The Annual Meeting of Physicians for a National Health Plan (PNHP)meeting was held Saturday, Nov. 2, at the Seaport Plaza Hotel in downtown Boston. Mass. Four hundred people attended, 100 of whom were medical students. Stephanie Woolhandler MD MPH and David Himmelstein MD, in their health policy update, gave the following information. There have been four million medically induced bankruptcies in the US in the past two years. The upper 1/5 of the population gained essentially all of the income during that time. For the upper .01%, the recession is over. For others recession persists. During the Eisenhower years, the top tax bracket was 90%, and during that time there was a very robust economic growth. The widening gap between income levels has a direct effect on survival. In 1970 there was a difference of one year in life span between the highest and lowest earners. In 2013 the difference in survival or life expectancy between the highest and lowest earners was six years. There has been no change in the health insurance overhead (26%). The fastest growing expense of health care is pharmaceuticals. Drug companies have been fined millions of dollars for misbehavior. They pay the ticket and keep on speeding. Hospice for profit is now cherry-picking for low-risk patients just as private insurance generally does and the same is true for dialysis companies. Medical entrepreneur-ism (doctorpreneurs) is increasing costs. Urologists purchase IMRT equipment and then self-refer.
We lag behind most other developing countries in life expectancy, infant mortality and maternal mortality, but we are number one in spending. We now spend $8,950 per capita for health care, of which $5,749 per capita is government-funded. Out-of-pocket payments have increased. Outcomes have not improved. Almost half of medical cost is due to administration.
Scotland has had the lowest increase in medical costs because it has resisted the tendency toward privatization which is occurring elsewhere in the United Kingdom. The Scots call their health care system owner-directed, not customer-directed.
In Massachusetts, under Romney-care, premiums have increased 9.7%, benefits have decreased 5%. The ACA uses 1,700 rules to figure out which plan a person qualifies for.
The ACA versus states.
Under the ACA, 42,000 Vermonters will remain uninsured; 28,000 will get insurance. Initial cost of the Exchange in Vermont is $170 million. Maintenance costs from 2015 to 2018 will be $5 million. The market does not create a competitive system. In New Hampshire, one of the plans cuts out half of the hospitals. In New York, there is a $3,000 deductible and 50% co-payment for coverage on the bronze plan. You need to know what diseases you are going to get. Woolhandler and Himmelstein looked up options of carriers in New York and found that the bronze plan from one carrier would be less expensive if you ended up with diabetes, more expensive if you needed treatment for breast cancer. Another bronze plan was just the opposite.
Most people will not be affected by the Affordable Care Act because they already qualify for health insurance through their employer or Medicaid or Medicare. Seven percent of the population will get coverage through the Exchanges.
“The Impact of Austerity on European Health Care Systems,” by Adam Gaffney MD. Denmark and Iceland increased social services during the economic downturn. Others such as Greece and Spain chose to start austerity. Unemployment went from 7% to 1% between 2007 and 2012. There was an increase in malnutrition, suicide, HIV, and malaria in Greece.
Arnold Relman said the single payer movement has to include doctors. US docs are not eager for profit-driven capitation, but this should not be seen as a rejection of single-payer. Rob Stone of Bloomington, Indiana said that hospital benchmarks of mortality and re-admissions can be skewed by the current tendency to use observation status for patients that might otherwise be considered re-admissions. The rule-making process has started to unravel the ACA. Complicated eligibilities, etc. have made it easier for insurance companies to cherry-pick. There has been a $3,000 overpayment for each Medicare Advantage patient each year.
In many parts of the country, Medicaid does not get you care. Himmelstein said that in New York even private insurance does not necessarily buy you care . You may need cash up front, for example, to see an orthopedist. A member of the audience from Rhode Island said that under a single-payer system the people and businesses would not have to be distracted by health care responsibilities.
Rachel Nardin of Massachusetts talked about Romney Care. She said that some, even with employer-sponsored plans, found policies too expensive, and that a substantial number of people lost Medicaid coverage because they did not know or remember that they had to renew each year. Only 5% of the uninsured in Massachusetts are uninsured because they think they don’t need insurance. Dr. Nardin made a point that I had heard before that there is increased access to “free” preventative care, but care delivered in response to symptoms of illness is no longer “free,” so people may be able to afford diagnosis but not treatment. There’s been no change in the number of medical bankruptcies in Massachusetts.
