Trump voters hate Trumpcare
#bettersimplercheaper #healthcareforall #singlepayer

NBC News/WSJ Poll: Just 12% in Key Trump Counties Back GOP Health Care Effort

Just 12 percent of Americans living in the counties that fueled Donald Trump's win in the 2016 presidential election support the Republican Party's efforts on health care, according to results from the NBC News/Wall Street Journal poll of these "Trump counties."

Asked their views on the health care legislation passed by the House of Representatives in May and backed by President Trump, 12 percent of the respondents in these counties — consisting of Republicans, Democrats and independents — called the bill a good idea, while 41 percent said it was a bad idea. Forty-seven percent had no opinion or say they’re not sure.

Even among Trump voters in these counties, only 25 percent believe the House GOP health care bill is a good idea, 16 percent think it’s a bad idea and 59 percent have no opinion or are unsure.

That’s compared with 75 percent of Hillary Clinton voters in these counties, who say the legislation is a bad idea, zero percent who say it’s a good idea and 26 percent who have no opinion or are unsure.

Last month’s national NBC/WSJ poll found that 16 percent of all Americans called the House bill a good idea, versus 48 percent who see it as a bad idea.

“It was kind of like they were walking a plank that they knew they were going to fall off from,” Democratic pollster Fred Yang said of Republican lawmakers who voted for this legislation. Yang and his firm Hart Research Associates conducted this NBC/WSJ poll with the GOP polling firm Public Opinion Strategies.

Senate Republican efforts to repeal and replace the Affordable Care Act collapsed Monday night, while another plan — a simple repeal of Obamacare with no replacement — was effectively killed Tuesday when three senators came out against it.

This NBC/WSJ poll's sample was taken from 439 counties in 16 states — Colorado, Florida, Georgia, Indiana, Iowa, Maine, Michigan, Minnesota, Missouri, Nevada, New Hampshire, North Carolina, Ohio, Pennsylvania, Virginia and Wisconsin — that either flipped from President Barack Obama to Trump, or where Trump greatly outpaced Mitt Romney's performance in 2012.

And there’s little difference in views of the GOP health care effort in these two different kinds of Trump counties.

In the “surge” counties, 13 percent of adults think the House legislation is a good idea.

And in the “flip” counties, just 12 percent think the bill is a good idea.

The rest of this NBC/WSJ poll – which was conducted July 8-12 of 600 adults in these counties, and has an overall margin of error of plus-minus 4.0 percentage points – will be released Wednesday morning.

In "Flip" counties, 342 interviews were conducted, which has a margin of error of plus-minus 5.3 percentage points. And in "Surge" counties, 258 interviews were conducted, and the margin of error there is plus-minus 6.1 percentage points. 

Medicare Advantage: fleece the healthy, dump the sick
#bettersimplercheaper #healthcareforall #singlepayer

As Seniors Get Sicker, They're More Likely To Drop Medicare Advantage Plans

When Sol Shipotow enrolled in a new Medicare Advantage health plan earlier this year, he expected to keep the doctor who treats his serious eye condition.

"That turned out not to be so," said Shipotow, 83, who lives in Bensalem, Pa.

Shipotow said he had to scramble to get back onto a health plan that he could afford and that his longtime eye specialist would accept. "You have to really understand your policy," he said. "I thought it was the same coverage."

Boosters say that privately-run Medicare Advantage plans, which enroll about one-third of all people eligible for Medicare, offer good value. They strive to keep patients healthy by coordinating their medical care through cost-conscious networks of doctors and hospitals.

But some critics argue the plans can prove risky for seniors in poor or declining health, or those like Shipotow who need to see specialists, because they often face hurdles getting access.

A recent report by the Government Accountability Office, the auditing arm of Congress, adds new weight to criticisms that some health plans may leave sicker patients worse off.

The GAO report, released this spring, reviewed 126 Medicare Advantage plans and found that 35 of them had disproportionately high numbers of sicker people dropping out. Patients cited difficulty with access to "preferred doctors and hospitals" or other medical care as the leading reasons for leaving.

"People who are sicker are much more likely to leave [Medicare Advantage plans] than people who are healthier," James Cosgrove, director of the GAO's health care analysis, said in explaining the research.

David Lipschutz, an attorney at the Center for Medicare Advocacy, says the GAO findings were alarming and should prompt tighter government oversight.

"A Medicare Advantage plan sponsor does not have an evergreen right to participate in and profit from the Medicare program, particularly if it is providing poor care," Lipschutz says.

The GAO did not name the 35 health plans, though it urged federal health officials to consider a large exodus from a plan as a possible sign of substandard care. Most of the 35 health plans were relatively small, with 15,000 members or fewer, and had received poor scores on other government quality measures, the report said. Two dozen plans saw 1 in 5 patients leave in 2014, much higher turnover than normal, the GAO found.

Medicare Advantage plans now treat more than 19 million patients and are expected to grow as record numbers of baby boomers reach retirement age.

Kristine Grow, a spokeswoman for America's Health Insurance Plans, an industry trade group, says Medicare Advantage keeps expanding because most people who sign up are satisfied with the care they receive.

