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Friday, April 7, 2017

Single Payer is the Clear Choice!

Paul Ryan, Speaker of the House, and his leadership Team, must have been scratching very hard for ‘YES’ votes from their own Party on the disastrous ObamaCare Replacement Act postponed for a vote until Friday, March 24, 2017, and then withdrawn because they did not have the votes to pass it. 
I say this, not just because the poorly written, poorly managed and poorly structured bill is a farce, but because it has now been revealed that an amendment to that Bill from Reps Collins and Faso from Upstate New York was approved by the Speaker to be quickly and quietly allowed into the re-written bill that was then to be presented and passed by a voice vote in the House.  Why?
 It’s not that it is so unusual; it’s very simple really.  It is such a transparent sham because the amendment, although it might eventually benefit other states, was at that moment aimed at “benefiting” just New York State.  It’s somewhat like certain amendments to the Tax Code – it only benefits one group.  Here’s what had to say about it:
The proposal by upstate Republicans Collins and Faso would prevent New York counties from shouldering the cost of Medicaid, leaving the responsibility to the state alone, New York media outlets reported. Collins argued that it would reduce the property tax burden for New Yorkers. ‘Year after year, Albany’s leadership relies on counties to foot the bill for New York State’s out-of-control Medicaid costs,’ Collins said in a statement. ‘Enough is enough’.”
Collins and Faso introduced the amendment with the support of (Republican) Reps. Elise Stefanik, Tom Reed and Claudia Tenney.  The amendment was crucial to getting Faso and Collins’ upstate New York Republican colleagues to support the GOP plan to replace the 2010 health care law signed by former President Barack Obama.”
As Politico reports: “New York State’s Medicaid program is paid for with county, state and federal dollars. The counties pay roughly 13 percent of the total Medicaid budget. Their contribution is capped so the percentage decreases every year. Collins’ amendment, which excludes large municipalities such as New York City, would bar federal reimbursements for state Medicaid funds raised from local governments, shifting roughly $2.3 billion in Medicaid spending from the counties to the state.  ‘Considering Rep. Tenney’s history as a staunch advocate for the taxpayer, this is a great opportunity for her to advocate for real property tax relief for the 22nd District,’ her spokeswoman, Hannah Andrews, said in an email.”
As much as those upstate Republicans want this amendment to be their ticket to being able to cover themselves when they (finally) get to cast an affirmative vote for the American Health Care Act, this is a political deal that benefits no one other than them.  They believe firmly that it gives them enough support from conservative Republicans in their districts to enable them to vote YES on AHCA without losing their districts to Democrats in 2018.  In fact, Rep. Claudia Tenney of the 22nd District was had even declared that she had been leaning to voting “No” on the AHCA, but with this amendment would change her vote to a “Yes.”  Thank you, congresswoman, for telling us exactly what this is – a backroom deal to save your SEAT.
However, the firestorm from congressional and NY state Democrats may not be to their advantage.  Gov. Andrew Cuomo has called them out for forcing the State to come up with an additional $2.3 billion to cover the effects of the amendment plus all the $8 billion it will cost the State if the AHCA is passed.  The DCCC has targeted all of their upstate districts for the 2018 election, declaring: “The House Republican repeal bill is an especially bad deal for New Yorkers, and this backroom amendment is nothing more than politicians putting lipstick on a pig.”  Last, but hardly least, it is not clear that the bill as amended will survive an eventual vote in the House.  If it does, the amendment itself may not be able to be considered by the Senate unless it meets that body’s stricter rules on what can be passed in the Senate by 51 votes rather than 60 votes.
Having given this nod to partisan politics, let us get to the real meat of the healthcare problem.
Have you stopped to consider what a mess we are going through just to maintain a health care system flawed by the free market, private payer myth. Think about it. 
  • Out of 36 developed countries, the USA healthcare system ranks last in terms of the overall efficiency and positive outcomes
  • The ACA was the first major reform that became the law of the land since the introduction of Medicare and Medicaid under LBJ; but the compromises that were necessary to get ACA passed took their toll and the obstructionist Republicans gutted important provisions before it started and after it became law.  The most glaring omission that now is apparent is the lack of a public option that would compete with private plans forcing private insurance companies to offer more competitive plans
  • The ACA has made great strides in covering previously uncovered or poorly insured citizens, extending Medicaid to millions, reforming nefarious practices of insurance companies to restrict sicker people from obtaining or maintaining coverage if they had a pre-existing condition or got very sick; lowering the percentage of premium increase, and requiring certain benefits be in all policies.  However, the resistance of insurance companies to this “interference of the federal government’ into ‘their business’ along with the continuous repeal efforts of the Right-wing Republicans, has resulted in a system that is being sabotaged instead of enhanced.
  • There are flaws in the ACA, of course – for example: restrictions on private plans are too lenient (as demanded by those insurance companies before the bill passed; consumer protection has been almost stripped clean; co-pays and deductibles have not been controlled; and a provision to reimburse insurance companies for early losses was denied funding by Republicans in 2014.
