goals. Dr. Chernew
notes a consensus among commission members that Medicare should not pay
more per beneficiary to the ACO program than it pays to the FFS program,
but Mr. Hackbarth, a former HMO executive, argues that unless Medpac is
prepared to recommend making doctors in the FFS program "uncomfortable,"
that is, make them suffer financially for staying in the FFS program,
doctors won't migrate into ACOs.
To sum up Medpac's dilemma: They want to "move away from the FFS
program" and "toward" the ACO and MA programs, and they know they can't
do that unless they starve the FFS program and fatten the ACO and MA
programs, but they don't want to starve FFS and fatten the ACO and MA
programs because that would violate fiscal neutrality.
To those who are unfamiliar with the groupthink that currently dominates
the debate about the American health care crisis, this dilemma seems
unnecessary, even nonsensical. It would seem that Medpac has it
backwards – that Medpac should support "moving away from the MA and ACO
programs" and "toward" the FFS program unless and until the MA and ACO
programs can demonstrate they cost no more than the FFS program. If
Medpac were to adopt this goal, it could also honor the fiscal
neutrality rule. That is, Medpac could simply recommend fiscal
neutrality and know that fiscal neutrality would bankrupt all or most MA
insurers, and would probably bankrupt all or most ACOs, and thereby
"move Medicare toward" the FFS program.
But Medpac gives no sign of taking that position despite decades of
evidence indicating MA insurers are less efficient than FFS providers,
and a small but growing body of evidence that ACOs are also less
efficient than FFS providers. As the excerpt above indicates, Katelyn
Smalley, a member of the Medpac staff, reported to the commission that
the latest results from the Pioneer ACO program indicate ACOs raise
rather than lower health care spending. Ms. Smalley said CMS reported
last summer that the 32 ACOs participating in the Pioneer ACO pilot cut
total spending by Medicare by half a percent but expenditures by the
ACOs rose by one to two percent. Neither Ms. Smalley nor any commission
member pointed out the obvious: While Medicare may have saved a half
percent, the health care system as a whole suffered an increase in total
spending on the order of half to one-and-a-half percent.
Medpac appears to suffer from a split personality. One personality has
the integrity to follow the evidence wherever it leads. It is this
personality which constantly calls on Congress to stop overpaying MA
plans. But Medpac's other personality suffers from two delusions that
afflict much of the US health policy establishment: (1)the delusion that
volume, not price and the administrative waste which contributes to high
prices, is the main cause of the US health care crisis; and (2) the
delusion that the managed care tools pioneered by HMOs will someday
demonstrate their ability to reduce volume and thereby lower medical
costs more than the managed care tools themselves cost.
Medpac is an influential voice in the US health policy wars. We must
hope that Medpac will soon recognize that the evidence does not support
an endless experiment with managed care and that what America really
needs is to move Medicare "toward" a true single-payer system, not just
for the elderly and the disabled but for all Americans.

Saturday, December 7, 2013

Fwd: qotd: Colin Powell calls for a universal, single payer system

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: Colin Powell calls for a universal, single payer system
Date: Sat, 7 Dec 2013 07:40:26 -0800
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>

Puget Sound Business Journal
December 5, 2013
Gen. Colin Powell calls for universal health care in the U.S.
By Valerie Bauman

Former Secretary of State and longtime Republican Colin Powell is
calling for a universal health care solution in the U.S.

"We are a wealthy enough country with the capacity to make sure that
every one of our fellow citizens has access to quality health care," he
said Thursday at a Seattle fundraiser for prostate cancer. "(Let's show)
the rest of the world what our democratic system is all about and how we
take care of all of our citizens."

The retired four-star general, a prostate cancer survivor, spoke at the
Prostate Cancer Survivors Celebration Breakfast, organized by UW
Medicine and the Fred Hutchinson Cancer Research Center.

Powell took the opportunity to share some of his own experiences and to
publicly call for a health care solution similar to those in Canada,
Japan and other countries that have a universal, single-payer system.

"I am not an expert in health care, or Obamacare, or the Affordable Care
Act, or however you choose to describe it, but I do know this: I have
benefited from that kind of universal health care in my 55 years of
public life," Powell said. "And I don't see why we can't do what Europe
is doing, what Canada is doing, what Korea is doing, what all these
other places are doing."


Comment: Colin Powell's is a very welcome voice in the groundswell of
support for single payer. As people better understand single payer, that
support will grow until we reach a threshold where even Congress will
join in.