She says patients in the GAO study mostly switched from one health plan to another because they got a better deal, either through cheaper or more inclusive coverage.

Grow says many Medicare Advantage plans offer members extra benefits not covered by standard Medicare, such as fitness club memberships or vision or dental care, and do a better job of coordinating medical care to keep people active and out of hospitals.

"We have to remember these are plans working hard to deliver the best care they can," Grow says. Insurers compete vigorously for business and "want to keep members for the long term," she adds.

Some seniors, wary of problems ahead, are choosing to go with traditional Medicare coverage. Pittsburgh resident Marcy Grupp says she mulled over proposals from Medicare Advantage plans but worried she might need orthopedic or other specialized health care and wanted the freedom to go to any doctor or hospital. She decided on standard Medicare coverage and paid for a "Medigap" policy to pick up any uncovered charges.

"Everything is already in place," says Grupp, a former administrative assistant who turns 65 this month.

The GAO report on Medicare Advantage comes as federal officials are ramping up fines and other penalties against errant health plans.

In the first two months of this year, for instance, the federal Centers for Medicare and Medicaid Services fined 10 Medicare Advantage health plans a total of more than $4.1 million for alleged misconduct that "delayed or denied access" to covered benefits, mostly prescription drugs.


SHOTS - HEALTH NEWS
Medicare Advantage Insurers Settle Whistleblower Suit For $32 Million

In some of these cases, health plans charged patients too much for drugs or failed to advise them of their right to appeal denials of medical services, according to government records. Industry watchers predict more penalties are to come.

Last month, CMS officials ended a 16-month ban on enrollment in Cigna's Medicare Advantage plans. CMS took the action after citing Cigna for "widespread and systematic failures" to provide necessary medical care and prescription drugs, policies officials called a "serious threat to enrollee health and safety."

A flurry of whistleblower lawsuits have surfaced, too. In late May, Freedom Health, a Florida Medicare Advantage insurer, agreed to pay nearly $32 million to settle allegations that it exaggerated how sick some patients were to boost profits, while getting rid of others who cost a lot to treat.

Freedom Health allegedly kept a list of some "unprofitable" patients that it discouraged from staying in the health plan, while encouraging healthier, "more profitable" members to remain, according to the whistleblower suit. Federal regulations prohibit health plans from discriminating based on a person's health.

Asked by Kaiser Health News for comment, Freedom Health corporate counsel Bijal Patel emailed a statement that read, in part: "We agreed to resolve the case so that we can continue focusing on providing excellent care."

Casey Schwarz, a lawyer with the Medicare Rights Center, a consumer service organization, notes that health plans are required to have a formal process for patients to appeal denials of medical services. She says patients should know their rights and insist on them.

"We want people to vote with their feet and leave plans not serving them," Schwarz says.


Kaiser Health News, a nonprofit health newsroom whose stories appear in news outlets nationwide, is an editorially independent part of the Kaiser Family Foundation.

Washington Post gets it wrong: Single Payer is the only affordable, sustainable health system reform

Washington Post gets it wrong: 

Single Payer is the only affordable, sustainable health system reform

The Washington Post's View Opinion
#bettersimplercheaper #healthcareforall #singlepayer

OBAMACARE LOOKS shaky, mostly because Republicans are sabotaging it. This, in turn, has rekindled calls on the left to create a European-style “single-payer” system, in which the government directly pays for every American’s health care. California lawmakers, for example, are considering such a plan for their state.
The single-payer model has some strong advantages. It is much simpler for most people — no more insurance forms or related hassles. Employers would no longer be mixed up in providing health-care benefits, and taxpayers would no longer subsidize that form of private compensation. Government experts could conduct research on treatments and use that information to directly cut costs across the system.
But the government’s price tag would be astonishing. When Sen. Bernie Sanders (I-Vt.) proposed a “Medicare for all” health plan in his presidential campaign, the nonpartisan Urban Institute figured that it would raise government spending by $32 trillion over 10 years, requiring a tax increase so huge that even the democratic socialist Mr. Sanders did not propose anything close to it.
Single-payer advocates counter that government-run health systems in other developed countries spend much less than the United States does on its complex public-private arrangement. They say that if the United States adopted a European model, it could expand coverage to everyone by realizing a mountain of savings with no measureable decline in health outcomes, in part because excessive administrative costs and profit would be wrung from the system.

In fact, the savings would be less dramatic; the Urban Institute’s projections are closer to reality. The public piece of the American health-care system has not proven itself to be particularly cost-efficient. On a per capita basis, U.S. government health programs alone spend more than Canada, Australia, France and Britain each do on their entire health systems. That means the U.S. government spends more per American to cover a slice of the population than other governments spend per citizen to cover all of theirs. Simply expanding Medicare to all would not automatically result in a radically more efficient health-care system. Something else would have to change.

