INGENIOUS!  ILLEGAL!

It took me a while to figure this one out, and I'm still not sure I have it 100% correct, so bear with me while I explain it step by step -- as much for my benefit as for yours:

The Drug maker Actelion recently had to pay $360 million to settle a government action alleging that it operated an illegal "kickback" scheme. Check on the New York Times article below:

DRUG MAKER HAS TO PAY $360 MILLION

I spent some time trying to understand this, and have come up with the following:

1)  Companies exist to make profits.

2)  The simplest way to make a profit is secure a monopoly on the product. That's essentially what drug makers get when they come up with a drug that does what no others can, or does it better. To reward the company's investment of effort and research, our government gives it a temporary patent, and while it lasts the drug maker charges as much for its medicine as it can get away with.

3)  But what if there are competing products on the market? The drug maker could collude with its competitors to fix prices -- but that's illegal (though some, as we've shown, are trying it anyway). Or it could offer coupons and other discounts to needy patients, thus blunting the public outrage over the price hikes, while they pass the full cost of the medicine onto the insurer, who then passes it on to us. Thus all is well -- at least in corporate board rooms.

4)  But what if that insurer is the Government, and the patient is on Medicare? Government law requires Medicare patients to pay a co-pay, partly to encourage them to choose a less expensive drug, and encourage among drug makers some Competition -- the  dreaded"C" word hated by drug makers.  Therefore many drug makers have come up with an ingenious plan to donate to "charities" that help with drug payments, which is legal so long as there's no collusion between the drug maker and the "charity",  for if any information were shared between them, it could go to swinging business to the drug maker and thus stifle Competition  -- that dreaded "C" word again -- one of the main reasons for the co-pay. Actelion however, ignored the law, got and used info from the "charity." Thus, in this scheme, Actelion got its charitable deduction, and got to pass along the full cost of the medicine to the government, which got stuck with the bill. Actelion got to have its cake and eat it, too. Neat, eh? 

The government doesn't think so, and has gone after not only Actelion, but many other drug companies, including United Therapeutics (who paid $210 million), and our darling, Pfizer ($24 million). Several others have disclosed they also are under investigation. In the Times, we read that

“Pharmaceutical companies cannot have it both ways — they cannot continue to increase drug prices while engaging in conduct designed to defeat the mechanisms that Congress designed to check such prices and then expect Medicare to pay for the ballooning costs,” Joseph H. Hunt, an assistant attorney general for the Justice Department, said in a news release.

And I say, as I've said previously, that if Single-Payer is to do more  than eliminate bureaucratic bloat and the obscene profits of healthcare CEO's, it's going to have to robustly address abuses such as these, together with others that we've detailed on this blog. 

Healthcare workers -- including doctors and nurses, and all those assisting, such as those who produce medical devices -- need to be compensated fairly. That should go without saying, but I need to say it here so I won't be misunderstood when I state that the Profit Motive must be completely eliminated from medicine!

Dio

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IS IT A QUESTION OF EMPATHY?

My daughter makes her living as an acupuncturist, of which she is an acknowledged master, with students coming up from New York to study with her. Some 30 years ago, when she was getting started,  she told me excitedly that the great J.R. Worsely, with whom she had studied, was coming to New York,  and that I had the opportunity to be seen by him if I so desired.  She said he was a great master, who by feeling your pulses, hearing your voice, taking in your odor, your complexion around the temples, and sensing your dominant inappropriate emotion, could tell almost immediately what you were like on the inside – invaluable information for an acupuncturist, who works with energetic imbalances.  JR , as they called him, was the man who single-handedly had brought the ancient Taoist discipline of five-element acupuncture to the West.  My daughter had told me much about him, so naturally I was curious and looked forward to meeting him.

But when the day arrived, and the Great Man strolled into the examination room, I took an instant dislike to him, though to this day I  don’t understand why.                                 

He looked me over, felt my pulses and then pronounced:  “You are a self-absorbed person lacking in empathy and compassion. What’s most important to you is what you want at any particular moment.”

I said nothing, but inwardly I flared. How dare he? How could he, when I had spent my life consciously struggling to be none of those things?  Later, after I had calmed down, I asked myself, could one be born with a lack of compassion? 

They say that poor people give to charity a much greater portion of their means than do the rich.  And when a poor person is braving death because she or he can’t afford the care that would cure them, their poverty-stricken neighbors, to help them, are far more likely to offer what little they can than would someone better off.  I suppose the reason is that having suffered hardships themselves, they know what it feels like.  

But people with money have spent their lives trying to distance themselves from exigencies of the poor. They have their own corporate insurance, thank you very much, and the plight of the poor is far from their minds.  As they approach the office buildings where they are employed, they resent being importuned by beggars on the street, and they give a wide berth to the homeless sleeping in corners or on grates.  Evidence of the poor can give a city a bad name, so considerable money is spent  not so much to help the homeless, but to hide them.  To reduce the risk of having them intrude on their peace, people with more money can choose an apartment with a doorman, or even a gated community. 

But while money and empathy seem to exist in inverse proportions to each other, there are significant exceptions.  There are some wealthy people who seem to feel the plight of the poor, and not only write checks, but, if they’re able, set up foundations to support a pet charity.  These are moved by a variety of factors, e.g.  remembering where they came from, wanting to “give back” to the community,  or simply having an active imagination allowing them to sense what it would feel like if they stood in a poor person’s shoes.  These people don’t need to be persuaded to support NYHA; they have persuaded themselves.