All insurance is not equal in giving people access to care. Under-insurance has increased in Massachusetts. They call it Swiss cheese insurance. There is no proven cost control–health care is consuming 43% of the Massachusetts state budget and is taking away from other social needs such as education. The tallest two buildings in Boston are insurance company buildings. They exemplify gross inefficiency in the use of our tax money.
Governor Peter Schumlin of Vermont was the keynote speaker. Schumlin thanked Deb Richter for her important role in bringing single-payer health care legislation to Vermont. He also thanked PNH P for its research and education. He said “I can’t think of anyone who hasn’t had a family member who has not suffered under our current health care system.” He talked about his grandfather who was an auto body repairman and had a series of jobs based on where his wife (Schumlin’s grandmother) could find work that carried health insurance. The grandmother retired at age 65 from work as a nursing home assistant at nine dollars per hour. That was the type of job where she could still get health insurance. In Vermont there is high social consciousness but fiscal conservatism. Schumlin feels that the US is unlikely to get single-payer health care until states lead the way. He said that most Americans believe that the more money you spend, the longer you live, but there is plenty of evidence that that is not true.
Vermont has a five-member Green Mountain Health Care Delivery Commission, which will deal with regulating hospital charges, hospital expansion, and changing Vermont’s reimbursement to be based on quality instead of quantity
goals in Vermont
1. Every resident will have a Green Mountain health care card.
2. Health care outcomes will improve; there will be less obesity and less smoking.
3. There will be fairness in how we pay for health care.
4. Vermont will continue to decrease costs.
5. Let providers do what they signed up to do, provide health care for people and not be administrators.
The Governor mentioned calling William Hsiao in 2011 to ask if he would be willing to do the feasibility study for Vermont. Dr. Hsiao first declined, and when the Governor asked why, Hsiao replied, “Although I’ve helped a number of other countries establish good health care systems, I’ve given up on America.” The Governor said “You can’t give up on America,” and quoted Gerald Friedman’s estimate of $400-500 billion savings if the nation had a single-payer system.
Schumlin said that employers generally are unaware of how much they pay for health care plans. It is often as high as 20% of payroll. He expects that a single-payer plan, when it goes into effect in Vermont, will pull business into the state because of less overall health care costs. He told how he’d decided to run for governor on a single-payer ticket. He was told by an expert advisor, “You’ve got to stop talking about single payer.” “The reason I got away with it,” he said, “is that there had been a strong grassroots movement in the state.” He said that we need to talk in plain English about your health care. He expects a media blitz by the health care industry, primarily insurance companies, in 2015. He thinks that the movement will need to raise $1 million to counter ads by the industry.
Relman asked “Are doctors part of the grassroots?” “We have lots of PNHP supporters but few activists, the Governor said. “If you want to get rich, don’t come to Vermont. We're not after your wallets, but we do want a system based on preventative care rather than crisis management. Schumlin said that the President told him, “We’ll get every waiver we can for you to make your system work.”
Donna Smith of Colorado reported on their Right to Health Care ballot initiative that now has 86,000 signers. It reads, “Shall there be an amendment to the Colorado Constitution concerning the provision of one public health insurance program to allow all Colorado residents access to a single standard of health care as a matter of human right and public good and, in connection therewith, requiring the General Assembly to enact legislation creating a public health insurance plan, requiring the Colorado Department of Revenue to collect a premium not to exceed 9% of an individual’s income to fund the plan, and prohibiting any control ordinance tracing their premiums by for-profit, nonpublic entity or corporation?”. Supporters of this initiative are staging media events such as the Polar Bear Plunge with banners and mottoes saying “Don’t leave any Coloradans Out in the Cold.”
Ben Day said that local ballot initiatives are allowed in Massachusetts and that ballot initiatives for right to health care have won in many voting districts, even in red zones.
Hank Abrons of California said that in 1984 proposition 8186 for single-payer health care was pulling 3:1 in favor. There was an insurance blitz and the measure was voted down 1 to 3. He thinks it’s virtually impossible to pass initiatives in California because they are so complex and expensive. He suggested having think-tank dinners of 15 to 20 people. He says it’s much easier to pass a defensive position (referendum) than it is to pass a positive position (initiative).