The Congressional Budget Office has released its score on the revised American Health Care Act. Here's what's in the report.
With monopoly buying power, the government could tighten up on health-care spending by dictating prices for services and drugs. But the government already has a lot of leverage. A big reason it does not clamp down now on health-care spending is that it is hard to do so politically.
Republicans have tarred the Affordable Care Act’s Medicare cuts as attacks on the cherished entitlement program. Doctors and hospitals have effectively resisted efforts to scale back the reimbursements they get from federal health programs. Small-town America does not want to give up expensive medical facilities that serve relatively few people in rural areas. A tax on medical device makers has been under bipartisan attack ever since it passed, as has the “Cadillac tax” on expensive health-insurance plans. When experts find that a treatment is too costly relative to the health benefits it provides, patients accustomed to receiving that treatment and medical organizations with a stake in the status quo rise up to demand it continue to be paid for.
A single-payer health-care system would face all of these political barriers to cost-saving reform and more. To realize the single-payer dream of coverage for all and big savings, medical industry players, including doctors, would likely have to get paid less and patients would have to accept different standards of access and comfort. There is little evidence most Americans are willing to accept such tradeoffs.

The goal still must be universal coverage and cost restraint. But no matter whether the government or some combination of parties is paying, that restraint will come slowly, with cuts to the rate of increase in medical costs that make the system more affordable over time. There are many options short of a disruptive takeover: the government can change how care is delivered, determine which treatments should be covered, control quality at hospitals, drive down drug costs and discourage high-cost health-care plans even while making the Obamacare system better at filling coverage gaps. 

What is the opportunity cost of doing heath care business American style?

Question - What is the opportunity cost of doing heath care business American style (i.e., with poor quality and inefficiency)?

Answer - American health care business as usual is costing the American taxpayer $1 trillion per year in quality and efficiency waste.  

#bettersimplercheaper #healthcareforall #singlepayer

Health care costs are the principal cause of the federal deficit. And health care costs crowd out other needed public services at all levels of government.  
Public spending on education, for instance, had it been optimal beginning with the first President Bush, could have provided a whole generation of Americans with better training and preparation for the 21st Century economy, which in turn could have improved our economic productivity as a nation.
 In summary, wasteful health care practices in the US are causing our government to fall into debt and shrinking our national ability to improve our productivity, dampening down economic growth by as much as 20% or $3 trillion/year.

From CBS News: Could Trumpcare affect employer-based health benefits?

From CBS News: Could Trumpcare affect employer-based health benefits?
#bettersimplercheaper #healthcareforall #singlepayer

Most of the conversation about the House GOP-passed health care plan concerned those buying insurance in the individual marketplace. But approximately half of all Americans have health insurance provided through their employers, so, how would the American Health Care Act affect their coverage if it were to become law?

The bill as it stands would have the potential to alter insurance coverage in two major areas — by nixing coverage requirements for employees at larger companies, and by — theoretically — making it possible for employees at larger companies to have to pay an unlimited amount for so-called "essential" health care benefits out of pocket.

On the first point, employees would no longer be guaranteed health insurance because their companies would no longer be required to provide it. The ACHA rolls back a key Affordable Care Act provision that required businesses with 50 or more employees to provide health insurance to employees working 30 hours or more a week. That was a long-expected provision of any GOP Obamacare repeal. Conservatives hope the rollback of that Obamacare stipulation will fuel growth in companies that were cautious to hire, or cut employee hours, so they wouldn't have to provide costly health care.

But the rollback of that Obamacare provision may not have a widespread effect, said Larry Levitt, senior vice president at the Kaiser Family Foundation.

"Most large employers offered insurance before the ACA, and will likely continue to," Levitt said. "It's really more on the margins that the employer mandate had an effect, in some lower-wage industries like retail, and restaurants and agriculture that were least likely to offer insurance."
That implication is pretty straightforward.

The slightly-more-complex implication of the House GOP bill on employer-based coverage means employees at large companies could theoretically pay an unlimited amount for health care on an annual or lifetime basis.

Here's how that could happen, according to Levitt and other health care experts.

Under current law, individuals are protected from spending a fortune on health care because their annual and lifetime expenses for so-called "essential" or "standard" benefits — things considered basic, like hospitalization, newborn care and prescription drugs — are capped. On top of that, under Obamacare, large businesses are prohibited from capping how much they will shell out for employees' essential benefit expenses, annually and throughout their lifetimes.

States each have their own definitions of what qualifies as an "essential" benefit. Larger companies up to this point, unlike smaller companies that must stick with their own state's standards for essential care, have been able to use any state's definition of essential benefits, no matter the business' location. Until now, such insurance shopping hasn't mattered much, since states' definitions of essential benefits vary little.

But the AHCA allows states to apply to the federal government for waivers to alter or eliminate entirely their definitions of essential benefits. States must prove to the federal government that such a waiver would reduce average premiums, increase enrollment, stabilize the health insurance coverage market or increase the choice of health plans in the state. Given the Trump administration's inclination to give states' leniency in executing policy, it would probably also be inclined to grant states waivers, said Matthew Fiedler, a fellow with the Center for Health Policy at the Brookings Institution.