And those with businesses big enough to support healthcare for their workers should see the financial advantages for themselves; they didn’t get big without a lively sense of the bottom line.

Likewise, it should be easy to demonstrate to lower and middle income employees that their overall expenses should be less.  When presented with the figures, these folks should need little imagination to see the benefits to themselves and their families.

The big challenge will be to appeal to businesses who currently are not required to pay anything for their employees health care.  Colleges need pay nothing to insure the health of their adjunct professors, nor do real estate agents need to support the health needs of their associates.  And, of course, small businesses who aren’t currently required to pay anything will be very reluctant to start chipping in to NYHA.  In some of these cases, the offset of lower property taxes – which will no longer be needed for Medicaid costs - may be enough  to sweeten the bitter pill; in others, the greater attractiveness of the state as working place may be persuasive.

But ultimately,  a little bit of empathy towards those whom high medical costs have sentenced to death, whose fate could conceivably come to the currently more fortunate or to someone close to them – the sense that there, but by the grace of God, go they – should be very persuasive.

Dio

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IT’S INEVITABLE

Dr. K. was one of the most conscientious family doctors I have ever met.  Her physical examinations were unrivaled in their thoroughness, and she knew how to listen; her patients – of whom my wife and I were two – felt they had in her a sympathetic friend of the family.  She was so popular, so good at what she did, that she was forced to stop taking new patients.

I’ve used the past tense because she’s no longer our doctor:  She has quit private practice to become the physician tending to the students at a local university. She misses her old patients, and misses the opportunity to follow patients as they continue through life.  But on balance, she feels that the move she made was right for her.  Her great strength is as a physician, but she was daunted by having to wrestle with insurance companies whose business aim, it seemed to her, was not in providing care but in denying it.

Her successor, Dr. D., is likewise a superb physician, but unlike her predecessor, is less daunted by the red tape that modern medicine – in this country – is heir to.  Once I had occasion to see her, and so I asked her what she thought about single-payer healthcare. Her mouth tightened, and after a pause she said, “well, the current system is broken, that’s for sure.”  I took that to mean that while something had to be done to solve this problem, she wasn’t sure that adopting single-payer was the right solution.

I got a more positive response at the ophthalmological clinic of Dr. F., who recently performed the cataract surgery that is allowing me to post this blog tonight.  The day of the surgery, I asked his anesthesiologist what he thought of single-payer.  He sighed, and said, “it’s inevitable.”  The next day, in a follow-up visit, I asked the surgeon himself about his opinion of the New York Health Act. Immediately he replied, “I’d prefer it to be a national program.”

“So would I,” I said. “But that’s not going to happen any time soon.”

He nodded, then said, “well, I’d have to say that...” then he paused, then continued: “yes, I do support it. It’s inevitable.”

Doctor F. and his anesthesiologist are not the only doctors who feel this way.  Earlier this year, the New England Journal of Medicine published a poll stating that the majority of American doctors now favor single-payer.  That’s quite a change from 57 years ago, when the American Medical Association hired Ronald Reagan to attack Medicare as “socialized medicine.” What has happened since then?

According to Meagan Day, writing in the American socialist magazine JACOBIN, it can be summed up in two words: “Physician Burnout,” which is defined, she says, by the University of California Riverside School of medicine as “1) a feeling of a lack of accomplishment; 2) feelings of cynicism; and 3) a loss of zeal, zest, and enthusiasm for work.” 

Ms. Day writes that “In our current system, there are usually three parties involved in every medical decision: the doctor, the patient, and the insurer. The doctor and patient may agree on a course of treatment, but the insurer decides whether it will be covered. And since many Americans can’t afford ever-growing out-of-pocket medical costs,  that often means that insurers have the final say in whether the treatment will be administered at all.

The majority of Americans receive health coverage from a private insurance company. And while doctors and patients are both theoretically focused on patient health, the insurer is driven by an entirely different motivation: to maximize profit. Insurance companies are financially motivated to deny claims, and they do it all the time, even in life-or-death situations. One in four patients with a chronic or persistent illness or condition have had claims for medication, tests, or procedures denied by their insurer. In 70 percent of those cases, the condition was described as serious. Only 1 percent of patients said they trusted their health insurance provider’s judgment over their doctor’s or their own — and yet the buck stops with insurance companies.

When they deny claims, insurers give doctors and patients all kinds of excuses packaged in obscure industry terminology: formulary exclusion, prior authorization. But the simple fact is that patients aren’t getting the care they need — and doctors aren’t getting the opportunity to actually do their job. All too often, this is deadly for patients. For doctors, it’s depressing and demotivating. It hinders physicians’ ability to practice medicine, makes them feel powerless at work, and divests them of a feeling of personal accomplishment.”

Ms. Day adds to that what she characterizes as a “jigsaw insurance network system” which often forces one to change doctors whenever one changes jobs, or when one’s employer changes insurance companies, resulting in a situation where, ”seeing little purpose in getting to know patients intimately, doctors can become cynical. The lack of continuity leads to feelings of alienation and disinvestment for physicians who may have been attracted to the profession by the prospect of helping and healing people.”