Philip Caper of Maine said that there have been 12 single-payer bills presented to the legislature in the past 20 years. Each one has been a step in educating the public. He said the good news about referendums is that the people can decide. That is also the bad news. He feels that The Health Care Movie is an excellent way to educate, and begins a showing of the movie at a house party by saying “I want you to watch and think about how what you see might apply to us.”. He said he admires the courage of the President, Michelle, Speaker Pelosi and others to have pushed the ACA into passage.
Dr. Relman suggested that we approach our medical societies. He feels that legislators will approve change only if they see that physicians are in favor. Working with medical societies have far fewer minds to change than working with entire legislatures. You can convince leaders of a medical association that their professional future lies in single-payer.
Bernie Sanders will introduce a companion bill to HR 676 in the Senate.
Jay Miller said it is important for us to convey a sense of possibility to our colleagues. He said that it will help us build relationships with other liberal advocates if we acknowledge how the ACA can help people, but also strongly criticized the shortcomings of the ACA. He said that there are many aspects of the health and care industry that are harmful. One that is not so obvious is the way that software is designed. Software is geared primarily towards billing purposes rather than communicating between care-givers. One medical student said that it hasn’t been articulated well that the client/practitioner relationship is sacrosanct and that the more complex the system is, the more jeopardy there is to that relationship.
Andy Coates summarized the morning by saying that you cannot cross a great chasm in two steps. It is not a democracy when we exclude half of the nation from adequate health care. It is the privilege and duty of doctors to advocate for all of us. Fighting for single-payer health care allows us to stay in our proper role as advocate for our patients. In order to get the attention of your listener and to appear relevant, you need to meet the “patient” where he/she is at the moment, and to address their greatest fear. Is it loss of income? Is it fear of something new? Fear of loss of adequate insurance such as Medicare? Is it loyalty to the President and the ACA? We need to re-frame our message so the average person understands how the activities of the health care industry are keeping health care away from us. Medicare meltdown: Wall Street and Washington DC are ruining Medicare. Corporations are just doing what they are expected to: maximize profit.
Dr. Lopez said, “As long as private insurance continues to be involved, we will get more of the same.” The medical student said we might reach a wider audience if we emphasize the administrative cost of 31%. Dr. Himmelstein said the medical profession is in a rut. Doctors are dispirited. Their practices are soul-draining. At Massachusetts General, things are horrible. Doctors feel they cannot protect their colleagues and the patients. It’s not primarily insurance companies, but our corporatization of medicine; i.e. insurance companies and other corporations are buying up health care practices.
Dr. Richter said single-payer is the most fiscally responsible. She feels the argument will not be won on moral grounds. “We are regressively financing health care. If we reduce health care costs and therefore allow more people disposable income, there will be more purchasing power. The rich can buy only so many Porsches, but everyone needs the necessities of life such as food, clothing, housing, and heating.”
The student said the slide on CEO salaries was his most effective slide. The one on how little the bronze plans covers is also impressive. Dr. Himmelstein passed out a green double-sided sheet entitled “A Perspective on the Relationship between National and State Single-Payer Work.” He lists seven opportunities that state campaigns allow. These include less trouble communicating with legislators, empowering local leadership, the likelihood of media outlets to cover state-based efforts versus national, that state legislators and local politicians as single-payer supporters can influence national leaders and sometimes become Congress people and senators. State programs can be tailored to address local problems such as rural coverage. State programs avoid some of the Washington-based lobbying and rule-making baggage. Saskatchewan is a good model for states. The obstacles for state movements, however, are the federal waivers, particularly for Medicaid and Medicare and SCHIP, ERISA rules, leaving Medicare outside the single payer stream of funding, the risk that waivers can be misused such as has happened when Arkansas fully privatized its Medicaid program, integrating federal workers and retirees, crossing state borders, portability of corporate political power, differences in governance between Canada and the US when thinking of emulating Saskatchewan. Applying the term single-payer to a state program that is compromised by corporate and federal government interference may sully the public image of such reform.
of Stephanie Woolhandler and John McDonnough
by Amy Goodman Monday, October 7, 2013