"If this became law -- which is obviously a big if -- that's a likely outcome," Fiedler said.
Here's the catch — if even one state successfully eliminates its definitions of essential benefits and declares that no benefits are essential, then any large company could defer to that state's definition and no longer have any cap on what employees pay out-of-pocket for "essential" benefits. This would effectively eliminate their legal requirement to cover unlimited essential benefits. There would simply be no essential benefits to cap.

"If one state waived the essential benefits entirely, then the employer could essentially require patients to pay an unlimited amount under their insurance plan, because no benefits would count as essential benefits anymore," Levitt said.

But Jim Capretta, a resident fellow at the free markets-focused American Enterprise Institute, said such a doomsday scenario of the GOP unraveling employer-based health care is unlikely.
"I think the idea that there's going to be this wholesale unwinding in protections in the employer system is very overrated," Capretta said.

Generally, employers want to offer benefits that are "attractive" to employees, Capretta said. Employer-based health care, he said, is driven "more heavily by employers wanting to offer benefits that are attractive to workers" than by government mandate.

It's unclear, however, what will happen to the House GOP bill in the Senate. Senators have indicated they will make significant changes to the bill, if not write their own bill entirely.

Basic facts and premises about health system reform: the how and why of single payer

Basic facts and premises about health system reform: the how and why of single payer
#bettersimplercheaper #healthcareforall #singlepayer

My friend, Lavarr Webb, published a comment about health system reform on his website "Utah Policy" this morning (May 9, 2017). It takes courage to speak up about health care, given that emotions are running high. I admire his willingness to further the public discussion about this issue, which I believe is the most important domestic policy problem the US faces. But I believe he has incorrectly characterized or misunderstood what the problem really is. Here is what he said paragraph by paragraph, followed (in parentheses) by my responses:

. . . the national furor over health reform all across the country, demonstrates how emotional and difficult this issue has become. It’s nearly impossible to stake out a sensible position that attracts widespread support, that responsibly deals with the healthcare crisis, while not requiring massive tax increases or running up the national debt.

(Naturally healthcare is an emotional issue. Few public policies hit closer to home than how or whether patients receive needed care for illness and injury. There is a position on healthcare that numerous polls over many years have shown has widespread support: single payer. And no, single payer health reform is not irresponsible. It will not require massive tax increases or a ballooning national debt. Supporting the status quo, business as usual in American health care, however, is irresponsible. It has always led to massive tax increases and is solely responsible for the growing federal deficit. Both democrats and republicans are and continue to be responsible for the disaster that is American health care, largely because elected officials from both parties have refused to even consider, much less debate and legislate, single payer health system reform.)

In the massive uprising against the healthcare plan just passed by the U.S. House, it’s easy to forget that Obamacare, in many ways, was a disaster. It was so unpopular that it contributed significantly to big Democratic losses in Congress and Republicans winning control over Congress and the presidency.
(There is surprisingly little difference between the American Health Care Act (which I will call Trumpcare)
and the Affordable Care Act (which most call Obamacare). House Republicans actually did not repeal most of Obamacare-6 of 10 titles in the Affordable Care Act were not even touched by the recently passed AHCA legislation. The uproar over Trumpcare is largely symbolic, partisan bickering. Both are bad policy, because both prop up business as usual in American healthcare, especially the private, for-profit health insurance business model. Yes, Obamacare was failing, because health insurance is a failed business model that only ever survived because of massive government subsidies coupled with most favored business treatment in laws and regulations. For the same reasons, Trumpcare is doomed to failure. Ds who are defending Obamacare and Rs who are promoting Trumpcare are both doing a disservice to American patients (meaning all of us at some point in our lives). Bickering between the two parties over health care is partisanship at its worst. There is no meaningful difference between the two parties on health care. In order to achieve real change in our health system the voters will need to throw members of Congress from both parties out of office.)

But Obamacare did bring a lot more people into the system of government benefits. And despite its many flaws, the Obamacare mandate that everyone buy health insurance, and everyone is covered in some fashion, created and strengthened the notion that healthcare access is an absolute right that everyone should enjoy, at a price they can afford, no matter their situation in life.

 (Obamacare mostly brought people into 'coverage' or 'healthcare access' through Medicaid, not the mandate to buy insurance. Tens of millions were still left out in the cold, without coverage, after implementation of Obamacare. Those who managed to get coverage quickly realized that the 'coverage' offered was a useless financial gimmick which did not protect them from financial disaster in the event of injury or illness and cost them more than they could afford anyway. It has become common among advocates to describe 'healthcare access' as a right, but of course that is not literally true. First of all, no one needs 'healthcare access' or health insurance, but everyone needs health care. The rights of Americans are listed in the Constitution, and health care is not among them. However, there is no right to asphalt in the Constitution either. None-the-less, I can drive from my house to the White House without interruption because we Americans have long since figured out that roads, highways, and freeways are infrastructure needed for the 21st century. Likewise, we have generously funded health care for decades because it is infrastructure needed to make pursuit of life, liberty, and happiness possible.)

Once a government benefit has been extended, it’s nearly impossible to withdraw it. Thus, as other commentators have stated, we’ve crossed a critical tipping point in this country. Everyone must have access to full medical benefits. And society (that’s you and me) must pay for it.