Friday, December 6, 2013

Fwd: qotd: Cleveland Clinic’s Steven Nissen supports single payer

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: Cleveland Clinic's Steven Nissen supports single payer
Date: Fri, 6 Dec 2013 10:08:15 -0800
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>

MedPage Today
December 5, 2013
10 Questions: Steven Nissen, MD
By Todd Neale

What's the biggest barrier to practicing medicine today? That's just the
first of 10 questions the MedPage Today staff is asking leading
clinicians and researchers to get their personal views on their chosen
profession. In this series we share their uncensored responses. Here,
answers from Steven Nissen, MD, of the Cleveland Clinic.

There, Nissen is chair of the Robert and Suzanne Tomsich Department of
Cardiovascular Medicine. A past president of the American College of
Cardiology and former chair of the FDA's Cardiovascular Renal Drugs
Advisory Committee, he has had a leading role in highlighting potential
risks associated with certain drugs, including rofecoxib (Vioxx) and
rosiglitazone (Avandia). In 2007, Nissen was included on Time Magazine's
list of "100 men and women whose power, talent, or moral example is
transforming the world."

1. What's the biggest barrier to your practicing medicine today?

The lack of a single-payer system. We waste enormous amounts of time and
energy dealing with insurance companies, whose major goal is figuring
out how not to cover patients.


Comment: A couple hundred thousand physicians are closet single payer
supporters. If only we could get more of them to out themselves, as
Cleveland Clinic's Steven Nissen has done here, maybe the public would
understand that we really could have an improved Medicare for everyone
since so many doctors agree.

Thursday, December 5, 2013

Fwd: qotd: Wall Street’s view of narrow networks

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: Wall Street's view of narrow networks
Date: Thu, 5 Dec 2013 13:56:26 -0800
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>

Center for Studying Health System Change
November 21, 2013
HSC's 18th Annual Wall Street Comes to Washington Conference

From the conference transcript:

Paul Ginsburg (President, Center for Studying Health System Change): Let
me move on to network innovations. And one thing that came up a little
bit in our first session was narrow- or limited-network products. And
let me start by asking about how are plans building limited networks? I
mean, in a sense, what are they looking for as far as which providers
would they like to have? How sophisticated are they in assessing the
value of different providers?

Carl McDonald (Director and Senior Analyst, Citi Investment Services): I
can go quick: Price. I'm done.

Paul Ginsburg: Okay. Actually, how sophisticated is the price?

Carl McDonald: Sorry? "How sophisticated..."

Paul Ginsburg: How sophisticated is the price? Is it price per episode?
Is it simply, you know, unit prices?

Carl McDonald: Yes, I mean, generally it's going to be the unit price,
or price per episode.

Matthew Borsch (Vice President, Goldman Sachs): Let me just offer one
thing that's happening. This is not quite to the tiered-network
strategy, or narrow-network strategy, per se, but it's topical right now
in that you've seen some of the health plans in Medicare Advantage
taking some pretty strong steps to narrow their networks. On the
physician side, it's been the most notable. In fact, there was a,
there's been some communication about that. There was a letter that was
posted yesterday from the health insurance industry to CMS, stressing
how important it was for the plans to be able to make these network
exclusions. But obviously, for doctors who've been, you know, contracted
in Medicare Advantage to suddenly be, to be terminated, where, in most
cases, they continue to participate on the commercial side, has created
some real blowback.

Paul Ginsburg: I had noticed that, and was wondering, it sounded to me
that this was different way that a plan pursues a more limited network.

Matthew Borsch: It is.

Paul Ginsburg: It seems as though, and I saw The Wall Street Journal
article a week or two ago about United, and it almost seemed as though
they were trying to get their star quality scores up by culling out the
physicians who contribute to low scores. And is that what it's about, Matt?

Matthew Borsch: Well, the truth is we don't really know.

Paul Ginsburg: Yeah.

Matthew Borsch: You know, that, that is, from our perspective, somewhat
of a black box, in terms of the decision making there. There are
multiple criteria. There's how each physician group feeds into the star
quality scores. There are utilization, efficiency metrics that they can
run on a broad, you know, larger companies can run on a broad set of
claims data.

There's also, frankly, the consideration of which Medicare Advantage
members are assigned to those physician groups. And again, I'm not
pointing to any one of these three as a factor but there you could
possibly have some effort to change the risk distribution of the
underlying membership.

Sheryl Skolnick (Managing Director & Co-Head of Research, CRT Capital
Group): So, just to put this in context, Medicare Advantage rates are
coming down very significantly next year. They're actually going down
next year from United's perspective, what? about 3 1/2 percent or so.

And when your rates go down, some of your plans, and some of your
providers in those plans will have to be terminated, because you need to
essentially shrink to a profitable size, or a sustainable size. So
that's part of what you're seeing, is instead of the proactive "We're
introducing a new benefit plan, we're going to build a narrow network,"
now you're seeing the reactive effect of United's always been a very
inclusive and broad based network. They've had some issues of adverse
publicity in St. Louis and some other places when they've tried to
narrow the network based on quality. There is a lot less push back on
that sort of thing now.

