Posts Tagged ‘Don McCanne’

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A Republican talks about single payer

May 20th, 2013

American College of Cardiology
ACC-in-Touch Blog
April 23, 2013
I Am A Republican… Can We Talk About A Single Payer System?
By David May

I am a Republican. For those who know me that is not a surprise. I live in a red state. I have never voted for a Democratic presidential candidate. I can field strip, clean and reassemble a Remington 12-gauge pump blindfolded. And on top of it, I think we should talk about having a single payer national health care plan. The reason is quite simple. In my view, we already have one; we just don’t take advantage of it.

Firstly, Medicare and the Center for Medicare and Medicaid Services (CMS) are de facto setting all of the rules now. They are a single payer system.  When we go to lobby the Hill, we lobby Congress and CMS.  Talking to Blue Cross, Aetna, Cigna and United Health care is essentially a waste of time. All the third party payers do is play off the Medicare rules to their advantage and profit. They have higher premiums, pay a somewhat higher benefit and have a significantly higher level of regulation which impedes the care of their customers.  This is no longer consumer choice but effectively extortion, a less than hidden shake down in which the “choice” for a family of four is company A at $900 per month or company B at $1100 per month.  The payers are simply taking advantage of the system, playing both ends against the middle.

Secondly, in order to move forward with true health care finance we need complete transparency in cost and expense… and we need it now. As was noted in a recent Time magazine piece on the hidden cost of health care, our current system is a vulgar, less than honorable construct more akin to used car sales than medical care, cloaked under the guise of generally accepted accounting principles and hospital cost shifting.

Thirdly, with a single payer system would potentially come real utilization data, real quality metrics and real accountability. The promise of ICD-10 with all of its difficulties is that of a much more granular claims-made data. We could use some granularity in health care data and we will never achieve it in big data quantities without a single payer system.

Lastly, I think that the physicians should be in charge of health care and not the insurance companies and hospital systems. With a single price structure, it becomes all about medical decision making, efficiency, the provision of care to our patients, and shared decision making, all of which we do well.

How, you might say, could a Republican come to such a position? The simple answer is I really think it is quite Republican.  Oh, I know there will be many raised eyebrows and many critics. I accept that.  I understand the fact that no single payer system is perfect, that it is “socialist,” that it is “un-American.”

I would submit to you, however, that it is un-American to allow many of our citizens to be uninsured, that it is un-American to shunt money away from a strong military in order to support a bloated, inefficient and fraud-laden health care system, that it is un-American not to be open and above board with the cost of what we do, the expense of that service and the profit that we make. Mostly, it is un-American to let this outrageous health care injustice continue.

David May, MD, PhD, FACC,

Chair of the Board of Governors of the American College of Cardiology.

Comment from Don McCanne, MD, of pnhpcalifornia.org:  David May provides an important lesson for those who think that the single payer concept falls on the far left of a linear political spectrum. Society is not linear; it’s four dimensional. If we look at all dimensions, single payer clearly prevails. We can thank Dr. May for shattering the traditional but flawed construct of health care ideology.

This Article and Quote of the Day by Don McCanne is republished by the California OneCare Campaign with thanks to Dr. May, to Don and to Physicians for A National Health Program-California, pnhpcalifornia.org.

Andrew McGuire, Executive Director, California OneCare Campaign

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Don McCanne, MD: Enough specialists for Medicare, but not Medicaid

January 14th, 2013

Healthcare crisis: not enough specialists for the poor

By Anna Gorman

Los Angeles Times, December 15, 2012

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

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

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

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

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

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

http://www.latimes.com/health/la-me-clinic-specialists-20121216,0,5422442,full.story

Comment:

By Don McCanne, MD

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

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

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

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

Re-posted with permission from pnhp.org.

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Don McCanne, MD: Medi-Cal could implode

December 20th, 2012

Court ruling could cut California spending on Medi-Cal

By Maura Dolan and Chris Megerian

Los Angeles Times, December 13, 2012

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

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

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

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

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

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

http://www.latimes.com/news/local/la-me-medi-cal-20121214,0,4784104,full.story

Comment:

By Don McCanne, MD

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

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

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

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

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

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

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

Re-posted with permission from pnhp.org.