 (No better illustration of this point about the impossibility of withdrawing a government benefit exists than the failure of Congress to withdraw the massive employer tax credits supporting the purchase of health benefits for employees after WWII. Offering tax free health insurance was a way for employers to recruit women to work in the factories producing needed war materiel during the war without raising wages and causing inflation. That tax credit is now worth $500 billion each year and is the principle reason why health insurance became the featured health financing business model in the US. When its costs are combined with those of tax funded programs like Medicare, Medicaid, CHIP, public employee health benefits, VA health care, etc, etc, etc, it is easy to see how Americans have come to be taxed at higher levels for health care than any other citizenry. $2 trillion in taxes are spent annually on health care in the US, out of total health care spending each year of $3 trillion. We don't need more tax money to fund American health care, we need to spend the already available public funds more efficiently. But efficiency is not possible with the for-profit health insurance business model, where overhead is routinely more than 25%. In contrast, Medicare overhead is more like 2% to 3%. Single payer health reform is administratively efficient and thus fiscally conservative.)

The trouble is, the only truly effective way to ensure that everyone has full access to healthcare is through a single-payer system. Essentially, put everyone on Medicare. That’s what the Democrats really want. And that may be where we’re headed.

(That's not what the democrats really want. Twice in my lifetime there has been a democrat in the White House and democrats leading both houses of Congress, both times with serious mandates from the electorate to do something about health system reform. Neither Pres. Clinton nor Pres. Obama even mentioned single payer. Single payer advocates were arrested by democrat members of the US Senate when they showed up at Senate Finance Hearings in 2009. Democrats as much as Republicans have acted to prop up the health insurance business model, repeatedly, down to their present defense of Obamacare. But single payer is what the American people want, according to polling from several different sources. And it is the only truly effective way to ensure that everyone has healthcare, and not just access to 'coverage'.)


Republicans want a market-based system. But we’ll never have a true free enterprise system in healthcare as long as employers provide health insurance and as long as insurance pays for most healthcare needs. If insurance provided only catastrophic coverage, and we paid for most procedures out of our own pockets, then free-market incentives would be injected into the system. We’d shop around and pay attention to what various health services cost.

(Both democrats and republicans want a 'market-based health care system' because the biggest source of political donations is the medical industrial complex. Politicians of both parties are paid to have the opinion that market forces will solve our health system problems. Trouble is, health care is not a commodity efficiently distributed through a free market. None of the prerequisites required for market efficiency are true of health care. Patients are not shoppers, or buyers who can beware. Doctors are not (or should not be) sellers who are self-interested. The transaction between 'buyer' and 'seller' in healthcare affects everyone

 (an economic principle called positive externality) and not just when the patient has tuberculosis or some other communicable disease which could infect others. The vast majority of health care dollars are spent in 'catastrophic' situations (trauma, heart attacks, strokes, etc) and most procedures, even common ones like appendectomies, are priced way out of the buying power of middle class Americans. Thus, the idea that catastrophic, individually owned health insurance

 (no employer benefit) will create a market situation is simply bogus. Further, care of chronic conditions, like diabetes, determines the frequency of catastrophic events, like heart attacks and stroke. So leaving every patient to fend for herself in 'shopping' and paying for care is foolishly increasing the rate we will need to use our pooled resources to care for emergencies. Finally, what healthcare actually costs is not at all related to what prices are set by the sellers. Because, unlike a real market commodity, there is no inverse relationship between demand for health care and its price. Nobody buys an appendectomy because it is on sale. And no price is too high for an appendectomy when in fact you have appendicitis. Also unlike a market, high quality care costs less than poor quality care. We have mediocre care in the US: too many clinically inappropriate services, too many patient injuries, and too few hospitals and clinics that consistently deliver care based upon current clinical science. And therefore we have highest costs in the world. Real health system reform begins with acknowledging that health care is not a market commodity and then improves health care quality and makes health care financing efficient.)

Healthcare has not been a free market system for many decades, and probably will never be. We’re not smart healthcare consumers. (Healthcare delivery has never been a free market system and never can be. Beginning with the massive tax credits which propped up the growth of the private for-profit health insurance business model from its very beginning, and on through the Hill-Burton Act which financed hospital construction across the nation, and continuing through the myriad of state, local, and federal health programs of today, everything about our health system that works at all is attributable to public funding. The private sector in health care has profiteered (in windfall style) from healthcare delivery in the US. Warren Buffet calls our medical industrial complex a worm eating away at the inside of the American economy. Indeed, American business is made less internationally competitive by our stupid insistence on employment health benefits. The problem is not that Americans are poor healthcare consumers. People in need of healthcare are patients, not consumers, shoppers, or buyers. Even with the internet, there is no way for a patient to arm him/herself with the clinical judgment necessary to make even simple decisions about their own care. Doctors are trained for a decade in order to prepare to make those decisions for their patients.)
Perhaps the U.S. Senate can cobble together some miracle system that gets everyone covered, despite pre-existing conditions, and does it without busting the budget or massively raising taxes. But I doubt it. (Correct. There will be no miracle from the US Senate. As long as the premise remains that health policy must be market-based, must prop up health insurance, and must be federal, there can be no good legislative outcome. The budget is already busted with the health care status quo. All of the federal debt on into the future is driven by the growing corporate welfare given to the medical industrial complex by politicians from both parties. )