  • Replacement bills – including the latest AHCA -- have been offered by Republicans, but their offerings are so flawed and lacking in substance that it is tragic and laughable at the same time.  As I have said – they know how to obstruct and lie, but they can’t govern because their limited government ideology, and their inability to handle reality and truth, prevent them from doing so.
  • The projected loss of insurance for 14 million people by the end of 2019 is a disaster waiting to happen. 
So, let us come back to basics.  What are we trying to achieve?  What is the purpose we want to accomplish?  What outcomes are we looking to see happen?  Is removing a tax burden from local counties any kind of solution to lack of affordable health care?  Is the abandonment to the states of what must be a federal program – Medicaid – is this the way to ensure equal health care and treatment across our whole land for elderly in long-term care facilities, for persons with developmental or acquired disabilities, for children in poverty? 
Instead of treating healthcare as a set of problems to be solved, we are seeing the politicization of healthcare as something to be manipulated for the gain of drug and insurance conglomerates, small businesses, certain religious denominations, political careers, law firms, lobbying firms, and a host of small and large affiliated businesses, including health care professionals and entities.  Strangely enough, people who need health care, including in need of insurance to help them obtain it, are the last to be considered in this imperative need to reform our measurably-flawed healthcare system. 
So – you ask – what are the basics?  We certainly need to search for some, which is more than the radical Republicans have ever done!  How about we start with the purpose of the Affordable Health Care Act.  Contrary to what I believe should be Title I of every ACT in Congress, Title I of the ACA does not spell out the purpose(s) and outcome(s) of the entire Act.  However, the various Titles do spell out some purposes and here they are, thanks to
  • Quality, affordable health care for all Americans
  • Improving the quality and efficiency of health care
  • Preventing chronic disease and improving public health
  •  Improving access to innovative medical therapies
  •  Community living assistance services and supports
  •  Work Force Development and Training does provide its own version of a purpose statement, when it says:
 “The Affordable Care Act’s main focus is on providing more Americans with access to affordable health insurance, improving the quality of health care and health insurance, regulating the health insurance industry, and reducing health care spending in the US.”
Let’s look next at some of the purposes of a comprehensive health care reform of the recent past to see if any are relevant for our present-day dilemma.
  • Provide health insurance to those who cannot afford it by helping them through subsidies. 
  • Those who meet certain qualifications can buy insurance on an exchange
  • Help businesses offer health insurance to their employees due to tax credits and more   affordable health insurance.
  •  Reduce insurance costs and provide better quality affordable health care to more people.
  • Tax penalty for those who choose not to purchase health insurance
SURPRISE – these are the aims behind the RomneyCare plan in Massachusetts!  Some of these suggestions came directly from the conservative Heritage Foundation.
2)  Let’s take a brief look at a Single-Payer Plan introduced earlier this year into the House by Rep. John Conyers (D) of Michigan:
Expanded & Improved Medicare for All Act
Summary: H.R.676 — 115th Congress (2017-2018).  Introduced in House (01/24/2017)
  • Provide all individuals residing in the United States and U.S. territories with free health care that includes all medically necessary care, such as primary care and prevention, dietary and nutritional therapies, prescription drugs, emergency care, long-term care, mental health services, dental services, and vision care.
  • Only public or nonprofit institutions may participate.
  • Patients may choose from participating physicians and institutions.
  • Health insurers may not sell health insurance that duplicates the benefits provided under this bill, but may sell benefits that are not medically necessary, such as cosmetic surgery benefits.
  • The bill sets forth methods to pay institutional providers and health professionals for services.
  • The program is funded by:
 (1) existing sources of government revenues,
 (2) increasing personal income taxes on the top 5% of income earners,
(3) progressive excise tax on payroll and self-employment income,
(4) a tax on unearned income, and
(5) a tax on stock and bond transactions.
(6) Amounts that would have been appropriated for federal public health care programs, including Medicare and Medicaid, are transferred and appropriated to carry out this bill.
  • The program must give employment transition benefits and assure priority in retraining and job placement to individuals whose jobs are eliminated due to reduced clerical and administrative work under this bill.
  • The Department of Health and Human Services must create a confidential electronic patient record system.
  • The bill establishes a National Board of Universal Quality and Access to provide advice on quality, access, and affordability. 
IF the GOP ever means to deal seriously and professionally with healthcare reform, and the savings that can accrue from such, they must consider a public option single-payer plan with other common-sense provisions that appear in the above plans.  However, if the GOP chooses to remain in a dark place where healthcare is considered something one must earn or merit or take as is (‘junk’ coverage level) because they believe not everyone has the RIGHT of being adequately cared for by professionals or fully covered by insurance -- then they must be met with total resistance and eventual electoral defeat.  Like education, healthcare is enormous enough in its implications to demand a bipartisan effort, expert advice, thorough debate and abundant appropriations that do not skimp on equality, justice and strength of provisions for enrollees.
