Photos from 2/27 Sanders March in Boston.
Photos from 2/27 Sanders March in Boston.
With the ACA under constant fire, it’s easy to think that single payer is off the table. Try getting that through Congress. Still, seems, here in Massachusetts, single payer supporters are not ready to give up.
On Wednesday night, Mass-Care invited former CMS director and gubernatorial candidate Don Berwick to a meeting on “What can be done legislatively to achieve Single Payer in Massachusetts.” An overflow group filled a small meeting room in the Downtown Crossing office shared by Mass Care and other progressive groups like The Women’s Institute for Leadership Development and the Industrial Workers of the World.
Berwick, who added single payer to his campaign platform, didn’t really need to make a case for the plan. He was preaching to the converted when he argued that turning the government into our insurer would help the country achieve “better care, better health and lower costs.”
It will have to happen on the state level, he said. “I don’t expect national leadership on this from either party.”
He cited the usual statistics – we spend 40 percent more per-capita than any other nation. Then he added a few more. While running for governor, he took a look at 15-year tends in the state budget. Funding was down for almost every item, he said. – local aid, parks, higher ed. For health care, state spending rose 72 percent in that period.
To pull that lens out a bit, he cited a recent Commonwealth Fund study that estimate the costs savings had the US had adopted a single –payer plan similar to one used in Switzerland: $15.5 trillion over 30 years.
None of these arguments has provided single payer with the kind of traction it needs to move into the mainstream.
“When you say, don’t worry, the state is going to be your insurer, that’s a hard sell,” Berwick said.
So, he and others are starting to emphasize another point – we are spending money on health care that could be better spent elsewhere. In other words, the co-pay may be so high on your knee surgery, you’re might not be able to pay the rent.
“There is a transfer of opportunity in society from other things to health care,” Berwick said.
Or pay for a week at the beach or a private college for your kids. As the discussion turned to how to sell the approach to the public, several people – including a group of medical students from BU – pointed out that high health care costs are not just a problem for the low–income and uninsured.
“How do we sell this to the middle class? “ asked Andy Hyatt, a first-year medical student at BU and a member of the school’s chapter of Physicians for a National Health Program. While it’s important to help the disadvantaged, he said, health for middle-income people “still sucks”
Just how to address that group is what these supporters of single payer health care are trying to figure out.
“We’re wondering what we as medical students can do,” asked Jawad M. Husain, also of the BU PNHP. “We want to practice in a system where we can treat people fairly.”
Berwick’s answer: “Political mobilization.” But he noted that the students will have to look outside the classroom for guidance on that. ” It’s not something I learned in medical school”
Former Medicare Chief and Democratic gubernatorial candidate Don Berwick apparently got a boost at a recent state convention, coming in third behind two front-runners. Former political editor Peter Canellos writer notes Berwick’s support for single payer in the Globe’s new “Capital” section:
When his rivals claimed he wasn’t really offering anything new — just another health care commission — Berwick doubled down by calling it “Medicare for all,” a description that pretty much suggests he’d eliminate private insurance.
Now, with the Democratic race down to three candidates — Berwick, and two party regulars with histories of failing to excite voters — single-payer will finally get the attention it merits as essentially the only markedly different policy proposal to emerge from either party. A bold move to show the Obama administration what real reform looks like? A takeover that will roil the system? A vehicle for finally bringing about equality in health care? A threat to Massachusetts’ world-class doctors and hospitals? Single-payer could be all those and more. And if Massachusetts were to broadly restructure its health system, yet again, reverberations would be felt across the nation.
The Globe tagged along with him earlier this week, starting with a scene at the WBUR studios.
Can Berwick, who ran Medicare and Medicaid in the Obama administration for 1½ years, appeal to voters outside the left wing of the Democratic Party?
He’d face the question twice more Monday, once from a Boston Herald reporter and again that evening at a Democratic gubernatorial forum in Jamaica Plain.
For Berwick, the question is misplaced because, he says, it underestimates the liberal impulse of the entire state — a state that elected Governor Deval Patrick and Senator Elizabeth Warren.
“This is a place where people really want to honor the idea that we are in this together, community by community,” he said in the WBUR interview. “And no, I don’t feel this is confined to some kind of fringe progressive wing.”
A bit here from Berwick on some of the Republican ideas for Medicare from out 2012 post.