It may take a few years, but we’re probably headed to a single-payer system. And if everyone has coverage for everything, there will be little incentive to be wise healthcare consumers. To make up for this defect, the system will impose its own controls. Healthcare will have to be rationed. Panels of doctors (the infamous death panels) will determine what levels of care are appropriate in what situations – and what prices will be. (This is the dystopian nonsense that has kept anyone from seriously discussing single payer. Look at every country that already has single payer health care. They spend far less than we do, they have better outcomes, and they routinely rate their health care experiences higher than do Americans. None of their citizens are going bankrupt because of illness or injury. They don't fund needed health services with bake sales or gofundme accounts. Single payer allows for setting prices that are truly related to what health goods and services actually cost. As opposed to American health care business as usual, where prices for a drug can rise 1000% overnight. Death panels have always been a scare tactic by the naysayers. What is really scary is that business as usual in American health care leads to the unnecessary death of more than 100,000 patients each year who die of preventable injuries while they are hospitalized. If the safety record of American hospitals were to be superimposed on the airline industry we would have a 747 crash every other week. That is what is truly frightening. Stop with the death panel nonsense.)

As in other countries with single-payer systems, we will see shortages and long waits for procedures. Market incentives to improve service and innovate will not exist.

(We have shortages in the US. Rationing happens in every health care system, but especially in our faux market system. We ration by ability to pay, meaning that for many, many Americans, there is no queu that they can even get into. And for those who can pay, they often receive too much service, also at an enormous cost of life and limb, and money. We Americans have a health care system that would rather make a sale than care for a patient. Here, with perverse market incentives, we allow our patients with pneumonia to become more sick than necessary, because a hospital make more money when a patient hits the ICU.)

But everyone will have some government-determined level of healthcare access and service. Wealthy people, of course, will be able to pay for the best healthcare in the world. (The best healthcare in the world is not possible, even for the most wealthy individual, without a society that pays to make it possible. No one can anticipate what kind of care they might need, or when they might need it. Having all kinds of expensive care always available is out of the reach of even Bill Gates. It is only available in first world economies where resources can be consistently devoted thereto. Public funds should only be used for care proven to be safe and effective, and then only the cheapest alternative, which is always the highest quality. Because, remember, high quality health care costs less, not more. Wealthy people will, likely, pay for that new, unproven treatment, but they will suffer the consequences too.)

The system of healthcare we had before Obamacare had all kinds of problems. Responsible people recognized we were in a healthcare crisis. While solving some problems, Obamacare created a lot of new ones. The House plan made some improvements, but many flaws remain. The Senate is going to struggle mightily to do any better. (Obamacare solved nothing. Trumpcare is no different. We will not fall into single payer health reform because of these policy failures. Those profiting from the status quo have enormous resources. There will be much heavy political lifting before single payer can be achieved. My preference, because it is constitutionally conservative, is that a state based system be allowed to evolve. California already has a single payer bill before its legislature. The US Senate would do all of us a favor by passing legislation to enable state based single payer health system reform.)

I suspect the healthcare issue is going to cause political headaches for many years to come. (I hope so. I hope that politicians from both parties begin losing elections over their poor health care policies.) - Dr Joe Jarvis

Time to face facts

Time to face facts. Americans don't need this financial product

We cannot vote away scarcity.

Our ongoing troubles with health care stem from an unwillingness to deal with certain facts. One of those facts is scarcity. “Scarcity” is a term from economics, and it refers to the fact that there is never enough of anything to satisfy every possible desire — the universe holds only so much, and human desire has a way of outgrowing whatever we have. So we have to come up with a way of dividing up that which is scarce. We have tried many different ways of doing that — war, caste systems, central planning — though mostly we’ve relied on the fact that everybody wants lots of different things, which makes it possible to trade. But buying and selling stuff is not, to be sure, the only way to divide up that which is scarce. Medical care is scarce: There are only so many doctors and hospital rooms; the pill factories can make only so many pills, and there are real limitations on the raw materials used to make those pills; heart stents don’t grow on trees, but, even if they did, they would be scarce, like apples and oranges and pears and avocados. An example: A few years ago, a friend of mine was deathly sick with a chronic cardiac condition. He learned that a doctor in another country — on another continent — had developed an experimental treatment for his condition. The chances of its working were not very high, but it had worked on others. The problem was, there were something like three doctors in the world who did that procedure, and approximately one who had done it with a great deal of success. His insurance would not pay for it, and the public-health system in his country would not even think of paying for it. But my friend was vastly wealthy, so he called up that doctor, offered him what I assume was a very large sum of money, put him on an airplane, and rented out space in the finest private hospital money could buy. Unhappily, the procedure was not successful, and he died.