And even if all the above were not so, the sheer labor involved in dealing with a plethora of insurance companies, each with its own requirements and protocols, is a significant drain on every medical practice in this country today. In NEJM’s CATALYST magazine, Marilyn Serafini cites a 2009 study by Lawrence Casalino, MD, PhD, Professor of Health Care Policy and Research at Weill Cornell Medical College.  “[He] put a dollar figure on the time that practitioners were devoting to administrative tasks. He estimated that physicians were spending 3 hours a week interacting with health plans (add another half hour for primary care), and that nursing and clerical staff spent 19.1 hours per week per physician. He estimated the national time cost at as much as $31 billion each year.”

When you take into account all the above, it’s little wonder that so many of our doctors are in favor of Single-Payer.  Now: If we can get the electorate to be aware of NYHA, and to see it – passionately -- as the medical salvation for all of us, then Single-Payer will be, indeed, inevitable.

WHY IS AMERICAN HEALTHCARE SO EXPENSIVE?

Part Two

In this blog’s early posts, we saw how Big Pharma exploits its near monopolistic powers by raising prices simply because it can, resulting in the shortened lives of many patients who have been priced out of living.

In the current two-part series, the first part showed the results of Physicians and other providers gaming the system by ordering unnecessary procedures – which benefits mainly them, unlike Patient Centered systems like the Mayo Clinic, where their salaried doctors have no incentive to drive up charges, and everything is focused on institution-wide teamwork in healing the patient.  The former is profit-driven, the latter patient-driven, resulting in better outcomes at lower costs.

So far, if we’ve been paying attention, we’d be justified in concluding that where patient care is concerned, considerations of profit are poison.

But what about Hospitals and Clinics, Dialysis Centers and the like? Are considerations of profit poison for them as well? The answer is a resounding YES, according to Steffie Woolhandler and David Himmelstein, the pre-eminent Physicians/Scholars, co-founders of the Physicians for a National Health Program,  the lead authors of the PNHP’s healthcare reform article published in the Journal of the American Medical Association, which in turn is the basis of H.R. 676 , the Single-Payer Bill from the House of Representatives. Woolhandler and Himmelstein are, in my opinion, the God-Parents of our movement. and are worth listening to.

They spell out their position in the article: IMPORTANCE OF ALIGNING HOUSE AND SENATE SINGLE-PAYER BILLS THE RIGHT WAY: Removing Medicare’s Profiteering Incentive is Key. I encourage you to read it:

Aligning House & Senate Versions of Single-Payer The Right Way.

Woolhandler and Himmelstein say that the Senate Bill, unlike the House Bill “...would, like Medicare, pay hospitals and other institutional providers on a per-patient basis, intermixing payments for current operating expenses with funding for future capital investments and profits. At present, hospitals’ success, and even survival, depends on generating profits (“surpluses” in non-profit facilities). Hospitals with a favorable bottom line can invest and add new buildings and programs, while unprofitable ones can’t modernize or expand, risking a downward spiral toward takeover or closure....It’s this profit imperative that drives hospitals’ financial gaming, e.g. upcoding, and concentration on the most lucrative services, such as elective cardiac and orthopedic services, rather than money losers like mental health. This payment mechanism (and S.1804 as a whole) also leaves the door open to investor-owned providers.”

The authors go on to explain why payment for performance schemes – in addition to requiring expensive bureaucratic overhead – provide “no evidence that they’ve improved patients’ outcomes in any setting.” Moreover – it should go without saying – the minute you have an investor-owned enterprise, you must compromise quality to ensure profits. Privately owned dialysis centers, for example, have far worse outcomes than community owned ones.

Contrast all this with the model provided by Scotland and several other European countries who pay these institutions the way we pay firehouses – globally – to take care of operating expenses. Our firehouses aren’t expected to make a “profit” to save for a new firetruck.  If they need one, they appeal to the local municipality to buy them one.

The House’s H.R. 676, similarly, would pay medical institutions globally, covering all operating costs, and would allow no “profits.” If new equipment or expansions are warranted, they would get them from the government, which – if it wanted to stay in office – would provide them promptly. And privately owned facilities would be made publicly owned by the government’s buying them out. This would be less expensive than  it might at first appear, partly because health facilities typically carry a debt load, and partly because it would not be done all at once, but over a period of time.

Everyone agrees that once established, Single-Payer would save money if for no other reason than obscene profits and bloated bureaucratic overhead would be eliminated (contrast Medicare’s 2% overhead with conventional insurance’s 12%).  While that is not small potatoes, it might well not be enough to meaningfully lighten the burden of healthcare on our economy.  As our authors point out:
“In sum, the financial viability of a single-payer reform turns on cutting administrative costs and minimizing incentives for financial gaming. Maintaining Medicare’s current payment strategies, as under S.1804, would be substantially costlier than adopting the non-profit global-budgeting strategy used in several other nations.”

Atul Gawande, physician/author of the article on which the previous post is based, is more blunt:

“When it comes to making care better and cheaper, changing who pays the doctor will make no more difference than changing who pays the electrician. The lesson of the high-quality, low-cost communities is that someone has to be accountable for the totality of care. Otherwise, you get a system that has no brakes. You get McAllen.”