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Don McCanne, MD: Six million will face penalties under the Affordable Care Act

October 8th, 2012

Payments of Penalties for Being Uninsured Under the Affordable Care Act

Congressional Budget Office

September 19, 2012

Beginning in 2014, the Affordable Care Act (comprising Public Law 111-148 and the health care provisions of P.L. 111-152) requires most legal residents of the United States to either obtain health insurance or pay a penalty tax. That penalty will be the greater of: a flat dollar amount per person that rises to $695 in 2016 and is indexed by inflation thereafter (the penalty for children will be half that amount and an overall cap will apply to family payments); or a percentage of the household’s income that rises to 2.5 percent for 2016 and subsequent years (also subject to a cap).

The Congressional Budget Office (CBO) and the staff of the Joint Committee on Taxation (JCT) have estimated that about 30 million nonelderly residents will be uninsured in 2016, but the majority of them will not be subject to the penalty tax. Unauthorized immigrants, for example, who are prohibited from receiving almost all Medicaid benefits and all subsidies through the insurance exchanges, are exempted from the mandate to obtain health insurance. Others will be subject to the mandate but exempted from the penalty tax—for example, because they will have income low enough that they are not required to file an income tax return, because they are members of Indian tribes, or because the premium they would have to pay would exceed a specified share of their income (initially 8 percent in 2014 and indexed over time). CBO and JCT estimate that between 18 million and 19 million uninsured people in 2016 will qualify for one or more of those exemptions. Of the remaining 11 million to 12 million uninsured people, some individuals will be granted exemptions from the penalty because of hardship, and others will be exempted from the requirement on the basis of their religious beliefs.

After accounting for those who will not be subject to the penalty tax, CBO and JCT now estimate that about 6 million people will pay a penalty because they are uninsured in 2016 (a figure that includes uninsured dependents who have the penalty paid on their behalf) and that total collections will be about $7 billion in 2016 and average about $8 billion per year over the 2017–2022 period. Those estimates differ from projections that CBO and JCT made in April 2010: About two million more uninsured people are now projected to pay the penalty each year, and collections are now expected to be about $3 billion more per year.

Most of the increase—about 85 percent—in the number of people who are expected to pay the penalty tax stems from changes in CBO and JCT’s baseline projections since April 2010, including the effects of legislation enacted since that time, changes in the economic outlook (primarily a higher unemployment rate and lower wages and salaries), and other technical updates. A small share—about 15 percent—of the increase in the number of uninsured people expected to pay the penalty results from the recent Supreme Court decision. As a result of that decision, CBO and JCT now anticipate that some states will not expand their Medicaid programs at all or will not expand coverage to the full extent authorized by the ACA. Such state decisions are projected to increase the number of uninsured, a small percentage of whom will be subject to the penalty tax.

Among the uninsured individuals subject to the penalty tax, many are expected to voluntarily report on their tax returns that they are uninsured and pay the amount owed. However, other individuals will try to avoid payments. Therefore, the estimates presented here account for likely compliance rates, as well as the ability of the Internal Revenue Service (IRS) to administer and collect the penalty.

CBO and JCT have also updated their estimates of the distribution of those penalty tax payments by income category. Table 1 (in PDF available at link) shows how much of those payments are projected to be made by or on behalf of people who are uninsured in 2016 (which the IRS will collect in 2017) in each of several income categories, measured as percentages of the federal poverty level (FPL). In general, households with lower income will be subject to the flat dollar penalty (with adjustments to account for the lower penalty for children and an overall cap on family payments), and households with higher income will owe a percentage of their income. In 2016, households with income that exceeds 400 percent of the FPL are estimated to constitute about one-third of people paying penalties and to account for about two-thirds of the receipts from those penalties.

http://www.cbo.gov/publication/43628

Comment:

By Don McCanne, MD

When it was decided to use the purchase of private plans as the model for insuring everyone, it was clear that the law must include a requirement to purchase plans and that the threat of assessing a penalty would have to be included to ensure compliance, otherwise adverse selection would have driven insurance premiums up even higher than their current intolerable levels. It was also clear that this still wouldn’t ensure universality because of various exceptions and non-compliance.

We now have a reasonably reliable estimate from the Congressional Budget Office that tells us that 30 million people will remain uninsured and that 6 million of them will be assessed penalties. That is a terrible outcome when considering that a single payer system would have covered everyone automatically, obviating the need for penalties.

Some will note that the penalty is not as onerous as it might have been since two-thirds of the total amount will be paid by households with incomes over 400 percent of the federal poverty level. The fact that more lower income households will be exempt from the penalty is hardly a reason to celebrate when considering that the price they do pay is remaining uninsured.

Re-posted with permission from pnhp.org.

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