So, let us turn finally to what a group of health professionals say is an adequate single-payer plan for all Americans.  (This constitutes a summary of a Post that occurred on October 23, 2011 on this site – I encourage you to read it for more detail on each of the following provisions)
What would be some of the savings from a single-payer health care system?  It is estimated by the Physicians for a National Health Program (PNHP) that “the reason we spend more and get less than the rest of the world is because we have a patchwork system of for-profit payers. Private insurers necessarily waste health dollars on things that have nothing to do with care: overhead, underwriting, billing, sales and marketing departments as well as huge profits and exorbitant executive pay. Doctors and hospitals must maintain costly administrative staffs to deal with the bureaucracy. Combined, this needless administration consumes one-third (31 percent) of Americans’ health dollars.   Single-payer financing is the only way to recapture this wasted money. The potential savings on paperwork, more than $400 billion per year, are enough to provide comprehensive coverage to everyone without paying any more than we already do.  Form
 “The ten largest health insurance companies insured roughly 118 million Americans in 2008. Compensation figures suggest that these 10 companies paid over $300 million dollars to their executives in 2009. While this is only a crude estimate, it serves to define a ballpark figure for overall executive compensation: hundreds of millions of dollars, at minimum. This is all money paid for by health insurance premiums that buys little or no health care. Some might call it a money pit for health care dollars.
While Cigna paid their CEO over $14 million to oversee the health coverage of 11.9 million people, Medicare's head, the administrator of the Centers for Medicare and Medicaid Services (CMS) makes around $140,000 a year overseeing the health insurance coverage of 40 million people.
Second, Hospital procedures have grown more costly and doctor's fees have also risen.  PNHP intends that National Health Insurance (NHI) would pay each hospital a monthly lump sum -a global budget - to cover operating expenses.  This amount would be negotiated yearly based on past expenditures, fiscal and clinical performance, projected changes in levels of services, wages and input costs, and proposed innovations.  Hospitals would not be allowed to bill for services covered by NHI, but equally important could not use any of their operating budget for expansion, profit, excessive executive incomes, marketing, or major capital purposes.  Privately-owned hospitals would be converted to non-profits and their owners would be compensated for past investment. This “global budgeting” would virtually eliminate billing, freeing substantial savings for enhanced clinical care.  Prohibiting use of operating funds for capital improvements would eliminate the primary financial incentive for excess interventions and services as well as its opposite (skimping on care) since neither strategy could result in institutional gain.
Third, the PHNP says NHI would include three payment options for physicians and other practitioners:  fee-for-service; salaried positions in institutions; salaried positions within group practices or HMOs.  Privately-funded HMOs and group practices would also be converted to non-profits.  Only institutions that deliver care could receive NHI payments, thus excluding many HMOs and groups that currently sub-contract services but don’t maintain clinical facilities.
The three proposed payment options uncouple physician payment and other operating costs from capital purchases.  Global negotiated budgets for institutional providers would eliminate billing costs; at the same time providing a stable and predictable financial support.  It could also stimulate development of community prevention programs (e.g. smoking cessation). 
Fourth, NHI will cover disabled Americans of all ages for all necessary nursing home and home care.  According to PNHP, a “local public agency in each community would determine eligibility and coordinate care.  Each agency would receive a single budgetary allotment to cover the full array of long term care services in its district.  The agency would contract with long-term care (not-for-profit) providers for the full range of needed services, eliminating the perverse incentives in the current system that often pays for expensive institutional care but not the home-based services that most patients would prefer.”  The program would encourage home and community-based services by supporting the 7 million unpaid caregivers that provide 70% of the care, and by supporting the expanded training of geriatric physicians, nurses and social workers who would assume leadership of this system.
Finally, NHI would pay for all medically necessary prescription drugs and medical supplies, based on a national formulary, established and updated by an expert panel.  The most important provision of this would be the negotiation by NHI with the drug and equipment manufacturers, based on costs (excluding extras like advertising and lobbying costs), resulting in very substantial savings which is not happening under the current multiple private-payer system.
Of course, this single-payer system will not solve all problems; i.e. improvements in environmental and occupational health will not automatically follow; need for improvements in quality will remain; medical school problems of high tuition and lack of minority representation will continue; some physicians will still succumb to temptations to enhance their earnings by encouraging unneeded services.  However, a framework for addressing such problems will be in place. 
However, it’s better than the alternatives, especially better than the multiple private-payer debacle; defined contribution schemes with lower-paid employees forced into skimpy plans; tax supplements and vouchers; turning Medicaid over to states.
An article under the heading of the PNHP concludes: “Incremental changes cannot solve these problems; further reliance on market-based strategies will exacerbate them.  What needs to be changed is the system itself.”
This change to a new system of health care insurance and delivery is still one of the most important steps we could take to save money and thus affect the national budget, to give relief to businesses, to cover all citizens with health insurance, and to literally bring relief to the pocket-books of millions thereby restoring confidence in our healthcare system and increasing the likelihood of better research and innovation than we have seen in a long time.”
Single-payer is the clear choice for reform of healthcare.  TrumpCare is not a choice it is a death sentence!