To me this means that setting up Single-Payer – by itself – will not be enough, unless it removes the profit motive, regulates  greed, minimizes the incentives to game the system, and unless it requires healthcare providers to meet carefully fashioned public standards . If this happens, the cost savings and improvements in care will be very great.

There will be plenty of arguments, pro and con, for everything that’s been said in all my posts. Our job is to stay on top of them, making sure that when reform is done, it’s done right.

Dio

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WHY IS HEALTHCARE SO EXPENSIVE IN THE USA?

Part One

A few days ago I came across a video entitled, The Real Reason American Healthcare is So Expensive. Almost 3 million people have watched it, You really should, too.

The Real Reason American Healthcare is So Expensive

In typing this just now, I couldn't help watching it again -- which made it my fourth time viewing it (it's that good).  What it shows is that the high cost of healthcare in this country is NOT because of what we spend on Medicare, Medicaid, and VA healthcare -- our versions of socialized medicine in this country. In those public expenditures, our costs are right in line with other countries. Where we exceed them is what we spend privately. That's where we go through the roof.

I love the enthusiasm of the young man in the video, who says he's "obsessed" with this data. He points out that we hear all the time that the government "can't say no, it's corrupt, it's inefficient, it's slow; if you want something done right you give it to the private sector. That is what we hear in America all the time," he says, "yet here we are, with the biggest private sector, spending the most."  And it's not because we Americans go to the doctor more, he says, showing that if anything, we go less. He goes on to state the obvious, that the capitalist free-market model, while it may be great for selling things, simply cannot work when providing healthcare to people, who, when they need it, are in no position to comparison shop for the best value, even if they knew the best thing to shop for. And when presented with a sky-high cost , they are in no position to say "no." We are left with a graphic of our healthcare system -- symbolized by a huge hospital building with many lines of "influence" running from it to the Capitol Building in Washington, DC,  Although there are no arrows to show in which direction the lines of "influence" are flowing, and the young man doesn't say so explicitly, I gather that they are flowing not from the Capitol, but to the Capitol, and that influence is in the form of dollars. Our healthcare system has grown so powerfully wealthy, he says, that it's going to be very hard to trim the cost of doctors and the services and medicines they prescribe. 

It's almost as if there has descended on us, like a poisonous fog, a culture of money, a phrase I borrowed from Atul Gawande's famous New Yorker article, The Cost Conundrum. You should read it: 

The Cost Conundrum

Here Gawande describes the medical goings-on in the small, not-very-prosperous McAllen Texas, which had -- at the time of Gawande's writing (2009) -- the most expensive healthcare market in the country. Many healthcare markets -- such as El Paso -- were far more prosperous yet spent on medical costs only half the money spent in McAllen. With all this money spent in McAllen, one might suppose that the healthcare delivered there was superior. Not so -- in fact, Gawande reports the reverse: 

"Medicare ranks hospitals on twenty-five metrics of care. On all but two of these, McAllen’s five largest hospitals performed worse, on average, than El Paso’s. McAllen costs Medicare seven thousand dollars more per person each year than does the average city in America. But not, so far as one can tell, because it’s delivering better health care."

Why then? Gawande quotes a general surgeon: "'We all know....there is overutilization here, pure and simple.' Doctors, he said. were racking up charges with extra tests, services and procedures."  It got to the point, he said, where “the way to practice medicine has changed completely. Before, it was about how to do a good job. Now it is about ‘How much will you benefit?”

Gawande contrasts all this with the practice at Mayo clinic, where doctors are not paid by procedure, but are salaried. The time they spend with patients is not a predetermined slot of 15 minutes,but is determined by the patient's need. And they regularly consult with other doctors in the practice, so that the outcome is a joint effort. Gawande writes that "No one there actually intends to do fewer expensive scans and procedures than is done elsewhere in the country. The aim is to raise quality and to help doctors and other staff members work as a team. But, almost by happenstance, the result has been lower costs." 

It's no accident that in my recent posting [Good News ... Sort Of], Mayo is one of the hospitals cited for combining with others to establish CIVICA RX, a company which will produce generic medicines that the current cartel has attempted to price out of reach of many people. Intermountain Healthcare, also cited by Gawande for good practice, is another co-founder of Civica. Are they exceptions? As far back as 2009, Gawande pessimistically predicted that the Mayo Model seemed to be losing traction, whereas the McAllen model seemed to be winning.

Despite the remarkable surge in demand for Single-Payer, it may be too soon to tell which model will win. As we saw in the video above, Bernie Sanders proposes a transition plan to ease us into a full scale Single-Payer, but from my point of view, the crucial question will be whether or not Bernie or anyone else can succeed in putting price controls on Big Pharma. That is the epic struggle to come. Meanwhile, NYHA has such controls written into it, and it behooves us to push for it, publicize it, and do everything we can to hasten the day when Single-Payer will be the law -- if not of our country, then of our State.

PS: If you'd like to leave a comment -- and I hope you will -- just click on the number of comments area and share your thoughts in the "comment box" that appears.

PPS: My surgery went well, and I'm doing fine. But an amusing thing happened. I heard one nurse comment to another that the downside for working for an eye surgeon is that while before surgery, some patients mention how nice looking they are,  they hear no such remarks after surgery, when the patients can see. And on a more serious note, both doctors present said Single-Payer was "inevitable."  More on that later, perhaps.