(Scarcity is an economic reality. It is a fact. But the example used here, an experimental treatment known only to three physicians in the entire world, is not a fact. It is not even a theory. Clinical science is not created just because someone somewhere can dream up possible treatments for serious human conditions. A dying man grasping at straws is an existential crisis not an illustration of scarcity in health care delivery. Known clinical science can be delivered, routinely, to most if not all members of the same society. We do not require that health care financing pay for interventions that do not work. If people want copper bracelets to treat arthritis, they should have to pay for them on their own. Public dollars would be wasted on useless gestures, such as described in this example of desparationl)

We cannot offer the same level of care to everybody with the same condition. They number in the millions, and the doctors who can perform that procedure number about three. (Or, at least they did ten years ago.) Even if they worked 16-hour shifts, seven days a week — even if we pressed them into slavery — they could see only so many patients and perform so many procedures, and those would amount to a tiny fraction of the number of people who might benefit from their attention. Because of scarcity, medical care eventually reaches the point where one of three things happens: Somebody puts out his hand and says “Pay me,” an officer of the government or an insurance company refuses to approve some treatment, or you die. Because we are a largely cooperative species, we do not like that very much. It seems unfair and unkind. So we try to make an end run around scarcity with things such as health insurance and government medical plans, both of which are based on the same economic principle: Someone else pays. But scarcity does not care who is paying: Scarcity is scarcity. In the most monopolistic public-health systems (e.g., the ones in the United Kingdom and Canada), there is a lot of saying “No,” though it is what we might call a “Japanese no” — saying “no” without actually saying it. They put you on a waiting list and hope you die before they actually have to say “No,” or they simply expect you to accept that some services and treatments are categorically unavailable. There is a reason New York City’s hospitals are full of rich Canadians who cannot afford the free health care at home. But a polite, indirect “No” is still a “No.” No means no. Insurance companies say “No” all the time, and we hate them for it. That is because of another fact that we refuse to deal with like mature, responsible adults: Insurance is not a medical product — it is a financial product.

(Agree-health insurance is a financial product, one that has been extraordinarily profitable. No one needs this financial product. People do need healthcare. And therefore people need a way to finance healthcare. Among the various ways to finance healthcare ever invented, health insurance is the most wasteful and useless. Since this article in National Review is allegedly about facts concerning health care delivery that need to be faced, let's face this fact: Americans waste $400 billion per year paying for the wasteful administrative practices of the health insurance business model. How much actual health care scarcity could that $400 billion each year pay for? Another fact: rich Canadians are not filling up New York City hospitals. There is zero evidence that that is the case. Another fact: at least Canadians seeking health care have a line that they can queu into. Millions of Americans can not even get into a line despite the fact that we outspend Canadians two to one for health care. Really, we spend twice as much on health care as do Canadians. And yet they have greater satisfaction with their health care system than do we and they have better results than do we. It is a fact that we Americans would be better off spending half as much on health care and getting better care than we are now. So let's get rid of the useless financial product that we don't need that is costing so much and killing us. Let's get rid of the health insurance business model.)

Most of us do not need to spend a great deal of money on health care during any given year for most of our lives. I myself pay for most of my medical expenses out-of-pocket, and, in any given year, they rarely add up to what my health-insurance premiums cost. But I do not have health insurance, and pay premiums for that health insurance, in order to have somebody else pay for my annual check-up or routine dental work. I have insurance because I might get hit by a bus or cancer or a heart attack, and, secondarily, because one day I will be old, if I am lucky, and old people have lots of medical expenses. Scarcity exists because of the nature of the physical universe, not because insurance executives are big meanies. Scarcity exists because of the nature of the physical universe, not because insurance executives are big meanies. (It’s okay to hate insurance executives — everybody hates insurance executives.) Insurance companies have to say “No” a great deal, whether they are run by nice people or by the sort of people who ordinarily run insurance companies. The Canadian government health-care system is in essence a big, generous insurance company owned by its customers and perfectly happy to run large losses indefinitely, and it still has to say “No” pretty often. Putting mandates on insurance companies is not a cure for scarcity. Sometimes, it makes things worse. Insurance companies operate by making a very careful study of actuarial information, which allows them to make remarkably accurate predictions about the medical needs of large populations with known demographic characteristics. Nobody knows whether any given 60-year-old man will have a heart attack this year, but stack up 10 million of them, and the pointy-headed actuarial nerds can tell you with a high degree of accuracy how many of them will. But we want insurance to be something different: We want it to be the conqueror of scarcity. So we do things like mandate coverage of preexisting medical conditions, which is to say, we demand that they place bets against things that already have happened. The usual metaphor here is offering fire insurance after the house already has burned down, and that is apt. We are asking them to bet against the Patriots in the 2017 Super Bowl after the fact, in 2018, in 2019, 2020, etc.