The unrelenting supporters of the single-payer approach to health reform have updated their website. And, it is a quite an update. The old MassCare site was sluggish — infrequently updated and often lacking links to upcoming events. Check it out here or click below. Also in health reform, check out WBUR’s Q & A with David Seltz, the new head of the state Health Policy Commission.
Hey, my tweet from the Mass Medical Society on their latest survey didn’t say that. It talked about a shortage of primary care docs — old news.
Then this came from MassCare:
Hello Single Payer Supporters – We have exciting news! For the first time ever the Massachusetts Medical Society has asked doctors what they think about health reform in its annual “Physician Workforce Survey” of 1,000 practicing physicians in the state. The results released today? Doctors picked single payer health reform over a public option, over high-deductible plans, over the Massachusetts health reform – in short, over every other option presented.
Strikingly, of all the options presented, modeling national health reform on the Massachusetts health care law (which is what actually happened) received the least support – even less support than eroding insurance coverage with high deductible plans. Respondents were asked to pick only one of five options – although many respondents probably support multiple of these options.
Here are the results, quoted in full:
“A new question was added to the Practicing Physician Survey this year to document how physicians view upcoming system changes in health care reform. On March 23, 2010, President Obama signed into law the comprehensive health reform legislation, the Patient Protection and Affordable Care Act. It should be noted that these questions were prepared and responded to prior to the passing of that Act. The following question was asked of each of the respondents:
Which of the following options should be included in U.S. health care reform? (Please read each of the following options carefully and check only one.)
1. Single-payer national health care system offering universal health care to all U.S. residents – 34%
2. Both public and private plans with a public buy-in option (allow businesses and individuals to enroll in a public Medicare-like health insurance plan that would compete with private plans) – 32%
3. Keep the existing mix of public and private plans, but allow insurers to sell plans with limited benefits and high deductibles to keep premiums low. State subsidies would help low-income individuals buy insurance. Individuals could choose to buy a less expensive catastrophic plan, more expensive comprehensive coverage, or no insurance at all. – 17%
4. Model health care reform on the Massachusetts health law of 2006, offering a national insurance exchange, government subsidies to low-income people to purchase health insurance, a mandate requiring residents who are not eligible for subsidized health plans to buy insurance or be fined, and fine employers who do not offer adequate health care plans to their employees. – 14%
5. Other (please specify). – 3%”
You can download the full report, which includes responses to this question broken out by age, gender, practice size, specialty, and more, on the MMS web-site (pages 86-90):
The Centers for Medicare and Medicaid Services and the Federal Trade Commission are just wrapping up today’s hearing on the anti-trust implications of accountable care organizations, hypothetical networks of doctors, hospitals and other providers that would team up to delivers comprehensive care. Go to #ACO on Twitter for a stream of updates or to the CMS page.
Here’ s how Medicare defines ACOs :
Groups of providers and suppliers who voluntarily meet certain statutory criteria, including quality measurements, can be recognized as accountable care organizations (ACOs). This designation allows them to share in the cost savings that they achieve for the Medicare program. Beginning January 1, 2012, these ACOs can qualify for bonus payments if they achieve a threshold savings amount.
The hearings come as the Patrick Administration is taking another run at pushing the concept of global payments, which need ACOs to work. The Globe explains:
The system, called global payments, would require doctors, hospitals, and other providers to band together into groups called accountable care organizations that would split the payments and better coordinate patient care, thereby improving quality.
These provider groups generally would get a flat per-patient fee, along with incentives for high-quality care, hopefully eliminating the incentive for unnecessary tests and procedures, and encouraging greater focus on preventing serious health problems from developing in the first place.
Now comes a long email from the single-payer supporters at Mass Care, who say the system won’t work. They argue that it is the rising cost of services – not overtreatment or volume of services — that is driving up costs. The group argues that ACOs and global payments represent nothing but a throw-back to capitation – the HMO system of paying per enrollee instead of per service.
And, we all know how well that went over.
Physicians for a National Health Plan, which also supports single payer, has a few comments to offer about ACOs today as well.
Since it is not posted on line, here is a bit from the Mass Care email:
Brace yourselves, because Massachusetts is poised to follow the path of managed competition, chronic disease management, and a dozen other ideas that didn’t work by implementing a cost control policy that is being called “Accountable Care Organizations,” or sometimes “Global Payment Reform” or “Global Capitation.” Unfortunately, there is no evidence that it will control costs, there is a real risk that it will be dangerous for patients, and it will without question undermine the continuity of care for all of us in a dramatic way.