ORGAN RECITAL

(A Personal Note)

My brother of blessed memory used to say, "the reason we retire is so that we'll have time to see the doctor."

Now that I'm in my eighties, with my wife not far behind, we see the truth in that joke, as we have become increasingly familiar with our doctor's offices. When we were young and starting our families, we, like others our age, talked incessantly (it seemed) about our children. But now our children are talking about their children, and we old folks, when we meet our friends, are conscious that we -- like others our age -- talk increasingly about our  medical adventures (!) We ask, "how are you," and we get in reply what we have come to call "an organ recital,"  And we give as good as we get.

I don't want to burden you with an organ recital now, but I do need to explain why you may not be hearing from me for the next few days. Tomorrow, 9:15 on Wednesday Dec. 19, I'll be arriving at a surgical center to undergo cataract surgery. Normally, it's not a big deal, as many of you who've had the procedure will attest -- although there are exceptions. And though I'm a bit apprehensive, I'm confident that I've chosen the best surgeon for this procedure in a fifty-mile radius, and I feel  I've reason to hope for the best.

But very likely, I will be instructed to "take it easy" and rest my eyes for a day or so afterwards, and because of the sedation involved, I probably won't be thinking as clearly as usual -- however clear that may be.  So it's fair to suppose I won't be making more posts for a few days or so. 

My wife says that I shouldn't worry about it, because this will give my readers a chance to catch up and read all the posts. (She says that I've made so many in the past few weeks, that she feels she can't keep up.)  

I hope -- God willing -- to return to the site in a few days.

Dio

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LONG TERM CARE: A BENEFIT WITH MORE THAN I HAD SUPPOSED

When my wife I arrived at the New Paltz Community Center at 3:05 pm, we were more than surprised at the crowd already there --  we were amazed. The two dozen or so people who had already arrived before us had braved -- as we did -- a torrential downpour of almost freezing rain. and they kept on coming. As we later learned, some had come from as far as two counties away. None of us wanted to miss Henry Moss, Ph.D, talk about the addition to the New York Health Act of Long Term Care, for which he is largely responsible.

Of course I had been in favor of  NYHA's inclusion of Long Term Care; I had generally supposed it would be a good thing, and had thought little more about it. But when Dr. Moss starting speaking about it, I began to realize that I had  no idea about how really crucial it was. The key is two-fold: First, he said, Millennials are having fewer children, so there will be fewer potential caregivers as the older generation starts to need them. And second, he said, when a parent or someone else does need care, the burden of that care is likely to fall upon a woman -- men are less inclined to care giving. It was that which turned on the light bulb in the head of the dimwit who happens to be your humble author, Dio. 

For as Dr. Moss continued to detail how these female caregivers might feel the need to give up full time work -- or even leave the work force entirely --  I remembered the dozens of men who had confessed to me that they were less than passionately in favor of single-payer because their corporate insurance was excellent, thank you very much, and while they were certainly conscious that others might have a problem, and while they were certainly concerned -- in a general sort of way -- they had other imperatives competing for their attention. 

But women on the other hand, feeling more obligated than men to care for loved ones, might be all the more passionately committed to the passage of Single-Payer if they knew it now includes a provision which especially benefits them -- long term care.  Our task is to make it known.

It feels a bit weird to have been reminded of self-interest in a room full of people who have proven they are anything but selfish. But I'm reminded of the way of the world. If you show someone that a policy benefits someone else, you might expect at best, an agreement that it is a good thing. But demonstrate to them that the policy is in their own self interest, and you get their attention.

My wife has just reminded me that there are more families than ever before where the woman is the principal breadwinner, and in single-parent families, that single parent is likely a woman. And in most families, the principal one taking care of the children tends to be the woman, and when she is tasked also with caring for a parent, she feels the strain of being pulled in two directions.

Our job is to get the electorate's attention -- including the women's.   

Dio

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VARIOUS FLAVORS OF HEALTHCARE REFORM

From VOX, recently, I received a very interesting article 

Democrats 8 Plans for Medicare for All

which attempts to spell out the eight plans for universal health care so far cooked up by Congressional Democrats.  Though there’s no chance of any one of them being adopted under the current administration, it was clarifying to read it, because it helped to identify what I wanted to see in healthcare legislation, and what I most definitely did NOT want to see there. I figured that it might do the same for you, so I thought I’d present the gist of it here. The article sums up the eight plans in the diagram I reproduce below:

Please note that all eight plans – as Vox reports them – assume the Government’s regulation of health care prices. So even if the least generous of the plans was adopted, the result – presumably – would be better than what we have now.

Plans Number 1 (the House of Representatives’ HR676),  and number 2 (the Senate’s S1804) both are paid for strictly by tax increases, and would offer broad coverage for everyone, with no co-pays, deductibles, or pre-existing conditions.  As such, they are the only true single-payer bills being considered. In fact there are only two differences between them both, which we will consider later. 

Note that insurance companies are deliberately excluded here – a consequential decision for the drafters, since traditionally, employers offering health insurance can deduct that expense from their taxes, which means, as Vox says, that “companies’ dollars stretch further when they buy workers’ health benefits than when they pay workers’ wages.”