But they're getting some push back on this one because in Connecticut
alone, for example, it's 2,000 providers. That's a lot in Connecticut.
It's not that big a state.

So, what you're seeing is, first, the unwinding. Second, I agree with
you completely, I think it is absolutely a strategy to get their star
scores up, because they're a major embarrassment. And they're clearly,
from their last conference calls, a focus of the company strategy for
Medicare Advantage for the next couple of years, is to get the star
scores up.

But I also, I agree with Matt, that there are many other factors at
work, most notably that they need to get all of these markets that
they've expanded rather broadly to get rid of the marginal plan, to get
rid of the marginal provider and, in some cases, the high cost member.

Robert Berenson (Institute Fellow, The Urban Institute): But I think
it's important to point to a major difference between the Medicare
managed care situation and commercial, which is that in Medicare, out of
network services are paid at Medicare rates, so that changes the whole
leverage situation. And it's the reason, I think, that hospitals
basically are in network at Medicare rates, or near to Medicare rates,
because they don't have the leverage.

Balance billing is a whole different situation. I'm actually surprised
that MA plans weren't more aggressive in the past, because they have the
protection for the out of network care. And others, there won't be such
push back from the beneficiaries hit with the complete balance bill, if
their physician is not in network, or something like that.

Paul Ginsburg: So, getting into the employer based, the commercial
space, you know, it looks like there's been substantial growth in small
group plans to have narrow networks. And, of course, so many of the
products of the exchanges are narrow networks.

And, any comments about that strategy, how it's going, is there going to
be, is there going to be push back by the public?

Sheryl Skolnick: For a long time the hospitals were telling us that
while Wall Street was busy talking about the narrowing of networks, they
weren't actually seeing it.

It was only when the exchange contracts came up that, even in the
beginning, there was some concern that some of the contracts that were
being signed weren't narrow-network contracts, in the very beginning of
the contracting. Towards the end of the contracting for reform these are
commercial, by the way, these are fundamentally commercial contracts.
So, by the end of the contracting, though, almost all of the contracts
being signed were for some sort of a narrowed network.

So, I think there was a very quick evolution in the thought process of
the plans in negotiating these things, where they very quickly realized:
This is one of the very few levers we have, we better pull it.

Paul Ginsburg: Yes. And, to what extent, as they form these networks, to
what extent are the savings going to come from keeping high cost
providers out, or getting discounts from providers?

Sheryl Skolnick: Yes. Yes.

Paul Ginsburg: Which is the dominant piece, or are they both very important.

Sheryl Skolnick: Very important.

Paul Ginsburg: Okay. That's the answer.


Comment: If insurers were marketing products designed primarily to get
their clients the health care that they need, you would think that they
would do their best to make sure that they cover essentially all of the
physicians that their clients would select. But they don't, and they are
narrowing even further their lists of contracted providers. Why? Wall
Street understands. It's not about quality or access. It's about the money.

Tuesday, December 3, 2013

Fwd: qotd: Bone Marrow as a commodity

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: Bone Marrow as a commodity
Date: Tue, 3 Dec 2013 11:07:12 -0800
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>

Bloomberg View
December 1, 2013
Why It's OK to Pay Bone-Marrow Donors
By Sally Satel

Locating a marrow donor is often a needle-in-a-haystack affair. The odds
that two random individuals will have the same tissue type are less than
1 in 10,000, and the chances are much lower for blacks.

Allowing compensation for donations could enlarge the pool of potential
donors and increase the likelihood that compatible donors will follow
through. So the ruling by a three-judge panel of the U.S. Court of
Appeals for the Ninth Circuit was promising news for the 12,000 people
with cancer and blood diseases currently looking for a marrow donor.

Shaka Mitchell, a lawyer in Nashville, Tennessee, and co-founder of the
nonprofit MoreMarrowDonors.org… invited a team of economists to evaluate
the effects of the ruling on people's willingness to join a registry and
to donate when they are found to be a match. The researchers were to
specifically assess whether cash payments would be any more or less
persuasive than noncash rewards or charitable donations.

Now comes the bad news. On Oct. 2, the U.S. Department of Health and
Human Services proposed a new rule that would overturn the Ninth
Circuit's decision. The government proposes designating a specific form
of bone marrow -- circulating bone-marrow stem cells derived from blood
-- as a kind of donation that, under the 1984 National Organ Transplant
Act, cannot be compensated.

The strongest opposition to compensation comes from the National Marrow
Donor Program, the Minneapolis-based nonprofit that maintains the
nation's largest donor registry. Michael Boo, the program's chief
strategy officer, says of reimbursement, "Is that what we want people to
be motivated by?"