(No, I don't want health insurers at all. The bets they place and the machinations that they put us through are expensive and wasteful. It costs money, my money, for pointy headed actuarial nerds and the mean insurance executives to come up with their numbers and rules and impose them on me. For what? To put it bluntly, that nerdiness and meanness is only useful to make health insurance profitable, because, remember, it is a financial product, not a health product. I want my public dollars to go for something we actually need, like health care, not a financial product. Health insurance as the massive, principle health financing business model in the US would not exist at all if it had not been propped up for 75 years by US tax policy. We Americans have been giving away $500 billion per year in the form of tax credits to employers who purchase health insurance for their employees. And health insurers take that half trillion and waste it on a business model that is useless.)

What might a health-care program that deals with reality look like? We could probably lower the cost of prescription drugs significantly by making the approval process less cumbrous and expensive, and maybe by tweaking a few intellectual-property procedures. We could do the same with medical devices and the like, though the so-called Affordable Care Act took the opposite approach, taxing those devices and making them scarcer. If we want more doctors, there are probably 1 million top-shelf physicians from around the world who would immigrate to the United States yesterday if we gave them the go-ahead. (Yes, that probably would lower the incomes of native-born doctors; we are going to be adults for the moment, and this is a question of trade-offs.) We could reduce the regulatory burden on insurance companies in an effort to lure more of them into the market, whereas the ACA added to their burdens and drove many of them from the marketplace. We could try to make ordinary, non-emergency medical care more of an ordinary product, one that people pay for the way they pay for food and housing and cars and World of Warcraft expansion packs and the other necessities of modern life, allowing insurance to be insurance: a financial product that helps to mitigate certain risks related to unexpected health-care costs. This would allow for the emergence of robust, competitive, consumer-oriented markets like we have in cellphones and pornography and other innovative markets where choices abound and prices keep going down because the consumer is king. But there will be scarcity. Somebody will put his hand out and say, “Pay me.” This brings up something economists call “elasticity of demand.” That is a fancy way of saying that when you roll into the local BMW dealer and find out that that i8 costs $150,000, you say, “No, thanks,” and you get a Honda Civic instead, but when you are rolled into the emergency room with a broken leg or a non-functioning heart, you don’t talk about prices at all, and, even if you did, you aren’t normally going to say “No” to any price when the alternative is sickness and pain and death. But not every medical procedure is a life-and-death matter, and, even in the matter of serial chronic conditions such as diabetes, there is opportunity for comparison shopping and negotiating. The other kind of medical problem is why you have insurance. We have perfectly functional markets in all sorts of life-and-death goods. They expect you to pay up at the grocery store, too, but poor people are not starving in the American streets, because we came up with this so-crazy-it-just-might-work idea of giving poor people money and money analogues (such as food stamps) to pay for food. It is not a perfect system, but it is preferable, as we know from unhappy experiences abroad, to having the government try to run the farms, as government did in the Soviet Union, or the grocery stores, as government does in hungry, miserable Venezuela. The Apple Store has its shortcomings, to be sure, but I’d rather have a health-care system that looks like the Apple Store than one that looks like a Venezuelan grocery store. There is a certain libertarian tendency to look at messes such as the Affordable Care Act and the American Health Care Act and throw up one’s hands, exclaiming: “Just let markets work!” We should certainly let markets work, but not “just.” We aren’t going to let children with congenital birth defects suffer just because they might have stupid and irresponsible parents, and we are not going to let old people who have outlived their retirement savings die of pneumonia because we don’t want to spend a couple of thousand bucks treating them. But we also do not have a society in which everybody is on Section 8 and food stamps, nor do we want one. Developing sensible, intelligently run, reasonably generous welfare programs for those who cannot or simply have not done it for themselves is a relatively small project, but trying to have government impose some kind of political discipline on the entirety of the health-care system — which is as explicit a part of the current daft Republican health-care program as it is of Obamacare — is a different kind of project entirely. Scarcity is not an economic theory. You can experience it for yourself any time you like, on a desert island or the streets of New York City. It is an aspect of reality, and the health-care reformers eventually will have to get around to taking reality into consideration.

(Now we get to something that is almost like a fact: elasticity of demand does not apply to health care. Demand for cars truly is elastic--a higher priced car will have a lower demand because fewer people can afford the high price. Not so in health care. Demand for open heart surgery remains the same no matter its price because no one wants open heart surgery unless they need it and when they need it, no price is too much. Demand for health care is driven not by price, but by epidemiology. People don't have appendectomies because they are on sale (low price today), they have them because they have abdominal pain and a doctor tells them that their appendicitis will kill them unless they submit to surgery. Health care is not a commodity. Market forces don't work in health care. Patients are not shoppers like patrons in an Apple Store. Most developed nations pay for health care publicly and their hospitals do not look like a Venezuelan grocery store. The false dichotomy presented here is foolish nonsense. Nor can we handle medical welfare as if it is like Section 8 housing or food stamps, given only to the unlucky few. We already fund health care principally by taxation. $2 trillion of our $3 trillion a year health economy is paid for by taxation. That is not a marginal operation, that is how we principally fund health care. That will provide for every American to have medically necessary care. As long as we don't waste that tax money on the useless wasteful business practices of a financial product.)

#bettersimplercheaper #healthcareforall #singlepayer

• Dr Joe Jarvis