Posts Tagged ‘uninsured’

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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: 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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The ER is no way to manage health care

October 1st, 2012

During a recent interview on “60 Minutes,” correspondent Scott Pelley asked Republican presidential nominee Mitt Romney  whether the government has a responsibility to provide care to the 50 million uninsured. Romney replied:

“Well, we do provide care for people who don’t have insurance…If someone has a heart attack, they don’t sit in their apartment and – and die. We – we pick them up in an ambulance and take them to the hospital and give them care. And different states have different ways of providing for that care.”

Last night in Santa Monica, I saw the excellent documentary The Waiting Room, after which, director Peter Nicks held a Q&A session. Upon seeing the film, Romney’s comments immediately come to mind. Everyone should see this film, especially anyone who thinks, like Romney, that the hospital emergency room is an adequate place for providing health care.

The Waiting Room, which is playing in Santa Monica through Oct. 4 and in the Bay Area Oct. 19-25, follows 24 hours in the lives of staff and patients at Oakland’s Highland Hospital. Most of the people who come to Highland Hospital are uninsured. Some have lost their jobs. Others are just barely getting by. And because they don’t have insurance, conditions that could have been treated under the care of a regular physician, instead become full-blown problems later on.

Fortunately, federal law mandates hospitals treat people in severe emergencies regardless of whether they are insured. But, as the film shows, most uninsured use the emergency room as their only source of primary care. The ER becomes their only option for treating chronic illnesses. What Romney and others who think like he does don’t recognize is that the ER isn’t designed or equipped to effectively manage people’s health care. The ER is designed to treat traumas. Yet emergency rooms all over the country are being flooded every day with people seeking treatment for minor illnesses and chronic diseases. The wait to be seen can take hours. And when trauma patients are wheeled in, those with less severe ailments are immediately bumped down the list, prolonging their agony and frustration. This is no way to do health care. But in the United States, we have put up with this intolerable situation for decades.

Nicks said that his film is deliberately apolitical. He said he wanted to show the human stories behind the health reform debate. I believe he was effective in doing that. The film has very little commentary. The viewer isn’t emotionally manipulated in one direction or another. The stories of the characters are simply presented as they unfold. Just showing how people navigate through the maddening bureaucracy of our broken healthcare system is enough.

After The Waiting Room‘s theatrical run, it will be shown on PBS. I think the film will open a lot of eyes into a world that is largely invisible to those Americans who have always had the privilege of continuous health coverage. But with the loss of a job, any of us could end up in the ER as the provider of last resort. Once the new federal healthcare law fully kicks in in 2014, the number of people inundating emergency rooms will ease somewhat, as more people become insured through the health exchanges. Yet, the ER will then mainly serve undocumented immigrants, who were shut out of federal health reform. And despite reform, some American citizens will still be unable to access insurance, because their income is too high to qualify for Medicaid or subsidies. The only way to completely ease the burden on our emergency rooms is to establish a national healthcare system, so all people in the U.S. can be treated for their illnesses in a controlled and timely manner.

Sylvia@californiaonecare.org

 

 

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