The legislature actually passed a bill back in 2008 that it hailed as “comprehensive cost control” legislation. Beyond kicking up a controversy over pharmaceutical gifts to physicians, the law contained almost no actual cost controls and a lot of new spending. But what it did contain was funding for a number of new studies. In a typically dysfunctional , Beacon Hill way, the first two of these studies were commissions tasked with deciding what the state would do to control costs; the last two of these studies were responsible for figuring out what was actually driving up health care costs in the first place.
So the task force on Payment Reform issued a report declaring (without actually bother to prove) that our fee-for-service payment system, by which we reimburse physicians per visit or per procedure, was driving up costs by giving them an incentive to overtreat patients. This task force recommended we instead move to a system of “global capitation” whereby we pay physicians and hospitals a fixed amount for treating a patient for a whole year, removing this incentive. This report – which is 100% wrong in its assumption that fee-for-service is a significant cause of rising health care costs – is the basis for the expected next round of health reform.
Next came the two very good studies looking at the causes of rising costs in Massachusetts: one by the Division of Health Care Finance and Policy, the other by the Attorney General’s office. They both came to the same conclusion: our costs were not rising because doctors or hospitals were overtreating patients, or because the quantity of care was rising from year to year; our costs were going up because the price of providing the same exact procedure, or the same exact visit, were going up from year to year. In fact, the AG’s report found that providers being paid fee-for-service in the state were no pricier than those being paid under a per-patient arrangement; this finding was accompanied by one of the most politically tactful footnotes you will ever encounter, encouraging those considering payment reform to have their heads examined.
When you go to a doctor, you expect evidence-based medicine, but don’t hold your breath for evidence-based health policy. The rush is now on to implement “Accountable Care Organizations,” which will prevent our health providers from overtreating patients – a problem that all of the state’s own research, in addition to virtually all national research and all international research tells us is not the actual problem. A very balanced 2009 review of the evidence on Accountable Care Organizations by the Brookings Institution concludes that there is little evidence they will have a large impact on costs, but the jury is still out and more experiments will be necessary to know more.
What we do know is that the version of ACOs being pushed in Massachusetts essentially revives two policies of the managed care revolution in the 1990s that were largely abandoned after massive patient and provider push-back: capitation and limited networks.
“Capitation” is the practice of paying providers a fixed amount to care for a patient over the course of the year: that amount will not go up or down, no matter how healthy or sick the patient becomes. What this means is that instead of insurance companies bearing the risk for a patient, providers bear the risk. If a patient is healthier than expected and uses little care, the provider will make money off of that patient; if the patient is sicker than expected or suffers an unexpected accident, the provider will lose money. The obvious problem is that, just as insurance companies have an incentive to avoid the sick when they bear the risk for patients, moving to a capitation system means that providers now have an incentive to avoid the sick. This led to a serious backlash when managed care companies first introduced capitation in the 1990s, and it is now an uncommon practice in Massachusetts.
Limited networks were also a hallmark of early managed care, forcing patients to receive care only from a limited number of hospitals and doctors. While this sounds like a fine way to reduce costs, it is fine only until you change jobs and have to leave the physicians you know and trust because they are out of network. Limited networks are an intentional barrier to access – they do not exist in countries with universal health care (that, is, all of the rest of them in the developed world) – and they undermine continuity of care, which is considered incredibly important for quality of care in the medical world. Limited networks have also become unusual in Massachusetts, but they would be imposed on virtually everyone if the proposal for accountable care organizations were implemented.
Dear Single Payer Supporters – On November 2, election day 2010, residents in fourteen representative districts in Massachusetts will have the opportunity to vote on a non-binding referendum question instructing their legislators to support single payer health care reform. These districts span 7 of the state’s 12 counties, and more than 75 cities and towns.
In 2008, a similar single payer referendum question appeared in ten representative districts, and won in all ten by landslide margins.
This year we have a much more diverse range of communities who will be voting, and few of the sitting representatives in these districts are currently co-sponsors of the single payer bill. It will be our priority this election season to get the word out and educate the public in these districts about what single payer health care reform would mean for their community, but we’ll need your help. Please offer to help out with voter education work, even if you will have limited time to commit this election season.
Thanks to all of those who put hard work into collecting signatures to put these questions on the ballot! Without work like this, our communities would not have the opportunity to have their voices on health reform heard.