HHS is presumably under pressure from the National Marrow Donor Program.
The department does not otherwise explain its proposed rule except to
claim that compensation runs afoul of the transplant act's "intent to
ban commodification of human stem cells" and to "curb opportunities for
coercion and exploitation, encourage altruistic donation and decrease
the likelihood of disease transmission."

Each year, 2,000 to 3,000 Americans in need of marrow transplants die
waiting for a match. Altruism is a virtue, but clearly it is not a
dependable motive for marrow donation.

(Sally Satel, is a psychiatrist and a resident scholar at the American
Enterprise Institute.)


Comment: Imagine trading bone marrow in the commodities market. It
could be very lucrative. In no time at all, the prices could be driven
over what we are now paying for the newer cancer drugs - $100,000 and
more - maybe much more. And don't stop at bone marrow. Think of the
trade that could be generated in other human organs.

Is there no end to the commodification of health care? How did we end up
here? Is the compulsion to look for market solutions so great that we
abandon all sense of humanity?

People who think like this - do they have a soul?

Monday, December 2, 2013

Fwd: qotd: Grading a Physician's Value — The Misapplication of Performance Measurement

Quote-of-the-day mailing list

-------- Original Message --------
Subject: qotd: Grading a Physician's Value — The Misapplication of
Performance Measurement
Date: Mon, 2 Dec 2013 12:28:18 -0800
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>

The New England Journal of Medicine
November 28, 2013
Grading a Physician's Value — The Misapplication of Performance Measurement
By Robert A. Berenson, M.D., and Deborah R. Kaye, M.D.

Perhaps the only health policy issue on which Republicans and Democrats
agree is the need to move from volume-based to value-based payment for
health care providers. Rather than paying for activity, the aspirational
goal is to pay for outcomes that take into account quality and costs. In
keeping with this notion of paying for value rather than volume, the
Affordable Care Act (ACA) created the "value-based payment modifier," or
"value modifier," a pay-for-performance approach for physicians who
actively participate in Medicare. By 2017, physicians will be rewarded
or penalized on the basis of the relative calculated value of the care
they provide to Medicare beneficiaries.

Although we agree that value-based payment is appropriate as a concept,
the practical reality is that the Centers for Medicare and Medicaid
Services (CMS), despite heroic efforts, cannot accurately measure any
physician's overall value, now or in the foreseeable future.

The value modifier is meant to provide differential payment to a
physician or physician group under the Medicare Physician Fee Schedule
on the basis of the quality of care furnished as compared with the cost.
To reduce the burden on physicians, CMS has based the value modifier on
the Physician Quality Reporting System (PQRS).

The meager rate of physician participation in the PQRS suggests that
something is fundamentally wrong — physicians simply do not respect the
measures, and for good reason. PQRS measures reflect a vanishingly small
part of professional activities in most clinical specialties. A handful
of such measures can provide a highly misleading snapshot of any
physician's quality. Research shows that performance on specific aspects
of care does not predict performance on other components of care.
Primary care physicians manage 400 different conditions in a year, and
70 conditions account for 80% of their patient load. Yet a primary care
physician currently reports on as few as three PQRS measures.

The challenge of accurately assigning costs to an individual physician
is similarly daunting. Current methods for case-mix adjustment do not
adequately capture variations in patients' illness severity,
complicating coexisting conditions, or relevant socioeconomic
differences — differences beyond the physician's control that affect the
cost of care. And we currently don't know how to attribute to an
individual physician the costs that Medicare beneficiaries generate
across the health care system.

Even if we had better measures, behavioral economists would still
challenge the pay-for-performance concept, at least for professionals
such as physicians and teachers, who must manage complex situations and
creatively solve problems. These critics argue that rewarding
professionals on the basis of a particular performance measure has the
potential to crowd out the intrinsic motivation to perform well across
the board, not just on the few activities being measured.


Comment: The "value-based payment modifier" - an adjustment in payments
to reward physicians for improving value in the health care they
provide, or to punish them for providing lower value - is yet another
example of the often misguided measures in the Affordable Care Act
allegedly designed to improve our health care system, when, in fact, the
fundamental reforms in the health care financing system that we really
needed were barely touched upon, in deference to the private insurance

It will be difficult to change from a volume-based system (fees based on
volume of services provided) to a value-based payment system when we
still do not know how to define the value of physician services, as Drs.
Berenson and Kaye explain to us in this NEJM article, though they do
suggest some other modest measures that might have some benefit.

It is fine to continue research on measures that have a potential for
improving value in health care, but it is almost criminal to ignore a
concept that has already been proven in other nations to dramatically
increase value - potentially a far greater increase than all of the
other measures combined that are included in the Affordable Care Act. Of
course, that concept is single payer financing. Let's first enact an
improved Medicare for all, and then we could tweak the system with
measures that might provide incremental improvements in value. But first
things first.