Taking that into account is Plan Number 3, Medicare Extra for All,  proposed by the think tank, Center for American Progress. This would achieve universal coverage for all legal residents through a combination of private and public insurance – at least for the next few decades.  The plan would let employers continue to offer coverage to their workers so long as it met federal guidelines. At the same time employers would be offered a similar, tempting option: to stop offering coverage and instead pay a payroll tax equivalent to what they currently were spending on health coverage.  But how tempting that offer would be depends on how generous the Medicare Extra plan turns out to be, a crucial detail which hasn’t been specified yet. What has been specified is that every new born would automatically be enrolled in the new plan, so that ultimately the resulting healthcare plan would look a lot like the single-payer plans being sponsored in Congress.

Plans 1, 2, and 3 are designed to bring healthcare coverage to everyone.  Not so the rest of them.

Plan 4, The Urban Institute’s Healthy America Plan aims to disrupt the employer market as little as possible. Recognizing that most people with employer plans are reasonably happy with them, they would set up new insurance marketplaces for those whose insurance isn’t very good anyway – mainly the Obamacare and Medicaid populations.  The cost of their insurance would be covered partially by tax increases, and partially by the premiums they'd pay into the system.

Plans 5 through 8 are buy-in programs – paid for in no way by higher taxes, but by the subscribers only. As such they would exclude all those unable to afford it.  For that reason I'm against them.

But I’m against buy-in programs also for another reason, and for that, let me refer to an email I just received which quotes Wendell Potter, whose every word here is worth reading and taking to heart:

“I spent 20 years as a health insurance executive before leaving my job as a vice president at Cigna. I can tell you firsthand that by focusing on a half-baked measure like a Medicare buy-in, Democrats would hand a huge gift to the private insurance industry while doing less than the bare minimum to help struggling businesses, workers, families and patients.... It’s time for Democrats to stop proposing health care reform that relies on insurance companies to play fair. After two decades in the for-profit health insurance industry, I can assure you they never will. They have no interest in doing anything that might in any way jeopardize profits. Their only interest is delivering profits to their shareholders. From that perspective, the status quo is very profitable. For everyone else, not so much.

Champion dramatic reforms, not half-measures!

Business owners are struggling to provide health insurance to their employees, workers' take-home pay is shrinking as their premiums go up, patients are literally begging for their lives on fundraising platforms like GoFundMe, doctors and hospitals are drowning in paperwork dealing with insurance claims departments, and more than 80 million people lack adequate health insurance. That number is increasing every year. Reform is desperately needed.

Democrats have the chance to be the champions of that reform if they don’t waste their energy on half-measures. Instead of thinking about how they can make small tweaks to the health care system, they should start thinking about how to enact dramatic reforms that will assure universal coverage while reducing costs and encouraging economic growth. Voters and taxpayers are asking for Medicare for All. It’s time to listen.”

For all these reasons, I’ve left Vox’s description of the four “buy-in” plans for you to read in the original document (see the link). You can make up your own minds. 

Dio

PS: If you’d like to leave a comment (and I hope you will) simply click on the number of comments area. In the comment box that appears, you can share your thoughts.

ACCORDING TO SPECTRUM,

SINGLE-PAYER MAY NOT PASS

EVEN WITH DEMOCRATS IN CONTROL

Just this morning, I got a link which you all should read:

Single-Payer May Not Pass Even With Democrats in Control

It lists 3 reasons -- (1) The cost, (2) The wariness of some unions, and (3) Cuomo's unwillingness to take risks.

The money figure -- $139 Billion -- in indeed formidable. But the article describes that cost as "just to establish the program" (implying that future costs might well be more), and a graphic is presented showing that $139 Billion virtually swallowing up the annual state budget (as if it would cost $139 Billion every year). The article's presentation so far, in my opinion, betrays its corporate slant, although it does concede that once implemented, the plan is expected to save taxpayers money, but finding the dollars for the initial startup could prove very challenging. The article does not mention how much money NYHA would save tax payers, which has been estimated in the billions. 

Granted, finding the start-up money will  be challenging, but that problem is not limitless; it is finite, which means it is possible to solve: Where there's a will, there's a way.

The wariness of some unions in endorsing NYHA is something we discussed in the previous post.  (If you haven't seen it, I encourage you to check it out). But I want to note here that the Spectrum camera shows the initial sponsor of the legislation, Gustavo Rivera, earnestly explaining that the latest version of the bill "is still being drafted. 'It's not ready yet,'"  It's hard to conceive that Rivera, the likely incoming Chair of the Senate Health Committee, would allow this bill to come to a vote if he thought it wouldn't pass. This is where the negotiations come in. We are going to find out that where there's a will, there's a way.

As for Cuomo, yes of course he's known to be cautious, but he is shown telling the Spectrum reporter that there would be a transition, there would be things he agreed with, things he disagreed with, "but one thing is for sure: we will make rapid, remarkable change."

How rapid? How remarkable? 

Well, here's my take on all this: The start-up cost, the union's reluctance, and Cuomo's caution -- each of these things will be brought up by members who in past years gladly got brownie points by voting for the bill, safe in the knowledge that with the conservative control of the Senate, it never would pass. But now that things are changed, these members will very likely remember the source of the money that got them elected -- much of it from corporate donors,  much in fact from the healthcare industry itself.  Indeed, the same can very likely be said of Cuomo himself. And his action, just as State lawmakers action, will depend on how much they see the electorate demanding it. 

That's where we come in, as activists, and as every day citizens. It's a call to action: We must work all the harder -- the feet of our lawmakers, and our Governor, must be held to the fire!

We must demonstrate  that for ALL our sakes, things can't go on the way they have been -- if for no other reason than its too wasteful of our treasure, not to mention our lives.  Let us raise up the general consciousness so  we can prove once again: 

IF WE HAVE THE WILL, THEY WILL FIND THE WAY.

Dio

PS: If you'd like to comment (and I encourage you to do so), click on the number of comments area, which will bring up a "comment rectangle" in which you can share your thoughts. Don't be afraid to teach me something! I'm learning all the time.

NOW COMES THE HARD -- AND MOST EXCITING PART!

Today -- Dec. 11. at 9:27 AM -- The Gothamist published an article titled  Powerful NY Unions Could Complicate Push For Single Payer Health Care. The link for it is below:

Possible Complications for Single Payer Healthcare

According to the article, there are two complications, actually: (1) Some unions, who have their own vested interests and concerns, and (2) A newly mobilized healthcare industry, which is now in overdrive spreading distortions and outright lies, which say that so-called "realities" of  Single-Payer are to be dreaded as causes of catastrophe.

For me, these developments are very exciting, because the growing intensity of Single-Payer's opposition indicates the increasing possibility of its enactment!

These two complications -- the diffidence of some unions, and the propaganda of the healthcare industry -- are too much to cover in one blog post. So I propose, in this post, first to deal with the unions:

The good news is that, as The Gothamist says,  The most powerful healthcare union in the state, 1199 Service Employees International Union (SEIU) is a backer, as is the New York State Nurse Association (NYSNA), BUT two other pivotal statewide unions, New York State United Teachers (NYSUT) and the Civil Service Employees Association (CSEA) have yet to endorse it.

Why this diffidence? In an article in Politico/New York, 

City unions say they dread impact of Single Payer in Albany

we read that the city unions fear that the coverage for their workers would be reduced, a concern that NYHA sponsors, Assemblyman Richard Gottfried and State Sen. Gustavo Rivera, say the bill is being revised to address. This concern is sensible and to be expected. But there's a second concern, which, from my point of view is much more fascinating: Up to now the union's membership has relied on their unions to negotiate healthcare benefits that are better than some others enjoy. But if all these benefits will be furnished by the NYHA, the importance of the unions would be diminished,  their collective bargaining leverage around health plans nullified, wiping out the city's roughly $1500-per-employee contribution to individual union funds.

As I see it, these unions' point of view seems to be that the more employees receive benefits outside the unions,  the less they need the unions. To union leaders this prospect may well seem  frightening.  These leaders may be struggling with the question: Which is more important -- prosperity of the workers, or prosperity of the unions?  For me the answer is embodied in what Gottfried says,
“As Gustavo and I keep telling them, this is what our parents raised us to do. We were not raised to screw city workers. Or any workers,” Gottfried said.

Another union leadership objection to NYHA, according to the Gothamist, is how will the Act treat Union members who work out of state? NYHA, as currently drafted, covers only people who make their dwelling in New York State. What happens to, say,  a member of a New York Electrical Union who does half his work in New York State, and the other half in New Jersey? The unions make a big deal of this. but one of the readers of the article had a simple answer: If you live or work in New York State, you pay taxes to it, because you receive benefits from it.  For this worker. as for many, the issues were simple, and what I found interesting was that virtually all the scores of comments were in favor of single-payer; the difficulties seem to be only in minds of the union leadership.

My take on all this? Let me just say that a few months ago, I had an email conversation with a congressional  candidate who was subsequently elected to the House. He said that he wasn't necessarily opposed to Single-Payer if, and only if, all the "stake-holders" could negotiate the required compromises. Since this was email, he couldn't see my snorting reaction: If by "stake-holders" he meant Big Insurance and Big Pharma, I could only retort that they had NO PLACE at the table! None whatever! Among my circle of friends, (all progressive Democrats), this Representative is what we call a "Corporate Democrat,"  and there is no doubt in my mind that the stake-holders he had in mind did indeed include Big Pharma and Big Insurance. But now, after reading this Gothamist article, I see that my Corporate Democrat was, in a sense, right!  The reality seems to be that we cannot move forward with NYHA unless we take into account the interests not only of the individual worker, but also of his or her union -- corporate-like though it may seem in the worker's eyes.  In this light we may view the comment of a reader:
Of course CSEA has yet to endorse it. They are the most corporation-like of all the unions that operate here in NYS.

Be that as it may, I wouldn't be surprised if there are many other perfectly legitimate entities who have a place at the negotiating table (and by legitimate, I mean NOT Big Pharma, and NOT Big Insurance)! 

Is all this getting complicated? Yes!

Should we therefore drop it? NO, NO, and NO!  (Did I remember to say no?)  Again, no. Rather, to strengthen our resolve, all we must do is think of the Hell which is our healthcare distribution system now. True, in our healthcare reform, the devil WILL BE in the details, and we must stay on top of them to make sure they're sorted right! 

And always, we must continue to show the Insurance and Pharmaceutical execs as the blood sucking Ghouls of Greed that they are, so that the public may be revolted by them! That's why I keep at this.

Dio

PS: I welcome comments. Just click on the number of  commnts area, and there will appear a "comment box" in which you can share your thoughts. Don't be afraid to teach me! From your comments, I'm learning all the time.

HOW TO LOSE SLEEP

It's quarter-to-one Monday morning, December 10th. I should be in bed, fast asleep. But I just read an article in the Washington Post entitled INVESTIGATION OF GENERIC 'CARTEL' EXPANDS TO 300 DRUGS.  Here's the link to it:

Generic drug price-fixing investigation expands to 300 drugs and 16 companies

I advise you not to read it unless you don't mind becoming very angry. That's what happened to me -- so much so, that my blood seemed to boil, and there was no way I could sleep without getting this post out. 

You see, like many of us, I had naively supposed that generic drugs were supposed to be significantly less expensive than the brand-name versions whose patent had expired. That's why the generic program had been created, I thought: To give other pharmaceutical outfits a chance -- once a patent had expired on a drug -- to compete with others to manufacture these drugs at a lower price. 

But now, with this Washington Post article, I learn that these pharmaceutical manufacturers meet and conspire to fix prices. They have their own little euphemisms: "The Sandbox" is the market-place where all the generic manufacturers are expected to "play nice" and not charge any less than the agreed-upon inflated price. "Fair Share" means divvying up the sales pie of so each of the companies can continue making money, and "Trashing the Market" refers to a company's refusing to abide by the unwritten rules and selling for lower than the prices the group has agreed upon.  And I learn that just as there is honor among thieves,  there is a code that everyone tries to abide by: LET NONE OF OUR AGREEMENTS BE COMMITTED TO WRITING!

This activity was known for a few years, and lawsuits were already in progress,  but when a Federal Judge recently ruled that more than a million emails. cell phone texts, and other documents could be shared among all the plaintiffs, and ...

What started as an antitrust lawsuit brought by states over just two drugs in 2016 has exploded into an investigation of alleged price-fixing involving at least 16 companies and 300 drugs, Joseph Nielsen, an assistant attorney general and antitrust investigator in Connecticut who has been a leading force in the probe, said in an interview.... “This is most likely the largest cartel in the history of the United States,” he said. 

The result is that long-standing out-of-patent medicines like Albuterol, which not long ago sold  for 13 cents a tablet, now sells for "more than $4.70." That's more than a 3400 percent increase. And the cartel does this not because there's been some impediment in the supply, as some of us had foolishly supposed.  No. They do it simply because they feel like it. To explain this behavior Neilson offered a single word:

(Emphasis mine.) 

Who pays for this? Everyone pays, singularly and collectively, whether we're on Medicare, regular insurance, or simply pay taxes, we pay through the nose.

Now many of  these profiteers' shenanigans, though ethically dubious, are perfectly legal. But conspiring to fix prices is -- much to the annoyance of these pharmaceutical pirates --  against the law. When this is pointed out to these folks, they proclaim with one voice: Try and Prove It!

(I'm not kidding, that's what they say.) Well, some dedicated prosecutors are trying to do just that -- prove it. Lets wish them luck. 

Let's do more than that: Let's channel our anger by telling  everyone we meet that ripping off the public in this way is downright UNAMERICAN -- sanctity of profits notwithstanding -- and must be resisted by reforming healthcare in this country to something that is NOT driven by the profit motive. 

That's what I'm trying to do by sharing this blog. And if all of you who read this will indeed share the word, rouse the anger, and SPREAD it, then I will be able to sleep tonight,

Goodnight!

Dio

PS: If you'd like to comment (and I hope you will), simply click on the number of comments area, and a "comment box" will appear in which you can share your views. Don't be afraid to teach me something!  Thanks to your comments, I'm learning all the time.

The Ticking Time Bomb

Yesterday,  there appeared in the New York times an opinion piece entitled The Ticking Time Bomb Under Obamacare: 

The Ticking Time Bomb

Its authors cite all the administration's current attempts  to completely destroy Obamacare, and they dwell particularly on what they call a "ludicrous" lawsuit in Texas, which attempts have the Obamacare mandate declared unconstitutional, on the basis that the mandate's penalty is zero, and that if the mandate must be excised, the entire act must be destroyed. According to the article,

"The judge overseeing the case was handpicked by Texas for his unfavorable view of the A.C.A. and has delayed until after the election what would be a disastrous decision with consequences for millions of Americans. Recent estimates say as many as 17 million could lose their health care in the first year alone."

I'm not doing justice to the scary details of this piece -- you really should click on the link above and read this terrifying article for yourself. If the judge acts as predicted, and the Supreme Court upholds him, it will be a disaster for the United States of America -- and that, of course, includes New York State. It includes every one of us who has a pre-existing condition, or merely a moderately sized bank account. This means we New Yorkers have no time to lose. Our  state legislators MUST  pass the New York Health Act; our citizenry must rise up and INSIST on it. I can think of no other recourse. If you can think of something else short of leaving the country, I'd love to know what it is. 

The Republicans are readying a full frontal assault on the ACA. We can't rely on the miracle of their failing this time. We must fight for our lives. Time's a-wasting.

Tick-tick, tick-tick.

Dio.

If you'd like to leave a comment, (and I encourage you to do so) just click on the number of comments area, which will cause to appear a rectangle in which you can share your thoughts.